Effect of centration and circularity of manual capsulorrhexis on cataract surgery refractive outcomes.

PURPOSE: To determine if postoperative refractive outcome in cataract surgery relates to centration or circularity of the capsulorrhexis. DESIGN: Prospective, observational study. PARTICIPANTS: One hundred thirteen eyes from 108 patients undergoing routine phacoemulsification cataract surgery with manual continuous curvilinear capsulorrhexis. METHODS: Patients underwent refraction, and digital retroillumination photographs were obtained 1 month and 1 year after surgery. Capsulorrhexis parameters were analyzed using computer photographic software. MAIN OUTCOME MEASURES: Postoperative spherical equivalent (SE), deviation from predicted refraction, and postoperative spectacle cylinder. RESULTS: At 1 month, mean capsulorrhexis circularity index was 0.83 ± 0.01 mm and mean decentration was 0.30 ± 0.14 mm. There was no significant correlation between either circularity or decentration and any of the refractive outcomes of SE, deviation from predicted refraction, or spectacle cylinder at 1 month or at 1 year. In contrast, an association between capsulorrhexis decentration and change in postoperative SE from 1 month to 1 year was observed: 56% of patients with more than 0.4 mm of decentration had a change in SE of more than 0.25 diopter (D) compared with 30% with 0.4 mm or less of decentration (P = 0.04). In eyes with incomplete capsulorrhexis-optic overlap, 60% had a change in spectacle cylinder of more than 0.50 D from 1 month to 1 year, compared with 15% of eyes with complete overlap (P = 0.004). CONCLUSIONS: Postoperative refraction at 1 year was not related to centration or circularity of the capsulorrhexis. However, decentration by more than 0.4 mm was associated with a 0.25-D change in SE and incomplete capsulorrhexis-optic overlap was associated with a 0.50-D change in spectacle cylinder from 1 month to 1 year.

Acute dysthyroid optic neuropathy exacerbated by orbital radiotherapy.

A 76-year-old lady presenting with acute dysthyroid optic neuropathy (DON) was stabilised with systemic intravenous methylprednisolone (IVMP). Two separate attempts at a treatment course of orbital radiotherapy (OR) were commenced and subsequently abandoned as there was an acute worsening of her DON during OR, despite cover with oral glucocorticoids and subsequently IVMP. The patient underwent urgent orbital decompression which normalised her vision and optic neuropathy. Our case likely represents worsening of DON due to soft tissue swelling secondary to OR despite cover with IVMP in a patient previously responsive to IVMP alone. Some authors advocate the use of OR in active DON as either a surgery delaying or surgery sparing alternative. This case report illustrates the rare risk of transiently worsening DON with OR. We highlight the need for close monitoring of optic nerve function if OR is utilised in this patient group.

Canthoplasty repair for canthal rounding.

BACKGROUND: Canthal rounding can occur following trauma or surgery to the medial or lateral canthus, causing possible aesthetic or functional deficits to patients. Several surgical techniques to repair canthal rounding have been described previously. We report a new technique for canthoplasty repair of canthal rounding with the use of illustrative cases. METHODS: This is a retrospective case series describing the technique using illustrative cases from across three sites (London [UK], Adelaide [Australia], Sydney [Australia]). Twelve patients with post-surgical canthal rounding were included. Information collected for our illustrative cases include patient demographics, diagnosis, complications, outcomes and further treatment. RESULTS: There were no peri- or post-operative complications. All except one patient reported good surgical outcomes after one procedure. In one patient there was rounding recurrence. CONCLUSIONS: Our patients reported excellent outcomes post-operatively without any significant scarring.

Comparison of silastic and banked fascia lata in pediatric frontalis suspension.

PURPOSE: To compare the use of Silastic and banked fascia lata in pediatric frontalis suspension surgery for functional success, ptosis recurrence, and infection and granuloma rates. METHODS: This retrospective study analyzed the medical records of 72 patients who underwent 131 frontalis suspension operations using either Silastic or banked fascia lata during the past 12 years at Children's Hospital at Westmead, Sydney, Australia. RESULTS: Functional success rates for primary frontalis suspension procedures were not significantly different for banked fascia lata and Silastic (60% versus 67.2%, respectively; P = .4666). Infection and granuloma rates also were not significantly different (7.1% for banked fascia lata versus 15.2% for Silastic; P = .1381). There was, however, a statistically significant difference between the two materials in ptosis recurrence (35.3% for banked fascia lata versus 13% for Silastic; P = .0062). CONCLUSIONS: Silastic was significantly better than banked fascia lata in terms of ptosis recurrence. Both materials were comparable in terms of functional success after one procedure and in infection and granuloma rates. Given the conflicting evidence presented in the literature, large prospective studies are needed to compare the use of the most common synthetic materials with banked fascia lata in pediatric frontalis suspension.

Use of Alleviating Maneuvers for Periocular Facial Dystonias.

IMPORTANCE: Patients with benign essential blepharospasm or hemifacial spasm are known to use botulinum toxin injections and alleviating maneuvers to help control their symptoms. The clinical correlates between the use of botulinum toxin injections and the use of alleviating maneuvers are not well established. OBJECTIVE: To determine whether the use of alleviating maneuvers for benign essential blepharospasm or hemifacial spasm correlates with disease severity or botulinum toxin treatment. DESIGN, SETTING, AND PARTICIPANTS: A prospective cross-sectional observational study (designed in September 2013) of 74 patients with benign essential blepharospasm and 56 patients with hemifacial spasm who were consecutively recruited from adnexal clinics at Moorfields Eye Hospital (January-June 2014) to complete a questionnaire and undergo a clinical review. Data analysis was performed in December 2015. MAIN OUTCOMES AND MEASURES: Prevalence and type of alleviating maneuvers used for blepharospasm and hemifacial spasm, dystonia severity, and dose and frequency of botulinum toxin injections. RESULTS: Of the 74 patients with blepharospasm, 39 (52.7%) used alleviating maneuvers (mean [SD] age, 70.4 [9.1] years); of the 56 patients with hemifacial spasm, 25 (44.6%) used alleviating maneuvers (mean [SD] age, 66.5 [12.7] years). The most commonly used maneuver was the touching of facial areas (35 of 64 patients [54.7%]); other maneuvers included covering the eyes (6 of 64 patients [9.4%]), singing (5 of 64 patients [7.8%]), and yawning (5 of 64 patients [7.8%]). Patients with blepharospasm who used alleviating maneuvers scored higher on the Jankovic Rating Scale (median score, 5 vs 4; Hodges-Lehmann median difference, 1 [95% CI, 0-2]; P = .01) and the Blepharospasm Disability Index severity score (median score, 11 vs 4; Hodges-Lehmann median difference, 4 [95% CI, 1-7]; P = .01) than patients with blepharospasm who did not use alleviating maneuvers. Patients with hemifacial spasm who used alleviating maneuvers scored higher on the 7-item Hemifacial Spasm Quality of Life scale (median score, 7 vs 3; Hodges-Lehmann median difference, 4 [95% CI, 1-7]; P = .01) and the SMC Severity Grading Scale (median score, 2 vs 2; Hodges-Lehmann median difference, 0 [95% CI, 0-1]; P = .03) than patients with hemifacial spasm who did not use alleviating maneuver. The severity of dystonia correlated with botulinum toxin treatment for patients with blepharospasm (r = 0.23; P = .049) and patients with hemifacial spasm (r = 0.45; P = .001). There was no difference found in botulinum toxin treatment between patients who used alleviating maneuvers and those who did not, in either the blepharospasm group (150 vs 125 units; Hodges-Lehmann median difference, 20 units [95% CI, -10 to 70 units]; P = .15) or the hemifacial spasm group (58 vs 60 units; Hodges-Lehmann median difference, 0 units [95% CI, -15 to 20 units]; P = .83). CONCLUSIONS AND RELEVANCE: Half of the patients with periocular facial dystonias used alleviating maneuvers. Their use was associated with more severe disease but not with increased use of botulinum toxin. This may help to guide future therapies, such as advice on maneuver augmentation or tailored devices.

A Web-based approach to low-cost telemedicine.

We have developed a Web-based application for managing e-consultations. This solves some of the problems inherent in peer-to-peer email communication. Referrals were from three hospitals in Vietnam. Each hospital was provided with Internet access for up to 4 hours a day for an initial 12-month period. In the first six months, six doctors from the Vietnamese hospitals submitted a total of 30 cases. Specialists in Sydney provided their expertise on a voluntary basis. Preliminary data suggest that the Vietnamese doctors found the system benefited their diagnostic and management decision making. Challenges have included equipment failures, language barriers and the difficulty of obtaining feedback. Successes have included the relationship building between doctors in the two countries. Preliminary results were encouraging and most of the Vietnamese doctors (five of the six) reported that they were slowly incorporating use of the system into their daily practice.