[YAG-laser treatment for traumatic hemophthalmia]

The paper deals with noninvasive YAG-laser surgery that is used in the treatment of hemophthalmia, particularly hemophthalmia of posttraumatic genesis. A Visulas YAG laser unit ("Karl Zeiss") was used for YAG laser radiation. Its energy parameters were 0.8 to 9.2 mJ; 2-10 impulses; 1-30 laser treatment sessions. YAG-laser radiation affected the altered part of vitreous body: from fresh blood to the emergence of hemophthalmia as adhesions and conglomerates. YAG-laser applied to pathological vitreous body changes in hemophthalmia is effective and causes their elimination with subsequent lysis. YAG-laser vitreolysis is the operation of choice in traumatic hemophthalmia and may be used not only as an independent surgical technique, but also an additional one in the surgical and medical treatment of hemophthalmia. YAG-laser application to the vitreous body reduces the time of treatment for traumatic hemophthalmia.

The Transcaruncular Approach to Orbital Fracture Repair

The transcaruncular approach to the medial orbit is growing in popularity and although reported complications are minimal, ophthalmic and orthoptic sequelae can occur after any conjunctival surgery and nonophthalmic surgeons should be aware of these. This study aims to document these sequelae in a cohort of patients having transcaruncular surgery. A retrospective case series of all consecutive patients undergoing orbital fracture repair through a transcaruncular approach for medial wall and floor fractures in two centers over a 2-year period was examined. Computed tomography findings, pre- and postoperative ophthalmic and orthoptic findings, including ocular motility (with Hess chart evaluation), Hertel exophthalmometry, slit lamp biomicroscopy examination, follow-up time, and occurrence of complications were recorded. Thirteen patients, mean age 34 years (range, 18-82 years), underwent repair for medial wall (n=5) or combined medial wall and orbital floor (n=8) fractures with median a follow up of 7 months (range, 2-18 months). Preoperative ocular injuries included conjunctival chemosis, eyelid swelling, subconjunctival hemorrhage, retinal haemorrhage, traumatic uveitis and traumatic mydriasis, eye movement restriction, and enophthalmos (range, 3-4 mm). Postoperatively, corneal epitheliopathy with reduced vision (6/60), orbital inflammation, inferior oblique underaction, and superomedial fornix symblepharon at the caruncular incision sight each occurred in one patient along with extensive subconjunctival hemorrhage and a suture-related conjunctival granuloma in others. All patients experienced an improvement in diplopia and globe restriction. Ophthalmic complications can occur with this approach, and so it may be advisable to seek an ophthalmic opinion with the aim of comanagement in planning this approach.

[Clinical and progressive features of macular hemorrhage secondary to retinal artery macroaneurysms]

INTRODUCTION

Retinal arterial macroaneurysm (RAM) is an acquired vascular retinal abnormality that has developed from a retinal arterial branch located in the macular area. It is responsible for decreased visual acuity when complications such as bleeding or retinal exudation occur. A ruptured RAM leads to severe premacular, submacular, or vitreous hemorrhage. The progression can be spontaneously favorable depending on the severity and the location of the hemorrhage. A poor visual prognosis is usually reported in subretinal hemorrhage. We reported the observation of four patients with macular hemorrhage secondary to ruptured RAM.

PATIENTS AND METHODS

Four patients--two males and two females, aged from 39 to 65 years, presented with sudden unilateral decreased visual acuity. An ophthalmologic exam with visual acuity measurement, anterior segment exam, ocular tonometry, and funduscopy was performed, completed with fluorescein retinal angiography. A Nd:Yag laser hyaloidotomy was done in two cases of premacular hemorrhage 1 week after its occurrence. Submacular hemorrhages were only observed using visual acuity measurement and ophthalmoscopic examination. The follow-up is 3-4 months.

RESULTS

Initial visual acuity varied from light perception to 2/10. The fundus examination showed a macular hemorrhage: subretinal in one case, preretinal in two cases, and in the last case the hemorrhage was both preretinal and subretinal. The diagnosis of MAR was confirmed by fluorescein angiography, which showed a hyperfluorescent arterial dilatation temporal to the macula. In the cases of submacular hemorrhage, the hemorrhage reduced spontaneously after simple monitoring. Final visual acuity was 4/10 and 5/10. For premacular subhyaloid hemorrhage treated with laser Nd:Yag drainage, the final visual acuity was 5/10 and 7/10.

CONCLUSION

Visual prognosis in premacular hemorrhage is improved by Nd:Yag laser treatment. Subretinal hemorrhage can have a spontaneous favorable outcome. Surgery should not be systematic. Comparative studies are necessary to apply indications.

Spontaneous Orbital and Periocular Hemorrhage in a Patient with Epithelioid Hemangioma

Epithelioid hemangioma, or angiolymphoid hyperplasia with eosinophilia, is a benign vascular lesion that infrequently involves the orbit. We report a case of spontaneous orbital and periocular hemorrhage in a patient with epithelioid hemangioma of the orbit. Ophthalmic examination was accompanied by CT and MRI, followed by histopathologic diagnosis. The patient presented with headache, eyelid bruising, and double vision. Ophthalmic examination showed ecchymosis, proptosis, and limited extraocular movements of the affected eye. Imaging studies showed a cystic right orbital mass. Histologic examination showed plump endothelial cells accompanied by lymphocytes, plasma cells, and eosinophils. A diagnosis of epithelioid hemangioma was rendered. To our knowledge, this is the first reported case of spontaneous orbital and periocular hemorrhage associated with epithelioid hemangioma. Epithelioid hemangioma should be considered in the differential diagnosis for patients presenting with spontaneous orbital or periocular hemorrhage.

[Long-term functional effect of pars plana vitrectomy in complications of proliferative diabetic retinopathy]

In the years 1997-2004, we operated on and at least one year followed-up due to complication of prolipherative diabetic retinopathy 47 eyes (40 patients), of the mean age 61 years. If we compare the initial visual acuity (VA) to the vision at the last examination in the late postoperative period, or at least one year after the surgery, we may state, that in 28 eyes (60%) the vision improved, in 11 eyes (23%) VA remained stable and in 8 eyes (17%) the vision decreased. In the late postoperative period, the visual acuity 1/60 (3/200 or 0.17) and better had 33 eyes (70%), VA 6/60 (20/200 or 0.1) and better 17 eyes (36%) and VA 6/12 (20/40 or 0.5) and better 2 eyes (4%). Comparing the VA at the time of the early postoperative period and the VA at the last examination in the late postoperative period, we observed, that mostly, in 34 eyes (72%) the VA did not changed during the months after the surgery, and, in one eye (2%), the VA even improved. It was confirmed to be realistic the favorite result of pars plana vitrectomy found in the early postoperative period may be preserved for the next month and years of patient's life.

Sub-Tenon anaesthesia: reduction in subconjunctival haemorrhage with controlled bipolar conjunctival cautery

PURPOSE

To evaluate the effect of controlled conjunctival cautery on the frequency and extent of subconjunctival haemorrhage (SCH) associated with sub-Tenon anaesthetic (STA) injection in patients with various clotting states.

METHODS

One hundred forty-four patients suitable for cataract surgery with STA were prospectively divided into four groups: group A (n=36) were on warfarin (INR 1.8-4.2); group B (n=48) on aspirin (75 mg); group C (n=12) on clopidogrel (75 mg); and group D (n=48) on no anticoagulant or antiplatelet agents. All patients had no other known coagulopathy. Each group was randomly divided into two subgroups, one of which received localised bipolar cautery under microscope control to the STA conjunctival entry site before tissue dissection, whereas the other served as a control. chi(2) and Fisher's exact tests were used to analyse the data with the SPSS package (v11.0).

RESULTS

Conjunctival cautery reduced the frequency of SCH from 67 to 6% in group A (P=0.0001); from 37.5 to 4% in group B (P=0.005); from 50 to 0% in group C (P=0.9); and from 17 to 0% in group D (P=0.55). This overall reduction in SCH was highly significant (P<0.0001), especially in groups A and B. No statistically significant reduction in the extent of SCH was found.

CONCLUSIONS

Controlled localised bipolar conjunctival cautery before STA injection may significantly reduce the frequency of SCH, especially in patients on warfarin or aspirin.

Sub-Tenon's anesthesia with aspirin, warfarin, and clopidogrel

PURPOSE

To review the frequency of hemorrhagic complications with sub-Tenon's anesthesia in patients on aspirin, warfarin or clopidogrel.

SETTING

St. James's University Hospital, Leeds, United Kingdom.

METHODS

Data were collected prospectively for patients having elective phacoemulsification under sub-Tenon's anesthesia. Seventy-five patients were on aspirin, 65 were on warfarin, and 40 were on clopidogrel. Seventy-five patients on no anticoagulants were used as the control group. No changes in the anticoagulant regimen were made prior to surgery.

RESULTS

No sight-threatening hemorrhagic complications were noted, and no surgery was postponed or cancelled due to an anesthesic complication. Subconjunctival hemorrhage occurred in 19% in the control group, 40% in the clopidogrel group, 35% in the warfarin group, and 21% in the aspirin group. The warfarin and clopidogrel groups had the highest incidence of subconjunctival hemorrhage (P<.05). The incidence of hemorrhages involving more than 1 quadrant was highest in these 3 groups; however, this did not achieve statistical significance (P = .37, Fisher exact test).

CONCLUSION

Data from this study support the continued use of anticoagulant agents among routine users during cataract surgery using a sub-Tenon's block.

The Effect of Topical Apraclonidine on Subconjunctival Hemorrhage and Flap Adherence in LASIK Patients

PURPOSE

To determine whether the use of topical apraclonidine just before the LASIK procedure prevents subconjunctival hemorrhage and to study its effect on postoperative flap adherence.

METHODS

Topical apraclonidine 0.125% was randomly applied to 1 eye of 66 myopic patients who underwent primary bilateral LASIK. Apraclonidine was instilled 1 hour prior to and 30 seconds before placing the vacuum ring of the microkeratome, whereas the other eye served as control. Thirty minutes after the operation, all patients were examined by the surgeon to evaluate hyperemia and identify flap-related complications (eg, slippage, dislocation, or flap folds). The size of subconjunctival hemorrhage was also evaluated on postoperative days 1 and 7. All 132 eyes in the study were examined after surgery to identify flap folds and/or their dislocation.

RESULTS

In the apraclonidine group, 48 (72.8%) eyes had no hyperemia, 16 (24.2%) eyes had mild hyperemia, 2 (3%) eyes had moderate hyperemia, and no (0%) eyes had severe hyperemia. In the control group, 37 (56.1%) eyes had mild hyperemia, 21 (31.8%) eyes had moderate hyperemia, 1 (1.5%) eye had severe hyperemia, and 7 (10.6%) eyes had no hyperemia. In the apraclonidine group, 44 (66.7%) eyes had no subconjunctival hemorrhage (grade 0); grade 1 was present in 19 (28.8%) eyes whereas grades 2 and 3 were present in 2 (3%) eyes and 1 (1.5%) eye, respectively. In the control group, 19 (28.8%) eyes showed grade 0, 13 (19.7%) eyes had grade 1, and grades 2 and 3 were present in 20 (30.3%) eyes and 14 (21.2%) eyes, respectively. Chi-square test showed a highly significant difference between the two groups (P < .001). No flap-related problems were reported in either group.

CONCLUSIONS

Topical apraclonidine applied before LASIK surgery may prevent immediate postoperative hyperemia and prolonged subconjunctival hemorrhage by its alpha-mimetic vasoconstrictor effect without inducing flap adherence complication.

The effect of aspirin and warfarin therapy in trabeculectomy

AIM

The management of patients on antiplatelet and anticoagulation therapy (APACT) in glaucoma surgery currently has no specific recommendations. We aimed to establish the risk of haemorrhagic complications and surgical outcome in patients on APACT in glaucoma surgery.

METHODS

We retrospectively examined 367 consecutive trabeculectomies performed between 1994 and 1998. Preoperatively 60 (16.4%) patients were on APACT (55 on aspirin and five on warfarin). The incidence of hyphaema and haemorrhagic complications between patients with and without APACT was documented. Surgical success was defined in two categories as an intraocular pressure (IOP) <21 mmHg and an IOP <16 mmHg 2 years following trabeculectomy with and without antiglaucoma medication.

RESULTS

None of the patients on aspirin suffered significant intra or postoperative haemorrhage. Aspirin was associated with a significantly higher risk of hyphaema (P=0.0015) but this was not found to significantly affect IOP control at 2 years. Patients on warfarin suffered haemorrhagic complications and trabeculectomy failure.

CONCLUSIONS

Aspirin appears to be safe to continue with during trabeculectomy. Patients on aspirin have an increased risk of hyphaema following trabeculectomy. This however does not appear to affect surgical outcome. Warfarinised patients are at risk of serious bleeding complications. They require careful monitoring pre- and postoperatively and are at risk of trabeculectomy failure.

Orbital subperiosteal hemorrhage while scuba diving

PURPOSE

To report an uncommon case of unilateral subperiosteal hemorrhage while scuba diving involving the orbit, a condition characterized by proptosis and associated severe ocular motility disturbances with displacement of the eyeball.

MATERIAL AND METHODS

Observational case report.

RESULTS

Unilateral subperiosteal hemorrhage in a 31-year-old woman while scuba diving at a depth of 20 meters. This was documented by clinical and radiographic examination. Computed tomography (CT) scan demonstrated a subperiosteal hemorrhage as a self-limited mass protruding into the left orbit. The process resolved without treatment and without visual or motility sequelae. A CT-scan, nuclear magnetic resonance, and conventional angiography did not show any venous abnormalities in the brain.

CONCLUSION

During scuba diving at a depth of 20 meters, the pressure is three atmospheres, whereas within the diving mask the pressure is one atmosphere if it is not equilibrated; thus, a negative pressure is created within the mask. Small vessels can be broken in the conjunctiva or subperiosteal space by this force. It is important to exclude vascular abnormalities, especially if there is a positive family history.

An unusual case of bloody tears

Conjunctival bleeding is usually caused by non accidental or accidental conjunctival laceration, conjunctival tumors and nasolacrimal sac tumors. We report here a rare case of conjunctival bleeding which was self induced using cinnamon bark.

[Evaluation of results of enucleations with orbital implant in children and adolescents]

PURPOSE

The aim of the research is the assessment of results of enucleation with orbital implant in children.

MATERIAL AND METHODS

Examinations included the group of 99 children between 6 months and 19 years of age. The examined group consisted of 39 boys (39.4%) and 60 girls (60.6%). 96 eyes were removed because of non-regressive retinoblastoma (despite applied treatment), two eyes with buphtalmus (with no light perception), as a result of glaucoma, and one case of medulloepithelioma. The applied implants were: Castroviejo--in 28 patients, Medpor--in 24 patients, Hydroxyapatite--46 patients. In one patient was applied Baush and Lomb orbital implant.

RESULTS

In 91 patients (91.9%) no significant complications occurred. In 2 patients (2%), the hemorrhage occurred during the surgery. Postoperative complications included: in 6 patients (6.1%) exposition of orbital implant was observed; in one patient the exposition was enlarging which led to removal of the implant; in 2 patients with implant exposition (2%) inflammatory granuloma occurred on the edge of the exposition. In one patient (1%) cyst of conjunctiva in the postoperative scar area occurred 3 months after operation.

CONCLUSIONS

Enucleation with orbital implant enables normal development of the orbit and improves cosmetic effect. The frequency of complications depends on type of applied orbital implant.

Herpes zoster ophthalmicus in an otherwise-healthy child

Herpes zoster ophthalmicus, although not uncommon in adults, is rarely found in children. Herein we present a case of pediatric herpes zoster ophthalmicus that is unique in 2 ways. First, the child had been vaccinated against varicella and otherwise had no known exposure to varicella-zoster virus. Second, the initial presentation of herpes zoster ophthalmicus was a painful and diffuse subconjunctival hemorrhage that appeared before any of its classic signs were observed. We report this case to document the possible occurrence of herpes zoster ophthalmicus in children who have been vaccinated against varicella and the possibility of a diffuse, painful subconjunctival hemorrhage as a presenting sign.

Penetrating ocular injury caused by venomous snakebite

PURPOSE

To report the case of a patient who experienced a penetrating ocular injury with direct intraocular injection of venom from a snakebite.

DESIGN

Case report.

METHODS

A 34-year-old man was bitten by a snake on his right eye. The snake was identified as Deinagkistrodon acutus. Antivenom was provided, but facial swelling, periorbital ecchymoses, massive subconjunctival hemorrhage, severe corneal edema, and exophthalmos of the right eye were noted. Dyspnea due to airway edema then developed.

RESULTS

He received emergent intubation. Evisceration was performed, and a continuously active bleeding scleral wound was found. No local infection developed under systemic and topical antibiotics. Pathologic examination of the excised cornea showed necrosis on the endothelial side.

CONCLUSIONS

Early evisceration was the treatment of choice for treatment of a penetrating ocular injury caused by venomous snakebite. Maintaining stable life signs and prevention of infection remained the major concerns.

An uncommonly serious case of an uncommon sport injury

BACKGROUND

A 55 year old man sustained a severe ocular injury when hit by a cricket ball even though he was wearing a helmet.

METHODS

A suprachoroidal haemorrhage was drained and dense intravitreal blood was removed. An inferior buckle was applied with the use of intraocular gas. A macular haemorrhage resolved slowly.

RESULTS

Despite several surgical procedures over 1.5 years, the final visual acuity of the patient was only 6/60 because of a dense macular scar.

CONCLUSIONS

Helmets worn as protection when playing cricket need to be designed better and be of better material. Eye protection should be worn at all levels of play.