Vitreoretinal surgery for retinal detachment in retinochoroidal colobomata.

PURPOSE: To report the management and outcome of retinal reattachment surgery in retinochoroidal coloboma. METHODS: Four patients with retinochoroidal colobomata presented to the Bristol Eye Hospital (a UK tertiary referral center for vitreoretinal surgery) with retinal detachment. INTERVENTION: All were type II colobomatous detachments (three patients with type IIB, one patient with type IID). All eyes underwent vitrectomy with endolaser and/or cryotherapy and three eyes underwent scleral buckling. Two eyes had internal tamponade with gas (SF6, C3F8) while the other two had silicone oil. Endolaser was applied over healthy retinal pigment epithelium. RESULTS: At last follow-up, all (100%) remained attached, with no recurrences. Three patients achieved visual acuity of 6/120 or better and were able to perform satisfactory near work with appropriate magnifiers. The last patient began with hand movement vision and retained similar vision but subjectively felt more navigational. CONCLUSIONS: Good anatomic and functional outcomes can be achieved in this patient group with combined vitrectomy with or without scleral buckling surgery. Endolaser retinopexy is effective over healthy RPE at the margin of the coloboma combined with either gas or oil internal tamponade.

Novel corneal features in two males with incontinentia pigmenti.

Incontinentia pigmenti (IP) is a rare X linked genetic disorder, which predominantly affects females. The mutations are usually lethal in males. Two male cases are presented; a genetic mosaic for the common IP deletion and another in whom the genetic abnormality has not yet been characterised. Emphasis is placed on the ocular features present in this disorder and in particular a novel corneal feature and its possible aetiology.

Benign idiopathic haemorrhagic retinopathy.

PURPOSE: To describe a new condition characterised by an unusual unilateral idiopathic haemorrhagic retinopathy. METHODS: A review is presented of patient histories from 5 patients with acute-onset unilateral idiopathic haemorrhagic retinopathy, including results of ophthalmological, haematological and fluorescein angiographic examinations. RESULTS: All patients had an extensive deep blot haemorrhagic retinopathy without significant vascular signs or abnormal optic discs. In 4 cases the haemorrhage was sufficiently severe to break through into the vitreous. Fluorescein angiography demonstrated normal arteriovenous flow, without capillary non-perfusion, vessel or disc leakage. Disc swelling, macular oedema and cotton wool spots were not seen at any stage in these patients. All patients recovered the visual acuity in the affected eye by 4 months. Systemic examination in all cases was unremarkable. CONCLUSION: This distinct and rare form of retinopathy is important to define since it has a good prognosis without treatment.

Laser pointers revisited: a survey of 14 patients attending casualty at the Bristol Eye Hospital.

AIMS: The largest clinical series of laser pointer exposures to date is described, to document any long term visual sequelae and assess objectively the visual threat from transient ocular exposure. METHODS: 14 cases were collected prospectively and triaged by ophthalmic nurses before referral to an ophthalmologist for a complete ophthalmic examination. Regardless of the need for clinical follow up, all patients were contacted by telephone at a mean interval of 10.5 months following exposure to inquire about new or persisting symptoms. RESULTS: 11/14 cases presented within 24 hours of exposure and 5/14 incidents were reported to the police. Reduced acuity in the affected eye compared with the contralateral were documented in 5/14 cases. The commonest physical sign was a punctate epitheliopathy, seen in 5/14 cases, and the commonest symptom was ocular discomfort, reported by 11/14 patients. There were no consistent retinal findings. Follow up by telephone survey revealed that two patients were wearing new glasses, but had not been refracted before the exposure; one had intermittent ocular discomfort; the remaining 11 were asymptomatic. CONCLUSIONS: This study is reassuring to the ophthalmology community and the general public in failing to demonstrate consistent, long term damaging effects of transient ocular exposure to laser pointer beams.

The National Diabetic Retinopathy Laser Treatment Audit. III. Clinical outcomes.

PURPOSE: To describe the short-term clinical outcomes for a cohort of patients undergoing first photocoagulation treatment for proliferative retinopathy or maculopathy in the United Kingdom. METHOD: Nine-month follow-up of the Royal College of Ophthalmologists' national audit of laser treatment for diabetic retinopathy. RESULTS: For eyes with maculopathy, 9.2% had had a deterioration in visual acuity equivalent to a doubling of the visual angle and 3.3% of eyes had a visual acuity of less than 6/60 at follow-up. There had been an improvement in the macular oedema or exudate in 64.6% and 77.3% respectively. Prognostic factors for a poorer visual acuity at follow-up were worse visual acuity at baseline, the presence of diffuse (vs focal) oedema and grid (vs focal) treatment. For eyes with proliferative retinopathy, the retinal neovascularisation had regressed fully in 50.8% of cases, whilst there had been no change or a deterioration in 10.3%. A visual acuity of less than 6/60 at follow-up was present in 8.6% of eyes. There was a poor morphological outcome at follow-up (as defined by rubeosis, new tractional detachment or having had a vitrectomy) in 7.2%. Risk factors for poor morphological outcome were the presence of 'high-risk characteristics', female sex and the presence of concurrent maculopathy at baseline. Regression of neovascularisation was associated with greater areas of retinal ablation at the initial treatment session. Although some eyes with proliferative retinopathy appeared to be undertreated initially compared with DRS and ETDRS protocols, some of these eyes did respond to lower amounts of treatment. CONCLUSION: For maculopathy, poorer outcome was related to worse visual acuity at baseline, diffuse (vs focal) maculopathy, and grid treatment. For proliferative retinopathy, poorer outcome was related to 'high-risk characteristics' and coexistence of maculopathy at baseline, and improvement was related to larger areas of ablation. The relationship of poor outcome with worse initial disease argues for earlier detection of retinopathy.

The National Diabetic Retinopathy Laser Treatment Audit. I. Maculopathy.

The National Diabetic Retinopathy Laser Treatment Audit is a prospective survey of laser treatment for diabetic retinopathy throughout the United Kingdom. This paper describes the methodology of the study and presents data on 546 patients who were undergoing their first photocoagulation treatment for diabetic maculopathy (without proliferative retinopathy) during a 2 month period in 1995. Validation of the level of participation, patient demographic features, sources of referral, the level of systematic screening and waiting times are described. Maculopathy was detected as a result of systematic screening in 65.2%, whilst 12.3% of cases presented symptomatically. The percentage of cases treated within 8 weeks of listing was 83.1%, whilst 7% waited for more than 12 weeks for their laser treatment. The retinopathy features and the type of treatment given are also described. The maculopathy was said to be predominantly exudative in nature in 69.8% of cases, and 96.2% of these eyes were treated with focal macular laser. The maculopathy was said to be diffusely oedematous in nature in 8.6% of cases, and 78.7% of these eyes were treated with grid macular laser.

The National Diabetic Retinopathy Laser Treatment Audit. II. Proliferative retinopathy.

The National Diabetic Retinopathy Laser Treatment Audit is a prospective survey of laser treatment for diabetic retinopathy throughout the United Kingdom. This paper presents data on 284 patients who were undergoing their first panretinal photocoagulation for proliferative retinopathy during a 2 month period in 1995, describing the demographic features, the level of systematic screening, the sources of referral, and the waiting times. For those cases where proliferative retinopathy was present at the first ophthalmology outpatient visit, the retinopathy was detected as a result of systematic screening in 46.8%, whilst 28.7% presented symptomatically. Of these patients 28.4% waited for more than 12 weeks from referral to the time of laser treatment, but once the patient had been listed for laser treatment this was performed within 8 weeks in 95.3%. The retinopathy features and the type of treatment given are also described. Compared with the DRS and ETDRS recommendations, at least 32.5-40.2% of eyes may be undertreated initially, and for those with high-risk characteristics these figures were at least 30.8-38.5%.

A simple snare for transscleral fixation of dislocated intraocular lenses.

PURPOSE: The construction and use of a surgical snare in retrieving and securing posterior chamber intraocular lenses is described. METHODS: The snare consists of a 10-O polypropylene suture threaded into a 25-gauge retrobulbar needle. This is used after a pars plana vitrectomy to retrieve the dislocated intraocular lens. The needle attached to the polypropylene suture is used to secure the lens haptic 1.5 mm behind the limbus. Two snares are used to secure the two lens haptics. CONCLUSIONS: The snare is easy to make with readily available materials. The use of this snare involves less intraocular and extraocular manipulations than other described methods.

Loss of vision before ophthalmic referral in blind and partially sighted diabetics in Bristol.

Data from all patients registered blind from diabetic retinopathy in Avon during a 16 month period were analysed with regard to management before hospital referral. The main findings were: 50% of the patients had no screening for retinopathy and were known to be diabetic; 25% were regularly screened for retinopathy (three quarters by local opticians); 22% were newly diagnosed as diabetic at the time of hospital referral. The degree of visual loss at the time of first hospital attendance was found to be marked (average 4.4 Snellen lines of acuity) but was not significantly different for different sources of referral. Only one eye of one patient had normal acuity at first attendance and 88% had lost two or more lines; 72% of registrations were a result of diabetic maculopathy. Delay from waiting for hospital appointments did not contribute significantly to the outcome in the group of patients studied.

Clinical and infrared pupillometry in central retinal vein occlusion.

Measurements of pupillary reactivity and size were recorded using neutral density filters and infrared pupillometry (IRP) in a prospective masked study of acute central retinal vein occlusion (CRVO) to quantify the two methods of measurement and to compare their value in the prediction of rubeosis. Thirty two patients were examined within 45 days of disease onset. The mean relative afferent pupillary defect (RAPD) with filters was significantly greater in patients who developed rubeosis than in those who did not (0.9 vs 0.3 log units; p = 0.012). Using IRP, the pupillary diameters in the dark (maximum) and in the light (minimum) were significantly greater, the rate of pupillary constriction was significantly lower, and the latency of constriction was significantly greater in affected eyes than in unaffected eyes. The differences between affected and unaffected eyes in the IRP parameters of latency, rate, maximum, and minimum pupillary diameters were significantly greater in patients who developed rubeosis than in those who did not. Discriminant analysis of the IRP parameters correctly and statistically significantly identified rubeotic patients with 83% sensitivity and 95% specificity. An RAPD of > or = 0.6 log units was 83% sensitive and 70% specific in this regard. It is concluded that pupillary reactions are abnormal in many patients with acute CRVO, as measured by both pupillometric methods. The degree of these abnormalities has a relationship to the development of rubeosis, and might prove useful in planning the follow up of these patients or in deciding whether to apply panretinal photocoagulation. The neutral density filter test is readily available but subjective. IRP is more specific, objective, and suited to further development, but requires sophisticated equipment.

The electro-oculogram in central retinal vein occlusion.

As part of a prospective masked study, the electro-oculogram (EOG) was recorded from 28 patients within 48 days of developing central retinal vein occlusion (CRVO). The EOG light peak/dark trough ratio (Lp/Dt) x 100 was significantly lower in the affected than in the unaffected eyes of patients (p < 0.001), and abnormally low in absolute terms in 20 patients (71%). All unaffected fellow eyes had a normal EOG ratio. The mean Lp amplitude of affected eyes was significantly smaller than that of unaffected eyes (p < 0.001), whereas the differences in mean Dt amplitudes between affected and unaffected eyes were not statistically significant. The Lp amplitude in the affected eye was 48% or less of that in the unaffected eye in the eight patients (29%) who developed rubeosis iridis during the 9 month follow-up, and in six others. No patient whose Lp amplitude in the affected eye was greater than 48% of that in the unaffected eye, developed rubeosis. It is concluded that the Lp amplitude is abnormal in patients with acute CRVO. The degree of this abnormality bears a relation to the development of rubeosis, which might prove a useful indicator of whether to institute or withhold panretinal photocoagulation.

Supplemental gas tamponade after conventional scleral buckling surgery--a simple alternative to surgical revision.

Supplemental intravitreal gas injection was used in the early postoperative period in an attempt to achieve long term retinal reattachment in 11 cases of failed scleral buckling surgery. Success was dependent on the presence of a correctly placed scleral buckle underlying all breaks. Surgical revision was thereby avoided in these patients. However, when the scleral buckle was inadequate the technique failed.

Visual field changes following hepatic transplantation in a patient with primary biliary cirrhosis.

A case of severe visual field restriction complicating primary biliary cirrhosis is described. The clinical features demonstrated vitamin A deficiency which did not respond to oral supplements of vitamin A. Hepatic transplantation restored the visual fields to near normal.

Retinal ischaemia and relative afferent pupil defects in central retinal vein occlusion.

A consecutive series of 40 patients were assessed for relative afferent pupil defects and retinal ischaemia by fluorescein angiography. A strong correlation was found between density of afferent defect and area of retinal non-perfusion. There was an increasing incidence of rubeosis iridis with more severe grades of afferent defects or ischaemia.

Blind and partial sight registration in Avon.

All blind and partially sighted registration forms for the county of Avon for a two-year period were analysed, and the findings are presented. Comparisons with the national figure published by Sorsby over 20 years ago show there has been no marked change in the rates of blind registration per 100,000 population with the exception of those for cataract, which show a large reduction. Diabetic registrations have remained similar, but this may represent an encouraging trend in view of the significant increase in the size of the diabetic population. Glaucoma may show some improvement in the future when time has elapsed for beta blockers and trabeculoplasty to be fully assessed. There has been an increase in the rate of registration from aging macular degeneration.

Ophthalmic survey of a diabetic clinic. I: Ocular findings.

A medical diabetic clinic was examined for evidence of diabetic eye disease. Of 681 patients invited for ocular examination 96.6% attended for screening. The results for insulin dependent diabetics (IDDs) and non-insulin dependent diabetics (NIDDs) were analysed separately and the major findings were: Cataracts were present in 40.8% of IDDs and 46.2% of NIDDs, with an increased incidence with advancing age. For younger age groups there were significantly more cataracts in IDDs than in NIDDs (p less than 0.001). Cataract extraction was required in 4.2% of the patients, which is higher than the general population. The presence of retinopathy was related to the duration of diabetes (p less than 0.001) but not to age of onset of diabetes. Retinopathy was found in 43.4% of IDDs and 20.1% of NIDDs. Sight threatening retinopathy was present in 13.3% of IDD and 4.3% of NIDD eyes. Advanced diabetic eye disease was seen in 0.6% of eyes.