Transverse chop: new or old phaco technique

BACKGROUND

Restrictive strabismus and diplopia are an uncommon complication of conjunctivodacryocystorhinostomy, with insertion of the Lester-Jones tube. A literature review revealed only 4 published reports of this complication with a total of 4 patients affected.

METHODS

We report on a series of 8 patients who presented with restrictive strabismus and diplopia following Jones tube insertion.

RESULTS

Time to presentation was variable and was found to occur from several months to as long as 6 years after insertion. Treatment included topical steroid therapy initially. Surgery was done to release adhesions and scarring if topical treatment failed. Mitomycin C was used in 2 patients. Only 4 of the 8 patients had successful resolution of their diplopia with either therapy.

INTERPRETATION

Diplopia following Jones tube insertion is an infrequent complication of surgery. Medical or surgical therapy can be help resolve symptoms but is often unsuccessful.

Congenital absence of the inferior rectus muscle--diagnosis and management

BACKGROUND

Congenital absence of the inferior rectus muscle is a rare cause of apparent inferior rectus palsy especially in the absence of associated cranial facial anomalies.

METHODS

We report three cases of isolated congenital absence of the inferior rectus muscle and its successful surgical management.

RESULTS

Failure of the normal embryologic development of the mesodermal complex around the eye can lead to agenesis of the extraocular muscles. In apparent palsies of the inferior rectus muscle and no definite cause, a high index of suspicion and orbital imaging can confirm the diagnosis of congenitally absent inferior rectus preoperatively. Surgical correction may involve inferior transposition of the horizontal rectus muscles.

CONCLUSIONS

Although rare, congenital absence of the inferior rectus muscle is a possible cause of apparent inferior rectus muscle palsy particularly in the absence of another identifiable cause. Strabismus surgery in conjunction with intramuscular botulinum toxin injection can offer significant improvement in function and cosmesis of these patients.

Proposed pathogenesis for the delayed postoperative opacification of the hydroview hydrogel intraocular lens

PURPOSE

To report the clinical, histopathologic, ultrastructural, and elemental features of 17 opacified Hydroview (Bausch and Lomb Surgical, Rochester, New York, USA) hydrogel intraocular lenses (IOL) necessitating explantation and discuss from a clinicopathologic perspective why these lenses became opacified. Interventional case series with clinicopathologic correlation.

METHODS

Seventeen hydrogel lenses were explanted from 17 different patients owing to decreased visual acuity or quality of vision an average of 29 months after uneventful phacoemulsification and IOL implantation and associated with a granular-appearing opacification superficially within the optic. Lenses were examined by light microscopy, transmission electron microscopy (TEM), and energy dispersion x-ray (EDX) spectroscopy. A control IOL was included in our study.

RESULTS

All explanted lenses showed positive staining for calcium by light microscopy. Transmission electron microscopy disclosed electron-dense crystalline deposits in the superficial substance of the IOL optic. Energy dispersion x-ray spectra analyses showed the presence of calcium and phosphorus mainly in the electron-dense periphery of the deposits in all of the specimens and the presence of silicon mainly in the electron-lucent center of the deposits in the majority of the specimens. No positive staining or deposits were observed on the IOL control or in the haptics.

CONCLUSIONS

Our study is the first to demonstrate that the calcium deposits are associated with silicon, which was presumably derived from the silicone gasket in the Surefold (Bausch and Lomb Surgical, Rochester, New York, USA) packaging system, manufactured specifically for this IOL. Silicon may act as a nidus for calcium deposition within the lens, which is consistent with our findings. There may be other factors involved, and this important clinical problem requires further study.

Complications associated with pegging hydroxyapatite orbital implants

OBJECTIVE

Prior studies of hydroxyapatite orbital implant complications have primarily focused on complications of the implant itself with only occasional mention of the complications associated with the peg system. This in part may be because of a low rate of pegging and, thus, a small sample size to evaluate. Therefore, a full range of complications that can occur with pegging has not been presented. The objective of this study was to determine the complications associated with pegging and to discuss ways to manage them.

DESIGN

Retrospective, noncomparative case series.

PARTICIPANTS/INTERVENTION

The authors analyzed all of the complications associated with pegging 165 of a possible 275 hydroxyapatite implants implanted by 2 surgeons over 7 years.

MAIN OUTCOME MEASURES

The following data were recorded: type of surgery performed, size of implant used, type of hydroxyapatite used, peg system used, time of pegging, follow-up duration, problems encountered, and treatment.

RESULTS

Sixty-two (37.5%) of the 165 patients who had pegged implants were found to have problems with their pegs. Twenty-one (33.8%) of the 62 patients with peg problems had more than 1 peg-related problem. Complications associated with pegging included discharge (37%; 23 of 62), pyogenic granulomas (30.6%; 19 of 62), peg falling out (29%; 18 of 62), poor transfer of movement (11.2%; 7 of 62), clicking (11.2%; 7 of 62), conjunctiva overgrowing peg (4.8%; 3 of 62), poor-fitting sleeve (4.8%; 3 of 62), part of sleeve shaft visible (4.8%; 3 of 62), peg drilled on an angle (4.8%; 3 of 62), hydroxyapatite visible around peg hole (3.2%; 2 of 62), peg drilled off-center (3.2%; 2 of 62), popping peg (3.2%; 2 of 62), and excess movement of peg (3.2%; 2 of 62). The most serious complication occurring in two individuals (3.2%) was implant infection requiring implant removal.

CONCLUSION

There are several potential complications that can occur after pegging the hydroxyapatite implant. These problems are generally of a minor nature but often require additional patient visits that would not ordinarily have been required if the peg was not in place. The most serious peg problem is implant infection, which may necessitate implant removal. These potential peg problems should be reviewed with the patient before the procedure is performed.

Ptosis secondary to amyloidosis of the tarsal conjunctiva and tarsus

PURPOSE

To report a case of chronic unilateral ptosis in a 63-year-old, otherwise healthy woman with visual restriction.

METHODS

We performed a biopsy on an enlarged tarsal plate that we believed had caused ptosis. A levator aponeurotic advancement was performed subsequently.

RESULTS

Histologic and ultrastructural examination of the biopsy specimen disclosed amyloidosis of the tarsal conjunctiva and tarsus. There was no evidence of systemic amyloidosis.

CONCLUSION

Localized amyloidosis involving the tarsal conjunctiva and tarsus is a rare cause of chronic eyelid thickening and ptosis.

Outward transcutaneous chemical migration: implications for diagnostics and dosimetry

Chemical substances migrate outwards from within the body to the skin surface by diffusion from cutaneous capillaries across the epidermis. Heretofore, study of transepidermal chemical emissions have been restricted to substances which are in the vapor phase at skin surface temperature. We have investigated outward transcutaneous chemical migration of nongaseous chemicals by devising an occlusive transcutaneous chemical collection system, consisting of a tape-encased plug of gelled saline in which activated carbon is dispersed. Investigations of nine chemicals in 'fuzzy' rats, rhesus monkeys, and man provide data which are consistent with a general theory of outward transcutaneous chemical migration. This noninvasive continuous transcutaneous sampling technique provides a new method for investigating skin permeability in vivo and may provide a basis for convenient diagnosis and monitoring of chemical exposure.