Visual Deficiency in Wallenberg’s Syndrome

The aim of this case report of a 47-year-old woman who suffered from acute right-sided medullar ischemic stroke was to define the range of visual impairment in Wallenberg’s syndrome (WS). The patient complained of unbearable environmental tilt and rotating visual perception. On examination, 11 months following the stroke, the patientm anifested rightsided postural inclination and gaze ipsipulsion. The fixation in primary position was unstable, after a conjugate ipsipulsion ensued, spontaneous corrective saccades and a horizontal-rotational jerking nystagmus beating away from the side of the lesion were generated. Monocular visual acuity (right eye: 0.4 logMAR distance and 0.2 logMAR near; left eye: 0.1 logMAR distance and 0.0 logMAR near) was significantly better than binocular (0.63 logMAR distance and near). Fluent reading was impossible. Contralateral smooth pursuits were more impaired. Saccades were defective manifesting right hypermetria and left hypometria. Visual field was constricted to central 10 – 20°. A diagnosis of Wallenberg’s syndrome was made. Occlusion was prescribed. Review of literature demonstrated lack of evidence-based guidelines for ophthalmic assessment and treatment of visual impairment in WS. Oculomotor abnormalities, oscillopsia and tilt illusion cause significant impact to daily life. Early post-stroke ophthalmological evaluation is thus mandatory in order to offer timing treatment

Specifičnosti biometrijskih čimbenika oka u glaukomskih bolesnika s pseudoeksfolijativnim sindromom mjerenih optičkom niskokoherentnom reflektometrijom

The aim of the study was to assess biometric factor aberrations and differences among groups of eyes with cataract and pseudoexfoliative syndrome, cataract and pseudoexfoliative glaucoma, and cataract and primary open-angle glaucoma (POAG), and to determine biometric factors of the eye specific for the group of glaucomatous patients with pseudoexfoliative syndrome by use of optical low-coherence reflectometry. This retrospective study included 72 patients, and the study sample of 102 eyes was divided into the following three groups according to diagnosis: 29 eyes with pseudoexfoliative syndrome and cataract; 36 eyes with POAG and cataract; and 37 eyes with pseudoexfoliative glaucoma and cataract. Data on biometric measurements (central corneal thickness, pupillary diameter, anterior chamber depth, lens thickness, axial length, retinal thickness, astigmatism and white-to-white) obtained by use of optical low-coherence reflectometry on a Lenstar LS 900® (Haag-Streit International) were collected and analyzed by thorough survey of medical documentation of patients scheduled for cataract surgery at Department of Ophthalmology, Sveti Duh University Hospital in Zagreb, Croatia. Comparative analysis of the groups yielded statistically significant differences in central corneal thickness (F2/99=7.066; p=0.001) and lens thickness (F2/96=5.133; p=0.008). The group of eyes diagnosed with pseudoexfoliative glaucoma and cataract had a significantly thinner cornea as compared with the other two groups and a significantly thicker lens as compared with the group of eyes with POAG and cataract. In conclusion, optical low-coherence reflectometry revealed differences in biometric factors among the three groups of eyes, with a statistically significantly thinner cornea and thicker lens in the group of glaucomatous patients with pseudoexfoliative syndrome.Cilj je bio optičkom niskokoherentnom reflektometrijom utvrditi odstupanja i razlike biometrijskih čimbenika između skupina ispitivanih uzoraka očiju s kataraktom i pseudoeksfolijativnim sindromom, kataraktom i pseudoeksfolijativnim glaukomom i kataraktom i primarnim glaukomom otvorenog kuta te odrediti biometrijske čimbenike oka specifične za skupinu glaukomskih bolesnika s pseudoeksfolijativnim sindromom. U retrospektivnu studiju bilo je uključeno 72 ispitanika, a uzorak su činila 102 oka podijeljena u tri skupine prema dijagnozi: 29 očiju s pseudoeksfolijativnim sindromom i kataraktom, 36 očiju s primarnim glaukomom otvorenog kuta i kataraktom, 37 očiju s pseudoeksfolijativnim glaukomom i kataraktom. Detaljnom analizom medicinske dokumentacije ispitanika predviđenih za operaciju katarakte u Klinici za očne bolesti Kliničke bolnice Sveti Duh u Zagrebu prikupljeni su i analizirani podaci biometrijskih mjerenja (centralna debljina rožnice, promjer zjenice, dubina prednje sobice, debljina leće, aksijalna duljina, debljina rožnice, astigmatizam i horizontalni promjer rožnice izmjereni primjenom optičke niskokoherentne reflektometrije na uređaju Lenstar LS 900®, Haag Streit International). Usporednom analizom skupina zabilježene su statistički značajne razlike za centralnu debljinu rožnice (F2/99=7,066; p=0,001) i debljinu leće (F2/96=5,133; p=0,008). Skupina očiju s dijagnozom pseudoeksfolijativnog glaukoma i katarakte imala je značajno tanju rožnicu u odnosu na ostale dvije skupine očiju i značajno deblju leću od skupine s primarnim glaukomom otvorenog kuta i kataraktom. U zaključku, primjenom optičke niskokoherentne reflektometrije utvrđene su razlike u biometrijskim čimbenicima promatranih skupina i statistički značajno tanja rožnica te zadebljana leća u skupini glaukomskih bolesnika s pseudoeksfolijativnim sindromom

Painless Acanthamoeba Keratitis in a Soft Contact Lens Wearer – Case Report

Aim of our paper is to present a case of painless Acanthamoeba keratitis in a soft contact lens wearer. A 17-year-old male, highly myopic, prolonged soft contact lens wearer, presented to us with painless red watery right eye having remarkably diminished vision. Last six weeks he was treated elsewhere for the microbial keratitis with no improvement. No pain was reported and on the direct questionnaire about it he denied it. There was marked mixed conjunctival and ciliary injection. A central stromal opacity with a pronounced surrounding corneal ring of inflammatory infiltration and epithelial defect was seen on biomicroscopy of the right eye. Circular pannus was already formed reaching epithelial defect overlying corneal ring infiltrate. Acanthamoeba spp in the corneal sample was confirmed. Prolonged therapy with 0.02% chlorhexidine digluconate solution combined with 0.1% hexamidine solution resulted in corneal healing left with a large central dense stromal opacity with circular pannus reaching peripheral third of the cornea but with very thin blood vessels and the best corrected visual acuity of 0.1 tested on Snellen chart. In conclusion, even in a lack of typical symptom for Acanthamoeba keratitis such as pain, this amoeba should be ruled out especially in a soft contact lens wearer

Modified Operative Technique for Involutional Lower Lid Entropion

The paper presents a modified operative technique for involutional lower lid entropion. The prospective noncomparative study of 101 lower eyelids of 88 patients undergoing surgery for involutional lower lid entropion was conducted in period from September 2005 until March 2012. Indication for the surgery was entropion, previously untreated, with moderate to severe horizontal lid laxity and no clinically relevant medial and lateral canthal tendon laxity. The operative technique is our modification of Quickert and Jones procedures. Photo was taken preoperatively and one month after surgery. Clinical follow-up was at 7th postoperative day, one month and six months after surgery and in case of the recurrence. Long-term follow-up was obtained via telephone interviews. There were 44 male (50%) and 44 female (50%) patients included in the study. The age of patients was in average 73.27±8.1 years (range 53–90 years). Early postoperative complication was localized lid swelling found in two patients starting 4–6 weeks postoperatively at the area of absorbable suture. It resolved spontaneously in two and three weeks respectively. There was recurrence of entropion in 11 eyelids (10.89%) of 10 patients. The mean interval between primary surgery and the recurrence was 17.45±14.84 months (range 4–48 months). In these eyelids Jones procedure was performed. However in four eyelids of four patients from the recurrent group an additional surgery needed to be performed after 6, 12, 12 and 17 months respectively. Our modification of surgical treatment for involutional lower lid entropion was effective in 89.11% of eyelids. Complications of the procedure were scarce

Common Bile Duct Obstruction Caused by the Hydatid Daughter Cysts

Echinococcosis is a human parasitary disease. In 2002, 29 new cases of liver echinococcosis were recorded in Croatia. Liver is the most common site of hydatid cysts. Nine patients with echinoccocal liver disease were operated in our department in 2002. Here we present a case where a patient with verified hydatid cyst in the left liver lobe developed high fever, jaundice, nausea, vomiting and pain in the upper abdomen. The symptoms were initially ascribed to the acute cholangitis. After unsuccessful antibiotic treatment, computerized tomography and endoscopic retrograde cholangiopancreatography (ERCP) were performed, demonstrating daughter cysts in the common bile duct. During ERCP, papilotomy was made and daughter cysts were extracted. Hydatid cyst was surgically removed, and a communication between the cyst and left hepatic duct was noted during surgery. Pericystectomy, choledochotomy, removal of remaining daughter cysts from the common bile duct, and sutures of left hepatic duct were performed. The patient recovered fully after the surgery. One of the possible complications of the liver hydatid cysts is the communication between cyst and the biliary tree. Such communications are usually asymptomatic, but symptoms can also mimic acute cholangitis and jaundice, which may lead to the misdiagnosis of the patient’s condition

Anesthesia management for children with eye injuries

Eye injuries in childhood are very common and an important cause of ocular morbidity. They are a leading cause of non-congenital unilateral blindness in children.The anesthesia management of children with eye injuries requires particular skills and is a challange for all anesthesiologists. The anesthesia management must prove safety for the child, but also must not endanger eye injury any further. In the politraumatized child, trauma principlesmust allways be applied. Life-threatening problems should be managed before sight-threatening problems. General anesthesia is a choice for majority of child en with an eye injury.Maintenance of anesthesia will depend on patient factors, local facilities and surgeon preferences. Extubation is better to be performed in deep anesthesia, breathing spontaneously, lying on the side to avoid coughing and straining as this increase the risk of ocular hemorrhage. Multimodal approach and combination therapy (e.g. dexamethason and ondasteron) will minimize PONV in children. Satisfactory postoperative analgesia is important to have a non-crying and calm child to avoid rise in IOP and postoperative hemorrhage

Retrospective Analysis of Reconstruction Techniques After Periocular Basalioma Excision

The paper presents our approach to reconstruction after periocular basalioma (pBCC) excision, especially of large lower lid (LL) and medial canthal (MC) pBCC. Retrospective analysis of data of 123 patients with pBCC, confirmed on histologic examination (HE), operated in period from 1998 to 2006, was performed. Oncologic safety margins of 3 mm were marked after local anesthesia was administered. Reconstruction was done in time of surgery. In pBCC away from a lid margin, adjacent myocutaneous flaps were used. For lid margin involving (LM) pBCC, size of 10 mm and less in horizontal diameter (HD), full-thickness lid excision was performed, combined with lateral canthotomy and/or Tenzel or McGregor flap. When size of LM pBCC was more than 10 mm in HD and it was on a LL, ipsilateral upper lid (UL) tarsoconjunctival (TC) graft combined with single pedicle transposition myocutaneous flap were used. The same size of LM pBCC on a UL required ipsilateral full-thickness LL “switch” flap and/or contralateral LL Hübner graft. In MC pBCC combined approach was used. The follow-up was up to 5 years. The 19 patients (15.4%) had positive tumor margin on HE. Five of them refused further surgery, but only two had recurrence. The rest of 121 patients had no recurrence during follow-up. In 5/14 patients, who underwent additional surgery, no tumor cells were found on HE. The 10/123 patients (8.1%) had complications. The imperative of our approach to reconstruction after pBCC was good functional and cosmetic result, avoiding prolonged lid closure. Accordingly, in large LL LMpBCC we used ipsilateral UL TC graft combined with single pedicle transposition myocutaneous flap. In MC pBCC combined approach was mandatory

Cross-Sectional Study of Ocular Optical Components Interactions in Emmetropes

Purpose of the paper was to evaluate ocular optical components (OOC) interactions in a large number of emmetropes. A cross-sectional study of 1,000 emmetropes, aged from 18–40 years, has been conducted. Complete ophthalmological examination, corneal radius (CR) measurement, keratometry and echobiometry of both eyes were performed. The highest correlation of OOC was that of axial length (Ax) with vitreal body (CV) on both eyes (r=0.79 for the right eye (RE); r=0.81 for the left eye (LE)). The axial length had a positive correlation with the anterior chamber depth (ACD) on both eyes as well, but the coefficient was very low (r=0.29 for the RE; r=0.32 for the LE). The only negative correlation Ax had on both eyes was with the lens (L) (r=–0.17 for the RE; r=–0.19 for the LE). Keratometry of the horizontal (K1) and vertical meridian (K2) showed a negative correlation with CV and Ax on both eyes (for K1 r=–0.64 for CV, r=–0.54 for Ax; for K2 r=–0.67 for CV, r=–0.68 for Ax). CR had a positive correlation with Ax (r=0.74) and CV (r=0.79). It showed a negative correlation with L (r=–0.58). CV had a high, positive correlation with Ax (r=0.72 for the RE; r=0.75 for the LE). The correlation with K1 and K2 was negative. Our study showed that the axial length, keratometry, corneal radius, lens thickness and vitreal body were the most important OOC that correlated with each other following a pattern in our group of emmetropes. They interacted in such a way that in the subjects with axial length above the average value, the vitreal body was longer but the lens was thinner and the cornea was of less power. This could explain at least one of the mechanisms of emmetropization

Retrospective Clinical Analysis of Free Conjunctival Autograft in Treatment of Pterygia

The paper is a clinical retrospective analysis of free conjunctival autograft in treatment of pterygia. In period from 1998 until 2006, 47 patients with pterygia were operated using free conjunctival autograft. There were 19 female and 38 male, average age 61 years. In the majority of patients (39/47) it was a primary pterygia. Eight patients were on topical antiglaucoma therapy. Free autograft was taken from superotemporal conjunctiva. Introduction of a single nylon suture to mark the epithelial side of the graft as well as the use of running 10–0 nylon suture for the graft that stays in up to two months, were our modifications of the standard technique. The mean follow-up was 18.79.8 months. Free conjunctival autograft was successfully taken in all patients. Four of them experienced transient graft edema. In glaucoma patients, delayed healing of the cornea, conjunctival harvest area and the graft was noted. The best corrected visual acuity was improved in all patients, from 1–3 Snellen lines. Recurrence of the pterygium was noted in three patients, two of them already with recurrent pterygium. Free conjunctival graft is a safe and effective method of pterygium surgery that produces only few complications and has low recurrence rate. We found useful switch from topical to systemic antiglaucoma therapy as well as adjunctive use of autologous serum drops in promoting and accelerating healing in glaucoma patient

Optical Coherence Tomography Angiography – A New Insight Into Macular Vasculature

Optical coherence tomography angiography (OCT-A) is a new non-invasive technology for imaging of retinal and choroidal vasculature of the macular area with resolution comparable to histological sections. OCT-A does not require usage of intravenous dye, contrary to fluorescein angiography, the current gold standard for imaging of retinal vessels, and indocyanine-green angiography, which is important for imaging of choroidal vessels. With the advancements in optical coherence tomography (OCT) scanning speeds and creation of powerful algorithms for improvement of image quality in recent years, OCT-A imaging of macular vasculature, superficial, deep and avascular retinal complex, as well as choriocapillaris and deep choroid has become available in everyday clinical practice. This review covers aspects important for understanding choroidal and retinal blood supply, as well as the development, mechanisms and clinical application of OCT and OCT-A technology. (Bajtl D, Bjeloš M, Bušić M, Rak B, Križanović A, Kuzmanović Elabjer B. Optical Coherence Tomography Angiography – A New Insight Into Macular Vasculature. SEEMEDJ 2019; 3(2); 63-75