Comparison of the effectiveness of detecting diabetic eye disease: diabetic retinal photography versus ophthalmic consultation.

INTRODUCTION: This study determines the accuracy of reading a Polaroid retinal photograph in the diabetic retinal photography programme as compared to a clinical fundal examination in the diagnosis of diabetic retinopathy. METHODS: A prospective study recording the additional findings obtained from clinical examination of the eye using indirect ophthalmoscopy and slit lamp biomicroscopy in a restructured tertiary hospital serving an urban community was performed. RESULTS: Seventy-eight eyes in 39 diabetic patients were reviewed by an ophthalmologist for diabetic changes seen on fundus photography. The sensitivity of diabetic retinal photography in diagnosing diabetic eye conditions was 91.6 percent, with a specificity of 99.8 percent and a positive predictive value of 95.6 percent. The degree of agreement kappa was 0.94. CONCLUSION: The use of diabetic retinal photographs to screen for diabetic eye disease achieved a high sensitivity by capturing diabetic retinal lesions. It was comparable to an examination performed by the ophthalmologist. With appropriate training, the person reading the diabetic retinal photographs can accurately diagnose diabetic eye conditions.

Optociliary shunt vessels in diabetes mellitus.

INTRODUCTION: Optociliary shunt vessels is classically described to be associated with optic nerve sheath meningioma, with the triad symptoms of optociliary veins, disc pallor and visual loss. Other clinical settings include retinal vein occlusion, chronic glaucoma, meningioma, and rarely as a congenital form. We report an interesting case series of three patients with diabetes mellitus presenting with optociliary shunts. METHODS: Patients who underwent diabetic retinopathy screening were referred to the eye clinic for abnormal findings. Between 2000 and 2001, out of a total of 3,360 patients, three diabetic patients with optociliary shunt vessels were found (0.1 percent). Optociliary shunt vessels were documented with fundus photography and fundal fluorescein angiography. RESULTS: All three patients had bilateral mild nonproliferative diabetic retinopathy with one having, in addition, bilateral diabetic maculopathy. Fluorescein angiography showed classical features of acquired optociliary shunts with no leakage. Systemic review did not show any secondary cause of the optociliary shunts. CONCLUSION: Our case series showed that optociliary veins can be associated with diabetes mellitus. The authors postulate that it may be due to venous insufficiency secondary to the process of diabetic microangiopathy and venous stasis.

Traumatic eye injuries due to large unusual foreign bodies: a Singapore case series.

PURPOSE: Traumatic eye injuries due to large foreign bodies (FB) are rare. The visual prognosis is often poor in these cases because of severe ocular damage. Staged surgical procedures with eventual enucleation or evisceration are often indicated. METHODS: Case series. RESULTS: The authors describe two patients with eye injury due to large FB with visual acuity of no light perception at presentation. Both had initial repair of the ocular injuries and removal of the FB. One patient with an intraocular FB eventually underwent enucleation; the other, with intraorbital FB, had evisceration as a secondary procedure. Orbital implantations were done in both. Neither of the patients had developed sympathetic ophthalmia at the last review. CONCLUSIONS: The visual outcome of eye injuries due to large FB is poor. Both enucleation and evisceration can be performed with low risk of sympathetic ophthalmia. Prevention remains the best approach to such devastating injuries.

Visually significant opacification of hydrophilic acrylic intraocular lenses--a clinico-pathological analysis.

PURPOSE: To describe the clinic-pathological analysis of the visually significant opacification of the Cirrus International Hydroflex foldable hydrophilic acrylic intraocular lens (IOL) (model SC600-2, Medical Developmental Research Inc., Clearwater, Florida) and to highlight that this IOL is the same model as the Acryflex SC600-2 IOL, by the same manufacturer. METHODS: Retrospective review of five eyes of four patients with opacification of their Cirrus International Hydroflex foldable hydrophilic acrylic IOLs (model SC600-2) after uncomplicated phacoemulsification and IOL implantation. Two IOLs were explanted from two patients 14 to 24 months after initial implantation. Each explanted lens was divided into equal halves, one half for scanning electron microscopy (SEM) study and the other half for transmission electron microscopy (TEM) examination. SEM and TEM samples were also subjected to energy dispersive X-ray analysis (EDX). RESULTS: The IOL opacification was detected 14 to 24 months after uncomplicated phacoemulsification and IOL implantation. EDX analysis showed that the crystals contained calcium and phosphorus, presumably calcium phosphate. CONCLUSIONS: The Cirrus International Hydroflex foldable hydrophilic acrylic IOL (model SC600-2) is associated with opacification, that appeared worse centrally than peripherally. This is the same model as the Acryflex SC600-2 IOL, made by the same manufacturer. The opacification consists of calcium and phosphate.

Neuro-ophthalmological manifestations of systemic lupus erythematosus in Asian patients.

PURPOSE: To report eight patients with diagnosed systemic lupus erythematosus (SLE) who presented with a variety of neuro-ophthalmological complications and outcomes. METHODS: A review of the follow up, subsequent management and outcomes of the neuro-ophthalmological complications of eight patients with SLE. RESULTS: The patients presented with a myriad of symptoms of varying severities. The most common manifestations were that of optic neuropathy and eye movement abnormalities. The outcome was variable ranging from complete recovery to optic atrophy with navigational visual acuity. Treatment was often empirical, although early treatment with corticosteroids has been tried with varying success, CONCLUSIONS: The pathophysiology in the neuro-ophthalmological manifestations of SLE is thought be due to vaso-occlusive disease of the small vessels of the nerve and brain, secondary to an autoimmune process. Ophthalmologists may need to consider the diagnosis of SLE in young women who present with a recent onset of neuro-ophthalmological symptoms and signs.

Diplopia as a complication of laser in situ keratomileusis surgery.

A case is presented of a patient with high myopia who developed vertical binocular diplopia after decentred laser in situ keratomileusis (LASIK) surgery with associated decompensation of pre-existing exophoria into an exotropia. A 40-year-old man underwent LASIK surgery for high myopia in his right eye. Preoperatively, he was approximately -26.00/-2.00 x 35 degrees with visual acuity of 6/12(-2) in that eye. He also had an asymptomatic exophoria. After LASIK surgery, he achieved a refraction of -3.25/-0.50 x 80 degrees with 6/21 best-corrected visual acuity. He also developed binocular diplopia. The ablation zone had been decentred upwards and there was also an exo- and hypo-deviation of his right eye. He was able to superimpose the two images in free space with vertical and horizontal prisms.A hard contact lens also resulted in superimposition of the two images. Vertical decentration of the ablation zone can induce a vertical prism effect after LASIK surgery and result in vertical diplopia. This together with abnormal optics also caused loss of best-corrected vision and decompensation of his pre-existing exophoria into an exotropia.

Tuberculous choroidal granulomas in a patient with systemic lupus erythematosus. A case report.

AIM: We report a case of tuberculous choroidal granulomas in a patient with systemic lupus erythematosis (SLE) who developed miliary tuberculosis (TB) and bilateral granulomas while on immunosuppressive medication. METHODS: The case notes of this patient were reviewed. RESULTS: The patient was first seen for base-line ophthalmic screening before anti-tuberculous medication was started. The patient was subsequently followed up at 2 weeks, 4 weeks and 2 months with fundal examination and photography. One choroidal granuloma was found in the right eye while another peripheral lesion involved the left eye. Both resolved in response to anti-tuberculous medication over a 2-month period with resultant chorioretinal atrophy and scarring. CONCLUSION: This case demonstrates the need to screen immuno-suppressed SLE patients who have miliary TB for possible eye involvement.

Central serous retinopathy complicating systemic lupus erythematosus: a case series.

Systemic lupus erythematosus (SLE) is a chronic autoimmune disorder with widespread manifestations including the eye. Central serous retinopathy (CSR) has been associated as a complicating event in SLE, although it is uncommon. We present a case series of four female Chinese SLE patients who developed CSR during the course of their systemic disease. All four presented clinically with typical CSR. Angiographic findings did not show evidence of choroidal ischaemia or delayed choroidal filling. Resolution of the serous retinal detachment occurred in all four patients. Recovery of vision was seen in three patients. The clinical outcome was similar to that occurring in the usual male population. Central serous retinopathy as a manifestation of SLE may be caused by various factors. These include SLE-associated choroidopathy, systemic hypertension, renal disease, retinal pigment epithelial dysfunction and glucocorticoid therapy.

Bilateral choroidal infarction in a patient with antiphospholipid syndrome: a case report.

PURPOSE: To report a case of bilateral choroidal infarction occurring as a complication of primary antiphospholipid syndrome. METHODS: The case notes of the patient were reviewed. RESULTS: A 25-year-old man with primary antiphospholipid syndrome and a previous history of deep vein thrombosis and pulmonary embolism, developed episcleritis and bilateral choroidal infarction, with deterioration of vision to 6/12 OD and counting fingers at 5 feet OS. Anticoagulation therapy with warfarin was administered and the patient's vision gradually improved to 6/6 OD and 6/9 OS. CONCLUSION: Primary antiphospholipid syndrome is associated with thrombotic phenomena, which may affect the ocular arterial and venous vasculature. Therefore, a detailed ophthalmological examination is warranted in those patients who present with ocular symptoms and deteriorating vision. Retinal fluorescein angiography is valuable in confirming the diagnosis when in doubt, and in determining the extent of vessel occlusion.

Trabeculectomy for acute primary angle closure.

OBJECTIVE: To analyze the results of trabeculectomy performed for all cases of acute primary angle closure (APAC). DESIGN: Retrospective, noncomparative case series PARTICIPANTS: Fifty-six consecutive patients who underwent trabeculectomy for APAC at two Singapore centers from 1993 through 1995. METHODS: The conventional treatment for APAC is to lower intraocular pressure (IOP) medically, after which laser peripheral iridotomy (PI) is performed. However, in Asian eyes, the acute attack is often refractory to standard treatment. Trabeculectomy is occasionally performed on eyes that do not respond to medical therapy, as well as eyes with APAC that respond to medical therapy but are assessed as having underlying chronic angle-closure glaucoma. In such cases, laser PI is not performed before trabeculectomy. MAIN OUTCOME MEASURES: The surgical outcome was assessed in terms of final IOP and the incidence of complications. Success was defined as final IOP less than 21 mmHg without medication, and qualified success was defined as final IOP less than 21 mmHg with medication. Patients whose IOP was more than 21 mmHg, required further glaucoma surgery, lost light perception, or whose eye became phthisical were classified as failures. RESULTS: The mean follow up was 22 months (range, 6-42 months). In group A, the medical failure group (n = 32), success in IOP control was obtained in 18 patients (56.2%), qualified success was achieved in 3 patients (9.4%), and failure resulted in 11 patients (34.4%). Ten patients (31.3%) encountered early postoperative complications such as shallow anterior chamber. In group B, the medical success group (n = 24), success in IOP control was achieved in 21 patients (87.5%), qualified success was achieved in 3 patients (12.5%), and there were no cases of failure. The incidence of postoperative complications was low (4 eyes [16.7%]). In terms of IOP outcome, trabeculectomy outcome was significantly worse in group A (P<0.001, Fisher's exact test). CONCLUSIONS: Because there is a high risk of surgical failure and complications, trabeculectomy may not be the procedure of choice in medically unresponsive cases of APAC.

Contraction to big endothelin-1, big endothelin-2 and big endothelin-3, and endothelin-converting enzyme inhibition in human isolated bronchi.

All three endothelin precursor peptides, i.e. big endothelin-1 (big ET-1), big endothelin-2 (big ET-2) and big endothelin-3 (big ET-3), produced contractile responses in human isolated bronchi, demonstrating the presence of functional endothelin-converting enzyme (ECE) in this tissue. The maximal contractile responses were equal to 108.4+/-8.0% (0.1 microM big ET-1; n=4), 85.2+/-11.8% (0.1 microM big ET-2; n=7) and 43.0+/-7.2% (0.1 microM big ET-3; n=5) of the reference response to acetylcholine (1 mM). The response to big ET-1 (0.1 microM), but not endothelin-1 (ET-1, 0.1 microM), was diminished after overnight storage of the tissue at 4 degrees C, demonstrating instability of the enzyme. The responses to all three big-endothelins were significantly inhibited, by the ECE inhibitors CGS 26393 and CGS 26303, in a concentration-related manner. The responses to the mature peptides ET-1, endothelin-2 (ET-2), and endothelin-3 (ET-3) were unaffected by CGS 26393 and CGS 26303. Phosphoramidon (10 microM) also produced an inhibition of the response to big ET-1 that was equivalent to that produced by CGS 26393 (10 microM). Combination of CGS 26393 (10 microM) and phosphoramidon (10 microM) did not produce an additive inhibition. These results demonstrate the presence of functional ECE for all three big endothelins in human bronchus and inhibition of the enzyme by newly developed orally active ECE inhibitors, as well as phosphoramidon. British Journal of Pharmacology (2000) 129, 170 - 176

Endogenous Klebsiella endophthalmitis.

PURPOSE: To report 4 cases of endogenous Klebsiella endophthalmitis. This disease is a rare but devastating complication of Klebsiella sepsis. Familiarity with its varied clinical presentations would aid in early diagnosis and institution of appropriate therapy. METHODS: We report 5 eyes of 4 patients with endogenous Klebsiella endophthalmitis from December 1995 to September 1996 and review the literature regarding previously successfully treated cases. RESULTS: The mean age of the patients was 67.5 years (range 37-85 years). One patient had bilateral involvement. At presentation, 3 eyes had a visual acuity of no perception of light (NPL) and the 1 patient with bilateral involvement had an acuity of counting fingers in one eye and 20/40 in the other. The primary source of sepsis was the pulmonary system in 2 patients, the hepatobiliary system in 1 patient and the urinary tract in 1 patient. One patient had coexisting diabetes mellitus. Two patients had a pupillary hypopyon. Local and systemic treatment with an aminoglycoside and cephalosporin was initiated. Despite treatment, 2 eyes remained NPL. One eye developed a globe perforation and was eviscerated. The patient with bilateral involvement was treated within 8 h and recovered fully with a final visual acuity of 20/20 in both eyes. CONCLUSION: It is important to have a high index of suspicion in patients with septicaemia presenting with intraocular inflammation, especially in diabetics with suppurative liver disease, urinary tract infection or pulmonary infection. As the visual prognosis for patients with Klebsiella endophthalmitis is generally poor, early diagnosis and treatment with intravenous and intravitreal antibiotics may improve the visual outcome.

Pilomatrixoma of the eyelids and eyebrows in children and adolescents.

PURPOSE: To review the clinical features of pilomatrixomas of the eyelids and eyebrows in children and adolescents. METHODS: The authors reviewed the medical records of 95 patients, all of whom were 20 years old or younger and had the histopathologic diagnosis of pilomatrixoma made from 1976 through 1995. Special attention was given to that subgroup of patients with tumors involving the eyelids and eyebrows. Data analyzed included age at diagnosis, patient sex, location and size of tumor, preoperative diagnosis, and clinical description of tumor. RESULTS: Eleven (12%) of 95 patients had lesions involving the eyelid or eyebrow. Six of those patients (55%) were female. Eight patients (73%) were 10 years old or younger, and three were 11 to 20 years old. The tumor occurred on the upper lid or in the brow in eight patients, the lower eyelid in two patients, and the medial canthus in one patient. Tumor diameter was 1 cm or less in all 11 patients. Pilomatrixoma was included in the preoperative differential diagnosis in only four of the 11 patients. The most common misdiagnoses were epidermoid and dermoid cyst. Three patients had pink or blue discoloration of the overlying skin, two had visible yellow-white patches in the tumor, and two had dilated vessels on the tumor surface. CONCLUSIONS: Pilomatrixoma is an uncommon tumor that can occur on the eyelids and in the brow region of children and adolescents. It is commonly misdiagnosed preoperatively as an epidermoid or dermoid cyst. Distinctive clinical features, however, suggest the correct diagnosis.

Visual outcome and complications after posterior capsule rupture during phacoemulsification surgery.

PURPOSE: To determine the visual outcome and incidence of complications after posterior capsule rupture during phacoemulsification surgery. METHODS: Forty-four eyes of 43 patients which sustained posterior capsule rupture or zonulysis during phacoemulsification surgery between April 1993 and May 1996 were retrospectively studied. Eyes With pseudoexfoliation syndrome, traumatic cataract and myopia > 6 dioptres were excluded from the study. The mean postoperative follow-up period was 26 months (range 3 to 47 months). RESULTS: Forty-one eyes had posterior capsule rupture and 3 eyes had zonulysis. Of these 44 eyes, 41 eyes had vitreous loss and anterior vitrectomy at the time of surgery or subsequently. Excluding 2 eyes with pre-existing conditions that precluded good vision, 36 out of 42 eyes (85.7%) achieved spectacle corrected visual acuity of 6/12 or better post-operatively. Of all 42 eyes, 20 had anterior chamber intraocular lens (ACIOL) implantation while the others had posterior chamber intraocular lens (PCIOL) implantation. For eyes with ACIOL, 17 out of 20 eyes (85.0%) had best corrected visual acuity of 6/12 or better. For eyes with PCIOL, 19 out of 22 eyes (86.4%) had best corrected visual acuity of 6/12 or better. CONCLUSIONS: Phacoemulsification surgery, even if complicated by posterior capsule rupture or zonulysis, is compatible with good visual outcome. This is provided prompt attention is paid to the management of complications.

Nocardia choroidal abscess in a patient with systemic lupus erythematosus.

PURPOSE: Nocardia asteroides, a respiratory saprophyte in humans, may cause localized infection of the lungs in debilitated or immunosuppressed individuals. Haematogenous spread to the eye via the choroidal circulation may result in choroidal abscess formation. METHOD: We report the development of a choroidal abscess in the left eye of a woman treated with steroids and cyclophosphamide for systemic lupus erythematosus. Haematogenous spread of N. asteroides from a localized infection of the lung (empyema) is thought to have been the cause of the choroidal abscess. RESULTS: Surgical drainage of the empyema combined with intravenously administered antibiotics resulted in resolution of the choroidal abscess and improvement of vision. CONCLUSIONS: A choroidal abscess, caused by haematogenous spread of N. asteroides, may respond to appropriate systemic antibiotic treatment alone and not require ocular treatment.

Periocular capillary hemangioma: a review for pediatricians and family physicians.

The pediatrician or family physician is usually the first person to examine an infant with a periocular capillary hemangioma. The physician should know that, in addition to being cosmetically disfiguring, capillary hemangiomas have the potential to cause serious ocular complications such as amblyopia, strabismus, proptosis, and optic atrophy. Prompt evaluation and management of periocular hemangiomas are essential in order to prevent permanent visual loss. Corticosteroids have been the mainstay in the treatment of patients with large periocular hemangiomas, but other therapeutic modalities such as radiation, interferon, and surgical excision also have been effective in selected patients. This review provides pediatricians and family physicians with information on the natural history, complications, and current management of periocular hemangiomas in infants.

Frontal sinus mucoceles causing proptosis--two case reports.

Paranasal sinus mucoceles can present with a multitude of different symptoms including ophthalmic disturbances. We describe two patients with frontal sinus mucoceles presenting with non-axial proptosis, and give details of their presentation, investigations and treatment. Possible ocular manifestations of mucoceles and the diagnostic imaging techniques used are discussed. The treatment of mucoceles is reviewed. It is stressed that a team approach involving the ophthalmologist, otolaryngologist and radiologist is essential for accurate diagnosis and management.