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COVID-19's infection control policies have hindered the Deliberate Practice of clinical examinations. Guided Mental Rehearsal (GMR) may overcome this obstacle by facilitating independent, repetitive practice. Underpinned by the 'Motor Simulation Theory,' GMR reinforces similar neuro-circuit activations during physical practice and was proven effective in surgical training.This prospective, randomized controlled study evaluated the efficacy of GMR versus 'peer-learning' of Confrontational Visual Field Examination (CVFE). Third-year medical-students without clinical Ophthalmology experience were recruited. Controls (Both groups did not exhibit a significant difference in pre-test scores (8.550GMR improved psychomotor but not cognitive aspect of learning CVFE. This may be attributable to GMR's theoretical resemblance with physical practice, with additional expert guidance. By enabling independent learning, GMR may also reduce the demand for teaching manpower and thus education cost in the future.

To detect the leakage points of central serous chorioretinopathy (CSC) automatically from dynamic images of fundus fluorescein angiography (FFA) using a deep learning algorithm (DLA). The study included 2104 FFA images from 291 FFA sequences of 291 eyes (137 right eyes and 154 left eyes) from 262 patients. The leakage points were segmented with an attention gated network (AGN). The optic disk (OD) and macula region were segmented simultaneously using a U-net. To reduce the number of false positives based on time sequence, the leakage points were matched according to their positions in relation to the OD and macula. With the AGN alone, the number of cases whose detection results perfectly matched the ground truth was only 37 out of 61 cases (60.7%) in the test set. The dice on the lesion level were 0.811. Using an elimination procedure to remove false positives, the number of accurate detection cases increased to 57 (93.4%). The dice on the lesion level also improved to 0.949. Using DLA, the CSC leakage points in FFA can be identified reproducibly and accurately with a good match to the ground truth. This novel finding may pave the way for potential application of artificial intelligence to guide laser therapy.

A 23-year-old man with a 3-year history of essential hypertension presented to the emergency department with blurred vision in his right eye for 2 weeks. His visual acuity was 6/30 in his right eye, and 6/12 in his left eye. Dilated fundus examination showed bilateral malignant hypertensive

Aim We aim to examine the association of plasma leucine-rich-α-2-glycoprotein 1 (LRG1) with diabetic retinopathy (DR) in type 2 diabetes. Methods At baseline visit, plasma LRG1 levels were assessed using ELISA. Central arterial stiffness was estimated by carotid-femoral pulse wave velocity (PWV). At follow-up visit (median = 3.2 years), digital color fundus photographs were assessed for DR. DR severity was categorized into non-proliferative DR (NPDR) and proliferative DR (PDR). Results DR was diagnosed in 396 (32.8%) of 1206 patients. DR has higher LRG1 than non-DR (19.5 ± 11.3vs.16.9 ± 8.9 μg/ml, p ≪ 0.001). After adjustment, LRG1 was not associated with DR (OR = 1.2, [95% CI, 0.96–1.30], p = 0.16). LRG1 was higher in PDR (n = 107) than NPDR (n = 270) (23.2 ± 15.4vs.18.1 ± 8.9 μg/ml, n = 270, p ≪ 0.001). After adjustment, with 1-SD increase in LRG1, the relative risk of NPDR and PDR was 0.99 ([0.83–1.18], p = 0.91) and 1.42 ([95% CI, 1.14–1.76], p = 0.002) (p-trend = 0.01), respectively. We didn't observe significant improvement in AUC after adding LRG1 into the model. Baseline PWV mediated 12.0% of the association between LRG1 and PDR (p = 0.03). Conclusion Baseline plasma LRG1 is associated with PDR, suggesting it maybe a promising biomarker for prediction for advanced proliferative stages of DR. The mediation result indicates the potential benefit of ameliorating central arterial stiffness to prevent PDR.

Diabetic retinopathy (DR) is one of the most important microvascular complications of diabetes and remains the leading cause of blindness in the working-age individuals. The exact aetiopathogenesis of DR remains elusive despite major advances in basic science and clinical research. Oxidative damage as one of the underlying causes for DR is increasingly being recognised. In humans, three hydroxycarotenoids, lutein (L), zeaxanthin (Z) and meso-zeaxanthin (MZ), accumulate at the central retina (to the exclusion of all other dietary carotenoids), where they are collectively known as macular pigment. These hydroxycarotenoids by nature of their biochemical structure and function help neutralise reactive oxygen species, and thereby, prevent oxidative damage to the retina (biological antioxidants). Apart from their key antioxidant function, evidence is emerging that these carotenoids may also exhibit neuroprotective and anti-inflammatory function in the retina. Since the preliminary identification of hydroxycarotenoid in the human macula by Wald in the 1940s, there has been astounding progress in our knowledge of the role of these carotenoids in promoting ocular health. While the Age-Related Eye Disease Study 2 has established a clinical benefit for L and Z supplements in patients with age-related macular degeneration, the role of these carotenoids in other retinal diseases potentially linked to oxidative damage remains unclear. In this article, we comprehensively review the literature germane to the putative protective role of two hydroxycarotenoids, L and Z, in the pathogenesis of DR.

To quantify the fundus color on digital color fundus photographs as a surrogate of myopic chorioretinal degeneration in myopic subjects using a novel computer software program. In this cross-sectional study, the following details were recorded in 152 eyes of 78 myopic subjects: Snellen visual acuity, refractive status, ocular biometric parameters, intraocular pressure, color fundus photography, and myopic chorioretinal degeneration index (MCDI) using an automated computer program. The mean age of the subjects was 32.58 ± 11.12 years (range, 21-62 years). Subjects with aged ≥40 years had a significantly higher MCDI when compared with subjects with aged

We describe two cases of orbital trapdoor fractures with medial rectus muscle incarceration.Small interventional case series.This is a retrospective university based report of two healthy males (11 and 14 years old) who developed diplopia following blunt orbital trauma. Both patients had decreased horizontal ocular motility of the involved eye with minimal additional evidence of trauma. Computed tomography (CT) demonstrated no significant bony displacement; however, the left medial rectus muscle was located within the ethmoid sinus in the first and had an abnormal size and shape in the second case. In both cases, during urgent surgical repair, the incarcerated medial rectus muscle was gently released from linear non-displaced medial wall fractures and ocular motility normalized postoperatively.In pediatric patients sustaining blunt orbital trauma, medial rectus incarceration should be considered and managed accordingly.

Background: Autonomic dysfunction is thought to be a contributory factor in primary angle-closure glaucoma (PACG) by precipitating pupil block in anatomically predisposed eyes. This study aimed to compare systemic autonomic function between subjects who had suffered a previous episode of acute angle closure (symptomatic PACG), those who had asymptomatic PACG, and age and sex-matched controls. Methods: Tests for systemic parasympathetic function included the heart-rate response to standing (30:15 ratio), heart-rate variation during deep breathing, and the ratio of the heart rate at phases IV and II of the Valsalva manoeuvre (Valsalva ratio). For assessment of the sympathetic nervous system, blood pressure was recorded supine and then after 2 and 5 min of standing. A modified sweat test, the sympathetic skin response, was recorded on the palm and sole. Results: A total of 30 subjects were examined: eight previous symptomatic PACG, eight asymptomatic PACG and 14 control subjects. The mean ages were similar, and all except one subject were Chinese. None of the subjects had evidence of systemic dysautonomia. There was no significant difference found between the groups for the 30:15 ratio, heart-rate variation during deep respiration and the Valsalva ratio. No significant orthostatic hypotension was detected in subjects with PACG. Abnormal sympathetic skin response was not more common in PACG subjects compared to control subjects. Conclusions: This study identified no systemic autonomic dysfunction in people with PACG.

Orbital fractures that require surgical intervention pose challenging problems to the trauma surgeon. Many options have been described to gain access to the subperiosteal plane orbit of the orbit. The approach to be adopted should be tailored to the site and extent of the fractures, and the experience of the surgeon. We prefer approaches that utilize hidden incisions as they provide safe surgical access but heal without visible scarring and are esthetically more acceptable to patients. We describe approaches to repair orbital fractures via hidden incisions in the caruncle, and the inferior conjunctival fornix.

Diabetic retinopathy (DR) is a leading cause of vision-loss globally among type 2 diabetes (T2DM) patients. Information on the economic burden of DR in Singapore is limited. We aim to identify the total annual direct medical costs of DR at different stages, and to examine factors influencing the costs. Four hundreds and seventy T2DM patients who attended the Diabetes Centre in a secondary hospital in Singapore in 2011–2014 were included. Digital color fundus photographs were assessed for DR in a masked fashion. Retinopathy severity was further categorized into non-proliferative DR (NPDR), including mild, moderate and severe NPDR, and proliferative DR (PDR). Medical costs were assessed using hospital administrative data. DR was diagnosed in 172 (39.5%) patients, including 51 mild, 62 moderate and 18 severe NPDR, and 41 PDR. The median cost in DR [2012.0 (1111.2–4192.3)] was significantly higher than that in non-DR patients [1158.1 (724.1–1838.9)] (p

PURPOSE To examine the spatial profile of macular pigment (MP) and its relationship with serum concentrations of lutein (L) and zeaxanthin (Z) in subjects from a Singapore Chinese population. METHODS In this cross-sectional study, the following details were recorded in 95 healthy subjects: sociodemographic, lifestyle information, body mass index (BMI), visual acuity, MP spatial profile using a macular densitometer, and serum L and Z. RESULTS The mean (SD) age of the population was 42.40 (± 13) years, ranging from 21 to 68 years. Females demonstrated significantly lower MP optical density (MPOD) than males (MPOD: females = 0.52 ± 0.17; males = 0.61 ± 0.21, P = 0.03). MP spatial profile was typical and atypical with central dip in 68 (85%) and 12 (15%) subjects, respectively. Age and BMI were found to be significant predictors for atypical MP spatial profile (age: odds ratio, OR = 1.06, 95% confidence interval, CI = 1.01-1.13, P = 0.04; BMI: OR = 1.17, 95% CI = 1.01-1.34, P = 0.03). A positive relationship was observed between MPOD and serum concentrations of L and Z, but only the latter relationship reached statistical significance (serum L: r = 0.12, P = 0.30; serum Z: r = 0.26, P = 0.02). CONCLUSIONS A central dip in MP spatial profile was observed with older age and higher BMI, the two known risk factors for AMD, suggesting that atypical MP spatial profile may be associated with an increased risk of AMD. Further studies with larger sample sizes are required to confirm these observations.

PURPOSE: To compare the intraocular pressure)–lowering effect and side effects of latanoprost 0.005% once daily with unoprostone 0.12% twice daily. METHODS: Sixty patients with primary open-angle glaucoma or ocular hypertension were randomized to receive either latanoprost once daily in the evening and placebo once daily in the morning, or unoprostone twice daily in the morning and evening. The study was double masked and followed a crossover design with two treatment periods of 1 month separated by a 3-week washout period. The intraocular pressure was measured at 9 am and 5 pm on the baseline and day 28 visits, and at 9 am on day 2 and day 14 visits of each treatment period. The 9 am measurement was taken 2 hours and 13 hours after the last drop of unoprostone and latanoprost, and the 5 pm measurement was at 10 and 21 hours, respectively. The mean of the measurements was calculated. Safety parameters were also recorded. RESULTS: Fifty-six patients completed both treatment periods and had intraocular pressure data available for evaluation. After 1 month of treatment, latanoprost significantly reduced intraocular pressure (mean ± SEM) by 6.1 ± 0.5 mm Hg (P < .001) and unoprostone by 4.2 ± 0.4 mm Hg (P < .001) adjusted from an overall baseline of 22.3 ± 0.5 mm Hg and 23.2 ± 0.4 mm Hg, respectively. The difference of 1.9 mm Hg between treatments was statistically significant in favor of latanoprost [P = .003, analysis of covariance (ANCOVA)]. Unadjusted analysis of responders using the percentage decrease in intraocular pressure showed that the proportion of responders in the latanoprost-treated group was greater than in the unoprostone-treated group. Adverse ocular symptoms and findings were mild in both treatment groups. Eye redness and ocular irritation were the most frequently reported events. CONCLUSIONS: Latanoprost once daily was significantly more effective in reducing intraocular pressure compared with unoprostone twice daily after 1 month of treatment in patients with primary open-angle glaucoma and ocular hypertension. Both drugs were well tolerated with few ocular adverse events.

High-pressure injection injury to the orbit and adnexa is a rare but potentially blinding type of trauma. Few cases of such injury have been reported in the literature. A 27-year-old Indian man accidentally injected paint material from a high-pressure nozzle gun into his left eye. Radiological investigation revealed the presence of paint material in the orbital tissues and the ethmoidal sinuses. The patient underwent two orbital surgeries to remove the paint material. He later developed signs suggestive of limbal stem cell failure and was treated with limbal stem cell autografting. He also has ophthalmoplegia with a compensatory anomalous head posture that was managed conservatively. We report the clinical course and outcome of this unfortunate patient to highlight the complexity of such an injury and the need for a multidisciplinary approach in its management.

Objective: To evaluate the outcome of late probing in a mixed Asian children population with congenital nasolacrimal duct obstruction (CNLDO) and whether probing was associated with an increased risk of infection. Method: A retrospective clinical study was conducted. A clinical diagnosis of CNLDO was defined in an infant who presented with a history of tearing and/or eye discharge up to 1 year of age with no other accompanying ocular pathology. All patients with a presumed diagnosis of CNLDO who had probing after 12 months of age were included in our study. Prior to probing, most patients had a trial of conservative treatment with massage and/or topical antibiotics. Intra-operative patency of probing was determined when metal to metal contact of the probe and forceps was achieved and/or when fluorescein dye was recovered from the nose after syringing. Successful probing was defined as a resolution of symptoms within 1 month after probing. Results: Seventeen patients involving 19eyes fulfilled our inclusion criteria for this study. Fourteen (82%) infants were Chinese, two Malays (12%) and the remaining one Indian (6%). There were 10 males(59%) and 7 females(41%) and the mean age at probing was 2.2 years(range, 14 months to 5years 6 months). The subjects were followed-up post-operatively for a mean duration of 21.2 months (range, 2 months to 8years). Successful probing in our series was 89.5% (17/19 eyes). Of the two eyes with persistent tearing, one resolved with massage about 9 months after the unsuccessful probing; the other was referred to the oculoplastic service for further management. Conclusion: Late probing after 13 months old appears to be an effective approach in the management of CNLDO in Asian infants.

To describe a case of orbital metastasis from an undifferentiated pelvic tumor with probable cervical origination.Case report. Detailed ophthalmologic examination, orbital CT and MRI, and orbital biopsy with histologic and immunohistochemical analysis.A 29-year-old woman with a history of untreated cervical dysplasia was hospitalized with flank pain, hematuria, and abnormal vaginal bleeding. Biopsy of a large mass, protruding from the cervix as a grape-like cluster, had cellular morphology and immunohistochemical staining patterns consistent with cervical cancer. Diplopia in downgaze developed shortly after hospitalization. Ophthalmic examination was notable for mild right lower eyelid fullness, 1.5 mm right relative proptosis, and a deficit in supraduction and infraduction of the right eye. Orbital MRI and CT revealed a 1.2 x 1.6-cm mass immediately inferior and posterior to the right globe without bone involvement. On biopsy, the mass had histology similar to that of the pelvic tumor. On metastatic workup, lesions were found involving the left femoral head, liver, and spinal column, with adjacent lymphadenopathy. Despite treatment with radiation and chemotherapy, the patient died several months later of causes related to the systemic disease.Orbital metastasis of cancer originating in the cervix, despite its rarity, should be considered when an orbital mass of unknown cause is present.

To report three patients who developed unilateral choroidal neovascularization (CNV) following laser in situ keratomileusis (LASIK) for high myopia. Retrospective chart reviews of three highly myopic patients who developed CNV following LASIK and who attended a tertiary care private practice were conducted. The clinical presentation of the patients was analyzed. All patients were treated with a combination of intravitreal ranibizumab and photodynamic therapy with verteporfin. Main outcome measures were clinical fundus appearance and best-corrected visual acuity (BCVA) after treatment. Two females and one male with a mean age of 34 ± 2.8 years underwent LASIK for high myopia in both eyes. The mean spherical equivalent was -11.42 diopters (D) (range -6.75 to -20.00). The mean time interval between LASIK and the appearance of symptoms was 9.3 ± 8.5 weeks. One patient developed an extrafoveal CNV at the edge of a laser photocoagulation scar, one developed a subfoveal CNV and the third patient developed a juxtafoveal CNV. The mean BCVA at the time of CNV presentation was 0.44 logMAR (range 0.10-0.70 logMAR). Following treatment, the mean BCVA improved to 0.17 logMAR with complete resolution of CNV in two patients. CNV is a rare but potentially blinding complication following LASIK. Short-term good visual outcome can be achieved with timely intervention with current treatment modalities.

Metastasis to the orbital soft tissues is relatively uncommon. We report a rare case of renal cell carcinoma with orbital metastasis as the first clinical manifestation. A 48-year-old-man presented with left proptosis and complete ptosis of three weeks duration. Radiological examination revealed a left intraconal heterogeneous cyst-like lesion with rim enhancement immediately deep to the left superior rectus muscle. Diagnosed as having orbital cysticercosis, he was prescribed oral albendazole and prednisolone. But there was no clinical improvement. An incisional biopsy performed showed metastatic poorly differentiated carcinoma. The patient complained of backache and weight loss in the interim. Magnetic resonance imaging (MRI) of the spine showed extensive vertebral metastasis to the thoracic and lumbosacral spine and the iliac bone, with an incidental detection of a large mass from the right kidney. Further MRI of abdomen and chest showed a large right renal mass presumed to be a renal cell carcinoma with extension into the right renal vein, intra-abdominal lymph nodes, and peritoneum. There were small nodules in the lung suggesting the possibility of pulmonary metastatic deposits. Renal cell carcinoma does not respond to chemotherapy, immunotherapy, or radiation; because of the disease's advanced stage, the patient received palliative treatment. There have been only two other reports in the literature of metastatic renal cell carcinoma in the orbit where the proptosis was the initial presenting feature similar to our case.

Vertical diplopia after blow out fracture repair is not uncommon; we report an unusual case of inferior rectus muscle (IR) transection presenting as a persistent infra-duction deficit after uncomplicated blow out fracture repair.We used multi-positional MRI to diagnose a transected IR with a contracted and posteriorly displaced muscle belly.Infra-duction improved after surgical repair of the transected IR.Multipositional MRI is a novel technology that can be used to assist in the decisive management of persistent post-operative infra-duction deficits and avoid prolonged periods of observation.

Although Stevens-Johnson syndrome has been reported to result in canalicular and nasolacrimal duct obstruction, reports of dacryocystocele formation are lacking. We describe the occurrence and management of bilateral dacryocystoceles related to Stevens-Johnson syndrome. A 45-year-old man, recovered from Stevens-Johnson syndrome, presented with bilateral medial canthal masses and intermittent overlying facial cellulitis. Examination revealed severe keratitis sicca with extensive corneal scarring, cicatricial occlusion of all puncta, and palpable medial canthal masses bilaterally. Computed tomography demonstrated bilateral cystic masses consistent with dacryocystoceles. Bilateral lacrimal sac/cyst excision was attempted, but the left cyst recurred within 6 months after surgery. A dacryocystorhinostomy was then performed, effectively marsupializing the cyst. The puncta were not canalized and stents were not placed. The masses have not recurred with 2 years of follow-up. Dacryocystoceles may arise in the setting of Stevens-Johnson syndrome. Successful management may be achieved with marsupialization to the nasal cavity (dacryocystorhinostomy).

Purpose This study evaluates the effect of unilateral blepharoptosis repair on contralateral eyelid position and assesses the relation between preoperative eyelid height interdependence, consistent with Hering law, and surgical outcome. Methods The medical records of 54 patients (21 men, 33 women; mean age, 65 years) who underwent external levator advancement for unilateral aponeurotic blepharoptosis were reviewed for preoperative and postoperative margin reflex distance (MRD) of the nonoperated eye. To assess the relation between preoperative Hering dependence (mechanical elevation of the ptotic eyelid causing a decrease in contralateral eyelid height) and postoperative eyelid position, the change in MRD of the nonoperated eye was compared between subjects who on preoperative evaluation did (n=18) and did not (n=36) demonstrate eyelid height interdependence, using the 2-sample t test. Results After unilateral blepharoptosis repair, the mean (+/- SD) change in contralateral MRD was -0.2 +/- 0.8 mm. There was no significant difference in contralateral MRD change in subjects with and without preoperative Hering dependence (-0.3 +/- 0.8 mm versus -0.2 +/- 0.9 mm, respectively, p=0.78). Seventeen percent (9 of 54) of patients had a contralateral MRD decrease of more than 1 mm. Three patients (5.6%) required contralateral blepharoptosis repair within 1 year of initial surgery. Conclusions After levator advancement for unilateral blepharoptosis, roughly 17% of patients will have a decrease in contralateral eyelid height of more than 1 mm, with 5% of patients requiring surgical repair during the first postoperative year. The degree of change in contralateral eyelid height cannot be reliably predicted by preoperative assessment of Hering dependence.

Purpose We describe the occurrence of maxillary and orbital osteogenic sarcoma in a child after treatment of contralateral orbital rhabdomyosarcoma with external beam radiation and chemotherapy. Design Interventional case report. Intervention Treatment of a maxillary and orbital rhabdomyosarcoma with surgical resection, systemic chemotherapy, and local radiation. Main outcome measures Occurrence and histology of secondary malignancy after orbital radiation. Results An eleven year-old male presented for evaluation of left facial swelling, occurring ten years after successful treatment of a right orbital embryonal rhabdomyosarcoma with chemotherapy and 5040 cGY of external beam radiation. Computerized tomography demonstrated a mass involving the left maxillary sinus and orbital floor. Biopsy demonstrated osteogenic sarcoma. Despite attempted total excision with radical maxillectomy, resection margins were found to have microscopic extension of the tumor. Postoperatively he was treated with systemic chemotherapy and local radiation. Eight months postoperatively he remains alive despite local progression. Conclusions Osteogenic sarcoma can occur as a secondary malignancy years after the successful treatment of orbital rhabdomyosarcoma with external beam radiation and chemotherapy. After orbital radiation, subjects should undergo routine lifelong examinations.

To describe the clinical features of two cases of intraoperative capsular block syndrome (CBS) mimicking expulsive hemorrhage.The Eye Institute at Tan Tock Seng Hospital, National Healthcare Group, Singapore.Two case reports.Two patients underwent phacoemulsification under retrobulbar anesthesia and developed severe globe hardening, shallow anterior chamber (AC) and uveal prolapse intraoperatively after hydrodissection. The AC spontaneously deepened in one patient and the operation was converted to extracapsular cataract surgery on suspicion of CBS with posterior capsule rupture, which was confirmed after nucleus expression; anterior vitrectomy was done and an anterior chamber lens implanted. At the eight post-operative month, his best-corrected visual acuity was 6/24 secondary to an epiretinal membrane in the macula. CBS, however, was not recognized in the other patient and caused posterior lens dislocation during attempted phacoemulsification. This patient underwent vitrectomy, removal of the lens nucleus and insertion of a posterior chamber intraocular lens in the sulcus the next day. His best-corrected visual acuity was 6/9 at the tenth postoperative month.Intraoperative CBS may mimic expulsive hemorrhage. Early diagnosis of this condition and proper management optimizes the visual outcome.

Purpose To compare the efficacy of low-dose intravenous methylprednisolone or conservative treatment in the management of traumatic optic neuropathy. Methods A non-randomized retrospective study of 21 patients (21 eyes) with traumatic optic neuropathy treated between October 95 and November 97 in a tertiary ophthalmology unit. Traumatic optic neuropathy was defined as traumatic visual loss with afferent pupillary defect in the absence of direct injury to the globe or optic nerve. The median follow-up period was one year. Nine patients were treated with 125-250 mg methylprednisolone 6-hourly intravenously for a mean of 3.3 days (range 2-5 days) and 12 patients were treated conservatively. Visual acuity (VA) was measured with a Snellen chart before and after treatment at each follow-up visit. Visual recovery was defined as an improvement of 2 or more Snellen lines one week post-injury or later. Results The patients' mean age was 37.1 years (range 12-65 years). There were more males (90.5%) than females (9.5%). Traumatic optic neuropathy was in 12 right eyes and 9 left eyes. The cause of injury included traffic accidents (52.4%), falls (28.6%), assault (14.2%) and others (4.8%). The mean interval between the injury and steroid therapy was 3.6 days (range 1-11 days). Visual recovery was observed in 44.4% of eyes treated with methylprednisolone and in 33.3% treated conservatively (p = 0.673, Fisher's exact test). Conclusions Intravenous methylprednisolone at the dosage and duration used in this retrospective study did not significantly improve the visual recovery of eyes with traumatic optic neuropathy compared to conservative treatment. However, this small sample may not be sensitive enough to detect a small difference in visual recovery rates, and further studies with larger samples may be warranted.

Purpose To determine the clinical characteristics and outcomes of patients with leukemic or lymphomatous involvement of the lacrimal drainage system (LDS). Methods A computerized retrieval system was used to identify patients with histologically proven leukemic or lymphomatous involvement of the LDS. Medical records were reviewed. Results Biopsies of the lacrimal sac or nasolacrimal duct obtained during dacryocystorhinostomies (DCR) performed at the Mayo Clinic (Rochester, Minnesota) between January 19, 1989, and August 26, 1997, were positive for leukemia or lymphoma in 11 patients (15 LDS). Ten patients had previously diagnosed leukemia or lymphoma; the interval between the diagnosis of systemic disease and DCR averaged 5.8 years (range, 7 months to 13 years; median, 5 years). The median age at the time of LDS involvement was 72 years (range, 49 to 85 years). Seven patients (64%) were women, and all were white. The median postoperative follow-up after DCR was 38 months (range, 10 to 65 months). Eight patients had leukemic infiltration of the LDS, 2 patients had B-cell lymphoma, and 1 patient had cutaneous T-cell lymphoma. Four patients had bilateral LDS involvement, and the remainder had unilateral disease (right eye, 1 patient; left eye, 6 patients). The most common initial presentation, in 9 patients (82%), was epiphora. Lacrimal irrigation of 2 LDS was deferred because of acute dacryocystitis. Of the remaining 13 systems, 8 were completely obstructed. The blockage was low (in the lower sac or in the nasolacrimal duct) in 6 systems and high (in the upper sac or common internal punctum) in 2 systems. Four LDS were anatomically patent to irrigation but were functionally obstructed. Chemotherapy was the primary treatment in 7 patients, whereas 4 patients underwent radiation therapy. Nine patients responded well to treatment, with alleviation of signs and symptoms, and none of these patients had local recurrence during the follow-up interval. Conclusions Leukemic or lymphomatous involvement of the LDS is an unusual cause of tearing in elderly patients, but it should be suspected in patients with known systemic disease. Treatment comprising multiple interventions improves the signs and symptoms of this complication of lymphoproliferative disorders in most patients.

Purpose: To describe the unusual clinical course of a patient with Rosai-Dorfman disease (RDD) affecting the eyelid and orbital tissues and involving the spinal cord. Methods: Case report. Results: A 68-year-old Indian man first presented in 1994 with a right lower eyelid lump for 1 year. An en bloc excisional biopsy was reported to show "reactive lymphoid hyperplasia with sclerosis." The patient subsequently defaulted follow-up and presented again in 1999 with bilateral lower eyelid masses and proptosis. Computerized tomography showed bilateral orbital, ethmoidal sinus, and frontal sinus soft tissue masses. Bilateral excisional biopsies of the orbital and eyelid masses showed histologic features of RDD. The patient had a history of paraplegia with decompression laminectomy and excision of an epidural mass in 1994. In addition, he underwent excision of soft tissue masses from the abdominal wall in 1993. Retrospective review of the histologic specimens from these two areas showed a histologic picture similar to that of eyelid specimens (in 1994 and 1999). Conclusions: It is important to consider RDD in addition to lymphoproliferative disorders in a patient with orbital and ocular adnexal masses. The initial histologic presentation may not be pathognomonic.

Purpose: To compare the complications and subjective experience of patients having argon laser suturelysis (LS) with those of patients having needle suturelysis (NS) for corneal astigmatism after extracapsular cataract extraction (ECCE). Setting: Department of Ophthalmology, Tan Tock Seng Hospital, Singapore. Methods: This prospective study comprised 30 patients (30 eyes) with more than 3.00 diopters of with-the-rule astigmatism after ECCE. A minimum of 5 weeks after surgery, 2 sutures along the steepest meridian were lysed by the same surgeon, 1 by a needle and the other by laser using a Hoskins lens. Patients were randomized to receive NS first followed by LS or LS followed by NS. The complications were recorded. The patients subjectively graded their fear and discomfort/pain during suturelysis using a scale from 0 to 10. Patient preference for either procedure was also recorded. Results: The complications of NS were conjunctival epithelial defect (17/30), subconjunctival hemorrhage (13/30), and corneal abrasion (4/30) and of LS, minor conjunctival burn (1/30) and conjunctival epithelial defect (1/30). The mean subjective fear and discomfort/pain scores in the NS group were significantly higher than in the LS group ( P = .0010 and P = .0014, respectively). Nineteen patients preferred LS, 3 preferred NS, and 8 had no preference for either procedure. Conclusion: Argon laser suturelysis was associated with fewer complications than NS and was preferred by patients.

The appearance of a hypopyon is an extremely uncommon finding in acute angle-closure glaucoma and only a few cases have been previously reported in the literature. We report a fifty-year-old female who, following a recent bereavement, presented with classical features of acute angle-closure glaucoma and a hypopyon. The eye developed a glaukomflecken and the patient underwent trabeculectomy, extracapsular cataract extraction and intraocular lens implantation with good post-operative results. Because hypopyon in acute angle-closure glaucoma is rare and may cause diagnostic confusion and hence therapeutic difficulties, this case is described to highlight this unusual clinical sign.

A patient presented with acute primary angle closure glaucoma with markedly elevated intraocular pressure. Two weeks after laser peripheral iridotomy and resolution of the acute attack, the patient was noted to have developed scattered retinal haemorrhages. The haemorrhages resolved over time with no visual sequelae. This is the first reported case of ocular decompression retinopathy after resolution of acute primary angle closure glaucoma.

We describe proptosis due to a subperiosteal orbital hematoma that originated from a subgaleal bleed caused by hair pulling. A 13-year-old boy presented with a one-week history of progressive proptosis after his older sister pulled his hair during an argument. Computerized tomography showed a subgaleal hematoma and a right superior subperiosteal orbital hematoma. Progressive proptosis and compressive optic neuropathy developed, necessitating surgical evacuation with a favorable outcome.Hair pulling can result in a subgaleal bleed with extension to the orbital subperiosteal space. When managing patients with a subgaleal hematoma, this vision-threatening complication should be considered and treated accordingly.

PURPOSE: To describe eyelid trauma as a cause of isolated neurogenic blepharoptosis. DESIGN: Observational case series. METHODS: Three previously healthy patients (two male and one female; aged 29 to 39 years) were evaluated for unilateral blepharoptosis following forceful anterior displacement of the upper eyelid. Two injuries occurred during domestic altercations and one while the patient was playing basketball RESULTS: All three patients had complete unilateral upper eyelid ptosis with no levator palpebrae superioris function, consistent with loss of innervation. Additional findings included minimal eyelid ecchymosis, eyelid edema, and subconjunctival hemorrhage in two cases. The remainder of the examinations was unremarkable with full ocular motility and no anisocoria. Without treatment, within 2 weeks, all three patients recovered completely with normal symmetric lid height and levator function. CONCLUSIONS: Isolated neurogenic blepharoptosis may result from traumatic anterior upper eyelid displacement. Resolution is likely within 2 weeks.

The authors describe a novel approach for the fixation of enucleated eyes during microsurgical procedures using common household plumbing accessories. The device consists of a ring adaptor with 4 roundended screws placed horizontally at its sides and a plastic hose connector. The enucleated globe is secured in the center of the ring adaptor by gently tightening the screws. The hose connector supports the posterior pole of the globe and is secured onto a styrofoam board that provides a platform for resting the surgeons hands. The device proved very satisfactory to residents during the teaching of cataract surgery and trabeculectomy on porcine eyes. Our globe fixation device is simple, inexpensive, effective, and readily available. It may be especially useful in developing countries. [Ophthalmic Surg Lasers 2001;32:166-167]