A Novel Method for the Delivery of Antimetabolites During Glaucoma Surgery.

Current techniques for the delivery of antimetabolites, such as mitomycin C, tend to be very variable among surgeons and risk uncontrolled contact with the conjunctivae, which may result in delayed wound healing, wound dehiscence, and wound leakage postoperatively. We describe a novel technique which appear to allow a more precise and reproducible delivery of antimetabolite to the target area with minimal contact with the conjunctival edge. The technique involves the injection of an antimetabolite-soaked wick into the subconjunctival space posterior to the scleral flap using an intraocular lens injector system.

Accidental Unilateral Mydriasis from Hyoscine Patch in a Care Provider.

The hyoscine patch is effective and is frequently used in motion sickness treatment. Not uncommonly, it is used to control excessive respiratory secretions in palliative patients. Patients, healthcare workers, and caregivers who administer these may experience a benign, although worrying, mydriasis should they inadvertently rub their eye after handling the patch. A 46-year-old staff nurse working in a stroke ward presented with sudden-onset unilateral enlarged pupil. To rule out any intracranial pathology, the stroke team requested an urgent head computed tomography (CT) scan, which showed no abnormality. Upon ophthalmology review, nonreactive dilated left pupil was noted. Examination was otherwise unremarkable with no focal neurology findings. Following further history, she recalled applying a hyoscine patch to a patient in the morning. Two days later, her left pupil returned to normal size. This unique presentation of pharmacological mydriasis reinforces the importance of a detailed targeted history to avoid unnecessary investigations and anxiety, as well as the importance of informing patients, healthcare workers, and caregivers of this peculiar side-effect.

Different strategies and cost-effectiveness in the treatment of primary open angle glaucoma.

Glaucoma is the second highest cause of blindness worldwide with an estimated half of the glaucoma population unaware of their disease. To date, intraocular pressure is the most important modifiable risk factor and lowering it has been proven to reduce progression of visual field loss associated with glaucoma. Different strategies are available to lower intraocular pressure and include medical, laser, or surgical treatment in the form of topical or systemic medications, argon or selective laser trabeculoplasty, and glaucoma drainage surgery such as trabeculectomy, deep sclerectomy, or other drainage devices. The effectiveness of these treatments has been well documented however their cost-effectiveness between the developed world and third world remains unclear.

Botulinum toxin as a postoperative diplopia test - it can also reduce the angle of deviation prior to surgery.

PURPOSE: To investigate how frequently botulinum toxin, when used as a postoperative diplopia test, reduces the angle of deviation prior to subsequent strabismus surgery. METHODS: A retrospective study of 39 adult patients with constant concomitant horizontal strabismus who had undergone botulinum toxin injections to assess the risk of postoperative diplopia and then subsequently underwent strabismus surgery. RESULTS: Fourteen out of 39 patients (36%) sustained a reduction of 15 prism diopters or more for near and/or distance when comparing the pre-injection angle of deviation with the preoperative angle of deviation. CONCLUSION: Approximately one-third of patients receiving botulinum toxin as a postoperative diplopia test maintained a significant reduction in the angle of their deviation prior to undergoing surgery.

Low dose orbital radiotherapy for thyroid eye disease.

PURPOSE: The use of low dose orbital radiotherapy for thyroid eye disease (TED) remains controversial. This is a review of patients with TED treated with radiotherapy in our department over the last twelve years. METHODS AND MATERIALS: Fifty-nine consecutive patients received low dose orbital radiotherapy of 20 Gray (Gy) for active TED at the Beatson Oncology Centre. Their records were retrospectively reviewed and data including duration of symptoms, clinical activity score (CAS) pre- and post-orbital radiotherapy, immunosuppression requirement, subjective assessment and range of rehabilitative surgery was collected. RESULTS: Before orbital radiotherapy, all fifty-nine patients had an initial response to glucocorticoids and therefore presumed to have active phase thyroid eye disease. They received retro-orbital radiotherapy of 20 Gy in 12 fractions over 2 weeks. After treatment, only five patients remained on steroids and only one patient had CAS ≥ 3 at last follow up. Response (change in CAS) to orbital radiotherapy was statistically significant from 3.17 ± 1.75 standard deviation (SD) to 0.73 ± 0.92 SD (P < 0.001) at mean follow up of 6.5 months. There was a reduction in CAS at each subsequent follow up for all subgroups when the patients were grouped according to disease severity i.e. mild TED(CAS 1-2), moderate (CAS 3-4), severe CAS (5-7) and optic neuropathy. CONCLUSIONS: We believe orbital radiotherapy has a definite role to play in the treatment of active thyroid eye disease. The majority of our patients experienced a reduction in their clinical activity scores after orbital radiotherapy and this was irrespective of the severity of thyroid eye disease.

The intraocular pressure reducing effect of brinzolamide as adjunctive therapy to latanoprost.

AIM: To determine the intraocular pressure (IOP) lowering effect of brinzolamide when added to latanoprost. MATERIALS AND METHODS: Patients who were simultaneously on brinzolamide and latanoprost were identified from the large prospective database of patients diagnosed with primary open angle glaucoma, normal tension glaucoma or ocular hypertension maintained in our glaucoma clinic. Only patients who had been on latanoprost for at least six weeks before introduction of brinzolamide were included. Their case notes were reviewed to determine the intraocular pressure at baseline, after addition of brinzolamide and prior to subsequent treatment change if any. RESULTS: Ninety-three patients were identified. Data for seventy-two patients were analysed. Average age was 70 with a male to female ratio of 4:5. The mean baseline IOP was 20.8 ± 4.6 mmHg with 47 diagnosed with primary open angle glaucoma, 16 with normal tension glaucoma and 9 with ocular hypertension. The reduction in IOP was 4.1 ± 0.9 mmHg (95% confidence limits, p < 0.001) at 4.0 months median follow up. This corresponds to 19.8% reduction of IOP from baseline. A 12.5% proportion of patients did not have a reduction in IOP, 3.2% and 2.1% reported ocular irritation and blurring of vision respectively. At last mean follow up of 45 months, 51% of patients remained on this treatment. CONCLUSIONS: In the majority of patients, brinzolamide reduced IOP by a further 19.8% in patients already on latanoprost monotherapy. This effect was maintained in 51% of patients after 42 months.

Leucocytoclastic vasculitis presenting as bilateral marginal keratitis.

Leucocytoclastic vasculitis is an immune-mediated, neutrophil-induced small vessel disease. Clinically, it presents with cutaneous palpable painless purpuric papules on the extremities. Ocular manifestation reported in the literature is rare and includes peripheral ulcerative keratitis, panuveitis and multifocal retinitis all preceded by cutaneous lesions. Herein a fatal case of leucocytoclastic vasculitis initially presenting with bilateral marginal keratitis without any cutaneous lesions is reported.