[COEXISTENCE OF ORBITAL VARICOSE VEIN AND THYROID ORBITOPATHY]

PURPOSE

To describe a thyroid orbitopathy patient who had asymmetric progression of exophthalmos due to orbital varicose vein.

PATIENT

A 55-year-old patient with thyroid orbitopathy had asymmetric progression of exophthalmos without complaints over 4 years of follow-up.

RESULTS

In repeated computerized tomography (CT) of the orbit, a dilation of the superior ophthalmic vein was noted on the more proptotic eye, in addition to bilateral excessive orbital fat. This finding was also confirmed on color Doppler imaging in valsalva manoeuver.

CONCLUSIONS

In patients with thyroid orbitopathy who have atypical progression course of their exophthalmos, repeated orbital CT scan is advocated to rule out other concurrent orbital disorders such as varicose veins.

[Leber's idiopathic stellate neuroretinitis]

AIM

To report a rare case of swollen optic disc with hard exudates at the center of the retina (macula) with an unknown etiology (idiopathic).

CASE REPORT

A 49 years old male complained of blurred vision in his left eye. He reported that ten years earlier a similar episode occurred in the right eye. Upon resolution of the macular edema we recognized hard exudates with a macular star pattern. After six months his central vision returned to normal with mild to moderate defects in his lower visual field.

IN SUMMARY

The literature describes various etiologies that have been reported due to the rare presentation of the macular star In our case we did not find any clear etiology, therefore, the diagnosis of Leber's idiopathic stellate neuroretinitis can be presumed.

The association between stage 3 or higher retinopathy of prematurity and other disorders of prematurity

OBJECTIVE

To evaluate the association between stage III or higher retinopathy of prematurity (ROP) and other prematurity disorders and parameters.

DESIGN

Retrospective, case-control study.

PARTICIPANTS

The subjects of the study were 55 consecutive premature neonates with stage III or higher ROP and 110 consecutive premature neonates without ROP.

METHODS

We compared consecutive premature neonates regarding the presence of ROP and other disorders as well as demographic and laboratory parameters.

RESULTS

Gestational age (p < 0.001); birth weight (p < 0.001); male sex (p = 0.031); bilirubin levels (p < 0.001); breast feeding (p < 0.001); clinical and laboratory sepsis (p < 0.001); number of sepsis events (p < 0.001); ventilation need (p < 0.001); number of ventilation days (p < 0.001); theophylline and surfactant use (p < 0.001); blood transfusions (p < 0.001); number of blood transfusions (p < 0.001); intraventricular hemorrhage and bronchopulmonary dysplasia (p = 0.001); and other factors differed in the two groups. The logistic regression model showed a correlation between low gestational age (OD 0.474, CI 0.359-0.626); male sex (OD 2.991, CI 1.077-8.305); blood transfusion (OD 14.159, CI 1.570-127.7); and sepsis (OD 12.376, CI 2.532-60.503).

CONCLUSIONS

Certain disorders and parameters, such as sepsis and blood transfusions, may be predict the appearance of stage III or higher ROP. Close monitoring of neonates with these findings is imperative. Early detection and treatment of sepsis and reduction of blood transfusions may decrease the incidence of ROP that requires treatment.

Delayed Suprachoroidal Hemorrhage after Reinstitution of Warfarin in Combined Procedure

A 79-year-old non-compliant male with pseudoexfoliative glaucoma and cataract in the left eye underwent uneventful combined phacoemulsification, posterior chamber intraocular lens insertion and trabeculectomy with mitomycin C through one port a week after replacement of warfarin with subcutaneous injections of enoxaparin (Clexane; Sanofi-Aventis, Netaniya, Israel). The intraocular pressure (IOP) following surgery was zero. Four days later, warfarin was restarted because of short ventricular tachycardia when the patient developed suprachoroidal hemorrhage and later hyphema and vitreous hemorrhages. The patient underwent drainage of the suprachoroidal hemorrhage. His IOP increased to 10 to 12 mm Hg while the bleb was functioning, but visual acuity remained poor because of chorioretinal retinal scarring from age-related macular degeneration. Premature reinstitution of warfarin may cause delayed hemorrhages if the postoperative IOP is low. Preoperative approval from the internist for a prolonged replacement of warfarin with lesser potent agents, or tightening of the scleral flap and releasing the sutures later in trabeculectomy in combined procedures may be warranted.

The spectrum of iatrogenic intraocular injuries caused by inadvertent cannula release during anterior segment surgery

OBJECTIVE

To evaluate the causes of inadvertent intraocular injuries resulting from the use of cannulas during anterior segment surgery. Method Retrospective review of all cases with inadvertent release of irrigation and viscoelastic cannulas during anterior segment surgery in 15 years.

RESULTS

Inadvertent release of cannulas occurred in 9 of 10 230 cases of anterior segment surgery during a 15-year period. The incidence of cannula release was 0.88 per 1000 procedures per year. Twenty percent of the surgeons who performed anterior segment surgery in this period were involved in this unfortunate event. Six cases occurred during cataract extraction and 3 during penetrating keratoplasty or replacement of corneal graft. The latter 3 cases included posterior capsule rupture and vitreous loss. Macular scar in 2 (22%) of the 9 cases was associated with poor visual outcome of counting fingers at 2.1 to 3.0 m (P = .03). In all other surgeries, the cannula caused iris or anterior chamber angle injury without consequences.

CONCLUSIONS

Inadvertent release of cannulas during anterior segment surgery is a rare, memorable, and unfortunate event. The severity of the injury may be related to the type of the surgical wound. In most cases, visual outcome is not compromised unless the cannula causes retinal disruption.

Paediatric vs adult retinal detachment

OBJECTIVE

To evaluate the causes, incidences, characteristics, and treatment outcomes of paediatric vs adult retinal detachment.

PATIENTS AND METHODS

One hundred and sixty (136 patients) out of 2408 consecutive retinal detachments (6.6%) at our facility occurred in children under the age of 18 years. Of them, 144 eyes (90%) of 127 (93%) children were treated and compared with a sample of 56 consecutive retinal detachments in 50 adults (over the age of 18 years). The parameters for comparison included cause, type of retinal detachment, its extent, macular involvement, number of tears, number and types of surgery, and the anatomic and functional surgical outcome.

RESULTS

Statistically significant differences were found in the type of retinal detachment. Rhegmatogenous RD was less common (P=0.004), and exudative RD was more common (P=0.021) in the paediatric group. Ocular trauma and ocular syndromes were more common in the paediatric group (P<0.001), while myopia, posterior vitreous detachment, and retinal detachment following cataract surgery were less common in this group compared with adults (P<0.001, <0.001, and 0.001, respectively). Ocular pathologies associated with retinal detachment were more common in the paediatric group (P<0.001). Initial and last visual acuity of >20/400, last visual acuity of >20/40, and retinal complete reattachment were higher in adults (P<0.001).

CONCLUSIONS

The type of retinal detachment, causes and outcomes were statistically different between paediatric and adult cases. The less successful functional and anatomical outcomes of retinal detachment surgery in children may reflect the different aetiologies and indicate the need for aetiology-specific treatment strategies according to each aetiology.

Intraoperative enoxaparin minimizes inflammatory reaction after pediatric cataract surgery

PURPOSE

To evaluate the effect of intraocular infusion of enoxaparin, a low-molecular-weight heparin, on postoperative inflammatory response in pediatric cataract surgery.

DESIGN

Prospective, comparative, consecutive interventional case series.

METHODS

Seventeen consecutive eyes (11 patients) underwent pediatric cataract surgery in two tertiary medical centers. During the procedure, balanced salt solution with enoxaparin (40 mg in 500 ml) was infused into the anterior chamber. Eleven consecutive eyes (eight patients) received balanced salt solution without enoxaparin in the infusion bottle. The inflammatory response in the anterior chamber was compared between the two groups by semiquantification with slit-lamp biomicroscopy. Postoperative inflammatory complications, including fibrin formation, intraocular lens precipitates, anterior and posterior synechiae, cyclitic and pupillary membrane formation, and anterior subluxation of the intraocular lens, were also compared. The follow-up period after surgery was between 3 and 36 months (average 12.3 months).

RESULTS

The number of cells and the degree of flare were minimal in the group with enoxaparin in the infusion bottle (P < .001). The total number of postoperative inflammation-related complications was also lower in the enoxaparin-treated group (P = .007). All corneas remained clear, and the endothelial cell count, which was performed in two patients, did not show substantial decrease in their density or changes in shape and size. No other enoxaparin-related complications were observed.

CONCLUSIONS

Infusion of enoxaparin during pediatric cataract surgery may minimize the postoperative inflammatory response and decrease the number of postoperative inflammatory related complications. Enoxaparin should also be evaluated for cataract surgery in other conditions where postoperative inflammation may be exacerbated.

Posterior capsule opacity and choroidal neovascularization in patients with age-related macular degeneration

BACKGROUND AND OBJECTIVE

To present a series of 3 patients with the dry form of age-related macular degeneration (AMD) in whom choroidal neovascularization (CNV) was observed following neodymium: yttrium-aluminum-garnet (Nd:YAG) capsulotomy.

PATIENTS AND METHODS

Three consecutive patients aged 80 to 87 years (average = 83.7 years) with hard drusen or retinal pigment epithelial changes underwent uneventful cataract extraction between 6 months and 20 years before undergoing Nd:YAG capsulotomy for posterior capsule opacity. The patients were examined for retinal changes before laser treatment and at regular intervals after treatment.

RESULTS

All patients developed CNV between 12 days and 1 month after capsulotomy that caused a decrease in the visual acuity from 20/20-20/40 to 20/200--counting fingers at 4 feet. The fellow eye did not show a substantial change in AMD over a year of follow-up. Two of the fellow eyes had disciform scar due to CNV before the cataract surgery, and these patients remained legally blind.

CONCLUSIONS

The development of CNV after Nd:YAG capsulotomy suggests a temporal association between the two and calls for further study. Because posterior capsule opacity may mask CNV, patients with dry AMD and posterior capsule opacity who experience decreased visual acuity or glare may undergo indocyanine green angiography before it is decided to perform Nd:YAG capsulotomy.

Orbital hydatid cyst manifested as expanding exophthalmos following blunt orbital trauma

A 14-year-old boy suffered right blunt orbital trauma. X-ray revealed a compressed fracture of the right ethmoidal sinuses. Three months after the trauma, progressive, painless right proptosis developed. Ocular examination revealed a severe proptosis and pronounced down displacement of the right globe without signs of orbital inflammation. A well-demarcated, extraconal right orbital cystic mass was seen on computerized tomography scan. The cyst contents were aspirated and found to contain echinococcal scolices and "hydatid sand." Hypertonic saline was injected and the cyst was excised. Progressive proptosis after blunt orbital trauma in patients from endemic areas should be suspected of being an orbital hydatid cyst.

Devastating endophthalmitis following penetrating ocular injury during night sleep from orthodontic headgear: case report and literature review

BACKGROUND

Complications associated with the use of extra-oral traction devices (orthodontic headgear or facebow) including facial and ocular injuries, are considered infrequent.

METHODS

We describe the case of a 12-year-old boy who was inadvertently injured by the metallic bow of orthodontic headgear during sleep and developed blinding intra-ocular infection (endophthalmitis).

RESULTS

The injury resulted in corneal perforation. Visual acuity at presentation was 20/60 but deteriorated rapidly to light perception despite prompt medical and surgical treatment for endophathalmitis. Sympathetic ophthalmia developed and was controlled with systemic corticosteroids and imuran. Bacterial cultures showed mixed infection by gram-negative bacilli and Streptococcus viridans. In 10 (91%) out of the 11 eyes that were reported including our case, the visual acuity was hand movement perception or less.

CONCLUSIONS

The increase in case reports of such injuries should prompt the establishment of a standard policy regarding the use of orthodontic headgear and increase awareness of orthodontists and ophthalmologists to the blinding potential of even trivial and minor ocular injuries by orthodontic headgear. Intervention should be one step ahead compared with ocular injuries from other foreign bodies.

Potential applications of optical coherence tomography in posterior segment trauma

BACKGROUND AND OBJECTIVE

To describe potential clinical applications of optical coherence tomography (OCT) in diagnosis and surgical timing in eyes with posterior segment trauma.

PATIENTS AND METHODS

In a noncomparative study, 7 consecutive patients who had open-globe or closed-globe injury and were found to have posterior abnormality that could also be detected by OCT are described.

RESULTS

All patients had documented OCT abnormalities in the posterior segment. In one patient with a penetrating injury, two metal foreign bodies were located in the posterior segment, one in the vitreous compartment coupled with inflammatory reaction and localized posterior vitreous detachment and the other embedded in the retina. In a second patient with a penetrating injury, OCT revealed the appearance of posterior vitreous detachment 5 days after injury. A closed-globe injury in one patient resulted in anterior optic neuropathy, manifested as disc edema and thickening of the circumpapillary retinal nerve fiber layer. The other patients had received blunt trauma and were found to have either full-thickness macular holes (2 patients), retinal pigment epithelium detachment at the papillomacular bundle site (1 patient), or macular edema (1 patient).

CONCLUSIONS

OCT may serve as an important adjunct imaging device in evaluation of injuries to the posterior segment, qualitatively and quantitatively. It has potential in diagnosing subtle key abnormalities and in follow-up of these injuries.

The course of epiphora after failure of silicone intubation for congenital nasolacrimal duct obstruction

BACKGROUND

One of the indications for dacryocystorhinostomy (DCR) in children with congenital nasolacrimal duct obstruction (CNLDO) is failure of silicone intubation. We evaluated the course of epiphora after failure of silicone intubation for CNLDO when DCR was not performed.

METHODS

In a comparative cohort study carried out at a tertiary referral center, ten eyes of seven consecutive children who had failure of silicone intubation manifested as persistent epiphora over 2 months and whose parents refused DCR were followed up for an average of 50.4 months (range 33-70 months). Three lacrimal drainage systems of three other children who had failure of silicone intubation underwent uneventful DCR.

RESULTS

In eight (80%) of the ten consecutive eyes with congenital nasolacrimal duct obstruction (six of the seven children, 86%), there was spontaneous complete resolution of the epiphora and normal dye disappearance test (DDT) at the end of the follow-up period. One child with Down's syndrome, allergic rhinitis, asthma and multiple site obstructions had improvement of symptoms but abnormal DDT. The epiphora in all three children who underwent DCR had disappeared by 6 months after surgery when the silicone tube was removed. No complications were noted during the follow-up.

CONCLUSIONS

Epiphora can spontaneously resolve after failure of silicone intubation in CNLDO, and DCR should no longer considered be compulsory in such cases unless complications evolve.

The clinicopathological spectrum of benign peripunctal tumours

PURPOSE

Because of the rarity of peripunctal tumours and their clinical classification as conjunctival or eyelid tumours, they have gained little attention in the literature. We conducted a retrospective study to illustrate the different clinical and histopathological spectrum of peripunctal tumours seen at two oculoplastics clinics.

METHODS

In a retrospective interventional clinicopathologic case series study, all the charts of patients with peripunctal tumours presented at an ophthalmic oncology clinic in Jerusalem, Israel and an oculoplastics clinic in Boston, USA were reviewed. The tumours were classified as epithelial and non-epithelial tumours. The symptoms caused by these tumours, their pattern of growth and their management were evaluated.

RESULTS

Fourteen peripunctal tumours were identified. Eleven out of 175 (6.3%) peripunctal disorders and out of approximately 4,000 (0.27%) surgical oculoplastics patients were seen at Massachusetts Eye & Ear Infirmary, Boston. Three were seen at Hadassah University Hospital, Jerusalem. Seven histopathological types of peripunctal tumours of epithelial, subepithelial or melanocytic origin causing punctal occlusion or displacement were identified. The tumours included compound and junctional naevi, non-pigmented compound naevus, epithelial, subepithelial inclusion cysts, verrucous and squamous papilloma, pyogenic granuloma and oncocytoma. All the tumours were benign. They involved the peripunctal or canalicular epithelium, the adjacent skin, the glandular epithelium or the subepithelium. They presented as a peripunctal mass or were accidentally disclosed but none of them resulted in epiphora.

CONCLUSIONS

Peripunctal tumours are rare. They exhibit different clinical types of growth and may be difficult to diagnose based on their clinical appearance alone. The location of peripunctal tumours potentially allows their extension from the conjunctival sac into the canaliculus and vice versa. Therefore, it is best to ascertain free margins when the tumour is excised.

Risk factors for failure of simultaneous penetrating keratoplasty and cataract extraction

OBJECTIVE

To evaluate the indications, complications, and outcomes of simultaneous cataract extraction and penetrating keratoplasty (PKP) and the risk factors for failure of the procedure.

SETTING

Tertiary referral medical center.

METHODS

In a retrospective noncomparative interventional case series, the charts of 66 consecutive patients (70 eyes) who had simultaneous PKP and cataract extraction using the same surgical technique were reviewed.

RESULTS

The mean follow-up was 32.4 months (range 6 to 125 months). The primary corneal graft remained clear in 48 eyes (69%) and failed in 22 eyes (31%). Sixteen eyes with a failed graft (73%) had 1 or 2 repeat keratoplasties; 8 (50%) were successful. At the end of follow-up, 56 eyes (80%) had a clear corneal graft. Nine eyes (41%) with a failed primary graft and 2 eyes (4%) with a clear primary graft had intracapsular cataract extraction (P<.001); 13 eyes (59%) and 46 eyes (96%), respectively, had extracapsular cataract extraction (P<.001). All eyes with a failed primary graft and 18 eyes (37%) with a clear primary graft had postoperative complications (P<.001). Eyes with a failed graft had more postoperative surgical interventions (P<.001). There were no statistical differences between eyes with clear grafts and eyes with failed grafts in sex, age, indications for surgery, corneal graft diameter, intraoperative vitreous loss, and intraocular lens placement.

CONCLUSIONS

Intracapsular cataract extraction, postoperative complications, and postoperative surgical interventions may increase the risk for graft failure in simultaneous cataract extraction and PKP. Intraocular lens implantation did not increase the risk for graft failure.

The Prevalence and Risk Factors for Donor Corneal Button Contamination and Its Association With Ocular Infection After Transplantation

BACKGROUND

One of the most serious complications of corneal transplantation is postoperative ocular infection, which may result in loss of the eye. Contamination of the donor corneal button before transplantation may result in such complication.

PURPOSE

To evaluate the prevalence of donor corneal button contamination, the spectrum of the contaminating microorganisms, and their sensitivity to antimicrobial agents. To investigate the risk factors for contamination of the donor corneal buttons and the effect of corneal button contamination on the prevalence of ocular infection in corneal transplanted patients.

SETTING

Tertiary referral medical center.

MATERIALS AND METHODS

Four hundred sixty-nine corneal transplantations were included in the study. Microbial cultures from the corneoscleral rims of the donor corneal buttons were obtained for isolation of bacteria and fungi and for their sensitivity to antimicrobial agents. Ocular microbial cultures were also obtained from corneal transplanted patients with clinical signs of ocular infection (ie, corneal scrapes from corneal ulcers and vitreous tap from eyes with endophthalmitis).

RESULTS

Seventy-nine donor corneal buttons (16.8%) had positive bacterial cultures, and none had positive fungal culture. Staphylococci (63.7%) and streptococci (11.3%) were the most common isolated bacteria. Sensitivity to vancomycin, amikacin, and gentamicin was found in 71.3%, 28.5%, and 22.3% of all isolated bacteria, respectively. Malignancy and cardiac diseases as causes of donor death were associated with donor button contamination (P = 0.043 and P = 0.011, respectively), and septicemia was a marginally significant risk factor (P = 0.059). Age and gender of the donor, duration from death to corneal button harvesting, and time from harvesting to transplantation were not found significant risk factors for contamination. Six of the corneal transplanted patients (1.27%) had infected corneal graft ulcer, and 1 (0.22%) had endophthalmitis. The infected corneal ulcer appeared between 3 and 14 days (average 5 days), and endophthalmitis was disclosed 8 months after transplantation. Two (33%) of the 6 patients with corneal ulcer had the same species as the donor corneal rim. Postoperative ocular infection occurred in 2 (2.5%) patients out of 79 who received contaminated corneal buttons compared with 5 (1.3%) out of 390 patients who received sterile corneal buttons (P = 0.335).

CONCLUSIONS

Postkeratoplasty infection of the recipient eye is infrequent despite relatively high prevalence of microbial contamination of the corneal buttons, suggesting that other risk factors for postoperative ocular infection are involved.

Secondary gelatinous-like keratopathy in corneal graft

PURPOSE

To describe the appearance of gelatinous-like keratopathy in a corneal graft.

METHODS

A 42-year-old healthy white man underwent phacoemulsification and placement of a posterior chamber intraocular lens. After the procedure, he developed pseudophakic bullous keratopathy and underwent 2 subsequent corneal transplantations because of failure of the primary corneal graft.

RESULTS

Over 14 months after the second transplantation, a flower-like gelatinous keratopathy appeared in the corneal transplant. The patient underwent superficial keratectomy, removal of the continuous suture, topical application of nitomycin C, and placement of therapeutic contact lens until reepithelialization. The condition did not recur in a follow-up of 6 months. Histologically, hyperplastic epithelium, subepithelial fibrosis, and hyaline material were noted.

CONCLUSION

Secondary gelatinous-like keratopathy may rarely affect corneal grafts causing a decrease in visual acuity. It may be a rare pathologic response to chronic pathophysiologic stress. Superficial keratectomy and application of topical mitomycin C with careful follow-up of the corneal graft may improve the visual outcome.

Congenital eyelid imbrication syndrome

PURPOSE

To describe congenital eyelid imbrication syndrome and its possible pathophysiology.

DESIGN

Clinical observational case report.

METHODS

A full-term newborn was examined after a vaginal delivery and uneventful pregnancy.

RESULTS

The upper eyelids were overlapping the lower eyelids when the eyes were closed or when the newborn was asleep. The upper eyelids resumed normal position gradually over a week without causing any symptoms or residual sequelae.

CONCLUSIONS

Eyelid imbrication syndrome is a rare cause of congenital eyelid malposition. It may be caused by inborn laxity of the upper medial and lateral canthal tendons that are tightened during the postnatal period, causing resolution of this condition.

Traumatic pediatric retinal detachment: a comparison between open and closed globe injuries

PURPOSE

To compare retinal detachment as a result of open and closed globe trauma in a pediatric age group.

DESIGN

Retrospective, comparative, consecutive, interventional case series study.

SETTING

Tertiary referral medical center.

PATIENTS AND METHODS

One-hundred thirty-eight (5.7%) of 2,408 retinal detachments that were treated at our facility between 1980 and 2000 occurred in children aged 18 years or younger. Of these, 37 eyes (26%, n = 36) had retinal detachment following open globe injury and 23 eyes (14%, n = 20) had retinal detachment following closed globe injury. Those were compared with regard to the retinal detachment characteristics, number, types and timing of surgeries, and the anatomic and functional surgical outcome.

RESULTS

Similar incidence was found in the type of retinal detachment, number of tears, extent, macular attachment type, and timing of surgery. Anatomic surgical success was achieved in 16 eyes (46%) with open globe injury and in 13 eyes (65%) with closed globe injury. The improvement in visual acuity was limited and comparable in both groups (23% to 25%), and lower than the expected according to the Ocular Trauma Score (OTS). The only predictor for favorable visual outcome of > or =20/200 was preoperative macular attachment (P =.003, Fisher exact test).

CONCLUSION

The type, extent, and severity of the retinal detachment were similar in both open and closed globe injuries, suggesting that the detachment is caused by secondary indirect impact of globe deformation. The anatomic and functional surgical outcome was guarded and similar, suggesting that further surgical innovation is required to improve the visual outcome in this age group.

Central retinal artery occlusion after peribulbar anesthesia

We describe the development of central retinal artery occlusion (CRAO) in 2 patients after peribulbar (periconal) anesthesia during uneventful phacoemulsification. Although peribulbar anesthesia avoids direct optic-nerve injury, indirect injury presenting as CRAO may occur from vasospasm in response to the injection.

Central serous chorioretinopathy associated with retinitis pigmentosa

Macular changes may appear in retinitis pigmentosa patients and include macular atrophy, cystoid macular edema, retinal cysts, and holes. However, other primary macular diseases have not been described in patients with retinitis pigmentosa, probably because of atrophy of the retinal pigment epithelium (RPE) and the overlying retina. We present a 35-year-old patient whose first symptom was an acute decrease in visual acuity due to central serous chorioretinopathy (CSCR). Retinitis pigmentosa was subsequently diagnosed. We assume that the macular RPE changes may be attributed to both cone and RPE atrophy or other macular pathophysiologic processes, one of which may be CSCR.

Visual functions following recovery from non-arteritic central retinal artery occlusion

BACKGROUND AND OBJECTIVE

Visual acuity and other visual functions may improve following treatment of central retinal artery occlusion (CRAO). A prospective, noncomparative case series study was conducted to investigate patients' visual functions after treatment of non-arteritic CRAO.

PATIENTS AND METHODS

Eight consecutive patients whose visual acuity improved following successful systematic treatment protocol for non-arteritic CRAO of less than 48 hours (one of them with patent cilioretinal artery) were evaluated for visual functions. The visual acuity in seven patients ranged from no light perception to counting fingers at 3 feet on presentation and improved to 20/100 to 20/20 following treatment. The visual tests included: blue-yellow (Farnsworth D-15) and green-red (pseudoisochromatic Ishihara color plates) color discrimination, contrast sensitivity, and visual fields. The patients were also evaluated for subjective daily function following treatment. All tests were also performed in the fellow uninvolved eye as a control.

RESULTS

The visual acuity following treatment improved from no light perception to counting fingers at 3 feet to an average of 20/65 (range, 20/20 to 20/100). Despite this improvement, six patients had dyschromatopsia to blue, green, or red whereas only two patients with a final visual acuity of 20/20 preserved their full color discrimination. All patients had decreased contrast sensitivity at mid-spatial frequency (6 cycles/min) or a more generalized decrease and visual field defects. All of the patients except one were satisfied with the visual outcome and daily function after treatment.

CONCLUSION

Despite improvement in visual acuity after treatment for CRAO, all patients had residual visual function abnormalities. These abnormalities may be attributed to partial recanalization, conversion of CRAO to multiple branch retinal artery occlusions, or different retinal susceptibility for ischemia.

Development and progression of cataract in patients required repeated corneal transplantation

PURPOSE

To evaluate the incidence of cataract development in patients required repeated corneal transplantations, the types of cataract and the effect of cataract extraction on the corneal regrafts survival.

PATIENTS AND METHODS

The charts of all the patients that underwent repeated corneal transplantation between 1985 and 1998 were reviewed for the development of cataract after the first or subsequent keratoplasties. In all, 80 patients underwent 122 repeated corneal transplantations, of which six underwent surgery in both eyes. The average follow-up period of all the patients with repeated keratoplasty was 89.5 months from the first keratoplasty.

RESULTS

Of 86 eyes 19 (22%) that underwent repeated keratoplasties developed cataract. The cataract developed between 1 month and 17 years (average 61.3 months) after the first transplantation. The incidence of cataract development was independent of the number of repeated keratoplasties. In certain patients, such as patients with acute and severe regraft immune rejection, the cataract progressed more rapidly. Despite different cataract extraction procedures, the grafts in 17 eyes of the 19 (89.5%) failed following cataract surgery and 16 of them underwent additional corneal regrafting. The regrafts in eight of the 16 regrafted eyes (50%) remained clear with improvement in visual acuity. At the end of the follow-up, 10 eyes of the 19 had clear regraft (53%) comparable with the rate of clear grafts in the entire regrafted group (51%, P=NS).

CONCLUSION

Corneal transplantation may be a trigger for slow development of cataract over years but repeated keratoplasties did not increase the risk for cataract development. Although failure of regrafts may occur after cataract extraction, subsequent corneal transplantation has a comparable survival and visual outcome with the entire regrafted group.

Metoprolol responding uveitis

BACKGROUND

Noninfectious uveitis is usually managed by topical and systemic corticosteroids and in refractory cases by immunosuppressive drugs.

OBJECTIVE

To describe a patient with noninfectious anterior and posterior uveitis, refractory to corticosteroids, and immunosuppressive therapy, which responded to systemic metoprolol.

PATIENT AND METHODS

A 49-year-old patient was treated for 3 years with topical and systemic corticosteroids and systemic cyclosporin A for a bilateral anterior and posterior uveitis of unknown origin. The treatment did not result in resolution of the uveitis. A bilateral uveitic glaucoma developed and necessitated neodymium : YAG laser iridotomies and antiglaucoma medications. A systemic beta-blocker, metoprolol tartrate 50 mg b.i.d., was administered for palpitations because of idiopatic paroxysmal supraventricular tachycardia and short ventricular tachycardia.

RESULTS

Following administration of metoprolol tartrate, the bilateral uveitis resolved. The corticosteroids and the cyclosporin A were withdrawn after 6 weeks without any recurrence. A trial to discontinue metoprolol after 6 months resulted in flare-up of the disease and only following its readministration the inflammation resolved. The patient is currently under metoprolol for a year without flare-ups.

CONCLUSIONS

The use of metoprolol tartrate in this patient resulted in resolution of bilateral noninfectious uveitis. This is the first report of non-antiinfectious, antiinflammatory, or immunosuppressive drug effective for uveitis. It is possible that a subgroup of resistant uveitis may respond to drugs other than the traditional drugs, such as metoprolol, and that other forms of uveitis of unidentified origin exist.

Correlation between optic disc atrophy and aetiology: anterior ischaemic optic neuropathy vs optic neuritis

BACKGROUND

The morphologic features of swollen disc in the acute stage of optic neuritis and anterior ischaemic optic neuropathy (AION) have been extensively investigated in contrast to the morphologic features of optic disc atrophy after these events.

OBJECTIVE

: A prospective study to evaluate the morphologic features of optic disc atrophy 6 months or more after optic neuritis and nonarteritic AION.

PATIENTS AND METHODS

A total of 35 optic discs after nonarteritic AION (n=27) and 24 after optic neuritis (n=19) in otherwise healthy subjects have been evaluated by direct fundoscopic examination with a +90 diopters lens and optic disc photography. The average age of patients at the onset of AION was 57.8 years (range: 38-80) and at the onset of optic neuritis was 32.6 (range: 19-46). The female:male ratio was 18 : 17 in the former and 15 : 9 in the latter. The evaluated parameters included: degree of rim pallor (0 to +3), location of rim pallor, height of rim above the retina, depth and width of cup, peripapillary retinal artery to vein (A : V) ratio, and peripapillary pigment epithelial atrophy. A comparison was made also with 17 age-matched normal discs of 17 patients. Statistical significance was calculated with chi(2) and Fisher's exact test.

RESULTS

Most of the discs after AION were paler (+2: 70%, +3: 26%) than after optic neuritis (normal colour: 8%, +1: 58%, P< or =0.007). Rim segmental involvement after AION was usually either superior 'altitudinal' (53%) or inferior 'altitudinal' (29%), whereas after optic neuritis, it was usually either temporal-central (papillomacular) (42%) or diffuse temporal (42%, P<0.0001). Discs had lower A : V ratio (1 : 3, 40%) after AION compared with optic neuritis (1 : 3, 8%) (P=0.007). There were no significant differences between the two groups in height of the rim, cupping, and peripapillary atrophy.

CONCLUSIONS

: A combination of the degree of rim pallor, location of rim pallor, and A : V ratio may be of value in assessing the aetiology of optic disc atrophy when no previous clinical data are available and a compressive lesion has been ruled out.

Blind canalicular marsupialization in complete punctal absence as part of a systematic approach for classification and treatment of lacrimal system obstructions

The procedure of choice for epiphora caused by bipunctal and canalicular obstruction is conjunctivodacryocystorhinostomy. Despite its high success rate, it may result in multiple complications, such as extrusion, migration, and secondary obstruction. The author describes a simple alternative procedure to conjunctivodacryocystorhinostomy for patients with epiphora caused by bipunctal and proximal canaliculus complete occlusion and a systematic approach to treat lacrimal system obstructions. Ten instances of bipunctal and proximal canaliculus absence in five consecutive patients, caused in four patients by ocular surface disorders (topical drug toxicity, herpetic keratoconjunctivitis, and trachoma), were treated by blunt dissection of the presumed lower punctal site under a surgical microscope. The punctal site was determined by several landmarks, the peaked medial lid margin, a dimple at that site, or an area of relative avascularity. The canaliculus was exposed and expanded to create a pocket. After the procedure, the lacrimal drainage system was found patent in nine of the 10 procedures. After one additional procedure, irrigation of the lacrimal drainage system revealed a nasolacrimal duct obstruction that was treated with dacryocystorhinostomy and silicone tube insertion. After these procedures, an objective resolution of the epiphora was noted in all patients. Epiphora resulting from lack of punctal and proximal canaliculus caused by ocular surface diseases may be treated with blind exposure and marsupialization of the proximal canaliculus instead of conjunctivodacryocystorhinostomy. If, in addition, the nasolacrimal duct is obstructed, a dacryocystorhinostomy may be performed. If this proposed procedure fails, the patient can still undergo conjunctivodacryocystorhinostomy or other procedures. The procedure may be part of a systematic approach to treat lacrimal drainage obstructions that is based on an association between the location and the cause of the obstruction.

Optic disc traction syndrome associated with central retinal vein occlusion

OBJECTIVE

To describe the association between ischemic central retinal vein occlusion (CRVO) and the development of optic disc (vitreopapillary) traction, as verified by optical coherence tomography (OCT).

METHODS

In a prospective, noncomparative, observational patient series, 3 women aged 51 to 64 years developed an ischemic type of CRVO. One patient underwent cannulation of the central retinal vein with injection of a tissue plasminogen activator. In each eye, the contour of the optic nerve head could not be accurately detected because of overlying fibrous tissue. Each patient underwent OCT examination 6 to 10 months (average, 8.3 months) after the occlusive event.

RESULTS

Optic disc traction was found by OCT in the 3 patients. In each, the disc was elevated, associated with either incomplete posterior vitreous detachment (2 eyes) or vitreopapillary fibrous membrane (1 eye). Secondary peripapillary retinal traction and macular or retinal detachment developed ("optic disc traction syndrome"). These findings were less marked, or not evident, on both clinical examination and ocular ultrasonography.

CONCLUSIONS

Optic disc traction and secondary localized retinal detachment can develop after ischemic CRVO and may contribute to the poor visual acuity. This syndrome should merit special attention before surgery for CRVO is planned. The use of OCT was helpful to diagnose this syndrome.

Update on treatment of retinal arterial occlusions

Retinal arterial occlusion remains a difficult clinical entity to manage. Treatment can best be categorized as conservative (ocular massage, pharmacologic, anterior chamber paracentesis) and invasive (catheterization of the proximal ophthalmic artery through the femoral artery with the infusion of thrombolytic agents). Most reports remain anecdotal due to its low incidence (0.85/100,000/y).

Endocrine abnormalities in patients with central serous chorioretinopathy

PURPOSE

To investigate and to identify endocrine and metabolic abnormalities in patients with central serous chorioretinopathy (CSCR).

DESIGN

Observational case series.

PARTICIPANTS

Twenty-four patients with CSCR.

METHODS

Serum and urinary catecholamines, glucocorticoids, mineralocorticoids, serum testosterone, and thyroid-stimulating hormone (TSH) function were evaluated prospectively.

RESULTS

Fifty percent (12 of 24) of patients with active acute CSCR showed elevated 24-hour urine cortisol or tetrahydroaldosterone levels. Serum aldosterone levels were low in 7 of 24 (29.1%) patients. Single morning plasma catecholamine levels were elevated in 7 of 24 patients, although 24-hour urine metanephrines (catecholamine breakdown products) were normal. Serum testosterone and TSH levels were normal in nearly all (23 of 24) patients.

CONCLUSION

Many patients with acute CSCR have elevated 24-hour urine corticosteroids, which may contribute to the pathogenesis of the disorder. Endogenous mineralocorticoid dysfunction is a newly described feature of CSCR.

Detachment of subfoveal choroidal neovascularization in age-related macular degeneration

PURPOSE

To report the entity of partial detachment and folding of subfoveal choroidal neovascularization (CNV) in age-related macular degeneration (ARMD).

DESIGN

Interventional case reports.

METHODS

Review of the features of CNV detachment in two patients with CNV due to ARMD by contact lens slit-lamp biomicroscopy, fluorescein angiography, optical coherence tomography, and three-dimensional confocal scanning laser indocyanine green (ICG) angiography.

RESULTS

One patient out of approximately 300 (0.5%) ARMD patients treated by photodynamic therapy (PDT) developed partial CNV detachment and folding 6 weeks after the second PDT treatment. Another patient out of approximately 100 (1.0%) ARMD patients treated by transpupillary thermotherapy (TTT) developed partial CNV detachment and folding 6 weeks after the second TTT treatment. The CNVs were large (2,500 microm to 4,500 microm) and located between the retina and the retinal pigment epithelium. In each, these findings were clearly visualized by slit-lamp biomicroscopy. Fluorescein angiography demonstrated an associated retinal pigment epithelium tear in one patient. Optical coherence tomography showed distinctive features and confocal scanning laser ICG further delineated the detached folded CNV. The best-corrected visual acuity improved in one patient from 20/80 to 20/40 and in the other from counting fingers at 6 feet to 20/200 after the CNV detachment.

CONCLUSIONS

Partial CNV detachment and folding represent a unique, not previously reported, and possibly favorable outcome of PDT and TTT. The low energy and selectivity of these treatments may explain this phenomenon.

Preexisting and postoperative glaucoma in repeated corneal transplantation

PURPOSE

To evaluate the incidence, risk factors, management, and visual outcome of postoperative glaucoma in comparison with preexisting glaucoma in repeated corneal transplantation.

METHODS

The charts of all the patients who underwent repeated corneal transplantation between 1985 and 1998 were reviewed for the occurrence of preexisting and postoperative glaucoma. Eighty patients underwent 122 repeated corneal transplantations, of which six underwent surgery in both eyes. The mean follow-up period from the primary keratoplasty was 89.5 months and the minimal follow-up period was at least 6 months after the last transplantation.

RESULTS

Postoperative glaucoma affected 29 eyes (34%) in 28 patients (35%) with repeated corneal transplantation. Herpetic scar as an indication for transplantation and a history of previous immune graft rejection were more common in patients who developed postoperative glaucoma compared with the entire regrafted group ( p= 0.016 and p< 0.001, respectively). The incidence of glaucoma usually increased with the increased number of keratoplasties. The following types of glaucoma were disclosed: closed angle (59%), corticosteroid induced (21%), open angle (11%), angle recession (3%), aqueous misdirection (3%), and unknown cause (3%). Surgical intervention was required in 62%. Glaucoma was controlled in nine eyes (31%) and resolved following regrafting or discontinuation of corticosteroids in four eyes (14%), of which five (17%) had clear regrafts. Better intraocular pressure control was achieved in those cases that did not require surgical intervention ( p= 0.019). In 15 eyes (52%), regrafts failed due to uncontrolled glaucoma and/or other causes. At the end of the follow-up period, visual acuity was 20/30 to 20/200 in 17%, counting fingers from less than 20 ft in 31%, hand movement/light perception in 35%, and no light perception in 17%. Six of the 86 eyes (7%) in six patients (7.5%) had preexisting glaucoma. Graft clarity and glaucoma control in patients with preexisting glaucoma were similar to those of postkeratoplasty glaucoma (50% had controlled glaucoma and 33% had clear regraft).

CONCLUSIONS

Glaucoma, either preexisting or postoperative, is one of the most devastating complications of repeated corneal transplantation and the cause for regraft failure and visual loss even when intensively treated. Close monitoring and early targeted therapy are warranted to increase the survival of repeated corneal transplants in eyes affected by glaucoma.

Systemic cyclosporin A in high failure risk, repeated corneal transplantation

AIM

To evaluate the efficacy of oral cyclosporin A in the prevention and treatment of immune graft rejection in heavily vascularised, repeated keratoplasties with high risk for failure.

METHODS

21 consecutive patients with 28 repeated corneal transplants and four quadrant vascularised recipient bed were treated with oral cyclosporin A for an average period of 12 months (range 1-41 months) and followed for an average period of 26.6 months (range 6-106 months). The average cyclosporin A blood level was 325 ng/ml (range 180-421 ng/ml). Within this group of 21 patients, another 12 regrafts were not treated with cyclosporin A and served as a control group.

RESULTS

Nine of the 28 regrafts (32%) treated with cyclosporin A remained clear. The Kaplan-Meier curve showed a constant decline in survival of the treated grafts, although the survival proportion during the first year of treatment was statistically higher for the treated group compared with the untreated group. Once immune regraft rejection occurred, the regraft failed despite treatment with cyclosporin A and extensive topical and systemic corticosteroids. Nine regrafts (32%) had immune graft rejection and all ultimately failed compared with five in the untreated regrafts (42%, p = NS). Ten other regrafts (36%) in the treatment group failed due to causes other than immune regraft rejection.

CONCLUSIONS

Systemic cyclosporin A has a limited beneficial effect in preventing immune graft rejection in repeated corneal transplants in a highly vascularised corneal bed. When immune graft rejection occurs in such regrafts, the prognosis is poor despite aggressive medical treatment. Causes other than immune regraft rejection may also result in poor visual outcome in patients with clear regrafts.