Vladimir Kratky

Effect of prophylactic nonsteroidal antiinflammatory drugs on cystoid macular edema assessed using optical coherence tomography quantification of total macular volume after cataract surgery

PURPOSE: To evaluate the efficacy of prophylactic administration of the topical nonsteroidal antiinflammatory drug (NSAID) ketorolac tromethamine 0.5% on acute (within 4 weeks of surgery) cystoid macular edema (CME) and total macular volume (TMV) in patients having phacoemulsification cataract surgery. SETTING: Department of Ophthalmology, Queens University, Hotel Dieu Hospital, Kingston, Ontario, Canada. METHODS: This open‐label nonmasked randomized (random number assignment) study comprised 106 eyes of 98 patients. Exclusion criteria included hypersensitivity to the NSAID drug class, aspirin/NSAID‐induced asthma, and pregnancy in the third trimester. Ketorolac tromethamine 0.5% was administered starting 2 days before surgery and for 29 days after surgery for a total of 31 days. The outcome measure was macular swelling, which was quantified by the optical coherence tomography. RESULTS: At 1 month, there was a statistically significant difference in TMV between the control group (0.4420 mm3) and the ketorolac group (0.2392 mm3), with the ketorolac group having 45.8% less macular swelling (P = .009). Multiple linear regression with backward selection indicated a 44.3% (P = .013) and 46.1% (P = .030) reduction in macular swelling in the ketorolac group at 1 week and 1 month, respectively. CONCLUSION: Used prophylactically after cataract surgery, ketorolac 0.5% was efficacious in decreasing postoperative macular edema.

Hertel Exophthalmometry without Orbital Rim Contact

BACKGROUND The Hertel exophthalmometer is the most widely used instrument for the measurement of globe malposition, but an absent or damaged lateral orbital rim will preclude its application. To circumvent this shortcoming, the authors have developed a fixation adapter that attaches to a standard Hertel instrument and transfers fixation to the forehead and nasion from the lateral orbit. METHODS The adapter design is presented and discussed, along with illustrative clinical cases. A study of 30 healthy patients was performed to assess the validity of the adapter with respect to the Hertel standard. The agreement was then evaluated by comparing the Hertel adapter measurements from each patient with that of the adapter. A Wilcoxon statistic was performed to assess differences in the paired values from each patient for both techniques. RESULTS Analysis on a sample (n = 30) of a healthy adult population does not show a statistical difference between the Hertel adapter and the adapter data (P > 0.05). In addition, more than 90% of the differences fall within +/- 1 mm (standard deviation = 1.02 mm) of the means for both eyes, which is within the accepted variance for the Hertel instrument. CONCLUSION The new fixation adapter promises to become useful in assessing trauma and surgical cases where the lateral orbital rim has been violated and will expand the application of Hertel exophthalmometry to these situations.

Melkersson-Rosenthal syndrome presenting with isolated bilateral eyelid swelling: a clinicopathologic correlation

Melkersson-Rosenthal syndrome (MRS) is a rare condition characterized by the triad of orofacial edema, facial nerve palsy, and furrowing of the tongue. The full triad is present in only 25% of patients. Isolated eyelid swelling is a very rare, and possibly under-diagnosed, presentation. A 60-year-old man was referred for assessment of chronic eyelid swelling of approximately 7 years’ duration. His general health was good and he had no known systemic medical conditions. His ethnic origin was Indian. Formal allergy testing had previously been performed by another physician as part of a work-up for his eyelid swelling. Examination revealed bilateral, nonerythematous, nonpitting, upper eyelid swelling, greater on the left side (Fig. 1) than on the right. The remainder of his ophthalmic examination was unremarkable. Investigations (including complete blood count, erythrocyte sedimentation rate, c-reactive protein, creatinine, urinalysis, angiotensin converting enzyme level, antineutrophil cytoplasmic antibodies, extractable nuclear antigens antibodies, double-stranded DNA antibodies,

Patterns and causes of epiphora referrals to a tertiary oculoplastic practice

OBJECTIVE To report the causative factors and surgical candidacy of patients referred to an oculoplastic surgery clinic for the complaint of epiphora. DESIGN Prospective observational study. PARTICIPANTS Consecutive patients (n = 159) referred to a tertiary care oculoplastic surgery clinic over a 12-month period for the complaint of epiphora. METHODS The causative factor most responsible for tearing was determined based on clinical examination by the principal investigator, who was blinded to referral source. Patients were considered surgical candidates with a diagnosis of significant nasolacrimal duct obstruction, lid malposition, or pump dysfunction. The primary outcome was the percentage of referrals that were surgical candidates, classified by referral source. RESULTS The most common cause of tearing was nasolacrimal duct obstruction, occurring in 53 of 159 (33%) patients. The percentage of surgical candidates was highest in referrals from ophthalmologists (82%), followed by optometrists (67%) and family physicians (55%; p = 0.011 for difference between ophthalmologists and family physicians). CONCLUSIONS Epiphora may be because of a variety of causes, some of which are amendable to surgical treatment. In the absence of an obvious cause, a trial of lubrication by the family physician is warranted before referral being made to an oculoplastic surgeon.

Orbital compartment syndrome in a burn patient without aggressive fluid resuscitation.

Abstract Introduction: Orbital compartment syndrome may rarely occur in the setting of burns where therapy includes aggressive fluid resuscitation. Case: We report a case of bilateral orbital compartment syndrome in a 13-year-old male, with superficial facial burns secondary to hydrobromic acid, who did not receive aggressive fluid resuscitation. The patient was treated successfully with bilateral lateral canthotomy and cantholysis. Comment: Facial burns may lead to orbital compartment syndrome without aggressive fluid resuscitation, likely due to excessive leakage of fluid and protein into the orbit combined with an inflammatory reaction.

Acute orbital inflammatory syndrome following H1N1 immunization

Conventional surveillance for an unknown primary cancer in ocular metastasis involves computed tomography imaging of the thorax and abdomen. Because testicular GCTs are the most common malignancy in men between 20 and 39 years of age, this case illustrates the significance of including a testicular examination or investigating the possibility of extragonadal GCTs when searching for a primary malignancy as the source of uveal metastasis presenting in young adult males.

Efficacy of Intravenous Mannitol in the Management of Orbital Compartment Syndrome: A Nonhuman Primate Model

Purpose: To report the efficacy of intravenous mannitol in the treatment of orbital compartment syndrome. Methods: An experimental study was conducted on 4 nonhuman primates (8 orbits). Orbital compartment syndrome was simulated by injecting autologous blood into both orbits of each nonhuman primate until a pressure of 80 mm Hg was reached (time 0). After 10 minutes, nonhuman primates were randomized to receive an infusion of either mannitol or saline, given over 15 minutes. Five minutes after the infusion was complete, lateral canthotomy and cantholysis was performed on both orbits in isolated steps every 5 minutes. During the study protocol, orbital and intraocular pressures were recorded every 5 minutes, with a final set of measurements at 60 minutes. The primary outcome measures were the mean change in pressure from time 0 to 60 minutes, as well as the mean change in pressure during the infusion period. Results: There was no statistically significant difference in the mean changes in orbital or intraocular pressure from time 0 to 60 minutes of the protocol. However, during the infusion period there was significantly greater decrease in both orbital and intraocular pressure in the mannitol compared with saline group (-34.0 vs. -9.3 mm Hg for orbital pressure [p = 0.03]; -34.8 vs. -9.7 mm Hg for intraocular pressure [p = 0.04]). Conclusions: While the definitive treatment of orbital compartment syndrome is lateral canthotomy and cantholysis, mannitol results in a rapid and clinically meaningful drop in orbital and intraocular pressure. The authors believe that their data support the routine use of mannitol in orbital compartment syndrome, especially when there is a delay in timely surgical management.

Dacryocystorhinostomy in Elderly Patients: Regional Anesthesia Without Cocaine

Elderly patients with nasolacrimal obstruction who are in poor health often pose a special anesthetic and surgical risk. General anesthesia and the use of cocaine packs may be contraindicated because of potentially dangerous side effects. Regional block dacryocystorhinostomy has gained popularity in all adult patient groups, but specifically it appears to be the procedure of choice in elderly patients. It is well suited for either hospital-based or ambulatory care. We describe our experience with the procedure in 25 consecutive patients (28 procedures), with emphasis on modification of our standard technique to suit regional blockade. Mechanisms of cocaine toxicity in the surgical setting are reviewed, and a method of local anesthesia without cocaine nasal packing is presented.

Avulsion of the Canalicular System

Avulsion of the common canaliculus from its attachment to the lacrimal sac should be suspected in cases involving either deep lacerations on the lateral side of the nose or traumatic telecanthus in midfacial trauma. Blunting of the canalicular angle and rounding of the inner canthus are confirming signs. A canaliculodacryocystorhinostomy can be performed to reanastomize the lacrimal drainage pathways and relieve epiphora.