Efficacy of Retinal Lesion Screening in Von Hippel-Lindau Patients With Widefield Color Fundus Imaging Versus Widefield FA.

BACKGROUND AND OBJECTIVE: Retinal hemangioblastoma is a retinal tumor in patients with Von Hippel-Lindau (VHL). The authors' objective was to determine whether widefield fluorescein angiography (FA) improves lesion detection. PATIENTS AND METHODS: Retrospective case series of VHL patients who underwent widefield fundus imaging and FA. Masked retina specialists graded fundus images as having: 1) definite retinal hemangioblastoma; 2) possible lesion; 3) no lesion. The number of lesions on FA was compared to widefield color imaging. RESULTS: One hundred six eyes of 55 patients were evaluated. A total of 94 lesions were identified on FA in 61.8% patients. Forty-three lesions (45.7%) were not identified on fundus images. Small lesion detection was significantly higher with FA compared to color imaging (P = .013). CONCLUSIONS: This study reports on improved detection of retinal hemangioblastomas with widefield FA compared to widefield fundus images. The authors recommend VHL monitoring guidelines to include periodic widefield FA to adequately screen for smaller lesions. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:e260-e265.].

Contralateral amaurosis after a retrobulbar block.

PURPOSE: To describe and discuss the workup and management of a rare complication of retrobulbar anesthesia, as well as CT and MRI findings of this complication. OBSERVATIONS: The patient underwent uncomplicated pars plana vitrectomy with membrane peel for epiretinal membrane removal. Shortly after completion of surgery, the patient noted that he could not see out of his non-operated eye. Visual acuity was bare hand motion, and physical exam revealed a dilated, non-reactive pupil with normal, well-perfused retina. Imaging revealed an air bubble in the optic nerve of the operated eye, suggesting penetration of the optic nerve sheath during retrobulbar block with posterior spread of anesthetic to the contralateral optic nerve. CONCLUSIONS AND IMPORTANCE: After imaging ruled out acute intracranial pathology and confirmed the correct diagnosis, the patient was monitored until vision in the non-operated eye returned to baseline. Excellent visual acuity was attained in the operated eye. Central spread of anesthetic after retrobulbar anesthesia is a rare but potentially life-threatening complication that must be promptly diagnosed and addressed.

Late ROP Reactivation and Retinal Detachment in a Teenager.

Exudative and tractional retinal detachments have been reported as late sequelae of retinopathy of prematurity (ROP). The authors report a case of unilateral retinal detachment in a 19-year-old patient with history of peripheral ablation for ROP in the contralateral eye. This late reactivation is likely due to persistent avascular retina producing constant low levels of vascular endothelial growth factor. Therefore, close follow-up and ablation of peripheral avascular retina should be considered in patients with ROP, regardless of treatment history, to decrease lifelong risk of severe complications, including retinal detachment decades later. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:625-628.].

Ophthalmic Manifestations of Facial Dog Bites in Children.

PURPOSE: To characterize ophthalmic manifestations and periocular injuries of pediatric facial dog bites. METHODS: A retrospective review of all children younger than 18 years who sought medical attention after a dog bite to the face between January 1, 2003 and May 22, 2014 was performed at a large tertiary pediatric hospital. Data on type and location of injury, surgical intervention, and complications were collected. RESULTS: A total of 1,989 children aged 0.19 to 17 years were identified with dog bites. Dog bites to the face occurred in most patients (n = 1, 414 [71%]). Of those children with facial dog bite injuries, 230 (16%) suffered ophthalmic manifestations. The average age was 4.3 years. Eyelid injuries occurred in 227 (99%) of children, 47 (20%) sustained canalicular system injuries, 3 (1.3%) suffered corneal abrasions, and 2 patients sustained facial nerve injury resulting in lagophthalmos. No patients suffered vision loss. Complications occurred in 32 patients (14%), with the most common being epiphora in 9 patients (28%), upper eyelid ptosis in 8 (25%), and prominent scar formation in 4 patients (13%). Thirteen children (5.7%) needed one or more secondary procedure to correct complications. CONCLUSIONS: The authors report the clinical features and management on the largest series of ophthalmic and periocular injuries associated with pediatric facial dog bites. These injuries occur in about 1 in 6 dog bites to the face and primarily involve the ocular adnexa. Despite early and appropriate surgical management, complications and the need for revision surgery are relatively common.

Hospital-based ocular emergencies: epidemiology, treatment, and visual outcomes.

BACKGROUND: Ocular trauma is recognized as the leading cause of unilateral blindness. However, few studies to date have focused on the clinical features of hospital-based ocular emergencies. Effectiveness of trauma centers in treating ocular emergencies was compared with treatment in traditional community hospital emergency departments. Demographics, causes, and nature of ocular emergencies, as well as visual outcome in community hospitals emergency departments and trauma centers, were also examined. METHODS: Records of 1027 patients with ocular emergencies seen between July 2007 and November 2010 at 3 community hospitals emergency departments and 2 hospitals with level II trauma centers were retrospectively examined. Unpaired t test and Pearson χ(2) test were used to determine statistical significance. RESULTS: The incidence of patients requiring ophthalmic intervention was 77.2 per 100 000 in the community hospitals and 208.9 per 100 000 in the trauma centers. Rates of ocular emergencies were higher in middle-aged, white men. Orbital fractures were found in 86% of all orbital contusion cases in trauma centers, whereas 66.7% of patients with fall injuries and open globe diagnoses resulted in legal blindness. CONCLUSIONS: The middle-aged, white men are more vulnerable to ocular injuries caused mainly by motor vehicle accidents. The ability of trauma centers to provide comparable increases in vision outcomes, despite treating more severe ocular emergencies, demonstrates the effectiveness of trauma centers. Patients diagnosed as having orbital contusions or who have fall injuries deserve careful evaluation because they are more likely to have more severe sight-threatening injuries.

Advanced Basal cell carcinoma in a patient with schizoaffective disorder: constraints and management.

The approach used by the authors for managing a patient with a schizoaffective disorder and advanced basal cell carcinoma involving the eyelids, orbit, and face is presented. Complexities included the advanced nature of the disease, neglect of the patient's condition due to schizoaffective disorder, the difficulty of obtaining informed consent, the required aggressive surgical intervention, reconstruction, and the necessary management during the postsurgical period. A multidisciplinary team approach with psychiatry, ophthalmology, ear, nose, and throat, plastic surgery, radiation oncology, oncology, legal, and bioethics specialties is required in patients with cognitive disabilities. Curative treatment requires complete excision, reconstruction, and proper postoperative care, which can be prohibitive in a schizophrenic patient from a surgical and ethical perspective. Staging of this condition after proper informed consent with biopsy, computed tomography, and magnetic resonance imaging is presented. The options for management are discussed, including surgical intervention and palliative care.

Safety of negative-pressure wound therapy over ocular structures.

This is a report of the use, efficacy, and theoretic safety of negative-pressure wound therapy over ocular structures as a part of surgical treatment for necrotizing fasciitis. We treated a 65-year-old man with facial necrotizing fasciitis requiring serial debridement and closure of extensive periorbital and nasal wounds with skin grafts. Negative-pressure wound therapy was first used as a bridge to allow temporary closure and to encourage granulation tissue development. It was then used as a bolster dressing to stabilize skin grafts in the complex wound, not amenable to tie-over dressings. Excellent functional and cosmetic reconstruction of the periorbital and nasal regions was achieved. After treatment, the patient's corrected vision was 20/20. To our knowledge, the use of negative-pressure wound therapy directly over ocular structures has not been previously documented. In this case, it was safely used over the eyes with no sequelae to the patient's vision.

Dry eye after laser in situ keratomileusis with femtosecond laser and mechanical keratome.

PURPOSE: To prospectively compare dry-eye symptoms after laser in situ keratomileusis (LASIK) with mechanical keratome-created flaps and femtosecond laser keratome-created flaps. SETTING: Department of Ophthalmology, Stanford University School of Medicine, Stanford, California, USA. DESIGN: Randomized clinical trial. METHODS: Fellow eyes were prospectively randomized to the mechanical keratome group and femtosecond laser keratome group. Patients had wavefront-guided LASIK using a mechanical keratome in 1 eye and a femtosecond laser keratome in the fellow eye. They completed dry-eye questionnaires preoperatively and 1, 3, 6, and 12 months postoperatively. The effect of laser ablation depth, sex, age, and flap thickness on dry-eye symptoms was also analyzed. RESULTS: The study enrolled 51 patients. There was no statistically significant change in dry-eye symptoms except in the femtosecond group 1 month postoperatively (mean increase 1.08) (P=.03). There were no significant differences in symptoms between the 2 groups (P=.7). The dry-eye score was 1.3 points lower in women than in men (P=.01). Central ablation depth, flap thickness, and age did not significantly affect the reported dryness. CONCLUSION: There appeared to be no statistically significant difference in self-reported dry-eye symptoms between the mechanical keratome group and the femtosecond laser keratome group.