New onset diplopia: 14 years after retinal detachment surgery with a hydrogel scleral buckle - PDF Document

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  1. Downloaded from on 28 August 2008 New onset diplopia: 14 years after retinal detachment surgery with a hydrogel scleral buckle I Leibovitch, J Crompton and D Selva Br. J. Ophthalmol. 2005;89;640 doi:10.1136/bjo.2004.053868 Updated information and services can be found at: These include: This article cites 7 articles, 2 of which can be accessed free at: References You can respond to this article at: Rapid responses Receive free email alerts when new articles cite this article - sign up in the box at the Email alerting top right corner of the article service Notes To order reprints of this article go to: To subscribe to British Journal of Ophthalmology go to:

  2. Downloaded from on 28 August 2008 Br J Ophthalmol 2005;89:639–645 639 PostScript .............................................................................................. advantage of the fact that the body makes more cholesterol at night. Statins reduce measured blood LDL-C within 4–6 weeks. In a study of 20 536 patients, this resulted in long term reduction in coronary heart dis- ease, stroke, and mortality.5 Simvastatin is derived synthetically from a fermentation product of Aspergillus tereus. Simvastatin is hydrolysed to an inhibitor of an enzyme responsible for cholesterol synth- esis. In the Multicenter Study, simvastatin slowed the progression of atherosclerosis, measured by vascular stenosis diameter on decreased significantly the development of new lesions.5 To our knowledge, there have been no previous reports on the effect of statins on eyelid xanthelasma. A PubMed search for keywords ‘‘statin and xanthelasma’’ and simvastatin and xanthelasma’’ yielded no relevant publications. The management of eyelid xanthelasma includes surgical exci- sion, microsurgical inverted peeling, laser inverted resurfacing, photovaporisation using carbon dioxide laser, and application of bichloracetic acid. Patients with the highest recurrence rate are those with elevated cholesterol. These local treatments do not address possible systemic associations. By observations in this report, we suggest that serum cholesterol be evaluated and if ele- vated, oral statin combined with dietary cholesterol restriction might result in resolu- tion of xanthelasma over time, but, more importantly, reduction of patient cardiac risk. completely resolved, leaving no clinical trace of subcutaneous lipid (fig 1B). He continued on his medications and serum cholesterol was normal. LETTERS If you have a burning desire to respond to a paper published in the BJO, why not make use of our ‘‘rapid response’’ option? Log on to our website (www.bjophthalmol. com), find the paper that interests you, and send your response via email by clicking on the ‘‘eLetters’’ option in the box at the top right hand corner. Providing it isn’t libellous or obscene, it will be posted within seven days. You can retrieve it by clicking on ‘‘read eletters’’ on our homepage. The editors will decide as before whether to also publish it in a future paper issue. Comment In the Lipids Research Clinics Program Prevalence Study, xanthelasma and corneal arcus were associated with increased levels of serum cholesterol and low density lipoprotein cholesterol (LDL-C), especially in young males.4 People with increased odds of having type IIa dyslipopro- teinaemia. Adjusted odds ratios for ischaemic heart disease in participants with xanthe- lasma and corneal arcus were generally increased. The study concluded that the clinical findings of xanthelasma or corneal arcus, especially in young people, helped to identify those with abnormalities.4 Management of patients with elevated LDL-C include both low cholesterol diet and cholesterol lowering medications, the most popular of which are the statins. There are currently five statin drugs on the market in the United States and these include lovasta- tin (Mevacor, Altocor), simvastatin (Zocor), pravastatin (Pravachol), fluvastatin (Lescol), and atorvastatin (Lipitor). The major effect of these medications is to lower LDL-C by slowing down the production of cholesterol and by increasing the liver’s ability to metabolise the LDL-C in the blood. Statins reduce LDL-C by approximately 40% and produce a modest increase in high density lipoprotein-cholesterol (HDL-C). These med- ications are given daily in the evening to take Anti-Atheroma either lesion had angiography, and plasma lipoprotein Disappearance of eyelid xanthelasma following oral simvastatin (Zocor) The major risk factors for coronary heart disease include smoking, elevated blood pressure, and elevated serum cholesterol.1 Risk reduction starts with identification of those at risk and then alteration of factors such as discontinuation of smoking, lowering of blood pressure, and reduction of serum cholesterol. Patients who should have blood cholesterol testing include those with family history of premature coronary heart disease or hyperlipidaemia, personal history of cor- onary heart disease, or clinical evidence of elevated lipids with features of xanthelasma, corneal arcus under age 50 years, and cuta- neous xanthomas at any age.1Two of the latter clinical features are ophthalmic and detection relies on the ophthalmologist. Xanthelasma appear as multiple yellow placoid lesions in the periocular skin and represent a concentration of lipocytes in the dermis.2There are numerous methods to manage the cosmetic appearance of xanthe- lasma, which typically involves surgical exci- sion or laser ablation.3We report a novel approach to management using oral choles- terol lowering medication and patience. C L Shields, A Mashayekhi, J A Shields Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, PA, USA P Racciato Pocono Medical Center, Stroudsburg, PA, USA Correspondence to: Carol L Shields, MD, Ocular Oncology Service, Wills Eye Hospital, 840 Walnut Street, Philadelphia, PA 19107, USA; doi: 10.1136/bjo.2004.053058 Accepted for publication 13 September 2004 Support provided by the Eye Tumor Research Foundation, Philadelphia, PA (CLS), the Macula Foundation, New York, NY (CLS), the Rosenthal Award of the Macula Society (CLS), and the Paul Kayser International Award of Merit in Retina Research, Houston TX (JAS). Case report In 1992, a 68 year old male smoker with a history of hypertension and elevated serum cholesterol was referred for evaluation of a newly diagnosed iris mass. On examination, the visual acuity was 20/20 in both eyes. The mass was diagnosed as a benign iris naevus and observation was advised. Coincidental bilateral medial canthal and upper and lower eyelid xanthelasma were detected (fig 1A). The largest xanthelasma measured 16 mm in diameter. Observation was advised with tentative plan for surgical excision in the future. The patient was advised to continue his antihypertensive medications and antic- holesterol medication (Zocor) 20 mg once daily). At the 6 month follow up the iris nevus was stable and the xanthelasma persisted. Yearly examinations were advised. The patient did not return for 10 years. Surprisingly, the xanthelasma had References 1 Farmer JA, Gotto AM Jr. The Heart Protection Study: expanding the boundaries for high-risk coronary disease prevention. Am J Cardiol 2003;3:3i–9i. 2 Shields JA, Shields CL. Atlas of eyelid and conjunctival tumors. Philadelphia: Lippincott Williams & Wilkins, 138–9. 3 Rohrich RJ, Janis JE, Pownell PH. Xanthelasma palpebrarum: a review and current management principles. Plast Reconstr Surg 2002;110:1310–14. 4 Segal P, Insull W Jr, Chambless LE, et al. The association of dyslipoproteinemia with corneal arcus and xanthelasma. The Lipid Research Clinics Program Prevalence Study. Circulation 1986;73:108–18. A 68 year old man with Figure 1 hypertension and elevated cholesterol and bilateral upper and lower eyelid xanthelasma. He was on oral simvastatin for hypercholesterolaemia. (A) January 1992. At presentation, the multifocal yellow xanthelasma are noted. (B) April 2002. After 10 years lost to ophthalmic follow up, the patient returned with complete resolution of xanthelasma. (oral simvastatin

  3. Downloaded from on 28 August 2008 640 PostScript 5 Dumont JM. Effect of cholesterol reduction by simvastatin on progression of coronary atherosclerosis: design, baseline characteristics, and progress of the Multicenter Anti-Atheroma Study (MAAS). Control Clin Trials 1993;14:209–28. eous leak after removal of the expanded explant.8In our patient, there was an area of thinned sclera, but the surrounding calcifica- tion and the early removal of the explant prevented vitreous leak. It is important to note that patients who have undergone scleral buckling with hydro- gel explants before 1995 are at risk of developing this complication. Symptoms of progressive diplopia, pain, and restriction of extraocular muscle movement in these patients should also raise the possibility of explant expansion. The assistance of a retinal surgeon may sometimes be required because of the increased risk of scleral thinning and leakage of liquid vitreous intraoperatively. New onset diplopia: 14 years after retinal detachment surgery with a hydrogel scleral buckle In 1979, the hydrogel explant (Miragel, Waltham, MA, USA) was introduced as a scleral buckling material in the surgical management of retinal detachment.1It was widely used in the 1980s and early 1990s as it was initially believed to be well tolerated, less prone to infection, and easy to manipulate.2 However, long term complications related to swelling and fragmentation of the explant have been reported over recent years,3–6 resulting in discontinuation of its use in 1995. I Leibovitch, J Crompton, D Selva Oculoplastic and Orbital Unit, Department of Ophthalmology, Royal Adelaide Hospital, University of Adelaide, South Australia, Australia Correspondence to: Dinesh Selva Oculoplastic and Orbital Unit, Department of Ophthalmology, Royal Adelaide Hospital, North Terrace, Adelaide, 5000, South Australia, Australia; Case report A 36 year old healthy man presented on 2003 with symptoms of mild right ocular discom- fort. Past ocular history included a right retinal detachment viously, using a 907 (365 mm) Miragel scleral buckle (Miragel, ments Research Associates, Waltham, MA, USA), sutured to the inferior sclera. On examination, visual acuity was 20/120 right and 20/20 left. There was no diplopia or limitation of eye movements. What was thought to be a small conjunctival cyst was noted inferiorly but, otherwise, the ocular examination was unremarkable and the retina was secure. A year later (2004), he presented with increasing marked right ocular discomfort and diplopia in all fields. His visual acuity was unchanged, but there was marked restriction of elevation and reduction in adduction of the right eye and binocular diplopia in all fields of gaze. A tense swelling of the inferior conjunctiva was noted (fig 1, top), intraocular pressure was normal, and the retina was flat with a moderate anterior buckle effect. Computed tomography (CT) (fig 1, bottom) demonstrated a right orbital circumferential soft tissue mass surrounding the lower half of the globe with a small area of calcification. The initial diagnosis was a postoperative giant conjunctival cyst and the patient underwent surgery. Intraoperatively, exploration revealed no conjunctival cyst, but a large encapsulated scleral buckle. The explant was friable, gel- like, and translucent, but could be removed in one piece (fig 2). A 3 mm diameter area of scleral thinning associated with calcification was found underlying the buckle inferotem- porally. At 1 month follow up the patient was asymptomatic with no diplopia, unrestricted extraocular movements, and the retina was flat. Top: Clinical photograph of the right Figure 1 eye showing bulging of the inferior fornix. Bottom: Coronal computed tomographic scan showing a circumferential soft tissue mass surrounding lower half of the globe and a small area of calcification on the inferotemporal sclera. doi: 10.1136/bjo.2004.053868 Accepted for publication 27 August 2004 repair 14 years pre- Medical Instru- References 1 Refojo MF, Natchiar G, Lui HS, et al. New hydrophilic implant for scleral buckling. Ann Ophthalmol 1980;12:88–92. 2 Tolentino FI, Roldan M, Nassif J, et al. Hydrogel implant for scleral buckling. Long-term observations. Retina 1985;5:38–41. 3 Marin JF, Tolentino FI, Refojo MF, et al. Long term complications of the MAI hydrogel intrascleral buckling implant. Arch Ophthalmol 1992;110:86–8. 4 Roldan-Pollares M, Castillo Sanz JL, Alwad El- Susi S, et al. Long term complications of silicone and hydrogel explants in retinal reattachment surgery. Arch Ophthalmol 1999;117:197–201. 5 Oshitari K, Hida T, Okada AA, et al. Long-term complications of hydrogel buckles. Retina 2003;23:257–61. 6 Kearney JJ, Lahey JM, Borirakchanyavat S, et al. Complications of hydrogel explants used in scleral buckling surgery. Am J Ophthalmol 2004;137:96–100. 7 Le Rouic JF, Bettembourg O, D’hermies F, et al. Late swelling and removal of miragel buckles: a comparison with silicone indentations. Retina 2003;23:641–6. 8 Metz HS, Rose S, Burkat C. Late-onset progressive strabismus associated with a hydrogel scleral buckle. J AAPOS 2004;8:72–3. patients with complications related to hydro- gel explant swelling. In nine cases the initial diagnosis was incorrect, being mainly Graves’ disease, idiopathic orbital fibrosis, and a subconjunctival inclusion cyst. In our case, there was a profound increase in the explant volume during a 14 year period. The resulting diplopia and restriction of extraocular movement as well as the clinical evaluation mimicked a giant orbital inclusion cyst. The correct diagnosis was only made intraoperatively. Scleral thinning and necrosis as seen in our case has been reported previously,7resulting in intraoperative vitr- Inverse globe retraction syndrome complicating recurrent pterygium Often larger and more aggressive than the original lesion, recurrent pterygia can cause visual symptoms that are most often second- ary to their mechanical effects on the cornea.1 We report a case of inverse globe retraction syndrome (that is, retraction during abduc- tion) due to the restrictive effect of a recurrent pterygium and the management of this complication. Comment Hydrogel explants are composed of a low molecular weight hydrophilic material that is water permeable. These explants have a tendency to absorb water over the years and increase dramatically in size. The resulting complications range from a non-tender sub- conjunctival mass to intraocular or external extrusion.3–6The long time lapse from buckle surgery may result in a high misdiagnosis rate. Kearney et al6reported 17 eyes of Case report A 28 year old man without a medical history or ocular symptoms underwent pterygium excision in his left eye with a superotemporal conjunctival autograft and intraoperative mitomyocin C. Three weeks postoperatively, he noted a feeling of pressure in the left eye Top: Intraoperative photograph Figure 2 showing the swollen hydrogel buckle under the inferior rectus muscle (arrow). Bottom: The hydrogel buckle after removal.

  4. Downloaded from on 28 August 2008 PostScript 641 rectus abnormality,2innervational misdirec- tion,3 and secondary to restriction from traumatic tissue capture in the medial orbital wall.4 5 The current another cause for the syndrome, globe restriction as a result of a leash effect from aggressive pterygium recurrence. The risk of pterygium recurrence after initial pterygium removal is minimised by the technique of conjunctival autograft with adjunctive mito- myocin C6; however, because aggressive recurrence is still possible initial pterygium surgery should only be performed for patients with significant cosmetic and/or functional concerns. For the management of inverse globe retraction syndrome recurrent pterygium in this case, the use of amniotic membrane as a tissue spacer per- mitted excellent functional improvement. preserved insight, and there had been no change in personality. On admission to our unit her visual acuity was 6/18 RE and 6/12 LE with the above correction. She was able to read slowly at N5 corrected with each eye but was unable to name any of the Ishihara plate numbers including the test plate, despite being able to name the colours, trace the outline of the numbers with her finger, and read numbers in normal print. Confrontation visual fields were essentially full although she was slow to recognise objects in her peripheral visual fields owing to an apparent narrowing of attention to foveal vision and had optic ataxia, in that she was unable to localise in space, by pointing, objects placed in her peripheral visual fields. On Goldmann peri- metry her visual fields appeared somewhat constricted, probably related to her difficul- ties with attention, but, importantly, no hemianopia was demonstrated Pupillary responses were normal as was fundal examination. On eye movement test- ing she had broken smooth pursuit eye movements, although she was able to gen- erate voluntary saccades. The rest of the neurological examination was unremarkable. Her mini-mental state examination score was 28/30. She had some deficits in verbal abstract reasoning and made occasional phonemic errors in speech. She had mild dyscalculia and dyspraxia, but she was able to differentiate left from right and name body parts. She had mild memory impairment, although these were mainly in tasks requir- ing visual input. She demonstrated simulta- nagnosia in that she was unable to see the whole of a picture and only described parts of it. On testing with the cortical vision screen- ing test1she passed the hue discrimination test, the word reading test, face perception test, the crowding test of letter reading and was able to detect the presence of a circle in the shape detection test but was unsure what to say if it was not present. On the symbol case demonstrates complicating The patient’s appearance at Figure 1 presentation in (A) primary gaze, (B) right gaze, (C) left gaze. There is relative enophthalmos in the left eye that increases during left gaze. During right gaze, adduction in the left eye occurs with less effort than abduction in the right eye. Correspondence to: A O Khan, King Khaled Eye Specialist Hospital, PO Box 7191 Riyadh, Saudi Arabia; (fig 1). doi: 10.1136/bjo.2004.053850 Accepted for publication 2 September 2004 and diplopia during left gaze. Two months postoperatively he presented to us and his ophthalmic examination was significant for the following—left eye: 2 mm enophthalmos relative to right eye, recurrence of the pterygium, globe retraction during left gaze secondary to a leash effect from the recurrent pterygium, and minimal abduction deficiency (fig 1). One month later, his examination was stable and surgery was scheduled. Intraoperatively forced ductions showed –1 (on a scale of 1 to 4) limitation of abduction in the left eye. The left eye was positioned in abduction and a 6 mm vertical incision was made in the nasal conjunctival 3 mm poster- ior to the limbus. A 566 mm graft of amniotic membrane (locally procured and kept frozen before use) was sutured in the resultant gap in the conjunctiva using 9–0 Vicryl suture after the conjunctival edges were undermined. Two months following this procedure, the patient’s feeling of pres- sure was relieved and there is neither diplopia nor globe retraction during left gaze (fig 2). References 1 Hirst LW. The treatment of pterygium. Surv Ophthalmol 2003;48:145–80. 2 Lew H, Lee JB, Kim HS, et al. A case of congenital inverse Duane’s retraction syndrome. Yonsei Med J 2000;41:155–8. 3 Chatterjee PK, Bhunia J, Bhattacharyya I. Bilateral inverse Duane’s retraction syndrome—a case report. Indian J Ophthalmol 1991;39:183–5. 4 Davidson TM, Olesen RM, Nahum AM. Medial orbital wall fracture with rectus entrapment. Arch Otolaryngol 1975;101:33–5. 5 Gittinger JW Jr, Hughes JP, Suran EL. Medial orbital wall blow-out fracture producing an acquired retraction syndrome. J Clin Neuroophthalmol 1986;6:153–6. 6 Sanchez-Thorin JC, Rocha G, Yelin JB. Meta- analysis on the recurrence rates after bare sclera resection with and without mitomycin C use and conjunctival autograft placement in surgery for primary pterygium. Br J Ophthalmol 1998;82:661–5. A Seeing is not believing We describe a case of posterior cortical atrophy presenting with progressive visuo- perceptual and visuospatial difficulties, but with no abnormalities on standard ophthal- mological examination. 120 105 90 7 0 75 60 135 45 6 0 5 0 150 30 Comment Inverse globe retraction syndrome is rare.2–5It has been reported as being caused by medial 4 0 3 0 165 15 V4e 2 0 1 0 II2e 90 8 0 7 0 6 0 5 0 4 0 3 0 2 0 1 0 1 0 2 0 3 0 4 0 5 0 6 0 7 0 8 0 90 180 0 1 0 Case report The patient, a 53 year old right handed woman, with well controlled primary gener- alised epilepsy, presented to her optometrist with a 1 year history of deterioration in vision. She had particular difficulties with walking downstairs and following text while reading. She could read 6/12+2 RE (with 20.75/20.25690 correction) (with 20.75 correction) LE. With +2.25 correction she could read N5 slowly with each eye. On subsequent ophthalmological review no significant abnormality was found on examination and no specific diagnosis was made. Over the following months her vision deteriorated. She reported difficulties follow- ing a line while writing and was unable to tell when a glass was full when pouring a drink. Her husband thought that she was unable to see things in her peripheral vision. This culminated in her crashing her car. She did not have any memory difficulties, she had 2 0 195 345 3 0 4 0 210 330 5 0 6 0 225 315 7 0 240 255 270 285 300 B 120 105 90 7 0 75 60 135 45 6/12+3 6 0 and 5 0 150 30 4 0 3 0 165 15 2 0 V4e 1 0 II2e 90 8 0 7 0 6 0 5 0 4 0 3 0 2 0 1 0 1 0 2 0 3 0 4 0 5 0 6 0 7 0 8 0 90 180 0 1 0 2 0 195 345 The patient’s appearance 6 weeks Figure 2 after amniotic membrane placement in (A) primary gaze, (B) right gaze, (C) left gaze. There is no longer globe retraction left eye during left gaze. During right gaze, adduction in the left eye occurs with effort similar to that needed for abduction in the right eye. 3 0 4 0 210 330 5 0 6 0 225 315 7 0 240 255 270 285 300 Goldmann perimetry (V4e and II2e). Figure 1

  5. Downloaded from on 28 August 2008 642 PostScript 7 Ayuso-Peralta L, Jime ´nez-Jime ´nez FJ, Tejeiro J, et al. Progressive multifocal leukoencephalopathy in HIV infection presenting as Balint’s syndrome. Neurology 1994;44:1339–40. 8 Tranel D. Assessment of higher-order visual function. Curr Opin Ophthalmol 1994;5:29–37. patients,3although difficulty with figure- ground discrimination cannot be excluded. Posterior cortical atrophy is a clinical and radiological diagnosis based upon the pre- sence of occipitoparietal abnormalities with initially preserved occipitotemporal (face and colour recognition) and anterior cerebral function.4 5It is thought to be as a result of Alzheimer’s disease, although the syndrome has been described with other pathologies—for example, sub- cortical gliosis, Creutzfeld-Jakob disease, and progressive multifocal thy.5 7Although it is rare, it should be suspected in any patient presenting with visuoperceptual or visuospatial difficulties in the absence of any signs on standard ophthalmological examination. tests for higher visual function deficits can then be employed.1 6 8 The corollary of this is that a patient with an established diagnosis of dementia should be tested for disorders of higher visual function, because a patient with otherwise mild cognitive deficits may still be driving.6 Radial optic neurotomy in combined cilioretinal artery and central retinal vein occlusion Combined cilioretinal artery and central retinal vein occlusion (CRVO) is a rare clinical finding, first Oosterhuis.1The pathogenesis of this condi- tion is not well established and remains controversial. Most reports postulate that the initial CRVO causes an elevation of the intraluminal capillary pressure and induces a consecutively reduced perfusion pressure at the arterial side. Since the perfusion pressure of the cilioretinal artery is lower than the central artery, it occluded.2–4 Recently described radial optic neurotomy (RON) involving pars plana vitrectomy (PPV) and radial incision of the optic nerve to treat CRVO.5We report this new surgical approach in a patient with combined cilioretinal artery occlusion and CRVO. cases,5 6 in most leucoencephalopa- described by Screening FLAIR MRI demonstrating mainly Figure 2 posterior cortical atrophy. becomes Opremcak relatively et al acuity test her Snellen equivalent was 6/18 with each eye, despite being able to read text at N5, which suggested that she had more difficulty in identifying shapes than words. She failed tests of shape discrimination and size discrimination to indicate bilateral occi- pital dysfunction and also failed tests of scattered dot counting and fragmented num- bers to indicate right parietal dysfunction. Blood tests and cerebrospinal fluid exam- ination were both normal. Magnetic reso- nance imaging demonstrated atrophy most marked in the both posterior parietal and occipital lobes (fig 2). A diag- nosis of posterior cortical atrophy was made. S J Hickman, D Alvares, H Crewes, R J Wise, A N Gale Royal Free Hospital, Pond Street, London NW3 2QG, UK Correspondence to: Simon J Hickman, Royal Free Hospital, Pond Street, London NW3 2QG, UK; Case report A healthy 64 year old woman complained of unilaterally blurred vision for the past 3 days. Her visual acuity (VA) was 20/200 in the right eye (RE) and 20/20 in the left eye (LE). The anterior segment in both eyes was unremarkable on slit lamp examination. Fundus examination RE demonstrated a whitening of the macula corresponding to an area supplied by an cilioretinal artery. The retinal veins were dilated, accompanied by adjacent retinal haemorrhages (fig 1A). The fundus of the left eye appeared normal. Fluorescein angiography (FA) RE revealed a delayed arteriovenous (AV) perfusion time of 13 seconds. Systemic patient did not reveal any general disease. Although treated systemically with corticos- teroids6and low dose heparin for 4 weeks, she developed CRVO oedema, extensive dilatation of the retinal veins, radial orientated intraretinal haemor- rhages, and cotton wool spots (fig 1B). On FA there was a reduced perfusion time of the cilioretinal artery in addition to the typical doi: 10.1136/bjo.2004.054429 Accepted for publication 28 September 2004 cerebral References 1 James-Galton M, Plant GT, Warrington EK. The cortical vision screening test (CORVIST). London: Thames Valley Test Company, 2001. 2 Balint R. Seelenla ¨hmung des ‘‘Schauens’’, optische Ataxie, Rau ¨mliche Sto ¨rung der Aufmerksamkeit. Monatsschrift fur Psychiatrie und Neurologie 1909;25:51–80. 3 Mendez MF, Cherrier MM. The evolution of alexia and simultanagnosia in posterior cortical atrophy. Neuropsychiatry Neuropsychol Behav Neurol 1998;11:76–82. 4 Benson DF, Davis RJ, Snyder BD. Posterior cortical atrophy. Arch Neurol 1988;45:789–93. 5 Victoroff J, Ross GW, Benson DF, et al. Posterior cortical atrophy. Neuropathologic correlations. Arch Neurol 1994;51:269–74. 6 Fletcher WA. Ophthalmological aspects of Alzheimer’s disease. Curr Opin Ophthalmol 1994;5:38–44. Comment This woman therefore presented with pro- gressive visuoperceptual difficulties, but had no abnormalities on ophthalmological examination. some features of Balint’s syndrome (that is, simultanagnosia and optic ataxia)2and other cognitive deficits. Her poor distance visual acuity may have been related to her poor visuospatial ability, given her good, albeit slow, near vision. Her inability to recognise any of the Ishihara plates, with otherwise normal colour vision, is probably a reflection of her other visuoperceptual difficulties, which has been reported before in similar and visuospatial She had evaluation of the with severe disc Colour fundus photography of the right eye. (A) 3 days after decrease of VA. A whitening of the macula corresponding to an area supplied Figure 1 by the cilioretinal artery (white arrow) can be seen. The retinal veins appear dilated and sparse retinal haemorrhages are visible. (B) 1 day preoperatively. The cilioretinal artery appears with reduced diameter (white arrow), typical picture of CRVO with disc oedema without visible disc margin, extensive dilatation of the retinal veins, radial orientated intraretinal haemorrhages, and several cotton wool spots are present. (C)10 weeks postoperatively. The optic disc appear with sharp margin, the diameter of the retinal veins are similar to those of the left eye. Chorioretinal whitening at the 2 and 4 o’clock position at the disc margin indicate the location, direction, and length of the radial cuts by RON (white arrows). Remaining signs of the CRVO, including retinal haemorrhages or macular oedema have vanished. The cilioretinal artery appears with physiological diameter.

  6. Downloaded from on 28 August 2008 PostScript 643 induces the formation of new chorioretinal shunt vessel.8In our case the goal of RON was to reduce the capillary pressure, there- fore increasing the perfusion in the cilioret- inal artery and thus improving central vision. Patients with combined occlusive AV disease may benefit from RON by improving their haemodynamic perfusion pressure, retinal anatomy, and consecutive central visual function. utilities typically reflect larger estimates of utility loss than those elicited from patients and result in a more favourable analysis of the cost effectiveness of preventive interven- tions than those relying on patient elicited utilities.2At the same time, estimating com- munity elicited utilities requires the develop- ment of easily understood scenarios to assist community members in understanding life with the disease,3after leading investigators prefer to rely on patient elicited utilities. Rather than dismiss the community elicited approach, economic evaluation in ophthal- mology would be greatly facilitated by devel- opment of a catalogue of community elicited utilities related to old disease developed through the standard gamble or time trade- off methods or responses to health status questionnaires that include algorithms to estimate health utilities. While the Browns caution against the use of functionally based health related quality of life instruments (for example, the NEI-VFQ) in economic evaluation, we would like to offer an alternative explanation for this concern. Most disease specific instruments are based in psychometric designed to measure change in the patient’s self reported health status in investigator defined domains.4Domain scores do not reflect the importance the respondent assigns to the activities, but scoring algorithms developed by the instrument designer. The result is a metric that is often meaningful to clinicians but does not reflect the value the patient or society places on the health state. This limits generalisability across disease groups, as well as investigators’ ability to comment on the most efficient method to screen for, or treat, an ophthalmic condition affecting multiple areas of physical, mental, or emotional function. Finally, the standard gamble elicitation method should not be dismissed off hand- edly. More frequent use of the time trade-off reflects the method’s intuitive appeal rather than theoretical superiority. As opposed to the time trade-off in which the anchor event (typically, death, blindness, etc) occurs in the future, in the standard gamble the event is immediate. This provides an estimate of the person’s risk preference unconfounded by time. The time trade-off consistently results in higher estimates of utility loss than the standard gamble,5 6potentially resulting in an overestimation of the cost-effectiveness of treatment or prevention. We hope that our comments will help future work to be pragmatic and theoretically sound. This is necessary if we are to properly characterise the appropriateness of our meth- ods as well as the value of our findings. signs of CRVO (fig 2A). Based on positive results of RON in CRVO, we offered this treatment to our patient. After she signed an informed consent, RON was performed with two radial cuts at the nasal edge of the optic disc. After 2 days disc oedema was signifi- cantly reduced with sharp visible disc mar- gins. Two months postoperatively the retinal haemorrhages, cotton wool spots, and disc oedema resolved and her VA improved to 20/ 25 RE (fig 1C). FA demonstrated a physiolo- gical AV perfusion time of less than 3 seconds and no signs of an occluded cilioretinal artery (fig 2B). S Mennel, K Droutsas, C H Meyer, J C Schmidt, P Kroll Department of Ophthalmology, Philipps-University Marburg, Germany Comment Combined cilioretinal artery occlusion and CRVO are discussed as a separate clinical entity in the literature,1–4and its treatment by RON has not been described. Opremcak et al postulated that a surgical decompression of the optic disc and scleral ring by RON may contribute to an improved venous perfusion in CRVO. Our patient demonstrated addi- tional signs of an arterial occlusion with delayed filling of the cilioretinal artery in the macula, which may induce permanent func- tional loss. The underlying pathomechanism of CRVO remain unknown, current discus- sion leans towards an intraluminal occlusion by a thrombus, increased extravasal pressure, or a combination of both as possible causes.7 In addition the therapeutic effect of RON is also questionable. It remains unclear as to whether RON causes a decompression of the optic disc increasing the ocular blood flow or Correspondence to: Stefan Mennel, MD, Department of Ophthalmology, Philipps-University Marburg, Robert-Koch-Strasse 4, 35037 Marburg, Germany; doi: 10.1136/bjo.2004.054858 Accepted for publication 20 October 2004 Financial support: none. Proprietary interest: none. theory and References 1 Oosterhuis JA. Fluorescein fundus photography in retinal vein occlusion. In: Henkes HE, eds. Perspectives in ophthalmology. Amsterdam: Excerpta Medica, 1968:29–47. 2 Schatz H, Fong AC, McDonald HR, et al. Cilioretinal artery occlusion in young adults with central retinal vein occlusion. Ophthalmology 1991;98:594–601. 3 Keyser BJ, Duker JS, Brown GC, et al. Combined central retinal vein occlusion and cilioretinal artery occlusion associated with prolonged retinal arterial filling. Am J Ophthalmol 1994;117:308–13. 4 Murray DC, Christopoulou D, Hero M. Combined central retinal vein occlusion and cilioretinal artery occlusion in a patient on hormone replacement therapy. Br J Ophthalmol 2000;84:549–50. 5 Opremcak EM, Bruce RA, Lomeo MD, et al. Radial optic neurotomy for central retinal vein occlusion: a retrospective pilot study of 11 consecutive cases. Retina 2001;21:408–15. 6 Hausmann N, Richard G. Effect of high dose steroid bolus on occlusion of ocular central artery: angiographic study. BMJ 1991;303:1445–6. 7 Hayreh SS. Management of central retinal vein occlusion. Ophthalmologica 2003;217:167–88. 8 Garcia-Arumi J, Boixadera A, Martinez- Castillo V, et al. Chorioretinal anastomosis after radial optic neurotomy for central retinal vein occlusion. Arch Ophthalmol 2003;121:1385–91. MAILBOX Value based medicine In a fine recent editorial, Drs Melissa and Gary Brown raised issues at the nexus of health policy and clinical science.1As utility assessment is relatively new to the visual sciences, understanding both the assump- tions behind this work and the consequences of relaxing those assumptions is essential for the conduct of high quality research and appropriate interpretation of the results. The use of community elicited utilities (that is, including people without the disease in the elicitation study) in economic evalua- tion should be given more than minimal consideration. Economic intended to inform health policy makers by assessing the value society places on the cure or prevention of disease. Community based S M Kymes Washington University School of Medicine, Department of Ophthalmology and Visual Sciences, 660 South Euclid, Campus Box 8096, Saint Louis, MO 63116, USA Fluorescein angiography of the right Figure 2 eye. (A) Preoperative, arterial phase (14 seconds after dye injection). A delayed filling of the cilioretinal artery becomes apparent (white arrow). The macular area supplied by the cilioretinal artery appear hypofluorescent as a result of retinal thickening. (B) 10 weeks postoperatively, arterial phase (14 seconds after dye injection). The filling of the cilioretinal artery occurs at 13 seconds and appears similar to the central retinal artery. There are no signs of non-perfused areas or ischaemia. K D Frick Johns Hopkins Bloomberg School of Public Health Department of Health Policy and Management, Baltimore, MD, USA Correspondence to: Dr Steven Kymes, Washington University School of Medicine Department of Ophthalmology and Visual Sciences, 660 South Euclid, Campus Box 8096, Saint Louis, MO 63116, USA; evaluations are doi: 10.1136/bjo.2004.063784 Accepted for publication 3 December 2004

  7. Downloaded from on 28 August 2008 644 PostScript posterior4 5segments, did not show apparent toxicity. Thus, it would be appreciated if the authors could clarify whether other potential con- founders were assessed in their study, includ- ing: (1) other causes of CMO such as diabetes, uveitis, and prostaglandin use; (2) operating time since phototoxicity from the operative microscope6is a risk factor for CMO development. It appears that only operations for patients in group B were performed by one surgeon, if operations for patients in group A (with trypan blue use) were done by trainees, the operative time is expected to be longer; (3) whether all patients received a fundus examination with dilated pupil after the operation. If these were only performed in patients with suboptimal visual acuities, the incidence of CMO may be underesti- mated. Finally, we concur with the authors’ view that we should try all means in terms of minimising any theoretical toxicities of try- pan blue. It is our routine to actively remove trypan blue with the bimanual irrigation aspiration system as soon as the anterior capsule has been stained. It is very effective and the potential toxicities may be reduced. References patients with that health state. In essence, patients who have lived with a health state are those best able to ascertain the quality of life associated with that health state. And it is usually worse than others imagine. In conclusion, we thank Kymes and Frick for their interest and comments and look forward to additional awareness in the arena of value based medicine. As increasing numbers of those who allocate healthcare resources become aware that value based medicine allows for higher quality care (by incorporating quality of life parameters that evidence based primary clinical trials often ignore) and the most resources, it will have a considerably greater role in the delivery of cost effective, quality healthcare. When that takes place, all will benefit. 1 Brown MM, Brown GC. Value based medicine: let’s get it right. Br J Ophthalmol 2004;88:979. 2 Krahn MD, Ritvo P, Irvine J, et al. Patient and community preferences for outcomes in prostate cancer: implications for clinical policy. Medical Care 2003;41:153–64. 3 Gold MR, Siegel JE, Russell LB, et al. Cost- effectiveness in health and medicine, 1st ed. New York: Oxford University Press, 1996. 4 Mangione CM, Lee PP, Gutierriez PR, et al. Development of the 25-Item National Eye Institute Visual Function Questionnaire. Arch Ophthalmol 2001;119:1050–8. 5 Salomon JA, Murray CJL. A multi-method approach to measuring health-state valuations. Health Economics 2004;13:281–90. 6 Jampel HD. Glaucoma patients’ assessment of their visual function and quality of life. Trans Am Ophthamol Soc 2001;99:301–17. efficient use of M Brown, G C Brown Authors’ reply We thank Drs Kymes and Frick for their excellent letter regarding utility analysis as a health related quality of life instrument. We agree that the use of primarily function based quality of life instruments such as the NEI- VFQ-25 may result in missing many impor- tant variables in the quality of life arena, as well as limit applicability across all diseases.1 In contrast, preference based quality of life instruments, such as utility analysis, are applicable across all diseases and encompass all variables that comprise quality of life, as well as the weighting of those variables. Of great additional importance is the fact that preference based instruments can be used in healthcare economic analyses, especially uti- lity analysis, while most function based instruments have not used.1 2 Concerning the use of time trade-off and standard gamble utility analysis, we have found that the time trade-off methodology is easier for patients to comprehend and also is more sensitive to milder health states since there is risk aversion to the consequence of immediate death associated with the stan- dard gamble variant.1 2Froberg and Kane3 have also shown that the time trade-off method of utility has greater test-retest reliability, intra-rater reliability and inter- rater reliability than standard gamble meth- odology. In our experience, time trade-off utilities generally demonstrate better con- struct validity1and a wider range between pre-intervention and post-intervention values than standard gamble utilities, thus resulting in more favourable cost utility analysis, rather then less favourable analyses. With regard to quality of life respondents, we remain firm in our adherence to the fact that a basic pillar of value based medicine is the use of utility values obtained from respondents with a health state in question.1 2 We have found that utility value diminution in patients who actually have age related macular degeneration ranges from 103% to 750% greater than the decrement estimated by treating ophthalmologists for the same condition.4 5This has been noted as well for non-ophthalmological health states.6 We respectfully disagree that community utility values generally overestimate the degree to which a disease decreases quality of life. In contrast, we and others4–9have noted that community and provider partici- pants asked to evaluate the quality of life associated with a health state using utility value analysis generally underestimate the decrement in quality of life compared to Center for Value-Based Medicine, PO Box 335, Flourtown, PA 19031-1404, USA Correspondence to: Dr Melissa Brown, Center for Value-Based Medicine, PO Box 335, Flourtown, PA 19031-1404, USA; doi: 10.1136/bjo.2004.063792 H K L Yuen, R F Lam, D S C Lam The Chinese University of Hong Kong, Hong Kong Accepted for publication 3 December 2004 References Correspondence to: Dennis S C Lam, The Chinese University of Hong Kong, Hong Kong; dennislam@ 1 Brown MM, Brown GC, Sharma, S. Evidence- based to value-based medicine. Atlanta, GA: AMA Press, 2005. 2 Brown MM, Brown GC, Sharma S, et al. Health care economic analyses and value-based medicine. Surv Ophthalmol 2003;48:204–23. 3 Froberg DG, Kane RL. Methodology for measuring health state preferences. II. Scaling methods. J Clin Epidemiol 1989;42:459–71. 4 Brown GC, Brown MM, Sharma S. Difference between ophthalmologist and patient perceptions of quality-of-life associated with age-related macular degeneration. Can J Ophthalmol 2000;35:27–32. 5 Brown GC, Brown MM, Sharma S, et al. The burden of age-related macular degeneration. A value-based analysis. Curr Opin Ophthalmol, (in press). 6 Fryback DG, Dasbach EJ, Klein R, et al. The Beaver Dam Outcomes Study: initial catalog of health-state quality factors. Med Dec Making 1993;13:89–102. 7 Stein JD, Brown MM, Brown GC, et al. Quality of life with macular degeneration. Perceptions of patients, clinicians and community members. Br J Ophthalmol 2003;87:8–12. 8 Landy J, Stein JD, Brown GC, et al. Patient, community and clinician perceptions of the quality of life associated with diabetes mellitus. Medical Science Monitor 2002;8:543–8. 9 Sharma S, Brown GC, Brown MM, et al. Validity of the time trade-off and standard gamble methods of utility assessment in retinal patients. Br J Ophthalmol 2002;86:493–6. doi: 10.1136/bjo.2005.066035 Accepted for publication 4 January 2005 been successfully References 1 Gouws P, Merriman M, Goethals S, et al. Cystoid macular oedema with trypan blue use. Br J Ophthalmol 2004;88:1348–9. 2 Melles GR, de Waard PW, Pameyer JH, et al. Trypan blue capsule staining to visualize the capsulorhexis in cataract surgery. J Cataract Refract Surg 1999;25:7–9. 3 Dada VK, Sharma N, Sudan R, et al. Anterior capsule staining for capsulorhexis in cases of white cataract: comparative clinical study. J Cataract Refract Surg 2004;30:326–33. 4 Feron EJ, Veckeneer M, Parys-Van Ginderdeuren R, et al. Trypan blue staining of epiretinal membranes in proliferative vitreoretinopathy. Arch Ophthalmol 2002;120:141–4. 5 Li K, Wong D, Hiscott P, et al. Trypan blue staining of internal limiting membrane and epiretinal membrane during vitrectomy: visual results and histopathological findings. Br J Ophthalmol 2003;87:216–9. 6 Donzis PB, DeBartolo DF, Lewen RM, et al. Light- induced maculopathy and cystoid macular edema. J Cataract Refract Surg 1988;14:84–5. Authors’ reply We thank Lam et al for their interest. In response to their comments, as stated in the article and demonstrated in figures 1B and C, the effect persists when co-morbidity such as diabetes is removed. Both groups’ surgery was performed by the same surgeon who did not have juniors attached to the list. Not all patients had dilated fundus exam- ination postoperatively. Clinically significant cystoid macular oedema (CMO) is unlikely in patients with visual acuities of 6/12 or better, although subclinical CMO can be demon- strated in up to 20% with fluorescein angio- graphy.1 Cystoid macular oedema with trypan blue use We read with interest the article by Gouws et al1on the apparent increased incidence of cystoid macular oedema (CMO) in phaco- emulsification patients when trypan blue was used to stain the anterior capsule. Trypan blue has been commonly used in both anterior and posterior segment sur- geries.2–4If trypan blue does cause macular toxicity, its risks should theoretically be higher when used in posterior segment surgeries. However, studies on the use of trypan blue, both in the anterior2 3and

  8. Downloaded from on 28 August 2008 PostScript 645 This retrospective study on a unique cohort of patients provided us with the opportunity to demonstrate a potential side effect with the use of trypan blue. A prospective trial is required to control for all the variables and confirm or refute our findings. For more information, contact the Media Office on 01227 823581/823100 or email News releases can also be found at: disciplines have been subjected. One special feature of the period described is that it also covers the first 40 years following the foun- dation of the Institute of Ophthalmology and the not always easy relationship between the hospital and the institute is recorded both openly and tactfully. The book comprises a number of chapters outlining the various aspects of the hospital development—for example, clinical, manage- rial, financial, etc. The first chapter is an overview involving all aspects of the hospital during the 40 years from 1963 to 2003. It provides a concise synopsis of all the forces bearing on the hospital; not only clinical but also in terms of research, teaching, and political upheaval. Indeed, for those younger ophthalmologists entering the profession at the present time this chapter gives a concise overview of those political influences that have shaped the lives of the NHS and its staff during recent decades. As the author points out in his preface the subsequent chapters take up the issues raised in the first chapter and analyse them in more detail. If one, therefore, picks up the book and reads it cover to cover there is a strong repetitive element but it was not really the author’s intention that the book should be necessarily read in this way. Each of the later chapters is written in a stand alone fashion dealing with clinical progress, academic development, research, management, and finance so that some repetition is inevitable. The major characters Moorfields development weight; particularly Professor Barrie Jones, under whose influence Moorfields progressed from a rather slow moving organisation to the establishment of all the subspecialist services we know today. Apart from rather a large number of nautical metaphors such as ‘‘calm waters,’’ ‘‘stormy seas,’’ and a few petty errors of detail, such as dates, this volume is a good read, particularly if approached as the author intended. He himself has made major con- tributions to the standing of Moorfields Eye Hospital and the book is written in the typically clear and polished style, reminiscent of his own scientific contributions. Trachoma control The latest issue of Community Eye Health (No 52) discusses new developments in the control of trachoma. For further information please contact: Journal of Community Eye Health, International Resource Centre, Inter- national Centre for Eye Health, Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK (tel: +44 (0)20 7612 7964; email: Anita.Shah@; online edition: uk). Annual subscription (4 issues) UK £28/ US$45. Free to developing country applicants. P Gouws, P Simcock Conquest Hospital, Hastings, UK Correspondence to: Peter Simcock, West of England Eye Unit, Royal Deom and Exeter Hospital, Exeter EX2 5DW, UK; doi: 10.1136/bjo.2004.069765 Accepted for publication 23 February 2005 Reference 1 Ursell PG, Spalton DJ, Whitcup SM, et al. Cystoid macular edema after phacoemulsification: relationship to blood-aqueous barrier damage and visual acuity. J Cataract Refract Surg 1999;25:1492–7. EVER 2005 meeting This will take place on 5–8 October 2005 in Vilamoura, Portugal. please contact: Christy Secretary, Kapucijnenover Leuven, Belgium (tel: +32 (0)16 233 849; fax +32 (0)16 234 For further Lacroix, 33, details EVER B-3000 097; email:ever@ BOOK REVIEW World Ophthalmology Congress 2006 – Brazil The World Ophthalmology Congress (which is replacing the International Congress of Ophthalmology) is meeting in February 2006 in Brazil. For further information on the congress and committees, scientific program and coor- dinators of different areas are available at the congress website www.ophthalmology2006. The History of Moorfields Eye Hospital, Volume III in the story given of are due Ed Peter K Leaver. London: Royal Society of Medicine Press Ltd, 2004, pp 360; £30. ISBN 1-85315-580-2. Like John Mortimer’s book of a similar title this third volume of the history of Moorfields Eye Hospital is an affectionate but critical look back at the hospital that has been a major influence in many ophthalmologists’ training and subsequent practice. The volume is written in a positive upbeat style but also describes some of the faults and difficulties that have beset it in the past four decades. In a complex organisation such as a hospital there are inevitable inefficiencies and pro- blems with personalities but the author has wisely stuck to the facts and has plotted the course of the management of the hospital in a very readable way; he has sensibly avoided petty confrontations and offers a lucid out- line of the course of Britain’s flagship ophthalmic hospital. The two previous histories of Moorfields described times past when ophthalmic prac- tice changed only gradually and political upheaval was minor. The current author has been in the unique position of being involved with Moorfields throughout the 40 years he describes. Given the turmoil, both profes- sional and managerial, that has engulfed the delivery of health care during this period he was fortunate that many of the individuals involved with the hospital were available for interview, thus providing first hand accounts of the good and bad times that affected the hospital. The various chapters outline lucidly the clinical and political changes of the time; Moorfields represents in microcosm all the influences to which NHS consultants of all CORRECTIONS doi: 10.1136/bjo.2005.42556corr1 In the letter entitled, Norrie disease and peripheral venous Ophthalmol 2004;88:1475) the ordering of the authors was incorrect. The correct order is Michaelides M, Luthert PJ, Cooling R, Firth H, Moore AT. The journal apologises for this error. R Grey insufficiency (Br J Bristol Eye Hospital, Lower Maudlin Street, Bristol BS1 2LX, UK; doi: 10.1136/bjo.2005.58032corr1 NOTICES Owing to an author error the name of one of the authors of the paper entitled, Long term effect on IOP of a stainless steel glaucoma drainage implant (Ex-PRESS) in combined surgery with phacoemulsification, appeared in the April issue of the journal (Br J Ophthalmol 2005;89:423–9) was omitted (S Gandolfi). The author list should be C Traverso, F De Feo, A Messas-Kapal, P Denis, S Levartovsky, E Sellem, F Badala `, Z Zagorski, A Bron, S Gandolfi, M Belkin. S Gandolfi is at the Clinica Oculistica, University of Parma, Italy. Worldwide clinical trials for new technique for early detection of eye disease A unique new non-invasive technique for high resolution optical imaging of the eye is receiving global acclaim. By combining two high-resolution imaging technologies, the new technique provides doctors with 3-D images of the retina, macula and the optic nerve. which