Patient's Perceptions of Importance of Discontinuing Antithrombotic Medication Before Oculoplastics Surgery.

This study aims to analyze patients' perspectives to ultimately gain insight into the patients understanding in 3 broad categories: their understanding of how their medications, supplements, and over-the-counter drugs work, their understanding of the risks these agents pose in a surgical setting, and their preferences for the continued use of the agents during and after oculoplastic surgery. To obtain these data, the authors prospectively surveyed 129 patients who had an oculoplastic surgery clinical evaluation at our tertiary care academic facility. Because no previously validated questionnaire on this topic existed, the authors utilized a novel questionnaire the authors developed. For antithrombotic medications, about 60% of patients felt there were risks associated both with stopping and continuing the agent during surgery. For antithrombotic supplements, more patients answered there were risks associated with continuing the agents during surgery versus stopping the agents during surgery (40% versus 25%, respectively). There was a relationship between patients' knowledge that they were on an antithrombotic prescription and their understanding of the risks associated with antithrombotic usage during surgery as well as sudden discontinuation of the prescription. With an understanding of the patient's point of view, surgeons will be equipped to have multifaceted conversations with their patients surrounding their medications, systemic health, and oculoplastic surgery.

Two-muscle surgical treatment of a compensatory head tilt in an adult with acquired downbeat nystagmus.

Kestenbaum-Anderson-like operations have proven beneficial in treatment of compensatory head tilt in patients with infantile nystagmus. However, their use in acquired vertical nystagmus in adults with head tilt has rarely been reported. Presented here is a case of a 52-year-old woman with acquired downbeat nystagmus with a significant head tilt who responded to a simple two-muscle surgery involving the superior recti. Cyclovertical muscle surgery should be considered a viable option in such patients who are refractory to medical intervention. Additionally, it appears that four-muscle vertical muscle recessions (two muscles per eye) may not be necessary to dampen vertical nystagmus since good results can be obtained with a single muscle recession bilaterally.

Review of 451 Patients Presenting With Orbital Wall Fractures: A Retrospective Analysis.

A retrospective review of the electronic medical records of patients presenting to the University Medical Center in Lubbock, Texas with orbital wall fractures. Clinical data such as associated ocular injuries and different management approaches are analyzed and discussed to help clarify the specific indications for, and timing of, a formal ophthalmologic examination. All patients who presented to the emergency department for an orbital fracture after suffering various types of traumas between 2008 and 2017 were included. The study reviewed 451 patients with orbital wall fractures with a wide variety of presentations as well as demographics. There were 411 cases of adults presenting with an average age of 34 years and 40 pediatric presentations with an average age of 14 years. The average age of the combined study population was 30 years. Only 16.9% of patients required surgical correction for their orbital fractures and assault accounted for nearly 50% of all the orbital fractures reviewed in this study. In this large retrospective review, no notable relationship was found between orbital wall fractured and ocular injury. Alarm symptoms for more visual threatening injuries such as retinal tears, detachments, open globe injury, and extraocular muscle entrapment are all reasonable indications to consult ophthalmology emergently. Most orbital fractures are not vision threatening, do not usually require surgical correction, and typically occur in the setting of assault.

Ectopic craniopharyngioma of the orbit: illustrative case.

BACKGROUND: Craniopharyngiomas are uncommon malformations of the sellar or parasellar region that are partly cystic and calcified and have low histological grade. The typical age of presentation is bimodal, with peak incidence rates in children at age 5 to 14 years and in adults at age 50 to 74 years. The usual clinical manifestations are related to endocrine deficiencies due to mass effect along with visual impairment and increased intracranial pressure. If a tumor is favorably localized, the treatment of choice is complete resection. OBSERVATIONS: The authors presented a unique case of a 61-year-old man with a suspicious cystic lesion in the right orbital roof that was causing right-sided headaches with pressure and pain in the right eye. Both computed tomography and magnetic resonance imaging were used for further evaluation and showed a suspicious lytic bone lesion that had an epicenter within the orbital rim, which was highly suggestive of a tumor of interosseous origin. After removal, the tumor was identified by pathology as a craniopharyngioma. LESSONS: The importance of this case report is in documenting a unique case of an ectopic craniopharyngioma in the orbit, adding to current hypotheses of the pathogenesis of ectopic craniopharyngiomas, and presenting an extensive review of literature.

Case report of instantaneous resolution of juvenile macular degeneration blindness after proximal intercessory prayer.

An 18-year-old female lost the majority of her central vision over the course of three months in 1959. Medical records from 1960 indicate visual acuities (VA) of less than 20/400 for both eyes corresponding to legal blindness. On fundus examination of the eye there were dense yellowish-white areas of atrophy in each fovea and the individual was diagnosed with juvenile macular degeneration (JMD). In 1971, another examination recorded her uncorrected VA as finger counting on the right and hand motion on the left. She was diagnosed with macular degeneration (MD) and declared legally blind. In 1972, having been blind for over 12 years, the individual reportedly regained her vision instantaneously after receiving proximal-intercessory-prayer (PIP). Subsequent medical records document repeated substantial improvement; including uncorrected VA of 20/100 in each eye in 1974 and corrected VAs of 20/30 to 20/40 were recorded from 2001 to 2017. To date, her eyesight has remained intact for forty-seven years.

Reevaluation of Current Prism Standards With Recommendations to Increase Accuracy in the Measurement of Strabismus.

PURPOSE: To critically evaluate the traditional standards for holding single prisms in measuring strabismus, with the specific goal being to increase the overall accuracy of clinical measurements. DESIGN: Reliability and validity analysis. METHODS: Using an analysis involving geometric optics, the effective prism power (EPP), measured in prism diopters (PD), was calculated for glass and acrylic prisms and was the main outcome measure. These results were also validated using optical bench measurements. No patients were involved. RESULTS: Plotting the calculated effective prism power as a function of rotational angle produced curves demonstrating that the frontal plane position lies along the flatter portions of the curves, while the Prentice position lies along the steeper portions of the curves. Calculated values of prism power for the standard clinical positions as well as the percentage errors from accepted standards were compared. Acrylic prisms can be held in the frontal plane position with acceptable amounts of error (<5%) for prisms up to 50 PD. Glass prisms are capable of producing significant errors for measurements much greater than 10 PD. CONCLUSIONS: The use of glass prisms as currently calibrated should be abandoned or at least limited to small measurements. Acrylic prisms produce acceptable errors if careful attention is given to their position.

Basal Encephalocele Presenting with Bitemporal Hemianopsia in an Adult Male.

Basal encephaloceles are uncommon malformations that are usually congenital in nature, although, occasionally, they can be traumatic. When they are congenital, they are associated with skull and facial midline defects, central nervous system abnormalities, and possible ocular and visual problems. The authors present a case of an adult male with a basal encephalocele who presented with a bitemporal hemianopsia. Ocular abnormalities, visual loss, and visual field deficits have previously been reported in patients with basal encephalocele; however, there does not appear to be any reported cases with formal visual field testing to demonstrate specific defects such as a bitemporal hemianopsia.

Mucosa-associated lymphoid tissue lymphoma with intraocular and orbital involvement: case presentation and review of the literature.

Primary ocular lymphomas are typically confined to either the eye or the orbit. Rarely, in immune-competent patients, lymphomas affect both the eye and the orbit simultaneously. Mucosa-associated lymphoid tissue (MALT) lymphomas are the most common ocular lymphomas. They usually present primarily in the orbit but sometimes can present primarily in intraocular tissue. MALT lymphomas that occur initially in the uvea can sometimes spread to the adjacent orbit. We report a case of progressively enlarging MALT lymphoma in a 62-year-old immune-competent patient causing a severe mass effect in the orbit and simultaneously presenting with intraocular involvement. There was radiographic evidence of lymphoma confined to the orbit with intraocular involvement. The simultaneous presentation makes it difficult to determine if the lymphoma initially presented in the orbit or intraocular tissue, although the orbital component was more impressive. The case also includes a literature review of simultaneous orbital and intraocular MALT lymphomas. The patient responded to systemic chemotherapy with regression in size of the lymphoma, relief of the mass effect seen in the orbit, and the regression of the intraocular involvement.

Lacrimal gland enlargement as an early clinical or radiological sign in thyroid orbitopathy.

PURPOSE: Characteristic ophthalmic signs of Thyroid Orbitopathy (TO) include exophthalmos, eyelid retraction, eyelid edema, restrictive extraocular myopathy, and optic neuropathy. In addition lacrimal gland (LG) enlargement can be observed in these patients. However TO has not usually been considered in the differential diagnosis of cases of isolated LG enlargement. OBSERVATIONS: A female patient at our institution (Texas Tech) was seen over a period from 2006 to 2012. This patient presented initially with LG enlargement as the primary clinical or radiologic sign of what later was diagnosed as TO. Computerized tomography and/or magnetic resonance imaging of the orbits were obtained and demonstrated isolated LG enlargement. CONCLUSIONS AND IMPORTANCE: This case represents, to our knowledge, the first report of LG enlargement as an initial presenting sign of TO. Further clinical and radiological studies looking at the natural history of TO would be useful to better understand the timing of LG involvement. In patients presenting with lacrimal gland enlargement, thyroid orbitopathy should be strongly considered in the differential diagnosis together with other causes of dacryoadenitis and LG tumors. This may save unnecessary and extensive diagnostic testing or even LG biopsies.

The effective corneal refractive surface as a function of a point in visual space: a three-dimensional analysis.

PURPOSE: To develop a three-dimensional optical model of the anterior segment which will provide a basis for understanding the effects of corneal and adnexal problems on vision. METHODS: A three-dimensional optical model of the anterior segment was developed to calculate the effective corneal refractive surface (ECRS), which is a specific area of cornea that refracts incident light rays arising from an object in visual space through the physical pupil (PP); light rays refracted by cornea outside the ECRS do not traverse the PP. This model incorporated the patient variables of central anterior chamber depth (A) and central corneal curvature (K). A vector analysis was combined with three-dimensional analytic geometry to create a unified solution for all object locations in visual space. A computer program in BASIC on a PC was developed to perform the calculations. RESULTS: The ECRS was circular for objects on the line of sight, but with increasing displacement from the fixation point it became oval and eventually crescent shaped. The size of the ECRS increased as the distance of the object from the eye increased, but it rapidly reached a limiting value at about 200 mm. The size of the ECRS increased with PP diameter, but showed only a small dependence on A and minimal dependence on K. CONCLUSION: This comprehensive optical model of object space and the anterior segment of the eye allows clinicians to better understand the effects of corneal light transmission on vision.

Microarray and protein analysis of human pterygium.

PURPOSE: Pterygium is a sunlight-related, ocular-surface lesion that can obscure vision. In order to identify specific genes that may play a role in pterygium pathogenesis, we analyzed the global gene expression profile of pterygium in relation to autologous conjunctiva. METHODS: Oligonucleotide microarray hybridization was used to compare the gene expression profile between human whole pterygium and autologous conjunctiva. Selected genes were further characterized by RT-PCR, western blot, and immunohistochemistry, and comparisons were made with limbal and corneal tissues. RESULTS: Thirty-four genes exhibited a 2 fold or greater difference in expression between human whole pterygium and autologous conjunctiva. Twenty-nine transcripts were increased and five transcripts were decreased in pterygium. Fibronectin, macrophage-inflammatory protein-4 (MIP-4), and lipocalin 2 (oncogene 24p3; NGAL) were increased 9, 5, and 2.4 fold, respectively, while Per1 and Ephrin-A1 were decreased 2 fold in pterygium. Western blots showed that fibronectin and MIP-4 were increased in pterygium compared to limbus, cornea, and conjunctiva. Immunohistochemical analysis showed fibronectin in the stroma; lipocalin 2 in the basal epithelial cells, basement membrane, and extracellular stroma; and MIP-4 in all areas of the pterygium. CONCLUSIONS: These data show both novel and previously identified extracellular-matrix-related, proinflammatory, angiogenic, fibrogenic, and oncogenic genes expressed in human pterygium. Comparisons of selected genes with limbal and corneal tissues gave results similar to comparisons between pterygium and normal conjunctiva. The increased expression of lipocalin 2, which activates matrix metalloproteinases (MMP), is consistent with our previous findings that MMP-9 and other MMPs are highly expressed in pterygium basal epithelium.

Topical apraclonidine in the diagnosis of suspected Horner syndrome.

Topical cocaine is used to confirm the clinical diagnosis of ocular sympathetic denervation, or Horner Syndrome (HS). Cocaine blocks re-uptake of norepinephrine (NE) by sympathetic nerve terminals in the iris dilator muscle, transiently increasing its concentration in the synaptic junction. Norepinephrine activates alpha1 receptors in the iris dilator to cause pupil dilation. In HS, cocaine fails to dilate the affected pupil as much as the unaffected pupil, but its indirect action makes it a weak dilator, and the test can give equivocal results. Cocaine is also a controlled substance and therefore difficult to obtain. A practical and reliable alternative to cocaine is apraclonidine, an ocular hypotensive agent that has a weak direct action on alpha1 receptors and therefore minimal to no clinical effect on the pupils of normal eyes. Patients with HS have denervation supersensitivity of the alpha1 receptors in the iris stroma of the affected eye, making the pupil dilator responsive to apraclonidine. In patients with HS, reversal of anisocoria occurs after bilateral instillation of apraclonidine 1% or 0.5%. Two cases that demonstrate this effect are reported. Apraclonidine should be considered a candidate to replace cocaine in the pharmacologic diagnosis of HS if a gold-standard comparison study confirms these results.

Effective corneal refractive diameter as a function of the object tangent angle in visual space.

PURPOSE: To determine whether the currently accepted method of selecting a minimum optical zone diameter for laser refractive surgery that is equal to or slightly greater than the dark-adapted pupil diameter provides a sufficient diameter of corneal surface to focus light arising from objects in the paracentral and peripheral visual field. SETTING: Department of Ophthalmology and Visual Sciences, Texas Tech University Health Sciences Center, Lubbock, Texas, USA. METHODS: An optical model of the anterior segment was developed to calculate the effective corneal refractive diameter (ECRD), which is the diameter of the area of cornea that refracts all incident light rays arising from an object through the physical pupil (PP). This model incorporates the patient variables of central anterior chamber depth (ACD), central corneal curvature (K(c)), and the diameter of the apparent entrance pupil (EP). The model was expanded to incorporate distant objects off the line of sight (LOS), described by their angular displacement from the fixation object in visual space (the object tangent angle delta(ob)). Results were calculated for the 360 meridian degree visual field (ie, for all objects in visual space perceptually displaced from the fixation object by angle delta(ob)). The effect of the prolate nature of the cornea was also investigated. RESULTS: The ECRD expanded rapidly as a function of PP and delta(ob) but was minimally influenced by K(c). Beyond a critical object tangent angle delta(c), light rays striking the corneal vertex were not refracted through the PP, and the ECRD became an annular surface centered on the corneal vertex. The delta(c) was not a function of K, but increased as the PP increased and decreased as the ACD increased. The prolate nature of the cornea had little influence on the ECRD, even for very peripheral light rays. CONCLUSIONS: The ECRD expands rapidly when considering distant objects only slightly displaced from the LOS. A patient treated with an optical zone equal to or slightly greater than the dark-adapted pupil diameter may experience vision quality loss for paracentral and midperipheral objects even under conditions of ambient indoor lighting.

Transient homonymous hemianopia and positive visual phenomena in nonketotic hyperglycemic patients.

PURPOSE: To report a case of a transient homonymous hemianopia in a patient with nonketotic hyperglycemia with negative magnetic resonance imaging (MRI) scans. DESIGN: Case report. METHOD: A 72-year-old woman with diabetes mellitus was referred to the neuro-ophthalmology service with hyperglycemia and multiple visual complaints. RESULTS: The patient was found to have a dense left homonymous hemianopia on examination. An MRI scan of the brain was negative for a lesion affecting the visual pathways. Resolution of the homonymous hemianopia and the patient's symptoms came with normalization of her blood glucose levels. CONCLUSION: Nonketotic hyperglycemia is an important diagnostic consideration in patients who present with homonymous visual field defects but have negative neuroimaging studies.

Rapid, painless unilateral vision loss in a 37-year-old healthy woman.

A 37-year-old woman experienced painless, progressive vision loss to no light perception in the left eye over the course of 3 days. The right eye was unaffected. On examination, the only other abnormal finding was a +4 left afferent pupillary defect. She was initially diagnosed with retrobulbar optic neuritis and admitted for treatment with intravenous methylprednisolone. Neuro-imaging revealed a large right anterior cerebral artery aneurysm that crossed the midline to compress the left optic nerve. The aneurysm was treated with coil embolization, which was technically successful but which did not lead to significant improvement in vision.

Pupil size and the ablation zone in laser refractive surgery: considerations based on geometric optics.

PURPOSE: To determine whether the currently accepted method of selecting a minimum ablation zone size for refractive surgery based on dark-adapted pupil diameter is substantiated by geometric optical analysis. SETTING: Department of Ophthalmology and Visual Sciences, Texas Tech University Health Sciences Center, Lubbock, Texas, USA. METHODS: An optical model of the anterior segment was developed to calculate the effective corneal refractive diameter (ECRD), which is the diameter of the area of cornea that refracts all incident light rays arising from objects along the line of sight though the physical pupil (PP). The concept of the entrance pupil (EP) was reexamined and developed, and the ECRD was calculated over a range of corneal curvatures (K), anterior chamber depths (ACDs), and EP sizes. The model was generalized to include oblique light rays. Calculations were performed using MatLab Optimization Toolbox software (The MathWorks). RESULTS: For a given EP size, the ECRD was significantly influenced by K and slightly influenced by ACD. CONCLUSIONS: For objects on the line of sight, the ECRD was smaller than the EP in all cases. Regarding rays from objects in the periphery, the ECRD expanded rapidly as the angle of oblique incidence increased. For objects on the line of sight, the ECRD is always smaller than the clinically measured pupil (EP) because the EP is substantially magnified relative to the PP. Ablation zones larger than the EP should, in theory, prevent scattered or defocused light rays from contributing to the foveal image. When considering objects in the periphery, the increase in ECRD is sufficiently rapid that current refractive procedures cannot stop scattered light from these objects from contributing to the retinal image.