Guy J. Ben Simon

Retrospective Analysis of Vitrectomy With and Without Internal Limiting Membrane Peeling for Stage 3 and 4 Macular Hole

BACKGROUND AND OBJECTIVEnTo evaluate the efficacy and safety of pars plana vitrectomy with indocyanine green (ICG)-assisted internal limiting membrane (ILM) peeling versus pars plana vitrectomy without ILM peeling for stage 3 and 4 primary idiopathic macular hole.nnnPATIENTS AND METHODSnSixty-two eyes of 60 consecutive patients with idiopathic macular hole underwent vitrectomy with gas (C3F8) injection. The first 46 eyes underwent vitrectomy without ILM peeling; of these, 14 had epiretinal membrane peeling and were excluded, leaving 32 eyes (no ILM group). The remaining 16 eyes underwent vitrectomy with ICG-assisted ILM peeling (ICG-ILM group). Follow-up data at 6 to 48 months postoperatively were recorded and analyzed.nnnRESULTSnMacular hole closure was achieved in 13 (81%) of 16 patients in the ICG-ILM group and 16 (50%) of 32 patients in the no ILM group (P = .036). Analysis of the data from eyes with closed holes indicates that the ICG-ILM group achieved a better mean final visual acuity compared with the no ILM group (20/60 vs 20/100, respectively) (P = .017). No complications were attributed to the use of ICG.nnnCONCLUSIONSnICG-assisted ILM peeling significantly increased the rate of hole closure in eyes with stage 3 or 4 idiopathic macular hole. The use of ICG did not adversely affect the visual acuity results, and it appears to be a safe adjunct to macular hole surgery.

Correction of pre-existing astigmatism during cataract surgery: comparison between the effects of opposite clear corneal incisions and a single clear corneal incision

BackgroundOpposite clear corneal incisions (OCCIs) have been reported to reduce pre-existing astigmatism (PEA) during cataract surgery. Our goal was to evaluate the effect of OCCIs on correcting PEA in cataract surgery.MethodsNon-randomized prospective study. Thirty-four patients with PEA of greater than 1.5 diopters (D) underwent clear cornea phacoemulsification cataract extraction with 3.2-mm OCCIs (OCCI group). The control group consisted of 23 successive patients with PEA <1.5xa0D who underwent cataract extraction without OCCI. Best-corrected visual acuity, keratometry and refraction were recorded for all patients pre-operatively and post-operatively.ResultsUsing keratometric findings, mean astigmatism correction was 1.3xa0D (±0.9 SD; decreased from 2.6xa0D pre-operatively to 1.4xa0D post-operatively) in the OCCI group but only 0.4xa0D in the control group (P<0.005), 8 months post-operatively. Vector analysis of astigmatism correction showed greater change for OCCI patients (1.8xa0D vs 1.0xa0D, P=0.002). Using the Holladay method for calculating surgically induced refractive change (SIRC), the OCCI group showed a higher value of SIRC (−1.6xa0D vs −0.97xa0D), but this was not statistically significant. The OCCI patients showed a greater and significant change in refraction spherical equivalent than the controls. No complications related to OCCI or cataract surgery occurred during the follow-up period.ConclusionsOpposite clear cornea incision seems to be a simple, predictable, safe and effective procedure in reducing pre-existing corneal astigmatism in cataract surgery. It has an enhanced effect in correcting astigmatism compared to a single clear cornea incision when using keratometric findings value but not when using refractive data. Future studies are needed to document the long-term effect of OCCI and to evaluate the correlation between incisions of different size and astigmatism correction.

Larger Osteotomies Result in Larger Ostia in External Dacryocystorhinostomies

OBJECTIVEnTo evaluate whether final ostium size is determined by the osteotomy created during dacryocystorhinostomy (DCR).nnnDESIGNnProspective nonrandomized study. Intraoperative measurements of bony osteotomy were taken during external DCR. Endonasal endoscopy with functional endoscopic dye testing and internal ostium photography were performed 3 months after surgery.nnnRESULTSnFifty patients (mean age, 63 years) underwent 55 DCRs. Postoperative nasal endoscopy with functional endoscopic dye testing was performed in 27 cases (49%), and measurements of intranasal ostia were feasible in 24 of them (86%). The mean follow-up time was 7 months (range, 3-12 months). Surgical success was achieved in 25 of 27 patients (93%) who underwent postoperative nasal endoscopy. There was no difference in either the intraoperative osteotomy size or the postoperative ostium size between failed and successful cases. The mean (SD) intraoperative osteotomy size was 256.3 (89.0) mm(2), and the mean (SD) postoperative ostium size was 9.6 (6.7) mm(2). The intraoperative osteotomy size correlated positively with the postoperative intranasal ostium size (r = 0.45; P = .03, Pearson bivariate correlation).nnnCONCLUSIONSnLarger osteotomies created during external DCR are correlated with larger postoperative ostia as measured by endonasal endoscopy and image analysis software. There is a trend toward greater success with larger osteotomies; however, failed cases in this series were not associated with smaller-sized intraoperative osteotomies.

En bloc excision in malignant tumors of the lacrimal drainage apparatus

Purpose: To describe the surgical technique and results of en bloc excision in a series of patients with extensive malignant tumors of the lacrimal drainage apparatus (LDA). Methods: This was a noncomparative, retrospective chart review of the clinical and pathologic findings of 11 patients presenting with a malignant tumor affecting the LDA who underwent en bloc excision of the lacrimal system. Results: Of the 11 patients, 7 were male. The mean age at presentation was 58 years (range, 39 to 81 years), and all cases were unilateral. Histopathology revealed 4 squamous cell carcinomas, 3 transitional cell carcinomas, 2 mucoepidermoid carcinomas, and 2 melanomas. Epiphora and a mass were the most common presentations. An external lesion could be identified in 4 cases. Irrigation of the lacrimal system revealed nasolacrimal duct obstruction in 2 cases and common canaliculus obstruction in another 2 patients. The entire LDA and surrounding bony tissues were excised through a lateral rhinotomy approach. Adjuvant radiotherapy was given in 4 cases. Nine patients remain alive and well after a mean follow-up of 2 years (range, 6 months to 7 years). Three cases showed distant disease and 2 patients died of metastatic melanoma involvement. Conclusions: The use of en bloc excision as a radical treatment to remove the complete LDA and surrounding bony structures affords good local tumor control and may provide the best opportunity for enhanced patient survival.

Delayed Epistaxis in External Dacryocystorhinostomy: Rate and Risk Factors

OBJECTIVEnTo report the incidence and risk factors associated with delayed epistaxis (2-8 days after the procedure) after external dacryocystorhinostomy (DCR).nnnDESIGNnWe identified and analyzed all cases of patients who underwent external DCR procedures at 2 institutions from January 1999 through December 2005. Cases of delayed epistaxis and their final surgical outcome were compared with those without it.nnnSETTINGnAll patients who underwent surgery and were examined at 2 public hospitals in Melbourne, Australia.nnnPATIENTSnA total of 374 patients who underwent 437 DCRs.nnnINTERVENTIONSnMedical treatment, hospitalization, and endonasal examination with cautery.nnnMAIN OUTCOME MEASURESnRate of delayed epistaxis and current and past use of antiplatelet medications.nnnRESULTSnOf the 374 patients (mean [SD] age, 62 [18] years; 280 [75%] were women) who underwent 437 external DCRs, 15 (3.4%) had an episode of delayed epistaxis. They were generally older and more likely to have a history of active dacryocystitis compared with those who did not develop delayed epistaxis. Preoperative use of aspirin, nonsteroidal anti-inflammatory drugs, or warfarin sodium was not associated with delayed epistaxis or poorer surgical outcome if these anticoagulants were discontinued preoperatively as instructed. None of the 15 patients with delayed epistaxis had continued ingesting anticoagulants before undergoing DCR. Patients who developed epistaxis (80%) had a significantly lower rate of satisfactory surgical outcome than those who did not (90%) (P = .02).nnnCONCLUSIONnThe risk of delayed epistaxis should be similar for patients taking or not taking anticoagulant agents if their use is stopped within a defined period of time before DCR.

Cryo‐assisted anterior approach for surgery of retroocular orbital tumours avoids the need for lateral or transcranial orbitotomy in most cases

Acta Ophthalmol. 2010: 88: 675–680

Comparison of lateral orbital decompression with and without rim repositioning in thyroid eye disease

PurposeRim-off lateral wall decompression may be associated with functional and cosmetic deficit. Our objective, therefore, was to describe the functional and cosmetic results of deep lateral orbital decompression with and without anterior rim repositioning for thyroid eye disease.MethodsIn this retrospective comparative case series all consecutive thyroid eye disease patients who underwent deep lateral wall decompression at the Royal Victorian Eye and Ear Hospital between 1990–2007 and the Goldschleger Eye Institute, Sheba Medical Center between 2008–2011 were included. Patients were divided into two groups: the “rim-on” group in which the anterior lateral orbital rim was repositioned and the “rim-off” group in which it was left off. Main outcome measures were: proptosis reduction, postoperative oscillopsia and diplopia, presence of visible or palpable lateral orbit depression.ResultsOne hundred and twelve patients who underwent 186 orbital decompressions were included in the final analysis. The average proptosis reduction for two- and three-wall decompressions ranged between 4.6-4.9xa0mm in the rim-on and 4.6-5.7xa0mm in the rim-off group respectively. The prevalence of postoperative oscillopsia was similar in both groups. The preoperative diplopia worsened in 17 patients (32.1xa0%) in the rim-on group and in seven patients (12.3xa0%) in the rim-off group (Pu2009=u2009.02, chi-square test). None of the patients developed visible or palpable lateral orbit depression.ConclusionsDeep lateral orbital decompression without anterior rim repositioning may be an effective approach to enhance functional and cosmetic outcomes in thyroid eye disease patients without increasing the risk of lateral wall depression or postoperative oscillopsia.

Therapeutic contact lenses vs. tight bandage patching and pain following pterygium excision: a prospective randomized controlled study

PurposeThe immediate postoperative management of patients undergoing pterygium excision usually includes eye patching in order to alleviate pain and prevent accidental tissue damage. Commonly applied tight patching with gauze bandages results in decreased field of monocular vision and discomfort. The aim of this study was to evaluate the patient-centered outcome of pterygium surgery when therapeutic contact lenses (TCL) are used instead of tight bandage patching in the first 24 postoperative hours.MethodsProspective randomized controlled study. Sixty patients with primary pterygium who underwent pterygium surgery consisting of conjunctival autografting with 10–0 Vicryl sutures were randomized into two groups, bandaged with TCLs and tight bandage patching.Main outcome measures: Degree of pain on an 0–10 scale, use of pain killers, level of patient discomfort, sleep quality, and visual acuity (VA).ResultsSixty patients were studied. The pain level and pain duration during the first postoperative day was significantly lower in the tight bandage patching group compared with the TCL group (Pu2009=u20090.034, Pu2009=u20090.04 respectively). Sleep quality was significantly poorer in the TCL group (Pu2009=u20090.004). The VA on the first postoperative day was similar for the two groups.ConclusionsThe application of TCL in the first 24xa0h after pterygium surgery resulted in more discomfort and pain and decreased quality of sleep compared with tight bandage patching. Despite the limitation in monocular vision and the inconvenience of gauze bandages, they are preferred over TCL for alleviating pain following pterygium surgery.

Lateral orbitotomy in the management of challenging exotropia.

The authors present an unorthodox surgical approach to reach the posterior segment of the lateral rectus muscle through a lateral orbitotomy and to manage difficult cases of recurrent exotropia. A review of the records of two patients with recurrent exotropia was done. After an anterior approach had been demonstrated to be inadequate due to shortening or fibrosis of the anterior part of this muscle following repeated surgeries, both patients underwent a lateral orbitotomy to reach the posterior segment of the lateral rectus muscle. Both patients achieved satisfactory ocular alignment following surgery with stable results, showing that this approach is a safe and effective surgical procedure.

Lower Lid Canthopexy Through Upper Lid Incision

Some surgeons routinely perform canthopexy in lower eyelid blepharoplasty. This can be done through a lower or upper eyelid. It eliminates unnecessary skin resection and is believed to restore tone and youthful contour.1