Intractable diplopia: a new indication for corneal tattooing

Nipple-areolar tattoo: Comprehensive review of history, theory, technique, and outcomes

Breast reconstruction aims to achieve a natural look and can involve manipulation or removal of the nipple-areola complex (NAC) as well. One of the final steps of the breast reconstruction process involves creation of the appearance of a new NAC, either via surgical intervention or medical tattooing. Medical tattooing involves little to no surgical intervention while still resulting in aesthetically pleasing results. This specific type of tattooing can be performed by a member of the plastic surgeon team, or a medical tattoo specialist. Integration of this method into plastic surgery practice can prove beneficial to the patient as a viable solution for aesthetically pleasing NAC recreation.

Incidence, risk factors and management of intractable diplopia

AIMS

There is a paucity of literature concerning intractable diplopia. The aims of this study were to determine the incidence of intractable diplopia in the UK, identify the causes and any associated risk factors, establish how cases are managed and if the treatment is successful and tolerated.

METHODS

A 1-year prospective observational study was undertaken via the British Ophthalmological Surveillance Unit (BOSU). This involved implementation of a reporting mechanism, which then triggered distribution of an incident questionnaire to explore clinical details concerning each case and a follow-up questionnaire 6 months later to explore how the case had been managed.

RESULTS

The incidence of intractable diplopia was 53 cases per year. The most common preceding events were strabismus surgery (32%), no known preceding event, that is,spontaneous (25%), severe head trauma (8%), cataract surgery (6%) and vitrectomy (6%). In the at-risk age group of 7 years and above, the incidence of intractable diplopia following strabismus surgery is 1 in 494 (95% CI; 1 in 296 to 790) cases. A total of nine different treatments were used in the management, with many patients receiving between two and four different methods. The overall success rate was poor, but most effective were opaque intraocular lenses (IOLs) (86%) and opaque contact lenses (50%).

CONCLUSION

Intractable diplopia is a relatively rare but important condition. The main risk factor is a pre-existing strabismus, and careful counselling is needed when planning surgical correction in patients with no demonstrable binocular function. Treatment success of intractable diplopia is high when using opaque IOLs, although with additional risk, but is often disappointing via other methods where it can be difficult to eradicate the diplopia successfully.

Opaque intraocular lens implantation: a case series and lessons learnt

Purpose

To report the use of opaque intraocular devices in three patients with complex neuro-ophthalmic symptoms.

Methods

A case series of three patients with neuro-ophthalmic symptoms requiring occlusion of one eye when alternative methods had failed to control symptoms. Morcher (Stuttgart, Germany) opaque intraocular implants were used in all patients.

Results

All three patients observed an improvement in symptoms following opaque intraocular device implantation. One patient (Case 2) required multiple devices for symptom relief.

Conclusion

Opaque intraocular occlusive devices are an increasingly popular choice for clinicians in patients with intractable diplopia but we highlight their use in patients with other complex neuro-ophthalmic symptoms. We learned a number of useful lessons in these patients as summarized in this case series.

Occlusive IOLs for intractable diplopia demonstrate a novel near-infrared window of transmission for SLO/OCT imaging and clinical assessment

PURPOSE

Occlusive intraocular lens (IOL) implantation is an effective therapeutic option in patients with intractable diplopia, visual confusion, and unsightly leukocoria. However, their use has been restricted by concerns that inability to visualize the retina may prevent the diagnosis of important posterior pole diseases. In this study, transmission spectra of occlusive IOLs were defined as a basis for acquiring scanning laser ophthalmoscopy/optical coherence tomography (SLO/OCT) images.

METHODS

Fifteen IOLs of three designs were examined: black small and large PMMA and black Lotus (Morcher GmbH, Stuttgart, Germany). Each IOL was placed between a broad-spectrum white light source and a spectroradiometer, to generate transmission spectra for each lens and determine the cutoff wavelength. Transmission in the near-infrared (NIR) range was confirmed with an 850-nm LED. A model eye was implanted with occlusive IOLs, and SLO/OCT scans were acquired with seven clinical SLO/OCT imaging systems.

RESULTS

Occlusive IOLs demonstrated high levels of transmission of NIR light. It was determined that most SLO/OCT scanners would achieve 99% to 100% transmission at their operational wavelengths of NIR light. Furthermore, all clinical SLO/OCT imaging systems were capable of imaging fine retinal features without attenuation through occlusive IOLs in a model eye.

CONCLUSIONS

In this study, a novel NIR window of high-level transmission was identified across the occlusive IOLs with applications to SLO/OCT imaging and NIR-based clinical assessment. The ability to acquire high-quality SLO/OCT scans to detect posterior pole disease may fundamentally change the current view on occlusive IOLs and encourage their use in patients with intractable diplopia.