Open-Globe Injury With Globe Penetration Leading to Complex Retinal Detachment After Intraoral Anesthetic Injection.

Purpose: To report a case of a suspected open-globe injury and globe penetration complicated by a rhegmatogenous retinal detachment (RRD) after administration of intraoral anesthetic injections during an endodontic procedure. Methods: A retrospective chart review was performed. Results: A 34-year-old woman presented with acute onset of flashes, floaters, and a curtain-like shadow across her field of vision. Four days previously, she had multiple left-sided anesthetic injections during an endodontic procedure. The visual acuity (VA) in the left eye was 20/25. Ophthalmoscopy showed a suspected globe-penetration site inferiorly, associated multilayered hemorrhages, and adjacent subretinal fluid. Laser demarcation of the inferior RRD was performed at sequential clinical visits. Through 8 months, the multilayered hemorrhages improved while proliferative vitreoretinopathy-associated tissue formation over the posterior pole caused macular distortion and mild visual deterioration. The VA in the left eye was 20/40 at the last follow-up. Conclusions: Iatrogenic globe penetration during intraoral anesthesia delivery associated with an endodontic procedure may result in globe injury.

Removal of posterior segment retained lens material using the OZil phacoemulsification handpiece versus Fragmatome during pars plana vitrectomy.

PURPOSE: To assess the utility of the torsional phacoemulsification handpiece compared to the Fragmatome during pars plana vitrectomy for removal of posterior segment retained lens material. DESIGN: : Retrospective comparative case series. METHODS: Thirty-four eyes of 34 patients at 2 centers who underwent pars plana vitrectomy for retained lens material with either torsional phacoemulsification or the Fragmatome were retrospectively reviewed. Lens material was graded by nuclear density and percentage of total nuclear size. The primary outcome measure was mean change in visual acuity. Secondary outcomes included intraoperative or postoperative complications, occurrence of mechanical malfunctions and metric data including the total ultrasound, phacoemulsification, and torsional times. RESULTS: In the torsional ultrasound group (17 eyes), mean nuclear density was 3.6 and mean size was 63%. Mean initial logarithm of minimum angle of resolution visual acuity was 1.58 (20/760) and improved to 0.66 (20/80) at postoperative Month 3, a gain of 0.92 (P = 0.003). One eye developed a self-limited, peripheral, serous, choroidal detachment intraoperatively, whereas two eyes developed postoperative cystoid macular edema. Mean total ultrasound, phacoemulsification, and torsional times were 76.7, 13.4, and 63.3 seconds, respectively. Mean total operative time to remove retained lens material (excluding vitreous gel removal) was 111 seconds. All the patients demonstrated excellent followability based on independent observations by the surgeons. In the Fragmatome group (17 eyes), initial logarithm of minimum angle of resolution visual acuity was 1.51 (20/640) and improved to 0.6 (20/80) at postoperative Month 3, a gain of 0.91 (P < 0.001). One eye developed a retinal detachment at postoperative Week 2, whereas 3 eyes developed postoperative cystoid macular edema. CONCLUSION: The use of torsional phacoemulsification during pars plana vitrectomy for retained lens material is a novel approach with potential advantages over the standard 20-gauge Fragmatome, including improved followability and purchase of lens material attributable to the addition of torsional movement.

Competency checklists for strabismus surgery and retinopathy of prematurity examination.

PURPOSE: To evaluate two checklist tools that are designed to guide, document, and assess resident training in strabismus surgery and examination of infants at risk for retinopathy of prematurity (ROP). METHODS: A panel of staff surgeons from several teaching institutions evaluated the checklists and provided constructive feedback. All former residents who had been trained via the use of these checklist tools were asked to take self-assessment surveys on competency in strabismus surgery and ROP examination. A Likert 5-point scale was used for all evaluations, with 1 being the lowest rating and 5 the highest rating. RESULTS: Six experts in strabismus and seven in ROP rated the checklists. Their comments were used to revise the checklists, which were sent to the same group for reevaluation. The mean Likert score for the final checklists was 4.9 of 5.0 for both checklists. Of 16 former residents, 9 responded to the self-assessments with a mean overall score of 4.1 (of 5.0) for strabismus surgery and 3.9 for ROP examination. CONCLUSIONS: These checklist tools can be used to assess the quality of a resident's training and experience in these specific ophthalmology skills. They are complementary to other curriculum and assessment tools and can serve to organize the educational experience while ensuring a uniformity of training.

Central serous chorioretinopathy associated with the use of ephedra.

PURPOSE: To report three cases of central serous chorioretinopathy (CSC) likely related to the use of body-building products containing ephedra. METHODS: Observational case series of three patients who presented with signs and symptoms of CSC. All cases had ocular coherence tomography and fluorescein angiograms to confirm the diagnosis. All admitted to current or previous use of ephedra containing products for body building. No patient had a history of current or prior use of steroids. RESULTS: The first patient presented in 2005 with a 7-month history of bilateral CSC. On careful history, the patient admitted to the use of ephedra during body-building exercises. After discontinuation of the ephedra, his CSC resolved. The second and third patients presented in 2007. Both had pigmented epithelial detachments in both eyes secondary to CSC and atrophic changes suggestive of old, resolved CSC. The second patient had admitted to the use of ephedra 3 years previously and Patient 3 was currently using an ephedra-containing body-building product. After Patient 3 discontinued the ephedra, his CSC too resolved. CONCLUSION: We report three cases of CSC related to the use of ephedra-containing products. All three cases were chronic, atypical, and bilateral in nature with two of three cases resolving after the discontinuation of the ephedra. This may be related to the sympathomimetic properties of ephedra as reported by Michael et al for pseudoephedrine. Given these findings, we suggest that questioning about ephedra products become standard when taking histories in suspected CSC cases.

Retinal pigment epithelial tears after intravitreal bevacizumab injection for exudative age-related macular degeneration.

PURPOSE: To determine the incidence of and the risk factors for the development of retinal pigment epithelial (RPE) tears after intravitreal bevacizumab (Avastin) injection for the treatment of exudative age-related macular degeneration (AMD). METHODS: A retrospective, multicentre, consecutive interventional case series of all patients with subfoveal exudative AMD treated with intravitreal bevacizumab between August 2005 and April 2007. The main outcome measures were pre- and post-RPE tear visual acuity and choroidal neovascular membrane lesion types, incidence of tears and time from first injection until development of the tear. RESULTS: A total of 920 eyes with exudative AMD were treated with intravitreal bevacizumab. Fifteen eyes from 15 patients developed a RPE tear for an incidence of 1.6%. The average patient age was 79 years. Fourteen of the fifteen eyes (93%) had an occult subfoveal choroidal neovascular membrane. Forty-seven per cent (7/15) of the RPE tears occurred within the first 6 weeks of treatment, and all tears occurred within the first 18 weeks of treatment initiation. The mean pre-injection visual acuity was 20/100 with a mean post-tear visual acuity of 20/200. In all 10 eyes in which the tear involved the fovea, the final visual acuity was poor. Six of the 15 eyes continued with bevacizumab/ranibizumab (Lucentis) injections after tear development, and four of these six eyes continued to have visual improvement. CONCLUSION: RPE tears occur after intravitreal bevacizumab injections for exudative AMD in approximately 1.6% of eyes and can cause severe vision loss. Maintenance of therapy may help preserve vision after RPE tear development.

A prospective, open-label, dose-escalating study of low molecular weight heparin during repeat vitrectomy for PVR and severe diabetic retinopathy.

BACKGROUND: To determine the maximum tolerated dose (MTD) of enoxaparin, a low molecular weight heparin (LMWH) was used during repeat vitrectomy for rhegmatogenous retinal detachment with proliferative vitreoretinopathy (PVR) and severe diabetic retinopathy. METHODS: From 25 patients, 29 eyes undergoing repeat vitrectomy for PVR (CP3 or greater) or severe diabetic retinopathy were included in the study. Patients had previously undergone an average of 2.1 previous vitrectomies (range 1-5). Enoxaparin was added to the infusion fluid in an escalating dose from 0.1 IU/ml to 6.0 IU/ml as tolerated. Intraoperative bleeding, postoperative fibrin, hyphema and vitreous hemorrhage were graded in an unmasked fashion using previously described grading scales. RESULTS: All patients completed the study, and the study was able to achieve the 6.0 IU/ml maximum dose on the dose escalation schedule. No patient experienced dose-limiting toxicity. Analysis showed no increase in intraoperative bleeding complications between low dose (1.0 IU/ml) enoxaparin (Mann-Whitney Test, P=0.029). CONCLUSIONS: Enoxaparin dose escalation did not result in a dose-dependent increase in acute side effects. The establishment of a well-tolerated dose of enoxaparin during repeat vitrectomy for PVR and severe diabetic retinopathy (6.0 IU/ml) provides a foundation for future studies.

Optic neuritis after anthrax vaccination.

OBJECTIVE: To report the occurrence of optic neuritis after anthrax vaccination in two patients. DESIGN: Observational case reports, review of literature. METHODS: Description of clinical history, examination, neuroimaging, and further studies in two patients experiencing optic neuritis in temporal association with anthrax vaccination. MAIN OUTCOME MEASURES: Visual acuity, visual fields. RESULTS: Two patients, 39 and 23 years of age, were seen with acute optic neuritis 1 month and 2 weeks, respectively, after anthrax booster vaccination and successfully treated with intravenous methylprednisolone. The first patient had a typical presentation and course of unilateral retrobulbar optic neuritis with excellent visual recovery. The second patient had a bilateral anterior optic neuritis and has required chronic immunosuppression to maintain his vision. Retinal and optic nerve autoantibodies were present in the second patient. No cross-reactive epitopes between anthrax vaccine and retina/optic nerve were identified. CONCLUSION: Optic neuritis is a potential adverse reaction of anthrax vaccination.