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Serious complications of cataract surgery include retinal detachment and endophthalmitis. In both cases, patients notice a sudden decrease in vision. In endophthalmitis, patients often describe pain. Retinal detachment frequently presents with unilateral visual field defects, blurring of vision, flashes of light, or floating spots.
The risk of retinal detachment was estimated as about 0.4% within 5.5 years, corresponding to a 2.3-fold risk increase compared to naturally expected incidence, with older studies reporting a substantially higher risk. The incidence is increasing over time in a somewhat linear manner, and the risk increase lasts for at least 20 years after the procedure. Particular risk factors are younger age, male sex, longer axial length, and complications during surgery. In the highest risk group of patients, the incidence of pseudophakic retinal detachment may be as high as 20%.
The risk of endophthalmitis occurring after surgery is less than one in 1000.
Corneal edema and cystoid macular edema are less serious but more common, and occur because of persistent swelling at the front of the eye in corneal edema or back of the eye in cystoid macular edema. They are normally the result of excessive inflammation following surgery, and in both cases, patients may notice blurred, foggy vision. They normally improve with time and with application of anti-inflammatory drops. The risk of either occurring is around one in 100. It is unclear whether NSAIDs or corticosteroids are superior at reducing postoperative inflammation.
Posterior capsular opacification, also known as after-cataract, is a condition in which months or years after successful cataract surgery, vision deteriorates or problems with glare and light scattering recur, usually due to thickening of the back or posterior capsule surrounding the implanted lens, so-called 'posterior lens capsule opacification'. Growth of natural lens cells remaining after the natural lens was removed may be the cause, and the younger the patient, the greater the chance of this occurring. Management involves cutting a small, circular area in the posterior capsule with targeted beams of energy from a laser, called capsulotomy, after the type of laser used. The laser can be aimed very accurately, and the small part of the capsule which is cut falls harmlessly to the bottom of the inside of the eye. This procedure leaves sufficient capsule to hold the lens in place, but removes enough to allow light to pass directly through to the retina. Serious side effects are rare. Posterior capsular opacification is common and occurs following up to one in four operations, but these rates are decreasing following the introduction of modern intraocular lenses together with a better understanding of the causes.
Vitreous touch syndrome is a possible complication of intracapsular cataract extraction.
Risk factors such as UVB exposure and smoking can be addressed. Although no means of preventing cataracts has been scientifically proven, wearing sunglasses that counteract ultraviolet light may slow their development. While adequate intake of antioxidants (such as vitamins A, C, and E) has been thought to protect against the risk of cataracts, clinical trials have shown no benefit from supplements; though evidence is mixed, but weakly positive, for a potential protective effect of the nutrients lutein and zeaxanthin. Statin use is somewhat associated with a lower risk of nuclear sclerotic cataracts.
Mild conjunctivochalasis can be asymptomatic and in such cases does not require treatment. Lubricating eye drops can be tried but do not often work.
If discomfort persists after standard dry eye treatment and anti-inflammatory therapy, surgery can be undertaken to remove the conjunctival folds and restore a smooth tear film. This conjunctivoplasty surgery to correct conjunctivochalasis typically involves resection of an ellipse-shaped segment of conjunctiva just inferior to the lower lid margin, and is usually followed either by suturing or amniotic membrane graft transplantation to close the wound.
Because the disorder often occurs in people with typical dry eye symptoms, it can be difficult to distinguish readily the discomfort caused by the dry eye from that directly related to the redundant conjunctiva.
Lenticonus (/len·ti·co·nus/ (len″tĭ-ko´nus)) [lens + L. conus, cone] is a rare congenital anomaly of the eye characterized by a conical protrusion on the crystalline lens capsule and the underlying cortex. It can reach a diameter of 2 to 7 mm. The conus may occur anteriorly or posteriorly. If the bulging is spherical, instead of conical, the condition is referred to as "lentiglobus". It produces a decrease in visual acuity and irregular refraction that cannot be corrected by either spectacle or contact lenses.
Biomicroscopically "lenticonus" is characterized by a transparent, localized, sharply demarcated conical projection of the lens capsule and cortex, usually axial in localization. In an early stage, retro-illumination shows an «oil droplet» configuration. Using a narrow slit, the image of a conus is observed. In a more advanced stage associated subcapsular and cortical opacities appear. Retinoscopically the oil droplet produces a pathognomonic scissors movement of the light reflex. This phenomenon is due to the different refraction in the central and the peripheral area of the lens. Ultrasonography also can illustrate the existence of a "lenticonus". A-scan ultrasonography may reveal an increased lens thickness and B- scanultrasonography may show herniated lenticular material, suggestive of a lenticonus. Amblyopia, cataract, strabismus and loss of central fixation may be observed in association with lenticonus posterior. Cataract, flecked retinopathy, posterior polymorphous dystrophy and corneal arcus juvenilis may be encountered in association with lenticonus anterior that occurs as a part of the Alport syndrome.
Exist two distinct types of "lenticonus" based on the face of the lens affected.
Vossius ring (also called "Vossius's ring" or "Vossius' ring") is due to blunt trauma to the eye. When the eye is injured, a circular ring of fainted or stippled opacity is seen on the anterior surface of the lens due to brown amorphous granules of pigment lying on the capsule. It has the same diameter as the contracted pupil, and is due to impression of the iris on the lens as a result of the force of a concussion injury, which drives the cornea and iris backward.
It is named after German ophthalmologist Adolf Vossius, who first described the condition in 1906.
Treatment of meniscal cysts consists of a combination of cyst decompression (intraarticular decompression versus open cystectomy) and arthroscopic repair of any meniscal abnormalities. Success rates are significantly higher when both the cyst and meniscal tear are treated compared to treating only one disease process.
Magnetic resonance imaging is the modality of choice for diagnosis of meniscal cysts. In their most subtle form, meniscal cysts present as focal areas of high signal intensity within a swollen meniscus. It is not uncommon for radiologists to miss this type of meniscal cyst because the signal intensity is not quite as great as fluid on T2 weighted sequences.2 When this fluid is extruded into the adjacent soft tissues, the swollen meniscus subsequently assumes a more normal shape, and the extruded fluid demonstrates a higher T2 signal typical of parameniscal cysts.
Medial meniscus horizontal tear extending into a meniscal cyst.
Sagittal T2 images of a medial meniscus horizontal tear extending into a meniscal cyst.
Large medial meniscus cyst.
When diagnosing, PLF should be differentiated from Ménière's disease. Tympanostomy has been reported to be a way to diagnose and cure PLF.
The disease incidence varies widely depending on the geographical location. The most extensive epidemiological survey on this subject has been carried out by Dharmasena et al. who analysed the number of neonates who developed neonatal conjunctivitis in England from 2000 to 2011. In addition to the incidence of this sight threatening infection they also investigated the time trends of the disease. According to them the incidence of Neonatal conjunctivitis (Ophthalmia Neonatorum) in England was 257 (95% confidence interval: 245 to 269) per 100,000 in 2011.
Tenonitis is an eye disease, an inflammation of the Capsule of Ténon.
In the recessive form corneal clouding is observed at birth or within the neonatal period, nystagmus is often present, but no photophobia or epiphora is seen. In the autosomal dominant type corneal opacification is usually seen in the first or second year of life and progresses slowly, and nystagmus is infrequently seen.
Treatment of herpes of the eye is different based on its presentation: epithelial keratitis is caused by live virus while stromal disease is an immune response and metaherpetic ulcer results from inability of the corneal epithelium to heal:
Congenital hereditary corneal dystrophy (CHED) is a form of corneal dystrophy which presents at birth.
A specific clinical diagnosis of HSV as the cause of dendritic keratitis can usually be made by ophthalmologists and optometrists based on the presence of characteristic clinical features. Diagnostic testing is seldom needed because of its classic clinical features and is not useful in stromal keratitis as there is usually no live virus. Laboratory tests are indicated in complicated cases when the clinical diagnosis is uncertain and in all cases of suspected neonatal herpes infection:
- Corneal smears or impression cytology specimens can be analyzed by culture, antigen detection, or fluorescent antibody testing. Tzanck smear, i.e.Papanicolaou staining of corneal smears, show multinucleated giant cells and intranuclear inclusion bodies, however, the test is low in sensitivity and specificity.
- DNA testing is rapid, sensitive and specific. However, its high cost limits its use to research centers.
- Demonstration of HSV is possible with viral culture.
- Serologic tests may show a rising antibody titer during primary infection but are of no diagnostic assistance during recurrent episodes.
Patients are advised to treat with bed rest and avoiding activities that increase intracranial pressure (i.e. weightlifting, valsalva, scuba diving, flying in airplanes) with the hopes of the membrane healing on their own. Appropriate Physical therapy / vestibular rehabilitation techniques can be helpful in managing symptoms of movement sensitivity.
Corneal-cerebellar syndrome (also known as Der Kaloustian-Jarudi-Khoury syndrome) is an autosomally resessive disease that was first described in 1985. Three cases are known: all are sisters in the same family.
Abdominal ultrasound will typically be normal. Liver function tests will typically be normal or unchanged from baseline as the infection does not involve the liver parenchyma. If a D-dimer is ordered, which it often is when there is pleuritic torso pain, it will usually be markedly elevated but other testing for pulmonary embolism will be normal. CT of the abdomen with IV contrast may show subtle enhancement of the liver capsule, but this may be missed by radiologists if they are not advised to look for it. Testing for gonorrhea and chlamydia should be performed to make the diagnosis. An endocervical or low vaginal swab should be taken to test for these organisms. Antibody testing is rarely required but may be considered if other tests are non-diagnostic and suspicion is high.
Laparoscopy is also rarely required, but may be performed when the diagnosis is uncertain and may reveal "violin string" adhesions of parietal peritoneum to liver.
Plica syndrome treatment focuses on decreasing inflammation of the synovial capsule. A nonsteroidal anti-inflammatory drug (NSAID) is often used in conjunction with therapeutic exercise and modalities. Iontophoresis and phonophoresis have been utilized successfully against inflammation of the plica and synovial capsule. Failing these, surgical removal of the plica of the affected knee may be necessary.
CBC, ESR, blood cultures, and sinus cultures help establish and identify an infectious primary source. Lumbar puncture is necessary to rule out meningitis.
Antibiotic ointment is typically applied to the newborn's eyes within 1 hour of birth as prevention against gonococcal ophthalmia. This maybe erythromycin, tetracycline, or silver nitrate.
Sinus films are helpful in the diagnosis of sphenoid sinusitis. Opacification, sclerosis, and air-fluid levels are typical findings. Contrast-enhanced CT scan may reveal underlying sinusitis, thickening of the superior ophthalmic vein, and irregular filling defects within the cavernous sinus; however, findings may be normal early in the disease course.
A MRI using flow parameters and an MR venogram are more sensitive than a CT scan, and are the imaging studies of choice to diagnose cavernous sinus thrombosis. Findings may include deformity of the internal carotid artery within the cavernous sinus, and an obvious signal hyperintensity within thrombosed vascular sinuses on all pulse sequences.
Cerebral angiography can be performed, but it is invasive and not very sensitive. Orbital venography is difficult to perform, but it is excellent in diagnosing occlusion of the cavernous sinus.
Magnetic resonance imaging (MRI) can be helpful in assessing for a ligamentous injury to the medial side of the knee. Milewski et al. has found that grade I to III classification can be seen on MRI. With a high-quality image (1.5 tesla or 3 tesla magnet) and no previous knowledge of the patient’s history, musculoskeletal radiologists were able to accurately diagnose medial knee injury 87% of the time. MRI can also show associated bone bruises on the lateral side of the knee, which one study shows, happen in almost half of medial knee injuries.
Knee MRIs should be avoided for knee pain without mechanical symptoms or effusion, and upon non-successful results from a functional rehabilitation program.
Imaging features of adhesive capsulitis are seen on non-contrast MRI, though MR arthrography and invasive arthroscopy are more accurate in diagnosis. Ultrasound and MRI can help in diagnosis by assessing the coracohumeral ligament, with a width of greater than 3 mm being 60% sensitive and 95% specific for the diagnosis. The condition can also be associated with edema or fluid at the rotator interval, a space in the shoulder joint normally containing fat between the supraspinatus and subscapularis tendons, medial to the rotator cuff. Shoulders with adhesive capsulitis also characteristically fibrose and thicken at the axillary pouch and rotator interval, best seen as dark signal on T1 sequences with edema and inflammation on T2 sequences. A finding on ultrasound associated with adhesive capsulitis is hypoechoic material surrounding the long head of the biceps tendon at the rotator interval, reflecting fibrosis. In the painful stage, such hypoechoic material may demonstrate increased vascularity with Doppler ultrasound.
Anterior-posterior (AP) radiographs are useful for reliably assessing normal anatomical landmarks. Bilateral valgus stress AP images can show a difference in medial joint space gapping. It has been reported that an isolated grade III sMCL tear will show an increase in medial compartment gapping of 1.7 mm at 0° of knee flexion and 3.2 mm at 20° of knee flexion, compared to the contralateral knee. Additionally, a complete medial ligamentous disruption (sMCL, dMCL, and POL) will show increased gapping by 6.5 mm at 0° and 9.8 mm at 20° during valgus stress testing. Pellegrini-Stieda syndrome can also be seen on AP radiographs. This finding is due to calcification of the sMCL (heterotopic ossification) caused by the chronic tear of the ligament.