[The impact of fireworks: the context of facial trauma]. / De impact van vuurwerk: achtergronden van het aangezichtsletsel.

In the Netherlands the general public can legally use fireworks on New Year's Eve. Despite the fact that the public is well aware of the dangers of fireworks, fireworks accidents occur in which the victims suffer a variety of injuries. In addition to burns, injuries to fingers and/or hands are most common. However, injuries to the eye, which can also involve facial trauma, frequently occur as well. Trauma mainly occurs as a result of the destructive effects of the wave of pressure released by the explosion. The best preventive measure would be to prohibit the use of fireworks by amateurs. Until such time, people should be advised to wear protective fireworks glasses when outside so that damage to the eyes from legal fireworks at least can be prevented.

[Diagnosis and treatment of orbital cellulitis]. / Diagnostiek en behandeling van orbitale cellulitis.

Orbital cellulitis is a rare disease usually caused by sinusitis. Generally, the prognosis of both preseptal cellulitis and orbital cellulitis is favourable. Radiological distinction should be made between an orbital abscess and subperiosteal empyema. Theoretically, empyema is more accessible to antibiotics and, as it arises in a pre-existing anatomical space, it needs less aggressive treatment than an abscess. In contrast, the wall of an abscess created by the bacteria is scarcely permeable to antibiotics. Indications for surgical drainage should be based on clinical findings and not on Chandler's classification. Loss of vision, an unresponsive pupil or a densely packed orbit are indications for immediate surgical drainage. Drainage of an orbital abscess may speed up recovery.

Does early response to intravenous glucocorticoids predict the final outcome in patients with moderate-to-severe and active Graves' orbitopathy?

PURPOSE: Intravenous glucocorticoids (ivGCs) given as 12-weekly infusions are the first-line treatment for moderate-to-severe and active Graves' orbitopathy (GO), but they are not always effective. In this study, we evaluated whether response at 6 weeks correlated with outcomes at 12 (end of intervention) and 24 (follow-up) weeks, particularly in patients initially unresponsive. METHODS: Our database (Bartalena et al. J Clin Endocrinol Metab 97:4454-4463, 10), comprising 159 patients given three different cumulative doses of methylprednisolone (2.25, 4.98, 7.47 g) was analyzed, pooling data for analyses. Responses at 6 weeks were compared with those at 12 and 24 weeks using three outcomes: overall ophthalmic involvement [composite index (CI)]; quality of life (QoL); Clinical Activity Score (CAS). Responses were classified as "Improved", "Unchanged", "Deteriorated", compared to baseline. RESULTS: Deteriorated patients at 6 weeks for CI (n = 8) remained in the same category at 12 weeks and 7/8 at 24 weeks. Improved patients at 6 weeks for CI (n = 51) remained in the same category in 63% and 53% of cases at 12 and 24 weeks, respectively. Unchanged patients at 6 weeks (n = 100) eventually improved in 28% of cases (CI), 58% (CAS), 32% (QoL). There was no glucocorticoid dose-dependent difference in the influence of early response on later outcomes. CONCLUSIONS: Patients who deteriorate at 6 weeks after ivGCs are unlikely to benefit from continuing ivGCs. Patients unresponsive at 6 weeks still have a significant possibility of improvement later. Accordingly, they may continue ivGC treatment, or, alternatively, possibly stop ivGCs and be switched to a second-line treatment.

Seven-year follow-up of unilateral multifocal pseudophakia in a child.

The purpose of the study was to report the long-term outcome of unilateral implantation of a multifocal intraocular lens (IOL) in a pediatric cataract. This study was carried out at Tertiary Academic Ophthalmology Department, AMC, Amsterdam. This is a case report study of a 7-year-old child with a unilateral irradiation cataract, in whom an apodized diffractive multifocal IOL (SN6D3, Alcon) was implanted at the time of cataract surgery. During the follow-up period, visual acuity was preserved at logMAR -0.1; the child did not develop amblyopia. Binocular single vision was established. Few glistenings were seen on the IOL. The non-operated eye developed more myopia during the follow-up period than the multifocally implanted eye. Straylight was increased to log(s) 1.83. Patient and parents satisfaction were high. In selected cases, unilateral implantation of apodized diffractive multifocal IOLs leads to good long-term results in terms of visual acuity and patient satisfaction. No untoward effects were seen, including few glistenings on the IOL. Straylight is increased, but subjectively not disturbing.

Straylight Measurements in Two Different Apodized Diffractive Multifocal Intraocular Lenses.

PURPOSE: To evaluate differences in straylight between eyes implanted with a hydrophilic multifocal IOL (Seelens MF; Hanita Lenses, Hanita, Israel) and a hydrophobic multifocal IOL (SN6AD1; Alcon Laboratories, Inc., Fort Worth, TX). METHODS: In a prospective cohort study, routinely obtained straylight measurements (C-Quant; Oculus Optikgeräte, Wetzlar, Germany) 3 months after standard phacoemulsification for either cataract or refractive lens procedures were compared. Patients were implanted with either the SeeLens MF IOL or the SN6AD1 IOL. Postoperative straylight values, visual acuity, and refractive outcomes were compared. RESULTS: The SeeLens MF IOL was implanted in 84 eyes and the SN6AD1 IOL in 79 eyes. The difference in straylight was 0.08 (P = .01), with the SeeLens MF IOL having less straylight. Postoperative CDVA was logMAR -0.03 ± 0.06 in the SeeLens MF group, and logMAR -0.02 ± 0.08 in the SN6AD1 group. Mean postoperative refraction was +0.01 ± 0.43 and +0.06 ± 0.35 D, respectively. CONCLUSIONS: The Seelens MF IOL showed a stray-light of log(s) 0.08 lower than the SN6AD1 IOL. In terms of spherical equivalent and visual acuity the lenses performed equally. More study will aid in understanding the causes and clinical impact of this difference.

Controversies in orbital reconstruction--I. Defect-driven orbital reconstruction: a systematic review.

In the 1980s, computed tomography was introduced as an imaging modality for diagnosing orbital fractures. Since then, new light has been shed on the field of orbital fracture management. Currently, most surgeons are likely to repair orbital fractures based on clinical findings and particularly on data obtained from computed tomography scans. However, an important but unresolved issue is the fracture size, which dictates the extent and type of reconstruction. In other fields of trauma surgery, an increasing body of evidence is stressing the importance of complexity-based treatment models. The aim of this study was to systematically review all articles on orbital reconstruction, with a focus on the indication for surgery and the defect size and location, in order to identify the reconstruction methods that show the best results for the different types of orbital fractures.

Controversies in orbital reconstruction--II. Timing of post-traumatic orbital reconstruction: a systematic review.

The timing of orbital reconstruction is a determinative factor with respect to the incidence of potential postoperative orbital complications. In orbital trauma surgery, a general distinction is made between immediate (within hours), early (within 2 weeks), and late surgical intervention. There is a strong consensus on the indications for immediate repair, but clinicians face challenges in identifying patients with minimal defects who may actually benefit from delayed surgical treatment. Moreover, controversies exist regarding the risk of late surgery-related orbital fibrosis, since traumatic ocular motility disorders sometimes recover spontaneously and therefore do not necessarily require surgery. In this study, all currently available evidence on timing as an independent variable in orbital fracture reduction outcomes for paediatric and adult patients was systematically reviewed. Current evidence supports guidelines for immediate repair but is insufficient to support guidelines on the best timing for non-immediate orbital reconstruction.

Acute sinusitis and blindness as the first presentation of chronic lymphocytic leukaemia.

Chronic lymphocytic leukaemia (CLL) is the most frequent form of leukaemia among adults in the Western world, presenting at a median age of 65 years. The diagnosis is usually made incidentally during routine blood examination while the disease is still in its early phase. We report a case of blindness of 24 hours due to acute sinusitis based on CLL localisation in a patient with undiagnosed CLL. Emergency endoscopic sinus surgery and intra- and extra-ocular orbital decompression were performed. The sinusitis resolved after surgery and intravenous antibiotics. Her vision improved within 24 hours and eventually recovered completely after six months. Her CLL remained in an indolent state, needing no active treatment. This case illustrates that blindness from a lymphoproliferative disorder may be treated with emergency endoscopic sinus surgery instead of conventional chemotherapy in order to salvage the vision first, even if the vision is lost for more than 24 hours.

Efficacy and safety of three different cumulative doses of intravenous methylprednisolone for moderate to severe and active Graves' orbitopathy.

BACKGROUND: Optimal doses of i.v. glucocorticoids for Graves' orbitopathy (GO) are undefined. METHODS: We carried out a multicenter, randomized, double-blind trial to determine efficacy and safety of three doses of i.v. methylprednisolone in 159 patients with moderate to severe and active GO. Patients were randomized to receive a cumulative dose of 2.25, 4.98, or 7.47 g in 12 weekly infusions. Efficacy was evaluated objectively at 12 wk by blinded ophthalmologists and subjectively by blinded patients (using a GO specific quality of life questionnaire). Adverse events were recorded at each visit. RESULTS: Overall ophthalmic improvement was more common using 7.47 g (52%) than 4.98 g (35%; P = 0.03) or 2.25 g (28%; P = 0.01). Compared with lower doses, the high-dose regimen led to the most improvement in objective measurement of ocular motility and in the Clinical Activity Score. The Clinical Activity Score decreased in all groups and to the least extent with 2.25 g. Quality of life improved most in the 7.47-g group, although not reaching statistical significance. No significant differences occurred in exophthalmos, palpebral aperture, soft tissue changes, and subjective diplopia score. Dysthyroid optic neuropathy developed in several patients in all groups. Because of this, differences among the three groups were no longer apparent at the exploratory 24-wk visit. Major adverse events were slightly more frequent using the highest dose but occurred also using the lowest dose. Among patients whose GO improved at 12 wk, 33% in the 7.47-group, 21% in the 4.98-group, and 40% in the 2.25-group had relapsing orbitopathy after glucocorticoid withdrawal at the exploratory 24-wk visit. CONCLUSIONS: The 7.47-g dose provides short-term advantages over lower doses. However, this benefit is transient and associated with slightly greater toxicity. The use of a cumulative dose of 7.47 g of methylprednisolone provides short-term advantage over lower doses. This may suggest that an intermediate-dose regimen be used in most cases and the high-dose regimen be reserved to most severe cases of GO.

Optimal management of Graves orbitopathy: a multidisciplinary approach.

Graves' thyroid disease is a relatively common disorder in endocrinology and general internal medicine practice. Graves' hyperthyroidism is mediated by circulating stimulating autoantibodies. Up to 60% of patients with Graves' hyperthyroidism develop some form of Graves' orbitopathy. Immune reactivity to the thyroid-stimulating hormone receptor is also thought to play a role in the immunopathogenesis of Graves' orbitopathy. Graves' orbitopathy is characterised by a wide open eye appearance, caused by upper eyelid retraction and soft-tissue swelling that causes exophthalmus. Symptoms include photophobia, sandy feeling in the eye, painful eye movements and diplopia. Visual acuity may be reduced. In some cases emergency treatment is necessary to prevent irreversible vision loss. Smoking should be stopped. Mild to moderate Graves' orbitopathy may be an indication for corticosteroid treatment or radiotherapy. Once inflammatory signs and symptoms have waned, surgery can be performed to correct residual diplopia, exophthalmus or lid retraction. The presence of Graves' orbitopathy has consequences for the management of Graves' hyperthyroidism. Adequately controlled Graves' thyroid dysfunction is likely to improve Graves' orbitopathy, while radioactive iodine treatment can worsen the condition. Due to the wide variety in clinical presentation and the possible interference between treatment of thyroid disease and eye disease, the management of more complicated patients with Graves' orbitopathy can best be performed in combined thyroid-eye clinics, in which the patient is seen simultaneously by the ophthalmologist and the endocrinologist.

Outcome of orbital decompression for disfiguring proptosis in patients with Graves' orbitopathy using various surgical procedures.

AIM: To compare the outcome of various surgical approaches of orbital decompression in patients with Graves' orbitopathy (GO) receiving surgery for disfiguring proptosis. METHOD: Data forms and questionnaires from consecutive, euthyroid patients with inactive GO who had undergone orbital decompression for disfiguring proptosis in 11 European centres were analysed. RESULTS: Eighteen different (combinations of) approaches were used, the swinging eyelid approach being the most popular followed by the coronal and transconjunctival approaches. The average proptosis reduction for all decompressions was 5.0 (SD 2.1) mm. After three-wall decompression the proptosis reduction was significantly greater than after two-wall decompression. Additional fat removal resulted in greater proptosis reduction. Complications were rare, the most frequent being worsening of motility, occurring more frequently after coronal decompression. The average change in quality of life (QOL) in the appearance arm of the GO-QOL questionnaire was 20.5 (SD 24.8) points. CONCLUSIONS: In Europe, a wide range of surgical approaches is used to reduce disfiguring proptosis in patients with GO. The extent of proptosis reduction depends on the number of walls removed and whether or not fat is removed. Serious complications are infrequent. Worsening of ocular motility is still a major complication, but was rare in this series after the swinging eyelid approach.

Favorable long-term results of primary pterygium removal by bare sclera extirpation followed by a single 90Strontium application.

PURPOSE: To describe and compare long-term (> or = 36 months) effects of patients with 86 primary pterygia treated with bare sclera extirpation (BSE) followed by Beta-RT or by sham irradiation. METHODS: Prospective, multicenter, randomized, double-blind study. After BSE of their pterygium, patients were randomized to either Beta-RT or sham irradiation. In the case of Beta-RT, within 24 hours after the operation, a 90Sr eye applicator was used to deliver 2500 cGy to the sclera surface at a dose rate of between 200 and 250 cGy/min. Sham irradiation was given using the same type of applicator without the 90Sr layer. After treatment, both a masked ophthalmologist and a radiation oncologist performed follow-up examinations. These were continued until either a relapse occurred or at least 36 months had elapsed. RESULTS: Adequate follow-up was available of 86 pterygia in 81 patients, treated between February 1998 and September 2002. Fifty-two (60%) patients were male. The mean age of the patients was 50 years (range: 24-77). After a follow-up of at least 36 months (mean: 40 months, SD:13.9 months), 5 out of 44 eyes (11%) treated with Beta-RT showed a recurrence versus 32 out of 42 eyes (76%) treated with sham-RT (after a mean follow-up of 22 months) (p<0.001). In the Beta-RT group, 80% were satisfied with the cosmetic result, whereas in the sham group this percentage was 41% (p<0.001). In the Beta-RT group, no scar or a white scar could be detected in 86% of the treated eyes, versus in 24% of the sham irradiated eyes (p<0.001). A change of keratometry (Javal) was seen in 5 patients (12%) following Beta-RT compared to 16 (38%) after sham irradiation (p=0.002). Complications were few: a granuloma was seen in three patients after sham irradiation, mild limitation of abduction in two Beta-RT patients versus in five after sham irradiation, and mild scleromalacia in one Beta-RT patient. CONCLUSIONS: Bare sclera extirpation of a pterygium without adjuvant treatment has an unacceptably high recurrence rate and therefore should be considered obsolete. Bare sclera extirpation of a primary pterygium followed by a single-dose Beta-RT is a simple, effective, and safe treatment with lasting results and very few complications.

Favorable effects of lacrimal plugs in patients with an anophthalmic socket.

BACKGROUND: The use of punctal plugs in the treatment of dry eyes is well established. Anophthalmic patients have less tears in the anophthalmic socket in comparison to their normal side, due to an absent corneal reflex (Lee & Elsie, 1981a,b). Many of those patients complain of dry eye symptoms, even when they are treated with tear replacement therapy. The authors wished to examine whether they could improve their dry socket complaints with punctal plugs. PURPOSE: To evaluate the clinical efficacy and tolerability of punctal plug (Smart Plugs) insertion in anophthalmic patients with symptoms of dry eye. PATIENTS AND METHODS: Interventional case series. Fifteen anophthalmic patients with dry eye symptoms, a Schirmer test of less than 3 mm and an open lacrimal passage were examined before and after insertion of punctal plugs. The patients were asked for their subjective evaluation of the treatment and were examined to evaluate the change. Schirmer tests were compared. Bacterial cultures were taken at both visits. RESULTS: Schirmer results of less than 3 mm in the anophthalmic socket were obtained in 75% of patients with dry eyes symptoms; 87% of patients in whom punctal plugs were inserted reported an improvement in dry eye sensation. More than half of the patients demonstrated less discharge (p < or = 0.05). Schirmer tests improved from 1.4 mm to 1.9 mm (p < or = 0.05). Patients with a Schirmer outcome of 2 mm or more tended to have less pathogenic bacterial cultures (p = 0.11). CONCLUSION: Punctal plugs improve the symptoms and signs of dry socket. Punctal plugs seem to reduce the pathogenic bacterial growth in the anophthalmic socket.

A questionnaire survey on the management of Graves' orbitopathy in Europe.

OBJECTIVE: To determine management patterns among clinicians who treat patients with Graves' orbitopathy (GO) in Europe. DESIGN AND METHODS: Questionnaire survey including a case scenario of members of professional organisations representing endocrinologists, ophthalmologists and nuclear medicine physicians. RESULTS: A multidisciplinary approach to manage GO was valued by 96.3% of responders, although 31.5% did not participate or refer to a multidisciplinary team and 21.5% of patients with GO treated by responders were not managed in a multidisciplinary setting. Access to surgery for sight-threatening GO was available only within weeks or months according to 59.5% of responders. Reluctance to refer urgently to an ophthalmologist was noted by 32.7% of responders despite the presence of suspected optic neuropathy. The use of steroids was not influenced by the age of the patient, but fewer responders chose to use steroids in a diabetic patient (72.1 vs 90.5%, P<0.001). Development of cushingoid features resulted in a reduction in steroid use (90.5 vs 36.5%, P<0.001) and increase in the use of orbital irradiation (from 23.8% to 40.4%, P<0.05) and surgical decompression (from 20.9 to 52.9%, P<0.001). More ophthalmologists chose surgical decompression for patients with threatened vision due to optic neuropathy, who were intolerant to steroids than other specialists (70.3 vs 41.8%, P<0.01). CONCLUSION: Deficiencies in the management of patients with GO in Europe were identified by this survey. Further training of clinicians, easier access of patients to specialist multidisciplinary centres and the publication of practice guidelines may help improve the management of this condition in Europe.

Surgical or medical decompression as a first-line treatment of optic neuropathy in Graves' ophthalmopathy? A randomized controlled trial.

OBJECTIVE: Only a small percentage of Graves' ophthalmopathy (GO) patients develop optic neuropathy with impending loss of visual acuity. Therapy with methylprednisolone pulses is the treatment of first choice in severe and active GO patients. When the effect is insufficient, patients are usually treated with surgical decompression. We investigated whether surgery could become the first-line treatment, thus preventing treatment with steroids. DESIGN AND SUBJECTS: We performed a randomized trial in 15 patients with very active GO and optic neuropathy. Six patients were treated with surgical decompression, and nine with methylprednisolone i.v. pulses for 2 weeks, followed by oral prednisone for 4 months. The primary outcome was determined by changes in visual acuity. If the eye disease deteriorated despite treatment or did not improve sufficiently, patients were switched to the other treatment arm. RESULTS: The severity and activity of GO in both groups were similar at baseline. The Clinical Activity Score (CAS) was 6.3+/- 0.8 in the surgical group vs. 6.0+/- 0.5 in the steroids group and the Total Eye Score was 24+/- 6 vs. 25+/- 6. In the surgery group, 5/6 patients (82%) did not respond because of insufficient improvement in vision (n=3) or persistent chemosis (n=2), and all needed further immunosuppression. In the steroids group, 4/9 patients (45%) did not improve in visual acuity (P=0.132 vs. surgery group), and these needed decompressive surgery. All patients in whom therapy failed were switched to the other treatment arm and visual acuity improved in almost all patients. Visual acuity improved from 0.36 (0.02--0.40) to 0.90 (0.63--1.0) in the surgery group and from 0.50 (0.32--0.63) to 0.75 (0.32--1.0) in the steroids group at 52 weeks. At long-term follow-up in the surgery group 3/6 patients required squint surgery and 5/9 patients in the steroids group. Eyelid surgery was performed in 5/6 patients in the surgery group and in 4/9 patients in the steroids group. CONCLUSION: Immediate surgery does not result in a better outcome and therefore methylprednisolone pulse therapy appears to be the first-choice therapy.

Reliability of exophthalmos measurement and the exophthalmometry value distribution in a healthy Dutch population and in Graves' patients. An exploratory study.

AIM: The purpose of this study was to test the reliability of an exophthalmometer commonly used in the Netherlands; to determine the exophthalmometry value distribution with this instrument and to assess the upper exophthalmometry limits of normal in a healthy, adult, Caucasian, Dutch population. Furthermore, to assess the effects of gender and age on exophthalmometry readings in this group and in a group of Graves' patients by comparing healthy, adult, Caucasian, Dutch individuals with adult, Caucasian, Dutch Graves' patients. METHODS: To test the reliability of our Hertel exophthalmometer, we determined the interobserver variation between two observers by measuring 160 eyes in healthy, adult, Caucasian, Dutch females and males (10 females and 10 males in each decade between 20 and 60 years of age). These data were also used for the assessment of the Hertel value distribution and for defining the upper limits of normal in these individuals by logistic regression analysis. The effects of disease, age and gender were established using these data plus data of a retrospective study of 393 adult, Caucasian, Dutch females (n=294) and males (n=99) with Graves' orbitopathy in whom Hertel values were measured with the same exophthalmometer. RESULTS: Exophthalmometry using an Hertel exophthalmometer appeared reliable (Pearson correlation coefficient for interobserver variation 0.89; 96% of the Hertel values measured by two observers were within the limits (of 2 mm) of agreement). Hertel values usually show a normal distribution in healthy individuals and in Graves' patients and are sex- and age-dependent, but there was no dependence on age in this small series in adults. Logistic regression analysis revealed an upper limit of normal of 16 mm in females and 20 mm in males in our group, using the exophthalmometer described. CONCLUSIONS: Exophthalmometry is reliable and absolute measurement of proptosis is feasible. International standardization of Hertel exophthalmometry is required in order to compare exophthalmometry data in the literature reliably.

[Lacrimal duct probing in young children with a congenital lacrimal duct obstruction at the Utrecht University Medical Center: generally an effective treatment]. / Traanwegsondage bij jonge kinderen met een aangeboren traanwegobstructie in het Universitair Medisch Centrum Utrecht: doorgaans een effectieve behandeling.

OBJECTIVE: To assess the results of lacrimal duct probing in young children with epiphora, due to a congenital nasolacrimal duct obstruction. DESIGN: Retrospective, descriptive. METHOD: Data were collected from medical dossiers on the results of lacrimal duct probing in children (0-48 months) with epiphora that was done in the period from January 1, 1997 to December 31, 2001 at the University Medical Centre in Utrecht, the Netherlands. The percentage of eyes that showed complete resolution of symptoms three months after the final probing was calculated. RESULTS: Of the 89 children who had undergone lacrimal duct probing, seven were excluded and in three children (six eyes) the data could not be retrieved. In 96 of the remaining 116 eyes (83%), the symptoms disappeared: this included 96% of the age group 0-12 months (n = 25), 85% of the 13-24 months-olds (n = 55), 77% of the 25-36 months-olds (n = 22) and 57% of the 37-48 months-olds (n = 14). No complications of probing were seen. CONCLUSION: In most children in the various age groups, epiphora disappeared. Thus, children do not need to be probed in the first year of life out of fear of failure at an older age. Whether or not probing shortens the duration of epiphora cannot be determined on the basis of either this study or the literature.