Pressure sore in a patient who underwent repair of a retinal tear with gas injection

Purpose: To demonstrate a pressure sore following strict head positioning in a patient who underwent encircling band, vitrectomy and gas injection. Methods: A male patient was admitted to the hospital with a large posterior horseshoe tear in the inferior temporal retina with severe vitreous traction and retinal detachment. Encircling band, vitrectomy cryotherapy and gas injection was performed. After surgery the patient was instructed to sit in a facedown position. Results: A pressure sore resulted from prolonged immobility of the right elbow due to face-down positioning following encircling band, vitrectomy and gas injection. Conclusion: A patient injection. Conclusion: A patient may rarely have compulsive personality traits that result in extreme compliance to the physician's recommendations; therefore, general instructions given for head positioning should include permission for a change in position when required, at least for brief periods of time.     

Self-assessment of angles of strabismus with photographic Purkinje I and IV reflection pattern evaluation

Background: Accurate assessment of the angle of strabismus, e.g. of variable angles of strabismus, is crucial in preoperative patient management and is usually performed in a clinical environment. Objective assessment by patients themselves, under everyday conditions, could contribute to a better preoperative work-up. A new objective evaluation procedure for the measurement of manifest angles of strabismus for near and distance fixation by the patient himself is presented. Methods: To account for the modified experimental setup used for the self-assessment, an amended computation procedure of Purkinje reflection pattern evaluation was developed. For measurement, patients and controls placed their head on a head/chin rest and fixated at 33 cm or 4 m distance in primary position. A reflex camera and three photo flash units were positioned on a special frame underneath the visual axis and in front of the subject so that both eyes could be photographed simultaneously. The camera's remote shutter control was released together with the photo flash units by the properly fixating subject. The angles of strabismus were obtained from the series of pictures through later evaluation of the Purkinje I and IV reflection patterns recorded in the photographs of the eyes. Results: Measurements of the ocular alignment in two control groups and in a group of strabismic subjects showed satisfactory accuracy of the self-assessment method compared to standard Purkinje reflection pattern evaluation and orthoptic measurements of the angle of strabismus. Conclusion: The modified self-assessment method can be used for the objective recording of angles of strabismus as needed in the preoperative work-up of patients with variable angles of strabismus, over prolonged periods of time, and outside a clinical setting.Presented in part as a poster at the 88th Annual Meeting of the Deutsche Ophthalmologische Gesellschaft in Baden-Baden, 1990     

Pars plana lensectomy in cases of cataract with juvenile chronic uveitis

Background: Classical cataract extraction in young patients with secondary cataract following juvenile chronic uveitis often is complicated by serious problems such as severe postoperative uveitis, hypotonia oculi and phthisis bulbi. Lensectomy with partial anterior vitrectomy might be a less inflammatory way of handling these cases. Methods: Over a 15-year period we have treated 10 eyes of 9 young patients (age from 8 to 30 years) with secondary cataract after chronic uveitis by pars plana lensectomy with partial anterior vitrectomy. A classical two-port technique was used with incisions at 4 mm from the limbus. The follow-up period varied from 3 to 12 years with an average of 8 years. There were five patients with chronic iridocyclitis, two with Fuch's heterochromic iridocyclitis, one with sympathetic ophthalmia and one with idiopathic panuveitis. Results: Seven eyes were corrected with contact lenses. During the entire follow-up period six had 20/20 visual acuity and one, 20/40. None of these patients reported tolerance problems with the contact lens. One patient has 20/20 visual acuity with spectacles. One patient who initially had 20/20 visual acuity with a contact lens developed retinal detachment 2 years after surgery, during pregnancy, and now has 20/40 vision after retinal surgery. She prefers not to wear the contact lens any longer because of diplopia. The visual acuity of one patient was no better than hand movement and his aphakia was never corrected. Complications included one vitreous haemorrhage necessitating a second vitrectomy, one retinal detachment during pregnancy and one retinal detachment with proliferative vitreoretinopathy. One patient with sympathetic ophthalmia has 20/20 vision after 9 years' follow-up but still needs systemic steroids and cyclosporine. Conclusion: Pars plana lensectomy, with anterior vitrectomy appears to be a relative safe way to treat secondary cataract in patients during the first 30 years of life.     

Pars plana vitrectomy for retinal detachment due to internal posterior ophthalmomyiasis after cataract extraction

Background: The authors report a case of posterior internal ophthalmomyiasis causing vitreous haemorrhage and retinal detachment after uncomplicated cataract extration. Case report: The patient suffered an abrupt vitreous haemorrhage 9 days after ECCE and posterior chamber IOL implantation. After 2 months the haemorrhage did not clear up and a retinal detachment arose. The patient underwent encircling scleral buckle, pars plana vitrectomy and fluid-gas exchange. In course of intervention the surgeon removed from the vitreous chamber a 14-mm-long round worm subsequently identified as a dipterous larva of the Sarcophagidae family. Discussion: The patient showed no sign of subretinal tracking or retinal breaks or holes. The sclerocorneal surgical wound seems the most likely site of entrance of the parasite, and this would then be the first reported case of myiasis with no RPE tracking.     

Ocular findings in trigonocephaly

Background: Trigonocephaly, caused by premature closure of the metopic suture, is a rare form of craniosynostosis. The aim of this study was to assess the visual outcome in children operated on for trigonocephaly Methods: We present eight cases of children with trigonocephaly surgically corrected by the same craniofacial technique. CT with 3D reconstruction was performed in all cases. Genitori defined three types of trigonocephaly according to the severity of the deformity of the skull base only types II and III were included in this study directed at evaluation of the ocular disorder. A complete eye examination was performed on all children by the same observer, with a follow-up of 2–6 years Results: 3D-CT reconstruction of the skull base showed that the frontozygomatic region was affected by the deformation. Ocular examination showed considerable astigmatism in most children with late operation. A low degree of strabismus was observed in most children Conclusion: This study demonstrated that reconstructive surgery should be performed by the age of 6 months, given the immaturity of the visual system up to that time. Close cooperation between neurosurgeons, pediatricians and ophthalmologists is of paramount importance in order to prevent this bone deformation exerting an adverse effect on visual development. The ophthalmologist must possess a basic understanding of the various craniosynostoses.     

Expression of mRNA coding for TNFα, IL-1β and IL-6 by cells infiltrating retinal membranes

Background: Cellular mechanisms of inflammation are thought to be involved in the pathogenesis of proliferative vitreoretinopathy, and cytokines, which are products of cell activation, are known to play an important role in the development and maintainance of inflammatory reactions. It was the aim of this work to investigate the presence of cells expressing cytokine mRNA within retinal membranes. Methods The presence of mRNA coding for the cytokines interleukin 1 (IL-1), interleukin 6 (IL-6) and tumour necrosis factor (TNF) was investigated in 19 epiretinal membranes obtained from eyes undergoing vitrectomy for the treatment of retinal detachment complicated by proliferative vitreoretinopathy. Results Cells expressing mRNA for IL-1 were observed in 7 membranes, cells positive for IL-6 mRNA were seen in 12 membranes, and cells exhibiting mRNA for TNF were present in 9 specimens. Only three membranes contained cells expressing mRNA for all the cytokines investigated. Four membranes possessed positive cells for IL-6 and TNF, two contained cells expressing mRNA for IL-6 and IL-1, and two others exhibited cells expressing mRNA for TNF and IL-1. Five membranes contained IL-6 mRNA-positive cells only, whilst two exhibited cells expressing mRNA for IL-1, or TNF only. Conclusion The present findings indicate that cellular activation may occur during the development of PVR, and suggest that these cytokines may be locally produced by cells infiltrating epiretinal membranes. The presence of IL-1, IL-6 and TNF mRNA-positive cells within retinal membranes provides further evidence of a pathogenic role of these cytokines in proliferative vitreoretinopathy.     

How often do patients need visual field tests?

Background: This study was undertaken to determine whether the interval between visual field tests affects the ability to detect progres sive glaucomatous field loss. Methods: One hundred and nineteen retinal locations which were deteriorating significantly by 1 dB/year (untreated normal tension glaucoma patients: 6 eyes) were studied. Analysis was repeated using thinned visual field tests: one test per year instead of the complete three per year over a period of 4 years. Results: The thinned tests identified only 45.4% of the deteriorating points over the 4-year period. Furthermore, there was a mean delay of 1.10 years in detection (P<0.01). Conclusions: Less frequent visual field testing detects fewer progressing locations and detects them later.Presented in part at the Association for Research in Vision and Ophthalmology Annual Meeting, May 1995 and at the American Academy of Ophthalmology Meeting, October 1995.The authors have no proprietary interest in any of the materials used in this study.     

Evaluation of IBMX-enhanced ocular hypotension after adrenergic agonists in the rabbit eye

Background: 3-Isobutyl-1-methylxanthine (IBMX), a phosphodiesterase inhibitor, enhanced the reduction of intraocular pressure more after administration of norepinephrine and epinephrine than after isoproterenol. The question arises of whether or not the IBMX-induced enhancement of ocular hypotension is exclusively due to ₂-adrenoceptor/cAMP stimulation.Methods: In groups of eight rabbits the ocular hypotensive responses after selective adrenergic agonists were studied in the presence and absence of phosphodiesterase inhibition with IB-MX.Results: Pretreatment with IBMX I%, applied topically, did not enhance the ocular hypotensive responses after phenylephrine (₁), B-HT920 (₂) and dobutamine (₁). The ocular hypotensive responses induced by salbutamol (0.001–0.5%) and higher concentrations of terbutaline were significantly enhanced by IBMX. Combined treatments of terbutaline 0.01% and B-HT920 0.2%, dobutamine 3% and phenylephrine 2%, and dobutamine 3% and B-HT920 0.2% were not associated with enhanced ocular hypotensive responses in the presence of IBMX. The only combination that was associated with a significant enhancement of ocular hypotension when combined with 1% IBMX was phenylephrine 2% and terbutaline 0.01%. A subthreshold dose of phenylephrine 0.1 % further increased the enhanced ocular hypotensive responses induced by salbutamol 0.025, 0.2 and 0.5% in combination with IBMX.Conclusions: Phosphodiesterase inhibition with IBMX enhances the ocular hypotensive effect induced by catecholamines not only by ₂-adrenoceptor/CAMP stimulation, but also by simultaneous ₁-adrenoceptor stimulation.     

Surgical risk factors for severe postoperative proliferative vitreoretinopathy (PVR) in retinal detachment with grade B PVR

Background: Previous studies have shown that grade B proliferative vitreoretinopathy (PVR) is a considerable risk factor for the development of severe postoperative PVR. We conducted a prospective study to elucidate which surgical procedures used in retinal detachment management may stimulate the PVR process in such eyes. Materials and methods: The study included 156 eyes of 152 consecutive patients with rhegmatogenous retinal detachment complicated by grade B PVR referred before any failed surgery and operated on between 1983 and 1993. The parameters evaluated by multivariate statistical analysis included the cumulative circumferential extent of the retinal tears, the extent of the scleral buckle, gas injection, vitrectomy, the method used for retinopexy, and the time of surgical management during the period of the study. Results: The incidence of severe postoperative PVR was 25.8% in eyes managed with cryotreatment versus 2.2% in eyes managed with argon laser photocoagulation (P=0.001). The rate of severe postoperative PVR was not influenced by the other surgical variables. Conclusion: We conclude that cryotherapy may be a risk factor for the development of severe postoperative PVR in retinal detachments associated with grade B PVR.     

HLA antigens in a Japanese family with Behçet's disease

Background: Familial Behçet's disease is rare. Methods: HLA antigens in a Japanese family with Behçet's disease were examined. Results: The affected patients had HLA B51, and unaffected family members also had the same antigen. Conclusion: It is likely that not only HLA B51 but also other factors may be involved in the pathogenesis of Behçet's disease in Japanese patients.     

Unusual retinal pigment epitheliopathy and choroidopathy in carcinomatosis: A rare case of cancer-associated retinopathy

Background: Cancer-associated retinopathy is a syndrome causing ocular symptoms. It is a rare entity and only a few cases have been reported. Methods: A 67-year-old woman with small-cell endometrial carcinoma suffering from deterioration of visual acuity is presented. Results: The patient presented with extensive mottled changes of the retinal pigment epithelium, accompanied by diffuse subretinal fluid in the posterior pole and exudative retinal detachments inferior in both eyes. Conclusion: This patient suffered from a rare variety of cancer-associated retinopathy.     

The effect of nasolacrimal occlusion on drug-induced mydriasis

Background: Nasolacrimal occlusion has been shown to improve the efficacy of some topically applied ocular drugs. The aim of this study was to investigate the effect of nasolacrimal occlusion on tropicamide-induced mydriasis. Methods: We compared pupillary dilatation by 0.125% tropicamide with and without nasolacrimal occlusion in 40 healthy volunteers. Results: Analysis of variance with repeated measures failed to show any advantage due to nasolacrimal occlusion in drug-induced mydriasis. Conclusion: Nasolacrimal occlusion did not increase the mydriasis obtained with 0.125% tropicamide.     

The use of tissue plasminogen activator in post-traumatic total hyphaema

Background: We wanted to evaluate whether intracameral injection of tissue plasminogen activator (tPA) is useful in managing traumatic hyphaema. Methods: Two eyes with total hyphaema after a severe penetrating injury were treated with a single intracameral injection of 25 g of tPA 5 and 14 days after the injury, respectively. Results: Most of the blood coagulum dissolved within 24 h, and in one of the two eyes the intraocular pressure decreased from 45 to 8 mmHg. The other eye was hypotonic. No re-bleeding or complications related to the use of tPA were noticed. Conclusion: The results in these two cases suggest that tPA is a useful adjunct in managing total hyphaema.     

Morphological differentiation of the conjunctival goblet cells in the chick (Gallus domesticus)

Background: These is no consensus in the literature regarding the differentiation of conjunctival goblet cells in vertebrates. Method: The conjunctival epithelium of the chick was studied before and after hatching in order to demonstrate the morphological evolution of the goblet cells. The entire conjunctiva was processed for light microscopy either on semithin sections stained with toluidine blue-pironine or on traditional sections stained with Alcian blue pH 2.5-PAS. Results: It was possible to demonstrate that goblet cells underwent remarkable changes in their secretory activity. At 12 h after hatching, isolated Alcian blue-positive cells were present in the fornix. At 24 h after hatching, cells positive for both Alcian blue and PAS were scattered among epithelial cells. Two days after hatching, cells which reacted positively only to PAS were also present. Conclusion: It is suggested that the differentiation of conjunctival goblet cells occurs first in the fornix, probably due to the particular vascular environment of this region, and then spreads all over the conjunctiva.     

Communication between the subretinal space and the vitreous cavity in the morning glory syndrome

Background: The aim was to describe a pathogenic mechanism for a rhegmatogenous retinal detachment in a 69-year-old man with the morning glory syndrome. Methods: During vitreous surgery for a retinal detachment, a membrane was removed that covered the optic disc anomaly and produced traction on the peripapillary retina. A retinal hole was found in tissue lying within the optic cup, and the hole was sealed using a autologous plasma —thrombin mixture. Silicone oil was used for retinal tamponade. Results: A retinal hole in tissue lying within the optic cup provided a fluid pathway between the vitreous cavity and the subretinal space. Following vitrectomy surgery, bubbles of silicone oil passed through the retinal hole into the subretinal space of the macula. Conclusion: This case demonstrates that a retinal hole in tissue lying within the optic disc anomaly of the morning glory syndrome provides a communication for fluid between the subretinal space and the vitreous cavity, resulting in a rhegmatogenous retinal detachment. Vitreous replacement with silicone oil resulted in the migration of silicone bubbles into the subretinal space.     

Double contour of the lens capsule edges after continuous curvilinear capsulorhexis

Background: After curvilinear capsulorhexis in cataract surgery often a double-ring shape of the remaining capsular margins can be observed. In order to better understand this phenomenon we performed a histological study of excised capsules after continuous curvilinear capsulorhexis. Methods: Ten anterior capsular specimens from cases with double-ring structure of the capsular margins after continuous curvilinear capsulorhexis (D-group) were examined light microscopically and compared with 10 normal cases (N-group) and 10 cases with pseudoexfoliation (P-group). Three cases from each group were also examined electron microscopically. Results: A characteristic step formation in the capsular edges and in addition horizontal capsular splits in the border zone between the zonular lamella of the anterior capsule and the capsule proper could be demonstrated histologically in the D-group. Conclusions: There seems to be a weak point of the capsular tissue in the border zone between zonular lamella of the lens and the capsule proper. The superficial splits that we found histologically in this region might be a precursor or forme fruste of true exfoliation. The outward-directed traction force exerted by the zonular fibers seems to lead to further disruption in this weakened layer of the lens capsule during capsulorhexis, producing a double-ring contour of the capsular margins.     

Relaxing incisions with compression sutures for control of astigmatism after penetrating keratoplasty

Background: Ten percent of patients with persisting postoperative astigmatism following penetrating keratoplasty (PK) require surgical re-intervention, despite an otherwise successful transplant. Relaxing incisions (RIs) in combination with compression sutures seem to be the preferable procedure. However, poor predictability and lack of long-term experience complicate the issue. Here we report the 2-year follow-up results of 25 patients with high PK astigmatism treated by means of RIs and compression sutures Methods: Commonly, free-handed RIs were placed at the graft-host interface and 10–0 nylon compression sutures were placed perpendicular to the incisions. PK sutures had been removed no less than 4 months prior to refractive surgery Results: Nineteen eyes regained a functional vision of >- 0.4. The net decrease in astigmatism was 6.1 ± 4.3 D (47 ± 21 %). The mean vector-corrected change in astigmatism was 13.1 ± 5.7 D. Cylinder axis variation was reasonably low, with a correlation of attempted versus achieved axis of r=0.85. Within the first 3 months after operation the induced astigmatism regressed by, on average, 5.5 ± 4.3 D, making intraoperative overcorrection necessary. As an inevitable side effect, refractive procedures resulted in a myopic shift (4.7 ± 6.9 D) in spherical equivalence Conclusion: RIs and compression sutures are very useful in reducing postkeratoplasty astigmatism if correction of extremely high cylinder (> 10 D) is not intended. However, predictability still remains unsatisfactory and more than one operation may be required.     

Vitrectomy for traction macular detachment in diabetic retinopathy

Background: A small number of eyes with proliferative diabetic retinopathy develop massive central fibrovascular membranes characterized by vitreoretinal tractions along the arcades and optic disk and retinal traction lines extending through the macula. The aim of our study was first to present the results of vitrectomy for removal of these central membranes and second to determine the correlation between preoperative parameters and postoperative visual outcome. Subjects and methods: We treated 28 eyes with severe central fibrovascular diabetic membranes by a modified bimanual en bloc excision technique during vitrectomy. Preoperative examination included general status, visual acuity, slit-lamp investigation, binocular funduscopy, ultrasound investigation and visual evoked potentials (VEP). Further, we analyzed intraoperative complications and postoperative anatomic and functional outcomes. Results: The retinas of 27 eyes with central traction retinal detachments were reattached by surgery. With a minimum of 6 months' follow-up, the macula remained attached in 24 eyes, while the retinas were completely attached in 22 eyes. Preoperative visual acuity was defective light perception to 0.1; an increase in visual acuity to maximal 0.1 was seen in 50% of the patients postoperatively. Preoperative visual acuity of light perception was associated with no functional improvement. Preoperative ultrasound investigation gave information about the real anatomic situation of the retina, especially if funduscopy was not possible. The other preoperative parameters could not predict correctly the functional outcome of vitrectomy in diabetics with severe central fibrovascular membranes because of the damage of the optic nerve and the retina. Conclusions: The high rate of anatomical rettachment after vitrectomy in diabetic eyes with severe central fibrovascular membranes is associated with a slight improvement of function; only preoperative visual acuity of hand motions or better was associated with an improvement of function.     

The retinal depression sign in diabetic retinopathy

Background: The retinal depression sign, an abnormal light reflex due to ischemia-induced focal inner retinal atrophy, was initially described in patients with sickle cell retinopathy. We undertook this study to characterize the finding in diabetic retinopathy. Methods: The fundus photographs of 97 consecutive patients with diabetic retinopathy seen in the Penn State University Ophthalmology Department were reviewed. We recorded age, sex, type of retinopathy, visual acuity and photographic details, including the presence or absence of the retinal depression halo. Results: The retinal depression sign was present in 9 of 22 patients age 45 years or under, versus 1 of 75 patients age 46 or older (P<0.0001, two-tailed Fisher's exact test). The presence or absence of retinal depression sign did not predict the type of retinopathy in a given patient. Eleven (70%) of the affected eyes had visual acuity 20/40. Conclusion: The retinal depression sign is common in younger patients with diabetes and should be distinguished from other macular lesions associated with diabetic retinopathy.     

Adaptation to monocular torsion after macular translocation

Purpose: To document the functional outcome of two patients following successful macular translocation for the treatment of severe subretinal hemorrhage in age-related maculopathy. Methods: The retina was surgically rotated around the optic nerve with translocation of the fovea either upward or downward to an area of healthy retinal pigment epithelium. In the postoperative period, visual function was carefully studied with emphasis on adaptation to torsion. Results: Visual acuity in one patient improved from 2/200 to 20/80 and the other patient remained at 20/200. Both patients developed horizontal and vertical strabismus with torsion of up to 55°. After a prolonged period of occlusion of the unoperated eye, both patients were subjectively able to adapt to monocular torsion. However, adaptation under binocular conditions did not occur. Conclusion: Macular translocation was successful in improving visual acuity in one patient, with no improvement in the second. Both patients had significant ocular torsion and strabismus, but under monocular conditions they were successful in perceptually adapting to the change in the visual environment. Fear of cyclotorsion should not be a deterrent to considering macular translocation as a possible treatment option for severe subretinal macular hemorrhage if the patient is willing to accept monocular vision.