Type IV hypersensitivity reactions to upper lid gold weight implants-is patch testing necessary?

AIMS: To report two cases of allergic reaction to upper lid gold weight implants in patients with facial nerve palsy and to identify the use of pre-implantation patch testing in predicting gold hypersensitivity. METHODS: One patient who had a positive family history of gold allergy and had undergone previous gold dental restoration underwent patch testing with gold sodium thiosulphate. The gold weight from the same patient was analysed using scanning electron microscopy and energy dispersive X-ray analysis, which can detect surface impurities. Tissue obtained during surgery to remove the gold weight from the second patient was examined histologically. RESULTS: Patch testing in the first patient gave a positive result. Analysis of the gold weight removed from the same patient confirmed 99.99% purity, and hence sensitivity to the gold itself was considered to be the cause of the inflammatory reaction. Histology of tissue taken from the eyelid of the second patient was consistent with type IV hypersensitivity. CONCLUSION: A personal and family history of gold allergy should be looked for before upper eyelid gold weight implantation. Patch testing should be performed for patients where there is doubt about whether gold has been the specific cause of previous allergic reactions, for patients who have undergone previous dental restoration involving gold, or if there is a positive family history of gold allergy.

Surgical management of iris defects with prosthetic iris devices.

PURPOSE: To evaluate the safety and efficacy of surgical implantation of prosthetic iris devices in patients with iris deficiency. METHODS: Nine patients with traumatic iris defects, congenital aniridia or iris coloboma, and surgical or optical iridectomies were included in a noncomparative case series. Cataract surgery with intraocular lens and prosthetic iris implantation was performed in 10 eyes. The visual acuity, subjective degree of glare disability, postoperative anatomic results, and intraoperative and postoperative complications were evaluated. RESULTS: The mean follow-up was 17.75 months (range 4-48 months). Best-corrected visual acuity improved in nine of 10 eyes (90%) and remained unchanged in one eye. Glare subjectively improved in four of five eyes (80%) of patients complaining of glare preoperatively. All eyes achieved the desired anatomic result. Intraoperative complications included one anterior capsular tear. Postoperative complications included a short period of mild postoperative anterior uveitis in four eyes. Secondary glaucoma was absent. CONCLUSION: In patients with iris deficiency, implantation of prosthetic iris device, and intraocular lens implant following cataract surgery appears to be safe and effective in reducing glare disability and improving visual outcomes.

Clinical outcome following cataract surgery in very elderly patients.

PURPOSE: The number of very elderly patients waiting for cataract surgery is predicted to increase. The aim of our study was to determine the clinical outcome following cataract surgery in this age group. METHODS: In this retrospective study, patients aged 96 years and above, who underwent cataract surgery between June 1993 and January 2001, were identified. Clinical data were retrieved from their medical records. Living patients were further invited for clinical examination. RESULTS: In all, 34 eyes of 21 patients (20 females) were identified. Six patients were deceased. In total, 30/34 eyes had phacoemulsification and four had extracapsular extraction. Preoperative vision was or=6/60 in 25/34 eyes (73.53%), >or=6/18 in 21/34 eyes (61.76%), and >or=6/9 in 10/34 eyes (29.41%). Visual acuity improved in 24/34 eyes (70.59%) and remained the same in 6/34 eyes. Complications included anterior capsule tear (three), zonular dialysis with vitreous loss (one), posterior capsule rupture with vitreous loss (one), incarceration of iris to paracentesis wound (two), postoperative uveitis (two), and posterior capsular opacification (19). In all, 7/34 eyes had undergone YAG capsulotomy. CONCLUSION: Surgeons should not be deterred from offering cataract surgery to the very elderly as successful visual rehabilitation is the norm. A further prospective multicentre study is required to confirm the benefits and assess the risks of cataract surgery in this age group.

Vitrectomy for phacolytic glaucoma in a patient with homocystinuria.

PURPOSE: To determine the successful treatment of unilateral phacolytic glaucoma by vitrectomy and trabeculectomy in a patient with homocystinuria whose lens had dislocated into the vitreous at least 15 years earlier. METHODS: In a 32-year-old woman with homocystinuria, bilateral dislocation of the lens into the vitreous, and phacolytic glaucoma in her left eye a three-port pars plana vitrectomy was performed with the patient under general anesthesia. The lens was removed and a trabeculectomy fashioned. Special precautions for general anesthesia included preoperative aspirin and compression stockings for thromboembolic prophylaxis and intraoperative dextrose infusion, 5%, to maintain intravascular volume and prevent hypoglycemia. RESULTS: The intraocular pressure and uveitis resolved postoperatively with improvement in the visual acuity and intraocular pressure, which returned to normal without further treatment. CONCLUSIONS: Phacolytic glaucoma is best resolved by removal of the exciting lens material. Pars plana vitrectomy with the patient under general anesthesia can be carried out safely despite the risks traditionally associated with homocystinuria.

Plasma viscosity or erythrocyte sedimentation rate in the diagnosis of giant cell arteritis?

Plasma viscosity (PV) has replaced the erythrocyte sedimentation rate (ESR) as a routine laboratory test in many hospitals. The finding of a normal PV but raised ESR in a case of biopsy proved giant cell arteritis (GCA) cast doubt on this substitution in cases of suspected GCA. To assess the equivalence of PV and ESR in the diagnosis of this disease 40 suspected cases were prospectively investigated with both tests. The correlation between the two tests was good (r = 0.742, p less than 0.0001). The substitution of one test for the other would appear to be justified in most cases of suspected GCA. In the presence of biopsy proved disease, however, the PV and ESR each produced 13.3% false negatives. These occurred both in combination with and independently of the other test showing that, when in error, the two tests may not be equivalent. In cases of doubt the performing of both PV and ESR tests together improves but does not achieve complete diagnostic accuracy. Clinical judgment based on careful assessment of all available symptoms and signs must remain the foundation of diagnosis.

Postmyelographic abducent nerve palsy in association with the contrast agent iopamidol.

Lateral rectus palsy is an uncommon event following contrast myelography. We report such a case, which fortunately proved to be transient, and speculate on its aetiology in terms of the anatomy of the sixth cranial nerve and the possible toxic effects of the contrast agent Iopamidol (Isovue; ER Squibb and Sons, Princeton, New Jersey, USA; Niopam, E Merk, U.K.).

Spontaneous recovery of vision following an orbital haemorrhage.

A 73-year-old man presented to casualty with a penetrating orbital injury and total loss of vision in the affected eye. He subsequently spontaneously recovered full vision. We stress the need for frequent assessment of vision before considering potentially hazardous surgical intervention.

The use of a biological adhesive to achieve sutureless epikeratophakia.

An adhesive made of concentrated human fibrinogen produced from samples of single donor blood by a simple cryoprecipitation method was tested for its ability to bond lamellar corneal buttons in vitro and found to have a bond strength of 140 gm/cm2. The adhesive was successfully used to attach experimental epikeratophakia grafts in a rabbit model. The results were similar to those reported from an earlier trial using a commercially available adhesive prepared from pooled multi-donor human plasma. This experimental trial of single-donor adhesive demonstrates the possibility of successful use of autologous fibrinogen adhesive in human epikeratophakia. Autologous adhesive would remove the possible threat of transmitted disease posed by multi-donor adhesive and avoid immune reactions to foreign proteins.

Experimental epikeratophakia with biological adhesive.

Successful experimental epikeratophakia grafting was done with the use of a biological adhesive. The use of an adhesive eliminated the need for any suturing of the corneal lenticule to the host cornea, and this method reduced the length of the operative procedure to only one third of the time that is taken when sutures are used. Tisseel (Immuno AG, Vienna), a commercially available two-component adhesive system based on human fibrinogen, which is activated by thrombin, was used. The glue was used in combination with an antifibrinolytic agent. With alteration of the operative technique and lenticule design, 70% of glued epikeratophakia grafts in a rabbit model were retained, compared with a 50% success rate with grafts applied without the use of an adhesive.

Retinal burns caused by exposure to MIG-welding arcs: report of two cases.

A new generation of arc welder has recently become widely available at a price which is within reach of most amateurs and part-time mechanics, known as the MIG welder (metal-arc inert gas welder). In MIG welding the arc is ensheathed in a stream of inert gas which prevents the molten metal from oxidising. The stream of gas changes the character of the emitted radiation, and it is possible that this type of welder poses a greater threat to sight than previously recognised. Radiation in the ultraviolet range emitted by arc welders is absorbed by the unprotected cornea and lens, giving rise to a keratoconjunctivitis, or 'arc-eye,' which, though intensely painful, is not considered a threat to sight. Radiation in the visible and near infrared spectrum, however, penetrates the eye to be absorbed by the retina and may cause thermal or photochemical damage which may be permanent and sight-threatening. Retinal injuries resulting from exposure to ordinary electric welding arcs have been reported, but such injuries are uncommon. Two cases of retinal burns resulting from exposure to MIG welder emissions which presented on consecutive days to the Leicester Royal Infirmary are presented. This is the first report of such injuries relating specifically to MIG welding.

A prospective survey to determine sources and diagnostic accuracy of glaucoma referrals.

Chronic simple glaucoma is a symptomless disease which may go undetected until irreversible loss of vision has occurred. This survey analyses the accuracy of diagnosis in patients referred from different sources to the Hospital Eye Service. Some general practitioners (GPs) appear not to have a good understanding of the disease.