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.

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.

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.

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.

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.

Preliminary study of argon fluoride (193 nm) excimer laser trabeculectomy. Scanning electron microscopy at five months.

There is an increasing interest in the use of the excimer laser in ophthalmology, particularly in refractive surgery. The argon fluoride (193 nm) excimer laser ablates tissue with a high degree of precision and without any mechanical or thermal damage to surrounding structures. In this study, the argon fluoride excimer laser was experimentally used in the rabbit model to perform a trabeculectomy. Clinical and scanning electron microscopic evaluations showed a successful and patent filtering procedure. At the five-month follow-up the trabeculectomy was smooth and regular and there was no evidence of inflammation or thermal damage on the surrounding structures.

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.

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.

Treatment needs of prisoners with psychiatric disorders.

OBJECTIVE: To describe the prevalence of psychiatric disorder and the treatment needs of sentenced prisoners in England and Wales. DESIGN: Population survey based on a 5% sample of men serving prison sentences. SETTING: Sixteen prisons for adult males and nine institutions for male young offenders representative of all prisons in prison type, security levels, and length of sentences. SUBJECTS: 406 young offenders and 1478 adult men, 404 and 1365 of whom agreed to be interviewed. MAIN OUTCOME MEASURES: History of psychiatric disorder, clinical diagnosis of psychiatrist, and required treatment. RESULTS: 652 (37%) men had psychiatric disorders diagnosed, of whom 15 (0.8%) had organic disorders, 34 (2%) psychosis, 105 (6%) neurosis, 177 (10%) personality disorder, and 407 (23%) substance misuse. 52 (3%) were judged to require transfer to hospital for psychiatric treatment, 96 (5%) required treatment in a therapeutic community setting, and a further 176 (10%) required further psychiatric assessment or treatment within prison. CONCLUSIONS: By extrapolation the sentenced prison population includes over 700 men with psychosis, and around 1100 who would warrant transfer to hospital for psychiatric treatment. Provision of secure treatment facilities, particularly long term medium secure units, needs to be improved. Services for people with personality, sexual, and substance misuse disorders should be developed in both prisons and the health service.

Point prevalence of mental disorder in unconvicted male prisoners in England and Wales.

OBJECTIVES: To determine prevalence of mental disorder among male unconvicted prisoners and to assess the treatment needs of this population. DESIGN: Semi-structured interview and case note review of randomly selected cross section of male remand population. Non-attenders were replaced by the next name on prison roll. SETTING: Three young offenders' institutions and 13 adult men's prisons. SUBJECTS: 750 prisoners, representing 9.4% cross sectional sample of male unconvicted population. MAIN OUTCOME MEASURES: Prevalence of ICD-10 diagnoses of mental disorder, and associated treatment needs. RESULTS: Psychiatric disorder was diagnosed in 469 (63%) inmates. The main diagnoses were: substance misuse, 285 (38%); neurotic illness, 192 (26%); personality disorder, 84 (11%); psychosis, 36 (5%); other and uncertain, 36 (0.5%). Subjects could have more than one diagnosis. The average refusal rate was 18%. In total 414 inmates (55%) were judged to have an immediate treatment need: transfer to an NHS bed, 64 (9%); treatment by prison health care services, 131 (17%); motivational interviewing for substance misuse, 115 (15%); and therapeutic community placement, 104 (14%). CONCLUSIONS: Mental disorder was common among male unconvicted prisoners. Psychosis was present at four or five times the level found in the general population. Extrapolation of our results suggests that remand population as a whole probably contains about 680 men who need transfer to hospital for psychiatric treatment, including about 380 prisoners with serious mental illness.

Risk assessment in psychiatry.

Risk assessment is part of an ongoing process of risk management, involving treatment interventions and reassessments by the multidisciplinary team. It requires monitoring and supervision over a long period, with the level of input varying according to clinical need at the time. Adherence to the principles of good clinical practice avoids most pitfalls in the management of risk.

A survey of pre-arrest drug use in sentenced prisoners.

The paper presents the results of a retrospective, self-report survey of pre-arrest drug use in a representative sample of 1751 men serving a prison sentence. Reported drugs used were cannabis (34%), opiates (9%), amphetamine (9%) and cocaine (5%), including 1% 'crack' users. Pre-arrest injecting was reported by 11% of inmates, including 68% of all opiate users and 57% of amphetamine users. Drug dependence was reported by 11%, including 7% dependent on opiates, 2% on amphetamines and 1% on cocaine. Relative to other drugs, the figure for cocaine is higher than is suggested by a previous clinic survey. Pre-arrest cannabis use was reported by 54% of black prisoners and 34% of white. White prisoners are more likely to report use of 'hard' drugs, drug dependence and injecting, but this masks a higher rate of cocaine use by black prisoners. Opiate use varied between health regions, from 3% of prisoners in the West Midlands to 25% of those from the Mersey region. These findings have implications for service provision and for an understanding of cultural influences on illicit drug use.

Gonioscopic changes in eyes with posterior chamber intraocular lenses.

The aim of this study is to determine the effects of posterior chamber implantation on angle structures. First, without previous knowledge of the position of lens haptics, 360 degrees gonioscopy was performed and any changes in the angle structures were recorded. Then, the pupil was dilated to determine the exact position of the intraocular lens haptics. The apposition of peripheral iris to angle structures or, at least, the narrowing of the angle corresponding to the lens haptic position was observed in almost all of the 117 examined eyes, with no difference found between bag and sulcus implantation. Peripheral anterior synechia overlying the lens haptic was observed in 49 (41.8%) of 117 eyes. Interestingly, we also noted that there was marked and well-limited clumping of pigment in the angle at 6 o'clock position in 67 (57.2%) of 117 eyes. In conclusion, we feel that posterior chamber intraocular lenses are not completely innocuous to the angle structures.