An orbital calcific cyst following exenteration.

A 77-year-old Asian female with a history of left orbit exenteration and lid-sparing reconstruction for recurrent sebaceous carcinoma presented with fluid-like sensation of the left orbit. Magnetic resonance imaging (MRI) demonstrated bright T2 signal and a cyst-like cavity within the exenterated orbit. Decision was made to proceed with surgical exploration and excision. A calcified, bone-like cavity was encountered intraoperatively and removed. Histopathology revealed dense fibrous connective tissue with areas of calcification without osseous metaplasia, suggestive of retained blood in the orbit that underwent dystrophic calcification. This case report illustrates a rare occurrence of a bone-like calcific cyst following exenteration.

The management of large-angle esotropia in Graves ophthalmopathy with combined medial rectus recession and lateral rectus resection.

PURPOSE: To describe surgical management and outcomes for large-angle esotropia of ≥50Δ secondary to Graves ophthalmopathy using combined initial nonadjustable medial rectus recessions and lateral rectus resections. METHODS: The medical records of consecutive patients undergoing strabismus surgery for large-angle esotropia secondary to Graves ophthalmopathy from 1995 to 2012 by a single surgeon at each of two institutions was performed. Patient characteristics, surgical technique, and pre- and postoperative measurements of ocular alignment were analyzed. A modified Gorman diplopia scale was used to assess outcome. RESULTS: Of 38 patients, 36 had bilateral nonadjustable medial rectus recessions and lateral rectus resections as initial treatment for esotropia, and 6 patients underwent simultaneous vertical muscle surgery. Mean preoperative horizontal deviation was 60Δ and mean preoperative vertical deviation was 10Δ. Of the 38 patients, 19 (50%) reached the primary outcome, including 5 of 6 (85%) who had no preoperative vertical strabismus. The indications for reoperation were vertical strabismus in 13 of 21 patients (62%), residual esotropia in 7 of 21 (33%), and consecutive exotropia in 1 of 21 (5%). With a median follow-up of 13.2 months after first surgery, 32 of 38 patients (84%) reached the secondary outcome. CONCLUSIONS: Combining nonadjustable medial rectus recessions with lateral rectus resections can be a beneficial primary treatment for large-angle esotropia in patients with Graves ophthalmopathy, especially in those patients with small or no associated vertical strabismus.

A Comparison of Resident-performed Argon and Selective Laser Trabeculoplasty in Patients With Open-angle Glaucoma.

PURPOSE: To compare intraocular pressure (IOP) reduction and complications of resident-performed argon laser trabeculoplasty (ALT) and selective laser trabeculoplasty (SLT). PATIENTS AND METHODS: This was a retrospective, interventional, comparative case series performed at the San Francisco Veterans Affairs Hospital. The study included 77 patients each undergoing 1 resident-performed ALT procedure from April 2006 through November 2009, and 81 patients each undergoing 1 resident-performed SLT procedure from November 2009 through December 2011. Reduction in IOP at 12 months and a longitudinal analysis across 24 months was determined. Secondary outcomes investigated included additional interventions of either repeat trabeculoplasty or trabeculectomy as well as change in eye drop medications. RESULTS: There was no evidence of a difference between IOP reductions in patients undergoing ALT compared with SLT at 12 months (P=0.41, linear modeling) or across all follow-up appointments (P=0.62, linear-mixed effects regression). Patients undergoing ALT had a significantly increased number of eye drops (+0.6 vs. -0.1 drops, P<0.001, Wilcoxon rank-sum test) and trend toward increased rates of additional interventions (P=0.06, Weibull regression). There was no difference in immediate postprocedure IOP rise between the 2 groups (P=0.75, Wilcoxon rank-sum test) or any evidence of change in visual acuity. CONCLUSIONS: We found no difference in IOP reduction between patients undergoing resident-performed ALT compared with SLT. However, patients undergoing ALT had a significant increase in eye drop medications and trend toward additional interventions compared with patients undergoing SLT.

Retinal morphology of patients with achromatopsia during early childhood: implications for gene therapy.

IMPORTANCE: While older children and adults with achromatopsia have been studied, less is known of young children with achromatopsia. OBJECTIVES: To characterize the macular and foveal architecture of patients with achromatopsia during early childhood with handheld spectral-domain optical coherence tomographic imaging and to make phenotype-genotype correlations. DESIGN, SETTING, AND PARTICIPANTS: Comparative case series of 9 patients with achromatopsia and 9 age-matched control participants at a tertiary ophthalmology referral center. MAIN OUTCOMES AND MEASURES: Patients underwent complete ocular examination, full-field electroretinography, handheld spectral-domain optical coherence tomographic imaging, and screening for genetic mutations. RESULTS: The mean (SD) age of the patients with achromatopsia was 4.2 (2.4) years, and the mean (SD) age of the control participants was 4.0 (2.1) years. Cone-driven responses to photopic single-flash or 30-Hz stimuli were nonrecordable in 7 patients and severely attenuated in 2. Rod-driven responses to dim scotopic single-flash stimuli were normal in 7 patients and mildly subnormal in 2. Six patients (67%) had foveal ellipsoid zone disruption, of which 1 had a hyporeflective zone. Four patients (44%) had foveal hypoplasia. The average total retinal thicknesses of the macula and fovea in the patients with achromatopsia were 14% and 17% thinner than in the control participants (P < .001 and P = .001), which was mostly due to the outer retina that was 18% and 26% thinner than in control participants (both P < .001), respectively. Genetic testing revealed a common homozygous mutation in CNGB3 in 5 patients with complete achromatopsia and heterozygous mutations in CNGA3 in 2 patients with incomplete achromatopsia. The youngest and worst-affected patient harbored compound heterozygous mutations in CNGB3 and a single mutation in CNGA3. CONCLUSIONS AND RELEVANCE: In early childhood, there is a spectrum of foveal pathology that is milder than reported in older individuals with achromatopsia, which suggests the need for early therapeutic intervention. Neither age alone nor genotype alone predicts the degree of photoreceptor loss or preservation. Thus, in anticipation of future gene therapy trials in humans, we propose that handheld spectral-domain optical coherence tomography is an important tool for the early assessment and stratification of macular architecture in young children with achromatopsia.

Resident-performed selective laser trabeculoplasty in patients with open-angle glaucoma.

IMPORTANCE To our knowledge, this is the first study to investigate effectiveness and complication rates of resident-performed selective laser trabeculoplasty (SLT). OBJECTIVES To evaluate the effectiveness and complications of SLT performed by resident ophthalmologists and to identify predictors for success. DESIGN, SETTING, AND PARTICIPANTS Retrospective case series of 81 patients with open-angle glaucoma undergoing 110 SLT procedures from November 17, 2009, through December 16, 2011, at the San Francisco Veterans Affairs Medical Center. INTERVENTION Resident-performed SLT. MAIN OUTCOMES AND MEASURES Intraocular pressure (IOP) reduction. Secondary outcomes included change in eyedrop medications, complication rates, and predictors of SLT success defined as a 20% reduction in IOP. RESULTS The mean IOP at baseline, defined as the average IOP of the 2 appointments prior to the SLT procedure, was 18.7 mm Hg. The mean decrease in postoperative IOP compared with baseline was 2.2 mm Hg (12%; 95% CI, 5%-19%) at 12 months and 3.3 mm Hg (18%; 95% CI, 13%-23%), 2.8 mm Hg (15%; 95% CI, 10%-21%), and 3.6 mm Hg (19%; 95% CI, 11%-27%) at 3, 6, and 24 months, respectively (all P < .001, linear mixed-effects regression). Success rates were 36% (95% CI, 27%-47%) at 12 months and 41% (95% CI, 31%-53%), 50% (95% CI, 40%-60%), and 39% (95% CI, 26%-53%) at 3, 6, and 24 months, respectively. The most common complication was a temporary IOP spike, with increases of at least 6 mm Hg occurring in 7% (95% CI, 4%-14%) of the population. The largest IOP spike was 11 mm Hg. Increased number of laser shots performed was not associated with better IOP control but was associated with a reduction in number of eyedrop medications (P = .02). Increased baseline IOP was associated with an odds ratio for success of 1.24 (95% CI, 1.08-1.44) at 3 months, 1.20 (95% CI, 1.05-1.37) at 6 months, and 1.31 (95% CI, 1.13-1.53) at 12 months of follow-up (P = .003, P = .006, and P < .001, respectively, logistic regression). In a multivariate analysis, baseline IOP remained the greatest predictor of effectiveness. CONCLUSIONS AND RELEVANCE Resident-performed SLT obtains outcomes similar to the IOP reduction reported in the literature for attending-performed SLT with low levels of complications. Increasing the number of shots in a treatment session may lead to less long-term need for eyedrop medications. In this patient group, higher baseline IOP was the strongest predictor of treatment effectiveness.

Extraintestinal Crohn disease causing bilateral nasolacrimal duct obstruction.

A 16-year-old boy presented with complaints of epiphora and bilateral palpably distended lacrimal sacs. He had a history of Crohn disease involving the small and large intestines, and a history of granulomatous cheilitis. Bilateral dacryocystorhinostomies were performed through an external approach and revealed multiple nodular masses in both lacrimal sacs, which on biopsy, contained granulomatous inflammation consistent with extraintestinal Crohn disease. A literature search from 1966 to the present using the PubMed database revealed three previous publications describing nasolacrimal duct obstruction associated with Crohn disease, but these cases did not show pathologic evidence of granulomatous inflammation. To our knowledge, this is the first reported case of extraintestinal Crohn disease with granulomatous inflammation affecting the lacrimal-outflow system.

Silver growth on micropatterned DNA chips: effect of growth conditions and morphology on I-V behavior.

An approach to the design of DNA-based electronics is presented, in which standard microfabrication processes are integrated with lithographic patterning of single-stranded oligonucleotides followed by hybridization to gold-labeled, complementary oligonucleotides and subsequent silver enhancement for signal amplification. The resulting bioinorganic devices demonstrate micron-sized geometric features, very little non-specific silver growth, a distinct silver morphology in the patterned region, and a 10(9)-fold increase in conductivity across an electrode gap when compared with control devices. This approach may prove useful for the fabrication of high fidelity, high-density arrays for DNA-based biosensing applications.