Chee-Chew Yip

A randomized double-masked crossover study comparing latanoprost 0.005% with unoprostone 0.12% in patients with primary open-angle glaucoma and ocular hypertension

PURPOSEnTo compare the intraocular pressure)-lowering effect and side effects of latanoprost 0.005% once daily with unoprostone 0.12% twice daily.nnnMETHODSnSixty patients with primary open-angle glaucoma or ocular hypertension were randomized to receive either latanoprost once daily in the evening and placebo once daily in the morning, or unoprostone twice daily in the morning and evening. The study was double masked and followed a crossover design with two treatment periods of 1 month separated by a 3-week washout period. The intraocular pressure was measured at 9 AM and 5 PM on the baseline and day 28 visits, and at 9 AM on day 2 and day 14 visits of each treatment period. The 9 AM measurement was taken 2 hours and 13 hours after the last drop of unoprostone and latanoprost, and the 5 PM measurement was at 10 and 21 hours, respectively. The mean of the measurements was calculated. Safety parameters were also recorded.nnnRESULTSnFifty-six patients completed both treatment periods and had intraocular pressure data available for evaluation. After 1 month of treatment, latanoprost significantly reduced intraocular pressure (mean +/- SEM) by 6.1 +/- 0.5 mm Hg (P <.001) and unoprostone by 4.2 +/- 0.4 mm Hg (P <.001) adjusted from an overall baseline of 22.3 +/- 0.5 mm Hg and 23.2 +/- 0.4 mm Hg, respectively. The difference of 1.9 mm Hg between treatments was statistically significant in favor of latanoprost [P =.003, analysis of covariance (ANCOVA)]. Unadjusted analysis of responders using the percentage decrease in intraocular pressure showed that the proportion of responders in the latanoprost-treated group was greater than in the unoprostone-treated group. Adverse ocular symptoms and findings were mild in both treatment groups. Eye redness and ocular irritation were the most frequently reported events.nnnCONCLUSIONSnLatanoprost once daily was significantly more effective in reducing intraocular pressure compared with unoprostone twice daily after 1 month of treatment in patients with primary open-angle glaucoma and ocular hypertension. Both drugs were well tolerated with few ocular adverse events.

Low-dose intravenous methylprednisolone or conservative treatment in the management of traumatic optic neuropathy

Purpose To compare the efficacy of low-dose intravenous methylprednisolone or conservative treatment in the management of traumatic optic neuropathy. Methods A non-randomized retrospective study of 21 patients (21 eyes) with traumatic optic neuropathy treated between October 95 and November 97 in a tertiary ophthalmology unit. Traumatic optic neuropathy was defined as traumatic visual loss with afferent pupillary defect in the absence of direct injury to the globe or optic nerve. The median follow-up period was one year. Nine patients were treated with 125–250 mg methylprednisolone 6-hourly intravenously for a mean of 3.3 days (range 2–5 days) and 12 patients were treated conservatively. Visual acuity (VA) was measured with a Snellen chart before and after treatment at each follow-up visit. Visual recovery was defined as an improvement of 2 or more Snellen lines one week post-injury or later. Results The patients mean age was 37.1 years (range 12–65 years). There were more males (90.5%) than females (9.5%). Traumatic optic neuropathy was in 12 right eyes and 9 left eyes. The cause of injury included traffic accidents (52.4%), falls (28.6%), assault (14.2%) and others (4.8%). The mean interval between the injury and steroid therapy was 3.6 days (range 1–11 days). Visual recovery was observed in 44.4% of eyes treated with methylprednisolone and in 33.3% treated conservatively (p = 0.673, Fishers exact test). Conclusions Intravenous methylprednisolone at the dosage and duration used in this retrospective study did not significantly improve the visual recovery of eyes with traumatic optic neuropathy compared to conservative treatment. However, this small sample may not be sensitive enough to detect a small difference in visual recovery rates, and further studies with larger samples may be warranted.

Orbital, adnexal, and unusual systemic involvement in Rosai-Dorfman disease

Purpose To describe the unusual clinical course of a patient with Rosai-Dorfman disease (RDD) affecting the eyelid and orbital tissues and involving the spinal cord. Methods Case report. Results A 68-year-old Indian man first presented in 1994 with a right lower eyelid lump for 1 year. An en bloc excisional biopsy was reported to show “reactive lymphoid hyperplasia with sclerosis.” The patient subsequently defaulted follow-up and presented again in 1999 with bilateral lower eyelid masses and proptosis. Computerized tomography showed bilateral orbital, ethmoidal sinus, and frontal sinus soft tissue masses. Bilateral excisional biopsies of the orbital and eyelid masses showed histologic features of RDD. The patient had a history of paraplegia with decompression laminectomy and excision of an epidural mass in 1994. In addition, he underwent excision of soft tissue masses from the abdominal wall in 1993. Retrospective review of the histologic specimens from these two areas showed a histologic picture similar to that of eyelid specimens (in 1994 and 1999). Conclusions It is important to consider RDD in addition to lymphoproliferative disorders in a patient with orbital and ocular adnexal masses. The initial histologic presentation may not be pathognomonic.

Outcome of late probing for congenital nasolacrimal duct obstruction in Singapore children.

Objective: To evaluate the outcome of late probing in a mixed Asian children population with congenital nasolacrimal duct obstruction (CNLDO) and whether probing was associated with an increased risk of infection. Method: A retrospective clinical study was conducted. A clinical diagnosis of CNLDO was defined in an infant who presented with a history of tearing and/or eye discharge up to 1 year of age with no other accompanying ocular pathology. All patients with a presumed diagnosis of CNLDO who had probing after 12 months of age were included in our study. Prior to probing, most patients had a trial of conservative treatment with massage and/or topical antibiotics. Intra-operative patency of probing was determined when metal to metal contact of the probe and forceps was achieved and/or when fluorescein dye was recovered from the nose after syringing. Successful probing was defined as a resolution of symptoms within 1 month after probing. Results: Seventeen patients involving 19eyes fulfilled our inclusion criteria for this study. Fourteen (82%) infants were Chinese, two Malays (12%) and the remaining one Indian (6%). There were 10 males(59%) and 7 females(41%) and the mean age at probing was 2.2 years(range, 14 months to 5years 6 months). The subjects were followed-up post-operatively for a mean duration of 21.2 months (range, 2 months to 8years). Successful probing in our series was 89.5% (17/19 eyes). Of the two eyes with persistent tearing, one resolved with massage about 9 months after the unsuccessful probing; the other was referred to the oculoplastic service for further management. Conclusion: Late probing after 13 months old appears to be an effective approach in the management of CNLDO in Asian infants.

Systemic autonomic function in subjects with primary angle‐closure glaucoma: a comparative study of symptomatic and asymptomatic disease presentation

Background:u2002Autonomic dysfunction is thought to be a contributory factor in primary angle‐closure glaucoma (PACG) by precipitating pupil block in anatomically predisposed eyes. This study aimed to compare systemic autonomic function between subjects who had suffered a previous episode of acute angle closure (symptomatic PACG), those who had asymptomatic PACG, and age and sex‐matched controls.

Intraoperative capsular block syndrome masquerading as expulsive hemorrhage.

Purpose To describe the clinical features of two cases of intraoperative capsular block syndrome (CBS) mimicking expulsive hemorrhage. Setting The Eye Institute at Tan Tock Seng Hospital, National Healthcare Group, Singapore. Methods Two case reports. Results Two patients underwent phacoemulsification under retrobulbar anesthesia and developed severe globe hardening, shallow anterior chamber (AC) and uveal prolapse intra-operatively after hydrodissection. The AC spontaneously deepened in one patient and the operation was converted to extracapsular cataract surgery on suspicion of CBS with posterior capsule rupture, which was confirmed after nucleus expression; anterior vitrectomy was done and an anterior chamber lens implanted. At the eight post-operative month, his best-corrected visual acuity was 6/24 secondary to an epiretinal membrane in the macula. CBS, however, was not recognized in the other patient and caused posterior lens dislocation during attempted phacoemulsification. This patient underwent vitrectomy, removal of the lens nucleus and insertion of a posterior chamber intraocular lens in the sulcus the next day. His best-corrected visual acuity was 6/9 at the tenth postoperative month. Conclusions Intraoperative CBS may mimic expulsive hemorrhage. Early diagnosis of this condition and proper management optimizes the visual outcome.

High-pressure paint gun injury to the orbit and ocular adnexa

High-pressure injection injury to the orbit and adnexa is a rare but potentially blinding type of trauma. Few cases of such injury have been reported in the literature. A 27-year-old Indian man accidentallyi njected paint material from a high-pressure nozzle gun into his left eye. Radiological investigation revealed the presence of paint material in the orbital tissues and the ethmoidal sinuses. The patient underwent two orbital surgeries to remove the paint material. He later developed signs suggestive of limbal stem cell failure and was treated with limbal stem cell autografting. He also has ophthalmoplegia with a compensatory anomalous head posture that was managed conservatively. We report the clinical course and outcome of this unfortunate patient to highlight the complexity of such an injury and the need for a multidisciplinary approach in its management.

Traumatic eye injuries due to large unusual foreign bodies: a Singapore case series

Purpose Traumatic eye injuries due to large foreign bodies (FB) are rare. The visual prognosis is often poor in these cases because of severe ocular damage. Staged surgical procedures with eventual enucleation or evisceration are often indicated. Methods Case series. Results The authors describe two patients with eye injury due to large FB with visual acuity of no light perception at presentation. Both had initial repair of the ocular injuries and removal of the FB. One patient with an intraocular FB eventually underwent enucleation; the other, with intraorbital FB, had evisceration as a secondary procedure. Orbital implantations were done in both. Neither of the patients had developed sympathetic ophthalmia at the last review. Conclusions The visual outcome of eye injuries due to large FB is poor. Both enucleation and evisceration can be performed with low risk of sympathetic ophthalmia. Prevention remains the best approach to such devastating injuries.

Hypopyon--an unusual sign in acute angle-closure glaucoma.

The appearance of a hypopyon is an extremely uncommon finding in acute angle-closure glaucoma and only a few cases have been previously reported in the literature. We report a fifty-year-old female who, following a recent bereavement, presented with classical features of acute angle-closure glaucoma and a hypopyon. The eye developed a glaukomflecken and the patient underwent trabeculectomy, extracapsular cataract extraction and intraocular lens implantation with good post-operative results. Because hypopyon in acute angle-closure glaucoma is rare and may cause diagnostic confusion and hence therapeutic difficulties, this case is described to highlight this unusual clinical sign.

Aesthetically acceptable approaches to orbital fractures

Abstract Orbital fractures that require surgical intervention pose challenging problems to the trauma surgeon. Many options have been described to gain access to the subperiosteal plane orbit of the orbit. The approach to be adopted should be tailored to the site and extent of the fractures, and the experience of the surgeon. We prefer approaches that utilize hidden incisions as they provide safe surgical access but heal without visible scarring and are esthetically more acceptable to patients. We describe approaches to repair orbital fractures via hidden incisions in the caruncle, and the inferior conjunctival fornix.