Warfarin in vitreoretinal surgery: a case controlled series.

INTRODUCTION: Warfarin is a commonly used anticoagulant whose effect in vitreoretinal surgery has not been well studied. METHODS: A series of 60 patients on warfarin therapy undergoing pars plana vitrectomy were retrospectively case controlled to 60 patients with similar presenting complaints. In addition, an online survey was performed of current practice in the UK. RESULTS: 2% of the patients receiving vitrectomy were on warfarin. There were 33 males and 27 females with a median age of 72.5 years; follow-up was for a mean of 0.88 years. The international normalised ratio (INR) ranged between 0.94 and 4.6 (median 2.3). Two cases of suprachoroidal haemorrhages occurred in the control group (one with preoperative choroidal haemorrhage from dislocated lens nucleus), while none occurred in the warfarin group. 12 patients with rhegmatogenous retinal detachment (RRD) in the warfarin group presented with vitreous haemorrhage compared with only four in the control group (p=0.04). From the online survey, 48 respondents (81%) would ask patients to withhold warfarin prior to vitreoretinal surgery based on the INR. CONCLUSIONS: There was no increase in complications in patients continuing to take warfarin compared with controls. Patients with RRD are more likely to have vitreous haemorrhage at presentation if they are on warfarin.

Factors prompting sneezing in intravenously sedated patients receiving local anesthetic injections to the eyelids.

PURPOSE: To investigate the frequency of sneezing among patients receiving intravenous sedation and periocular local anesthetic for oculoplastic procedures in a single center. To identify potential risk factors involved. DESIGN: Prospective, consecutive, interventional case series in a single tertiary-referral oculoplastic unit. PARTICIPANTS: A total of 294 patients undergoing 314 isolated oculoplastic procedures, performed under intravenous sedation with periocular local anesthetic from November 2007 to November 2008. METHODS: Prospective data collection on patient demographics, history of photic sneezing, intravenous sedative, depth of sedation, nasal oxygen, and periocular infiltration site. Standard local anesthetic was used in all cases, but the intravenous sedation was at the discretion of the attending anesthesiologist (7 in total). MAIN OUTCOME MEASURES: Sneezing or attempted sneezing within 5 minutes of injection of the local anesthetic, as determined by agreed observation between attending staff. RESULTS: Sneezing was observed in 16% of cases. No association was found between sneezing and patient age or presence of nasal oxygen. A weakly positive association was observed with male gender (55% sneezers vs. 37% non-sneezers, P = 0.03, relative risk [RR] = 1.5, confidence interval [CI], 1.1-2.0), bilateral infiltration (65% vs. 40%, P = 0.005, RR = 1.6, CI, 1.2-2.1), and upper eyelid infiltration (73% vs. 54%, P = 0.01, RR = 1.4, CI, 1.1-1.7). Photic sneezing was described in 47% of sneezers and 19% of non-sneezers (P = 0.0004, RR = 2.6, CI, 1.6-4.0). Because propofol was given to 95% of patients, no association with sneezing could be ascertained. However, opioid derivatives were found to be protective (12% vs. 43%, P<0.0001, RR = 0.3, CI, 0.1-0.6), whereas midazolam doubled the risk of sneezing (45% vs. 22%, P = 0.0008, RR = 2.1, CI, 1.4-3.0). Deep sedation (Ramsay score 5-6) also strongly increased the sneeze risk (65% vs. 23%, P<0.0001, RR = 2.8, CI, 2.1-3.8). CONCLUSIONS: Propofol-based intravenous sedation, in combination with periocular local anesthetic injections, induces sneezing in approximately one sixth of general oculoplastic cases. Male gender, a history of photic sneezing, bilateral or upper eyelid infiltration, deep sedation, and the concurrent administration of midazolam all increased the risk, whereas adjunctive opioid use reduced the risk.

A case of acquired trichomegaly following treatment with erlotinib.

A woman on erlotinib treatment for lung cancer presented with a corneal ulcer from aberrant eyelash touch. She developed coarse, hyperpigmented and irregular eyelash and eyebrow growth a few months following treatment. She was treated successfully with epilation, eyelash trimming, lid hygiene and intensive topical lubrication. This is the first case report in the UK of trichomegaly with associated corneal ulceration. Erlotinib is an epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor that has recently been approved for use as a chemotherapeutic agent by the National Institute for Health and Clinical Excellence. Ophthalmologists and oncologists should be aware of the adnexal and ocular surface changes that can occur, and that simple interventions may be used to manage them.