Vivek B. Pandya

Endophthalmitis following cataract surgery: The sucking corneal wound

We were quite surprised, and also concerned, to note that a patient given the proposed Northern European panacea for prevention of endophthalmitis following cataract surgery (that is, intracameral cefuroxime) developed bilateral postoperative endophthalmitis. This occurred 4 days after bilateral cataract surgery performed at the same sitting. A recent editorial stated that the major risk factors for the development of postoperative endophthalmitis included corneal incisions, age (especially older than 80 years), and loss of posterior capsule integrity, which would allow direct access of bacteria into the vitreous. Further, it was recognized that there are essentially 2 opportunities for bacteria to enter the eye during cataract surgery: at the time of surgery and in the early postoperative period before epithelialization of an unsutured wound. This leads to the notion that sutured corneal incisions may reduce the risk for developing endophthalmitis in the postoperative period. In a laboratory model using India ink, Taban et al. demonstrated that aqueous aspirates from 3 eyes with sutureless clear corneal incisions had increased spectrophotometric readings (P!.01). This was in contrast to the readings from aspirates in eyeswith sutured corneal incisions, which showed no increase in absorbance level from baseline. This demonstrates that ingress of India ink occurs through sutureless clear corneal incisions, representing the potential passage of microorganisms into the eye. In sutureless cataract surgery, wound sealing is generally achieved by stromal hydration at the completion of the case. However, some evidence suggests that the wound is compromised when closure is not reinforced with suturing. Vasavada et al. demonstrated in routine cataract surgery that wounds sealed by stromal hydration allowed ingress of trypan blue into the anterior chamber. Notably, trypan blue was detected in the anterior chamber within 2 minutes of stromal hydration. A recent study by Praveen et al. confirmed this finding in 3 phacoemulsification techniques; the ingress was worst with bimanual phacoemulsification. Herretes et al. reported ingress of blood-tinged fluid into the anterior chamber after the incisions were sealed by stromal hydration. These results have led to the conclusion that clear corneal incisions may not always be self-sealing.

External Dacryocystorhinostomy: Assessing Factors that Influence Outcome

Purpose: To present the experience of external dacryocystorhinostomy (DCR) at a tertiary referral center and investigate factors that may affect clinical outcomes. Methods: The clinical records of all patients who underwent external DCR at Sydney Eye Hospital between May 2000 and August 2007 were reviewed. Data were collected in regards to patient demographics, preoperative assessment, operative details, surgical technique, postoperative management, and clinical outcomes. This information was then analyzed, with emphasis on factors that influence surgical outcomes and success. Results: A total of 338 cases were reviewed. The mean age at time of surgery was 64.82 years and the majority of patients were female (65%). Epiphora was the major preoperative symptom. Assisted local anesthesia and day stay surgery were the most common surgical settings. There was a statistically significant difference in theatre time between consultant and trainee surgeons (P < 0.00001). The mean final follow-up time was 11 months. Overall, 77.3% of patients had full resolution of symptoms and 20.8% had partial resolution. Only five patients (1.9%) had no resolution of symptoms. There was no significant difference in outcomes between consultants and trainees. Patients with anatomical nasolacrimal obstruction had significantly better outcomes compared with functional obstruction (P = 0.04). The postoperative fluorescein dye disappearance test was a good predictor of clinical success (P = 0.005). Silicone intubation for greater than 6 months was associated with better outcomes (P = 0.002). Conclusions: The results at our tertiary center are comparable to results stated in the literature. In our series, only the amount of nasolacrimal obstruction and duration of postoperative intubation influenced surgical success.

Nocardia transvalensis resistant to amikacin: an unusual cause of microbial keratitis.

Purpose: To report a case of microbial keratitis caused by Nocardia transvalensis with resistance to amikacin. Methods: Case report. Results: A 51-year-old man was referred with a 10-week history of ocular pain, photophobia, redness, and blurred vision. At his initial presentation, a corneal foreign body was removed and he was diagnosed with anterior uveitis, with commencement of topical corticosteroid therapy and ofloxacin. Despite treatment, he experienced ongoing foreign body sensation and glare. At presentation to our clinic, a central epithelial defect with multiple stromal infiltrates in a wreath pattern was identified and a diagnosis of infective keratitis was made. He was initially commenced on topical amikacin, oral trimethoprim-sulfamethoxazole, and oral voriconazole. Corneal scraping confirmed Nocardia species. Microbiological culture revealed N. transvalensis as the causative organism, with resistance to several antibiotics, including amikacin. Clinically, there was only partial response of the keratitis to initial therapy. Treatment was changed to oral trimethoprim-sulfamethoxazole and topical ciprofloxacin, with eventual clinical improvement. Conclusions: This is the first reported case of N. transvalensis keratitis. In patients with Nocardia keratitis and only partial response to amikacin treatment, this isolate should be considered as it is resistant to aminoglycoside antibiotics.

Does unintentional macular translocation after retinal detachment repair influence visual outcome

Background:  To document the occurrence of postoperative macular translocation after retinal detachment repair and discuss its influence on visual outcome.

Tattoo-associated Uveitis With Choroidal Granuloma: A Rare Presentation Of Systemic Sarcoidosis.

Purpose: The authors report a rare case of systemic sarcoidosis manifesting as bilateral granulomatous panuveitis and multiple tattoo granulomas. Methods: Case report. Results: A 30-year-old man presented with headaches, ocular pain, photophobia, and blurred vision. He was found to have significant skin inflammation, predominantly involving areas of tattoos. Fundoscopic examination revealed bilateral granulomatous panuveitis with small focal choroidal lesions. Skin biopsy demonstrated granulomatous inflammation of the dermis with tattoo pigment evident in numerous histiocytes. He was diagnosed with systemic sarcoidosis. Conclusion: The authors report another rare case of tattoo-associated uveitis, in which inflammation is limited to tattooed skin and the uvea. This uncommon presentation may prove informative in elucidating the pathogenesis of systemic sarcoidosis.

Tattoo-Associated Uveitis

dependent variables are linear and the dependent variable is normally distributed. Table 2 showed the results from the univariate and multivariate analyses with discrepant assumptions on the distribution of the same variables. Sixty eyes could be regarded as a sufficiently large number according to the central limit theory; it seems more appropriate to use the Pearson correlation coefficient, a parametric method, as a univariate version of the multiple regression analysis in Table 2.

Primary cutaneous B cell lymphoma presenting as recurrent eyelid swelling

Primary cutaneous lymphoma represents a distinct clinical entity within the spectrum of haematological malignancy. A case of primary cutaneous B cell lymphoma is reported, presenting in an 87-year-old female with a 2-year history of intermittent swelling and discolouration of the right upper and lower eyelids, in the absence of systemic symptoms. Histopathological examination of an incision biopsy revealed a lymphoid infiltrate in the dermis with immunophenotypic features of B cell lymphoma. Staging investigations confirmed the absence of systemic disease. Treatment with oral chemotherapy was undertaken with a good response. Ophthalmologists should include primary cutaneous lymphoma in the differential diagnosis of recurrent eyelid swelling.Primary cutaneous lymphoma represents a distinct clinical entity within the spectrum of haematological malignancy. A case of primary cutaneous B cell lymphoma is reported, presenting in an 87‐year‐old female with a 2‐year history of intermittent swelling and discolouration of the right upper and lower eyelids, in the absence of systemic symptoms. Histopathological examination of an incision biopsy revealed a lymphoid infiltrate in the dermis with immunophenotypic features of B cell lymphoma. Staging investigations confirmed the absence of systemic disease. Treatment with oral chemotherapy was undertaken with a good response. Ophthalmologists should include primary cutaneous lymphoma in the differential diagnosis of recurrent eyelid swelling.

The Role of Mucosal Flaps in External Dacryocystorhinostomy

Purpose: To determine whether a mucosal anastomosis fashioned at the time of external dacryocystorhinostomy (DCR) influences postoperative outcome. Methods: The clinical records of all patients who underwent external DCR at Sydney Eye Hospital between May 2000 and August 2007 were reviewed. Data were collected in regards to surgical technique, clinical outcomes and postoperative management. Chi-square statistical analysis was done to determine the significance of the different flap techniques on surgical success. Results: A total of 260 medical records were reviewed. The main outcome measure was postoperative resolution of symptoms. The mean final follow-up time was 11 months. There was no statistically significant difference in outcome between patients who had both anterior and posterior flaps sutured, compared to those who had anterior flap sutures only (73% vs 79%, p = 0.51). Patients who had no sutured flaps had an overall success rate of 89% compared to those that had at least the anterior flaps sutured together (76%); this difference was not significant (p = 0.45). Conclusion: There was no statistical difference in symptom outcome between patients in whom both mucosal flaps were sutured, those who had only the anterior flap sutured, or those who did not have either flap sutured at the time of surgery.

Management of Fusarium keratitis and its associated fungal iris nodule with intracameral voriconazole and amphotericin B

A retrospective case report on the management of a 56-year-old man who was diagnosed with Fusarium keratitis with an associated iris fungal nodule. He presented with persistent right ocular pain, redness, photophobia and reduced vision following an injury six weeks earlier. Conservative management with topical antibiotics and intracameral injections was successfully used to treat a rare case of Fusarium keratitis with an associated fungal iris nodule. The patient had complete resolution of his vision. Therefore, conservative management of the fungal nodule is a successful therapy without the risk of anterior chamber dissemination, which may occur with surgical resection.A retrospective case report on the management of a 56‐year‐old man who was diagnosed with Fusarium keratitis with an associated iris fungal nodule. He presented with persistent right ocular pain, redness, photophobia and reduced vision following an injury six weeks earlier. Conservative management with topical antibiotics and intracameral injections was successfully used to treat a rare case of Fusarium keratitis with an associated fungal iris nodule. The patient had complete resolution of his vision. Therefore, conservative management of the fungal nodule is a successful therapy without the risk of anterior chamber dissemination, which may occur with surgical resection.

The grape: an appropriate model for continuous curvilinear capsulorhexis.

The cornerstone of helping surgical trainees achieve a cost-effective level of surgical expertise and competency is provision of adequate supervised training and repetition to consolidate newly learned skills. When helping trainees learn new surgical procedures, surgical tutors often recommend dividing the procedure into the component steps. We believe this philosophy is particularly beneficial in assisting trainees master the continuous curvilinear capsulorhexis (CCC) step of endocapsular phacoemulsification. Trainee surgeons have noted phacoemulsification and capsulorhexis as the most challenging steps of the procedure, and a recent publication suggests that sculpting and fragmentation are the most difficult. Experienced surgeons readily recognize that the most important early step in safe phacoemulsification is a high-quality capsulorhexis. The use of synthetic or animal eyes as well as surgical simulators have been described in learning this step. The attendant costs and limited access of animal models and surgical simulators pose significant problems in phacoemulsification training. We suggest the use of red globe grapes (Vitus vinifera) as an alternative model for CCC training. Grapes and tomatoes have been mentioned, to our knowledge with no literature support, as being useful for practicing capsulorhexis. The grape is readily available, irresistibly cheap, and has an elastic skin