Angiographic evidence of peripheral ischemia in diabetic retinopathy and the risk of impending neovascularisation.

The appearance of biomicroscopic evidence of neovascularisation is the main indication for scatter laser treatment in patients with known diabetic eye disease. We describe a patient with an unusually aggressive variant of proliferative disease and a distinct angiographic signature. In an interventional case report with angiographic findings, we found that angiographic evidence of extensive capillary dropout in patients with known diabetic retinopathy should translate into a low threshold for panretinal photocoagulation treatment based on a high risk for progression to sight-threatening proliferative disease. Angiography may be a useful adjunct in stratifying patients with diabetic eye disease according to risk. Those with extensive ischemia, even without neovascularisation, should be considered for early panretinal photocoagulation.

Presumed non-accidental injury with retinal haemorrhages--findings from a tertiary referral centre in the United Kingdom.

AIM: To describe the clinical and demographic features of patients with retinal haemorrhages from presumed non-accidental injury (NAI) at a tertiary referral centre in Leeds over a 2-year period. METHODS: All patients with retinal haemorrhages from presumed NAI between 1 January 2007 and 31 December 2008 were retrospectively identified from the hospital RetCam® (Clarity Medical System, Pleasanton, CA, USA) database. Case-notes, fundus photographs and radiological studies were retrieved for all patients and examined. RESULTS: Over the study period, 14 infants had retinal haemorrhages secondary to presumed NAI. All were male with a mean age of 18 ± 15 weeks (range 2-47) and came from areas with a mean Index of Multiple Deprivation (IMD 2007) rank of 34 ± 27% (range 0.97-68). Seizure/collapse was the reason for presentation in 71% (10/14). Retinal haemorrhages were bilateral in 64% (9/14) and unilateral in 36% (5/14). They were single-layered in 71% (10/14) and multi-layered in 29% (4/14). Subdural haemorrhages were found in 93% (13/14) and were symmetrical in 77% (10/13). Skeletal survey was positive in 28% (4/14). CONCLUSIONS: In the context of presumed NAI, there is a strong association between presence of retinal haemorrhages and the likelihood of underlying subdural haemorrhage. In this region, male infants under 12 months, from deprived areas, appear to constitute a vulnerable group.

Monovision: a refractive consideration in cataract surgery after vitrectomy?

Cataract is the most common complication of vitrectomising surgery in the phakic eye. Progressive nuclear sclerosis (NS) causes a myopic shift. This change in refractive status can predispose to the development of monovision in presbyopic individuals. Recognition of adaptation to monovision is important when undertaking sequential cataract surgery. Our case describes a patient whose adaptation to monovision was only recognised after its reversal. Predisposing factors are discussed and lessons highlighted.

First-year experience of chemotherapy for advanced retinoblastoma in Tanzania: disease profile, outcomes, and challenges in 2008.

PURPOSE: To examine the profile of retinoblastoma in a national tertiary referral center in Tanzania and to report first-year outcomes of its treatment using chemotherapy. METHODS: All patients with retinoblastoma referred in 2008 were included. Disease was classified on clinical grounds as ocular, orbital, or metastatic. Those with ocular and orbital disease received chemotherapy. Remission was the main outcome measure and defined as absence of disease at the end of treatment. RESULTS: In 2008, 37 patients (20 males and 17 females) with retinoblastoma were referred to Ocean Road Cancer Institute. The mean delay from the first sign of disease to presentation at hospital was 10.4 ± 8.7 months. Disease was ocular in 32% (12 of 37), orbital in 57% (21 of 37), and metastatic in 11% (4 of 37). Of those with ocular disease, 67% (8 of 12) completed chemotherapy and all (8 of 8) achieved remission. In contrast, 48% (10 of 21) with orbital disease completed chemotherapy and only 50% (5 of 10) achieved remission. The difference in outcome between the groups was statistically significant (P = .001, Fisher exact test). CONCLUSION: The profile of retinoblastoma in Tanzania is skewed toward severe invasive disease. Despite the introduction of chemotherapy, further improvements in mortality and morbidity can only be achieved through emphasis on early detection.

Diaton tonometry: an assessment of validity and preference against Goldmann tonometry.

BACKGROUND: To assess agreement between the Diaton, a new transpalpebral tonometer, and Goldmann applanation tonometry, the accepted gold standard. DESIGN: Comparative study of two devices in a hospital setting. PARTICIPANTS: Two hundred and fifty-one patients attending the eye casualty and general ophthalmology clinics at St James' University Hospital, Leeds between February and December 2009. METHODS: Intraocular pressure was measured using Goldmann applanation tonometry and Diaton tonometry by one examining ophthalmologist. Patient preference for either technique was also recorded. MAIN OUTCOME MEASURES: Intraocular pressure measured by Diaton was compared with intraocular pressure measured by Goldmann applanation tonometry. Limits of agreement were determined using the Bland-Altman method. RESULTS: Two hundred and fifty right eyes underwent both Goldmann applanation tonometry and Diaton tonometry. Mean intraocular pressure was 13.8 ± 3.6 mmHg using Goldmann applanation tonometry and 13.2 ± 4.3 mmHg using Diaton tonometry. Upper and lower limits of agreement were +8.4 mmHg and -9.6 mmHg, respectively. Order of intraocular pressure measurement and positioning did not influence limits of agreement in a clinically significant manner. Overall, more patients expressed preference for Diaton tonometry (40.2%) than Goldmann applanation tonometry (30.3%). Those aged 50 or less were more likely to prefer Diaton tonometry. CONCLUSIONS: The Diaton tonometer is portable, lightweight, user-friendly and well tolerated by patients. However, it shows poor agreement with Goldmann applanation tonometry, thereby precluding it from being regarded as a substitute in routine clinical practice.

Multiple parallel-line endotheliitis--a form of herpes simplex keratitis?

PURPOSE: To report a case of multiple parallel-line endotheliitis with a possible link to herpes simplex virus. CASE REPORT: An 89-year-old woman presented with new onset reduced vision in her left eye. Her visual acuity with pinhole was 20/120 with the affected eye and 20/30 in the right. She had a white left eye with significant corneal edema and keratic precipitates. These were arranged in a striking pattern of multiple parallel lines resembling railroad tracks. She responded very well to topical steroid and was found to have positive immunoglobulin G and immunoglobulin M titers for herpes simplex virus. CONCLUSIONS: Multiple parallel-line endotheliitis may represent a mild expression of herpes simplex keratitis. It appears to be exquisitely sensitive to topical steroid on its own suggesting that immune response has a dominant role in its pathogenesis.

Drusen and the misleading optic disc.

Optic disc drusen are acellular calcified deposits occurring in small optic discs. They have a prevalence of up to approximately 2% and are bilateral in 75% of cases. Their size and fundosc pic visibility increase with age, and they are commonly responsible for the misdiagnosis of papilloedema by the unwary. Although largely asymptomatic, they can be associated with vascular problems affecting the optic nerve. Ocular ultrasonography is the most sensitive method for their detection. This article highlights their commonly encountered clinical presentations and the practical aspects of diagnosis and management.

Goldmann tonometry versus the Tono-Pen XL for intraocular pressure measurement: an evaluation of the potential impact on clinical decision making in glaucoma.

AIM: To assess the validity of the Tono-Pen XL as an alternative to the Goldmann applanation tonometer (GAT) for the measurement of intraocular pressure (IOP) in patients with ocular hypertension (OHT) and glaucoma. METHODS: Over a 3 month period, patients with OHT or glaucoma attending a general clinic had IOP measurements taken using the Tono-Pen XL and the GAT. Tono-Pen measurements were taken by suitably trained nursing staff, while Goldmann tonometry was performed by the examining ophthalmologist. RESULTS: There were 124 eyes of 62 patients in this study. Overall, mean IOP was 18.3 +/- 4.8 mmHg using GAT and 18.8 +/- 5.5 mmHg using the Tono-Pen. Using the Bland-Altman method, the upper and lower limits of agreement between the two devices were +10.6 mmHg and -9.6 mmHg, respectively. Significant over- and under-estimates of IOP were noted in 10 (16%) patients. CONCLUSION: Our findings suggest that the Tono-Pen XL cannot be used as a substitute for GAT in the management of patients with glaucoma or OHT.

Anatomical correlate of a persistent paracentral scotoma after an airbag injury.

Ocular injuries caused by deploying airbags are well-described in the literature and can be either mechanical or chemical in nature. To the authors' knowledge, this is the first report describing an isolated paracentral scotoma noted immediately after an airbag injury. The use of optical coherence tomography revealed an anatomical correlate of the scotoma. The authors discuss a likely mechanism for focal damage to the retina based on these findings.

The efficacy of 5% povidone-iodine for 3 minutes prior to cataract surgery.

PURPOSE: To evaluate the efficacy of 3 minutes of 5% povidone-iodine for skin and conjunctival antisepsis prior to cataract surgery as recommended by the European Society of Cataract and Refractive Surgeons. METHODS: A prospective controlled study of 54 patients undergoing unilateral cataract surgery by phacoemulsification was undertaken. The eye undergoing surgery was prepared with 5% povidone-iodine for 3 minutes. The other eye served as control. Swabs were taken from both eyes prior to application of 5% povidone-iodine and 3 minutes after. Proportion of culture-positive swabs, mean number of species, and growth of isolates on culture were compared at different times and between the two groups. RESULTS: Coagulase-negative Staphylococcus (CoNS) was the main species isolated from culture-positive swabs. Use of 5% povidone-iodine for 3 minutes resulted in a statistically significant reduction in proportion of culture-positive swabs (87% vs 30%, p<0.001), mean number of species (0.96-/+0.47 vs 0.30-/+0.46, p<0.001), and growth of CoNS (heavy: 30% vs 0%, moderate: 23% vs 6%, light: 47% vs 94%, p=0.004). No such changes were observed in the control group. CONCLUSIONS: Use of 5% povidone-iodine for 3 minutes prior to cataract surgery achieves a significant reduction in organisms such as CoNS from lid and conjunctival flora.