Erin M. Shriver

Prospective randomized comparison of 3-day versus 1-hour preoperative ofloxacin prophylaxis for cataract surgery

PURPOSE To determine the efficacy of reducing conjunctival bacterial flora with topical ofloxacin when given for 3 days compared with 1 hour before surgery. DESIGN Prospective, randomized, controlled trial. PARTICIPANTS Ninety-two eyes from 89 patients were randomized to a control group (48 eyes) or study group (44 eyes). METHODS All patients from both groups received topical ofloxacin 0.3% 1 hour before surgery and a 5% povidone iodine scrub of the periorbital area before surgery. The patients in the study group received additional ofloxacin four times daily for 3 days before surgery. MAIN OUTCOME MEASURES Conjunctival cultures were obtained at five separate time points and were inoculated in solid and liquid culture media. The presence of bacteria was determined, quantified, and identified. RESULTS Forty-two percent of eyes in the control group had positive conjunctival culture immediately before surgery, compared with 19% of eyes in the study group (P < 0.05). Immediately after surgery, 34% and 14% of eyes had positive cultures in the control and study groups, respectively (P < 0.05). Quantitatively, fewer bacteria were isolated from eyes in the study group compared with those in the control group for culture samples that were obtained both before povidone iodine scrub and at the conclusion of surgery (P </= 0.05). CONCLUSIONS The application of topical ofloxacin for 3 days before surgery appears to be more effective in eliminating bacteria from the conjunctiva than an application of ofloxacin 1 hour before surgery.

Antibiotic resistance patterns of ocular bacterial flora: A prospective study of patients undergoing anterior segment surgery

PURPOSE To determine the antibiotic susceptibility patterns of conjunctival bacterial flora isolated preoperatively from patients undergoing anterior segment surgery. DESIGN Prospective observational study. PARTICIPANTS One hundred fifty-six eyes from 139 patients scheduled for anterior segment surgery were enrolled over a 6-month period from August 2001 to February 2002. METHODS Conjunctival cultures were obtained on the day of surgery before povidone-iodine or antibiotic application. MAIN OUTCOME MEASURES Bacterial isolates were identified and tested for antibiotic susceptibility using the Kirby-Bauer disc-diffusion technique. RESULTS Among the 156 eyes studied, 36 were from patients who had undergone either bilateral surgery or more than one surgery in the same eye. Only the first eyes of the 120 patients that underwent initial ocular surgery were included in our analysis. Of these 120 eyes, 21 (18%) showed no bacterial growth. Of the 143 bacterial strains isolated from the remaining 99 eyes, 112 (78%) were coagulase-negative staphylococci (CNS). Among the CNS, greater than 90% were susceptible to cefotaxime, levofloxacin, imipenem, meropenem, vancomycin, and each of the aminoglycosides except neomycin. Between 70% and 90% of the CNS were susceptible to cefazolin, neomycin, ciprofloxacin, ofloxacin, norfloxacin, and chloramphenicol. Less than 70% of the isolated CNS were sensitive to the penicillin analogues, ceftazidime, erythromycin, and tetracycline. CONCLUSIONS Preoperative conjunctival isolates of CNS seem to be most sensitive to vancomycin, the aminoglycosides (except neomycin), and levofloxacin.

Teprotumumab for thyroid-associated ophthalmopathy

BACKGROUND Thyroid‐associated ophthalmopathy, a condition commonly associated with Graves’ disease, remains inadequately treated. Current medical therapies, which primarily consist of glucocorticoids, have limited efficacy and present safety concerns. Inhibition of the insulin‐like growth factor I receptor (IGF‐IR) is a new therapeutic strategy to attenuate the underlying autoimmune pathogenesis of ophthalmopathy. METHODS We conducted a multicenter, double‐masked, randomized, placebo‐controlled trial to determine the efficacy and safety of teprotumumab, a human monoclonal antibody inhibitor of IGF‐IR, in patients with active, moderate‐to‐severe ophthalmopathy. A total of 88 patients were randomly assigned to receive placebo or active drug administered intravenously once every 3 weeks for a total of eight infusions. The primary end point was the response in the study eye. This response was defined as a reduction of 2 points or more in the Clinical Activity Score (scores range from 0 to 7, with a score of ≥3 indicating active thyroid‐associated ophthalmopathy) and a reduction of 2 mm or more in proptosis at week 24. Secondary end points, measured as continuous variables, included proptosis, the Clinical Activity Score, and results on the Graves’ ophthalmopathy–specific quality‐of‐life questionnaire. Adverse events were assessed. RESULTS In the intention‐to‐treat population, 29 of 42 patients who received teprotumumab (69%), as compared with 9 of 45 patients who received placebo (20%), had a response at week 24 (P<0.001). Therapeutic effects were rapid; at week 6, a total of 18 of 42 patients in the teprotumumab group (43%) and 2 of 45 patients in the placebo group (4%) had a response (P<0.001). Differences between the groups increased at subsequent time points. The only drug‐related adverse event was hyperglycemia in patients with diabetes; this event was controlled by adjusting medication for diabetes. CONCLUSIONS In patients with active ophthalmopathy, teprotumumab was more effective than placebo in reducing proptosis and the Clinical Activity Score. (Funded by River Vision Development and others; ClinicalTrials.gov number, NCT01868997.)

The Use of Titanium T-Plate as Platform for Globe Alignment in Severe Paralytic and Restrictive Strabismus

PURPOSE To evaluate the long-term effectiveness of improved ocular alignment using a suture/T-plate anchoring platform system. DESIGN Retrospective, noncomparative, interventional case series. METHODS setting: Institutional. study population: Seven consecutive patients with large angle deviations attributable to paralytic and/or restrictive strabismus managed jointly by orbital and strabismus surgeons. intervention procedure: The T-plate base is anchored to the orbital rim with the shaft projecting toward the orbital apex to simulate the origin of the affected muscle. A nonabsorbable suture serves as the coupling element linking the muscle insertion to the tip of the T-plate such that the suture coincides with the axis of the dysfunctional muscle and yields a pull vector to simulate the passive tensile force of the muscle. Information analyzed included patient demographics, etiology of strabismus and characteristics, prior muscle surgeries, secondary interventions, subjective appraisal of diplopia, and final ocular alignment measurements. main outcome measures: Subjective appraisal of diplopia, final ocular alignment in primary gaze, and late stability. RESULTS All 7 patients showed marked reduction in ocular deviation with a median change of 33 prism diopters (PD) and a range of 7 to 72 PD. For the 6 patients with medial rectus dysfunction, the final ocular alignment ranged from 6 to 18 PD of residual exotropia in primary gaze. The patient with sixth nerve palsy had 5 PD of residual esotropia. There were no failures after an average of 59.4 months of follow-up. CONCLUSIONS A globe tethering technique using a suture/titanium T-plate anchoring platform system effectively treats refractory cases of paralytic and restrictive strabismus with large angles of deviation.

Combined transcranial-orbital approach for resection of optic nerve gliomas: A clinical and anatomical study

PURPOSE To examine the feasibility of monocanalicular intubation in external dacryocystorhinostomy (EX-DCR). METHODS Monocanalicular intubation using the mini-Monoka tube (S1-1500u, FCI Ophthalmics, Marshfield Hills, MA, U.S.A.) was performed in 18 patients undergoing EX-DCR. The tube was placed at the superior canaliculus in 16 cases and at the inferior canaliculus in 2 cases and was removed 3 months postoperatively. All cases were followed for at least 6 months postoperatively. RESULTS The mini-Monoka was well tolerated in all patients. One case of spontaneous tube dislocation and 2 cases of presumed tube migration were recorded on the 15-day interval. Success rates on the 6-month interval were 88.88% (16/18), 94.44% (17/18), and 66.66% (12/18), concerning patency upon irrigation, resolution of mucopurulent epiphora, and resolution of watery epiphora, respectively. CONCLUSIONS Monocanalicular intubation using mini-Monoka in EX-DCR is safe and effective. The technique may have advantages over bicanalicular intubation, such as easier insertion and removal, easier probing and irrigation though the unintubated canaliculus and, more importantly, less risk of punctal or corneal damage.Purpose: To describe a combined transcranial-orbital approach for en bloc resection of optic nerve gliomas with preservation of the annulus of Zinn that minimizes recurrence and prevents postoperative paralytic ptosis. Methods: Design: A retrospective, noncomparative, interventional case series. Study Population: All patients who underwent optic nerve glioma resections using this technique with the authors between 1994 and 2010. Procedure: A transcranial-orbital approach is used to resect the intracranial segment of the optic nerve glioma from 2 mm anterior to the chiasm to the posterior extent of annulus of Zinn. The proximal transected edge of the nerve is examined intraoperatively for tumor margin clearance. Through a superior orbitotomy exposure, the entire retrobulbar segment of the tumor is transected from the globe to the annulus of Zinn. A simulation of the procedure in a cadaver and en bloc resection of the orbital apex are performed to demonstrate the subdural plane of dissection within the annulus of Zinn. Main Outcome Measures: Postoperative outcome measures include: health of the ipsilateral globe, paralytic ptosis, postoperative complications, and tumor recurrence. Results: Eleven patients underwent resection of optic nerve gliomas using this technique. No patients had tumor recurrence or developed postoperative paralytic ptosis. Conclusions: The combined transcranial-orbital approach with preservation of the annulus of Zinn is a safe and effective way to remove optic nerve gliomas and ensure tumor clearance while avoiding paralytic ptosis.

En bloc resection of lacrimal sac tumors and simultaneous orbital reconstruction: Surgical and functional outcomes

Purpose: To describe a surgical technique of en bloc resection of lacrimal sac tumors by the shared expertise of 2 specialists to achieve optimal tumor margin clearance and the simultaneous reconstruction of the bony defect to preserve ocular functions and cosmesis. Methods: All patients who had resection of malignant nasolacrimal drainage system tumors using the combined technique and posttreatment protocol between 1997 and 2011 were studied in this retrospective, noncomparative, interventional case series. A combined medial maxillectomy and medial orbitotomy for en bloc resection of the lacrimal sac tumor was followed by reconstruction with a tailored contoured titanium mesh to support the globe and eyelid. Disease relapse, disease survival, ocular functions (vision loss, motility, globe dystopia, and diplopia), and cosmesis (medial canthal tendon dystopia and eyelid retraction) were documented. Results: Fourteen patients with malignant lacrimal sac tumors underwent en bloc resection. Postoperative radiation was ultimately administered to 9 patients. All patients but one were alive at last follow up. Tumor recurred locally in 2 patients with a regional recurrence in a third patient. Complications from radiation therapy included skin breakdown over the mesh (9/14 patients) with nasocutaneous fistula, medial canthal tendon dystopia (2/14 patients), and corneal perforation in a patient with recurrent disease. Despite removal of the tear drainage system, only 7 of 14 patients reported epiphora. None of the patients developed diplopia after resection and radiation therapy. Conclusions: The combined sinus–orbit approach is an effective method of managing lacrimal sac tumors to achieve optimal tumor clearance from the orbit and nasal cavity. Simultaneous reconstruction of the bony defect with a contoured titanium mesh provides a fixation anchor for the medial canthal tendon and globe support and serves as a supporting platform for the lower eyelid and cheek to minimize midface collapse. Postoperative radiation is associated with skin flap breakdown and nasocutaneous fistula formation.

Intimate partner violence

Purpose: To evaluate the prevalence of intimate partner violence (IPV) in a large population of female orbital floor fracture patients and provide recommendations on effectively identifying and referring IPV survivors. Methods: Retrospective review of facial fracture patients examined at the University of Iowa Hospitals and Clinics between January 1995 and April 2013. International Classification of Diseases, Ninth Revision, codes and medical record review were used to determine the prevalence of IPV victimization and clinical outcomes. Results: A total of 1,354 women and 4,296 men sustained facial fractures. Of these, 405 women and 1,246 men sustained orbital floor fractures. Leading mechanisms of orbital floor fractures in women were motor vehicle collisions (29.9%) and falls (24.7%). Twenty percent had no etiology documented. Intimate partner violence–associated assault was the third leading documented cause of orbital floor fractures in women (7.6%) followed by non–IPV-associated assault (7.2%). Among women with orbital floor fractures due to assault, leading patterns of injury included the following: isolated orbital floor fractures (38.7%, 12/31 in IPV patients; 55.2%, 16/29 in non-IPV patients), zygomaticomaxillary complex fractures (35.5%, 11/31 in IPV patients; 17.2%, 5/29 in non-IPV patients), and orbital floor plus medial wall fractures (16.1%, 5/31 in IPV patients; 24.1%, 7/29 in non-IPV patients). Involvement of ancillary services was documented in 20.0% (7 law enforcement and 5 social service agencies, 12/60) of assault-related orbital floor fracture cases. Ascertainment of patient safety was documented in 1.7% (1/60) of these cases. Conclusions: Ophthalmologists treating orbital floor fracture patients should maintain a high index of suspicion for IPV and screen accordingly. Following IPV disclosure, patient safety should be assessed and referral provided.

Salivary gland dysfunction and nasolacrimal duct obstruction: stenotic changes following I-131 therapy.

Radioactive iodine has long been used in the treatment of cancers of the thyroid. While salivary complications secondary to I-131 therapy in association with xerophthalmia are well documented, there is little in the literature addressing simultaneous nasolacrimal duct obstruction with salivary gland dysfunction. The authors present 2 patients with epiphora from bilateral nasolacrimal duct obstruction and concurrent sialadenitis following I-131 ablation therapy for papillary thyroid carcinoma. These cases highlight the lacrimal and salivary duct complications resulting from I-131 therapy, introduce the possibility of a shared mechanism of damage, and demonstrate the availability of effective treatments for both conditions. Ophthalmologists see patients with epiphora from I-131 therapy and should be aware of the possible concurrent symptoms caused by salivary duct stenosis to make timely and appropriate referrals.

Intimate partner violence: An underappreciated etiology of orbital floor fractures

Purpose: To evaluate the prevalence of intimate partner violence (IPV) in a large population of female orbital floor fracture patients and provide recommendations on effectively identifying and referring IPV survivors. Methods: Retrospective review of facial fracture patients examined at the University of Iowa Hospitals and Clinics between January 1995 and April 2013. International Classification of Diseases, Ninth Revision, codes and medical record review were used to determine the prevalence of IPV victimization and clinical outcomes. Results: A total of 1,354 women and 4,296 men sustained facial fractures. Of these, 405 women and 1,246 men sustained orbital floor fractures. Leading mechanisms of orbital floor fractures in women were motor vehicle collisions (29.9%) and falls (24.7%). Twenty percent had no etiology documented. Intimate partner violence–associated assault was the third leading documented cause of orbital floor fractures in women (7.6%) followed by non–IPV-associated assault (7.2%). Among women with orbital floor fractures due to assault, leading patterns of injury included the following: isolated orbital floor fractures (38.7%, 12/31 in IPV patients; 55.2%, 16/29 in non-IPV patients), zygomaticomaxillary complex fractures (35.5%, 11/31 in IPV patients; 17.2%, 5/29 in non-IPV patients), and orbital floor plus medial wall fractures (16.1%, 5/31 in IPV patients; 24.1%, 7/29 in non-IPV patients). Involvement of ancillary services was documented in 20.0% (7 law enforcement and 5 social service agencies, 12/60) of assault-related orbital floor fracture cases. Ascertainment of patient safety was documented in 1.7% (1/60) of these cases. Conclusions: Ophthalmologists treating orbital floor fracture patients should maintain a high index of suspicion for IPV and screen accordingly. Following IPV disclosure, patient safety should be assessed and referral provided.

Reply re: "intubation of the ostium and nasolacrimal duct with a single self-linking silicone stent in external dacryocystorhinostomy"

Purpose: To describe a stent placement method that eliminates stent prolapse in external dacryocystorhinostomy. Methods: A retrospective, institutional review board– approved case series of patients undergoing external dacryocystorhinostomy with an alternative stenting method. Following anastomosis of the posterior flaps, one arm of a Crawford silicone stent is passed through each canaliculus. Both arms are then passed through the nasolacrimal duct and retrieved in the inferior meatus. The 2 distal arms are redirected in the nose; one arm is looped around the proximal portions within the lacrimal sac and tied to the second arm. The stent is self-linked around the inferior turbinate. Results: Nine patients underwent external dacryocystorhinostomy with alternative stenting. None experienced postoperative stent prolapse. At last follow-up (average, 38 months; range, 5–102 months), 8 patients reported resolution of tearing and exhibited normal dye clearance. On compression of the lacrimal sac, none of these 8 patients exhibited reflux of stagnant tears or dye through the canaliculi. Conclusions: This alternative method improves stent retention by using the inferior turbinate as a stopper to eliminate stent prolapse. The self-linking nature obviates the need and expense of additional biomedical devices.