Katherine Masselos

Zoledronic Acid Infusion and Orbital Inflammatory Disease

A 57-year-old man presented with a 4-day history of increasing orbital pain and swelling in the right eye. A diagnosis of orbital inflammatory disease due to bisphosphonate infusion was made.

Patient perceptions of second eye clear corneal cataract surgery using assisted topical anaesthesia

AimTo assess patient recall of intraoperative pain, anxiety, fear, and sensory (visual and auditory) perceptions during second eye clear corneal cataract surgery using assisted topical anaesthesia (ATA), in comparison with first eye cataract surgery using the same technique.MethodsThis prospective, consecutive, observational study was conducted in a free-standing dedicated ophthalmic day surgery centre. A voluntary questionnaire was distributed to 129 consecutive patients who underwent clear corneal cataract surgery using ATA. Two patients had to be converted to block anaesthesia, and were excluded.Patients were asked to rate intraoperative pain, anxiety, and fear using a visual analogue scale (VAS), and recollection of intraoperative visual and auditory perceptions. Results were analysed using the Mann–Whitney U and Spearman correlation tests.ResultsThere were 70/127 (55%) patients undergoing first eye cataract surgery and 57/127 (45%) undergoing second eye surgery. There was no significant difference in mean pain, anxiety, and fear scores between those undergoing the second eye operation compared with those undergoing their first eye operation. Similarly, there was no significant difference in sensory perceptions between the two cohorts. Overall, there was a small but significant positive correlation between recall of visual and auditory perceptions and combined pain, fear, and anxiety scores (r=0.33, P=0.0002).ConclusionThere was no significant difference in levels of intraoperative pain, anxiety, fear, and sensory perceptions experienced by patients between the first eye and second eye surgeries. We recommend that preoperative counselling for a patients second eye be as comprehensive as for the first eye surgery.

Corneal indentation in the early management of acute angle closure.

PURPOSE To describe in detail corneal indentation (CI) in the management of a series of patients treated for acute angle closure (AAC). DESIGN Retrospective, consecutive, noncomparative case series. PARTICIPANTS Seven consecutive patients (8 eyes) referred to the authors with the diagnosis of AAC. Patients presented to the Prince of Wales Hospital, Randwick, or to the private practices of the authors. INTERVENTION Seven patients (8 eyes) underwent CI as part of their early management for AAC. MAIN OUTCOME MEASURES Reduction in intraocular pressure (IOP), symptoms of AAC and pain relief. RESULTS Of the 7 patients, complete data were available for 6. The IOP was significantly reduced (P<0.05) and 3 of 4 patients with severe acute pain reported early resolution of pain after CI. The average reduction in IOP was 20.9 mmHg (range +1 to -45). All patients subsequently underwent definitive management with laser peripheral iridotomies or lensectomy using phacoemulsification. Three patients treated acutely with CI without any medical agents had a mean IOP reduction of 21 mmHg (range, 20-23) after indentation. CONCLUSIONS Corneal indentation is a rapid, portable, and effective method of reducing elevated IOP in the setting of AAC. It can be performed with instrumentation that is readily at hand and allows for rapid pain relief. This reduction in IOP improves corneal clarity and permits further definitive management of the patient with AAC. FINANCIAL DISCLOSURE(S) The authors have no proprietary or commercial interest in any materials discussed in this article.

Laser corneal biofilm disruption for infectious crystalline keratopathy

Crystalline keratopathy can be successfully treated by the Nd:YAG laser. We present two cases of crystalline keratopathy managed this way. A 36‐year‐old female contact lens wearer presented with crystalline keratopathy following recent treatment with topical steroids and antibiotics for a corneal abscess. In this case crystalline keratopathy developed despite the intensive topical antibiotic treatment. A 55‐year‐old man with a history of acne rosacea, chronic myelomonocytic leukaemia, asthma and Crohns disease presented with crystalline keratopathy following an episode of infectious keratitis. Treatment with the Nd:YAG laser to the area of involvement was instituted in both cases. Noticeable resolution occurred within days, with subsequent full recovery. No side‐effects from the use of the Nd:YAG laser were noted. There have been only two cases previously reported using this treatment modality.

The Lanindar test: a method of evaluating patient suitability for cataract surgery using assisted topical anaesthesia

AimTo evaluate an office-based Lanindar (light and nociceptive interaction noting distress and response) test to assist in the assessment of patient suitability for assisted topical anaesthesia (ATA) during phacoemulsification.MethodsThe Lanindar test was carried out at the preoperative assessment of 716 consecutive patients in the office of one of the authors (ICF). A standard desk lamp was shone in each patients eye after pupillary dilation, while simultaneously elevating the upper eyelid digitally. A negative test indicated patient hypersensitivity to the light and aversion to digital pressure on the upper eyelid. A positive test was indicated by the patient feeling comfort and lack of blepharospasm and withdrawal in response to the light and digital pressure. χ 2 and Fishers exact tests were used to assess the association between Lanindar results and suitability for ATA. The positive predictive value and specificity of the test as an indicator of patient suitability for ATA were calculated. Visual acuities at 1 and 4 weeks post-operative periods were compared between the ATA and ALA/GA (assisted local anaesthesia/general anaesthesia) group of patients.ResultsAbout 86.7% were Lanindar positive and 98.9% of these patients tolerated ATA. χ 2 and Fishers exact tests demonstrated a significant association of a positive Lanindar test with successful ATA (χ 2=660, P<0.001, Fishers: P<0.001). The positive predictive value and specificity of the test were 98% (95% CI=98.04–99.7%) and 93.14% (95% CI=88.23–98.04%), respectively. Visual acuity outcomes were similar in the ATA and ALA/GA groups.ConclusionThe Lanindar is a simple, highly specific, office-based test to determine patient suitability for phacoemulsification under ATA.

The grape: an appropriate model for continuous curvilinear capsulorhexis.

The cornerstone of helping surgical trainees achieve a cost-effective level of surgical expertise and competency is provision of adequate supervised training and repetition to consolidate newly learned skills. When helping trainees learn new surgical procedures, surgical tutors often recommend dividing the procedure into the component steps. We believe this philosophy is particularly beneficial in assisting trainees master the continuous curvilinear capsulorhexis (CCC) step of endocapsular phacoemulsification. Trainee surgeons have noted phacoemulsification and capsulorhexis as the most challenging steps of the procedure, and a recent publication suggests that sculpting and fragmentation are the most difficult. Experienced surgeons readily recognize that the most important early step in safe phacoemulsification is a high-quality capsulorhexis. The use of synthetic or animal eyes as well as surgical simulators have been described in learning this step. The attendant costs and limited access of animal models and surgical simulators pose significant problems in phacoemulsification training. We suggest the use of red globe grapes (Vitus vinifera) as an alternative model for CCC training. Grapes and tomatoes have been mentioned, to our knowledge with no literature support, as being useful for practicing capsulorhexis. The grape is readily available, irresistibly cheap, and has an elastic skin

Consistency of Structure-Function Correlation Between Spatially Scaled Visual Field Stimuli and In Vivo OCT Ganglion Cell Counts

Purpose To investigate the effect of stimulus size and disease status on the structure-function relationship within the central retina, we correlated the differential light sensitivity (DLS) with Goldmann stimulus size I to V (GI-V) and optical coherence tomography (OCT) derived in vivo ganglion cell count per stimulus area (GCc) within the macular area in normal subjects and patients with early glaucoma. Methods Humphrey Field Analyzer 10-2 visual field data with GI through V and Spectralis OCT macular ganglion cell layer (GCL) thickness measurements were collected from normal and early glaucoma cohorts including 25 subjects each. GCc was calculated from GCL thickness data and correlated with DLSs for different stimulus sizes. Results Correlation coefficients attained with smaller stimulus size were higher compared to larger stimulus sizes in both normal (GI-GII: R2 = 0.41-0.43, GIII-GV: R2 = 0.16-0.41) and diseased cohorts (GI-GII: R2 = 0.33-0.41, GIII-GV: R2 = 0.19-0.36). Quadratic regression curves for combined GI to V data demonstrated high correlation (R2= 0.82-0.90) and differed less than 1 dB of visual sensitivity within the GCc range between cohorts. The established structure-function relationship was compatible with a histologically derived model correlation spanning the range predicted by stimulus sizes GI to GIII. Conclusions Stimulus sizes within critical spatial summation area (GI-II) improved structure-function correlations in the central visual field. The structure-function relationship was identical in both normal and diseased cohort when GI to GV data were combined. Congruency of GI and GII structure-function correlation with those previously derived with GIII from more peripheral locations further suggests that the structure-function relationship is governed by the number of ganglion cell per stimulus area.

Upper eyelid laxity.

Dear Editor: We were pleased to read the paper by Mills et al regarding evaluation of upper eyelid position after horizontal surgical tightening in patients with floppy eyelid syndrome (FES). In their study, the main outcome measure was the change in upper eyelid margin reflex distance after standard pentagonal wedge resection, in a series of 24 eyelids in 18 patients. The authors correctly noted a limitation of their study, which was that the degree of eyelid laxity was not graded before surgery. One of the most important etiological factors in eyelid malposition is laxity of the canthal tendons. Therefore, clinical assessment of the medial and lateral canthal tendons (MCT and LCT) is essential to the understanding and management of many eyelid disorders. In 2002, we described a simple and easily remembered clinical grading scheme for assessing the normality of medial and lateral canthal tendon function in the lower lid. Moreover, our grading system described a simple clinical method of assessing pathological laxity of the lower lid, in relation to the MCT and LCT. Over the last 6 years, we have found that our grading scheme has been reliable. It is easily performed in the office, and given the large numbers of patients seen with this abnormality, is historically reproducible. This technique for assessing MCT and LCT laxity for the lower lid is carried out by using digital lid distraction in a lateral and then medial direction. The patient is seated with the eyes in the primary position. The lower lid is grasped lateral to the lower punctum. Having achieved a firm but gentle grasp of the skin and associated underlying orbicularis muscle, the lid is initially moved laterally to assess the MCT laxity, and medially for the LCT, ensuring the punctum remains apposed to the globe. For the upper lid, the examiner likewise ensures that the punctum remains on the globe while distracting the lid laterally (MCT laxity assessment) (Figure 1 [available at http://aaojournal.org]) noting the position of the medial side of the punctum in relation to fixed ocular structures. These structures for upper lid assessment are seen in (Figure 2 [available at http://aaojournal.org]). For medial distraction (LCT laxity assessment), the structures are seen in (Figure 3 [available at http://aaojournal.org]). To our knowledge, there has been no grading scheme produced for assessment of MCT and LCT laxity in the upper lid.

Management of angle-closure glaucoma in East Asian eyes : a response to argon laser iridotomy-induced bullous keratopathy, a growing problem in Japan

We were suitably impressed to read the article entitled “Argon laser iridotomy-induced bullous keratopathy—a growing problem in Japan” by Ang et al ,1 advocating a change in management of primary angle-closure glaucoma (PACG). A case of ours follows, illustrating the point that a large dosage of argon laser may be required to create an iridotomy. In 1993, a 46-year-old woman of East Asian descent presented to another hospital in Sydney, Australia with bilateral acute angle-closure glaucoma. After initial topical and systemic treatment, she underwent bilateral argon laser iridotomies (ALI). Because of her dark irides, this procedure took almost an hour to perform in each eye and was unsuccessful. She then underwent bilateral trabeculectomies, with minimal effect. …