CYSTOID MACULAR EDEMA AFTER FOUR-POINT SCLERAL FIXATION OF INTRAOCULAR LENS.

PURPOSE: To assess the incidence of cystoid macular edema (CME) associated with 4-point Gore-Tex suture intraocular lens (IOL) scleral fixation, before and after institution of routine intravitreal triamcinolone acetonide prophylaxis and long-term topical nonsteroidal anti-inflammatory drug usage. METHODS: Consecutive patients were included after IOL implantation with concurrent pars plana vitrectomy for spontaneous IOL dislocation due to pseudoexfoliation syndrome. We compared short-term prophylactic nonsteroidal anti-inflammatory drugs only (Group A) to prophylactic intravitreal triamcinolone acetonide and long-term nonsteroidal anti-inflammatory drugs (Group B). RESULTS: Twenty-six eyes of 26 patients with pseudoexfoliation syndrome and spontaneous IOL dislocation were studied. Mean logMAR visual acuity improved from 1.27 ± 0.80 (20/375 Snellen equivalent) preoperatively to 0.46 ± 0.39 (Snellen 20/43) postoperatively (P < 0.001). Visual outcomes were similar for Groups A and B. In Group A, 10/16 eyes had CME, 4/16 had chronic CME longer than 6 months, and 1 longer than 12 months. In Group B, 1/10 had CME (which was both chronic and refractory). CONCLUSION: In eyes with pseudoexfoliation syndrome and spontaneous IOL dislocation, 4-point Gore-Tex suture IOL ab externo fixation yielded good visual outcomes, although CME was observed more than reported elsewhere. Prophylactic intravitreal triamcinolone acetonide and long-term nonsteroidal anti-inflammatory drugs seem to reduce the risk of postoperative CME.

Intacs adjustment surgery for keratoconus.

PURPOSE: To describe the visual outcome of keratoconic eyes managed with Intacs (Addition Technology, Inc.) that required additional Intacs surgery (defined as any combination of removal, exchange, addition, or shifting of an Intacs segment). SETTING: Private refractive surgery center, Jerusalem, Israel. METHODS: This retrospective noncomparative interventional consecutive small case series studied all eyes of a cohort of 58 keratoconic eyes managed with Intacs that had additional Intacs surgery. The uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity, manifest refraction, videokeratography, and patient questionnaires on visual function were assessed. These outcome measures were compared before Intacs implantation, before Intacs adjustment, and 1 year after the final Intacs adjustment. Eyes having any intervention other than Intacs surgery were excluded. RESULTS: Of 58 keratoconic eyes managed with Intacs, 7 had additional Intacs surgery. After the initial Intacs surgery, 6 of these eyes had UCVA < or =20/100 and 1 had UCVA of 20/50. After the final Intacs adjustment, 3 eyes achieved UCVA > or =20/40, 5 achieved UCVA > or =20/70, and 2 remained <20/200. The indications for Intacs adjustments were increased astigmatism in 4 eyes, induced hyperopia (overcorrection) in 3, and undercorrection in 1. One eye had both surgically induced astigmatism and hyperopia. Induced astigmatism and hyperopia were most often managed by removing the superior segment. The undercorrected eye, having initially received a single inferior segment, was treated by implanting a superior segment. CONCLUSIONS: Approximately 10% of keratoconic eyes managed with Intacs may require Intacs adjustment surgery, which often has a good outcome.

Dental fractures on acute exposure to high altitude.

There is little in the literature on dental restoration breakage in the aviation environment since reports of problems in combat aviators in War World II. We report two cases of dental fractures during acute exposure to a hypobaric environment. Case 1 was a young officer who suffered an amalgam restoration breakage during a 25,000-ft decompression chamber simulation. Case 2 occurred in an experienced aviator who had a tooth cusp fracture in a molar with a defective amalgam restoration during an unpressurized helicopter flight to 18,000 ft. In both cases, after removing the defective fillings, deep secondary caries were found; both teeth were successfully restored. Because hard-tissue tooth fracture during a high-altitude flight is a rare event, few flight surgeons or dentists are familiar with this phenomenon. We recommend regular dental examinations with careful assessment of previous dental restorations in aircrew subject to decompression.

Keratoconus managed with intacs: one-year results.

OBJECTIVES: To describe the visual outcome of keratoconus managed with Intacs implantation (Addition Technology Inc, Fremont, Calif) and to define criteria that predict good outcome. METHODS: This retrospective, nonrandomized, comparative, consecutive case series studied 58 eyes of 43 patients with keratoconus managed by Intacs implantation. The outcome measures were analyzed pre-Intacs and 1 year post-Intacs. Preoperative parameters were correlated with outcome. MAIN OUTCOME MEASURES: Uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), manifest refraction, videokeratography, and patient questionnaires. RESULTS: Intacs were implanted in all eyes with no intraoperative complications. Six eyes underwent additional Intacs surgery. Post-Intacs, the mean +/- SD UCVA improved from less than 20/200 +/- 0.1 line to 20/50(-3) +/- 3.1 lines, the mean +/- SD BSCVA was unchanged at 20/32 +/- 2.0 lines, the mean +/- SD spherical equivalent improved from -3.88 +/- 1.64 to -1.04 +/- 1.51 diopters (D), and the mean +/- SD astigmatism improved from 3.34 +/- 2.23 to 1.97 +/- 1.51 D. Twenty-five eyes had a good outcome (UCVA> or =20/40). Multiple regression selected BSCVA, astigmatism, and spherical myopia as the preoperative predictors of outcome. CONCLUSIONS: Intacs improve myopia and regular astigmatism in keratoconus. Milder keratoconus (BSCVA>20/32(-2) and astigmatism<3.50 D) and significant spherical myopia (>-1.75) predict better outcome.

Retinal detachment in eyes with vitreous loss and an anterior chamber or a posterior chamber intraocular lens: comparison of the incidence.

PURPOSE: To compare the incidence of retinal detachment within 6 months of cataract surgery complicated by vitreous loss in eyes with a posterior chamber intraocular lens (PC IOL) or an anterior chamber IOL (AC IOL). SETTING: Department of Ophthalmology, Kaplan Medical Center, Rehovot, Israel. METHODS: In this retrospective consecutive nonrandomized comparative case series, all cases of cataract surgery complicated by vitreous loss between January 1991 and March 1998 were reviewed. Included were patients who had thorough anterior vitrectomy and primary IOL implantation and at least 6 months follow-up. Exclusion criteria were congenital and traumatic cataract, previous intraocular surgery, and previous retinal detachment. Patients receiving an unsutured single-piece poly(methyl methacrylate) (PMMA) PC IOL formed the PC group, while those receiving flexible open-loop single-piece PMMA AC IOLs formed the AC group. The incidence of postoperative retinal detachment in the 2 groups was compared. RESULTS: Of the 151 eyes of 149 patients, 66 received a PC IOL and 85 received an AC IOL. Two eyes (3.0%) in the PC group and 2 (2.4%) in the AC group developed retinal detachment; the difference between groups was not statistically significant (P = 1.00, Fisher exact test). CONCLUSIONS: In eyes that have vitreous loss and thorough anterior vitrectomy, AC IOL implantation did not appear to increase the incidence of retinal detachment.

Self-inflicted (factitious) conjunctivitis.

PURPOSE: To describe the diagnosis and management of self-inflicted factitious conjunctivitis in conscripted soldiers. DESIGN: Prospective, noncomparative, consecutive case series. PARTICIPANTS: Seventeen conscripted soldiers. METHODS: Soldiers with chronic conjunctivitis (>3 weeks) were referred by ophthalmologists, and cases of shorter duration were referred by primary-care physicians. All cases underwent thorough ophthalmic and systemic history and examination, as well as questioning regarding their military units, military duties, and social background. Exclusion criteria were any condition that may cause conjunctivitis. Inferior fornix specimen microscopy and culture and eye photography were performed in most cases. In cases suspected of self-inflicted conjunctivitis all medication, besides lubricant drops, was stopped. Underlying psychosocial problems were investigated and managed. Cases were followed for at least 3 months after resolution of the conjunctivitis, at which point the diagnosis was confirmed, and the case entered the analysis. MAIN OUTCOME MEASURES: Resolution of the conjunctivitis. RESULTS: Seventeen consecutive cases of self-inflicted conjunctivitis, 8 of long duration and 9 of short duration, were studied. All cases demonstrated inconsistent clinical findings. The ocular signs most suggestive of self-inflicted conjunctivitis were purulent discharge purposely left on the lashes and periorbital skin, discharge more severe than in conjunctival hyperemia, less conjunctival chemosis than in hyperemia, mainly inferior conjunctival involvement, and an uninvolved cornea. Five of the 8 chronic cases had significant underlying psychologic or social problems. Their conjunctivitis resolved only after their underlying problems were addressed. Two cases admitted introducing freshly scraped dental plaque into the lower conjunctival sac. In the remaining 15 the similarity of the clinical findings suggested that a similar method was used. CONCLUSIONS: In the context of a subject standing to gain by assuming the sick role and after exclusion of ocular pathology, self-inflicted conjunctivitis can be reliably diagnosed by noting the characteristic clinical profile. Effective management includes addressing the underlying psychologic and social problems.