Fornix reconstruction in ocular pemphigoid with Goretex surgical membrane

After separation of symblepharons in ocular pemphigoid, transplantation of nasal or bucal mucosa is recommended to prevent recurrent lid fusion; however, it is not always successful. BACKGROUND: An 86-year-old patient was referred to our eye clinic because of trichiasis in ocular pemphigoid. In the right eye, the only functional eye, fusion of the lower lid and the globe was present. There was severe trichiasis with multiple lesions of the cornea and beginning neovascularization. The left eye showed complete fusion of the lid fissure and neovascularization of the cornea. To prevent the right eye from suffering the fate of the left, we tried to find a simple surgical method that could easily be performed on the multimorbid patient. METHOD: Under parabulbar anesthesia we separated the lower lid from the globe until free passive motility of the lower lid was achieved. A cut-to-size piece of Gore-Tex surgical membrane was prepared and fixated with resorbable u-sutures on the inner lid. The membrane was left in place for 4 weeks until suture lysis. A silicone tube, which was transitorily fixed to the outer lower lid, had an additional ectropionizing effect. Three months later, lower-lid ectropion surgery was performed, combined with tarsectomy to obtain a long-term effect. RESULT: Six months later the lower-lid fornix had stabilized, and the lid and globe had good motility. The corneal lesions had healed. CONCLUSION: The use of 0.1 mm membrane prevents penetration of cell because of the microstructure. Similar to the "bare sclera" technique, which is used in selected cases in strabismus or pterygium surgery, the inner lid and sclera were epithelialized separately from the remaining conjunctiva. The surgical membrane prevented recurrence of the symblepharon. We think the presented technique is an easy, quick method of preventing recurrence of lid fusion after separation of symblepharons.     

Delivery of high concentrations of inspired oxygen via Tusk mask

A case of surgical repair of progressive exophthalmos of the right eye in a 43-year-old woman with neurofibromatosis Type 1 (NF1) is presented. Preoperatively, the patient's ocular movements and visual fields were intact. Visual acuity was 20/30 on the right side and 20/20 on the left. Computerized tomography scanning demonstrated complete absence of the superolateral orbital wall on the right side with a large meningocele protruding into the right orbit. Intraoperatively, a new superolateral wall was constructed using the inner table of the left frontal bone as a bone transplant. A free galeoperiosteum flap was used for water-tight dural reconstruction. A few weeks postoperatively the patient's exophthalmos showed remarkable resolution. Her ocular movements, visual acuity, and visual fields remained unchanged. In conclusion, reconstruction of the superolateral wall and repair of a meningocele in a patient with NF1 is worthwhile and can be followed by excellent cosmetic results. More important, the patient's visual functions remain preserved.     

Serial magnetic resonance imaging shows separate medial and lateral medullary infarctions resulting in the hemimedullary syndrome

PURPOSE: To report two cases in which cystoid macular edema developed after initiation of topical latanoprost for glaucoma. METHODS: Case reports. One pseudophakic eye in each of two patients treated with latanoprost for glaucoma developed decreased vision and cystoid macular edema. Latanoprost was discontinued, and the cystoid macular edema was treated with topical corticosteroids and ketorolac. RESULTS: After discontinuing latanoprost and starting corticosteroids and ketorolac, visual acuity improved from counting fingers to 20/60 in one patient's left eye and from 20/100 to 20/25 in the other patient's right eye. The macular edema resolved in both eyes. CONCLUSIONS: Topical latanoprost may be associated with cystoid macular edema; this may be related to a prostaglandin-like action.     

Mutation analysis of the glial cell line-derived neurotrophic factor gene in Parkinson''s disease

PURPOSE: To describe bilateral hemorrhage of the posterior segment and secondary angle-closure glaucoma as sequelae of anticoagulation therapy in a nanophthalmic patient. METHODS: An 80-year-old man who was nanophthalmic and was undergoing anticoagulation therapy presented with declining visual acuity in left eye. Six months later, he experienced declining visual acuity in his right eye. RESULTS: In the LE and six months later in the RE, ocular examination disclosed angle-closure glaucoma and a hemorrhagic retinal detachment. Peripheral iridoplasty successfully treated the initial attack. The subretinal hemorrhage was successfully drained by pars plana vitrectomy, retinotomy, and air-fluid exchange in the left eye. Anatomic success and intraocular pressure control were obtained, but visual recovery was limited. CONCLUSION: Intraocular hemorrhage and angle-closure glaucoma are potential complications of anticoagulation therapy in a patient with nanophthalmos.     

Impaired increase of prostaglandin E2 in gastric juice during steroid therapy in children

BACKGROUND: Lightning can cause a number of ocular complications. A case involving a patient who developed a cataract and reversible maculopathy in both eyes after being struck by lightning is reported. METHODS: The patient was evaluated for cataract and macular edema by ophthalmoscopic examination, fluorescein angiography, and potential acuity meter. RESULTS: Maculopathy developed that was characterized initially by a retinal cyst with surrounding edema. Later, the lesions evolved to simulate a full-thickness hole. These lesions subsequently resolved, and the patient's visual acuity improved to 20/20 in each eye after cataract extraction. CONCLUSION: Because the visual prognosis for lightning-induced maculopathy is potentially different than that for full-thickness macular holes, careful retinal examination is essential in the preoperative workup.     

HTLV-I associated myelopathy with macular degeneration

The authors report a case of macular involvement in a patient with HTLV-I associated myelopathy (HAM). The patient was a 10-year-old girl who noticed sudden decreased vision in her right eye in November 1987. The corrected visual acuity was 0.01 in the right eye and 1.0 in the left eye. Fundus examination of the right eye disclosed mild optic disc pallor. The macula appeared to have pigmentary mottling with superficial irregular retinal reflex that was three disc diameters in size. Fluorescein angiography revealed a discoid hypofluorescent area in the macula, surrounded by mottled hyperfluorescent areas. She had no contributory family history of ocular disease, but had a history of blood transfusion during an operation for patent ductus arteriosus and ventricular septal defect at the age of 8 months. In November 1990, she developed gait disturbance due to spastic paraparesis and was admitted to our hospital. Antibodies to HTLV-I were markedly elevated in serum (titer, 1:8192) and in cerebrospinal fluid (titer, 1: 1024). She was diagnosed as HAM. Two months later, she developed encephalopathy and bilateral optic disc atrophy.     

Defective phagocytosis in systemic lupus erythematosus

The authors describe a case of traumatic retinal dialysis with retinal detachment from a water balloon slingshot during a "water balloon war." A 31-year-old woman presented with decreased visual acuity in her right eye 2 days after being hit by a water balloon. The visual acuity in the right eye was counting fingers and fundus examination showed subtotal retinal detachment secondary to a superonasal dialysis. The patient underwent a scleral buckling procedure with external drainage, and at 18 months visual acuity was stable at 20/50 with attached retina. Water balloon eye injuries can result in permanent visual loss. More public awareness needs to be created regarding the potential harmful effects of this commonly used "toy."     

Spontaneous dislocation into the vitreous of a poly(methyl methacrylate) disc lens 9 years after surgery

A 76-year-old woman had sudden visual loss 9 years after an extracapsular cataract extraction with implantation of a poly(methyl methacrylate) disc intraocular lens (IOL) in the capsular bag. Slitlamp examination showed the disc IOL had luxated into the vitreous through a linear inferior opening in the capsular bag; the IOL lay on the retinal surface. A pars plana vitrectomy was performed. The vitreous cavity was filled with perfluorocarbon liquid, floating the IOL to behind the iris. The IOL was removed through a limbal incision, then another type of IOL was implanted in the ciliary sulcus using transscleral fixation. Thirty days after surgery, best corrected visual acuity (BCVA) was 20/20. At 2 months, total retinal detachment appeared with a large superior retinal dialysis. Another pars plana vitrectomy was performed and the scleral-fixated IOL removed through a limbal incision. Internal gas tamponade was used. The eye was left aphakic. Final BCVA was 20/25.     

Brown-McLean syndrome occurring in a corneal graft

PURPOSE: To present a case of Brown-McLean syndrome occurring in a transplanted cornea. METHODS: Retrospective case report. RESULTS: A patient had penetrating keratoplasty performed for bullous keratopathy 6 years after intracapsular cataract extraction in the right eye. She developed atypical Brown-McLean syndrome in the left eye 6 years after extracapsular cataract extraction with pupil-support intraocular lens (IOL) insertion and later IOL removal. The clear corneal graft in the right eye developed peripheral stromal and epithelial edema with pigmentation of the endothelium, consistent with Brown-McLean syndrome 9 years after keratoplasty. CONCLUSION: Brown-McLean syndrome can occur in a grafted cornea, although the features may differ from those seen in ungrafted corneas.     

A second generation of artificial cornea (Biokpro II)

The properties of a new second-generation colonizable artificial cornea were evaluated in humans. The prosthesis consisted of a peripheral rim of a translucent microporous fluorocarbon polymer (expanded polytetrafluoroethylene) fused with the polymer of the central optic. The optic was made of medical-grade polydimethylsiloxane coated with polyvinylpyrrolidone. Its refractive power was 42.2 diopters and it measured 7.0 mm in diameter and 0.55 mm in thickness. The geometry of the optic was tested by high-frequency ultrasound and intraocular pressure and distensibility were measured in an artificial chamber. Prostheses were implanted in one eye of 13 humans. The average follow-up was 6 months (range 3-9 months). Most of the eyes (11/13) were clinically stable after a 7 months follow up. Seven patients had visual acuity improvements. Mean corrected final visual acuity was 20/200 (range, 20/30 to light perception). Five anatomical failures occured (two extrusions, two retroprosthetic membranes, one endophthalmitis). The new optical core, junction, and surface properties of the polymers offer many advantages, quicker colonization of the supporting skirt, and an optical core with a geometry similar to that of a normal human cornea. Epithelial cells did not migrate over the interface and optical core. It seems that formation of an epithelium over the artificial device is essential for the long-term stability of the implant.     

A technique of minilaparotomy-assisted vaginal hysterectomy

PURPOSE: To report a patient with acute retinal pigment epitheliitis examined less than 24 hours after onset of symptoms. METHOD: One day after the onset of blurred vision in her left eye, a 33-year-old woman had a best-corrected visual acuity of LE, 20/60 -2. The left eye had classic uniform golden-colored nodules in a honeycomb pattern in the foveal retinal pigment epithelium. Intravenous fundus fluorescein angiography disclosed staining of the foveal pigment epithelium. RESULTS: One month after initial examination, visual acuity was LE, 20/20, and fine subfoveal pigmentary clumping was present. CONCLUSION: The pigmentary maculopathy of acute retinal pigment epitheliitis may be nonspecific, resulting from more than one type of primary foveal inflammation.     

Retinoscopy after excimer laser photorefractive treatments

Photorefractive keratectomy (PRK) is capable of changing the refractive power of the human cornea. Retinoscopy is an objective method of measuring the refractive power of the eye. The authors performed PRK in 28 myopic eyes with the Aesculap Meditec MEL 60 ArF excimer laser. During a prospective study, the subjective and objective refractive power of the eyes were assessed and compared 6 months after PRK. The average preoperative refractive error was: -5.11 +/- 2.51 D and -5.08 +/- 2.20 D on the right side (n = 16) and on the left side (n = 12), respectively. In order to obtain the best corrected visual acuity 6 months after PRK, the right and left eyes needed an average of -0.09 +/- 0.26 D and -0.33 +/- 0.64 D postoperative correction, respectively. The postoperative refractive change could be verified with the retinoscopy at +/-0.5 D accuracy. The authors describe a double refractive corneal ring after PRK, which may disturb retinoscopy. The post-PRK refractive change can be verified by retinoscopy. Postoperative funduscopy, fundus photography and possible future retinal procedures were not disturbed by the double corneal refractive rings in myopic eyes.     

Pattern of ocular dominance columns in human striate cortex in strabismic amblyopia

Previous experiments in animals have shown that early unilateral eyelid suture, a model of amblyopia induced by cataract, causes shrinkage of ocular dominance columns serving the deprived eye in the striate cortex. It is unknown whether the ocular dominance columns are affected in amblyopia produced by strabismus. We examined specimens of striate cortex obtained postmortem from a 79-year-old woman with a history of amblyopia in her left eye (20/800) since age 2 from accommodative esotropia. Four years prior to her death, she suffered an ischemic infarct of the left optic disc. This injury to the left optic disc made it possible to label the ocular dominance columns using cytochrome oxidase histochemistry. The pattern of ocular dominance columns was reconstructed throughout most of the right striate cortex. No shrinkage of columns was found. In the left cortex only half the column mosaic was labelled, because the patient had some residual vision in the temporal retina of her left eye. The columns within the labelled portion of the overall mosaic appeared normal. These findings indicate that shrinkage of ocular dominance columns does not occur in humans with amblyopia caused by accommodative esotropia. The ocular dominance columns are probably no longer susceptible to shrinkage at the age when most children with this condition begin to develop amblyopia.     

Molecular basis of lipoamide dehydrogenase deficiency in Ashkenazi Jews

PURPOSE: To measure binocular function and patient satisfaction with monovision induced by photorefractive keratectomy (PRK) in myopic presbyopic patients. SETTING: Refractive Department, Cleveland Clinic, Cleveland, Ohio, USA. METHODS: This study comprised 21 myopic presbyopic patients with monovision induced by PRK. Sixteen emmetropic patients who had PRK served as a control group. Monovision was induced by undercorrecting the nondominant eye by 1.25 diopters for near vision and correcting the dominant eye with emmetropia for distance vision. Monocular and binocular uncorrected Snellen visual acuities at 20 feet and 13 inches, manifest refraction, ocular dominance, stereopsis at 20 feet and 13 inches, monocular and binocular contrast sensitivities, Worth-4-Dot test at 20 feet and 1/3 of a meter, and fusional convergence amplitudes were examined in each patient. RESULTS: In the monovision group at near and distance, 20 patients (95.3%) had binocular visual acuity of 20/25 or better. No patient in the monovision group used reading glasses postoperatively; 4 of 16 patients (25.0%) in the control group used such glasses. All patients maintained binocular fusion and stereo acuity ranging from 40 to 800 seconds of arc. Mean patient satisfaction was 86% (range 40% to 100%). In the control group, 12 patients (75.0%) had binocular distance visual acuity of 20/25 or better and 11 (68.8%) had binocular near visual acuity of 20/25 or better. CONCLUSION: Monovision PRK patients had better near vision than control PRK patients, with minimal compromise in stereo acuity and overall high patient satisfaction.     

Equivalence in periodontal trials: a description for the clinician

AIMS: To describe the clinical picture and electrophysiological findings in Müller cell sheen dystrophy, a recently reported retinal dystrophy. METHOD: A basic ophthalmological evaluation as well as recording of standard electro-oculography and electroretinography were performed in one patient at the onset of visual loss and after 1 year of follow up. RESULTS: A 61 year old woman presented with visual loss in the right eye. Multiple folds at the level of the internal limiting membrane were seen at the posterior pole in both eyes. Macular oedema was present in the right eye. The visual acuity of the right eye was 6/30 and of the left 6/9. A paracentral scotoma was found in the right eye. Electro-oculographic examination of both eyes gave normal results. Electroretinography (ERG) revealed reduced b-wave and flicker amplitudes in the right eye; these potentials were normal for the left eye. The ON response in the right eye was reduced and delayed; it was normal in the left eye. A further loss of visual function was noted 1 year later in the right eye, but the ophthalmoscopic findings were unchanged. The ERG of the right eye had a negative waveform when dark adapted. Light adapted responses showed an unusual delayed b-wave, broad and delayed ON and OFF responses and a missing flicker response, suggesting a Müller cell dysfunction. Light adapted responses were slightly reduced in the left eye. CONCLUSIONS: Electrophysiological data indicate Müller cell dysfunction as a background of functional loss in Müller cell sheen dystrophy. This is in agreement with previously reported histological findings in this disorder.     

Epidemiology of motor vehicle crash-related serious eye injuries

The Eye Injury Registry of Alabama has been collecting epidemiologic, treatment, final outcome, and rehabilitation information on serious ocular trauma since 1982. By December 31, 1989, 150 motor vehicle crash-related eye injuries had been registered. This is the largest series of motor vehicle crash-related serious eye injuries reported. The mean age of those injured was 29 years; 61% were between 16 and 35 years of age, and 73% were males. Ten individuals (7%) suffered bilateral eye injuries. The retina was injured in 47% of eyes. The initial visual acuity was 19/200 or worse (legal blindness) in 47% of eyes. Of eyes with at least 3 months of follow-up, 63% had worse than 20/200 initial visual acuity and 41% remained legally blind. Twelve percent of eyes required removal. Possibly due to the large number of blunt ruptures, motor vehicle crash-related eye trauma carries a particularly unfavorable treatment prognosis. Prevention of these injuries is therefore of extraordinary importance.     

Endoscopic management of biliary fistula

A 78-year-old woman complained of ocular pain in the right eye. Thirty-three months before, the patient had a pterygium excised and mitomycin C, 0.04%, was instilled 3 times a day postoperatively for 10 days in the right eye. The same surgery was performed and the same drug was used for a course of 5 days in the left eye. Corneoscleral ulceration and corneal performation occurred in the right eye. The lesions were successfully treated with a lamellar patch graft with reserved corneosclera. We believe that it may not be safe to instill 0.04% mitomycin C 3 times a day postoperatively for 10 days.     

Outcomes and ocular growth rates after intraocular lens implantation in the first 2 years of life

PURPOSE: To evaluate the outcomes and ocular growth after intraocular lens (IOL) implantation in the first 2 years of life. SETTING: University-affiliated eye institute. METHODS: The medical records of consecutive children under 24 months of age who had cataract extraction with IOL implantation were reviewed. Change in axial length over time, postoperative complications, need for additional surgery, predicted versus actual postoperative refraction, and visual outcomes were recorded. Complication rates were compared with those in a similar group of age-matched patients who were left aphakic at the time of surgery. RESULTS: Twenty-two eyes of 17 patients aged 12 days to 22 months had IOL implantation. Length of follow-up ranged from 2 to 36 months (mean 14 months). Visual acuity measurement, limited to fixation-preference testing in most patients, revealed amblyopia in the operated eye in the majority of cases. Postoperative refractive error, predicted using the Holladay formula, showed a mean error in prediction of 1.5 diopters (D) (range -1.8 to 4.1 D). Serial axial lengths in 11 patients with a mean follow-up of 20 months showed no significant difference in growth in the fellow versus the operated eye. There was no significant difference in complication rates between pseudophakic patients and the age-matched aphakic group. However, in 14 of 32 aphakic eyes (44%), a notation in the chart indicated that the patient had stopped wearing glasses or contact lenses for at least 2 months. CONCLUSION: Intraocular lens implantation appeared to be a safe and effective alternative to contact lens or spectacle correction of aphakia in children younger than 2 years of age. It may aid amblyopia treatment by eliminating periods of uncorrected aphakia.     

Asymmetrical vertical phorias indicating dissociated vertical deviation in subjects with normal binocular vision

We measured the symmetry of phoria angles in six normal subjects. Subjects were selected on the basis of good visual acuity and stereopsis, normal binocular eye alignment and, apart from mild refraction errors, absence of ocular abnormalities. They were instructed to look at a word on a reading chart at 2 m distance. Each measurement consisted of five subsequent intervals of 5 s duration. During these five intervals viewing was binocular, with the right eye only, binocular, with the left eye only, and binocular, respectively. Each experiment consisted of twelve measurements. Eye movements were measured with scleral coils suited for measuring in horizontal, vertical and torsional directions. Five out of six subjects displayed an asymmetrical vertical phoria; one subject showed an alternating hyperphoria; four displayed a left over right vertical phoria that was largest for left eye occlusion. Only one subject showed a symmetrical vertical phoria. Both the size of the vertical phorias and the size of the asymmetries in these vertical phorias were very small: on average 0.16 +/- 0.01 and 0.17 +/- 0.01 degree, respectively. The direction of the vertical phoria asymmetries (the largest left over right was found with left eye occlusion) and the fact that asymmetries were found more often in vertical than horizontal and torsional phorias suggest that these asymmetries are related to dissociated vertical deviation. These results suggest that dissociated vertical deviation, often observed in subjects with a disruption of binocular vision early in life, reflects the enhancement of a phenomenon that is present in normal subjects as well.     

The effect of immunotoxins directed against CD80 and CD86 on primary T-cell alloresponses

A 13-year-old boy presented with acute loss of vision in his right eye of 2 weeks' duration. He had a high fever and was ill for several days, then improved but suffered recurrent episodes of sweating and a high fever. Ophthalmoscopy of the right eye showed optic disk edema, mild vitreous cells, and minimal exudates in the macula. Bartonella henselae titers were positive. A diagnosis of optic disk edema with a macular star secondary to cat-scratch disease was made. The patient was treated with doxycycline and made a dramatic improvement to visual acuity of 20/30 with a minimal residual relative central scotoma. The optic disk edema and macular star resolved, and the patient was left with mild optic atrophy in the right eye.