An unusual complication of crawford tube insertion.

The authors describe an unusual and challenging complication of bicanalicular (Crawford) stent insertion that has previously never been reported. A 27-year-old man sustained multiple lacerations to the left (L) periocular and facial areas with a glass bottle. He was admitted under the care of the Plastic Surgical team at another institution and underwent repair of the facial, eyelid, and canalicular lacerations in the operating room. During the surgery, a Crawford stylet was guided in the L inferior canaliculus but was not retrieved nasally. Neuroimaging revealed that the metallic stylet of the Crawford tube was within the orbit, extending via the superior orbital fissure into the middle cranial fossa. The patient was then transferred under the care of the neurosurgical team and underwent a combined orbital/neurosurgical procedure to retrieve the stylet.

Rating papilloedema: an evaluation of the Frisén classification in idiopathic intracranial hypertension.

The appearance of the optic disc is a key measure of disease status in idiopathic intracranial hypertension (IIH). The Frisén classification describes stages of optic disc swelling (grades 0-5). It is the only classification of papilloedema, and is used internationally in clinical and research practice. Despite this, there has been very limited evaluation of the scale. We assessed the inter-rater reproducibility and ability to discriminate optic disc changes over time using the Frisén classification compared with a system of ranking papilloedema severity in patients with IIH. Paired disc photographs (before and after treatment) were obtained from 47 patients with IIH (25 acute and 22 chronic). Six neuro-ophthalmologists blinded to patient identity, clinical information and chronology of the photographs reviewed the discs and allocated a Frisén grade and ranked the paired discs in order of papilloedema severity (disc ranking). A total of 188 optic disc photographs were reviewed. All six reviewers agreed in only three comparisons (1.6%) when using the Frisén classification, compared with 42 comparisons (45.2%) when using disc ranking. The probability of agreement between any two reviewers was 36.1% for Frisén grade and 70.0% for disc ranking. Disc ranking had significantly greater sensitivity for finding differences in degree of disc oedema, identifying a difference in 75.3% of paired photographs compared to 53.2% detected using the Frisén classification (p < 0.001). This study demonstrated the limited reproducibility and discriminative ability of the Frisén classification in identifying changes in serial optic disc photographs in IIH. Simple optic disc ranking appears to be a more sensitive and reliable tool to monitor changes in optic disc appearance. The use of disc ranking in clinical practice and research studies is recommended to monitor alterations in optic disc appearance until alternative schemes, specific to IIH, have been developed.

The significance of DNA mismatch repair genes in the diagnosis and management of periocular sebaceous cell carcinoma and Muir-Torre syndrome.

OBJECTIVE: The aims of this study were to determine the significance of expression of DNA mismatch repair proteins in detecting systemic malignancies in a series of patients with periocular sebaceous cell carcinoma and to determine the clinical characteristics and frequency of Muir-Torre syndrome in this cohort. DESIGN: The study was a retrospective non-comparative interventional case series. PARTICIPANTS: 31 patients with histologically proven sebaceous cell carcinoma of the eyelid participated in the study. METHODS: The authors made use of retrospective chart review and immunohistochemical staining of specimens. MAIN OUTCOME MEASURES: The main outcome measures are as follows: location, tumour size, sites of origin, growth patterns, management, histopathological and immunohistochemical findings, metastasis, other visceral malignancies and mortality. RESULTS: The median age of presentation of the 31 patients in this study was 71 years (range 35-92 years). There was a near-equal gender distribution (M:F-14:17). The average follow-up was 72 months. Seventeen patients had tumours arising from the upper lid, 13 from the lower lid and 1 from the caruncle. Nine patients had clinical Muir-Torre syndrome. Four patients were positive for microsatellite instability complexes and four were negative. Histologically, 14 patients had a high-grade tumour, 13 were intermediate grade and 4 were low grade. Based on the in situ pattern, six patients had a bowenoid pattern, five had both bowenoid and pagetoid patterns and two had a pagetoid pattern. Eighteen patients had no in situ disease detected. Twenty-one patients were alive without disease, and two were alive with disease. Six patients had died, five from other causes and one from the disease. CONCLUSIONS: Visceral malignancies are common in patients with periocular sebaceous cell carcinoma. Approximately one in eight demonstrated a heritable risk for further visceral malignancy through failure to express DNA mismatch repair proteins. Diagnosis of periocular sebaceous cell carcinoma should prompt physicians to search for other associated malignancies. Immunohistochemical characterisation of these sebaceous lesions is useful in identifying increased risk in affected patients and family members.

Glaucoma management trends in Australia and New Zealand.

BACKGROUND: To describe self-reported patterns of care for glaucoma of ophthalmologists in Australia and New Zealand and summarize current practice styles and patterns associated with glaucoma management. METHODS: A questionnaire of glaucoma management practices was mailed to all ophthalmologists registered with the Royal Australian and New Zealand College of Ophthalmologists in June 2003. The questionnaire assessed practice preferences for medical management, examination techniques and indications for surgery. The results were cross-tabulated by age, country and subspecialty training in glaucoma. RESULTS: Fifty-one per cent of 761 surveys were returned, 14% being from glaucoma specialists. New Zealand ophthalmologists proceeded to surgical management of glaucoma earlier than did their Australian colleagues. Australian ophthalmologists tended to use argon laser trabeculoplasty more frequently. Ninety-six per cent of ophthalmologists routinely use gonioscopy in diagnosing glaucoma. Disc drawings and recording cup:disc ratios were the most commonly used methods of documenting disc morphology; glaucoma specialists were more likely to use imaging technologies. SITA-Standard 24-2 was the most commonly used modality of perimetry, and was favoured by glaucoma specialists. CONCLUSIONS: This survey represents the first Australian and New Zealand effort to identify glaucoma management practices. Although a substantial consensus was found in most areas of treatment, a few areas showed diversity. The information gathered will enable ophthalmologists to compare their own practices with those of their colleagues. In addition, this survey provides a baseline allowing future trends in management to be determined.

Glaucoma prescribing trends in Australia and New Zealand.

PURPOSE: To summarize current practice styles and patterns associated with glaucoma management in ophthalmologists of Australia and New Zealand as derived from a survey. METHOD: A questionnaire was sent to all Australian and New Zealand ophthalmologists, which anonymously assessed demographic characteristics and prescribing patterns for each major class of glaucoma medication. RESULTS: A total of 761 questionnaires were sent with a response rate of 51%. Of respondents 14% were glaucoma subspecialists. In 69%, the first-line drug-class of choice was a prostaglandin analogue. New Zealand ophthalmologists favoured beta-blockers as their first-line agent because of cost, government restrictions and familiarity. Most respondents stated "hypotensive efficacy" as the most important factor in class choice. Alpha-2-agonists, carbonic anhydrase inhibitors and miotics were considered second-line agents, because of side-effects and lack of hypotensive potency. CONCLUSIONS: The choice of first-line agent for the treatment of glaucoma differed between Australian and New Zealand ophthalmologists, in part as the result of government restriction of prostaglandin-class drugs. Practice patterns seen in Australasia parallel the current evidence base reported in peer-reviewed literature.

Giant cell arteritis.

Giant cell arteritis (GCA) is an immune-mediated vasculitis, affecting medium- to large-sized arteries, in individuals over the age of 50 years. Visual loss is a frequent complication of GCA, and once it occurs it tends to be both permanent and profound. Although major advances have been made in recent years in genetics, molecular biology and the description of the vessel wall morphology, the aetiology and pathogenesis of GCA are still incompletely understood. Over the years there has been much debate over whether polymyalgia rheumatica and GCA are separate or linked entities. Recent investigations support that polymyalgia rheumatica and GCA are two different expressions of the same underlying vasculitic disorder. A single cause or aetiological agent has not as yet been identified. Except for the histopathology of the arterial wall, there are no laboratory findings specific for GCA, and no particular signs or symptoms specific for the diagnosis. GCA typically causes vasculitis of the extracranial branches of the aorta and spares intracranial vessels. Transmural inflammation of the arteries induces luminal occlusion through intimal hyperplasia. Clinical symptoms reflect end-organ ischaemia. Branches of the external and internal carotid arteries are particularly susceptible. Corticosteroids remain the only proven treatment for GCA, the regimen initially involving high doses followed by a slow taper. However, early detection and treatment with high-dose corticosteroids is effective in preventing visual deterioration in most patients.

Correlation of the multifocal visual evoked potential and standard automated perimetry in compressive optic neuropathies.

PURPOSE: To evaluate the relationship between abnormalities detected by the multifocal visual-evoked potential (mfVEP) compared with those detected by static achromatic automated perimetry in patients with compressive optic neuropathy. METHODS: Fifteen patients of mean age 50.8 years, with known compressive optic neuropathy from chiasmal lesions, underwent monocular mfVEP and 24-2 SITA-standard Humphrey visual field (HVF; Carl Zeiss Meditec, Dublin CA) testing in each eye. Visual field spatial agreement and extent of involvement were analyzed by assigning a severity score to each quadrant, based on pattern deviation and amplitude deviation probability plots. RESULTS: HVF mean deviation (MD) was -6.54 +/- 7.43 dB (mean), and the mfVEP mean AccuMap Severity Index (ASI; ObjectiVision Pty. Ltd., Sydney, Australia) score was 81 +/- 74. MD and ASI correlated significantly (r = -0.55, P = 0.024). Although both mfVEP and HVF reported approximately the same proportion of visual fields as abnormal (70%, 21/30, and 87%, 26/30, respectively), 19% (5/26) with abnormal HVF were labeled normal or borderline by mfVEP. The agreement for field quadrants between instruments was 69% (kappa = 0.33). mfVEP severity scores for quadrants and hemifields were higher than scores for HVF in the same eyes. The superotemporal quadrant showed the strongest correlation between techniques (r = 0.73, P = 0.002). CONCLUSIONS: In the first study to compare mfVEP to HVF in patients with compressive optic neuropathy, there was good qualitative and quantitative agreement between tests, though findings were in only modest agreement in some areas. The injury caused by compressive optic neuropathy may be usefully identified by mfVEP. Improved methods of analysis may increase the diagnostic utility of the method.

Comparison of the Proview pressure phosphene tonometer performed by the patient and examiner with the Goldmann applanation tonometer.

OBJECTIVE: To compare the results of Proview pressure phosphene tonometry (PPPT) performed by the patient and an examiner with Goldmann applanation tonometry (GAT). METHODS: A comparative case series of 96 (192 eyes) consecutive patients from a glaucoma clinic was conducted. Intraocular pressure (IOP) was measured with GAT by one examiner, PPPT by another examiner, and PPPT by the patient. All examiners were masked to the results from any preceding IOP measurement. RESULTS: The coefficient of repeatability for repeated measurements for the GAT was +/-0.48 mmHg. The limits of agreement for self-measurement of IOP with the PPPT and examiner measured IOP with PPPT were 6.3 mmHg and 4.8 mmHg, respectively. The limits of agreement between GAT and self assessed PPPT were +/-11.8 mmHg (mean difference of 0.63 mmHg). When the same comparison was made between GAT and examiner assessed PPPT, the results were limits of agreement of +/-10 mmHg (mean difference of 2.86 mmHg). No significant difference was identified in the agreement of the GAT and the PPPT when subanalysed for age of patient or diagnosis (P > 0.05). The limits of agreement between self-assessed IOP with the PPPT and the GAT were +/-8.2 for those with IOP <20 mmHg and +/-14.9 mmHg for those with IOP>20 mmHg. CONCLUSIONS: Poor agreement exists between IOP measured by GAT and PPPT measured by an examiner or by the patient.