Isolated traumatic neurogenic ptosis with delayed recovery.

PURPOSE: To describe the entity of isolated neurogenic ptosis due to presumed tractional injury to the nerve of innervation of the levator palpebrae superioris, with recovery occurring over a period up to 6 months. METHODS: Retrospective case review. RESULTS: Three cases of presumed neurapraxic injury to the nerve of innervation to the levator palpebrae superioris are described. Two cases had a clear history of traction to the upper eyelid. There was no evidence of damage to other extraocular muscles or their nerves of innervation in 2 cases and mild transient superior rectus underaction in 1. Maximal recovery occurred over a period of up to 6 months. CONCLUSIONS: Traumatic neurapraxic injury to the nerve of innervation to the levator palpebrae superioris may occur in certain types of upper eyelid injury, most notably when there is significant forward traction applied to the upper eyelid. Although recovery may occur within weeks, as previously described, this series illustrates that recovery may take up to 6 months.

Medical management of periorbital necrotising fasciitis.

Necrotising fasciitis (NF) is a rapidly progressing necrotizing infection of the subcutaneous tissue and superficial fascia with secondary necrosis of overlying skin. Periorbital NF, albeit uncommon, has a reported mortality of 8-15% and rate of vision loss of 13.8%. Early surgical debridement has been advocated as a critical factor in the management of these patients however, emerging reports describe successful outcomes with intravenous antibiotic therapy alone. We describe a patient who was treated conservatively with good results.

Bilateral viral retinitis in a patient with immune deficiency because of purine nucleoside phosphorylase deficiency.

BACKGROUND: Progressive retinal outer necrosis is a devastating viral necrotizing retinitis, which affects predominantly immunocompromised patients. We report a case in which the ocular findings led to a search for an underlying immune deficiency, established as congenital purine nucleoside phosphorylase deficiency. METHODS: Retrospective, interventional case report. RESULTS: We describe the clinical features and management of the disease. CONCLUSION: This is the first report of bilateral varicella zoster virus retinitis with underlying purine nucleoside phosphorylase deficiency. It highlights the importance of thorough investigation in apparent immunocompetent patients presenting with viral retinitis, as this may indicate an undiagnosed primary immunodeficiency.

Temporary Gortex (polytetrafluoroethylene) spacer for the treatment of fornix shortening following severe alkali chemical injury.

BACKGROUND: Gortex is an inert, smooth, flexible material, which is well tolerated in situ. We describe a case of fornix shortening secondary to alkali injury, which was treated successfully with a temporary Gortex patch. METHOD: Retrospective case report. RESULTS: A patient with Grade IV chemical injury developed significant symblepharon formation 47 days after the initial injury. Following an initial failed mucous membrane graft the patient had a Gortex patch sutured into the upper lid fornix which acted as a spacer to allow epithelisation of the bulbar conjunctiva. The Gortex patch was removed after 25 days, and at 6 months' follow-up, there was no recurrence of symblepharon formation. CONCLUSION: Industry-related severe ocular chemical injury is a rare occurrence. It can lead to symblepharon formation and destruction of the conjunctival fornix. In this case a Gortex spacer was successfully used to prevent symblepharon formation and reform the upper eyelid fornix after severe chemical injury.

Subspecialization of the ophthalmic literature: a review of the publishing trends of the top general, clinical ophthalmic journals.

PURPOSE: To investigate the publishing trends of the top general clinical ophthalmic journals and to report: (1) the proportions of articles published in terms of ophthalmic subspecialty, (2) the study design used, (3) any changes in publishing trends, and (4) any differences in the quality of study design between the subspecialties. DESIGN: Retrospective, database review. PARTICIPANTS: All original articles published in the top general, clinical ophthalmology journals from 2005 through 2009. METHODS: All general, clinical ophthalmic journals were selected from the top 20 journals based on 2008 impact factor. All abstracts from original articles were reviewed, and the subject matter was recorded as belonging to 1 of the 11 ophthalmic subspecialties. After the content of the article was assigned, then the study design was recorded as one of the following: nonanalytic study, case-control or cohort study, randomized control trial, meta-analysis, laboratory science article, or systemic review. MAIN OUTCOME MEASURES: Subspecialty of the article and the study design used. RESULTS: Seven journals were included, and 12 426 abstracts were reviewed. Articles relating to medical retina were the most prevalent (29.1%), and those relating to strabismus were the least prevalent (2.3%). Case-control or cohort studies comprised most study designs (40.1%), with meta-analyses comprising the least (0.3%). The mean number of articles per year was 2485 (standard deviation, 125.1), remaining stable over the study period. Medical retina articles were significantly more common in 2009 than in 2005 (chi-square, 11.2; P = 0.0008), whereas the proportion of oculoplastic articles was significantly reduced (chi-square, 16.9; P<0.0001). Cataract and refractive surgery had the highest proportions of articles using the higher forms of study design (7.8%), and oculoplastics had the highest proportion of nonanalytic studies (64.5%). CONCLUSIONS: There are great differences across the specialty of ophthalmology in the subject matter of published literature, probably driven by recent advances in treatments. Medical retina is the subspecialty that is most represented in the literature, with strabismus being the least represented. Cataract and refractive surgery articles have the greatest proportion of higher-quality research strategies. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Live or Let Die: Epithelial Flap Vitality and Keratocyte Proliferation Following LASEK and Epi-LASIK in Human Donor and Porcine Eyes.

PURPOSE: To determine the relationship between epithelial flap vitality and stromal keratocyte proliferation following two epithelial refractive techniques: epi-LASIK and laser epithelial keratomileusis (LASEK). METHODS: Human corneas were maintained in organ culture and underwent standard -6.00-diopter ablation. Rates of stromal keratocyte proliferation were detected 1 week postoperative using a Ki67 antibody specific to proliferating cells. Images were captured with a laser scanning confocal microscope and analyzed by a masked observer. Epithelial flap vitality was determined with propidium iodide using fresh porcine corneas. Epithelial flaps were created with Gebauer Epikeratome epi-LASIK or alcohol-assisted LASEK method. Flaps treated with 100% alcohol and uninjured corneas were used as controls. RESULTS: The number of proliferating keratocytes was greatest at 1 week in the epi-LASIK corneas (P<.001). Cell vitality was greatest in the epi-LASIK flaps and declined in the LASEK and 100% alcohol flaps (P<.001). CONCLUSIONS: In this in vitro setting, epi-LASIK results in an epithelial flap with significantly more live cells. There is also a greater number of proliferating stromal cells following epi-LASIK at 1 week. Based on these in vitro observations, epi-LASIK may result in greater levels of haze compared to LASEK.

Look beyond the red eyes!

This is a case of a 63-year-old gentleman who presented with persistent red eyes to the eye clinic for several months. He had been seen in the eye department on several visits when he was noted to have red ears too. This led to further review in the rheumatology and ear, nose and throat clinic to confirm the diagnosis of relapsing polychondritis. He was treated successfully with systemic steroids.

Globe preservation surgery for a paranasal tumor with orbital extension.

Orbital exenteration is a rare radical procedure used for the treatment of locally invasive or potentially life threatening orbital tumors. The procedure results in significant visual and psychosocial disability. Recently there has been a shift toward a subtotal extenteration with maximum preservation of orbital tissue and globe in appropriate cases. We describe the management dilemma of a patient with orbital extension of a frontal sinus squamous cell carcinoma. The patient underwent combined craniofacial and transnasal macroscopic excision with globe preservation. Traditional approach for a sinus tumor that has invaded the orbit would be an exenteration. The favorable outcome of the case reported here raises the possibility of considering this approach more frequently.

Corneal confocal microscopy in Darier disease.

PURPOSE: We report ocular findings in a patient with Darier disease. In particular, we discuss the in vivo confocal images. METHOD: A retrospective noninterventional case report. RESULTS: Confocal microscopy revealed collections of intercellular material, separating the cells of the patient's basal corneal epithelium. Discrete foci of this material were scattered throughout the central corneal basal epithelium in both eyes. These deposits had a similar reflectance as corneal nerves, were 3-5-microm thick, and of note in places conformed to the cell borders. CONCLUSIONS: The findings of abnormal intercellular collections at the basal epithelial layer of the cornea correlate with the previously reported histological findings. They are consistent with the abnormal keratocyte-to-keratocyte adhesions that are described both in the skin and cornea of Darier disease. The abnormalities we describe occurred in the absence of other ocular signs of Darier disease. These findings on confocal microscopy may help with the diagnosis and monitoring of disease progression.

Increased sequestration of matrix metalloproteinases in ageing human Bruch's membrane: implications for ECM turnover.

PURPOSE: The ageing of Bruch's membrane is associated with progressive reduction in the degradation of the capacity for ECM turnover mediated by the matrix metalloproteinase (MMP) system. In this study, the free and bound pools of all gelatinase species were quantified to aid in assessing the likelihood of reduced availability of pro-MMPs for activation in ageing Bruch's membrane. METHODS: Bruch's membrane from macular locations (10 eyes; donor age range, 21-84 years) was mounted in Ussing chambers and eluted with phosphate-buffered saline to release the free pool of MMPs. Free and bound pools of MMPs were subjected to gelatin zymography, and individual gelatinase species were quantified by densitometric scans. RESULTS: The zymograms displayed six gelatinase species: four corresponding to the pro- and active forms of MMP-2 and -9 and two high-molecular-weight polymeric forms designated HMW1 and -2, corresponding to approximate molecular masses of 195 and 391 kDa, respectively. The ageing of Bruch's membrane was associated with an exponential increase in the percentage of pro-MMPs bound to the membrane (pro-MMP-2: %age bound = 0.54 exp(0.04 x age), r = 0.87, P < 0.01; and pro-MMP-9: %age bound = 5.0 exp(0.03 x age), r = 0.8, P < 0.01). A similar exponential increase was seen in the percentage of bound HMW1 species (%bound = 11.7 exp(0.018 x age; P < 0.05). The HMW2 species was virtually all bound to the membrane, but some release was observed in the very elderly. CONCLUSIONS: The ageing of Bruch's membrane was associated with progressive sequestration of MMPs reducing the free concentration and potential for activation. These changes may underlie the reduction in degradation that leads to the age-related increase in the thickness of the membrane.

The role of visually evoked potentials in the management of hemispheric arachnoid cyst compressing the posterior visual pathways.

We report a case of an occipital arachnoid cyst in an infant, managed on the basis of changes in visually evoked potentials (VEPs). A significant asymmetry of VEP responses prompted neurosurgical intervention, which improved visual behavior and electrical response to both pattern and flash stimuli.

Scleral hydraulic conductivity and macromolecular diffusion in patients with uveal effusion syndrome.

PURPOSE: To determine whether uveal effusion syndrome (UES) is caused by altered scleral permeability to water and large molecules. METHODS: Transscleral water movement was measured using surgically removed sclera clamped in a modified Ussing chamber and connected to a water column set at intraocular pressure. Sclera was also clamped between two hemichambers, and transscleral diffusion of FITC-dextrans (4.4-77 kDa) was measured with a spectrophotometer. Clinical data were prospectively collected using postal questionnaires. RESULTS: Ten patients (mean age, 63 years; mean spherical equivalent, +4.7 D) had a median preoperative visual acuity of 0.20 that improved to 0.33 after surgery. Nine eyes showed visual improvement, three worsened, and two were unchanged. Histology showed disorganization of collagen fibrils, with amorphous deposits expanding the interfibrillary spaces. The mean thickness (+/-1 SD) of the excised scleral specimens was 585 +/- 309 microm, and the mean specific hydraulic conductivity was 23.9 +/- 27.5 x 10(-14) cm(2), compared with 5.8 +/- 3.9 x 10(-14) cm(2) in age-matched control specimens (P = 0.068). Three specimens had hydraulic conductivity above the 95% CI of the controls. Control eyes showed a significant reduction in diffusion coefficient (D) with age. Eyes had a mean D of 5.69 +/- 5.35 x 10(-8) cm(2) x s(-1), similar to control eyes (6.14 +/- 2.40 x 10(-8) cm(2) x s(-1), 20 kDa dextran). In one eye, the result was higher than the 95% CI of the control; in three, it was lower. CONCLUSIONS: UES is not caused by reduced scleral hydraulic conductivity, which tends to be higher than expected. Reduced macromolecular diffusion may impede the normal transscleral egress of albumin with subsequent osmotic fluid retention in some, but not all eyes.

In the bag IOL dislocation following uncomplicated phacoemulsification.

We present two cases of early post-operative, in the bag intraocular lens (IOL) dislocation following uncomplicated phacoemulsification. Dislocation occurred in the presence of capsular fibrosis and anterior capsular phimosis. One patient was a known diabetic, the other diagnosed with pseudoexfoliation syndrome. These are recognised risk factors for capsular fibrosis. Surgical management included enlargement of the anterior capsular opening using intraocular micro-scissors and vitreous cutter to facilitate the removal of the dislocated IOL from the capsular bag. Both patients achieved a satisfactory visual outcome following IOL exchange with a rigid, sulcus fixated posterior chamber IOL (PCIOL). We discuss the risk factors for capsular fibrosis and propose preventative strategies to reduce the incidence of in the bag IOL dislocation.

Fellow eye comparison between the 1CU accommodative intraocular lens and the Acrysof MA30 monofocal intraocular lens.

PURPOSE: To examine the near visual clinical performance of an accommodative intraocular lens (IOL) when compared with a standard monofocal IOL in a fellow eye comparison. DESIGN: Prospective, randomized fellow eye comparison. METHODS: Thirty patients (60 eyes) with bilateral cataracts but otherwise normal eyes were recruited from a single university hospital cataract waiting list. Patients were randomized to receive either the 1CU accommodative IOL in their first eye or the Acrysof MA30 monofocal IOL. The alternative lens was then implanted in the second eye 4 to 6 weeks later. At all follow-up visits, a full assessment was made of distance, near and reading visual performance, and accommodative amplitude. RESULTS: Data are available for all patients at 6 months and 20 patients at 1 year. At 6 months, no difference was found in distance-corrected visual acuity between the two IOLs. Of the 1CU eyes, nine patients (30%) could read J6 or better at a reading speed of 80 words/min or better. In these nine patients, the mean difference in the amplitude of accommodation between the two eyes was 0.71 diopters. CONCLUSIONS: No measurable variable distinguished eyes that developed functional reading vision from those that did not. The accommodative IOL appears to produce improved near vision in some eyes, but it does not work in all eyes, and in eyes where there is apparent accommodation, there is a discrepancy between subjective reading performance and the modest measured increase of accommodative amplitude.

Comparison of posterior capsule opacification rates between hydrophilic and hydrophobic single-piece acrylic intraocular lenses.

PURPOSE: To determine the effect of intraocular lens (IOL) material on the development of posterior capsule opacification (PCO) at 1 year. SETTING: Department of Ophthalmology, St. Thomas' Hospital, London, United Kingdom. METHODS: One hundred six eyes of 53 patients with bilateral cataract and no other ocular comorbidity were prospectively randomized to receive a hydrophobic acrylic or hydrophilic acrylic single-piece IOL in the first eye to have surgery. The alternate IOL was implanted in the fellow eye 4 to 6 weeks later. All surgery was performed by a single surgeon. Postoperative follow-up was 1 day, 1 and 6 months, and 1 year. At each visit, the best corrected high- and low-contrast visual acuities were assessed and a high-intensity digital retroillumination photograph was taken. Posterior capsule opacification was assessed from the digital images by a single operator using a dedicated software program and calculated as the percentage area of opacified capsule. RESULTS: One year postoperatively, the median percentage area of PCO was 50.3% in the hydrophilic IOL group and 4.9% in the hydrophobic IOL group (P<.001). The difference in PCO was not accounted for by loss of contact between the capsulorhexis and IOL surface. Further analysis showed that lens epithelial cells tended to invade the posterior capsule at the haptic-optic junction. This was more marked in the hydrophilic IOL group. CONCLUSIONS: The rate of PCO was significantly higher with the hydrophilic IOL. However, the results cannot be attributed to the IOL material alone as they show the importance of both IOL material and design.

Traumatic cataract and intralenticular foreign body.

Traumatic cataracts resulting from penetrating injuries occur most frequently from projectile metallic foreign bodies. The majority of intraocular foreign bodies cause sight-threatening damage including traumatic cataract in up to 25% of the cases. A case of traumatic cataract and retained intralenticular foreign body that was removed successfully with phacoemulsification and foldable intraocular lens implantation in the capsular bag is described. This case report highlights the benefit in planning surgical management as a two-staged procedure after appropriate investigations.