SELF-DESIGNATION OF THE TREATED EYE BEFORE INTRAVITREAL INJECTIONS: Prevalence and Predictors of Incorrect Calling.

PURPOSE: To identify risk factors for incorrect self-identification of the treatment eye before intravitreal injections. METHODS: This prospective study included consecutive patients who were asked to designate the eye for which the intravitreal injection was intended and were subsequently divided into two groups according to whether or not they identified the correct eye. RESULTS: Overall, 349 eyes (n = 349) were included, and 8.6% (n = 30) designated the incorrect eye or did not know which eye was intended for treatment. Incorrect designation was associated with diabetic macular edema (odds ratio [OR] = 0.33 [0.15-0.75]), first injection in the intended eye or ≥1 year since previous injection (OR = 0.34 [0.14-0.87]), Arabic native tongue (OR = 0.48 [0.22-1.01]), previous injection to the fellow eye (OR = 0.26 [0.10-0.64]), and concurrent treatment of both eyes (OR = 0.35 [0.16-0.74]). Multivariate analysis showed the first injection or ≥1 year since last injection in the treatment eye (R2 = 2.24%, P = 0.004, OR = 0.20 [0.07-0.57]) and previous injection in the fellow eye (R2 = 6.55%, P < 0.001, OR = 0.20 [0.07-0.52]) as significant independent predictors of incorrect identification. CONCLUSION: Several factors are associated with a greater probability for incorrect patient's self-identification of the eye laterality intended for intravitreal injections. These findings may help identify patients with a higher risk of such potential errors.

Hydration of small leaking corneal perforations with cefuroxime.

PURPOSE: To describe a new technique for sealing small corneal perforations after penetrating trauma. METHODS: Corneal perforations in six eyes were sealed using a stromal cefuroxime hydration technique. This technique is identical to the current method used to seal leaking incisions upon completion of cataract surgery except for the use of cefuroxime instead of balanced salt solution. Additionally, cefuroxime was intentionally injected into the anterior chamber. A therapeutic contact lens was used after the hydration. Comparison was made in eight eyes with small traumatic corneal perforation that was sealed using therapeutic contact lenses without hydration. RESULTS: This novel technique was applied in six cases, with leakage stopping immediately following hydration in each of these eyes. In cases presenting with a shallow or flat anterior chamber, this maneuver produced immediate reformation of the chamber. Of note, the corneal scars after hydration were minimal with little effect on visual acuity. When compared to eyes with small corneal perforations which were sealed with therapeutic contact lenses without hydration, all cases that were hydrated with cefuroxime were sealed immediately, as opposed to cases treated without hydration. Furthermore, the eyes that underwent hydration with cefuroxime had a worse average visual acuity on admission, a better average visual acuity 1 month post-trauma, and a shorter average length of hospitalization. CONCLUSIONS: This new technique offers five major advantages: (1) Immediate sealing of the corneal perforation is achieved. (2) Definitive treatment can be achieved at the slit lamp. (3) Since neither stitches nor glue is applied, healing is achieved with minimal scarring and discomfort. (4) Little equipment is required. (5) Injection of cefuroxime into the anterior chamber provides prophylaxis against infection.

Comparison of anti-vascular endothelial growth factors, laser treatments and a combination of the both for treatment of central retinal vein occlusion.

AIM: To compare changes in visual acuity and macular edema in patients with central retinal vein occlusion (CRVO) treated with intravitreal injections of bevacizumab, macular grid photocoagulation combined with pan retinal photocoagulation (PRP), or both (bevacizumab+grid+PRP). METHODS: Our study is a retrospective cohort clinical study that examined patients that suffered from ischemic CRVO with macular edema. Study inclusion criteria were ischemic CRVO with macula edema and the availability of complete medical records for at least 12mo after treatment. Excluded were patients with diabetes or any other retinal disease. We reviewed the medical records of patients treated in one ophthalmology department-comparing changes in visual acuity and macular edema in patients treated with intravitreal injections of bevacizumab vs those that were treated with macular grid photocoagulation and PRP or both. The main outcome measures were the differences in best corrected visual acuity (BCVA) and in macular thickness, as assessed by optical coherence tomography, between the enrollment and the final follow up visits. RESULTS: Sixty-five patients met inclusion criteria. There were no statistically significant differences among the three groups in the mean changes in macular thickness as measured by ocular coherence tomography (131.5±41.2, 108.6±29.2, and 121.1±121.1, P=0.110), or in visual acuity (0.128±0.077, 0.088±0.057, and 0.095±0.065), for intravitreal injections, macular grid photocoagulation+PRP and a combination of the treatments, respectively, P=0.111. The proportions of patients with macular edema after treatment were: 26.1%, 28.6%, and 14.3%, respectively, P=0.499. CONCLUSION: Similar benefit was observed for intravitreal injections, laser photocoagulation, or a combined regimen in the treatment of CRVO. A non-statistically significant trend for reduction in macular edema was observed following combined treatment.

Is Episcleritis Associated to Glaucoma?

OBJECTIVE: The aim of this study was to show possible connection between episcleritis and open-angle glaucoma. DESIGN: This was a retrospective study. MATERIALS AND METHODS: Data on 21 patients who suffered from episcleritis and had no previous attack of episcleritis or glaucoma were collected for a period of 8 years (from 2004 to 2011). RESULTS: Six of the 21 patients of the study group (28.6%) were diagnosed as suffering from glaucoma. Four patients had a diffuse conjunctival congestion, 1 had sectoral congestion, and for 1 patient there was no record of conjunctival congestion. Two of the 6 patients with episcleritis and glaucoma experienced recurrent episcleritis events during the follow-up period. CONCLUSIONS: This study suggests an association between episcleritis and open-angle glaucoma.

Bevacizumab for CRVO Associated CME: Effect of Timing and Frequency of Injections on Final Visual Outcome.

Purpose. Injection of anti-VEGF antibody into the vitreous body is a well-established treatment for ischemic central retinal vein occlusion (CRVO) associated macular edema. Various treatment regimens regarding the timing, number, and frequency of injections have been proposed. Methods. We reviewed the medical records of 68 patients treated by intravitreal bevacizumab (Avastin) injections for macular edema due to CRVO. We examined final visual acuity six months following the last injection in relation to injection policy (one primary injection followed by subsequent injections based on anatomical response versus a prescheduled protocol of one injection per month for the first 3 months) and in relation to the time lapsing from CRVO diagnosis to the first injection. Results. Mean visual acuity improved more for patients treated by a protocol of 3 prescheduled injections than for those treated with one primary injection. Improvement in mean visual acuity was greater for patients who received their first injection within the first month than those treated after 3 months (P < 0.01). Conclusion. A protocol of three prescheduled injections of bevacizumab, starting within one month of a CRVO event, was associated with better visual outcome compared to single injection and/or treatment starting more than 3 months following the time of diagnosis.

Ascorbate prophylaxis with mitomycin-C for corneal haze after laser-assisted sub-epithelial keratectomy.

BACKGROUND: Corneal haze is a significant complication of photorefractive keratectomy (PRK) and laser-assisted subepithelial keratectomy (LASEK). OBJECTIVES: To evaluate the effect of ascorbic acid supplementation in addition to perioperative topical mitomycin-C for the prevention of haze after LASEK. METHODS: We performed a retrospective, non-randomized case series study of two groups of 48 consecutive patients (96 myopic eyes) who had LASEK surgery. The treatment group was given ascorbic acid (vitamin C) orally, 500 mg, twice daily from 1 week before to 2 weeks after surgery. The control group was not offered any additional treatment. Ascorbate supplementation was the only difference in the postoperative treatment protocol between the treatment and control groups. Haze was assessed on a scale from 0 to 4 at the 1 year visit. RESULTS: Overall, 33.3% and 37.5% of the patients in the treatment and control groups respectively developed corneal haze. The trend of increased haze severity in the control group did not reach statistical significance. CONCLUSIONS: Our results showed that systemic ascorbate supplementation does not have an additional effect on the prevention of haze after LASEK compared to the effect of topical mitomycin-C alone.

Topical glaucoma therapy as a risk factor for nasolacrimal duct obstruction.

PURPOSE: To investigate a possible association between primary open-angle glaucoma (POAG) and primary acquired nasolacrimal duct obstruction (PANDO). DESIGN: Retrospective, comparative study. METHODS: The study group consisted of 209 consecutive eyes (178 patients) whose lacrimal system had PANDO in patients more than 50 years of age during the 10-year study period. The control group consisted of 183 consecutive eyes (183 patients) that underwent cataract surgery during the same period. The main outcome measures were prevalence of POAG in study and control groups and the effect of topical glaucoma therapy use profile on PANDO prevalence. Medical records of all patients included in the study were reviewed. Data collected included demographic details and history and characteristics of POAG treatment. RESULTS: The prevalence of POAG in the PANDO group (23%) was significantly higher than that of the control group (6%; P < .0001). The average history of POAG was longer in the PANDO group (14.10 +/- 5.59 years) compared with the control group (9.55 +/- 7.23 years; P = .025). The average number of topical glaucoma therapy drugs per glaucomatous eye in the PANDO group (1.58 +/- 0.92) was significantly higher than that of the control group (0.73 +/- 0.90; P = .002). Bilateral nasolacrimal duct obstruction (NLDO) was more common among glaucoma patients in the PANDO group (38.23%) compared with nonglaucoma patients in the same group (11.80%; P = .0002). A significantly higher percentage of glaucoma patients in the PANDO group (69%) were treated with timolol, compared with glaucoma patients in the control group (18%; P = .005). CONCLUSIONS: Chronic use of timolol-containing topical glaucoma therapy preparations in glaucoma patients is associated with an increased risk for the development of NLDO. Large-scale prospective studies are needed to ascertain this association.

Effect of timing of external dacryocystorhinostomy on surgical outcome.

PURPOSE: To present our experience with external dacryocystorhinostomy (DCR) outcome and to compare cases of early and late DCR. METHODS: Retrospective data review of all patients who had external DCR with silicone intubation in a 7-year period. Data were collected and analyzed concerning patients' preoperative and postoperative symptoms, and the lacrimal drainage system examination before, during, and after surgery. RESULTS: In all, 162 patients underwent 195 DCR surgeries for nasolacrimal duct obstruction. Success was achieved in 81% of surgeries. Success rates were higher in patients who had early DCR (tearing only or early inflammatory signs of the lacrimal sac, 84% success) than in cases that had late DCR (more than 6 months after inflammation started, 77% success). These differences were statistically insignificant. Failure of DCR was much higher in posttraumatic DCR than in DCR for other etiologies. Complications (in 9% of surgeries) were generally mild and infrequent, except 1 case of meningitis. CONCLUSIONS: In experienced hands, external DCR has good postoperative success with a low complication rate. Early DCR does not have a substantial advantage over late surgery with regard to surgical outcome.

Orbital fractures complicated by late enophthalmos: higher prevalence in patients with multiple trauma.

PURPOSE: To present our experience with orbital fracture treatment outcomes in patients with multiple trauma and those suffering localized orbital trauma. METHODS: Retrospective data review of all patients examined for ocular motility problems and/or enophthalmos following orbital trauma in a 4-year period. RESULTS: Forty-three patients were included in the study: 31 (72%) had localized orbital trauma (LOT) and 12 (28%) had concomitant traumatic insults to other organs (MT). More orbital walls were affected in MT patients than in LOT patients, and the incidence of zygomatic fracture was higher in MT patients. Late enopthalmos was much more prevalent in the MT group compared with the LOT group. Differences of outcome of extra ocular motility disturbance between groups in our series did not reach statistical significance. CONCLUSIONS: The findings of more walls affected and higher incidence of zygomatic fractures in MT patients probably represent a stronger impact of the original insult, causing both more damage to other organs and more severe damage to the orbit. The increased rate of late enophthalmos in MT patients may be associated with their primary presentation to the emergency room with potentially life-threatening injuries. Under such circumstances, thorough ophthalmologic examination is nearly impossible, both because the patient cannot cooperate sufficiently and because medical priorities dictate concentration on taking care of the injuries threatening life. The lack of a thorough ophthalmic examination prevents early comprehensive treatment.

Desferrioxamine and zinc-desferrioxamine reduce lens oxidative damage.

Our purpose was to investigate the quality and morphology of cultured bovine lenses after exposure to hyperbaric oxygen (HBO) in the presence or absence of desferrioxamine (DFO) or zinc-desferrioxamine (Zn-DFO). Intact bovine lenses were cultured and exposed to HBO of 100% oxygen at 2.5 ATA for 120 min. One hundred and fifty lenses were included in the present study. Lenses were divided into study groups of 25 lenses each: (1a) HBO-exposed lenses; (1b) control lenses extracted from the contralateral eyes of group 1a and exposed to normal room air. (2a) HBO-exposed lenses treated with DFO; (2b) control lenses extracted from the contralateral eyes of group 2a exposed to normal room air in the presence of DFO (3a) HBO-exposed lenses treated with Zn-DFO; (3b) control lenses extracted from the contralateral eyes of group 3a, exposed to normal room air in the presence of Zn-DFO. Lens optical quality and structural changes were assessed. Oxygen toxicity to lenses was demonstrated by decreased light transmission, increase in focal length variability and a decrease in morphological integrity. Light intensity measurements showed a distinct pattern in control lenses. A different pattern was noticed for hyperbaric oxygen-exposed lenses. Focal length variability values were stable in control lenses and increased significantly in oxygen-exposed lenses. Structural damage to lenses was demonstrated by the appearance of bubbles between lens' fibers possibly demonstrating failure of lens tissue to cope with oxygen load. All measured parameters showed that both Zn-DFO and DFO attenuated the oxidative damage. The effect of DFO was small whereas Zn-DFO demonstrated a significantly stronger effect. Treatment of hyperbaric oxygen-exposed lenses with DFO only marginally reduced the oxidative damage. Treatment with Zn-DFO was superior in reducing the oxidative damage to lenses. These results indicate a possible role for Zn-DFO in the prevention of cataracts.

Zinc-desferrioxamine reduces damage to lenses exposed to hyperbaric oxygen and has an ameliorative effect on catalase and Na, K-ATPase activities.

Our purpose was to investigate the effects of exposure to high partial pressure of oxygen on lens optical quality and on the activities of lenticular catalase and Na, K-ATPase in culture and to examine the effect of zinc-desferrioxamine (Zn-DFO) addition to cultured lenses exposed to high oxygen partial pressure on these parameters. Bovine lenses, kept in organ culture, were exposed to different combinations of partial pressure of oxygen with and without addition of Zn-DFO complex (20 microM) and examined during a 14-day period. Lens optical quality, catalase, and Na, K-ATPase activity were compared between study and control groups. Two hundred lenses were included in the present study. Decreased lenticular optical quality and decreased catalase and Na, K-ATPase activities were observed in lenses exposed to hyperbaric oxygen. Lenses exposed to normobaric oxygen showed a reduction in these parameters to a lesser degree. The damaging optical and enzymatic effects of oxygen on lenses in culture increased in magnitude along the culture period. Addition of Zn-DFO to the culture just before the exposure to hyperbaric oxygen eliminated most of the optical and enzymatic oxygen-induced damage. Addition of Zn-DFO after the first exposure demonstrated reduction in the oxidative damage induced reduction of optical quality in a time-dependent manner - the later the addition of Zn-DFO took place the smaller the protective effect observed. High oxygen load has toxic effects on bovine lenses in organ culture conditions as determined by optical parameters as well as reduction of catalase and Na, K-ATPase activities. These toxic effects can be attenuated by introducing Zn-DFO just before lenses are exposed to oxygen. The beneficial effect of Zn-DFO, applied after lenses have been exposed to hyperbaric oxygen, on the oxidative damage was time-dependent - the earlier the application the more significant the observed protective effect. The present results may indicate a possible future role for Zn-DFO as a protective agent against oxygen-induced human cataract formation.

[Globe subluxation in thyroid orbitopathy].

We report the clinical and radiographic findings of a female patient who presented to the emergency room in acute distress due to a subluxated globe. The patient had a 10 year history of poorly controlled Grave's disease and associated orbitopathy. In the past, one previous report dealt with this rare phenomenon in association with Grave's disease and attributed the mechanism of this acute event to enlargement of the orbital fat compartment and extensibility of nearly normal extraocular muscles ("lipogenic"--type I orbitopathy). To the best of our knowledge, this case is the first documented report of this unusual event occurring in a patient with significant involvement of the extraocular muscles which caused a resultant crowding of the orbital apex, disturbance to venous outflow and severe orbital congestion. In conclusion, acute globe subluxation may rarely happen in "myogenic" (type II) thyroid orbitopathy.

One medial triangular Tutoplast sling as a frontalis suspension for adult myogenic blepharoptosis.

PURPOSE: The treatment of choice for medium to severe blepharoptosis with minimal or no levator function is frontalis suspension with a sling, using a rectangular or rhomboid sling placement technique. We describe the short-term, follow-up results of frontalis suspension surgery for adult myogenic blepharoptosis using Tutoplast, a commercially available fascia lata allograft. METHODS: We conducted a consecutive, interventional case study. All adult (>25 years of age) patients operated for non-traumatic myogenic ptosis during a 1-year period were included. All underwent frontalis suspension using one medial triangular Tutoplast sling. Success was judged according to lid position and complications. RESULTS: Successful surgical results were judged by lid level, lid symmetry and lid contour. During a mean follow-up of 9 months, the success rate was 91% in all three criteria and 100% in at least two out of three. No major complications were observed. The most prevalent minor complication was the need for lubrication treatment in 26% of the operated patients. CONCLUSION: The use of Tutoplast for frontalis suspension in cases of adult myogenic ptosis is safe and has a high success rate in the early postoperative period. Further large-scale studies are necessary to ascertain the longterm results and the applicability of this material to other indications.

[Upper lid frontalis suspension as a treatment for essential blepharospasm].

BACKGROUND: Essential blepharospasm is a progressive disease of unknown etiology causing a significant decline in the quality of life of patients suffering from the disease. Currently used treatment for this condition is repeated injections of Botulinum toxin. Some of the patients' therapeutic response to Botox injections is insufficient, and some develop ocular complications. GOALS AND METHODS: This report presents our experience with sling frontalis suspension for essential blepharospasm in 4 patients with follow-up periods of six months to 2 years. A literature review is presented and discussed. RESULTS: A treatment trial with Botox injections was attempted in all four patients. Three of the patients showed insufficient treatment response. Three of the patients developed side effects of recurrent episodes of upper lid ptosis following injections. In all four patients that underwent operations significant reduction of blepharospasm was observed. In two of the patients Botulinum toxin could be discontinued, in one patient treatment intensity could be reduced, and in three--treatment complications were prevented. All four patients reported a high degree of satisfaction from treatment results. CONCLUSIONS: Our results indicate that sling frontalis suspension for essential blepharospasm is a safe and efficient treatment for essential blephrospasm with a high degree of patient satisfaction. Further large-scale studies are needed to substantiate our results.