Multidetector computed tomographic angiography in isolated third nerve palsy.

OBJECTIVE: To evaluate whether multidetector computed tomographic angiography (CTA) scanners can detect a clinically significant intracranial aneurysm in the circle of Willis causing an isolated third nerve palsy (ITNP). DESIGN: Retrospective cross-sectional study. PARTICIPANTS: One hundred thirty-seven patients who presented with an ITNP were examined by multidetector CTA scanners. METHODS: All patients whose symptoms were caused by a compressive cerebral aneurysm were identified. The remaining patients were observed clinically to exclude the possibility of a missed cerebral aneurysm causing the ITNP. No patient underwent diagnostic conventional cerebral angiography (CCA), but all patients who underwent treatment underwent CCA at the time of the treatment. MAIN OUTCOME MEASURES: Accurate identification of a cerebral aneurysm that may cause an ITNP. RESULTS: A cerebral aneurysm causing an ITNP was detected in 27 patients (19.7%). The smallest maximal diameter of a clinically significant aneurysm was 5.7 mm. Of the 27 patients, 25 underwent endovascular coiling at which time CCA confirmed the aneurysm. In no case was another lesion found by CCA. Of the patients without an aneurysm, 81 of 110 (74%) made a complete spontaneous recovery. In no patient was there clinical evidence to suggest that a compressive cerebral aneurysm had been missed on CTA. CONCLUSIONS: Multidetector CTA is a safe and effective diagnostic imaging tool in detecting clinically significant aneurysms when a patient presents with an acute ITNP. We no longer perform CCA to detect a causative aneurysm or determine the type of treatment offered in these patients.

Surgeon experience and patient comfort during clear corneal phacoemulsification under topical local anesthesia.

PURPOSE: To evaluate patient comfort during topical anesthesia clear corneal phacoemulsification surgery performed by a surgeon in the learning curve or by an experienced surgeon. SETTING: Royal Alexandra Hospital, Paisley, Scotland, United Kingdom. METHODS: This study comprised 46 consecutive patients having phacoemulsification under topical anesthesia of proparacaine 0.5% (Proxymetacaine. Surgery was performed by a surgeon during his learning curve (n = 20) or by an experienced surgeon (n = 26). No sedation or intracameral anesthesia was used in either group. All patients had clear corneal phacoemulsification with foldable acrylic posterior chamber intraocular lens implantation. Each patient's subjective experience of overall pain perioperatively (period immediately surrounding and during surgery) and worst pain perceived during surgery was measured immediately after surgery using a 10-point visual analog scale. RESULTS: There was no significant difference in patient-reported pain scores for overall pain perioperatively (P =.47, Wilcoxon rank sum test) and the worst pain perceived during surgery (P =.32, Wilcoxon rank sum test). CONCLUSIONS: Topical anesthesia with proparacaine provided similar and reasonable analgesic effects in patients having surgery by a surgeon in the learning curve and those having surgery by an experienced surgeon. The discomfort perceived during surgery performed by an experienced surgeon was less, although not statistically significantly different.

Patient comfort during clear corneal phacoemulsification with sub-Tenon's local anesthesia.

PURPOSE: To assess patient comfort with and without intravenous (i.v.) cannulation during 1-quadrant sub-Tenon's anesthesia during phacoemulsification. SETTING: Royal Alexandra Hospital, Paisley, Scotland, United Kingdom. METHODS: This prospective masked controlled clinical trial comprised 119 patients having elective clear corneal phacoemulsification. Fifty had sub-Tenon's anesthesia with an i.v. cannula; 23, sub-Tenon's anesthesia without an i.v. cannula; and 46, topical anesthesia of proparacaine 0.5% without an i.v. cannula. No patient received sedation. All patients had clear corneal phacoemulsification with foldable posterior chamber intraocular lens implantation. The patients' subjective pain experience was measured immediately after surgery by a single independent observer using a 10-point visual analog scale. RESULTS: The mean patient-reported pain was low in all 3 groups. The mean i.v. cannula-related pain score in the sub-Tenon's group with an i.v. cannula (1.00; range 0 to 8) was higher than the mean general pain score (0.46; range 0 to 5) and worst pain experienced during surgery score (0.64; range 0 to 3). In the topical anesthesia group, 8 patients (17%) reported greater discomfort directly or indirectly related to the subconjunctival antibiotic injection at the end of surgery. CONCLUSION: Patient-reported pain caused by placing an i.v. cannula in the sub-Tenon's group significantly altered overall patient comfort during the surgical experience. Thus, the routine use of i.v. access during clear corneal phacoemulsification under sub-Tenon's anesthesia should be avoided to improve patient satisfaction.