Carotid arterial surgery using local anesthesia: a private practice retrospective study

Carotid endarterectomy has recently become one of the more controversial operations. The tremendous increase in the number of endarterectomies performed, coupled with the apparent increase in morbidity and mortality associated with this operation in some studies, have brought into question the indications and results of the procedure. The potential for complications from the procedure itself, as well as increased morbidity and mortality from surgery on the elderly, make carotid endarterectomy a dangerous operation that must be done carefully and thoughtfully. The authors have performed carotid endarterectomies exclusively under local anesthesia to more closely evaluate the neurologic status of the patient. They believe that the operation performed in this manner obviates the use of a shunt and its inherent complications in greater than 80 per cent of the patients. This, coupled with the fact that many of the patients also have severe cardiac disease and the use of local anesthesia causes less hemodynamic changes and stress, should make carotid endarterectomy under local anesthesia the preferred approach.

Surgical reversal of a subacute complete unilateral visual loss from an ovarian metastasis to the pituitary gland

A 56-year-old woman with ovarian papillary cystadenocarcinoma that metastasized to the pituitary gland sought treatment with a 7-day history of total loss of vision in one eye. Ten days after transsphenoidal tumor resection, the patient's vision suddenly returned to baseline. This unusual case indicates that surgical decompression of the optic nerve and chiasm can completely salvage vision, even after prolonged total visual loss.

Acute monocular blindness secondary to fibrous dysplasia of the skull: a case report

An unusual case of acute monocular visual loss secondary to fibrous dysplasia is presented. Orbital and optic canal decompression restored vision completely. A review of the pertinent literature revealed that operative intervention may be curative in patients with acute monocular visual loss. This finding contrasts with the chronic visual decline found secondary to fibrous dysplasia of the skull.

External carotid artery revascularization: indications, operative techniques and results

The external carotid artery (ECA) is an important collateral pathway in patients with ipsilateral internal carotid artery (ICA) occlusion and recurrent symptoms. An ipsilateral ECA revascularization can improve cerebral perfusion or eliminate an embolic source. In the past 11 years 11 patients underwent operation, 6 times for amaurosis fugax and 5 times for transient ischaemic attacks. Eight times ECA endarterectomy was performed for stenosis and/or ulceration. Eight times closure or separation of the ICA stump with thrombus was carried out. There were no perioperative neurological deficits or deaths, with the exception of 3 patients who already had a long-standing deficit due to the ICA occlusion. All patients were relieved of their ocular or hemispheric symptoms in a follow-up period of 8 years. Two late strokes occurred after 1 1/4 and 4 years. Ipsilateral ECA revascularization is an effective and safe operation and has good long-term results.

A "development aid" approach to Third World surgical blindness

Establishing local production of intraocular lenses (IOLs) and sutures should be as much a part of surgical blindness prevention assistance to Third World countries as teaching extracapsular cataract extraction with IOL implantation, because it would increase financial independence and encourage economic growth.

[Patients with late-life vision damage in occupational rehabilitation. Preliminary ophthalmologic treatment, concomitant manifestations and an illustration provided by the growing number of patients with juvenile diabetes]

The rehabilitation centre in Veitshöchheim (near Würzburg) offers different kinds of training programs for the adult visually handicapped. This is usually preceded by a long time of unemployment. Diabetes mellitus was the third most common disease at the centre and 25% of the patients with diabetes mellitus were already legally blind. In a retrospective study we looked at the medical and ophthalmological treatment and the education the 76 patients with diabetes mellitus had received before coming to the rehabilitation center. All charts from February, 87, to September, 90, were included in the study. According to the classification of visual acuities by the WHO we formed four groups (less than or equal to 1/50; 1/35-0.1; 0.125-0.3; greater than 0.3) and compared them with each other. In the groups with the lowest visual acuity the medical management of the diabetes mellitus had been much poorer than in the better groups. Related to the bad visual acuity was the higher incidence of proliferative diabetic retinopathy and the significantly lower percentage of panretinal lasercoagulations. 47% of the patients with diabetes mellitus had been trained in jobs that would not have been recommended to a potential visually disabled by an ophthalmologist or the office for labour exchange. Only in 10% of the cases could a job be maintained by the help of technical devices (including low vision aids). To ensure best medical treatment and counselling concerning the choice of an appropriate job a close team work between practising ophthalmologist, general practitioner, and the office for labour exchange is needed. Thereby the cost and psychological impact of a retraining program could hopefully be lowered.

Photorefractive keratectomy with an argon fluoride excimer laser: a clinical study

The results of excimer laser photorefractive keratectomy (PRK) in 16 blind and 120 sighted eyes (136 patients) are presented. Follow up for the blind eyes was 22 months and for the sighted eyes 8 to 18 months (mean, 1 year). A Summit Technology UV200 excimer laser with fluence fixed at 180 mJ/cm2, beam diameter 4 mm, a frequency of 10 Hz, and ablation rate of 0.22 mu per pulse was used. The range of preoperative myopia was - 1.50 diopters to - 17.50 D (spherical equivalent). Ninety percent of patients undergoing a -2.00 D correction and 75% of patients undergoing a -3.00-diopter correction were within +/- 1.00 D of intended refraction at 6 months. This figure fell to 40% and 20% for the groups undergoing -6.00 D and -7.00 D corrections, respectively. While the trend is toward undercorrection, around 70% of patients in all groups have benefited from a reduction of their myopia by at least half that intended. A variable degree of anterior stromal "haze" was detected in 110 patients (92%) despite a rigid high dose topical corticosteroid regime over 3 months. Best spectacle corrected visual acuity, however, was greater than or equal to preoperative levels in 111 patients (93%). Six patients experienced a reduction of one line of Snellen acuity at 6 months and three of the high myopes lost two lines. No patients lost more than two lines of Snellen acuity. Ninety-four patients (78%) noticed a "halo" around lights at night, more marked in the early postoperative period, which we attribute to the 4-millimeter diameter ablation zone. With a large pupil, both central and paracentral cornea can contribute simultaneously to the retinal image. We have demonstrated considerable individual variation in response to this surgery, which is more marked in high myopia. Although follow up at the present time is limited, to date PRK appears to be a safe procedure that holds considerable promise for refractive surgery in the future.

Laser thermokeratoplasty by means of a pulsed holmium:YAG laser for hyperopic correction

A new technique of hyperopic correction similar to radial thermokeratoplasty is presented. A pulsed Holmium:YAG laser was used, emitting a wavelength of 2.06 microns. The laser light was guided by a quartz fiber and focused by means of a handpiece. Eight of 16 coagulations located on rings concentric to the pupil resulted in central corneal steepening. The refractive change increased with the applied pulse energy above a threshold of about 10 mJ per pulse and was constant between 15 and 35 mJ per pulse. The effect decreased linearly with greater distance from the center. Four blind human eyes demonstrated that the parameters evaluated in the human cadaver eyes can be transferred to the living eye. Immediately after surgery, folds in Descemet's membrane parallel to the limbus appeared. With time, they gradually diminished but were still persistent after 4 months. Hyperopic changes of up to 5.00 diopters were obtained, remaining stable for 4 months.

Myopic excimer laser photorefractive keratectomy: an analysis of clinical correlations

In this study, we examined the correlations among various factors that may affect the results of central photorefractive keratectomy for myopia. Data analyzed from our studies of blind, partially sighted, and normally sighted eyes included patient age, attempted correction, time to re-epithelialization, postoperative corneal clarity, refraction (relative spherical equivalent), and uncorrected visual acuity. We found that larger attempted corrections resulted in less accurate refractions and poorer uncorrected visual acuity. Older patients tended to have better results than younger patients, regardless of the amount of attempted correction. The relationship between the amount of attempted correction and corneal clarity was weak. There was a statistical correlation between corneal clarity scores and uncorrected visual acuity, but the range of corneal clarity scores was small and even the highest scores were probably not in the range that interfered with vision, so the relationship was probably not causal. The rate of epithelial healing did not appear to affect either refractive or visual results, and was not affected by patient age. These findings may be useful in guiding future efforts to improve the results of this new surgical procedure for the correction of refractive error.

Reversible visual loss after shunt malfunction

Report on three hydrocephalic, shunt dependent children, who became blind due to shunt malfunction and rapidly decreased intracranial pressure. They regained vision several days (one case) or several months (2 cases) after shunt revision. The related literature is reviewed and possible pathophysiological mechanisms are discussed.

Optic nerve decompression via the lateral facial approach

Two cases of visual loss after lateral orbital wall fracture are presented: one with retrobulbar hematoma and evidence of optic nerve compression who failed to respond to lateral canthotomy and high-dose corticosteroid administration, and the second with immediate, total blindness associated with fracture of the bony optic canal. In both, extradural decompression of the orbit and optic nerve was achieved through the lateral facial approach with partial return of visual acuity and without surgical complications. The role of orbital and optic nerve decompression in the management of patients with blindness following orbital trauma is controversial. Orbital decompression may be of value for cases of post-traumatic visual loss unresponsive to medical management. If optic nerve injury is suspected as the cause, the additional step of decompression of the optic nerve is a logical but unproven procedure. The indications for optic nerve decompression are not established and should be considered only within the context of the specific needs of the individual patient.

Excimer laser (193 nm) myopic keratomileusis in sighted and blind human eyes

Ten blind and 13 sighted human eyes underwent excimer laser (193 nm) keratomileusis. The radiant exposure was 180 mJ/cm2 with an ablation zone diameter of 3.5 mm. The follow-up of the blind eyes ranged from 9 to 11 months, whereas that of the sighted eyes was at least 6 months. The intended refraction change was -3.0 and -5.0 D in the blind eyes and ranged from -1.5 to -7.0 D in the sighted eyes. After 3 months, 12 of 13 sighted eyes (92%) achieved a refraction between +/- 1.0 D, whereas after 6 months 77% of the refractions were in this range. Temporary subepithelial haze occurred in all eyes except some of the -3.0 D blind eyes. After 6 months, the subepithelial haze had resolved to a clinical non-significant level (trace to grade 0.5 haze), except in one eye that showed a focal scar.

Blindness following blepharoplasty: two case reports, and a discussion of management

We present two cases of unilateral permanent visual loss following four-eyelid blepharoplasty. Clinical and radiographic evidence suggested orbital hemorrhage was the cause of visual loss in both cases. In particular, electrophysiologic tests indicated that optic nerve dysfunction, and not retinal ischemia, was responsible for loss of vision. Timely orbital decompression is the cornerstone of managing these dramatic cases.

Treatment of visual loss in pseudotumor cerebri associated with uremia

Ten patients with pseudotumor cerebri associated with renal insufficiency had papilledema and elevated intracranial pressure, but neurologic examinations and CT were normal. The 40% frequency of severe visual loss, 20/100 or worse, was higher than expected for pseudotumor cerebri. While furosemide was effective in 3 patients with renal transplants, administration of corticosteroids to 2 other patients did not halt progressive loss of vision. The visual function of 2 patients deteriorated even after lumboperitoneal shunting. Five patients underwent fenestration of the optic nerve sheath. This procedure improved the visual acuity of 3 patients and stabilized vision in the others. While the pathogenesis of pseudotumor cerebri in renal insufficiency is unknown, optic nerve sheath fenestration is the surgical treatment of choice for visual loss unresponsive to medical therapy.

Causes of blindness and restoration of sight for the students in the School for the Blind, Khon Kaen

One hundred and twenty-seven students from the School for the Blind, Khon Kaen, were seen between August 1984 and December 1987. There were 92 males (72.4%) and 35 females (27.6%). The age ranged from 3 to 19 years with the predominant age group being 6-15 years. The majority of the students (95.3%) resided in the Northeast. Only 26 students (20.5%) had positive family histories. Blindness caused by lesions affecting the whole eye was the leading cause of blindness (36.2%). About half of the cases of blindness were preventable and treatable. Most of them (58.3%) were second grade blind. Of all the students seen, 26 students (20.5%) were subjected to treatment for restoration of sight. Only 19 students had complete follow-up post-operative vision. The average visual improvement after treatment was forty-two per cent. The category of blindness was changed to the better side. Blindness was decreased. Visual impairment increased 36.8 per cent after treatment.

Surgical treatment of blindness secondary to intraorbital hemorrhage

Rapid progression to blindness due to intraorbital hemorrhage following various forms of trauma requires immediate, aggressive intervention, with the potential to restore vision. Orbital decompression via either an external ethmoidectomy or transantral approach is described. The diagnosis, anatomy, and pathogenetic mechanisms relevant to these cases are reviewed.

The optic neurogram: evaluation of CSF "block" caused by compressive lesions at the optic canal

Patients with progressive blindness resulting from bony proliferative diseases such as osteopetrosis may benefit from optic canal decompression. A radiologic technique is described whereby the practicality of surgical optic canal widening is evaluated preoperatively using the intrathecal water-soluble contrast agent lopamidol. Conceptually, if a patient who is losing vision demonstrates a block on the optic neurogram, then likely there is still sufficient neural tissue within the optic canal and sheath to cause obstruction, and therefore decompression may be indicated. However, if preoperatively there is no block to lopamidol, then surgical intervention is not indicated, as the nerve has already undergone severe atrophy to the point of "autodecompression." Cases of differing etiologies, with and without blocks, illustrate the utility of the method and point out the importance of early surgical management to prevent irreversible damage to the optic nerve.

[Surgical treatment of traumatic amaurosis]

Exploration of the optic canal was performed in 5 patients with traumatic amaurosis. Fractures of the optical canal were found in 4 cases. One case in which the canal was intact was interpreted as evulsion of the optic nerve. Vision improved in one of the cases with a fractured optical canal. Exploration of the optic nerve is recommended in cases of traumatic amaurosis, always provided that the indication is correct.

Carotid endarterectomy for amaurosis fugax without angiography

Angiography has associated morbidity and mortality, but it is the road map for the vascular surgeon. Can blood vessels be safely operated on without first obtaining an angiogram? It was the purpose of this retrospective analysis to ascertain the need for and value of carotid angiography in patients with amaurosis fugax. Twenty-eight patients (18 men and 10 women) with an average age of 66.4 years (range 58 to 71 years) had histories consistent with amaurosis fugax and were operated on for it. They did not have a history of transient ischemic attacks or stroke. Histories were reviewed for cardiac disease, smoking, hypertension, and diabetes. All patients were studied by noninvasive methods (bidirectional Doppler analysis, oculoplethysmography, carotid phonoangiography, and real-time B-mode ultrasonography), cerebral computerized tomographic scan, and angiography. Nineteen of the 28 patients (11 men and 8 women) had fluorescein angiography. All preoperative computerized tomographic scans were negative. Findings on real-time B-mode ultrasonography suggested significant ulcerated plaque in all of the patients. Angiography could only confirm ulcerated areas in 17 of the 28 patients. Of the patients studied by fluorescein angiography, 17 of 19 (10 men and 7 women) had confirmed embolic lesions. Surgery confirmed ulcerative lesions in all of the 28 patients. Results of this study indicate that if a patient has a history consistent with amaurosis fugax, a negative computerized tomographic scan, and a positive real-time B-mode ultrasonogram, an angiogram may not be necessary.