Recovery of orbital fat pad prolapsus and deepening of the lid sulcus from topical bimatoprost therapy: 2 case reports and review of the literature.

OBJECTIVES: To report 2 cases of resolution of orbital fat pad prolapsus and deepening of the lid sulcus caused by topical bimatoprost therapy, and to review the literature. METHODS: This was a retrospective, observational chart review. RESULTS: A 54-year-old man with normotensive glaucoma presented with recovery of left lower lid orbital fat pad prolapsus, deepening of the lid sulcus, and iris color and eyelash changes 8 months after initiation of bimatoprost therapy in his left eye (OS). After stopping bimatoprost, his eyelashes and the lower lid orbital fat pad partially regained their natural appearance at 2 months and 4 months, respectively. However, there was no improvement of the left upper eyelid deepening and the iris hyperpigmentation, even after 30 months. A 75-year-old man with unilateral pseudoexfoliative glaucoma had been treated with bimatoprost OS. Three months after initiation of the therapy, his examination showed recovery of the inferior and superomedial orbital fat pad prolapsus, a deep and prominent upper lid sulcus with eyelash changes, and iris hyperpigmentation OS. Five months after discontinuation of bimatoprost, the eyelashes and superomedial orbital fat pad improved. Twenty-four months later, the inferior orbital fat pad partially got its natural appearance back, but the upper lid sulcus was slightly more deep and prominent than the fellow right eye. There was no alteration in iris hyperpigmentation. CONCLUSION: Clinicians and patients should be aware of these possible effects of topical bimatoprost therapy. These adverse effects may not be completely reversible after discontinuation of the medication.

Pituitary apoplexy: an overview of 186 cases published during the last century.

BACKGROUND: Pituitary apoplexy is a rare and life-threatening complication occurring in 0.6-10.5% of all cases of pituitary adenomas. Although the association between pituitary apoplexy and visual dysfunction has been recognized for a long time, the optimal management of this problem still remains controversial. The purpose of this overview was to present the surgical experience by analyzing the literature on the management of pituitary apoplexy for better treatment of these cases. MATERIALS AND METHOD: To establish a new guideline for the surgical treatment of this entity, publications reported during the last century and databases containing medical literature were analyzed. In addition, an illustrative case with pituitary apoplexy presenting with complaints of sudden onset severe headache associated with nausea, vomiting, and a sudden loss of vision was described. In fact, the experience in our complicated patient prompted us to review the available literature on the management of pituitary apoplexy to date. CONCLUSIONS: Based on an overview of 186 cases of apoplectic pituitary adenoma presenting with monocular or binocular blindness, we highlight the importance of correct diagnosis and an early, but not necessarily emergency, surgery within the first week of admission to optimize visual outcome of such patients. The illustrative case further exemplifies the value of close interaction between members of the management team for optimal outcome.

Medical control of intraocular pressure with brinzolamide 1% after phacoemulsification.

BACKGROUND: To compare the effectiveness of only 1 drop of topical brinzolamide 1% with dosing every 12 hours and with no ocular hypotensive medication following clear corneal phacoemulsification surgery. METHODS: This prospective, randomized, double-blind study was composed of 60 eyes of 60 patients who underwent uneventful clear corneal phacoemulsification surgery under topical anesthesia. There were no intraoperative complications. Eyes were randomized to receive only 1 drop of topical brinzolamide 1% immediately after surgery, 1 drop of brinzolamide 1% every 12 (q12h) hours starting immediately after speculum removal, or no ocular hypotensive medication (control group). Intraocular pressure (IOP) was measured preoperatively and at 4 to 6 hours and 18 to 24 hours postoperatively by a Perkins tonometer. RESULTS: Preoperative IOP was not significantly different among the 3 groups. IOPs of both the brinzolamide 1 drop group (p = 0.000) and the brinzolamide q12h group (p = 0.001) were significantly lower than those of the control group at 4 to 6 hours postoperatively. The same result was observed at 18 to 24 hours postoperatively in the brinzolamide q12h group (p = 0.001) but not the brinzolamide 1 drop group (p = 0.489). The brinzolamide q12h group had significantly lower IOP compared with the brinzolamide 1 drop group (p = 0.000) at 18 to 24 hours postoperatively. None of the eyes in the medication groups, but 1 eye (5%) in the control group, had postoperative IOP elevation > or =30 mm Hg at 4 to 6 hours; such an elevation was not encountered at postoperative 18 to 24 hours. Preoperative to postoperative IOP increase of >5 mm Hg at 4 to 6 hours postoperatively was seen in 4 (20%), 4 (20%), and 14 (70%) eyes in the brinzolamide 1 drop group, the brinzolamide q12h group, and the control group, respectively. INTERPRETATION: The current study reveals that 1 drop of brinzolamide 1% is sufficient to control IOP within the first 4 to 6 hours following uneventful phacoemulsification, whereas 12-hour dosing is necessary for prolonged control of IOP.

Prevention of suture exposure in transscleral intraocular lens fixation: an original technique.

BACKGROUND: In this retrospective study, we evaluated our surgical outcomes of transscleral intraocular lens (IOL) fixation and introduced a simple, quick, and effective method to fixate and bury the sutures in the sclera to avoid suture exposure. METHODS: Eyes were divided into 3 groups according to surgical technique. Half-thickness scleral flaps were prepared, and polypropylene suture ends were cut short in group 1 (12 eyes). Suture ends were left long without flaps in group 2 (47 eyes) and were buried into the scleral tunnel in group 3 (21 eyes). RESULTS: The suture exposure rate was significantly lower in group 3 (0%) compared with group 2 (p = 0.006) and group 1 (p = 0.040). There was no significant difference in group 1 (25%) compared with group 2 (27.6%) (p = 1.000). INTERPRETATION: Burying the suture ends into the scleral tunnel is a simple, safe, and effective technique for avoiding suture exposure in scleral-fixated IOL implantation.

Usage of remifentanil and fentanyl in intravenous patient-controlled sedo-analgesia.

Our aim was to investigate the effects of patient-controlled sedo/analgesia with fentanyl or remifentanil during cataract surgery with phacoemulsification method under topical anaesthesia. The ethical committee has approved the prospective, randomized, double-blind study. ASA I-III, 120 patients underwent cataract surgery were randomly allocated to 3 groups. Fentanyl was administered in 0.7 microg/kg loading, 10 microg bolus dose with 5 minutes lockout time, remifentanil was administered 0.3 microg/kg loading, 20 microg bolus dose with 3 minutes lockout time by patient controlled analgesia (PCA) equipment. In the control group, saline solution was given without any analgesic drug. Cardiorespiratory system findings, verbal pain scale and sedation scores were recorded preoperatively and intraoperatively at the 5th, 10th, 15th, 20th and 30th minutes. Discomfort during surgery, pressing the PCA button, and complications were recorded. The verbal pain scale scores was significantly lower in the drug groups than the those in control group at the 15th minute. The sedation scores was significantly higher in the remifentanil group at the 5th minute (p=0.019) and in the fentanyl group at the 10th minute (p=0.007) than those in the control group. The number of patients pressing the PCA button was much higher in the control group than the drug groups (p<0.05). Patient comfort and surgeon satisfaction were higher in the drug groups (p<0.05). Intravenous-PCA sedo/analgesia addition to topical anaesthesia provides an advantage in sedo/analgesia, patient comfort, and surgeon satisfaction. PCA is a convenient and safe method, especially at the beginning of the operation when anxiety is intense, and during healon/lens implantation.

Treatment of two postoperative endophthalmitis cases due to Aspergillus flavus and Scopulariopsis spp. with local and systemic antifungal therapy.

BACKGROUND: Endophthalmitis is the inflammatory response to invasion of the eye with bacteria or fungi. The incidence of endophthalmitis after cataract surgery varies between 0.072-0.13 percent. Treatment of endophthalmitis with fungal etiology is difficult. CASE PRESENTATION: Case 1: A 71-year old male diabetic patient developed postoperative endophthalmitis due to Aspergillus flavus. The patient was treated with topical amphotericin B ophthalmic solution, intravenous (IV) liposomal amphotericin-B and caspofungin following vitrectomy. Case 2: A 72-year old male cachectic patient developed postoperative endophthalmitis due to Scopulariopsis spp. The patient was treated with topical and IV voriconazole and caspofungin. CONCLUSION: Aspergillus spp. are responsible of postoperative fungal endophthalmitis. Endophthalmitis caused by Scopulariopsis spp. is a very rare condition. The two cases were successfully treated with local and systemic antifungal therapy.

Medical control of intraocular pressure after phacoemulsification.

PURPOSE: To compare the effectiveness of oral acetazolamide, topical brinzolamide 1%, and no ocular hypotensive medication after phacoemulsification. SETTING: Adnan Menderes University Department of Ophthalmology, Aydin, Turkey. METHODS: This prospective randomized double-blind study comprised 60 eyes of 52 patients having phacoemulsification under topical anesthesia. There were no intraoperative complications. Eyes were randomized to receive oral acetazolamide 500 mg 1 hour preoperatively followed by 250 mg acetazolamide every 6 hours, 1 drop of brinzolamide 1% every 12 hours starting immediately after speculum removal, or no ocular hypotensive medication. Intraocular pressure (IOP) was measured using a Perkins tonometer preoperatively and 4 to 6 hours and 18 to 24 hours postoperatively. RESULTS: The preoperative IOP was not significantly different between the 3 groups. Four to 6 hours postoperatively, the acetazolamide group (P=.002) and brinzolamide group (P=.001) had significantly lower IOP than the control group. The same trend was observed at 18 to 24 hours in the brinzolamide group (P=.001) but not the acetazolamide group (P=.018). The IOP levels were not significantly different between the acetazolamide group and brinzolamide group at any postoperative time point. No eye receiving medication and 2 eyes (10%) in the control group had an IOP of 30 mm Hg or higher 4 to 6 hours postoperatively. Compared with preoperatively, an IOP increase of more than 5 mm Hg was seen at 4 to 6 hours in 3 eyes (15%), 2 eyes (10%), and 14 eyes (70%) in the acetazolamide, brinzolamide, and control group, respectively. CONCLUSION: Brinzolamide was as effective as acetazolamide in preventing IOP elevation 4 to 6 hours after phacoemulsification and more effective than acetazolamide at 18 to 24 hours.

Effect of single-dose fentanyl on the cardiorespiratory system in elderly patients undergoing cataract surgery.

STUDY OBJECTIVES: To evaluate the effects of fentanyl on the cardiorespiratory system in elderly patients undergoing cataract surgery with phacoemulsification method. DESIGN: Randomized, prospective, double-blind study. SETTING: University hospital. PATIENTS: 70 ASA physical status I, II, and III patients (>60 years) who underwent cataract surgery with topical anesthesia. INTERVENTIONS: Patients were randomly divided into two groups. The fentanyl group (35 patients) received fentanyl in 0.7 microg/kg bolus doses in a 2-mL balanced salt solution prior to surgery. The control group (35 patients) received a 2-mL balanced salt solution without any analgesic drug. MEASUREMENTS AND MAIN RESULTS: Systolic (SBP), diastolic (DBP), mean arterial pressure (MAP), heart rate (HR), peripheral oxygen saturation (SpO(2)), respiratory rate (RR), end-tidal carbon dioxide (ETCO(2)), inspired CO(2) concentration, and sedation scores were measured preoperatively and at 5, 10, 15, 20, and 30 minutes intraoperatively. Postoperatively, patients were questioned about the presence of intraoperative pain. In the fentanyl group, no significant differences were observed in SPB, DBP, MAP, RR, or peripheral SpO(2). In the control group, RR was higher than baseline values at 10, 15, and 20 minutes. Diastolic blood pressure was higher than baseline values at 20 minutes. End-tidal CO(2) and inspired CO(2) levels were higher than baseline levels in both groups at all measurement times. Intraoperative ETCO(2) levels were higher in the fentanyl group than the control group (p < 0.01). Finally, no hypoxemia was observed in either group. CONCLUSION: Fentanyl can be used safely in 0.7-microg/kg dosages in elderly patients to improve patient comfort without any cardiorespiratory side effects, when undergoing cataract surgery with topical anesthesia.

The effect of Seprafilm on adhesions in strabismus surgery-an experimental study.

PURPOSE: Seprafilm (Genzyme, Cambridge, MA) is a bioabsorbable membrane composed of sodium hyaluronate and carboxymethylcellulose. Adhesions occurring after strabismus surgery may affect surgical outcome. The purpose of our study was to histopathologically evaluate the influence of Seprafilm on postoperative adhesions. METHODS: Seven adult male New Zealand albino rabbits were used. The superior rectus muscle was resected 3 mm, and a fornix-based limbal conjunctival dissection was made inferonasally in both eyes. In one eye of each rabbit, Seprafilm was inserted between the conjunctiva and superior rectus and under the dissected inferonasal conjunctiva. The fellow eye of each rabbit, having undergone superior rectus resection and inferonasal conjunctival dissection without Seprafilm, served as the control group. The rabbits were killed and the eyes were enucleated at 6 weeks after surgery. Histopathological sections were analyzed for inflammation and fibrosis by staining them with hematoxylin-eosin and Masson trichrome, respectively. Inflammation and fibrosis were graded on a scale of 0 to 4. RESULTS: Compared with the control eyes, there was no significant difference with regard to inflammation either at the area of superior rectus resection or the area of conjunctival dissection (P.655 and P.157, respectively). Significantly less fibrosis occurred in the surgical areas where Seprafilm was used compared with the control group (P.046 and P.015, respectively) both at the area of superior rectus resection and the area of conjunctival dissection. CONCLUSION: This study shows that Seprafilm significantly decreases postoperative adhesions between the conjunctiva, muscle, and sclera. Application of Seprafilm may prove useful in strabismus surgery especially where adhesion formation may influence the outcome and in cases where recurrent conjunctival dissection may be needed.

Effect of corneal drying on central corneal thickness.

PURPOSE: To determine the amount of corneal thinning induced by corneal drying, and to discuss its possible consequences on applanation pressure. PATIENTS AND METHODS: Two sets of central corneal thickness measurement from 100 eyes of 100 patients were taken by ultrasonic pachymeter at time settings of 0, 15, 30, 45, and 60 seconds. During the first set (group 1), patients were asked to blink voluntarily between the measurements. During the second set (group 2), the same patients were prevented from blinking during the measurements. RESULTS: Mean central corneal thickness at 0 second in groups 1 and 2 were 547.0 +/- 37.4 microm, and 546.7 +/- 37.6 microm, respectively. Corneal thickness did not change significantly in group 1, but did significantly decrease in group 2. Rate of thinning increased linearly during the first 30 seconds, and then leveled around 0.3 microm/s up to 60 seconds. Mean corneal thickness decreased 3.0% during the 60 second drying. The decrease in thickness was significant when each time point in group 2 was compared with the preceding one (P < 0.01). Neither age nor 0 second corneal thickness in group 2 showed a significant correlation with the amount of corneal thinning at 60 seconds. CONCLUSION: Corneal thickness may significantly decrease during 1 minute of drying. Decreased thickness may result in underestimation of applanated pressure as well as central corneal thickness.

Botulinum toxin A in the treatment of adherence syndrome.

The effect of botulinum toxin A is investigated in the treatment of adherence syndrome related to strabismus surgery. An 18-year-old boy with decompensated right congenital fourth nerve palsy underwent ipsilateral superior rectus muscle recession and inferior oblique muscle disinsertion. During the early postoperative period, a right hypotropia with limitation of elevation developed and the result of the forced duction test was positive for passive elevation of the right eye. Botulinum toxin A was injected into the right inferior rectus muscle on the 15th postoperative day and orthophoria was achieved 1 week later. A repeat injection of botulinum toxin A was performed 6 months later. On follow-up 2 1/2 years later, his eyes remained orthophoric with limitation of elevation in the right eye and the patient was satisfied with the result. This case demonstrated that adherence syndrome can be treated successfully by botulinum toxin A injection if it is administered during the acute phase, before the development of fibrous scar tissue.

Patient-controlled analgesia and sedation with fentanyl in phacoemulsification under topical anesthesia.

PURPOSE: To investigate the effects of intravenous (IV) patient-controlled sedation/analgesia with fentanyl during phacoemulsification surgery under topical anesthesia. SETTING: Adnan Menderes University Medical School, Departments of Ophthalmology and Anesthesiology and Reanimation, Aydin, Turkey. METHODS: In this double-blind randomized study, 68 patients were randomly allocated to 2 groups. In the fentanyl group comprising 34 patients, fentanyl was administered by patient-controlled analgesia (PCA) equipment in 5 microg bolus doses with a lockout period of 5 minutes after an IV loading dose of 0.7 microg/kg in 2 mL balanced salt solution. In the control group comprising 34 patients, a balanced salt solution was given without an analgesic drug by PCA equipment. Verbal pain scale (VPS) and sedation scores were recorded preoperatively and 5, 10, 15, 20, and 30 minutes after the start of surgery. Patient comfort and surgeon satisfaction were assessed postoperatively. RESULTS: The sedation score was higher in the fentanyl group than in the control group at 5 and 10 minutes (P =.006 and P =.012, respectively). The VPS scores were higher in the control group than in the fentanyl group at 15 and 20 minutes (P =.02 and P =.016, respectively). Patients pressed the button for additional analgesia 2.6 times +/- 3.9 (SD) in the control group and 0.9 +/- 1.6 times in the fentanyl group (P =.025). Patient and surgeon satisfaction were higher in the fentanyl group than the control group (P =.023 and P =.018, respectively). CONCLUSIONS: The results of this study suggest that IV PCA with fentanyl has supplemental effects on analgesia and sedation during cataract surgery under topical anesthesia and increases patient comfort and surgeon satisfaction.

Anesthesia with EMLA cream for botulinum A toxin injection into eyelids.

We investigated the efficacy of an eutectic mixture of local anesthetics (EMLA) in reducing the pain of a botulinum toxin injection into eyelids. 17 patients with facial dyskinesia (9 blepharospasm and 8 hemifacial spasm) who had been treated regularly with botulinum toxin injections received EMLA cream and placebo. The pain was assessed by the ophthalmologist and the patient. Injection with EMLA cream showed lower pain scores (mean 1.82 +/- 2.13, median 1) than injection with placebo (8.76 +/- 2.17; p = 0.0001). Percutaneous anesthesia induced by EMLA cream is an effective and safe method which improves the comfort in patients who need repeated botulinum toxin injections for their facial dyskinesia.