Horner's syndrome and sixth nerve paresis secondary to a petrous internal carotid artery aneurysm

We describe a report of a child with a horner's syndrome and sixth nerve paresis secondary to a petrous internal carotid artery (ICA) aneurysm. Management of this condition involved coiling of the aneurysm and the use of botulinum toxin to manage his strabismus and associated symptoms.     

Technical aspects of laser treatment for acute retinopathy of prematurity under topical anesthesia

Retinopathy of prematurity (ROP) is a significant cause of childhood blindness. The criteria for laser therapy have been revised from threshold ROP to include the earlier stage of high-risk prethreshold ROP. Laser photocoagulation is an established technique for the treatment of ROP. However, the detailed procedure and techniques for laser photocoagulation have not yet been published. Adequate and appropriate laser photocoagulation for ROP is different from the application of lasers in adult retinal vascular diseases, and many ophthalmologists need to be trained in this technique if the outreach of ROP treatment programs is to improve. Laser under topical anesthesia has been practiced in India as a preferred modality especially due to logistics and risks of general anesthesia in these pre-term babies. We discuss the details of the technique as practiced at tertiary care ophthalmic hospitals in India, so that the nuances in treatment parameters and clinical decision-making can be usefully applied to ophthalmic practice. This will ultimately lead to safe and effective treatment delivery in ROP.     

An evaluation of medical college departments of ophthalmology in India and change following provision of modern instrumentation and training

AIM: To evaluate teaching and practice in medical college ophthalmology departments in a representative Indian state and changes following provision of modern instrumentation and training. STUDY TYPE: Prospective qualitative study. MATERIALS AND METHODS: Teaching and practice in all medical colleges in the state assessed on two separate occasions by external evaluators. Preferred criteria for training and care were pre-specified. Methodology included site visits to document functioning and conduct interviews. Assessments included resident teaching, use of instrumentation provided specifically for training and standard of eye care. The first evaluation (1998) was followed by provision of modern instrumentation and training on two separate occasions, estimated at Rupees 34 crores. The follow-up evaluation in 2006 used the same methodology as the first. RESULTS: Eight departments were evaluated on the first occasion; there were 11 at the second. On the first assessment, none of the programs met the criteria for training or care. Following the provision of modern instrumentation and training, intraocular lens usage increased dramatically; but the overall situation remained essentially unchanged in the 8 departments evaluated 8 years later. Routine comprehensive eye examination was neither taught nor practiced. Individually supervised surgical training using beam splitters was not practiced in any program; neither was modern management of complications or its teaching. Phacoemulsification was not taught, and residents were not confident of setting up practice. Instruments provided specifically for training were not used for that purpose. Students reported that theoretical teaching was good. CONCLUSIONS: Drastic changes in training, patient care and accountability are needed in most medical college ophthalmology departments.     

Facial implants

By offering safe, long-term correction of volume depletion and contour defects, facial implants maintain a unique position in the armamentarium of the cosmetic surgeon. Careful patient assessment and selection of the appropriate implant type, size, and shape maximize results. Proper postoperative follow-up helps to treat any complications before they become a serious problem. Most patients have volume loss as part of their facial aging. Facial implants play an important role in panfacial rejuvenation.     

Potential clinical impact of cardiovascular magnetic resonance assessment of ejection fraction on eligibility for cardioverter defibrillator implantation

Background

For the primary prevention of sudden cardiac death, guidelines provide left ventricular ejection fraction (EF) criteria for implantable cardioverter defibrillator (ICD) placement without specifying the technique by which it should be measured. We sought to investigate the potential impact of performing cardiovascular magnetic resonance (CMR) for EF on ICD eligibility.

Methods

The study population consisted of patients being considered for ICD implantation who were referred for EF assessment by CMR. Patients who underwent CMR within 30 days of echocardiography were included. Echocardiographic EF was determined by Simpson’s biplane method and CMR EF was measured by Simpson’s summation of discs method.

Results

Fifty-two patients (age 62±15 years, 81% male) had a mean EF of 38 ± 14% by echocardiography and 35 ± 14% by CMR. CMR had greater reproducibility than echocardiography for both intra-observer (ICC, 0.98 vs 0.94) and inter-observer comparisons (ICC 0.99 vs 0.93). The limits of agreement comparing CMR and echocardiographic EF were – 16 to +10 percentage points. CMR resulted in 11 of 52 (21%) and 5 of 52 (10%) of patients being reclassified regarding ICD eligibility at the EF thresholds of 35 and 30% respectively. Among patients with an echocardiographic EF of between 25 and 40%, 9 of 22 (41%) were reclassified by CMR at either the 35 or 30% threshold. Echocardiography identified only 1 of the 6 patients with left ventricular thrombus noted incidentally on CMR.

Conclusions

CMR resulted in 21% of patients being reclassified regarding ICD eligibility when strict EF criteria were used. In addition, CMR detected unexpected left ventricular thrombus in almost 10% of patients. Our findings suggest that the use of CMR for EF assessment may have a substantial impact on management in patients being considered for ICD implantation.     

Results of intraocular lens implantation with capsular tension ring in subluxated crystalline or cataractous lenses in children

Purpose:

To evaluate the outcome of intraocular lens (IOL) implantation using capsular tension ring (CTR) in subluxated crystalline or cataractous lenses in children.

Setting:

Tertiary care setting

Materials and Methods:

We prospectively studied 18 eyes of 15 children with subluxation of crystalline or cataractous lenses between 90° up to 210° after phacoemulsification, CTR and IOL implantation. Each child was examined for IOL centration, zonular dehiscence and posterior capsular opacification (PCO).

Results:

Age of the patient ranged between five to 15 years. Out of 18 eyes, seven had traumatic and 11 had spontaneous subluxation of crystalline or cataractous lens. Phacoemulsification was successfully performed with CTR implantation in the capsular bag. Intraoperative zonular dialysis occurred in two eyes. Anterior vitrectomy was performed in six eyes to manage vitreous prolapse. IOL implanted was polymethyl methacrylate (PMMA) in eight eyes, hydrophobic acrylic in seven and hydrophilic acrylic in three. Follow-up ranged from 24 months to 72 months. Sixteen eyes had a best corrected visual acuity of 20/40 or better. Nine eyes developed significant PCO and were managed with Neodymium Yttrium Aluminum Garnet (Nd:YAG) laser posterior capsulotomy. One eye with acrylic IOL in the capsular bag had IOL dislocation after two years which was managed with vitrectomy and secondary trans-scleral fixation of IOL.

Conclusions:

Phacoaspiration with CTR implantation makes capsular bag IOL fixation possible in most of the eyes with subluxated crystalline or cataractous lenses. PCO still remains a challenge in children with successful phacoaspiration with CTR implantation