Ebner R, Devoto MH, Well V, Bordaberry V, Mir C, Martinez H, Bonelli V, Niepomniszcze V Br J Ophthalmol. 2004;88:1380-86.

There is no gold standard of treatment for the thyroid associated ophthalmopathy (TAO) in the early (inflammatory) stages of the disease. Corticosteroids reduce the transitory manifestations of TAO but their multiple adverse effects make the risk/benefit relation unsatisfactory. The beneficial effects of steroids used locally (subconjunctival or retrobulbar injections) in the treatment of TAO have been reported in the literature. In authors knowledge there is no study designed to demonstrate the advantages of steroids used locally (periocular injections) improving TAO in the early stages. We also analysed the impact of secondary effects associated with local steroid administration. The purpose of this study was to evaluate the efficacy of periocular triamcinolone acetonide for the treatment of thyroid associated ophthalmopathy (TAO), and the presence of ocular or systemic adverse effects. This multicentre prospective pilot study was performed on patients diagnosed with Graves’ ophthalmopathy less than 6 months before entry to the study. Patients were admitted to the study and were randomised into two groups: treatment and control. The treatment group received four doses of 20 mg of triamcinolone acetate 40 mg/ml in a peribulbar injection to the inferolateral orbital quadrant. Both groups were evaluated by measuring the area of binocular vision without diplopia on a Goldmann perimeter and the size of the extraocular muscles on computed tomography (CT) scans. Ophthalmological and systemic examinations were done to rule out ocular and systemic adverse effects. Follow up was 6 months for both groups. 50 patients were eligible for the study. 41 patients completed the study. There was an increase in the area of binocular vision without diplopia in the treatment group (Σ initial: mean 231.1 (SD 99.9) and final absolute change, mean 107.1 (SD 129.0)) compared to the control group (Σ initial: mean 350.7 (SD 86.5) and final absolute change, 4.5 (SD 67.6)). The sizes of the extraocular muscles mean were reduced in the treatment group (mean (inferior rectus initial values): 1.3 (0.7), final percentage change: -13.2 (25.7), medial rectus initial values: 1.2 (0.6), final percentage change: -8.2 (20.7), superior rectus-levator palpebrae initial values: 1.2 (0.6), final percentage change: 9.5 (29.1), lateral rectus initial values: 1 .0 (0.4), final percentage change: 11.5 (20.6)) compared to the control group (inferior rectus initial values: 0.9 (0.3), final percentage change: -4.0 (21.5), medial rectus initial values: 0.9 (0.3), final percentage change: 0.6 (22.4), superior rectus-levator palpebrae initial values: 0.9 (0.3), final percentage change: 12.5 (37.5), lateral rectus initial values: 0.9 (0.4), final percentage change: -0.5 (31.6)). Both measurements (degree of diplopia and muscle thickness) were statistically significant between groups (initial -final). No systemic or ocular adverse effects were found. Authors concluded that triamcinolone administered as a periocular injection is effective in reducing diplopia and the sizes of extraocular muscles in TAO ophthalmopathy of recent onset. This form of treatment is not associated with systemic or ocular side effects.

  Mitomycin C for pterygium: long term evaluation

  Raiskup F, Solomon A, Landau D, llsar M, Frucht-Pery J Br J Ophthalmol 2004;88:1425-8.

  Pterygium is a common ocular surface disorder treated by surgical excision. Pterygia are more prevalent in patients living in regions closer to the equator. Histologically, an epithelial lining covers atrophic conjunctiva that extends beyond the limbus onto the cornea. Underneath this epithelium is a bulky mass of thickened, hypertrophic, and degenerated connective tissue characterised by elastoid degeneration. One of the major limitations of pterygium excision is the high rate of postoperative pterygium recurrence. The reported postoperative recurrence rate of pterygium excision alone ranges from 55.9%² to 89%. In an effort to reduce the recurrence rate, adjunctive therapy such as beta irradiation, mitomycin C, 5-fluorouracil, and thiotepa have been used with varying success during the last three decades. Mitomycin C (MMC) use, intraoperatively or postoperatively, is one of the adjunctive treatments that can significantly reduce the rate of pterygium recurrence. MMC is an antibiotic isolated from Streptomyces caespitosus. It is an alkylating agent that is bioreductive because it undergoes metabolic activation through a cytochrome P-450 reductase mediated reaction to create an alkylating agent. MMC damages cells by crosslinking DNA, forming covalent bonds with the guanine in DNA. MMC inhibits the synthesis of DNA, RNA, and protein and is radiomimetic in many of its actions. Uncontrolled use or overdose of MMC may cause severe complications. In the ophthalmic literature, a variety of mild and severe complications were reported when pterygium excision was combined with topical MMC use. These complications occurred within the early postoperative period. Only two reports indicated long term complications related to MMC, after pterygium excision. The purpose of this study was to evaluate long term complications after pterygium excision with mitomycin C (MMC) application. Forty three eyes of 43 patients were examined. Sixty three per cent of patients had pterygium surgery with intraoperative application of 0.02% MMC for 5 minutes and 37% of patients received MMC 1% or 2% drops four times daily for 2 weeks postoperatively. In three patients, pterygium recurred within 18 months. The only complication was mild conjunctiva! avascularity in areas of pterygium excision in 30% of patients. The authors concluded that long term evaluation revealed that the use of MMC in pterygium surgery is safe, but for a strict selection of patients, controlled use of MMC and long term follow up are required.

  Neurological concomitants of uveitis

  Smith JR, Rosenbaum JT Br J Ophthalmol. 2004;88: 1498-9.

  Uveitis may be associated with a variety of diseases including distinct ocular syndromes, immunologically mediated systemic diseases, infections, and masquerading syndromes such as malignancies. Despite recognition of a close anatomical relation, as well as immunological similarities, between the eye and the brain, the association between uveitis and neurological disease has rarely been considered. Clearly, the recognition of such associations has implications for visual and systemic prognosis and impacts patient management. Authors conducted a retrospective review of all patients who attended a tertiary referral uveitis service over a 15 year period to (1) establish the prevalence of concomitant neurological disease in patients with uveitis, (2) identify the neurological disorders that occur in association with uveitis, and (3) describe the types of uveitis that are associated with the most common neurological diagnoses. The purpose of this study was to describe the prevalence and types of neurological disease that occur in association with uveitis. Retrospective review of medical records of patients attending a tertiary referral uveitis service over a 15 year period. Of 1450 patients with uveitis, 115 (7.9%) had neurological disease that was considered to be causally related to the eye inflammation. The most frequent neurological associations were Vogt-Koyanagi-Harada disease, primary central nervous system lymphoma, multiple sclerosis, and herpes virus infections. The authors concluded with remarks that neurological disease is common among patients attending a uveitis service. The distinctive characteristics of the uveal inflammation may be useful in diagnosing the neurological disease.

  Prediciting time to refractive stability after discontinuation of rigid contact lens wear before refractive surgery

  Tsai PS, Dowidar A, Naseri A, McLeod J Cataract Refract Surg. 2004; 30:2290-94

  Successful refractive surgery depends on an accurate and stable refraction before the procedure. The refractive state of the eye is strongly governed by the corneal curvature. Although the corneal curvature is usually stable in the general adult population corneal warpage after prolonged contact lens use is well docomented. Corneal warpage can include refraction, steepening or flattening of the corneal curvature, an increase in regular or irregular as a decrease in best corrected visual acuity. The corneal changes are most pronounced with hard poly (methyl methacrylate) (PMMA) and rigid gas-permeable (RGP) contact lenses, although they can occur with soft contact lenses. Partial or complete reversal of cornea warpage will often occur with discontinuation of contact lenses. Because of this phenomenon, many practitioners keep refractive surgery candidates out of contact lenses for various amounts of time before the initial visit. While some practitioners assume stability after waiting a standard time period (typically 3 weeks), others apply a rule of thumb such as a week of lens wear cessation for each year of rigid lens use. An alternative is to perform repeat examinations to document refractive stability before a refractive procedure. Unfortunately, the time to stabilization is highly variable. In some patients, the refraction will stabilize in a few weeks; in others, it may take up to several months. It is currently unclear what factors influence the time to achieve corneal stability. The purpose of this study was to determine whether discontinuing rigid contact lenses for 3 weeks is sufficient to achieve refractive stability and if not, to identify factors, including indicators of corneal warpage, that are associated with prolonged corneal instability. Charts of patients seen for refractive surgery consultation from January 1999 to March 2001 were reviewed. Patients with a history of rigid gas-perme-able (RGP) contact lens use were identified and instructed to discontinue wearing lenses 3 weeks before the initial examination. Patients were examined at 3-week intervals until a stable refraction was achieved (within ±0.25 diopter (D) sphere and 0.25 D cylinder with less than 25 degrees of axis orientation). Visual acuity, subjective refraction, and corneal topography were obtained at each visit. Of 55 eyes of 28 patients, 31 eyes achieved refractive stability by the second visit (early-stability group) and 24 eyes required more than 2 visits to achieve stability (late-stability group). No statistically significant between-group difference was observed in age, sex, refractive cylinder, topographic cylinder, difference between refractive and topographic cylinders, surface regularity index, surface asymmetry index, or spherical equivalent at the initial examination. The number of years of contact lens wear was significantly different between the groups (P = .05). The authors concluded that the time for contact lens-induced corneal changes to reach a steady state after cessation of lens wear is highly variable. Among the variables examined, including those indicating corneal warpage, the factor that correlated with the required time to refractive stability after discontinuation of RGP wear was the length of time of contact lens use. Patients who are long-term RGP wearers should be counseled that multiple visits will likely be required before a stable refraction is obtained.

Intravitreal Triamcinolone Acetonide and Intraocular Pressure

  Smithen LM, Ober MD, Maranan L, Spaide RF Am J Ophthalmol. 2004; 138: 740-43. Intravitreal triamcinolone acetonide is an increasingly common treatment for a variety of ophthalmic conditions induced by uveitis, veno-occlusive disease, diabetes, and choroidal neovascularization. The applications of intravitreal triamcinolone expand, there is growing interest in the safety of corticosteroid injections. There does not appear to be much, if any, demonstrable toxicity immediately after intravitreal triamcinolone injection; over the long term, however, many patients eventually develop increased intraocular pressure (IOP). Although topical, periocular, and systemic corticosteroid administration can cause ocular hypertension and glaucoma, details of the incidence and magnitude of the IOP rise after intravitreal injection of triamcinolone is limited. The purpose of this study was to analyze the incidence of intraocular pressure (IOP) elevation following intravitreal triamcinolone injection. Charts of patients undergoing intravitreal triamcinolone injection in one clinical practice were reviewed. A pressure elevation was defined as a pressure of 24 mm Hg or higher during follow-up. There were 89 patients with a mean age of 76.4 years. The mean baseline IOP was 14.9 mm Hg with a mean change of 8.0 mm Hg. Thirty-six patients (40.4%) experienced a pressure elevation to 24 mm Hg or higher at a mean of 100.6 days (SD = 83.1 day) after treatment. Of nonglaucomatous patients with baseline IOP of 15 mm Hg or above, 60.0% experienced a pressure elevation, compared with only 22.7% of those with baseline pressures below 15 mm Hg (relative risk = 2.1, P < .01). In glaucoma patients, 6 of 12 (50%) experienced a pressure elevation, and this elevation was not correlated with baseline pressure. Thirty-two patients (36.0%) received repeat injections, and there was no difference in the incidence of procedure elevation in patients receiving multiple injections versus those receiving a single injection. Pressure elevation was controlled with topical medications in all patients. The authors concluded that IOP elevation after intravitreal triamcinolone injection is common and may take an extended period of time to manifest. The proportion of patients who developed a pressure elevation to at least 24 mm Hg was much higher for those with baseline IOP 15 mm Hg or greater.

Imaging for Neuro-ophthalmic and Orbital Disease

Lee AG, Brazis PW, Garrity JA,White M. Am J Ophthalmol. 2004; 138:852-62.

  Imaging techniques for visualizing pathology of the brain and orbit continue to evolve and improve. The clinician now has a wide variety of diagnostic tests from which to choose. This article provides a brief summary of the most commonly used techniques of interest to ophthalmologists (e.g., computed tomography (CT) and magnetic resonance imaging (MR), digital subtraction angiography (DSA); reviews the recent literature on newer modalities for imaging (e.g., MR angiography (MRA), CT angiography (CTA), MR venography, and diffusion-weighted imaging (DWI)); updates clinicians regarding special MR imaging sequences (for example, postcontrast, fat suppression, fluid attenuation inversion recovery); and discusses functional imaging (e.g., functional MRI, positron emission tomography, and single photon emission computed tomography (SPECT)). The purpose of this study was to provide an update on imaging of the brain and orbit for ophthalmologists. A systematic English-language Medline search and summary of recent literature on imaging of brain and orbit was performed. Computed tomography and magnetic resonance (MR) scanning are the mainstays for the evaluation of most disorders involving the brain and orbit. Computed tomography angiography and magnetic resonance angiography are relatively newer applications that are useful for the evaluation of arterial and venous disorders. Special sequences such as fat suppression and fluid attenuation inversion recovery are useful techniques for specific ophthalmic indications. Diffusion weighted imaging and perfusion-weighted imaging are improving the evaluation of acute stroke. Functional MRI, positron emission tomography scanning and single photon emission computed tomography may provide useful information regarding brain or tumor metabolism. Magnetic resonance spectroscopy has expanded our knowledge of brain function. Newer imaging studies have improved our diagnostic abilities on many fronts, including new sequences, new applications of imaging studies, and functional imaging of brain. The authors concluded that new imaging techniques for brain and orbit have an increased potential for improving diagnostic yield. Accurate and timely communication with the neuroradiologist can optimize the prescription and interpretation of imaging in ophthalmology.