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Importance: Using an ophthalmic viscoelastic device to manage early postoperative hypotony after Baerveldt glaucoma implant (BGI)., Background: To determine the outcome of intracameral sodium hyaluronate injection for early postoperative hypotony treatment after BGI., Design: A retrospective study., Participants: One-hundred-and-thirty-eight patients (176 eyes) had BGI from January 2012 to November 2015. Those who had hypotony within 3 months postoperatively were studied., Methods: Hypotonous eyes were injected with 0.1 mL sodium hyaluronate 1.4% intracameral on the slit-lamp. The patients were followed up weekly and the injection repeated up to 3 times if hypotony persisted. The tube was tied surgically as a last resort., Main Outcome Measures: The intraocular pressure and best-corrected visual acuity at week 1, 2, 3, 4, 6 and month 4 were assessed., Results: Thirty (17.0%) out of 176 eyes developed early postoperative hypotony. The median intraocular pressure and median best-corrected visual acuity when hypotony first presented were 3 mmHg and 0.8 logMAR. Two eyes were excluded as they had more than 0.1 mL injection. Eight (29%) of the 28 hypotonous eyes resolved after one injection, seven (25%) required two and 10 (36%) needed three injections. Three (11%) eyes had surgical tube tie. The median intraocular pressures were 5, 7, 8, 10, 11 and 13 mmHg at week 1, 2, 3, 4, 6 and month 4 post-injection. The median best-corrected visual acuity were 0.60, 0.50, 0.50, 0.45, 0.40 and 0.40 logMAR for the same period., Conclusions and Relevance: Standardised intracameral 0.1 mL sodium hyaluronate 1.4% is an effective and safe way to manage early postoperative hypotony after BGI., (© 2018 Royal Australian and New Zealand College of Ophthalmologists.)

Purpose: To investigate the outcome of transscleral cyclophotocoagulation (TCP) in the treatment of acute angle closure (AAC) refractory to medical treatment., Methods: This is a retrospective interventional case series. The inclusion criteria include patients diagnosed with AAC who had TCP. Pre-TCP and post-TCP intraocular pressure (IOP), visual acuity, and AAC treatment were analyzed. The complications and the results of subsequent treatments including lens extraction if performed were also assessed., Results: Thirteen eyes (13 patients) met the study criteria. The median time to TCP from presentation was 5 days (range 3-30 days). The mean presenting IOP was 56 ± 6 mm Hg (range 48-70 mm Hg) and the medically treated mean IOP before TCP was 40 ± 5 mm Hg (range 34-52 mm Hg). All patients (100%) responded to TCP. The mean post-TCP IOP at day 1 and months 1, 3, 6, 12, and 24 were 19, 23, 19, 19, 18, and 17 mm Hg. There was 1 case of hyphema post-TCP. Lens extraction ± goniosynechialysis was performed in 10 patients (77%) from 1 month post-TCP onwards. The mean IOP prior to lens extraction was 26 mm Hg (range 19-32 mm Hg). The mean IOP 3 months after lens extraction was 15 mm Hg (range 8-19 mm Hg). The mean number of topical IOP-lowering medications 12 months post-TCP was 1.1., Conclusions: Transscleral cyclophotocoagulation is effective and safe in reducing IOP in patients with AAC refractory to medical and laser peripheral iridotomy treatments. We advocate that TCP should be considered early in the management of AAC refractory to medical treatment to avoid irreversible optic neuropathy.

Purpose: The purpose was to investigate the survival of Descemet stripping automated endothelial keratoplasty (DSAEK) in eyes with an Ahmed glaucoma valve (AGV)., Methods: The study had a retrospective case-series of patients with an AGV in the anterior chamber undergoing a DSAEK. Included in the analysis were graft size, number of previous operations, post-operative glaucoma medications, post-operative intraocular pressure (IOP) control, graft size and donor factors (age, endothelial cell density, and post-mortem time). A generalised linear model with binary logistic regression was used to test for an effect on graft survival at 1 year and 1.5 years., Results: Fourteen eyes from 13 patients were included. The survival rate of the first DSAEK at 6, 12, 18, 24 and 30-months was 85%, 71%, 50%, 36% and 30%, respectively. The mean duration to graft failure was 12.9 ± 6.2 months. Five of the seven failed first grafts went on to have a repeat DSAEK. The mean follow-up in this subgroup was 30.7 ± 18.4 months. The survival rate of second DSAEK at 6, 12, 18 and 24 months was 100% (5/5), 100% (5/5), 75% (3/4) and 67% (2/3). Only one second DSAEK failed in the duration of the study and went on to receive a third DSAEK which failed at 18-months. The mean IOP within the first year was significantly lower for grafts that survived at 1 and 1.5 years (17.4 mmHg, 16.9 mmHg) than for grafts that failed (19.4 mmHg, 19.4 mmHg) (p = 0.04, p = 0.009)., Conclusion: DSAEK is a viable alternative to PK to restore visual function in eyes with an AGV sited in the anterior chamber. IOP is an important risk factor for graft failure.

Aim: To evaluate the refractive outcome of Toric Lentis Mplus intraocular lens (IOL) implant., Methods: This is a retrospective case series. Consecutive patients with corneal astigmatism of at least 1.5 D had Toric Lentis Mplus IOL implant during cataract surgery. The exclusion criteria included irregular astigmatism on corneal topography, large scotopic pupil diameter (>6 mm), poor visual potential and significant ocular comorbidity. Postoperative manifest refraction, uncorrected distance visual acuity (UDVA), best-corrected distance visual acuity (BCVA), uncorrected intermediate visual acuity (UIVA) at 3/4 m and uncorrected near visual acuity (UNVA) were obtained., Results: There were 70 eyes from 49 patients in this study. Patients were refracted at a median of 8.9wk (range 4.0 to 15.5) from the operation date. Sixty-five percent of eyes had 6/7.5 (0.10 logMAR) or better, and 99% 6/12 (0.30 logMAR) or better postoperative UDVA. Eighty-nine percent could read Jaeger (J) 3 (0.28 logMAR) and 95% J5 (0.37 logMAR) at 40 cm. The median magnitude of astigmatism decreased from 1.91 D to 0.49 D (Wilcoxon, P<0.001) after the operation. The range of the cylindrical error was reduced from 1.5-3.95 D (keratometric) preoperatively to 0.00-1.46 D (subjective refraction transposed to corneal plane) postoperatively., Conclusion: Toric Lentis Mplus IOL has good predictability in reducing preexisting corneal astigmatism.

Aim: To compare visual acuity and central macular thickness (CMT) changes in neovascular age related macular degeneration patients treated with either 6 weekly bevacizumab regimen or 4 weekly ranibizumab on an as required basis., Methods: Patients made an informed choice between bevacizumab 1.25 mg or ranibizumab 0.5 mg. The selected treatment was administered in the first 3 visits. Bevacizumab patients were followed-up 6 weekly and ranibizumab 4 weekly. Retreatment criteria was based on the reduction of >5 letters in the best-corrected visual acuity (BCVA), the presence of retinal fluid on optical coherence tomography (OCT) or new retinal haemorrhage., Results: Visual acuity at 2y bevacizumab patients gained 7.0 letters and ranibizumab 9.2 (P=0.31, 95% CI -6.4 to 2.0). At 2y 86% of bevacizumab and 94% ranibizumab patients had not lost 15 letters or more (P=0.13). Mean CMT decreased at 2y bevacizumab by 146 µm, ranibizumab 160 µm (P=0.72). Mean number of injections was at 2y bevacizumzb 11.9, ranibizumab 10.3 (P=0.023)., Conclusion: Bevacizumab 6 weekly on an as required basis was not demonstrably non-inferior to ranibizumab 4 weekly pro re nata (prn) in terms of BCVA and change in CMT. In the bevacizumab group, one more injection was required in the second year compared to the ranibizumab group.

Purpose: To determine the refractive effects of paired opposite clear corneal incisions (OCCIs) on with-the-rule (WTR) and against-the-rule (ATR) astigmatism at 1 and 6 months postoperatively., Methods: This is a retrospective cohort study. Consecutive eyes from different patients who had OCCIs for keratometric astigmatism of 1.5 to 2.5 diopters (D) were included. They were divided into group A with the steepest meridian at 90 ± 20 and groups B and group C with the steepest meridian at 180 ± 20 degrees. The keratome width used for groups A and B was 3.2 mm and for group C was 3.5 mm. Keratometry by partial coherence interferometry, manifest refraction, and visual acuities were measured at 1 and 6 months postoperatively., Results: Twenty-eight eyes were included in each group. The median of surgically induced astigmatism (SIA) magnitude at 1 month postoperatively for groups A, B, and C were 1.7, 1.1, and 1.7 D, respectively (P < 0.001). A post hoc test showed that SIAs of groups A and C were significantly greater than that of group B. Six months postoperatively, the medians were 1.6, 0.8, and 1.5 D (P < 0.001). The change was significantly different from 1 month for groups B and C (P = 0.001 and P = 0.006, respectively). The median uncorrected distant visual acuity was better for groups A and C compared with group B at 1 month (P = 0.016)., Conclusions: A paired OCCI has a significantly greater refractive effect on WTR than ATR astigmatism correction. The SIA for ATR astigmatism reduces significantly more than for WTR astigmatism correction at 6 months.

Aim: To determine the reduction of choroidal melanoma thickness 6 months after ruthenium 106-brachytherapy according to chromosome 3 status, which correlates strongly with metastatic death., Methods: Transscleral fine needle aspiration biopsy was performed prior to the insertion of a radioactive plaque if the tumour was deemed sufficiently thick and anterior for such a procedure. Transretinal biopsy with a 25-gauge vitreous cutter was performed for thin and posterior tumour within a month of plaque removal. The chromosome 3 status was determined by fluorescence in situ hybridisation from 2002 until 2006, and by either multiplex ligation-dependent probe amplification and/or microsatellite analysis after this period until the end of the study. The choroidal melanoma dimensions were obtained from outpatient visits., Results: 149 eyes from 149 patients were included. The mean age was 60.8 years. 84 eyes (56.4%) had disomy 3 and 65 eyes (43.6%) monosomy 3. The median pretreatment tumour thickness was 3.0 mm in disomy 3 and 4.1 mm in monosomy 3 tumours (p=0.018). The follow-up duration medians were 6.3 months for disomy 3 and 6.4 months for monosomy 3 tumours (p=0.68). The rates of thickness reduction were 6.7% and 7.0% per month, respectively (p=0.59). Thickness reduction exceeding 50% occurred in 32 (38.1%) disomy 3 and 24 (36.9%) monosomy 3 tumours., Conclusions: The rate of choroidal melanoma regression after ruthenium-106 brachytherapy does not appear to correlate with chromosome 3 loss, suggesting that tumour thickness reduction 6 months after treatment is unlikely to predict survival., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

This case illustrates an overlooked metastatic lung carcinoma to the orbit. The rapid onset of symptoms and oedema mimicked a cellulitis. The patient was initially treated with a broad-spectrum topical and intravenous antibiotic therapy. The white blood cell count (WBC) and C reactive protein (CRP) were normal. Compressive optic neuropathy and serous retinal detachment ensued. The initial chest x-ray revealed lung shadows; however, this was not reviewed. Eventually, CT of the chest was organised and showed a lung mass. The management of such a case remains a challenge for the uninitiated, and high index of suspicion is required to ensure early appropriate management. Despite complete resolution of the swelling with sequential chemotherapy (cisplatin and etoposide) and radiotherapy, the visual prognosis remained grim.

A man with rosacea developed bilateral eyelid edema from wearing a continuous positive airway pressure nasal mask daily. The edema was refractory to steroid, diuretics, and lymphatic drainage massage. The effect may be related to cumulative venous congestion and lymphostasis due to the continuous positive airway pressure treatment.

Beta-blockers are a well-known prophylactic treatment for migraine; however, treatment by the ocular route has not been widely considered. This case illustrates the resolution of a visual field defect associated with migraine and improvement of symptoms possibly due to administration of a topical beta-blocker. This novel method of treatment especially when visual field defects are present may have a place in the management of migraine.

Aim: To investigate the current management trend in blebitis among glaucoma consultants registered with the Royal College of Ophthalmologists (London)., Method: An anonymous survey consisting of 13 questions to ascertain blebitis management was posted to the glaucoma consultants. A χ(2) test was used to analyse the correlation patterns among respondents' answers to the questionnaire., Results: Out of 112 questionnaires, 68 (61%) were returned. Fifty-five per cent of the consultants admit blebitis patients into hospital for treatment. Seventy-four per cent obtain a conjunctival swab, and 28% instil iodine on the conjunctiva as part of their treatment regime. Thirty-four per cent use topical fluroquinolone monotherapy, 28% cefuroxime and gentamicin, 18% fluroquinolone with cefuroxime, and 9% ceftazidime and vancomycin. Fluroquinolones are the only oral antibiotics used by those who routinely prescribe oral treatment (69%). One-fifth of respondents use intravitreal antibiotic in treating blebitis patients. Eighty-two per cent surveyed include topical corticosteroids as part of their treatment regime. Ninety-one per cent use a topical cycloplegic. Twenty-three per cent of the respondents treat blebitis as endophthalmitis, even without or with only mild anterior chamber (AC) activity. Thirty-eight per cent would do so if there was moderate AC activity, and 34% if there was severe AC activity including a hypopyon., Conclusion: A wide variation exists in the management of blebitis among glaucoma consultants. A standard treatment regime does not exist at the moment. Further research is needed to ascertain effective strategies to manage this condition.

Aim: To apply the control chart method to retrospectively analyse the variation in postcataract surgery endophthalmitis., Methods: The endophthalmitis data between 01/07/97 and 30/06/07 (10 years) at the Royal Gwent Hospital were analysed using the control chart method. Certain criteria related to the control chart were employed to detect unusual variations and early outbreaks of endophthalmitis., Results: A total of 21 032 cases of cataract were performed in that period, with a mean annual incidence of 0.16%. The control chart could provide a reliable method to detect an early outbreak of endophthalmitis before it was suspected and acted on. The chart provided visual information of the altering trends of endophthalmitis cases and allows unusual variations to be detected early., Conclusion: The control chart is potentially a sensitive method to detect anomaly in the cases of postcataract surgery endophthalmitis. Its control limits are dynamic and factor in recent performance to detect any unusual variation.

Purpose: To compare the visual outcomes in patients with bilateral implantation of AcrySof ReSTOR multifocal intraocular lenses (IOLs) (Alcon Laboratories) or ReZoom multifocal IOLs (Advanced Medical Optics) 6 months after cataract surgery., Setting: Orsett and Southend Hospital, Essex, United Kingdom., Methods: This study comprised patients who had uneventful bilateral cataract extraction with implantation of ReZoom (n = 50) or ReSTOR (n = 50) multifocal IOLs. Parameters analyzed included binocular uncorrected distance, intermediate, and near acuities; spectacle independence; subjective visual symptoms; and patient satisfaction. All parameters were evaluated 6 months after second-eye surgery., Results: All patients had binocular uncorrected distance visual acuity of 20/32 or better; there was no statistically significant difference between the 2 groups. The mean binocular uncorrected near acuity was 20/26 (J1.22) in the ReSTOR group and 20/34 (J2.34) in the ReZoom group (P<.0001). The mean binocular uncorrected intermediate visual acuity was 20/42 and 20/34, respectively (P = .003). Patients in the ReZoom group reported greater satisfaction with intermediate vision (P = .04). No statistically significant difference was found in satisfaction with near vision. Eighty-six percent of ReSTOR patients and 70% of ReZoom patients did not wear glasses for daily activities; the overall satisfaction was not statistically significantly different between groups. There was no significant difference between groups in photic phenomena., Conclusions: The ReSTOR IOL provided better near vision and the ReZoom IOL better intermediate vision. Both multifocal IOLs gave excellent distance vision. Photic phenomena were comparable and clinically acceptable. ReSTOR patients had greater spectacle independence for near vision and ReZoom patients for intermediate vision. Overall spectacle independence was not statistically significantly different.

Purpose: To compare the visual outcome and subjective visual symptoms in patients who had implantation of the AcrySof ReSTOR multifocal intraocular lens (IOL) (Alcon Laboratories) with those in patients who received the AcrySof SA60AT monofocal IOL (Alcon Laboratories) in cataract surgery., Setting: Southend Hospital, Essex, United Kingdom., Methods: Eighty eyes of 40 patients received the ReSTOR multifocal IOL after cataract extraction. They were closely paired in age, sex, and ocular findings with patients who had monofocal IOL implantation during the same period. The distance and near visual acuities were compared, and patient satisfaction with their vision, visual symptoms, and spectacle dependence was assessed using a standardized questionnaire., Results: There was no significant difference in the mean uncorrected and best corrected distance visual acuities between the groups. An uncorrected distance visual acuity of 20/30 or better was achieved in 93.8% eyes in the multifocal group and 82.5% in the monofocal group and of 20/20 or better in 57.5% and 40.0%, respectively (P = .18). Uncorrected near visual acuity was 20/30 or better in 75.0% of eyes in the multifocal group and 3.8% in the monofocal group. Reading glasses were required by 2.5% in the multifocal group and by 92.5% in the monofocal group. Satisfactory uncorrected intermediate distance vision was achieved in 75.0% of eyes in the multifocal group and 87.5% in the monofocal group (P = .089); 85.0% of patients in the multifocal group and 7.5% in the monofocal group never had to wear glasses. Moderate glare was reported by 21.3% in the multifocal group and 7.5% in the monofocal group (P = .008); no patient reported severe glare. In the multifocal group, severe halos and moderate halos occurred in 3.8% [corrected] of eyes and 16.3% [corrected] of eyes, respectively., Conclusions: The AcrySof ReSTOR IOL provided predictably good uncorrected distance and uncorrected near acuities. Spectacle independence was significantly higher with this multifocal IOL, which outweighed the photic symptoms it caused.