Consultation Section: refractive surgical problem.
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Adult↗
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Surgical technique for anterior segment surgery in pediatric patients using 25-gauge instruments.
Many surgical techniques for the management of vitreous prolapse in the wound, secondary pupillary membrane, and congenital cataract in pediatric patients have been described. We report our experience using 25-gauge instruments and describe intraoperative and postoperative advantages.
Anterior Eye Segment↗
Outbreak of toxic anterior segment syndrome associated with glutaraldehyde after cataract surgery.
PURPOSE: To present clinical findings of a cluster of cases of toxic anterior segment syndrome (TASS) after uneventful phacoemulsification cataract surgery. SETTING: Department of Ophthalmology, Akdeniz University, Antalya, Turkey. METHODS: Six eyes of 6 patients developed TASS after uneventful phacoemulsification cataract surgery with implantation of a 3-piece acrylic IOL performed by 2 ophthalmologists on the same day. Clinical findings included corneal edema, Descemet's membrane folds, anterior chamber reaction, fibrin formation, and irregular, dilated, and unreactive pupils. RESULTS: Glutaraldehyde 2% solution was used inadvertently by the operating room staff who cleaned and sterilized reusable ocular instruments before autoclaving. None of the affected corneas improved. Additional surgical procedures were required and included penetrating keratoplasty, trabeculectomy, and glaucoma tube implantation. CONCLUSIONS: Glutaraldehyde in concentrations generally used for cold sterilization is highly toxic to the corneal endothelium. The operating room staff involved in sterilizing instruments should be well educated about and careful to follow the protocols to properly clean and sterilize reusable ocular instruments.
Aged↗
Pupillography refines the diagnosis of diabetic autonomic neuropathy.
Although diabetic autonomic neuropathy involves most organs, diagnosis is largely based on cardiovascular tests. Light reflex pupillography (LRP) non-invasively evaluates pupillary autonomic function. We tested whether LRP demonstrates autonomic pupillary dysfunction in diabetics independently from cardiac autonomic neuropathy (CAN) or peripheral neuropathy (PN). In 36 type-II diabetics (39-84 years) and 36 controls (35-78 years), we performed LRP. We determined diameter (PD), early and late re-dilation velocities (DV) as sympathetic parameters and reflex amplitude (RA) and constriction velocity (CV) as parasympathetic pupillary indices. We assessed the frequency of CAN using heart rate variability tests and evaluated the frequency of PN using neurological examination, nerve conduction studies, thermal and vibratory threshold determination. Twenty-eight (77.8%) patients had abnormal pupillography results, but only 20 patients (56%) had signs of PN or CAN. In nine patients with PN, only pupillography identified autonomic neuropathy. Four patients had pupillary dysfunction but no CAN or PN. In comparison to controls, patients had reduced PD, late DV, RA and CV indicating sympathetic and parasympathetic dysfunction. The incidence and severity of pupillary abnormalities did not differ between patients with and without CAN or PN. LRP demonstrates sympathetic and parasympathetic pupillary dysfunction independently from PN or CAN and thus refines the diagnosis of autonomic neuropathy in type-II diabetics.
Adult↗
Acute ophthalmoplegia with pupillary areflexia associated with anti-GQ1b antibody.
Raised anti-GQ1b antibody is associated with Miller Fisher syndrome, Guillain-Barre syndrome (GBS) with ophthalmoplegia, Bickerstaff's brain stem encephalitis, acute ophthalmoparesis without ataxia and ataxic GBS without opthalmoplegia. We report a rare case of acute ophthalmoplegia associated with anti-GQ1b antibody that also had pupillary areflexia. A 35-year-old Chinese lady presented with external ophthalmoplegia, pupillary areflexia and no other abnormalities of cranial nerves, muscle tone, deep tendon reflexes, limb power or cerebellar dysfunction. Anti-GQ1b IgG antibody titre was significantly elevated, while neuroimaging of brain and orbital structures, nerve conduction study and cerebral spinal fluid examination were normal. Pupillary areflexia should be recognized as another feature that may be present in conditions associated with raised anti-GQ1b antibody.
Acute Disease↗
Prognostic predictors of thalamic hemorrhage.
BACKGROUND AND OBJECTIVE: There is no study evaluating the role of clinical, evoked potential and radiological parameters in the prognosis of thalamic hemorrhage employing multivariate logistic regression analysis, thus we aimed to evaluate the role of these parameters in predicting the 3 month outcome following thalamic hemorrhage. SETTING: Tertiary care referral teaching hospital. METHODS: Fifty-three patients with CT proven thalamic hematoma were evaluated. Conscious level was assessed using the Glasgow Coma Score (GCS), severity of stroke by the Canadian Neurological Scale (CNS), while muscle tone, tendon reflexes and power were also recorded. Hematoma size and type, and evidence of ventricular extension were obtained from the CT scan. Hematomas were classified as (A) thalamic with postero-lateral extension or (B) thalamic without postero-lateral extension. Central motor conduction to upper limb and median somatosensory evoked potentials (SEP) were recorded. Outcome was defined at 3 months on the basis of the Barthel Index (BI) with good being a BI of 12 or greater and poor a BI of less than 12. Best predictors of outcome were evaluated by single variable logistic regression analysis followed by multivariate logistic regression. RESULTS: Age ranged between 35 and 85 years; 18 were women. Mean GCS was 10.4 and CNS was 3.9. Thirty-one patients had type A hematomas and 22 type B. The hematoma was small in 5, medium in 35 and large in 13 patients. Ventricular extension was present in 34 patients. Motor evoked potentials were unrecordable in 36 and central motor conduction time was prolonged in 8 patients. Median SEP was unrecordable in 37 and N9-N20 conduction time was prolonged in 2 patients. At 3 months, 8 patients had died, 24 had good and 21 had poor outcome. On univariate logistic regression analysis diabetes mellitus, GCS, pupillary asymmetry, CNS score, type and size of hematoma and motor and somatosensory evoked potentials were significant in relation to outcome. On multivariate logistic regression analysis, the best predictors of outcome at 3 months were the type of hematoma and CNS score. CONCLUSION: CNS score and CT appearance of hematoma are the best predictors of 3 month outcome following thalamic hemorrhage. The proposed model for outcome assessment is simple and easy to apply and could have wide clinical application.
Adult↗
Retinoblastoma and simulating lesions: role of imaging.
Although the diagnosis of retinoblastoma (Rb) is made primarily by means of clinical examination, CT and MR imaging are helpful to confirm the diagnosis, determine the extent of the intraocular tumor, and exclude extraocular or intracranial involvement. They are also valuable in differentiating Rb from lesions that simulate Rb.
Diagnosis, Differential↗
Comparison of various pupil dilatation methods for phacoemulsification in eyes with a small pupil secondary to pseudoexfoliation.
PURPOSE: To compare 4 methods for intraoperative pupil dilatation in eyes with pseudoexfoliation syndrome and insufficient pupil size during phacoemulsification. DESIGN: Prospective, randomized, comparative, interventional case series. PARTICIPANTS: Forty eyes of 40 patients with pseudoexfoliation and maximally dilated pupil size smaller than 3.5 mm. INTERVENTION: Mechanical pupil dilatation with iris-retractor hooks (group I), polymethyl methacrylate (PMMA) pupil dilator-ring (Morcher, Stuttgart, Germany) (group II), Beehler pupil dilator (group III), and bimanual stretching (group IV). MAIN OUTCOME MEASURES: Performance (pupil size achieved), complications, and added surgical time. RESULTS: The mean pupil sizes achieved with the PMMA pupil-dilator ring, Beehler pupil dilator, and bimanual stretching were 5.9+/-0.6 mm, 5.5+/-0.8 mm, and 4.9+/-0.7 mm, respectively. A square-shaped pupil was achieved with iris-retractor hooks, and the mean size of the largest circle that can fit in this square was 5.6+/-0.6 mm. There were no statistically significant differences in the postdilatation pupil sizes between the 4 study groups (P>0.05). Apart from self-limited intraoperative hemorrhage from pupil margin, iris sphincter rupture was the only observed complication related to mechanical pupil dilatation. This occurred in 4 eyes in groups I and III, 3 eyes in group IV, and 1 eye in group II (P>0.05). The mean added surgical time for placement of iris-retractor hooks and for implantation of a PMMA pupil-dilator ring was 297+/-51 and 176+/-54 seconds, respectively. The additional time required for pupil dilatation with the Beehler pupil dilator and bimanual stretching was 65+/-8 and 55+/-10 seconds, respectively. The time needed for pupil dilatation in groups I and II is significantly longer than that in groups III and IV (P<0.001). CONCLUSIONS: All 4 methods used in this study were effective procedures for the mechanical dilatation of small pupils secondary to pseudoexfoliation syndrome. Iris-retractor hooks and the PMMA pupil-dilator ring are the most time-consuming techniques but have the advantage of a stable pupil size throughout the surgery. The PMMA pupil-dilator ring causes the least iris trauma. The Beehler pupil dilator and bimanual stretching technique were the least time-consuming methods for mechanical pupil dilatation.
Aged↗
Pupil dilatation methods.
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Capsulorhexis↗
Bilateral cataract and corectopia after laser eyebrow [corrected] epilation.
PURPOSE: To report a patient with bilateral cataract and corectopia after laser epilation of the eyebrows. DESIGN: Single interventional case report. METHODS: A 27-year-old woman with a history of bilateral eyebrow laser epilation complained of oval pupils, reduced visual acuity, and photophobia immediately after laser epilation of both upper-eyelid regions. The following examinations were performed: visual acuity, slit-lamp examination, pupillary light reflex, perimetry, tonometry, gonioscopy, and funduscopy with contact lenses. The follow-up period was 9 months. MAIN OUTCOME MEASURES: Visual acuity, intraocular pressure, inflammation, and pupillary distortion. RESULTS: Her best baseline visual acuities were 20/25 (right) and 20/40 (left). Examination showed bilateral corectopia with superior iris atrophy, iris stroma clump at the pupillary margin, and pigment residues in the inferior chamber. A cataract developed in the anterior subcapsular regions of the lenses. CONCLUSIONS: Laser epilation at the eyelid may result in irreversible cataract and iris atrophy.
Adult↗
Origin of the relative afferent pupillary defect in optic tract lesions.
OBJECTIVE: To determine the percent decussation of pupil input fibers in humans and to explain the size and range of the log unit relative afferent pupillary defect (RAPD) in patients with optic tract lesions. DESIGN: Experimental study. PARTICIPANTS AND CONTROLS: Five patients with a unilateral optic tract lesion. METHODS: The pupil response from light stimulation of the nasal hemifield, temporal hemifield, and full field of each eye of 5 patients with a unilateral optic tract lesion was recorded using computerized binocular infrared pupillography. Six stimulus light intensities, separated by 0.5-log unit steps, were used; 12 stimulus repetitions were given for each stimulus condition. MAIN OUTCOME MEASURES: For each stimulus condition, the pupil response of each eye was characterized by plotting the mean pupil contraction amplitude as a function of stimulus light intensity. The percentage of decussating afferent pupillomotor input fibers was calculated from the ratio of the maximal pupil contractions elicited from each eye. The RAPD was determined pupillographically from full-field stimulation to each eye. RESULTS: In all patients, the pupil response from the functioning temporal hemifield ipsilateral to the tract lesion was greater than that from the functioning contralateral nasal hemifield. This temporal-nasal asymmetry increased with increasing stimulus intensity and was similar in hemifield and full-field stimuli, eventually saturating at maximal light intensity. The log unit RAPD did not correlate with the estimated percentage of decussating pupil fibers, which ranged from 54% to 67%. CONCLUSIONS: In patients with a unilateral optic tract lesion, the pupillary responses from full-field stimulation to each eye are the same as comparing the functioning temporal field with the functioning nasal field. The percentage of decussating fibers is reflected in the ratio of the maximal pupil contraction amplitudes resulting from stimulus input between the two eyes. The RAPD that occurs in this setting reflects the difference in light sensitivity between the intact temporal and nasal hemifields. Its magnitude does not correlate with the difference in the number of crossed and uncrossed axons, but its sidedness contralateral to the side of the optic tract lesion is consistent with the greater percentage of decussating pupillomotor input.
Adolescent↗
Tubercular endophthalmitis simulating retinoblastoma.
PURPOSE: To report a case of tubercular endophthalmitis simulating retinoblastoma. METHODS: Case report. An 8-year-old female presented with a history of complete loss of vision and a white pupillary reflex in the left eye of 3 month's duration. RESULTS: Retinoblastoma could not be excluded on the basis of clinical examination and relevant investigational studies. In the left eye, a computed tomography (CT) scan demonstrated a large vitreous mass with foci of calcification. Enucleation in the left eye was performed, and histopathological examination revealed a chronic granulomatous endophthalmitis and acid-fast bacilli consistent with tubercular pathology. CONCLUSION: This case illustrates that tubercular endophthalmitis with leukocoria and a vitreous mass containing focal calcification may simulate retinoblastoma.
Blindness↗
Anterior ischemic optic neuropathy after a trans-Atlantic airplane journey.
PURPOSE: To report a case of anterior ischemic optic neuropathy after a trans-Atlantic airplane journey. DESIGN: An observational case report. METHODS: A 48-year-old healthy man presented with severe visual loss in his left eye within 12 hours after a 15-hour-long trans-Atlantic airplane flight. The patient underwent slit-lamp examination, funduscopy, fluorescein angiography, automated perimetry, and various blood examinations. RESULTS: Visual acuity was LE: 20/30, and a mild left eye relative afferent pupillary defect was noted. Funduscopic evaluation revealed an edematous optic disk in the left eye with a para-diskal retinal hemorrhage. Fluorescein angiography revealed a leaking optic disk, and perimetry showed an inferior hemi-field scotoma. Anterior ischemic optic neuropathy was diagnosed. CONCLUSION: Prolonged airplane travel may compromise vision either by a thromboembolic mechanism caused by prolonged immobilization or by a vasospasm mechanism induced by the low oxygen pressure during the flight.
Aerospace Medicine↗
Sneeze-induced visual and ocular motor dysfunction.
PURPOSE: The purpose of this report is to describe two neuroophthalmic complications that are related by their temporal association with a sneeze. DESIGN: We describe observational case reports of two patients. METHODS: Both patients were examined, and their conditions were diagnosed and treated according to standard indications for each neuroophthalmic condition. RESULTS: The first case describes a patient who had previously undergone intracranial surgery, including removal of the clivus and later developed a trochlear nerve paresis after a sneeze. The second case describes a patient who repeatedly demonstrates transient decreased perfusion to his right central retinal artery and an associated afferent papillary defect after sneezing. CONCLUSION: The mechanical and hemodynamic forces involved in sneezing are formidable and may cause permanent cranial neuropathy or temporarily alter ocular blood flow in certain patients.
Adult↗
The detection of a relative afferent pupillary defect.
PURPOSE: To describe a simple technique that detects a subtle relative afferent pupillary defect. DESIGN: Observational report. METHODS: With the patient seated at a slit lamp and the slit illumination turned off, a transilluminator light is swung back and forth between the eyes. The examiner observes the direct pupil light response and the consensual light response under slit-lamp magnification. CONCLUSION: Using slit-lamp magnification, the examiner may observe small amplitudes of pupillary movement in the evaluation of a relative afferent pupillary defect.
Diagnostic Techniques, Ophthalmological↗
Management of pupillary block glaucoma in phakic patients after vitrectomy with silicone oil injection.
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Glaucoma↗
Progressive outer retinal necrosis in immunocompetent patients treated initially for optic neuropathy with systemic corticosteroids.
PURPOSE: To report two cases of progressive outer retinal necrosis occurring in immunocompetent individuals after treatment with corticosteroids for presumed optic neuropathy. DESIGN: Observational case report. SETTING: University-based tertiary eye hospital. METHODS: Retrospective review of existing clinical records. RESULTS: Two patients were treated empirically with systemic corticosteroids for suspected inflammatory papillopathy. Subsequently, both were diagnosed with necrotizing herpetic retinitis with features of progressive outer retinal necrosis. Anterior chamber paracentesis confirmed varicella-zoster infection. Both patients were human immunodeficiency virus negative; one patient with rheumatoid arthritis was taking etanercept. Both became completely blind in one eye despite intensive treatment with antiviral medication intravenously and intravitreally. CONCLUSIONS: Progressive outer retinal necrosis is not confined to patients with underlying severe immunodeficiency, such as acquired immune deficiency syndrome. Initial treatment of acute, unexplained vision loss with systemic corticosteroids may lead to catastrophic visual loss in patients with evolving necrotizing herpetic retinopathy.
Acyclovir↗
Unilateral leukocoria in off axis flash photographs of normal eyes.
PURPOSE: To describe an optical phenomenon producing leukocoria in off axis flash photographs of children who have a normal ophthalmic examination. DESIGN: Observational case series. METHODS: Description of three otherwise well children who presented to a pediatric ophthalmologist with unilateral leukocoria seen in flash photographs. The children underwent a full ophthalmic examination, including dilated fundus examination. RESULTS: All ophthalmic examinations were normal. The photographs were all found to be approximately 15 degrees off axis with the leukocoria seen in the eyes where the flash illuminated the nasal retina. CONCLUSIONS: Leukocoria can be seen in normal eyes when the child is not fixing directly on the camera. That is due to reflection off the optic nerve head.
Artifacts↗