Long-term outcomes of needle revision of failing deep sclerectomy blebs.

PURPOSE: To report on long-term outcomes of mitomycin C (MMC)-augmented needle revision of failing deep sclerectomy (DS) blebs. METHODS: Retrospective database search of all needle revisions with MMC for DS blebs between 2002 and 2008 was conducted. Sixty-six eyes of 66 patients were included in the study. Subconjunctival MMC 0.01-0.02 mg was injected 15 min before needle revision. Complete success was defined as intraocular pressure ≤ 18 mmHg or 20% decrease from baseline with no glaucoma medications or further surgical procedures. Partial success was based on the same criteria, but with medications. RESULTS: Mean follow-up after index needle revision was 67.8 ± 24.8 months (range 1-10 years). The mean number of needle revisions was 1.6 ± 0.8 (range 1-4). Two or more procedures were done in 31 eyes (47.0%). Mean preoperative intraocular pressure was 23.2 ± 6.9 mmHg. Complete and partial success rates were 64% and 71% at 1 year, 57% and 68% at 3 years, and 40 % and 58 % at 5 years after surgery, respectively. Early needle revision, within 6 months of index surgery, was significantly associated with failure, both on uni- and multivariate tests. Significant complications included delayed hypotony in five eyes (7.6%), delayed bleb leak in two eyes (3.0%), endophthalmitis in one eye (1.5%), and corneal oedema in two eyes (3.0%). CONCLUSIONS: Needle revision with subconjunctival MMC may successfully lower the intraocular pressure in eyes with a failing DS bleb in the long term. Complications known to be associated with trabeculectomy and MMC were anticipated and observed in our DS group.

Perineural Spread of Cutaneous Squamous Cell Carcinoma Manifesting as Ophthalmoplegia.

An 89-year-old female presented with horizontal diplopia and was diagnosed with VI nerve palsy attributed to a microvascular event. She subsequently progressed to develop an orbital apex syndrome, with neuroimaging demonstrating tumour invasion. Eighteen months earlier, she had squamous cell carcinoma of the forehead excised with clear margins. Intraneural and perineural spread of squamous carcinoma from the face to the cranial cavity is an important cause of delayed cranial nerve palsies after local excision of the skin tumour.

The use of Densiron-68™ as a perioperative surgical tool.

Agents such as Densiron-68™, with specific gravity slightly greater than that of water (1.06 g/cm(3)), have been developed to tamponade the inferior retina following retinal detachment repair procedures. The minimal force that would result from the sinking of such an agent in balanced saline solution is not considered sufficient to permit the use of Densiron-68™ as a surgical tool to displace subretinal fluid and stabilise the retina perioperatively. We report five cases where Densiron-68™ was instilled directly into a saline-filled eye with an unstable retinal detachment. The detachment was reduced and the Densiron-68™ left in situ. Four cases involved giant retinal tears and the fifth an inferior retinal detachment with no breaks identified. The injection of Densiron-68™ as a single manoeuvre to flatten the retina and to simultaneously provide postoperative tamponade was successfully used in these five patients. Six months after removal of Densiron-68™ the retina remained flat in all five cases. This previously unfamiliar technique provides an additional surgical option to gain control in cases of complicated retinal detachment with a mobile retina, especially if inferior tamponade is required.

A hairy affair: tarantula setae-induced panuveitis requiring pars plana vitrectomy.

Cases of ocular inflammation following penetration by urticating hairs from caterpillars and tarantulas have been previously reported and although rare, the condition is increasingly being recognised as a cause of chronic panuveitis. The long-term outcomes and prognosis of this condition are not well known. This article describes a case of chronic panuveitis as a result of ocular penetration by tarantula setae, and its challenging management that ultimately required pars plana vitrectomy. Interventional case report: A 29-year-old male presented with chronic panuveitis secondary to tarantula-hair penetration. Initial management with mechanical removal of hairs from the cornea and intensive topical steroid therapy for 18 months did not adequately control his symptoms. Pars plana vitrectomy was carried out and at 6-month follow-up the patient was symptom-free without any pharmacological therapy. We propose early pars plana vitrectomy as a management option for treatment-resistant panuveitis in cases of ophthalmia nodosa secondary to setae-related injury.

Unusual case of Scedosporium apiospermum keratitis following phacoemulsification in a systemically well patient.

UNLABELLED: We report the case of a 65-year-old immunocompetent woman who developed Scedosporium apiospermum keratitis after clear-corneal phacoemulsification. A 3.5 mm by 2.7 mm full-thickness stromal infiltrate, corresponding to the superior 2.75 mm clear-corneal incision, was observed 44 days postoperatively. Treatment included preservative-free voriconazole 1.0% hourly, ofloxacin 0.3% 6 times a day, oral voriconazole 200 mg once daily, natamycin 5.0% hourly, dexamethasone 0.1% 4 times a day, and ocular cyclosporine 4 times a day. After 4 months of treatment, the new vessels had regressed, the infiltrate had disappeared, and residual deep scarring remained; the uncorrected distance visual acuity was 0.8 logMAR. To our knowledge, this is the first case of S apiospermum keratitis following clear-corneal phacoemulsification. Another unusual feature is that there were no risk factors for fungal keratitis, specifically no history of trauma, systemic illness, immunosuppression, or contact lens wear. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Bridging the gap: theory-based design of a microsurgical skills course for ophthalmology residents.

OBJECTIVE: Although theory-based schemes for course design are widely used in educational settings, making use of cognitive theory in the design of surgical skills courses in ophthalmology is rare. The primary aim of this study is to describe the application of instructional design, an established theory-based approach in course design, to the development of a surgical skills course for ophthalmology residents. The secondary aim of this study is to assess the educational effect of this theory-based course. DESIGN: A 1-day skills course was designed according to Gagné׳s events of instruction model, which was employed as a template for the instructional sequence of learning steps. Skills acquisition following the implementation of the model was measured with precourse and postcourse assessments. SETTING: Moorfields Eye Hospital organized the 1-day annual intermediate surgical skills course, which was hosted at the Royal College of Ophthalmologists' microsurgical skills laboratory. PARTICIPANTS: A total of 20 ophthalmology residents of Moorfields Eye Hospital participated in the study. RESULTS: A 1-day surgical skills course was formulated according to the instructional design principles outlined. The 4 objectives of the course (corneal suturing, corneal gluing, intravitreal injections, and eyelid suturing) were addressed in a parallel fashion as to allow for multiple objectives to be processed simultaneously, in the context of the instructional design sequence. Assessments demonstrated significant improvement in skills acquisition for the 4 course objectives. CONCLUSIONS: Instructional design is a valuable tool for planning effective surgical training courses as it is portable, allowing its application to a wide variety of outcomes and settings, and its terminology is simple and understandable to those working in clinical education.