Ankoor S. Shah

Cataract surgery and diabetes.

Purpose of review Recent studies have focused on interventions to minimize progression of retinal disease in diabetic patients undergoing cataract surgery. Here, we review the evidence for progression of diabetic retinal disease with cataract surgery and critically analyze the interventions proposed to minimize it. Recent findings Peri-operative intravitreal bevacizumab, sub-Tenons triamcinolone, and panretinal photocoagulation (PRP) after cataract surgery (instead of before) have been examined as ways to improve cataract surgery results in diabetic patients. The bevacizumab and triamcinolone results are promising, but the inclusion criteria are variable, the sample sizes are small, and the follow-up is short. Postsurgery PRP shows improved cataract surgery results in diabetics with more severe retinopathy up to 1 year after surgery. Summary Recent studies do not support the generalized conclusion that phacoemusification surgery causes progression of retinopathy and macular edema in all diabetic patients. In certain populations of diabetic patients undergoing cataract surgery, peri-operative triamcinolone and bevacizumab may blunt the progression of diabetic macular edema and diabetic retinopathy. The optimal timing of PRP in relation to cataract surgery in patients with more severe retinopathy warrants further evaluation.

Automated detection of ocular alignment with binocular retinal birefringence scanning

We previously developed a retinal birefingence scanning (RBS) device to detect eye fixation. The purpose of this study was to determine whether a new binocular RBS (BRBS) instrument can detect simultaneous fixation of both eyes. Control (nonmyopic and myopic) and strabismic subjects were studied by use of BRBS at a fixation distance of 45 cm. Binocularity (the percentage of measurements with bilateral fixation) was determined from the BRBS output. All nonstrabismic subjects with good quality signals had binocularity >75%. Binocularity averaged 5% in four subjects with strabismus (range of 0-20%). BRBS may potentially be used to screen individuals for abnormal eye alignment.

Diffusion-weighted magnetic resonance imaging of bilateral simultaneous optic nerve infarctions

AN 85-YEAR-OLD MAN presentedwithcomplete loss of vision. Duringtheweekprior topresentation,hereportedgraduallyprogressiveblurred anddarkvisioninbotheyeswithdramaticworseningonthedayofpresentation.Hehadnoothersymptoms,includingheadache.Hismedicalhistory was significant for hypertension and peripheral vascular disease. On examination, his blood pressure was elevated. There was no cranial artery tenderness. He was alert withintactlanguageandmemory.Visual acuity was light perception OU. Both pupils were 4 mm and nonreactive to light. Eye movements were normal,andcornealreflexeswereintactandsymmetric.Funduscopicexamination showed bilateral optic nerve head edema with right optic nervesectoralpallorandaleftmacularinfarction(Figure,AandB).The remainderoftheneurologicalexamination was normal. Magnetic resonanceimagingshowedrestricteddiffusion (Figure, C and D) with a reduced apparent diffusion coefficient signal (not shown) within the leftintraorbitalopticnerveandatthe right anterior optic nerve. The platelet count was 1134/µL, the erythrocytesedimentationratewas40mm/h, and the C-reactive protein level was 17.7 mg/L (to convert to nanomoles per liter, multiply by 9.524). COMMENT

Predictors and outcomes of ocular hypertension after open-globe injury.

Purpose:Evaluate predictors and outcomes of ocular hypertension after open-globe injury. Patients and Methods:This is a retrospective, case-control study reviewing records of consecutive patients with open-globe injuries treated at Massachusetts Eye and Ear Infirmary between February 1999 and January 2007. Of 658 patients treated, 382 had at least 2 months of follow-up and sufficient data to be included. Main outcome measures are visual acuity, intraocular pressure (IOP), and type of glaucoma intervention employed. Results:Sixty-five (17%) patients developed ocular hypertension defined as IOP≥22 mm Hg at >1 visit or requiring treatment. Increased age (P<0.001), hyphema (0.025), lens injury (P<0.0001), and zone II injury (P=0.0254) are risk factors for developing ocular hypertension after open-globe injury. Forty-eight (74%) patients with ocular hypertension were treated medically, 8 (12%) underwent filtering or glaucoma drainage device surgery, 5 (8%) had IOP normalization with observation, while 4 (6%) required anterior chamber washout with no other glaucoma surgery. Patients with ocular hypertension had an average maximum IOP=33.4 mm Hg at a median follow-up of 21 days, with most patients maintaining normal IOP at all follow-up time points. Visual acuity improved over time with median acuity of hand motions preoperatively, and 20/60 at 12 and 36 months. Conclusions:Ocular hypertension is a significant complication after open-globe injury that sometimes requires surgical intervention. Predictive factors can alert physicians to monitor for elevated IOP in the first month after trauma. Most patients with traumatic ocular hypertension had improved visual acuity and IOP normalization over time.

Ocular Blast Injuries in Mass-Casualty Incidents: The Marathon Bombing in Boston, Massachusetts, and the Fertilizer Plant Explosion in West, Texas

PURPOSE To report the ocular injuries sustained by survivors of the April 15, 2013, Boston Marathon bombing and the April 17, 2013, fertilizer plant explosion in West, Texas. DESIGN Multicenter, cross-sectional, retrospective, comparative case series. PARTICIPANTS Seventy-two eyes of 36 patients treated at 12 institutions were included in the study. METHODS Ocular and systemic trauma data were collected from medical records. MAIN OUTCOME MEASURES Types and severity of ocular and systemic trauma and associations with mechanisms of injury. RESULTS In the Boston cohort, 164 of 264 casualties were transported to level 1 trauma centers, and 22 (13.4%) required ophthalmology consultations. In the West cohort, 218 of 263 total casualties were transported to participating centers, of which 14 (6.4%) required ophthalmology consultations. Boston had significantly shorter mean distances to treating facilities (1.6 miles vs. 53.6 miles; P = 0.004). Overall, rigid eye shields were more likely not to have been provided than to have been provided on the scene (P<0.001). Isolated upper body and facial wounds were more common in West largely because of shattered windows (75.0% vs. 13.6%; P = 0.001), resulting in more open-globe injuries (42.9% vs. 4.5%; P = 0.008). Patients in Boston sustained more lower extremity injuries because of the ground-level bomb. Overall, 27.8% of consultations were called from emergency rooms, whereas the rest occurred afterward. Challenges in logistics and communications were identified. CONCLUSIONS Ocular injuries are common and potentially blinding in mass-casualty incidents. Systemic and ocular polytrauma is the rule in terrorism, whereas isolated ocular injuries are more common in other calamities. Key lessons learned included educating the public to stay away from windows during disasters, promoting use of rigid eye shields by first responders, the importance of reliable communications, deepening the ophthalmology call algorithm, the significance of visual incapacitation resulting from loss of spectacles, improving the rate of early detection of ocular injuries in emergency departments, and integrating ophthalmology services into trauma teams as well as maintaining a voice in hospital-wide and community-based disaster planning.

Adjustable nasal transposition of split lateral rectus muscle for third nerve palsy.

IMPORTANCE Third nerve palsy causes disfiguring, incomitant strabismus with limited options for correction. OBJECTIVE To evaluate the oculomotor outcomes, anatomical changes, and complications associated with adjustable nasal transposition of the split lateral rectus (LR) muscle, a novel technique for managing strabismus associated with third nerve palsy. DESIGN, SETTING, AND PARTICIPANTS Retrospective medical record review appraising outcomes of 6 consecutive patients with third nerve palsy who underwent adjustable nasal transposition of the split LR muscle between 2010 and 2012 with follow-up of 5 to 25 months at a tertiary referral center. INTERVENTION Adjustable nasal transposition of the split LR muscle. MAIN OUTCOMES AND MEASURES The primary outcome was postoperative horizontal and vertical alignment. Secondary outcomes were (1) appraising the utility of adjustable positioning, (2) demonstrating the resultant anatomical changes using magnetic resonance imaging, and (3) identifying associated complications. RESULTS Four of 6 patients successfully underwent the procedure. Of these, 3 patients achieved orthotropia. Median preoperative horizontal deviation was 68 prism diopters of exotropia and median postoperative horizontal deviation was 0 prism diopters (P = .04). Two patients had preoperative vertical misalignment that resolved with surgery. All 4 patients underwent intraoperative adjustment of LR positioning. Imaging demonstrated nasal redirection of each half of the LR muscle around the posterior globe, avoiding contact with the optic nerve; the apex of the split sat posterior to the globe. One patient had transient choroidal effusion and undercorrection. Imaging revealed, in this case, the apex of the split in contact with the globe at an anterolateral location, suggesting an inadequate posterior extent of the split. In 2 patients, the surgical procedure was not completed because of an inability to nasally transpose a previously operated-on LR muscle. CONCLUSIONS AND RELEVANCE Adjustable nasal transposition of the split LR muscle can achieve excellent oculomotor alignment in some cases of third nerve palsy. The adjustable modification allows optimization of horizontal and vertical alignment. Imaging confirms that the split LR muscle tethers the globe, rotating it toward primary position. Case selection is critical because severe LR contracture, extensive scarring from prior strabismus surgery, or inadequate splitting of the LR muscle may reduce the likelihood of success and increase the risk of sight-threatening complications. Considering this uncertainty, more experience is necessary before widespread adoption of this technique should be considered.

The pediatric traumatic hyphema.

The traumatic hyphema, defined as blood in the anterior chamber (AC) of the eye after trauma, occurs at a rate of approximately 17 per 100,000 per year. Between 70% and 75% of these patients are children, with a male-female ratio of at least 3:1. The complications of hyphema include corneal blood staining, elevated intraocular pressure (IOP), optic atrophy, and glaucoma. These complications can lead to visual impairment or even blindness. Children are an especially important population of hyphema patients, both because they comprise the majority of patients and because of important considerations in their treatment and management including amblyopia and compliance. This review broadly defines the traumatic hyphema: pathophysiology, classification, examination, complications, medical and surgical management, and long-term issues, with special attention toward the pediatric population.

A Novel Technique for Amniotic Membrane Transplantation in Patients with Acute Stevens-Johnson Syndrome

Cryopreserved amniotic membrane (AM) transplantation is an emerging technique that is becoming the gold standard for the management of acute Stevens-Johnson syndrome (SJS) and its more severe variant, toxic epidermal necrolysis (TEN). We describe a novel surgical technique utilizing a single, large sheet of AM (5 x 10 cm) and a custom-made forniceal ring, which facilitates AM placement. Our technique is easy to use and minimizes suturing and manipulation of ocular tissues, resulting in decreased operative time. This technique may be applied in the management of multiple ocular surface disease processes, including chemical or thermal burns, severe ocular graft versus host disease (GVHD), and other autoimmune diseases.

Intraocular lens implantation in penetrating ocular trauma.

Approximately 55 million eye injuries limit productivity across the world yearly. Open-globe injuries, defined as full-thickness wounds of the cornea and/or sclera, occur with an annual incidence of 200,000 cases per year worldwide and require prompt surgical intervention to minimize morbidity. In cases with lens capsular violation and cataract formation, primary lensectomy has become the standard of care over the past 30 years. However, the timing of intraocular lens (IOL) implantation after lensectomy is debated. Here, we review the literature regarding the timing of IOL implantation after penetrating ocular injury and traumatic cataract, and we provide an algorithm to help guide management in these cases.

Treatment of Ocular Pyogenic Granuloma With Topical Timolol

Importance Pyogenic granulomas, acquired vascular lesions, form on the ocular or palpebral surface related to inflammation from chalazia, trauma, or surgery. They can be unsightly, spontaneously bleed, and cause irritation to patients. Observations A case series is presented of 4 consecutive children with acquired ocular surface pyogenic granulomas treated at Boston Children’s Hospital from 2014 to 2016 with only topical timolol, 0.5%, twice daily for a minimum of 21 days. In all cases, complete resolution occurred within the treatment period with no recurrence for at least 3 months. There were no adverse effects from the timolol during follow-up. Conclusions and Relevance This case series of 4 children, while limited to no greater than 12 weeks of follow-up and without control children, suggests that ocular surface pyogenic granulomas respond to topical timolol treatment, which has a lower adverse-effect profile than conventional topical steroid treatments or other medical or surgical therapies. If confirmed in larger studies with longer follow-up and controls, this may be the desired treatment modality.