The Evolution of an Optic Nerve Head Granuloma Due to Sarcoidosis

Sarcoidosis can affect the optic nerves by means of optic disc oedema secondary to posterior uveitis, optic disc oedema secondary to raised intracranial pressure, optic neuritis, optic atrophy secondary to compression or infiltration from a primary central nervous system lesion, and primary granuloma of the optic nerve head. The authors report the use of optical coherence tomography in assessing the response to immunosuppression in a 57-year-old woman with an optic nerve head granuloma.

Use of flucinolone acetonide for patients with diabetic macular oedema: patient selection criteria and early outcomes in real world setting

INTRODUCTION

Fluocinolone acetonide slow release implant (Iluvien®) was approved in December 2013 in UK for treatment of eyes which are pseudophakic with DMO that is unresponsive to other available therapies. This approval was based on evidence from FAME trials which were conducted at a time when ranibizumab was not available. There is a paucity of data on implementation of guidance on selecting patients for this treatment modality and also on the real world outcome of fluocinolone therapy especially in those patients that have been unresponsive to ranibizumab therapy.

METHOD

Retrospective study of consecutive patients treated with fluocinolone between January and August 2014 at three sites were included to evaluate selection criteria used, baseline characteristics and clinical outcomes at 3-month time point.

RESULTS

Twenty two pseudophakic eyes of 22 consecutive patients were included. Majority of patients had prior therapy with multiple intravitreal anti-VEGF injections. Four eyes had controlled glaucoma. At baseline mean VA and CRT were 50.7 letters and 631 μm respectively. After 3 months, 18 patients had improved CRT of which 15 of them also had improved VA. No adverse effects were noted. One additional patient required IOP lowering medication. Despite being unresponsive to multiple prior therapies including laser and anti-VEGF injections, switching to fluocinolone achieved treatment benefit.

CONCLUSION

The patient level selection criteria proposed by NICE guidance on fluocinolone appeared to be implemented. This data from this study provides new evidence on early outcomes following fluocinolone therapy in eyes with DMO which had not responded to laser and other intravitreal agents.

'Toy' laser macular burns in children: 12-month update

PURPOSE

There is increasing evidence that high-powered hand-held laser devices cause retinal injury. We present 12-month follow-up data for three patients that we previously reported with such retinal injuries.

METHODS

A retrospective case series of three children with maculopathy secondary to exposure to high-power hand-held laser devices. All children underwent clinical examination and spectral domain optical coherence tomography (SD-OCT) at presentation and follow-up. Fundus-controlled microperimetry was also undertaken 12-19 months after exposure.

RESULTS

Three children sustained macular injury after exposure to a high-powered hand-held laser. Acutely, they presented with a 'vitelliform-like' maculopathy with reduced vision. Over the course of follow-up, the best corrected Snellen acuity in all three patients improved to 'normal' levels (range 6/6-6/9). Long-term deficits in foveal retinal sensitivity were identified in two patients using fundus-controlled microperimetry. SD-OCT imaging showed persistent disruption of the foveal outer photoreceptor layers in all three children.

CONCLUSION

Although visual acuity improved over time, deficits in microperimetry and SD-OCT persisted. All three children had retinal pigment epithelium changes, requiring follow-up for longer-term sequelae of laser injuries such as expansion of retinal atrophy and development of choroidal neovascular membranes.

Treatment of aberrant facial nerve regeneration with botulinum toxin A

PURPOSE

To assess the effect and efficacy of botulinum toxin type A (BTX-A) at reducing and maintaining eyelid synkinesia in aberrant facial nerve regeneration, while concurrently observing for the presence of side effects to differing treatment doses.

METHODS

A prospective interventional study of five patients with eyelid synkinesia resulting from aberrant regeneration of the facial nerve. Patients were treated with injections of either 120, 80 or 40 units of BTX-A (Dysport) into the orbicularis oculi. Objective and subjective reduction in synkinesia, maintenance of response and presence of side effects were recorded.

RESULTS

All five patients had improvement of the synkinesia with BTX-A treatment. Lower doses were found to be as effective as higher doses. Mean duration of abolished synkinesia was three months. Two patients developed a ptosis which resolved spontaneously. None of the patients treated with the lowest dose of 40 units developed a ptosis.

CONCLUSION

Low-dose BTX-A has a lower incidence of ptosis and is effective in the treatment of aberrant facial nerve regeneration.

Hyaluronidase allergy after peribulbar anesthesia with orbital inflammation

A 70-year-old woman previously exposed to hyaluronidase during ophthalmic surgery had excision of hypertrophic bulbar conjunctival tissue in the right eye. Hyaluronidase was added to the peribulbar anesthetic agent. Five days postoperatively, the patient presented with proptosis in the right eye, extraocular muscle restriction, and decreased visual acuity. She was apyrexial with a normal white cell count; computed tomography of the orbits showed a diffuse increase in soft tissue density. Clinical features were unchanged after 24 hours of intravenous antibiotics, but subsequent administration of high-dose oral steroids led to clinical improvement.