One-year visual outcome of secondary piggyback pinhole device implantation in pseudophakic eyes with irregular corneal astigmatism and iris trauma.

PURPOSE: Retrospective case series evaluating the efficacy and safety of implanting XtraFocus™ pinhole device in pseudophakic patients with irregular corneal astigmatism with concurrent or standalone iris defect. METHODS: Electronic case records were searched for: uncorrected distance visual acuities (UDVA) and corrected distance visual acuities (CDVA), automatic or manifest refraction and spherical equivalent (SE). All main outcomes were evaluated preoperatively and postoperatively at 1, 3, 6, 9 and 12 months, along with patients' satisfactory outcome and complications. RESULTS: Eleven pseudophakic eyes of 11 patients with a mean age of 54 (range 27-81) years were included. Median UDVA improved significantly from logMAR 0.7 (range 0.1-1.22) pre-operatively to 0.4 (range 0-1.3) at 1-month (p = 0.002); median CDVA remained unchanged at logMAR 0.4 (range 0-0.1) pre-operatively and 0.4 (range 0-0.8) at 1-month (p = 0.36). There were no significant statistical differences in both UDVA and CDVA between the post-operative periods. Ten patients (90.9%) had initial UDVA improvement at 1-month post op. Eight (72.7%) patients expressed satisfaction with improved vision or reduction of glare/halos. Three (27.3%) patients had unsatisfactory visual outcome resulting in 2 requested for implant explantation due to worsening of glare and distressing floaters. CONCLUSIONS: XtraFocus™ is effective in improving vision or reducing glare in pseudophakic patients with irregular corneal astigmatism or intragenic iris trauma, with over 70% expressed satisfactory outcome. Disturbing floaters and glare preclude its use in some resulting in implant explantation.

Randomized, controlled trial comparing respiratory and analgesic effects of interscalene, anterior suprascapular, and posterior suprascapular nerve blocks for arthroscopic shoulder surgery.

Background: Interscalene brachial plexus block (ISB) provides excellent analgesia for arthroscopic shoulder surgeries but is associated with adverse effects including hemidiaphragmatic paresis. We aimed to compare the respiratory effects, forced vital capacity (FVC), and forced expiratory volume in 1 second (FEV1) between suprascapular nerve block (SSB) and ISB. METHODS: Sixty patients were recruited and randomized into ISB, anterior SSB, and posterior SSB groups. FVC, FEV1, and diaphragmatic excursion were evaluated at baseline and 30 minutes after intervention. Blocks were performed under ultrasound guidance with 15 ml of 0.5% ropivacaine. Pain scores were assessed at 6, 12, and 24 hours postoperatively. RESULTS: The ISB group showed a reduced FVC of 31.2% ± 17.5% (mean ± SD), while the anterior and posterior SSB groups had less reduction of 3.6% ± 18.6% and 6.8% ± 6.5%, respectively (P < 0.001). The ISB group showed more reduction in diaphragmatic excursion than the anterior and posterior SSB groups (median [IQR]): -85.7% (-95.3% to -63.3%) vs. -1.8% (-13.1% to 2.3%) and -1.2% (-8.8% to 16.8%), respectively (P < 0.001). The median pain scores (IQR) in the ISB and anterior SSB groups were lower than those in the posterior SSB group at 6 hours on movement: 0 (0-2), 1.8 (0-4.5) vs. 5 (2.5-8), respectively (P = 0.002). There was no significant difference in oxycodone consumption postoperatively. CONCLUSIONS: Anterior SSB preserves lung function and has a comparable analgesic effect as ISB. Thus, it is recommended for arthroscopic shoulder surgeries, especially in patients who have reduced lung function.

Refractive surprise after routine cataract surgery with multifocal IOLs attributable to corneal epithelial basement membrane dystrophy.

We describe two patients in whom postsurgical refractive error occurred after routine refractive lens exchange cataract surgery with multifocal intraocular lens insertion most likely attributable to the presence of underlying corneal epithelial basement membrane dystrophy (EBMD). In Case 1, there was an unexpected hyperopic postoperative spherical equivalent refractive error of +1.50 diopters and in Case 2, a cylindrical refractive error of 2.75 diopter cylinder. We examine the possible causes of error and discuss potential management strategies to prevent and address these unpredictable postoperative outcomes. The importance of comprehensive and careful ocular surface assessment before cataract or refractive surgery as part of the presurgical workup is reemphasized. EBMD can be subtle and if overlooked, can affect the validity of biometric keratometric measurements preoperatively, resulting in an inaccurate biometry measurement, incorrect IOL selection, and reduced visual performance and patient satisfaction.

Outcome of Descemet stripping automated endothelial keratoplasty in eyes with an Ahmed glaucoma valve.

PURPOSE: The purpose was to investigate the survival of Descemet stripping automated endothelial keratoplasty (DSAEK) in eyes with an Ahmed glaucoma valve (AGV). METHODS: The study had a retrospective case-series of patients with an AGV in the anterior chamber undergoing a DSAEK. Included in the analysis were graft size, number of previous operations, post-operative glaucoma medications, post-operative intraocular pressure (IOP) control, graft size and donor factors (age, endothelial cell density, and post-mortem time). A generalised linear model with binary logistic regression was used to test for an effect on graft survival at 1 year and 1.5 years. RESULTS: Fourteen eyes from 13 patients were included. The survival rate of the first DSAEK at 6, 12, 18, 24 and 30-months was 85%, 71%, 50%, 36% and 30%, respectively. The mean duration to graft failure was 12.9 ± 6.2 months. Five of the seven failed first grafts went on to have a repeat DSAEK. The mean follow-up in this subgroup was 30.7 ± 18.4 months. The survival rate of second DSAEK at 6, 12, 18 and 24 months was 100% (5/5), 100% (5/5), 75% (3/4) and 67% (2/3). Only one second DSAEK failed in the duration of the study and went on to receive a third DSAEK which failed at 18-months. The mean IOP within the first year was significantly lower for grafts that survived at 1 and 1.5 years (17.4 mmHg, 16.9 mmHg) than for grafts that failed (19.4 mmHg, 19.4 mmHg) (p = 0.04, p = 0.009). CONCLUSION: DSAEK is a viable alternative to PK to restore visual function in eyes with an AGV sited in the anterior chamber. IOP is an important risk factor for graft failure.

Porous Versus Nonporous Orbital Implants After Enucleation for Uveal Melanoma: A Randomized Study.

PURPOSE: To compare hydroxyapatite with acrylic implants after enucleation for uveal melanoma with respect to eyelid position, ocular motility, implant complications, and patient satisfaction. METHODS: Patients undergoing primary enucleation for uveal melanoma between May 2005 and November 2012 at the Liverpool Ocular Oncology Centre, United Kingdom, were randomized between hydroxyapatite and acrylic implants. Questionnaires were sent to patients and ocularists to comment on the main outcomes. RESULTS: A total of 416 patients were recruited in the study, of whom 281 were included, with 49.5% (139/281) and 50.5% (142/281) receiving a hydroxyapatite (HA) or acrylic (AC) implant. Mailed questionnaires completed at ≥18 months by patients showed no significant differences between the groups in eyelid position, prosthetic motility, socket complications, and patient satisfaction. Complications included implant extrusion (1% vs 4%), enophthalmos (26% vs 26%), and superior sulcus deformity (24% vs 24%) with HA and AC implants, respectively, (Fisher exact test p > 0.0125 in all, Bonferroni correction). Questionnaires completed by ocularists indicated no significant differences in eyelid opening, prosthetic motility, and other complications at 6 months (Fisher exact test, p > 0.05 in all); there was a higher prevalence of ptosis with AC than HA implants (46% vs 25%, p = 0.03) and a greater need for ocularists' treatment with HA than AC (50% vs 28%, p = 0.03). CONCLUSIONS: Patient-reported outcomes after enucleation for uveal melanoma indicate no major differences between hydroxyapatite and acrylic implants in surgical outcomes and patient satisfaction. There was a higher prevalence of ptosis with AC and a greater need of ocularists' visits with HA at around 6 months observed by ocularists.

6-weekly bevacizumab versus 4-weekly ranibizumab for neovascular age-related macular degeneration: a 2-year outcome.

AIM: To compare visual acuity and central macular thickness (CMT) changes in neovascular age related macular degeneration patients treated with either 6 weekly bevacizumab regimen or 4 weekly ranibizumab on an as required basis. METHODS: Patients made an informed choice between bevacizumab 1.25 mg or ranibizumab 0.5 mg. The selected treatment was administered in the first 3 visits. Bevacizumab patients were followed-up 6 weekly and ranibizumab 4 weekly. Retreatment criteria was based on the reduction of >5 letters in the best-corrected visual acuity (BCVA), the presence of retinal fluid on optical coherence tomography (OCT) or new retinal haemorrhage. RESULTS: Visual acuity at 2y bevacizumab patients gained 7.0 letters and ranibizumab 9.2 (P=0.31, 95% CI -6.4 to 2.0). At 2y 86% of bevacizumab and 94% ranibizumab patients had not lost 15 letters or more (P=0.13). Mean CMT decreased at 2y bevacizumab by 146 µm, ranibizumab 160 µm (P=0.72). Mean number of injections was at 2y bevacizumzb 11.9, ranibizumab 10.3 (P=0.023). CONCLUSION: Bevacizumab 6 weekly on an as required basis was not demonstrably non-inferior to ranibizumab 4 weekly pro re nata (prn) in terms of BCVA and change in CMT. In the bevacizumab group, one more injection was required in the second year compared to the ranibizumab group.

A case of misconstrue proptosis.

This case illustrates an overlooked metastatic lung carcinoma to the orbit. The rapid onset of symptoms and oedema mimicked a cellulitis. The patient was initially treated with a broad-spectrum topical and intravenous antibiotic therapy. The white blood cell count (WBC) and C reactive protein (CRP) were normal. Compressive optic neuropathy and serous retinal detachment ensued. The initial chest x-ray revealed lung shadows; however, this was not reviewed. Eventually, CT of the chest was organised and showed a lung mass. The management of such a case remains a challenge for the uninitiated, and high index of suspicion is required to ensure early appropriate management. Despite complete resolution of the swelling with sequential chemotherapy (cisplatin and etoposide) and radiotherapy, the visual prognosis remained grim.