Blindness associated with platelet-rich plasma temporomandibular joint injections.

This case report highlights an ocular complication associated with platelet-rich plasma temporomandibular joint injections. This pioneering treatment can risk irreversible visual loss. This case highlights the importance of an experienced technique, in depth understanding of facial anatomy, and promptly recognising and referring the patient to a specialist to manage the complication should it arise.

The Cataract National Dataset electronic multicentre audit of 55,567 operations: risk stratification for posterior capsule rupture and vitreous loss.

AIMS: To identify and quantify risk factors for posterior capsule rupture or vitreous loss or both (PCR or VL or both) during cataract surgery and provide a method of composite risk assessment for individual operations. METHODS: The Cataract National Dataset was extracted on 55,567 operations from 12 National Health Service (NHS) Trusts using an electronic patient record (EPR) system between November 2001 and July 2006. Risk indicators for variations in the rate of 'PCR or VL or both' were identified by univariate and multivariate analyses. Adjusted odds ratios (ORs) were used to formulate a composite 'bespoke' risk for individual cases. RESULTS: Overall 'PCR or VL or both' rate was 1.92% (95% CI=1.81-2.04%). Risk indicators for this complication were increasing age, male gender, presence of glaucoma, diabetic retinopathy, brunescent/white cataract, no fundal view/vitreous opacities, pseudo-exfoliation/phacodonesis, reducing pupil size, axial length > or = 26.0 mm, the use of the alpha-blocker doxazosin, inability to lie flat and trainee surgeons performing operations. Adjusted ORs for these variables are used to estimate overall composite risk across multiple risk indicators in the form of a predicted probability of PCR or VL or both. Predicted probability for this complication ranged from less than 0.75% to more than 75%, depending on risk profile of individual operations. CONCLUSIONS: Higher-risk cases can be predicted, thus better informing the consent process and allowing surgeons to take appropriate precautions. Case-mix is a major determinant of the probability of an intraoperative complication. A simple composite risk estimation system has been developed.

A comparison of HRT II and GDx imaging for glaucoma detection in a primary care eye clinic setting.

PURPOSE: To evaluate the performance of the HRT II (Heidelberg retinal tomograph) and GDx (glaucoma detection) retinal nerve fibre analyzer in GDx when used in the primary care eye clinic setting for glaucoma screening. PATIENTS AND METHODS: The study was prospective, cross-sectional, and hospital-based. One-hundred and twelve patients, 59 women and 53 men with a mean age of 57.8 years (range 18-85 years), had consecutive HRT II disc imaging and GDx retinal nerve fiber layer analysis. The Moorfield's regression classification and the 'GDx number' were used to predict the likelihood of glaucoma. A separate clinician, masked to the instrument results determined a definitive diagnosis, based on clinical examination. The extent of agreement between instrument prediction and the clinician diagnosis of glaucoma was examined by generating sensitivity and specificity tables. RESULTS: The HRT II had a sensitivity of 0.79 (95% CI: 0.60-0.92) and a specificity of 0.70 (95% CI: 0.60-0.78). The positive predictive value of the HRT II was 0.43 (95% CI: 0.29-0.57). Using a GDx number of 50 as 'cutoff' for glaucoma detection, the GDx had a sensitivity of 0.80 (95% CI: 0.59-0.93) and a specificity of 0.72 (95% CI: 0.61-0.80), with a positive predictive value of 0.43 (95% CI: 0.28-0.59). CONCLUSIONS: For glaucoma detection, neither the HRT II nor the GDx are effective as stand-alone screening devices in the primary care setting.

Silicone oil concentrates fibrogenic growth factors in the retro-oil fluid.

AIM: To determine whether silicone oil concentrates protein and growth factors in the retro-oil fluid. METHODS: A laboratory analysis of intraocular fluid and vitreous specimens obtained from patients undergoing removal of silicone oil, revision vitrectomy, or primary vitrectomy for macular hole, proliferative vitreoretinopathy (PVR), or retinal detachment. Patients were prospectively recruited from routine vitreoretinal operating lists. Vitreous cavity fluid and vitreous samples were analysed for the presence of transforming growth factor beta (TGF-beta2), basic fibroblast growth factor (bFGF), interleukin 6 (IL-6), and total protein using either commercially available enzyme linked immunosorbent assays (ELISA) or protein assay kits. RESULTS: The median levels of bFGF, IL-6, and protein in the retro-oil fluid were raised (p<0.05) compared to all the other vitreous and vitreous cavity fluid samples. bFGF, IL-6, and protein levels were raised in PVR vitreous compared to non-PVR vitreous. TGF-beta2 levels were not significantly raised in retro-oil fluid or in PVR vitreous. CONCLUSIONS: The concentration of fibrogenic (bFGF) and inflammatory (IL-6) growth factors and protein is raised in retro-silicone oil fluid. This may contribute to the process of retro-oil perisilicone proliferation and subsequent fibrocellular membrane formation.

Long term outcome of secondary glaucoma following vitreoretinal surgery.

PURPOSE: To determine the long term outcome of secondary glaucoma following retinal reattachment surgery. METHOD: A longitudinal retrospective study was undertaken of the medical records of patients referred to the Glaucoma Service at Moorfields Eye Hospital following retinal reattachment surgery. The main outcome measures were final intraocular pressure (IOP), progression in cup:disc ratio, and final visual acuity outcome. RESULTS: A total of 70 eyes of 70 patients (41 males and 29 females) were identified and included in the analysis. Mean increase of IOP 2-3 weeks following the first vitreoretinal procedure was 6 (SD 3) mm Hg. After a mean follow up of approximately 4 years the mean IOP had significantly decreased from 33 (SD 10) to 16 (SD 8) mm Hg (p<0.001). The visual outcome of eyes with final IOP less than 6 or greater than 21 mm Hg was significantly worse compared with those eyes with a normal (6-21 mm Hg) range of pressure (p = 0.022 and p = 0.009 respectively). Despite the effective control of IOP in the majority of patients during the follow up period, there was mild progression of the mean vertical cup:disc ratio from 0.6 (SD 0.2) to 0.7 (SD 0.2) (p<0.001). CONCLUSION: Secondary glaucoma is a major complication following retinal reattachment surgery. Medical treatment is successful in lowering IOP in most patients. In persisting cases surgical treatment is very effective, however it can be associated with an increased risk of postoperative hypotony. Despite apparently adequate IOP control there may be progressive cupping of the optic disc.

Giant cell arteritis mimicking idiopathic orbital inflammatory disease.

PURPOSE: To report an unusual presentation of giant cell arteritis, referred from primary care, mimicking orbital apex syndrome. CASE REPORT: A 72 year old woman was referred with a two week history of pyrexia, dull right eye ache, 2mm of right proptosis, mild conjunctival chemosis and restriction of right eye movements. RESULTS: An erythrocyte sedimentation rate (ESR) was 90 and fluorescein angiography showed almost complete choroidal non-perfusion suggestive of giant cell arteritis. Temporal artery biopsy confirmed the diagnosis. CONCLUSIONS: Giant cell arteritis (GCA) typically presents with anterior ischemic optic neuropathy (AION), choroidal ischemia, central retinal artery occlusion, infrequently manifesting as an ocular motility problem, but has rarely been known to mimick idiopathic orbital inflammatory disease. Prompt recognition and therapy can minimize the chance of ipsilateral ocular involvement and protect the fellow eye.

Simple retinal detachments: identifying the at-risk case.

The success rate of retinal reattachment surgery has now reached over 90%. The major cause of failure is attributable to the development of proliferative vitreoretinopathy (PVR). It is a complex process comprised of events that are similar to those of the wound healing response with inflammation, migration and proliferation of a variety of cells. These membranes can exert traction and reopen previously closed retinal breaks, create new breaks, and distort or obscure the macula. In the early part of this century the success rate of retinal reattachment surgery was virtually nil and it was not until a better understanding of the pathophysiology of retinal detachment was gained that the success rate improved. It was Gonin who emphasised the relationship between vitreous detachment and traction resulting in retinal tears that led to treatment aimed at closing retinal breaks. To increase even further the final success rate in the treatment of 'simple retinal detachments' a better understanding of the risk factors for PVR is needed in patients presenting with acute retinal detachments. Such risk factors can be broadly divided under the headings of preoperative risk factors, best surgical management and possibly adjuvant therapy.

Adjuvant 5-fluorouracil and heparin prevents proliferative vitreoretinopathy : Results from a randomized, double-blind, controlled clinical trial.

PURPOSE: To assess the safety and efficacy of adjuvant combination therapy using 5-fluorouracil (5-FU) and low molecular weight heparin (LMWH) for prevention of proliferative vitreoretinopathy (PVR) after vitrectomy and retinal reattachment surgery. DESIGN: Prospective randomized, double-masked, placebo controlled trial. PARTICIPANTS: One hundred seventy-four high-risk patients were randomized to receive either 5-FU and LMWH therapy or placebo. Patients were selected from all patients undergoing primary vitrectomy for rhegmatogenous retinal detachment. METHOD: Results of standard surgery with 5-FU and LMWH therapy or placebo were compared at the 6-month follow-up. MAIN OUTCOME MEASURES: Development of postoperative PVR, retinal reattachment at 6 months after surgery, single operation reattachment rate, number of reoperations, and best-corrected visual acuity. RESULTS: There were 87 patients in the 5-FU and LMWH therapy group and 87 in the placebo group. The incidence of postoperative PVR was significantly lower (P = 0.02) in the 5-FU and LMWH therapy compared with the placebo group. In 26.4% (23/87) of the placebo group and in 12.6% (11/87) of the 5-FU and LMWH group, postoperative PVR developed. In the 5-FU and LMWH group, the number of patients undergoing more than one operation was 19.5% (17/87) and the number of reoperations resulting from PVR was 52.9% (9/17). In the placebo group, the number of patients undergoing more than one operation was 25.3% (22/87) and the number of reoperations resulting from PVR was 72.7% (16/22). The difference in visual acuity was not statistically different in the two treatment groups, although those patients in whom postoperative PVR developed tended to have poorer vision (P < 0.0001). There were no differences in complication rates between the two groups. CONCLUSIONS: There is a significant reduction in the incidence of postoperative PVR in patients receiving the 5-FU and LMWH therapy and in the reoperation rate resulting from PVR. This trial shows that incidence of PVR can be reduced with inexpensive and simple pharmacologic treatment with 5-FU and LMWH and should be used routinely in the treatment of patients at risk of developing PVR.

How to predict proliferative vitreoretinopathy: a prospective study.

PURPOSE: To determine prospectively the accuracy of a predictive risk formula for the development of postoperative proliferative vitreoretinopathy (PVR) when applied in a clinical setting. DESIGN: Prospective noncomparative interventional case series. PARTICIPANTS: Two hundred nineteen subjects undergoing primary vitrectomy for rhegmatogenous retinal detachment were studied. METHOD: By use of a formula-based discriminant rule, subjects were classified as either high or low risk for the development of PVR. All subjects were followed prospectively. OUTCOME MEASURES: Development of postoperative PVR as defined by the updated the Retina Society Classification. RESULTS: Complete data were available on 212 of 219 subjects. There were 130 subjects identified as low risk and 82 subjects as high risk; 9.2% of the low-risk (12 of 130) compared with 28% (23 of 82) of the high-risk subjects had postoperative PVR develop. This difference was statistically significant (P < 0.001). CONCLUSIONS: Our study has shown that using a clinical model it is possible to identify subjects at greater risk of PVR developing after primary vitrectomy.

Risk factors for proliferative vitreoretinopathy after primary vitrectomy: a prospective study.

AIM: To assess clinical variables and vitreous protein as risk factors for the development of postoperative proliferative vitreoretinopathy (PVR). METHODS: A prospective study was conducted on 140 patients with a rhegmatogenous retinal detachment in whom a primary vitrectomy was performed. 12 clinical variables were recorded and vitreous samples obtained for measurement of protein concentration. Univariate and multivariate logistic regression analysis was used to determine the risk factors for PVR. RESULTS: Complete data were available for 136 of 140 patients. 40 of the 136 patients (29.4%) developed postoperative PVR. Univariate regression revealed that significant (p<0.05) risk factors included aphakia, presence of preoperative PVR, size of detachment, the use of silicone oil, and high vitreous protein level. Multivariate regression analysis revealed only aphakia (odds ratio 2.72), the presence of preoperative PVR (odds ratio 3.01), and high vitreous protein concentration (odds ratio 1.11) to be significant (p<0.05) independent, predictive risk factors for the development of PVR. CONCLUSIONS: This study has shown that the significant risk factors for PVR are preoperative PVR, aphakia, and high vitreous protein levels. Two models (clinical factors only and clinical factors and vitreous protein) were constructed to predict the probability of developing postoperative PVR and may be used to identify those at risk for possible intravitreal pharmacological treatment.

Biofilm on scleral explants with and without clinical infection.

PURPOSE: Biofilm is a glycocalyx matrix secreted by microorganisms that confers protection against host defenses and antimicrobial treatment. Biofilms have been implicated in the persistence of scleral buckle infections. This study aimed to evaluate the incidence of biofilm growth on scleral explants and the relationship to explant infection. METHODS: Scleral explants were obtained following removal for infection or extrusion or during repeat surgery. Explants were fixed with rhuthenium red and examined by scanning electron microscopy to visualize the glycocalyx. RESULTS: A total of 28 explants were analyzed. Ten were removed because of either infection or extrusion and 18 were removed during repeat surgery. The mean time to removal of explants was 36 months in the infection/extrusion group and 12 months in the others. Biofilm was identified on five explants-two removed because of infection/extrusion and three for surgical indications. Bacterial elements were identified in all biofilms. CONCLUSIONS: Biofilm was identified on explants removed because of infection or exposure and on explants removed for technical reasons at repeat surgery. This implies that bacterial contamination and biofilm formation occur without exposure of the explant, probably due to inoculation at the time of initial surgery. Biofilms may contribute to the persistence of scleral explant infections but a causative role in buckle extrusion is unproved.

Endoscopic orbital decompression for thyroid eye disease.

BACKGROUND: Thyroid eye disease is a disorder of immune function resulting in extraocular myopathy and an increase in retrobulbar fat. These changes lead to the clinical features found in thyroid eye disease including proptosis, eyelid retraction, restrictive myopathy and sometimes compressive optic neuropathy. Orbital decompression is undertaken for optic nerve compression, exposure keratopathy or cosmesis. Previously this involved an external approach with the removal of the medial orbital wall along with the floor. An intranasal endoscopic approach with the removal of the medial orbital wall and part of the floor has recently been advocated as an alternative procedure. METHODS: We present the results of 7 patients who underwent endoscopic orbital decompression. The effects on optic nerve function, proptosis and ocular motility were assessed. Symptoms before and after surgery were monitored. RESULTS: The surgery was found to be successful in all cases with a reduction in proptosis and minimal effect on ocular motility. The surgery was also associated with a low post-operative morbidity. CONCLUSION: We suggest endoscopic orbital decompression is an effective and safe treatment for dysthyroid eye disease.

Electron microscopy findings on an intraocular lens in the uveitis, glaucoma, hyphaema syndrome.

PURPOSE: To report the electron microscopic findings on an explanted intraocular lens in a patient with the uveitis, glaucoma, hyphaema syndrome. METHODS: Scanning and transmission electron microscopy were undertaken on a coccoon of cellular material from the tip of the intraocular lens haptic. RESULTS: Scanning electron micrographs showed densely packed coccoid-like structures on the haptic surface. By transmission electron microscopy these structures proved to be melanosomes. CONCLUSIONS: The scanning electron micrographs described in this report are similar to those reported in patients with chronic post-operative uveitis, but to our knowledge have not been shown before in association with the uveitis, glaucoma, hyphaema syndrome. Transmission electron microscopy determined that the coccoid-like structures were melanosomes. The melanosomes are probably derived from damaged pigment epithelial cells or iris stromal melanocytes secondary to recurrent chafing of the haptic against the posterior surface of the iris.