Dilated pupils and loss of accommodation following diode panretinal photocoagulation with sub-tenon local anaesthetic in four cases

Pupillotonia after endolaser retinopexy during vitrectomy for retinal detachment: a prospective cohort study comparing circumferential and focal retinopexy

PURPOSE

To determine differences in postoperative pupil diameter in eyes that undergo pars plana vitrectomy (PPV) for rhegmatogenous retinal detachment (RRD) with endolaser retinopexy (ELR), comparing 360° vs focal ELR.

METHODS

Patients with uncomplicated RRD who underwent PPV were prospectively analysed regarding the postoperative pupil diameter difference (PDD) between the affected eye and the partner eye. Group 1 underwent 360° ELR and group 2 received focal ELR. Postoperative vision and complications, including redetachment rate, macular oedema and epiretinal membrane formation, were also compared.

RESULTS

A total of 72 patients, 42 in group 1 and 30 in group 2, were analysed. PDD, as observed at 6 weeks, was significantly greater than the preoperative values in both groups 1 and 2. It increased by a mean of 1±1.11 mm in group 1 and by 0.5±0.78 in group 2. This initial increase in PDD receded over time, but remained statistically significant in both groups, even at 6 months. The top 20% of patients with the largest PDD change comprised 13 out of 15 eyes from group 1, which was a statistically significant overrepresentation (p=0.0435).

CONCLUSIONS

Moderate pupillotonia was induced post-ELR in vitrectomy and correlated to the extent of ELR. The pupillotonia effect of ELR was significantly less marked in pseudophakic eyes.

Limbal Epithelial Stem Cells in the Diabetic Cornea

Continuous replenishment of the corneal epithelium is pivotal for maintaining optical transparency and achieving optimal visual perception. This dynamic process is driven by limbal epithelial stem cells (LESCs) located at the junction between the cornea and conjunctiva, which is otherwise known as the limbus. In patients afflicted with diabetes, hyperglycemia-induced impairments in corneal epithelial regeneration results in persistent epithelial and other defects on the ocular surface, termed diabetic keratopathy (DK), which progressively diminish vision and quality of life. Reports of delayed corneal wound healing and the reduced expression of putative stem cell markers in diabetic relative to healthy eyes suggest that the pathogenesis of DK may be associated with the abnormal activity of LESCs. However, the precise role of these cells in diabetic corneal disease is poorly understood and yet to be comprehensively explored. Herein, we review existing literature highlighting aberrant LESC activity in diabetes, focusing on factors that influence their form and function, and emerging therapies to correct these defects. The consequences of malfunctioning or depleted LESC stocks in DK and limbal stem cell deficiency (LSCD) are also discussed. These insights could be exploited to identify novel targets for improving the management of ocular surface complications that manifest in patients with diabetes.

Diabetic Retinopathy – Diagnostics and Treatment Guidelines

Diabetic retinopathy is one of the most common complications of diabetes mellitus and represents a serious health, social and economic problem. With the expected increase in the number of patients with diabetes, it is becoming the leading cause of severe vision loss in the working-age population.  The presented guidelines summarize the current knowledge about this disease in order to standardize and update the procedures for the diagnosis, classification and treatment of diabetic retinopathy.

Complications in Retinal Surgery: A Review of Corneal Changes Following Vitreoretinal Procedures

Purpose:

The purpose of this article is to discuss the early- and late-onset corneal complications that can occur following vitreoretinal surgery.

Methods:

A systematic review of the literature was conducted using PubMed and Google Scholar databases. Articles detailing the clinical findings and the associations between surgical techniques, irrigating solutions, and microsurgical instruments used for vitreoretinal surgery and postoperative corneal complications were included in this review.

Results:

Vitreoretinal surgery can be associated with corneal complications such as persistent corneal epithelial defects, neurotrophic keratopathy, band keratopathy, ocular surface disruption, and endothelial cell damage. Risk factors for the development of cornea complications after posterior segment surgery include history of uncontrolled diabetes mellitus, aphakia or pseudophakia, disrupted anterior lens capsule integrity, use of irrigating solutions without appropriate buffers, use of contact viewing lenses intraoperatively, intraocular gases or silicone oil after vitrectomy, and prolonged duration of surgery.

Conclusions:

Corneal complications secondary to vitreoretinal surgery are multifactorial, but more commonly arise in diabetic patients, those with preexisting ocular comorbidities, and under certain surgical-related conditions. Special pre-, peri-, and postoperative considerations, with a focus on early identification and management of risk factors, are required to help decrease the incidence of corneal complications.

[Internal ophthalmoplegia after retinal laser photocoagulation]

Laser photocoagulation of the retina is a highly effective technique for preventing visual loss in patients with a wide range of eye fundus diseases. The procedure involves creating thermal burns in the eye fundus accompanied by tissue coagulation, but unfortunately it can lead to possible side-effects and potential complications in the future. Some of the rare complications following retinal laser photocoagulation discussed in this article are accommodative weakness and pupil dilation with eventual transitory myopia and corneal sensitivity impairment. This literature review aims to provide an objective summary of global scientific literature on the issue of internal ophthalmoplegia developing after retinal laser photocoagulation, and describes in detail the current state of the problem including reported occurrences, inciting factors and underlying pathophysiology.

Bilateral Adie's Pupil following Laser Treatment of the Ischemic Peripheral Retina for Uveitis: A Case Report

Adie's pupil is a neurological condition of unknown origin with unusual, asymmetric presentation known as anisocoria with the enlarged pupil failing to react to light. It is believed that this pupillary abnormality results from damage to the ciliary ganglion or postganglionic short ciliary nerves. Affected individuals (usually female) may be symptomatic with photophobia or difficulty reading in the diseased eye. Although most Adie's pupil cases are idiopathic, previous studies have associated photocoagulation and uveitis with symptom onset. To the best of our knowledge, there have been no reports of specific means of preventing Adie's pupil. We describe a patient who experienced varying severities of Adie's pupil after separate laser treatments of the ischemic peripheral retina for uveitis. Fluorescein angiography revealed peripheral retinal nonperfusion in the bilateral eyes of a 37-year-old Japanese female who had been suffering from posterior uveitis. To avoid proliferative changes, 360° laser photocoagulation of the retinal nonperfusion region located in the far periphery was first delivered to the left eye over 2 sessions. Soon after treatment, the patient complained of acute photophobia and blurred vision in the treated eye. Ocular examination revealed left pupil dilation and poor light sensitivity, although the pupil was reactive to a close stimulus. The left pupil also displayed positive denervation sensitivity based on the dilute pilocarpine (0.125%) test. Adie's pupil was diagnosed based on these observations. Three months later, similar, albeit milder, findings were observed in her right eye after 360° peripheral laser photocoagulation that was more conservatively performed over 4 sessions. Four months after the first treatment, her subjective visual function had improved, and the pupil diameter had decreased to a normal size in both eyes without additional treatment. We encountered a patient whose severity of Adie's pupil was apparently reduced by more conservative laser photocoagulation of the ischemic peripheral retina.

Assessment of pupillary light reflex using dynamic pupillometry in laser-treated eyes with retinal vein occlusion

PURPOSE

This study aims to evaluate the pupillary light reflex measured with dynamic pupillometry in patients who underwent retinal laser photocoagulation due to unilateral retinal vein occlusion (RVO).

METHODS

A total of 48 patients with unilateral RVO were included in the study. Thirty-four patients had undergone retinal laser photocoagulation while the remaining 14 patients that did not undergo laser treatment were observed for control purposes. Of the laser-treated eyes, 14 eyes (41.2%) had central RVO (CRVO) and 20 eyes (58.8%) had branch RVO (BRVO). Among the 14 patients with RVO without laser treatment, nine eyes (64.3%) had CRVO and five eyes (35.7%) had BRVO. Pupillary light reflexes were assessed with dynamic pupillometry (MonPackOne®; Metrovision, France). The parameters of the eyes with RVO were compared with that of fellow healthy eyes.

RESULTS

Mean patient age was 65.8 ± 10.4 years and median time after photocoagulation was 25.5 months. Eyes that received laser photocoagulation had lower pupil contraction amplitude (p = 0.037), prolonged contraction latency (p = 0.027), slower contraction velocity (p = 0.043), and slower dilation velocity (p < 0.001) compared to healthy fellow eyes. Subgroup analysis revealed that eyes with CRVO had lower contraction amplitude (p = 0.013) and slower dilation velocity (p = 0.003), and eyes with BRVO had slower dilation velocity (p = 0.003). Non-laser-treated eyes with RVO revealed no significant difference in any of the pupillary light reflex parameters compared to fellow eyes.

CONCLUSION

Laser-treated eyes with RVO demonstrated changes in pupillary light reflex parameters including reduced contraction amplitude, prolonged contraction latency, and slower contraction and dilation velocities measured with dynamic pupillometry.

Effect of Aflibercept on Diabetic Retinopathy Severity and Visual Function in the RECOVERY Study for Proliferative Diabetic Retinopathy

PURPOSE

To evaluate the effect of intravitreal aflibercept on diabetic retinopathy (DR) severity and visual function in patients with proliferative DR (PDR) without diabetic macular edema (DME).

DESIGN

Prospective, longitudinal, multicenter clinical trial.

PARTICIPANTS

Forty eyes of 40 patients with PDR and no DME were enrolled in this study. Patients were randomized into monthly and quarterly 2-mg aflibercept injection cohorts and were treated over a period of 12 months.

METHODS

All patients underwent ultra-widefield fundus imaging including pseudocolor and fluorescein angiography using an Optos 200Tx device.

MAIN OUTCOME MEASURES

Severity of DR at baseline, month 6, and month 12 was evaluated using the DR severity scale (DRSS). The DRSS scores were correlated with the 25-item Visual Function Questionnaire (VFQ-25) and 39-item Visual Function Questionnaire (VFQ-39) scores at baseline and month 12.

RESULTS

Mean age of the patients was 48.2 years (range, 25-75 years), mean duration of diabetes mellitus was 16.1 years (range, 2-36 years), and median glycated hemoglobin level was 8.8% (IQR, 7.4%-10%). Both monthly and quarterly groups demonstrated a statistically significant regression in DRSS from baseline to month 12 (P < 0.001). The monthly group demonstrated a statistically significant greater regression of DRSS score at the month 6 visit compared with the quarterly group (P = 0.019). However, the difference between the two groups became statistically insignificant at month 12 visit (P = 0.309). Also no difference was found in mean VFQ-25 and VFQ-39 composite scores between the monthly and quarterly groups at month 12 (P = 0.947 and P = 0.921, respectively). The improvement in mean VFQ-25 and VFQ-39 composite scores at month 12 was correlated significantly with improvement in DRSS score (r = 0.384 and P = 0.039, and r = 0.361 and P = 0.046, respectively).

CONCLUSIONS

In this study of eyes with PDR without DME, both monthly and quarterly aflibercept injection groups showed significant improvement in DR severity at month 12 compared with baseline. The improvement in DRSS score was associated with an improvement in VFQ-25 and VFQ-39 composite score.

Methods for achieving adequate pupil size in cataract surgery

PURPOSE OF REVIEW

Cataract surgery is the most common surgical procedure performed worldwide. Small pupils have been an eternal challenge for cataract surgeons; insufficient pupil dilation is associated with increased complication rates, including capsule rupture, vitreous loss, iris trauma or postoperative inflammation. The aim of the current review is to present the methods for pupil dilation and the risk factors for a small pupil in a cataract patient.

RECENT FINDINGS

Risk factors for intraoperative small pupil include diabetes, intraoperative floppy iris syndrome, pseudoexfoliation syndrome, receiving glaucoma medications, having undergone previous ocular surgery and iris sphincter sclerosis from aging. There is a wide range of options to manage the small pupil, including pharmacological treatment, mechanical stretching, dilation with iris hooks or pupil expanders. We recommend a stepwise approach for intraoperative pupil dilation, from pharmacological mydriasis to pupil expanders.

SUMMARY

The current article discusses risk factors for a small pupil and the methods for pupil dilation in a cataract patient. Every cataract surgeon needs to be ready to cope with a small pupil, both manifesting preoperatively and intraoperatively.

Near reading speed changes after panretinal photocoagulation in diabetic retinopathy patients: a prospective study using an iPad application for the measurement of reading speed

PURPOSE

To investigate the changes in the near reading speed after panretinal photocoagulation (PRP) in diabetic retinopathy patients.

METHODS

This non-randomized, prospective, clinical study enrolled diabetic retinopathy patients who underwent PRP from January 2016 to June 2017. The near reading speed was measured before and 1 week, 1 month, and 4 months after PRP by using an iPad application for the assessment of reading speed; near best-corrected visual acuity (BCVA) and subfoveal choroidal thickness (SFCT) were also analyzed. The reading speed of age-matched healthy individuals was compared with that of diabetic retinopathy patients.

RESULTS

Forty-seven patients were enrolled in this study. The baseline near reading speed of diabetic retinopathy patients was significantly slower than that of age-matched healthy controls. The near reading speed was reduced at 1 week after PRP, but recovered at 1 and 4 months after PRP. Near BCVA showed a similar pattern after PRP. SFCT increased at 1 week after PRP and significantly decreased at both 1 and 4 months after PRP.

CONCLUSION

The near reading speed of diabetic patients was significantly slower than that of age-matched healthy controls. The speed was temporarily reduced at 1 week after PRP, potentially due to short-term impairment of parasympathetic nerve innervation.

The role of anti-vascular endothelial growth factor (anti-VEGF) in the management of proliferative diabetic retinopathy

Diabetes is a major cause of visual impairment among working-age adults in the United States. The proliferative form of diabetic retinopathy is associated with severe vision loss (acuity <5/200). The standard treatment in proliferative diabetic retinopathy (PDR) is panretinal photocoagulation (PRP), which is effective but has established side effects such as peripheral visual-field constraints. Vascular endothelial growth factor (VEGF) is thought to drive the process of vascular proliferation. Drugs targeting VEGF (anti-VEGF) have been studied extensively in diabetic macular edema (DME), and results have shown that diabetic retinopathy regresses with anti-VEGF treatment. Recent studies show that anti-VEGF is not inferior to PRP for PDR while treatment is maintained, though recurrence rate when anti-VEGF treatment is stopped is unclear. In vitreous hemorrhage where PRP cannot be performed, use of anti-VEGF medications can treat underlying PDR and delay or reduce need for vitrectomy. Limitations of anti-VEGF treatment, however, require careful patient selection and monitoring. This review discusses recent clinical trials and guidelines for anti-VEGF use in PDR.

Evidence-Based Treatment of Diabetic Retinopathy

Diabetic retinopathy (DR) is the most frequent microvascular complication from diabetes and requires annual screening and at least annual follow-up. A systemic approach to optimize blood glucose and blood pressure may halt progression to severe stages of DR and obviate the need for ocular treatment. Although there is evidence of benefit from fenofibrate or intravitreous antiVEGF treatment for eyes with nonproliferative DR (NPDR), these therapies are not standard care for NPDR at this time. Some patients with severe NPDR, especially those with type 2 diabetes, benefit from early panretinal photocoagulation (PRP). Once DR progresses to proliferative DR (PDR), treatment is often necessary to prevent visual loss. PRP remains mainstay treatment for PDR with high-risk characteristics. However, intravitreous antiVEGF injections appear to be a safe and effective treatment alternative for PDR through at least two years. Vitreoretinal surgery is indicated for PDR cases with non-clearing vitreous hemorrhage and/or tractional retinal detachment.

Changes in pupil size following panretinal retinal photocoagulation: conventional laser vs pattern scan laser (PASCAL)

PurposeTo evaluate and compare the possible changes in pupil size subsequent to panretinal laser photocoagulation (PRP) via conventional laser and pattern scan laser (PASCAL).Patients and methodsForty eyes of 40 patients with diabetic retinopathy were included. 20 eyes had a PRP via conventional laser and formed Group 1. 20 eyes had a PRP via PASCAL laser and formed Group 2. The participants underwent standard ophthalmologic examination at baseline. Automated infrared pupillometry were performed at baseline and month 1.ResultsThe mean pupillary measurements (mm) for Group 1 (in the order photopic, mesopic, and scotopic conditions) were 2.88±0.34, 3.38±0.40, and 3.95±0.38, and changed to 3.64±0.42, 4.18±0.42, and 4.58±0.48, respectively. There was significant increase in pupil size at month 1 (P<0.001, P<0.001, and P<0.00, respectively). For Group 2, they were 2.90±0.38, 3.43±0.36, and 3.90±0.40, and changed to 3.18±0.42, 3.74±0.36, and 4.10±0.38, respectively. There was significant increase in pupil size at month 1 (P=0.018, P=0.014, and P=0.014, respectively). The pupil size increased significantly in both groups in all illumination conditions.ConclusıonWe have demonstrated via automated infrared pupillary measurements that PRP may significantly increase pupil size whether it is performed with conventional laser or PASCAL laser.

Transient Deficit of Accommodation After Laser Barrage for Retinal Tear

PURPOSE

To report a case of transient loss of accommodation after laser photocoagulation for peripheral retinal tear. Loss of accommodation is one of the lesser known and less common complications of peripheral retinal laser photocoagulation. In fact, only a few works concerning this issue have been published so far. Deficit of accommodation has been described only after extensive laser treatment of the peripheral retina. To the best of our knowledge, this is the first case that reports this complication after treatment limited to a small retinal area. We discuss the possible pathogenetic mechanism of this phenomenon.

CASE REPORT

A 25-year-old healthy myopic woman came to the eye clinic for flashes and floaters in her right eye. Fundus evaluation revealed a small horseshoe retinal tear at the 6 o'clock position. She was treated with prophylactic retinal laser barrage in the right eye. Twelve days later, she returned to our Retinal Clinic because of difficulty with near vision. The problem started soon after the laser procedure. On examination, her distance visual acuity was 20/20 wearing her glasses. The patient could read J1+ at 33 cm with the left eye and required a +3.00D addition over her corrective lens to read J1+ with the right eye. The accommodative disturbance resolved itself spontaneously and gradually within 3 months of laser treatment.

CONCLUSIONS

We believe that transient loss of accommodation, although rare, should be included during pretreatment discussion with young patients regarding the possible side effects of laser photocoagulation, even if this is limited to a small area of the peripheral retina.

Diabetic Retinopathy Clinical Practice Guidelines: Customized for Iranian Population

Purpose:

To customize clinical practice guidelines (CPGs) for management of diabetic retinopathy (DR) in the Iranian population.

Methods:

Three DR CPGs (The Royal College of Ophthalmologists 2013, American Academy of Ophthalmology [Preferred Practice Pattern 2012], and Australian Diabetes Society 2008) were selected from the literature using the AGREE tool. Clinical questions were designed and summarized into four tables by the customization team. The components of the clinical questions along with pertinent recommendations extracted from the above-mentioned CPGs; details of the supporting articles and their levels of evidence; clinical recommendations considering clinical benefits, cost and side effects; and revised recommendations based on customization capability (applicability, acceptability, external validity) were recorded in 4 tables, respectively. Customized recommendations were sent to the faculty members of all universities across the country to score the recommendations from 1 to 9.

Results:

Agreed recommendations were accepted as the final recommendations while the non-agreed ones were approved after revision. Eventually, 29 customized recommendations under three major categories consisting of screening, diagnosis and treatment of DR were developed along with their sources and levels of evidence.

Conclusion:

This customized CPGs for management of DR can be used to standardize the referral pathway, diagnosis and treatment of patients with diabetic retinopathy.

Changes in Pupil Size Following Panretinal and Focal/Grid Retinal Photocoagulation: Automatic Infrared Pupillometry Study

PURPOSE

To evaluate possible changes in pupil size subsequent to panretinal and focal/grid laser photocoagulation.

METHODS

Sixty-four eyes of 64 participants were included. Thirty-two eyes with planned panretinal photocoagulation formed Group 1, and 32 eyes with planned focal retinal photocoagulation formed Group 2. The participants underwent full ophthalmologic examination at baseline. Automated infrared pupillometry was performed at baseline and month 1.

RESULTS

The mean pupillary measurements (in millimeters) for Group 1 (in order photopic, mesopic, scotopic) were 3.09 ± 0.69 mm, 3.66 ± 0.85 mm, and 3.87 ± 1.01 mm and changed to 3.34 ± 0.74 mm, 3.82 ± 0.92 mm, and 4.03 ± 1.02 mm. There was a significant increase in pupil size at month 1 (P = 0.001, P = 0.001, P = 0.003). For Group 2, they were 2.65 ± 0.87 mm, 3.08 ± 1.08 mm, and 3.18 ± 1.19 mm and changed to 2.92 ± 0.72 mm, 3.45 ± 0.76 mm, and 3.57 ± 0.88 mm. There was no significant difference in pupil size at month 1 (P = 0.151, P = 0.106, P = 0.095).

CONCLUSION

We have demonstrated through automated infrared pupillary measurements that panretinal laser photocoagulation may significantly influence pupil size and focal/grid laser photocoagulation may not.

Decreased Corneal Sensation and Subbasal Nerve Density, and Thinned Corneal Epithelium as a Result of 360-Degree Laser Retinopexy

PURPOSE

To assess the effects of 360-degree laser retinopexy on human corneal subbasal nerve plexus and to investigate correlations among corneal subbasal nerve plexus density, corneal epithelial thickness, and corneal sensitivity.

DESIGN

Prospective, observational, nonrandomized study.

PARTICIPANTS

A total of 15 eyes of 15 patients who underwent pars plana vitrectomy (PPV) with 360-degree laser retinopexy for retinal detachment (RD) and 15 eyes of 15 patients who underwent PPV for macular hole (MH) without laser treatment.

METHODS

Corneal sensation, corneal epithelial thickness, and corneal subbasal nerve plexus density were assessed before surgery and 6 months after surgery via in vivo confocal microscopy, anterior segment optical coherence tomography (AS-OCT), and Cochet-Bonnet esthesiometry (Luneau Ophthalmologie, Paris, France).

MAIN OUTCOME MEASURES

Corneal subbasal nerve plexus density, corneal epithelium thickness, and central corneal sensitivity.

RESULTS

Compared with baselines values, the mean subbasal nerve density (P < 0.001), mean corneal epithelium thickness (P = 0.006), and mean corneal sensitivity (P < 0.001) in the RD group were significantly decreased 6 months after surgery by 74.3%, 4.7%, and 56.6%, respectively. Conversely, in the MH group there were no significant differences in the mean subbasal nerve density (P = 0.34), mean corneal epithelial thickness (P = 0.19), and mean corneal sensitivity (P = 0.42) between preoperative and 6-month postoperative values (0.7%, 0.4%, and 0.8%, respectively). The postoperative decrease in corneal subbasal nerve density after laser retinopexy was associated with a decrease in corneal epithelium thickness (r(2) = 0.42; P = 0.006) and a decrease in corneal sensitivity (r(2) = 0.48; P = 0.004). The postoperative decrease in corneal sensitivity poorly correlated with the decrease in corneal epithelial thickness (r(2) = 0.24; P = 0.045). Postoperative corneal nerve density decreased as total laser energy increased (r(2) = 0.51; P = 0.002).

CONCLUSIONS

Subbasal corneal nerve plexus density decreases after 360-degree laser retinopexy and is accompanied by epithelium thinning and decreased corneal sensation. Surgeons should eschew heavy confluent retinal laser treatment, and corneal sensitivity should be assessed postoperatively to determine whether significant anesthesia has occurred. In such instances, prophylactic measures may be warranted against the development of neurotrophic ulcers.

Permanent tonic pupil following inferior oblique myectomy

The postoperative dilation of the pupil following an inferior oblique weakening procedure is a disconcerting event. Previous studies have reported nearly full recovery of the pupil within a few months. We report the case of a patient with who experienced permanent tonic pupil following inferior oblique myectomy.

Bilateral Adie's Tonic Pupil and Hyperopic Shift in Idiopathic Sclerochoroidal Calcification

Sclerochoroidal calcification is a rare but recognised ophthalmic manifestation seen mostly in elderly Caucasian individuals. The lesions, often bilateral, appear as yellow-white irregular subretinal lesions usually found along the mid-peripheral fundus. Though typically asymptomatic, sclerochoroidal calcification has rarely been associated with parafoveal involvement, choroidal neovascularisation, and serous detachment of the calcifications. Visual involvement is typically minimal, and neovascularisation is often visually insignificant. We present a rare case of sclerochoroidal calcification in a 64-year-old Caucasian female who presented with painless progressive bilateral vision loss and a hyperoptic shift with subsequent development of bilateral sequential Adie's tonic pupil. To the best of our knowledge, this is the first such report in the English language literature.

Reversal of pupillary atonia after removal of an encircling band

: We describe a patient who developed an atonic pupil after placement of an encircling band during retinal detachment surgery. When the band was removed 18 months later, the pupil signs showed partial recovery demonstrating a degree of reversibility of the parasympathetic paresis. We speculate that in this case mechanical deformation of the sclera by the encircling band had produced a conduction block of the short posterior ciliary nerve fibers as they pass forward in the underlying suprachoroidal space.

Tonic Pupil and Corneal Anesthesia after Vitrectomy and Encircling Band for Retinal Detachment in an Ex-Premature Child

An 11-year-old boy presented with a total retinal detachment in his right eye. He had a bilateral 360° argon laser treatment for an active retinopathy of prematurity performed after his birth. He underwent an uneventful pars plana vitrectomy, encircling band, 810-nm diode endolaser and heavy silicone oil (Densiron(®)) endotamponade. A tonic pupil and abolition of corneal sensitivity, with a large epithelial defect, were observed during the postoperative period. We discuss the possible etiopathogenic mechanisms of the long and short ciliary nerves damage, and the role that retinopathy of prematurity and retinal detachment laser treatment and the encircling band placement might have played in the development of the tonic pupil and the corneal anesthesia.

Tonic pupil following pars plana vitrectomy and endolaser

Tonic pupil was observed in a 67 year-old patient following a retinal detachment repair with pars plana vitrectomy, endolaser and silicone oil tamponade performed under retrobulbar anesthesia. The probable location of disturbance is the postganglionic parasympathetic fibers in the short ciliary nerves along their course to the pupil in the suprachoroidal space. A likely explanation for this phenomenon is injury to short ciliary nerves by endolaser treatment.

Accommodative loss after retinal cryotherapy

PURPOSE

To investigate the effects of peripheral retinal cryotherapy on accommodative amplitude in patients with retinal lattice degeneration.

DESIGN

Prospective, observational case series.

METHODS

We studied 92 eyes in 69 patients (age range, 13 to 79 years) treated with cryotherapy for lattice degeneration between December 2001 and September 2004. Pretreatment and posttreatment accommodative amplitudes were measured. Acute accommodative loss was calculated from the difference between accommodative amplitudes before treatment and one week after treatment. We investigated the time course of accommodative amplitudes, acute accommodative loss in different age groups and in pretreatment accommodative amplitude groups, the influence of cryotherapy numbers on accommodative amplitude, and the influence of cryotherapy sites on accommodative amplitude.

RESULTS

No significant difference was noted between pretreatment and posttreatment accommodative amplitudes in the overall subject cohort. Dividing subjects by age revealed significant decreases in accommodative amplitude only among patients in their 10s and 20s at one and three weeks after treatment. Accommodative amplitude was lowest among those in their 10s, followed by that among those in their 20s (P < .01). Accommodative amplitudes recovered to pretreatment level by six weeks. Acute accommodative loss was greatest in those in their 10s compared with other age groups (P < .01). A significant correlation was observed between acute accommodative loss and cryotherapy numbers (P = .03; r = 0.41).

CONCLUSIONS

The decrease in accommodative amplitude was greatest at one week after treatment and recovered to pretreatment levels after six weeks. Accommodative amplitude showed the greatest decrease after cryotherapy among patients in their 10s and 20s. A decrease in accommodative amplitude was observed with increased numbers of cryotherapy spots administered.

A review of sub-Tenon's block

The place of sub-Tenon's block in ophthalmic surgery is now established. This block was introduced into clinical practice in the early 1990s as a simple, safe and effective technique. Since then, techniques have evolved, newer cannulae have been introduced and many complications, both minor as well as major, have been reported. This review deals with the recent developments in sub-Tenon's block.