Justin O'Day

Blepharospasm and Hemifacial Spasm: Randomized Trial to Determine the Most Appropriate Location for Botulinum Toxin Injections

PURPOSEnThe purpose of the study is to analyze the effectiveness and side effects of botulinum toxin using four different treatment site applications to determine the most successful treatment regime with the least side effects.nnnMETHODSnIn a prospective trial, 92 patients (50 blepharospasm and 42 hemifacial spasm) were assigned randomly to 1 of 4 different treatment groups (standard [S], brow [B], inner orbital [IO], or outer orbital [OO]). Each treatment group had a different pattern of injection sites in the orbicularis. A total of 285 treatments were given, and the mean follow-up time was 16.4 months.nnnRESULTSnIn the blepharospasm group, patients assigned to the standard group had a significantly longer duration of effect than for those in the brow, inner orbital, and outer orbital groups (8.1 weeks compared with 4.5, 4.2, and 3.1 weeks, respectively; P < 0.001). In the hemifacial spasm group, patients in the outer orbital group had significantly shorter duration of effect than those in standard, brow, or inner orbital group (7.2 weeks compared with 12.6, 12.8 and 10.4 weeks, respectively; P < 0.001). The four major complications of botulinum toxin treatment were epiphora, ocular irritation, ptosis, and diplopia. The inner orbital treatment produced significantly more episodes of ptosis (13% of treatments). However, the standard treatment produced the most epiphora and ocular irritation (18% of treatments).nnnCONCLUSIONSnThe position of the injection sites around the orbicularis influences the effectiveness and side effects of botulinum toxin treatment for patients with blepharospasm and hemifacial spasm. The further the treatment is away from the eyelid margin, the lower the risk of ocular side effects. The standard treatment produces the longest duration of effect in the blepharospasm group but with the most transient ocular irritation and epiphora. In the hemifacial spasm group, the brow treatment has an equally long duration of effect as that of the standard treatment with fewer side effects.

Congenital fibrosis of the vertically acting extraocular muscles maps to the FEOM3 locus

Abstract. The diagnosis of congenital fibrosis of the extraocular muscles (CFEOM) encompasses several different inherited strabismus syndromes characterized by congenital restrictive ophthalmoplegia affecting extraocular muscles innervated by the oculomotor and/or trochlear nerves. The OMIM database (http://www.ncbi.nlm.nih.gov/Omim/) currently contains four familial CFEOM phenotypes: CFEOM1–3, which map to the FEOM1–3 loci (MIM 135600, 602078, 604361), respectively, and congenital fibrosis of the vertically acting extraocular muscles (MIM 600638), reported in a single family without a corresponding genotype. We have had the opportunity to study the reported family with this fourth phenotype and now demonstrate that their phenotype can be reclassified as CFEOM3 and that it maps to FEOM3, flanked by D16S498 to 16qter, with a maximum lod score of 6.0.

Astigmatic change 1 year after excimer laser treatment of myopia and myopic astigmatism

Purpose: To evaluate the surgically induced astigmatism (SIA) 1 year after excimer laser photorefractive astigmatic keratectomy (PARK) and photorefractive keratectomy (PRK). Setting: Royal Victorian Ear and Eye Hospital, Melbourne, Australia. Methods: This study comprised 333 PARK patients and 155 PRK patients treated with a VISX 20/20 excimer laser and followed prospectively for 12 months. Vector analysis of the change in astigmatism was used to calculate the SIA in the PRK group and the percentage of astigmatism corrected in the PARK group. Results: Among patients with low cylinders astigmatic correction varied greatly, particularly in those treated for large amounts of myopia. The spherical PRK treatments yielded a mean induced postoperative astigmatism of 0.47 diopter. There was a linear relationship between this inadvertent SIA and increasing myopia. Conclusion: Excimer laser surgery for myopia creates a low degree of random, unpredictable SIA that may be the result of irregular epithelial thickening during postoperative healing. This creates a background noise of astigmatic change upon which the targeted astigmatic correction is superimposed.

Photodynamic therapy in the management of juxtapapillary capillary haemangiomas

Capillary haemangiomas occurring on or adjacent to the optic disc pose unique therapeutic problems. Their natural history is highly variable, but has a propensity to lead to the development of progressive exudate with marked deterioration in visual acuity, often culminating in retinal detachment and vitreal haemorrhages. On reviewing the literature, no therapeutic modality has demonstrated an efficacy in treating the lesion and providing an acceptable visual acuity result. A case of a 61‐year‐old man with a left‐sided juxtapapillary capillary haemangioma treated with verteporfin photodynamic therapy is described. The patients visual acuity improved from 6/36 to 6/12 initially, with an appreciable reduction in exudate and lesion size. Subsequent treatments failed to eradicate the lesion, with visual acuity stabilizing at 6/60. With larger cohorts of patients and variable treatment parameters, the true efficacy of photodynamic therapy to treat these lesions may be determined.

Predictability of excimer laser treatment of myopia and astigmatism by the VISX Twenty-Twenty

Background: To determine the predictability of excimer laser photorefractive keratectomy (PRK) to correct myopia, astigmatism, or both between −1.00 and −19.00 diopters (D). Setting: Royal Victorian Eye and Ear Hospital, East Melbourne, Australia. Methods: This study comprised 1218 consecutive eyes treated with a VISX TwentyTwenty excimer laser and followed prospectively for 12 months. Low myopia was treated with one ablation zone (6.0 mm), high myopia with two ablation zones (5.0 and 6.0 mm), and extreme myopia with three ablation zones (4.5, 5.0, and 6.0 mm). Maximum spherical treatment was 15.00 D at the corneal plane. Data were analyzed to determine the predictability of the postoperative outcomes by preoperative refraction. Results: Nine hundred eighty eyes (80.5%) were available for the 12 month follow‐up. The predictability of refraction and uncorrected and best corrected visual acuities progressively decreased with increasing myopia, although a comparable percentage of spherical correction was achieved at each diopter of myopia. The likelihood of losing lines of best corrected visual acuity and corneal haze increased with increasing myopia. Conclusion: These data can be used to counsel patients of likely outcomes of excimer laser PRK to correct myopia.

Conjunctival Involvement with Mycosis Fungoides in a Patient Receiving PUVA Therapy

A 40-year-old woman had documented mycosis fungoides of the skin. Over a period of five years, she had undergone intermittent treatment with psoralen long-wave ultraviolet light (PUVA) therapy. Despite regression of the skin lesions, tumor plaques developed in her eyelid and conjunctiva within the area shielded by dark glasses. Light and electron microscopic examination of a biopsy from the conjunctival plaque confirmed that the lesion was a deposit of mycosis fungoides. Local radiotherapy resulted in complete regression of these ocular lesions. The conjunctiva may well be an iatrogenic sanctuary site when this disease is treated with PUVA therapy.

Restoration of ocular circulation and some visual function following external carotid endarterectomy

A 66-year-old man awoke with a sharp pain in his left eye associated with blurring of vision, which progressed to total loss of left eye vision within the hour. On examination (4 h after onset), his left visual acuity was count fingers. He was found to be in rapid atrial fibrillation, and had a left central retinal artery occlusion (CRAO) with an embolus apparent at the disc. At that time, he was haemodynamically stable. Treatment instituted at that time included oral acetazolamide, ocular massage, ocular paracentesis and inhaled carbogen (95% oxygen and 5% carbon dioxide). Subsequently, the embolus moved, resulting in an inferior branch retinal artery occlusion. (Fig. 1a,b) There was a corresponding superior field defect noted. He was then anticoagulated with heparin, and given digoxin to control his heart rate. From day 4 to day 9, he described three episodes of transient left eye visual loss lasting about 20 min each. These episodes were not associated with systemic hypotension. Carotid angiogram showed a totally occluded left internal carotid artery (ICA) and thrombus in the carotid bifurcation involving the external carotid artery (ECA). Over the next few days, he had continuing fluctuation in his vision, going from total visual loss to ‘grey’ vision. Fundus examination revealed persistent cloudy swelling of the posterior pole, particularly the inferior macular region. Fragments of emboli were seen in superior and inferior branches of the retinal circulation. In addition, large fresh choroidal infarcts with cloudy outer retinal swelling were seen temporal to the macula (Fig. 2a). Fluorescein angiography at that stage Clinical and Experimental Ophthalmology (2000) 28, 329–331