Edwin C. Figueira

Intermittent exotropia: comparison of treatments

Purpose:  To identify the best treatment option for intermittent exotropia.

Ophthalmic Involvement in Inherited Epidermolysis Bullosa

Eye involvement in inherited epidermolysis bullosa (EB) can occur as a spectrum of symptoms and signs. This article describes these signs and symptoms. It also offers options for treatment.

Endophthalmitis following cataract surgery: The sucking corneal wound

We were quite surprised, and also concerned, to note that a patient given the proposed Northern European panacea for prevention of endophthalmitis following cataract surgery (that is, intracameral cefuroxime) developed bilateral postoperative endophthalmitis. This occurred 4 days after bilateral cataract surgery performed at the same sitting. A recent editorial stated that the major risk factors for the development of postoperative endophthalmitis included corneal incisions, age (especially older than 80 years), and loss of posterior capsule integrity, which would allow direct access of bacteria into the vitreous. Further, it was recognized that there are essentially 2 opportunities for bacteria to enter the eye during cataract surgery: at the time of surgery and in the early postoperative period before epithelialization of an unsutured wound. This leads to the notion that sutured corneal incisions may reduce the risk for developing endophthalmitis in the postoperative period. In a laboratory model using India ink, Taban et al. demonstrated that aqueous aspirates from 3 eyes with sutureless clear corneal incisions had increased spectrophotometric readings (P!.01). This was in contrast to the readings from aspirates in eyeswith sutured corneal incisions, which showed no increase in absorbance level from baseline. This demonstrates that ingress of India ink occurs through sutureless clear corneal incisions, representing the potential passage of microorganisms into the eye. In sutureless cataract surgery, wound sealing is generally achieved by stromal hydration at the completion of the case. However, some evidence suggests that the wound is compromised when closure is not reinforced with suturing. Vasavada et al. demonstrated in routine cataract surgery that wounds sealed by stromal hydration allowed ingress of trypan blue into the anterior chamber. Notably, trypan blue was detected in the anterior chamber within 2 minutes of stromal hydration. A recent study by Praveen et al. confirmed this finding in 3 phacoemulsification techniques; the ingress was worst with bimanual phacoemulsification. Herretes et al. reported ingress of blood-tinged fluid into the anterior chamber after the incisions were sealed by stromal hydration. These results have led to the conclusion that clear corneal incisions may not always be self-sealing.

Granulation tissue in the eyelid margin and conjunctiva in junctional epidermolysis bullosa with features of laryngo-onycho-cutaneous syndrome.

Eye and adnexal involvement in epidermolysis bullosa can range from symptoms of mild irritation resulting from conjunctival involvement to severe cicatrization of the ocular surface and adnexa. We describe a unique case of granulation tissue in the eyelid margin and conjunctiva in a patient with junctional epidermolysis bullosa. The eyelid granulation tissue resembled granulomas that seen in laryngo–onycho–cutaneous syndrome, which is caused by a mutation in an isoform of the LAMA3 gene, LAMA3a. On investigation, our patient had a combination of a unique mutation in LAMA3 and the mutation I17N in LAMA3a, providing further evidence that laryngo–onycho–cutaneous syndrome is a variant of junctional EB.

Successful "medical" orbital decompression with adjunctive rituximab for severe visual loss in IgG4-related orbital inflammatory disease with orbital myositis.

IgG4-related disease (IgG4-RD) is an inflam matory condition of unknown etiology that can cause tumefactive lesions in a number of tissues and organs, including the orbit and ocular adnexa. Diagnostic criteria for IgG4-RD, including pathology and clinical features and pathology, have been recently proposed.1 This study presents the first case of unilateral acute visual loss secondary to IgG4-related orbital inflammatory disease with orbital myositis that was complicated by severe compressive optic neuropathy. After initial treatment with pulsed intravenous methylprednisolone, followed by rituximab and radiotherapy, there was a marked improvement in orbital inflammation and clinical and radiological improvement in the compressive optic neuropathy. After 9 months of follow up, the orbital inflammatory disease remained in remission.

Frequency of simultaneous nasal procedures in endoscopic dacryocystorhinostomy.

Purpose: To assess the frequency of simultaneous nasal procedures in powered endoscopic dacryocystorhinostomy performed by oculoplastic surgeons. Design of Study: Retrospective, multicenter study. Methods: Demographic, clinical, and surgical data of consecutive endoscopic dacryocystorhinostomy cases at 3 oculoplastic centers, over periods of 6, 4, and 2.2 years, respectively, were reviewed. The rates of simultaneous nasal procedures (septoplasty, turbinectomy, and polypectomy) were studied. Complication rates in the patients who had simultaneous endonasal procedures were analyzed. Results: Five hundred seventy-six cases (mean age: 63.2 years [16.2–94 years], women: 67.3%). Of the total cohort of patients, 14.1% required a simultaneous endonasal procedure during endoscopic dacryocystorhinostomy, 11.9% (range among surgeons: 5.2%–15%) required septoplasty, 1.5% required middle turbinate surgery, and 0.34% required polypectomy. Of the 81 patients with concomitant procedures, 1 had postoperative epistaxis, and 1 had an asymptomatic septal adhesion. The anatomical and functional success rates for the entire cohort were 95.6% and 87.8%, respectively. Conclusions: A significant proportion of patients undergoing endoscopic dacryocystorhinostomy may require concomitant endonasal procedures. Hence, endonasal lacrimal surgeons using techniques that aim to marsupialize the entire lacrimal sac may benefit from expertize in the management of concomitant nasal pathologic study.

Factors Influencing the Incidence of Postoperative Endophthalmitis

EDITOR: HAVING READ THE ARTICLE BY WYKOFF AND ASSOCIATES, we were impressed to read that the endophthalmitis rate at the Bascom Palmer Eye Institute (BPEI) was 2.8 per 10 000 for cataract surgery. 1 Although there is a range in the endophthalmitis rate reported in the literature, the currently accepted rate around the developed world is approximately 1 per 1000, or 1 per 2000 after intracameral antibiotics. 2,3 This suggests that BPEI may have an endophthalmitis rate of one quarter of rest of the developed world. Unfortunately, in New South Wales, Australia, the rate recently was shown to be more than 8 per 1000. 4 Perhaps in Australia something is very different from the sunny, healthy clime of Florida. Herein we raise some questions in relation to the study by Wykoff and associates. The authors stated that it is unlikely that any cases were missed in their 6-week follow-up in the light of the requirements of their Quality Assurance Committee. However, this assertion may not be able to be validated. Moreover, the patients in whom endophthalmitis developed may not have returned to BPEI for treatment. It was stated that the cataract surgery was being converted from subconjunctival or scleral incisions to unsutured clear corneal incisions during the period of the study. However, there was no documentation of the incision types, wound sizes, the frequency of wound suturing, or the level of experience of the surgeon, all of which are known to affect the incidence rate of endophthalmitis. Some studies have collected cases of endophthalmitis based on self-reporting of the complication by surgeons. 5 This type of reporting is known to be unreliable. Furthermore, a recent British study documented definitively that studies with positive results are more likely to be reported and published than those with negative results. 6

Management of periorbital basal cell carcinoma with orbital invasion

Basal cell carcinoma (BCC) is the most common eyelid malignancy; however, orbital invasion by periocular BCC is rare, and management remains challenging. Established risk factors for orbital invasion by BCC include male gender, advanced age, medial canthal location, previous recurrences, large tumor size, aggressive histologic subtype and perineural invasion. Management requires a multidisciplinary approach with orbital exenteration remaining the treatment of choice. Globe-sparing treatment may be appropriate in selected patients and radiotherapy and chemotherapy are often used as adjuvant therapies for advanced or inoperable cases, although the evidence remains limited. We aim to summarize the presentation and treatment of BCC with orbital invasion to better guide the management of this complex condition.

Apocrine adenocarcinoma of the eyelid: case series and review.

Purpose: To report 2 patients with apocrine adenocarcinoma of the eyelid and review the literature. Design: Noncomparative, retrospective case series and review. Participants: Clinical data of 2 patients with histopathologic diagnoses of apocrine adenocarcinoma of the eyelid were obtained from medical records. The histopathology and immunohistochemistry data for the 2 cases were studied. A retrospective review was performed on all reported cases of eyelid apocrine carcinoma. Main Outcome Measures: Clinical features, histopathology, immunohistochemistry, and clinical course following treatment are reported. The results of a retrospective review of clinical presentations, local and systemic spread, treatment method, and prognosis from published case reports on eyelid apocrine adenocarcinoma are discussed. Results: One patient had orbital invasion at presentation. This patient had radiotherapy alone and had no systemic or local recurrence at 2 years. One patient underwent a 4-mm margin wide surgical excision. This patient had no local or systemic recurrences at 1 year. A review of the literature suggests that the prognosis of adnexal apocrine tumors is indeterminate and variable. Most patients have successful outcomes following local surgical excision. Radiotherapy has been used as an adjunctive treatment for local metastatic disease. Conclusions: Apocrine adenocarcinoma is a rare adnexal tumor of the eyelid, which may present with orbital invasion.

Tunnel vision and night blindness in a 52-year-old man.

The Medical Journal of Australia ISSN: 0025729X 5 September 2011 195 5 287-288 ©The Medical Journal of Australia 2011 www.mja.com.au Lessons from Practice Vitamin A deficiency is a systemi an individual’s risk of blindness, s ity.1 It is rare in developed countri deficiency and xerophthalmia in reported in patients with malabs disease, in those who have had m in people with alcoholism, and in and other psychiatric disorders.3-6 c illness which can increase evere infections and mortales like Australia.2 Vitamin A developed countries are orption syndromes or liver ajor gastrointestinal surgery, those with anorexia nervosa This case is unique because our patient did not have any of these risk factors. This case also highlights the importance of clinicians regularly taking a thorough dietary history, especially in the context of other indications of nutritional insufficiencies, such as osteoporosis and previous vitamin B12 deficiency. Vitamin A is a fat-soluble vitamin found as retinol in dairy products and as provitamin A carotenoids in some fruits and green leafy vegetables.1,7-9 The first clinical evidence of vitamin A deficiency often occurs in the visual system and produces xerophthalmia. The ocular changes of Clinical record