Ocular manifestations and the clinical course of carotid cavernous sinus fistulas in Asian patients.

PURPOSE: To study the clinical course with regard to both the angiographic and visual outcomes of carotid cavernous fistulas (CCFs). BACKGROUND: Carotid cavernous sinus fistulas (CCFs) are conditions which often present with ocular signs and symptoms. The clinical presentation of CCFs is varied according to the anatomy, haemodynamics and size of the CCF. CCFs causing significant symptoms or vision loss should be treated with embolization. METHODS: This is a retrospective review of the medical records of all CCF cases seen in the Singapore National Eye Centre from September 2002 to December 2011. RESULTS: 45 patients who had confirmed CCF on conventional cerebral angiography were included. Anterior draining CCFs presented with orbital congestion while posterior draining CCFs presented with pain, diplopia and cranial nerve palsies. Mild residual symptoms were still present in 85% of treated direct CCFs despite complete angiographic closure however 52% of treated dural CCFs had complete resolution of symptoms despite only half of those achieving angiographic closure. Treated and untreated dural CCFs had similar outcomes (87% versus 76% recovered or improved (p > 0.05)). Poor outcomes can result from residual diplopia or vision loss from complications of the CCF itself (e.g. compressive optic neuropathy, glaucoma, retinopathy) or complications from CCF embolization treatment (e.g. central retinal artery occlusion). CONCLUSION: Presenting symptoms and signs are related to the angiographic drainage of CCFs. Angiographic outcomes after embolization treatment may not always correlate with clinical outcomes.

Outcomes of Repeat Anterior Lamellar Keratoplasty.

PURPOSE: To describe the outcomes and complications of repeat anterior lamellar keratoplasty (ALK) after a failed primary ALK. METHODS: This was a retrospective case series. Twenty-three eyes of 22 patients who underwent repeat ALK for optical indications from January 1, 1991, to December 31, 2017, were included. Clinical data were recorded from the Singapore Corneal Transplant Study database. Outcome measures were graft survival, best-corrected visual acuity (BCVA), and complications. RESULTS: Of the 780 cases of ALK performed for optical indications during the study period, 23 cases (2.9%) underwent repeat ALK. Primary ALK comprised of 16 deep ALK and 7 automated lamellar therapeutic keratoplasty cases. After repeat ALK, 21 eyes had further dissection down to the descemetic or predescemetic plane, whereas 2 eyes had graft exchange for failed automated lamellar therapeutic keratoplasty. The graft survival of repeat ALK was 93.2%, 86.1%, and 78.3% at 1, 3, and 5 years, respectively. There were 4 cases of graft failure with a mean time to failure of 2.0 ± 1.7 years. After the repeat ALK procedure, 63.6% and 66.7% of eyes achieved a BCVA of LogMAR +0.3 (20/40) or better at 1 and 2 years, respectively. Five eyes (17.4%) had an intraoperative microperforation. CONCLUSIONS: In the case of a failed ALK graft for a range of optical indications, a repeat ALK procedure offers a viable and safe surgical option with good long-term graft survival and visual outcomes, while avoiding the various disadvantages of performing penetrating keratoplasty, especially the risk of allograft endothelial rejection.

Comparison of a commercial spectral-domain OCT and swept-source OCT based on an angiography scan for measuring circumpapillary retinal nerve fibre layer thickness.

BACKGROUND/AIMS: To assess the agreement in measuring retinal nerve fibre layer (RNFL) thickness between spectral-domain (SD; Cirrus HD, Carl Zeiss Meditec, USA) optical coherence tomography (OCT) and swept-source (SS; Plex Elite 9000, Carl Zeiss Meditec) OCT using an OCT angiography (OCTA) scanning protocol. METHODS: 57 participants (12 glaucomatous, 8 ocular hypertensive and 74 normal eyes) were scanned with two OCT instruments by a single experienced operator on the same day. Circumpapillary RNFL thicknesses were automatically segmented for SD-OCT and manually segmented for SS-OCTA scans. Agreement of global RNFL thickness, as well as average thickness in four quadrants was assessed using intraclass correlation coefficients (ICCs). RESULTS: There was excellent agreement in the inferior and superior quadrants and the global (all ICC >0.90), followed by good agreement in the temporal (ICC=0.79) and nasal (ICC=0.73) quadrants. The ICC values were similar in the subgroups except within the ocular hypertension group, where the nasal quadrant was less agreeable (ICC=0.31). SS-OCTA-derived RNFL thickness was on average 3 µm thicker than SD-OCT, particularly in the nasal (69.7±11.5 µm vs 66.3±9.3 µm; p<0.001) and temporal (75.6±13.7 µm vs 67.9±12.3 µm; p<0.001) quadrants. CONCLUSIONS: RNFL measurements taken with SS-OCTA have good-to-excellent agreement with SD-OCT, which suggests that the RNFL thickness can be sufficiently extracted from wide-field OCTA scans.

Bilateral uveitis secondary to bisphosphonate therapy.

BACKGROUND/AIMS: To highlight the potential ocular side effects of bisphosphonate therapy and the importance of a proper drug history in patients who present with uveitis. METHODS: We report 2 cases of bilateral uveitis secondary to bisphosphonate therapy. Both patients were on nitrogen-containing bisphosphonates when they developed symptoms of bilateral anterior uveitis. A uveitis screen done in both cases was normal. RESULTS: The uveitis in both patients resolved after discontinuation of the bisphosphonates, and there has been no recurrence of symptoms during the duration of the follow-up of 6 and 5 months, respectively. CONCLUSION: All patients receiving bisphosphonates who develop ocular signs and symptoms should be referred promptly to an ophthalmologist. The offending drug should be discontinued once the diagnosis is made, in order to prevent involvement of the contralateral eye and recurrent or chronic ocular inflammation. Patients who are susceptible to the nitrogen-containing bisphosphonates should be switched to the non-nitrogen-containing bisphosphonates.

Updates on the Surgical Management of Pediatric Glaucoma.

Childhood glaucoma is known to be one of the most challenging conditions to manage. Surgical management is more complicated than in adults because of differences in anatomy from adults along with variations in anatomy caused by congenital and developmental anomalies, wide-ranging pathogenetic mechanisms, a more aggressive healing response, and a less predictable postoperative course. Challenges in postoperative examination and management in less cooperative children and the longer life expectancies preempting the need for future surgeries and reinterventions are also contributing factors. Angle surgery is usually the first-line treatment in the surgical management of primary congenital glaucoma because it has a relatively good success rate with a low complication rate. After failed angle surgery or in cases of secondary pediatric glaucoma, options such as trabeculectomy, glaucoma drainage devices, or cyclodestructive procedures can be considered, depending on several factors such as the type of glaucoma, age of the patient, and the severity and prognosis of the disease. Various combinations of these techniques have also been studied, in particular combined trabeculotomy-trabeculectomy, which has been shown to be successful in patients with moderate-to-advanced disease. Newer nonpenetrating techniques, such as viscocanalostomy and deep sclerectomy, have been reported in some studies with variable results. Further studies are needed to evaluate these newer surgical techniques, including the use of modern minimally invasive glaucoma surgeries, in this special and diverse group of young patients.

Syphilitic uveitis in a Singaporean population.

PURPOSE: To report the presentations of syphilitic uveitides in Singapore. METHODS: Retrospective noncomparative observational case series of 18 eyes from 12 patients with ocular syphilis between 2004 and 2009. RESULTS: Patients were mainly male (91.7%). Median age was 49.5 (24-84) years. Initial visual acuity varied from 6/6 to counting fingers (CF) and was ≥6/12 in 7 eyes (38.8%). Blurring of vision (n = 11, 61.1%) was the most common presenting complaint. Anterior uveitis and panuveitis were both most common (n = 6, 33.3%). Treponemal and nontreponemal serologies were positive in 12 (100.0%) and 10 (83.3%) patients, respectively. Patients were treated systematically with penicillin therapy by infectious disease physicians. CONCLUSIONS: Ocular syphilis is seeing a worldwide resurgence. Although anterior uveitis and panuveitis were most common in this study, there was a large spectrum of ocular manifestations. Syphilitic uveitides can potentially cause severe loss of vision but are effectively treated by an appropriate regimen of penicillin.

Imaging late capsular bag distension syndrome: an anterior segment optical coherence tomography study.

BACKGROUND: Anterior segment optical coherence tomography (ASOCT) was used to categorize and provide insights into the etiology of capsular bag distension syndrome (CBDS). METHODS: A prospective review was undertaken of 10 cases who presented with signs of late CBDS 5-11 years after uneventful phacoemulsification with in-the-bag posterior chamber intraocular lens implantation. RESULTS: All 10 patients presented with a milky collection within the distended capsular bag without raised intraocular pressure or a shallow anterior chamber. ASOCT was used to confirm the diagnosis in all cases, and a hyperintense signal was seen in the space between the posterior chamber intraocular lens and the posteriorly bowed posterior capsule. The continuous curvilinear capsulorhexis was measured to be between 3.18 mm and 4.70 mm. Three cases had uncorrected visual acuity better than 6/12. Uncomplicated Neodymium-doped Yttrium Aluminium Garnet (Nd:YAG) posterior capsulotomy was performed in eight patients, with no resulting change in the intraocular lens position (measured by ASOCT) or subjective refraction. CONCLUSION: Our study showed that ASOCT is a useful modality to differentiate this condition clearly from posterior chamber intraocular lens opacification and to investigate its causation. Nd:YAG posterior capsulotomy proved to be a safe and successful treatment for late CBDS with no change in biometric or refractive parameters.

Postoperative complications after glaucoma surgery for primary angle-closure glaucoma vs primary open-angle glaucoma.

OBJECTIVES: To investigate the incidence of postoperative complications arising in the first year after trabeculectomy and combined phacotrabeculectomy in eyes with primary angle-closure glaucoma (PACG) vs those with primary open-angle glaucoma (POAG). METHODS: This was a retrospective study of all glaucoma operations done at a Singapore hospital from January 9, 2001, to December 30, 2004. The types of glaucoma surgery included trabeculectomy and phacotrabeculectomy, all with mitomycin C or fluorouracil. The incidences of postoperative complications and reoperations were analyzed. For those who underwent bilateral or repeated operations, only the first operated eye of each subject was included. RESULTS: A total of 446 subjects with PACG (112 who underwent trabeculectomy and 334 who underwent phacotrabeculectomy) and 816 subjects with POAG (208 who underwent trabeculectomy and 608 who underwent phacotrabeculectomy) were analyzed. Postoperative complications occurred in 65 of 1262 eyes (5.2%) overall, with 27 eyes (8.4%) in the trabeculectomy group (PACG: 8.0%; 95% confidence interval [CI], 4.3%-14.6%; POAG: 8.7%; 95% CI, 5.5%-13.3%; P > .99) and 38 eyes (4.0%) in the phacotrabeculectomy group (PACG: 5.1%; 95% CI, 3.2%-8.0%; POAG: 3.5%; 95% CI, 2.3%-5.2%; P = .31). The rate of complications was significantly higher in the trabeculectomy group than the phacotrabeculectomy group overall (P = .003), but there was no significant difference between the POAG and PACG groups overall (POAG: 4.8%; 95% CI, 3.5%-6.5%; PACG: 5.8%; 95% CI, 4.0%-8.4%; P = .53). The commonest complication found was hypotony with overfiltration (23 cases [1.8%]), followed by bleb leak (11 cases [0.9%]). There was no significant difference in incidence of reoperations between POAG (2.7%; 95% CI, 1.8%-4.1%) and PACG (4.0%; 95% CI, 2.6%-6.3%) (P = .27). CONCLUSION: The incidences of postoperative complications and reoperations in the first year after glaucoma surgery were similar for PACG and POAG.

Intracameral fibrin tissue sealant as an adjunct in tectonic lamellar keratoplasty for large corneal perforations.

PURPOSE: To report a technique of intracameral injection of Tisseel fibrin sealant as an adjunct in the performance of tectonic deep anterior lamellar keratoplasty in cases with preexisting or intraoperative macroperforation. METHODS: Patients with corneal perforations up to 4 mm in greatest dimension first had the defect sealed externally with cyanoacrylate adhesive or fibrin sealant. An air bubble was injected into the anterior chamber (AC), followed by intracameral Tisseel fibrin sealant. This was injected via a 21-G cannula or needle, introduced into the AC from the limbus, with the tip positioned just under the perforation. Fibrin sealant was injected to completely cover the perforation site. Deep anterior lamellar keratoplasty then proceeded with a manual technique without chamber loss. Postoperatively, slit-lamp examination to assess resolution of fibrin sealant and graft status was performed, and visual acuities and intraocular pressures were recorded. RESULTS: Two patients with preexisting corneal perforations and 1 patient with an intraoperative perforation were included. In all patients, lamellar dissection proceeded uneventfully after intracameral fibrin injection. Fibrin sealant in the AC spontaneously resorbed by the second postoperative week. There were no postoperative intraocular pressure spikes and no cases of severe anterior uveitis. All grafts were clear at last follow-up with no evidence of endothelial decompensation. CONCLUSIONS: Intracameral fibrin sealant injection seems to be a safe adjunct to allow completion of deep anterior lamellar keratoplasty in cases with corneal perforation with the aim of avoiding higher risk penetrating keratoplasty. Cases were characterized by a lack of complications postoperatively, and no cases of persistent double AC were encountered.