Robert W Lingua

Splenic epidermoid cysts.

Four patients with splenic masses were operated upon and found to have epidermoid cysts of the spleen, a rare lesion comprising less than 10% of benign, nonparasitic splenic cysts. The patients were young and had vague, non-specific symptoms which were related to the size of the slowly enlarging splenic mass. Three patients had palpable masses. Contrast gastrointestinal studies and intravenous urography will help exclude mass lesions of the gastrointestinal or genitourinary tract. Sonar scan may confirm the cystic nature of the lesion and localize it to the spleen. A review of 42,327 autopsy records at the Los Angeles County-University of Southern California Medical Center revealed 32 benign splenic cysts found incidentally at autopsy. Hemorrhage, infection, rupture, and rarely, malignant change are complications of splenic cysts. Splenectomy is recommended to eliminate the symptoms produced by the cyst and prevent the potential complications.

Contrast sensitivity in dyslexia

Contrast sensitivity was determined for dyslexic and normal readers. When testing with temporally ramped (i.e. stimuli with gradual temporal onsets and offsets) gratings of 0.6, 4.0, and 12.0 cycles/deg, we found no difference in contrast sensitivity between dyslexic readers and controls. Using 12.0 cycles/deg gratings with transient (i.e. abrupt) onsets and offsets, we found that dyslexic individuals had, compared to controls, markedly inferior contrast sensitivity at the shortest stimulus durations (i.e. 17, 34, and 102 ms). This deficit may reflect more sluggish temporal summation. There was no difference in sensitivity to 0.6 cycles/deg gratings with transient onsets and offsets. Under these conditions, the two groups showed a consistent and equal increase in sensitivity relative to the ramped baseline condition at 0.6 cycles/deg at the longer stimulus durations. This demonstrates that dyslexic readers have no deficit in their ability to detect stimulus transients, a finding which appears to be inconsistent with a transient system deficit. That detection of the low-frequency stimuli was mediated by the transient system is further indicated by the fact that these stimuli were more susceptible to forward masking than were the high-frequency stimuli. The effects of masking of both high and low spatial-frequency stimuli were about equal for dyslexic readers and controls. This is not in agreement with the transient system deficit theory, according to which one would expect there to be less masking of high spatial-frequency stimuli in the case of dyslexic readers.

Sequelae of botulinum toxin injection.

A total of 136 injections was given to 83 patients for strabismus (99 injections), blepharospasm (29 injections), and spastic entropion (eight injections). All four patients with entropion experienced temporary benefits and early recurrence; one injection resulted in temporary paralytic ectropion. Two of 13 patients treated for blepharospasm developed transient bilateral blepharoptosis. Temporary and related sequelae of extraocular muscle injection included one periocular hemorrhage, one total ophthalmoplegia, and a 44% incidence (29 of 66 patients) of blepharoptosis, which in two patients lasted more than six months. Within three days of injection one patient developed homolateral acute herpes simplex keratitis and a second died of an acute myocardial infarction. No causal relationship for these events has been established.

Thyroid eye disease presenting after cataract surgery.

Strabismus presenting after cataract surgery has been attributed to a variety of disorders, some of which are unrelated to the surgery. When thorough ophthalmologic and neurologic examinations fail to elucidate a definitive etiology, the motility disturbance is often ascribed to operative trauma to the orbital soft tissues. In a series of 58 patients with strabismus presenting after cataract surgery, eight (14%) were found to have previously unsuspected thyroid eye disease. Three of the eight patients had past histories of systemic dysthyroidism, but none reported diplopia prior to cataract extraction. Three of the remaining five patients showed normal thyroid function tests. Absence of diplopia prior to cataract extraction in these patients may be due to: 1) poor vision precluding diplopia until surgical restoration of sight; 2) intraoperative aggravation of the inflammatory process in otherwise subclinical thyroid eye disease; or 3) onset of clinical thyroid eye disease that was temporally associated with cataract surgery by chance. Thyroid eye disease should be included in the differential diagnosis of all patients presenting with binocular diplopia following cataract surgery. Suitable neuroimaging studies may be needed to confirm the diagnosis.

Cataract extraction and intraocular lens implantation in an infant with a monocular congenital cataract

Abstract A cataract extraction and primary capsulotomy with intraocular lens (IOL) implantation was performed on a 17‐day‐old infant with a monocular mature congenital cataract. The IOL power, calculated at the time of surgery, was undercorrected to compensate for the growth of the eyeball. Two additional surgical procedures were required to resolve visual axis obstruction caused by lens epithelial cell proliferation. Follow‐up was 18 months, during which amblyopia prevention therapy was instituted.

Topical intrastromal steroid during laser in situ keratomileusis to retard interface keratitis

PURPOSE To evaluate the effect of an intraoperative topical intrastromal steroid on the incidence and severity of nonspecific diffuse intralamellar keratitis (NSDIK). SETTING T.L.C. The Laser Center, Brea, California, USA. METHODS This prospective study included 2 cohort groups, each consisting of 105 consecutive eyes treated with laser in situ keratomileusis (LASIK) for myopia and astigmatism. Group A received the standard LASIK medication protocol and Group B, an additional drop of prednisolone sodium phosphate 1% solution on the undersurface of the cap immediately after it was reflected, prior to initiating the laser treatment. After the laser treatment was completed, the flap was repositioned; 1 minute after the steroid application, the interface was irrigated. All patients were examined postoperatively and placed in 1 of 4 categories: no interface keratitis, grade 1 (mild), grade 2 (moderate with decreased vision), or grade 3 (severe with decreased vision). RESULTS The incidence of NSDIK in Group A was 17.1% (18 eyes); 14 eyes (78.0%) were grade 1 and 4 (22.0%), grade 2. The incidence in Group B was 6.7% (7 eyes); all eyes were grade 1. Topical intrastromal steroid application significantly reduced the incidence and severity of NSDIK (P < .01). CONCLUSION We propose that intraoperative intrastromal steroid application is a safe and effective way to reduce the incidence and severity of NSDIK.

Synergistic Divergence and Jaw-Winking Phenomenon

Synergistic divergence is a congenital syndrome of monocular adduction deficit, with simultaneous abduction of both eyes on attempted gaze into the field of action of the paretic medial rectus muscle. Based on electromyographic data, it has been speculated that it is a neural miswiring disorder related to Duanes retraction syndrome. The association between Duanes retraction syndrome and the Marcus Gunn jaw-winking phenomenon, another neural miswiring disorder, has been previously reported. The authors describe a patient with both bilateral synergistic divergence and Marcus Gunn jaw-winking phenomenon.

Histopathologic and Ultrastructural Analysis of Congenital Corneal Staphyloma

Although the visual prognosis for eyes with congenital corneal staphyloma has been considered hopeless, we successfully treated a 1-month-old girl with this condition. We performed two penetrating keratoplasties, operating on the left eye first and then, one week later, on the right eye. During each procedure, we totally resected the staphyloma and excised the iris which was adherent to the posterior surface of the cornea. We then sutured an 11-mm corneal button into place with 34 interrupted 10-0 nylon sutures. Light and transmission electron microscopy of the Descemets membrane and endothelium. The left eye had two rejection episodes and underwent a second penetrating keratoplasty. The graft in this eye is now opaque. The child follows objects well with her right eye.

Laser in situ keratomileusis to correct residual myopia and astigmatism after radial keratotomy

PURPOSE To evaluate the safety and efficacy of laser in situ keratomileusis (LASIK) in selected post-radial-keratotomy (RK) eyes with residual myopia and astigmatism. SETTING TLC-The Brea Laser Eye Center, Brea, California, USA. METHODS Nine eyes of 6 patients who had had RK but had residual myopia and/or astigmatism had LASIK. All RK eyes had 8 radial incisions, were more than 1 year post-RK, had no epithelial inclusion cysts or corneal disease, and had had no subsequent ocular surgery. Follow-up was a minimum of 13 months, at which time uncorrected visual acuity (UCVA), best corrected visual acuity (BCVA), manifest refraction, cycloplegic refraction, keratometry, central and peripheral pachymetries, intraocular pressure, and a subjective assessment of visual function were obtained. RESULTS At the last follow-up, the mean spherical equivalent (SE) was -0.156 diopter (D) +/- 0.174 (SD). All eyes treated for distance vision had a UCVA of 20/25 or better. No patient lost BCVA. No intraoperative or postoperative complications occurred. Seven eyes had morning and evening measurements. The mean change in manifest SE from morning to evening was -0.143 D. Six of the 7 eyes (86%) had 0 to 1 Snellen line change in UCVA from morning to evening. The subjective questionnaire revealed a high degree of satisfaction with overall vision, minimal glare, and less fluctuation in daily vision than before LASIK. CONCLUSION Laser in situ keratomileusis is safe and efficacious for reducing residual myopia and astigmatism in properly selected RK patients.

The problem of cycloplegia in the pediatric age group: a combination formula for refraction.

Cycloplegic refraction and indirect ophthalmoscopy are essential to evaluation of the pediatric patient. Unfortunately, along with this practice occur the attendant risks of toxicity and the unpleasantness of instillation. The literature that documents the development of cycloplegic agents is often contradictory regarding efficacy and side effects. It is presented for perspective. We have found that efficacy and discomfort are inseparable; however, as with efficacy and toxicity they are directly related to the concentration used. The case is therefore made to use each agent in its minimal effective concentration and thereby minimize both discomfort and toxicity. Our combination of 1.3% cyclogyl, .167% mydriacil, and 1.6% phenylephrine accomplishes effective cycloplegia for refraction and indirect ophthalmoscopy, has a rapid onset and short duration, works reliably in dark irides, is accomplished in a single encounter with the patient, and exhibits none of the side effects of the individual agents in our series.