BAX and BCL-2 polymorphisms, as predictors of proliferative vitreoretinopathy development in patients suffering retinal detachment: the Retina 4 project.

PURPOSE: To compare the distribution of BCL-2 -938C>A (rs2279115) and BAX -248G>A (rs4645878) genotypes among European subjects undergoing rhegmatogenous retinal detachment (RRD) surgery in relation to the further development of proliferative vitreoretinopathy (PVR). METHODS: A case-control gene association study, as a part of Retina 4 project, was designed. rs2279115 and rs4645878 polymorphisms were analysed in 555 samples from patients with RRD (134 with PVR secondary to surgery). Proportions of genotypes and AA homozygous groups of BCL-2 and BAX polymorphisms between subsamples were analysed in two phases. Genotypic and allelic frequencies were compared in global sample and in subsamples. RESULTS: BAX: Differences were observed in the genotype frequencies and in AA carriers between controls and cases in the global series. The odds ratio (OR) of A carriers in the global sample was 1.7 (95% CI: 1.23-2.51). Proportions of genotypes in Spain + Portugal were significant different. The OR of A carriers from Spain and Portugal was 1.8 (95% CI: 1.11-2.95). BCL-2: No significant differences were observed in genotype frequencies. However, proportions of genotypes in Spain + Portugal were significant. A protective effect (OR: 0.6 95% CI: 0.43-0.96) was found in A carriers from Spain and Portugal. CONCLUSIONS: Results suggest that A allele of rs4645878 could be a biomarker of high risk of developing PVR in patients undergoing RD surgery. The possible role of BCL-2 (inhibitor of necroptosis pathway) as a possible new target in PVR prophylaxis should be investigated.

Surgical technique: modified lateral tarsorrhaphy.

PURPOSE: The signs of thyroid eye disease include proptosis, eyelid retraction, and exposure of the ocular surface, resulting in a symptomatic and unsatisfactory aesthetic appearance. A number of surgical techniques have been proposed to treat the eyelid sequelae of thyroid eye disease, which vary in both complexity and potential complications; the authors propose a novel technique for correcting inferolateral scleral show. This technique is proposed for cases of mild inferior scleral show (2 mm or less). METHODS: This retrospective consecutive case series includes 7 eyes of 5 patients from 2003 to 2006. All patients underwent surgery by a single surgeon at Moorfields Eye Hospital, London, UK. The surgical technique is composed of 3 principal steps: 1) marking of intended lateral tarsorrhaphy, 2) gray line split and anterior lamella excision, and 3) suturing of upper and lower limbs of lateral canthal tendon/lateral ends of tarsal pates) and canthal angle reformation. RESULTS: Seven eyes of 5 patients underwent the procedure; all patients were women, and their mean age was 49.6 years (range 29-67). Mean inferior scleral show was reduced from 2.0 mm preoperatively (range 1.5-2.5) to 0.3 mm postoperatively (range 0.0-0.5) at 49-month follow up. There were no complications related to the surgical technique, and all patients were satisfied with the postoperative result. One patient with proptosis measuring 24 mm required 2-wall orbital decompression 20 months later. CONCLUSIONS: Patient selection is important for the effective use of the modified tarsorrhaphy technique and should be reserved for those with 2 mm or less of inferior scleral show. Two principal factors to be considered before this eyelid surgery and the use of a box suture in reformation of the lateral canthal angle are discussed. Although a number of surgical procedures are available to manage eyelid malposition secondary to thyroid eye disease, they vary in complexity and severity of complications. The modified tarsorrhaphy technique was effective in the treatment of a specific group of patients who had undergone previous orbital and eyelid surgery for thyroid eye disease.

Risk of iatrogenic peripheral retinal breaks in 20-G pars plana vitrectomy.

PURPOSE: To estimate the frequency and risk factors for entry site and other peripheral iatrogenic retinal breaks in eyes undergoing standard 20-G 3-port pars plana vitrectomy. DESIGN: Single-center, retrospective, interventional case series. PARTICIPANTS: A total of 645 eyes undergoing pars plana vitrectomy at Moorfields Eye Hospital during the period June 1, 2005, to June 1, 2006, for indications excluding rhegmatogenous retinal detachment. METHODS: Case note review. Exclusion criteria were preexisting retinal breaks or rhegmatogenous retinal detachment, previously vitrectomized eyes, and iatrogenic breaks posterior to the equator. MAIN OUTCOME MEASURES: Frequency, anatomic location, and risk factors associated with iatrogenic peripheral retinal breaks and rate of postoperative rhegmatogenous retinal detachment. RESULTS: Iatrogenic peripheral retinal breaks occurred in 98 of 645 eyes (15.2%) intraoperatively. Eleven of 645 cases (1.7%) experienced postoperative rhegmatogenous retinal detachment caused by undetected or new peripheral retinal breaks. Breaks were most common during surgery for tractional retinal detachment (22.2%), macular hole (18.1%), dislocated intraocular lens implants (16.7%), and epiretinal membrane (13.9%). Overall, breaks were more common in the superior retina (P<0.01), with 41.5% occurring in the 10 and 2 o'clock positions. Eyes requiring surgical induction of a posterior vitreous detachment had 2.9 times greater odds of developing iatrogenic peripheral retinal breaks (95% confidence interval, 1.8-4.7, P<0.001) than eyes with preexisting posterior vitreous detachment. Similarly, phakic eyes had 2.4 times higher odds (95% confidence interval, 1.42-3.96, P = 0.001) of break formation. CONCLUSIONS: Iatrogenic peripheral retinal breaks caused by vitrectomy are more common than previously indicated. Approximately 4 in 10 breaks are related to traction at sclerotomy entry sites. Eyes undergoing surgery for tractional retinal detachment seemed to have the highest risk for break formation. Similarly, phakic eyes and eyes that require induction of a posterior vitreous detachment have more than double the risk for break formation.

Bilateral infiltrative disease of the extraocular muscles: a rare clinical presentation of early stage chronic lymphocytic leukemia.

Orbital involvement in chronic lymphocytic leukemia (CLL) is highly unusual and most commonly involves hemorrhage or soft tissue infiltration in advanced disease. We report a case of rapid onset bilateral orbital muscle infiltration as the presenting feature of early stage CLL. In addition, we demonstrate clinico-pathological correlation with an identical chronic B-cell lymphocytic infiltrate in both orbit and bone marrow, with good response of the orbital disease to local radiotherapy.

Evaluation of a toric intraocular lens with a Z-haptic.

PURPOSE: To evaluate the efficacy and rotational stability of the MicroSil 6116TU foldable 3-piece silicone toric intraocular lens (IOL) (HumanOptics). SETTING: Department of Ophthalmology, Hillingdon Hospital, Uxbridge, Middlesex, United Kingdom. METHODS: This prospective observational study included 21 eyes of 14 consecutive patients with more than 1.50 diopters (D) of preexisting corneal astigmatism having cataract surgery. Phacoemulsification was performed, and a MicroSil 6116TU toric IOL was inserted through a 3.4 mm temporal corneal incision. LogMAR uncorrected visual acuity (UCVA), best corrected visual acuity, refraction, keratometry, and cylinder axis of the toric IOL were measured. RESULTS: The mean preoperative refractive and keratometric astigmatism was 3.52 D +/- 1.11 (SD) and 3.08 +/- 0.76 D, respectively. Six months postoperatively, the logMAR UCVA in eyes without ocular comorbidity (n = 14) was 0.20 +/- 0.15 (Snellen 20/32). Seventy-nine percent (11 eyes) had a visual acuity of 0.24 (Snellen 20/35) or better. The mean refractive astigmatism at 6 months was 1.23 +/- 0.90 D. Vector analysis using the Holladay-Cravy-Koch method showed a mean reduction in refractive astigmatism of 2.16 +/- 2.33 D. The mean difference between intended and achieved cylinder axis at 6 months was 5.2 degrees (range 0 to 15 degrees). No IOL rotated more than 5 degrees during the follow-up period. CONCLUSIONS: The MicroSil 6116TU toric IOL reduced visually significant keratometric astigmatism and increased spectacle independence. The IOL was stable in the capsular bag, showing no significant rotation up to 6 months postoperatively.