Post-septal upper eyelid loading for treatment of exposure keratopathy secondary to non-cicatricial lagophthalmos.

Exposure keratopathy may result in ocular surface dryness, pain, corneal ulceration and loss of vision. Upper eyelid loading is an effective surgical treatment for paralytic lagophthalmos but has been criticised for complications of implant exposure and poor cosmesis. We therefore reviewed the safety and efficacy of our technique of upper eyelid post-septal loading for exposure keratopathy in this context. A retrospective case notes analysis was undertaken of 38 patients who had upper eyelid loading, all with post-septal weight placement, for correction of lagophthalmos. Patient demographics, indications for surgery, outcomes and complications were analysed. The mean age of all patients was 59.6 years. Exposure keratopathy was secondary to facial nerve paralysis in all but two patients, with tumor excision being the commonest underlying aetiology (63.8%). The mean implant weight used was 1.4 grams. Pre-operatively, all 38 patients had ocular discomfort despite maximal use of lubricating eye drops but post-operatively, 29 patients (76.3%) were comfortable without any such drops. Mean lagophthalmos on blink and gentle closure improved from 7.42mm and 5.47mm pre-operatively to 2.18mm and 1.18mm post-operatively (p < 0.001). Similarly, before surgery all patients had some corneal staining but after surgery 37 patients (97.4%) had none. The gold weight was removed in four patients (10.5%), due to chronic inflammation in three and due to mild astigmatism in one. No patient had exposure of the weight and one patient had a ptosis repair 6 months after surgery. Upper eyelid loading was effective in reducing both signs and symptoms of exposure keratopathy related to lagophthalmos in our series. Patients were very satisfied with the surgical outcome and complications related to exposure and cosmesis were very rare.

Rare presentation of orbital metastasis in multiple myeloma.

Orbital manifestations are rarely observed in multiple myeloma (MM) and when they occur, they are often the first manifestation. We report a rare occurrence of vision loss in a 51-year-old female from orbital metastases in MM without proptosis or diplopia. The ophthalmic presentation of MM is usually progressive proptosis, pain, diplopia, and visual loss. The presence of metastasis in MM indicates poor prognosis and orbital metastases have worse survival rates. In conclusion, in cases of profound vision loss with no obvious cause, neuroimaging should be performed to evaluate the orbital extent of the disease and exclude intracranial pathology.

Longitudinal Study to Assess the Quantitative Use of Fundus Autofluorescence for Monitoring Disease Progression in Choroideremia.

BACKGROUND: Characterisation of preserved autofluorescence (PAF) area in choroideremia (CHM) and its validity for monitoring disease progression in clinical trials is of importance. METHODS: Eighty patients with molecularly confirmed CHM were recruited. PAF area was measured manually by 2 graders and half-life was calculated based on exponential decay model. RESULTS: Mean age at baseline and follow-up examination was 38.1 (range, 10-69) and 40.7 (range, 11-70) years. Mean follow-up interval was 29 months (range, 6-104). The median LogMAR visual acuity was 0.10 (OD) and 0.18 (OS). Interobserver repeatability for PAF area was -0.99 to 1.03 mm2 (-6.46 to 6.49% of area). There was a statistically significant relationship between age and rate of PAF area loss (r2 = 0.28, p = 0.012). The half-life for PAF area was 13.7 years (range, 1.7-216.0 years). The correlation between half-life and age was stronger than between half-life and log transformed baseline PAF area, although neither was statistically significant. CONCLUSIONS: The intra- and inter-observer PAF area measurement variability provides a baseline change, which must be overcome in a clinical trial if this metric were to be used. Treatments must slow progression to alter the exponential decay in a timely manner accounting for naturally slow progression patterns.

Retinal thickness measurements in sickle cell patients with HbSS and HbSC genotype.

OBJECTIVE: Temporal macula thinning has been reported in sickle cell patients, but it remains unclear if there is a difference between HbSS and HbSC genotypes. We aimed to quantitatively compare macular thickness between eyes with HbSS and HbSC genotype. DESIGN: Retrospective descriptive study. METHODS: Consecutive patients seen over a 5.5-year period in the Ophthalmology Department at St Thomas' Hospital, London, were identified. Macular optical coherence tomography images were retrospectively analyzed. The retinal thickness in all 9 subfields of the Early Treatment Diabetic Retinopathy Study (ETDRS) grid was compared between HbSS and HbSC eyes. Right eyes and left eyes were analyzed independently, as well as averaged measurements from both eyes. Comparison was made between the 2 genotypes, adjusting for age and sex, and for multiple testing. Scans were excluded in cases of poor fixation or ocular comorbidity affecting retinal thickness. RESULTS: 132 HbSC and 120 HbSS patients were identified. Scans from 166 right and 153 left eyes were included (with approximately equal numbers of HbSS and HbSC genotypes). Mean retinal thickness was lower in HbSS eyes compared with HbSC eyes in all subfields of the ETDRS grid, but in most subfields the difference was <10 microns. Differences reached statistical significance for outer superior, inferior, and temporal subfields and the inner temporal subfield (p < 0.05). CONCLUSION: Although the HbSC genotype is more strongly associated with proliferative retinopathy, HbSS patients had on average more macular thinning.

Phacoemulsification plus endoscopic cyclophotocoagulation versus phacoemulsification alone in primary open-angle glaucoma.

PURPOSE: To examine the efficacy and safety of combined phacoemulsification and endoscopic cyclophotocoagulation (phaco-ECP) compared to phacoemulsification alone in patients with primary open-angle glaucoma (POAG). METHODS: We performed a retrospective notes review of 99 consecutive clinical records of patients with POAG from 2 London eye departments. A total of 69 patients who underwent phaco-ECP and 30 sex- and age-matched control patients who underwent cataract surgery alone were included. Data on intraocular pressure (IOP), visual acuity (VA), number of ocular hypotensive medications, and postoperative complications were collected over 12 months. The primary outcome measure was defined as an IOP within normal limits (<21 mm Hg) and at least a 20% reduction in IOP from baseline. RESULTS: Mean IOP was significantly decreased in both groups after 1 year (p<0.001 from baseline). The success rate was significantly higher in the phaco-ECP group (69.6%) than in the phaco group (40%) after 1 year (p = 0.004). Reduction in mean IOP and number of medications was also greater in the phaco-ECP group after 1 year (IOP reduction: 4.5 ± 5.13 mm Hg vs 1.83 ± 3.61 mm Hg; p = 0.007; number of medications reduction: 0.73 ± 0.71 vs 0.23 ± 0.56; p = 0.001). Both groups achieved a similar improvement in VA. There was a higher incidence of minor and self-limiting complications in the phaco-ECP group (p<0.047). CONCLUSIONS: Phaco-ECP resulted in a greater reduction in IOP and number of medications than phacoemulsification alone in POAG.

Sixteen-year follow-up of hyperopic laser in situ keratomileusis.

PURPOSE: To assess the long-term efficacy and safety of hyperopic laser in situ keratomileusis (LASIK). SETTING: Department of Ophthalmology, St. Thomas' Hospital, London, United Kingdom. DESIGN: Prospective cohort study. METHODS: Hyperopic LASIK was performed using a mechanical microkeratome, an optical zone of 6.5 mm, and a blend zone of 1.5 mm. Simple hyperopia was treated. RESULTS: The mean patient age was 51.6 years (range 34 to 60 years). Preoperatively, the mean spherical equivalent (SE) was +3.74 diopters (D) (range +1.25 to +6.50 D). The mean attempted correction was +3.64 D (range +1.5 to +6.0 D). The mean follow-up was 16.5 years. The mean SE was +0.28 D (range -1.0 to +1.5 D) at 12 months, +0.84 D (range -0.75 to +3.35 D) at 5 years, and +1.74 D (range -0.75 to +4.13 D) at 16 years, representing an increase in hyperopia of +1.47 D ± 1.43 (SD) between 1 year and 16 years (P < .0001) and of +1.13 ± 0.8 D between 5 years and 16 years (P < .03). The uncorrected distance visual acuity improved at 16 years (P < .0001); corrected distance visual acuity (CDVA) was unchanged (P < .2). The efficacy index was 0.5 and the safety index, 1.09. One eye (3%) lost 2 lines of CDVA. Keratometry remained stable between 1 year and 16 years (P < 1.0). Four eyes (12%) had cataract surgery, and 2 (6%) had laser iridotomy. There was no ectasia. CONCLUSIONS: After hyperopic LASIK, an increase in hyperopia occurred between 1 and 5 years and 16 years. At 16 years, efficacy was limited but with no sight-threatening complications. FINANCIAL DISCLOSURES: Dr. Marshall was a consultant to Summit Technology, Inc. Dr. O'Brart holds a noncommercial research grant from Alcon Laboratories, Inc. None of the other authors has a financial or proprietary interest in any material or method mentioned.

Eighteen-year follow-up of hyperopic photorefractive keratectomy.

PURPOSE: To investigate the long-term efficacy of hyperopic photorefractive keratectomy (PRK). SETTING: University Hospital, London, United Kingdom. DESIGN: Prospective case series. METHODS: Patients with a follow-up of 18 years ± 0.7 (SD) attended for examination. All had spherical corrections with a 6.5 mm optical zone and 1.5 mm blend zone. RESULTS: Twenty-five patients (45 eyes) were included. The mean preoperative spherical equivalent (SE) refractive error was +4.11 ± 1.8 diopters (D) (range +1.125 to +7.25 D). Between 1 year and 18 years, in eyes that had no cataract surgery (n = 34), there was a +1.14 ± 1.48 D increase in the mean SE (P < .0002). The increase between 7.5 years and 18.0 years did not reach clinical significance (P = .1). Uncorrected distance visual acuity improved at 18 years (P < .02). Corrected distance visual acuity (CDVA) was reduced (P < .001). The efficacy index was 0.47, and the safety index was 0.83. Six eyes (18%) lost 2 lines of CDVA, of which 4 eyes had preexisting cataract. Keratometry remained stable between 1 year and 18 years (P = .2). Forty percent still had traces of peripheral haze, and 4 (9%) had Salzmann-like changes. Eleven eyes (24%) had cataract surgery and 4 (9%) had laser iridotomy. There was no evidence of ectasia. CONCLUSIONS: Hyperopic PRK showed an increase in hyperopic SE between 1.0 year and 7.5 years but was generally stable thereafter. The efficacy was limited. Peripheral haze was evident in 40% of cases with Salzmann-like changes in some. Ocular comorbidity in relationship to cataract was common and reduced CDVA. FINANCIAL DISCLOSURE: Dr. Marshall was a consultant to Summit Technology, Inc. No author has a financial or proprietary interest in any material or method mentioned.

The environmental deposition of influenza virus from patients infected with influenza A(H1N1)pdm09: Implications for infection prevention and control.

In a multi-center, prospective, observational study over two influenza seasons, we sought to quantify and correlate the amount of virus recovered from the nares of infected subjects with that recovered from their immediate environment in community and hospital settings. We recorded the symptoms of adults and children with A(H1N1)pdm09 infection, took nasal swabs, and sampled touched surfaces and room air. Forty-two infected subjects were followed up. The mean duration of virus shedding was 6.2 days by PCR (Polymerase Chain Reaction) and 4.2 days by culture. Surface swabs were collected from 39 settings; 16 (41%) subject locations were contaminated with virus. Overall, 33 of the 671 (4.9%) surface swabs were PCR positive for influenza, of which two (0.3%) yielded viable virus. On illness Day 3, subjects yielding positive surface samples had significantly higher nasal viral loads (geometric mean ratio 25.7; 95% CI 1.75, 376.0, p=0.021) and a positive correlation (r=0.47, p=0.006) was observed between subject nasal viral loads and viral loads recovered from the surfaces around them. Room air was sampled in the vicinity of 12 subjects, and PCR positive samples were obtained for five (42%) samples. Influenza virus shed by infected subjects did not detectably contaminate the vast majority of surfaces sampled. We question the relative importance of the indirect contact transmission of influenza via surfaces, though our data support the existence of super-spreaders via this route. The air sampling results add to the accumulating evidence that supports the potential for droplet nuclei (aerosol) transmission of influenza.

A pilot clinical trial on a Variable Automated Speed and Sensing Treadmill (VASST) for hemiparetic gait rehabilitation in stroke patients.

INTRODUCTION: Impairments in walking speed and capacity are common problems after stroke which may benefit from treadmill training. However, standard treadmills, are unable to adapt to the slower walking speeds of stroke survivors and are unable to automate training progression. This study tests a Variable Automated Speed and Sensing Treadmill (VASST) using a standard clinical protocol. VASST is a semi-automated treadmill with multiple sensors and micro controllers, including wireless control to reposition a fall-prevention harness, variable pre-programmed exercise parameters and laser beam foot sensors positioned on the belt to detect subject's foot positions. MATERIALS AND METHODS: An open-label study with assessor blinding was conducted in 10 community-dwelling chronic hemiplegic patients who could ambulate at least 0.1 m/s. Interventions included physiotherapist-supervised training on VASST for 60 min three times per week for 4 weeks (total 12 h). Outcome measures of gait speed, quantity, balance, and adverse events were assessed at baseline, 2, 4, and 8 weeks. RESULTS: Ten subjects (8 males, mean age 55.5 years, 2.1 years post stroke) completed VASST training. Mean 10-m walk test speed was 0.69 m/s (SD = 0.29) and mean 6-min walk test distance was 178.3 m (84.0). After 4 weeks of training, 70% had significant positive gains in gait speed (0.06 m/s, SD = 0.08 m/s, P = 0.037); and 90% improved in walking distance. (54.3 m, SD = 30.9 m, P = 0.005). There were no adverse events. DISCUSSION AND CONCLUSION: This preliminary study demonstrates the initial feasibility and short-term efficacy of VASST for walking speed and distance for people with chronic post-stroke hemiplegia.