Late onset sclerotomy dehiscence in a patient with Marfan syndrome presenting as recurrent episodes of raised intraocular pressure.

A man in his 50s presented to the eye emergency department on three separate occasions complaining of blurred vision and discomfort in the left eye. He had a history of Marfan syndrome and had undergone bilateral 20-gauge (G) pars plana vitrectomy and lensectomy 20 years prior for ectopia lentis. On examination he had epithelial corneal oedema, raised intraocular pressure >40 mm Hg and conjunctival chemosis, which later appeared as a bleb-like conjunctival elevation. Acute treatment with oral acetazolamide and topical ocular hypotensive agents produced a marked reduction in intraocular pressure to 2-4 mm Hg. A presumed diagnosis of a leaking scleral wound was made. He underwent scleral exploration under general anaesthesia and a leaking sclerotomy was uncovered. The defect was repaired successfully using a scleral patch graft. Late dehiscence of a sclerotomy has been reported rarely in patients with Marfan syndrome. This is the first reported case to present atypically with intermittent episodes of raised intraocular pressure rather than with hypotony.

Spontaneous hyphaemas requiring a closer look.

We present four cases of acute blurred vision that presented to the Ophthalmology Emergency Department of University Hospital Waterford. All four patients were found to have a spontaneous hyphaema with neither neovascular cause nor traumatic history. The pathophysiology was initially uncertain. On closer investigation, these patients were found to have rare iris microhaemangiomas (IMs) or Cobb's haemangiomas. They were all treated conservatively and made full recoveries. Though some reports recommend treating IM prior to intraocular surgery, one of these patients proceeded to have uncomplicated cataract surgery at a later date with no need for prior intervention.

A minor lid laceration concealing a potentially life-threatening injury.

A 29-year-man presented with an injury to his left upper lid, having stumbled onto the tip of a pool cue. He presented with minimal signs and symptoms, initially thought as a minor lid laceration and was managed with lid suturing. Two months later, he presented with vertical diplopia on upward gaze and showed a picture consistent with traumatic Brown's syndrome. Subsequent imaging revealed the extent of orbital injury and confirmed a retained foreign body embedded in the frontal lobe of the brain. This was surgically removed and found to represent the tip of the pool cue. Postoperatively, the patient made a good recovery, although he still has a slight residual diplopia on upward gaze.

Brimonidine and apraclonidine as vasoconstrictors in adjustable strabismus surgery.

INTRODUCTION: Conjunctival and episcleral bleeding can interfere with visualization of anatomic structures during strabismus surgery. In the United Kingdom, dilute adrenaline (epinephrine) is routinely used to induce vasoconstriction at the beginning of strabismus surgery. Because it causes mydriasis and mildly inhibits accommodation, it is relatively contraindicated if early postoperative suture adjustment is planned. PURPOSE: To test whether topical alpha(2)-adrenergic agonists (brimonidine 0.2% and apraclonidine 1%) are useful alternatives to topical adrenaline (epinephrine) in adjustable suture strabismus surgery. METHODS: Prospective observational pilot study. Brimonidine 0.2% or apraclonidine 1% was applied to the medial or lateral conjunctiva of 10 consecutive adult patients undergoing strabismus surgery with adjustable sutures under general anesthesia. Video images were taken before and up to 20 minutes after instillation. The surface area of ocular surface blood vessels on the acquired images was quantified at selected intervals using imaging software. RESULTS: Both agents induced potent transient vasoconstriction of ocular surface vessels. Within 5 minutes of application, brimonidine reduces blood vessel surface area by 69.2% (95% CI, 50.4-88); this effect persists for 20 minutes. Apraclonidine reduces vessel area by 64.6% (95% CI, 57.2%-72%) within 10 minutes and begins to wear off over the following 10 minutes. CONCLUSIONS: Both brimonidine and apraclonidine may be useful alternatives to topical adrenaline (epinephrine) in adjustable suture strabismus surgery.