Susan Lindley

Tuberculosis of the Orbit

Two cases of orbital tuberculosis in white Canadians are reported. The two patients did not suffer from pulmonary tuberculosis, the orbital disease was associated with tuberculosis sinusitis in the first case and blood-borne from constrictive tuberculous pericarditis in the second case. Acid-fast bacilli are difficult to detect in the pathological specimens and the diagnosis is usually based on the following: (1) the positive tuberculin skin test; (2) the caseating granulomatous inflammatory lesion on histopathology, which is highly suggestive of active tuberculosis; (3) the positive culture for Mycobacterium tuberculosis if the specimens are obtained early in the course of the disease; and (4) the complete resolution of the disease with the specific antituberculous medications.

Orbital infarction and melting in a patient with systemic lupus erythematosus

OBJECTIVE To present a patient with systemic lupus erythematosus who developed infarction and melting of the orbit secondary to her systemic disease. DESIGN A case report. PARTICIPANT A 61-year-old white woman with a 5-year history of systemic lupus erythematosus. METHODS The patient presented with left orbital pain, limitation of extraocular movements, and a fistula from the ethmoid sinus to the upper eyelid. A detailed examination with computerized tomography, ultrasound, and a comprehensive medical evaluation with laboratory testing was performed. Histopathologic analysis with special stains of the orbital tissues was also performed. RESULTS Histopathologic examination of the biopsy specimens revealed the features of an inflammatory process involving the orbit, similar to a panniculitis. These include a lymphocytic reaction with a predominance of plasma cells, vasculitis with occlusion, and thickening of the vessel walls, necrosis, and hyalinization of fat. CONCLUSION This is a unique case in which infarction and melting of the entire orbital structures occurred in the presence of systemic lupus erythematosus. The underlying disease process is a lupus-related panniculitis. The authors stress that this is a very rare entity and that other diseases should be ruled out before entertaining this diagnosis.

Visualization of posterior lens capsule integrity by 20-MHz ultrasound probe in ocular trauma.

PURPOSE To evaluate the use of the 20-MHz ultrasound probe in facilitating visualization of the posterior lens capsule in ocular trauma. DESIGN Interventional case report. METHODS Serial examinations using 10-MHz, 20-MHz, and 50-MHz ultrasound technologies were performed on the anterior segment of the right eye of an 18-year-old man referred with a diagnosis of globe penetration and secondary traumatic cataract. RESULTS Cross-sectional echograms of the anterior segment using the 20-MHz ultrasound showed posterior lens capsule integrity. CONCLUSION When verifying the status of the posterior lens capsule in cases of ocular trauma, the 20-MHz ultrasound probe is a useful and novel approach.

Uveal effusion after cataract surgery : An Echographic study

PURPOSE To determine the incidence of uveal effusion after cataract surgery and to relate its presence to selected preoperative, intraoperative, and postoperative variables. DESIGN Prospective consecutive observational case series. PARTICIPANTS Two hundred seven eyes of 205 subjects undergoing cataract surgery. METHODS Several preoperative, intraoperative, and postoperative variables of potential significance in uveal effusion after cataract surgery were studied. On the first postoperative day and within 2 weeks after the surgery, subjects were examined clinically and echographically with B-scan for evidence of suprachoroidal (uveal) effusion. When effusion was present, follow-up examinations were performed until complete resolution was documented. MAIN OUTCOME MEASURES Echographic presence of uveal effusion in the postoperative period. RESULTS Uveal effusion was documented echographically in 12 patients (5.8%). Only one of these cases was clinically evident. All effusions were small and resolved with no intervention. The presence of postoperative hypotony related to wound leak (intraocular pressure <10 mmHg) was significantly correlated with uveal effusion after cataract surgery (P<0.0001). The combination of oral acetazolamide and topical pilocarpine gel given after the surgery also correlated with effusion (P<0.02). Intraoperative complications and prolonged phacoemulsification time were not shown to be risk factors for effusion. CONCLUSIONS Uveal effusion is rarely seen after modern, small-incision, closed-system cataract surgery. It is correlated with postoperative hypotony related to wound leak and with the administration of both oral acetazolamide and topical pilocarpine after surgery.

Acquired restrictive strabismus and high axial myopia: diagnosis and management

OBJECTIVE This paper documents the clinical, ultrasound, magnetic resonance imaging (MRI), and anatomic characteristics of 6 patients with esohypotropia and high axial myopia. The results of strabismus surgery performed on these patients are evaluated. STUDY DESIGN Retrospective cohort study. PARTICIPANTS Six patients with esohypotropia and high axial myopia were selected from the practice of the second author (Michael Flanders). METHODS We extracted the history and data from the preoperative and postoperative ophthalmic and orthoptic examinations, recorded the surgical procedures, and tabulated the postoperative results. A- and B-scans, orbital MRI images, and photo documentation were obtained for all patients. Supramaximal recession and resection on the horizontal rectus muscles, using adjustable sutures, was performed in all patients. A surgical outcome was deemed successful if, in primary position, postoperative horizontal ocular alignment measured 15 prism diopters (PD) or less and (or) if diplopia was eliminated. RESULTS Echographic and MRI findings demonstrated an enlarged globe in all cases. Globe flattening on the orbital walls was found in 5 cases. Lateral rectus depression was visualized on MRI images in 4 cases. Surgical success was obtained in all patients. The average preoperative primary position esotropia measured 60 PD (25 to 90 PD) and the esodeviation after surgery was 7.0 PD (0 to 15 PD). Ductions were also improved. CONCLUSIONS Different surgical approaches to realignment of eyes with high myopia and esohypotropia have been attempted. In this study, supramaximal amounts of recession and resection on the rectus muscles provided satisfactory results.

Neuroretinal Rim Area Change in Glaucoma Patients With Visual Field Progression Endpoints and Intraocular Pressure Reduction. The Canadian Glaucoma Study: 4

PURPOSE To compare rim area rates in patients with and without the visual field (VF) progression endpoint in the Canadian Glaucoma Study and determine whether intraocular pressure (IOP) reduction following the endpoint altered rim area rate. DESIGN Prospective multicenter cohort study. METHODS setting: University hospitals. PATIENT POPULATION Two hundred and six patients with open-angle glaucoma were examined at 4-month intervals with standard automated perimetry and confocal scanning laser tomography. INTERVENTION After the endpoint, IOP was reduced by ≥20%. OUTCOME MEASURES Univariate analysis for change in rim area rate and multivariable analysis to adjust for independent covariates (eg, age, sex, and IOP). RESULTS Patients with an endpoint (n = 59) had a worse rim area rate prior to the endpoint compared to those without (n = 147; median [interquartile range]: -14 [-32, 11] × 10(-3) mm(2)/y and -5 [-14, 5] × 10(-3) mm(2)/y, respectively, P = .02). In univariate analysis, there was no difference in rim area rate before and after the endpoint (median difference [95% CI], 8 (-10, 24) × 10(-3) mm(2)/y), but the muItivariate analysis showed that IOP reduction >2 mm Hg after the endpoint was strongly linked to a reduction in rim area rate decline (8 × 10(-3) mm(2)/y for each additional 1 mm Hg reduction). CONCLUSIONS Patients with a VF endpoint had a median rim area rate that was nearly 3 times worse than those without an endpoint. Lower mean follow-up IOP was independently associated with a slower decline in rim area.

Is fasting required before cataract surgery

Do patients need to fast before cataract surgery? The question has been discussed for well over a decade, and those ophthalmologists who work in hospitals where fasting is not required may be surprised that the debate is still going on. The purpose of fasting is to reduce the risk of anaesthesia-related pulmonary aspiration of gastric contents and the consequent risk of aspiration pneumonia. Fasting practices vary greatly, even among hospitals within the same university. Local policies within each hospital are established by the Department of Anaesthesiology. In hospitals where fasting for cataract surgery is routine, ophthalmologists are well aware that patients can experience difficulties related to fasting. Hunger and thirst add to the stress and discomfort of the surgical experience. Headaches, nausea, dizziness, and fainting can result from prolonged starvation (for example, in patients who have been fasting since midnight for surgery in the afternoon). Medications such as antihypertensives may be missed, even when patients are instructed to take all their regular medications before surgery, “because I usually take them with breakfast.” Diabetics, especially insulin-dependent diabetics, can have their control adversely affected in either direction by fasting, despite adjustments of their medications. The Canadian Ophthalmological Society’s cataract surgery guidelines state: “If topical anesthesia without i.v. opiate or sedative is administered, fasting is not necessary (consensus).” However, the Canadian Anesthesiologists’ Society’s Guidelines to the Practice of Anesthesia state: “Fasting policies should vary to take into account age and preexisting medical conditions and should apply to all forms of anesthesia, including monitored anesthesia care.” They do not specifically address cataract surgery under topical anaesthesia or sedation. The American Academy of Ophthalmology also has no specific guidelines on fasting for cataract surgery. Outside North America, some guidelines are more specific. The Royal College of Anaesthesia and the Royal College of Ophthalmology of the United Kingdom issued joint guidelines in 2001 that state: “If surgery is planned under LA (local anesthesia) diabetic patients should have their usual medication and oral intake.” They also state: “Starvation is not necessary for conscious sedation. However, in view of the risk of unexpectedly deeper sedation, it is desirable to develop local protocols in conjunction with the department of anaesthesia.” Separate guidelines from the Royal College of Ophthalmology in 2004 state: “It is unnecessary to fast patients for local anaesthetic cataract surgery.” In 2007, the Clinical Practice Committee of the Scandinavian Society of Anaesthesiology and Intensive Care Medicine published an update on preoperative fasting guidelines that states: “It looks like pre-operative fasting ensures very little extra patient safety, and at the expense of patient comfort.” The Committee does emphasize the potential danger of “heavy” sedation and non-fasting. However, any sedation during cataract surgery is generally light enough to allow for continued patient cooperation during the surgery. A published letter from Calgary cited 30 000 cases of cataract surgery with no change in dietary or medication routine and no adverse outcomes, even though several of the patients lost consciousness. Zacharias and Chirnside summarized the issue in an article in Evidence-based Anaesthesia and Intensive Care with the statement, “It appears that there really is no need for fasting before cataract surgery done under local anaesthetic. The evidence for this is based on case reports and experience of anaesthetists and ophthalmologists involved with this procedure.” Sanmugasunderam and Khalfan, with their study in this issue of the CJO, have contributed significantly to the discussion. They document 5125 cases of cataract surgery performed without fasting and with no recognized adverse outcomes of aspiration or aspiration pneumonia. The authors recognize the limitations of a retrospective L’article de Gan et ses collègues soulignent l’importance de bien comprendre que la prestation des soins dans un centre académique se fait en équipe. Selon le degré de responsabilité, le choix des cas appropriés aux capacités d’un résident donné et la surveillance diligente des professeurs—groupe sélect d’ophtalmologistes à travers le pays qui se consacrent à la formation des résidents—la profession médicale a constamment démontré qu’elle pouvait atteindre d’excellents résultats tout en permettant à ses résident de faire des chirurgies. Certains ont même soutenu que les patients avaient un devoir moral de permettre la participation des résidents à leurs soins, notamment dans un système de soins de santé financé à même les fonds publics. Le moment est peut-être venu pour nous d’abandonner le secret et de promouvoir la vérité, dont nous devrions être très fiers.