Naz Raoof

The incidence and prevalence of idiopathic intracranial hypertension in Sheffield, UK.

Background and purpose:  The purpose of this study was to identify the incidence and prevalence of idiopathic intracranial hypertension (IIH) in Sheffield, UK.

‘Toy' laser macular burns in children

PurposeLaser ‘toys’ can be purchased online and imported with relative ease; the variety of such devices is a potential public safety concern. We describe five children with maculopathy following exposure to laser ‘toys’.MethodsCase series of maculopathy following exposure to laser ‘toys’.ResultsFive children were seen in our Ophthalmic Unit with macular injuries following exposure to laser ‘toys’. Clinically, three children had an acute vitelliform-like maculopathy which resolved to leave sub-foveal retinal pigment epithelium changes with reduced vision. One case was complicated by a choroidal neovascular membrane.ConclusionLaser ‘toys’, which resemble laser pointers, are increasingly available over the internet. Such ‘toys’ may not meet safety standards. Retinal injury in childhood following exposure to laser ‘toys’ is a public safety concern.

‘Toy’ laser macular burns in children: 12-month update

PurposeThere is increasing evidence that high-powered hand-held laser devices cause retinal injury. We present 12-month follow-up data for three patients that we previously reported with such retinal injuries.MethodsA retrospective case series of three children with maculopathy secondary to exposure to high-power hand-held laser devices. All children underwent clinical examination and spectral domain optical coherence tomography (SD-OCT) at presentation and follow-up. Fundus-controlled microperimetry was also undertaken 12–19 months after exposure.ResultsThree children sustained macular injury after exposure to a high-powered hand-held laser. Acutely, they presented with a ‘vitelliform-like’ maculopathy with reduced vision. Over the course of follow-up, the best corrected Snellen acuity in all three patients improved to ‘normal’ levels (range 6/6–6/9). Long-term deficits in foveal retinal sensitivity were identified in two patients using fundus-controlled microperimetry. SD-OCT imaging showed persistent disruption of the foveal outer photoreceptor layers in all three children.ConclusionAlthough visual acuity improved over time, deficits in microperimetry and SD-OCT persisted. All three children had retinal pigment epithelium changes, requiring follow-up for longer-term sequelae of laser injuries such as expansion of retinal atrophy and development of choroidal neovascular membranes.

Vision and multiple sclerosis

Multiple sclerosis can affect vision in many ways, including optic neuritis, chronic optic neuropathy, retrochiasmal visual field defects, higher order cortical processing, double vision, nystagmus and also by related ocular conditions such as uveitis. There are also side effects from recently introduced multiple sclerosis treatments that can affect vision. This review will discuss all these aspects and how they come together to cause visual symptoms. It will then focus on practical aspects of how to recognise when there is a vision problem in a multiple sclerosis patient and on what treatments are available to improve vision.

Effect of superior oblique weakening on vertical alignment and horizontal and vertical incomitance in patients with A-pattern strabismus

PURPOSE To determine the relationship between the magnitude of preoperative A pattern and the correction of vertical alignment and horizontal and vertical incomitance in patients treated with superior oblique muscle-weakening procedures for A-pattern strabismus. METHODS The records of consecutive patients who underwent surgery for A-pattern strabismus between 1997 and 2008 were retrospectively reviewed. Both horizontal (from up- to downgaze) and vertical (from right to left gaze) incomitance were assessed. RESULTS Twenty-six patients were treated with superior oblique muscle-weakening procedures (either tendon spacer or nasal or posterior 7/8 temporal tenotomy, with or without simultaneous rectus muscle surgery). In these patients, the A pattern improved from 36Δ preoperatively (range, 15Δ-75Δ) to 6Δ postoperatively (range, 0Δ-16Δ). The magnitude of the reduction in A pattern correlated strongly with the size of preoperative A pattern (r=0.92), whereas the reduction in the magnitude of the vertical incomitance correlated weakly with the magnitude of the preoperative deviation (r=0.56). There was no significant correlation between the magnitude of the A pattern and the vertical incomitance (r=0.25). Of the 9 patients with preexisting primary position vertical deviation≥6Δ, 5 required additional vertical rectus muscle surgery. CONCLUSIONS Superior oblique muscle-weakening surgery improved the A pattern but did not reliably improve the primary position vertical deviation and lateral gaze vertical incomitance. Patients with associated primary position vertical deviations of >6Δ preoperatively tended to have a greater likelihood of requiring additional strabismus surgery.

What is the significance of vortex vein invasion in uveal melanoma

PurposeTo correlate vortex vein invasion with established prognostic factors for uveal melanoma.MethodsEnucleated eyes with a confirmed histopathological diagnosis of uveal melanoma with vortex vein invasion were identified, over a 10-year period. Established uveal melanoma prognostic factors, with tumour genetics were correlated with vortex vein invasion and patient survival.ResultsMicroscopic vortex vein involvement was present in 29 of 244 (11.9%) uveal melanomas. Of 29, 6 (20.7%) tumours had macroscopic evidence of vortex vein invasion. Of 29, 14 (48.3%) tumours also showed evidence of non-vortex vein, ‘direct’ scleral invasion. 23 (79.3%) of 29 melanomas involved only the choroid. The mean maximum diameter of tumours with vortex vein invasion was 15.8 mm and the mean thickness was 9.7 mm. The uveal melanoma was a discrete nodule in 27 of 29 (93.1%) cases. Histologically, 8 of 29 tumours (27.6%) were spindle cell, 19 of 29 (65.5%) were mixed cell, and 2 of 29 (6.9%) were epithelioid cell type. Of 29, 22 (75.9%) uveal melanomas with vortex vein invasion contained extracellular matrix networks and loops. Genetic abnormalities correlated with poor prognosis were seen in 25 of 29 (86.2%) tumours with vortex vein invasion. Liver metastasis was confirmed in 19 of 29 (65.5%) patients with vortex vein invasion. No patients with uveal melanomas showing vortex vein invasion suffered orbital recurrence of disease following enucleation.ConclusionsThe trends show that vortex vein invasion is associated with a choroidal location, large tumour size, spindle cell bias, presence of extracellular matrix loops/networks and genetic markers. A higher proportion of patients with vortex vein invasion progress to develop liver metastasis compared with the general uveal melanoma population.

Auditory and Visual Health after Ten Years of Exposure to Metal-on-Metal Hip Prostheses: A Cross-Sectional Study Follow Up

Case reports of patients with mal-functioning metal-on-metal hip replacement (MoMHR) prostheses suggest an association of elevated circulating metal levels with visual and auditory dysfunction. However, it is unknown if this is a cumulative exposure effect and the impact of prolonged low level exposure, relevant to the majority of patients with a well-functioning prosthesis, has not been studied. Twenty four male patients with a well-functioning MoMHR and an age and time since surgery matched group of 24 male patients with conventional total hip arthroplasty (THA) underwent clinical and electrophysiological assessment of their visual and auditory health at a mean of ten years after surgery. Median circulating cobalt and chromium concentrations were higher in patients after MoMHR versus those with THA (P<0.0001), but were within the Medicines and Healthcare Products Regulatory Agency (UK) investigation threshold. Subjective auditory tests including pure tone audiometric and speech discrimination findings were similar between groups (P>0.05). Objective assessments, including amplitude and signal-to-noise ratio of transient evoked and distortion product oto-acoustic emissions (TEOAE and DPOAE, respectively), were similar for all the frequencies tested (P>0.05). Auditory brainstem responses (ABR) and cortical evoked response audiometry (ACR) were also similar between groups (P>0.05). Ophthalmological evaluations, including self-reported visual function by visual functioning questionnaire, as well as binocular low contrast visual acuity and colour vision were similar between groups (P>0.05). Retinal nerve fibre layer thickness and macular volume measured by optical coherence tomography were also similar between groups (P>0.05). In the presence of moderately elevated metal levels associated with well-functioning implants, MoMHR exposure does not associate with clinically demonstrable visual or auditory dysfunction.

Visual Outcomes from Shunting for Idiopathic Intracranial Hypertension

ABSTRACT A retrospective notes review was conducted for 50 consecutive patients who underwent shunt surgery for idiopathic intracranial hypertension (IIH). The decimal visual acuity and the mean radial degrees (MRD) of the I4e isopter of the Goldmann visual field were measured pre-operatively and after a mean follow-up period of 1123 days (range: 13–3551 days). A ventriculo-peritoneal shunt was the first procedure in 38 patients and a lumbo-peritoneal shunt in 12. The mean decimal visual acuity of the worse affected eye improved from 0.75 to 0.84, p = 0.011. The MRD score of the worse affected eye improved on average from 25.6° to 35.5°, p < 0.0001. In those with significant pre-operative visual impairment in their worse affected eye (defined as an MRD score ≤30°), the MRD score improved on average from 10.3° to 26.5°, p = 0.0008. The mean number of surgical procedures for each patient was 2.8 (range: 1–15). Taking all surgical procedures into account, post-operative complications were experienced by 30 patients. At last follow-up, 28 patients still complained of headache, 8 of whom had the intervention performed primarily for headache. Shunting can improve visual function in patients with IIH. There is significant post-operative morbidity and often the need for repeated procedures. Headache also commonly remains in these patients. There is a need for a randomised controlled trial of operative interventions in IIH. Sample size calculations for such a trial to treat significant vision loss are presented.

Successful use of intravitreal bevacizumab and pascal laser photocoagulation in the management of adult Coats' disease

Traditional methods of managing exudative retinal detachment secondary to Coats’ disease have been associated with varying degrees of success. We describe a case of a 34 year-old male who presented with a sub-total exudative retinal detachment of the right eye that encroached upon the macula, associated with a vasoproliferative tumor secondary to Coats’ disease. The patient under-went successful treatment with two intravitreal injections of bevacizumab (Avastin, Genetech Inc., San Francisco, CA, USA) combined with targeted laser photocoagulation with a 532 nm Pascal laser (Topcon Corp., Tokyo, Japan). The visual acuity improved 5 days after the second intravitreal injection from 6/18 to 6/5, with no residual macular edema and complete regression of the vasoproliferative tumor. The improvement in visual acuity was maintained at 12 months post-treatment. We believe this is the first case report describing the successful use of Pascal laser photocoagulation with intravitreal bevacizumab in the treatment of Coats’ disease. Our aim was to defer laser treatment until ‘near total’ retinal reattachment and regression of the vasoproliferative tumor was achieved. There are, however, reports of vitreous fibrosis in patients with Coats’ disease treated with intravitreal bevacizumab. This suggests further long-term follow-up studies are required in patients treated with this approach.

The Value of Fusional Convergence Amplitudes in Esodeviation Surgery Without Adjustable Sutures

PURPOSE To explore the application of preoperative fusional convergence amplitudes in the selection of a target angle for non-adjustable suture strabismus surgery with deteriorated intermittent esotropia and diplopia. METHODS Thirty-one consecutive cases of presumed acquired non-accommodative, deteriorated intermittent esotropia managed surgically between 2005 and 2016 were reviewed retrospectively. For each individual, a target angle (deviation angle for which surgery was based) was selected preoperatively after analysis of fusional convergence amplitudes. Outcomes in patients selected for overcorrection at 6 meters (target angle > angle in primary position at 6 meters) were compared to those who had planned surgery based on a target angle that did not exceed their measured angle (target angle ≤ angle in primary position) at 6 meters. RESULTS All 31 patients achieved binocular single vision in primary position at both near and 6 meters without prisms, orthoptic therapy, or additional surgery at 4 to 6 months postoperatively. Greater mean correction in the target angle > angle in primary position group compared to the target angle ≤ angle in primary position group was observed, but this difference was not statistically significant (P = .57). CONCLUSIONS Among this diagnostically specific cohort with intermittent esotropia with symptomatic diplopia and measurable binocular single vision preoperatively, targeted surgery based on an analysis of preexisting fusional convergence amplitudes had an outcome that compared favorably to that of documented adjustable suture strabismus surgery. [J Pediatr Ophthalmol Strabismus. 2018;55(6):375-381.].