The accessory tendon of extensor hallucis longus muscle and its correlation to hallux valgus deformity: a cadaveric study.

PURPOSE: The accessory tendon (AT) of the extensor hallucis longus (EHL) is a common anatomic variation, whose clinical significance remains debatable. The purpose of this study was to investigate the incidence and morphology of accessory EHL tendons in cadavers and to examine any possible correlation to the occurrence and severity of hallux valgus (HV) deformity. METHODS: We examined any possible correlation between the AT presence and the cadavers' age and the HV deformity in 98 female adult cadaveric feet. The HV and intermetatarsal (IMA) angles were measured and compared with the relative angle between the primary EHL tendon and AT as well as the length of the AT. RESULTS: AT was present in 26.5% and HV deformity existed in 36.7% of all feet. There was a high prevalence (65.4%) of HV deformity in feet with AT, but the HV angle and IMA were similar in feet with AT and without AT. No significant correlations were found between AT morphological characteristics and the cadavers' age or the HV angle and IMA. CONCLUSIONS: In conclusion, there is a high incidence of HV deformity in cadaveric feet with AT of EHL (almost 2/3), but there is no correlation between the severity of the HV deformity and the presence or characteristics of the AT.

Bilateral exudative retinal detachment in a child with orbital pseudotumor.

We describe a 15-year-old girl who presented with bilateral exudative retinal detachment, a previously unreported complication, due to orbital pseudotumor. She initially responded to steroids, but subsequently became steroid dependent. Azathioprine was effective in controlling further relapses during follow-up of 22 months.

Long-term follow-up of trabeculectomy without antimetabolites in patients with uveitis.

PURPOSE: To determine the long-term success rate after trabeculectomy without antimetabolites in patients with uveitis. METHODS: Review of data from all patients with uveitis who underwent trabeculectomy for uncontrolled intraocular pressure secondary to intraocular inflammation between May 1990 and December 1994. Results were compared with those from a group of patients with primary open-angle glaucoma matched for sex and surgeon. RESULTS: The uveitis group consisted of 32 eyes (20 patients). Maximum control of intraocular inflammation was achieved for a minimum of 2 months before surgery. Mean (+/-SD) age was 40.0 +/- 12.5 years (range, 14 to 67 years), with a median (+/-SE) follow-up of 53.0 +/- 1.8 months (range, 33 to 84 months). The primary open-angle glaucoma group consisted of 33 eyes (23 patients), with a mean age of 62.0 +/- 13.7 years (range, 26 to 81 years) and a median follow-up of 63.0 +/- 12.0 months (range, 34 to 299 months). The overall 5-year success rate (intraocular pressure < or =21 mm Hg with or without topical medication) for the uveitis group was 78% compared with 82% for the primary open-angle glaucoma group (P = .7). The absolute 5-year success rate (intraocular pressure < or =21 mm Hg with no medication) for the uveitis group was 53% compared with 67% for the primary open-angle glaucoma group (P = .87). CONCLUSIONS: In the absence of other risk factors, such as Afro-Caribbean race and previous intraocular surgery, and with adequate preoperative control of inflammation, trabeculectomy without antimetabolites may be considered the primary surgical procedure for increased intraocular pressure in patients with uveitis.

Immunomodulatory therapy for chronic tubulointerstitial nephritis-associated uveitis.

PURPOSE: To describe the clinical course and treatment with immunomodulatory agents in patients with tubulointerstitial nephritis and uveitis syndrome. METHODS: Retrospective analysis of the charts of six patients with tubulointerstitial nephritis and uveitis syndrome. RESULTS: The mean (+/-SD) age was 24.3 (+/-16.5) years, range 13 to 49 years. Four patients were children, and two were adults. Three were men, and three were women. Five of the six patients had anterior uveitis, and one had panuveitis. All patients had several relapses despite treatment with topical, regional, and oral steroids and methotrexate in one case. The introduction or modification of immunosuppressants (methotrexate, azathioprine, or cyclosporin A) achieved control of the uveitis and prevented relapses over a mean (+/-SD) follow-up period of 19.66 (+/-10.01) months, range 6 to 34 months. No treatment-related side effects were observed. CONCLUSIONS: Tubulointerstitial nephritis and uveitis syndrome is a distinct disease entity in which the nephritis typically resolves, but the uveitis often becomes chronic and is treatment resistant. Immunomodulatory agents can achieve control of the inflammation and prevent relapses.

Gas-permeable scleral contact lens therapy in ocular surface disease.

PURPOSE: To describe the therapeutic benefits of nonfenestrated gas-permeable scleral contact lenses in the management of patients with ocular surface disease. METHODS: The charts of 49 consecutive patients (76 eyes) with ocular surface disease whose management included the use of gas-permeable scleral contact lenses were reviewed. We also developed a questionnaire to assess the impact of lens wear on subjective aspects of activities of daily living. RESULTS: The mean age of the 49 patients was 44.6 years (range, 3 to 87 years); 31 patients were female and 18 were male. The most common indication for fitting of the lenses was Stevens-Johnson syndrome (54 [71%] of the 76 eyes). Other indications included ocular cicatricial pemphigoid, exposure keratitis, toxic epidermal necrolysis, postherpetic keratitis, congenital deficiency of meibomian glands, superior limbal keratoconjunctivitis, Sjögren syndrome, and inflammatory corneal degeneration. The mean follow-up was 33.6 months (range, 2 to 144 months). Improvement in best-corrected visual acuity (defined as a gain of 2 or more Snellen lines) was observed in 40 (53%) of the eyes. In eight (53%) of the 15 eyes with active corneal epithelial defects at the time of lens fitting, the defects healed, whereas in the remaining seven eyes the corneal epithelial defects remained unchanged. Forty-five (92%) of the 49 patients reported improvement in their quality of life as a result of reduction of photophobia and discomfort. The mean wearing time of the gas-permeable scleral contact lenses was 13.7 hours per day (range, 4 to 18 hours). Many patients had preparatory surgical procedures before lens fitting (for example, punctal occlusion or mucous membrane grafting), and some had visual rehabilitation surgical procedures (for example, keratoplasty and/or cataract surgery) after lens fitting. CONCLUSIONS: Gas-permeable scleral contact lens wear provides an additional effective strategy in the surface management and visual rehabilitation of patients with severe ocular surface disease.

Intraocular lens removal from [corrected] patients with uveitis.

PURPOSE: To report a series of patients with uveitis and cataract who had undergone cataract extraction with posterior chamber intraocular lens implantation and who subsequently had the intraocular lens removed because of progressive intraocular damage from inflammation. METHODS: Review of the records of 19 patients after removal of a posterior chamber intraocular lens. The decision to perform surgery was based on standard criteria after evaluation at a single uveitis referral center. RESULTS: The complications leading to intraocular lens removal were perilental membrane (eight eyes), chronic low-grade inflammation not responding to anti-inflammatory treatment (eight eyes), and cyclitic membrane resulting in hypotony and maculopathy (three eyes). After intraocular lens removal the inflammation subsided and the visual acuity improved or stabilized in 14 of the 19 eyes. The causes of further reduction in the visual acuity of the other five patients were macular edema (two patients), maculopathy resulting from hypotony (one patient), retinal detachment (one patient), and vitreous hemorrhage (one patient). CONCLUSIONS: Intraocular lens implantation can form part of a reasonable plan for visual rehabilitation of patients with uveitic cataract, but inclusion of an intraocular lens in the plan is not always in the overall long-term best interest of the patient. Intraocular lens removal may salvage useful vision for patients who continue to exhibit complications secondary to uveitis after cataract extraction and intraocular lens implantation, provided the intraocular lens is removed before irreparable damage has been done to macula or optic nerve.

Degree, duration, and causes of visual loss in uveitis.

BACKGROUND/AIMS: Uveitis is a major cause of visual morbidity in the working age group. The authors investigated the duration, degree, and causes of visual loss in uveitis patients with the aim of better defining the visual morbidity and identifying potential risk factors. METHODS: A retrospective, non-interventional, observational survey of 315 consecutive patients attending a tertiary referral uveitis service. RESULTS: The mean duration of follow up was 36.7 months. Reduced vision (< or =6/18) was found in 220/315 (69.95%) of the patients with a subset of 120 patients having vision < or =6/60. Unilateral visual loss occurred in 109 (49.54%), while 111 (50.45%) had bilateral loss. The mean duration of visual loss was 21 months. Of the 148 patients with pan-uveitis, 125 (84.45%) had reduced vision, with 66 (53%) having vision < or =6/60. Main causes of visual loss were cystoid macular oedema (CMO) (59/220, 26.8%), cataract (39/220, 17.7%), and combination of CMO and cataract (44/220, 20%). The following were predictive of a poorer visual prognosis: pan-uveitis (p = 0.0005), bilateral inflammation (p = 0.0005), increasing duration of reduced vision (p = 0.0005), an Indian or Pakistani ethnic background (p = 0.004), and increasing patient age (p = 0.02). CONCLUSION: Prolonged visual loss occurred in two thirds of uveitis patients, with 70 (22%) patients meeting the criteria for legal blindness at some point in their follow up. Older patients with bilateral inflammation and an increasing duration of reduced vision are at the greatest risk of severe visual loss (< or =6/60). CMO and cataract were responsible for visual loss in 64.5% of patients.

Heparin surface modified intraocular lenses in uveitis.

A retrospective analysis of the results of cataract surgery using heparin surface modified intraocular lenses (HSM-IOL) performed on patients with uveitis between August 1989 and July 1993 was undertaken. In total, 32 eyes of 28 patients with various types of uveitis underwent extracapsular cataract extraction and implantation of a posterior chamber HSM-IOL. In four patients, cataract extraction was combined with trabeculectomy. The post-operative follow-up period ranged from two to 51 months (average 16 months). The visual acuity improved in 31 of 32 eyes (96.8%) with 28 eyes (87.5%) seeing 6/18 or better. In four eyes (12.5%), the visual acuity was only 6/60 due to longstanding, pre-operative cystoid macular oedema. Posterior synechiae developed in eight eyes (25%), inflammatory deposits were noticed on the IOL surface in five eyes (15.6%), and three eyes (9.3%) required YAG laser posterior capsulotomy. These results suggest that HSM lenses are associated with minimal post-operative complications and appear safe to be used in human uveitic eyes.

Does trabeculectomy influence the course of uveitis?

It was our clinical impression that patients with uveitis who had undergone trabeculectomy had an improvement in their intraocular inflammation following surgery. We undertook a retrospective review of the notes of all patients who underwent unaugmented trabeculectomy for uncontrolled intraocular pressure secondary to uveitis between September 1990-July 1994, at the Uveitis Service of the Birmingham and Midland Eye Centre, UK. The severity of the inflammation and the number of relapses post-trabeculectomy were compared to those during the pre-trabeculectomy period. A total of 32 eyes of 20 patients with various types of uveitis were included in the study. Mean age was 40 years (SD+/-2.5), range: 14-67 years, median follow-up of 53 months (SE+/-1.8), range: 33-84 months. An improvement in the pattern of uveitis post-trabeculectomy, defined as reduction in the severity of the inflammation and the number of relapses, was seen in 23 out of 32 (71.9%) eyes. Furthermore, five out of 15 patients in this group had either their systemic treatment stopped or the number of systemic agents reduced. Another five eyes (15.6%) showed no change in the pattern of uveitis. The remaining four eyes (12.5%) suffered an increase in the number of relapses or increased severity of inflammation requiring additional treatment. It appears that trabeculectomy may have a beneficial effect on the course of uveitis. The mechanism for this is not clear.

Trabeculectomy in uveitis Are antimetabolites necessary at the first procedure?

A retrospective study was undertaken analysing the results of trabeculectomy without antimetabolites in 33 eyes with uveitis compared to 33 eyes with primary open angle glaucoma (POAG). Both groups were matched for surgeon with a median follow-up of 19 months (range 2-44 months) for the uveitis group and 24 months (range 6-92 months) for the POAG group. The overall one and two year success (IOP ± 21 mmHg with or without medication) was 92% and 83% respectively for the uveitis group and 96% for both years for the POAG group (p = 0.241, Mantel-Haenszel test). These results indicate that the success of trabeculectomy in patients with inflammatory glaucoma compares well with that of the POAG group. In the absence of other risk factors, primary trabeculectomy without the use of antimetabolites should be considered as the first choice of surgical treatment for raised intraocular pressure in patients with intraocular inflammatory disease.

Peripapillary choroidal neovascularisation in sarcoidosis.

PURPOSE: To describe a rare manifestation of sarcoidosis. METHODS: Case report of a patient with histologically proven sarcoidosis, who developed peripapillary choroidal neovascularisation in the absence of uveitis or optic nerve disease. RESULTS: Oral corticosteroids achieved reduction in the size of the peripapillary choroidal neovascularisation. Laser treatment was effective in treating the remaining peripapillary choroidal neovascularisation, resulting in improvement of visual acuity. CONCLUSIONS: Isolated peripapillary choroidal neovascularisation is a previously unreported complication of sarcoidosis. A combination of oral corticosteroids and laser can be successful in treating this type of lesion, thereby preventing permanent visual loss.

Pars plana vitrectomy in patients with intermediate uveitis.

OBJECTIVE: To describe the effect of pars plana vitrectomy in patients with intermediate uveitis. METHODS: Retrospective analysis of the clinical course and visual outcome following pars plana vitrectomy in patients with intermediate uveitis. RESULTS: Thirty-two patients (43 eyes) were included in the study. Pars plana vitrectomy was combined with cataract surgery in 22 of 43 eyes. The intermediate uveitis was associated with sarcoidosis in 16 eyes and multiple sclerosis in five eyes, and was idiopathic in 22 eyes. The mean (+/-SD) follow-up was 45.6 (+/-38) months (range: 6-146 months). In 19 of 43 eyes (44.1%), there was improvement in the course of uveitis, allowing the discontinuation of immunosuppressive treatment in seven patients. Cystoid macular edema resolved in 12 of 37 eyes (32.4%). Forty of 43 eyes achieved a better or retained their initial visual acuity. The remaining three eyes deteriorated by two or more lines in the Snellen chart due to the progression of cataract, chronic cystoid macular edema, and glaucomatous optic atrophy, respectively. CONCLUSIONS: The results of this study suggest that pars plana vitrectomy may have a beneficial effect on the course of uveitis and the associated complications of cystoid macular edema, thereby reducing the need for long-term immunosuppression. Pars plana vitrectomy combined with simultaneous cataract surgery can improve the visual outcome in these patients.

Cement penetration and stiffness of the cement-bone composite in the proximal tibia in a porcine model.

PURPOSE: To assess the stiffness of the cement bone composite and the depth and uniformity of cement penetration into the surface of the tibial component during total knee reconstruction in a porcine model. METHODS: The effectiveness of 3 protocols were compared: 2 commonly used cementing techniques-finger-packing of cement on the cut surface followed by impaction, and coating of the undersurface of the prosthesis with cement followed by impaction-and a new method using a tibial cement-pressurising device. Cement penetration was measured by computed tomography; stiffness was determined by hydraulic penetration testing. RESULTS: Cement penetration at a depth of 1 mm was significantly greater following coating the undersurface of the prosthesis than following finger-packing (p=0.008). There was no significant difference at deeper levels or between the tibial-pressurising device group and either of the 2 other groups at any level (p>0.3 in all cases). Differences in surface stiffness by tibial plateau region were found in tibiae that had been cemented using finger-packing and in those that had had their undersurface coated, but not in tibiae that had been cemented using the tibial-pressurising device. CONCLUSION: The tibial cement-pressurising device eliminated regional differences in stiffness seen with other cementing methods. Elimination of these differences by using this device should reduce micromotion and the incidence of aseptic loosening of tibial base plates in total knee arthroplasty.

Cytomegalovirus retinitis in chronic lymphocytic leukaemia.

PURPOSE: To describe a rare association of cytomegalovirus (CMV) retinitis. PATIENTS AND METHODS: Report of three patients with chronic lymphocytic leukaemia (CLL) who developed CMV retinitis. RESULTS: The diagnosis was established by the detection of CMV DNA by polymerase chain reaction analysis of aqueous and/or vitreous humour. CD4+ T-lymphocyte count was reduced in two patients and normal in the third one. There was bilateral involvement in two of the three patients. There was delay of 8-10 months in diagnosis. The visual outcome was poor in four out of the five eyes involved owing to optic atrophy or total retinal detachment with proliferative vitreoretinopathy. CONCLUSION: Increased awareness of CMV retinitis in patients who have received immunosuppression for haematological malignancies, such as CLL, could lead to earlier diagnosis and possibly better visual outcome.

Surgically induced miosis during phacoemulsification in patients with diabetes mellitus.

PURPOSE: To assess the incidence of surgically induced miosis during phacoemulsification in diabetic patients. METHODS: A total of 76 patients with diabetes mellitus were compared to 76 age- and race-matched controls. A combination of cyclopentolate 1%, phenylephrine 2.5% and diclofenac sodium 0.1% was applied topically 60, 45 and 30 min before surgery. Adrenaline mixed with buffered saline solution was used for irrigation during surgery. The procedure included phacoemulsification and implantation into the bag of a foldable acrylic implant. Measurements of the horizontal pupillary diameter were taken at three stages: before corneal incision, after phacoemulsification, and at the end of surgery. The duration of phacoemulsification was also recorded. RESULTS: Surgically induced miosis or dilation of the pupil was defined as constriction or dilation noted at any interval during surgery. The pairs of diabetic-control were grouped into three groups: those in which constriction was noted, those in which dilation was noted, and those in which there was no change in pupil size during the procedure. Surgically induced miosis was noted more often in the diabetics (McNemar's test, chi(2), P=0.016). The mean pupil size at the beginning of surgery was 7.38 (+/-0.95) mm in the diabetics as compared to 7.65 (+/-0.89) mm in the control group. No statistically significant difference was noted between the two groups (paired t-test, P=0.07). The mean (+/-SD) duration of phacoemulsification in the diabetic group was 2.31 (+/-1) min as compared to 2.05 (+/-0.82) min in the control group. No statistically significant difference was found between the two groups (paired t-test, P=0.08). CONCLUSION: Surgically induced miosis occurred more often in the diabetics. Therefore, it is advisable that phacoemulsification in this group of patients is undertaken by an experienced surgeon.

Diabetic retinopathy progression and visual outcome after phacoemulsification in South-Asian and Afro-Caribbean patients with diabetes.

PURPOSE: To determine diabetic retinopathy or maculopathy progression and visual outcome following phacoemulsification in South-Asian and Afro-Caribbean patients with diabetes. METHODS: Review of notes of patients with type II diabetes undergoing phacoemulsification by one surgeon. The inclusion criteria were: (a) South-Asian or Afro-Caribbean ethnicity, (b) monocular cases with a minimum postoperative follow-up of 6 months, and (c) binocular cases with an interval of at least 6 months between the operation in the two eyes. The nonoperated eye was used as control. The development or progression of diabetic retinopathy or maculopathy and final visual acuity were recorded. RESULTS: In all, 30 diabetic patients were included. There were 19 South-Asians (Pakistani, Indian, and Bangladeshi) and 11 Afro-Caribbeans. The mean (+/-SD) age was 68.9 (+/-10) years. Retinopathy or maculopathy progression was noted in seven patients (23.4%), two South-Asians, and five Afro-Caribbeans. There was no significant difference in the number of operated and fellow eyes whose retinopathy or maculopathy progressed postoperatively. Progression of retinopathy or maculopathy occurred more often in Afro-Caribbeans compared to South-Asians (P=0.02, logistic regression analysis). The mean (+/-SD) postoperative follow-up was 12.4 (+/-6.5) months. Visual acuity improved by at least two or more Snellen lines in 19 eyes (63.3%); 26 eyes (86.7%) achieved a final visual acuity of at least 6/12. CONCLUSIONS: Afro-Caribbeans may be at a higher risk of progression of retinopathy or maculopathy after phacoemulsification.