The accessory tendon of extensor hallucis longus muscle and its correlation to hallux valgus deformity: a cadaveric study.

PURPOSE: The accessory tendon (AT) of the extensor hallucis longus (EHL) is a common anatomic variation, whose clinical significance remains debatable. The purpose of this study was to investigate the incidence and morphology of accessory EHL tendons in cadavers and to examine any possible correlation to the occurrence and severity of hallux valgus (HV) deformity. METHODS: We examined any possible correlation between the AT presence and the cadavers' age and the HV deformity in 98 female adult cadaveric feet. The HV and intermetatarsal (IMA) angles were measured and compared with the relative angle between the primary EHL tendon and AT as well as the length of the AT. RESULTS: AT was present in 26.5% and HV deformity existed in 36.7% of all feet. There was a high prevalence (65.4%) of HV deformity in feet with AT, but the HV angle and IMA were similar in feet with AT and without AT. No significant correlations were found between AT morphological characteristics and the cadavers' age or the HV angle and IMA. CONCLUSIONS: In conclusion, there is a high incidence of HV deformity in cadaveric feet with AT of EHL (almost 2/3), but there is no correlation between the severity of the HV deformity and the presence or characteristics of the AT.

Bilateral exudative retinal detachment in a child with orbital pseudotumor.

We describe a 15-year-old girl who presented with bilateral exudative retinal detachment, a previously unreported complication, due to orbital pseudotumor. She initially responded to steroids, but subsequently became steroid dependent. Azathioprine was effective in controlling further relapses during follow-up of 22 months.

Cytomegalovirus retinitis in chronic lymphocytic leukaemia.

PURPOSE: To describe a rare association of cytomegalovirus (CMV) retinitis. PATIENTS AND METHODS: Report of three patients with chronic lymphocytic leukaemia (CLL) who developed CMV retinitis. RESULTS: The diagnosis was established by the detection of CMV DNA by polymerase chain reaction analysis of aqueous and/or vitreous humour. CD4+ T-lymphocyte count was reduced in two patients and normal in the third one. There was bilateral involvement in two of the three patients. There was delay of 8-10 months in diagnosis. The visual outcome was poor in four out of the five eyes involved owing to optic atrophy or total retinal detachment with proliferative vitreoretinopathy. CONCLUSION: Increased awareness of CMV retinitis in patients who have received immunosuppression for haematological malignancies, such as CLL, could lead to earlier diagnosis and possibly better visual outcome.

Cement penetration and stiffness of the cement-bone composite in the proximal tibia in a porcine model.

PURPOSE: To assess the stiffness of the cement bone composite and the depth and uniformity of cement penetration into the surface of the tibial component during total knee reconstruction in a porcine model. METHODS: The effectiveness of 3 protocols were compared: 2 commonly used cementing techniques-finger-packing of cement on the cut surface followed by impaction, and coating of the undersurface of the prosthesis with cement followed by impaction-and a new method using a tibial cement-pressurising device. Cement penetration was measured by computed tomography; stiffness was determined by hydraulic penetration testing. RESULTS: Cement penetration at a depth of 1 mm was significantly greater following coating the undersurface of the prosthesis than following finger-packing (p=0.008). There was no significant difference at deeper levels or between the tibial-pressurising device group and either of the 2 other groups at any level (p>0.3 in all cases). Differences in surface stiffness by tibial plateau region were found in tibiae that had been cemented using finger-packing and in those that had had their undersurface coated, but not in tibiae that had been cemented using the tibial-pressurising device. CONCLUSION: The tibial cement-pressurising device eliminated regional differences in stiffness seen with other cementing methods. Elimination of these differences by using this device should reduce micromotion and the incidence of aseptic loosening of tibial base plates in total knee arthroplasty.

Degree, duration, and causes of visual loss in uveitis.

BACKGROUND/AIMS: Uveitis is a major cause of visual morbidity in the working age group. The authors investigated the duration, degree, and causes of visual loss in uveitis patients with the aim of better defining the visual morbidity and identifying potential risk factors. METHODS: A retrospective, non-interventional, observational survey of 315 consecutive patients attending a tertiary referral uveitis service. RESULTS: The mean duration of follow up was 36.7 months. Reduced vision (< or =6/18) was found in 220/315 (69.95%) of the patients with a subset of 120 patients having vision < or =6/60. Unilateral visual loss occurred in 109 (49.54%), while 111 (50.45%) had bilateral loss. The mean duration of visual loss was 21 months. Of the 148 patients with pan-uveitis, 125 (84.45%) had reduced vision, with 66 (53%) having vision < or =6/60. Main causes of visual loss were cystoid macular oedema (CMO) (59/220, 26.8%), cataract (39/220, 17.7%), and combination of CMO and cataract (44/220, 20%). The following were predictive of a poorer visual prognosis: pan-uveitis (p = 0.0005), bilateral inflammation (p = 0.0005), increasing duration of reduced vision (p = 0.0005), an Indian or Pakistani ethnic background (p = 0.004), and increasing patient age (p = 0.02). CONCLUSION: Prolonged visual loss occurred in two thirds of uveitis patients, with 70 (22%) patients meeting the criteria for legal blindness at some point in their follow up. Older patients with bilateral inflammation and an increasing duration of reduced vision are at the greatest risk of severe visual loss (< or =6/60). CMO and cataract were responsible for visual loss in 64.5% of patients.

Diabetic retinopathy progression and visual outcome after phacoemulsification in South-Asian and Afro-Caribbean patients with diabetes.

PURPOSE: To determine diabetic retinopathy or maculopathy progression and visual outcome following phacoemulsification in South-Asian and Afro-Caribbean patients with diabetes. METHODS: Review of notes of patients with type II diabetes undergoing phacoemulsification by one surgeon. The inclusion criteria were: (a) South-Asian or Afro-Caribbean ethnicity, (b) monocular cases with a minimum postoperative follow-up of 6 months, and (c) binocular cases with an interval of at least 6 months between the operation in the two eyes. The nonoperated eye was used as control. The development or progression of diabetic retinopathy or maculopathy and final visual acuity were recorded. RESULTS: In all, 30 diabetic patients were included. There were 19 South-Asians (Pakistani, Indian, and Bangladeshi) and 11 Afro-Caribbeans. The mean (+/-SD) age was 68.9 (+/-10) years. Retinopathy or maculopathy progression was noted in seven patients (23.4%), two South-Asians, and five Afro-Caribbeans. There was no significant difference in the number of operated and fellow eyes whose retinopathy or maculopathy progressed postoperatively. Progression of retinopathy or maculopathy occurred more often in Afro-Caribbeans compared to South-Asians (P=0.02, logistic regression analysis). The mean (+/-SD) postoperative follow-up was 12.4 (+/-6.5) months. Visual acuity improved by at least two or more Snellen lines in 19 eyes (63.3%); 26 eyes (86.7%) achieved a final visual acuity of at least 6/12. CONCLUSIONS: Afro-Caribbeans may be at a higher risk of progression of retinopathy or maculopathy after phacoemulsification.

Is digital image compression acceptable within diabetic retinopathy screening?

AIMS: The National Screening Committee (NSC), whilst recommending the use of digital mydriatic retinal photography for diabetic retinopathy screening, has not yet accepted the use of digitally compressed images for grading. By greatly reducing the file size, however, compression of images is invaluable for storage and for its rapid transmission across computer networks. We undertook a study to compare the different levels of JPEG compression with the original bit-mapped image to determine whether there was any loss of clinical detail following compression. METHODS: Three hundred and thirty images were analysed in this study. These images had been captured from 66 eyes consecutively photographed in a diabetic retinopathy screening programme, using a Sony DXC-950 P 3CCD colour video camera mounted on a Canon CR6-45NMf fundus camera. Single 45 degrees macula-centred images were taken from each eye. The images were compressed using the JPEG algorithm within Adobe Photoshop (version 4.0) and then displayed with a Sony Trinitron colour monitor. Four different levels of compression were used, JPEG-1, JPEG-2, JPEG-3, JPEG-4, and an objective analysis was undertaken using 'lesion counts'. The compressed images were assessed separately and blindly and the results compared with their original BMP images. RESULTS: Eight BMP images could not be evaluated (five right eye and three left eye). A total of 290 images were therefore used in the final evaluation. All the JPEG-1 images with file sizes between 16 and 24 kb were found to be 'pixelated', while the JPEG-4 images (66-107 kb) appeared similar to the original BMP (1.3 Mb) images. Both JPEG-2 and JPEG-3 images had significantly lower counted lesions than the BMP images. CONCLUSIONS: From our findings we can conclude that only some degree of image compression (compression ratios of 1 : 20 to 1 : 12) with file sizes of 66-107 kb is permissible using JPEG format, whereas the images obtained after higher compression ratios may not be suitable for diabetic retinopathy screening.

Surgically induced miosis during phacoemulsification in patients with diabetes mellitus.

PURPOSE: To assess the incidence of surgically induced miosis during phacoemulsification in diabetic patients. METHODS: A total of 76 patients with diabetes mellitus were compared to 76 age- and race-matched controls. A combination of cyclopentolate 1%, phenylephrine 2.5% and diclofenac sodium 0.1% was applied topically 60, 45 and 30 min before surgery. Adrenaline mixed with buffered saline solution was used for irrigation during surgery. The procedure included phacoemulsification and implantation into the bag of a foldable acrylic implant. Measurements of the horizontal pupillary diameter were taken at three stages: before corneal incision, after phacoemulsification, and at the end of surgery. The duration of phacoemulsification was also recorded. RESULTS: Surgically induced miosis or dilation of the pupil was defined as constriction or dilation noted at any interval during surgery. The pairs of diabetic-control were grouped into three groups: those in which constriction was noted, those in which dilation was noted, and those in which there was no change in pupil size during the procedure. Surgically induced miosis was noted more often in the diabetics (McNemar's test, chi(2), P=0.016). The mean pupil size at the beginning of surgery was 7.38 (+/-0.95) mm in the diabetics as compared to 7.65 (+/-0.89) mm in the control group. No statistically significant difference was noted between the two groups (paired t-test, P=0.07). The mean (+/-SD) duration of phacoemulsification in the diabetic group was 2.31 (+/-1) min as compared to 2.05 (+/-0.82) min in the control group. No statistically significant difference was found between the two groups (paired t-test, P=0.08). CONCLUSION: Surgically induced miosis occurred more often in the diabetics. Therefore, it is advisable that phacoemulsification in this group of patients is undertaken by an experienced surgeon.

Peripapillary choroidal neovascularisation in sarcoidosis.

PURPOSE: To describe a rare manifestation of sarcoidosis. METHODS: Case report of a patient with histologically proven sarcoidosis, who developed peripapillary choroidal neovascularisation in the absence of uveitis or optic nerve disease. RESULTS: Oral corticosteroids achieved reduction in the size of the peripapillary choroidal neovascularisation. Laser treatment was effective in treating the remaining peripapillary choroidal neovascularisation, resulting in improvement of visual acuity. CONCLUSIONS: Isolated peripapillary choroidal neovascularisation is a previously unreported complication of sarcoidosis. A combination of oral corticosteroids and laser can be successful in treating this type of lesion, thereby preventing permanent visual loss.

Pars plana vitrectomy in patients with intermediate uveitis.

OBJECTIVE: To describe the effect of pars plana vitrectomy in patients with intermediate uveitis. METHODS: Retrospective analysis of the clinical course and visual outcome following pars plana vitrectomy in patients with intermediate uveitis. RESULTS: Thirty-two patients (43 eyes) were included in the study. Pars plana vitrectomy was combined with cataract surgery in 22 of 43 eyes. The intermediate uveitis was associated with sarcoidosis in 16 eyes and multiple sclerosis in five eyes, and was idiopathic in 22 eyes. The mean (+/-SD) follow-up was 45.6 (+/-38) months (range: 6-146 months). In 19 of 43 eyes (44.1%), there was improvement in the course of uveitis, allowing the discontinuation of immunosuppressive treatment in seven patients. Cystoid macular edema resolved in 12 of 37 eyes (32.4%). Forty of 43 eyes achieved a better or retained their initial visual acuity. The remaining three eyes deteriorated by two or more lines in the Snellen chart due to the progression of cataract, chronic cystoid macular edema, and glaucomatous optic atrophy, respectively. CONCLUSIONS: The results of this study suggest that pars plana vitrectomy may have a beneficial effect on the course of uveitis and the associated complications of cystoid macular edema, thereby reducing the need for long-term immunosuppression. Pars plana vitrectomy combined with simultaneous cataract surgery can improve the visual outcome in these patients.

Gas-permeable scleral contact lens therapy in ocular surface disease.

PURPOSE: To describe the therapeutic benefits of nonfenestrated gas-permeable scleral contact lenses in the management of patients with ocular surface disease. METHODS: The charts of 49 consecutive patients (76 eyes) with ocular surface disease whose management included the use of gas-permeable scleral contact lenses were reviewed. We also developed a questionnaire to assess the impact of lens wear on subjective aspects of activities of daily living. RESULTS: The mean age of the 49 patients was 44.6 years (range, 3 to 87 years); 31 patients were female and 18 were male. The most common indication for fitting of the lenses was Stevens-Johnson syndrome (54 [71%] of the 76 eyes). Other indications included ocular cicatricial pemphigoid, exposure keratitis, toxic epidermal necrolysis, postherpetic keratitis, congenital deficiency of meibomian glands, superior limbal keratoconjunctivitis, Sjögren syndrome, and inflammatory corneal degeneration. The mean follow-up was 33.6 months (range, 2 to 144 months). Improvement in best-corrected visual acuity (defined as a gain of 2 or more Snellen lines) was observed in 40 (53%) of the eyes. In eight (53%) of the 15 eyes with active corneal epithelial defects at the time of lens fitting, the defects healed, whereas in the remaining seven eyes the corneal epithelial defects remained unchanged. Forty-five (92%) of the 49 patients reported improvement in their quality of life as a result of reduction of photophobia and discomfort. The mean wearing time of the gas-permeable scleral contact lenses was 13.7 hours per day (range, 4 to 18 hours). Many patients had preparatory surgical procedures before lens fitting (for example, punctal occlusion or mucous membrane grafting), and some had visual rehabilitation surgical procedures (for example, keratoplasty and/or cataract surgery) after lens fitting. CONCLUSIONS: Gas-permeable scleral contact lens wear provides an additional effective strategy in the surface management and visual rehabilitation of patients with severe ocular surface disease.

Immunomodulatory therapy for chronic tubulointerstitial nephritis-associated uveitis.

PURPOSE: To describe the clinical course and treatment with immunomodulatory agents in patients with tubulointerstitial nephritis and uveitis syndrome. METHODS: Retrospective analysis of the charts of six patients with tubulointerstitial nephritis and uveitis syndrome. RESULTS: The mean (+/-SD) age was 24.3 (+/-16.5) years, range 13 to 49 years. Four patients were children, and two were adults. Three were men, and three were women. Five of the six patients had anterior uveitis, and one had panuveitis. All patients had several relapses despite treatment with topical, regional, and oral steroids and methotrexate in one case. The introduction or modification of immunosuppressants (methotrexate, azathioprine, or cyclosporin A) achieved control of the uveitis and prevented relapses over a mean (+/-SD) follow-up period of 19.66 (+/-10.01) months, range 6 to 34 months. No treatment-related side effects were observed. CONCLUSIONS: Tubulointerstitial nephritis and uveitis syndrome is a distinct disease entity in which the nephritis typically resolves, but the uveitis often becomes chronic and is treatment resistant. Immunomodulatory agents can achieve control of the inflammation and prevent relapses.

Evaluation of foldable intraocular lenses in patients with uveitis.

OBJECTIVE: To evaluate various foldable posterior chamber intraocular lenses (IOLs) after phacoemulsification in patients with uveitis. DESIGN: A prospective, noncomparative, interventional case series. PARTICIPANTS: Forty-nine consecutive patients (60 eyes) with various types of uveitis (anterior, n = 20; posterior, n = 1; panuveitis, n = 37, intermediate, n = 2). INTERVENTION: All patients underwent phacoemulsification with foldable posterior chamber IOL implantation. All eyes were free of active inflammation at the time of surgery. A variety of IOL biomaterials were implanted: acrylic (n = 30), silicone (n = 17), and hydrogel (n = 13). MAIN OUTCOME MEASURES: Detailed examination was performed by one masked observer. Several parameters were compared for each implant biomaterial, including level of best corrected Snellen visual acuity at final follow-up, presence of posterior synechiae, anterior capsular phimosis, posterior capsule opacification, and the degree of cellular deposits on the IOL optic. RESULTS: There were 26 males and 23 females, aged 9 to 83 years (mean, 48 years). Follow-up ranged from 1 to 33 months (mean, 17.03 months). At final follow-up, 56 eyes (93.3%) had an improvement in visual acuity compared with preoperative levels as follows: 34 eyes (56.6%) achieved an improvement of four or more Snellen lines, and 44 eyes (73.3%) achieved 20/30 or better. Giant cells, observed on the IOL optic in 19 eyes (31.7%), were most often seen on the acrylic biomaterial at the 1-month follow-up, although this was not found to be statistically significant. Scratch marks produced by the lens-introducing forceps were seen in 24 eyes (40.0%), mainly on the acrylic and hydrogel optics. Posterior capsule opacification (PCO) occurred in 49 eyes (81.7%), with only 5 eyes requiring laser capsulotomy. There was no association between PCO and the various lens biomaterials. Other causes for reduced visual acuity included glaucomatous optic neuropathy (n = 5) and cystoid macular edema (n = 8). CONCLUSIONS: The use of foldable IOLs in eyes with uveitis is safe, but the optimal biomaterial has yet to be found.