Seyhan B. Özkan

Anesthesia with EMLA® Cream for Botulinum A Toxin Injection into Eyelids

We investigated the efficacy of an eutectic mixture of local anesthetics (EMLA®) in reducing the pain of a botulinum toxin injection into eyelids. 17 patients with facial dyskinesia (9 blepharospasm and 8 hemifacial spasm) who had been treated regularly with botulinum toxin injections received EMLA cream and placebo. The pain was assessed by the ophthalmologist and the patient. Injection with EMLA cream showed lower pain scores (mean 1.82 ± 2.13, median 1) than injection with placebo (8.76 ± 2.17; p = 0.0001). Percutaneous anesthesia induced by EMLA cream is an effective and safe method which improves the comfort in patients who need repeated botulinum toxin injections for their facial dyskinesia.

Chemodenervation in Treatment of Upper Eyelid Retraction

Upper-eyelid retraction is a common sign of thyroid-associated eye disease (TAED), and these patients are highly bothered by the appearance of their eyes. In this study, botulinum toxin A (BTA) was injected into the levator palpebrae superioris muscle in 8 eyes of 4 patients in an attempt to control the abnormal elevation of the upper eyelid. BTA provided control of the upper-eyelid retraction, and the cosmetically acceptable effect lasted for 3-4 months. It was concluded that BTA is an effective method of treatment in this condition. Since it has a temporary effect, it can safely be used to provide relief of symptoms related to upper-eyelid retraction during unstabilized periods of TAED, which may last as long as several years in some patients.

Magnetic resonance imaging in evaluation of congenital and acquired superior oblique palsy

BACKGROUND According to the recently popularized classification of superior oblique (SO) palsy based on congenital variations of the tendon, the primary pathology is the abnormality of the SO tendon rather than an innervational problem in congenital cases. If this hypothesis is true, denervation atrophy of SO muscle should not occur in patients with congenital SO palsy. METHODS Eight patients with traumatic and nine patients with definite congenital SO palsy underwent magnetic resonance imaging (MRI) of the orbit. SO muscle width and cross-sectional area measurements were taken from coronal images and compared with the clinically uninvolved superior oblique muscles. RESULTS Atrophy of varying degrees was observed in the SO muscle both in congenital and acquired cases. No significant difference was found in the appearance of the SO muscle between acquired and congenital SO palsy groups. CONCLUSION We have been unable to demonstrate abnormalities of the SO tendon in both groups. The MRI appearance of the SO muscle suggested that in congenital SO palsy, the pathology is not limited to the tendon; there also is an abnormality of the muscle itself.

Effect of sildenafil on ocular haemodynamics.

Purpose To study the effect of sildenafil, which is an effective agent for the treatment of erectile dysfunction, on ocular haemodynamics.Methods In this prospective study we examined the effect of a single oral dose of 50 mg sildenafil (Viagra) in a group of healthy young male volunteers, by using colour Doppler ultrasound imaging to measure haemodynamic variables in the central retinal artery (CRA), short temporal posterior ciliary artery (STPCA) and ophthalmic artery (OA). The following examinations were performed on both eyes immediately before and 1 h after a single oral dose of 50 mg sildenafil: visual acuity, intraocular pressure (IOP), colour vision, anterior segment, fundus appearance, resting heart rate, blood pressure and colour Doppler measurements.Results After sildenafil administration, peak systolic velocity, mean velocity and end-diastolic velocity significantly increased in the OA of both eyes. All Dopper indices remained non-significant for the CRA and STPCA of both eyes. Sildenafil did not cause any significant change in IOP, colour vision, visual acuity, systolic blood pressure or diastolic blood pressure. However, heart rate measurements increased significantly after sildenafil administration compared with baseline (p = 0.003).Conclusion The increased flow velocity in the ophthalmic artery seems to be due to a vasodilator effect of sildenafil.

Patient-controlled analgesia and sedation with fentanyl in phacoemulsification under topical anesthesia

Purpose: To investigate the effects of intravenous (IV) patient‐controlled sedation/analgesia with fentanyl during phacoemulsification surgery under topical anesthesia. Setting: Adnan Menderes University Medical School, Departments of Ophthalmology and Anesthesiology and Reanimation, Aydin, Turkey. Methods: In this double‐blind randomized study, 68 patients were randomly allocated to 2 groups. In the fentanyl group comprising 34 patients, fentanyl was administered by patient‐controlled analgesia (PCA) equipment in 5 &mgr;g bolus doses with a lockout period of 5 minutes after an IV loading dose of 0.7 &mgr;g/kg in 2 mL balanced salt solution. In the control group comprising 34 patients, a balanced salt solution was given without an analgesic drug by PCA equipment. Verbal pain scale (VPS) and sedation scores were recorded preoperatively and 5, 10, 15, 20, and 30 minutes after the start of surgery. Patient comfort and surgeon satisfaction were assessed postoperatively. Results: The sedation score was higher in the fentanyl group than in the control group at 5 and 10 minutes (P = .006 and P = .012, respectively). The VPS scores were higher in the control group than in the fentanyl group at 15 and 20 minutes (P = .02 and P = .016, respectively). Patients pressed the button for additional analgesia 2.6 times ± 3.9 (SD) in the control group and 0.9 ± 1.6 times in the fentanyl group (P = .025). Patient and surgeon satisfaction were higher in the fentanyl group than the control group (P = .023 and P = .018, respectively). Conclusion: The results of this study suggest that IV PCA with fentanyl has supplemental effects on analgesia and sedation during cataract surgery under topical anesthesia and increases patient comfort and surgeon satisfaction.

Medical control of intraocular pressure after phacoemulsification

Purpose: To compare the effectiveness of oral acetazolamide, topical brinzolamide 1%, and no ocular hypotensive medication after phacoemulsification. Setting: Adnan Menderes University Department of Ophthalmology, Aydin, Turkey. Methods: This prospective randomized double‐blind study comprised 60 eyes of 52 patients having phacoemulsification under topical anesthesia. There were no intraoperative complications. Eyes were randomized to receive oral acetazolamide 500 mg 1 hour preoperatively followed by 250 mg acetazolamide every 6 hours, 1 drop of brinzolamide 1% every 12 hours starting immediately after speculum removal, or no ocular hypotensive medication. Intraocular pressure (IOP) was measured using a Perkins tonometer preoperatively and 4 to 6 hours and 18 to 24 hours postoperatively. Results: The preoperative IOP was not significantly different between the 3 groups. Four to 6 hours postoperatively, the acetazolamide group (P = .002) and brinzolamide group (P = .001) had significantly lower IOP than the control group. The same trend was observed at 18 to 24 hours in the brinzolamide group (P = .001) but not the acetazolamide group (P = .018). The IOP levels were not significantly different between the acetazolamide group and brinzolamide group at any postoperative time point. No eye receiving medication and 2 eyes (10%) in the control group had an IOP of 30 mm Hg or higher 4 to 6 hours postoperatively. Compared with preoperatively, an IOP increase of more than 5 mm Hg was seen at 4 to 6 hours in 3 eyes (15%), 2 eyes (10%), and 14 eyes (70%) in the acetazolamide, brinzolamide, and control group, respectively. Conclusion: Brinzolamide was as effective as acetazolamide in preventing IOP elevation 4 to 6 hours after phacoemulsification and more effective than acetazolamide at 18 to 24 hours.

Colour Doppler Imaging of Superior Ophthalmic Vein in Thyroid-Associated Eye Disease

PURPOSE One of the possible etiologies of proptosis in patients with thyroid-associated eye disease is stated to be passive orbital venous congestion caused by the occlusive and constrictive changes of the superior ophthalmic vein (SOV). In an attempt to clarify the validity of this claim, quantitative information on the flow velocity of the SOV was obtained by colour Doppler imaging in 24 patients with thyroid-associated eye disease and compared with data from the control group. METHODS On clinical examination, ocular motility, proptosis, soft tissue involvement, and the presence of optic neuropathy were evaluated. The interaction of these signs with the flow velocity of the SOV was investigated in conjunction with computed tomographic (CT) findings such as extraocular muscle enlargement, dilatation of the SOV, and apical crowding of the orbit. RESULTS The mean blood flow velocity was significantly decreased in patients compared to the control group (P <.05). The CT measures that contributed to significant decreases in SOV blood flow velocity were apical crowding (P <.05) and the coexistence of horizontal and vertical extraocular muscle involvement (P <.05). Among the clinical measures, significant decreases could be attributed to soft tissue findings (P <.01) and to optic neuropathy (P <.05). CONCLUSIONS External compression of the SOV may contribute to the SOV blood flow decrease in orbits afflicted with thyroid eye disease, but proptosis is not relevant to the SOV blood flow decrease.

Evaluation of congenital Brown's syndrome with magnetic resonance imaging

The magnetic resonance (MR) findings in congenital Browns syndrome were investigated. Sixteen involved eyes of 12 patients were compared with 20 eyes of 10 controls. An enlargement of the tendon-trochlea complex was observed in congenital Browns syndrome. In addition, the appearance of the tendon-trochlea complex was irregular in shape and of intermediate signal intensity. The MR appearances in patients with a satisfactory or poor response to surgery did not show any significant differences from each other or from those in patients who had not undergone surgery. This was also the case for the patient with spontaneous improvement. The MR examination in congenital Browns syndrome suggested that the abnormality was located at the tendon-trochlea complex but clinically it does not give a clue about the outcome of the disease.

Corynebacterium minutissimum endophthalmitis: Management with antibiotic irrigation of the capsular bag

Chronic endophthalmitis, due to Corynebacterium minutissimum, developed in a patient following uncomplicated extracapsular cataract extraction and posterior chamber intraocular lens (PC-IOL) implantation. In this case, which to our knowledge is the first reported case of Corynebacterium minutissimum endophthalmitis, chronic inflammation persisted for 8 months with fluctuations in the inflammation. The specimens from the capsular bag yielded positive culture, but the vitreous culture was negative. The case was successfully treated by a capsular bag irrigation with vancomycin.

Botulinum Toxin A in the Treatment of Adherence Syndrome

The effect of botulinum toxin A is investigated in the treatment of adherence syndrome related to strabismus surgery. An 18-year-old boy with decompensated right congenital fourth nerve palsy underwent ipsilateral superior rectus muscle recession and inferior oblique muscle disinsertion. During the early postoperative period, a right hypotropia with limitation of elevation developed and the result of the forced duction test was positive for passive elevation of the right eye. Botulinum toxin A was injected into the right inferior rectus muscle on the 15th postoperative day and orthophoria was achieved 1 week later. A repeat injection of botulinum toxin A was performed 6 months later. On follow-up 2 1/2 years later, his eyes remained orthophoric with limitation of elevation in the right eye and the patient was satisfied with the result. This case demonstrated that adherence syndrome can be treated successfully by botulinum toxin A injection if it is administered during the acute phase, before the development of fibrous scar tissue.