George Kalantzis

Angioid streaks, clinical course, complications, and current therapeutic management.

Angioid streaks are visible irregular crack-like dehiscences in Bruch’s membrane that are associated with atrophic degeneration of the overlying retinal pigmented epithelium. Angioid streaks may be associated with pseudoxanthoma elasticum, Paget’s disease, sickle-cell anemia, acromegaly, Ehlers–Danlos syndrome, and diabetes mellitus, but also appear in patients without any systemic disease. Patients with angioid streaks are generally asymptomatic, unless the lesions extend towards the foveola or develop complications such as traumatic Bruch’s membrane rupture or macular choroidal neovascularization (CNV). The visual prognosis in patients with CNV secondary to angioid streaks if untreated, is poor and most treatment modalities, until recently, have failed to limit the devastating impact of CNV in central vision. However, it is likely that treatment with antivascular endothelial growth factor, especially in treatment-naive eyes to yield favorable results in the future and this has to be investigated in future studies.

Acquired color vision and visual field defects in patients with ocular hypertension and early glaucoma

Purpose: To study acquired color vision and visual field defects in patients with ocular hypertension (OH) and early glaucoma. Methods: In a prospective study we evaluated 99 eyes of 56 patients with OH without visual field defects and no hereditary color deficiencies, followed up for 4 to 6 years (mean = 4.7 ± 0.6 years). Color vision defects were studied using a special computer program for Farnsworth–Munsell 100 hue test and visual field tests were performed with Humphrey analyzer using program 30–2. Both tests were repeated every six months. Results: In fifty-six eyes, glaucomatous defects were observed during the follow-up period. There was a statistically significant difference in total error score (TES) between eyes that eventually developed glaucoma (157.89 ± 31.79) and OH eyes (75.51 ± 31.57) at the first examination (t value 12.816, p < 0.001). At the same time visual field indices were within normal limits in both groups. In the glaucomatous eyes the earliest statistical significant change in TES was identified at the first year of follow-up and was −20.62 ± 2.75 (t value 9.08, p < 0.001) while in OH eyes was −2.11 ± 4.36 (t value 1.1, p = 0.276). Pearson’s coefficient was high in all examinations and showed a direct correlation between TES and mean deviation and corrected pattern standard deviation in both groups. Conclusion: Quantitative analysis of color vision defects provides the possibility of follow-up and can prove a useful means for detecting early glaucomatous changes in patients with normal visual fields.

Total extrusion of a silicone encircling band through the muscle insertions presenting as orbital cellulitis

Abstract Introduction: We present an unusual case of anterior migration of a solid silicone encircling band 9 years after scleral buckling surgery. Materials and Methods: An 83-year old woman presented with acute onset of pain and discharge in her left eye. She had undergone cataract surgery complicated by endophthalmitis and managed with pars plana vitrectomy nine years earlier. Results: The patient was treated with transection and removal of the extruding encircling band. Pain ceased within two days. Two weeks postoperatively, the conjunctiva was well adapted without any discharge, ocular motility was as preoperatively. Discussion: Anterior migration of an encircling band through all four rectus muscle insertions is a very uncommon late complication following scleral buckling surgery. The remarkably good preservation of ocular motility in our case can be attributed to the slow advancement of the encircling band over nine years, which allowed a gradual reattachment of the rectus muscle insertions to the sclera.

Spontaneously resolved exudative retinal detachment caused by orbital cellulitis in an immunocompromised adult

Spontaneously resolved exudative retinal detachment caused by orbital cellulitis in an immunocompromised adult

Different Types of Conjunctival Papilloma Presenting in the Same Eye

A 31-year-old Black man presented with two oval masses in his right conjunctiva. The tumors were completely excised and histology showed that the inferior lesion was a conjunctival squamous papilloma with pigmentation while the superior one was an inverted conjunctival papilloma, which grew in an endophytic manner. Follow up examination one year later showed no recurrence. Literature search revealed no previous report of simultaneous appearance of these types of papilloma in the same eye. Management of conjunctival squamous papillomas is difficult and is complicated by multiple recurrences in contrast to inverted conjunctival papillomas where no recurrences have been reported after complete excision. Thus, histopathology is an absolute necessity even when papillomas appear in the same eye.

Nd: YAG capsulotomy for posterior capsule opacification after combined clear corneal phacoemulsification and vitrectomy

Purpose: To evaluate the efficacy and safety of Neodymium:YAG (Nd:YAG) laser capsulotomy for posterior capsule opacification (PCO) following combined phacoemulsification and vitrectomy for the treatment of cataract in association with macular hole (MH) or epiretinal membrane (ERM). Methods: Retrospective clinical study of 34 eyes of 34 patients who underwent combined cataract surgery and vitrectomy, developed PCO, and subsequently underwent Nd:YAG laser capsulotomy. Follow-up examinations included visual acuity measurement, evaluation of intraocular lens (IOL) centration, intraocular pressure (IOP) measurement, and dilated fundus examination. Results: Nd:YAG laser capsulotomy was performed in all 34 eyes. The mean age of the patients was 65.08 years (range 45–87) and the mean follow up period was 11.05 months (range 4–23). The mean time elapsed between the last intraocular operation and the development of PCO was 10.00 months for patients with previous ERM and 15.33 for those with MH (P = 0.001, t-test for equality of means). None of our patients developed recurrence of MH, retinal detachment, IOL dislocation, or permanent IOP elevation. Conclusion: In our study, the most remarkable observation is that no complication occurred after the YAG capsulotomy, possibly because the eyes were vitrectomized and vitreous seems to play an important role in the occurrence of post-Nd:YAG complications. In addition we noted that PCO seems to occur earlier in the eyes undergoing combined surgery for cataract and ERM when compared with those where combined phacoemulsification and vitrectomy are performed for cataract and MH.

Punctal function in lacrimal drainage: the 'pipette sign' and functional ectropion.

The aim was to assess the movements of the inferior punctum during blinking and discuss pertinent clinical applications.

Rapidly enlarging eyelid mass.

Figure. A, Large upper-eyelid pilomatrixoma associated with mechanical ptosis and reddish discoloration of the skin; small chalky nodules can be seen through the skinB, Computed tomography. A 5-year-old girl presented to her primary care physician with a large rapidly enlarging right upper eyelid mass after an accidental trauma to the eyebrow area. The child was otherwise well with no history of constitutional symptoms or pain. Medical history was unremarkable. An initial diagnosis of a nonresolving hematoma was made. After a history of rapid growth over 12 weeks after the initial trauma she was referred to our eye institution (Figure, A). Visual acuity was normal, with no afferent pupillary defect. Findings of the physical examination showed mechanical ptosis with no eyelid erythema, edema, or tenderness. There was a solitary oval-shaped subcutaneous mass, which was firm to palpation. It was not freely mobile from the overlying skin which had reddish-to-blue discoloration with visible calcification. There was no globe proptosis or dystopia, and eye movements were normal. Fundoscopy showed no signs of optic neuropathy. Systemic examination was unremarkable except for an enlarged ipsilateral pre-auricular lymph node. Differential diagnosis included pilomatrixoma, pyogenic granuloma, epidermal and dermoid cyst, capillary hemangioma, juvenile xanthogranuloma, and rhabdomyosarcoma. Computed tomography (Figure, B) urgently was performed to exclude rhabdomyosarcoma. Imaging showed a well-defined superficial ovoid complex mass which enhanced avidly with intravenous contrast administration. It had a central non-enhancing component with few flecks of calcification. There was no intra-orbital extension or underlying bone involvement. Excision biopsy was expedited. The tumor was completely excised through a skin crease incision and submitted en bloc for diagnostic histology. This revealed a well-circumscribed oval nodule measuring 2.3 1.5 cm. There were no intraoperative or postoperative complications. Light microscopy showed sheets of basaloid cells with foci of characteristic shadow cells. Marked inflammatory reaction was noted, dominated by giant multinucleated cells. Histopathologic findings were consistent with a diagnosis of pilomatrixoma, with no evidence of malignancy. Complete surgical excision was curative with no evidence of tumor recurrence during the 6-month follow-up. Eyelid pilomatrixoma is a rare benign neoplasm tumor originating from the matrix of the hair root. It can occur almost anywhere on the body but has a propensity to occur in the head and neck region, often involving the eyelid or eyebrow. It is most commonly seen in children and adolescents, with a slight female predominance existing. Patients

Post-cataract surgery diplopia: aetiology, management and prevention

Diplopia is an infrequent but distressing adverse outcome after uncomplicated cataract surgery. Many factors may contribute to the occurrence of this problem, including prolonged sensory deprivation resulting in disruption of sensory fusion, paresis of one or more extraocular muscles, myotoxic effects of local anaesthesia, optical aberrations (for example, aniseikonia) and pre‐existing disorders (for example, thyroid orbitopathy). The purpose of this review is to present the aetiology and clinical features of diplopia after cataract surgery and to discuss the possible modalities for the prevention and treatment of this frustrating complication.

Difficult indirect carotid-cavernous fistulas – alternative techniques to gaining access for treatment

Aims Carotid-cavernous fistulas (CCFs) are abnormal communications between the carotid arterial system and the cavernous sinus that occur mainly in elderly. Occasionally, treatment of indirect CCFs with conventional endovascular approach through large veins or the inferior petrosal sinus may not be possible. In these cases, a direct surgical cut down on to the superior ophthalmic vein (SOV) is necessary. We describe three such cases of embolization of CCFs through SOV, and their results. Methods A retrospective case notes review of treated patients over the past 10 years in one tertiary center constituted our methodology. Results The fistulas in two cases were successfully coiled with complete obviation of symptoms and signs. The third case was complicated due to difficulty in canulating a deeply seated vein and so had to be abandoned and catheterized through contralateral superior petrosal sinus and treated with liquid embolic material Onyx® successfully. Conclusion In cases where conventional access to the cavernous sinus may not be possible due to local variations of anatomy, multidisciplinary surgical approaches via the SOV provide an alternative route to successfully and safely close a CCF. However, unexpected anatomical variations could also be encountered within the SOV for which the surgeon should be prepared.