Retinal detachment after post-operative endophthalmitis: clinical characteristics, outcomes and risk factors.

PURPOSE: To describe clinical characteristics, risk factors, and outcomes of rhegmatogenous retinal detachment (RRD) following treatment of postoperative endophthalmitis (PE). METHODS: Analysis of cross-referenced data from two service reviews of patients with RRD and bacterial PE treated between 01/01/2013 and 01/07/2020. The main outcome measure was final best-corrected visual acuity (BCVA). Secondary measures include proportion of patients with BCVA of ≤ 0.3 logMAR and ≥ 1.0 logMAR, rate of phthsis, and rate of eye removal. RESULTS: Ninety-four cases of PE were analysed finding 21 cases of RRD (22%). Seven (35%) experienced recurrent RRD. Seven eyes (35%) were left with permanent silicone oil fill. All RRD cases had vitrectomy. After PE with RRD the median BCVA was 1.1 logMAR, compared with 0.4 logMAR for PE without RRD (p < 0.04). Fifty-seven percent (12/21) of RRD eyes attained BCVA of ≥ 1.0 logMAR vs. 29% (21/73) of PE without RRD (p = 0.01). Nineteen percent (4/21) of eyes with RRD attained BCVA of ≤ 0.3 logMAR, whereas those without RRD did so in 43% (31/73) of cases (p = 0.02). Five eyes with RRD (24%) and 2 eyes without RRD (3%) developed phthisis (p < 0.01). Three non-RRD cases required removal of the eye (4%, p = 0.46). Higher bacterial virulence was associated with worse final BCVA (2.1 logMAR vs. 0.3 logMAR; p < 0.01). RRD rate did not differ by bacterial virulence (OR 1.9; CI95: 0.6-6.9; p = 0.24). CONCLUSIONS: RRD following PE leads to worse clinical outcomes. Eyes which developed RRD were more likely to have undergone vitrectomy. Final BCVA was worse in cases with more virulent micro-organisms.

A Case of a Spontaneous Self-resolving Retrobulbar Hemorrhage Following 3,4-Methylenedioxy-methamphetamine Use.

This case report discusses the case of a 23-year-old male patient who experienced retrobulbar pain, diplopia, proptosis, and mild lower eyelid bruising after consuming 3,4-methylenedioxy-methamphetamine. The symptoms settled over 10 days and vision returned to normal without intervention. The authors discuss the differential diagnosis relevant to the presenting complaints and propose several mechanisms linking 3,4-methylenedioxy-methamphetamine use to spontaneous nontraumatic intraorbital hematoma.

Case report: a diagnostically challenging conjunctival mass caused by the Epstein-Barr virus.

We present a paediatric case of infectious mononucleosis in a 13-year old, manifesting with follicular conjunctivitis and a conjunctival mass in one eye with no evidence of leucocytosis on the blood count. The diagnosis was confirmed following surgical excision and biopsy. The case represented a diagnostic challenge due to its atypism and given the steady increase in the prevalence of EBV-related ocular diseases in the last years, this report can serve as an example to prompt earlier serological tests to identify the aetiology in similar cases. This is important because EBV can be treated with acyclovir early in the active viral phase.

A smartphone lens attachment improves the quality of referrals to eye casualty.

BACKGROUND/OBJECTIVES: In recent years, eye casualty clinics have seen significant increases in patient numbers with reduced capacity. COVID-19 has exacerbated this issue and demonstrated the potential of telemedicine as a solution. Our study evaluated the potential benefit of a smartphone-based lens attachment to improve the referral pathway for anterior segment related complaints in eye casualty. SUBJECTS/METHODS: Fifty-four consecutive patients with anterior segment complaints were recruited. A questionnaire was completed with each patient to simulate the history from the point of referral. White light and cobalt blue photos were captured using a smartphone lens. The clinician reviewing the patient was asked to document the actual diagnosis and the appropriate time-frame within which they felt the patient could safely have been seen within; both with and without the option of management advice at the time of triage. The subsequent images and questionnaires were reviewed by a single consultant Ophthalmologist who was independent to the data collection process. The assessor was asked to make a diagnosis and management plan based upon the questionnaire ('History'), and the questionnaire with the photo ('History with Image'), as well as rate their clinical confidence on a 1-5 scale. RESULTS: Diagnostic accuracy was significantly higher in "History with Image" (98.2%), when compared to "History" only (48.2%). "History with Image" prevented significantly more appointments when compared to "History" alone, at similar levels to retrospective clinic review. Preventable appointments were increased if clinical advice was possible. Timeframe of appointments between 'History with Image' and 'Clinic' appointments was similar. Clinical'Confidence was significantly higher at 4.5 with 'History with Image' when compared to 2.37 with 'History Only'. CONCLUSION: A low-cost smartphone lens attachment, alongside a standardised clinical questionnaire, can improve the referral pathway to the hospital eye service by reducing unnecessary appointments, while improving clinical confidence and diagnostic accuracy during triage. Further work to evaluate referral pathways, including the development of systems that allow for secure image transmission are needed to understand the feasibility for the widespread adoption of this technology.

Clinical study of laminar resorption: Part 2- outcomes, review and proposal for classification.

PURPOSE: To analyze and review the clinical features and main outcomes of laminar resorption from the UK osteo-odonto-keratoprosthesis (OOKP) cohort. METHODS: A retrospective review of case records was undertaken for patients who underwent keratoprostheses between 1996 and 2014 at the Sussex Eye Hospital, Brighton, UK. The main clinical outcomes of resorption, including its clinical signs, complications, treatments, and laminar survival, were evaluated. RESULTS: Sixty-four patients (25-females, 39-males) were included, and in total, 74 laminae (3-tibial, 11-allografts, 60-autografts) were implanted. The age of the patients ranged from 20 to 91 years. Focal laminar thinning was the first sign of detectable resorption in 50% of autografts and 27% of allografts. All the tibial grafts and 55% of allografts presented with complications of resorption like endophthalmitis and aqueous leakage as the first signs of resorption. The survival of first implanted autografts was 82.4%(±6.3%) at 18 years, which was enhanced to 91.5%(±5.0%) by prophylactic exchanges of critically resorbed laminae with new laminae. Visual acuity survival analysis did not reveal a statistically significant difference between grafts with and without resorption for all graft types (p = 0.825). Patients treated with Alendronic acid and acetazolamide demonstrated trends toward the slower progression of resorption, but this was not statistically significant. CONCLUSIONS: Focal laminar thinning was the common presenting feature of resorption in autografts. Timely replacement of the resorbed laminae with new laminae should be considered to avoid complications. Alendronic acid supplementation may be considered in high-risk cases of resorption to reduce further progression.

Clinical study of laminar resorption: Part 1 - Factors affecting laminar resorption.

PURPOSE: To analyse the factors affecting laminar resorption in the UK osteo-odonto-keratoprosthesis (OOKP) cohort and present a detailed review. METHODS: A retrospective review of the case records of the patients who underwent OOKP between 1996 and 2014 was performed at the Sussex Eye Hospital in Brighton, UK. RESULTS: Sixty-four patients (25 females and 39 males) were included, and 74 laminae were implanted consisting of 3 tibial grafts, 11 tooth allografts and 60 tooth autografts. In total, 69% (n = 51) showed resorption. Non-smokers had better oral health compared to smokers (71% vs 50%, respectively). Poor oral health was strongly associated with poor quality dentition and edentulism (p < 0.001). The laminar thickness and waiting for the time between stages 1 and 2 surgeries did not show significant influence on the onset and progression of resorption. From the Cox multivariate analysis for autografts, smoking, age and gender were not associated with a statistically significant difference in the rates of resorption. The maximum number of laminae with resorption belonged to Stevens-Johnson syndrome patients (n = 32 or 43%). CONCLUSIONS: Two-thirds of the cases of resorption were detected in the first three years of OOKP, and the maximum were noted in the first year of follow up (40%). The laminar thickness did not influence the post-operative onset and progression of resorption. The presence of resorption after stage 1 did not show a measurable effect on the onset and progression of post-stage 2 resorption.

Detection of laminar resorption in osteo-odonto-keratoprostheses.

PURPOSE: To compare the clinical examination and computerized tomography (CT) scanning methods for the detection of laminar resorption in eyes with osteo-odonto-keratoprosthesis (OOKP). METHODS: Patients who developed laminar resorption after OOKP surgery and had at least one CT scan of the lamina during the follow-up were included. Case records and CT images and reports were retrospectively reviewed. Each lamina of the eye was regarded as a case. The imaging and clinical data were collected in Microsoft Excel, and statistical analysis was performed on Stata-v14. The agreements and sensitivities of both the methods were compared. RESULTS: Forty patients out of 64 were found to have laminar resorption. A total of 48 laminae were studied, which had data on the presence or absence of resorption. The sensitivity and specificity of clinical detection of resorption were 87.5% (CI 68%-97%) and 37.5% (CI 8.5%-75.5%), respectively. Whereas, the sensitivity and specificity of CT scan were 81% (CI 61%-93%) and 50% (CI12%-88%), respectively. Both the methods have detected resorption in 21 out of 32 laminae having both the clinical and CT scan data. There is a fair agreement between the two techniques in the identification of thinned laminar sites. CONCLUSIONS: Clinical detection of laminar resorption in OOKP eyes is equally sensitive to the CT scanning. Resorption can be detected even in its early stages by clinical palpation in experienced hands. Frequent CT scanning is not indicated to detect laminar resorption. Both methods complement each other. Thinned laminar segments should be compared and correlated with both the methods for full evaluation of resorption.

A randomized, fellow eye, comparison of keratometry, aberrometry, tear film, axial length and the anterior chamber depth after eye rubbing in non-keratoconic eyes.

BACKGROUND: To investigate the effect of eye rubbing on keratometry (K), aberrometry, tear film break-up-time (TFBUT) and anterior chamber depth (ACD). METHODS: Volunteers without any corneal pathology or dry eyes were randomised to rubbing in one eye and the fellow-eye was control. Eye rubbing was performed for 2 min. Primary outcomes studied were anterior and posterior K changes. Secondary outcomes were changes in TFBUT, axial length (AL) & ACD, K changes in various zones, asphericity and aberrometry. Pre and post rubbing K, aberrometry, ACD and TFBUT were assessed in a predetermined sequence. The relationship of the above parameters to axial length (AL) was also assessed. Astigmatism was analysed using vector analysis. RESULTS: Pre versus post rubbing, anterior flatter K further flattened (42.51 ± 1.52 D vs. 42.36 ± 1.53 D, p = 0.003) and the changes to J0 vector in central cornea (-0.16 ± 0.26 D vs. -0.27 ± 0.33 D, p = 0.038) suggested change to against-the-rule (ATR) astigmatism. There was significant change in Z2+2 polynomial following rubbing. We found a positive correlation between axial length and change in posterior K (r = 0.335, p = 0.020). The TFBUT reduced following eye rubbing (15.3 s vs. 13.9 s, p = 0.0001). There was a positive correlation between AL and increase in ACD post rubbing (r = 0.300, p = 0.038). There was a positive correlation between ACD and change in mean posterior K (r = 0.305, p = 0.035). CONCLUSIONS: In healthy eyes, following eye rubbing, there is a significant change in TFBUT and central anterior K changes towards ATR astigmatism. Longer eyes had more changes in posterior K and ACD. Whereas, eyes with deeper ACD showed more steepness of posterior K. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT02131740.

Vent Incisions to Facilitate Peripheral Unfolding of the DMEK Graft.

PURPOSE: To present the results of 15 cases in which a modified technique of Descemet membrane endothelial keratoplasty (DMEK) with vent incisions was used to assist unfolding of tight peripheral inward folds. METHODS: This is a retrospective case series of 15 consecutive eyes that underwent a modified vent incision technique for DMEK. Six oblique, small-size (1 mm) vent incisions parallel to the limbus and 3.5 mm from the center were performed after descemetorhexis. The graft was opened with standard no-touch techniques and was partially attached to the stroma with air injection. Then, in cases with remaining tight inward folds despite gentle corneal tapping, jets of balanced salt solution were pulsed through the vent incisions directed at the peripheral folds to achieve complete unfolding. RESULTS: Descemet membrane endothelial keratoplasty was performed in 2 phakic eyes (14%) and 13 pseudophakic eyes (86%). Six cases (40%) required fluid injection through the vent incisions: 3 corresponded to grafts from younger donors (54, 41, and 29 years old), and 3 had a 9.0-mm-sized graft. Complete graft unfolding was successfully achieved in 14 cases (93%), and in 1 case (7%), peripheral folds remained because of spontaneous bleeding in the anterior chamber. A clear cornea was achieved in all cases, and there were no postoperative complications associated with the vent incisions. CONCLUSIONS: This technique provides a different DMEK no-touch approach that could be used in challenging cases of graft unfolding such as young donors and/or large-sized grafts. It may also avoid excessive unfolding times and direct manipulation that are related to higher endothelial cell loss.