'Can you touch your toes?' spondyloarthropathies and acute anterior uveitis for primary eyecare practitioners.

The rheumatological diseases known as spondyloarthropathies (SpAs) are reviewed with respect to the current classifications of SpAs and from the perspective of ophthalmic practitioners. The focus is on the most common spondyloarthropathy, ankylosing spondylitis (AS), and the key symptoms, such as inflammatory back pain. The association with HLA-B27 and acute anterior uveitis (AAU) and the major clinical considerations for primary eye care practitioners are reviewed. An atypical case study illustrates difficulties in the detection and diagnosis of ankylosing spondylitis.

The Prevention of Recurrent Cholesteatoma in CWU Surgery: The Use of Titanium Sheeting.

OBJECTIVE: Assessment of the outcomes of a technique of prevention of recurrent cholesteatoma in canal wall up (CWU) mastoidectomy, using titanium sheeting to repair the external auditory canal wall. PATIENTS: Sixty four cholesteatoma cases were managed during a period from 2007 to 2015. The cases were unselected; the surgery was performed by the senior author. Cholesteatoma Patterns Were: Forty two attic, nine pars tensa, seven combined attic-pars tensa, three congenital, and three other. Primary surgery was undertaken in 33 cases. INTERVENTIONS: All cases underwent CWU surgery that employed canal wall repair using fine titanium sheeting combined with overlying organic material to repair canal wall defects. Drum repairs employed cymba conchae cartilage-perichondrium composite grafts. Chain reconstruction used Spanner struts or Grace Alto PORPs or TORPS. RESULTS: Two cases suffered mesotympanic residual disease, and three, mesotympanic recurrence one of which extended into the attic. Two other cases incurred atticomastoid residues. Transient myringitis occurred in three cases. CONCLUSION: The surgery was judged on its ability to avoid atticomastoid recurrence, and was regarded as highly successful. The titanium sheeting offers a relatively simple but effective technique. The mesotympanic complications are those also commonly found in both CWD and other CWU methods. As in other CWU procedures, the problems of the open cavity were avoided.

Traumatic abdominal wall herniation: case series review and discussion.

BACKGROUND: Traumatic abdominal wall hernia (TAWH) is a rare type of hernia occurring secondary to blunt trauma to the abdomen. Its management remains controversial within the surgical community, mainly due to complexities in diagnosis, appropriate surgical approach and timing of closure. METHOD: Cases were identified retrospectively, via interviews with trauma surgeons at a Tertiary Trauma Centre, the Royal Brisbane & Women's Hospital, in Brisbane, Australia. In addition, data were collected via in-house trauma and operative databases. RESULTS: Five cases of TAWH were identified over a 3-year period. All cases involved injuries sustained from motor vehicle or motor bike accidents. Diagnosis was purely clinical in one case and clinically suspected, then confirmed by computed tomography in the remainder. Herniation was managed by immediate closure in one instance, delayed/staged closure in three cases and conservative management in the remainder. In addition, three of the five patients were obese. At minimal 3-month follow-up, no evidence of recurrence of herniation was present in four of the five cases. One case was lost to follow-up. CONCLUSIONS: TAWH is a complex injury to manage and no one approach is all encompassing. Correct diagnosis is essential as this allows proper planning for the method and timing of repair. This series highlighted that incorrect seatbelt placement, especially in the obese population, may be a risk factor for increased incidence of TAWH.

Acquired cholesteatoma: classification and outcomes.

OBJECTIVE: Reclassification of acquired cholesteatoma into the commonly observed presentations of this condition to provide a simple and clear grouping that indicates the pathology, management, and outcomes of the group cases. PATIENTS: Virgin acquired cholesteatoma cases from a single center managed from 1986 to 2008 (515 cases). INTERVENTIONS: Cases were managed by transcanal (20%) or intact canal wall techniques. Wall repairs successively used autograft cartilage (transcanal and early intact canal wall mastoidectomy cases), hydroxylapatite plates (1989-2007), or titanium sheeting (2007). Drum repairs used cartilage-perichondrial composite grafts. Assembly techniques were the preferred ossiculoplasty method. RESULTS: Distribution: attic, 41%; pars tensa, 45%; and combined attic-pars tensa, 14%. Unclassifiable cases (n = 14) were excluded. Contralateral disease was present in 15% and effusions in 34% during or after surgery. Cell formation was most extensive in attic disease, least in combined patterns. Ossicular pathology was worse in the collapsed drum cases. Attic cases had the best hearing outcomes but risked recurrent disease, which required precise countermeasures. Overall, the combined pattern group carried the worst prognosis. CONCLUSION: Compared with previous methods, the clinical classification proved simple, descriptive, and comprehensive. It provides a readily discerned practical basis for clinical management and research purposes.

'My pupil has gone black!' Subluxation of a total cataractous lens.

A patient with a history of longstanding opaque cataract and a white pupil reported a return to a black pupil, which was the result of lens subluxation. The case was complicated by optic nerve coloboma of the Morning Glory syndrome type and a total retinal detachment.

Branch retinal artery occlusion during a migraine attack.

A 60-year-old male with a history of migraine presented with evidence of branch retinal arterial occlusion that developed at the time of an attack of retinal migraine. The diagnosis of branch arterial occlusion secondary to migraine was made after exclusion of numerous possible medical conditions. The possible role of vasospasm in this condition is discussed.

Acute anterior uveitis in primary care.

Acute anterior uveitis is an important ocular disease of considerable interest to therapeutically and non-therapeutically qualified optometrists. This review examines the role of optometrists in the primary care setting and gives guidelines for appropriate care of patients with anterior uveitis. Diagnosis and differentiation from other forms of anterior segment inflammation are the initial requirement. In parallel, possible medical conditions associated with acute anterior uveitis must be considered, with appropriate referral to medical practitioners. In uncomplicated cases of recurrent acute anterior uveitis, optometrists can initiate topical treatment and monitor resolution of inflammation, while being aware of possible complications of both the disease and its treatment. It is especially important in new attacks of anterior uveitis to liaise with the patient's general practitioner about medical investigation for underlying disease. Atypical, complicated or severe anterior uveitis should be promptly referred for specialist care.

Dual macroaneurysms on the same retinal arteriole.

A case of two macroaneurysms on the same retinal arteriole is presented. After observation of these lesions for some weeks, an increased threat to the macula from oedema led to laser photocoagulation. Although treatment did not hasten resolution, the patient has remained asymptomatic. The aetiology and natural history of macroaneurysms are discussed.

Hemianopic visual field loss as the first clinical evidence of occipital arteriovenous malformation.

A 43-year-old patient presenting with a highly congruous homonymous hemianopia was shown by neuro-imaging to have a very large arteriovenous malformation of the brain. The significance of finding this visual field defect, its unusual cause and the absence of symptoms other than longstanding migraine with aura are discussed.

Curious cilia cases.

Eyelashes can be observed in unusual anatomical locations after falling out of their hair follicles. Loose lashes can inadvertently enter a lacrimal punctum or with more difficulty, a Meibomian gland orifice They may even penetrate through anterior surface layers such as the conjunctiva or skin of the lid. There may be some diagnostic problems, occasionally questions of management and in rare instances, some risk of morbidity. Four cases are illustrated.

Perspectives on migraine: prevalence and visual symptoms.

About 20 per cent of women and 10 per cent of men experience migraine at some time in their lives, of whom about one half to two thirds will have had a migraine attack in the previous 12 months. Prevalences of this order have been found in a survey of patients in an Australian optometric practice. Between one third and one half of migraineurs experience sensory or motor aura. Visual aura are by far the most common of the aura. A high proportion (more than 40 per cent) of migraineurs presenting for routine optometric examination will not have had their headache or aura formally diagnosed. Optometrists can give reassurance by providing a formal diagnosis and, when appropriate, they can refer their migraine patients to sources of advice on how the frequency and severity of their attacks might be ameliorated. The diagnosis of migraine is straightforward when the migrainous episode and any associated aura follow a classical pattern. However, diagnosis is often challenging, especially for aura occurring without headache, when the aura are atypical, when the first attack of migraine occurs after the age of 50 years, when there are persistent visual field losses or when there are pupillary anomalies or extra-ocular muscle palsy and diplopia associated with the migraine. Unusual presentations must be approached with care, using a good knowledge of the diversity of migraine, careful history taking and a thorough ocular and visual examination. As visual field losses can be associated with migraine and migraine may be a risk factor for low-tension glaucoma, visual field examination is often indicated for patients with a history of migraine. In some cases of migraine, referral for neurological work-up will be necessary before concluding that the headache and visual symptoms can be attributed to migraine.

Normal tension glaucoma: diagnostic features and comparisons with primary open angle glaucoma.

BACKGROUND: A significant proportion of patients diagnosed under the broad classification of open angle glaucoma actually has normal tension glaucoma (NTG). It has many clinical features that overlap with primary open angle glaucoma (POAG), yet there is a question of whether it has a different aetiology in which intraocular pressure plays less of a role. METHODS: The epidemiology and clinical features of normal tension glaucoma are reviewed with particular reference to possible differences from primary open angle glaucoma, which might permit differentiation. The pathophysiology is discussed, outlining recent research in cell death (apoptosis), axonal damage and neuroprotection. DISCUSSION AND CONCLUSION: There is considerable evidence that NTG develops with little contribution from the effect of intraocular pressure. However, the clinical diagnosis of NTG is often one of exclusion and the differentiation of NTG from POAG remains difficult because many clinical signs are suggestive but not definitive of NTG. More accurate diagnosis may be possible when individual patients exhibit a greater number of signs. Some evidence suggests that NTG with relatively high pressures (greater than 15 mmHg) is more likely to progress than NTG with relatively low pressures. Clinicians must be particularly alert to the possibility of NTG because IOP, a clinical marker for some glaucomas, is absent.

Diabetes mellitus: a brief history, epidemiology, definition and classification.

Diabetes mellitus is a systemic disease of great significance to optometrists. This review includes a brief history of the key discoveries in the understanding of diabetes from ancient times and a summary of the present knowledge of diabetes with respect to prevalence, epidemiology and major complications. The currently accepted classification of diabetes mellitus includes the major categories of type 1 and type 2 diabetes, specific diabetes types and gestational diabetes. The definition of diabetes has also been revised recently. The new diagnostic criterion for diabetes mellitus is a confirmed fasting plasma glucose equal to or greater than 7.0 mmol/L, with a reduced reliance on the role of oral glucose tolerance testing.