Incidence of intra-operative floppy iris syndrome in a U.K. district general hospital and implications for future workload.

AIM: IFIS is a recently described condition observed during cataract surgery. However, its true incidence in the U.K. population is unknown. Our aim was to assess the incidence of IFIS associated with tamsulosin in patients undergoing cataract surgery in a U.K. district general hospital. METHOD: A prospective observational study of patients on tamsulosin undergoing cataract surgery was carried out over a six month period to determine the incidence of IFIS and to document outcomes of those cases. The patients were identified during routine pre-operative assessment. RESULTS: 1462 cataract cases were performed over six months. From these cases, 23 eyes of 16 patients who were taking Tamsulosin were recruited into the study. All the patients were men and the mean age was 76 years. A small pupil was demonstrated intra-operatively in 69% (16/23) of the eyes. A floppy iris or iris prolapse during surgery was noted in 57% (13/23) of the eyes. Complications reported included posterior capsule rupture in one case (4%) and iris trauma in five cases (22%). A best corrected visual acuity of 6/9 or better was achieved in 21/23 cases. The incidence of IFIS in patients undergoing cataract surgery over six months is 0.9%. CONCLUSION: IFIS appears to be strongly associated with tamsulosin use. The increasing use ofthis drug in the elderly male population is likely to increase the workload on our cataract service. Prospective risk stratification for such patients to be operated by senior surgeons is therefore recommended.

Photodynamic therapy combined with systemic corticosteroids for choroidal neovascularisation secondary to punctate inner choroidopathy.

AIM: To report on visual acuity (VA) and angiographic outcomes in patients presenting with subfoveal choroidal neovascular membranes (CNV) secondary to punctate inner choroidopathy (PIC), treated with photodynamic therapy (PDT) with verteporfin combined with systemic corticosteroids. METHODS: A prospective case series of patients with subfoveal CNV secondary to PIC was analysed. All patients were treated with PDT combined with oral prednisolone (1 mg/kg body weight/day) which was started 5 days before PDT. Fluorescein angiography was performed at baseline and every 3 months post-treatment to establish the size, position, and activity of the CNV. Visual acuity was measured using the ETDRS scale. Further PDT treatment was carried out at follow-up visits if there was angiographic evidence of ongoing CNV activity. RESULTS: Five female patients with a mean age of 30.4 years (range 25-43 years) were treated over a 12-month period. The mean greatest linear diameter (GLD) of the CNV was 1.66 mm (range 0.46-3.28 mm). A mean improvement in vision of nine ETDRS letters (range -15-20 letters) after treatment was found, which was maintained at final follow-up. The mean follow-up time was 12 months (range 10-14 months). The mean number of PDT treatments was two (range 1-3). CONCLUSIONS: The vaso-occlusive effect of PDT combined with the vasostatic and anti-inflammatory effect of systemic oral prednisolone appears to be a safe and effective option in the primary treatment of subfoveal CNV in patients with PIC.

Combined orbital floor betamethasone and depot methylprednisolone in uveitis.

PURPOSE: To evaluate the outcome of orbital floor injection of betamethasone and methylprednisolone in the management of uveitis, with particular reference to its efficacy in avoiding increase in systemic immunosuppressive drugs. METHODS: A sample of all patients attending the Uveitis Service at Moorfields Eye Hospital was carried out over a three-month period. All patients who had received one or more orbital floor injections of betamethasone (4 mg) and methylprednisolone (Depo-Medrone; 40 mg) in the management of their uveitis were identified and the case notes reviewed. RESULTS: A total of 48 patients who had received 75 orbital floor injections were identified during the sample period. Most patients had either panuveitis (n = 24) or pars planitis (n = 14). One-month post-injection visual acuity (VA) had improved by at least one Snellen line after 33/75 injections (44%) and at least two lines after 11/75 (15%), was unchanged after 25 (33%), but had deteriorated in 14 (19%). VA was not recorded after 3/75 injections. The only complications recorded were periorbital haemorrhage (n = 1) and complaints of persistent pain after an injection (n = 1). Symptoms (pain and subjective vision) improved after 36/75 injections (47%), were unchanged after 24 (32%), and were reported as worse after five (7%). Additionally, three patients reported an improvement in symptoms which lasted less than one month. Signs other than VA were improved after 28/75 (37%), were unchanged after 38 (51%), and deteriorated after only one injection. Of the 31 patients given orbital floor injections to avoid systemic therapy, seven (23%) subsequently went on to require it, and the clinical course then improved in 45%. CONCLUSIONS: Combined orbital floor injection of betamethasone and methylprednisolone can result in improved visual acuity, symptoms, and signs of inflammation in uveitis, and may therefore avoid the necessity for increased systemic medication.

Combined pars plana vitrectomy and sutured posterior chamber implant.

OBJECTIVE: To describe the surgical technique, visual acuity results, and complications of sutured posterior chamber intraocular lenses with complete pars plana vitrectomy. METHOD: A retrospective review of 63 eyes was combined with a telephone survey of the patients and their ophthalmologists. RESULTS: The preoperative diagnoses were trauma, 25 eyes; ectopia lentis, 24 eyes; aphakia following retinal detachment surgery, 7 eyes; cataract surgery, 6 eyes; and endophthalmitis, 1 eye. Mean follow-up was 20 months. Preoperative best-corrected visual acuity was 20/40 or better in 36% (23 of 63 eyes), 20/60 to 20/120 in 33% (21 of 63 eyes), and 20/200 or worse in 31% (19 of 63 eyes) improving to 20/40 or better in 76% (48 of 63 eyes), 20/60 to 20/120 in 18% (11 of 63 eyes), and 20/200 or worse in 6% (4 of 63 eyes) at final follow-up. Preoperative complications included iatrogenic retinal breaks in 3 cases, difficulty with a fixation suture in 1 case, and mild vitreous hemorrhage in 1 case. Postoperative complications included retinal detachment in 2 cases, choroidal hemorrhage in 1 case, intermittent pupil capture in 9 cases, self-limiting vitreous hemorrhage in 3 cases, and late intraocular lenses dislocation in 1 case. CONCLUSIONS: Suturing a posterior chamber implant concurrently, or following, a complete pars plana vitrectomy is a safe procedure. Complete vitrectomy may reduce the rate of long-term complications. Optimal visual rehabilitation can be achieved without the need for contact lens wear with an acceptable additional risk of surgical complications. Arch Ophthalmol. 2000;118:905-910

Phototherapeutic smoothing as an adjunct to photorefractive keratectomy in porcine corneas.

PURPOSE: To study the smoothing effect of phototherapeutic keratectomy (PTK) using masking fluids as an adjunct to standard photorefractive keratectomy ablations. METHODS: Six fresh porcine corneas underwent -6.00, -10.00, and -15.00 D sphere ablations using the VISX Star excimer laser. Multizone treatments to a maximum 6.5 mm radially symmetrical bed were used with a fluence of 160 mJ/cm2. Three of the treatments were supplemented with a thin layer of balanced salt solution and 6 microm of full beam PTK. The corneas were examined by electron microscopy. RESULTS: Smoother treatment zones were apparent in corneas undergoing PTK following PRK. The effect was more marked at higher dioptric ablations. CONCLUSION: PTK may improve surface smoothness after PRK, especially for higher dioptric ablations.

The long-term use of botulinum toxin for adult strabismus.

PURPOSE: To characterize patients choosing repeated botulinum toxin injection as a treatment for their strabismus, and assess their demand for it over time (up to 8 years). METHOD: Patients who had undergone at least eight injections were identified and their clinical records analyzed for diagnosis, demographic details, and demand for toxin injections with time. To establish any predictive variables, the details for these cases were compared with those of matched controls who had undergone fewer injections. Lastly, a questionnaire was mailed to research patients' views as to the indications and preferences for regular toxin injection as a method of treatment. RESULTS: Ninety-five patients were identified (34 men, 61 women; median age 37 years), of whom 35 had consecutive exotropia and 16 had secondary exotropia. Other diagnoses represented were residual and primary deviations, restrictive exotropias, and oscillopsias. A trend of fewer injections over the attendance period was seen, and the only complication observed was upper lid ptosis in 1% of injections. Cases exhibited similar demographic composition to matched controls, but were more likely to have consecutive exotropia or secondary esotropia as a diagnosis. Univariate analysis showed evidence (p < 0.001) of an association between the number of previous operations and the odds of being a case. No evidence was found that cases and controls lived at differing distances from our hospital. The questionnaire found that 71% of patients stated appearance as the prime reason for seeking treatment, and 37% stated simplicity of toxin therapy as their reason for reattendance. Twenty-six percent of the patients were disillusioned with the results of previous surgery and preferred toxin therapy as a means of controlling their symptoms. CONCLUSION: Botulinum toxin injection is an appropriate long-term treatment for some strabismus patients who choose not to undergo further surgery. A trend toward fewer injections with time was observed, and no adverse effects were associated with long-term treatment.

Twelve year follow-up of unfenestrated polysulfone intracorneal lenses in human sighted eyes.

PURPOSE: To evaluate unfenestrated polysulfone intracorneal lenses (ICLs) in human sighted eyes 12 years after their implantation and to assess eyes that had the ICLs explanted. SETTING: A department of clinical ophthalmology at a general hospital and the Department of Pathology at the National Institute of Ophthalmology, London, Great Britain. METHODS: In this retrospective study, seven eyes were evaluated 12 to 14 years after ICL implantation. Case notes were scrutinized for preoperative ophthalmic history, and patients were interviewed and examined to establish outcome of the ICL implantation. Histopathological correlates were made for two study patients who had had ICL explantation and penetrating keratoplasty (PKP). RESULTS: Uncorrected visual acuity in eyes retaining the ICL ranged between hand motion and 20/40, improving to 20/32 with correction. Corneal clarity varied between complete lucency to extensive opacity on each ICL surface. No corneal vascularization, endothelial decompensation, or uveitis was seen in eyes with clear ICLs. Acuity in eyes in which the ICL was explanted was between 20/20 corrected and finger counting in cases of PKP and between 20/200 and hand motion in eyes after lamellar keratoplasty. CONCLUSION: Despite satisfactory surgical technique in some eyes, unfenestrated polysulfone appears to be associated with color change and varying degree of stromal opacity in eyes evaluated 12 years postoperatively and thus cannot be considered clinically acceptable.

The early results of excimer laser photorefractive keratectomy for compound myopic astigmatism.

UNLABELLED: An excimer laser (VISX Twenty/Twenty Excimer Refractive System) was used to treat 51 eyes for myopia and astigmatism. Uncorrected pretreatment visual acuity was between 6/18 and 6/60 (log unit +0.45 to +1.0) in 59% and worse than 6/60 in 29%. The mean pretreatment spherical refractive error was -4.05 dioptre (range 1.25 to 13.25), and the mean pretreatment cylindrical error was -0.97 dioptre (range 0.25 to 4.00). RESULTS: Uncorrected visual acuity measured 6/6 or better (log unit 0.0 or less) in 80% at three months, and averaged 6/6 for all eyes at six months post-treatment, with 75% eyes obtaining 6/6 or better. The mean post-treatment spherical error decayed according to pre-treatment values, with a mean sphere of -0.20 dioptre for eyes initially less than -2.00 dioptre, -0.40 dioptre (for those between -2.25 and -3.00), -0.71 dioptre (for those between -4.25 and -5.00), and -1.15 dioptre for eyes initially above -6.25 dioptre. Vectored cylindrical correction exhibited response proportional to initial refraction, with a mean post-treatment cylinder of -1.83 dioptre for eyes formerly averaging -3.08 dioptre, -0.55 dioptre (eyes initially averaging -1.63 dioptre), and -0.51 dioptre (eyes initially averaging -0.67 dioptre). Vector analysis of post-treatment astigmatism showed 58% eyes exhibiting 51 or more degrees of axis shift, although 34% eyes remained within 20 degrees of their pretreatment axis. CONCLUSIONS: An effective reduction in spherocylindrical error was achieved with all eyes, although axis misalignment was a common event.