Micropulse transscleral diode laser cyclophotocoagulation in the treatment of refractory glaucoma

Background: Transscleral diode laser cyclophotocoagulation (TSCPC) is an established method of treatment for refractory glaucoma, but is associated with significant complications. This study evaluates the efficacy and safety of a new form of TSCPC using micropulse diode laser and trans‐pars plana treatment with a novel contact probe. Methods: Prospective interventional case series of 40 eyes of 38 consecutive patients with refractory glaucoma treated with micropulse TSCPC with a novel probe. Outcomes measured were success, hypotony and response rates. Results: The mean age of patients was 63.2 ± 16.0 years. The mean follow‐up period was 16.3 ± 4.5 months. The mean intraocular pressure (IOP) before micropulse TSCPC was 39.3 ± 12.6 mmHg. Mean IOP decreased to 31.1 ± 13.4 mmHg at 1 day, 28.0 ± 12.0 mmHg at 1 week, 27.4 ± 12.7 mmHg at 1 month, 27.1 ± 13.6 mmHg at 3 months, 25.8 ± 14.5 mmHg at 6 months, 26.6 ± 14.7 mmHg at 12 months and 26.2 ± 14.3 mmHg at 18 months (P < 0.001 at all time points). No patient had hypotony or loss of best‐corrected visual acuity. The overall success rate after a mean of 1.3 treatment sessions was 72.7%. Conclusion: Micropulse TSCPC is a safe and effective method of lowering IOP in cases of refractory glaucoma and is comparable with conventional TSCPC.     

Orbital colour Doppler imaging in chronic ocular ischaemic syndrome

Background: The clinical syndrome of chronic ocular ischaemia may be difficult to diagnose due to its wide range of non-specific presentations, and its diagnosis often implies the presence of underlying severe carotid occlusive disease. Colour Doppler imaging (CDI), a recent advance in ultrasonography that allows for colour-encoded blood flow data of a vascular structure to be displayed simultaneously on a conventional real-time gray-scale B mode image, has been used in the assessment of ocular and orbital vasculature. Method: Four patients with chronic ocular ischaemic syndrome whose diagnoses were aided by CDI are presented. Results: Orbital CDI was successful in confirming the diagnosis in all four cases. Reversal of blood flow in the ophthalmic arteries was demonstrated. Central retinal vessels were not detected with CDI in all four patients with complete occlusion of the ipsilateral internal carotid artery. One of the four patients had intermittent reversal of ophthalmic arterial flow ipsilateral to the 60% stenosed internal carotid artery. Conclusion: This non-invasive technique is an excellent alternative to invasive vascular studies such as angiography for the diagnosis and evaluation of the chronic ocular ischaemic syndrome.     

Reconstruction of Syndactyly and Polysyndactyly of the Toes With a Dorsal Pentagonal Island Flap: A Technique That Allows Primary Skin Closure Without the Use of Skin Grafting

Syndactyly and polysyndactyly are common congenital conditions involving the foot, and surgery to reconstruct the toes may be indicated for cosmetic, psychological, and practical reasons. A dorsal flap is traditionally used for web space reconstruction, with skin grafts for the bases of the toes. Skin grafting has associated morbidity and can result in pigmentation mismatch. Single-stage direct closure with a specially designed flap has advantages including a reduction of morbidity from avoidance of skin grafting and shorter surgery. Four patients (6 feet) were included in the study. There were 2 cases of syndactyly and 2 cases of polysyndactyly. Bilateral involvement occurred in 2 patients. The average age was 18 months at time of first surgery. Direct closure was achieved with a dorsal pentagonal island flap with dorsal and plantar triangular flaps. The average duration of follow-up was 19.8 months. At final follow-up, all patients had acceptable web depth and pulp contour. The distance between the proximal interphalangeal joints of adjacent toes and the web slope of the reconstructed web space were acceptable. Complications included partial synechiae, cellulitis, and keloid formation. The dorsal pentagonal island flap is an acceptable technique in providing another means for single-stage reconstruction of the web space in syndactyly and polysyndactyly. Good functional and cosmetic outcomes can be expected. However, the potential complication of keloid formation can affect cosmesis and overall outcome, and must be understood by patients and parents.     

Esophageal strictures following endoscopic variceal sclerotherapy

We have evaluated 169 patients with portal hypertension receiving endoscopic variceal sclerotherapy in order to assess the predisposing factors, clinical profile, and treatment response of sclerotherapy-induced esophageal strictures. Of the 129 patients included in the final analysis, 20 (15.5%) developed persistent esophageal stricture. No significant difference was found with respect to age, nature of sclerosant (absolute alcohol, ethanolamine oleate, or sodium tetradecyl sulfate), etiology of portal hypertension, Child's class, initial variceal score, or intensity of sclerotherapy schedule between the patients who developed strictures and those who did not. However, female sex (P less than 0.01) and persistent esophageal ulceration (P less than 0.05) did predispose to stricture formation. Sclerotherapy-induced strictures presented with a variable grade of dysphagia, were always solitary, and were localized to the lower end of esophagus. Most of these could be dilated rapidly using Eder-Puestow metal olives (3.15 +/- 0.80 dilatation sessions per patient). Stricture formation did interrupt an effective sclerotherapy program but only temporarily, and successful variceal obliteration could be obtained after stricture dilatation.