Endoscopic endonasal management of prolapsed silicone tubes after dacryocystorhinostomy

BACKGROUND: Loss or prolapse of silicone tubes at the medial canthus may occur after dacryocystorhinostomy (DCR) surgery. Repositioning of the prolapsed tubes is often difficult and can necessitate early removal of tubes. The goal of this study was to determine the incidence of tube prolapse after DCR, review the methods used to reposition them, and identify the optimum management. DESIGN: Retrospective, noncomparative, interventional case series. PARTICIPANTS: A total of 205 adults patients who had DCR with intubation by a specialist lacrimal service in West London over a 3-year period. METHODS: Patients with spontaneous tube loss or prolapse were identified from clinic attendance and case note review. MAIN OUTCOME MEASURES: Incidence and timing of prolapse, techniques used for repositioning and success, whether prolapse recurred, and further intervention necessary. RESULTS: Five (2.5%) had tube loss or prolapse or both, all within the first month after surgery. The tubes were repositioned initially in four patients, but prolapse recurred in two patients necessitating further intervention. Only nasal endoscopy enabled precise tube visualization and endonasal manipulation with eventual tube stability. CONCLUSIONS: Tube prolapse is rare after DCR surgery. The tubes can be pushed back in, but prolapse may recur unless the endonasal aspect is addressed. The position of the tie or knots should be inspected endonasally and the tubes further secured if indicated. Repositioning is best managed with endoscopic assistance, which is a simple office procedure.     

Natural history of trachomatous scarring in the Gambia: Results of a 12-year longitudinal follow-up

PURPOSE: The sight-threatening complications of trachoma are trichiasis and corneal opacity, and these remain the world's most common cause of preventable blindness. The aim of the study was to investigate the rate of progression of trachomatous conjunctival scarring to trichiasis and corneal opacity and to investigate risk factors for such progression. DESIGN: A 12-year, longitudinal study of the incidence and risk factors for the development of trichiasis and corneal opacity in a cohort of patients initially identified with trachomatous scarring in The Gambia. PARTICIPANTS: Six hundred thirty-nine subjects with some degree of trachomatous scarring were identified from the 1986 survey, and attempts were made to trace all these subjects. METHODS: Successfully traced subjects were interviewed, examined, and graded for trachoma. MAIN OUTCOME MEASURES: (1) Twelve-year rates of progression. (2) Risk factors for progression of disease. RESULTS: Three hundred twenty-six of six hundred thirty-nine (51%) subjects were traced and examined, 108 (17%) had died, and 205 (32%) were lost to follow-up. After 12 years, 6.4% (95% confidence interval [CI], 4.0-9.97) of scarred subjects had trichiasis develop, 5.96% (95% CI, 3.67-9.42) had corneal opacity develop, 16.51% (95% CI, 12.71-21.13) had visual impairment/blindness develop, and 2.5% (95% CI, 1.2-5.0) had corneal visual impairment/blindness develop. Mandinka ethnicity was a risk factor for trichiasis (odds ratio [OR], 4.3; 95% CI, 1.3-14.4), and trichiasis at baseline was a risk factor for corneal opacity (OR, 8.4; 95% CI, 1.8-39.2). History of lid surgery for trichiasis was associated with corneal opacity at follow-up (OR, 4.4; 95%CI, 1.4-14.0). Older age was a significant risk factor for development of trichiasis, corneal opacity, and visual loss (OR, 1.07; 95% CI, 1.01-1.12). Bilateral cataract was present in 40% of traced subjects and was associated with the incidence of visual impairment/blindness (OR, 9.4; 95%CI, 4.5-19.6) CONCLUSIONS: This is the first study to demonstrate the link between trichiasis and future corneal opacity, and it provides the rationale for performing lid rotation surgery on patients with trichiasis who do not yet have corneal opacity. The association between corneal opacity at follow-up and previous surgery among trichiasis patients suggests late presentation as a problem. The planning of surgical services will be aided by the incidence figures generated by this study.     

Lower eyelid medial canthal tendon laxity grading: an interobserver study of normal subjects

OBJECTIVE: To describe a simple grading system for medial canthal tendon (MCT) laxity and measure its reproducibility. STUDY DESIGN: Observational case series and interobserver variability study. PARTICIPANTS: Fifty subjects (100 lower eyelids) without eyelid disease. The age range was 19 to 98 years. METHODS: Subjects without eyelid pathology or previous surgery were selected. Two ophthalmologists assessed the position of the inferior punctum in relation to the cornea with the patient in primary gaze. Two measurements were made, the first with the lower eyelid at rest and then with the lateral distraction test. Both observers were masked to the other observer's measurements. MAIN OUTCOME MEASURES: Kappa statistics to show the strength of agreement between the two observers for the resting and lateral distraction eyelid positions. RESULTS: High kappa values were found for resting position (agreement in 92 of 100 eyelids) and for lateral distraction testing (agreement in 85 of 100 eyelids). The range of resting positions was from position -1 to position 1. The range of laterally distracted positions was from position 0 to position 5. Overall, a very high level of agreement was achieved between observers. CONCLUSIONS: This grading system for MCT laxity is simple, easy to learn and reproducible, easier than measuring in millimeters, and has an advantage over merely saying the tendon is "lax" or "not lax." We propose this standardized grading system in the evaluation of patients with entropion and ectropion to identify those patients who may benefit from MCT stabilization/plication.     

Cyclodiode photocoagulation for refractory glaucoma after penetrating keratoplasty.

OBJECTIVE: This study analyzes the results of intraocular pressure (IOP) reduction by contact diode cycloablation (cyclodiode) in cases of refractory glaucoma after penetrating keratoplasty. DESIGN: Retrospective noncomparative, interventional case series. PARTICIPANTS: Twenty-eight eyes in 28 patients attending the Moorfields Eye Hospital. INTERVENTION: Cyclodiode (40 applications x 1.5 W x 1.5 seconds over 270-300 degrees ) was used to control the IOP in refractory glaucoma after penetrating keratoplasty. MAIN OUTCOME MEASURES: Postoperative IOP, graft status, visual acuity, and number of antiglaucoma medications were recorded after cyclodiode treatment. RESULTS: Cyclodiode resulted in a reduction of IOP from a median of 33 mmHg (interquartile range [28, 40.5]) to a median of 15 mmHg (interquartile range [12, 20.5]). Most patients had a significant lowering in IOP with a median reduction of 16 mmHg (interquartile range [12, 25]; P < 0.0001). IOPs of 6 to 21 mmHg were achieved in 22 patients (79%). Sixteen patients (57%) required more than one treatment with cyclodiode to control the IOP, with three patients (11%) requiring three treatments and two patients (7%) requiring four treatments. Visual acuity improved (> two Snellen lines of acuity) in three patients (11%) and remained the same (+/- one Snellen line) in 17 patients (61%). The mean number of antiglaucoma medications before cycloablation was 2.6 and was 1.8 after treatment (P < 0.001). Of the 19 patients (68%) with originally clear grafts, three grafts (16%) developed opacification. One patient (4%), with a history of nanophthalmos and recurrent uveal effusion, had delayed hypotony (IOP < 6 mmHg) occurring 46 months after the diode treatment. All patients had at least 6 months follow-up. CONCLUSIONS: These patients have often undergone multiple previous complicated ocular interventions and are often not suitable for filtration surgery. Reduction of IOP with maintenance of visual acuity and a good safety profile was achieved in most patients in this study but may require multiple treatments. We propose cyclodiode as an effective treatment for many patients in the management of refractory glaucoma after penetrating keratoplasty.     

Superior rectus-levator synkinesis: a previously unrecognized cause of failure of ptosis surgery

PURPOSE: To describe a previously unreported type of ptosis associated with abnormal synkinesis between the superior rectus muscle and the levator palpebrae superioris. DESIGN: Retrospective noncomparative case series. PARTICIPANTS: Seven cases with congenital or longstanding unilateral ptosis presenting to a regional, tertiary referral, oculoplastic service. Six of these cases were seen within a period of 2 years. METHODS: Detailed observations of eyelid, ocular, and pupil movements of both eyes were performed before the planning of ptosis surgery anterior levator resection. MAIN OUTCOME MEASURES: Magnitude of ptosis and its variation with the position of gaze. RESULTS: Ptosis present in the primary position disappeared or markedly reduced with upgaze so that measurements of levator function were apparently normal. Close examination of the relative movement of the eyelids revealed evidence of superior rectus to levator synkinesis occurring during upgaze. In three cases the synkinesis was recognized only after failed ptosis surgery. Once recognized, two of these cases underwent further surgery with an excellent result. Three other patients all had successful surgery. CONCLUSIONS: Superior rectus to levator synkinesis may be easily overlooked if eyelid elevation in upgaze is ascribed to normal levator function rather than a synkinetic movement. We draw attention to the importance of identifying this relatively common condition to plan appropriate ptosis surgery. The lack of levator muscle tone in the primary position of gaze means that an augmented resection of the levator muscle should be performed.     

Identifying early glaucomatous changes. Comparison between expert clinical assessment of optic disc photographs and confocal scanning ophthalmoscopy

OBJECTIVE: To compare the ability of expert clinicians, using qualitative assessment of stereoscopic optic disc photographs, and confocal scanning laser ophthalmoscope imaging to discriminate between healthy persons and patients with early glaucoma. DESIGN: Comparative instrument validation study. PARTICIPANTS: Seventy-two healthy persons and 51 patients with early glaucoma (average visual field mean deviation, -3.6 dB). Early glaucoma was defined as a history of ocular hypertension and a reproducible visual field defect scoring 5 or less in the Advanced Glaucoma Intervention Study classification, regardless of optic disc appearance. INTERVENTION: Stereoscopic optic nerve head (ONH) photography and Heidelberg Retina Tomograph (HRT) imaging, (Heidelberg Engineering GmbH, Dossenheim, Germany). MAIN OUTCOME MEASURES: Ability of clinical assessment of stereoscopic ONH photographs and analysis of HRT parameters, taking into account the optic disc size, to detect early glaucomatous optic disc changes. RESULTS: The specificity of the majority opinion of five observers to detect early glaucomatous optic disc changes was 94.4%, with a sensitivity of 70.6%. Using the HRT analysis, the specificity was 95.8% and the sensitivity was 84. 3%. CONCLUSIONS: Heidelberg Retina Tomograph image analysis that takes into account the optic disc size is more sensitive than clinical assessment of stereoscopic optic disc photographs in distinguishing between healthy persons and patients with early glaucoma.     

Efficacy of supplementary intracameral lidocaine in routine phacoemulsification under topical anesthesia

OBJECTIVE: To determine whether the routine use of supplementary intracameral lidocaine has any benefit over topical anesthesia alone when performing phacoemulsification surgery. DESIGN: A prospective single-center, randomized, double-masked, clinical trial. PARTICIPANTS: A total of 204 patients undergoing phacoemulsification surgery with lens implantation under planned topical anesthesia. METHODS: Patients were randomly allocated to receive either topical anesthesia plus 0.5 ml intracameral balanced salt solution or topical anesthesia plus 0.5 ml preservative-free 1% intracameral lidocaine. MAIN OUTCOME MEASURES: On the day after surgery, patients were asked to document the discomfort they had experienced using a visual analog scale. Intraoperative discomfort, postoperative discomfort, and discomfort caused by the microscope light were assessed. RESULTS: Multiple linear regression analysis did not show any significant relationship between the use of intracameral lidocaine and either intraoperative (P = 0.34) or postoperative (P = 0.45) pain scores. There was a small reduction in the discomfort caused by the operating microscope when intracameral lidocaine was used (P = 0.04). CONCLUSIONS: In this study, the routine use of intracameral lidocaine as a supplement to topical anesthesia was shown not to have a clinically useful role.     

Effective small-incision surgery for involutional lower eyelid entropion

OBJECTIVE: The aim of this study was to develop an effective and minimally invasive operation to correct lower eyelid entropion that would address both the horizontal and vertical laxity. DESIGN: A prospective, noncomparative, interventional case series. PARTICIPANTS: Thirty-five consecutive patients with involutional entropion, aged 62 to 92 years (mean, 77.1 years), had surgery on 45 lower eyelids. Of the 45 procedures, 33 (73%) had a primary procedure and 12 (27%) were reoperations. INTERVENTION: A lateral tarsal strip with diagonal tightening of the orbital septum and lower lid retractors to the lateral orbital rim was performed via a 1-cm lateral canthal incision. MAIN OUTCOME MEASURES: Complications and surgical outcome were monitored clinically for between 12 and 24 months after surgery. RESULTS: The results were analyzed from 42 eyelids (33 patients) with a mean follow-up of 17.1 months (range 12-24 months). Two patients died and one dropped out of the study 3 months after the second eyelid operation. In 36 cases (86%), the entropion was cured. Transient lateral orbital rim tenderness was noted in six cases (14%), and one patient had a wound infection. Anatomic recurrences were detected in six eyelids of six patients, and five of these (83%) were asymptomatic. CONCLUSIONS: This surgical approach has been found effective in 86% of eyelids. Adequate clinical followup has proven essential for accurate evaluation of entropion surgery.     

Mapping the visual field to the optic disc in normal tension glaucoma eyes

PURPOSE: To establish the anatomical relationship between visual field test points in the Humphrey 24-2 test pattern and regions of the optic nerve head (ONH) DESIGN: Cross-sectional study. PARTICIPANTS: Glaucoma patients and suspects from the Normal Tension Glaucoma Clinic at Moorfields Eye Hospital. METHODS: Sixty-nine retinal nerve fiber layer (RNFL) photographs with well-defined RNFL defects and/or prominent bundles were digitized. An appropriately scaled Humphrey 24-2 visual field grid and an ONH reference circle, divided into 30 degrees sectors, were generated digitally. These were superimposed onto the RNFL images. The relationship of visual field test points to the circumference of the ONH was estimated by noting the proximity of test points to RNFL defects and/or prominent bundles. The position of the ONH in relation to the fovea was also noted. MAIN OUTCOME MEASURES: The sector at the ONH corresponding to each visual field test point, the position of the ONH in relation to the fovea, and the effect of the latter on the former. RESULTS: A median 22 (range, 4-58), of a possible 69, ONH positions were assigned to each visual field test point. The standard deviation of estimations was 7.2 degrees. The position of the ONH was 15.5 degrees (standard deviation 0.9 degrees ) nasal and 1.9 degrees (standard deviation 1.0 degrees ) above the fovea. The location of the ONH had a significant effect on the corresponding position at the ONH for 28 of 52 visual field test points. CONCLUSIONS: A clinically useful map that relates visual field test points to regions of the ONH has been produced. The map will aid clinical evaluation of glaucoma patients and suspects, as well as form the basis for investigations of the relationship between retinal light sensitivity and ONH structure.     

Retrograde intubation dacryocystorhinostomy for proximal and midcanalicular obstruction

Objective

Retrograde intubation of canaliculi during dacryocystorhinostomy can restore canalicular patency in cases otherwise managed with bypass tubes. The surgical technique and success for this procedure are discussed.

Accuracy of clinical estimates of intraocular pressure in Chinese eyes

PURPOSE: To investigate the validity of clinical estimates of intraocular pressure (IOP) in Chinese people. DESIGN: Prospective, cross-sectional, hospital-based in vivo study. PARTICIPANTS: Twenty-three ethnic Chinese adults (aged 35-82 years) undergoing routine phacoemulsification surgery were examined. TESTING: "True" IOP was measured with a solid-state hemodynamic monitor through a cannula in the anterior chamber. IOP was set successively to 10, 20, and 30 mmHg in each subject, using a reservoir of balanced salt solution. Intraocular pressure was simultaneously estimated by use of a hand-held applanation tonometer (Perkin's) and a Tono-Pen. The association between ocular biometric variables and measurement error was examined. MAIN OUTCOME MEASURES: The median of three readings at each IOP level was taken as the IOP estimate of each instrument. Measurement error was calculated as the mean difference (tonometer minus direct measurement). RESULTS: The error for the hand-held applanation tonometer was -1.6, -4.3 and -5.7 at 10, 20, and 30 mmHg, respectively. For the Tono-Pen the measurement error was +0.4, -2.0, and -4.1 at 10, 20, and 30 mmHg, respectively. We could identify no association between measurement error and corneal thickness or curvature, anterior chamber depth, or axial length. CONCLUSIONS: The applanation tonometer and Tono-Pen underestimate the true IOP in Chinese eyes. Error increases as true IOP increases. These tonometers do not give an accurate estimate of IOP in East Asians.     

Iatrogenic limbal stem cell deficiency following drainage surgery for glaucoma

Objective

To describe conjunctival epithelial overgrowth of the cornea after surgery for glaucoma.

Plasma antioxidant vitamins and carotenoids and age-related cataract.

OBJECTIVE: To investigate the relationships between plasma concentrations of antioxidant vitamins and carotenoids and nuclear, cortical, and posterior subcapsular cataracts in a group of elderly men and women. DESIGN: Cross-sectional survey. PARTICIPANTS: Three hundred seventy-two men and women, aged 66 to 75 years, born and still living in Sheffield, England. METHODS: The Lens Opacities Classification System (LOCS) III was used to grade nuclear, cortical, and posterior subcapsular lens opacities. Fasting blood samples were taken to assess plasma concentrations of vitamin C, vitamin E, alpha-carotene, beta-carotene, lycopene, lutein, zeaxanthin, and beta-cryptoxanthin. MAIN OUTCOME MEASURES: Logistic regression analyses of the associations between plasma vitamin concentrations and cataract subtype, adjusting for age, gender, and other risk factors. RESULTS: After adjustment for age, gender, and other risk factors, risk of nuclear cataract was lowest in people with the highest plasma concentrations of alpha-carotene (odds ratio [OR], 0.5; 95% confidence interval [CI], 0.3-0.9, P for trend 0.006) or beta-carotene (OR, 0.7; 95% CI, 0.4-1.4, P for trend 0.033). Risk of cortical cataract was lowest in people with the highest plasma concentrations of lycopene (OR, 0.4; 95% CI, 0.2-0.8, P for trend 0.003), and risk of posterior subcapsular cataract was lowest in those with higher concentrations of lutein (OR, 0.5; 95% CI, 0.2-1.0, P for trend 0.012). High plasma concentrations of vitamin C, vitamin E, or the carotenoids zeaxanthin and beta-cryptoxanthin were not associated with decreased risk. CONCLUSIONS: These findings suggest that a diet rich in carotenoids may protect against cataract development, but because they are based on observational data, they need to be confirmed in randomized controlled trials.     

Peripheral nasal field defects in glaucoma

One hundred fifty-one eyes of 101 consecutive patients with chronic open-angle and low tension glaucoma showed typical visual field changes. Sixty of the eyes had a nasal step, either alone or in combination with other defects. In 17 of these eyes, it was possible to demonstrate an isolated scotoma in the nasal periphery. It was concluded that the peripheral nasal step is a nerve fiber bundle defect that in its earliest phase produces a scotoma. In this sense, it behaves similar to the more central defects, rather than simply as a depression of isopters nasally.     

Treatment of herpes zoster ophthalmicus: a systematic review and Canadian cost-comparison

Objective

A systematic review and cost comparison were conducted to determine the optimal treatment of active herpes zoster ophthalmicus (HZO) in immunocompetent adults.