NOVEL OPTICAL COHERENCE TOMOGRAPHY FINDINGS OF A CASE OF SYMPATHETIC OPHTHALMIA AFTER 23-GAUGE VITRECTOMY.

PURPOSE: Sympathetic ophthalmia (SO) is a rare panuveitis after trauma to one eye. We present a case of SO after 23-gauge transconjunctival vitrectomy, including optical coherence tomography evidence of response to treatment. To our knowledge, this is the first SO case report to include spectral domain optical coherence tomography images of Dalen-Fuchs nodules. METHODS: Observational case report of a case of SO after two pars plana vitrectomies in the fellow eye. RESULTS: A 67-year-old woman who had an operation for her pseudophakic left eye for a macula-off retinal detachment. She had two surgeries and later on had a total retinal detachment with vision of no perception of light. Eighteen months later, she presented back with a panuveitis with vitritis in her other eye and a visual acuity of 6/18. Dalen-Fuchs denoting SO was found. Treatment was commenced, and multimodal imaging was performed. CONCLUSION: Sympathetic ophthalmia is a known complication after vitrectomy. Optical coherence tomography can be invaluable in monitoring diagnosis and progression of Dalen-Fuchs nodules.

Primary photodynamic therapy for small amelanotic choroidal melanomas: consecutive case series of 69 patients with at least 24-month follow-up.

AIMS: To investigate the success and recurrence rates and visual outcomes in a large case series of amelanotic posterior choroidal melanomas treated by means of primary photodynamic therapy (PDT) with verteporfin. METHODS: Retrospective case series from a single specialist ocular oncology centre. All patients had a clinical diagnosis of choroidal melanoma and were selected for PDT based on tumour characteristics. Included patients had at least 24 months of follow-up from initiation of treatment and all but one had not received treatment prior to PDT. RESULTS: 69 patients were included. Mean tumour thickness was 1.9 mm (range 0.5-4.4), while the mean basal diameter was 6.9 mm (range 2.4-11.0). Included lesions were stage cT1a (n=66) or cT2a (n=3). The mean duration of follow-up from treatment initiation was 57 months (range 24-116 months). Seven lesions (10%) failed to respond to PDT. 10 patients (16%) experienced recurrence during follow-up. Overall success rate in this series was 75% (n=52). 83% of successfully treated patients (n=43) maintained or gained vision by final follow-up. Visual outcomes were significantly better in those patients who received PDT therapy alone in comparison to those who needed other treatments for their melanoma (Fisher's exact test, p=0.004). Unfortunately, one patient (1.4%) in the series developed systemic metastases and died. CONCLUSION: Selected amelanotic posterior uveal melanomas may be successfully treated with PDT with retention of good vision in the majority of cases, maintained with a mean of 57 months (minimum of 24 months) of follow-up.

Cystoid Macular Oedema as a Presenting Feature of Vitreoretinal Lymphoma.

A 69-year-old female presented with right vitreous cells and cystoid macular oedema (CMO). One year previously, she had received two cycles of attenuated methotrexate-based chemotherapy for primary central nervous system (CNS) lymphoma, abandoned due to toxicity. There was no past ocular history of note aside from mild cataract. Due to her history of previous CNS lymphoma, we suspected vitreoretinal lymphoma (VRL), but the presence of the CMO made this unlikely. She underwent a diagnostic vitrectomy. Histology and immunohistochemistry showed the presence of a high-grade B-cell VRL.

Unilateral Conjunctival in situ Squamous Carcinoma with Bilateral Conjunctival Chlorpromazine-Induced Secondary Melanosis Masquerading as in situ and Invasive Melanoma.

PURPOSE: To describe the clinical and histopathological features of a 61-year-old male with a history of eczema, asthma and schizophrenia on long-term chlorpromazine medication, who developed a unilateral limbal tumour in association with bilateral melanosis. PROCEDURES: The patient was referred for a routine cataract assessment, and an incidental pink gelatinous limbal lesion was detected on the left side, associated with bilateral speckled brown conjunctival pigmentation. The limbal lesion and brown pigmentation were biopsied. The tissue was fixed in standard buffered formalin and processed to paraffin wax, and sections were stained with haematoxylin and eosin. Tissue from the pigmented area was also processed for transmission electron microscopy. RESULTS: The biopsy from the limbal lesion showed an in situ squamous carcinoma associated with prominent numbers of intra-epithelial eosinophils. The biopsy of the pigmented area showed bilateral melanosis without atypia. The latter was attributable to an increase in melanin production rather than to melanocyte hyperplasia. Melanophages were also present in the adjacent substantia propria. These pigment changes were entirely compatible with chlorpromazine-induced secondary melanosis. CONCLUSIONS: This paper highlights the first documented occurrence of in situ squamous carcinoma with bilateral chlorpromazine-induced conjunctival secondary melanosis. This clinically masqueraded as in situ melanoma/primary acquired melanosis and invasive melanoma. Bilateral melanosis is rare, has many causes and, in this case, was drug induced. This highlights the importance of thorough history taking and illustrates that not all pigmented and amelanotic lesions are in situ melanomas, primary acquired melanosis or invasive melanomas. Lastly, atopy was a risk factor for the development of this in situ squamous carcinoma.

Online self-administered training of PTSD treatment providers in cognitive-behavioral intervention skills: results of a randomized controlled trial.

Despite potential advantages in scalability and efficiency of web-based training for trauma providers, few controlled trials of feasibility and effectiveness of web-based mental health training have been performed. Our study compared web-based training in 3 intervention skills (motivation enhancement [ME], goal setting [GS], behavioral task assignment [BTA]) with web-based training plus telephone consultation, and a no-training control. The primary outcome measures included objective measures of skills acquisition (standardized patient assessments). Results showed significant differences among the training conditions. The overall tests of differences among the groups were statistically significant for ME and BTA skills (p < .001 and p = .005, respectively), but not for GS (p = .245). The web training plus consultation group improved in ME skills by 0.35 units compared to 0.12 units in the web only group (p < .001) and no change in the control group (p = .001). For BTA skills, the web training plus consultation improved by 0.27 units compared to 0.17 units in the web only group (p = .175) and no change in the control group (p = .004). Overall, these findings support the use of web-based dissemination for large-scale training programs for trauma providers in health care delivery systems. Further studies are needed to clarify the specific role of consultation as an adjunct to web-based training.

Reexploration and inferior oblique myectomy temporal to the inferior rectus to treat persistent inferior oblique overaction.

PURPOSE: Persistent symptomatic inferior oblique (IO) muscle overaction (IOOA) after IO muscle weakening surgery is a common problem. We describe the results of reexploration and myectomy of the IO muscle using a standard inferotemporal approach to treat this clinical entity. METHODS: A retrospective noncomparative consecutive series of patients referred for treatment of persistent IOOA. The following preoperative and postoperative measurements were recorded in each case: (1) the ductions and versions of the overacting IO muscle and its antagonist superior oblique (SO) muscle; and (2) alternate prism cover test, using loose prisms at 6 m, in primary position and right- and leftgaze. The preoperative and longer term postoperative findings were compared. RESULTS: Eight patients were identified. Three had previously undergone a standard IO myectomy, and five had undergone a standard IO muscle recession. The median period of postoperative follow-up was 12 months (range, 7 months to 2 years). The IOOA was eliminated in three patients and a reduction of IOOA of at least 1 unit was achieved in all patients. Seven patients showed improvement of their SO muscle underaction on versions, postoperatively. All patients achieved a marked improvement in their alignment across the three standard horizontal positions of gaze. The mean vertical deviations pre- and postoperatively was 23(Delta) versus 7(Delta) in contralateral gaze, 17(Delta) versus 4(Delta) in primary gaze, and 7(Delta) versus 1(Delta) in ipsilateral gaze. CONCLUSIONS: Reexploration and myectomy of the IO muscle near to the temporal border of the inferior rectus muscle is a reliable and effective way of treating persistent IOOA.

Visually significant persistent outer retinal fluid following closure of a macular hole.

PURPOSE: We report two cases of persistent outer retinal fluid defects following macular hole surgery. METHODS: Twenty-eight consecutive patients who underwent macular hole surgery performed by a single surgeon were examined pre- and postoperatively using slit-lamp biomicroscopy and optical coherence tomography (OCT). RESULTS: Two patients from this series were identified by OCT as having persistent outer retinal fluid defects after macular hole surgery, despite closure of the holes on biomicroscopy. One patient had only a small defect present at 6 weeks, with very good visual improvement, which was later shown to have resolved. The second had a large persistent defect and no postoperative improvement in vision despite the eventual resolution of the fluid 17 months later. CONCLUSIONS: Large pockets of persistent outer retinal fluid defects as shown on OCT may reduce final visual acuity in patients following macular hole surgery.