The association of prenatal alcohol exposure on the cognitive abilities and behaviour profiles of 4-year-old children: a prospective cohort study.

OBJECTIVE: To examine the association of prenatal alcohol exposure (PAE) on cognitive abilities and behaviour profiles of 4-year-old children. DESIGN: Prospective cohort study. SETTING: Cape Town, South Africa. POPULATION: A cohort of 500 children. METHODS: Children from the Safe Passage Study, which prospectively collected PAE, were included. Cognition and behavioural profiles were assessed. Children with and without PAE were compared. Mean scores were compared, with P ≤ 0.05 considered significant. Results were adjusted for confounding factors. MAIN OUTCOME MEASURES: The Kaufman Assessment Battery for children measured intellectual and mental ability; the NEPSY-II instrument assessed neurocognitive performance. The caregiver completed the Preschool Child Behaviour checklist to rate the child's problem behaviours and competencies. RESULTS: Two hundred children had no PAE, 117 children had mild to moderate PAE (with no binge episodes), 113 children had heavy PAE (with one or two binge episodes), and 70 children had very heavy PAE (with three or more binge episodes). Women who binge drank had significantly higher rates of smoking, marijuana use, and methamphetamine use. Low to moderate PAE had no effect on cognitive ability and behaviour. Very heavy PAE was associated with problems performing simultaneous as well as sequential functions, lower scores in the language and sensorimotor domain, and more attention and pervasive developmental problems. CONCLUSIONS: Low to moderate PAE was not associated with cognitive processing or developmental problems. Women who had many binge drinking episodes during pregnancy were the most at risk for cognitive processing, neurocognitive, and behaviour problems in their children at 4 years of age. TWEETABLE ABSTRACT: Low to moderate prenatal alcohol use was not associated with cognitive or behavioural problems in 4-year-olds.

Association between Increased Uterine Activity, as Recorded Noninvasively from the Anterior Abdominal Wall at 34 Weeks' Gestation, and Preterm Birth.

Background: There is a need to accurately identify pregnant women at risk for preterm birth as early as possible. Recent developments in technology enable the recording of uterine electrical activity (electrohysterogram) from the anterior abdominal wall in a non-invasive way. Objective: To investigate whether uterine activity recorded under resting conditions at a gestational age of 34 weeks could identify a risk of preterm birth. Study design: A commercial antenatal holter device with its dedicated software was used to record and store raw data of the maternal and fetal electrocardiograms and uterine activity for the Safe Passage Study. Uterine activity was recorded under resting conditions from 34 weeks' gestation in epochs of 250 ms (millisecond) for at least 30 min. From this database the raw data, recorded at a mean gestational age of 34 weeks, of 50 women who had preterm deliveries were selected for comparison with data of women who had term deliveries. Mean uterine activity, expressed in microvolt (µV)/epoch, was used for the comparison. Results: After exclusion of 25 participants where labour was induced or augmented and another three for other reasons, 36 remained in each group. The participants in each group were comparable in respect of maternal age, gravidity, parity, gestational age at recruitment and duration of recording. Uterine activity in the preterm group (60.3 µV/epoch) differed significantly (p<0.01) from that of the comparison group (52.4 µV/epoch). Using a cut-off point of 52.3 µV/epoch as obtained from receiver operator characteristic curves (area under the curve 0.72), the sensitivity and specificity of identifying risks of preterm labour were 81% and 50% respectively. Conclusion: Results of this small study are promising but need to be confirmed in larger studies and preferably at earlier gestational age.

Accelerations of the Fetal Heart Rate in the Screening for Fetal Growth Restriction at 34-38 Week's Gestation.

OBJECTIVES: To use machine learning to determine what information on Doppler velocimetry and maternal and fetal heart rates, collected at 20-24 weeks gestation, correlates best with fetal growth restriction according to the estimated fetal weight at 34-38 weeks. STUDY DESIGN: Data of 4496 pregnant women, collected prospectively for the Safe Passage Study, from August 2007 to August 2016, were used for the present analysis. Doppler flow velocity of the uterine, umbilical, and middle cerebral arteries and transabdominally recorded maternal and fetal ECGs were collected at 20-24 weeks gestation and fetal biometry collected at 34-38 weeks from which the estimated fetal weight was calculated. Fetal growth restriction was defined as an estimated fetal weight below the 10th centile. Accelerations and decelerations of the fetal and maternal heart rates were quantified as gained or lost beats per hour of recording respectively. Machine learning with receiver operative characteristic curves were then used to determine which model gives the best performance. RESULTS: The final model performed exceptionally well across all evaluation metrics, particularly so for the Stochastic Gradient Descent method: achieving a 93% average for Classification Accuracy, Recall, Precision and F1-Score to identify the fetus with an estimated weight below the 10th percentile at 34-38 weeks. Ranking determined that the most important standard feature was the umbilical artery pulsatility index. However, the excellent overall accuracy is likely due to the value added by the pre-processed features regarding fetal gained beats and accelerations. CONCLUSION: Fetal movements, as characterized by gained beats as early as 20-24 weeks gestation, contribute to the value of the flow velocimetry of the umbilical artery at 34-38 weeks in identifying the growth restricted fetus.

Smoking and drinking habits of women in subsequent pregnancies after specific advice about the dangers of these exposures during pregnancy.

BACKGROUND: Although women are informed about the dangers of drinking and smoking during pregnancy when they book for antenatal care, it is uncertain whether this advice is accepted, or whether attempts are made to apply it in subsequent pregnancies. OBJECTIVES: To assess how pregnant women respond to the advice to refrain from smoking and drinking during pregnancy in subsequent pregnancies. METHODS: Research staff were trained to obtain accurate prospective information on smoking and drinking during pregnancy in a prospective study, using well-standardised methods. Care was taken to inform participants about the dangers of smoking and drinking during pregnancy. They were also given pamphlets on these dangers in their own language and a list of telephone numbers where they could find help to quit should they need it. This information was repeated at subsequent study visits (ranging from 1 to 3, depending on the gestational age at which they enrolled). Gestational age was determined by early ultrasound. Z-scores of birthweight for gestational age were determined according to the INTERGROWTH-21st study. Pregnancy outcomes of women who enrolled twice (n=888) or three times (n=77) in the Safe Passage Study were compared with those of women in the first enrolment (n=889). RESULTS: The proportion of drinkers did not change significantly (p=0.058) from the first to the second and third enrolments (63.8%, 59.0% and 54.6%, respectively). A similar trend was found for smokers (73.3%, 72.2% and 68.4%, respectively). Cannabis use was reported by 15.1%, 9.7% and 12.0% (p<0.005) of women, respectively, and use of methamphetamine by 10.1%, 6.6% and 12.7% (p<0.005). There was an increase in the rate of preterm births from 15.5% to 17.5% and 24.7%, respectively, but the increase was not significant. Although mean birthweight was lower in the third enrolment compared with the second, the difference was not significant. The z-score of birthweight for gestational age was significantly lower in the second enrolment compared with the first. CONCLUSIONS: Detailed information on the adverse effects of smoking and drinking during pregnancy was not effective in the population studied. Other methods to reduce or stop these toxic exposures should therefore be investigated. A short inter-pregnancy interval, as demonstrated by three enrolments in 7.5 years, is associated with preterm labour and fetal growth restriction, and is probably indicative of the role played by confounders such as poor socioeconomic conditions and drug exposure during pregnancy.

Recognition and referral of girls with Attention Deficit Hyperactivity Disorder: case vignette study.

BACKGROUND: Compared with boys, girls with Attention Deficit Hyperactivity Disorder (ADHD) are under-recognized. Parents commonly discuss concerns with teachers, who play an important role in the recognition and referral of children with ADHD. We investigated whether the predominating subtype of symptomatology influences teacher recognition of affected girls. METHODS: A total of 212 teachers from 40 randomly selected primary schools in England participated in a postal questionnaire study. The questionnaire consisted of a case vignette (based on DSM-IV criteria) describing a girl with either combined or predominantly inattentive subtype ADHD. Each school received an equal number of each type of vignette for distribution. Further questions elicited teachers' conceptualization of the girl's difficulties and need for specialist referral, their views on treatment modalities and demographic data. RESULTS: Most (98%) teachers recognized the presence of a problem but mainly conceptualized the girl's behaviour as reflecting attentional (89%) or emotional (62%) difficulties. Teachers were less likely to correctly identify a girl with inattentive than combined subtype ADHD (14% vs. 43%) or recommend clinical referral (50% vs. 59%) for her. Few (15%) teachers thought that medication might be helpful for a girl meeting diagnostic criteria for ADHD. CONCLUSIONS: Teachers are able to recognize ADHD-related behaviours and impairments but conceptualize these as reflecting attentional or emotional difficulties rather than as relating to a disorder (ADHD). Teachers' conceptualization of ADHD and views about medication are important factors that could affect accurate recognition and referral. Improving teachers' knowledge about ADHD, especially the inattentive subtype, could assist in tackling gender-related barriers to care.

Axillary lymph node dissection for patients with invasive breast cancer at Charlotte Maxeke and Chris Hani Baragwanath Academic Hospitals.

BACKGROUND: The extent of axillary surgery correlates with its morbidity and sentinel lymph node biopsy (SLNB) has become the standard of care in clinically node-negative (cN0) patients.This study aims to evaluate the application of SLNB and axillary lymph node dissection (ALND) and the associated risk factors for node-negative ALND in our units. METHODS: We included female patients with primary breast cancer who underwent axillary surgery in the breast units at Charlotte Maxeke Johannesburg Academic Hospital and Chris Hani Baragwanath Academic Hospital from March 2013 to March 2015. Univariate and multivariable logistic regression models were used to determine factors associated with pathological node-negative (pN0) ALND. RESULTS: 505 patients were included and 344 patients were staged clinically node-positive (68.1%), 161 (31.9%) were assessed as clinically node-negative and deemed eligible for SLNB. Sensitivity of clinical nodal staging was 85.9% with a positive predictive value of 76.5%. The majority of patients (313, 61.9%) underwent primary surgery while 192 (38.1%) underwent surgery after NACT. We performed 118 SLNBs and 387 ALNDs of which 97 were pathologically node-negative. Risk was not increased after NACT (OR 1.06, p = 0.790). We identified a significant risk in patients with triple-negative and HER-2 enriched subtypes compared to hormone receptor-positive patients (OR 3.05, 95% CI: 1.6-5.7, p = 0.001 and OR 2.25, 95% CI: 1.1-4.8, p = 0.035). CONCLUSION: The prevalence of pN0 ALND was 25.06%. In our cohort a significantly higher risk was found in hormone receptor-negative tumours. Preoperative nodal assessment needs to be optimised and include pathological confirmation. SLNB needs to be extended to patients after NACT despite resource-constraints.

The association between preterm labour, perinatal mortality and infant death (during the first year) in Bishop Lavis, Cape Town, South Africa.

BACKGROUND: We present further analyses from the Safe Passage Study, where the effect of alcohol exposure during pregnancy on sudden infant death syndrome and stillbirth was investigated. OBJECTIVES: To describe pregnancy and neonatal outcome in a large prospective study where information on the outcome of pregnancy was known in >98.3% of participants and ultrasound was used to determine gestational age (GA). METHODS: As part of the Safe Passage Study of the PASS Network in Cape Town, South Africa, the outcomes of 6 866 singleton pregnancies were prospectively followed from recruitment in early pregnancy until the infant was 12 months old to assess pregnancy outcome. Fetal growth was assessed by z-scores of the birth weight, and GA at birth was derived from early ultrasound assessments. The effects of fetal growth restriction and preterm delivery on pregnancy outcome were determined. RESULTS: There were 66 miscarriages, 107 stillbirths at ≥22 weeks' gestation, 66 stillbirths at ≥28 weeks' gestation, 29 and 18 neonatal deaths at ≥22 and ≥28 weeks' gestation, respectively, and 54 post-neonatal deaths (28 days - 12 months). The miscarriage rate was 9.6/1 000 and the infant mortality rate 12.4/1 000. Of the births, 13.8% were preterm. For deliveries at ≥22 and ≥28 weeks, the stillbirth rates were 15.7 and 9.8/1 000 deliveries, respectively. For deliveries at ≥22 and ≥28 weeks, the neonatal death rates were 4.3 and 2.7/1 000 live births, respectively. For these pregnancies the perinatal mortality rates were 20.0/1 000 (≥22 weeks) and 12.5/1 000 (≥28 weeks), respectively. Only 15.9% of stillbirths occurred during labour (in 15.9% of cases it was uncertain whether death had occurred during labour). In the majority of cases (68.2%) fetal death occurred before labour, and 82.2% of stillbirths and 62.1% of neonatal deaths occurred in deliveries before 37 weeks. Including the miscarriages, stillbirths and infant deaths, there were 256 pregnancy losses; 77.3% were associated with deliveries before 37 weeks. Only 1.8% of all the women were HIV-positive, whereas the HIV-positive rate was 3.7% among those who had stillbirths. Birth weight was below the 10th centile in 25.6% of neonatal and post-neonatal deaths compared with 17.7% of survivors. CONCLUSIONS: Preterm birth and fetal growth restriction play significant roles in fetal, neonatal and infant losses.

Primary vitrectomy with Densiron-68 for rhegmatogenous retinal detachment.

BACKGROUND: To report a retrospective non-comparative interventional study on the effectiveness and ocular tolerance of a heavy silicone oil tamponade (HSO, Densiron-68) for primary inferior rhegmatogenous retinal detachment (RRD). METHODS: Forty-one eyes of 41 consecutive patients were recruited between January 2004 and August 2006. Primary vitrectomy with Densiron-68, a heavy silicone oil, was used in all cases. Inclusion criteria were primary RRD with at least one retinal break between 4 and 8 clock hours. The study protocol consisted of a minimum of eight clinic visits: baseline, surgery, 1 week, 1 month and 3 months after the initial surgery; removal of oil and 1 week, 1 month and 3 months postoperatively. The primary endpoint was anatomical re-attachment of the retina. Cases were judged successful when there was reattachment of the retina in the absence of any tamponade agent. The secondary endpoint was to record the visual function and any complications arising from the surgery. Out of 41 patients initially included in the study, 33 completed all follow-up visits. RESULTS: Anatomical success was achieved in 91% of cases (30 out of 33) with one retinal operation, and rose to 94% (31 out of 33) with additional surgery. Mean visual acuity improved from logMAR 1.19 (SD 0.9) to 0.5 (SD 0.51, p = 0.001). No significant ocular hypertension, clinically significant emulsification of the tamponade or inflammation developed during follow-up. CONCLUSION: With Densiron-68, high anatomical and functional success rates can be achieved with primary vitrectomy for RRD and predominantly inferior pathology.

Effects of alcohol, cigarettes, methamphetamine and marijuana exposure during pregnancy on maternal serum alpha-fetoprotein levels at 20-24 weeks'gestation.

OBJECTIVE: To examine the effects of cigarette, marihuana and methamphetamine smoking and consumption of alcohol during pregnancy on maternal serum alpha-fetoprotein (MSAFP) levels at 20-24 weeks. STUDY DESIGN: In the Safe Passage Study (SPS) more than 12,000 pregnant women were prospectively followed up during pregnancy and until the infant was one year old to examine the effects of exposure to alcohol during pregnancy on stillbirth and sudden infant death syndrome. The present study is a cross-sectional secondary analysis of MSAFP analyses done at 20-24 weeks gestation in 1,679 SPS participants, recruited at the Bishop Lavis Community Health Centre, Cape Town, South Arica. RESULTS: Low or moderate alcohol consumption with or without smoking, nor methamphetamine or marihuana use affected mean MSAFP levels. High MSAFP levels were associated with high alcohol consumption, young age, low body mass index (BMI) (<18 kg/m2) or small mid upper arm circumference (MUAC) (<230mm). High MSAFP levels were associated with stillbirth, preterm birth, abruption and a birth weight z-score of less than -1. CONCLUSION: The study confirms the association between high MSAFP levels and adverse pregnancy outcomes but, although exposure to smoking or drinking is associated with adverse pregnancy outcomes including stillbirth, MSAFP levels were not affected by any of these exposures except for continued high consumption of alcohol. The observed association between higher MSAFP levels and maternal nutritional status (as demonstrated by the lower MUAC and BMI) could explain some of the correlations of poor socioeconomic conditions with higher stillbirth rates effect.

Bereaved mothers' attitudes regarding autopsy of their stillborn baby.

BACKGROUND: Here we present additional information from the Safe Passage Study, where the effect of alcohol exposure during pregnancy on sudden infant death syndrome and stillbirth was investigated. OBJECTIVE: To explore bereaved mothers' attitudes toward obtaining an autopsy on their stillborn baby, and the future implications of consenting or non-consenting to autopsy in retrospect. METHODS: Demographic data was obtained by a questionnaire. A largely qualitative mixed-methods approach was used to meet the aims of the study, using an exploratory and descriptive research design to provide a detailed description of maternal attitudes. A semi-structured questionnaire based on information from literature and reflections on practice was administered during individual interviews. RESULTS: We interviewed 25 women who had had a recent stillbirth. The time interval between the time of consenting to autopsy and completing this study ranged from 6 to 18 months. Most participants reported that autopsy results provided peace of mind and helped alleviate their feelings of blame. Participants who were unable to comprehend the results reported negative reactions to receiving autopsy results. The majority of participants were of the opinion that they benefited from consenting to autopsy. CONCLUSION: Autopsy and the disclosure of its results generally contribute positively to coping following stillbirth.

Visual loss following removal of intraocular silicone oil.

AIM: To investigate the cause of visual loss following removal of intraocular silicone oil in patients who underwent vitrectomies for retinal detachment or giant retinal tear. METHODS: The clinical records of three cases with visual loss following removal of silicone oil were reviewed. Investigations carried out included fundus fluorescein angiogram, optical coherence tomography, and electrophysiological studies. RESULTS: Visual acuities dropped from 6/9 to 6/36 in two cases and 6/24 to 3/24 in the third. None of the three cases had macula detachment at any stage. Fundus fluorescein angiogram and optical coherence tomography were normal in all cases. Pattern electroretinogram showed reduced amplitudes of the P50 and N95 components. Multifocal electroretinogram indicated a selective damage to the central part of the macula. CONCLUSIONS: The results suggest that the abnormality arises predominantly in the central part of the macula, especially the outer and middle layers. However, the exact mechanism still remains obscure.

A pilot study on the use of a perfluorohexyloctane/silicone oil solution as a heavier than water internal tamponade agent.

AIMS: To report a prospective two centred non-comparative interventional pilot study of a solution of perfluorohexyloctane and silicone oil (Densiron-68) as a heavier than water internal tamponade. METHODS: 42 consecutive patients were recruited. The indications include proliferative vitreoretinopathy, retinal detachments arising from inferior retinal breaks, and inability to posture. RESULTS: The success rate with one operation using Densiron was 81% and with further surgery 93%. At the end of the study all tamponade agents were removed in 90% of patients. Visual acuity improved from mean logMAR of 1.41 (SD 0.64) to 0.94 (SD 0.57), p = 0.001. There was little evidence of dispersion and excessive inflammation. CONCLUSION: This new tamponade agent is being compared to conventional silicone oil in a prospective international randomised trial.

Modulation of retinal pigment epithelial cell behavior by Agaricus bisporus lectin.

PURPOSE: To determine whether Agaricus bisporus lectin (ABL) binds retinal pigment epithelial cells (RPEs), to conduct a preliminary viability study of RPEs exposed to ABL, and to evaluate the effects of ABL on RPE proliferation and RPE-mediated matrix contraction in vitro. METHODS: Using cultured bovine RPEs, immunohistochemistry was used to study ABL binding. Morphologic and trypan blue exclusion techniques were used for toxicity studies. The effect of ABL on RPE proliferation was investigated by [methyl-3H]-thymidine incorporation. The effect of ABL on RPE-mediated matrix contraction was evaluated with RPE-populated three-dimensional collagen matrices. RESULTS: ABL bound to RPE cells. This binding was inhibited by asialomucin. No change in RPE morphology or trypan blue exclusion compared with controls was observed in RPEs incubated with 5 to 60 microg/ml ABL for 3 days. Twenty-four-hour incubations of RPEs with ABL significantly inhibited RPE proliferation in a dose-dependent way, 40 microg/ml ABL inhibited proliferation by 83% (SE 14, P<0.05). ABL showed a dose-dependent significant inhibition of RPE-mediated collagen matrix contraction over 3 days, with 93% inhibition compared with controls by 40 microg/ml lectin (P<0.05). The inhibitory effect of ABL on proliferation and gel contraction was partly reversible after eliminating ABL from the culture medium. CONCLUSIONS: Bovine RPE cells bind ABL, and preliminary evaluations suggest that levels of ABL that are nontoxic to the cells potently inhibit RPE proliferation and RPE-mediated matrix contraction. ABL deserves further investigation as a potential inhibitor of RPE proliferation and cell-mediated matrix contraction in anomalous reparative processes such as proliferative vitreoretinopathy and as a laboratory tool for RPE behavioral studies.

Multifixation campimetry on line: a perimeter for the detection of visual field loss using the internet.

More widespread perimetry would improve opportunities for preventing visual handicap from ocular and intracranial diseases, some of which are life threatening. With internet access becoming more ubiquitous, the authors have developed multifixation campimetry on line, for qualified practitioners and lay individuals around the world, free of charge.

Endoresection of choroidal melanoma.

AIMS: The results of 52 endoresections for choroidal melanoma are reported. METHODS: The current technique involves vitrectomy, retinal incision over or peripheral to the tumour, haemostasis by raising intraocular pressure and by moderate hypotensive anaesthesia, choroidal incision around tumour, endoresection with vitrector, endodiathermy to bleeding points and residual tumour, fluid-air exchange to reattach retina, endolaser to achieve retinal adhesion around the coloboma and destroy residual tumour in the sclera, silicone oil injection with removal after 12 weeks, cryotherapy to the sclerotomies, and adjunctive ruthenium plaque radiotherapy in selected cases. RESULTS: Patients receiving primary endoresection had a mean age of 53 years, a mean largest basal tumour diameter of 8.2 mm, and a mean tumour thickness of 3.9 mm. 40 tumours extended to within 2 disc diameters of the optic disc, with 17 involving disc. Follow up ranged from 40 days to 7 years (median 20 months). At the last visit, 90% of eyes were retained, with vision of 6/6-6/12 (two), 6/18-6/36 (three), 6/60 to counting fingers (18), hand movements (nine), and light perception (four). The main complications were retinal detachment in 16 and cataract in 25. Secondary endoresection (11) was performed after plaque radiotherapy (four), photocoagulation (four), trans-scleral local resection (two), and proton beam radiotherapy (one), with retention of the eye in nine cases. By the close of the study, no patients developed definite local tumour recurrence but one died of metastatic disease 41 months postoperatively. CONCLUSION: Depending on tumour location, endoresection may conserve central vision or temporal field when radiotherapy would be expected to cause optic neuropathy. Longer follow up is necessary to establish the efficacy of tumour control.

Does cryotherapy before drainage increase the risk of intraocular haemorrhage and affect outcome? A prospective, randomised, controlled study using a needle drainage technique and sustained ocular compression.

AIMS/BACKGROUND: A prospective, randomised, controlled clinical trial was conducted to investigate the effect of performing cryotherapy before drainage of subretinal fluid (SRF) on the incidence of intraocular haemorrhage (IOH) in the management of retinal detachment. METHODS: Eighty eyes of 80 patients with rhegmatogenous retinal detachment requiring SRF drainage were recruited. Thirty four cases were randomised to receive drainage before cryotherapy (drainage, air injection, cryotherapy, and explant = DACE group) while 46 cases had drainage after cryotherapy (cryotherapy, drainage, air injection, and explant = CDAE group). All cases had trans-scleral drainage of SRF using a 27 gauge hypodermic needle combined with prolonged, intraocular hypertension. RESULTS: There was a low incidence of IOH associated with drainage in both groups with no statistically significant difference between the groups (DACE group = 2.9%; CDAE group = 4.3%; p = 0.43). There was no significant difference between the groups in the rate of anatomical success with a single operation (DACE group = 82.4%; CDAE group = 86.9%; p = 0.38). There was no significant difference between the groups in the visual outcome. An improvement of two Snellen lines or more occurred in 52.9% of the DACE group and in 56.5% of the CDAE group (p = 0.93). CONCLUSION: It was concluded that the surgical sequence of applying cryotherapy before drainage of SRF can be safely and effectively performed. The sequences CDAE and CDE, when air injection is not required, along with DACE should all be part of the surgical repertoire for the management of retinal detachments.

Vitreous penetration of levofloxacin in the uninflamed phakic human eye.

AIMS: To assess the vitreous penetration of oral levofloxacin (a new fluoroquinolone antibiotic with improved Gram positive activity) in uninflamed phakic eyes. METHODS: 15 patients for macula hole surgery were recruited to the study. 10 received a single 500 mg dose of levofloxacin by mouth preoperatively. Five acted as controls. Serum and undiluted vitreous samples were obtained at surgery and analysed by HPLC. RESULTS: Levofloxacin was detectable 2.5 hours after administration in the vitreous. A peak concentration of 1.6 microg/ml (or mg/l) was measured between 2.5 and 4 hours post-dose. CONCLUSION: Oral levofloxacin reaches the vitreous rapidly in the uninflamed phakic eye. Levels did not reach MIC(90) for the commonest infecting organisms. Nevertheless, levofloxacin would be expected to be active against a higher proportion of infecting organisms than either ciprofloxacin or ofloxacin.

Trypan blue staining of internal limiting membrane and epiretinal membrane during vitrectomy: visual results and histopathological findings.

AIMS: To report on the use of trypan blue (TB) 0.06% for staining the internal limiting membrane (ILM) and epiretinal membrane (ERM) during vitrectomy and report on their histology. METHOD: 14 consecutive patients with idiopathic macular hole or macular pucker (seven patients each) were prospectively recruited for ILM or ERM peel respectively. After pars plana vitrectomy and induction of posterior vitreous detachment, 0.5 ml TB 0.06% in phosphate buffered saline (VisonBlue) was injected over the posterior pole in an air filled eye and left for 2 minutes. The stained tissue was peeled with intraocular forceps. Specimens were evaluated using histochemical and immunohistochemical methods. RESULTS: The average follow up was 4.4 months. Internal limiting membranes and epiretinal membranes were stained satisfactorily in all cases and removed successfully. Eight patients (57%) had improvement of 2 or more Snellen lines. All seven macular holes closed. In the ERM cases, no residual membranes were observed clinically, at the latest follow up. No complications relating to the use of the dye were encountered intraoperatively or postoperatively. Of the 14 procedures, nine (four macular hole and five macular pucker) yielded sufficient tissue for histopathological evaluation. Histological and immunohistological assessment revealed that the morphology of these specimens was similar to that observed in macular hole ILM and macular pucker ERM removed without the aid of dye. CONCLUSION: TB staining facilitated the identification and delineation of ILM and ERM removal during the surgical management of macular holes and macular pucker. The visual outcome of this series and the specimens removed suggest they are no different from those without TB staining. Its use in posterior segment appears to be safe but further studies are required to investigate its long term safety.

Case selection in macular relocation surgery for age related macular degeneration.

BACKGROUND: To date there has been no randomised controlled trial demonstrating the safety and efficacy of macular relocation surgery (MRS) for age related macular degeneration (AMD). Vision can be improved in some patients and made worse in others despite successful surgery or because of complications. PURPOSE: To determine which patients would benefit from MRS. METHODS: Twenty nine patients with exudative AMD took part in a prospective, non-comparative, interventional study. Macular relocation surgery involved phacoemulsification, vitrectomy, 360 degrees retinotomy, excision of choroidal neovascular membrane, and macular relocation using an infusion of 5-fluorouracil and low molecular weight heparin as adjuvant to prevent proliferative vitreoretinopathy. Patients underwent protocol refraction preoperatively and six-monthly postoperatively by designated optometrists. Preoperative fundus fluorescein angiograms were read by masked observers and the lesions were classified according to a set protocol. The main outcome measures were visual improvement, final vision of better than 20/400, reading speed, critical print size. Logistic and multiple stepwise linear regressions were used to identify independent factors which predicted the main outcomes. RESULTS: Preoperative visual acuity (20/120 or worse) and lesion type (predominantly classic or submacular haemorrhage) were significantly associated with visual improvement (coefficient of regression B = 26.8, p<0.001 and B = 14.9 with p = 0.045 respectively). There were no significant independent factors which predicted a final distance logMAR visual acuity of 1.3 (20/400) or any arbitrary definition of blindness. CONCLUSIONS: The study showed that it was possible to select cases that were more likely to experience an improvement in vision following MRS.

Determinants of visual outcome after pars plana vitrectomy for posteriorly dislocated lens fragments in phacoemulsification.

PURPOSE: To evaluate the visual outcome of patients with posteriorly dislocated lens fragments after phacoemulsification managed with pars plana vitrectomy (PPV) and identify risk factors for poor visual outcome. SETTING: Vitreo-Retinal Service, St. Paul Eye Unit, Liverpool, United Kingdom. METHODS: The medical records of all patients who had PPV for posteriorly dislocated lens fragments after phacoemulsification between March 1993 and August 1998 were retrospectively reviewed. Demographics, preexisting eye conditions, details of the previous cataract surgery, findings at presentation, details of the vitreoretinal procedure, final visual acuity, and complications observed during the follow-up were evaluated. Univariate and multiple regression analyses were used to determine the significance of these clinical variables as determinants of poor visual outcome (visual acuity 6/12 or worse). RESULTS: Of the 106 patients identified, 89 had a full set of data and were included in the study. In 79 patients (89%), PPV was performed from 1 to 357 days (median 15 days) after cataract extraction. In 10 patients (11%), PPV was done on the same day as the cataract surgery. Sixty-two patients (69%) had a final visual acuity of 6/12 or better. Preexisting eye disease (P <.01), PPV delayed for more than 4 weeks (P <.03), occurrence of retinal detachment after vitrectomy (P <.01), and the use of ultrasound (US) fragmentation (P <.01) were statistically significantly correlated with a poor visual outcome. CONCLUSIONS: Posterior dislocated lens fragments after phacoemulsification were safely retrieved using PPV. It appears that intervening early (within 4 weeks) and avoiding the use of US fragmentation are associated with a better visual outcome and reduced rate of postoperative complications.