Long-term refractive changes in children following ptosis surgery: a case series and a review of the literature.

The purpose of the study was to evaluate the long-term changes in refractive error in children with congenital ptosis managed with unilateral levator resection, and to provide a brief literature review and discuss the possible mechanisms for refractive change in the post-operative period. We present a retrospective consecutive case series of children (4-11 years old) who underwent unilateral levator resection, performed by a single ophthalmic surgeon to manage congenital ptosis between 1998 and 2001 at Maidstone Hospital, Kent. Cycloplegic refraction data were obtained prior to surgery and at the last clinic visit post surgery (minimum follow-up 12 months). The refractive changes in the non-operated contralateral eye were used as age-matched controls. Data were analysed for changes in refractive sphere and cylinder. Forty-three patients underwent levator resection during this 3-year period. Complete refraction data were available for 13 patients. The mean age at the time of levator resection was 6.7 years. The refractive error was greater on the side with the ptosis (61 %). At the last clinical follow up (mean 36.3 months; SD 34 months), the mean spherical change in the operated eye was 0.41D (range 0.12-1.50D), compared to a mean change of 0.40D (range 0.25-2.00D) in the non-operated eye. The mean cylindrical change in the operated eyes was 0.38D (range 0.25-1.00D), compared to a mean of 0.21D (range 0.50-1.75D) in the non-operated eye. In conclusion, this study did not show a significant change in refractive error following levator resection surgery for congenital ptosis.

A case report of orbital haemorrhage associated with endoscopic sinus surgery and reversible sight loss: a multidisciplinary approach to management.

We report a case of intraoperative orbital haemorrhage as a complication of endoscopic sinus surgery performed under general anaesthesia. Initial unilateral complete visual loss occurred, but recovered due to accurate and early diagnosis combined with urgent surgical intervention. This patient's case is reported to illustrate the importance of early recognition of clinical signs and how a stepwise approach to management can result in a favourable visual outcome. Moreover, the mechanisms and pathophysiology of visual loss due to orbital haemorrhage following endoscopic sinus surgery are discussed.

Blepharoptosis following anterior segment surgery: a new theory for an old problem.

Blepharoptosis is a well-known complication following anterior segment surgery. However, its precise aetiology remains elusive. There are currently two widely held views on the pathogenesis of persistent postoperative ptosis, namely the speculum and bridle suture theories. However, both suggested explanations fail to address important anatomical and epidemiological features of this condition. Until now, the majority of published literature describing persistent postoperative ptosis following anterior segment surgery has largely concentrated on dehiscence of the levator aponeurosis as the common mechanism underlying this postoperative complication. However, numerous studies have failed to show any correlation between pre or postoperative skin crease positions in such patients. This review article discusses previously proposed mechanisms responsible for both transient and persistent ptosis. Furthermore, we propose an alternative mechanism for the development of ptosis following anterior segment surgery, namely horizontal stretch of the upper eyelid induced by the use of the speculum. This mechanism also provides a plausible explanation for less commonly described oculoplastic complications, such as lower lid malpositions, following anterior segment surgery. Postoperative ptosis may also act as a paradigm for the development of involutional ptosis in general. In view of the frequency with which ophthalmologists perform anterior segment procedures such as cataract surgery, postoperative ptosis represents a significant concern for all ocular surgeons. Identifying the underlying mechanism is imperative, not only to identify those patients at greatest risk, but also to perhaps provide novel surgical approaches to the management of this complication.

Self-Monitoring of Intraocular Pressure Outside of Normal Office Hours Using Rebound Tonometry: Initial Clinical Experience in Patients With Normal Tension Glaucoma.

PURPOSE: To determine the value and accuracy of 24-hour intraocular pressure (IOP) phasing using Icare ONE rebound tonometry (RTONE), in subjects with normal tension glaucoma (NTG). METHODS: Eighteen consecutive patients with treated NTG were studied, all subjects had undergone 24-hour IOP phasing during a 1-year period. Each patient had daytime (08:00 to 16:00) IOP phasing with Goldmann applanation tonometer at 2-hourly intervals; at these same time points an IOP reading was also obtained by the patient using RTONE. Self-measured IOPs were then recorded at home using RTONE between 18:00 and 06:00 (at 2-hourly intervals). The frequency with which the phasing results altered clinical management was evaluated. RESULTS: The mean peak IOP was significantly higher during nighttime phasing (15.78±4.8 mm Hg) compared with daytime phasing (12.83±2.7 mm Hg, P=0.0018) and clinic IOP measurements (11.8±1.6 mm Hg, P<0.0001). Following IOP phasing a change in management occurred in 10 of 18 patients (56%). In the majority of these patients, a peak IOP was identified during nighttime phasing compared with daytime phasing, this difference was significant (P=0.0090). There were strong correlations between the IOP measurements obtained with Goldmann applanation tonometer and RTONE (Spearman r values >0.60, P<0.001). CONCLUSIONS: This study suggests that in patients with NTG with progression that is disproportionate to their clinic IOP measurements, 24-hour phasing can reveal higher IOP spikes than those identified during typical office hours. RTONE is a safe, easy to use, and accurate device for self-monitoring of IOP.

Lowering the limit: reducing the CD4 T-cell threshold for ophthalmic screening in patients with HIV in an ethnically diverse UK population.

BACKGROUND: Before highly active antiretroviral therapy, cytomegalovirus (CMV) retinitis was a major threat to vision in individuals with HIV. We investigate whether ophthalmic screening of asymptomatic HIV patients still has value in the highly active antiretroviral therapy era and consider CD4 thresholds in line with the world literature and UK experience. METHODS: A retrospective chart review was conducted of all patients seen by the HIV Ophthalmic Service of a UK university hospital both before (2007-2008) and after (2011-2012) introduction of a threshold of CD4 lower than 100 cells/mm(3). Data collected included CMV and HIV RNA load, CD4 cell counts and CD4 percentage, CMV-immunoglobulin G status, ocular symptoms, and evidence of HIV-related ocular disease. RESULTS: In total, 54 patients were referred to the HIV ophthalmic service. Three patients failed to attend, resulting in complete data for 51 patients (n=24 for 2007-2008; n=27 for 2011-2012). Seven patients had ophthalmic manifestations of their HIV; these cases had lower CD4 counts than those with normal examinations (median [interquartile range], 9 [7-80] versus 175 [44-394]; P=0.0039; Mann-Whitney test). Six cases had HIV retinopathy without sight loss; one case had sight-threatening CMV retinitis associated with a CD4 count of 6 cells/mm(3). CONCLUSION: Before 2008, our practice was to screen all asymptomatic patients with CD4 counts lower than 200 cells/mm(3). Screening asymptomatic patients with CD4 counts below 100 cells/mm(3) was not associated with any missed or late-presenting cases of CMV retinitis in our HIV population.

Central serous chorioretinopathy secondary to trauma.

The first case of central serous chorioretinopathy secondary to blunt trauma is presented. Optical coherence tomography performed on presentation, 3 days after trauma, demonstrated a neurosensory detachment of the macular, thus confirming clinical findings. At 3 months after injury, the retina had spontaneously flattened at the macular and vision had returned to normal.

Phacoemulsification and foldable intraocular lens implantation combined with 23-gauge transconjunctival sutureless vitrectomy.

PURPOSE: To evaluate the effectiveness, technical feasibility, outcomes, and complications of phacoemulsification and intraocular lens (IOL) implantation combined with 23-gauge transconjunctival sutureless vitrectomy. SETTING: Ophthalmology Department, Calderdale Royal Hospital, Halifax, United Kingdom. METHOD: This retrospective noncomparative interventional case series evaluated the results of 23-gauge transconjunctival sutureless vitrectomy combined with phacoemulsification and IOL implantation. Primary outcome measures included suture, complication, and hypotony rates; logMAR visual acuity; and intraocular inflammation. RESULTS: Sixty consecutive patients (60 eyes) were included. The mean visual acuity was 0.87 logMAR +/- 0.68 (SD) preoperatively and 0.46 +/- 0.34 logMAR 6 weeks postoperatively; the improvement was statistically significant (P<.0001). The 23-gauge ports were self-sealing in all eyes but 4 (6.7%), in which a single pars plana port was sutured. The mean intraocular pressure was 24.0 +/- 15.6 mm Hg 1 day postoperatively. Eight eyes (13.0%) had postoperative hypotony (<10 mm Hg); all recovered spontaneously within 24 hours. Of the eyes in which long-term tamponade was not necessary (n =12), all 3 with no endotamponade and 3 of 9 with air tamponade had postoperative hypotony; the difference was not statistically significant (P = .09). CONCLUSIONS: Combined transconjunctival sutureless vitrectomy and phacoemulsification was effective and safe in managing simultaneous cataract and vitreoretinal pathology. The self-sealing incisions did not adversely affect the overall surgical or visual outcomes, led to faster visual rehabilitation, and reduced ocular inflammation. The use of air tamponade when no long-term endotamponade was necessary appeared to reduce the risk for hypotony.