Complications of phacoemulsification

Charles Kelman performed the first phacoemulsification operation in 1967, but it was not until 1971 that the technique had been sufficiently refined to allow its use by others. Now over 2,000 surgeons have been trained in the technique, and more than 100,000 cases have been performed. However, extended follow-up in any given series has been difficult because of the wide geographic distribution of patients, and interpretation is hampered by the frequent insertion of intraocular lenses in these patients. The present series attempts to carefully document operative and postoperative complications encountered in a consecutive series of patients whose senile cataracts were treated by phacoemulsification.     

Microperimetry in multiple evanescent white dot syndrome

BACKGROUND: This study investigates a new instrument, called the Microperimeter-1 (MP-1), which maps areas of retinal sensitivity, in a series of patients with multiple evanescent white dot syndrome (MEWDS). METHODS: A retrospective observational case series from a private retina practice, in which 3 patients with a diagnosis of MEWDS underwent testing with the MP-1. RESULTS: All 3 patients in this series showed an enlarged blind spot on MP-1 testing. INTERPRETATION: Microperimetry is a useful tool in visual field testing for patients with MEWDS. The MP-1 allows retinal sensitivity mapping to be displayed on a fundus photograph, which permits correlation of scotomata with retinal pathology.     

Retinal detachment in myopic eyes after intracapsular and extracapsular cataract extraction

We analyzed two consecutive series of cataract extractions in patients with moderate to severe myopia for the incidence of postoperative retinal detachment. One series consisted of 122 intracapsular cataract extractions without surgical loss of vitreous and the other series consisted of 151 extracapsular (phacoemulsification and planned extracapsular) cataract extractions without loss of vitreous and with intact posterior capsules. All patients were 40 years of age or older and all were followed up for one to four years. We defined moderate to severe myopia as an aphakic refraction of +7.00 diopters spherical equivalent or less. The rate of postoperative retinal detachment was greater in the intracapsular series (seven of 122 cases; 5.74%) than in the extracapsular series (one of 151 cases; 0.66%).     

Trabeculectomy with iridencleisis.

An iridencleisis is added to the original trabeculectomy technique of Cairns as modified by Watson for the surgical treatment of glaucoma. The steps are described with special reference to the fashioning of the iridencleisis as an iris tongue lying curled upon itself with the pigmented layer lining the inner aspect of the iris resting between the scleral flaps. Two series of patients from Africa and one series from the USA show postoperative intraocular tensions of 24 mmHg or less in 90% to 98% of patients. The Caucasian series from the USA had 94% with pressures of 21 mmHg or less. At least 90% in all three series were controlled without continued glaucoma medication.     

Improving the reporting of clinical case series

PURPOSE: To describe common errors in the analyses and data presentation of a clinical case series and to suggest simple solutions. DESIGN: Instructional examples. METHODS: Problems with commonly used data analysis and reporting techniques in clinical case series are described using both theoretical examples and those from the literature. RESULTS: An analysis reporting the proportion of a series of patients with variable follow-up does not adequately account for the differential follow-up among patients and is a potentially misleading way to present data. Instead, the proportion of patients at presentation (or study entry) and the rate during follow-up should be reported. Similarly, an analysis in which the final visual acuity of a series of patients with variable follow-up is reported does not adequately account for the effect of time and also may be misleading. Reporting of the rates of visual acuity events during follow-up (e.g., falling below a specified threshold, such as 20/50 or worse) is preferred. Alternatively, when there is nearly complete follow-up, reporting the distribution of visual acuity at specified time points (e.g., 1 year after study presentation) is appropriate. Small case series should not be overinterpreted because of the effects of chance, and appropriate statistical analyses should be employed. CONCLUSIONS: Clinical case series often suffer from several potential reporting flaws. Correction of these flaws would permit the proper interpretation of the data and allow for the ability to combine data from several case series to assemble more meaningful and reliable conclusions.     

Double irradiation for macroscopic radioresistance or recurrence of melanomas of the posterior uvea: clinical, ballistic, therapeutic and prognostic aspects. Series of 19 cases among 462 patients

We describe two comparative series of patients treated with double-dose betaraysbrachytherapy (106 Ruthenium) between 1983 and 1994, and double-dose proton beam therapy between 1991 and 1996. The indications for double-dose irradiation with the same radio-element corresponded to "macroscopically abnormal" situations: immediate and prolonged radioresistance, recurrence or secondary radioresistance. Thirteen cases are called series 1 (Ruthenium) and 6 cases are called series 2 (protons). The series 1 allows a more reliable study as far as follow-up is higher (5.8 to 7.5 years) than in series 2 where the follow-up is shorter (13.6 to 29 months). Although double-dose irradiation was macroscopically efficient in 11 out of 13 cases in series 1, and in 3 out of 6 cases in series 2 (stabilization or decrease of tumour height measured before the second therapeutic session), 2 patients are deceased and 1 has a metastatic disease in the group "recurrence" of Ruthenium serie. Another one has also a metastatic disease in the group "recurrence" of protons series. Nevertheless double-dose radiotherapy allows a complementary decrease or stabilization of tumour height after a first session. It also decreases the indications for enucleation if there is no severe anatomic complications, when a tumour does not regress or recurs after a first session of radiations.     

Outcomes in retinoblastoma, 1974-2005: the Children's Hospital, Westmead

BACKGROUND: To report the 31-year experience of outcomes in retinoblastoma from a single centre. METHODS: A retrospective analysis of consecutive cases of retinoblastoma diagnosed and treated at the Westmead Children's Hospital, Sydney between 1974 and 2005 was performed. The subjects were analysed as two groups: those diagnosed between 1974 and 1989 (series alpha) and those diagnosed between 1990 and 2005 (series beta). RESULTS: There were a total of 142 patients included in the study, with a median follow up of 72 months. There were 84 patients with unilateral disease and 58 patients (116 eyes) with bilateral disease. The total enucleation rate remained high throughout both series for those with unilateral disease: 89% (series alpha) and 95% (series beta). There was a reduction in enucleations performed for those with bilateral disease from 68.4% (series alpha) to 43.6% (series beta) (P < 0.025). There were no bilateral enucleations performed after 1995. Actuarial Kaplan-Meier curves showed that 56% of all preserved eyes had not recurred at a median follow up of 95 months and 78.1% had avoided enucleation. Overall 43% of preserved eyes attained a visual acuity better than or equal to 6/12 and 55% achieved a visual acuity better than 6/60. There were four deaths due to retinoblastoma. Five patients were diagnosed with a second non-ocular malignancy. The most common treatment-related complications were cataracts, facial deformity, sepsis and febrile neutropaenia. CONCLUSIONS: The introduction of newer globe-preserving treatments for retinoblastoma was associated with equivalent visual outcomes, stable mortality rate and a greater number of short-term complications but avoided the late side-effects associated with external beam radiotherapy.     

Two-port pars plana vitrectomy surgery: a prospective interventional case series

BACKGROUND AND OBJECTIVE: Current literature review fails to disclose any series describing the use of two-port vitrectomy in adult patients. This study was performed to determine the feasibility and efficacy of pars plana vitrectomy surgery using two (rather than three or four)-port access for treatment of diabetic patients with nonclearing vitreous haemorrhage due to retinal neovascularization. DESIGN: Interventional prospective case series: to measure ability to allow for long-term resolution of chronic uncomplicated vitreous haemorrhage in diabetic patients, and to study the frequency and nature of complications associated with this technique. METHODS: Two-port pars plana vitrectomy (with endolaser treatment and membrane delamination if necessary) was performed in a prospective series of 12 consecutive diabetic patients with nonclearing vitreous haemorrhage due to retinal neovascularization. RESULTS: Successful removal of vitreous haemorrhage resulted in all patients. No visually significant intraoperative complications occurred. Best postoperative visual acuity correlated with lenticular and macular perfusion status. CONCLUSION: Two-port pars plana vitrectomy is an efficient (and potentially safer and faster) alternative to the standard three-port vitrectomy in selected patients.     

CLINICAL FEATURES OF DEGENERATIVE RETINOSCHISIS

To elucidate clinical characteristics, typical and reticular degenerative retinoschisis are characterized histopathologically in a series of 2319 autopsy eyes, and clinically in a series of 77 eyes in 43 patients. In the autopsy series, typical degenerative retinoschisis was seen in 1.02% of the cases and 0.69% of the eyes; and reticular degenerative retinoschisis was seen in 1.62% of the cases and 0.95% of the eyes. Histopathology was correlated with clinical observations in adult patients with typical and reticular degenerative retinoschisis. On the basis of these observations, consideration was given to the clinical manifestations and management of typical and reticular degenerative retinoschisis.     

Acquired lower eyelid epiblepharon in patients with thyroid eye disease

PURPOSE: To describe a series of patients with acquired epiblepharon secondary to thyroid-related orbitopathy. METHODS: Retrospective case series of 9 patients with thyroid-related orbitopathy who had epiblepharon. RESULTS: Seven patients had epiblepharon in both lower eyelids and 2 patients had it in one lower eyelid. Six of the 9 patients were Asian. Each patient had punctate keratopathy. Epiblepharon resolved in all but one patient after treating coexisting manifestations of thyroid-related orbitopathy. One patient required epiblepharon repair. CONCLUSIONS: We describe a new finding of acquired epiblepharon in the setting of thyroid-related orbitopathy. The majority of patients have spontaneous resolution of the epiblepharon after other surgical procedures for thyroid-related orbitopathy.     

The Results of Surgical Treatment of Esotropia

The results of surgical treatment of esotropia in a series of 225 patients are described. Successful results were obtained in 54 - 5% after re-operation. The series consisted of two groups, one of 121 patients and the other of 104 patients, and results in the second group were somewhat better than in the first. The better results in the second group seemed to be associated with more successful reduction in amblyopia pre-operatively, and a greater use of large operations initially namely medial rectus recession/lateral rectus resection operations. The presence Of to vertical component to the oculo-motor im-balance and also onset in the first year of life Were associated with poor results throughout the series, while if the eyes were straight at any time during the patient's visits before operation, a good result was much more likely with surgery. Refractive error did not affect results. The presence of a vertical component to the deviation was associated with poor results, but surgical correction of this seemed to give satisfactory result Early operation did not seem of advantage in this series. Medial rectus recession did not seem a, very effective operation in this series except in purely accommodational esotropia.     

Orbital fractures in children

PURPOSE: To describe the demographics, etiologic factors, clinical presentations, and outcomes of orbital fractures in children. METHODS: This was a retrospective case series of 96 consecutive patients under 18 years of age with orbital fractures presenting to the Massachusetts Eye and Ear Infirmary, including both hospitalized and nonhospitalized patients. RESULTS: Orbital fractures in children were most frequently the result of sports, assault, or motor vehicle accident. The majority of patients did not require hospitalization and were treated as outpatients. The medial wall and floor of the orbit were the most frequent locations of fracture. Approximately half of the patients in this series required surgery, most often for entrapment. There were no cases of persistent diplopia in patients in whom surgery was performed or was not indicated. Associated ocular injuries were observed in half of the patients. CONCLUSIONS: In this series of hospitalized and nonhospitalized patients, orbital fractures in children had a location pattern similar to that most frequently observed in adult patients (floor and medial wall). Orbital fractures in children frequently require surgery. The high prevalence of ocular injury in children with orbital fractures emphasizes the need for a comprehensive ophthalmic evaluation.     

Evisceration techniques and implant extrusion rates: A retrospective review of two series and a survey of ASOPRS surgeons

PURPOSE: To compare implant extrusion rates in two retrospective series of patients, treated by different surgeons, and to determine if there are preferred evisceration and implant insertion techniques among oculoplastic surgeons. METHODS: A retrospective review of cases of evisceration and implant insertion and a survey of oculoplastic surgeons. RESULTS: The implant extrusion rate was zero in the author's series of 53 patients, compared with 27.1% (54 of 192 implants) in series treated by other surgeons. Statistically significant differences were found between the two series in surgical technique, wound care, and duration of antibiotic administration. The author routinely performed posterior sclerotomy, whereas the other surgeons did not. Average implant size was 18.8 mm in the author's series, compared with 13.7 mm in the other series. Antibiotic therapy was administered for 10 to 18 days in the author's series, compared with 28 to 46 days in patients treated by other surgeons. The response rate to the survey was 65% (223 of 343 surveys). Among the surgeons surveyed, immediate and secondary implant techniques were used in nearly equal frequency. Delayed implant technique is used least frequently. Reported implant extrusion rates varied greatly among surgeons, ranging from 0% to 20%. Only 3.9% of surgeons expressed a concern over sympathetic ophthalmia. CONCLUSIONS: Injudicious antibiotic use and smaller implants do not decrease the risk of implant extrusion. The survey revealed that immediate and secondary implant techniques are used with equal frequency. The theoretical risk of sympathetic ophthalmia does not appear to be a concern to most surgeons.     

Periocular microcystic adnexal carcinoma: management and outcome with Mohs' micrographic surgery

PURPOSE: To report a series of patients with periocular microcystic adnexal carcinoma (MAC) treated with Mohs' micrographic surgery (MMS). DESIGN: Prospective, interventional case series. METHODS: This series included all patients treated with MMS for periocular MAC, who were monitored by the Skin and Cancer Foundation Australia between 1993 and 2002. RESULTS: There were 5 patients (4 males, 1 female) with a mean age of 52 +/- 12 years. Four tumors were located in the medial canthus and one in the lower lid.The tumor was initially misdiagnosed as basal cell carcinoma in 3 patients and squamous cell carcinoma in 1 patient. The average number of excision levels required for complete removal of the tumor during MMS was 2.2 (range 1-6). Perineural invasion was recorded in one patient.Five-year follow-up data was available for 3 patients, and there was no tumor recurrence in any of these cases. CONCLUSION: The low 5-year recurrence rate of periocular MAC with MMS emphasizes the importance of margin-controlled excision of this tumor.     

Papilomatosis conjuntival en niños tratada con interferón alfa-2b tópico coadyuvante

A series of paediatric patients is presented in whom topical interferon alpha-2b was used as a co-adjuvant treatment for conjunctival papilloma. This condition is frequently associated with human papillomavirus infection. There is little information on the pediatric population with the use of interferon for the treatment of these lesions. In this case series, adjuvant treatment with topical interferon alpha-2b in paediatric patients showed no recurrence and good tolerance.     

Acanthamoeba keratitis: risk factors and outcome.

AIMS/BACKGROUND--This study was initiated to investigate risk factors for and outcome of Acanthamoeba keratitis. METHODS--Results of treatment were studied in 22 patients (23 eyes) presenting to Bristol Eye Hospital between 1985 and February 1995. Details related to the use and disinfection of contact lenses were also obtained. An additional two patients who were seen at Bristol but mainly treated elsewhere were surveyed for contact lens related information only. RESULTS--The incidence of Acanthamoeba keratitis rose substantially in the 1990s: three patients presented before 1990, while the remaining 21 presented between January 1990 and February 1995. Eleven patients have presented since january 1994. All of the patients in this series were contact lens wearers, 16 (67%) using daily wear disposable contact lenses. Contact lens disinfection data were available in 22 patients of whom 11 (50%) were using chlorine disinfectant. Other types of disinfection were much less common. Four patients (18%) had not used any disinfectant. During the course of the series the average diagnostic delay has fallen markedly, although in 77% of patients a diagnosis of a viral keratitis, most commonly herpes simplex, was made on first presentation. All but three of the series were treated with a combination of polyhexamethylene biguanide and propamidine isethionate. Penetrating keratoplasty was performed in 9/23 eyes (39%); in all of these eyes diagnosis was delayed for at least 6 weeks. All but one of the eyes in the series achieved a visual acuity of 6/9 or better after treatment, and 18 eyes (78%) saw 6/6 or better. CONCLUSIONS--Most patients with Acanthamoeba keratitis can now expect a good visual result and cure by medical therapy alone is favoured by early diagnosis.     

Metachronous tumor development in unilateral retinoblastoma

PURPOSE: A series of 205 retinoblastoma (RB) patients referred to the Department of Ophthalmology at the University of Siena (Italy) was evaluated in order to assess the proportion of unilateral cases later developing tumors in the companion eye ("metachronous" bilateral retinobastoma) (MBRB). METHODS: The total number of unilaterally affected patients developing tumors in the fellow eye was recorded and the risk factors assessed for the development of asynchronous bilateral retinoblastoma, i.e., family history, tumor multifocality and early age at diagnosis. RESULTS: Only two out of 133 (1.5%) unilateral retinoblastoma patients in our series could be considered affected by MBRB. CONCLUSIONS: The incidence of MBRB in our series was negligible (1.5% of all unilateral cases) compared to other reports. None of the reported risk factors for the development of tumors in the fellow eye was relevant in the present series. Although close follow-up of some unilateral cases is still recommended, thorough examination of the fellow eye, to search for lesions in the peripheral retina, is essential in all cases of unilateral RB. MBRB may be a distinctive clinical entity with specific clinical, genetic and prognostic features. However, all these aspects need to be better investigated in larger series.     

拟诊黄斑微小锥细胞损伤初步研究

目的对一组视力下降而眼底及荧光素眼底血管造影(FFA)正常,只有频域相干光断层扫描(FD-OCT)才能发现的黄斑中心凹微小病变的患者进行归纳总结。设计回顾性病例分析。研究对象北京同仁医院眼科门诊12例(13眼)符合要求者。方法询问上述患者病史,并行视力、眼底彩色照相、FFA、FD-OCT、多焦视网膜电图(mfERG)、视野等检查。主要指标OCT图像上视网膜形态学改变。结果 4例患者有光损伤或手术史,8例病因未明。视力:0.06～0.2者3眼,0.3～0.5者3眼,0.6～1.0者7眼。患眼眼前节正常,5眼(38.5%)黃斑中心有一小黄色斑,其余正常。FFA正常。FD-OCT示患眼黄斑中心凹曲线正常,厚度正常,仅在黄斑中心凹处,视网膜内外感光层(IS/OS层)及外节与色素上皮绒毛连接部有极局限缺失区,范围<300μm,外界膜及视网膜色素上皮层正常。mfERG检查7例,4例正常3,例3眼中,1眼振幅密度中度下降,2眼轻度下降。视野检查4例,中心视野均正常。结论对由多种因素引起的视力下降而眼底及FFA正常,只有FD-OCT显示黄斑中心凹处视网膜有微小改变的一类疾病拟诊为黄斑微小锥细胞损伤。     

Simple dacryops: a case series and review of the literature

In this prospective, small case series, 3 patients with simple dacryops were analyzed along with a review of literature. All 3 patients in this series had classical clinical features of simple dacryops. All of them underwent complete cyst removal with the aid of a cryoprobe. Histopathology was compatible with dacryops. In 2 of the 3 patients, the cyst revealed calcification, which to the best of our knowledge has not been reported. None of the patients developed a recurrence. In conclusion, simple dacryops is an easily recognized clinical entity. This entity has been infrequently reviewed in the older literature, and in the last decade only 6 cases have been reported. Most of the patients underwent complete excision of the cyst with no recurrences.     

Long-term survival after ruthenium plaque radiotherapy for uveal melanoma. A meta-analysis of studies including 1,066 patients.

PURPOSE: Most case series of patients managed by brachytherapy for uveal melanoma are small and survival data show considerable inter-study variation. The aim of this study was to summarise similarly structured case series by meta-analysis. METHODS: A systematic review generated 5 similarly structured case series including survival data for 1,066 patients treated by ruthenium plaque radiotherapy for uveal melanoma. After assessing the inter-study clinical heterogeneity, data were weighed for study size and pooled. RESULTS: Patient and radiotherapy characteristics were largely homogenous, but tumour size varied considerably between studies. The 5-year melanoma-related mortality rate was 6% for small and medium tumours (T1/T2) and 26% for large (T3) tumours. The 5-year and 10-year melanoma-related mortality rates for a balanced set of tumours with small, medium and large tumours being present in similar proportions were 14% and 22%, respectively. CONCLUSION: Case series of patients with uveal melanoma managed by brachytherapy may be pooled to increase sample size and study power. The present estimate of survival following ruthenium plaque radiotherapy compares favourably with previously summarised data of survival after enucleation for similarly sized tumours.