Acute glaucoma presentations in the elderly.

Acute glaucoma classically presents with severe pain, redness, and reduced vision in the affected eye, and severe cases can also have systemic symptoms. We report three cases of acute glaucoma in elderly patients. The diagnosis of acute glaucoma in a patient who presents with sudden onset of a painful, red eye with reduced visual acuity, a hazy cornea, and a fixed, semi-dilated pupil is comparatively straightforward. However, any patient with headache, malaise, or gastrointestinal disturbance, especially with clinical signs of an acute red eye and reduced vision, should alert doctors to the possibility of acute glaucoma. This is especially important in elderly people, who may not volunteer any specific ocular symptoms.

Phacoemulsification in a patient with marked cervical kyphosis.

A patient with long-standing ankylosing spondylitis and chronic uveitis needed cataract extraction in his only eye. Extensive spinal deformities, including cervical kyphosis, prevented him from being positioned satisfactorily for surgery using a routine head-end or temporal position for the surgeon. The best possible position for surgery was achieved using an orthopedic operating table, which allowed the patient's head to be reclined to a position of 60 degrees to the horizontal. Successful combined phacoemulsification and trabeculectomy was then performed, although the angle of approach for the surgeon and the operating microscope was awkward.

Visual outcome with the array multifocal intraocular lens in patients with concurrent eye disease.

PURPOSE: To evaluate whether the distance visual outcome with the Array(R) multifocal intraocular lens (IOL) is comparable to that of a monofocal IOL in eyes with concurrent disease and to assess whether these eyes benefit from the IOL's multifocality. SETTING: Department of Ophthalmology, Arrowe Park Hospital, Wirral, United Kingdom. METHODS: This prospective study comprised 133 eyes of 111 patients with cataract and concurrent disease such as macular degeneration, glaucoma, and diabetic retinopathy. Eighty-one eyes (70 patients) received an Array multifocal IOL after phacoemulsification. A control group of 52 eyes (41 patients) received a monofocal IOL of similar design (AMO SI-40NB). Visual outcomes in terms of uncorrected and best corrected distance and near acuities were evaluated. RESULTS: In both the multifocal and the monofocal IOL groups, the number of eyes achieving a best corrected visual acuity of 6/12 and N8 or better (55 and 37 eyes, respectively) was comparable (P > or =.999; 95% confidence interval [CI] -0.152 to 0.172). There was a borderline statistically significant difference in the number of eyes achieving an uncorrected visual acuity of 6/12 or better and N8 or better in the multifocal IOL (11 eyes) and monofocal (2 eyes) groups (P =.047, 95% CI -0.001 to 0.196). A significantly higher number of eyes in the multifocal group (40 eyes) than in the monofocal IOL group (4 eyes) achieved a distance-corrected acuity of 6/12 and N8 or better (P =.0001; 95% CI 0.274 to 0.539). CONCLUSIONS: The Array multifocal IOL produced distance visual outcomes comparable to those of the AMO SI-40NB monofocal IOL in patients with concurrent eye disease. A significant proportion of these patients benefited from the IOL's multifocality. Management of associated eye disease was not compromised by the nature of the IOL.

Bilateral anterior ischaemic optic neuropathy due to optic disc drusen.

PURPOSE: To report a case of bilateral anterior ischaemic optic neuropathy due to buried optic disc drusen. METHODS: Case report. RESULTS: A 64-year-old man presented with swollen optic discs and features suggestive of anterior ischaemic optic neuropathy (AION) in the left and right eye on two separate occasions ten months apart. Detailed ocular examination at presentation and systemic investigations did not reveal an underlying cause for the AION. At a later follow-up, optic disc drusen were noted in both eyes as partial optic atrophy had set in. This was confirmed by ultrasound B scan and demonstration of autofluorescence. CONCLUSIONS: In patients presenting with AION uncommon underlying causes must be considered. Routine ultrasound B scan at presentation can easily establish or exclude optic disc drusen as an underlying cause.

Lacrimal canalicular stenosis associated with systemic 5-fluorouacil therapy.

PURPOSE: Ocular side effects of systemic 5-fluorouracil therapy include excessive lacrimation which often resolves on cessation of therapy. Permanent stenosis of lacrimal puncta and canaliculi is rare. This report highlights this uncommon complication of 5-fluorouracil therapy. METHODS: Report of two cases and review of literature. RESULTS: Severe stenosis of puncta and canaliculi may be associated with prolonged systemic 5-fluorouracil therapy. CONCLUSION: It is important for both the oncologist and ophthalmologist to be aware of the potential ocular toxicity of 5-fluorouracil. Surgical management to relieve the epiphora is often challenging, and early intervention may be beneficial.

Effectiveness of optometrist screening for diabetic retinopathy using slit-lamp biomicroscopy.

PURPOSE: To assess the effectiveness of optometrists as screeners for diabetic retinopathy using slit-lamp binocular indirect ophthalmoscopy through dilated pupils. METHODS: Prospective study of a screening scheme. Screening was performed by 27 locally accredited optometrists in their practice. The referral protocol used a new simple grading system of retinopathy, especially designed for use in an optometrist screening programme. All positive referrals and 10% of negative referrals were reexamined by an ophthalmologist. Sensitivity, specificity, likelihood ratios and technical failure rates were calculated. RESULTS: The optometrists screened 4904 people with diabetes in 18 months. 'Subthreshold' (screen negative) reports accounted for 4438 (90.5% of 4904); 429 (9.67%) of these were re-examined at secondary screening. There was disagreement regarding grading in 13 patients, of whom 5 (1.16% of 429) had sight-threatening retinopathy (STDR); this extrapolates to 52 patients if all the 4438 test-negatives had been examined. Of the 371 'threshold' patients, 112 (30.18%) were false positives; the commonest cause for false positive referral was drusen in patients with background diabetic retinopathy. The sensitivity for identification of STDR was 76% (95% CI 70% to 81%) and specificity 95% (95% CI 95% to 96%). The likelihood ratio of a positive test indicating STDR was 16.54 (95% CI 14.17 to 19.23) and that of a negative test 0.25 (95% CI 0.20 to 0.32). The technical failure rate was 0.2%. CONCLUSIONS: Suitably trained and accredited community optometrists performed well when screening for diabetic retinopathy using slit-lamp biomicroscopy through a dilated pupil. This was facilitated by the use of simple grading and referral criteria. The sensitivity, positive likelihood ratio and specificity were high.

Prevalence of blindness and visual impairment in a population of people with diabetes.

PURPOSE: To assess the prevalence of visual impairment and the underlying causes in a population of people with diabetes. METHOD: A population-based study of a defined population of people with diabetes in a district in the North West of England was done. There were 7652 known people with diabetes, representing 2.12% of target general population of 361050. The main outcome measures were the prevalence of blindness and significant visual impairment (less than 6/18 corrected vision in their better eye) and the underlying causes. RESULTS: Visual acuity data on 6482 (84.7%) of the 7652 individuals were obtained. Of these, 184 had significant visual impairment (prevalence 2.84%) including 49 who were blind (vision of less than 3/60 in their better eye, prevalence 0.75%); if blindness was defined as vision less than or equal to 6/60, prevalence was 1.13% (n = 73). Details of 3 individuals could not be ascertained. Only 67 were registered, either as partially sighted (n = 42) or as blind (n = 25). In the majority (n = 133; 68%) of these 181 individuals the visual impairment was due to causes other than diabetic retinopathy. CONCLUSIONS: The prevalence of blindness and visual impairment in our population of people with diabetes was low. Non-diabetic eye disease accounted for the majority of this visual impairment. This provides essential baseline data against which future progress can be assessed. Screening and treatment can greatly reduce the incidence of visual impairment due to diabetic retinopathy, but its impact on overall visual impairment rates in the population of people with diabetes will be more modest.