Peri-orbital surgical emphysema following endoscopic dacryocystorhinostomy.

BACKGROUND: Peri-orbital surgical emphysema is a rare complication that can occur after lacrimal surgery. It has only been described in isolated cases, following external dacryocystorhinostomy (n = 2) and Lester Jones tube insertion (n = 1). METHOD: A retrospective, non-comparative case series was conducted of patients who developed surgical emphysema following endoscopic dacryocystorhinostomy. RESULTS: A total of 356 endoscopic dacryocystorhinostomy cases (primary, n = 316; revision, n = 40) were performed over a six-year period. Seven cases of post-operative surgical emphysema were identified, all of which were preceded by uncontrolled sneezing, nose-blowing or coughing within the first week of surgery. The occurrence of surgical emphysema post-endoscopic dacryocystorhinostomy in our centre was 7 in 356, or 2 per cent, over six years. CONCLUSION: This is the first study to report the occurrence of surgical emphysema post-endoscopic dacryocystorhinostomy. Clinicians may wish to suggest patients stifle the aforementioned triggers within the first week to reduce the potential for surgical emphysema.

Microbial keratitis in corneal grafts: predisposing factors and outcomes.

PurposeTo identify the nature of microbial keratitis in corneal grafts and the clinical outcomes at a tertiary hospital in the United Kingdom.Patients and methodsA retrospective case series of microbial keratitis in corneal grafts at the Royal Victoria Infirmary, Newcastle upon Tyne over a 17-year period (1997-2014).ResultsA total of 759 consecutive corneal grafts were identified from the Cornea Transplantation database. Of these, 59 episodes of microbial keratitis occurred in 41 eyes of 41 patients (5.4%; 19 male, 46.3%). Median patient age was 73 years (SD=19.4 years). The most common indication for corneal transplantation was bullous keratopathy (11/41, 26.8%). There were 34/59 (57.6%) episodes of culture-positive graft keratitis; Streptococcus pneumoniae and Staphylococcus aureus were each isolated in 5/34 (14.7%) culture-positive episodes. In all, 35/59 (59.3%) episodes of microbial keratitis occurred in 22 previously failed grafts and 3 de novo graft failures. Gram-negative keratitis was more likely to cause reduced BCVA after (χ2-test, P=0.02). Median graft duration was 49.5 months (SD=43.7 months). Failed grafts were significantly older (median 69 vs 27 months, P=0.009).ConclusionThis represents the longest published follow-up data on microbial keratitis and is the only of its kind in the United Kingdom. The incidence of 5.4% is comparable to that within the developed world. Graft age was significantly associated with graft failure in microbial keratitis; the ongoing risk of microbial keratitis warrants providing patients with long-term open access to hospital eye services.

Outcomes of lower eyelid retractor recession and lateral horn lysis in lower eyelid elevation for facial nerve palsy.

PurposeTo report outcomes and complications of lower eyelid retractor recession and lateral horn lysis (RR) for lower eyelid elevation in patients with facial nerve palsy (FNP).Patients and methodsRetrospective review. Patients with FNP undergoing RR alone (group 1) or with adjunctive procedures (canthal suspension-group 2, tarsorrhaphy-group 3, and full-thickness skin graft-group 4) during a 5-year period were included. Patient demographics, lagophthalmos, occurrence of eyelid malpositions, recurrent retraction, and repeat procedures were noted from medical records. Measures of lower eyelid height (LEH) and lid lag on downgaze were obtained from standard photographs.ResultsForty-two patients (23 females, mean age was 59 years) were included. Mean follow-up was 24 months (range 6-77). Median improvement in LEH following surgery was significant in Group 1 (0.90 mm, IQR: 0.37-0.91, P=0.20) and in Group 2 (0.51 mm, IQR: 0.30-1.37, P<0.001), respectively. Median improvement in blink lagophthalmos was 3.00 mm (IQR: 3.00-3.50, P=0.02) in Group 1 and 3.50 mm (IQR: 1.75-5.00, P<0.001) in Group 2. Median improvement in lagophthalmos on gentle eye closure was 2.00 mm (IQR: 1.50-3.00, P=0.02) in Group 1 and 1.00 mm (IQR: 0-2.13, P=0.006) in Group 2. No new cases of ectropion were noted. 23.5% of patients required a repeat RR at a mean interval of 20 (range 1-70) months and a further 9.8% required a third procedure at a mean interval of 21 (range 18-29) months.ConclusionRR improves lower eyelid retraction and lagophthalmos in FNP either alone or when combined as an adjunctive procedure. It does not aggravate paralytic ectropion although repeated retractor recessions may be required to improve retraction.

Angiographic features and disease outcomes of symptomatic retinal arterial macroaneurysms.

PURPOSE: Symptomatic retinal arterial macroaneurysms (RAM) are primarily investigated by fundus fluorescein angiography after presenting with visual disturbance. The natural history includes spontaneous regression and occasionally occlusion of the arteriole distal to the aneurysm. RAM may be managed conservatively. Interventional treatment options include focal argon laser photocoagulation, Nd:YAG laser hyaloidotomy, and pars plana vitrectomy. The purpose of this study was to elicit the rates of distal vessel occlusion and aneurysm thrombosis in RAM at presentation, and their relevance to the treatment of RAM. Furthermore, visual outcomes were examined. METHODS: Retrospective review of cases of RAM presenting to a tertiary ophthalmology care centre was accomplished in a university teaching hospital. The angiographic features, treatment indications, and visual outcomes in patients with RAM were recorded. Angiographic features noted were distal vessel patency and aneurysm thrombosis at presentation. RESULTS: Ten patients with RAM were identified. Ninety percent had an angiographically patent distal arteriole, with 40 % showing spontaneous thrombosis of the aneurysm sac at presentation. Patients presenting with a spontaneously thrombosed RAM were managed conservatively, those with flow within the aneurysm wall were treated with focal laser, and those with subhyaloid haemorrhage underwent Nd:YAG laser hyaloidotomy. LogMAR visual acuity improved from 0.3 (±0) at presentation to 0.15 (±0.1) in the conservative group, and from 0.78 (±0.23) to 0.24 (±0.18) in those who underwent one intervention. One patient lost vision after multiple RAM. CONCLUSION: Thrombosis within the aneurysm wall is an important feature in deciding to treat RAM, and selective use of interventions improves vision in affected patients.

Oxidative stress, mitochondrial dysfunction and calcium overload in human lamina cribrosa cells from glaucoma donors.

PURPOSE: Oxidative stress is implicit in the pathological changes associated with glaucoma. The purpose of this study was to compare levels of oxidative stress in glial fibrillary acid-negative protein (GFAP) lamina cribrosa (LC) cells obtained from the optic nerve head (ONH) region of 5 normal (NLC) and 4 glaucomatous (GLC) human donor eyes and to also examine mitochondrial function and calcium homeostasis in this region of the ONH. METHODS: Intracellular reactive oxygen species (ROS) production was examined by a thiobarbituric acid reactive substances (TBARS) assay which measures malondialdehyde (MDA), a naturally occurring product of lipid peroxidation and is used as an indicator of oxidative stress. Mitochondrial membrane potential (MMP) and intracellular calcium ([Ca(2+)](i)) levels were evaluated by flow cytometry using the JC-1 (5,5',6,6'-tetrachloro-1,1',3,3'-tetrabenzimidazolecarbocyanine iodide) and fluo-4/AM probes respectively. Anti-oxidant and Ca(2+) transport system gene and protein expression were determined by real time polymerase chain reaction (RT-PCR) using gene-specific primer/probe sets and western immunoblotting, respectively. RESULTS: Intracellular ROS production was increased in GLC compared to NLC (27.19 ± 7.05 µM MDA versus 14.59 ± 0.82 µM MDA, p < 0.05). Expression of the anti-oxidants Aldo-keto reductase family 1 member C1 (AKR1C1) and Glutamate cysteine ligase catalytic subunit (GCLC) were significantly lower in GLC (p = 0.02) compared to NLC control. MMP was lower in GLC (57.5 ± 6.8%) compared to NLC (41.8 ± 5.3%). [Ca(2+)](i) levels were found to be higher (p < 0.001) in GLC cells compared to NLC. Expression of the plasma membrane Ca(2+)/ATPase (PMCA) and the sodium-calcium (NCX) exchangers were lower, while intracellular sarco-endoplasmic reticulum Ca(2+)/ATPase 3 (SERCA) expression was significantly higher in GLC compared to NLC. Subjection of NLC cells to oxidative stress (200 µM H(2)0(2)) reduced expression of Na(+)/Ca2(+) exchanger 1 (NCX 1), plasma membrane Ca2+ ATPase 1 (PMCA 1), and PMCA 4 as determined by RT-PCR. CONCLUSIONS: Our data finds evidence of oxidative stress, mitochondrial dysfunction and impaired calcium extrusion in GLC cells compared to NLC cells and suggests their importance in the pathological changes occurring at the ONH in glaucoma. Future therapies may target reducing oxidative stress and / or [Ca(2+)](i).