Ophthalmology Review

Posted by afarahi at 12:40 AM

March 20, 2003

A NEW TORIC LENS
Cataract & Refractive Surgery March 2003

A company of the group HumanOptics AG (Erlangen, Germany), has worked during the past few years to develop a three-piece, foldable toric IOL. The MicroSil Toric IOL is available in powers of between -3.00 and 31.00 D and cylindrical powers ranging from 2.00 to 12.00 D (Figure 1). This IOL, type MS 6116 TU, is a posterior chamber lens (PCIOL) and features stable PMMA haptics in a z-design, as well as a 6-mm optic made of silicone. The IOL’s overall diameter is 11.6 mm.The optic of the lens is marked with two peripheral lines, which indicate the steep axis. The formation of the haptics impedes the spontaneous rotation of the IOL after implantation. The surgeon folds the lens within the box, thus avoiding unnecessary manipulation or false positioning. Implanting the MicroSil Toric lens is somewhat more difficult than inserting a conventional PCIOL because of the shape of its haptics. The surgeon should begin with a capsulorhexis large enough to accommodate them and then insert the inferior haptic into the capsular bag in the usual manner. To insert the superior haptic, he should use an implantation forceps. Then, he must rotate the lens so that its lines align with the steep meridian, which he marked preoperatively at the slit lamp. Manual rotation is possible, even after aspirating the viscoelastic material. With the MicroSil Toric IOL, a good refractive result is best achieved by paying close attention to the wound architecture, the IOL calculation, and the influence of rotational stability within the capsular bag.

Posted by mehdi khanlari at 01:23 PM

Understanding Postsurgical Haze
Cataract & Refractive Surgery March 2003

In the past, one of the main issues regarding PRK was that some patients developed visually significant haze weeks to months following the surgery (Figure 1).

CAUSES
UV ExposureI became very interested in postoperative haze during my cornea fellowship in 1996 and 1997. Approximately 3 months after a seemingly successful PRK, one of my patients left for a 4-day deep-sea fishing trip off the coast of Mexico. When he returned, he had severe haze. He also revealed that he had been exposed to a great deal of sunlight because he had not worn sunglasses during his trip.Laser EnergyThe second main risk factor for developing postoperative haze relates to the amount of laser energy applied to the cornea. Patients with higher degrees of myopia (&Mac179; 6.00 D) seem to run the greatest risk of haze because they require deeper ablations. Similarly, larger optical zones entail deeper ablation and therefore a greater risk of postoperative haze. Prior Corneal SurgeryPrevious corneal surgery such as RK, LASIK, and even corneal transplantation has been reported as a risk for haze following PRK.3,4

PREVENTION
UV ProtectionThe most basic method of haze prevention is for patients to wear sunglasses with complete UV protection and to avoid exposure to high levels of UV radiation during the first year following PRK or LASEK.Vitamin C In a forthcoming study, Dr. Stojanovic treated patients with 1,000 mg of vitamin C q.d. for 1 week preoperatively and during the first 2 weeks following PRK. He found that the patients’ risk of haze decreased from 3.7% to zero with oral vitamin-C supplementation.Mitomycin CThe prophylactic use of mitomycin C (MMC) is the subject of intense controversy in the field of refractive surgery. The investigators also reported that prophylactic MMC was relatively safe but noted that its use required them to reduce the laser energy treatment by 10%. Nevertheless, we do not currently know the long-term risk posed by the application of MMC on the central cornea. For that reason, many surgeons question the appropriateness of using the agent for all patients with higher levels of myopia.

MANAGEMENT OF VISUALLY
SIGNIFICANT POSTOPERATIVE HAZE The first step in treating postoperative haze is to apply topical steroids. If the haze fails to clear in 4 to 6 weeks, the next step is to remove the scar. A few years ago, this would have involved manual debridement with a diamond bur, applying MMC 0.02% to the corneal surface to prevent the further development of haze, and then allowing the cornea to heal. Today, many refractive surgeons elect to perform a superficial PTK on these patients, followed by the application of MMC to prevent the haze from recurring.6 The reason for this change in procedures is that a manual keratectomy is more likely to produce an irregular corneal surface that can render follow-up treatments more challenging.

Posted by mehdi khanlari at 12:59 PM

Help for Patients With Corneal Scarring :BioMask
Cataract & Refractive Surgery March 2003

Patients who have lost BCVA due to irregular astigmatism from cornealscarring have new hope for an improved quality of life.Frederic K. Kremer, MD, recently reported on the efficacy of a substance called BioMask (Maverick Technologies, Inc. Clearwater, FL), which is a polymer gel that the surgeon molds between the irregular cornea surface and a customized rigid gas permeable contact lens.13 The gel is reported to have the following qualities: an excimer laser ablation rate similar to that of the human cornea; adequate viscosity to fill formal irregularities; excellent adherence to corneal tissue; the ability to be molded to any required curvature; a short solidification time; and easy removal. Results of BioMask in patients with corneal opacities and irregular astigmatism show promise, especially in those with Salzmann’s degeneration, those who underwent prior refractive surgery, and/or those who exhibit corneal dystrophies. Patients with previously induced scars did not fair as well in terms of improved BCVA but did show a 50% symptomatic improvement. The authors report that a significant amount of clinical evaluation must be performed with the BioMask. The reported steep learning curve includes canting of the applanator lens and difficulty in handling the polymer.13

Posted by mehdi khanlari at 12:46 PM

Refractive Challenge : LASIK or Lensectomy?
Cataract & Refractive Surgery March 2003

CASE HISTORY
A 58-year-old white male with no history of medical problems presented with an interest in undergoing LASIK in order to become free of his bifocals. He reported having abandoned his contact lenses 10 years earlier “because they were too much of a hassle.” Although he described no particularly adverse visual symptoms, upon questioning, the patient admitted that he did not like driving at night because he experienced “halos and bright lights.” He acknowledged that he would require reading glasses postoperatively.The preoperative examination revealed that the patient had 2.5-mm photopic pupils and dark brown irides that dilated to 4.5 mm in the dark. He wore +3.50-D spherical bifocals with an add of +1.75 D. His bilateral manifest refraction was +2.75 D with an add of +2.25 D. The patient’s average keratometry reading was +46.50 D OU. His BSCVA was 20/20 OU. Upon questioning, the patient recalled that his optometrist had changed his glasses’ prescription slightly during the previous year. Biomicroscopy revealed normal corneas without guttata, a lustrous tear film, and a rating of 0.5 to 1.0 on the nuclear sclerosis and opalescence sections of the LOCS scale (Figure 1). His lenticular cortex could have been interpreted as less than totally clear but was basically unremarkable, as was the capsule. The patient’s fundus examination was also normal.

HOW WOULD YOU PROCEED?
1. Is this patient a good candidate for LASIK?
2. If not, should he be considered for another refractive procedure now or in the future?
3. What are the relative risks and advantages of an intraocular procedure (either a phakic or replacement lens implant versus a keratorefractive procedure such as LASIK or PRK)?

Posted by mehdi khanlari at 11:04 AM

Cataract Challenge : Aqueous Misdirection Syndrome
Cataract & Refractive Surgery March 2003

CASE PRESENTATION
A 56-year-old white female complaining of decreased vision presented with a +2 to +3 nuclear sclerotic cataract in her left eye. I planned to perform cataract surgery utilizing the AdvanTec NeoSoniX technology on the Series 20000 Legacy Phacoemulsification system (Alcon Laboratories, Inc., Fort Worth, TX), and to implant an IOL. I found no pre-existing ocular conditions that warranted concern.I began the procedure by administering topical anesthesia to the cornea and then making a clear corneal wound superiorly, followed by a circular capsulorhexis. During hydrodissection of the nucleus, I discerned a distinct posterior fluid wave, indicating that the epinucleus had separated from the cortex. Following a successful four-quadrant fracture, I removed the final nuclear fragments using the Kelman phaco handpiece (Alcon Laboratories, Inc.) and with the help of the NeoSoniX technology. Next, I used the phaco handpiece to remove the epinucleus, and I accomplished this without incident. I began I/A with a flexible silicone handpiece (Alcon Laboratories, Inc.) and intermittently aspirated the posterior capsule. At this point, pressure began to build in the eye, the chamber grew shallower, and it became impossible to remove the cortex. I surmised that the increased bulk of the flexible silicone sleeve might have damaged some zonules upon entry into the anterior chamber. As a result, an aqueous misdirection syndrome had developed within the eye which caused fluid traveling from the I/A tip to be diverted into the vitreous cavity via an area of weakened zonules.

HOW WOULD YOU PROCEED?
1. Would you simply proceed with the surgery?
2. Postpone the procedure until the IOP normalized?
3. Surgically decompress the globe while the patient is on the table?

Posted by mehdi khanlari at 10:56 AM

March 19, 2003

New toric IOL corrects high corneal astigmatism after cataract surgery
Eurotimes March 2003

RESULTS from recent Austrian study show that a new foldable, toric IOL with z-haptics can correct high corneal astigmatism and produce a good visual outcome, Irene Dejaco-Ruhswurm MD told the annual meeting of the German Society of Ophthalmology. She and her team at the University Clinic for Ophthalmology and Optometry, Vienna, Austria implanted individually crafted toric silicone IOLs (MicroSil 6116 TU, Schmidt) in 14 eyes of nine patients. Four of the patients had previously undergone keratoplasty.The MicroSil 6116 lens is a three piece foldable silicon IOL with z-haptics. The diagonal length is 11.6 mm and the optical diameter 6.0 mm.The mean preoperative keratometric astigmatism was 5.28 D (± 3.53 D) and the mean preoperative refractive astigmatism 3.73 D (± 1.52 D). Four of the patients underwent PK. The mean cylindrical power of the implanted IOLs was 5.50 D (± 2.74 D.) The refractive astigmatism was reduced to +0.68 D (± 0.75 D) following surgery. The mean amount of postoperative keratometric astigmatism was +4.62 D (± 3.32 D). Visual acuity without correction was 0.55. With spherical correction, it registered 0.7 and BCVA acuity was 0.8. The researchers observed no significant IOL rotation in nine patients followed for six months or more. At the XX ESCRS Congress in Nice in September last year, Dr Sven Kulus and colleagues from the Klinik Dardenne in Germany reported that the MS 6116 performed well in six eyes with high astigmatism following keratoplasty. Post-PK keratoplasty astigmatism was reduced from a mean of 7.5 D to 2.4 D following IOL implantation.

Posted by mehdi khanlari at 08:58 AM

Thermotopography shows ‘enormous promise’ for diagnosis and treatment of eye diseases
Eurotimes March 2003

INITIAL experience with infrared thermotopography at the Heidelberg University Eye Clinic in Germany suggests that heat patterns can provide valuable information for the diagnosis and treatment of a variety of eye diseases.Infrared thermotopography shows promising results as a means of detecting eye diseases which induce or involve a change in the temperature of the anterior segment. It can easily detect and visualise even the smallest differences in the corneal surface temperature
Figure1:Standard thermotopogram of a left eye of a healthy subject.
The iridocyclitis patients revealed a "hot ring" in the area of the corneal rim above the ciliary body. The temperature difference between the central cornea and the sclero-corneal interface was widened (³T 1.8°C). In all, the corneal surface temperatures in these eyes were 2.2°C higher than in the control group.
Figure2:Active untreated iridocyclitis. At the cornea-sclera border a ring of enhanced thermal activity can be found
The investigators also measured a high temperature zone in patients with scleritis, due to the increased local circulation.The eye surface temperature in eyes with ophthalmic herpes zoster was no higher than in normal eyes. The dendrites, however, were more apparent due to the minimal temperature difference with the environment.
The researchers noted a temperature difference of up to 3°C between eyes which had undergone cataract surgery and non-operated eyes. The increase in the surface temperature is related to eye trauma. Furthermore, a more rapid temperature decrease was observed in the area of the breaking tear film than in neighbouring corneal zones. Infrared thermotopography is an important differential diagnostic tool that has become a well-grounded method in other medical disciplines. It has been employed to control the by-pass circulation during cardiac surgery and is a means of investigating the differential diagnosis of peripheral vascular closure.
Infrared thermotopography is implemented in dermatology and for breast cancer diagnostics.Also, infrared phototopography can be used to detect an increase in corneal temperature during cataract surgery, which allows excellent visualisation due to the phaco energy, especially in non-pulse mode.

Posted by mehdi khanlari at 08:04 AM

March 17, 2003

How to Help the Allergic Contact Lens Wearer
Review of Ophthalmology March 2003

Ocular allergy is a common and significant problem. As much as 20 percent of the general population in the United States, or 50 million people, may suffer from allergic conjunctivitis. Without proper treatment, patients, particularly contact lens wearers, may face a major disruption of their work, productivity and daily functioning. This article will review ocular allergy in this population and address ways that ophthalmologists can alleviate their symptoms.Read More

Posted by mehdi khanlari at 10:56 PM

CLE Pearls
Ophthalmology Management March 2003

1-Because CLE patients have soft nuclei, not hard lenses, breaking the posterior capsule presents a more important risk than corneal edema. Use a phaco tilt technique, where hydrodissection brings the nucleus out of the bag.
2-You'll need minimal ultrasound power and can generally perform the procedure almost completely using aspiration, irrigation, and very minimal chopping.
3-Because hyperopes have shallow anterior chambers, it's a little more difficult to perform the procedure in these patients. Ensure that the incision's entry point isn't too far posterior because a short eye has the added risk of iris prolapse.
4-With extreme hyperopes, keep in mind that they may be nanophthalmic.
5-For presbyopic patients, keep expectations reasonable. The accuracy of IOL power calculations is key, and accuracy diminishes when the axial length is far outside the bell curve. Let the patient know that there is a chance of an enhancement.
6-Though it depends on the surgeon's comfort level and the patient selected, the procedure may be performed without an anesthesiologist present.

Posted by mehdi khanlari at 09:04 AM

March 16, 2003

Epipolis laser-assisted keratomileusis or epi-LASIK
Eyeworld March2003

Seeking a new solution to separate the epithelial sheet, Pallikaris developed the subepithelial separator (SES), a microkeratome-based device. Investigators will use the device for a surface ablation procedure they have named after the Greek word meaning superficial: Epipolis laser-assisted keratomileusis or epi-LASIK. During epi-LASIK the SES is positioned on the eye and, using a blunt blade and low suction, it mechanically separates a hinged epithelial sheet without alcohol. The sheet is reflected nasally onto a contact lens. After laser ablation, the sheet is replaced along with the contact lens.
“In contrast to alcohol-assisted separation where the cleavage plane is within the basement membrane, mechanical separation takes place under the basement membrane, thus preserving its integrity,” Pallikaris said. “It is believed the basement membrane provides the stability and support that keep the epithelium intact and is significant for the viability of the epithelial disks.” Furthermore, separation requires minimal manipulation, which may be beneficial for flap viability.Since the device doesn’t cut into the stroma, it presents fewer flap concerns. “If your flap falls off in LASIK, this is a big disaster. If this sheet of cells falls off, it’s no big deal. You have photorefractive keratectomy,” said Marguerite B. McDonald, MD, clinical professor of ophthalmology, Tulane University, and director of the Southern Vision Institute, New Orleans.

Posted by mehdi khanlari at 11:45 PM

Refractive surgeons recommend aggressive postop tear schedule
Eyeworld March2003

Surveys indicate that up to 80% of patients have dry eye symptoms at least transiently in the early postoperative period after LASIK. “These patients not only need casual tear supplementation, they need aggressive supplementation following surgery,” Our choice is to have aggressive artificial tear replenishment, with the preference for preservative free solutions. We ask the patients to use drops every hour, because a less aggressive schedule often leads to noncompliance,” Solomon said. “We found that the patients who used them on a strict schedule had less staining of their conjunctiva and cornea indicating that the ocular surface was healthier. The quality of life questionnaire similarly found less visual fluctuation and improved comfort in varying conditions,” he said. “That’s why I’m a big proponent of artificial tears, a minimum of four and preferably six times a day for a month, whether the patients feel they need them or not.”

Posted by mehdi khanlari at 11:36 PM

Howard Fine, MD : Riding a Harley- Davidsons
Cataract & Refractive Surgery Today Jan 2002

What are some of the areas you’re presently researching? The major emphasis of the current clinical research my colleagues and I are working on involves power modulations in phacoemulsification, decreasing the invasiveness of cataract surgery, and increasing the rapidity of visual rehabilitation, all under the umbrella of cold phaco. What do you feel are the most promising developments in ophthalmics right now? I think that down the road, refractive lens exchange will be the dominant refractive surgical procedure.
What was your most memorable experience while in surgery? I was performing cataract surgery on a one-eyed patient, at a time when we used to perform a retrobulbar before we started surgery. I had the feeling that I ‘d perforated the patient’s eye with the injection. I kept the needle where it was, and asked the nurse to put an indirect ophthalmascope on me and hand me a condensing lens. I could see the needle going into the eye through the vitreous cavity and then out of the eye, indicating a double perforation, which sets the stage for a horrible retinal detachment. I asked the assistant to take a retinal cryoprobe and freeze the edge of the needle close to the hub. This transmitted cold along the metal shaft of the needle, which created a cryopexy scar at both the entrance perforation and the exit perforation. Next, I performed the cataract extraction. The patient had two scars in the retina, at the entrance and exit wounds. Happily, the holes were not dangerously close to the macula, and he never had a day’s worth of trouble. That case happened nearly 30 years ago, and I’ve seen the patient continuously every year.
As a surgeon, do you have any heroes or role models? I suppose my biggest heroes in ophthalmology are Charles Kelman, MD, who innovated phacoemulsification, and Drs. Richard Kratz, Robert Sinskey, James Little, and Jared Emery, who were early converts to phaco. The insights and teachings of these men enhanced the lives of millions of people throughout the world, and in addition, fostered satisfying careers for many of us who followed.
Tell us about riding Harley-Davidsons. All my life I’ve been attracted to motorcycles—I love it. I have five of them now, and two on order. I love everything about riding; it’s a great stress reliever because you have to concentrate on all of the conditions while you are driving in order to avoid an accident. It’s a thrill I can’t explain, I can only tell you that I never feel as alive as when I’m on a motorcycle. I also I like the fact that in addition to being Dr. Fine, I have the image of being a motorcyclist.

Posted by mehdi khanlari at 11:19 PM

Cataract Challenge : Traumatic Subluxated Brunescent Cataract
Cataract & Refractive Surgery Today Jan 2002

CASE PRESENTATION
An 88-year-old white male farmer suffered a concussive injury to his right eye when an air hose blew off its machinery attachment. The injury occurred 4 months prior to presentation, during which time the patient experienced progressively decreasing vision. His best-corrected visual acuity (BCVA) in the damaged eye was 20/200. The cornea was clear, however there was a fixed 5.5-mm iridoplegia. There was 4+ brunescent nuclear sclerosis and a 4+ posterior subcapsular cataract present (Figure 1). Pressures were normal in both eyes, and they did not show any reverse relative afferent pupillary defect. The BCVA of the fellow eye measured 20/50, with 3+ brunescent nuclear sclerosis and an otherwise normal examination.

HOW WOULD YOU PROCEED?
1. What are the patient’s options for visual rehabilitation?
2. Would you plan phacoemulsification, and if so, how?
3. Where would you place the incision?
4. What IOL would you choose, and why?

Posted by mehdi khanlari at 11:02 PM

March 15, 2003

Choroidal neovascularization in phakic eyes with anterior chamber intraocular lenses to correct high myopia
J Cataract Refract Surg 2003; 29:270–274 © 2003 ASCRS and ESCRS

To analyze the appearance, incidence, and characteristics of choroidal neovascularization (CNV) in patients with high myopia corrected by implantation of a phakic anterior chamber intraocular lens (PACL),The CNV observed in 294 consecutive eyes (181 patients) implanted with a PACL for the correction of high myopia (-7.0 to -38.0 diopters) was studied. The mean follow-up was 50.6 months ± 32.8 (SD) (range 6 to 120 months).Choroidal neovascularization occurred in 5 eyes (1.70%); 3 eyes were in women, and 2 were in men. The interval between PACL implantation and CNV was 63.2 ± 27.3 months (range 18 to 87 months). The CNV was subfoveal in 4 eyes and juxtafoveal in 1 case... The authors concluded that; implantation of a PACL to correct high myopia was followed by a small incidence of CNV (cumulative risk of 5.4% at 87 months). The appearance of CNV was followed by a significant decrease in BSCVA.

Posted by agholami at 10:25 PM

March 14, 2003

A new multifocal IOL : Restor Lens
Eye word Mar 2003

A unique multifocal IOL, the AcrySof Restor lens, will soon offer practitioners a new option for returning both near and distance vision to patients. The Restor lens works unlike anything else currently available, functioning as a hybrid refractive/diffractive optic.This IOL uses the principle of diffraction to create both near and distant images. Unlike a zonal progressive lens such as the Array , the Restor lens is not dependent upon pupil size. Like all zonal refractive lenses, the image quality of the Array lens is pupil dependent and limited by the resulting light that passes through the refractive zones,Since the diameter of these zones is fixed, the amount of energy available to create near and distance images is dependent upon pupil size. Another advantage of the Restor design is that blends the diffractive region into the refractive periphery, using a proprietary "apodization" technique, with the aim of reducing the incidence of glare, halos, and other unwanted visual side effects that have come to be associated with multifocal lenses.Restor lens expectes to approve for distribution outside the United States sometime this year. The lens is also currently in U.S. Food and Drug Administration clinical trials
EMKH
.

Posted by mtmdop at 05:37 PM

Jack T. Holladay, MD : his background in engineering
Cataract & Refractive Surgery Today

I finished my master’s of electrical engineering degree in 1971 at Southern Methodist University in Dallas and began work on my PhD with a subspecialization in biomedical engineering. I found the medical applications of engineering very exciting. During medical school, I kept my engineering skills sharp by working part-time as a computer programmer for the medicine department, and then with research projects in ophthalmology. It was during this time that I developed my first ophthalmic device, the Brightness Acuity Tester from Marco, used for glare testing in cataract patients. During my undergraduate and graduate training in engineering, I was fortunate to work part-time at a company that created many night-vision devices for the military. Devices such as infrared viewers and image intensifiers had just been developed, and environmental testing and refinements were in progress. This work gave me a great deal of exposure to design optics and applications to vision. This optical background is critical for my current work in refractive and cataract surgery. Wavefront technology, contrast sensitivity, and topography are all tools that we have developed and refined based on the principles of electrical engineering. Today, it is even more important with our lasers and the improved optical design of IOLs. My optical background is what made IOL calculations so interesting.

Posted by mehdi khanlari at 08:43 AM

Acupuncture For Blepharospasm
Medical Acupuncture, Volume 14 / Number 1

A case of essential blepharospasm that did not respond to conventional ophthalmologic treatments is presented herein.
The patient was a 51-year-old woman who developed facial and eye twitches which gradually increased over 1 year. Gabapentin, propranolol, and cyclobenzaprine were ineffective; spasms worsened. An ophthalmologist injected botulinum toxin 4 times. Her symptoms improved mildly, but then the twitches became more significant. Her eye blinks and facial twitches worsened, and she lost peripheral vision.
Treatment included needle acupuncture . Total time span of treatment was slightly less than 2 months. The patient showed >95% improvement, sustained after 3 months of no further treatments.
CONCLUSION: Acupuncture can be an effective treatment in difficult cases of blepharospasm,

Posted by afarahi at 03:01 AM

How to manage posterior capsule rupture during cataract surgery
Ophthalmology Times February 15, 2003

The early signs of posterior capsule (PC) rupture during cataract surgery and employing proper surgical techniques will help ensure good visual and anatomic outcomes, according to Louis D. Nichamin, MD. Cataract surgeons are faced with two main enemies when this complication occurs: hypotony and unnecessary infusion
Recognizing a change in capsular integrity is very important. Residents are taught to look for deepening of the anterior chamber, as a classic sign of this problem.
But an earlier sign is the deepeningof the posterior chamber"As soon as the capsular zonular network is breached in some way, there is suddenly an increase in space between the back of the iris and the anterior surface of the lens capsulestop working and stay in position one. Be sure to maintain infusion, inject viscoelastic through the side port, and then slowly withdraw from the main wound. At this point, try to avoid losing the lens. If the nucleus is dropping posteriorly, one can employ the posterior-assisted levitation (PAL) technique, described by Charles Kelman, MD. This technique involves rescuing nuclei by placing an instrument such as a spatula or viscoelastic cannula through a pars plana incision, and then raising the nuclear material back up and into the anterior chamber. When faced with an open posterior cap-sule, cataract surgeons must be careful about unnecessary infusion, which is "enemy number 2," . "The only amount of infusion that should be entering the eye should equal the amount of material that we are removing from the eye. There should be low flow and a steady state within the anterior chamber." A vitrectomy may have to be performed if vitreous is present in the anterior chamber,. His goal is to preserve as much capsule as possible and not convey unnecessary vitreoretinal tractional forces. To perform an anterior vitrectomy, a bimanual technique is recommended. The main incision is abandoned for two side-port incisions. Usually the surgeon already has created one side-port incision for the non-dominant hand. The other side-port incision can be made with a microvitreoretinal (MVR) blade, which is a 20-gauge stiletto blade, he said. Another option for vitrectomy is the placement of the cutter through the pars plana. The advantage of this approach is that the cataract surgeon can easily go up into the anterior chamber and pull the vitreous back. Also, vitreous can be more easily cleaned from the wounds, he said. Of course, undertaking a pars plana incision for the first time in a complicated case may be nerve-racking. Wet lab experience is recommended, Dr. Nichamin said. During vitrectomy, the cutting speed should be maximized to a speed as high as 1,500 times per minute while maintaining low vacuum. When removing lens material, the cutting speed may need to be decreased and vacuum increased. Also, remember to release the vacuum when repositioning the vitrector, he said.

Posted by mehdi khanlari at 01:00 AM

Clinical trials show pirenzepine gel reduces progression of myopia in children
Ophthalmology Times February 15, 2003

Novartis Ophthalmics and Valley Forge Pharmaceuticals Inc. have entered into a licensing agreement for a novel eye medication ,2% pirenze-pine gel , for myopia, which in phase II clinical trials reduced progression of the disease by 50% in the first 12 months of therapy. We found that pirenzepine decreased myopic progression by 50% in the treated group as opposed to the placebo group over 1 year," Dr. Siatkowski said. "The results were highly statistically significant."Pirenzepine is a selective M1-muscarinic antagonist that slows down the axial growth of the eye. It is similar to atropine, which also has been shown to reduce myopic progression in a dose-dependent fashion, but should cause fewer problems for patients"The unpleasant side effects of atropine are mostly due to the M3-muscarinic re-ceptor antagonistic activity. Pirenzepine has some M3 activity, but it's much more se-lective for M1, and that's what helps make it more tolerable for the patient, with a better safety profile and fewer side effects," he added.

Posted by mehdi khanlari at 12:42 AM

The MP-1 Micro-Perimeter from Nidek
Ophthalmology Management March 2003

Now, a new instrument from Nidek makes it possible to precisely overlay visual field information obtained by perimetry on a non-mydriatic photograph of the retina. Combining these two data sources lets you see where visual field defects coincide with visible structural anomalies

Posted by mmiraftab at 12:09 AM

March 13, 2003

LaserScan approval.
Ophthalmology Management March 2003
LaserSight Inc. said it has received FDA approval to increase the laser pulse repetition rate of its LaserScan LSX precision microspot scanning system from 200 Hz to 300 Hz. The company said increasing the pulse repetition rate decreases treatment time while improving patient comfort, patient compliance and clinical management.

Posted by mmiraftab at 11:18 PM

Alcon Launches New OTC Artificial Tear
Ophthalmology Management March 2003

Alcon, Inc. recently introduced Systane Lubricant Eye Drops for dry eye, an over-the-counter product that the company says represents an advancement of artificial tear technology."Systane contains a unique gelling and lubricating polymer system formulated to adjust to each patient's individual tear film pH," says Kim Marek, Alcon senior product manager for dry eye. "The polymerizing protection of Systane is achieved through the interaction of hydroxy propyl guar, demulcents and the patient's natural tears."Systane delivered superior relief of dryness and foreign body sensation when compared with a leading artificial tear. These results were achieved with four applications of Systane daily.
In other Alcon news, the company has developed a new, once-daily formulation of its flagship ocular allergy drug Patanol. The company said two recently completed clinical trials demonstrate that the new formulation is both safe and effective. Alcon, which currently markets Patanol in a twice-daily formulation, said the new formulation could be approved later this year.

Posted by mmiraftab at 11:11 PM

March 12, 2003

Iris cyst secondary to latanoprost mimicking iris melanoma
AJO/ March, 2003

Purpose: To report an ocular side effect of topical latanoprost therapy.
Methods: A 73-year-old woman on latanoprost for primary open-angle glaucoma developed an iris cyst simulating an iris melanoma. Results: The lesion disappeared over 8 weeks when latanoprost was stopped.
Conclusions: In managing patients with iris-pigmented lesions, the list of medications should be reviewed. If the patient takes latanoprost, a trial off latanoprost is warranted.

Posted by pakravanmd at 01:40 AM

PRK O.K. for U.S. Army Special Forces Using Night Vision Goggles
Ophthalmology /March, 2003

SAN FRANCISCO – The refractive surgery technique known as photorefractive keratectomy, or PRK, causes no loss of visual resolution, and in fact improves uncorrected visual acuity and visual resolution during use of night vision goggles under a range of night sky conditions. In this study, 38 eyes of 19 active-duty U.S. Army Special Forces soldiers received PRK. This study should provide impetus to the U.S. military to consider laser vision correction for all combat soldiers with poor vision. Our remarkable soldiers deserve no less.” Some previous studies have shown side effects after PRK, such as glare, halo, and starburst, noticeable mostly under night viewing conditions. These side effects occur in the early postoperative period, and usually diminish within six months to a year. In a previous military study of PRK, a reduction in contrast sensitivity resolved after three months.

Posted by pakravanmd at 01:22 AM

March 11, 2003

In Vivo Confocal Microscopy of Fleck Dystrophy and Pre-Descemet's Membrane Corneal Dystrophy
Cornea,March 2003

Biomicroscopy revealed bilateral, fine, dust-, and flour-like opacities in the corneal stroma for the Fleck dystrophy patient. In the pre-Descemet's membrane corneal dystrophy patient, biomicroscopy showed opacities larger than those in the first patient. Both patients were then examined by in vivo CM. Confocal microscopy of the Fleck dystrophy showed intracellular deposits throughout the stroma. In pre-Descemet's membrane corneal dystrophy, however, these and the extracellular deposits were observed immediately anterior to Descemet's membrane. The thicknesses of the corneas were 560 and 650 ìm for Fleck and pre-Descemet's membrane corneal dystrophy, respectively. The surface epithelium, subbasal nerves, and endothelium showed normal morphology in both patients.
In vivo CM is a valuable tool in diagnosing rare corneal dystrophies when the final diagnosis is difficult to obtain with conventional methods.

Posted by shebadollahi at 08:56 PM

Visual Rehabilitation After Severe Alkali Injury With Piggyback Hyper O2 Contact Lenses
Cornea,March 2003

More than 15 years after a severe bilateral alkali injury, multiple surgical procedures including repeat bilateral penetrating keratoplasty, severe tear deficiency, and chronic ocular surface disruption, the patient achieved 20/30 best-corrected vision through the simultaneous use of a hyper O2rigid gas permeable contact lens over a hyper O2soft contact lens.
The patient has tolerated this piggyback combination without any adverse reactions or complications, and his corneal graft remains clear and healthy.Visual rehabilitation for conditions that compromise the ocular surface can be accomplished by utilizing newer soft and rigid contact lens materials that facilitate oxygen transmission, thereby promoting epithelial healing and improving safety in extended wear situations.

Posted by shebadollahi at 08:44 PM

Persistence of fundus fluorescence after use of indocyanine green for macular surgery
OSN,2003

To investigate the possible persistence and characteristics of infrared fluorescence of the fundus for several months after deep vitrectomy with intraocular injection of indocyanine green (ICG),the results of an interventional, noncomparative, prospective case series presented.In seventeen patients after standard three-port pars plana vitrectomy and posterior vitreous detachment, 0.1 to 0.2 ml of an ICG solution at a concentration of 2.5 mg/ml was injected through a 5-µm sterile filter over the posterior pole and left in place for 3 minutes. The stained internal limiting membrane was then peeled off. Patients had postoperative infrared fundus photographs at each visit.The day after surgery, no green ICG staining of the fundus was visible on biomicroscopy. However, infrared photography showed diffuse fluorescence of the fundus. At 1 and 3 postoperative months, infrared fundus photography showed an intensely fluorescent optic nerve disc. In patients with macular hole, the center of the macula also exhibited faint granular fluorescence. At 6 months postoperative or later, only the optic disc remained fluorescent, but the fluorescence was far less intense than at 3 months. Infrared photographs of the fellow eyes exhibited no fluorescence.This study showed,that after intraoperative use of ICG for macular surgery, fluorescence of the optic disc and of the macular center after macular hole surgery persisted for months in all cases. ICG may accumulate in the macular pigment epithelium and optic nerve, raising the problem of the as yet unknown pharmacokinetics of ICG after intravitreous administration and of its long-term safety.

Posted by kjalali at 08:34 PM

Matrix Metalloproteinase Inhibition Modulates Postoperative Scarring after Experimental Glaucoma Filtration Surgery
Investigative Ophthalmology and Visual Science. 2003;44:1097-1103
To determine whether postoperative application of a broad-spectrum matrix metalloproteinase (MMP) inhibitor, GM6001 (ilomastat), reduces scarring after glaucoma filtration surgery. In a randomized, prospective, masked-observer study, 40 New Zealand White rabbits underwent modified glaucoma filtration surgery. Surgical outcome was significantly prolonged in the ilomastat-treated group compared with the vehicle-treated group (P < 0.001). At day 30, all the blebs had survived except two in the ilomastat-treated group, whereas no blebs survived to day 30 with vehicle treatment (n = 11). The intraocular pressure remained significantly lower throughout the course of the experiment in the ilomastat group compared with the vehicle group (P < 0.0017). Histologically, less scar tissue was observed at the sclerostomy site with inhibition of MMP, compared with vehicle treatment. The data presented suggest that the healing response after surgery can be modulated by inhibiting the effects of MMPs. Inhibition of MMP significantly improved surgical outcome by reducing the amount of scar tissue produced. By targeting the actions of these proteolytic enzymes, a more controlled and physiological method of modulating scarring may be achieved.
Related articles : 1 2

Posted by mmiraftab at 12:31 PM

TGFß-Induced Factor: A Candidate Gene for High Myopia
Investigative Ophthalmology and Visual Science. 2003;44:1012-1015

Posted by mmiraftab at 12:22 PM

The role of unilateral temporal artery biopsy
Ophthalmology,March,2003

In this cohort study follow-up information for patients with unilateral negative temporal artery biopsy(TAB)was reviewed for potential adverse outcomes caused by missed or delayed diagnoses of GCA. . One (1%) subjects of 88 had a subsequent positive contralateral TAB; no adverse outcomes occurred for this subject or for any other subjects with unilateral negative TAB. The most common indications for biopsy in subjects with unilateral negative TAB were elevated erythrocyte sedimentation rate (ESR) (74%), headache (69%), visual complaints (58%), and ophthalmic signs (52%. In conclusion: in the hands of experienced physicians, a unilateral TAB is sufficient to exclude a diagnosis of GCA in populations for which clinical suspicion is low. Jaw claudication, pale optic disc edema, particularly "chalky white" disc edema, fever, or any systemic symptom other than headache should raise suspicion for a diagnosis of GCA.

Posted by afarahi at 12:14 PM

CROSSWORD PUZZLE

Posted by mmiraftab at 12:14 PM

Diplopia After Refractive Surgery
Arch Ophthalmol. 2003;121:315-321
The causes of postoperative diplopia could be traced to 1 of 5 mechanisms. These included technical problems, prior need of prisms, aniseikonia, iatrogenic monovision, and improper control of accommodation in patients with strabismus. The recommended screening techniques would have identified all patients in this series as being at risk for postoperative diplopia with the exception of those in whom technical problems were responsible. Diplopia can become manifest after refractive surgery. With proper attention paid to risk stratification and recommended screening criteria, the incidence of this complication can be minimized.

Posted by mmiraftab at 12:09 PM

March 10, 2003

Optic disc excavation in the atrophic stage of Leber's hereditary optic neuropathy: comparison with normal tension glaucoma
Graefe's Archive for Clinical and Experimental Ophthalmology

Abnormal optic disc excavations are reportedly seen in patients with Leber's hereditary optic neuropathy (LHON), a mitochondrial dysfunction disease. We examined the disc morphology in the eyes of patients with LHON at the atrophic stage and compared it to that in eyes with normal-tension glaucoma (NTG).We studied 15 LHON patients with the 11778 mutation, 15 patients with NTG, and 25 normal subjects. The optic disc morphology was analyzed by Heidelberg retinal tomography (HRT). Ten parameters of the optic disc obtained by HRT were evaluated, including the diagnostic classification of glaucoma. Six of the nine morphological HRT parameters of the LHON patients, the exceptions being disc area, mean cup depth, and maximum cup depth, differed significantly from those of the normals. NTG patients had a significantly greater mean and maximum cup depth than LHON patients. The HRT glaucoma diagnostic software classified 22 (73%) of the 30 optic discs in LHON patients as glaucomatous..The optic discs at the atrophic stage of LHON eyes have glaucoma-like morphological changes. However, the cups were significantly deeper in NTG than LHON. The similarity in the optic disc findings in LHON and NTG suggests that alterations in mitochondrial function may be related to optic disc excavations.

Posted by mehdi khanlari at 11:34 PM

Inverted pneumatic retinopexy
Ophthalmology March,2003

Eleven patients presenting with rhegmatogenous retinal detachments with causative inferior retinal breaks. Patients were followed for a minimum of 3 months (mean, 5.1 months). Primary retinal reattachment was obtained in 10 of 11(91%) patients. One patient sustained a redetachment secondary to proliferative vitreoretinopathy, resulting in a single operation reattachment rate of 82%. Final reattachment was obtained in 11 of 11 (100%) patients. Mean visual acuity improved about 3 lines from 20/60 to 20/30, with 11 of 11 patients experiencing improvement in their visual acuity. Two patients required an additional surgical procedure to achieve final anatomic success. No new breaks were identified in the postoperative period, and no complications resulted from the pneumatical procedure.
Inverted pneumatic retinopexy can successfully repair retinal detachments with inferior retinal breaks under appropriate conditions.
ESMM

Posted by mriazi at 12:37 AM

Debate over Selective Laser Trabeculoplasty continues
OCULAR SURGERY NEWS 2003

While one surgeon argues that selective laser trabeculoplasty is a safe alternative to ALT, another counters that the data is sparse. Two eminent glaucoma specialists speaking here found little to agree on as they debated if selective laser trabeculoplasty is preferable to argon laser trabeculoplasty for the treatment of open-angle glaucoma.
Mark A. Latina, MD, who is credited with developing selective laser trabeculoplasty (SLT) technology, believes it is safer and generally more effective than ALT. In his argument in favor of SLT, he stressed that it should not be dismissed because it is a newcomer. “Historically, new technologies that appear to result in similar outcomes have elicited controversy ... but in all these cases the newer technologies prevail,” Dr. Latina said. He cited phacoemulsification and YAG laser iridotomy as two examples of now commonly practiced techniques that met with initial resistance and controversy., Dr. Wilson emphasized a need for more comprehensive and long-term studies.
He also said surgeons should approach Dr. Latina’s endorsement with a “note of caution and a hint of doubt” because his professional and financial interest in the new technology “may have altered some of the dispassionate objective assessment that scientists like Dr. Latina are known for.”

Posted by mmiraftab at 12:36 AM

First Results With Wavefront-guided Photorefractive Keratectomy for Hyperopia
Journal Of Refractive Surgery Vol. 18 No. 5 September/October 2002

To compare the results of traditional laser photoablation and wavefront-supported customized ablation (WASCA) in hyperopic (H-PRK).
comparing two treatment groups, each comprising 40 eyes of 20 patients. Wavefront aberrations were examined using a Shack-Hartmann aberrometer. Preoperative refraction was similar in the two groups; in the traditional H-PRK group (Group 1) it was +3.10 ± 0.85 D, and in the WASCA-guided group (Group 2) it was +2.90 ± 0.80 D. H-PRK was performed flying-spot excimer laser..In Group 1, mean postop ref was +0.14 ± 0.24 D, and in Group 2, -0.10 ± 0.25 D; mean UCVA was 0.92 ± 0.16 in Group 1 and 0.95 ± 0.18 in Group 2. Mean BSCVA was 0.96 ± 0.04 in Group 1 and 1.06 ± 0.13 in Group 2. In Group 1, 67.5% (27 of 40 eyes), and in Group 2, 85% (34 of 40 eyes) were within ±0.50 D of target refraction. Regarding change of SCVA in Group 1, 5% (2 of 40 eyes), and in Group 2, 20% (8 of 40 eyes) gained one Snellen line compared to the preoperative; in Group 1, 10% (4 of 40 eyes), and in Group 2, 12.5% (5 of 40 eyes) lost two Snellen lines. In Group 2, the root mean square value for the higher order aberration increased from the initial 0.134 to 0.257 µm at 6 months after surgery.WASCA-guided hyperopic-PRK treatment was found to be safe and predictable. The results were better than those achieved with traditional PRK performed using the same flying-spot type excimer laser.
ESMM

Posted by alireza habibollahi at 12:34 AM

Clinicians explore the possibility of ‘good’ aberrations
OCULAR SURGERY NEWS 3/1/03

Researchers and surgeons are trying to determine whether all high-order aberrations are harmful to vision, or if some might be helpful.Listen to enough discussion of wavefront-customized refractive surgery and you will hear clinicians discussing the existence of “good” aberrations. The discussion usually involves the super-vision enjoyed by some pilots and baseball players, and just what these people’s eyes have that others do not. The message often is that some optical aberrations are good, and they should be preserved in patients’ eyes. Correcting some eyes to perfect sphericity might actually worsen that patient’s vision rather than improve it.Others say an aberration is an aberration, and any aberration will decrease the quality of an optical image.

Posted by mmiraftab at 12:26 AM

Anemia and Papilledema
AJO April 2003

Anemia may play a role in the occurrence of raised intracranial pressure and papilledema. Because most patients are not known to be anemic when papilledema is discovered, the authors suggest that a complete blood count be obtained in patients with isolated intracranial hypertension, especially in the absence of known associated factors such as obesity or medication, or when treatment aimed at lowering intracranial pressure fails to improve the patient's symptoms.

Posted by mmiraftab at 12:20 AM

March 09, 2003

Effect of bimatoprost on patients with primary open-angle glaucoma or ocular hypertension who are nonresponders to latanoprost
Ophthalmology (2003) 110: 609-614

Fifteen patients were enrolled. Random allocation to treatment to a single eye only of every subject. Eligibility criteria: (1) IOP > 22 mmHg in both eyes on current treatment (on three separate readings > 24 hours apart), (2) angle wide open in both eyes, (3) no pseudoexfoliation and/or pigment dispersion in either eye, (4) documented medical history consistent with < 10% IOP decrease in both eyes on 2-month treatment with latanoprost 0.005% every day. The following variables were measured at each study visit: (1) IOP (Goldmann applanation tonometry, 5 readings, 8 AM, 12 noon, 4 PM, 8 PM, and 12 midnight); (2) visual acuity (Early Treatment of Diabetic Retinopathy Study chart, logarithm of the minimum angle of resolution); (3) estimate of conjunctival hyperemia based on 5 standard photographs (graded as "none," "trace," "mild," "moderate," and "severe"). IOP data (mean and standard deviation) were the following: baseline = 24.7 ± 0.9 mmHg, after washout = 24.8 ± 1.1 mmHg, after latanoprost phase = 24.1 ± 0.9 mmHg, after bimatoprost phase = 18.1 ± 1.7 mmHg. IOP on bimatoprost proved lower than both baseline (P < 0.0001) and latanoprost (P = 0.0001). Thirteen of 15 patients showed a 20% IOP decrease with bimatoprost treatment. None of the 15 patients showed a 20% decrease of IOP after 30 days of latanoprost treatment. No significant IOP changes were observed in the fellow untreated eye in each patient throughout the study. Trace-to-mild conjunctival hyperemia was recorded more often with bimatoprost phase (P = 0.035).Thirteen of 15 patients, who were nonresponders to latanoprost, 0.005%, 2D, were successfully treated with bimatoprost, 0.03%, 2D. Bimatoprost treatment was associated with a higher incidence of trace-to-mild conjunctival hyperemia than latanoprost.

Posted by mmiraftab at 11:55 PM

Attempted bilateral manual enucleation (gouging) during a physical assault
Ophthalmology (2003) 110: 575-577

A 37-year-old female cocaine user was attacked by a drugged man who tried to gouge out her eyes. The attack took place approximately 1 hour before her arrival at the hospital. Other than drug use, her medical history was unremarkable. She was conscious at admission. She had no light perception in either eye. There was extremely severe proptosis of both eyeballs, right more than left, with periorbital hematomas and subconjunctival hemorrhages and chemosis. Intraocular pressure was approximately 30 mmHg in the right eye and 60 mmHg in the left eye. The pupils were middilated and did not react to light. Vitreous hemorrhage was observed in the right eye, with only partial visualization of subretinal hemorrhages around the disc. In the left eye, retinal venous pulsations and choroidal hemorrhages were seen around the disc. The computed tomographic scan showed normal brain structures with no evidence of intracranial hemorrhage. It revealed proptosis of both globes (right more than left), with evidence of intraconal hemorrhage. The right globe seemed disfigured, and severance of extraocular muscles was observed . Lateral canthotomy for orbital decompression was performed in the emergency room, and the patient was treated with intravenous acetazolamide, IV mannitol, and drops of aproclonidine 0.5% and timolol 0.5%. Orbital exploration under general anesthesia was performed. Severe edema of periorbital tissues, laceration of the conjunctiva and Tenon capsule, and active retrobulbar hemorrhage were observed. All extraocular muscles in the right globe, with the exception of the superior rectus, were ruptured, and there was prolapse of the orbital fat. No evidence of globe perforation could be found in either eye. In the left eye all extraocular muscles were torn. The left lateral rectus muscle could not be identified. All the other muscles in both eyes were repaired by sewing two parts of each muscle together or by reinsertion to the original site. Hemostasis was achieved, and after closure of the conjunctiva, anterior chamber paracentesis was performed in both eyes to relieve the high intraocular pressure.After surgery, the patient was treated with IV cefuroxime 750 mg three times daily, intravenous methylprednisolone 250 mg four times daily, oral acetazolamide 1 g/day, and topically by timolol 0.5%, aproclonidine 0.5%, and latanoprost. Dexamethasone 1 mg, neomycin 5 mg, atropine 1%, and ciprofloxacin were also administered. Intraocular pressure decreased to normal in 48 hours. Vision in the left eye recovered to 2-meters finger count within 24 hours of surgery. The right eye remained blind with no light perception and dense vitreous hemorrhage. Ultrasonographic imaging of the right eye revealed avulsion of the right optic nerve and vitreous incarceration into the posterior sclera . Hemorrhagic choroidal detachment was noted around the disc in the left eye.One week after surgery, the patient’s corrected visual acuity in the left eye improved to 20/60 with resolution of the suprachoroidal hemorrhage. Fluorescein angiography demonstrated peripapillary hemorrhages and choroidal rupture under the disc in the left eye . The visual field of the left eye showed concentric narrowing, especially in its upper and temporal parts.Two weeks after surgery, anterior segment ischemia was demonstrated in the blind right eye by greenish flare and iris discoloration. There was no movement of the right globe; normal function of the left superior rectus, inferior oblique, and medial rectus muscles; limited function of the left superior rectus and left inferior rectus muscles; and almost no function of the left lateral rectus muscle. Antiglaucoma treatment and prednisone 80 mg/day were continued with slow tapering of the corticosteroid. At the 6-month follow-up, the patient’s condition remained stable.

Posted by mmiraftab at 11:48 PM

Correction of astigmatism with short arc-length intrastromal corneal ring segments
Ophthalmology (2003) 110: 516-524

To evaluate the refractive effect of 130° short arc length intrastromal corneal ring segments (ICRS) designed to correct myopia concurrent with astigmatism. Ten eyes of 6 patients with manifest refraction spherical equivalent between -1.00 and -6.00 diopters (D), manifest cylinder correction between 1.00 and 6.00 D, and best spectacle-corrected visual acuity of 20/20 or better. At 6 months, uncorrected visual acuity was 20/20 or better in 80% of eyes (8/10) and 20/40 or better in all eyes. Eight of 10 eyes (80%) were within ±0.25 D of plano spherical equivalent manifest refraction. There was no loss of best spectacle-corrected visual acuity, and 6 of 10 eyes (60%) gained a line. Reduction of keratometric cylinder by ICRS thickness was statistically significant (P = 0.039). Preliminary results of visual and refractive performance after correction of compound myopic astigmatism using short arc length ICRS are promising.

Posted by mmiraftab at 11:40 PM

March 06, 2003

Young patient has bilateral elevation of optic nerves: What is your diagnosis?
Ophthalmology Times February 15, 2003

An 11-year-old female was referred to the emergency room at Bascom Palmer Eye Institute from an outside optometrist after presenting there for a routine eye exam. The referral was to evaluate the patient's optic nerves. Her history was significant for frontal headaches lasting about 1 hour at a time occurring two to three times a week, as well as intermittent nausea occurring two to three times a month The symptoms had been present for the last 6 months. She denied any change in vision, diplopia, pain with eye movements, or photophobia. Medical history was unremarkable. Ocular history was significant for an intermittent esotropia. The patient was taking no medications and had no allergiesFamily history was non-contributory. Initial examination in the emergency room revealed a healthy-appearing female in no acute distressBest-corrected visual acuity was 20/20 OD and 20/25+ OS. Confrontation visual fields and ocular motility were full OU. Pupils were pharmacologically dilated. IOPs were 19 mm Hg OD and 21 mm Hg OS. Slit-lamp examination was within normal limits OU. Dilated funduscopic examination of the right eye (Figure 1) was significant for a small optic nerve with no visible cup and blurring of the disc margins secondary to elevation of the optic nerve. The left eye (Figure 2) revealed similar findings with slightly less elevation of the optic nerve. The remainder of the funduscopic examination was within normal limits OU.

Posted by mehdi khanlari at 08:17 PM

Magnified image: Implanted telescope might enable vision
Ophthalmology Times February 15, 2003

Saratoga, CA-VisionCare Ophthalmic Technologies Inc. is enrolling patients in a multi-center, phase II/III clinical trial to determine the safety and efficacy of its Implantable Miniature Telescope (IMT). The tiny precision telescope-about the size of a pea-is implanted in one eye as an outpatient procedure. It provides 32 or 2.22 magnification, projecting the magnified image over a wide field of the retina to improve the ability to recognize images that were previously difficult or impossible to see. The eye with the implant provides central vision, while the remaining eye provides peripheral vision. The device is being evaluated in patients with moderate to severe bilateral central vision impairment caused by dry or scar-stage wet age-related macular degeneration (AMD)or Stargardt's macular dystrophy. In a phase I trial, 14 patients received the IMT implant. One year later, most patients' vision doubled, gaining three or more lines of distance or near visual acuity and im-proving their ability to perform daily activities. The most common complication was transient inflammation. The upcoming trial will enroll 200 pa-tients who have either dry or scar-stage wet AMD or Stargardt's macular dystrophy in both eyes, are 55 or older, and have no other major eye disease, except cataract. Individuals who have undergone surgery for cataracts in both eyes are not eligible.


For more information, visit www.visioncareinc.net or call 408/872-0526

Posted by mehdi khanlari at 07:48 PM

Diquafosol filing
Ophthalmology Times February 15, 2003

Durham, NC-Inspire Pharmaceuticals Inc. will submit a new drug application (NDA) to the FDA by mid-2003 for diquafosol (INS365 Ophthalmic) for the treatment of dry eye.
Phase II and III results showed the solution offered statistically significant improvement over the placebo in corneal and conjunctival staining. The studies also showed symptomatic benefit, with strong trends in various symptoms and statistically significant improvement in patient-reported worst symptom score and clearing of for-eign-body sensation

Posted by mehdi khanlari at 07:41 PM

Istalol
Ophthalmology Times February 15, 2003

Senju Pharmaceutical Co. has filed a new drug application for a new formulation of timolol for the treatment of glaucoma. The FDA is reviewing the application. ISTA holds the marketing rights to the product in the United States, and has named the product Istalol. The drug was developed by Senju to be applied topically, once daily.

Posted by mehdi khanlari at 07:36 PM

Careful preoperative planning: Posterior polar cataract
Ophthalmology Times February 1, 2003

Posterior polar cataract is an invitation to capsule rupture and so cataract surgery in these cases necessitates thorough patient counseling, careful preoperative planning, and adaptations in intraoperative technique, said Samuel Masket, MD. "Surgeons must prepare themselves for capsule rupture, so they can manage that complication successfully if it occurs. Posterior polar cataract tends to be bilateral because it is dominantly inherited with variable expressivity.According to Daljit Singh, MD, the finding of a series of small, lens-like satellites around the main cataract can be used as a clue that a defect is present. On the other hand, Dr. Masket indicated his experience shows there tends not to be a capsule defect in eyes with a combined nuclear/posterior polar cataract, which typically is seen in patients aged 60 years and older. In addition, the surgeon must have strategies for handling a rupture if it occurs. Modifications in technique begin with creation of the capsulorhexis, which should be made smaller than the optic of the planned IOL, thereby enabling capsule capture of the optic portion of an IOL that must be placed in the ciliary sulcus, Dr. Masket said. In addition, the endonucleus should be defined by hydrodelineation rather than hydrodissection, because the latter technique may "blow out" the posterior capsule. Dr. Masket suggests removing the endonucleus first. Then, with the use of a dispersive viscoelastic, the epinucleus and cortex should be dissected. In the absence of a defect, the surgery can proceed routinely, although capsule polishing should be avoided. "Since the posterior capsule is often thin, it is far better and easier to use the Nd:YAG laser postoperatively than to have to deal with vitreous intraoperatively," . If a hole is identified in the posterior capsule, the surgeon should not withdraw the phaco handpiece from the eye immediately, but should first lower the infusion bottle height and inject air or a dispersive viscoelastic agent to maintain chamber depth. Then, the phaco tip can be safely removed from the eye. For cortex removal, Dr. Masket indicated he prefers a dry bimanual system. However, if vitreous is present in the aspiration, cataract removal should be stopped to allow removal of vitreous from the anterior segment. When working in bimanual fashion, it may be necessary to work through a pars plana incision and afterward place air in the chamber to ascertain that no vitreous presents to any of the incisions, After successful management of vitreous,If the capsulotomy was properly sized, a very stable IOL environment can be created by depressing the optic edges and placing them behind the anterior capsule, keeping the haptic loops in the ciliary sulcus. For viscoelastic removal in cases complicated by vitreous loss he prefers to use the vitrector to remove any vitreous remaining in the anterior segment. He next fills the chamber with air through the side-port incision to prevent forward migration of the lens, hydrates the incisions, and exchanges the air for balanced salt solution. All incisions are tested with fluorescein dye and point pressure at normal IOP to discern that they are hermetically sealed.

Posted by mehdi khanlari at 07:29 PM

March 05, 2003