A new approach in the surgical management of anterior capsular phimosis syndrome.

Anterior capsular opacification and contraction syndrome is a well-recognised complication of uneventful phacoemulsification. It often results in a clinically significant reduction in vision secondary to central opacification, intraocular lens decentration and tilt. We report 3 cases of anterior capsular phimosis, which we treated using a new technique, where long, fine pointed scissors are used to cut the anterior capsule radially towards the edge of the lens optic and the edge is then grasped with capsulorrhexis forceps and the anterior capsule is torn away. The tear occurs at the edge of the optic because the anterior and posterior capsules are fused at this point. We believe that our technique offers a superior alternative for the effective, safe and quick management of anterior capsular phimosis, thereby improving the intraoperative fundus view for vitreoretinal surgery or delivery of laser treatment.

Surgical management of optic disc pit associated maculopathy.

PURPOSE: To report the surgical outcome in seven cases of optic disc pit associated maculopathy. METHODS: This was a retrospective case-note analysis of presenting features, pre- and postoperative visual acuities, surgical procedures, complications, and follow-up. The principal treatment in all the cases was pars plana vitrectomy, posterior hyaloid peel, endolaser to the papillomacular bundle temporal to the disc, and internal tamponade with gas or silicone oil. RESULTS: Of the four male and three female patients, two were children. All the patients had posterior hyaloid peeling during the vitrectomy and endolaser. Six patients had intraocular gas tamponade and one had silicone oil. Four patients needed a second surgical procedure to obtain a satisfactory anatomic and visual outcome. Postoperatively, four patients had an improvement of 2 or more Snellen lines. One patient with a history of multiple surgeries developed high intraocular pressure postoperatively and cataract. The mean follow-up period was 9.1 months. CONCLUSIONS: Serous retinopathy associated with optic disc pit responds well to early vitrectomy, endolaser, and internal tamponade. Silicone oil was effective in one refractory case. Cumulative data are required to define the management of this condition.

The removal of silicone oil from the anterior chamber in phakic eyes.

The appearance of large silicone oil globules in the anterior chamber of phakic eyes leads to serious intraoperative and postoperative problems. Using hyaluronate sodium, the silicone can be safely removed from the anterior chamber, the crystalline lens may be saved, and the posterior segment procedure can be completed.

Previously undiagnosed lymphoma presenting as recurrent dacryocystitis.

Lymphoma occurring in the lacrimal sac is uncommon and usually occurs in patients with known systemic disease. We report the case of an 82-year-old woman who presented with recurrent right dacryocystitis and a mass in the left lower eyelid. The results of the biopsy of the eyelid and fine-needle aspiration of the swelling arising from the lacrimal fossa demonstrated low-grade B-cell non-Hodgkin's lymphoma. This unusual presentation and the histopathological features are described.

Shifting subretinal fluid in rhegmatogenous retinal detachment.

In a consecutive series of 470 cases of rhegmatogenous retinal detachment 25 (5%) were found to have shifting subretinal fluid (SRF) at the preoperative examination. The study showed that the association between SRF and rhegmatogenous retinal detachment is unusual but not rare. Shifting SRF was most often associated with aphakic and longstanding retinal detachment, and found in cases in which the retinal holes were small.

Is padding necessary after cataract extraction?

The results of a prospective study to assess the value of padding eyes following cataract surgery are reported. A group of eyes dressed with a petroleum jelly mesh, gauze pad, and cartella shield were compared with a group dressed only with a cartella shield. Study of the eyes and lids before and after operation, including the taking of lid margin and fornix swabs for culture, suggested that there was no significant difference in the bacterial presence between the two groups. The eyes dressed with a cartella shield alone appeared less prone to discharge. The relative merits of different types of dressing are discussed.

Ocular hypertension and posture.

Thirty-seven patients with ocular hypertension (OH) and 29 age matched controls were studied. Intraocular pressure (IOP) measurements were made in the sitting position and, immediately after changing posture, in the lying position. Sixty-three (85%) of the OH eyes and all the control eyes showed either stable IOP readings on changing posture of small elevations up to 3 mmHg. Eleven (15%) of the OH eyes showed larger elevations of IOP, between 5 and 9 mmHg when the patients changed to the lying position. We suggest that an IOP measurement in the lying position should be included in the routine evaluation of the patient with ocular hypertension.

Ofloxacin compared with chloramphenicol in the management of external ocular infection.

The safety and efficacy of 0.3% ofloxacin in treating bacterial ocular infections was compared with that of 0.5% chloramphenicol in a parallel-group, randomised clinical trial at five sites. Clinical and microbiological improvement rates were studied in 84 culture-positive patients. Patients with suspected bacterial ocular infections were evaluated for clinical improvement and were included in drug safety and comfort analyses. Clinical improvement did not differ significantly between drug treatments. All patients completing the study (79 assigned ofloxacin, and 74 chloramphenicol) showed clinical improvement. Clinical improvement in the culture-positive groups was 100% (41/41) after ofloxacin treatment, and 95% (41/43) after chloramphenicol treatment. Microbiological improvement rates were similar for the two drugs: 85% (33/39) improved with ofloxacin, and 88% (38/43) improved with chloramphenicol. Both drugs were well tolerated. Adverse reactions possibly due to the study medication occurred in 1% (1/89) of those who received ofloxacin, and in 4% (4/93) of those who received chloramphenicol.

Issues raised by a case of orbital metastatic disease.

The clinical, radiological and histopathological findings in an 81-year-old man presenting with lung carcinoma metastatic to the orbit are described. Orbital biopsy was complicated by postoperative visual loss and failed to contribute significantly to the final diagnosis. The authors believe that in cases of possible orbital metastases a primary neoplasm should be excluded by means of a complete oncological assessment before proceeding to biopsy.

High-resolution optical coherence tomography demonstration of membranes spanning optic disc pits and colobomas.

OBJECTIVES: To demonstrate the features of optic disc pits and colobomas revealed by high-resolution optical coherence tomography (OCT) and their association with the development of maculopathy. METHODS: Subjects with disc pits or colobomas and no other ocular history underwent full ophthalmic examinations including logMAR visual acuity and contrast sensitivity. Fundus photographs and high-resolution OCT images were obtained. RESULTS: Seven patients were identified with optic disc pits or colobomas aged 25 to 63 years. Five patients had a unilateral optic disc pit, one had a unilateral disc coloboma, and another had bilateral disc colobomas. Apart from one eye with a grossly anomalous disc, vision was logMAR 0.4 or better in all eyes. In three of five eyes without maculopathy, a complete membrane could be identified traversing the optic disc cup that was absent or deficient in the three eyes with maculopathy. One patient with optic disc pit and marked schisis-like separation of the retinal layers throughout the macula was asymptomatic with logMAR visual acuity of 0.0 and normal achromatic contrast sensitivity. CONCLUSIONS: In this small series of patients with optic disc pits or colobomas, it was possible to identify a membrane spanning the optic disc cup, and it is speculated that this may protect against the development of maculopathy. Schisis-like separation of retinal layers can be associated with normal visual function.

Posterior polar cataract surgery - a posterior segment approach.

PURPOSE: To suggest a surgical approach that would pre-empt uncontrolled posterior capsular rupture and consequent posterior segment complications associated with posterior polar cataract surgery. DESIGN: An interventional case series. METHODS: This was a prospective, interventional study undertaken at a tertiary referral ophthalmic unit. Eleven eyes of eight patients underwent planned pars plana vitrectomy, lensectomy and posterior chamber sulcus fixated intra-ocular lens implantation. Demography, presenting features, pre- and post-operative visual acuities, complications and length of follow-up were recorded. A single surgical technique was performed in all the cases. RESULTS: Five male and three female patients with a mean age of 49.7 years, underwent this procedure. The median-corrected pre-operative visual acuity was 6/12 and the same post-operatively was 6/6. The only major per-operative complication was one case of accidental iridectomy. Post-operatively there were transient choroidal folds in one case, mild posterior segment haemorrhage in another and retinal detachment in one patient. The mean follow-up period was 13 months. CONCLUSIONS: This surgical technique offers a relatively controlled and predictable approach to posterior polar cataract surgery compared to others described in the literature. Although this technique is not without complications, the visual outcome is usually good.

Arrangements for the management of urgent retinal detachments in the United Kingdom and Eire in the year 2000: results of a survey.

PURPOSE: To ascertain the current provision of facilities for the management of vitreo-retinal (V-R) emergencies, and attitudes of V-R surgeons towards the management of V-R emergencies within the United Kingdom and Eire. METHODS: To obtain this information, all 82 consultant members of the Britain and Eire Association of Vitreo-Retinal Surgeons (BEAVRS) were requested to complete a 14-part postal questionnaire in the year 2000. Seventy-eight questionnaires were completed and returned. Data from the questionnaires were collated on a Microsoft Access Database and then statistically analysed using SPSS. The Student's t-test was used to assess relationships between continuous variables, and the Chi-squared and Fisher's Exact tests were used to compare non-parametric data. Analyses of the first 13 parts of the questionnaire are presented in this report. RESULTS: The majority of V-R surgeons (59%) practise in teaching hospitals. There are greater numbers of V-R surgeons per unit in teaching hospitals as compared to District General Hospitals (DGHs). Ophthalmic theatre and ophthalmic theatre staff availability are theoretically high (92.3% and 84.6% respectively) and evenly distributed between teaching hospitals and DGHs, but in reality, access may be difficult. Most V-R surgeons take part in an on-call rota with general ophthalmology colleagues. This formal commitment may be infrequent. Only a small proportion of V-R surgeons (28.3%) officially provide a continuous fixed on-call V-R rota, though in practice, a larger proportion do seem to provide this type of cover informally. Most V-R fellows are located in teaching hospitals (89.5%), and are usually on either a formal or informal on-call rota. Only one unit has a formal continuous on-call rota for fellows allowing no more than 72 hours duty per week. The mean time given in response to the question as to the ideal time within which surgery of an acute macula on supero-temporal retinal detachment should be carried out was 29 hours. Most V-R surgeons would not support, in court, a colleague whose patient lost vision through delay in treating a macula on detachment. CONCLUSIONS: The findings of this survey have important implications for providing a reliable service and for proper cover for doctors in training.

Pigmented paravenous retinochoroidal atrophy: a literature review supported by a unique case and insight.

Pigmented paravenous retinochoroidal atrophy (PPRCA) is a rare disorder of unknown origin characterised by bone corpuscle pigmentation accumulation along the distribution of the retinal veins. In addition there are peripapillary pigmentary changes as well as areas of chorioretinal atrophy adjacent to the perivenular pigmentary changes. The finding of PPRCA is usually incidental and does not affect vision. The literature regarding this condition is reviewed. Its natural course has been considered controversial. Observation of the initial insult leading to PPRCA has not previously been reported. A case that provides a photographic record over 20 years of the development of this condition from the initial insult, including the gradual development of the characteristic fundus appearance, is described. The initial presentation was with a sudden reduction of vision and gross diffuse macular oedema in one eye, which was rapidly followed by similar involvement of the fellow eye despite treatment. Thus it was possible to examine the patient at the stage of the initial insult, 5 years before the development of the typical and pathognomonic retinal changes of PPRCA. The clinical and electrophysiological findings are discussed, as also is the relevance of this case to the literature reviewed.