A template for reducing ophthalmology outpatient waiting times: community ophthalmic care.

BACKGROUND: Through an Irish Health Service Executive (HSE) initiative to tackle excessive hospital outpatient waiting times, 996 patients referred to the Ophthalmology Outpatient Department (OPD) of the Mater Misericordiae University Hospital (MMUH), Eccles Street, Dublin 7, Ireland, were outsourced to a community medical eye clinic (CMEC) for consultation with specialist-registered ophthalmologists. AIMS: The study aims to determine if patients referred as routine to the OPD department could be managed in a community setting. METHODS: 996 patients were reviewed in the CMEC, and their data was collected and placed into a spreadsheet for analysis. RESULTS: 61.2% of patients referred to the OPD were fully managed in the community clinic, and 34.9% required ophthalmic surgery in hospital. CONCLUSIONS: By facilitating direct listing of some of the surgical patients to the hospital theatre list, 89.8% of the 996 referrals received treatment without needing to attend the hospital outpatients department.

Odontogenic orbital abscess with intracranial and pulmonary involvement.

A 58-year-old woman presented to the emergency department with left ptosis and complete ophthalmoplegia. Imaging demonstrated a left orbital abscess. Her past medical history included cavitatory lung disease and "aseptic" meningitis 2 months previously. An anaerobic organism and commensal of the oral flora, Peptostreptococcus sp., was cultured from the orbital abscess. The patient was found to have a carious upper molar with chronic buccal abscess, which was extracted. This case presents an uncommon pathogen arising from an odontogenic infection as the etiology for orbital abscess, cavitatory lung disease, and meningitis in one patient.

Comparing the Tonojet disposable tonometer with the traditional Goldmann tonometer in glaucomatous and non-glaucomatous eyes.

Applanation tonometry is widely performed as the most accurate method of measuring intraocular pressure in the clinical setting. Disposable tonometer heads reduce the risk of transmitting infection during applanation and eliminate tonometer head cleaning, which is time-consuming. We performed a study to investigate whether the Tonojet disposable tonometer (Luneau, France) gave comparable intraocular pressure measurements to the standard Goldmann tonometer produced by Haag Streit (Switzerland). The study was performed in a busy general secondary referral ophthalmology clinic in Beaumont Hospital over a 15-day period. We measured intraocular pressure with the Goldmann and Tonojet tonometers in 293 eyes. Patients were randomised as to which tonometer was used first. A diagnosis of glaucoma or ocular hypertension was noted. Central corneal thickness (CCT) was measured. The measurements taken with the Tonojet were on average 2.2 mmHg lower than corresponding measurements taken with the Goldmann applanation tonometer head. The bias was present over the entire range of pressures. The 95 % limits of agreement between the two tonometers ranged from -5.9 to +1.4 mmHg. In the cohort of eyes with ocular hypertension/glaucoma the difference was significantly higher (2.8 vs. 2.1 mmHg). The bias was independent of CCT. We found that the Tonojet disposable tonometer tends to underestimate intraocular pressure compared with the Goldmann. The bias is non-systematic, present over the entire range of pressures and independent of corneal thickness. We conclude that the Tonojet is not sufficiently accurate to constitute a suitable alternative to the Goldmann.

Ophthalmological screening of a paediatric cochlear implant population: a retrospective analysis and 12-year follow-up.

AIMS: To determine the nature and prevalence of ophthalmological findings for a cohort of children in a paediatric cochlear implant program and to assist the clinician in devising an investigative plan for this population. METHODS: Retrospective medical record review of children who underwent multichannel cochlear implantation at a tertiary care hospital between February 1996 and July 2008. RESULTS: In all, 141 children (mean age 28 months, range 16 months to 9 years) had complete medical record documentation consisting of orthoptic and opthalmological examination, including cycloplegic refraction. A total of 59 children (41.8%) had ocular abnormalities with refractive errors being the most common abnormality. Hypermetropia was the most common refractive error and was found in 21 children (14.8%). Strabismus was found in six patients, with constant esotropia being the most common. Ocular pathology (excluding refractive or muscle abnormalities) were found in nine patients (6.3%). Three patients had syndromes associated with ocular findings including Waardenburg and Usher syndrome. During the follow-up period, 14 children were fitted with prescription lenses, 3 had strabismus surgery, and 2 underwent ptosis. CONCLUSIONS: Routine orthoptic and ophthalmologic examination can be beneficial in the initial evaluation of children assessed for cochlear implants. Electroretinography is useful in evaluating children with unexplained congenital sensorineural hearing loss, suggestive symptoms including night blindness, unexplained reduction in visual acuity, or delayed motor milestones. Routine yearly follow-up may aid in the detection of changing refractive errors and the possibility of later-onset retinal degeneration.

Visual outcomes and graft survival following corneal transplants: the need for an Irish National Corneal Transplant Registry.

PURPOSE: To evaluate visual outcomes and corneal graft survival at 12 months postoperatively, and to demonstrate the need for an Irish National Corneal Transplant Registry. METHODS: Retrospective, single surgeon, single center, analysis of 44 consecutive corneal transplants was performed between 2001 and 2005. RESULTS: Forty-four eyes of 41 patients underwent penetrating keratoplasty (n = 37), lamellar keratoplasty (n = 6) or limbal graft (n = 1). Indications for surgery (%) were keratoconus 45.45%; bullous keratopathy 2.7%; graft failure 9%; Fuchs endothelial dystrophy 2 4.5%; Irido corneal endothelial syndrome 2.27% and tectonic 15.9%. Visual outcome at 1 year (%) were as follows: improved by one or more Snellen lines (79.5%); disimproved by one or more Snellen lines (9%); unchanged (11.5%). Graft survival at 1 year was 93%. DISCUSSION: Although our findings compare favourably with those of the Australian Corneal Graft Registry, there is no Irish Corneal Transplant Registry with which to compare our results.

Long term follow up of nasolacrimal intubation in adults.

BACKGROUND/AIMS: The authors have previously reported a short term mean 15 month follow up of nasolacrimal intubation in adults. The effectiveness of this procedure for long term (mean 78 months) control of epiphoria is assessed here. METHODS: 65 eyes from 40 patients who underwent nasolacrimal intubation were followed. Mean age at intubation was 59.2 years. The mean follow up period was 6.2 years. The results were based on long term symptomatic improvement. RESULTS: Complete long term resolution of symptoms was reported in 50.7%. A partial improvement was reported in 38.5%, and no improvement in 10.7%. A better outcome was associated with a canalicular than nasolacrimal duct obstruction. On long term follow up 16.9% required dacrocysto-rhinostomy (DCR). CONCLUSION: Nasolacrimal intubation, a minimally invasive procedure is successful in the long term control of epiphora. Selection of patients with canalicular duct obstruction gives higher success rates with fewer patients subsequently requiring the DCR procedure.

Voriconazole in the treatment of fungal osteomyelitis of the orbit in the immunocompromised host.

Scedosporium apiospermum is an uncommon cause of fungal infection in the orbit and sinus. Morbidity and mortality rates in immunocompromised patients are high. We review the first case of Scedosporium apiospermum orbito-sinus infection that was successfully treated with the new antifungal agent voriconazole. We highlight the efficacy of this drug, particularly in the treatment of osteomyelitis of the orbit and sinus, which may lead to an improvement in survival rates after Scedosporium infection.

Patient pain during different stages of phacoemulsification using topical anesthesia.

PURPOSE: To assess the pain experienced by patients during the different stages of phacoemulsification cataract surgery performed under topical anesthesia. SETTING: Ophthalmic teaching hospital, Dublin, Ireland. METHODS: This prospective study comprised 100 consecutive patients having phacoemulsification under topical anesthesia. Patients were asked to grade the pain they experienced during the different stages of the procedure using a visual analog pain scale from 0 to 10. The pain experienced during the procedure was compared with that experienced after the instillation of a drop of amethocaine. RESULTS: The overall mean pain score was 1.46. The highest mean pain score, which was during the phacoemulsification stage of the procedure, was not significantly more than the score for the administration of the topical anesthetic agent. The duration of surgery was not related to the level of pain during the procedure. CONCLUSIONS: Topical anesthesia was effective in phacoemulsification cataract surgery. Because the highest mean score was not significantly higher than that for the administration of the anesthetic agent, it is possible to counsel patients before surgery that the pain they experience during the procedure will be no worse than that during administration of the anesthetic drops.

Demonstration of biofilm in infectious crystalline keratopathy using ruthenium red and electron microscopy.

OBJECTIVE: Bacterial biofilm formation has been implicated in the pathogenesis of infectious crystalline keratopathy. Biofilm cannot be visualized by electron microscopy without the addition of a fixative that stabilizes the polysaccharide-rich bacterial extracellular matrix that surrounds the bacterial colonies in a biofilm. We used ruthenium red as a fixative to evaluate corneal biopsy specimens for the presence of bacterial biofilm in three cases of infectious crystalline keratopathy (ICK) and five cases of chronic microbial keratitis without crystalline changes. DESIGN: Case series with clinicopathologic correlation. PARTICIPANTS: Eight patients underwent corneal biopsy or therapeutic keratoplasty as part of their management for chronic unresponsive microbial keratitis. METHODS: The corneal specimens removed were trisected for microbiology, pathology, and transmission electron microscopy (TEM). The TEM specimens were fixed in 2.5% glutaraldehyde in 0.1 M sodium cacodylate buffer with 0.05% ruthenium red. MAIN OUTCOME MEASURES: Demonstration of bacterial biofilm with TEM. RESULTS: TEM demonstrated organisms with a surrounding extracellular matrix consistent with a bacterial biofilm in the three cases of ICK but not in the five other cases of chronic microbial keratitis. CONCLUSIONS: The presence of biofilm in ICK can be demonstrated with TEM with appropriate fixation techniques that stabilize the bacterial extracellular matrix. Biofilm stains intensely with periodic acid-Schiff because of the polysaccharide-rich extracellular matrix and weakly with Gram stain because of the high proportion of nonviable organisms. Biofilm formation occurs in ICK but probably not in chronic bacterial keratitis without crystalline changes. Secretion of an extracellular matrix by bacteria to form a biofilm is a response to a nutrient-deprived environment in which growth and replication is depressed. The extracellular matrix of the biofilm may mask bacterial antigens, explaining the relative lack of inflammatory response in these infections. It may also be one of the mechanisms explaining the resistance to in vivo antimicrobial therapy when in vitro sensitivities have been proven.

Diabetic retinopathy in Down's syndrome.

AIM: To determine the prevalence of diabetic retinopathy in patients with Down's syndrome and diabetes mellitus. METHODS: Nine patients with Down's syndrome and diabetes mellitus were assessed. Factors recorded included type and duration of diabetes, level of diabetic control, blood pressure, urinalysis, and results of ophthalmological examination. RESULTS: The duration of diabetes ranged from 8 to 41 years (mean 17.6 years). All had satisfactory glycaemic control and blood pressure measurements on the low side of normal (mean 106.6/70 mm Hg). One patient had early background diabetic retinopathy. The remainder had no evidence of diabetic retinopathy. CONCLUSION: The low prevalence of diabetic retinopathy in these Down's syndrome patients, despite the long duration, is an interesting finding. It suggests some inherent protective factor against the development of diabetic retinopathy in this patient subgroup.

Demonstration of the key role played by the PufX protein in the functional and structural organization of native and hybrid bacterial photosynthetic core complexes.

The role of a component of the bacterial photosystem, the PufX protein, was examined by heterologous expression of the pufX gene from Rhodobacter capsulatus in a strain of R. sphaeroides that lacks the native pufX gene. The strain of R. sphaeroides containing the R. capsulatus PufX protein was capable of efficient transduction of light energy despite a low degree of sequence conservation between the PufX proteins from the two species. The organization of the hybrid reaction center/LH1 photosystem in strains of R. sphaeroides containing the R. capsulatus LH1 antenna complex was affected differently by the R. sphaeroides and R. capsulatus PufX proteins. We discuss the implications of our findings for the role of the PufX protein in organizing the bacterial photosystem for efficient transduction of light energy.

Nasolacrimal intubation in adults.

BACKGROUND/AIMS: Silicone intubation has been shown to be successful in the management of epiphora in children. The effectiveness of this procedure was assessed in adults. METHODS: 70 eyes from 53 patients underwent nasolacrimal intubation. Mean age at intubation was 54.7 years. Mean follow up period was 15 months. The results were based on improvement of symptoms. RESULTS: Complete resolution of symptoms was reported in 54.3%. A partial improvement was reported in 14.3%, a transient improvement in 10%, and no improvement in 21.4%. A better outcome was associated with canalicular than with nasolacrimal obstructions (complete resolution of symptoms in 75.9% versus 25%). Only 17.1% have subsequently required dacryocystorhinostomies. CONCLUSION: Silicone intubation of the nasolacrimal system is a successful procedure in the management of adult epiphora.

Medulloepithelioma of the optic nerve head.

Medulloepithelioma of the optic nerve is a rare developmental tumor. We describe a 2-year-old boy with profound loss of vision associated with a visible tumor of the optic nerve head in his left eye. A clinically diagnosed retinoblastoma necessitated left eye enucleation. The histopathological diagnosis was malignant medulloepithelioma that was incompletely resected. Further tumor resection was required, and the patient received adjunctive chemotherapy and radiotherapy. Four years after treatment, the patient has neither clinical nor radiological evidence of tumor.

Laser intrastromal keratomileusis for high myopia and myopic astigmatism.

BACKGROUND: Laser intrastromal keratomileusis (LASIK) is an evolving technique which enables high degrees of myopia (> 8.0 dioptres) and myopic astigmatism to be corrected. This paper describes initial experience with this procedure. It also details the methodology, the results, the problems encountered, and discusses retreatment procedures. METHODS: 51 eyes (48 primary cases and three retreatments) underwent LASIK for simple myopia or compound myopic astigmatism. After the keratotomy was fashioned with a Chiron corneal shaper, the ablation was performed with either a Summit or Meditec excimer laser. The actual preoperative astigmatism ranged from -0.5 D to -6.0 D (in the astigmatic myopic LASIK (AML) series), while the range of preoperative myopia in the combined myopic LASIK (ML) and AML series was -8.0 D to -37.0 D. Of the ML cases, group 1 (-8.0 to 15.0 D (dioptres)), group 2 (> -15.0 to -20.0 D), and group 3 (> -20.0 D) had mean preoperative myopia values (spherical equivalent) of -11.26 D, -16.84 D and -27.78 D. The same groupings (1, 2, and 3) for the AML cases had respective values of -9.702, -17.4, and -23.08. In the AML series the mean preoperative astigmatism was -2.109 D. Follow up ranged from 8 to 27 months (mean 15.8 months). Six of the cases required retreatment. RESULTS: There was a reduction in best corrected visual acuity (BCVA) (of 1 Snellen line) in seven of the primary cases (14.5%) (three in the ML group and four in the AML group), and in one of the retreatment cases. The BCVA improved in 28 cases (58%) in the primary treatment group. The mean correction attempted (spherical equivalent) for the ML groups 1, 2, and 3 was 10.51 D, -14.5 D, and -27.78 D, versus a mean correction achieved of -9.445 D, -15.625 D, and -21.571 D. Similarly, for the AML groups, attempted correction values were -9.702 D, -17.4 D, and -23.08 D, while the values achieved were -6.95 D, -51.425 D, and -15.708 D. Regression was minimal and stabilisation of the refractive result was achieved in all groups, except group 3 of the ML series, by the 3 month examination period. The mean postoperative astigmatism in the AML series was -0.531 D. Vector analysis of the AML series showed that the mean surgically induced astigmatism was +0.93 D. The most common complication encountered was undercorrection, which occurred in 35 cases-23 cases in the ML group and 12 cases in the AML series. Twenty eight per cent of the ML cases, and 25% of the AML cases were within plus or minus 1.5 D of the attempted refraction. CONCLUSION: For the correction of high myopia and myopic astigmatism, LASIK results in less postoperative pain and relatively little subepithelial haze compared with high myopic photorefractive keratectomy. Furthermore, a stable refraction and reasonably predictable outcome occurs much earlier. High myopia up to -37.0 D can be corrected, albeit with some limitations at the extremes of myopia-in terms of the amount of myopia correctable; this represents a limitation of the technique. Retreatment is a technically straightforward and effective way to treat undercorrection. Undercorrection, the main complication seen in our series, should become less common when the ablation algorithms are further refined.

Urokinase thrombolysis as initial therapy for acute and non-acute ischemic extremities.

Limb ischemia, both acute and chronic, presents a risk to life and limb with mortality rates from 3% to 37% and amputation rates of the same range. Our experience with urokinase thrombolysis as the initial therapy for acute and non-acute ischemic extremities over 57 consecutive cases of native arterial occlusion by either thrombus or embolus has resulted in no mortality and only 3.5% requiring amputation (2 of 57). In 74% of cases initial thrombolytic therapy was followed by either balloon angioplasty (35 patients) or surgery (7 patients) to relieve the underlying cause of obstruction (i.e., stenosis, occlusion or aneurysm). Thrombolysis alone was sufficient and effective treatment in the remaining 26% (15 patients).

Pneumatic retinopexy versus scleral buckling: a randomised controlled trial.

Pneumatic retinopexy (PR) is a technique for repairing certain retinal detachments which is easier to perform than conventional sceral buckling (SB) surgery but has comparable results. We performed a prospective, randomised, controlled trial to determine for ourselves whether PR is a safe and acceptable procedure. Twenty patients presenting consecutively with retinal detachments which fulfilled the selection criteria were randomised to have their detachments repaired by either PR or SB, ten patients in each group. The suitable patients had a single retinal break or small group of breaks of not greater than one clock hour in size, situated within the superior eight clock hours of retina. Patients with significant proliferative vitreoretinopathy or other fundus disorders were excluded. All patients in the PR group had local anaesthesia while all those in the SB group had general anaesthesia. Successful reattachment of the retina was achieved with one or more procedures in 90 percent of the PR group and in 100 percent of the SB group. We feel that narrowing the selection criteria for PR may further improve the success rate.

Long-term follow up of primary trabeculectomy for infantile glaucoma.

BACKGROUND: The treatment for infantile glaucoma is surgical. Treatment options include goniotomy, trabeculotomy, combined trabeculotomy-trabeculectomy, and trabeculectomy. METHODS: Patients who had a follow up of 5 years or longer after primary trabeculectomy were examined to determine the long term stability in infantile glaucoma. RESULTS: In eyes with primary infantile glaucoma 92.3% achieved control of their glaucoma with a single trabeculectomy; 100% achieved control with two trabeculectomies; 85.7% of eyes with secondary infantile glaucoma achieved control with a single trabeculectomy. There were no serious complications experienced in either group. CONCLUSION: Primary trabeculectomy is a safe and successful operation for infantile glaucoma.

Early changes in the choroidal vasculature of rats occurring with experimentally induced hypertension.

We investigated the early changes in the choroidal vasculature in rats following surgically induced renovascular hypertension. Renovascular hypertension was induced in a group of 12 male Wistar rats using a modified Goldblatt procedure. The rats were divided into four groups, each being sacrificed at weekly intervals, the first group being sacrificed 1 week following the procedure. Vascular casts were prepared of the choroidal circulation using acyl resin (mercox). These were then studied using the scanning electron microscope. No abnormality of the choroidal circulation was noted for the first 2 weeks. At 3 weeks, when a rise in the average mean arterial pressure was noted, nodular lesions were seen in the choroidal arteries and choriocapillaris. These lesions were present in far greater numbers by 4 weeks. It seems likely that the nodular lesions described are microaneurysms and may contribute to the pathogenesis of the clinically described Elschnig spot.