Contact lens wear and IOL power calculation before cataract surgery: a cautionary tale.

PURPOSE: To present a case of erroneous corneal measurements, which led to inaccurate predicted intraocular lens (IOL) power. METHODS: A 60-year-old woman underwent preoperative assessment for cataract surgery. The predicted IOL power was 19.5 D. RESULTS: Repeated biometry led to different measurements and an 11.0-D powered IOL was inserted. The predicted IOL power was incorrect, as the patient had worn contact lenses during the preoperative assessment. CONCLUSIONS: This case demonstrates that errors can occur, and it is essential to fully understand the principles of biometry and the refractive issues of cataract surgery to avoid postoperative refractive errors.

Is visual outcome compromised when next day review is omitted after phacoemulsification surgery? A randomised control trial.

AIMS: To examine the safety implications of omitting first day clinical review following phacoemulsification cataract surgery. METHODS: 362 patients were randomly assigned to "same day discharge" (SDD) or "next day review" (NDR). All patients were reviewed approximately 2 weeks after surgery. RESULTS: Of the 174 patients randomised to NDR, 14 (8.0%) were treated for raised intraocular pressure (25-48 mm Hg) on the first postoperative day. Four received increased topical steroids for uveitis (two) and corneal oedema (two). One patient was treated for a significant wound leak. 12 (6.9%) required additional reviews before 2 week follow up for treatment of the following complications: drop toxicity (six), raised intraocular pressure (five), and corneal abrasion (one). Of the 188 randomised to SDD, six (3.2%) returned to the department before the planned review for reassurance of patients' concerns regarding eye symptoms (three), drop toxicity (one) and follow up of previously raised intraocular pressure (one). There were two cases of iris prolapse in the SDD group. In one case, the complication was anticipated and early review had been arranged. Postoperative acuities of 6/12 or better were achieved in 83% of both SDD and NDR patients (p = 0.96 by chi(2) test). Postoperative quality of life scores at 4 months indicating "no or hardly any concern about vision" (VCM1 questionnaire index <1.0) were achieved in 67% SDD and 72.5% NDR (p = 0.26). CONCLUSION: The intention to discharge patients on the day of surgery, with planned postoperative review at 2 weeks, was associated with a low frequency of serious ocular complications. Differences in the proportions achieving a good visual outcome between the two groups, based on 2 week visual acuity and 4 month quality of life, were not significant.

A 10 year retrospective survey of cataract surgery and endophthalmitis in a single eye unit: injectable lenses lower the incidence of endophthalmitis.

AIM: To study the incidence of endophthalmitis following cataract surgery over a 10 year period, and to examine ways in which this may be related to changes in surgical technique. METHODS: All cases of endophthalmitis occurring over a 10 year period within a single ophthalmic unit in the United Kingdom were reviewed, and possible risk factors identified. RESULTS: During the study period, as the technique of extracapsular cataract surgery was replaced by phacoemulsification, there was a commensurate reduction in the incidence of endophthalmitis. Injectable IOLs were associated with the lowest risk of postoperative endophthalmitis (0.028%). CONCLUSIONS: Injectable intraocular lenses do not make contact with the ocular surface and this may result in the observed lower rate of endophthalmitis. This, and the ease with which they can be inserted through small incisions, support their use as the first line method of lens insertion.

Paediatric dacryocystorhinostomy.

Of 258 cases of dacryocystorhinostomy performed on children in the period September 1981 to September 1991, 130 were for simple, unresolved congenital nasolacrimal duct obstruction. Other indications for surgery included punctal agenesis, lacrimal fistula, post-traumatic and post-inflammatory canalicular obstruction. Of 177 children without canalicular pathology, 171 (96%) were relieved of symptoms with one operation, without canalicular intubation. Of 81 cases with canalicular disease, 55 of 70 (79%) who underwent DCR plus canalicular intubation, and 10 of 11 who underwent DCR plus Lester-Jones tube, were substantially improved with one operation. No child required peroperative or postoperative blood transfusion. Dacryocystorhinostomy in childhood, in experienced surgical hands, is a safe procedure, achieving relief of symptoms in most cases, particularly in the absence of canalicular disease.

Spontaneous hemorrhage within the rectus muscle.

PURPOSE: To describe, in three patients, the rare condition of spontaneous hemorrhage within the rectus muscle. METHODS: The records of three patients with a diagnosis of spontaneous hemorrhage within a rectus muscle were reviewed. RESULTS: Three adults had sudden unilateral painful proptosis with clinical and computed tomographic findings consistent with hemorrhage within a rectus muscle; in two patients, the presence of recent hemorrhage was confirmed on magnetic resonance imaging. In all three patients, the hemorrhage resolved spontaneously. CONCLUSIONS: Spontaneous hemorrhage within a rectus muscle may occur in otherwise healthy adults without any apparent underlying cause. In the absence of visual deterioration, no treatment is required, and complete clinical resolution may be anticipated.

Primary vitrectomy for rhegmatogenous retinal detachment.

One hundred and twenty-four eyes with a rhegmatogenous retinal detachment, considered to be at high risk of failure if treated conventionally, underwent vitrectomy and internal tamponade, with or without scleral buckling, as the primary procedure. The retina was reattached in 64.5% of eyes after one operation, 75.0% after two, and in 83% of eyes after more than two operations, with no difference in the success rate between those eyes which underwent vitrectomy alone, and those that received adjunctive scleral buckling; duration of surgery was significantly shorter, however, in the former group. Twenty percent of eyes redetached in association with proliferative vitreoretinopathy, and 20% of phakic eyes developed posterior subcapsular lens opacities after surgery. Vitrectomy is now an established method in the management of selected cases of rhegmatogenous retinal detachments.

Management of the subluxed crystalline lens.

There has been a traditional reluctance to remove a subluxed (ectopic) lens because of the high surgical risk. The use of closed intraocular microsurgical techniques, however, now allows greater intraoperative control with few complications. The authors present the results of subluxed lens extraction, by limbal or pars plana lensectomy, in 44 eyes of 24 patients, in which the indication for surgery was lens subluxation causing a reduction in visual acuity or uncorrectable refractive error. Visual acuity was improved in all cases after surgery, with no significant complications. Patients with reduced visual acuity secondary to ectopic lenses have a good visual prognosis after lensectomy using a closed intraocular microsurgical technique.

Sympathetic ophthalmia: visual results with modern immunosuppressive therapy.

Sympathetic ophthalmia is a rare bilateral panuveitis that follows penetrating injury to one eye. The use of systemic corticosteroids has transformed the prognosis, and good acuity in the sympathizing eye can now be achieved. The use of immunosuppressive drugs, such as cyclosporin and azathioprine, in combination with the steroids, allows control of the intraocular inflammation at a much lower steroid dose, with concomitant reduction in the systemic side effects that accompany the use of systemic steroids.

Use of orbital floor steroids in the management of patients with uniocular non-necrotising scleritis.

Most cases of non-necrotising scleritis can be successfully treated with non-steroidal anti-inflammatory drugs. If these are ineffective, then high-dose systemic corticosteroids, with all their attendant side-effects, are usually required. We have used orbital floor injections of depot steroid in the management of nine patients with non-necrotising scleritis in an attempt to avoid the use of systemic steroids, or to allow the dose of steroids to be reduced while maintaining disease control. A temporary reduction in inflammation was achieved in all cases, which allowed the use of systemic steroids to be avoided altogether in two patients and delayed in the others. Non-steroidal anti-inflammatory drugs and systemic corticosteroids remain the mainstay of treatment for non-necrotising scleritis, but orbital floor injections may be a useful adjunct in certain cases.

Use of cyclosporin in the management of steroid dependent non-necrotising scleritis.

Many patients with non-necrotising scleritis can be treated adequately with non-steroidal anti-inflammatory drugs or steroids. But, as many of them are young, treatment may present problems if they require high doses of steroids to control the scleral inflammation and then relapse when the dosage is reduced. Five such patients were treated with a combination of steroids and low-dose cyclosporin therapy, and in all cases the scleritis remained under control on a much lower dose of steroids than when steroids were used alone. Cyclosporin is therefore a useful drug in the management of younger patients dependent on high-dose steroids to control their scleral inflammation.

Binocular diplopia in unilateral aphakia: the role of botulinum toxin.

We have treated 12 unilaterally aphakic patients, with a manifest squint and binocular diplopia, with botulinum toxin injection to the appropriate horizontal rectus muscle, in an attempt to reduce the angle of squint and thereby resolve the diplopia. In all cases a short-term reduction in the angle of squint was achieved. In nine patients, whose aphakia was corrected with a contact lens, and eight of whom had had their lenses removed because of trauma, this reduction was only temporary. In three patients, however, who had had a non-traumatic cataract removed, replaced with a posterior chamber implant, control of the deviation was maintained long after the acute effect of the toxin had disappeared, with the development of coarse binocular single vision, a fusion range, and abolition of all diplopia. The possible reasons for these different responses are discussed and it is suggested that in cases of binocular diplopia following lens extraction, botulinum toxin treatment should be considered prior to any extraocular muscle surgery, as temporary reduction of the deviation may be sufficient to allow recovery of binocular single vision.

Hemifacial atrophy: an unusual cause of enophthalmos.

We report on two cases of enophthalmos, caused by maxillary atrophy, a rarely reported monostotic forme fruste of hemifacial atrophy.

Topical flurbiprofen: an effective treatment for episcleritis?

Topical flurbiprofen was compared with placebo and prednisolone 0.3% in the treatment of episcleritis by a randomised double-blind trial. Seventy-seven eyes were included in the trial. Rapid spontaneous improvement in symptoms and signs was noted in the majority of cases. There was no significant difference between the cure-rates of patients treated with flurbiprofen and placebo over a 3-week trial period. The proportion of patients treated with prednisolone 0.3% who were cured was significantly higher than in either of the other groups after 3 weeks.

Sporadic diffuse corneal endotheliitis.

We studied two patients with acute diffuse corneal endotheliitis who had no family history of the disease. Endothelial specular photographs taken during and after an attack of endotheliitis demonstrate the deposition of inflammatory material on edematous endothelial cells, with areas of focal endothelial cell loss that resolved with treatment. These cases are distinctly different than the previously described "idiopathic" primary endotheliitis entities, which have included focal or sectoral areas of corneal edema, corneal edema in association with a migrating rejection line, or diffuse edema occurring as a dominantly inherited condition. No definitive causative agents have been established. It is likely that the disease results from an immune response to autoantigens or antigens from an unidentified viral infection. The pathogenesis may be similar to that of corneal homograft rejection.