Minimally invasive pterygium surgery: a new approach for prevention of recurrence.

PURPOSE: To introduce a novel approach for pterygium excision, to report recurrence rates, and to compare with conjunctival autografting. DESIGN: A comparative, prospective clinical case series design was used. METHODS: The study population consisted of 155 patients with unilateral primary or recurrent pterygia. All patients underwent pterygium excision, either by conventional conjunctival autografting (Group A) or by the minimally invasive pterygium excision (MIPE) technique (Group B). The new technique involves making a limbal incision of the conjunctiva through the body of pterygium, removing the head of the pterygium by blunt dissection, keeping the adjacent Tenon capsule intact, and performing a small conjunctival autograft to cover the epithelial defect. The recurrence rate of each technique was compared statistically. RESULTS: There were 84 patients in Group A and 71 patients in Group B. The recurrence rates were 18% at 1 year after surgery in the conjunctival autografting technique and 4.2% in the MIPE technique. The MIPE technique had significantly lower recurrence rates compared with conjunctival autografting technique (p<0.0001). CONCLUSIONS: The MIPE technique had lower recurrence rate and fewer postoperative complications than the conjunctival autografting technique. Preserving the Tenon capsule and minimizing conjunctival excision in pterygium surgery does not appear to increase the recurrence rate in the 1- year period. However, the effectiveness of this technique in preventing recurrences needs to be proven with more than 1-year results, which we plan to report in the future.

Factors affecting changes in astigmatism before and after suture removal following penetrating keratoplasty.

PURPOSE: To analyze the factors related to changes in astigmatism before and after suture removal in patients who underwent penetrating keratoplasty (PK). METHODS: The study group consisted of 171 consecutive PKs in 171 patients. Keratometric astigmatism was measured before and after suture removal in all patients. The vectorial difference for each eye was calculated between the examination before suture removal and the first year after suture removal. The vectorial difference values were compared with the possible factors affecting astigmatic change such as age of the patient, donor-recipient trephine diameter difference, preoperative diagnosis, and time of suture removal. All sutures were removed completely in one session. The vectorial difference values of all groups were compared with each other statistically. RESULTS: Before suture removal, the mean cylinder was 4.40 +/- 3.24 D; it was 3.96 +/- 2.19 D at 1 year after suture removal. The net difference of astigmatism was -0.27 +/- 3.50. The mean value of vectorial difference for all patients was 4.93 +/- 4.02 D. There was a statistically significant negative correlation between the trephine diameter difference and the vectorial difference (r= -0.582, p<0.01). There was a significant change in vectorial difference values in patients with high pre-suture removal astigmatism. Patients with keratoconus had a positive correlation between the pre-suture removal astigmatism and the vectorial difference (r=0.615, p=0.038). CONCLUSIONS: After suture removal following PK, unexpected high levels of astigmatic change could be encountered due to donor-recipient trephine diameter difference and underlying primary diagnosis such as keratoconus. In particular, high level astigmatism before suture removal has a greater risk of increased astigmatic change after suture removal.

Posterior chamber lens implantation techniques in posterior capsular rupture.

PURPOSE: To evaluate posterior chamber lens implantation techniques and their results in patients in whom posterior capsular rupture and zonular dialysis arose during cataract operation. METHODS: Forty-three cataractous eyes of 43 consecutive patients with complicated cataract operations such as posterior capsular rupture or zonular dialysis were accepted into this prospective study between November 1999 and January 2001. Intraocular lens implantation to ciliary sulcus was achieved without sutures in 19 cases (Group 1), with one suture from 12 o'clock quadrant in 14 cases (Group 2), and with two sutures from 3 to 9 o'clock quadrants in 10 cases (Group 3). Patients were followed up for 3 months after operation and evaluated for best-corrected visual acuity, refractive astigmatism, corneal edema, anterior chamber depth and inflammation, synechia at angle, intraocular pressure, lens tilt and decentration, intraocular hemorrhage, cystoid macular edema, and retinal detachment. RESULTS: There was no difference among groups in best-corrected visual acuity, refractive astigmatism, corneal edema, anterior chamber depth and inflammation, intraocular pressure, lens tilt and decentration, cystoid macular edema, or retinal detachment. Anterior chamber and vitreous hemorrhage and peripheral anterior synechia were significantly higher in Group 3 when compared with Group 1 (p = 0.009, p = 0.009, and p = 0.004). CONCLUSIONS: In all cases with posterior capsular rupture and zonular dialysis, different posterior chamber lens implantation techniques could be performed, beginning with the least invasive procedure suitable for the conditions with the least complications.

Aspergillus niger infection of exenterated orbit.

PURPOSE: To present two immunocompetent patients with Aspergillus niger infection of the exenterated orbit. METHODS: Case reports. RESULTS: The patients were treated with oral itraconazole and socket irrigation with amphotericin B. The sockets cleared completely; no growth was observed on reculturing. CONCLUSIONS: A niger infection of an exenterated socket can be effectively treated with oral itraconazole and topical amphotericin B in immunocompetent patients.

Substance misuse as a marker of vulnerability among male prisoners on remand.

BACKGROUND: More treatment for substance misuse should be provided within prisons. AIMS: To examine differences between prisoners on remand with substance misuse problems and other prisoners on remand. METHOD: Random selection and interview of unconvicted male prisoners (n = 750, a 9.4% sample), plus examination of the prison medical record. RESULTS: Of the sample of 750, 253 subjects (33.7%) reported either drug- or alcohol-related health problems or dependency. Compared with other prisoners on remand, they reported more childhood adversity, conduct disorder, self-harm, past psychiatric treatment and current mood disorder, and had fewer qualifications, were more likely to be unemployed and have more housing difficulties. CONCLUSIONS: One-third of unconvicted men in prison report substance-related problems, and these are a marker for vulnerability within a disadvantaged population. Health care providers should involve this group in treatment and rehabilitation, both inside prison and following release.

Microtubule organizing centers and the origin of centrioles during spermatogenesis in the pteridophyte Phylloglossum.

Spermatogenesis in the lycophyte Phylloglossum is characterized by profound ultrastructural changes that involve complex microtubule arrays and discrete microtubule organizing centers (MTOCs). The first visible MTOC is an electron-opaque acentriolar centrosome that organizes the mitotic spindles in late spermatogeneous cells. In the spermatid mother cell, centrioles arise de novo within the pericentriolar matrix of the MTOC. Approximately 20 centrioles, which ultimately function as basal bodies, originate in each of two branched "blepharoplasts." Constituent centrioles of each organelle radiate from a central region where they are interconnected by cartwheel cylinders, each with nine-fold symmetry. The development and structure of this novel centriolar-generating organelle suggests a direct evolutionary link with the bicentriole of other lycophytes, and are consistent with the concept that multiflagellated spermatozoids in Phylloglossum evolved independently of those in other pteridophytes. During spermiogenesis, two additional structurally defined MTOCs organize the ton and locomotory apparatus, which comprises 20 staggered flagella over a multilayered structure. An MTOC that overlies the multilayered structure and consists of a cloud of electron-opaque material is involved in repositioning basal bodies and generating flagella. The spline, a band of up to 200 microtubules, provides the architectural framework for development and maintenance of cell shape and is organized by the lamellar strip, a highly structured MTOC. Microtubule arrays during spermatogenesis in Phylloglossum are diverse and include mitotic, cytokinetic, cytoskeletal, and locomotory assemblages. MTOCs responsible for the nucleation and organization of these arrays are among the most elaborate and morphologically distinct of any described in land plants.

Outcome of admission to a medium secure psychiatric unit. I. Short- and long-term outcome.

BACKGROUND: This is the first long-term follow-up of patients discharged from a medium secure unit. AIMS: To describe the short- and long-term outcomes of admission for all patients discharged during a 14-year period. METHOD: A longitudinal cohort study of all 234 patients discharged from the Denis Hill Unit, Bethlem Royal Hospital, between 1980 and 1994, followed for an average 6.6 years. RESULTS: Although 48% of admissions were from prison, only 8% returned there, with most being transferred to another psychiatric bed. One-fifth of patients spent none of the follow-up time in the community; 75% of patients had at least one readmission; only 24% were convicted of further offences. CONCLUSIONS: Re-offending rates are comparable with those for patients discharged from high-security hospitals, and much lower than those for released prisoners. The high readmission rates indicate the need for a range of services to maintain former patients in the community.

Outcome of admission to a medium secure psychiatric unit. 2. Role of ethnic origin.

BACKGROUND: A follow-up of patients discharged from medium secure psychiatric units is used to compare outcome in patients of different ethnic origin. AIMS: To test the hypothesis that there are systematic differences in clinical outcome between ethnic groups. METHOD: A descriptive, longitudinal cohort study of discharges from a medium secure unit is used to compare the 125 patients of White/European ethnic origin and the 104 patients of Black/African-Caribbean origin. RESULTS: Patients of African-Caribbean origin were admitted at three times the rate of White patients, had a higher prevalence of psychosis and a lower prevalence of personality disorder. There was no difference in outcome as measured by location at follow-up, readmission or re-offending. CONCLUSIONS: The higher rate of admission of African-Caribbean patients is consistent with a higher level of demand. There is a need for studies of the pathways by which patients from ethnic minorities reach medium-security accommodation, with a view to early intervention.

Keratitis complicated by endophthalmitis 3 years after astigmatic keratotomy.

Endophthalmitis after keratotomy is rare and usually occurs soon after surgery. A 56-year-old woman with mild dry-eye symptoms developed keratitis complicated by endophthalmitis 3 years after astigmatic keratotomy (AK). The keratitis lasted for less than 1 day in the upper keratotomy incision. Corneal cultures yielded. Pseudomonas aeruginosa. Keratitis progressed to endophthalmitis 1 day after the detection of keratitis. The inflammation was controlled with intravitreal, subconjunctival, topical, and systemic antibiotics. This case demonstrates the potential risk of endophthalmitis developing very shortly after late keratitis of AK incisions. Vigorous early treatment and close follow-up seem justifiable in any keratitis associated with a keratotomy incision.

Unilateral refractive keratotomy for anisometropia.

BACKGROUND: In anisometropia, the asymmetry of refractive error produces disparity of image magnification (aniseikonia) that can create visual discomfort, especially when asymmetry is 3.00 diopters or more. METHODS: A prospective study of 20 eyes of 20 patients between 18 and 61 years of age who underwent unilateral radial and/or transverse keratotomy was conducted; results of at least 12 months follow-up are presented. The efficacy of keratotomy was evaluated by the following criteria: 1) change in spherical and cylindrical refraction, 2) decrease in refraction difference between two eyes of each patient, 3) change in spectacle-corrected visual acuity, and 4) change in binocular vision functions and asthenopic complaints. RESULTS: Mean decrease in spherical refractive error was 3.66 +/- 1.58 D (range, 1.25 to 7.50 D) and 2.08 +/- 0.81 D (range, 1.00 to 3.50 D) in astigmatic refraction. The mean refraction difference between two eyes was 4.90 +/- 2.20 D preoperatively, and this difference regressed to 1.79 +/- 1.42 D postoperatively. Spectacle-corrected visual acuity increased in seven eyes (35%), remained the same in 12 eyes (60%) and decreased in one eye (5%). All patients reported relief of asthenopic complaints. Fusion amplitudes increased in 12 (60%) patients. Stereoscopic vision improved in five (25%) patients. CONCLUSION: Monocular refractive keratotomy can significantly decrease anisometropia.

Substance misusers remanded to prison--a treatment opportunity?

AIMS: To describe self-reported levels of substance misuse before arrest among remanded prisoners (unconvicted prisoners awaiting trial), to assess their degree of dependency on opiates and stimulants and to record their experiences of treatment in prison. DESIGN: Random selection of subjects from prisons chosen to give a geographical spread across England and Wales; self-report at semi-structured interview, plus examination of the prison medical record. SETTING: Thirteen male prisons, three Young Offenders' Institutions and three womens' prisons. PARTICIPANTS: Nine hundred and ninety-five consenting, unconvicted prisoners, randomly selected from all locations within the prisons: 750 men (9.4% sample) and 245 women (82.2% of all remanded women). MEASUREMENTS: CAGE Questionnaire, Severity of Dependence Scales (SDS) for daily users of opiates and/or stimulants. FINDINGS: Before arrest, 145 (19.3%) men and 72 (29.4%) women had been dependent on street drugs; 91 (12.1%) men and 16 (6.5%) women were solely dependent on alcohol. Seventeen (2.3%) men and four (1.6%) women reported injecting drugs during this imprisonment. Mean SDS scores were 10.6 for opiate and 7.7 for stimulant users. 244 (25%) of all subjects described withdrawal symptoms on reception into custody; 157 (16%) reported being prescribed some symptomatic relief; 235 (24%) requested treatment at interview. CONCLUSIONS: By extrapolation, 1905 people--23% of all unconvicted prisoners--want treatment for substance misuse. This apparent shortfall in provision must be addressed; the rapidity with which remanded prisoners return to the community dictates that prison and community services should be closely linked.

Monoscleral fixated lens implantation in eyes with partial loss of capsular or zonular support.

A technique is described in which a posterior chamber intraocular lens (IOL) is implanted in eyes with partial loss of posterior capsule or zonular support. The IOL's inferior haptic is placed over the residual capsule and the superior haptic is fixated to the ciliary sulcus with a polypropylene suture. In 17 eyes that had surgery using this technique, mean postoperative visual acuity was 20/25; complications included irregular pupil, iris capture, pupil block, hyphema, localized peripheral anterior synechia, IOL tilt, suture exposure, and cystoid macular edema.

The Bentham Unit: a pilot remand and assessment service for male mentally disordered remand prisoners. II: Report of an independent evaluation.

BACKGROUND: Findings are presented from an evaluation of a pilot remand and assessment service--the Bentham Unit. The aims of the Bentham Unit are to provide rapid assessment, identify mentally disordered remand prisoners, and speed their transfer from prison to NHS care, where a need is indicated. METHOD: The number, rate and speed of referral, assessment and transfer to NHS care of offenders remanded to Wormwood Scrubs prison during periods before and after the Bentham Unit opened were compared. RESULTS: The service attracted a large volume of referrals. Between the two periods, significant increases in the numbers of referrals and hospital disposals, and major reductions in the interval between reception on remand into the prison, NHS assessment and transfer to NHS care, were observed. CONCLUSIONS: The aims of the unit were met. Implications for service configurations are discussed.