Irish Journal of Medical Science (1971 -) (2018) 187 (Suppl 2):S7–S10 https://doi.org/10.1007/s11845-018-1763-8

ABSTRACTS

Proceedings of the RAMI Section of Ophthalmology Meeting, Friday 7th April 2017 in the Killashee House Hotel, Naas

# Royal Academy of Medicine in Ireland 2018

Randomised controlled trial to assess efficacy of music in reducing pain in panretinal photocoagulation for treatment of diabetic retinopathy C Quigley, R Ellard, H Al Arreyedh, T Droney, F Harney, D Townley Dept. of Ophthalmology, Galway University Hospital Background: Panretinal Photocoagulation (PRP) reduces blindness by 50% in patients with proliferative diabetic retinopathy. Pain during PRP is known to occur in most patients, to a greater or lesser extent. When severe, patient discomfort may necessitate general anaesthesia, with inherent risk of morbidity and mortality. The efficacy of music in reducing pain is unknown. Aims: The aim of this study is to assess the efficacy of music via RCT of classical music versus usual laser, and also to identify the variables associated with increased pain. Methods: This was a single centre prospective randomized controlled trial. Research ethics board approval was granted prior to initiation, participants were recruited between September and December 2016. Participants were randomized, and demographic details were recorded. Outcome variables included numeric pain score immediately after and again 24 hours post laser, and vital signs, including heart rate and blood pressure before and immediately after laser. Ability of the patient to follow the laser physician's directions was assessed. Logistic regression was used in pain score analysis, unadjusted and adjusted for other factors predictive of pain. Participants were given the opportunity to give feedback about the laser treatment. Results: A total of 27 participants were recruited into the study, including 15 males (55.6%), mean age 51± 15 years, of whom 18 were randomly allocated to the music group, and 9 to the usual laser group. Just over half of participants reported pain immediately after laser, n= 14 (51.9%), amongst whom the median pain score was 5 out of 10 (IQR: 3-6). One day later pain was reported in a further n=6 participants (22%), of whom the median pain score was again 5 out of 10 (IQR: 3-6). Of the total 27 participants, 26 (96%) could follow all directions of the physician carrying out the laser. Music was not associated with pain score at either time point, however of those who gave feedback (n=9), improved experience with music was reported in n=6 (66%). Pain immediately after laser was associated with total laser energy dispensed (p=0.04), and females reported higher pain scores; 6.6 ± 1.7 versus 2.3 ± 1.5 in males (p =0.004). Pain at 24 hours was also associated with total laser energy dispensed (p=0.004) and with female sex (p=0.05). After adjustment for all other variables measured, these associations were removed. Overall there was no

significant difference in vital signs, including heart rate and blood pressure, before and after the laser, however change of blood pressure, was associated with total energy dispensed, which for systolic and mean arterial blood pressure persisted on adjustment (p=0.03 and p=0.0004). Significant adverse outcomes occurred in two participants, one of whom fainted during the procedure, and the second attended an out of hours General Practitioner service for injectable analgesia the evening following laser, due to intractable pain. Both patients were in the music group. Conclusions: Laser PRP can be associated with patient discomfort, with higher levels of pain reported in females, in keeping with prior studies. Higher reported pain, and greater change in blood pressure, was associated with total energy dispensed. Classical music was not effective in reducing reported pain.

Sudden loss of vision M Mohamed, S Pharrell, A Cullinane Ophthalmology Dept., Cork University Hospital, Cork A 52-year-old male presented to the Eye Casualty complaining of loss of central vision in the left eye since waking, he experienced one episode of photopsia the previous night. He had a history of intermittent chronic cough and pyrexia for 6 weeks and was receiving oral ciprofloxacin for respiratory tract infection diagnosed by his GP one week prior to presentation. On examination, his best corrected visual acuity was 6/5 in the right eye and 6/60 in the left eye. Anterior segment examination and intraocular pressure were normal. Dilated fundus examination revealed white eliptical subfoveal elevated choroidal lesion surrounded by a rim of hemorrhage in the left eye. There was no vitritis present. Within 12 hours, signs of vitritis developed around the choroidal lesion. At 48 hours the vision reduced to hand motion and the patient reported pain in the eye, the vitritis became more dense, (grade 4+) with loss of fundal view. Empirical intravitreal antibiotics administered with ceftazidime and vancomycin, topical chloramphenicol, dexamethasone and cyclopentolate drops started. Topical dexamethasone was tapered over a period of two months. Six months following presentation, the best corrected visual acuity remained 1/60 in the eye, there were no signs of active inflammation in the eye and posterior synechiae had resolved, however, a pale elevated lesion persisted at the macula. Here we discuss his investigations findings and management.

S8 Serous Retinal Detachment in Dome Shaped Maculopathy with Multimodal Image Analysis

Ir J Med Sci (2018) 187 (Suppl 2):S7–S10 Case report of Prostaglandin associated periorbitopathy (PAP) K Mc Elhinney, N Rahman, P Lee

RM Murphy, K Stephenson, DJ Keegan Ophthalmology Dept. St. Vincent’s University Hospital Dept. of Ophthalmology, Mater Misericordiae University Hospital, Dublin Introduction: Dome maculopathy is a rare and only recently reported entity typically seen in high myopia. It frequently presents as a painless decrease in visual acuity and its diagnosis is now aided by the progression in available imaging modalities. Case Description: A 53-year-old hyperopic male presented for ophthalmic assessment following an acute, painless, decrease in vision in his right eye. He had no medical history, but a previous diagnosis of resolved central serous retinopathy 3 years prior. Corrected distance visual acuity at presentation was 6/15 and 6/7.5 in his right and left eyes respectively. Anterior segments and intraocular pressures were normal. Stereobiomicroscopy of the right fundus revealed perimacular pigmentary clumping with convex protrusion of an edematous macula. Spectral Domain Optical Coherence Tomography confirmed a serous retinal detachment, both intra and subretinal fluid, and a thickened choroid on a classically bulging dome-shaped macula. Fundus Autoflourescence, Fluorescein Angiography and B-Scan Ultrasound were performed and the findings are discussed. Discussion: There are no previously published reports of the existence of DSM in hyperopia. We discuss the disease entity in its presentation, diagnosis and novel treatment strategies.

Comparison of differences between final refraction and target refraction in Lenstar and Contact biometry groups post phacoemulsification and IOL insertion K Mc Elhinney, N Rahman, N Horgan Ophthalmology Dept. St. Vincent’s University Hospital Objectives: To compare the difference between final post-operative refraction and our refraction target in Lenstar and Contact biometry groups Methods: Internal audit using SVUH Ophthalmology patient’s medical records to analyse pre- and post-operative refraction, visual acuity, biometry, keratotomy and final refraction target. Sample selected from those who attended post-operative follow up clinic appointments in 2016. 20 patients who had Contact biometry and 20 patients who had Lenstar biometry selected. Results: Analysis showed that final refraction was -1.60 ±0.55 Dioptres (95% confidence interval) with Contact biometry and -1.00 ±0.40 Dioptres (95% confidence interval) with Lenstar biometry. Comparing this to target refraction of plano (-0.5 Dioptres), it is apparent that the Lenstar group was closer to the target with a reduced variance in final refraction value. It was also shown that the differences between keratomy values postoperatively and pre-operatively differed less in our Lenstar group (k1difference =-0.22, k2difference = 0.14) in comparison to the Contact group (k1difference =-0.29, k2difference = 0.33). Conclusions: Albiet a small sample set, it was shown that Lenstar biometry gives a final refraction value closer to our target of plano, with less variance in final refraction outcome and with less effect on keratomy of the eye following surgery when compared with Contact biometry.

Case description: An 85-year-old female (CC) on long term bimatoprost (0.01%) eye drops once daily for right eye chronic open angle glaucoma. CC previously had a trabeculectomy in her left eye as a therapeutic management choice for same, and was thusly not receiving bimatoprost eye drops in her left eye. After over 10 years of therapeutic prostaglandin analogue use, it was noted that CC had unilateral right sided upper eyelid sulcus deepening and loss of periorbital fat. There were no reported changes in extraocular eye movement or changes in visual acuity. CC also had no relevant concurrent medical conditions. Discussion: Prostaglandin analogues (PGAs) are used as an effective first-line therapy in combating glaucoma by increasing uveoscleral outflow and reducing intraocular pressure. First described in 2004, a constellation of changes associated with prolonged PGA use have been referred to as prostaglandin associated periorbitopathy (PAP). These changes include upper eyelid sulcus deepening, dermatochalasis, relative enophthalmos, loss of eyelid fullness, and loss of inferior orbital fat pads. The exact mechanism of PAP is unknown but it is hypothesised that the PGF2∝(alpha) analogue effect will block adipogenesis leading to periocular fat atrophy seen in PAP – this has been supported by preaponeurotic fat biopsies. It is also thought that PGF2∝(alpha) activation can stimulate Muller’s muscle leading to upper lid retraction, increasing lid height. PAP changes were most significant with bimatoprost, followed by travoprost and latanoprost. PAP changes have been noted to be reversible upon discontinuation, with a mean resolution time of 9 months. PAP is a rare and underappreciated adverse side effect to PGAs and a differential diagnosis to consider in those presenting with ptosis, dematochalasis or enophthalmos. With the increasing prevalence of glaucoma and current prescribing of PGAs, PAP prevalence is likely to rise. Thus, ophthalmologist awareness of PAP is important in preventing its potentially sequelae. Endophthalmitis Following Intravitreal Injection: An Unusual Organism L Martyn, H Alarrayedh, D Townley Dept. of Ophthalmology, University Hospital Galway, Galway Introduction: Endophthalmitis is an ophthalmic emergency where inflammation of the intraocular cavities is usually caused by a grampositive bacterial infection. Vision prognosis is directly related to time of onset to treatment. Gram-negative organisms can also cause endophthalmitis and usually carry a worse prognosis. Endophthalmitis is a recognised complication of intravitreal injection with a reported incidence of 0.021% or 2.1 in 10,000 injections1. Description: An 80-year-old male presented with decreased visual acuity, pain and discharge in the left eye following bilateral ranibizumab (Lucentis) intravitreal injection 4 days prior. He also had a concurrent respiratory infection. On examination visual acuity was reduced to light perception. There was dense haemorrhagic chemosis, purulent discharge and a 1.5mm hypopyon. The right eye was normal. He was commenced on intravitreal vancomycin and ceftazidime injections in the left eye, ciprofloxacin and cefuroxime orally. Conjunctival swabs, vitreous and aqueous taps were sent for culture and sensitivities.

Ir J Med Sci (2018) 187 (Suppl 2):S7–S10 He underwent 2 pars plana vitrectomy procedures as an inpatient however visual acuity remained at light perception. Haemophilus influenzae was isolated and the patient was followed as an outpatient with continued treatment. The patient’s visual acuity remained at light perception. Discussion: In this case we present an unusual pathogen causing endophthalmitis. There has only been one documented case in the literature2 of H. Influenzae infection following intravitreal injection with final visual acuity at 6/75. We will discuss the presentation, management and outcome for the patient as well as endophthalmitis prevention. A prior case series examining endophthalmitis due to Haemophilus influenzae found that this condition is strongly associated with poor visual outcomes despite prompt treatment with appropriate intravitreal antibiotics3. References: 1. Dossarps D et al. FRCR net. Endophthalmitis after Intravitreal Injections: Incidence, Presentation, Management, and Visual Outcome. American Journal of Ophthalmology 2015. 2. Artunay et al. Incidence and management of acute endophthalmitis after intravitreal bevacizumab (Avastin) injection. Eye (London, England) 2009. 3. Yoder et al. Endophthalmitis caused by Haemophilus influenzae. Ophthalmology 2004 A case of choroidal effusion with dramatic proptosis during cataract surgery T Murphy, P O'Reilly Ophthalmology Dept., University Hospital Limerick Purpose: To examine the factors that caused intraoperative choroidal effusion in this case, to convey a detailed review of the case, to examine the postoperative outcome, to examine the published literature. Setting: University Hospital Limerick, Ireland KP, a 65-year-old lady with no previous ophthalmic history and VA of 6/12 presented for left eye phacoemulsifaction and IOL insertion. Pre-operative examination and medical observations were normal. She received a routine sub-tenons block with xylocaine and adrenaline mixed with hyaluronidase prior to commencing cataract surgery. Side port incision was made. The anterior chamber was noted to dramatically shallow, with associated irido-corneal touch. It then rapidly deepened, with loss of the red reflex. The eye then underwent dramatic proptosis, but was not tense on palpation. The cataract surgery was halted. Results: The patient was examined one hour post operatively. Visual acuity was CFs. AC remained very deep. The eye was well formed, but soft. Significantly, proptosis had resolved. Bscan ultrasound confirmed the globe was well formed. CT orbits were performed day 1 post operatively, with no scleral perforation observed. Choroidal detachments were present on fundal examination. The patient was observed over the following 3 weeks, with VA returning gradually to 6/12, IOP to 10, and resolution of choroidals. Conclusions: Choroidal effusion during cataract surgery is a rare complication, with minimal documentation in the literature. There is no documentation in the literature of associated proptosis. Hyaluronidase allergy is postulated to be a contributing factor in this case. The patient is undergoing allergy testing. Thus, choroidal effusion with associated dramatic proptosis is a rare and significant intraoperative complication of cataract surgery.

S9 Hip Pain – An Unusual Cause of Vision Loss G Guevara, C Baily, P Logan Dept. of Ophthalmology, Mater Misericordiae University Hospital We present a recent case of retinal toxicity secondary to cobalt toxicity following hip replacement. A 57-year-old man was referred to ophthalmology with a history of gradual painless deterioration in vision acuity bilaterally. The patient had a significant history of hypertrophic cardiomyopathy, pericarditis, peripheral neuropathy, polycythemia and hypothyroidism. Ocular examination revealed very poor vision with RVA 2/60 and LVA 1/60. Of note, there was no RAPD and he had normal anterior segment and fundal examination. Previous visual acuity in 2010 was 6/6 both eyes. The patient subsequently developed pain in his right hip. He had previously undergone right hip replacement in 2005 followed by revision in 2013. CT demonstrated fluid-attenuation collections consistent with metallosis. Cobalt and chromium levels were extremely high, well beyond toxicity levels. The patient underwent removal of his hip replacement and currently has a spacer in situ awaiting a delayed 2nd stage revision. Metallosis is the infiltration of metallic debris in soft and bony tissues usually following metal on metal contact following arthroplasty and typically occurs some years after the initial operation1. The metallic fragments are thought to cause toxicity and end organ damage by migration to distant sites or by phagocytosis of some particles causing local inflammatory reactions2. Systemic complications of metallosis including neuropathy, cardiomyopathy, and hypothyroidism have been previously described in the literature3. Animal studies have also shown that toxic levels of cobalt induce photoreceptor degeneration. It has been postulated that this is because Cobalt chloride is a hypoxia-mimicking compound, which exerts hypoxia-like effect on the local retina microenvironment3. References: 1. Chang JD, Lee SS, Hur M, Seo EM, Chung YK, Lee CJ Revision total hip arthroplasty in hip joints with metallosis: a single-center experience with 31 cases. J Arthroplasty. 2005 Aug; 20(5):568-73. 2.. Bullough PG. Metallosis J Bone Joint Surg Br. 1994 Sep; 76(5):687-8. 3. Giampreti A, Lonati D, Ragghianti B, et al. N-Acetyl-Cysteine as Effective and Safe Chelating Agent in Metal-on-Metal Hip-Implanted Patients: Two Cases. Case Reports in Orthopedics. 2016; 2016:8682737. https://doi.org/10.1155/2016/8682737. 4. Hara A, Niwa M, Aoki H, Kumada M, Kunisada T, Oyama T, Yamamoto T, Kozawa O, Mori H. A new model of retinal photoreceptor cell degeneration induced by a chemical hypoxia-mimicking agent, cobalt chloride. Brain Res. 2006 Sep 13; 1109(1):192-200.

Discrepancy in foveal depression location on clinical examination and OCT imaging T Murphy, P O'Reilly Ophthalmology Dept., University Hospital Limerick Purpose: To determine discrepancy of location of the foveal depression between OCT imaging and clinical examination, to examine the frequency of same and characteristics of patients with discrepancy in foveal depression location, to determine the distance between location of foveal depression on fundal photograph and true foveal depression location on OCT scan.

S10 Setting/Venue: University Hospital Limerick, a tertiary level vitreo-retinal referral centre Methods: Macular OCT scans and corresponding fundal photographs from 1/1/16 to 6/2/17 from individual eyes were reviewed. Scans where pathology obscured foveal depression location were excluded. An examiner determined the clinical location of the fovea and foveal depression on fundal photograph for each individual eye. This was compared to the true location of the fovea and foveal depression on the OCT image obtained for the same eye. An examiner documented correspondence or discrepancy of location of foveal depression between imaging methods, and distance between foveal depression on OCT imaging and fundal photograph in eyes with location mismatch. Results: Six-hundred and seventy-seven (677) scans of individual eyes were included for review. Seventeen (17) scans with discrepancy in foveal depression location on OCT and fundal photograph were identified i.e.

Ir J Med Sci (2018) 187 (Suppl 2):S7–S10 location mismatch in 2.5% of scans. Only one patient had non correspondence of foveal location present in both eyes. 75% of cases where foveal position on fundal photograph did not correspond with true position on OCT were female. The average age of patients’ with discrepancy was 63.6 years, with an age range of 13-78 years. The measure of discrepancy between foveal depression position on OCT and fundal photograph ranged from 0.85-2.88mm, with an average distance of 1.41mm. Conclusions: There is a significant level of discrepancy between appearance of foveal depression on fundal photograph and actual foveal depression position on OCT image. There has been no previous documentation of same in the literature. This has a significant impact on future treatment of macular pathologies, specifically where the application of focal macular laser is concerned, as presumed perifoveal application may significantly impair vision. Further investigation is necessitated here.