Myopia intervention and ultraviolet radiation related eye diseases: A narrative literature review.

There has been an increased understanding of the protective effect of two or more hours in high lux light on the development and progression of myopia. The aim of myopia management is to reduce the incidence of high myopia and sight-threatening myopic complications. Equally important are the sight-threatening complications of ultraviolet radiation (UVR) on the eye and adnexal structures. This review will analyze the literature for both these epidemics to help guide public health policy. Whilst increasing childhood high lux light exposure is important, consideration of a holistic eye health policy should ensure that UV eye diseases are also prevented. The advent of ultraviolet (UV) fluorescence photography has increased our understanding that significant UV eye damage occurs in childhood, with 81% of children aged 12-15 years having signs of UV eye damage. Hence, the need to reduce myopia and protect from UV-related eye diseases needs simultaneous consideration. Advocating for eye protection is important, particularly as the natural squint reflex is disabled with dark sunglasses lenses. The pathways UV reaches the eye need to be considered and addressed to ensure that sunglasses offer optimum UV eye protection. The design of protective sunglasses that simultaneously allow high lux light exposure and protect from UVR is critical in combating both these epidemics.

Bilateral blurry vision - a case study.

CASE STUDY: Henry, 60 years of age, was referred by his general practitioner with a 3 month history of blurred vision in the left eye on a background of decreasing vision in both eyes over the preceding 6 months. He had not had his eyes examined for many years. His past medical history included hypertension,hypercholesterolaemia, type 2 diabetes mellitus, chronic renal impairment and peripheral vascular disease. Henry admitted to noncompliance with his medications and medical appointments.

The effect on quality of life of long-term botulinum toxin A injections to maintain ocular alignment in adult patients with strabismus.

BACKGROUND: There is considerable evidence to show that strabismus patients report their quality of life (QoL) as lower than normal controls. While the majority of patients with strabismus are treated with surgery there are a number of cases where surgery is not possible and good long-term ocular alignment can be maintained with repeated injections of botulinum toxin. METHODS: 65 patients who had undergone over 25 injections of botulinum toxin A for long-term control of their deviation were identified and asked to fill in and return the Adult Strabismus questionnaire (AS-20) to assess their QoL. RESULTS: 46 questionnaires were available for analysis. The mean AS-20 score in our patients compared favourably with that reported for normal controls and was much higher than that reported for patients with strabismus. CONCLUSION: Long-term injections with botulinum toxin A is a good treatment for maintaining ocular alignment if squint surgery is not indicated and those patients receiving treatment score near the level of normal controls in QoL terms.

A newborn with unilateral limb enlargement.

On routine neonatal examination, a newborn term male was noted to have unilateral enlargement of the right lower limb, loose thickened red skin over the palm and widening of all the fingers on the right hand. His body was pinker and warmer on the right side compared with the left and he had a right undescended testicle and hypoplastic scrotum. Radiological examination of the lower limbs demonstrated the enlargement of the soft tissue of the right lower limb compared to the left (Fig. 1). Therefore, the diagnosis was unclear from this constellation of findings and an ophthalmic assessment was requested.

Microbial keratitis after corneal laser refractive surgery.

Corneal laser refractive surgery is increasingly being performed on patients with the aim of improving unaided vision. Most candidates for surgery have excellent spectacle- or contact lens-corrected vision. Although microbial keratitis following refractive surgery is a rare complication, and usually has a good visual outcome, it can be sight-threatening. The spectrum of pathogens differs to other causes of microbial keratitis, such as contact lens-associated keratitis, and a different management approach is required. Postoperatively, patients are prescribed topical steroids and broad-spectrum topical antibiotics, typically fluoroquinolones. These do not cover unusual organisms, such as fungi, Nocardia, Acanthamoeba and some atypical mycobacteria. In post-laser-assisted in situ keratomileusis microbial keratitis, the lamellar flap should be lifted to acquire samples for specific microbiological examination, including these atypical organisms. Confocal microscopy is a noninvasive test that provides morphological information, and is operator dependent, but may assist in the rapid diagnosis of fungal, Acanthamoeba or Norcardia keratitis. PCR is not in widespread use, but has high sensitivity and specificity, and may facilitate early diagnosis and specific treatment of the causative organism, which is critical in obtaining the best clinical outcome.

Pharmacological mydriasis secondary to ipratropium bromide: a cause of unilateral dilated pupil.

Ipratropium bromide is a commonly used bronchodilator which has been rarely reported to cause pharmacological mydriasis. We report a 22-year-old woman using 6-hourly nebulised ipratropium from a multi-dose preparation, who presented with a unilateral dilated pupil which resolved spontaneously over 24h after discontinuation of her ill-fitting nebuliser mask which had been directing the drug toward that eye. No alternative cause was found despite extensive investigations. Greater recognition of this iatrogenic cause of reversible pupillary dilatation may avoid the need for unnecessary investigations.

Ultraviolet fluorescence photography: patterns in established pterygia.

PURPOSE: To investigate established pterygia using our newly developed ultraviolet fluorescence photography (UVFP) system. DESIGN: Prospective observational case series. METHODS: setting: Prince of Wales Hospital, Sydney, Australia. study population: Fourteen patients (both eyes) attending the Ophthalmology Clinic at Prince of Wales Hospital for assessment of their established pterygia. There were eight men and six women, with an age range of 26 to 62 years. A total of 15 (75%) of 20 had primary pterygia, and five (25%) of 20 had recurrent pterygia. There were no specific exclusion criteria. observation procedures: Ultraviolet and standard (control) photographs were taken of the nasal and temporal interpalpebral regions bilaterally. main outcome measures: The presence of established pterygia detected by standard photography and the corresponding presence and patterns of areas of fluorescence detected by UVFP. RESULTS: In the 14 patients, 20 established pterygia were identified on standard photography. On UVFP, four patterns of fluorescence of established pterygia were identified. Of the 20 pterygia, six (30%) of 20 demonstrated fluorescence at the leading edge of the pterygium, seven (35%) of 20 demonstrated fluorescence at the limbus, three (15%) of 20 demonstrated fluorescence at both the leading edge and the limbus, and four (20%) of 20 demonstrated no visible fluorescence. CONCLUSIONS: In this study, we describe patterns of fluorescence in established pterygia by UVFP. We hypothesize that the areas of fluorescence represent areas of cellular activity within the pterygium. The patterns of fluorescence may be useful to further understand of pterygium growth and pathogenesis.

Red eye and a rodent ulcer.

A 58-year-old woman presented with a 1-week history of poor vision in the right eye associated with a red eye. She was transferred for vitreoretinal management of suspected endophthalmitis. On examination, she had extensive ulceration of her forehead, exposing a pulsating mass covered with white antiseptic powder. The ulcer extended to involve the nose and right upper eyelid. Computed tomography demonstrated widespread erosion of the frontal bone, exposing the dura; histopathology confirmed the lesion to be basal cell carcinoma. The ulcer had slowly progressed for 30 years, but the patient was in denial about her condition. She had kept the ulcer well hidden by combing her hair forward over it. She was married, with an adult child, and was employed as a courier. Despite three assessments of her eye by medical staff in the preceding 24 hours, the diagnosis of the extensive basal cell carcinoma had been missed as she had refused to lift her hair for a complete examination.

Ultraviolet fluorescence photography to detect early sun damage in the eyes of school-aged children.

PURPOSE: To develop a method to detect precursors of ocular sun damage using ultraviolet fluorescence photography (UVFP). DESIGN: Observational cross-sectional study METHODS: settings: Preschool, primary, and high school in Sydney, Australia. study population: 71 children ages 3 to 15 years old (both eyes). Inclusion criteria were children attending the schools who gave consent. There were no exclusion criteria. observation procedures: UV and standard (control) photographs were taken of the nasal and temporal interpalpebral regions bilaterally. main outcome measures: Presence of areas of increased fluorescence detected by UVFP, or presence of pinguecula detected by standard photography. RESULTS: Established pingueculae, on standard photography, were seen in seven of 71 (10%) children; all were 13 years of age or older. On UVFP, all of these pingueculae demonstrated fluorescence. In total, 23 of 71 (32%) had increased fluorescence detected on UVFP, including the seven of 23 (30%) with pingueculae. Of the remaining 16 of 23 (70%), the changes were only detectable using UVFP. Fluorescence on UVFP was seen in children ages 9 years and above, with prevalence increasing with age. The presence of fluorescence (in at least one region) was 0 of 15 (0%) for children ages 3 to 5 years, 0 of 12 (0%) of children ages 6 to 8 years, 6 of 23 (26%) for those ages 9 to 11 years, and 17 of 21 (81%) of those ages 12 to 15 years. CONCLUSIONS: We hypothesize that the areas seen to fluoresce on UVFP but not detectable on control photography represent precursors for ophthalmohelioses. Our preliminary data strongly suggests that UVFP is a sensitive method for detecting early ocular sun damage occurring many years before clinical manifestations.

Congenital rubella cataract: a timely reminder in the new millennium?

Maternal infection with rubella in the first trimester is an important cause of congenital cataract. Any injury affecting the foetus following maternal rubella infection in the phase of organogenesis results in congenital defects collectively termed as congenital rubella syndrome (CRS). Although rubella embryopathy is a less common cause for congenital cataract than in the past, it is still seen. The number of cases reduced to one in 1997 after which there were no new cases till 2002. However, there have been two new cases of CRS in 2003. Herein another one in early 2004 is reported. Outbreaks of CRS will continue until the percentage of susceptible individuals is reduced to a minimum through immunization. The majority of rubella cases in Australia are confined to young female immigrants, many coming for marriage. We must continue to immunize children, identify and immunize vaccine failures and susceptible women before they become pregnant, and to screen pregnant women so they can be vaccinated after delivery.

A rapidly fatal case of T-cell lymphoma presenting as idiopathic orbital inflammation.

A 41-year-old Caucasian woman presented with a painful, red right eye with minimal systemic symptomatology, and was initially diagnosed with right idiopathic orbital inflammation. Ten days later, she developed abdominal and respiratory symptoms; this led to her demise within a further week. Post-mortem examination demonstrated widespread extranodal NK/T- cell lymphoma (nasal type), involving the right posterior orbit, lungs, uterus, left adrenal gland, pericardium and meninges. Thorough physical examination with early orbital biopsy should be considered to exclude underlying treatable pathology in managing patients with presumed idiopathic orbital inflammation.

Cavernous haemangioma in the orbital apex: stereotactic-guided transcranial cryoextraction.

A 55-year-old Caucasian woman presented with an orbital cavernous haemangioma superior to the optic nerve in the orbital apex. Preoperative imaging demonstrated a mass involving the superomedial and superolateral quadrants of the posterior orbit. A stereotactic fronto-orbital approach was performed by the neurosurgical team, and cryoextraction of the lesion was accomplished by the ocular plastic surgical team.

Sudden visual loss after uneventful cataract surgery: Snuff syndrome.

We describe a case in which the patient had routine, uneventful cataract surgery and developed snuff syndrome on day 1 postoperatively. The patient had pseudoexfoliation syndrome and normal intraocular pressure that was well controlled by timolol and previous laser trabeculoplasty. Although the visual result had been good after surgery in the first (right) eye with a best corrected visual acuity (BCVA) of 6/5, this adverse event, which decreased the BCVA in the left eye from 6/24 preoperatively to hand movements postoperatively, was unexpected. Systemic evaluation failed to identify a specific cause. Data were collected prospectively on 1000 subsequent, consecutive cases of cataract surgery, but we were unable to find pathogenetic data on this occurrence.

Acute haptic-induced pigmentary glaucoma with an AcrySof intraocular lens.

A 49-year-old man had uneventful endocapsular phacoemulsification with in-the-bag implantation of an AcrySof SA60AT single-piece intraocular lens (IOL) (Alcon) in the right eye. Twenty-seven days postoperatively, he presented with ocular pain, intraocular pressure of 48 mm Hg, 360 degrees of hyperpigmentation of the trabecular meshwork, and iris pigment epithelial atrophy in the region of the upper temporal haptic, which had dislocated into the sulcus. The patient made an excellent recovery following IOL removal and exchange. Scanning electron microscopy of the explanted IOL demonstrated that the haptic had a rough lateral surface and anterolateral edge. We do not think this IOL should be implanted in the sulcus placement of the heptics. In this article, we report the case of a patient with an AcrySof SA60ATIOL (Alcon) who developed acute pigmentary glaucoma when the inferior haptic slipped out of the bag and came into contact with the pigmented iris and ciliary body.

Wernicke's encephalopathy presenting with upbeating nystagmus.

The case of a 49-year-old woman with Wernicke's encephalopathy is described, in which primary position upbeating nystagmus was the chief ocular sign. Although there was no history of excessive alcohol consumption, Wernicke's encephalopathy was diagnosed on a background of anorexia nervosa. The diagnosis was supported by the patient's symptomatic and clinical recovery following thiamine therapy.