Traumatic dislocation and successful re-enclavation of an Artisan phakic IOL with analysis of the endothelium.

PURPOSE: To present a case of traumatic dislocation of an Ophtec Artisan phakic intraocular lens (PIOL) and an analysis of the endothelial cell count. METHODS: The patient presented with blurred vision in his left eye after sustaining a brow laceration. History included uncomplicated bilateral implantation of an Artisan PIOL to correct myopia. RESULTS: The brow laceration was sutured and topical dexamethasone 0.1% qid was prescribed. One week after presentation, the PIOL was relocated. Postoperatively, endothelial cell count analysis was performed in both eyes. CONCLUSIONS: A decrease in the hexagonality of the endothelial cells was noted in both eyes, which was substantially lower in the injured eye.

Visual perception during phacoemulsification cataract surgery under subtenons anaesthesia.

AIM: The aim of this study was to record the subjective visual experience of patients during phacoemulsification and intraocular lens implantation under subtenons anaesthesia. METHODS: Prospective, nonrandomised, cohort, postoperative questionnaire based study. Patients selected underwent routine phacoemulsification and intraocular lens implantation under regional subtenons anaesthesia. chi(2) and Fisher's exact tests (two-tail) were used to evaluate the data. RESULTS: A total of 104 patients were selected, 38 (36.5%) were male and 66 (63.5%) were female. The mean age of patients was 74.0+/-8.8 years. In all, 87.5% saw light during the operation with 9.6% finding this painful. Photophobia was highest among younger patients (P=0.002). Coloured lights were seen by 56.7% and 13.5% found the visual experience frightening. Frightening visual experiences were significantly associated with the perception of colour (P=0.005) and photophobia (P=0.003). A volume of anaesthetic greater than 4 m was associated with a significant reduction in anxiety as a result of the visual experience (P=0.003). None of the other visual phenomena recorded were associated with a frightening visual experience. CONCLUSIONS: Patients undergoing regional anaesthesia experience a wide variety of visual sensations during cataract surgery. Perception of colour and volumes of anaesthetic less than 4 m appear to be associated with the visual experience being more frightening. Detailed preoperative counselling is mandatory. It should include comprehensive information about visual perception during the procedure relieving the patients from unnecessary distress.

First day follow up for routine phacoemulsification?

AIMS: To determine the postoperative morbidity on day 1 after uncomplicated phacoemulsification. METHODS: A prospective study was performed on 100 otherwise healthy eyes after uncomplicated phacoemulsification and lens implant. Patients were examined on the first postoperative day and any deviation from a set postoperative protocol was recorded. RESULTS: Transient intraocular pressure rises of 30 mm Hg or greater were seen in three eyes. These all settled after a single dose of oral acetazolamide 250 mg. CONCLUSIONS: The results of this study reinforce the clinical impression that the need for day 1 routine follow up in this selected group of patients is questionable and probably unnecessary.

Meta-analysis of systemic anti-fibrinolytics in traumatic hyphaema.

We report a meta-analysis of randomised, controlled, clinical trials of systemic anti-fibrinolytics in traumatic hyphaema. Outcome measures were rate of secondary haemorrhage and final visual acuity. An estimate of the overall odds ratio for each outcome measure was calculated both by combining the logarithms of the odds ratios, and by the Mantel-Haenszel method. The results confirm a beneficial effect of systemic antifibrinolytics on the rate of secondary haemorrhage, but not on final visual acuity.

The medical management of traumatic hyphaema: a survey of opinion among ophthalmologists in the UK.

Current attitudes to the medical management of traumatic hyphaema were investigated by means of a postal survey. A single page questionnaire was sent to all consultant ophthalmologists in the UK who were members of the college of ophthalmologists. The response rate was 50%. Opinion was sharply divided on the use of bed rest, padding and topical therapy. However, there was almost universal agreement that systemic therapy, either steroids or antifibrinolytics, were not indicated.

Trans-scleral fixation of dislocated posterior chamber intraocular lenses using a 9/0 microsurgical polypropylene snare.

We describe a new technique for retrieval, sulcus relocation and trans-scleral fixation of posteriorly dislocated (posterior chamber intraocular lenses (PC-IOLs) in a closed eye using a 9/0 polypropylene snare instrument adapted specifically for this purpose. Our experience is described of the first 5 consecutive cases in which the snare was used. The posteriorly dislocated PC-IOL was successfully relocated in 4 of these cases but per-operative fracture of a lens haptic necessitated removal of the IOL in the fifth. A number of surgical techniques have already been described in the management of this problem but we consider the polypropylene snare to offer the advantages of a simpler technique that obviates the need for either manipulation of needles within the eye or complex suturing procedures.

Pseudophakic malignant glaucoma: Nd:YAG capsulotomy as a primary treatment.

Malignant glaucoma is one of the most serious but rare complications of anterior segment surgery. It is best known following trabeculectomy but has been reported following a wide variety of anterior segment procedures including extracapsular cataract extraction with posterior chamber lens implantation. It is notoriously refractory to medical treatment alone and surgical intervention has had only limited success. An additional treatment option in pseudophakic eyes is that of peripheral Nd:YAG posterior capsulotomy, which is minimally invasive and can re-establish forward flow of posteriorly misdirected aqueous through into the drainage angle of the anterior chamber. We report our experience of seven cases of malignant glaucoma in pseudophakic eyes and of the successful use of Nd:YAG posterior capsulotomy in re-establishing pressure control in five of these eyes, thereby obviating the need for acute surgical intervention.

Community ophthalmology pilot study.

A randomly selected sample of subjects over 75 years old or housebound in three London inner city general practices were screened for eye disease by an ophthalmologist and an ophthalmic trained nurse. All subjects were examined at specialist outreach clinics run at the surgery of their general practitioner (GP), except for the housebound who were assessed by domiciliary visit. Patients presenting to their GP with an eye problem during the study were also seen at the outreach clinic at the GP's request. Over the 3-month period of the study, 126 over-75s, 62 housebound and 35 GP referrals were seen. This pilot study found high prevalence rates of treatable eye disease in the elderly and housebound subjects and these are compared with the findings of other epidemiological surveys. The needs for health care provision to this sector of the community and the feasibility of providing it through outreach clinics are also discussed.

The treatment of bullous rhegmatogenous retinal detachment.

We describe the results of a consecutive series of 97 cases of bullous superior retinal detachment treated by conventional surgery. The retinal detachments were characterized by either a single retinal break or multiple retinal breaks confined within 1 clock hour and no proliferative vitreoretinopathy. The surgery involved sequential drainage of subretinal fluid, injection of air, cryotherapy and the application of local explant. All cases would otherwise be suitable for pneumatic retinopexy. The anatomical success rate was 85.5% with a single operation and 97% with further procedures. We report on the complications encountered and appraise the advantages and disadvantages of this operation. Forty-five of the 97 cases had detachment of the macula for less than 2 weeks, and 35 of the 45 (80%) achieved a visual acuity of 6/18 or better. These visual results challenge the assertion that better visual outcome might be attained with pneumatic retinopexy.

Cytokines in proliferative vitreoretinopathy.

This study determined the presence of interleukin 1 (IL-1), interleukin 6 (IL-6), tumour necrosis factor alpha (TNF alpha), tumour necrosis factor beta (TNF beta), interferon gamma (IFN gamma), transforming growth factor beta 2 (TGF beta 2) and fibroblast proliferation activity (FPA) in vitreous aspirates from eyes undergoing vitrectomy for the treatment of retinal detachment complicated by proliferative vitreoretinopathy (PVR) or uncomplicated retinal detachment (RD). Cadaveric vitreous from normal subjects were used as controls. The results showed that IL-1 and IL-6 predominated in vitreous from eyes with PVR or RD, and that concentrations of IL-6 greater than 20 pg/ml were more frequently found in PVR than in RD (p = 0.031) or control specimens (p = 0.006). Low levels of TNF alpha were observed in 4/18 eyes with PVR, 1/15 eyes with RD and 1/15 control vitreous, and small concentrations of TNF alpha were seen in 3/18 eyes with PVR, 1/15 eyes with RD and 2/15 control vitreous. IFN gamma was detected in 12/18 eyes with PVR, but only in 5/15 eyes with RD (p = 0.048) and 6/15 control specimens. TGF beta 2 was present in all vitreous samples at concentrations ranging from 100 to 4,500 pg/ml with no significant differences among the three groups. Control vitreous possessed the greatest FPA when compared with vitreous from eyes with PVR (p = 0.031) or RD (p = 0.048). These observations provide further evidence that cytokine-mediated pathways of inflammation are involved in the pathogenesis of PVR and point to the possible involvement of IL-1, IL-6 and IFN gamma in cellular interactions leading to chronicity.

Blood-aqueous barrier breakdown associated with rhegmatogenous retinal detachment.

We compared the integrity of the blood-aqueous barrier (BAB) between normal eyes and those with first-time rhegmatogenous retinal detachment (RRD) using the technique of anterior segment fluorophotometry. We found significantly greater anterior segment fluorescence in eyes with retinal detachment (p = less than .001) thereby demonstrating quantitatively for the first time that there is significant damage to the BAB associated with RRD. We have also shown that the BAB permeability returns to normal within two months of successful reattachment of the retina. The origin of this transient increase in BAB permeability is unknown but its severity and duration may well be of significance in the pathogenesis of complications associated with RRD such as uveitis, rubeosis and proliferative vitreoretinopathy.

Results and complications of conventional repair of bullous retinal detachment using posterior segment air injection.

The aims of this retrospective study were to determine the outcome of retinal detachment repair using the drainage, air injection, cryotherapy and explant surgical sequence ('D-ACE' technique) for bullous retinal detachments and also to identify the complications attributable to the injection of the gas. The D-ACE technique was used to repair 206 detachments over a ten year period of which 138 (67%) were successfully re-attached with a single operation. The sub-group of these patients (n = 66) with bullous retinal detachments who would be considered suitable for repair using the technique of pneumoretinopexy (PR) showed a single operation success rate of 85% after D-ACE. Complications attributable to the gas injection occurred in 18 eyes (8.5%). In only four of these (1.9%) did retinal surgery ultimately fail as a result of complications caused by injection of the gas, which represents 10% of all the failures. The results of this series show that the serious complication rate from injecting air into the vitreous cavity is low and that the success rate for treating relatively uncomplicated bullous retinal detachments using the D-ACE technique compares favourably with the results of other published series using either the D-ACE procedure or pneumoretinopexy.

Foetal heart rate and maternal emotional state.

Forty-five pregnant women rated themselves for hostility, depression and anxiety. Maternal and foetal heart rates were recorded while they listened to a tape through headphones. The foetuses of anxious mothers showed pronounced responses to certain taped stimuli but this effect was not found for mothers with high hostility or depression scores.

Psychometric ante-natal predictors of post-natal depressed mood.

One hundred and nine women were studied during the course of pregnancy in an attempt to predict which of them would later rate themselves as suffering from depressed mood up to twelve months post-natally. The psychometric measures used comprised the Zung Self-Rating Scale to measure depression, the DSSI/SAD sub-scale to measure anxiety and the Hostility and Direction of Hostility Questionnaire. Post-natal depression observed up to twelve months post-partum was positively associated with first trimester ante-natal scores on all three measures. The HDHQ and the DSSI/SAD measures were good predictors of depression at six weeks post-partum and both correlated significantly at six and nine months post-partum, whereas the Zung measure predicted depression at nine and twelve months as well as at six weeks post-partum. Parity was significantly associated with severe depression at six months post-partum.

Treatment of hypertension in pregnancy by relaxation and biofeedback.

In a study of the effectiveness of systematic relaxation training alone or combined with biofeedback in the treatment of hypertension in pregnancy, 60 women were seen weekly for 6 weeks. 18 were given relaxation therapy alone (group A), 18 relaxation plus biofeedback (group B), and there were 24 controls. Whereas two-thirds of the control group had to be admitted to hospital during their pregnancies, less than a third of each experimental group had to be admitted. The experimental groups also had significantly lower systolic and diastolic blood pressure than the control group. There were no significant differences between groups A and B in hospital admission rates or blood-pressure measurements.