Clinical manifestations and treatment outcomes in dissociated strabismus complex (DSC) patients.

Objective: To demonstrate clinical manifestations and treatment outcomes in dissociated strabismus complex patients. Methods: Charts of patients who attended the Muscle Clinic at Siriraj Hospital from July 1998 to June 2002 were reviewed. Information regarding the patient’s age, sex, eye deviation, visual acuity, binocular function, head posture, degree of dissociated vertical deviation (DVD), dissociated horizontal deviation (DHD), dissociated torsional deviation (DTD), inferior oblique overaction (IOOA) and the treatments were obtained. Results: Seventy-three subjects from 1,335 strabismic patients were included in the study (5.5% of all strabismic patients attended the Muscle Clinic during the study time). The mean age of DSC patients was 8 years old. Among all DSC patients, 65.8% had esodeviation; 23.2% had exodeviation; and, 11% had isolated DSC. Latent nystagmus was found in 11% of the patients. Abnormal head posture was found in 16.4% of the patients. About fifteen percent of DSC patients had binocular function. All DSC patients had DVD but only 5 patients had DHD; no DTD was found. The treatment of DHD was correction of the horizontal deviation that coexisted with vertical deviation. As for DVD, there were many surgical procedures for correction such as superior rectus muscle (SR) recession, inferior oblique muscle (IO) recession, inferior oblique muscle anteriorization and inferior rectus muscle (IR) resection. Both unilateral and bilateral surgeries were performed. Regardless of the procedures, the total success rate was 78.4% (the residual of hyperdeviation was 10 prism diopters (PD) or less).The group of patients, who had surgical correction in only one eye, had a significant deviation in the non-operated eye after the surgical treatment. Conclusions: DSC was composed of DVD, DHD, DTD and latent nystagmus. DVD was the predominant manifestation in most cases of DSC. DSC was usually bilateral and was seen in subnormal binocular function patients. Esotropia was the most common deviation associated with DSC patients. Many surgical procedures were used to correct DVD such as bilateral large SR recession or IO anteriorization. In unilateral surgery, the manifestation of the deviation in the non-operated eye was always be found. Bilateral surgery was suggested but may be performed in asymmetrical degree. In this study, the overall success rate was 78.4%.

Outcomes of cataract surgery in senile cataract patients at Siriraj Hospital: a prospective observational study.

The present study was done to assess the results of cataract surgery performed in Siriraj Hospital by comparing phacoemulsification and extracapsular cataract extraction techniques in senile cataract patients within a 3-month period. The prospective observational study of a representative sample of 379 patients (409 eyes) who underwent cataract surgery in Siriraj Hospital from January 1, 2004 to March 31, 2004. Identical clinical assessment protocol was used to compare the improvement of postoperative visual acuity and surgical complications between two surgical techniques and different surgeons. Of the 409 eyes, phacoemulsification was performed on 373 eyes (91.2%), and extracapsular cataract extraction was performed on 36 eyes (8.8%). Departmental staff operated on 326 eyes (79.7%) and ophthalmology residents operated on 83 eyes (20.3%). The primary outcome was postoperative visual acuity. Visual acuity was improved > or = 2 Snellen chart lines in 278 of 373 eyes (74.5%) in the phacoemulsification group, and > or = 2 lines in 31 of 36 eyes (86.1%) in the extracapsular cataract extraction group. A small risk of surgical complications was found in the present study. Posterior lens capsule rupture was the most frequent complication found (10/ 409 eyes), followed by corneal injury (9 of 409 eyes). Endophthalmitis was the most severe complication in the present study, occurring in 1 of 409 eyes. There was a significant difference in postoperative visual improvement between phacoemulsification and extracapsular cataract extraction techniques. Final visual acuity in the phacoemulsification group was better than in the extracapsular cataract extraction group.

Surgical techniques of cataract surgery and subsequent postoperative endophthalmitis.

OBJECTIVES: To compare the incidence and characteristics of patients with endophthalmitis after extracapsular cataract extraction (ECCE) to those after phacoemulsification MATERIAL AND METHOD: Records of patients receiving intravitreal antibiotic injection to treat endophthalmitis after cataract surgery between Jan 2001 and Dec 2004 were reviewed. Demographic data and other characteristics including associated diseases, details of cataract surgical procedure and intraoperative complication, onset of endophthalmitis after cataract surgery, presenting symptoms and signs of endophthalmitis, how endophthalmitis was managed, causative organisms, duration of hospitalization and results of treatment were collected. This information was compared between those of endophthalmitis patients after ECCE and those after phacoemulsification. RESULTS: There were 5 cases who developed endophthalmitis after ECCE and 31 cases after phacoemulsification. The incidence was 0.365% after ECCE and 0.279% after phacoemulsification (p = 0.589). Visual acuity (VA) before cataract surgery in ECCE group was worse than the phacoemulsification group (median VA: counting fingers vs 6/36, p = 0.001). Median onset of endophthalmitis was 8 days after ECCE and 6 days after phacoemulsification. Presenting symptoms and signs were similar. Causative agents were identified in 4 (80%) and 14 (45%) cases in the ECCE and phacoemulsification groups respectively. Gram-positive bacteria were the major cause of infection in both groups. Endophthalmitis caused by citrobacter sp. in ECCE group and enterococcus or streptococcus sps. the phacoemulsification in the group ended up with enucleation or no light perception. CONCLUSION: The present study has not demonstrated an apparent difference between endophthalmitis after ECCE and those after phacoemulsification. Endophthalmitis after either procedure can be managed as the same condition.

Corneal lattice dystrophy, a concealed ophthalmic problem in Thailand.

One single family of corneal lattice dystrophy was examined and interviewed to elucidate the variety of clinical manifestations, factors associated with visual impairment, and the impact on the patient's quality of life. Forty-three out of 88 family members (48.9%) were affected. The inheritance pattern was autosomal dominant. Corneal haze grading from 1 to 4 was 5.3 per cent, 26.3 per cent, 43.4 per cent, and 25 per cent respectively. Surface irregularity grading from 1 to 4 was 18.4 per cent, 39.5 per cent, 32.9 per cent, and 9.2 per cent respectively. Forty-five per cent of the patients had VA < or = 20/200. Corneal haziness, irregularity, corneal erosion and disease duration were significantly related to visual impairment (p < 0.05). This disturbed the patient's activities such as reading (79.1%), working (62.8%) and daily life (69.8%). Corneal lattice dystrophy within the same family may present with different manifestations depending on the severity and duration of the disease and might be misdiagnosed. Inadequate knowledge among patients was susceptible to the high prevalence of the disease leading to impaired quality of life.

Comparison of topical prednisolone acetate, ketorolac tromethamine and fluorometholone acetate in reducing inflammation after phacoemulsification.

AIMS: To compare the efficacy and ocular adverse effects of topical prednisolone acetate, ketorolac tromethamine, and fluorometholone acetate in reducing inflammation after phacoemulsification. METHOD: One hundred and twenty eyes were enrolled in a prospective, investigator-masked, randomized controlled trial. Each drug was prescribed 4 times a day for 28 days. The following data were recorded weekly: visual acuity, intraocular pressure, slit lamp biomicroscopy, grading of cells and flare in the anterior chamber, and ocular symptoms. RESULTS: The number of eyes with a minimal amount of cells in the anterior chamber in the ketorolac group was less than the prednisolone group on day 7 (11:20, p = 0.008) and day 14 (23:31, p = 0.015), and than fluorometholone group on day 7 (11:21, p = 0.011). Intraocular pressure in the prednisolone group was higher than the ketorolac group on day 21 (14.6:12.2 mmHg, p = 0.016). One eye in the prednisolone group had intraocular pressure of 32 mmHg. Burning sensation was reported frequently in the ketorolac group. CONCLUSION: All 3 drugs were effective in reducing post-operative inflammation. The efficacy of prednisolone acetate and fluorometholone acetate was comparable. Ketorolac tromethamine showed less efficacy than corticosteroids, however, it did not induce ocular hypertension.

Childhood onset myasthenia gravis.

The authors share experiences in taking care of 27 cases of childhood onset myasthenia gravis (MGS). In all cases, the diagnosis was confirmed by a combination of clinical examination and Neostigmine test. The majority (92%) had localized ocular myasthenia with median onset of symptoms at 33 months of age. About 24 per cent of them progressed to generalized MGS. A few (8%) presented with respiratory failure that required ventilatory support with onset of symptoms at about 22 months. Thymectomy was performed in 10 cases. Complete and partial remissions were achieved in about 70 per cent and 26 per cent of cases respectively with the combination of an immunosuppressant (azathioprine) and a Cholinesterase inhibitor (pyridostigmine). None experienced a myasthenic crisis with proper management and good follow-up using the above combinations.

Spontaneous lens dislocation.

We present a multidisciplinary approach to a patient with spontaneous lens dislocation. A 39-year-old female developed blurred vision in both eyes one year prior to presentation. This symptom could not be corrected with spectacles. Her previous history showed progressive bilateral myopia since the age of ten and a single episode of syncope without exertion 16 months before presentation. Ophthalmic examination demonstrated cataracts with upward and outward displacement of the crystalline lenses in both eyes. Manifest refraction and keratometry displayed moderate myopia with high lenticular astigmatism in both eyes. Marfan syndrome was suspected on the basis of general physical examination and a complete cardiovascular examination performed by the geneticist and the cardiologist respectively. In addition, the role of the cardiovascular-thoracic surgeon in the management of Marfan syndrome is presented.

Mitochondrial genetics of mitochondrial diseases in Thailand.

Mitochondrial diseases are a heterogenous group of disorders with various biochemical defects in the oxidative phosphorylation system. They are included in the differential diagnosis of many cases of multisystem disease even though the neuromuscular and central nervous system are mainly involved. The complexity of the disease can make it difficult for the clinician to diagnose. The number of the patients suffered from Mitochondrial disease is expected to be increasingly found each year. We present here the mitochondrial diseases with their underlying molecular genetics in the mitochondrial DNA found in Thai patients.

Retinal arterial obstruction: The etiology and visual result.

A series of 17 consecutive patients with central retinal artery obstruction (CRAO; 15 patients, 16 eyes) and branch retinal arterial obstruction (BRAO, two patients) were studied at Siriraj Hospital between January 1994 and June 1997 with respect to cause, associated factors and visual result. The study group compressed 13 men and four women with a mean age of 48 years. Hyperlipidemia was the most common underlying disorder in those patients aged less than 45 years. Retinal emboli and increased intraocular pressure were identified as the ocular in three patients. The visual result improved in four patients, two each of whom had interval times from onset to treatment of less than six hours and more than 48 hours. No light perception vision at the initial examination occurred in 3 patients and none had improved vision.