Igal Leibovitch

The efficacy of optic nerve ultrasonography for differentiating papilloedema from pseudopapilloedema in eyes with swollen optic discs

Purpose:u2002 To evaluate the diagnostic yield of optic nerve ultrasonography (US) in distinguishing between papilloedema (swollen discs owing to raised intracranial pressure) and pseudopapilloedema.

OCT assessment of morphological changes of the optic nerve head and macula in idiopathic intracranial hypertension

OBJECTIVEnTo assess the morphologic changes of the optic nerve head and macula in patients with idiopathic intracranial hypertension (IIH) with optical coherence tomography (OCT).nnnMETHODSnData was extracted from the medical records and Stratus OCT images of IIH patients.nnnRESULTSnNinety-one eyes of 48 IIH patients were divided into 3 groups according to their clinical optic disc appearance. Average retinal nerve fiber layer (RNFL) thickness was statistically different between the groups: normal optic disc/mild elevation group (N=20) - 89 μm (95% CI, 80-98 μm), mild elevation group (N=51) - 109 μm (95% CI, 101-117 μm), and papilledema group (N=20) 124 μm (95% CI, 100-153 μm) (P=0.004). Fast macular thickness map did not demonstrate a significant difference between the groups for most measured macular areas (N=49 eyes).nnnCONCLUSIONSnPeripapillary RNFL measurements correlated with the clinical appearance of the optic discs, suggesting that OCT may assist in the follow up of IIH patients.

Lateral wedge resection: a simple technique for repairing involutional lower eyelid entropion.

BACKGROUND Lower lid involutional entropion is a common eyelid pathology affecting the elderly population. Most of the reported surgical techniques are mainly based on a lateral tarsal strip anchored to the orbital rim. OBJECTIVES To report the surgical outcome using a simple single‐stitch lateral wedge technique to repair involutional lower entropion. METHODS This single‐surgeon, retrospective, noncomparative cases series included all patients with involutional lower eyelid entropion who were operated on using the lateral wedge technique. RESULTS Fifty‐eight eyelids of 52 patients (46 unilateral, 6 bilateral; 27 men, 25 women; age, mean 67±10; range 50–85) underwent surgical repair. Immediate resolution of entropion and associated ocular symptoms was achieved in 55 eyelids (94.9%). One case had postoperative ectropion that completely resolved spontaneously after 4 weeks, and one had wound dehiscence that healed completely without any intervention. Another patient had residual entropion that resolved after an additional surgical repair. No other cases of recurrence were noted during a mean follow‐up period of 16 months (range 6–24 months). CONCLUSION This minimally invasive single‐stitch lateral wedge technique is a simple and effective procedure for repairing involutional lower eyelid entropion and is associated with low recurrence and complication rates. Igal Leibovitch, MD, has indicated no significant interest with commercial supporters.

Colour Doppler ultrasound imaging findings in paediatric periocular and orbital haemangiomas

Purpose:u2002 To evaluate the combined grey‐scale ultrasonography (US) and colour Doppler imaging (CDI) as the first and primary imaging modalities in diagnosing paediatric orbital haemangiomas.

Induced sputum for identifying sarcoidosis in patients with uveitis.

OBJECTIVEnTo evaluate the value of the induced sputum technique in diagnosing sarcoidosis as the cause of uveitis.nnnDESIGNnComparative case series.nnnPARTICIPANTSnSeventeen patients with uveitis. Two control groups were used. The first included 10 patients with sarcoid without uveitis; the second included 5 healthy volunteers.nnnTESTINGnSputum was induced by a 20-minute inhalation of 3.5% saline using an ultrasonic nebulizer. Samples were studied by differential counts of 200 cells on cytopreps stained by Giemsa. T lymphocyte subset analyses were done by fluorescence-activated cell sorter using the monoclonal antibodies CD4 (T helper cells) and CD8 (T suppressor-cytotoxic cells). Angiotensin-converting enzyme (ACE) serum levels were obtained.nnnMAIN OUTCOME MEASURESnA CD4/CD8 ratio >2.5 and an ACE level >145 microl/ml/minute were considered to be abnormal.nnnRESULTSnThe difference in the CD4/CD8 ratios in the induced sputum examination between the group of patients with an elevated ACE level and the group of patients with an ACE level within normal limits was statistically significant (P = 0.0001).nnnCONCLUSIONSnThe induced sputum examination showed increased CD4/CD8 ratios in patients with uveitis who also had elevated ACE levels, suggesting the presence of sarcoidosis.

Unexpected pathologies in patients referred for endoscopic DCR

The objective of this study is to describe a series of patients with different pathologies mimicking nasolacrimal duct obstruction (NLDO), diagnosed with the use of a computed tomography (CT) scan prior to a scheduled endoscopic dacryocystorhinostomy (DCR). This study is a retrospective report. We reviewed the medical records of 47 consecutive patients (57 sides) with long-standing epiphora between 2007 and 2012. All patients were referred to our tertiary Medical Center with a diagnosis of NLDO and were expected to undergo endoscopic dacryocystorhinostomy (DCR). They all underwent routine sinus CT scan prior to surgery. All scans, as well as the demographic and medical characteristics of these patients were reviewed. Of all 47 patients enrolled, in 4 patients (7xa0% of all sides), unexpected pathologies, other than nasolacrimal system distention, inflammation or infection were identified preoperatively. These included squamous cell carcinoma of the lacrimal sac and nasolacrimal duct, rhinoscleroma at Hasner’s valve region, a compressing ethmoidal mucocele and a case of dacryocystocele. These unusual pathologies mandated a different management and surgical approach. In all four cases, a preoperative CT scan helped in identifying the pathology and in localizing the lacrimal apparatus in relation to the paranasal sinuses. Different nasal, paranasal and lacrimal pathologies may mimic primary acquired NLDO. A high index of suspicion, a thorough clinical evaluation and utilizing preoperative imaging may lead to an alteration of patient management and to a completely different surgical approach.

Adie’s Tonic Pupil-Induced Angle-Closure Glaucoma

A 52-year-old woman was diagnosed as having Adie’s tonic pupil in her right eye. She reported few episodes of blurring of vision in her right eye in the recent few months. On one of the routine follow-up visits, right intraocular pressure (IOP) was 70 mm Hg and on gonioscopy the angle was closed 360°. Medical treatment resulted in IOP reduction and laser iridotomy was then performed. This is, to our knowledge, the first description of intermittent angle-closure glaucoma attacks induced by a tonic pupil. The possibility of angle-closure glaucoma should be considered in patients with a tonic pupil, especially with symptoms of blurred vision or ocular pain.

Early loss of monocanalicular silicone tubes in congenital nasolacrimal duct obstruction: Incidence, predictors, and effect on outcome

PURPOSEnTo study predictors and implications on outcome of premature silicone tube-loss, a post-operative complication of monocanalicular intubation (MCI) performed for treatment of congenital nasolacrimal duct obstruction (CNLDO).nnnMETHODSnWe conducted a retrospective analysis of cases of post-operative loss of monocanalicular silicone tubes occurring at one medical center from January 2007 to December 2013.nnnRESULTSnDuring the study period monocanclicular silicone tubes were lost in 24/54 eyes (44%) of 19/46 children. Multivariate regression analysis identified bilateral intubation as an important predictor of early tube-loss (r=0.54, P=0.006). Seven of eight (88%) children who had both eyes intubated prematurely lost their tubes compared to 12/38 (32%) children who had unilateral intubation (P=0.005). Treatment success was lower in eyes with early tube-loss (17/24 eyes, 71%) compared to eyes with full tube retention (25/30 eyes, 83%), however this difference was not statistically significant (P=0.333). In our study, treatment outcome correlated with duration of intubation (r=0.51, P=0.002). Surgical success was achieved in 33/39 eyes (85%) in which the tubes were retained at least 2 months compared to 7/15 eyes (47%) with shorter period of intubation (P=0.012).nnnCONCLUSIONSnSpontaneous tube-loss is a post-operative complication of monocanalicular silicone intubation that can occur more frequently than previously reported in certain populations. Tube-loss occurring soon after surgery is often associated with persistent symptoms and increased need of reoperation.

Avoiding dacryocystorhinostomy in cases of epiphora caused by inferior meatus obstruction

AimsTo determine the role of inferior meatus pathologies as an underdiagnosed cause of epiphora.MethodsThis study was conducted in the oculoplastic institution of Tel Aviv medical center—a regional referral center. A retrospective review of files of patients presenting to the lacrimal clinic with nasolacrimal duct obstruction between October 2010 and September 2016. Cases in which a pathology of the inferior meatus was identified and treated are presented in this article.ResultsDuring this time frame, we preformed 186 endoscopic dacryocystorhinostomy surgeries. Out of those, eight patients (4.3%) were diagnosed and treated for pathology causing an obstruction of the inferior meatus. Seven of our patients were females; the mean age was 24 years. A wide range of pathologies were found: cysts, dacryoliths, membranes obstructing the inferior meatus, and concheal obstruction. All patients went through endoscopic treatment targeted at the cause of obstruction. During follow-up (average 35 months) only two patients remained symptomatic and were referred for an endonasal endoscopic dacryocystorhinostomy.ConclusionsInferior meatus obstruction is an underdiagnosed cause of epiphora. Multiple pathologies may co-exist in the same patient. In select cases of NLDO, diagnosis and treatment can be done endoscopically, avoiding the need for dacryocystorhinostomy.

Recurrent orbital inflammation in a patient with multiple sclerosis treated with interferon‐beta

described in the literature as being opacified to some degree. In this case, however, the fluid was entirely transparent and there was a shallow anterior chamber, which are both said to be features of the early rather than the late type of CBS. However, the time of presentation was far beyond the 2-week postoperative window for the early type of CBS. This case is significant as it highlights the need for one to be vigilant for distension of the capsular bag, even in the absence of an opacified substance, long after the normal window for occurrence of transparent fluid early CBS of 1 day to 2 weeks has passed. Such a presentation might be even more pertinent in an eye that lacked posterior capsule opacification, where a bowed posterior capsule with an accumulation of transparent fluid could be a subtle sign that might be missed upon examination unless specifically looked for. All those caring for patients who have undergone cataract surgery should be aware of these features, including the very late presentation of a transparent form of CBS described here.