Rhegmatogenous retinal detachment presentation and surgery in uveitic eyes.

BACKGROUND/AIMS: To explore the occurrence, uveitis activity, features, rate of proliferative vitreoretinopathy (PVR) and outcomes following rhegmatogenous retinal detachment (RRD) in a large tertiary referral uveitis service. METHODS: Retrospective analysis of subjects attending between 2008 and 2019. Multivariate analysis of risk factors for RRD was calculated. Nelson-Aalen plots were used to demonstrate cumulative risk of RRD. Outcomes of RRD surgery and prognostic indicators were analysed. RESULTS: Two thousand four hundred and forty-seven (2447) subjects (3516 eyes) with uveitis included. The mean follow-up was 5.7 years (19 767 eye-years); 56 eyes developed a RRD (1.6%). Thirty-two eyes had surgery in our unit. Risk factors for RRD were posterior uveitis or panuveitis (HR 3.386, p<0.001), male gender (HR 2.045, p=0.029) and infectious aetiology (HR 1.942, p=0.044). PVR was present in six (18.8%) eyes at presentation, and a further four (12.5%) developed it after the primary surgery. Final follow-up data showed 16 (50%) moderate or severe visual loss, although 29 (90.6%) had anatomical reattachment without oil in situ. CONCLUSIONS: There is a high rate of RRD in uveitis eyes. This is accompanied by high rates of PVR and redetachment. Anatomical success was high, but visual outcomes remain unpredictable.

Prevalence of refractive error, visual impairment and access to eyecare for the homeless in Wales, United Kingdom.

BACKGROUND/AIMS: To investigate visual impairment and disability, refractive error, and barriers to eye care in the homeless in Cardiff, United Kingdom. METHODS: Prospective cross-sectional study carried out on participants in homeless shelters in Cardiff. We collected participants socio-demographic profile, ocular history and access to eyecare services. Quantitative data included near and distance visual acuity and a non-cycloplegic refraction. RESULTS: A total of 100 participants were studied in this study. Prevalence of myopia was 19% and hyperopia 17%. Mean SE (Spherical Equivalent) for myopia -2.42D (95% CI: -1.65 to -3.19 D), for hyperopia this was +2.22D (95% CI: + 1.66 to +2.79). The prevalence of astigmatism was 36% (mean: 1.67 D, 95% CI: -0.88 to 0.94, n = 100). The number of participants with visual acuity (VA) worse than 6/12 was 11% in comparison to 0.89% and 1.1% in the general Cardiff and Welsh population respectively (p < 0.05). Additionally, 1% of the homeless subjects were registerable as blind (visual acuity worse than 3/60 in the better eye). Barriers to eyecare services were high, with 50% not seen by an optometrist within the last 5 years. CONCLUSIONS: These findings indicate a significant disparity in ocular health, visual acuity and refractive error amongst the homeless in comparison with the general population.

Can Applying a Risk Stratification System, Preoperatively, Reduce Intraoperative Complications during Phacoemulsification?

SIGNIFICANCE: Adopting a risk stratification system and appropriate listing of cases reduces the rates of intraoperative complications during phacoemulsification. Such listing would allow both safe surgery and enhance training, by ensuring an appropriately experienced surgeon is available to operate on a case or supervise and teach a junior surgeon. PURPOSE: To assess if the application of a simple, robust, validated preoperative scoring system can reduce the rates of intraoperative complications if patients are assigned to the appropriately experienced surgeon's list and surgical time is modified accordingly. METHODS: Prospective data collection. One thousand one hundred and thirty five (1135) consecutive patients undergoing phakoemulsification cataract surgery were assessed preoperatively according to weighted criteria. According to the points of risk they accumulated using this system, the patients were preoperatively allocated to one of the four risk groups. The total rate of intraoperative complications for each risk group as well as the rate of each reported complication for each risk group was calculated. RESULTS: The rate of intraoperative complications through the risk groups was 1 = 0.62%, 2 = 0.44%, 3 = 0.18%, and 4 = 0% (P = .005). Thirty-seven per cent 37% (n = 420) of all operations were performed on eyes of patients carrying at least one risk factor for intraoperative complications. The overall rate of any intraoperative complication was 1.2% (n = 14). There was a 0.4% (n = 5) rate of a posterior capsule tear with 2 of these cases with vitreous loss. CONCLUSIONS: Risk stratification, allowing adequate theatre time and appropriate surgical experience, can reduce the rates of intraoperative complications. The risk stratification system allows for better planning of surgical lists and could be used as a transition for those trainees deemed to have sufficient experience for the more 'challenging' cases under adequate supervision.

Is the severity of refractive error dependent on the quantity and extent of retinal laser ablation for retinopathy of prematurity?

BACKGROUND/AIM: To test the hypothesis severity of acquired refractive error in Retinopathy of Prematurity (ROP) is dependent on the quantity of laser treatment delivered. METHODS: Two groups (treated and untreated infants) were age and weight matched. Data on the number of laser burns and Retcam II retinal images were analysed using computer aided design software to determine the proportion of area treated. Data were collected until the age of 6 years. RESULTS: The study comprises 43 infants (86 eyes). Twenty-one infants (42 eyes) in the treated group, mean gestational age (GA) was 26.40 (±2.5) weeks versus 27.30 (±1.7) weeks in the matched untreated group (P = 0.650). Birth weight (BW) in the treated group was 812 g (±86) and 804 g (±135) (P = 0.185) in the untreated group. Mean refractive error at 72 months was -2.23 (±4.06) in the treated group and +2.04 (±0.90) in the untreated group (P < 0.005). At 72 months 50% of treated eyes were myopic versus 19% of controls (P = 0.013). Mean laser burns applied were 1855 (±659), mean proportion of retina treated 45% (±10). Myopic eyes had a mean treatment area of 49% (±13) versus 43% (±10) hypermetropia and 42% (±5) emmetropia (P = 0.030). A larger treatment area was associated with a higher degree of myopia and anisometropia at 72 months (P < 0.050). These associations were not found for hypermetropia. CONCLUSIONS: The extent of myopia after retinal laser ablation for ROP is higher if a greater number of laser burns or a larger proportion of the retina is treated.

Factors influencing pupil behaviour during femtosecond laser assisted cataract surgery.

AIM: Femtosecond laser assisted cataract surgery is associated with pupillary constriction. This study aims to look at patient and surgical factors predisposing to abnormal pupil behaviour during FLACS. METHODS: This prospective observational study included all patients undergoing FLACS in the Princess of Wales Hospital, Bridgend, UK between February and June 2017. Pupils were measured at three time points; immediately before and after laser pre-treatment, and at the start of surgery. Pupil behaviour during surgery was noted in descriptive terms, patient demographic, co-morbidities, eye measurements, suction on time, shifting time and laser energy levels were recorded. RESULTS: Seventy-three eyes were included. Average patient age was 74.84 ±â€¯9.1 years. Mean horizontal pupil sizes immediately before and after femto pre-treatment were 7.87 ±â€¯0.87 mm and 7.7 ±â€¯0.89 mm respectively (P < 0.0005). Mean horizontal pupil size at the start of surgery was 6.83 ±â€¯1.43 mm (P < 0.0005). Short capsulotomy-pupil distance (P = 0.01), shallower anterior chamber (P = 0.0012), smaller pre-operative pupil size (P = 0.045) and longer suction on time (P = 0.0019) were significantly associated with intra-operative miosis during FLACS. Sustained mydriasis was observed in eyes in whom topical diclofenac was used within 2 h of surgery. CONCLUSIONS: FLACS can result in significant pupil miosis. Eyes particularly at risk are ones with smaller pre-operative pupils and shallower anterior chambers and those subjected to longer suction on time. Well-timed NSAIDs application could be protective against this phenomenon.

Radiation retinopathy treated successfully with aflibercept.

Aflibercept (aflibercept) is a novel anti-vascular endothelial growth factor drug indicated for wet age-related macular degeneration and macular oedema secondary to retinal vein occlusion and diabetic macular oedema. While only newly introduced on the market, it is growing in popularity and over 5.5 million doses have been prescribed worldwide. Due to its versatile mechanism, it is indicated for numerous eye pathologies, and in particular, has been adapted to treat various types of retinopathy. To our knowledge, this is the first case report of solely using aflibercept to treat cystoid macular oedema in radiation retinopathy.

Demographics of older keratoconics in Wales and their mortality rates-Where are the older keratoconics?

AIM: The aim of this study was to identify keratoconics at least 40 years of age attending Welsh optometric hospital services, look at their demographics and mortality rates, and test the hypothesis that they die earlier than the general population. METHODS: Keratoconic patients born before 1972 were identified retrospectively through contact lens services across 5 hospitals in Wales, United Kingdom. Patients' notes were reviewed to confirm the diagnosis and collect demographic data. The Exeter patient registration system was used to trace if patients were deceased or alive. General population data was obtained from the Office for National Statistics. RESULTS: A total of 202 keratoconics at least 40years of age were identified. The mean age was 50.8years, 62% of patients were male and 97% Caucasian. Mean age at diagnosis was 28.7 years. Two patients were deceased, one died in 2012 and one in 2013. In 2012 mortality rates for studied patients and the general populations were 0.005 and 0.019, respectively (p 0.03). CONCLUSIONS: Mortality rates for the identified keratoconics were found to be significantly lower than the mortality rates for the general population in 2012. Collected data represents 52% of expected keratoconics over the age of 40, calculated based on disease prevalence, study inclusion criteria and population numbers within the regions included in the study. Thus suggesting the reason for lack of older keratoconics in the National Health Service optometric clinics could be non-attendance rather than higher mortality rates.

Forehead necrosis, one of the many facades of giant cell arteritis.

Giant cell arteritis (GCA) is known to be a potentially blinding condition. Swift diagnosis can aid in preventing permanent visual loss and, more importantly, protect the contralateral eye. Classical symptoms include jaw claudication, myalgia and new-onset headache. We present two cases of GCA with scalp necrosis, a rare feature associated with this condition. In the first case, forehead necrosis preceded the visual symptoms by 2 days. In the second case it was noted a few weeks after the patient presented with profound unilateral loss of vision. Scalp necrosis is an important sign that should prompt those approached by these patients to consider GCA.

A corneal dendritic lesion with a skin eruption: eczema herpeticum, an important differential diagnosis.

Eczema herpeticum is a rare and potentially life-threatening viral infection. We present the case of a 54-year-old man who presented to the emergency eye clinic with a dendritic ulcer and a facial rash. An initial diagnosis of herpes zoster ophthalmicus was suspected. On follow-up, the rash had begun to rapidly disseminate and was no longer respecting dermatome boundaries. A diagnosis of eczema herpeticum was made and appropriate treatment started. This case highlights the importance of a comprehensive history and close inspection of skin lesions in patients with herpetic eye disease.

'The nodule that disappeared' spontaneous regression of an eyelid noduloulcerative lesion mimicking the features of a basal cell carcinoma.

We describe a case of a clinically apparent basal cell carcinoma (BCC) with spontaneous regression. Histological confirmation of the diagnosis was not possible, and an immunological basis for regression is presumed. The understanding of such immunologically mediated regression of BCCs could provide future therapeutic targeting and research is ongoing.