Self-retaining bicanaliculus stents as an adjunct to 3-snip punctoplasty in management of upper lacrimal duct stenosis: a comparison to standard 3-snip procedure.

PURPOSE: To evaluate the efficacy of self-retaining bicanaliculus stents when used as an adjunct to 3-snip punctoplasty in comparison with standard 3-snip procedure between fellow eyes. METHODS: Prospective, randomized, comparative study. Thirty-two eyes of 16 consecutive patients with acquired, nontraumatic stenosis of the proximal lacrimal duct were randomly distributed into 2 equal study groups. Lower punctal stenosis was a standard prerequisite. Group A (16 eyes) received a simple 3-snip punctoplasty, while group B (16 fellow eyes) underwent a modified 3-snip punctoplasty combined with insertion of self-retaining bicanaliculus stents. Duration of follow ups: 6 months. Anatomical, functional, and subjective parameters were evaluated. RESULTS: A statistically significant difference in anatomical success rates was observed in favor of group B (p = 0.011) 6 months postoperatively. Complete relief from epiphora was noted in 8 eyes of group B compared with 2 eyes of group A (p = 0.057). In regard to mixed (absolute and partial) functional success rates, group B exceeded with statistically significant difference (15 eyes group B vs. 6 eyes group A; p = 0.002). A nasolacrimal duct obstruction was subsequently diagnosed in 3 of the nonpatient eyes. Reintroduction of silicone tubes was required in 4 eyes of group B. CONCLUSIONS: The use of self-retaining bicanaliculus stents seems to improve anatomical, functional, and subjective scores when combined with standard 3-snip punctoplasty in patients with acquired upper lacrimal duct stenosis.

Isolated orbital fibrous dysplasia associated with ipsilateral keratoconus.

INTRODUCTION: Fibrous dysplasia is a primary orbital bone tumor, described as a benign disorder in which proliferation of fibrous tissue and osteoid replaces and distorts the bone from which it derives. Unilateral keratoconus is a rare entity. Herein, we report a case of an extensive ethmoidal fibrous dysplasia associated with ipsilateral keratoconus, and review the literature on the subject. MATERIALS AND METHODS: A 22-year-old man presented with left painless proptosis evolving over 10 years. There was associated ipsilateral epiphora and gradual visual loss. On examination his visual acuity was 20/20 OD and CF OS. His left globe was displaced lateraly 12 mm, with 9 mm of proptosis. The extraocular movements were normal. Left nasolacrimal duct obstruction was noted. Clinical signs of keratoconus were present only in the left cornea. High resolution corneal topography confirmed unilateral keratoconus and a CT scan showed an ovoid mass with a well defined sclerotic margin arising from the left ethmoid sinus and invading the orbit. RESULTS: The patient underwent resection of the lesion via a modified Lynch incision. Complete regression of proptosis was observed immediately after surgery. Histopathological examination revealed irregular trabeculae of woven bone in different levels of maturation in a moderately cellular fibrous matrix without nuclear atypia. Trabeculae were without osteoblastic rimming or osteoclastic resorption. There has been no recurrence over a 2-year follow-up period. CONCLUSION: To our knowledge, the coexistence of unilateral isolated craniofacial fibrous dysplasia with ipsilateral keratoconus has not been reported so far.

Bilateral Herpes Simplex Virus-related Peripheral Ulcerative Keratitis Leading to Corneal Perforation in a Patient with Primary Herpes Simplex Virus Infection.

PURPOSE: To present a case of bilateral peripheral ulcerative keratitis (PUK) caused by primary herpes simplex virus-1 (HSV-1) infection resulting in corneal perforation. CASE REPORT: A 24-year-old man presented at the eye casualty of our clinic, with a 20-day history of severe pain, redness, photophobia, and tearing in both of his eyes. Slit-lamp examination revealed bilateral superior corneal perforation. A laboratory work-up that included immunological testing for infectious and autoimmune factors showed primary HSV infection. Positive PCR analysis of corneal scrapings for HSV confirmed initial end-organ ocular infection. Because the patient showed progressive HSV-1-related PUK resulting in bilateral superior corneal perforation with iris prolapse, he was prescribed both systemic and topical acyclovir and prednisone. He then underwent bilateral surgical intervention, namely eccentric penetrating keratoplasty in one eye and a two step procedure in the other, whereby two corneal patch grafts and an amniotic membrane transplant were initially used, followed 1 month later by a large diameter penetrating keratoplasty. CONCLUSION: In cases of PUK, differential diagnosis should include infectious and autoimmune diseases. Primary HSV should also be considered as a potential cause of this form of keratitis, which, if left untreated, can lead to devastating outcomes. To our knowledge, this is the first published case of bilateral PUK caused by primary HSV-1 infection.

Pendular eyelid flap: a novel technique for the management of extensive congenital upper lid colobomas.

We present a novel technique for the surgical management of sizeable medial upper eyelid colobomas that entails advancement of an ipsilateral upper lid flap sustained by a levator aponeurosis-Müller-conjunctiva pedicle and combined with a lateral semicircular flap from the affected lid. The technique was used in 4 consecutive pediatric patients of mean age 21.2 months and mean coloboma size 12.3 mm and resulted in sufficient cornea protection, rapid rehabilitation, and satisfying cosmesis.

Generic trypan blue as possible cause of a cluster of toxic anterior segment syndrome cases after uneventful cataract surgery.

Five of 16 patients having uneventful cataract surgery over 2 consecutive days presented on the first postoperative day with painless, unexpected blurry vision; marked limbus-to-limbus corneal edema; and severe anterior chamber inflammation with hypopyon and fibrin formation. Review of the records showed the 5 patients had received an intracameral injection of generic trypan blue solution 0.06% to facilitate the capsulorhexis. Patients who had not received the trypan blue injection had an uneventful first-day check and subsequent course. Management comprised intense topical steroids and close follow-up, which led to gradual improvement in all cases. The batch of trypan blue vials was withdrawn, and there were no additional cases of toxic anterior segment syndrome (TASS). This TASS cluster highlights a rarely reported cause of the syndrome, underscoring the need for thorough documentation of solutions and/or medications used intraoperatively and surgeon awareness of possible adverse events.

Safety and efficacy of chloral hydrate for procedural sedation in paediatric ophthalmology: a systematic review and meta-analysis.

PURPOSE: Although chloral hydrate (CH) has been used as a sedative for decades, it is not widely accepted as a valid choice for ophthalmic examinations in uncooperative children. This study aimed to systematically review the literature on the drug's safety and efficacy. METHODS: We searched PubMed, EMBASE, ISI Web of Science, Scopus, CENTRAL, Google Scholar and Trip database to 1 October 2015, using the keywords 'chloral hydrate', 'paediatric' and 'procedural sedation OR diagnostic sedation'. A meta-analysis of randomised controlled trials (RCTs) was performed. RESULTS: A total of 6961 articles were screened and 104 were included in the review. Thirteen of these concerned paediatric ophthalmic examination, while 13 others were RCTs and were meta-analysed. CH was reported to have been administered in a total of 24 265 sedation episodes in children aged from <1 month to 18 years. The meta-analysis showed CH had a higher OR (2.95, 95% CI 1.09 to 7.99) for successful sedation compared to other sedatives, but significant limitations apply. The commonest reported adverse events (AE) were not serious (eg, paradoxical reaction or transient vomiting) and required no intervention. Severe AE, including two deaths, were related to comorbidity, overdose or aspiration. CONCLUSIONS: Despite the paucity of high quality evidence, the existing literature suggests that the use of CH for procedural sedation in children appears to be an effective alternative to general anaesthesia, and it can be safe when administered in the hospital setting with appropriate monitoring and vigilance for intervention.

Training of Resident Ophthalmologists in Cataract Surgery: A Comparative Study of Two Approaches.

Purpose. To evaluate and compare the efficacy of two different training methods in resident-performed phacoemulsification surgery. Methods. 502 eyes of 467 patients who underwent resident-performed phacoemulsification were included in the study by reviewing their medical records. Residents were allocated into two groups according to the method applied during their training in cataract surgery; Group A included residents that were trained with the "step-by-step" method and Group B those trained with the "one-step" method. Primary outcome was the incidence of main complications, defined as posterior capsular ruptures and/or zonular dehiscence with vitreous loss. Results. Each resident performed a median of 63 phacoemulsification surgeries. A statistically significant difference (p = 0.0032) was noted in the main complications rate between the two groups, yielding a mean of 17.3% in Group A and 7.25% in Group B. Other intraoperative complications were not shown to differ statistically significantly between study groups (p > 0.05). Among the first 40 surgeries of each resident, main complications rate differed also statistically significantly (p = 0.0048) between Group A (21.67%) and Group B (8.5%), while a better surgical performance-yielding statistical significance in Group A (p = 0.017) was indicated in both groups between the 20th and the 30th procedure. Conclusions. Training in cataract surgery using the "one-step" method may lead to an improvement in surgical competency, when measured by complications rates and, therefore, to significantly better quality of training for resident ophthalmologists.

Contribution of integrated teaching in the improvement of an undergraduate ophthalmology curriculum.

PURPOSE: Conventional medical curriculum is the rule of medical teaching in Greek Medical Schools. Medical students are often taught irrelevant details with little or no reference to their potential clinical significance. Alternatively, integrated teaching warrants that the complete teaching material is covered by each faculty member not considering areas of personal expertise. The aim of this study was to evaluate the implementation of integrated teaching in ophthalmic training. METHODS: The main outcome measures of this retrospective study were a) comments and recommendations made anonymously by the fifth-year medical students in the evaluation questionnaires filled in at the end of their training, and b) scores obtained by students in their final examination at the end of their training in the 2nd Department of Ophthalmology as part of the core Curriculum of the Medical School of the Aristotle University of Thessaloniki. The latter outcome was analyzed with respect to the implementation of integrated teaching. RESULTS: The score obtained by students in the final examination, which is an objective outcome measure, increased significantly after the implementation of integrated teaching. The final grade (scores out of 10) of students who were trained with the integrated system (6.17±1.67, mean ± standard deviation) was significantly higher compared to those (5.52±2.20) trained with the conventional system (P<0.001). The positive outcome of this process was evident as there was a significant increase in the number of students satisfied with the teaching process compared to previous academic years. CONCLUSION: Based on the experience of eight academic years and as a result of interactive assessment process our department has modified its medical student teaching process from conventional to integrated; all teaching staff members are involved in the teaching process, while students are divided in small groups. In conclusion, integrated teaching in small student groups appears to be an efficient teaching method (for both theoretical and clinical skills) of ophthalmic training for medical students.

Safety and efficacy of combined immunosuppression and orbital radiotherapy in thyroid-related restrictive myopathy: two-center experience.

PURPOSE: To evaluate the safety and efficacy of oral steroids when combined with long-term oral azathioprine (AZA) and orbital radiotherapy in patients with active thyroid-related restrictive myopathy. METHODS: A total of 88 patients from adnexal outpatient clinics of Bristol Eye Hospital, UK, and 2nd Department of Ophthalmology at Aristotle University of Thessaloniki, Greece, were enrolled in a retrospective, twin-center study. All patients were diagnosed with active thyroid eye disease and concomitant restrictive myopathy. Treatment included oral AZA, low-dose steroids, and orbital radiotherapy (20 Gy). Clinical activity scores as well as orthoptic assessments were consistently evaluated. Clinical activity scores, improved levels of diplopia, and single muscle excursions were considered major criteria for treatment success. RESULTS: Clinical success was achieved in 54 (61.4%), 57 (64.8%), and 61 (69.3%) patients at 3-, 6-, and 12-month time points, respectively, after the initiation of the combined treatment. At 18 months following initiation of treatment, the percentage of treatment success reached 73.9% (n = 65). Nine patients developed AZA-related side effects. In 4 patients the drug had to be discontinued. CONCLUSIONS: Combined immunosuppression with orbital radiotherapy appears to reduce morbidity in patients with marked restrictive myopathy by improving major motility parameters such as diplopia and duction amplitude.

Acute postoperative Staphylococcus schleiferi endophthalmitis following uncomplicated cataract surgery: first report in the literature.

INTRODUCTION: We report a rare case of acute postoperative Staphylococcus schleiferi endophthalmitis following an uneventful cataract extraction.
 METHODS: An 83-year-old woman underwent uneventful phacoemulsification without receiving the usual intracameral cefuroxime solution due to cephalosporin intolerance. Two days postoperatively, she presented with acute ocular pain and blurred vision in the operated eye. Ophthalmic examination revealed signs of acute keratitis and endophthalmitis. Corneal scrapes and vitreous taps were sent for cultivation and analysis. The patient received intravitreal antibiotics at the same time.
 RESULTS: Cultivation grew S schleiferi, a pathogen commonly found in dogs. Following microbiological report, the patient received a repeated intravitreal injection of 1 mg/0.1 mL vancomycin combined with fortified topical vancomycin drops. One week later, the inflammation subsided completely while the corneal ulcer healed and visual acuity improved dramatically. Further examination revealed the existence of the same pathogen in a specimen obtained from the dog owned by the patient's family.
 CONCLUSIONS: This description of S schleiferi endophthalmitis highlights the need to provide alternative intracameral antibiotic solution in the operating room and avoid direct contact with dogs during the first postoperative period after intraocular surgery.

Association of ocular hypotensive medication types with dynamic contour tonometry and Goldmann applanation tonometry measurements in a glaucoma and ocular hypertensive population.

PURPOSE: The aim of this study was to evaluate the association between different intraocular pressure (IOP)-lowering medications and IOP measurements by dynamic contour tonometry (DCT) and Goldmann applanation tonometry (GAT) in a glaucoma and ocular hypertensive population. METHODS: In a prospective, observational case series study, 410 eyes from 410 consecutive patients with open-angle glaucoma (OAG) or ocular hypertension (OHT), were enrolled. All eyes included in the study received unaltered ocular hypotensive medication for at least 6 months before IOP measurement. All eyes underwent 2 GAT and 3 DCT measurements, and their means were used for the analysis. RESULTS: DCT-GAT IOP difference (ΔIOP) did not differ statistically significantly (P=0.49) between OAG and OHT group yielding a mean±SD of 4.26±2.02 mmHg and 4.41±2.25 mmHg, respectively. The number of IOP-lowering agents did not have any statistically significant influence on ΔIOP (p=0.177), DCT (P=0.28) and GAT (P=0.13) measurements. A statistically higher ΔIOP was revealed in monotherapy patients receiving Carbonic Anhydrase Inhibitors (CAIs) (ΔIOP=5.75 mmHg) in comparison to patients receiving Prostaglandin Analogs (ΔIOP=4.09 mm Hg) or beta Blockers (ΔIOP=3.78 mmHg) as single topical therapy (F=4.373, P=0.005). Eyes treated with CAIs as a part of the ocular hypotensive therapy yielded a significantly greater ΔIOP (P=0.0035) than those without CAIs in the therapeutic schema. CONCLUSIONS: The difference between DCT and GAT IOP measurements is found to be statistically significantly higher in patients receiving CAIs either as monotherapy or as a part of a combined ocular hypotensive treatment, while DCT and GAT readings remain unaffected. The type of diagnosis and the number of ocular hypotensive medications had no statistically significant influence on ΔIOP.

Surgical outcomes in phacoemulsification after application of a risk stratification system.

BACKGROUND: The purpose of this study was to determine whether application of a risk stratification system during preoperative assessment of cataract patients and subsequent allocation of patients to surgeons with matching experience may reduce intraoperative complications. METHODS: Nine hundred and fifty-three consecutive patients (1109 eyes) undergoing phacoemulsification cataract surgery were assigned to two groups, ie, group A (n = 498 patients, 578 eyes) and group B (n = 455 patients, 531 eyes). Patients from group A were allocated to surgeons with varying experience with only a rough estimate of the complexity of their surgery. Patients from group B were assigned to three risk groups (no added risk, low risk, and moderate-high risk) according to risk factors established during their preoperative assessment and were respectively allocated to resident surgeons, low-volume surgeons, or high-volume surgeons. Data were collected and entered into a computerized database. The intraoperative complication rate was calculated for each group. RESULTS: The intraoperative complication rate was significantly lower in group B than in group A (group A, 5.88%; group B, 3.2%; P < 0.05). Patients from group B with no added risk and allocated to resident surgeons had a significantly lower rate of intraoperative complications than those from group A allocated to resident surgeons (group A, 7.2%; group B, 3.08%; P < 0.05). CONCLUSION: Our study demonstrates that allocation of cataract patients to surgeons matched for experience according to a uniform and reliable preoperative assessment of their risk of complications allows for better surgical outcomes, especially for resident surgeons.

Corneal perforation as a primary manifestation of keratoconus in a patient with underlying rheumatoid arthritis.

PURPOSE: The purpose of this study is to report a case of corneal perforation in a patient with undiagnosed keratoconus and underlying rheumatoid arthritis. METHODS: This is a retrospective case study based on the patient's medical records and followed by a brief review of the literature. RESULTS: A 53-year-old patient was referred to our department for acute pain and sudden decrease of visual acuity in his left eye. Corneal perforation was detected and attributed to a previously undiagnosed and untreated keratoconus. Additional laboratory work-up and clinical examination revealed a coexisting rheumatoid arthritis. Amniotic membrane was originally transplanted in order to maintain the structural integrity and promote healing of the perforated eye. Subsequently, the patient underwent a penetrating keratoplasty, though with unfavorable results due to postoperative endophthalmitis. CONCLUSIONS: Rheumatoid arthritis may be associated with higher risk of corneal perforation in patients with ectatic degenerative diseases such as keratoconus.

The effect of subconjunctival ranibizumab on primary pterygium: a pilot study.

PURPOSE: A prospective interventional pilot study was performed to estimate the effect of ranibizumab injection on the clinical and histological picture of primary pterygium. METHODS: Five patients with primary pterygia received a single subconjunctival injection of ranibizumab (0.3 mg), whereas 5 nontreated pterygia served as controls. The treated pterygia were surgically removed 3 days, 1 week, 2 weeks, 1 month, and 2 months after the injection, respectively. Digital photographs of the pterygia were taken immediately before injection, 1 week after, and on the day of operation. RESULTS: Ranibizumab was well tolerated by all patients, and no side effects were reported. However, it had no effect on the extent of vascularization of pterygium, regardless of the interval between injection and operation. No regression of pterygium vessels was noted in any of the patients. Immunohistochemical analysis also showed no particular differences in the number of vessels stained positive for vascular endothelial growth factor A, in the intensity of vessel staining among the treated pterygia, and between the treated and the nontreated pterygia. CONCLUSIONS: Subconjunctival ranibizumab at a single dose of 0.3 mg was not associated with any side effects but had no effect on the extent of vascularization of primary pterygium in our study.

Parosteal osteosarcoma of the orbit.

A 60-year-old woman was referred to Bristol Eye Hospital because of a progressive, painless, right proptosis. CT revealed a well-defined, hyperdense lesion adjacent to the lateral orbital wall. A marginal excision was performed. The mass was stony-hard, lobulated, and encapsulated. Histopathologic findings were consistent with a low-grade parosteal osteosarcoma. Parosteal osteosarcoma is a rare osteogenic tumor that usually affects the long bones. It represents a malignant, though well differentiated, tumor that has a relatively good prognosis after a wide excision. However, local recurrences are not rare and have been associated with dedifferentiation. The latter affects the prognosis adversely and, thus, regular follow-ups are strongly suggested after the initial tumor excision. In the present case, no further treatment was administered and the patient was reported disease free 26 months after surgery.