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OBJECTIVE: Postoperative delayed wound healing, surgical site infections (SSIs), and other wound complications are associated with increased morbidity and health-care costs. In cardiothoracic surgery, wound complications can have life-threatening consequences. In recent years, negative pressure wound therapy (NPWT) has been applied over closed surgical incisions to help reduce tension and protect from external contamination. We report our initial experiences using a closed incision negative pressure therapy (ciNPT) over clean, closed sternotomy incisions at an Irish tertiary referral centre. METHOD: A retrospective record review identified 10 patients (4 females, 6 males) where ciNPT was used following sternotomy for cardiac surgery or other mediastinal surgery between January 2012 and March 2013. RESULTS: The patients had an average age of 71.5±14.18 years (range: 44-89 years). Patient comorbidities included obesity, hypertension, active tobacco use, chronic obstructive pulmonary disease, and diabetes mellitus. Patients underwent coronary artery bypass grafting (CABG), aortic valve replacement (AVR), AVR and CABG, or removal of a thymic mass or mediastinal cyst. ciNPT was left in place for an average of 6±0.82 days. All incisions healed without complications. CONCLUSION: ciNPT use should be considered for patients at risk for postoperative SSI development or other wound complications.

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INTRODUCTION: We present a case of enhanced S-cone syndrome (ESCS)-associated choroidal neovascularisation (CNV) treated successfully with intravitreal bevacizumab therapy. METHODS/CASE REPORT: A 14-year-old with a known retinal dystrophy presented with acute visual deterioration. Fluorescein angiography demonstrated CNV, and treatment was initiated with an anti-vascular endothelial growth factor (anti-VEGF) agent, with significant improvement in vision. Subsequent electroretinogram examination of the patient and her younger sister showed severely reduced rod responses with accentuated fast cone (S-cone only) response, confirming the diagnosis of ESCS as the underlying dystrophy. CONCLUSION: CNV is a rare complication of ESCS that is responsive to anti-VEGF therapy. Although cystic retinal lesions may develop in patients with retinal dystrophies due to multiple possible aetiologies, CNV is a known cause of macula oedema in these patients that requires treatment with different agents, namely anti-VEGF therapy. Rapid visual loss in patients with inherited retinal disorders should prompt immediate clinical assessment to exclude CNV, and if CNV is detected, anti-VEGF therapy can preserve vision.

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Saffron (Crocus savitus) is a Middle-Eastern herb with strong antioxidant properties. Its major constituents, safranal, crocin, and crocetin, are also antioxidants and bear structural similarities to other well-known natural antixodant substances, such as zeaxanthin. Given the role of oxidative stress in many diseases, considerable interest has been shown into the potential role of saffron supplementation as a treatment for a range of diseases. In vitro and animal studies have provided evidence that saffron and its constituents may be potent therapies for a range of pathologies, including Alzheimer's disease, age-related macular degeneration (AMD) and cardiac ischemia. Whether these findings translate into clinical efficacy, however, has as of yet been incompletely assessed. This makes assessing the role of saffron supplementation in these diseases difficult. Here, we review the current human clinical evidence supporting saffron supplementation as a treatment for a range of pathologies and the underlying science supporting its use.

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AIM: The Virtual Ophthalmology Clinic (VOC) is an interactive web-based teaching module, with special emphasis on history taking and clinical reasoning skills. The purpose of this study was to determine the impact of VOC on medical students' learning. METHODS: A randomised controlled trial (RCT) was conducted with medical students from the University of Sydney (n=188) who were randomly assigned into either an experimental (n=93) or a control group (n=95). A pre- and post-test and student satisfaction questionnaire were administered. Twelve months later a follow-up test was conducted to determine the long-term retention rate of graduates. RESULTS: There was a statistically significant (P<0.001) within-subject improvement pre- to post rotation in the number of correctly answered questions for both the control and experimental groups (mean improvement for control 10%, 95% CI 1.3-2.6, and for experimental 17.5%, 95% CI 3.0-4.0). The improvement was significantly greater in the experimental group (mean difference in improvement between groups 7.5%, 95% CI 0.8-2.3, P<0.001). At 12 months follow-up testing, the experimental group scored on average 1.6 (8%) (95%CI 0.4 to 2.7, P=0.007) higher than the controls. CONCLUSION: On the basis of a statistically significant improvement in academic performance and highly positive student feedback, the implementation of VOC may provide a means to address challenges to ophthalmic learning outcomes in an already crowded medical curriculum.

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BACKGROUND AND PURPOSE: Transverse sinus stenosis is common in patients with IIH. While the role of transverse sinus stenosis in IIH pathogenesis remains controversial, modeling studies suggest that stent placement within a transverse sinus stenosis with a significant pressure gradient should decrease cerebral venous pressure, improve CSF resorption in the venous system, and thereby reduce intracranial (CSF) pressure, improving the symptoms of IIH and reducing papilledema. We aimed to determine if IIH could be reliably treated by stent placement in transverse sinus stenosis. MATERIALS AND METHODS: We reviewed the clinical, venographic, and intracranial pressure data before and after stent placement in transverse sinus stenosis in 52 of our own patients with IIH unresponsive to maximum acceptable medical treatment, treated since 2001 and followed between 2 months and 9 years. RESULTS: Before stent placement, the mean superior sagittal sinus pressure was 34 mm Hg (462 mm H(2)0) with a mean transverse sinus stenosis gradient of 20 mm Hg. The mean lumbar CSF pressure before stent placement was 322 mm H(2)O. In all 52 patients, stent placement immediately eliminated the TSS pressure gradient, rapidly improved IIH symptoms, and abolished papilledema. In 6 patients, symptom relapse (headache) was associated with increased venous pressure and recurrent stenosis adjacent to the previous stent. In these cases, placement of another stent again removed the transverse sinus stenosis pressure gradient and improved symptoms. Of the 52 patients, 49 have been cured of all IIH symptoms. CONCLUSIONS: These findings indicate a role for transverse sinus stent placement in the management of selected patients with IIH.

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AIMS: To determine the outcome of treatment with subconjunctival triamcinolone acetate for non-necrotising anterior scleritis and to review the literature on this treatment. METHODS: A retrospective, interventional case series of 12 patients who had failed systemic therapy, treated with 25 subconjunctival triamcinolone for non-necrotising anterior scleritis. RESULTS: Complete resolution of symptoms and signs of scleral inflammation occurred after 23 out of the 25 injections administered. For the remaining two injections, it was necessary to increase oral corticosteroids to obtain complete resolution. No treated eye lost vision after subconjunctival triamcinolone therapy. No patient developed scleral necrosis after subconjunctival therapy. Four patients developed a rise in intraocular pressure after treatment. The mean follow-up was 9 months with a range of 1-20 months. Scleritis relapsed in 38% of eyes and required repeat subconjunctival triamcinolone therapy. CONCLUSION: This study provides evidence that subconjunctival triamcinolone therapy is an efficacious treatment with a prolonged duration of effect in selected patients with non-necrotising scleritis.

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AIM: To investigate the incidence and patterns of acute anterior uveitis (AAU) in Central Australia and specifically to study the relative frequency of AAU in Australian Aborigines compared with that in non-Aboriginal patients. METHODS: Prospective, observational study of all patients seen by the Central Australian Ophthalmology service over an 8-month period. RESULTS: The incidence rate of AAU in Central Australia was 35.9 cases/100,000 population per year. Forty-two per cent of the 1955 patients seen during the study period were Australian Aboriginal patients; however, all but one patient with AAU were Caucasian. The difference in the incidence of AAU between the Indigenous and non-Indigenous populations was statistically significant (p = 0.03, Fisher's exact test). Four of the nine Caucasian patients with AAU were HLA-B27-positive. The single case of AAU in an Australian Aborigine was a recurrent episode of HLA-B27-positive AAU. A family history of this patient revealed that both her grandfathers were Caucasian. CONCLUSION: The incidence and pattern of AAU in Central Australia is comparable with that in other geographical regions. However, AAU occurs very infrequently in Australian Aborigines compared with that in the non-Indigenous population of Central Australia, further implicating the importance of genetic factors in the pathogenesis of AAU.

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AIM: A retrospective comparative case series was studied to determine whether the use of prostaglandin (PG) analogues to treat raised intraocular pressure (IOP) in patients with uveitis resulted in an increase in the frequency of anterior uveitis or cystoid macular oedema (CMO). METHODS: 163 eyes of 84 consecutive patients with uveitis and raised IOP treated with a PG analogue at two tertiary referral uveitis clinics were identified over a 3-month period. Control eyes were selected as those uveitic eyes of the same patients, which were treated with topical IOP-lowering agent(s) other than a PG analogue. Pretreatment IOP was compared with the mean IOP during PG analogue treatment. The frequency of anterior uveitis and CMO during PG analogue treatment was compared with the frequency of these complications in the control eyes during non-PG IOP-lowering treatment. RESULTS: Significant IOP reductions were observed during PG analogue treatment. There was no significant difference in the frequency of anterior uveitis in those eyes treated with PG analogues and those treated with non-PG agents (p = 0.87, Fisher exact test). None of the 69 uveitic eyes without a previous history of CMO developed this complication. There was no increase in the frequency of visually significant CMO during PG treatment compared with that during non-PG treatment (p = 0.19, Fisher exact test). CONCLUSION: This study demonstrates that PG analogues are potent topical medications for lowering raised IOP in patients with uveitis and are not associated with increased risk of CMO or anterior uveitis.

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AIM: To characterise the clinical and pathological features of 24 patients with biopsy proven Idiopathic Orbital Inflammatory Syndrome (IOIS). METHODS: Retrospective case series. RESULTS: The study included 14 men and 10 female patients, ranging in age from 14 to 75 years. The presenting symptoms and signs included pain (14/24), swelling/mass (19/24), diplopia (9/24), proptosis (15/24), extraocular muscle restriction (13/24), decreased vision (5/24) and ptosis (4/24). Histopathology was varied and included classical orbital pseudotumour (9/24), sclerosing orbital pseudotumour (13/24), vasculitic orbital pseudotumour (1/24) and granulomatous orbital pseudotumour (1/24). Treatments included oral steroids (19/24), intravenous steroids (1/24), methotrexate, azathioprine, mycophenalate and ciclosporin. Forty-two per cent of the patients had recurring episodes during the follow-up period, with 29% of patients requiring two or more treatment regimens to maintain remission. Two-thirds of patients (16/24) had complete resolution of their symptoms and signs. There was no correlation between the histopathological subtype, relapse rate or symptoms and resolution of signs. CONCLUSION: Idiopathic Orbital Inflammatory Syndrome has variable clinical and pathological features. Although, in some patients, symptoms and signs resolve spontaneously, most require treatment with oral steroids and additional immunosuppressant drugs or radiotherapy. The clinical and pathological features do not correlate with treatment outcomes.

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AIMS: To examine the visual outcome and identify risk factors for postoperative uveitis, macular oedema and neodymium-doped yttrium aluminium garnet (Nd:YAG) capsulotomy after phacoemulsification and intraocular lens (IOL) implantation in patients with uveitis. METHOD: This is a retrospective review of the medical records of 101 eyes of 101 patients. One eye was randomly selected for inclusion in patients who had bilateral surgery. Patients with juvenile arthritis, keratouveitis and lymphoma-associated uveitis were excluded. RESULTS: At the first postoperative and final visits, visual acuity was significantly better (p<0.001), and 64.4% and 71.3% of patients, respectively, had achieved >or=2 Snellen's lines of visual improvement. The cumulative probability of doubling of the visual angle was 52% over 6 years of follow-up, and this occurred at a higher rate in the presence of preoperative retinal or optic nerve lesions (HR (95% CI) 4.49 (1.41 to 14.29)). Within 3 months after operation, uveitis was more likely to develop in female patients (OR (95% CI) 6.21 (1.41 to 27.43)) and in the presence of significant intraoperative posterior synechiae (OR (95% CI) 8.43 (1.09 to 65.41)); macular oedema was more likely to develop in patients who developed postoperative uveitis (OR (95% CI) 7.45 (1.63 to 34.16)). Nd:YAG capsulotomy occurred at a higher rate in patients aged

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AIM: To compare the efficacy and tolerability of latanoprost versus brimonidine in the treatment of open-angle glaucoma, ocular hypertension or normal-tension glaucoma. METHOD: Systematic review of randomised controlled trials comparing latanoprost and brimondine, identified by searches including Medline, Embase and Cochrane Controlled Trials Register. Two reviewers independently assessed trials for eligibility and quality and extracted data. Data were synthesised (random effects model) and expressed as the absolute mean intraocular pressure (IOP) reduction difference from baseline to end point for efficacy and relative risk for adverse events. Subgroup analysis and regression were used to explore heterogeneity according to patient characteristics, trial design and quality. RESULTS: 15 publications reporting on 14 trials (1784 participants) were included for meta-analysis. IOP reduction favoured latanoprost (weighted mean difference (WMD) = 1.10 mm Hg (95% confidence interval (CI) 0.57 to 1.63)). Significant heterogeneity was present (chi(2)(13) = 38.29, p = 0.001, I(2) = 66.0%). Subgroup analysis showed greater WMD for studies where data were analysed from end points >6 months duration, cross-over design, open-angle glaucoma or ocular hypertension and monotherapy. Multiple regression showed no significant association of WMD with trial duration (t(9) = 1.92, p = 0.09), trial design (t(9) = 1.79, p = 0.11), trial quality (t(9) = -0.46, p = 0.66), or monotherapy or adjunctive therapy (t(9) = -2.14, p = 0.06). Fatigue was less commonly associated with latanoprost (RR = 0.27, 95% CI 0.08 to 0.88). Publication bias was not evident on visual inspection of a funnel plot. CONCLUSION: Latanoprost is more effective than brimonidine as monotherapy in lowering IOP. Brimonidine is associated with a higher rate of fatigue.

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AIMS: To determine the long term outcome of Molteno implants inserted using a modified surgical technique that eliminates the need for a donor scleral graft. METHODS: Retrospective case series involving a medical record analysis of 35 consecutive patients undergoing first Molteno implant surgery for refractory glaucoma. The main outcomes included life table analysis of intraocular pressure control following surgery and frequency of intraoperative and postoperative complications. RESULTS: There were no complications related specifically to the modified method of tube placement. Medium term intraocular pressure control was similar to other series. CONCLUSIONS: This simplified method for the insertion of Molteno implants eliminates the need for a donor scleral graft while maintaining the implant's ability to control intraocular pressure.

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Microbial agents have an important role in the pathogenesis of various inflammatory eye diseases, such as uveitis and keratitis. Microbial infections of the eye such as microbial keratitis, ocular onchocerciasis, bacterial endophthalmitis, viral retinitis, and other infectious uveitis are unfortunately common. In addition, microbial agents have been implicated in the pathogenesis of "non-infectious" immune mediated diseases such as HLA-B27 associated acute anterior uveitis. Toll-like receptors (TLR) are a family of pattern recognition receptors that initiates rapid host innate immune response to microbial components known as pathogen associated molecular patterns, which are unique to a given class of microbes, such as lipopolysaccharide of Gram negative bacteria. Recent in vitro and in vivo studies have demonstrated the expression and function of TLRs in the eye, with significant implications for better understanding of ocular immunity and the pathogenesis of inflammatory eye diseases affecting the cornea, uvea, and retina.

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Idiopathic orbital inflammation (IOI) is a well-recognised pathological process usually confined to the orbit. It is an orbital mass lesion characterised by infiltration of soft tissues by inflammatory cells and fibrous tissue. It is essentially a diagnosis of exclusion. Extraorbital extension (EOE) is rare and, to the best of the authors' knowledge, inclusive of our series, there have been 22 cases of IOI with EOE reported in the literature. We describe four patients with IOI with EOE-their presentation, histopathological findings and management strategies. Histopathology of three patients revealed sclerosing and one had a nonspecific variant of IOI. In our series, all four patients required additional immunosuppression. Hence, corticosteroid therapy often needs to be supplemented by radiotherapy and/or immunosuppressive therapy.

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In cases of severe macromastia, the free nipple graft technique has been the traditional alternative to pedicle transposition. Distress over nipple survival in large reduction mammaplasty and long pedicle transposition is largely responsible for this.A retrospective investigation of the records of 142 reduction mammaplasty patients was carried out to determine whether nipple survival or overall complication rates were significantly different in patients undergoing larger (>1500 g per side) as compared with smaller reductions (< 1500 g per side). The 2 patient groups were compared with respect to mild or severe complications. Data were analyzed using Fisher exact test and 2-sample t tests. A P value of < 0.05 was considered statistically significant. No patient in either group had total nipple loss. There were no statistically significant differences in major or minor complications between the 2 groups. In our experience, the inferior pedicle, Wise pattern reduction is a reliable and predictable method of reduction, appropriate for all breast sizes and pedicle lengths.

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BACKGROUND/AIMS: Microglia are the primary antigen presenting cells in the central nervous system and the retina, and can harbour viral antigens that may damage neural tissue via the release of neurotoxins. All cells bearing CD4 molecules and co-receptors (members of the chemokine receptor and Fcgamma receptor families) are potential targets for the human immunodeficiency virus (HIV). In this study, retinal microglia (in vitro and in situ) were investigated for the expression of candidate HIV-1 binding receptors. METHODS: Cultured human retinal microglia and frozen sections of human retinas were used. Immunohistochemistry was used to investigate expression of cell surface receptors necessary for HIV-1 infection: CD4, CC chemokine receptor 5 (CCR5), and Fcgamma receptors. RESULTS: Human retinal microglia expressed detectable levels of CD4, CD16, CD64, and CCR5 in vitro and Fcgamma receptor I (CD64) in situ. CONCLUSIONS: Human retinal microglia express several candidate receptors required for viral binding and as such may be a potential reservoir for HIV-1 infection.

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PURPOSE: To describe the clinical features of two cases of Leber's hereditary optic neuropathy (LHON) precipitated by antiretroviral treatment for human immunodeficiency virus (HIV) infection. METHODS: Two cases of LHON (from an expected four new cases a year throughout Australia) were identified in men on treatment for HIV infection. RESULTS: Two HIV-infected men were receiving combination antiretroviral therapy that included nucleoside analogues. Both patients carried the 14 484 mitochondrial DNA mutation and were distantly related (seventh cousins). Although both men presented with sequential visual loss typical of LHON and one had a known close relative affected by LHON, the correct diagnosis was delayed in both cases. The final visual outcome was profoundly reduced in both instances and cessation of antiretroviral therapy did not result in recovery of vision in one patient. CONCLUSION: Patients with a family history of LHON who require antiretroviral treatment should be warned of the high risk of severe visual loss. The underlying mechanism of antiretroviral side effects may help characterize the other trigger factors for LHON.

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AIM: To determine the expression and distribution of matrix metalloproteinases (MMPs) and their inhibitors (TIMPs) in the normal human iris and ciliary body. METHODS: Seven postmortem human eyes were fixed with formalin. The iris and ciliary body were dissected out and embedded in paraffin. The expression of MMPs -1, 2, 3, and 9, and TIMPs 1-4 in the iris and ciliary body was determined by a novel immunofluorescence technique and the results graded by masked observers. RESULTS: Positive staining for MMPs and TIMPs was observed in all regions of the anterior uvea, and was more intense in the ciliary body than in the iris. Most MMPs and TIMPs showed similar patterns in their distribution. In the ciliary body, staining was strongest in the epithelium, and was localised to the epithelial cell cytoplasm, except for TIMP-3 which was strongly expressed in the basement membranes. In the iris, staining was most noticeable in the anterior border and anterior epithelial layer. Blood vessels in the stroma of the iris and ciliary body also stained moderately for MMPs and TIMPs. CONCLUSION: Both MMPs and TIMPs are widely expressed in the anterior uvea, with a positive correlation between their expressions. Their differential localisation in the ciliary body suggests they may have a role in maintaining homeostasis in the uveal tract.

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