James Scott Schutz

Topiramate-induced acute bilateral angle closure and myopia: pathophysiology and treatment controversies

Purpose TO discuss the unusual features of topiramate-induced acute angle closure glaucoma, its pathophysiologic mechanisms, and treatment controversies, and to report the first anterior segment optical coherence tomography (OCT) of this condition. Methods Literature review and case report with OCT findings. Results Topiramate-induced angle closure is usually bilateral and associated with acute myopia; the ocular pressure is often not very highly elevated. Ciliochoroidal detachment with ciliary body anterior rotation is typically present and was demonstrated easily in our case with anterior segment OCT. Pilo-carpine exacerbates this condition and peripheral iridotomy is not indicated, nor is iridoplasty Treatment consists of replacing topiramate with appropriate medication, strong cycloplegia, and topical steroids. Conclusions It is important to recognize this form of acute secondary angle closure in order to treat it properly, avoiding harmful medication and unnecessary surgery.

Are ocular injection anesthetic blocks obsolete? Indications and guidelines.

Purpose of review In this era of topical anesthesia for ocular surgery, anesthetic ocular blocks are still important when profound anesthesia and akinesia are required. Although injection ocular blocks, retrobulbar and peribulbar anesthesia, have been supplanted for most ocular surgery in many centers by sub-Tenons irrigation block because of its superior safety profile, still worldwide, injection blocks remain popular. Recent findings We present here the results of a survey of the literature published over the last 5 years to assess current international preferences for ocular anesthesia injection blocks. We discuss the reasons why sub-Tenons anesthesia is not more universally popular and advocate for its greater acceptance because of safety. Specific narrow indications for performing injection ocular blocks are presented. Also, guidelines for performing retrobulbar anesthesia which reduce the risk of serious ocular complications are provided as well as our rationale for preferring retrobulbar to peribulbar anesthesia. Summary Sub-Tenons block should be performed in the operating theatre in preference to retrobulbar or peribulbar anesthesia except for limited indications. When injection ocular block is deemed necessary, we feel that retrobulbar anesthesia with the technique described may be safer than peribulbar anesthesia.

Pediatric Ocular Rosacea

A case of severe pediatric ocular rosacea was effectively treated after 2.5 years of misdiagnosis. A high index of suspicion should be maintained in children with ocular surface disease, with or without dermatologic rosacea, to correctly diagnose ocular rosacea and avoid morbidity and complications.

Posterior-assisted levitation in cataract surgery.

Purpose of review Posterior-assisted levitation (PAL) is a surgical maneuver for dealing with rupture of the posterior capsule or zonular dehiscence with threatened or actual subluxation of the nucleus or entire lens into the vitreous during phacoemulsification. PAL is often unknown or overlooked, especially by young or inexperienced surgeons. Recent findings The advantages of PAL are, first, that it often enables completion of phacoemulsification and intraocular lens placement without conversion to an open eye with nuclear expression and second, it prevents luxation of nucleus, nuclear fragments, or the lens into the vitreous avoiding the necessity for trans pars plana vitrectomy (TPPV)-lensectomy. PAL has recently been criticized by vitreoretinal surgeons as dangerous and to be avoided. However, there is no large series or controlled study showing that the PAL maneuver is associated with an excessive complication rate as compared to cases of nuclear or lens subluxation in the vitreous managed by TPPV-lensectomy with or without previous PAL. Summary PAL is a simple technique that can be extremely helpful. In cases in which the PAL maneuver is unsuccessful and in cases with complete luxation of nucleus or lens into the vitreous, the patient should be referred for TPPV-lensectomy.

Acute anticholinergic syndrome from Atropa belladonna mistaken for blueberries.

Purpose To report the first case in the ophthalmic literature of acute anticholinergic syndrome after ingestion of Atropa belladonna mistaken for blueberries. Methods A 36-year-old woman presented to our ophthalmic emergency department with complaints of blurry vision, lightning flashes, disorientation, loss of balance, agitation, and anxiety for 24 hours. Ophthalmic examination revealed bilateral pupillary dilatation and paresis of accommodation. Additional symptoms of the anticholinergic syndrome were elicited on further questioning. Results Anticholinergic intoxication was suspected and the patient admitted to have eaten six “blueberries” found in the forest the previous day. The patient identified Atropa belladonna as the source of the berries she had eaten when shown photographs of the plant and its fruit. The recommendations of the Swiss Toxicological Information Centre were followed and physostigmine, the antidote for severe poisoning when 10 or more berries are ingested, was not administered. Conclusions Accidental ingestion of Atropa belladonna berries may cause patients to first consult an ophthalmologist. It is important to recognize the anticholinergic syndrome caused by such intoxication in order to make a proper diagnosis, avoid unnecessary testing, and provide expedient appropriate treatment when required.

Feigned Visual Loss Misdiagnosed as Occult Traumatic Optic Neuropathy: Diagnostic Guidelines and Medical-legal Issues

The medical-legal problem of occult traumatic optic neuropathy diagnosed in patients who actually have feigned visual loss (malingering) is reviewed along with guidelines for suspecting and differentiating feigned visual loss from true traumatic optic neuropathy. We explain why we feel the term occult optic neuropathy is inappropriate and misleading, and the medical-legal consequences of this misdiagnosis are discussed.

The value of the ophthalmological independent medical examination: analysis of 344 cases

Aim: The aim of the study was to assess the value of the ophthalmological independent medical examination (IME) for detecting malingering, exaggerated or feigned symptoms, and incorrect causal relationship. Design: Retrospective observational cohort study. Methods: Consecutive examinees (n = 344) who underwent an IME by a single examiner between 1998 and 2005 in the setting of an ophthalmological group practice were included in the study. Diagnoses were made to at least a degree of medical certainty. Main outcome measures were frequency of exaggerated, feigned and non-causally related pathology and symptoms. Results: In 172 claimants (50%), the symptoms and pathology claimed were fully substantiated. The other 172 claimants were found to have either exaggerated or totally feigned symptoms and/or symptoms and pathology misattributed (non-causally related to the claimed accident or incident). The most frequent feigned/exaggerated symptoms were visual loss (74%), ocular pain/discomfort (28%), visual field loss (19%), headaches (17%) and photophobia (13%). Visual field loss and the symptoms of ocular discomfort, headaches, dizziness and epiphora were more frequent in the feigning group (p<0.01). In contrast, complaints of swelling and deformity were more frequent (p = 0.001) among the examinees with real pathology. Review of the medical records provided helpful information in 163/172 cases in the feigning group. Conclusions: An ophthalmological IME is useful for detecting malingering, as well as symptoms and pathology not causally related to a claimed accident or injury or actually pre-existent to a claimed date. The advantages of an IME compared with relying on treating-doctor records, clues for diagnosing feigning and incorrect causal relationship, and guidelines for performing an ophthalmological IME are discussed.

Phacolytic glaucoma: are there 2 forms?

We report a case of acute phacolytic glaucoma in which only protein was present in the anterior chamber without macrophages. We propose that this study represents a type of phacolytic glaucoma characterized by a hyperacute presentation caused by rapid leakage of degenerated lens proteins into the aqueous humor as opposed to a second type with a more gradual onset and with phacolytic macrophages in the aqueous humor resulting from an immunologic response to liquefied lens proteins. Thus, 2 forms, perhaps at ends of a spectrum of clinical manifestations of phacolytic glaucoma, may exist with distinct characteristics and pathophysiology.

Traumatic retinal detachment-the difficulty and importance of correct diagnosis

Accurate characterization of a retinal detachment as traumatic is often difficult, but is important because it may instigate a careful search for occult coexistent traumatic pathology, affect the prognosis and the treatment of both eyes, influence insurance coverage benefits and medical-legal determinations, and is essential for epidemiologic studies. We review the epidemiology and pathophysiology of traumatic retinal detachment, common obstacles to correct diagnosis, diagnostic guidelines, and outline categories of traumatic causal relationships. Because there is no generally accepted definition of traumatic retinal detachment, we offer a practical one. Categorization as traumatic should be based on the particular history and physical examination rather than epidemiologic criteria.

What degree of anaesthesia is necessary for intraocular surgery? It depends on whether surgery is “open” or “closed”

“Closed” intraocular surgery is characterised by some degree of pressurisation of the globe, positive intraocular pressure, during almost all of the procedure so the eye is not markedly hypotenous more than momentarily. In closed surgery characteristically, the incisions are self sealing or small and easily closed with suturing, and second, the eye is pressurised by an infusion line.1 Phacoemulsification2 and trans pars plana vitrectomy3 are typical forms of closed intraocular surgery. “Open” intraocular surgery4 is characterised by globe decompression to or close to atmospheric pressure for significant periods of time, typically with an incision which is not self sealing, such as nuclear expression extracapsular cataract surgery, penetrating keratoplasty and trabeculectomy. 1. What is positive vitreous pressure? 2. How is the choice of anaesthetic technique affected by whether intraocular surgery is closed or open? 3. What are the consequences of converting from closed to open surgery, specifically from phacoemulsification to nuclear expression? See page 1413 for answers From questions on page 1400 1. “Positive vitreous pressure” (PVP)4 5 is apparent pressure forward against the lens-iris diaphragm from the vitreous, movement of the vitreous body anteriorly during intraocular surgery. PVP does not arise from any inherent expansile force generated within the vitreous body nor from elastic forces of …