Management of a rhegmatogenous retinal detachment in a low-resource setting: treatment options when there is no vitreoretinal surgeon.

We discuss the case of a 49-year-old soldier with a macula-on rhegmatogenous retinal detachment in Sierra Leone. The case highlights the challenge of accessing visually preserving ophthalmic specialist care in sub-Saharan Africa (SSA) for vitreoretinal (VR) disease. It highlights a shortage of VR surgeons in SSA, limited examination facilities, the larger issue of accessing specialist care urgently and the costs associated with accessing surgery out-of-country. It also identifies a shortage in epidemiological data on the issue which limits the assessment of the scale of the problem.

Heavy silicone oil: a "novel" intraocular tamponade agent.

Advances in vitreoretinal surgery have greatly increased the anatomical re-attachment rate in cases with proliferative vitreoretinopathy. Intraocular tamponade agents have been in use by vitreoretinal surgeons for nearly a century. The effectiveness of an internal agent relies on its ability to make contact with the internal surface of the vitreous cavity. In the short term, this is controlled by the agent's specific gravity and interfacial tensions. In the long term, the viscosity of the material is critical to maintaining its integrity and thus reducing dispersion. The commonly used tamponade agents such as perfluoropropane (C3F8), sulfur hexafluoride (SF6), and silicone oil are "lighter than water" hence, float upward in the aqueous. A consequence of this is that in the upright position the superior retina is very well supported, leaving the inferior retina less well so. More recently, there has been interest in the development of "heavier than water" long-term tamponade agents that sink in the eye. Heavy silicone oil is a transparent, homogenous solution of two substances used as a single tamponade agent with improved properties and a specific gravity greater than water. Densiron (one of the two available heavy silicone oil's) is a mixture of perfluorohexyloctane (F6H8, with a specific gravity of 1.35 g/ml and viscosity of 2.5 mPas), and conventional silicone oil (specific gravity of 0.97 g/ml and viscosity of 5700 mPas depending on the molecular weight). The specific gravity of Densiron is 1.06 g/ml and the viscosity is 1400 mPas, making it a novel heavier-than-water, long-term internal tamponade agent, which means that in the upright position it sinks and provides support for the inferior retina.

Patient expectation and satisfaction after macular hole surgery.

PURPOSE: To assess patient expectation, visual improvement, and patient satisfaction after macular hole surgery. METHODS: Fifty-three consecutive patients completed a self-administered questionnaire after macular hole surgery. Responses for expectation of visual improvement before surgery and subjective visual assessment after surgery were scored from 0 to 10 (0 = no improvement in vision, 10 = full improvement). Visual acuity was measured using Snellen charts and converted to logMAR equivalent for statistical analysis. Wilcoxon and Mann-Whitney U tests were performed using the Minitab statistical software program; p < 0.05 was considered significant. RESULTS: Thirty-eight (71%) patients were satisfied with the outcome, 14 (26%) were not, and 1 was uncertain. Both satisfied and dissatisfied patients had no difference in baseline preoperative best-corrected visual acuity (BCVA; 6/60 and 6/60, respectively). There was also no significant difference in median postoperative BCVA between both groups (6/24 and 6/29, respectively, p = 0.6). In satisfied patients, median vision expectation score of 6 was equally similar to the median subjective postoperative vision improvement score of 6, p = 0.7. However, in dissatisfied patients, median vision expectation score (8) was significantly higher than median postoperative subjective vision improvement score (1), p = 0.0001. The commonest reason for dissatisfaction was perceived visual reduction (7/14 patients). CONCLUSIONS: In the dissatisfied patients, expectation was significantly higher, and subjective assessment of vision after surgery was lower than in satisfied patients, although they had similar improvement in BCVA. Visual acuity and patient satisfaction are not always directly correlated. An important factor in patient satisfaction is expectation.

Full-thickness macular hole formation associated with pigment epithelial detachment: link or coincidence?

To report two cases of full-thickness macular hole (FTMH) formation associated with pigment epithelial detachment (PED). Two patients presenting with visual loss and metamorphopsia were evaluated with fundal fluorescein angiography (FFA) and optical coherence tomography (OCT). Case 1: Fundus examination and FFA revealed a small subfoveal PED. Subsequent serial OCT elucidated the progressive formation of a FTMH. Case 2: Fundus examination and FFA revealed a small PED and changes suggestive of central serous retinopathy (CSR). Subsequent OCT illustrated a FTMH with an underlying small PED at the base of the hole. It is possible that, in at least some cases of macular hole formation, there may be a causative link with PED. To my knowledge, this is the first report of full-thickness macular hole formation associated with pigment epithelial detachment.

Sequential versus combined penetrating keratoplasty and cataract surgery.

PURPOSE: To compare the refractive and visual outcomes of combined penetrating keratoplasty and cataract surgery (triple procedure) with those of sequential surgery (penetrating keratoplasty followed by secondary cataract extraction and posterior chamber intraocular lens implantation). METHODS: Forty-six consecutive patients undergoing triple procedure or sequential surgery performed by two surgeons were reviewed retrospectively. The triple procedure group consisted of 23 patients and the sequential surgery group also consisted of 23 patients. Refractive and visual outcomes were collected and analyzed with at least 1 year of follow-up for both groups. Both the difference from target and the variability of the refractive outcome were analyzed. RESULTS: Best spectacle corrected visual acuity of 6/12 or better was achieved in 16 eyes (69.8%) in the triple procedure group and in 19 eyes (82.6%) in the sequential surgery group. For both the triple and sequential groups, there was no difference between the mean postoperative refractive outcome (-2.73/+1.05 x 109 SD = 4.30/1.42/4.43) and (-1.33/+0.79 x 175 SD = 2.39/1.16/2.33) compared with the mean target refraction (-0.77, SD = 1.16 and -0.43, SD = 0.99), (p = 0.39 and 0.48), respectively. In addition, there was no significant difference in the variability of the refractive outcome between the two groups (p > 0.99). CONCLUSIONS: Sequential surgery appears to offer no significant advantages over the triple procedure in terms of refractive predictability or variability. There was a slight trend toward more patients achieving 6/12 or better vision in the sequential group.

Can the sequential use of conventional silicone oil and heavy oil be a strategy for the management of proliferative vitreoretinopathy?

INTRODUCTION: Densiron is a novel long-term tamponade. Its specific gravity is 1.06 g/mL and as such it is heavier than water and provides support for the inferior retina. As proliferative vitreoretinopathy (PVR) has a propensity for the inferior retina, we used Densiron on a consecutive series of 97 cases with inferior pathology. We hypothesised that the sequential use of conventional and heavy silicone oil is a strategy for the management of PVR. MATERIALS AND METHODS: A consecutive interventional case series involving the use of Densiron for PVR cases was studied. Patients were selected if conventional silicone oil and Densiron were used sequentially. Anatomical success was defined as total re-attachment in the absence of any tamponade agent for at least 3 months post oil removal. RESULTS: Of the 97 patients, 10 patients fulfilled the criteria. Surgery involving Densiron was successful in re-attaching the retina in 7 of 10 cases, with one sequence of alternating light then heavy oil operation, and with one further surgery using silicone oil in the remaining 3 cases. The mean LogMAR preoperative vision was 1.57 and the postoperative vision was 0.82. In 8 of 10 patients, the final vision was 20/200 or better; in 5 of 10 patients, 20/80 or better. The mean follow-up was 19.5 months (range, 9 to 45). CONCLUSIONS: The sequential use of conventional silicone oil and Densiron may be a strategy in reducing the number of re-operations. Our case series shows that despite multiple surgical procedures, favourable visual outcome can be achieved.

Intralenticular metallic foreign body.

We report the case of a 58-year-old man who despite having an intralenticular metallic foreign body maintained good vision for at least 40 years. We describe the natural course of intraocular foreign body and the healing capacity of the anterior lens capsule as well as management issues to consider when dealing with intraocular foreign bodies.