Assessment of adequate removal of ophthalmic viscoelastic device with irrigation/aspiration by quantifying intraocular lens 'Judders'.

BACKGROUND: To assess the efficacy of 'Judders' as a technique reflecting adequacy of removal of ophthalmic viscoelastic device in cataract surgery. DESIGN: Prospective, consecutive, single surgeon study. PARTICIPANTS: Cohort of 223 patients undergoing phacoemulsification. METHODS: 'Judders' are periodic, abrupt, horizontal displacements of the intraocular lens causing balanced salt solution to displace retropseudophakic ophthalmic viscoelastic device. The number of 'Judders' was correlated with axial length, anterior chamber depth, and preoperative and postoperative intraocular pressure. MAIN OUTCOME MEASURES: Number of 'Judders', axial length, anterior chamber depth, day 1 postoperative intraocular pressure. RESULTS: The mean number of 'Judders' was 3.2. There was a positive association between the number of 'Judders' and axial length, but not between number of 'Judders' and anterior chamber depth. Mean preoperative intraocular pressure was 14.5 mmHg; mean day 1 postoperative intraocular pressure was 15.6 mmHg. Intraocular pressure rose in 47% of cases. In six cases (5%), intraocular pressure rose greater than 10 mmHg (range 11-23 mmHg) from the preoperative level. CONCLUSIONS: Aspirating ophthalmic viscoelastic device with the irrigation/aspiration tip posterior to the intraocular lens may be associated with the risk of a posterior capsule tear. Maintaining the irrigation/aspiration tip anterior to the intraocular lens may offer a significant safety advantage. The number of 'Judders', usually 3-4, appears to be a safe and reliable end-point of complete ophthalmic viscoelastic device removal. There were significantly more 'Judders' in eyes with a longer axial length. The safety and efficacy of 'Judders' are reflected by the stable mean postoperative intraocular pressure.

Neuroradiological Endovascular Intervention for Diplopia in a Case of Aneurysmal Aberrant Regeneration of the Third Nerve.

Aberrant regeneration of the third nerve occurs as a result of synkinetic 'miswiring' of the third nerve following its injury, such as in third cranial nerve palsy due to tumor, trauma, or aneurysm. The case presented is an elderly woman with new vertical diplopia, which led to a diagnosis of a third cranial nerve palsy, thought to be caused by a 5 mm blister aneurysm of the posterior communicating artery. However, neuro-ophthalmological evaluation diagnosed aberrant regeneration of the third nerve, with the cause of her new vertical diplopia being an ipsilateral fourth nerve palsy. The patient underwent endovascular treatment of her aneurysm using stent-assisted coiling. This procedure was complicated by an episode of air embolism, from which the patient made a good recovery. This patient's presentation demonstrates that the cause of any diplopia must be established, and presents a novel, semi-schematic illustration of aberrant regeneration of the third nerve that should aid clinicians in its recognition.

Granulicatella adiacens subacute bacterial endocarditis as the underlying cause of type II mixed cryoglobulinaemia.

A 57-year-old man with type II mixed cryoglobulinaemia presented to the emergency department with a history of worsening lethargy, malaise and non-drenching night sweats in a relapsing-remitting pattern. He was diagnosed with type II mixed cryoglobulinaemia 7 months ago following episodes of fever, night sweats, lethargy and malaise associated with a non-blanching, purpuric, raised erythematous rash that responded partially to immunosuppressive therapy and short courses of oral antibiotics. A single blood culture then yielded Granulicatella adiacens which was reported as a possible contaminant and therefore, not pursued. Despite numerous other investigations, the underlying cause of his type II cryoglobulinaemia remained undetermined. On his current presentation, the physical examination revealed signs of infective endocarditis. Two further blood cultures grew G. adiacens. The diagnosis of infective endocarditis was established on a transoesophageal echocardiography, and the subsequent antibiotic and surgical therapy resulted in complete remission of his type II mixed cryoglobulinaemia.

Acute intraoperative rock-hard eye syndrome and its management.

PURPOSE: To evaluate the use of pars plana needle aspiration of retrolenticular fluid in the immediate management of an acute intraoperative rock-hard eye syndrome (AIRES). SETTING: Private practice, Sydney, Australia. DESIGN: Retrospective case series. METHODS: Data over an 18-month period were collected to evaluate efficacy, complications, and visual outcomes in patients who had pars plana needle aspiration for management of AIRES, which is an acute intraoperative shallowing of the anterior chamber and a marked increase in intraocular pressure (IOP) during phacoemulsification cataract surgery but without evidence of a choroidal hemorrhage. Preoperative and postoperative (1 day, 1 week, and 1 month) data were evaluated. Resolution of AIRES and postoperative posterior segment status, IOP, and corrected distance visual acuity (CDVA) were the main outcome measures. RESULTS: Acute intraoperative rock-hard eye syndrome occurred in 6 (1.45%) of 413 surgeries. All 6 patients were women with a mean age of 81 years. Four patients had dense nuclear cataracts. In each case, the anterior chamber depth and IOP normalized immediately after pars plana needle aspiration and the procedure concluded uneventfully. Mild vitreous hemorrhage was observed in 1 patient postoperatively. At 1 month, the IOP was normal in 5 of 6 cases, while the CDVA was 20/12 in 5 of 6 cases. CONCLUSION: Although the etiology of AIRES is iatrogenic, immediate resolution was achieved uneventfully with pars plana needle aspiration, which appears to be a safe management technique with satisfactory outcomes.

Technique to exclude temporal lash incursion in phacoemulsification surgery.

UNLABELLED: We describe the use of a Steri-Strip to exclude lashes in cataract surgery cases in which the lashes impinge on the operative field. The technique has been used in 25 cases and achieved uniformly successful lash exclusion. In 6 cases, the strip became partially dislodged and required repositioning intraoperatively, after which it achieved complete lash exclusion. No complications have been observed. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.