Shai M. Bar-Sela

A feasibility study of an Internet-based telemedicine system for consultation in an ophthalmic emergency room.

We examined the feasibility of a low-bandwidth, Internet-based tele-ophthalmology system for consultation in an ophthalmic emergency room. Forty-nine patients (98 eyes) with complicated cases were seen during night shifts in the ophthalmic emergency room. Ocular images were taken using a slit-lamp connected to a video camera, processed and transmitted to a senior physician by email. A telephone was used for real-time audio communication. Each case was re-examined by the same senior physician the following day. The time needed to capture and to process the images was 5 min (SD 2). Each case was given a feasibility score (0-100%), which was defined as the contribution made by the transmitted images in presenting clinical details which could not have been described verbally. High feasibility scores (mean scores ranging from 85 to 90) were found for the following images: ocular surface, anterior chamber, anterior chamber angle, pupils, lens, optic nerve and macula. In contrast, images of vitreous and peripheral retina received low feasibility scores (mean score 65). There was 100% agreement between the diagnosis made during consultation and the on-site examination made by the senior ophthalmologist later on. Ninety-eight percent of the patients stated that they would prefer being examined under the telemedicine system on their next emergency room visit, rather than the traditional resident on-site examination.

Astigmatism outcomes of scleral tunnel and clear corneal incisions for congenital cataract surgery

PurposeTo evaluate astigmatism outcomes after congenital cataract surgery with intraocular lens implantation using clear corneal or scleral tunnel incisions.MethodsWe retrospectively reviewed the medical records of 46 children (67 eyes), aged 2 months to 12 years, who had undergone nontraumatic cataract extraction and intraocular lens implantation between 1996 and 2001, using a scleral tunnel incision (group 1), or a clear corneal incision (group 2). Refractive astigmatism was measured at 1 week, 3 months, and 5 months after surgery. Paired t-test was used to compare those variables, and Spearmans correlation was used to determine their relation to patients age.ResultsMean±SD astigmatism at 1 week postoperatively was 3.1±2.8 Diopter (D) and 2.1±1.7 D in groups 1 and 2, respectively. It significantly reduced to 1.1±1.2 D and 0.9±1.0 D, respectively, in the two groups at 5 months postoperatively (P<0.007). In both groups patients’ age was significantly correlated with 1-week postoperative astigmatism (group 1: r=0.64; P=0.001; group 2: r=−0.58; P=0.003), and with the change in cylinder magnitude between 1 week and 3 months postoperatively (group 1: r=−0.67; P=0.001; group 2: r=0.50; P=0.013).ConclusionChildren who underwent congenital cataract surgery using clear corneal or scleral tunnel incisions showed high postoperative astigmatism at 1 week postoperatively, which spontaneously reduced during 5 months follow-up. Therefore, suture removal is not necessary in those cases.

Changes in Astigmatism After Congenital Cataract Surgery and Foldable Intraocular Lens Implantation

PURPOSE To evaluate the changes in astigmatism after cataract extraction and implantation of a foldable intraocular lens (IOL) in children. Only eyes with astigmatism of 3.0 D or more were included in the study. METHODS The charts of children who had undergone surgery for nontraumatic cataract using a foldable IOL were retrospectively reviewed. In 13 eyes with astigmatism of 3.0 D or more, the refraction was tested and recorded at 1 week, 3 months, and 5 months postoperatively. A paired t test was used to compare the variables. RESULTS Mean astigmatism 1 week postoperatively was 4.7 +/- 1.9 D (range, 3.0-10.0 D). Thereafter, the astigmatic component of the refractive error underwent a spontaneous steady decline, reaching a mean value of 0.9 +/- 0.9 D (range, 0-2.25 D) 5 months after surgery. The difference between the mean values at 1 week and 5 months was statistically significant (P < .0001). CONCLUSION Children who underwent congenital cataract surgery and IOL implantation showed a significant spontaneous reduction in astigmatism postoperatively.

The relationship between patient age and astigmatism magnitude after congenital cataract surgery.

Purpose To evaluate the magnitude of refractive astigmatism after congenital cataract surgery and to define its correlation with patient age. Methods The authors retrospectively reviewed the charts of all pediatric patients who underwent congenital cataract extraction with intraocular lens (IOL) implantation through a 3.0-mm clear corneal incision from 1998 to 2003, and had no suture removal for 5 months afterward. Thirty-four children were included, aged 2 months to 15 years. Refractive astigmatism was assessed manually 1 week, 3 months, and 5 months after surgery by an experienced optometrist. The paired t test was used to compare the magnitude of postoperative astigmatism at different postoperative periods. Spearman correlation was used to determine the correlation between patient age and the postoperative refractive astigmatism. Results Mean refractive astigmatism in all patients was 1.8±1.5 diopters (D) at 1 week post-operatively. It significantly decreased to 1.0±0.7 D at 3 months postoperatively (p=0.001), and to 0.8±0.7 D at 5 months postoperatively (p=0.03). The change in astigmatism was significantly greater during the first 3 postoperative months than during the following 2 months (p=0.04). Patient age was significantly correlated with 1 week postoperative astigmatism (Spearman coefficient, r = −0.46; p=0.006) and with 3 months postoperative astigmatism (Spearman coefficient, r =–0.37; p=0.03). Conclusions Congenital cataract surgery using a small, clear corneal incision for IOL implantation caused high early postoperative astigmatism, which spontaneously regressed thereafter. Younger patients had higher early postoperative astigmatism.

Long-term outcomes of triamcinolone acetonide-assisted anterior vitrectomy during complicated cataract surgery with vitreous loss.

Purpose To report the long‐term outcomes of triamcinolone acetonide–assisted anterior vitrectomy during complicated cataract surgery with vitreous loss. Setting Tel Aviv Medical Center, Tel Aviv, Israel. Design Case series. Methods Consecutive patients who had triamcinolone acetonide–assisted anterior vitrectomy for complicated cataract surgery with vitreous loss between January 2010 and January 2012 were studied. The main outcome measures were the results of the ocular examination and spectral‐domain optical coherence tomography of the macula at the last follow‐up visit 12 months or more postoperatively. The ocular examination included corrected distance visual acuity (CDVA), intraocular pressure (IOP), and anterior segment and fundus biomicroscopy. Results The study included 15 patients (15 eyes) with a mean age of 71 years (range 50 to 92 years). The mean follow‐up was 21 months (range 12 to 29 months). At the last follow‐up, the mean CDVA was statistically significantly better than preoperatively (0.24 logMAR ± 0.31 [SD] versus 0.89 ± 0.81 logMAR) (P=.0033); all patients had improved CDVA over the preoperative values. Except for 1 patient with a macular scar, all the patients had a CDVA between 20/40 and 20/20. At last follow‐up, 1 patient required 2 IOP‐lowering medications that had been used preoperatively as well. The mean IOP was 15.3 ± 2.4 mm Hg. There were no cases of residual vitreous strands in the anterior chamber, inflammatory reactions, triamcinolone acetonide crystals, retinal breaks, retinal detachment, or pseudophakic cystoid macular edema. Conclusion Triamcinolone acetonide‐assisted anterior vitrectomy during complicated cataract surgery with vitreous loss was safe and effective. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Retinal Toxicity of Intravitreal Melphalan in Albino Rabbits

Background: Intravitreal melphalan injections have been used for treating retinoblastoma with vitreous seeds. The aim of this study was to evaluate the safety margins for intravitreal melphalan, using clinical observations, electrophysiological testing and morphological observations. Methods: In this experimental study, 18 albino rabbits, were treated with intravitreal injection of 0.1 ml melphalan solution to the right, experimental eye, and were divided into 4 dose groups: 5 μg (N=4); 15 μg (N=4); 30 μg (N=5); 60 μg (N=5). The left, control eye, of each rabbit was injected with 0.1 ml saline. Clinical examination, electroretinography (ERG) and visual evoked potentials (VEP) were conducted at baseline and periodically throughout the 4-week follow-up. The eyes were then enucleated and the retinas were prepared for histology and glial fibrillary acidic protein (GFAP) immunocytochemistry. Results: No clinical, ERG, or histologic damage were found in rabbits treated with 5 μg melphalan. However, expression of glial fibrillary acidic protein was detected in retinal Muller cells of the experimental eyes and not in the control eyes. With all other doses of melphalan, dose-dependent funduscopic changes, ERG amplitude, histological damage and GFAP expression were found. VEP responses were similar between the experimental eyes and control eyes of all rabbits regardless of melphalan dose injected into the eye, indicating no change in retinal output. Conclusions: These findings indicate that intravitreal melphalan dose of 5 μg in rabbits, approximately equivalent to 10 μg in human, appears to be safe, but induce a mild stress to the retina. However, higher doses are toxic, and their utilization should be executed with caution, particularly if visual potential exists.