A case report of ophthalmic artery emboli secondary to Calcium Hydroxylapatite filler injection for nose augmentation- long-term outcome.

BACKGROUND: Filler injection for face augmentation is a common cosmetic procedure in the last decades, in our case report we describe long-term outcomes of a devastating complication of ophthalmic artery emboli following Calcium Hydroxylapatite filler injection to the nose bridge. CASE PRESENTATION: A healthy 24-year-old women received a Calcium Hydroxylapatite filler injection to her nose bridge for the correction of nose asymmetry 8 years post rhinoplasty. She developed sudden right eye ocular pain and visual disturbances. Visual acuity was 20/20 in both eyes and visual field in the right eye showed inferior arch with fixation sparing and supero-temporal central scotoma. Examination revealed marked periorbital edema and hematoma, ptosis, ocular movements limitation, an infero-temporal branch retinal artery occlusion and multiple choroidal emboli. Eighteen months post initial presentation ptosis and eye movements returned normal and choroidal emboli absorbed almost completely. However, visual acuity declined to 20/60, visual field showed severe progressive deterioration with a central and supero-nasal field remnant and the optic disc became pallor. CONCLUSION: Cosmetic injection of calcium hydroxylapatite to the nose bridge can result in arterial emboli to the ophthalmic system with optic nerve, retinal and choroidal involvement causing long term severe visual acuity and visual field impairment.

Effect of Corneal Thickness on the Penetration of Topical Vancomycin.

PURPOSE: To study the influence of corneal thickness on intraocular penetration of topical ophthalmic drops, using vancomycin 50 mg/mL drops as a model. METHODS: The study included 58 eyes of 58 patients undergoing phacoemulsification cataract extraction. The central corneal thickness was measured by ultrasonic pachymetry on the day of surgery. Thirty minutes before the surgery, one drop of topical vancomycin 50 mg/mL was instilled three times with 10-minute intervals: 30 minutes, 20 minutes, and 10 minutes before the surgery. At the beginning of surgery, a small specimen of aqueous humor was aspirated and sent to the laboratory for measurement of drug concentration to determine the effect of corneal thickness on vancomycin concentration in the anterior chamber. RESULTS: There was insufficient amount of aqueous humor for analysis in 9 samples, leaving a total of 49 samples. The mean central corneal thickness was 539.7 (±39.5) µm (range, 458 to 635 µm). The mean vancomycin concentration in the anterior chamber was 0.220 (±0.209) µg/mL. There was no significant association between vancomycin concentration and corneal thickness (r = -0.07, p = 0.62, Pearson correlation). When patients were divided into three groups based on the mean (±1 SD) central corneal thickness, no significant differences in vancomycin concentrations (in micrograms per milliliter) were encountered: 0.267 (±0.247) (for corneal thickness <500.2 µm), 0.209 (±0.212) (for corneal thickness of 500.2 to 579.2 µm), and 0.200 (±0.160) (for corneal thickness >579.2 µm) (p = 0.73, analysis of variance). CONCLUSIONS: Corneal thickness does not influence the penetration of topically applied vancomycin into the anterior chamber.

Outcomes of refractive error correction in pseudophakic patients using a sulcus piggyback intraocular lens.

PURPOSE: The purpose of this study was to assess the results of a sulcus intraocular lens (Sulcoflex) for pseudophakic refractive errors following phacoemulsification cataract surgery. METHODS: This retrospective clinical observational cohort study included consecutive eyes in which a Sulcoflex was implanted. Uncorrected distance visual acuity and corrected distance visual acuity as well as refractive outcomes were assessed. The minimum follow-up time required for inclusion was 3 months. RESULTS: In total, 15 eyes (n = 15) were evaluated. The mean follow-up was 14 months (range: 3-18 months). The Sulcoflex aspheric (653L) was implanted in 13 eyes and the Sulcoflex toric (653T) in two eyes. The preoperative mean logMAR (Snellen) uncorrected distance visual acuity and corrected distance visual acuity were 0.88 (20/150) and 0.27 (20/40), respectively. The postoperative mean logMAR (Snellen) corrected distance visual acuity was 0.15 (20/30). The preoperative mean spherical equivalent was -0.22 ± 5.95 D and the postoperative mean spherical equivalent was -1.59 ± 1.45 D. There was a significant and strong correlation (r = 0.64, p < 0.001) between the attempted and the achieved spherical equivalent. CONCLUSION: The Sulcoflex is a safe and viable option for patients with residual refractive error following cataract surgery.

Early Refractive and Clinical Outcomes of High-Myopic Photorefractive Keratectomy as an Alternative to LASIK Surgery in Eyes with High Preoperative Percentage of Tissue Altered.

OBJECTIVE: To analyze the safety and efficacy of high-myopic PRK as an alternative to LASIK surgery in patients with a high preoperative percentage tissue altered (PTA). DESIGN: Retrospective interventional case series. PARTICIPANTS: Charts of 256 consecutive eyes that underwent PRK with application of mitomycin-C 0.02% for high myopia were retrospectively reviewed. METHODS: Refractive (refraction and refractive accuracy) and visual outcomes (uncorrected and corrected visual acuities), as well as occurrence of haze in the eyes with preoperative PTA expected to be higher than 40% with a 110-micron flap if undergoing LASIK surgery, were analyzed. RESULTS: Mean follow-up was 7.3 ± 4.8 months. A total of 187 of 256 eyes (73.0%) were included in the analysis because they were expected to have a PTA greater than 40%, should they have undergone LASIK surgery. The actual mean PTA of those eyes following PRK was 31.8 ± 2.2%, and none had a PTA ≥ 40%. UDVA of 20/16, 20/20, and 20/25 or better was achieved in 1.2% (2 eyes), 65.5% (112 eyes), and 85.4% (146 eyes), respectively. The percentage of eyes with postoperative SE within ±0.5 D and ±1.0 D of planned SE was 71% and 93%, respectively. None of the eyes lost 2 or more lines of CDVA. The rate of stromal haze, managed successfully with topical steroids only, was 4.8%. CONCLUSION: High-myopic PRK with application of mitomycin-C in the eyes at risk of developing ectasia because of high preoperative PTA was demonstrated to be a safe and effective alternative to the LASIK procedure.

Acute esotropia after epidural anesthesia.

BACKGROUND: Cranial nerve palsy after dural puncture is an uncommon complication. The sixth cranial nerve is the most commonly affected because of its long intracranial course. We report a case of acute comitant esotropia that occurred after unintentional dural puncture. CASE: A young woman presented with acute onset comitant esotropia 1 week after epidural anesthesia for a normal vaginal delivery during which the dura was unintentionally punctured. Magnetic resonance imaging revealed diffuse pachymeningeal enhancement, typically seen after dural puncture. Resolution was spontaneous. CONCLUSION: Puncture of the dura should be considered when acute strabismus is diagnosed shortly after epidural anesthesia.

Increased red blood cell aggregation in patients with idiopathic intracranial hypertension. A hitherto unexplored pathophysiological pathway.

It was the objective of this study to explore the possibility that the aggregation of red blood cells is enhanced in individuals with increased intracranial hypertension (IIH). This is a prospective cross sectional examination in a cohort of patients with IIH and matched controls. The aggregation of red blood cells in the peripheral venous blood was determined by using a slide test and image analysis. We have presently included a group of 33 women with IIH and the same number of women matched for age, body mass index, vascular risk factors and medications. A significant (p = 0.038) increment in fibrinogen concentrations was noted in the patients (341 +/- 60.8 mg/dl) as opposed to the controls 307.9 +/- 64.8). The same stands for the aggregation of red blood cells (aggregation parameter of 8.7 +/- 4.9 in patients vs.5.9 +/- 3.2 in the controls, p = 0.001). We noted an increment in the aggregation of red blood cells in the peripheral blood of 33 women with IIH as opposed to matched controls. Being associated with capillary slow flow, these findings might be relevant to the ethiopathogenesis of this disease.

The effect of cataract surgery on ocular dominance.

PURPOSE: The aim of this study is to assess whether eye dominance may change after cataract surgery. METHODS: This is a prospective case series. Cataract surgery candidates were examined prior to surgery for best-corrected visual acuity, eye dominance, and handedness. Patients with ocular conditions that may affect visual acuity were excluded from the study. A month following surgery, best-corrected visual acuity and eye dominance examinations were repeated. RESULTS: The study included 33 patients with a mean age of 70.5±9.4 years. Eighteen patients (54.5%) had right eye dominance. Following surgery, seven patients (21.2%) had a change in eye dominance. The change in dominance was linked to improved visual acuity in the operated eye and to a younger age, although with no statistical significance. CONCLUSION: This is the first study reported in the literature to show that ocular dominance is a plastic characteristic following cataract surgeries. The results may change the importance given to eye dominance measurement prior to surgeries that rely on this examination, such as monovision surgeries.

Long-term outcomes of triamcinolone acetonide-assisted anterior vitrectomy during complicated cataract surgery with vitreous loss.

PURPOSE: To report the long-term outcomes of triamcinolone acetonide-assisted anterior vitrectomy during complicated cataract surgery with vitreous loss. SETTING: Tel Aviv Medical Center, Tel Aviv, Israel. DESIGN: Case series. METHODS: Consecutive patients who had triamcinolone acetonide-assisted anterior vitrectomy for complicated cataract surgery with vitreous loss between January 2010 and January 2012 were studied. The main outcome measures were the results of the ocular examination and spectral-domain optical coherence tomography of the macula at the last follow-up visit 12 months or more postoperatively. The ocular examination included corrected distance visual acuity (CDVA), intraocular pressure (IOP), and anterior segment and fundus biomicroscopy. RESULTS: The study included 15 patients (15 eyes) with a mean age of 71 years (range 50 to 92 years). The mean follow-up was 21 months (range 12 to 29 months). At the last follow-up, the mean CDVA was statistically significantly better than preoperatively (0.24 logMAR ± 0.31 [SD] versus 0.89 ± 0.81 logMAR) (P=.0033); all patients had improved CDVA over the preoperative values. Except for 1 patient with a macular scar, all the patients had a CDVA between 20/40 and 20/20. At last follow-up, 1 patient required 2 IOP-lowering medications that had been used preoperatively as well. The mean IOP was 15.3 ± 2.4 mm Hg. There were no cases of residual vitreous strands in the anterior chamber, inflammatory reactions, triamcinolone acetonide crystals, retinal breaks, retinal detachment, or pseudophakic cystoid macular edema. CONCLUSION: Triamcinolone acetonide-assisted anterior vitrectomy during complicated cataract surgery with vitreous loss was safe and effective.

Retreatment with Ozurdex for macular edema secondary to retinal vein occlusion.

PURPOSE: To review the current practice of retreatment with Ozurdex injections in patients with macular edema (ME) secondary to retinal vein occlusion (RVO), and to recommend simple guidelines for Ozurdex reinjection in management of RVO. METHODS: This was a multicenter retrospective study of patients who received more than 2 Ozurdex injections for the treatment of ME in RVO. Recorded parameters included percent of patients with a 15-letter gain, visual acuity (VA) improvement from baseline, change in central macular thickness (CMT), time to reinjection, and occurrence of any complications. RESULTS: A total of 128 patients were included, 58 (45.3%) with central RVO (CRVO) and 70 (54.7%) with branch RVO (BRVO). Mean interval for Ozurdex reinjection was 5.9 months following the first injection and 8.7 months following the second. A >15-letter gain in VA was observed in 34 (48.8%) patients with CRVO and 16 (28%) patients with BRVO. Mean overall VA improvement at month 6 did not show significance (p>0.05); however, a significantly better mean VA improvement was seen in treatment-naïve eyes (p<0.03). The CMT was significantly reduced compared to baseline. The mean CMT decreased by 214.6 µm in eyes with BRVO (n = 53) and by 355.1 µm in eyes with CRVO (n = 63) (p = 0.002). Complication rates were very low. CONCLUSIONS: Repeated injections of Ozurdex are effective and have a favorable safety profile. In current practice, the retreatment interval with Ozurdex injections might be too long, precluding the full therapeutic potential of this treatment modality. A strategy for managing RVO patients treated with Ozurdex on an as-needed basis is provided.