Raymond Kwok-Kay Tse

Retrospective case series on the long-term visual and intraocular pressure outcomes of phacomorphic glaucoma

PurposeTo analyse the long-term visual acuity (VA) and intraocular pressure (IOP) outcomes in phacomorphic glaucoma.Patients and methodsA retrospective analysis of 100 consecutive, acute phacomorphic glaucoma cases from January 2000 to April 2009 was conducted at The Caritas Medical Centre in Hong Kong. All cases underwent cataract extraction after IOP control with medication and/or laser.ResultsDuring a 3.1±2.6-year follow-up, the mean visual improvement was 1.1±0.9 LogMAR units with improvements in 81.7% of cases. A shorter duration from symptoms to cataract extraction resulted in greater visual improvement (r2=0.1, P=0.001). In all, 80.5% of the cases had IOP⩽21 mm Hg without any glaucoma treatment; 19.5% required 1.6±0.7 glaucoma eye drops; and 3.7% required additional laser iridotomy or trabeculectomy for IOP control at 1.8±2.3 years. The vertical cup–disc ratio (VCDR) of the index eye was 0.6±0.3. Gonioscopy revealed an averaged Shaffer grading of 3.0±1.0 and 99±90 degrees of peripheral anterior synechiae (PAS). The Humphrey automated perimetry mean deviation was 5.2±2.7 and the pattern standard deviation was −15.9±10.ConclusionOver 80% of phacomorphic patients had long-term visual improvements and normalization of IOP after cataract extraction. A shorter attack seemed to offer better VA. Post-operatively, most have open angles with some degree of PAS formation, and glaucomatous optic neuropathy is evident from enlarged VCDRs and visual field defects. At least 2 years of follow-up is useful to detect a 20% glaucoma progression possibly requiring additional glaucoma treatments.

Calcification of a hydrophilic acrylic intraocular lens: Clinicopathological report

A 72-year-old man who had phacoemulsification with implantation of an Akreos Adapt Advanced Optics (AO) IOL in the left eye complained of blurring vision 4 months postoperatively. Multiple fine white granules were found within the IOL. Intraocular lens exchange was performed at 7 months, and the explanted IOL was sent for histopathological analysis. Diffuse fine white granules were seen within the explanted IOL material just beneath the surface; they were stained positive by alizarin red and the von Kossa method. Scanning electron microscopy confirmed the presence of calcium deposits in the IOL material. Blood and aqueous were drawn from the patient for biochemical analysis, and the results were normal. We believe this is the first clinicopathological report of calcification of the Akreos Adapt AO IOL.

Clinical evaluation of the intraoperative refraction technique for intraocular lens power calculation.

OBJECTIVE To evaluate clinically the intraoperative refraction technique for intraocular lens (IOL) power calculation using 2 existing formulas proposed by Ianchulev and Leccisotti and to derive alternative formulas for this technique. DESIGN Comparative case series. PARTICIPANTS One hundred eighty-two eyes from 182 patients with cataract. METHODS Recruited patients were separated into a normal cornea group and a special group that included eyes with surgically altered corneas. Phacoemulsification was carried out for all cases. Intraoperative aphakic autorefraction using a portable autorefractor was performed. An IOL with power calculated before surgery then was implanted. In each eye, postoperative refraction was obtained. The IOL power that would have achieved emmetropia was calculated retrospectively. Aphakic autorefraction readings obtained during surgery were used to calculate the aphakic spherical equivalent (SE). The 2 formulas incorporating aphakic SE were applied to calculate the target IOL power. Comparison then was made to determine the accuracy of the formulas. MAIN OUTCOME MEASURES A difference (referred to as IOL difference) was calculated by subtracting the adjusted emmetropic IOL power determined by postoperative refraction from the emmetropic IOL power calculated by the 2 formulas using intraoperative aphakic SE. RESULTS One hundred forty-four patients were in the normal cornea group and 18 were in the special group. In the normal group, the Ianchulev formula showed a relatively accurate prediction for IOL power to achieve emmetropia over almost the full range of axial length except in extremely long eyes. The Leccisotti formula tended to overestimate IOL power and worked particularly poorly in short eyes. It worked best in long eyes. In the special group, neither of the 2 formulas was able to show superiority universally. Using data from the normal group, alternative formulas for IOL power calculation were derived. These new formulas then were validated on the special group that showed good estimation. CONCLUSIONS The Ianchulev formula could be applied to most eyes, with the exception of those in highly myopic subjects. The Leccisotti formula showed good performance in myopic patients. For eyes falling into the special group, an alternative formula, correction factor, or both, may be required. The new formulas reported herein may be an option. FINANCIAL DISCLOSURE(S) The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Retrospective analysis of the risk factors for developing phacomorphic glaucoma.

Aim: To determine the risk factors for developing phacomorphic glaucoma in eyes with mature cataracts. Materials and Methods: This is a case-control study comprising of 90 eyes with phacomorphic glaucoma and 90 age- and sex-matched control eyes with mature cataracts without phacomorphic glaucoma. Patients with pre-existing glaucoma, previous intraocular surgery and /or absence of documented axial lengths were excluded from this study. Binary logistic regression analysis of the variables, axial length and anterior chamber depth, was performed. Anterior chamber depth of the contralateral eye was used as a proxy measure of the pre-phacomorphic state in the eye with phacomorphic glaucoma as majority of them first presented to our center during the phacomorphic attack without prior measurements of the pre-phacomorphic ACD or lens thickness; therefore, their anterior chamber depth would not be representative of their pre-phacomorphic state. Axial length of 23.7 mm was selected as a cut-off for dichotomized logistic regression based on the local population mean from published demographic data. Results: The mean age was 73.1 ± 10.2 years. All phacomorphic and control eyes were ethnic Chinese. The mean presenting intraocular pressures were 49.5 ± 11.8 mmHg and 16.7 ± 1.7 mmHg in the phacomorphic and control eyes respectively (P< 0.0001), whilst the median Snellen best corrected visual acuity were light perception and hand movement in the phacomorphic and control eyes respectively. Eyes with phacomorphic glaucoma had shorter axial length of 23.1 ± 0.9 mm median when compared with that of control eyes, 23.7 ± 1.5 mm (P = 0.0006). Eyes with AL ≤ 23.7 mm were 4.3 times as likely to develop phacomorphic glaucoma when compared with AL > 23.7 mm (P = 0.003). Conclusion: Axial length less than ≤ 23.7 mm was a risk factor for developing phacomorphic glaucoma. Eyes with AL shorter than the population mean were 4.3 times as likely to develop phacomorphic glaucoma compared with eyes with longer than average AL. In an area where phacomorphic glaucoma is prevalent and medical resources are limited, patients with AL shorter than their population mean may be considered for earlier elective cataract extraction as a preventive measure.

Continuous curvilinear capsulorhexis in intumescent or hypermature cataract with liquefied cortex

&NA; We describe a technique to prevent milky liquefied cortical matter from obscuring the view of the anterior chamber and radial tears caused by high intracapsular pressure in eyes with hypermature or intumescent cataract. The continuous curvilinear capsulorhexis (CCC) is created in a sealed anterior chamber without capsule staining or viscoelastic material. Ninety‐four consecutive CCCs were performed by a single surgeon over 24 months using the method. A successful CCC was achieved in all eyes. Four cases had complications that occurred late in the surgery and were not related to the CCC.

Acute renal failure after topical fortified gentamicin and vancomycin eyedrops.

PURPOSE To report a case of acute renal failure after topical fortified gentamicin and vancomycin eyedrops in the treatment of endophthalmitis. METHODS A 67-year-old lady with diabetes mellitus was treated for bleb-related endophthalmitis. After intravitreal antibiotics, she was given oral ciprofloxacin, fortified gentamicin, and vancomycin eyedrops. She developed acute renal failure a few days after therapy. Blood tests and ultrasound of the urinary system were performed to investigate for the cause of the renal failure. RESULTS No apparent cause of renal failure could be identified in our patient. Autoimmune markers and ultrasound of the urinary system were unremarkable. Fortified gentamicin and vancomycin eyedrops were stopped on day 9 and 13, respectively. The renal function recovered dramatically. The gentamicin level was checked 2 days after it had been stopped, and the serum level was 0.34 mg/L. Renal function improved on supportive management without dialysis. Serum creatinine level completely normalized 2 months later. CONCLUSIONS This is the first article that demonstrated a detectable level of serum gentamicin level after usage of topical eyedrops. This is also the first article demonstrating that nephrotoxicity of topical fortified gentamicin and vancomycin eyedrops was found. The acute renal failure in our patient recovered completely after cessation of the eyedrops.

Verrucous carcinoma: a rare tumor of the eyelid.

A 72-year-old gentleman presented with a left upper eyelid mass existing for several years but progressively increased in size over 2 weeks. Clinically the 1.5 × 1-cm firm, pigmented and sessile mass resembles a large wart. Excisional biopsy of the mass reveals a diagnosis of verrucous carcinoma. Verrucous carcinoma rarely occurs in the eyelid, and this is the first reported case of its occurrence in an Asian patient. As its appearance simulates that of a wart, it may be mistaken as the latter. Deep excisional biopsy is required in differentiating the two. Although being rare, ophthalmologists have to be aware of the diagnosis to avoid missing this potentially curable malignant lesion in patients presenting with eyelid tumors.

Successful Treatment of Pseudallescheria boydii Keratitis with Topical Natamycin as Monotherapy

PURPOSE To report a case of Pseudallescheria boydii keratitis successfully treated with topical natamycin as monotherapy. METHODS Interventional case report describing the clinical presentation, histopathologic findings, course, and treatment of a patient with P. boydii keratitis. RESULTS A 50-year-old male electrician with a 4-day history of right eye pain and blurring of vision was referred. There was history of right eye injury while hammering and examining a hole in the ceiling. Examination showed a corneal abscess with overlying epithelial defect measuring 2 mm in diameter. Histopathologic investigation revealed septate hyaline cylindrical hyphae with acute angle branching and formation of oval to pyriform conidia truncated at the base, compatible with P. boydii. The patient was treated with topical natamycin 5%, which eradicated the infection, resulting in a final best-corrected visual acuity of 6/7.5. CONCLUSION The fungus P. boydii can cause keratitis. The success rate for treatment was generally thought to be poor. Early detection and treatment is important in improving the outcome. This is believed to be the first reported case of P. boydii keratitis successfully treated with topical natamycin as monotherapy.

Muir-Torre Syndrome in a Middle-Aged Chinese Patient with Sebaceous Carcinoma of the Eyelid

Abstract Muir-Torre syndrome is a rare, autosomal dominant condition characterized by the presence of a skin tumor of sebaceous differentiation and visceral malignancies. We reviewed the case of a 46-year-old Chinese man who had a bleeding mass over the right upper eyelid. He had a history of colon cancer and a family history satisfying the Amsterdam criteria for hereditary non-polyposis colorectal cancer syndrome with germline mutation in the MutS homolog-2 gene. The eyelid lesion was excised completely and submitted for histopathologic examination which showed sebaceous carcinoma. Frozen section and conjunctival map biopsy showed no residual malignancy or local metastasis. Post-operative positron-emission tomography with combined computed tomography did not reveal any residual or visceral malignancy. He had no recurrence in the 32-month follow-up period. We should consider Muir-Torre syndrome in patients with sebaceous carcinoma, especially in the presence of personal and/or family history of visceral malignancies.