was this an effective long-term solution for this patient, or just a temporary fix for the bullae?

Thank you for sharing this case. I always feel a little frustrated when I can't get a child to 20/20 and have to send them to a pediatric ophthalmologist to help me determine if they are malingering or not.

This is a great case of psuedotumor cerebri because it usually presents in overweight females of childbearing age. However, I doubt you saved the patient's life. Most cases of psuedotumor can cause blindness if left untreated but usually are not life threatening.

jmeany@ev1.net,I would not recommend this as a first-line or prophylatic treatment. Firstly, all glaucoma medications, no matter what their safety profile is, have some unwanted side effects. Secondly, consider the cost of the medications--I don't think that any insurance plan would pay for glaucoma medications as a preventative treatment. Thirdly consider how much the IOP would be lowered--it would definitely be ineffective in those with low IOPs. Lastly, osmotic preparations are quite effective.Thanks for your thought-provoking question.--Deegan

Can this be recommened for profolacti treatment ??

Deegan,Thanks for sharing this very impressive case. I work extensively in cornea and have a number of PBK and Fuch's cases where I will try this treatment. Makes a lot of sense - thanksPaul

Johti,I have asked that myself. For CAPE dystrophy, one must consider the progression of the disorder. I propose three different stages. Early stage is just the RPE disruption without retinal envolvement, without vision decrease. Moderate stage is RPE and retinal atrophy with slight reduction in vision. Severe is RPE and retinal atrohy with severe vision loss. In this case, I would imagine little to no anomalous findings on a focal ERG. With progression, I'm sure focal ERG will show findings.Little of the RPE is affected that an EOG will not show much variation of the arden ratio.As for the Farnsworth D-100, this is tedious and not practical for the clinical setting. Usually I reserve this for academic purposes.In my opinion, central VA, Amsler grid, photography is the best way monitor this patient. The ERG, EOG are merely diagnostic.--Deegan

I have a query1) What will be results in these kind patients with focal ERG?2) As we know most of the retinal condition will have B-Y colour defects. So still ISHIHARA's colour vision charts valid? Or do you recommend for FM 100hue test, since plane to monitor his condition.

I would like to what will be rsults in this kind patienrs with focal ERG?

Thanks for the comments. My initial thought was a surgical abrasion, but on talking to the surgeon this was ruled out. The surgeon was confident that the bandage lens would be adaquate, and was only suggesting further treatment if the abrasion did not respond. I saw the patient several days later and the cornea had full epithelial coverage with VA near 20/20. I will try to get more detailed info from the surgeon concerning the more detailed questions. Thanks, Bill Vickers

Is it possible that the corneal insult could have been a result of the surgery. If that is the case, it will heal without treatment. I would wait a few days before intervening.

Looks like an inadvertant epithelial abrasion to me. Does this patient have a previous history of "exposure" keratitis, keratitis sicca, other "dry eye" related keratopathy, EBMD, or even systemic disease that would contribute to a neurotrophic keratitis? If not, all the more to consider just an accidental abrasion...especially one day post op. If this becomes non-healing and/or inflammatory (infiltrative) then perhaps you can be suspicious of a more "exotic" etiology. In my opinion, tarsorraphy seems a little extreme to even think about so soon...shouldn't that be the last choice? What if it turns out to be infectious? Topical treatment and/or bandage lenses should do the trick.Regards,John R. Martinelli, ODMartinelli Eye Clinic and Laser CenterCharleroi, PAhttp://www.martinelli-eye.com

This is terrific! Never heard of this before, and it's wonderful to see it offered by optometrists for other optometrists. Thank you for a great site.

Thank you for the educational photos of an interesting case. What was the retinal gas that was used? What was the patient's VA? How long does it take to resolve (i.e., the membrane to re-attach)?

Theresa, I have been using 8.8 B.C. -0.50 Acuvue lenses as bandage lenses for a long time. Almost every time I use them the cornea is very edematous at 1 day. If I have to go more than one day it's even worse. I know a lot of people are going to start using Ciba Night&Day for bandage lenses but I ordered a couple of plano power Proclear lenses to try them as bandage lenses because of the great acceptance I have experienced from my cosmetic lens wearing patient population to Proclear. The fact that the lens comes in plano power really didn't sway me in this case. I am more interested in the physiological response to the lens. I was not disappointed by the Proclear lens in this case. There seemed to be much less edema compared to using Acuvue lenses. This is only my first experience using Proclear for this purpose. We'll see how it goes in the future.

A fascinating case. That poor woman must have been in excruciating pain till she saw Dr. Rubin. Any particular reason the Proclear contact lens was used? Because it comes in plano power? An interesting case from us all to learn from. Thanks for submitting it.

Thanks for the compliment. I have a fairly simple setup for taking these images. I have a BioVid system. This system consists of a PC with special video capture card and software (ImageDoctor), a foot pedal, and the BioVid camera itself. It is available through Walt Mayo, O.D. - web site http://www.mayomultimedia.com/capkits.html. Disclaimer: I have no financial interest in the BioVid system.

good photos. What type of slit lamp capture system are you using?

I think Dr. Kosanovich makes an excellent point regarding the use of cycloplegia in these cases. Another optometric "pearl".Regarding Dr. Roline's question about recurrent erosion:I have not seen recurrent erosion in cases of thermal burns to the cornea. Therefore, I did not institute the classic prophylactic treatment for RCE consisting of hyperosmotic drops while awake and/or ointment QHS X 3-4 months. I have only seen cases of RCE after deep traumatic injury as is seen in fingernail injury, tree branch, etc. I would certainly treat any RCE as it presents. However, I could not argue against such prophylactic treatment.

Was anything done to prevent recurrent erosions?

Excellent case. My compliments to Dr. Rubin on the management. I have found that two drops of 5% Homatropine in the affected eye, prior the bandage contact lens, helps keep the patient more comfortable. At the 1 day visit, I expect them to still be dilated and less photophobic. They may even come into the office with a smile.

Theresa,Yes, the hemorrhage did resolve without any intervention. The hemorrhage was the result of shearing forces against the retinal vessels during PVD. The presence of hemorrhage certainly increases one’s suspicion of the presence of a retinal break. This was another good reason for the retinal consult. Unfortunately, the retinal consult with scleral depression had unexpected consequences.David M. Rubin, O.D.

The use of a sceral depressor could definitely have caused this.The haptics take about 3/12 to fibrose into the bag.(plate haptics take longer)The real question is ...Is this a justifiable complication of the retinal exam...Answer ...most definitely yes !( The IOL can be repositioned...who wants to miss a ret det ?

Very interesting case. The retinal specialist obviously pushed with too great a force. Did the retinal hemorrhage self-heal?

>> I have done scleral depression on many patientswith i.o.l's & never had this problem.Respectfully yours,Jerome Samelson, O.D.

Regarding your questions on the case of David Rubin's IOL anterior dislocation: 1. Yes, in this case the act of scleral depression appeared to have caused it. 2. In this case, there was a predisposing factor. It appeared that the IOL optic had been expressed anteriorly out of the capsular bag by fibrosis of the anterior capsule to the posterior capsule. The optic now more anterior in position and not protected by an anterior capsular rim was easily mobilized forward by scleral depression allowing partial optic pupillary capture upon postdilatation miosis. 3. Predispositions would include sulcus-placed IOLs, especially those with a 0-degree angulatiopn between the optic and the haptics. IOLs that have 5, 6, or 10-degree posterior angulation of the optic-haptic junctions have more posteriorly located optics. 4. Yes, observing an optic in the sulcus could alert one to the possibility of optic capture on postdilatation miosis. For this reason, we are very cautious about over-dilating eyes with a piggyback IOL in the sulcus. 5. Optic pupillary capture can occur anytime after surgery; theoretically, after at least 6 weeks of capsular fibrosis around the haptics, and, hopefully, in front of the optic edge by the anterior capsule (if the anterior capsulorhexis was made properly smaller than the IOL opotic), then this phenomenon could be prevented. 6. Precautions include avoiding scleral depression early after loop-haptic PC-IOL implantation; possibly using a mirrored contact lens to view the peripheral retina if necessary; and encouraging surgeons to implant loop-haptic PC-IOLs with angulated haptics inside capsular bags with anterior CCC openings smaller than the optic diameter. Best regards,Harry Grabow, M.D.Sarasota Cataract & Laser InstituteSarasota, FL

Steroid will clear the edema and the shallow detachment will likely resolve on its own. If not, instead of a surgical repair, I have seen a frank 33-45 per cent detachment repair itself to 20/20 with the use of 5% NaCl, which creates an osmotic gradient, drawing water out of the cornea toward the surface, along with the normal fluid currents in the anterior chamber waffing, floating the endo back onto the stroma and curing itself with simple chemistry. I think the patient took a salt drop every 1 or 2 hours while awake and the problem fixed itself over a week or two! It was amazing!

Them there are alot of greasy mutton-fat deposits; the patient may or may not be sensitive, but I'm sure the VA is down. NSAID's or and PForte will clear those over 3-4 weeks; Hitting them with a laser may only irritate the eye more, excite it; the haptic may be the cause; if it continues to rub the iris, the MD may make a stab incision and re-locate the IOL haptic in the office with a surgical microscope if the situation is recurrent in nature. That is what my old boss would do, after 7-8K IOL's of experience.

This is an excellent photo. What camera system did you use to acquire it? Patient's with persistent corneal edema such as this should be returned to the surgeon as they may need surgical repair. I would probably wait only 1-2 weeks post-op before sending them. Each surgeon and each patient are different so a phone consult with the surgeon upon initial diagnosis is my recommendation.

I've wondered before if these could be related to a sensitivity to the IOL material. It isn't unusual for a patient to be unable to wear silicone nosepads. What happens if one of these patients gets a silicone IOL?