Harry Bennett

Neurofibromatosis type 1 presenting with Horner's syndrome

Committee about childhood screening for amblyopia. We hope the very large number of ophthalmologists who support BOSU, including those who contributed specifically to our study, will be reassured about the quality and value of work undertaken through BOSU. Far from employing ‘suspect methodology’, BOSU uses a well-established approach to provide a unique and powerful resource for the epidemiological study of uncommon ophthalmic disorders, which is envied outside the UK. The BOSU ensures that an evaluation of ascertainment is included in the study methodology and reported as part of the findings. In time, the studies undertaken through it can be expected to contribute a significant body of evidence on which clinical practice and policy will be basedFas the example of the British Paediatric Surveillance Unit, now in its 17th year and on which BOSU is modelled, so clearly shows. It would be a great pity if BOSU were prevented from fulfilling this potential role in ophthalmology in the UK.

Does a small central Nd:YAG posterior capsulotomy improve peripheral fundal visualisation for the vitreoretinal surgeon?

BackgroundTo evaluate the effect of Nd:YAG capsulotomy for posterior capsular opacification (PCO) on visualisation of the peripheral fundus with scleral indentation.MethodsPatients undergoing Nd:YAG capsulotomy for PCO were examined pre- and four weeks post- Nd:YAG capsulotomy. In order to give a quantitative measure of visualisation of the peripheral retina, a novel scalar measurement was developed. Changes in the degree of visualisation following Nd:YAG capsulotomy were calculated.ResultsThere was a significant improvement in fundal visualisation of the retinal periphery with scleral indentation following Nd:YAG capsulotomy (p = 0.001).ConclusionPeripheral fundal visualisation with scleral indentation improves following a small central Nd:YAG capsulotomy. This finding is important in relation to the detection of peripheral pseudophakic retinal breaks, particularly in those patients deemed at high risk following Nd:YAG capsulotomy.

Corneal endothelial evaluation after phacoemulsification and silicone oil removal via an anterior approach.

Purpose: To determine the effect of simultaneous phacoemulsification and silicone oil removal via an anterior approach on the endothelial cell density (ECD). Methods: In this prospective study, the authors measured the ECD before and 6 weeks after surgery using an automatic noncontact specular endothelial microscope. Nine patients underwent phacoemulsification and silicone oil removal via an anterior approach using a closed system and separation of irrigation/aspiration function. Results: Of nine patients, four (five eyes) were diabetic and five (five eyes) were nondiabetic. The postoperative ECD of the entire population was statistically different (P < 0.01) from baseline and the average endothelial cell loss was 6.7%. Conclusions: Combined phacoemulsification and silicone oil removal via an anterior approach using a close system and separation of irrigation/aspiration function is safe to the corneal endothelium.

Delayed opacification of a PMMA intraocular lens.

In recent years, several forms of intraocular lens (IOL) opacification have been reported. Hydrophilic acrylic IOLs have been explanted for granulations within their optics, which are thought to be calcific in nature. Central haziness has been noted in early-generation silicone IOLs and more recently in the Hydroview IOL. In addition, surface calcification has been seen in hydrophilic and hydrophobic acrylic IOLs. Opacification of IOLs made of poly (methyl methacrylate) (PMMA), however, is less common. We recently reviewed a 79-year-old man complaining of gradual loss of vision in both eyes and metamorphopsia in the right eye. The patient had had successful small-incision extracapsular cataract surgery in the right eye with implantation of a 3-piece Domilens IOL (PMMA optic) 8 years earlier, followed by a similar procedure using an identical IOL 4 years later. The procedures were uneventful, and there was no report of intraoperative IOL damage. On discharge, visual acuity was limited to 6/12 N8 in both eyes due to coexisting age-related macular degeneration (ARMD) but no IOL abnormality was noted. Our examination revealed a deterioration of visual acuity to 6/24 N18 in the right eye and 1/60 N48 in the left eye with concomitant worsening of the ARMD in both eyes. More surprisingly, discrete white areas of snowflake-like opacification were seen within the substance of the IOL in the left eye. A diffuse central haziness was also noted within the IOL optic (Figure 1, left). The older, identical IOL in the right eye was clear (Figure 1, right). There was no significant posterior capsule opacification in either eye. Serum calcium was checked and found to be normal. We did not think the patient would significantly benefit from IOL explantation as the ARMD in the left eye was particularly advanced. We reported this case to the suppliers of the Domilens PMMA IOL, but they have not yet replied. Trivedi et al. recently described similar snowflake opacification within the substance of PMMA IOLs.

Risk stratifying retinal breaks.

OBJECTIVE Argon laser retinopexy has been the primary treatment for retinal breaks for many decades. Prevention of progression to retinal detachment (RD) is the main objective. The benefit of laser retinopexy is well documented, although little has been reported on the risk factors for progression to RD. By addressing this issue, patients at high risk can be identified, and more timely specialist retinal input can be sought. METHODS Data over a 6-month period from 45 consecutive patients undergoing laser retinopexy were reviewed. Patients were categorized into complete success (no more than 1 laser treatment), qualified success (no more than 3 laser or cryotherapy treatments), and treatment failure (more than 3 laser or cryotherapy treatments or progression to RD). RESULTS Complete success was observed in 53.5% of patients, a further 34.9% of patients achieved a qualified success, and the remainder of the patients (11.6%) fell into the treatment failure category. About 9.3% of patients required cryotherapy, and 7.0% of patients underwent RD surgery. Patients with a bridging blood vessel and vitreous hemorrhage were significantly more likely to be in the treatment failure category than those without. RD was significantly associated with the presence of vitreous hemorrhage. CONCLUSIONS Patients with retinal breaks associated with bridging blood vessels and vitreous hemorrhage are at greater risk for poorer outcome. The area of subretinal fluid was not linked to failure. If complete laser of a tear is not possible or if concerns remain regarding treatment efficacy, prompt referral to a retina specialist for further management is recommended.

Early Vitrectomy for Spontaneous, Fundus-Obscuring Vitreous Hemorrhage

American Journal of Opthalmology - In Press.Proof corrected by the author Available online since lundi 11 janvier 2016

Retinal detachment following laser retinopexy.

Editor, R etinal breaks have been treated by argon laser retinopexy for many decades (Gratton et al. 1984). Its use was first reported by Zweng (1972) in the 1960s and has since become established as the primary mode of treatment for retinal breaks. Prevention of progression to retinal detachment (RD) is the main objective and is dependent on numerous factors (Levin et al. 2009). Retinal breaks are difficult to treat if they are very anterior and if there is significant subretinal fluid or vitreous haemorrhage present. The benefit of laser retinopexy for symptomatic retinal breaks is well documented (Hyams et al. 1974; Smiddy et al. 1991; Blindbaek & Grauslund 2014), although little information exists regarding and risk of developing RD, despite this being the main objective. We performed a subgroup analysis of all patients recruited in the Scottish retinal detachment study at one centre. Patients who had received prior laser retinopexy were identified, and case notes were retrospectively analysed. We looked at location, size and number of breaks initially treated, the time interval between treatment and RD and whether further breaks were found at the time of RD. Further information such as laser parameters, visual acuity, refractive error, subretinal fluid, vitreous haemorrhage and other co-morbidities were also recorded. Additionally, all patients who had undergone laser retinopexy over the study period were identified from the laser record logbook given that a dated, contemporaneous entry, with patient details, is a mandatory requirement for every laser procedure. From this, we are able to estimate the RD rate following laser retinopexy for retinal breaks. The Scottish retinal detachment study was a prospective populationbased epidemiology study (Mitry et al. 2009). Between 1 November 2007 and 31 October 2009, a comprehensive system was established in which each patient with primary RRD in UK was approached for study inclusion. Criteria for inclusion into this study were patients recruited into the Scottish retinal detachment study at one centre who had received previous laser retinopexy. Nine patients were identified as suitable for inclusion into the study, six male three female with a mean age of 53.7 years. A distinct feature enables these patients to be divided into two groups. Five developed RD within 100 days of the initial retinopexy (early RD); the remaining four developed RD between 747 and 1739 days (late RD). Over this time period, 158 patients underwent laser retinopexy. Five of these patients (early RD group) developed a RD giving a RD rate of 3.16% within 3 years. Four patients had multiple breaks at presentation requiring retinopexy (three early RD, onr late RD); six had significant subretinal fluid of >1 clock hour (four early RD, two late RD). Five patients had vitreous haemorrhage (four early RD, one late RD) at the time of initial retinopexy. All early RDs had new breaks identified at the time of RD, whereas in the late RD group, two patients had new breaks and two had progression from the same break. Laser retinopexy is a safe and effective treatment for symptomatic retinal breaks. Our patients can be divided into early RD and late RD groups, as the two seem to have different characteristics. In our series, early detachments occurred from new or missed breaks. This emphasizes the importance of complete peripheral retinal examination to ensure that breaks are not missed as even those with multiple breaks did not detach early from the treated breaks. Of the patients in the late RD group, two detached from the same treated retinal break. This may be due to initial undertreatment with slow progression, or from minor innocuous ocular trauma, which may progress to RD through areas of weak retinal adhesion. The primary objective when performing a laser retinopexy is to prevent RD. The failure rate of primary laser retinopexy has not been previously reported. Our study provides information regarding the rate of RD following laser retinopexy which may be of benefit when consenting patients to the procedure. Importantly, patients must be informed that despite seemingly adequate initial treatment, some patients still develop RD from new breaks and this may occur after a significant period of time has passed.

Complete Occlusion Of The Anterior Capsular Opening By Fibrocellular Membrane Assoicated With Retained Silicone Oil: A Clinicopathologic Correlation

Background: To report the clinicopathologic features of a fibrocellular membrane in a pseudophakic eye with retained silicone oil in the absence of any capsular contraction syndrome, necessitating repeat anterior capsulorhexis. Methods: Clinicopathologic report of a case. Results: Histopathologic study of the membrane showed absence of any true periodic acid Schiff–positive capsule within the specimen. Clinically, there was no evidence of any anterior capsular contraction. The fibrocellular membrane may have occurred as a result of inflammatory and mechanical effects of silicone oil in the anterior chamber or as a result of the intraocular lens design. Conclusion: The authors report the clinicopathologic features of a fibrocellular membrane occluding the anterior capsular opening in a pseudophakic eye with retained silicone oil, in the absence of any capsular contraction. The stimulus for its formation may have been the inflammatory and mechanical effects of retained silicone oil in the anterior chamber.

Accuracy of biometric formulae in hypermetropic patients undergoing cataract surgery

Purpose: To audit and analyse the accuracy of current biometric formulae on refractive outcomes following cataract surgery in patients with axial length less than 22 mm. Methods: A total of 84 eyes from 84 patients with axial length <22 mm were identified from consecutive patients undergoing cataract surgery retrospectively at a single university hospital. All subjects had biometry using the IOLMaster (Carl Zeiss Meditec, Inc, Dublin, CA, USA) and a Sensar AR40 intraocular lens implant (Abbott Medical Optics, CA, USA). One eye from each patient was randomly selected for inclusion. Prediction errors were calculated by comparing expected refraction from optimized formulas (SRK/T, Hoffer Q, Haigis and Holladay 1) to postoperative refraction. A national survey of ophthalmologists was conducted to ascertain biometric formula preference for small eyes. Results: The mean axial length was 21.00 ± 0.55 mm. Mean error was greatest for Hoffer Q at −0.57 dioptres. There was no significant difference in mean absolute error between formulae. SRK/T achieved the highest percentage of outcomes within 0.5 dioptres (45.2%) and 1 dioptre (76.2%) of target. Shallower anterior chamber depth was associated with higher mean absolute error for SRK/T (p = 0.028), Hoffer Q (p = 0.003) and Haigis (p = 0.016) but not Holladay (p = 0.111). Conclusion: SRK/T had the highest proportion of patients achieving refractive results close to predicted outcomes. However, there was a significant association between a shallower anterior chamber depth and higher mean absolute error for all formulae except Holladay 1. This suggests that anterior chamber depth with axial length should be considered when counselling patients about refractive outcome.