Sudden onset peripheral visual deficit secondary to retinal artery spasm in Raynaud's phenomenon.

A 32-year-old doctor, who has a medical history of primary Raynaud's disease and previous scotomas, presented to eye clinic with sudden onset blurring of vision (infero-nasally) with no other associated symptoms. The patient had good visual acuity bilaterally (6/6) and no anterior chamber activity or conjunctival hyperaemia. Findings consistent with a nerve fibre layer infarct were noted in the right eye, with unremarkable examination of the left eye. Optical coherence tomography (OCT) and optical coherence tomography angiography (OCTA) images were obtained, which showed an area of capillary shut down in keeping with a nerve fibre layer lesion. Previous literature pertaining to similar symptoms is sparse with symptoms such as migraines, epilepsy and visual loss being stated. This case provides further evidence of Raynaud's associated retinal artery spasm, with complete resolution at 4 weeks. We also demonstrate the accessibility of OCT and more importantly OCTA for investigation of sudden onset visual deficit.

Treating Diabetic Macular Oedema (DMO): real world UK clinical outcomes for the 0.19mg Fluocinolone Acetonide intravitreal implant (Iluvien™) at 2 years.

BACKGROUND: To compare visual function and structural improvements in pseudophakic eyes with diabetic macular oedema (DMO) treated with the 0.19mg Fluocinolone Acetonide (FAc) intravitreal implant (IluvienTM) in a 'real world' setting. METHODS: A single centre retrospective evaluation of patients with DMO unresponsive to conventional treatment treated with the FAc implant according to UK guidelines. Primary efficacy endpoint was best corrected visual acuity (BCVA); secondary endpoints included optical coherence tomography evaluations of the macula (a) central retinal and (b) peak macular thickness collected at annual time points. Primary safety endpoint was new rise in IOP >27mmHg or glaucoma surgery. Patients with <1 year follow-up were excluded. RESULTS: Twenty-nine eyes were included, with mean(SD) follow up of 792(270) days. Improvement in BCVA and reduction in macular oedema was noted at all timepoints. Mean improvement in BCVA from baseline was 6 ETDRS letters at year 1(n=29), 6.5L at year 2(n=22) and 11L at year 3(n=6). Mean central retinal thickness at baseline was 451 microns, 337 microns at year 1, 342 microns at year 2 and 314 microns at year 3. Two eyes required IOP-lowering drops post implant. Supplementary treatment for persistence or recurrence of DMO was necessary in 18 eyes over the total study period of 3 years with mean time to supplementary treatment being 12 months. CONCLUSIONS: Our evaluation of the 0.19mg FAc implant delivered in a real-world setting, provides additional evidence that it is effective and safe in the treatment of patients with DMO, and can provide sustained benefit for patients with previously refractory disease.

Avastin and Lucentis: what do patients know? A prospective questionnaire survey.

OBJECTIVES: To assess patients' knowledge of their drug therapy for neovascular macular degeneration and to identify which aspects of the drug they considered most important if given the option of switching to an alternative drug. DESIGN: Prospective questionnaire survey. SETTING: Wolverhampton, England. PARTICIPANTS: A total of 126 patients attending our hospital service for intravitreal ranibizumab therapy for neovascular macular degeneration. MAIN OUTCOME MEASURES: Using a questionnaire, patients were asked questions pertaining to aspects of drug therapy in neovascular macular degeneration. Fields covered included drug names, knowledge of alternative drugs, cost of drugs and their views on switching to another drug. RESULTS: Eighty (63.5%) had heard of Lucentis (ranibizumab) and 31 (24.6%) were aware of Avastin (bevacizumab). Of the latter 31 patients, 20 did not have a preference between Avastin and Lucentis. These patients felt that the factors they would consider important for them to consider switching were effectiveness (10, 50%), specialist recommendation (8, 40%), safety (2, 10%) and cost (0). CONCLUSIONS: Introducing a cheaper, off-label alternative in the therapy of macular degeneration in the presence of a licensed option has been extensively debated. Many patients have no knowledge of this controversial issue but it is likely that efficacy and recommendation by clinicians are more important than cost to patients who may consider switching to the off-label Avastin.

Levator-Muller's muscle recession with tarsorrhaphy: a technique for corneal protection in cases with cicatricial upper eyelid retraction.

AIMS: Cicatricial upper eyelid retraction with exposure keratopathy and impending corneal perforation requires prompt intervention. Standard procedures such as isolated levator recession, botulinum toxin, and lid weights will only induce a partial ptosis. Conventional tarsorrhaphy, though ideal to achieve complete closure, is likely to result in dehiscence in these cases. We describe a one-stage technique of levator and Muller's muscle recession combined with a tarsorrhaphy used in four patients with an impending corneal perforation due to cicatricial lagophthalmos. METHODS: This is an interventional, non-comparative retrospective case series of four patients who had undergone tarsorrhaphy in combination with levator recession. RESULTS: In all four cases, it was not possible to mechanically close the eyelids preoperatively due to cicatricial lid retraction involving the middle lamella. The aetiology for lagophthalmos was varied: (Case 1) bilateral sclerosing metastatic breast cancer involving the lids; (Case 2) severe anterior and middle lamella shortening due to actinic changes; (Case 3) middle and posterior lamella shortening due to glaucoma treatment and multiple surgery (Case 4) due to traumatic facial scarring and seventh nerve palsy. In all cases, the corneal thinning and epithelial defects resolved completely following surgery. In one case, we were able to partially reopen the tarsorrhaphy for further corneal surgery. DISCUSSION: We describe a safe, effective and reversible surgical procedure for managing cases with cicatricial upper eyelid retraction, which would otherwise lead to serious corneal complications.