J Singh

Floppy iris behaviour during cataract surgery: associations and variations

Aim: To assess the association of floppy iris behaviour during cataract surgery with use of α-1-antagonists and diabetes mellitus. Methods: 1842 eyes of 1786 patients undergoing phacohoemulsification surgery were prospectively enrolled. The use of commonly prescribed α-1-antagonists and the presence or absence of diabetes mellitus were noted. The occurrence of any of the features of the intraoperative floppy iris syndrome (IFIS) was noted by surgeons blinded to the patient’s history. Results: 57% of patients receiving tamsulosin showed features of IFIS compared with 1% of the non-tamsulosin group (p<0.001). Of these, more than half the patients manifested the syndrome in an incomplete form. Only 1 of the 51 patients receiving other α-1-antagonists had IFIS. Diabetes was also not associated with IFIS (p = 1). Conclusions: Tamsulosin is significantly associated with floppy iris behaviour during cataract surgery. But not all of these patients will necessarily show all or any features of IFIS. The floppy iris syndrome is likely to represent a continuum of severity. Various undefined factors, diabetes not being one of them, may have a contributory role. Non-selective α-1-antagonists are unlikely to be associated with IFIS.

Success rate and complications of intraoperative 0.2 mg/ml mitomycin C in trabeculectomy surgery

Adjunctive chemotherapy with Mitomycin C (MMC) has been used in an attempt to modulate the wound healing response in glaucoma filtration surgery. A consecutive series of 20 eyes from 18 patients undergoing trabeculectomy with MMC intraoperatively was studied. Sixteen cases were considered high risk regarding surgical success and 4 patients with low tension glaucoma (LTG) required lower intraocular pressure (IOP) to prevent further visual field loss. Surgical technique involved the use of a limbal-based conjunctival flap and MMC 0.2 mg/ml applied via a sponge (under the scierai flap) to both scierai and conjunctival surfaces for 5 minutes. The mean follow-up period was 12.7 months (range 3-24). There were 17 successful eyes. Of these, 14 are high pressure glaucoma eyes with a mean pre-operative IOP of 30.9 ± 10.9 mmHg and a mean postoperative IOP of 15.3 ± 5.2 mmHg (p = 0.001). The remainder of the successful cases include 4 patients with LTG with a mean pre-operative IOP of 17.8 ± 0.5 mmHg and a mean postoperative IOP of 6.8 ± 0.7 mmHg (p = 0.001). Serious complications included chronic repeated bleb leaks (n = 2) and scierai necrosis (n = 2). There was one case of hypotonous maculopathy. These results are comparable with those of other studies. Despite a relatively low dose of MMC serious side-effects were encountered. Management of these complications is described, and how these effects may be prevented by altering scierai exposure to MMC. In addition a possible explanation for the serious side-effects of MMC-treated trabeculec-tomies is presented.

Enhancement of post trabeculectomy bleb formation by laser suture lysis.

AIMS: To study the efficacy of laser suture lysis in the promotion of filtration and bleb formation during the early postoperative period after trabeculectomy. METHODS: This was a prospective study of 20 eyes from 20 patients undergoing trabeculectomy. Patients were entered into the study if, after a trial period of ocular massage, the intraocular pressure (IOP) was greater than 21 mm Hg 48 hours after surgery. Other criteria for inclusion were a deep quiet anterior chamber, no bleb formation, and a patent internal ostium on gonioscopy. Suture lysis was performed using a frequency doubled neodymium YAG (532 nm) laser and a Hoskins lens. The IOP was measured within 5 minutes of lysis and gentle ocular massage was employed if there was no spontaneous bleb formation. A further suture was lysed if at this stage there was still no bleb associated with a high IOP. RESULTS: Suture lysis was successful in all cases in the early postoperative period. The mean IOP before lysis was 33.8 (SD 8.9) mm Hg and the IOP immediately after lysis was 13.2 (7.9) mm Hg. Eighteen (90%) patients had successfully controlled IOP (mean 14.1 (3.6) mm Hg) without medication after a mean follow up of 6 months. CONCLUSION: Laser suture lysis is a safe and effective method of promoting filtration following trabeculectomy. It can avoid surgical manipulation of the scleral flap with its associated risks of bleb failure and thereby contributes to a successful operative outcome.

Perfluorodecalin-induced intravitreal inflammation.

Objective To report an unusual case of intravitreal inflammation in a human eye caused by the presence of residual perfluorodecalin in a case of giant retinal tear and retinal detachment. Methods The posterior capsule of the lens, which was infiltrated with deposits, was collected during surgery. The specimen was stained with hematoxylin and eosin, with periodic acid-Schiff, and for melanin. Part of it was examined with electron microscopy. Immunohistochemical staining was performed to demonstrate CD68 antigens, cytokeratin, and glial fibrillary acid protein. Results Vacuolated macrophages and retinal pigment epithelial cells infiltrated the posterior capsule. Electron microscopy showed the presence of membrane-lined vacuoles within the macrophages. A monolayer of epithelial cells covered the cellular infiltration. Conclusion Residual perfluorodecalin can induce an intraocular chronic macrophage response.

Cracked cartridges during foldable intraocular lens implantation

Abstract We describe five routine phacoemulsification procedures in which a longitudinal split in the injector cartridge occurred during foldable intraocular lens (IOL) implantation. In some cases, this was associated with a broken lens. All lenses (STAAR AA‐4203VF) were folded, and implantation was attempted through a 3.5 mm corneal or scleral incision. Visual outcome was not adversely affected in any case. The systems for introducing foldable IOLs have not been perfected, and further refinements in materials and techniques are required.

Retinal detachment in Scotland is associated with affluence

Aim: Socio-economic deprivation plays a major role in health and disease, but its role in retinal detachment has not been studied. Data from the Scottish Retinal Detachment Study were used to investigate any association between retinal detachment, macular status at presentation and deprivation. Methods: Prospective multicentre population-based observational study. Data were collected on all patients with primary retinal detachment presenting in Scotland between 1 November 2007 and 31 October 2008. Every patient was allocated a validated deprivation ranking according to their postcodes based on the Scottish Index of Multiple Deprivation (SIMD), which takes into account income, employment, health, education, housing, geographic accessibility and crime in 6505 postcode-based datazones. The patients were divided into four quartiles according to their SIMD ranking. Results: 572 patients were included. The annual incidence of detachment declined from 15.4/100 000 in the most affluent quartile to 13.6/100 000 in the second, 9.3/100 000 in the third and 6.9/100 000 in the most deprived (χ2 for trend = 50.2, p<0.0001). The trend was more marked for men than for women but was present in both sexes. There were no differences in the rate of macula-off detachments or the number of quadrants detached. Rates of pseudophakic and myopic detachment were evenly distributed across all quartiles. Conclusions: Retinal detachment appears to be associated with affluence. This has not been previously reported and may be partly responsible for the variation in estimates of the incidence of retinal detachment. It may also have implications for service planning. The reason for this association is unknown.

Cataract classification system for risk stratification in surgery

Risk stratification for cataract surgery is an important step for a patient proceeding with cataract surgery. It allows the surgeon to have a more meaningful discussionwith the patient regarding individualized risk, and it means that hospital/surgeon statistics can be compared accurately, which is important for revalidation purposes. There are advantages for trainees in that low-risk patients can be used for more junior trainees or for trainee-independent lists and high-risk patients can be used for more senior trainees. Patients benefit from information about the surgeon grade in their cataract journey. Three scoring systems for the prediction of posterior capsule rupture during phacoemulsification

Total exudative detachment as a first presentation of von Hippel Lindau disease

Von Hippel Lindau disease is a rare condition characterised by retinal and central nervous system haemangioblastomas. It is also associated with renal cell carcinoma, phaeochromocytoma, and renal, pancreatic, and epididymal cysts. The disease usually presents with neurological symptoms and/or visual disturbance; angiomas if seen in the retina can often be treated in an attempt to prevent progression to retinal detachment. We report a young girl with von Hippel Lindau disease whose initial presentation was with a total exudative retinal detachment. A 14 year old girl presented to the eye casualty department with no perception of light in her left eye. She gave a 2 month history of gradual, painless loss of vision, but had delayed previously mentioning her symptoms. Past ocular history was unremarkable; an optometrist visit a year previously was normal. She was otherwise well. Slit lamp examination on the left …

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.

Use of pegaptanib in the treatment of vitreous haemorrhage in idiopathic retinal vasculitis.

Use of pegaptanib in the treatment of vitreous haemorrhage in idiopathic retinal vasculitis