Advanced Search Results using Datatables (Abstract Full Search)

rehan84@doctors.org.uk

– To describe the rare presentation of perineural spread of atypical SCC in the infraorbital nerve

– To discuss recommended investigations for detecting orbital metastatic disease via perineural spread.

– To discuss the role of orbital exenteration in the management of advanced orbital malignancy

We present the interesting case of a 65 year old Caucasian gentleman who was originally diagnosed and successfully treated for orbital MALT cell lymphoma causing external compression of the lacrimal sac. He presents 7 years later with very atypical SCC of the lip, paraesthesia of the cheek and initial normal orbital imaging. High definition orbital imaging, Hess charts and photomicrographs are presented.

Incisional biopsy of a lesion arising from the roof of the bony infraorbital canal showed a diagnosis of SCC . He underwent orbital exenteration with clearance of his ptyregopalatine fossa and right maxillectomy with adjuvant radiotherapy. Histology showed advanced perineural spreading SCC up to the pterygopalatine fossa with identical morphology to his previously excised upper lip squamous cell cancer. We discuss the role of exenteration surgery in the management of advanced metastatic SCC to the orbit and the pathophysiology and management difficulties of perineural spreading SCC.

The need for a thorough cranial nerve examination in the follow up of patients with a known history of head and neck SCC, specifically extra ocular movements, facial sensation and cervical lymphadenopathy which may indicate metastatsis or more devastatingly orbital invasion.

January 27, 2013 at 2:45 pm

paulflavahan@doctors.net.uk

Periorbital necrotizing fasciitis is a severe infection of subcutaneous soft tissue and underlying fascia. It causes severe morbidity and even loss of life if facial, cervical or intracranial extension occurs.

Very few case reports of periorbital necrotising fasciitis exist, (less than 60 worldwide in 20 years), and there are no epidemiological studies. The British Ophthalmological Surveillance Unit (BOSU) provides a mechanism to collect national data on incidence, aetiology, morbidity and mortality.

A prospective observational study was undertaken utilising the BOSU reporting system. Questionnaires were sent to all reporting ophthalmologists in the UK to gather information on cases of periorbital fasciitis identified over a 2 year period.

29 cases of documented periorbital necrotising fasciitis were confirmed by returned questionnaires . Two thirds of reported cases had no precipitating event, the remaining third mainly followed surgery or trauma. Strep A was the causative organism identified in 75%, either alone or with concurrent infection and antibiotic sensitivities are discussed. Systemic complications occurred in the majority of cases, with sepsis and death occurring in 3.6%. Over 50% of surviving patients had significant subsequent morbidity, reduced acuity (<6/18) being a common outcome.

Periorbital necrotising fasciitis is a rare dangerous condition. In the UK, it has an incidence of ~0.033 per 100,000. It frequently occurs without a precipitating event, Strep A being the most common causative organism. Mortality remains a potential outcome, and survivors suffer significant morbidity.

January 30, 2013 at 9:23 pm

sidgoel@hotmail.com

Medial lid BCC involving the canaliculus often leads to a sacrificed canalicular system during clearance surgeries with appropriate margins. This often leaves the patient with watery eyes.

We present a case of an 86 years old woman with BCC of the left lower lid involving the punctum and proximal canaliculus(photos available) causing a mass and epiphora. A full thickness complete excision was performed with margins. The reconstruction was performed preserving the distal canalicular system which was externalized to the caruncular area by the use of silicone intubation and tissue placement around the tube.

Post operatively excellent lid position was achieved but importantly tube removal left a patent “medialised and externalised” distal inferior canaliculus. The patient was relieved of epiphora. Patency was established anatomically and functionally by syringing and Jones dye clearance (endoscope images available)

We propose that lid tumour involvement of the punctual area should not ring a death knell for the involved canalicular system. If distal canaliculus can be preserved then “medialisation and externalisation” with the help of tubes and reconstruction around the tubes can help prevent watery eyes.

February 6, 2013 at 10:03 am

m_edmunds@doctors.org.uk

Patients increasingly use the internet to access information related to their disease. Health literacy is known to be poor, with multiple agencies (e.g. US Department of Health and Human Services [USDHHS]) recommending that patient-orientated literature be written at a fourth- to sixth-grade (9-12 years of age) reading level to assist understanding. We aimed to assess readability of online literature specifically for thyroid eye disease (TED).

Readability of the content of the 50 highest ranked TED patient-orientated online resources was analysed. Webpages were identified using the Google search term ‘thyroid eye disease’. Extraneous text (e.g. hyperlinks, affiliations, disclaimers) was removed. Relevant text proceeded to readability analysis using three validated measures: Flesch Reading Ease Score (FRES), Flesch-Kincaid Grade Level (FKGL) and Simple Measure of Gobbledygook (SMOG). Readability was categorised by USDHHS standards.

The majority (58%) of TED online patient literature were of UK origin. Most (46%) were from not-for-profit websites and 24% from commercial websites. Mean webpage word count was 1191 (SD 733, range 195 – 3867). Mean FRES was 45 (SD 8.9, range 24–64), mean FKGL 12 (SD 1.8, range 7.2-17) and mean SMOG 13 (SD 1.4, range 9.6–17), each equivalent to reading level of >12th grade and “difficult” on the USDHHS classification. There was no significant difference with country of origin or website type.

Readability scores for online TED patient-orientated materials are inferior to those recommended. Although readability is only one aspect of comprehension, screening TED online material, and subsequent revision, is crucial to increase patient knowledge, satisfaction and compliance.

February 6, 2013 at 10:15 am

Tahrinasalam@hotmail.com

We present our experience of patients presenting to Moorfields Eye Hospital with orbital or periocular TB, over a ten year period.

A retrospective non- comparative review of all patients with a diagnosis of orbital or periocular TB from 2001 to 2011.

8 cases were identified over this ten year period: 4 cases of orbital TB, 3 cases of cutaneous TB and 1 case of dacrocystitis. All patients were from the Asian or African sub continent with a female to male ratio of 3:1. Their age at the time of presentation was in the range of 19-78 years. 3 patients had previously been diagnosed with respiratory TB, but were not on current treatment or under review in this country. Only one patient had knowledge of previous BCG vaccination and all patients gave a history of TB contact in the last 5 years. No patients were immunocompromised.

The UK has one of the highest incidence rates of TB in Western Europe. In 2010 in the UK 8,483 cases of tuberculosis were reported with a rate of 13.6 cases per 100,000 population. London accounted for the highest proportion of cases in the UK (39%), and the highest rate of disease (42 cases per 100,000).

Orbital and periocular TB may be difficult to diagnose with more emphasis on clinical suspicion rather than a positive culture result. The management of orbital and periorbital TB is not only surgical but medical and social. Although surgical intervention may alleviate symptoms and prevent visual loss, the use of ATT is essential in the treatment of the disease. The patient and their immediate family need to be counselled about the public health issues surrounding the infection and safe guarding strategies need to be implemented.

February 11, 2013 at 2:57 pm

jooleong919@doctors.org.uk

To determine if racial variation is a determining factor for needing an orbital decompression in thyroid-associated ophthalmopathy (TAO).

Retrospective interventional case series of patients with thyroid orbitopathy

The racial ratio in the referral population in Leicestershire UK from the 2001 census is 94.7% Caucasian, 3.7% Asian, 0.8% mixed, 0.3% Afro-caribbean and 0.5% other.

The average follow-up duration was six years.

The trigger factors associated with TAO identified were poorly controlled thyroid function (194), smoking (334), stress (75) and systemic infection (54). On average, each patient who underwent orbital decompression had 1.8 trigger factors in comparison to 1.34 trigger factors in patients who did not undergo orbital decompression.

50 patients underwent unilateral orbital decompression and 81 had bilateral orbital decompression. The racial ratio of patients who had orbital decompression was 90.84% Caucasian, 6.10% Asian, 2.29% Afro-caribbean and 0.76% others. The p-value from Chi-square test was 0.053 (ie race might not be a determining factor in needing orbital decompression among thyroid orbitopathy patients).

The indications for orbital decompression were medically controlled or refractory active thyroid orbitopathy (67 Caucasians, 6 Asians, 1 others) and cosmesis (52 Caucasians, 2 Asians, 3 Afro-caribbeans).

The racial ratio of medically controlled or refractory active thyroid orbitopathy patients undergoing orbital decompression was 90.54% Caucasian, 8.11% Asian and 1.35% others.

Our result shows that TAO is equally common among all races in our referral population. Racial variation may not be a determining factor for needing an orbital decompression among TAO patients.

February 11, 2013 at 3:53 pm

jooleong919@doctors.org.uk

To evaluate the post-operative outcomes and to investigate the association between the race and incidence of reactivation following orbital decompression for thyroid orbitopathy.

Retrospective interventional case series of patients with thyroid orbitopathy.

212 eyes of 131 patients were included. The average follow-up duration was seven years. The indications for orbital decompression were medically controlled or refractory active thyroid orbitopathy (67 Caucasian, 6 Asian, 1 others) and cosmesis (52 Caucasian, 2 Asian, 3 Afro-caribbean). Following orbital decompression, the number of patients who had experienced improvement were 43 lid retraction and 122 exophthalmos. One patient had post-operative complication of hypoglobus. There were 5 cases of reactivation i.e.2.36% (all Caucasian, two had 1 trigger factor, one had 2 trigger factors and one had 3 trigger factors). The p-value from Chi-square test was 0.554 (ie race might not be a trigger factor for thyroid orbitopathy reactivation)

Reactivation is rare and more likely in patients with multiple trigger factors. Race may not be a trigger factor for thyroid orbitopathy reactivation.

February 11, 2013 at 3:58 pm

james.neffendorf@gmail.com

Botulinum toxin is a valuable technique in producing a protective ptosis when surgical tarsorrhapy is neither desired nor practical. Recognised side effects are ptosis, failure and temporary diplopia, and it is widely considered to be a safe treatment modality. We report a unique case regarding a catastrophic complication of botox tarsorrhaphy with high relevance to ophthalmic practice. We highlight the importance of such a complication, in what is often viewed in ophthalmic departments as a fairly trivial procedure. The case is combined with a review of the relevant literature.

A 41 year old gentleman who had undergone previous corneal graft surgery many years previously, was admitted with presumed right microbial keratitis and treated with intensive topical antibiotics. Corneal culture was sterile. Translid Botulinum tarsorrhaphy was performed, attempting to promote epithelial coverage of cornea.

Within 96 hours, BCVA dropped from 6/60 to no perception of light, accompanied by rapid gross proptosis. Treatment with intravenous antibiotics, antivirals and antifungals was unsuccessful. CT imaging demonstrated a large inflammatory reaction with no evidence of infection. Evisceration was performed one week following initial presentation. Histology showed intense inflammation and scleral necrosis, whilst microbiological analysis was sterile.

We have shown a rapid inflammatory orbital response likely secondary to botulinum toxin tarsorrhaphy, resulting in evisceration. We would like to highlight to clinicians the potential side effects of such treatment, and emphasise the importance of early recognition in future cases.

February 11, 2013 at 5:17 pm

mrosabonilla@gmail.com

Lower eyelid ectropion is most frequently seen in older age, we describe a young patient known to be HIV positive on highly active antiretroviral therapy (HAART), who presented with ectropion unrelated to the previously described aetiologies.

Case report

40 year old HIV positive patient who presented to our clinic with a watery, uncomfortable left eye and a left lower eyelid ectropion. He was on HAART with Sustiva® and Kivexa®. After proving positive to herpes simplex virus type 2 on a conjunctival swab, he was put on Acyclovir 400mg BD by his physician 5 months prior to our visit, with no improvement in his lid pathology.

On examination, no evidence of a periorbital tumour or significant skin cicatrisation was evident and on CT scan his orbital structures were found to be normal.

A lateral tarsal strip with inverting sutures was performed and because of the unknown aetiology biopsy samples of both conjunctival and skin were taken for histopathological analysis. These were found to be normal.

Following surgery the ectropion completely resolved with a good functional and cosmetic outcome.

Eyelid malpositions in HIV+ patients have been reported to be mainly related with Karposi’s sarcoma lesions and muscle wastage and lipoatrophy as side effect of HAART therapy. Whilst the changes were subtle, and in the presence of normal tissues on CT and histological examination, it was considered that lid laxity was the cause of the lid malposition. Although we have not found any previous report of such association, we hypothesize the possible involvement of the disease process and treatment with antiretroviral therapy contributed to the change in our patient’s tissue strength. We consider that it is important to record such a case as it is an infrequent occurrence.

February 11, 2013 at 10:37 pm

Sabah.Stafanous@chesterfieldroyal.nhs.uk

To present an audit of 46 cases who had the new ectropion procedure between2/11-5/12& show pre&post op.photos of excellent results. After full conversion to the new entropion method(lateral diamond excision & retractor plication)that Carol Lane described6/08&auditing&presenting 50 successful cases at BOPSS&ESOPRS in 2010 I modified the method for ectropion surgery which included;Lateral or medial pentagon(LP/MP)excision to shorten the eyelid,+/-3snip,retropunctal cautery(RPC)or medial diamond of tarso-conjunctiva(MD). This was prompted by the complication associated with the old method(lateral tarsal sling)including;Short&long term recurrence&sling slippage,long term tenderness,rounding of lateral canthus&change of appearance,lateral upper lash entropion&stopping antiplatelets.

Retrospective case notes review&a large number of pre&post op. photos.

Between 2/11&5/12 46 eyes of 38 patients had the new method,all had LA&D/C surgery

19whole ectropion,3 lateral,14medial,3cicaticial&7physiological pump failure

34had LP+/-3S,RPC or MD.12had MP+/-MD,3S or RPC

41had 2&5 had 3post op.visits

All46 had satisfactory cosmetic&anatomical lid position

7with physiological pump failure had satisfactory lid position,5complete resolution of watering,2improved symptoms but residual symptoms

The new ectropion procedure has excellent functional&cosmetic results

No complications in 46 eyes(notching,gaping,trichiasis,infection&bleeding)

Cheaper as only 1-2sutures of 6/0 vicryl,no cutting cautery&only reusable equipments

No rounding,tenderness, stitch granuloma or lateral canthus disturbance as with the old LCS

Not expecting recurrence as no slippage

less post op.visits&no need to stop antiplatelets

continue method&future reaudit

February 15, 2013 at 2:09 pm

dovhersh@gmail.com

To present a case of dysThyroid optic neuropathy (DON) exacerbated by orbital radiotherapy (OR) under IV Methylprednisolone cover in a patient previously responsive to IV Methylprednisolone alone. To review the literature pertaining to the use of OR in clinically active grade IV Thyroid Eye Disease (TED). To present an alternate position to the use of OR in clinically active grade IV TED as advocated by some authors in the recent literature.

Case report and literature review

A 76 year old lady presenting with Grade IV TED and DON was stabilised with systemic IV Methylprednisolone and then referred for OR. Three separate attempts at a treatment course of OR were commenced and subsequently abandoned. On each occasion OR was aborted as there was an acute worsening of her DON during OR despite cover with PO and subsequently IV Steroids. She underwent urgent orbital decompression which normalised her vision and optic neuropathy.

Our case probably represents worsening of DON due to soft tissue swelling secondary to OR despite cover with IV Methylprednisolone in a patient previously responsive to IV Methylprednisolone alone. Recently authors (Kazim et al 2012) have advocated the use of OR in active DON as either a surgery delaying or surgery sparing alternative. This case illustrates the risk of using of OR in clinically active DON. We highlight the need for close monitoring of optic nerve function following orbital radiotherapy in this patient group.

February 15, 2013 at 4:29 pm

sureshsagili@yahoo.com

We describe a minimally-invasive technique and report our experience of posterior approach levator plication (“levatorpexy”) for congenital ptosis.

Retrospective review of a consecutive series of 16 patients with congenital ptosis that underwent levatorpexy ptosis repair under general anaesthesia. This surgical procedure involves exposing the posterior surface of the levator muscle through a transconjunctival approach. The levator muscle is advanced and plicated using a suture passed through its posterior surface, partial-thickness, to tarsal plate and tied on the skin. No tissue (conjunctiva, Muller’s muscle, levator) are excised during this procedure. Data collected included margin reflex distance (MRD), symmetry of eyelid height, contour and complications. Surgery was considered successful if the following three criteria were simultaneously met: A postoperative MRD of ≥2 mm and ≤4.5 mm, inter-eyelid height asymmetry of ≤1 mm, and satisfactory eyelid contour.

Sixteen patients were included in this study. Mean age was 9.1 years ( 3 to 26 years ). Mean post operative follow up was 8.1 months ( 4 to 24 months). Preoperative phenylephrine test was positive in 81% of patients. Mean levator function was 8.3mm (3-15mm). Mean preoperative MRD was 1.5mm and the mean postoperative MRD was 2.6mm. Fourteen patients(87%) achieved the desired eyelid height and fulfilled our criteria set for success.

Posterior approach levatorpexy appears to be a safe and effective procedure for correction of congenital ptosis particularly with moderate or better levator function.

February 17, 2013 at 8:08 pm

sureshsagili@yahoo.com

Squamous cell carcinoma of lacrimal caruncle is a rare entity. We report the management and outcomes of squamous cell carcinoma of the caruncle.

Multi-centre interventional case series

Case 1, underwent wide margin surgical excision with adjuvant topical chemotherapy for a poorly differentiated SCC. He later developed regional lymph node metastasis and required modified radical neck dissection. Case 2, underwent wide margin surgical excision with cryotherapy and adjuvant topical chemotherapy for an invasive moderately differentiated SCC. She later developed a recurrence and underwent orbital exenteration. Case 3, was a moderately differentiated SCC treated with wide margin excision alone.

We report the management and outcomes of 3 cases of caruncle SCC. Although rare, SCC of the caruncle can be associated with greater potential for local recurrence and/or regional metastasis. Regular follow up is required to identify local recurrence or regional metastasis early and initiate appropriate treatments early in the course of disease recurrence.

February 17, 2013 at 8:22 pm

rathierajendram@hotmail.com

To describe the baseline features,management and outcomes of the largest British cohort of thyroid eye disease patients to be described.

A casenote review of all new thyroid eye disease (TED) patients attending the Orbital Clinic at Moorfields Eye Hospital under one consultant (GER) between 1997 to 2002 inclusive. Change in proptosis and diplopia were recorded at baseline and after 3 years of treatment or at discharge from the service.

Of 500 new TED patients seen during this time period 425 (85%)notes were available for review.72% were female.The age range was 18 – 89 years old with a median of 47 years old. 52% were smokers at their initial visit. Almost half (46%) presented to our department withprominent eyes. 17% was diplopia and only 4% reported visual loss as their presenting symptom. 128 patients (30%) had conservative management only,15% (n=65) had medical management alone and 35% (n=149) had surgical treatment alone. A combination of medical and surgical management was used in one fifth (83 patients). 68.9% of patients presenting with proptosis (>21mm) improved with our management and 67.2% of patients with diplopia (using Gorman diplopia score)improved.

A large proportion of patients seen at our centre presented with prominent eyes and diplopia reflecting the services offered at Moorfields Eye Hospital. A high percentage were smokers at presentation and this was higher than that in the general population. After treatment, almost 1/3 had residual diplopia or proptosis which confirms that thyroid eye disease is a difficult disease to manage with often permanent changes.

February 18, 2013 at 2:37 pm

rathierajendram@hotmail.com

The correct identification of active thyroid eye disease is key in deciding on management. Diffusion weighted imaging (DWI) is an MRI sequence which demonstrates acute inflammation by calculation of the Apparent Diffusion Coefficient (ADC). It could therefore be used to detect early inflammation in active TED. This study aimed to evaluate the correlation between ADC and Clinical Activity Score (CAS) in thyroid eye disease patients.

15 TED patients (3 males) were recruited as a subgroup of a randomised controlled thyroid eye disease treatment trial. MRI data were acquired from all patients at baseline and repeat scan in over half of the patients (n=6) at an average of 7 months after the initial scan. All patients underwent clinical assessment at similar time points. Regions of interest (ROIs) outlining medial, inferior, lateral and superior rectus muscles for each eye were drawn on the short-TE images. The superior rectus was evaluated in a combined ROI with the levator palpebrae superioris because of their close proximity. The average and maximum SIR, T2 relaxometry and ADC were calculated for each muscle and across all muscles.

The average of the intra-muscle mean ADCs across all extraocular muscles also correlated significantly with CAS (p=0.03). The practicality of determining the displacement of a proton on two scans was subject to significant artefact however.

A correlation between muscle ADC and CAS was found. The difficulty in measuring the movement of a proton with potential artefact makes this method of assessing disease activity difficult to determine however and therefore unlikely to be a robust technique. The search for a definitive measure continues.

February 18, 2013 at 3:03 pm

ruben.kannan@gmail.com

To illustrate a novel technique of securing the transosseous lateral canthoplasty sutures to the lateral orbital rim as opposed to passing a suture needle through the bony tunnel in close proximity to the globe. We propose a new solution to an ‘old’ technical problem.

In a retrospective case series of seven patients in our practice in Leicester, we have utilised a silk ‘lasso’ technique to allow the seamless passing of Prolene lateral canthal sutures through the lateral orbital rim in lateral canthoplasties. This flexible technique simplifies the transosseous fixation of the lateral canthus as well as making it safer. This technique is illustrated with a short video.

Using the ‘lasso’ technique, we have eased the process of fixing the lateral canthus transosseously and reduced the operating time to 15 minutes or less in our series with good long-term results.

We recommend the ‘lasso’ technique of transosseous lateral canthal fixation as a simple, safe option in lateral canthoplasties.

February 18, 2013 at 7:13 pm

c.murphy3@nhs.net

To investigate the annual trends in the rates per 100,000 of population of evisceration, enucleation and exenteration performed in Scotland and England over the last 22 years.

A retrospective analysis of the rates of enucleation, evisceration and exenteration carried out yearly in Scotland and England between 1989-2011. The following OPCS codes were used to identify cases C01.1, C01.2 and C01.3. The numbers of procedures were obtained from Information and Statistic Department Scotland and Hospital Episode Statistics. Mid year population estimates were obtained from the General Register office for Scotland and the Office for National Statistics.

Over the past 22 years there has been a 65.2% reduction in the rate of eye removal in Scotland and England. Exenteration rates have remained static. Rates per 100,000 of enucleation have decreased from 1.76 to 0.74. Rates per 100,000 of evisceration have increased from 0.41 to 0.62. The trend of reduced eye removal and decreased enucleation rates has been more pronounced in Scotland.

This paper illustrates a decrease in eye removal over the past 22 years in Scotland and England. There has been a shift in surgical practice with a change away from enucleation and a preference towards evisceration. We discuss our results in the context of current literature and hypothesize reasons for the changing trends.

February 18, 2013 at 7:32 pm

CHUAOXFORD@HOTMAIL.COM

SIlicone intubations during dacryocystorhinostomy (DCR) are usually done with prepackaged silicone tube with metal probes. However, such preparations are expensive and can cause trauma to the eye or the canalicular system during manipulation. We like to describe a simple technique of canalicular silicone intubation during DCR without the use of probe. This technique can cut down the cost of DCR surgery and be used in instances where the probes accidentally detach from the silicone tubes during manipulation.

A lacrimal probe is used to pass the sheath of a 20-gauge intravenous catheter through the punctum into the lacrimal sac that has been open. 5/0 prolene is threaded through the sheath to form a loop on the ocular side. The silicone tube is passed through the prolene loop and both ends of the prolene on the side of the lacrimal sac are pulled tight to move the sheath and the tube out from the cavity of the sac. The process is repeated for the other canaliculus. The tubes are passed out through the rhinostomy site, and tied inside the nose.

This technique was performed in 20 consecutive DCRs. The patients were followed up for 12 months. Three patients had recurrent epiphora due to stenosis of the anastomosis between the nasal flap and lacrimal sac.

This technique reduces the cost of DCR operation by using only silicone tube. In addition, it can be used in cases where the metal probe accidentally detaches from silicone tube during manipulation.

February 19, 2013 at 5:35 am

CHUAOXFORD@HOTMAIL.COM

To describe a new surgical technique and results of the lower paralytic ectropion repair by orbicularis oculi suspension performed through small skin incision.

Seven patients who suffered from lower lid ectropion secondary to lower facial nerve palsy were recruited for this new technique. This technique was performed by making a small incision of 1cm over the superolateral orbital rim and dissected down to the periosteum. Two stab incisions one above another was made in the lateral third of the eyelid. An 18-gauge intravenous catheter needle was used to introduce a 2/0 prolene from the orbital rim through the stab incisions to lift and suspend the orbicularis muscle to the lateral orbital periosteum. Measurements were taken of the palpebral apertures and the lower margin reflex distances pre- and post-operation.

The follow-up period ranged from 3 to 12 months. All patients experienced improvement of lagophthalmos. Preoperative palpebral aperture and margin reflex distance were 12.9 ± 0.9 mm and 8.6 ± 0.8 mm respectively and the postoperative results were 9.9 ± 0.7 mm and 6.4 ± 0.5 mm respectively.

The early results showed that this new technique provides good support for patients with lower paralytic ectropion. It is easy to learn with short recovery time.

February 19, 2013 at 5:41 am

CHUAOXFORD@HOTMAIL.COM

We describe a technique of correcting mild ptosis untilizing a suture method. It is a modification of conjunctival Müllerectomy but without the need of tissue removal.

Two small stab skin incisions are made centrally in the upper eyelid at the level of the skin crease. A non-absorbable suture is passed through the tarsus from each incision. The suture is then passed transconjunctivally in the upper fornix to pick up Muller’s muscle. The suture is then passed through the tarsal plate and exits through the same stab incision to be tied and buried. The ptosis is corrected by plication of the Muller-conjunctival complex.

This technique is used successfully in 15 eyelids (15 patients) with mild ptosis. All patients achieved satisfactory postoperative aesthetic and functional results.

This method is a safe and easy method of correcting mild ptosis. It has the advantages of minimal perioperative bleeding and postoperative swellings.

February 19, 2013 at 6:40 am

kanminxue@gmail.com

It is unclear whether application of mitomycin C (MMC) to the osteotomy site during dacryocystorhinostomy (DCR) increases surgical success rates. Published studies involve small sample sizes and provide conflicting conclusions. We conduct the first meta-analysis of the effect of MMC in DCR surgery.

A literature search was conducted in PubMed, EMBASE and Cochrane Library. Only randomised controlled or non-randomised comparative studies were included. Other inclusion criteria included: adults with post-saccal lacrimal obstruction, both primary and revision surgery, external (EX-DCR) and endonasal (EN- DCR), and publication in the English language. Outcome was based on objective anatomical patency of the nasolacrimal system. Statistical analysis was performed using RevMan 5.1 software.

Of 61 articles retrieved, 17 studies involving a total of 942 DCR procedures met our inclusion criteria. The mean concentration of MMC was 0.3 mg/ml. The failure rate with MMC was significantly lower than control for primary EX-DCR (risk ratio 0.41; 95% CI: 0.21-0.77; p = 0.005), but not for primary EN-DCR (risk ratio 0.80; 95% CI: 0.45-1.43; p = 0.45).

Four controlled trials of revision DCR were identified (all EN-DCR). The failure rate of revision EN-DCR with MMC was significantly lower than control (risk ratio 0.49; 95% CI: 0.26-0.94; p = 0.03) but moderate heterogeneity was noted between the studies (I2 = 30%).

Adjunctive use of MMC significantly reduces the failure rate of primary EX-DCR and revision EN-DCR. Current evidence does not support the use of MMC in primary EN-DCR. Further trials are required to evaluate the effect of MMC in revision EX-DCR.

February 19, 2013 at 12:15 pm

drlisanelson@hotmail.com

Medial canthus sinonasal fistula is associated with troublesome aesthetic and functional issues. Corneal irritation and drying results from escape of both air and secretions from the nasal cavity across the ocular surface as well as misting of spectacles if worn. Reconstruction of such fistulae is associated with a high rate of recurrence and thus presents a difficult surgical challenge.

This paper describes the senior author’s surgical approach to manage medial canthus sinonasal fistulae utilizing an interpolated forehead flap combined with extended galeafrontalis and pericranial flap for stepped closure. The technique of flap elevation and inset is discussed, with emphasis on key maneuvers to prevent sinus recurrence. A retrospective review of consecutive cases is presented.

Four patients were treated using this technique over 12 months. In all cases, fistulae developed following adjuvant radiotherapy for tumour resection. Flap elevation was performed in combination with a bicoronal approach in 2 patients and via direct forehead approach in 2 patients. No post-operative complications or recurrence of fistula have occurred over 12 months follow-up.

The success of this technique is attributed to inclusion of a galeafrontalis and pericranial extension to the forehead flap. In addition, the fistula site must be prepared to accommodate the flap by dissection of a wide subcutaneous pocket. This stepped method of closure provides an effective barrier to air and nasal secretions and also achieves an excellent aesthetic outcome.

February 20, 2013 at 7:20 am

m_edmunds@doctors.org.uk

Autoantibodies to insulin-like growth factor-1 receptor (IGF-1R-Ab) are thought to have a role in the pathogenesis of Thyroid-Associated Ophthalmopathy (TAO) in those with Graves’ Disease (GD). Previous studies have demonstrated that:

1) IGF-1R expression is higher on orbital fibroblasts, T and B lymphocytes from TAO subjects compared with healthy controls (HC);

2) TAO serum triggers orbital fibroblasts to produce T cell chemoattractants and inflammatory mediators, effects abrogated by IGF-1R monoclonal antibody;

3) Microarray analysis identifies IGF-1R signalling gene overexpression in TAO orbital tissue.

We aimed to develop assays to effectively measure IGF-1R-Ab in serum of TAO patients as compared with GD and HC subjects.

Two distinct ELISA-based assays were developed and validated to reproducibly detect and quantify commercial IGF-1R monoclonal antibody. The assays were not influenced by levels of IGF-1 itself, nor any other monoclonal antibody. Using these assays, sera from 110 TAO patients (20 clinically active, 90 quiescent), 67 GD patients and 78 age- and sex-matched HC were analysed.

Both assays found no significant difference in IGF-1R-Ab between GD, TAO and HC individuals. There was no correlation between IGF-1R-Ab level and TAO activity or severity, nor with thyroid status (hyper-, hypo- or euthyroid) or cigarette smoking history.

Despite the weight of available evidence for a role of IGF-1R autoimmunity in TAO, we found no difference in IGF-1R-Ab levels between our GD, TAO and HC subjects. Complementary studies are required to further characterise IGF-1R-Ab and evaluate their pathogenic importance in TAO.

February 20, 2013 at 12:54 pm

nizardin@doctors.org.uk

Tension pneumo-orbit is a rare ophthalmic emergency which mandates prompt identification and decompression to prevent irreversible optic nerve damage. A one-way valve mechanism occurs leading to air entering but not exiting the orbit. This leads to an orbital compartment syndrome with potential for significant visual loss.

Our purpose is to:

– describe the rare presentation of a sight threatening orbital compartment syndrome.

– discuss the assessment and investigation of tension pneumo-orbit.

– describe the medical and surgical management of such a condtion in the acute setting.

We present the interesting case of a 44 year old Asian gentleman who previously has had surgical correction for an orbital floor fracture and presents with left retro-orbital pain, diplopia and worsening visual acuity following a traumatic mid-facial injury. Facial photographs, CT and intra-operative images are included.

Our patient underwent numerous emergency orbital decompression procedures at the bedside with supplementary medical management to stabilise vision in the acute setting. Subsequently, he underwent definitive surgical management under the ENT team for his orbital compartment syndrome with good post-operative visual outcome.

Tension pneumo-orbita is a rare yet sight-threatening complication of orbital skeletal fractures. Clinical awareness and prompt orbital decompression is vital to prevent visual compromise. This case successfully re-enforces the role of emergency endoscopic endonasal orbital decompression in patients with tension pneumo-orbita. Furthermore, it highlights the instrumental role of a multi-disciplinary approach to the surgical management of a potentially devastating condition.

February 20, 2013 at 9:50 pm

sallyameen@yahoo.co.uk

The 2009 Amsterdam Declaration on Graves Orbitopathy (GO) received widespread endorsement by clinicians. However the administrative and funding arrangements for the multidisciplinary management of this disfiguring and potentially sight threatening disease appear not to have been clearly identified in current NHS primary and secondary care provisions.

The purpose is to establish whether there is a preferred practice pattern among GO experts in the UK and to provide supportive evidence that aids in implementing the declaration.

An online questionnaire was emailed to all members of the British Oculoplastic Surgery Society (BOPSS) and responses collected over 3 cycles sent out over a period of 4 months in 2012. This included questions about the preferred disease severity classification, immunosuppressive agents, use of orbital radiotherapy and multidisciplinary clinics.

Sixty questionnaires were sent out to working emails obtained through the BOPSS website. 38 (63.3%) completed responses were received. 17 (43.5%) used CAS classification system. 36 (95%) used steroids as their first line immunosuppressant, with 36% oral, 13.5% peribulbar injections & 50.5% intravenous methylprednisalone. 1 (2.6%) clinician referred patients for orbital radiotherapy. 18 (47.8%) operated as part of a multidisciplinary team. 11 (29.2%) encountered difficulties with treating patients in a multidisciplinary setting.

The survey highlights that the treatment of GO patients is still varied across the country with less than 50% of BOPSS members participating in a multidisciplinary team. These results are shared with TEAMeD, the UK group responsible for implementing the Amsterdam Declaration, to help standardise our practice nationwide.

February 21, 2013 at 8:57 am

m_edmunds@doctors.org.uk

Although 30-50% of Graves’ Disease (GD) patients develop Thyroid-Associated Ophthalmopathy (TAO), it is not yet possible to predict which will be affected and which will be in the 3-5% who develop sight-threatening manifestations. Distinct pathologies may result in specific changes in metabolism, and the systems biology methods used in metabolomics, can derive a “metabolic fingerprint” from the analysis of metabolites in body fluids or tissues. This approach has provided useful insights in, for example, diabetes mellitus, rheumatoid arthritis and multiple sclerosis. We assessed the value of metabolomic profiling as a novel means of differentiating these patients and investigating underlying pathological processes in a large cohort of GD, TAO and healthy controls (HC).

Nuclear magnetic resonance (NMR) spectra of the serum of 110 TAO (20 clinically active, 90 quiescent), 67 GD and 78 age- and sex-matched HC were acquired using NMR spectroscopy. Data was subjected to principal component analysis (PCA) and partial least squares discriminant analysis (PLS-DA). Correlation between metabolite profiles and GD and TAO diagnostic criteria and TAO disease activity and severity were assessed using partial least squares regression (PLS-R).

PCA and PLS-DA analysis of NMR spectra was able to segregate TAO and HC sera into two distinct groups, with GD sera interspersed between these. Metabolomic analysis was also able to discriminate inactive and active TAO subjects and hyperthyroid and euthyroid GD patients.

Metabolomics offers the possibility of discriminating GD and TAO (active and inactive) patients and may, in future, be a useful diagnostic, prognostic and monitoring tool.

February 21, 2013 at 12:19 pm

CHUAOXFORD@HOTMAIL.COM

Asian blepharoplasty is the most common cosmetic eyelid surgery performed in East Asian. However, most western trained oculoplastic surgeon has little exposure to Asian blepharoplasty. I like to share my experience of incisional Asian blepharoplasty from high failure rate to satifsfactory results.

Review of the first 100 cases of Asian blepharoplasty performed by a Western trained oculoplastic surgeon(author).

The failure rate was high (disappearance of the skin creases) when the surgeon applied upper blepharoplasty learnt in the West. The success rate increased when the surgeon made some important modifications to the technique.

Asian blepharoplasty has a learning curve that is steeper and longer than the usual upper blepharoplasty performed in Caucasians. This study highlights the areas needing extra attention for Western trained oculoplastic surgeons performing Asian blepharoplasty.

February 21, 2013 at 1:43 pm

CHUAOXFORD@HOTMAIL.COM

Upper eyelid skin crease (popularly known as double eyelid) is absent in about 50% of the East Asian population. However, there have not been studies looking at the effects of the upper eyelid skin creases on palpebral aperture and levator function.

Measurements of the skin creases, palpebral apertures and levator functions were taken of 97 Chinese males and 101 Chinese females aged between 18 and 26.

Upper eyelid creases were absent in both eyes in 30.8% and absent in one eye in 6.6% of the study subjects. In the male subjects, the mean values of the palpebral aperture were 9.8 ± 1.1 mm in eyes with skin creases and 8.9 ± 1.0 mm in eyes without. The mean values for the levator function were 15.2 ± 1.8 mm and 12.8 ± 1.5 mm respectively. These results were statistically significant (p<0.001). In the female subjects, the mean values of the palpebral aperture were 9.6 ± 1.0 mm in eyes with skin creases and 8.6 ± 1.2 mm in eyes without. The mean values of the levator function were 14.9 ± 1.5 mm and 12.2 ± 1.9 mm respectively. These results were statistically significant (p<0.001).

Eyes with upper eyelid skin creases have larger palpebral apertures and levator excursions than eyes without upper eyelid skin creases.

February 21, 2013 at 1:48 pm

cm.yeo@doctors.org.uk

Sutures may fall or “ping” out of needle holders when grasped incorrectly. Finding lost sutures +/- needles is often difficult in the ophthalmic operating environment due to their size and colour. Lost sutures waste time and constitute a health hazard. This study aims to give a guide as to the maximum distance that such sutures may travel.

Sutures of differing lengths were “pinged” from a Barraquer needle holder under constant conditions (height 95cm) in an ophthalmic operating theatre. Horizontal measurements were taken from directly below the point of “ping” to the swage of the suture needle. 6 different commonly used sutures (5.0 Prolene W8721, 5.0 Vicryl W9953, 6.0 Vicryl W9952, 6.0 Vicryl W9760, 6.0 Prolene W8807 and 5.0 Silk W468) at 3 different lengths (full length, 14cm, 6cm) were studied over 5 repetitions. Means, standard deviation and confidence intervals were calculated.

For 6cm sutures the mean distance travelled ranged from 43.4cm (SD:8.02, 95%CI:36.37-50.43) for 6.0 Prolene W8807 to 147.2cm (SD:24.84,95%CI:125.42-168.98) for 5.0 Silk W468. For full length sutures the mean distance travelled ranged from 26.3cm (SD:4.70,95%CI:22.18-30.42) for 6.0 Prolene W8807 to 60.1cm (SD:27.84,95%CI:35.70-84.50) for 6.0 Vicryl W9552. 5.0 Vicryl W9553 sutures travelled less than identically needled 6.0 Vicryl W9552. With only one exception did the suture with the shortest length not travel furthest.

Distances travelled by sutures appeared to relate to both length and gauge. Monofilament Prolene appeared to travel shorter distances than similar gauged filament sutures. When searching for monofilament Prolene sutures the radius of review should be about 75cm, but this may need to be doubled for short filament sutures.

February 21, 2013 at 3:00 pm

koutroumanos@doctors.org.uk

Geste Antagoniste, manoeuvres able to reduce the severity of dystonic movements, are found – according to recent evidence- in 71.2% of patients with Benign Essential Blepharospasm.

We aim to describe a novel method of utilizing the effects of Geste Antagoniste (GA) using specially modified pressure-point spectacles for the reduction of blepharospasm symptoms and to demonstrate its effects on functional improvement and quality of life.

The case of a 60-year old male patient with severely debilitating blepharospasm is reported.

Specially modified spectacles able to apply pressure on the patient’s specific GA area were developed. Formal severity and disability scores were completed by the patient prior to and following the use of these spectacles.

Within three weeks of issuing the spectacles, a vast improvement in the patient’s ability to undertake activities of daily living and his quality of life was demonstrated, with a dramatic drop in all measured disability indices.

We describe the effect and illustrate the design of these spectacles thereby demonstrating a previously unreported, non-invasive and cost-effective approach to utilizing the effects of this organic sensory trick.

February 21, 2013 at 9:19 pm

christina.miller@med.uni-muenchen.de

Synkinesis describes an undesired facial movement accompanying a voluntary movement. It may affect all facial muscle groups.

The purpose is to present a patient with ocular to oral synkinesis treated with Botulinum toxin A.

We present a case of ocular to oral synkinesis – midface movements on blinking. The

patient was managed by a multi-disciplinary team following her facial nerve palsy which recovered incompletely. She presented with prominent contractions of the musculature of the modiolus associated with eyelid closure, which interfered with smiling and was extremely upsetting for her. She was treated with targeted selective Botulinum toxin administration to the synkinetic muscles.

Our patient demonstrated good resolution of synkinesis following Botulinum A treatment presented in pre-treatment and post-treatment videos.

This presentation illustrates ocular to oral synkinesis and the result of treatment with Botulinum toxin A.

February 21, 2013 at 11:17 pm

fizza.mushtaq@gmail.com

We present the case of a 56 year old Caucasian lady who was referred to the oculoplastic and orbital clinic with right sided slowly progressive non pulsatile proptosis.

The patient presented with a 2 year history of right eye proptosis with no history of trauma or diplopia. She was otherwise fit and well using no regular medications. Her LogMAR vision at presentation was -0.06 (RE) and -0.2 ( LE).

Examination revealed a right afferent pupillary defect and 4mm proptosis. This was associated with an increased vertical palpebral aperture and superior scleral show. Ocular motility of the right eye was reduced in up gaze and adduction with lid lag seen in down gaze. Fundoscopy was unremarkable with no optic disc swelling. Colour vision was normal and visual fields were full.

Routine bloods including thyroid function tests were normal, however thyroid peroxidase auto antibodies were markedly raised. A clinical diagnosis of thyroid eye disease was made.

Routine Neuroimaging was ordered and to our surprise there was no radiographic evidence of thyroid eye disease. Both the MRI scan and subsequently an orbital CT scans revealed an extensive meningioma overlying the sphenoid wing and temporal bone. This was associated with hyperostosis of the right sided orbital bones. The extra ocular muscles were of normal size and there was no sign of orbital fat proliferation.

A diagnosis of spheno-orbital meningioma was made and the patient referred to the neurosurgeons for surgical de-bulking.

Although initial presentation was consistent with thyroid eye disease, neuroimaging revealed a diagnosis of spheno-orbital meningioma, which would have been over looked in the absence of orbital imaging.

February 22, 2013 at 12:18 pm

kieranokane@doctors.org.uk

To see whether surgical correction of entropion and ectropion results in an improvement in quality of life as well as functional or cosmetic status. Also whether this improvement is in general, social or physical wellbeing (as described in the Glasgow Benefit Inventory scale)

All patients undergoing correction of ectropion or entropion between January and December 2011 were contacted by phone and interviewed with an 18-point questionnaire (the Glasgow Benefit Inventory) used extensively in ENT surgery, following a Likert 5-point scale. The scale ranges from -100 to +100, with a score of 0 indicating no change. Patients were able to decline or opt-out at any point in the interview

31 of 63 patients (45%) of patients completed the questionnaire, 61% of whom were male. The mean GBI for entropion and ectropion surgery was +19.2 (95% confidence intervals 11.95-27.56.) vs +32.7 for Dacrocystorhinostomy and +24.9 for Ptosis. The ‘general wellbeing’ subscale showed an improvement of +29.8 (21.23-38.4), social wellbeing +10.93 (2.7-19.2) and the physical wellbeing scale showed a deterioration of -10.4 (0.03—20.9)

Ectropion and entropion surgery provides an increased quality of life for patients, particularly in terms of their general and social wellbeing. However, it appears to be detrimental to their physical health. The authors question whether this harmful effect should limit the patient groups surgery is attempted on.

February 22, 2013 at 2:18 pm

dovhersh@gmail.com

To describe a case of Endophthalmitis and orbital necrotizing inflammation secondary to Mucormycosis-causing Lichtheimia Corymbifera, treated with systemic antifungals without aggressive debridement.

Case report and literature review

A 60 year old diabetic immunocompetent male presented with endophthalmitis and marked peri-orbital inflammation in a rubeotic eye. The patient was managed with early evisceration. Post-evisceration mycology confirmed Lichtheimia corymbifera infection.

Systemic antifungal (Pozaconazole) therapy was commenced for a period of 3 months as advised by the Mycologist. The patient did not undergo further surgical debridement and continues to improve on systemic treatment alone.

Lichtheimia corymbifera has been reported to be a causative organism of rhinocerebral mucormycosis where aggressive surgical debridement/exenteration is the usual management. This case was successfully managed with systemic anti-fungals, close clinical and radiological monitoring without aggressive surgical debridement.

February 22, 2013 at 3:55 pm

mrosabonilla@gmail.com

There is no evidence in the literature regarding compliance with medical treatment following surgery in oculoplastic patients. We have designed a survey to assess postoperative treatment compliance and acceptability in our patients and report our findings.

30 consecutive postoperative patients were recruited and divided into two groups of 15 patients (Group A and Group B). Group A was given treatment with guttae chloramphenicol QDS, guttae dexamethasone QDS and chloramphenicol ointment at night. Group B received treatment with guttae chloramphenicol TDS and chloramphenicol ointment at night. Both groups were asked to use the treatment for 2 weeks following eyelid surgery. Patients were then given an anonymised questionnaire to assess compliance and acceptability of the treatment at their 1st postoperative visit, at 2weeks following surgery.

Preliminary results showed that the overall compliance rate was high (in excess of 90%). Those in Group B showed a higher compliance rate and oc chloramphenicol was the most acceptable component of the post operative regime. Group A patients more frequently discontinued treatment ahead of the 2 week deadline.

As opposed to the compliance rates in glaucoma that are 75% in average, we have found that compliance with both postoperative treatment regimes is higher than expected. Preliminary results show no statistical difference between the 2 groups but more patients completed 2 weeks of treatment with the simpler treatment protocol. We believe that the more acute nature of the pathology and the recent surgery are strong motivators to follow the prescription, although more complicated prescriptions are associated with lower compliance rates.

February 22, 2013 at 4:23 pm

mrosabonilla@gmail.com

The mainstay of treatment for a lower lid cicatricial ectropion is a full thickness skin graft ( FTSG). A FTSG has attendant problems including the need for a tie-over dressing, graft take and often delayed secondary ectropion due to contracture with possibility of further surgery. We describe a simple alternative without the attendant problems associated with a FTSG.

This involves a laterally based transposition flap ( Modified Tripier) using the lower edge of a blepharoplasty incision, with a broad base that ends at a level higher than the outer canthus. This transposition flap is turned down to fill the gap left after a sub ciliary incison has been made to relieve the cicatricial tissue. This myo cutaneous flap, acts as a hinge to provide a lateral lift which aids in the post operative cosmesis. The flap can be used medially or laterally with good results.

Seven patients who underwent an upper to lower lid tranpositon flap are illustrated. Three patients had a cicatricial ectropion and four underwent an anterior lamellar excision for a lower lid BCC.

Cosmetically the results are excellent and none of the patients have had any intra or post op complications. The average follow up was 9.4months (SD 4.1).

This technique provides a useful alternative to a full thickness skin graft. It has several advantages over a graft including reduced graft loss and uptake related problems, better vascularity and lateral elevation and the inconvenience of a tie-over dressing is avoided. This flap can be used for other lower lid pathology including reconstruction after an anterior lamellar BCC excision. However if lid laxity is noted a lateral canthopexy is required to ensure an optimal result.

February 22, 2013 at 4:54 pm

v.joganathan@doctors.net.uk

Periocular and orbital amyloidosis is not common. It may occur de novo or associated with systemic disease.

We present two different cases of periocular amyloidosis and describe the variable presenting features, management and outcome.

Case 1: An 80 year old gentleman presented with 6 month history of left lower lid painless variable lid swelling. Examination revealed thickened left lower lid tarsal plate with redness and cystic change of the overlying palpebral conjunctivae on the medial side of the lower lid. Biopsy and evaluation confirmed kappa light chain associated amyloidosis however haematological investigations were all normal. Incidentally the lower lid of the right eye also showed cystic changes over the past year. Patient remains asymptomatic over the past year and is under observation.

Case 2: A 43 year old lady presented with 18 month history of right sided ptosis. Her past medical history was unremarkable. Examination found normal visual acuities, eye movements, intraocular findings and optic nerve function. She had a 2cm by 1 cm soft sub levator swelling of the right upper lid attached to the tarsal plate. Debulking biopsy and evaluation showed lambda associated amyloidosis without any systemic disease. 5 months later she had progression of growth with enlargement of soft tissue growth on MRI scan. Further debulking and ptosis repair has been arranged.

Ocular pain is invariably a rare sign in periocular amyloidosis. Symptoms are related to structural pressure with upper lid lesions often presenting with ptosis and intraocular lesions with ocular motility dysfunction. Surgical debulking often resolves symptoms but re-growth is likely. Conjunctival involvement is common and in these cases, meticulous debulking is necessary in the symptomatic patient to avoid unnecessary goblet cells loss and morbidity. The treatment aim is to preserve anatomy as much as possible whilst resolving symptoms. Biopsy and histological and haematological evaluation is mandatory to ascertain definite diagnosis. Amyloidosis although rare should be considered in the differential diagnosis of unusual presentations of periocular lesions.

February 22, 2013 at 7:56 pm

sonalinagendran@doctors.org.uk

We aim to evaluate the Frimley Park Hospital oculoplastic virtual clinic service.

A prospective audit of 44 patients booked for a case note review in the virtual clinic over 3 months. All patients had previously been seen in the outpatient clinic. Parameters assessed included the investigations reviewed, the timing between investigations and the virtual clinic appointment and the clinic outcome.

Of the 44 patients audited, 26 were booked for review of histology results, 13 for review of visual field test results, 2 for blood test results, 1 for imaging results, 1 after a cardiology review and 1 as a telephone consultation following an outpatient appointment. Following the virtual clinic 12 patients were booked directly for an operation, 26 patients were discharged and 2 patients required a second virtual clinic review, as the investigations ordered were not complete. In total only 6 patients required an outpatient appointment after a virtual clinic review. The average time from investigation result to review in the virtual clinic was 3.4 weeks. No adverse events were attributed to the use of virtual clinics.

Virtual clinics are an efficient way to increase capacity in the oculoplastic outpatient service and improve the new to follow up ratio without compromising care. They save patients unnecessary journeys to hospital and allow doctors to review and act on results in a timely manner. Virtual clinics may be used by ophthalmologists of all grades and we recommend that trainees adopt minor ops virtual clinics as a useful educational tool to reflect on cases seen. Care must be taken to differentiate between urgent and routine cases and time virtual clinics accordingly.

February 22, 2013 at 8:22 pm

sofia.theodoropoulou@ipswichhospital.nhs.uk

Our aim is to describe the periorbital changes induced by chronic topical therapy with daily bimatoprost 0.03%. The purpose of this paper is to present the two year follow up data of our case series of patients on topical bimatoprost, with assessment of the reversibility of these changes after discontinuation of the medication.

We assessed consecutive patients on topical bimatoprost 0.03% therapy using photographic evidence and clinical examination (adnexal measurements) to compare untreated eyes with eyes receiving therapy for up to five years. Upon discontinuation of the medication for 3 to 4 years, photography and clinical examination were repeated.

In eyes treated with bimatoprost we noted periorbital fat atrophy, deepening of the upper eyelid sulcus, relative enophthalmos and involution of dermatochalasis compared with the fellow untreated eye. By inspecting old photographs we confirmed that these changes were not present prior to bimatoprost use.

After discontinuation of the medication for at least 3 years, adnexal measurements , combined with photos, showed persistent deepening of the upper lid sulcus and relative enophthalmos in eyes previously receiving bimatoprost therapy. These results indicate that the periorbital changes induced by bimatoprost are not reversible.

Doctors and patients should be aware of the potential of bimatoprost to produce periorbital changes, which are irreversible. This is the first case series reporting a poorly recognised side effect of a commonly used topical antihypertensive. More importantly the current conception amongst glaucoma specialists and pharmaceutical companies that these changes are reversible, has not been confirmed.

February 22, 2013 at 10:16 pm

basharmohammed22@hotmail.com

Eye removal is a required competency for UK ophthalmic trainees, but can be a difficult area in which to gain real-life experience. We tested feasibility, acceptability and face validity of a porcine simulation for teaching and OSATS assessment of ophthalmic trainees on ocular evisceration.

Seven trainees participated in the wetlab, supervised by three consultants. After an introductory presentation on eye removal indications and techniques by an oculoplastic consultant, trainees worked in pairs to perform an evisceration each. Commercially available disposable instrument packs were used. Fresh pig’s heads were bisected sagittally. The eyes’ tough nictitating membranes were removed and stay sutures used to improve exposure. A marble was used as a simulated implant delivered via a glove finger introducer. The wetlab cost around fifty pounds per participant, although instruments can be reused in future sessions. Three senior trainees were assessed using the OSATS tool. All participants completed feedback questionnaires.

Every trainee completed an evisceration. All trainees rated the simulation as useful for understanding the technique and improving their confidence in performing the procedure. Some differences were noted between the porcine model and human patients, particularly difficulty in completely removing the uvea, but face validity was rated highly by those with real patient experience. Consultant assessors felt able to evaluate trainees effectively.

A pigs’ head wetlab is a feasible method for teaching evisceration, which trainees valued highly, and provides a practical method to complete a core assessment in the ophthalmic training e-portfolio.

February 23, 2013 at 1:25 pm

limrongxuan@gmail.com

To report a case of anterior orbital cellulitis secondary to an infected scleral buckle developing 20yrs after placement and without frank buckle extrusion

Case report

A 77-year-old man presented with a 2 week history of a red, sore right eye. He was diabetic with treated proliferative diabetic retinopathy and had undergone a right retinal detachment repair with scleral buckling in the 1980s. On examination, he was afebrile. Visual acuities were CF RE (normally 6/36) and 6/9 LE. He had a swollen, ptotic right upper lid and a chemosed, injected conjunctiva, with some mucopurulent discharge. His right extra-ocular movements were markedly restricted but there was no proptosis. A working diagnosis of anterior orbital cellulitis was made and he was commenced on intravenous co-amoxiclav. CT and MRI scans demonstrated soft tissue swelling in the right anterior orbit, close to his scleral buckle, without significant lacrimal gland involvement. There was no posterior orbital extension and his sinuses were clear. A VR opinion did not implicate the buckle due to its longstanding placement and lack of extrusion. A right eye swab grew Pseudomonas aeruginosa. Despite appropriate antibiotics, he developed endopthalmitis with a hypopyon. A tap was performed but no organisms cultured. 7 days after admission, his scleral buckle was removed, which grew Pseudomonas on culture. His symptoms improved

immediately after surgery. Within 1 week, his RE was quiet with full eye movements. 3 months later, his right vision was 6/36 and his retina remained flat.

Scleral buckle infection can lead to an anterior orbital cellulitis, despite a long interval from initial surgery and without frank buckle extrusion

February 23, 2013 at 4:23 pm

elightman@doctors.org.uk

Intraorbital foreign bodies (IOrbFbs) offer a diagnostic and management dilemma to the ophthalmic surgeon. A high index of suspicion is required in any potential penetrating injury, especially high velocity injuries and management needs to be tailored to the individual patient’s case. This study reviews 5 IOrbFb cases along with other published cases, to create a set of criteria for when IOrbFBs are indicated for surgical exploration and removal.

The management of 5 IOrbFb cases which presented to the Royal Hallamshire Hospital in Sheffield over the period of a year (2011-2012) were reviewed and analysed along with a collection of published cases producing a set of criteria for when IOrbFBs are indicated for surgical exploration and removal.

All 5 of the patients underwent a focused examination and CT head, except in the case of a wooden foreign body where the imaging modality of choice is an MRI. The treatments in these patients and the in the literature varied according to the nature and location of the foreign body, associated damage, symptomatology of the patient and potential surgical risks, which are the facets in which the criteria are based.

Evidence based guidelines for which IOrbFBs are indicated for surgical exploration and removal will facilitate good clinic decision making. Increasing awareness of the diagnostic and management issues associated with IOrbFbs amongst ophthalmologists, and use of a multidisciplinary team approach where necessary, will help in better outcomes for similar patients.

February 23, 2013 at 4:26 pm

jooleong919@doctors.org.uk

To examine different treatment modalities for functional epiphora and evaluate the outcomes.

A retrospective interventional case series from a tertiary referral centre.

96 lacrimal systems of 63 patients were included.

All patients had thorough slit lamp examination, lid/punctal assessment, lacrimal sac wash out and endoscopic examination. 16 patients underwent lacrimal scintigraphy. In our group we did not find scintigraphy adding to our clinical decision making.

All patients with signs or symptoms suggestive of ocular surface problems were given clear written instruction on lid hygiene and were prescribed artificial tears and steroid nasal spray.

18 patients (9 unilateral, 9 bilateral) achieved symptomatic improvement following medical treatment alone.

16 lower lid tightening procedures (LTS) were performed of which 12 were successful.

19 external DCRs were performed. 17 were successful.

19 endonasal DCRs alone were performed. 14 experienced symptomatic improvement.

The 5 nasolacrimal duct intubations failed after short initial success.

2 patients declined surgical intervention.

No major complication was observed.

The treatment of functional epiphora should begin with treating potential ocular surface problems and lid laxity. DCR is the commonest lacrimal system procedure which can be effective and safe in experienced hands. Intubation from our study has been shown to be of limited value.

February 23, 2013 at 4:46 pm

drgeorgekalantzis@hotmail.com

Harlequin ichthyosis is an extremelly severe hereditary autosomal recessive skin disorder with remarkable hyperkeratosis and increased formation of epidermal scales giving the appearance of fish skin. Cicatricial ectropion due to excessive dryness of the skin is the most common ocular manifestation resulting in exposure keratopathy. The aim of this study is to present our experience with two children suffering from Harlequin ichthyosis that underwent correction of their cicatricial ectropia.

A retrospective case notes review of two patients with Harlequin ichthyosis.

The first patient (six weeks old) had bilateral upper eyelid cicatricial ectropia which were successfully treated with posterior auricular skin grafts. The second one had severe bilateral upper and lower eyelid cicatricial ectropia with a risk of exposure keratopathy and was treated initially (at the age of 6 months) by two sessions of subcutaneous hyaluronic acid injections (Restylane subQ). After the initial correction of the lids’ malopisition, recurring bilateral ectropia necessitated repeated administration of hyaluronic acid under the eyelids resulting in improvement of ectropion. New recurrence was corrected by the use of skin autografts which resulted in well positioned eyelids and full eyelid closure.

Cicatricial ectropion in Harlequin ichthyosis can be effectively corrected with skin grafts. However, injection of dermal fillers can provide adequate tissue expansion in the early period of a premature baby. This will allow the child to mature in order to make general anaesthesia safer and improve the quality and quantity of skin that should be harvested for grafting.

February 23, 2013 at 6:57 pm

drgeorgekalantzis@hotmail.com

Silicone oil (SO) is commonly used following complicated retinal detachment (RD) surgery. Neurological complications of SO endotamponade are rare.We report a case of cerebral migration of intraocular SO mimicking an orbital mass with posterior cerebral migration.

Observational case report.

A 74-year-old lady presented with a six-month history of chronic headaches and photophobia. She had a history of high myopia with multiple left RD surgery and SO endotamponade 20 years ago. Ophthalmological examination showed a phthisical left eye with a superonasal soft epibulbar mass. Neurological examination was unremarkable. Differential diagnosis included lymphoma, orbital metastases or choroidal melanoma. Computed tomography showed a left globe mass with posterior extension along the optic nerve with intracranial foci. Conjunctival and caruncular biopsy showed reactive lymphoid infiltration with no evidence of lymphoma. Magnetic resonance imaging findings were consistent with migration of intravitreal SO along the ipsilateral optic nerve with subsequent extension to the chiasm and subarachnoid space. The possibility of the SO causing chemical meningitis was raised. However, the patient’s headaches improved without treatment and it was decided not to pursue any further diagnostic work up.

Cerebral migration of intraocular SO may present with headaches due to possible chemical meningitis and can be misdiagnosed as an orbital mass with extraorbital spread or intracranial metastasis.

February 23, 2013 at 7:13 pm

christina.miller@med.uni-muenchen.de

To investigate the incidence of several different types of synkinesis following facial nerve palsy in patients presenting to an Oculoplastics clinic. Synkinesis describes an undesired facial movement accompanying a voluntary movement. It may affect all facial muscle groups following facial nerve palsy.

Patients were observed prospectively using a standardized synkinesis questionnaire. Each patient was instructed to perform intentional movements such as puckering lips, lifting eyebrow, snarl and eyelid closure. Synkinetic movements recorded included chin dents, lifting mouth, platysma contraction and eyelid closure, the latter being the most familiar to ophthalmologists.

The reported incidence of synkinesis post facial palsy varies greatly from 15 to 100% depending on the cohort of patients studied. We present data collected at Southampton Eye Unit to show the high frequency of post facial palsy synkinesis and the varying types of synkinesis encountered.

In post facial nerve palsy patients, the synkinetic movement ophthalmologists are most commonly aware of is eyelid closure. Other sites of synkinetic movements are often under diagnosed in the ophthalmology clinic. The presence of synkinesis may have a distressing effect on facial function, cosmesis and quality of life and early diagnosis combined with rehabilitation may be beneficial. It is therefore important for ophthalmologists to be aware of the frequency of all types of synkinetic movements following facial nerve palsy.

February 23, 2013 at 8:56 pm

chrismclean@nhs.net

A novel conformer shell is described which has been used in cases of evisceration. The shell was comfortable and maintained deep conjunctival fornices allowing the satisfactory fitting of an artificial eye.

FCI hydroxyapatite orbital implants are securely packaged and kept firmly in place by two hemispherical silicone cups. The cups are flexible and match the size of the implant. After the orbital implant was positioned and the conjunctiva closed, one of these silicone cups was then used as a conformer shell to maintain the upper and lower conjunctival fornices. Prior to insertion, a central drainage hole was made in the shell.

The conformer was confortable, and was kept in position for eight weeks until a new artificial eye was available. The cosmetic result after surgery was good.

This easily adapted, comfortable conformer shell provided good conjunctival support which led to a successful result.

February 23, 2013 at 10:09 pm

chrismclean@nhs.net

Dermatoscopy is a valuable technique which aids the diagnosis of a variety of skin lesions. It is often not practical to use a dermatoscope for periocular lesions. We describe a technique of dermatoscopy for periocualr lesions utilising a slit lamp.

A variety of periocular lesions were examined with a slit lamp in combination with a lens and coupling fluid. Details which were not apparent on slit lamp examination became visible with the application of the lens and therefore improved diagnostic accuracy.

A number of different lesions are illustrated with the technique of slit lamp dermatoscopy. This useful method can help to refine the diagnosis of periocular skin lesions.

Slit lamp dermatoscopy is a useful adjunct in the diagnosis of skin lesions without the need for any additional expensive equipment.

February 23, 2013 at 11:13 pm

sjyothi2005@gmail.com

Embolisation of carotid-cavernous fistulas (CCFs) through conventional approach may not be possible at times because of anatomical variations. In these cases the only approach available could be a direct surgical cut down on to the superior ophthalmic vein (SOV) to embolise CCFs. We present a review of 3 cases

All cases had pre op 3D CT scan to visualise the surgical anatomy and were approached through an upper lid skin crease incision just below the superior orbital rim. SOV was isolated and a 16G canula secured with silk. The position confirmed in vascular radiology suite and coils inserted into the fistula

Three female patients (mean age: 72 yr; range: 51-83 yr) have undergone this procedure. The fistulas in two cases were successfully coiled with complete obviation of symptoms and signs. The third case was complicated due to difficulty in canulating a deeply seated SOV and so had to be abandoned and catheterised through the contralateral superior petrosal sinus. Other complications included mild transient paraesthesia, noted in immediate post-op period, and mild lid lag secondary to wound contracture during the follow-up period in the first case. The second case was completely uneventful with good result

In cases where conventional access to the cavernous sinus may not be possible, surgical approach via the superior ophthalmic vein (SOV) provides an alternative route to successfully and safely close a CCF. However, unexpected anatomical variations could also be encountered within the SOV for which the surgeon should be prepared. These were the only 3 cases in the last 10 years suggesting that ophthalmic experience with this procedure is diminishing

February 23, 2013 at 11:43 pm

samuelyslee@gmail.com

Severe congenital ptosis occluding the visual axis requires early surgical intervention to prevent visual compromise (amblyopia). The levator is very dystrophic in such cases, with poor function, and nocturnal and downgaze lagophthalmos.. Brow suspension is the procedure of choice using nylon, prolene or silicone. There is very little in the literature on use of silicone in such cases.

We conducted a retrospective analysis of visual and cosmetic outcomes for infants with congenital ptosis undergoing silicone brow suspension surgery between August 2008 and December 2012. Visual acuity, refraction, palpebral fissure width, lagophthalmos and lid contour were recorded for all cases at presentation, and at 6 weeks and 6 months after surgery.

Lid height and contour were symmetrical in 86% cases at 1 year follow up. Mean duration of nocturnal lagophthalmos with corneal exposure was 3.4 months (SD = 2.59 ) and downgaze lagophthalmos was 3.0 months (SD = 2.33) 2 patients developed brow granuloma over the forehead wound at 2 months and 1 year post-operatively. Both eventually required removal of silicone, but the ptosis recurred in only one of these cases, and underwent further uncomplicated surgery with silicone rods.

Silicone brow suspension surgery is very effective in the management of severe congenital ptosis in infancy, with rapid improvement in amblyopia. The complication rate is low, and lagophthalmos improves rapidly, typically within 3 months.

February 24, 2013 at 12:46 am

deeparathore4@gmail.com

To assess the value of periocular punch biopsy,its diagnostic yield and possible risks of tumour clearance.

Retrospective case note analysis of 269 consecutive patients, who underwent diagnostic periocular punch biopsies from 2005-2012.Patients were split into two groups: Group A with clinically suspected malignancy and Group B with atypical lesions of uncertain aetiology.Punch biopsy specimens were compared with clinical diagnosis and final histology from excision biopsy.

Group A (251) confirmed malignancies in 176 (70%) .Group B (18) confirmed non-malignant lesions in 14 (77.77%).Periocular malignancy was confirmed in 4 (22.2%) from Group B.Clinical characteristics when used alone in diagnosis of suspicious carcinoma had a positive predictive value of 97.77% and a negative predictive value of 15.73%% hence a sensitivity of 70% and a specificity of 77.77%.From final histology of133 paraffin sections,111( 83.5%) had evidence of residual tumour and no residual tumour was seen in 22(16.5%) after initial diagnostic punch biopsy.All Punch biopsy results concurred with histology on excision.Tumour size ranged from 1.5mm-35mm.19.5% of patients with malignant tumours on punch biopsy had a tumour size ≤5mm.Of these 38.5% had no residual tumour and 61.5%had some residual tumour.Unnecessary surgical intervention was avoided in 75(30%) of Group A with a strong clinical suspicion of malignancy.

Diagnostic punch biopsy is valuable prior to suspected tumour excision as it avoids unnecessary surgery in suspicious lesions that turn out to be benign. It also helps in histologically sub-typing malignant lesions as well as providing guidance about the depth of invasion. However there is a risk of clearing the tumour with the punch biopsy.

February 24, 2013 at 1:46 am

kwesi@amissaharthur.com

Long-term use of anti-glaucoma medications has been shown to affect the naso-lacrimal tract. These changes may be associated with the medications themselves, the preservatives, and/or the duration of topical treatment. To date no studies have looked into the effect of topical anti-glaucoma medications on the success rate and survival of Dacryocystorhinostomy (DCR ) surgery.

Retrospective consecutive “single consultant firm” case series from 2006 to 2012.

External DCR surgery was performed in 21 eyes of 20 patients with glaucoma. The mean age was 77±8. There were six males and fourteen females. The mean length of follow up was 22 months (range 0-73). Postoperative sac washout was performed in 14 eyes, of which seven were patent, three were partially patent and four were obstructed. Using patient reported outcome measures 76% of eyes (16/21) had a good improvement of their symptoms and 90% (19/21) had a moderate or good improvement. One eye had a repeat DCR which remains patent.

The effect of topical anti-glaucoma medications on DCR surgery based on our retrospective study involving small numbers reveals a lower objective success rate than is commonly quoted. It appears that DCR surgery in such a select group of patients carries a guarded prognosis, which should be highlighted during the consenting process. It is perhaps necessary to consider adjuvant agents such as mitomycin-C and/or preservative free anti-glaucoma medications postoperatively for this cohort.

February 24, 2013 at 2:34 am

deeparathore4@gmail.com

To report the outcome of an immunocompromised male with invasive sino-orbital aspergillosis.

Clinical, histological, radiological findings and management are presented.

A 39-year-old Asian male diagnosed with T acute lymphoblastic leukemia, achieved complete morphological and immunophenotypic remission following chemotherapy. Soon after, he developed signs of left orbital cellulitis. CT revealed left orbital inflammatory changes with no abscess and opacification of left fronto-ethmoid and maxillary sinuses. Despite antibiotics, orbital inflammation worsened and fungal infection was suspected. He underwent endoscopic drainage of left ethmoid and maxillary antrum and commenced on Amphotericin B. Ethmoid sinus mucosal biopsy showed fungal hyphae elements suspected to be either Mucor or Aspergillus, hence Posaconazole was added. He continued to deteriorate with worsening of orbital signs. Patient was considered for further debridement and removal of eye. However a more conservative decision was made and he underwent left fronto-spheno-ethmoidectomy with medial maxillectomy and removal of fungal ball from the medial orbit not invading periosteum. PCR from sinus drainage confirmed Aspergillus. Following second debridement and systemic antifungal, he had complete resolution of orbital and sinus symptoms with a visual acuity of 6/6.

Invasive aspergillosis in an immunocompromised individual, can cause orbital and intracranial extension associated with rapid and aggressive clinical course resulting in orbital exenteration for control of disease. Our case demonstrates that prompt and repeated aggressive surgical debridement and appropriate systemic antifungal can significantly improve the prognosis thus avoiding the need for orbital exenteration.

February 24, 2013 at 2:50 am

aneesanazreen@yahoo.co.uk

To present the clinical manifestations,radiological features and management of patients with craniofacial fibrous dysplasia involving the orbit.

Retrospective interventional case series of 6 patients who presented to our unit with craniofacial fibrous dysplasia. Main outcome measures included signs and symptoms,radiological features,management and outcome.

Six patients with craniofacial fibrous dysplasia were reviewed. There were 4 females and 2 males. Age at diagnosis ranged from 4 years to 45 years with an average of 12 years. 5 patients had idiopathic fibrous dysplasia and one had McCune Albright’s syndrome.The most common clinical presentation was facial swelling (3) followed by proptosis (2) and bilateral optic atrophy (1).All 5 of them had polyostotic disease.Bilateral lesions occurred in three patients.4 patients had reduced visual acuity due to optic nerve compression,2 patients did not have ocular symptoms. All patients underwent computed tomography.Optic canal involvement was found in 4 patients.The most commonly involved bone was sphenoid (4),skull base (1),while the patient with McCuane Albright syndrome presented with retro bulbar haemorrhage from ophthalmic artery aneurysm.4 patients underwent debulking surgery in conjuction with neurosugeons,2 were managed conservatively.In one patient the disease progressed considerably and required further procedures.There were no postoperative complications in our series.Histology confirmed the diagnosis.

Knowledge of the condition,radiological features and associations of Fibrous dysplasia are important to ensure accurate early diagnosis and appropriate management of this rather difficult to diagnose and manage condition.

February 24, 2013 at 8:17 am

elena.novitskaya@gmail.com

Especially in the era of general practice commissioning, the onus is on GPs to decide which eyelid lesions warrant referral to specialist clinics. Misdiagnosis of eyelid pathology could result in a failure to refer or delay in prioritizing out patient referral. This study compares the diagnostic accuracy of GPs with that of consultant and trainee ophthalmologists.

A prospective study of patients referred by GPs to the oculoplastic clinic with eyelid lesions between October 2011 and January 2013. Only patients requiring a biopsy, following independent diagnoses by a trainee ophthalmologist and a consultant oculoplastic surgeon, were included.

Of the 48 patients studied to date, a GP diagnosis was not indicated in 14 cases (29%). Histopathological findings correlated with the GPs’ diagnosis, trainees’ diagnosis and consultants’ diagnosis in 47%, 83% and 90% respectively. The divergence between the GP diagnosis and ophthalmologists’ diagnosis, when compared with histopathology was highly significant. (p=0.001 and 0.003 for consultants and trainees respectively).

The study revealed a highly significant disagreement between the diagnoses of primary care physicians and ophthalmologists when compared to histopathological findings, with the ophthalmologists demonstrating greater diagnostic accuracy. This highlights the importance of specialist assessment of patients with eyelid neoplasms for accurate diagnosis and appropriate management. Furthermore, in almost 1/3 of cases no preliminary diagnosis was made by the referring GP which results in difficulty prioritizing eyelid lesions, and can result in unnecessary harm.

February 24, 2013 at 10:49 am

a.solebo@ucl.ac.uk

To describe an uncommon but treatable cause of bilateral severe sight threatening keratoconjunctivitis in order to aid future identification of cases

Case report

A 95 year old woman presented with bilateral relapsing chronic purulent conjunctivitis and corneal epitheliopathy despite confirmed organism sensitivity to topical antibiotics. Bilateral peripheral corneal melt and a further right descemetocele developed at which point giant fornix syndrome was diagnosed. Sweeping of the superior and inferior fornices using povidone iodine supplemented by subconjunctival gentamicin and a course of topical antibiotics resulted in prompt and sustained improvement of the purulent conjunctivitis and stabilisation of corneal status.

Giant fornix syndrome is to be considered in cases of bilateral recurrent or relapsing purulent conjunctivitis in the elderly population. Medical treatment may result in improvement, however recurrence or recalcitrant disease may require surgical repair.

February 24, 2013 at 12:52 pm

chrismclean@nhs.net

Cilium incarnatum internum and externum are rare conditions. A case is presented where both conditions are present in the same patient.

A patient presented with discomfort in the right eye. On examination abnormal lashes were seen growing underneath the skin of the rigtht upper eyelid and the right lower eyelid. On everting the right upper eyelid several lashes were seen to be growing through from the conjunctival surface of the right upper eyelid and were abrading the cornea.

The abnormal conjunctival lashes were epilated which provided immediate relief. The multiple abnormal lashes underneath the skin of both the right upper and lower lids were left in situ as they were not associated with any discomfort, inflammation or infection. The patient continues to be followed up.

Cases of cilium incarnatum are rare, and usually involve a single abnormal eyelash. This case is unique in that both cilium incarnatum internum and externum were present together and multiple eyelasahes were involved.

February 24, 2013 at 2:07 pm

hnaveed660@gmail.com

Currently, deep lateral orbital wall decompression is the favoured procedure for Graves orbitopathy due to its effectiveness and safety. In light of this, we present a radiological study identifying the volume and geometrical relationships of the deep lateral orbital wall with respect to fixed orbital landmarks.

36 normal orbits from 18 Caucasian patients, aged 19-88years (mean:55years), were retrospectively analysed using 0.75mm CT reconstructions. The axial plane was standardised using the thickest section of the lateral rectus muscle in line with the planum sphenoidale. The geometric position of the posterior border of the lateral wall was recorded with respect to the orbital rim, sagittal midline and posterior aspect of the globe. Coronal sections were used to measure horizontal and vertical thickness of the lateral orbital wall at 3 points along its length in reference to the lateral rectus muscle. The combined mean measurements were used to generate 3D volumetric and geometric models.

Mean distances between the posterior border of the lateral wall in relation to the orbital rim and posterior globe were 31.4mm(σ=3.78) and 17.1mm(σ=4.32) respectively. Mean angle of the lateral orbital wall was 42°(σ=7.04) with respect to the midline. Average thickness of the lateral orbital wall was 2.65mm(σ=1.12) anteriorly, 3.66mm(σ=1.40) centrally and 8.65mm(σ=3.08) posteriorly. The trigone was noted to have the greatest volume along the lateral wall.

We have described the volume and geometrical relationships of the deep lateral orbital wall in a Caucasian population which can be used with radiology to plan lateral approaches to decompression surgery and as an intraoperative navigational aid.

February 24, 2013 at 2:57 pm

aneesanazreen@yahoo.co.uk

To share the experience of this challenging group of patients with reduced or poor response to repeated botulinum toxin injections for blepharospasm and apraxia of the lid.

A retrospective interventional case series of 10 patients who underwent surgeries for blepharospasm in whom response to botulinum toxin injections were inadequate. We evaluated the long-term results, complication rates and patient acceptance of this intervention

10 patients underwent surgical procedures for blepharospasm of which 7 were males. The mean age at the time of surgery was 63years. All of them except one patient were treated with botulinum toxin injections previously with no improvement even after increasing the dose of toxin. The average interval between the initial injection and surgery was 12 months. All had bilateral procedures. 8 patients had orbicularis stripping, 1 patient had mersilene mesh brow suspension and another patient had a brow lift. 7 patients required additional surgeries and further toxin treatment. 3 patients experienced immediate improvement not requiring further injections. 4 patients noted the enhanced effect of subsequent botulinum toxin injections which was previously ineffective. Time from surgery to treatment with toxin varied considerably.

Blepharospasm resistant to botulinum toxin is a challenging clinical problem.This subgroup of patients did well eventually with the surgical procedures.

February 24, 2013 at 3:51 pm

aneesanazreen@yahoo.co.uk

Is to analyse the effectiveness of botulinum toxin injection in treating periocular spasms.

A 10 year retrospective case notes review of 168 patients who received botulinum toxin injection for periocular spasm. They were evaluated based on indications,ocular complaints,treatment outcomes and complications.

One hundred and sixty eight patients received botulinium toxin injection for periocular spasm of which 84(50 %)had essential blepharospasm,38 (27%) had hemifacial spasm,41 (24%)had facial palsy with aberrant reinnervation including iatrogenic causes,4 (2%) apraxia of the eyelid opening and 1(0.5%)other causes.The age group ranged from 28 to 90 years with the mean age of 62 years.57% (95) of females and 43% (73)of males received toxin.All patients underwent thorough ophthalmic examination to exclude ocular surface diseases.Patients with hemifacial spasm were investigated with MRI brain to rule out vascular loop and cerebropontine angle lesions prior to injection. Dose varied between 2.5U to 5U.The majority of patients received injection to 2 lids 57% (96) followed by 4 lids 33% (56) and 7% (12) lacrimal gland;however 2.3%(4) declined treatment.Muscle spasm reduced significantly within 2 days of the first injection and effect lasted for 10 to 12 weeks.96% of patients had regular injections every 3 months.Complications related to the treatment included transient ptosis 1%(2), diplopia 0.5% (1)and watering 0.5% (1).One patient needed surgical correction for toxin induced ptosis. 6%(10)patients who were unresponsive to botulinum toxin underwent orbicularis stripping(8) and frontalis brow suspension(2).

Treatment with botulinum toxin was effective in periocular spasm, with very low complication rates.

February 24, 2013 at 4:03 pm

alihassan@nhs.net

To highlight a rare case of a 32-year-old male with groin and axillary hidradenitis suppurativa who developed a painful nodule in the left medial canthus and secondary lacrimal abscess.

Case note review of the clinical history, examination, results of investigations and detail of medical and surgical management. Pre-operative, intra-operative and post-operative photographs are included.

The patient presented with a painful firm, erythematous, subcutaneous mass in the left medial canthus. At presentation there was a mildly elevated white cell count of 12.4. Initial management involved IV antibiotics and steroid.

MRI showed a defined ring enhancing lesion, anterior to the orbital septum within the subcutaneous fat. Mucosal thickening within the left maxillary sinus and ethmoidal air complexes was noted.

The patient underwent surgical exploration. He was found to have a cutaneous fistula which tracked through the left obicularis oculi into the medial canthal tendon and into the left lacrimal sac. Another fistula connected the lacrimal sac to adjacent structure and the lacrimal bone was found to be eroded. The procedure involved excision of a subcutaneous deep-seated nodule, marsupialisation of the infected communicating sinus tracts and drainage of a lacrimal sac abscess as part of an external dacryocystorhinostomy with silicone tubes.

Hidradenitis suppurative is a skin disease that results in chronic infection of the apocrine sweat glands, typically affecting the axilla and groin. Facial involvement has been documented but it is rare to develop periorbital lesions. Our case highlights a superficial appearing nodule which had involved several underlying adnexal structures.

February 24, 2013 at 5:33 pm

csn_chia@yahoo.co.uk

To compare the outcomes of two methods of correcting horizontal lid laxity, lateral wedge excision (LWE) versus lateral tarsal strip (LTS), for treatment of functional epiphora.

Retrospective review of all patients who underwent lower lid tightening procedures indicated for functional epiphora between January 2010 to December 2012. Functional epiphora was primarily defined as tearing in the presence of patent nasolacrimal duct on syringing. Patients with lid problems (floppy eyelids, ectropion, entropion, facial nerve palsy) and hypersecretion were excluded.

A total of 55 procedures were performed in 45 patients (mean age 68 years, 56% males). There were 17 LWE and 38 LTS. Overall, significant improvement of epiphora was subjectively reported by patients in 6 out of 17 (35%) cases of LWE compared to 21 out of 38 (55%) cases of LTS (p=0.33, Chi-squared test). Complete resolution was achieved in 4 cases of LTS but only 1 case in LWE. This one case subsequently had recurrent epiphora. Further procedures were required in 7 out of 17 (41%) cases of LWE compared to 9 out of 38 (24%) cases of LTS, and this was statistically significant (p=0.03, Chi-squared test). However, there were more complications related to pain and sutures with LTS (n=8, 21%) compared to LWE (n=1, 6%). The complications were transient.

This study confirms our clinical impression of 50% success rates of improving and/or resolving functional epiphora by correcting horizontal lid laxity. LTS may provide better outcomes although there is transient post-operative discomfort.

February 24, 2013 at 6:05 pm

rynn.lee@gmail.com

The majority of congenital dacryoceles will resolve with massage of the swollen lacrimal sac with some requiring surgical intervention. We investigate our outcomes of surgical intervention of this condition.

Three neonates presented with unilateral dacryoceles. Conservative treatment in the form of massage resulted in the resolution of one case, two cases required endoscopic marsupialisation of the nasal cyst under general anaesthesia.

Conservative treatment resulted in resolution of one case, the other two resolved immediately with endonasal marsupialisation of the nasal cysts.

Simple endonasal marsupialisation of nasal cysts resolves dacryoceles with immediate resolution of symptoms. Timely treatment of congenital dacryoceles is important as respiratory distress can develop especially in untreated bilateral cases.

February 24, 2013 at 6:12 pm

rynn.lee@gmail.com

Idiopathic orbital inflammation is a rare paediatric condition, often requiring systemic immunosuppression for a prolonged period of time. We investigate the use of intravenous methyl-prednisolone in the treatment of this condition as an alternative to immunosuppression.

Case review of two cases of idiopathic orbital inflammation that were successfully treated with a course of intravenous methyl-prednisolone over a period of 6 months to 1 year.

The two cases were treated successfully with 4 to 6 weekly courses of intravenous methyl-prednisolone over 6 to 12 months, with resolution of symptoms.

These two cases demonstrate that the condition can be successfully treated with intravenous methyl-prednisolone, without the side effects of weekly immunosuppression.

February 24, 2013 at 6:17 pm

rynn.lee@gmail.com

To demonstrate the use of dacryocystography and the Ritleng monocanalicular intubation system in the management of congenital nasolacrimal duct obstruction with a lacrimal sac fistulae.

Case report of management of 4 eyes of 2 children with nasolacrimal duct obstruction with a lacrimal sac fistulae. Dacryocystography was used to identify the location of the lacrimal sac fistulae as well as the site of nasolacrimal duct obstruction. Following probing, the fistulae were excised and the dacryocystography repeated to rule out regurgitation through the fistulous tract. The nasolacrimal system was then intubated with a monocanalicular silicone stent (Ritleng stent), which was removed 3 months post operatively.

The Ritleng intubation system was used successfully following lacrimal sac fistulectomy in all 4 eyes. Both children did not require further surgery and have remained symptom free. The fluorescein dye disappearance test (FDDT) was negative post operatively.

The authors found the Ritleng intubation system to be easy to introduce during surgery and easy to remove in clinic without anaesthesia. Dacryocystography helped locate the site of the fistula, the site of the NLDO, and to confirm adequate closure of the fistulous tract intraoperatively.

February 24, 2013 at 6:23 pm

diptitrivedi1980@gmail.com

Congenital anophthalmia and post enucleation socket contracture are difficult to manage and require serial socket expansion. This is often addressed with use of hydrogel expanders and custom made conformers combined with temporary suture tarsorrhaphy allowing expansion in the required direction by creating a closed space.

We report a series of 7 children undergoing temporary cyano-acrylate glue tarsorrhaphy instead of the conventional suturing technique.

We undertook a retrospective case series of all children undergoing temporary tarsorrhaphy using the cyanoacrylate glue technique from January 2010 to January 2013 at the Birmingham Children’s Hospital. We reviewed case notes specifically looking at age of the child at first glue application, underlying diagnosis, indications for treatment, number and timing of reapplication of glue, procedure setting and complications.

The underlying diagnosis was post enucleation socket following retinoblastoma (3 patients), anophthalmia (3 patients) and 1 post exenteration socket following medulloepithelioma. The age range was 3 weeks to 14 years.

Indications were socket expansion (4 patients), forniceal lengthening (2 patients) and to reposition the prosthesis and prolapsed conjunctiva following enucleation.

The first visit post op ranged from 2.5 weeks to 2.5 months, with an average of 4.5 weeks. Subsequent visits ranged from 3 days to 13 weeks with mean of 4 weeks and median of 3.5 weeks. There were a total of 33 episodes of reapplication of glue ranging from 5 days from first application to 12 weeks. 2 patients required only the initial application. There were 2 episodes that required additional gluing due to child picking at glue. One patient required 18 episodes of regluing, during serial socket expansion. There were no adverse outcomes and all tolerated the glue well.

Our study demonstrates that this technique allows quick and efficient temporary tarsorrhaphy with relative ease of reapplication in a clinic setting, avoiding the need for multiple general anaesthetics.

February 24, 2013 at 6:24 pm

andre@doctors.org.uk

Approximately half of all patients with myasthenia gravis (MG) first present to an Ophthalmologist, with ptosis and diplopia being the most common complaints. Medical management remains the first line of therapy but in up to a third, ptosis surgery is appropriate. The published evidence for clinicians managing this group is scanty; the previous largest series described only 10 patients. We report a large series of experience for ptosis surgery in patients with MG.

Retrospective review of eighteen patients (with a further eight awaited), who were symptomatic despite medical treatment undergoing eyelid surgery between 1992-2012. Outcome measures included improvement in lid height, length of success, need for further procedures and complications.

Eighteen patients with MG underwent 39 eyelid procedures. The mean age at surgery was 59 years (range 8-75 years) and mean follow-up 32 months (range 3-112 months). 9/18 patients had ocular MG, 8/18 systemic and 1/18 congenital systemic MG. 12 patients underwent ptosis surgery, with 7 undergoing bilateral procedures, resulting in 19 primary procedures. 11/19 were anterior approach levator advancements, 3/19 posterior approach, 3/19 brow suspensions and 2/19 tarsal switch procedures. Postoperative symptoms or signs of exposure keratopathy occurred in 3 patients, necessitating eyelid lowering in 1 eyelid of 1 patient. 12/19 eyelids operated upon required further lid heightening surgery, after an average of 27 months (range 0.5-87 months).

Ptosis surgery can achieve eyelid elevation in patients with MG with only a low risk of exposure keratopathy as long as the aims of surgery are carefully addressed. This approach necessitates repeat surgeries in a large proportion of patients.

February 24, 2013 at 6:27 pm

andre@doctors.org.uk

Ichthyosis is a group of hereditary conditions in which ectropion develops because of skin contracture. Secondary lagophthalmos is a challenging problem that presents to the Oculoplastic Surgeon with only a limited number of reports on its management. We report a case of sight-threatening bilateral upper and lower eyelid retraction and cicatricial ectropion managed non-surgically with hyaluronic acid with detailed photographic description of technique.

Injections were performed under general anaesthesia. Restylane Lidocaine (Q-Med UK) hyaluronic acid gel was injected via multiple small puncture sites. The upper eyelid was initially injected above the superior border of the tarsal plate in a sub-orbicularis plane, with subsequent injection into a deeper preaponeurotic plane. The lower eyelid was then injected, initially below the inferior border of the tarsal plate in the same multi-plane levels extending as deep as the lower eyelid retractors (effectively acting as a spacer). The end point was elevation of the lower eyelid with resolution of lagophthalmos. A total of 1cc was injected into each eyelid.

A 3-year-old boy with congenital ichthyosis and a history of two failed corneal grafts in the left eye due to eyelid retraction leading to perforation 6 months earlier was treated. At presentation, visual acuity was 4/60 and HM with significant lagophthalmos on closure (4-5 mm). A left penetrating keratoplasty was performed and four weeks later, he successfully underwent tissue expansion as described. At his most recent visit visual acuity was 6/15 in each eye.

Injectable hyaluronic acid gel can be a quick, safe, repeatable and reversible method of eyelid expansion and alternative to skin grafts in ichthyosis.

February 24, 2013 at 6:38 pm

andre@doctors.org.uk

Basal cell carcinoma (BCC) is an extremely common malignancy. We present two cases of advanced BCC on the eyelids that metastasized to the parotid region after local excision and review the literature.

A 68-year-old male presented with a neglected BCC at the left lateral canthus. Following wide exenteration, his post-operative MRI showed no residual disease. A year later, he developed a mandibular mass confirmed histologically to be infiltrative BCC after radical parotidectomy.

An 86-year-old male presented 3 years after an incompletely excised lateral canthal BCC with recurrence and a pre-auricular mass. He underwent Mohs surgery with adjuvant radiotherapy to the lateral orbital wall. A partial parotidectomy confirmed BCC infiltration into the gland.

BCC metastasis is thought to occur more commonly in younger patients (average onset 45 years), with a protracted course of 9-18 years between onset and distant spread. A rarer subgroup has been proposed with a smaller primary tumour and an unpredictable time until metastasis. Metastasis of BCC from the mid-face has been reported in a series of exenterations from the Mayo clinic in 1989 and from the eyelid in 1995. Reviewing the literature since that publication there are at least 6 other reports of metastasis from eyelid tumours, 5 of which occurred after orbital exenteration. The average age of these cases with details of our 2 patients, suggest that this occurs in an older age group (mean onset age 67 years) with a much shorter time before metastasis (5 years).

We suggest that metastatic BCC from periocular lesions appears to affect an older age group than previously described with a shorter duration before distant spread.

February 24, 2013 at 6:46 pm

andre@doctors.org.uk

Operating theatre utilisation has become the principal measure of NHS operating theatre service performance. We look at how Oculoplastic Surgeons compare to other Surgeons and if there is an argument that a whole day operating is more efficient than two half-days.

The study covered all elective day case and inpatient operations performed at an Oculoplastic Tertiary Referral Centre between 2010-2013 under the supervision of a single Consultant. Prospectively entered data relating to the time patients were sent for, arrival time in theatre, anaesthetic time, first cut and closure were retrieved from the hospital database. Procedure durations were calculated through subtraction of the recorded time when anaesthetic administration was commenced to the time of closure at the end of the procedure. Operating list utilisation rates were the principal study outcome measure. This was calculated through division of the sum of total list procedure time by the allocated session duration.

The Audit Commission reported that Trust average theatre utilisation is 73%. We found at our Trust, the mean theatre list utilisation rate during the study period was 85%, with a significant difference found between half and whole day theatre sessions (p < 0.01). The figure is higher than the suggested optimal ‘end utilisation’ performance target of 77%.

Our results, despite pertaining to a single centre will be of relevance to other units and should provide evidence for service delivery and efficiency planning. This could also serve as a benchmark to compare theatre efficiency in other units.

February 24, 2013 at 6:50 pm

alihassan@nhs.net

To highlight two cases of previously undiagnosed Hereditary Haemorrhagic Telangiectasia (HHT) with ocular adnexal involvement. In the first case a 60-year-old female developed epistaxis following lacrimal probing and irrigation. In second case 68-year old female presented with bleeding from her right eye and was found to have subtarsal telangiectasia.

Case note reviews of the history, examination and clinical course in each case.

Case 1 – A 60-year-old female presented with epiphora. Past medical history was significant for previous GI bleeding (unknown cause) Eye examination was unremarkable. She underwent probing and irrigation of the nasolacrimal system, which resulted in massive epistaxis requiring nasal packing. Following this she was diagnosed with HHT.

Case 2 – A 68-year old female presented with recurrent bleeding from her right eye. Past history of epistaxis and anemia. On examination she appeared pale, eversion of her right upper eyelid revealed telangiectasia. Inspection of the face revealed violet blood vessels on her lower lip and telangiectasia of the tongue and soft palate. Appropriate referral for further management was made.

HHT is a rare hereditary vascular dysplasia which causes blood vessel walls weakening. the condition is characterised by telangiectasia which prone to rupture and bleed.

Both cases remind to ask epistaxis and bleeding tendencies history and to carefully inspect of the face, lips, tongue, and hands if we suspect HHT. Lacrimal probing and irrigation should be avoided until appropriate investigations have been carried out if the condition is suspected.

February 24, 2013 at 7:10 pm

imranjawaid000@hotmail.com

Congenital ptosis can lead to deprivation amblyopia and in bilateral cases can lead to abnormal head posture. Further, there is a significant negative psychological consequence associated with ptosis.

Repair of congenital ptosis is challenging and several surgical procedures are documented. These include autogenous fascia lata, silicone band, polytetrafluoroethylene, 4-0 Nylon, mersilene mesh and others.

An alternative is Supramid suture. Supramid is a non-absorbable monofilament suture.

We present a retrospective analysis of a series of 20 eyes with congenital ptosis. These patents had correction of their ptosis with either Supramid suture (9 eyes) or autogenous fascia lata (11 eyes). All patients under the age of 4 had surgical correction with Supramid sutures. There was a minimum of 6 months follow up.

Our results show a sustained increase in the palpebral aperture and good contour of the lid with excellent patient satisfaction in both groups of patients.

There were 2 incidences of recurrence in the Supramid group. One occurred at 2 months because of a slipped suture and another occurred at 18 months due to a traumatic injury causing suture rupture. Both of these cases underwent repeat procedures with uneventful outcomes.

Autogenous fascia lata is well described to allow a very predictable outcome and patient satisfaction in the older paediatric age group. However, Supramid suture is an effective treatment for congenital ptosis in the under 4 year age group where fascia lata is not readily harvestable. It also has the advantages of coming pre-loaded. A randomised controlled trial is needed in order to determine the most effective procedure in this age group.

February 24, 2013 at 7:20 pm

poitelea.c@gmail.com

The dynamics of the blink reflex are poorly understood. Our project aims to characterise blink kinematics using ultra-high frame rate video capture and to evaluate this method with respect to other techniques

25 healthy volunteers (11 males and 14 females) participated in this study. The motion of the voluntary blink was recorded at 600 frames per second rate. The palpebral aperture was measured every 5 ms of the recorded videos. Palpebral aperture values were plotted as a function of time and the corresponding blinking speed was determined by calculating the gradient on each consecutive pair of aperture points. Once all the blinking speed values were measured, they were averaged at each time point in order to produce a master curve. The peak speed was taken to be the maximum speed calculated and the average speed was evaluated by dividing the initial palpebral aperture by the time taken for closing or opening.

The palpebral aperture measurements ranged from 7.4 to 12.8 mm (mean of 9.8 mm). One voluntary blink could be divided into four phases;:closing, closed, early-opening and late-opening. The typical blink duration was 600 ms. Opening and closing phases exhibited different characteristics: much faster closing action compared with opening. The peak speed was 250 mm/s and 160 mm/s during closing- and opening-phase, respectively. The closed-phase and the late opening-phase took the shortest and longest time, respectively.

Comparing the results in the present study with other reported findings demonstrates that high-speed camera technique provides highly reliable results and its advantages over the other techniques can make it a more reliable method to investigate the kinematics of human blinking.

February 24, 2013 at 8:12 pm

haziqc@gmail.com

To describe patient demographic, mechanism, location and severity of injury, seniority of surgeon and timing of Mini-Monoka extrusion/removal to determine their relationship with long-term canalicular laceration survival outcomes based on symptoms in a large case series.

A cross sectional case study was conducted based on a series of consecutive canalicular laceration repairs presenting to an ophthalmic tertiary centre between September 2009-2012. Epidemiological, demographic and details surrounding the trauma/surgery, with rates of postoperative epiphora following Mini-Monoka stent extrusion were analysed. Symptomatic outcomes were explored via telephone interview.

Thirty-nine patients underwent canalicular laceration repair with Mini-Monoka stents. Failures were noted in 4 (10.2%) patients, all of which occurred within the first 7 months and were injuries that were limited to the lid only in terms of associated ocular trauma. Three were lower canalicular and one bicanalicular with two involving the central third and one medial and lateral third of the canaliculus anatomically. There was a 3:1 sharp to blunt trauma and Fellow to Consultant surgeon ratio. Trauma to surgery time was within a day for 3 cases and at 2 days in the fourth patient. Stent removal was at 5,12 and 16 weeks with one self-extrusion at 2 weeks. A Kaplan Meier survival analysis confirms that failures ocurred in the early postoperative period.

Postoperative failure is an early complication of Mini-Monoka canalicular repair with a frequency of 10%. It is more common in sharp trauma and junior surgeons but appears to be independent of anatomical location, timing of surgery after trauma and post-operative stent removal.

February 24, 2013 at 9:54 pm

lngai@nhs.net

Lacrimal gland cysts are uncommon and rarely become infected or inflamed. We present a case report of recurrent inflammation of a lacrimal cyst mimicking and initially treated as orbital cellulitis.

Patient case history is presented, including CT, B-scans and histology, and relevant literature is reviewed.

A 29-year old Nigerian student attended eye casualty with three episodes of painful, chemosed right eye with restricted eye movements. Exophthalmometry, vision and pupils were normal. These episodes were treated as recurrent orbital cellulitis and appeared to respond to antibiotics, but he was referred to the oculoplastic service due to the atypical recurrent presentations. Clinical examination after resolution of the acute episode suggested a mass in the lateral orbit. B-scan showed a fluid-filled cyst and CT confirmed a cystic mass measuring 11 X 16 X 13 mm, arising adjacent to the inferior border of the mildly enlarged lacrimal gland and extending along the lateral orbital wall. The cyst was excised via anterior orbitotomy and contained clear fluid. Surgery was curative and histology revealed the lesion to be a lacrimal gland cyst.

This is the first case to our knowledge of a lacrimal cyst presenting with recurrent episodes of infection or inflammation. Differential diagnoses included ruptured dermoid, bacterial abscess or larval cyst. Dacryops typically present as non-tender, lateral lid swelling with translucent cysts arising from the superotemporal orbit. Examples arising deeper within the orbit can be difficult to diagnose clinically, and can cause proptosis and globe displacement. Sonography and imaging aid diagnosis and excision in such cases.

February 24, 2013 at 10:24 pm

mike@mikewearne.com

To present a new algorithm for the diagnosis and management of periorbital dermatoses, including an update on modern treatment strategies.

Review of the current literature, clinical examples and development of a step-by-step clinical tool for patients presenting with periorbital skin disease.

A wide range of cutaneous dermatoses are seen by ophthalmologists including numerous types of contact dermatitis, atopic eczema, rosacea and psoriasis vulgaris. A variety of clinical appearances can make the aetiology challenging. Close attention to skin morphology including scale, induration, papules, pustules and vesicles is essential to allow for accurate diagnosis and successful treatment.

An algorithm, based on the clinical phenotype, provides a structured approach for the assessment of patients presenting with periorbital skin problems. It can aid accurate diagnosis resulting in appropriate investigations and the formulation of a suitable management plan.

February 24, 2013 at 10:36 pm

devonshire.eye@gmail.com

This is a video demonstration on the process of importing, tagging and organizing digital images

A Canon EOS 60D digital single lens reflex camera and a 60mm macro lens are used to capture the photographs. The images are imported into the computer using Adobe Lightroom 3 software where files are renamed according to a standardized convention and stored in folders. The folders are arranged chronologically on the hard drive. The images are tagged with diagnosis and other keywords to facilitate retrieval at a later date. The digital images are encrypted using Trucrypt software and backed up in multiple hard drives.

Digital images are shown to be organized in chronological folders. The file names renamed in a specific convention and specific keywords are added to the metadata of the image files. The files are backed up after being encrypted in Trucrypt which is an open source encryption software.

Clinical images captured on a camera can be organized into a database and secured in line with the requirements of data protection act.

February 24, 2013 at 11:10 pm

devonshire.eye@gmail.com

The purpose of this study is to evaluate the consent process for clinical photography

Informed written consent is obtained by one of the authors (CO) before clinical photographs are taken. The photographs are used for teaching, research, and publication. The consent form contains tick boxes to allow patients to specify how the photographs may be used. The options are 1. Teaching 2. Teaching at conferences 3. Research 4. Publication in medical journals 5. Publication in patient information leaflet and 6. Publication to the Internet. We retrospectively reviewed signed consent forms from march 2012 to September 2012. The information was entered into Microsoft Excel for analysis.

A total of 114 patients gave their consent for clinical photography. There was no patient refusing photography. 98 patients (86%) gave full consent; 9 patients (7.9%) refused all forms of publication of their images but gave consent for their photographs to be used for teaching and research purposes. 6 patients (5%) declined consent for online publication only but freely consented for teaching, conference and other forms of publications. Only 1 patient refused consent for their images to be published in patient information leaflet.

Patients are generally happy for their photographs to be taken for teaching and research purposes. However, it is important to specify the purpose of the photography as there are significant number of patients who may not give full consent.

February 24, 2013 at 11:18 pm

chrismclean@nhs.net

A case of recurrent upper eyelid eversion in a child is described. A 9 year old boy presented with a completely everted left upper eyelid, with grossly swollen, palpebral conjunctiva. He had learning difficulties and his parents described how he would often rub his upper eyelids vigorously, something which they had tried to prevent him from doing. He had suffered a similar episode of left upper eyelid eversion two years earlier.

Due to the severity of the conjunctival swelling the child was admitted for observation and treated with regular Maxitrol ointment. An attempt was made to try to tape down the left upper eyelid but the child would not comply with this treatment. The following day there was no visible improvement in the conjunctival swelling and the lid was still completely everted. After 24 hours, the treatment was changed to topical adrenaline 1 in 1,000. The adrenaline was dripped onto a small gauze swab and this was applied to the conjunctiva for 1-2 minutes.

Within 2 hours there was a dramatic improvement in the degree of conjunctival swelling, and by four hours the left upper lid had started to invert. The following morning, the upper lid was in normal position, and these was only a small degree of residual conjunctival injection.

A case of childhood upper eyelid eversion is reported, which was unresponsive to the standard treatment of regular lubricating ointment. The use of topical adrenaline is described, which resulted in a dramtic improvement in the condition.

February 24, 2013 at 11:36 pm

srigore@gmail.com

Understanding variations in lacrimal and nasal bony anatomy are important when planning dacyrocystorhinostomy surgery. This pilot study seeks to identify associations between anatomical features of lacrimal sac fossa and nasal anatomy, and compare these structures between racial groups.

Retrospective comparative observational case series.

High-resolution computerized tomography scans were reconstructed to obtain 0.75mm coronal and axial sections for measurements of the lacrimal sac fossa and nasal anatomy. Thickness and proportions of maxillary and lacrimal bones in the fossa were measured at three levels: upper, middle and lower. Nasal bridge height and maximal nasal bone length were also measured. Observers were blinded to patient race. Statistical tests: Mann-Whitney U and Spearman rank coefficient.

60 orbits of 60 patients were included (39 right, 31 left; 41 Caucasians, 19 black). Only normal orbits were included. Upper level maxillary bone thickness was thicker (p=0.016) and constituted a greater portion of the lacrimal sac fossa than the lower level (p= 0.002); lacrimal bone thickness was not significantly different at different levels (p=0.1). Nasal bridge height was weakly inversely correlated to the upper slice maxillary and lacrimal bone thickness (Spearman rank coefficient -0.47). We additionally identified significant ethnic differences in nasal bridge height (p=0.015) and maxillary bone thickness (p=0.03).

The negative correlation between nasal bridge height and maxillary bone thickness in the upper level lacrimal sac fossa trended towards significance. Differences in lacrimal sac fossa and nasal anatomy were identified between racial groups.

February 24, 2013 at 11:49 pm

manassesdt@hotmail.com

To describe a case series of patients with an orbital mass diagnosed histologically as a solitary fibrous tumour (SFT) of the orbit.

A case series and literature search.

Prior to 2003 there were 42 published cases of SFT of the orbit. Due to improvements in immunohistochemical diagnosis, the rate of published cases has increased in recent years. The most common postulated diagnoses prior to histological examination are hemangioperictyoma, fibrous histiocytoma, cavernous haemangioma, neurofibroma, schwannoma and optic nerve sheath meningioma.

Solitary fibrous tumour of the orbit should no longer be considered a rare diagnosis. It should be considered in the differential diagnosis of orbital tumours that are presumed to be benign, both because of the potential for recurrence and metastasis, and due to the need for immunohistochemical staining to differentiate it from potentially malignant tumours such as haemangioperictyoma

February 24, 2013 at 11:55 pm

manassesdt@hotmail.com

To illustrate how squamous cell carcinoma (SCC) can masquerade as a typical history of sinusitis and to describe the features that can help to prevent the diagnosis being missed.

A case series and literature search.

We present three cases of SCC, initially diagnosed and treated as sinusitis, which contributed to a delay in diagnosis. We illustrate the clinical features in our cases and those in the published literature that can increase the index of suspicion.

A CT scan should be considered in recurrent sinusitis, as a plain radiograph can be unhelpful in differentiating sinusitis from sinonasal tumours. Clinical features such as facial paraesthesia, anosmia, cranial neuropathy, intractable pain and proptosis warrant urgent investigation.

February 25, 2013 at 12:02 am

andre@doctors.org.uk

Dog bites are a frequent cause of facial injuries in both children and adults. The management of bite wounds is controversial and current data on infection risk is inconsistent.

The authors assess the approaches to the immediate repair of facial dog bites referred to a tertiary referral centre over a 10-year period, between 2002 and 2012. A series of 66 patients with periocullar and facial dog bites required surgical intervention during this period.

The majority of patients were children, with a mean age of 15 years. 53% were male. Irrigation of wounds was always performed and parenteral antibiotic therapy (Co-Amoxiclav unless there was a known allergy to penicillin) was used to avoid infection. One case of postoperative wound infection was noted. Special attention has been attached to the functional and aesthetic outcome. Two surgical revisions were required because of scarring and in most cases, we saw good-to-excellent results.

The aim of immediate surgical repair is to obtain a satisfactory cosmetic result and to avoid infection. Good cosmetic results with a minimal risk of wound infection (1 cheek wound infection) can be achieved when clear principles are adhered to.

February 25, 2013 at 8:30 am

agoawalla@gmail.com

To present three cases of low grade unilateral acute orbital inflammation affecting localised muscle complexes in patients who were euthyroid at presentation but subsequently developed thyrotoxicosis.

Three euthyroid patients presented with vertical diplopia due to idiopathic orbital inflammation involving the levator complex or inferior rectus muscles were monitored for thyroid dysfunction.

In all three cases, the patients presented with vertical diplopia due to unilateral inflammatory enlargement of extraocular muscles. All three had negative results on blood tests for thyroid autoantibodies at presentation. Biopsies of enlarged muscle in all three cases showed inflammatory infiltrate, confirmed by immune-histo-chemical analysis. The delay until development of thyroxicosis ranged from three years to 15 years after initial presentation with orbital inflammation. All three patients only became positive for thyroid stimulating hormone receptor (TSHR) antibodies after becoming hyperthyroid and two out of three then developed more typical Graves’ orbitopathy.

This case series of orbital inflammation highlights the need to monitor such patients’ thyroid function and thyroid autoantibody status even if they are euthyroid and negative for TSHR and thyroid peroxidase antibodies at first presentation. This clinical picture could represent a subset of Graves’ orbitopathy in which the pathogenesis relates to an as yet unrecognized antibody. Similar disease affecting the horizontal recti may not present clinically because of greater horizontal than vertical fusional range.

February 25, 2013 at 9:09 am

christina.miller@med.uni-muenchen.de

A case report of a rare, aggressive and malignant orbital tumour.

A 67-year old male patient presented with a 6-months history of a progressive non-painful proptosis and increasing diplopia.

Examination revealed a decreased visual acuity of 20/10 with a relative afferent pupillary defect. The ocular movement was constricted in upgaze. Slit lamp examination only showed an injected conjuntiva, the optic disc was normal. Computer tomography demonstrated a hypodense extraconal oval shaped lesion localized in the superomedial quadrant of the orbit extending into the apex mimicking a mucocele with similar Hounsfield Units.

We present the first case of a pleomorphic orbital liposarcoma that resolved under extensive surgery, adjuvant chemotherapy and radiotherapy. No recurrence was observed for 18 months following our treatment plan.

Liposarcoma of the orbit is – unlike other locations – an extremely rare malignancy. To the date, only 4 cases of pleomorphic primary orbital liposarcoma have been described. The prognostic factor is depending on tumour size, location, morphologic type, histologic grade and adequacy of initial therapy. Because of the tumour location and its invasive growth pattern, complete resection is mostly not possible. Incomplete surgical management of these tumours is the reason for a high recurrence rate and a low survival time.

To the date, the optimal treatment of these tumours, especially when involving rare sites like the orbit, is very controversial. A multidisciplinary approach of orbital liposarcomas is unevitable to avoid further progression of the disease.

February 25, 2013 at 11:16 am

manosira@doctors.net.uk

To describe a technique for correcting lower eyelid punctal ectropion with an inferiorly displaced or retracted medial eyelid due to facial nerve palsy, by extending a suture sling along the pre-tarsal lower eyelid when performing transcaruncular medial canthal tendon plication

Video of technique.

Correction of lower eyelid malposition in facial palsy.

We report a technique for incorporating a suture sling to transcaruncular-approach MCT plication when the medial canthus has retracted or descended thus requiring support and a posterior vector. It avoids rounding of the medial canthal angle that may occur with traditional medial canthoplasty. Transcaruncular MCT plication is well described. Incorporating a suture sling to potentially reduce single point-fixation cheese-wiring and early dehiscence is minimally invasive, non-excisional and repeatable.

February 25, 2013 at 12:50 pm

cassandrasobajo@doctors.org.uk

Mohs surgery is an established technique in the management of peri-ocular tumour removal. This study aims to re-audit the patient’s journey through the Mohs reconstruction service provided at Royal Bolton Hospital and to assess the effect on treatment waiting times following the appointment of a second oculoplastic consultant.

A total of 30 patients were identified to have had peri-ocular reconstructive surgery under two oculoplastic consultants between January 2012 and December 2012. Of which n=29 had prior Mohs surgery. Data relating to their management was collected retrospectively from case notes. This data was compared with the original audit performed between March 2006 and November 2007.

The same number of Mohs reconstructive procedures were performed in 2012 and 2007 (n=29). Mean time from referral to specialist clinic appointment was 6.6 weeks in 2012 compared with 9.3 weeks in 2007, with mean time from listing for Mohs surgery to reconstructive surgery at 16.1 weeks in 2012 and 21.1 weeks in 2007. An average of 2.90 clinic appointments was observed with 93.1% of patients having a diagnostic biopsy in 2012 (2.60 clinic appointments and 82.1% diagnostic biopsy in 2007). The most common procedure in both years was a full thickness skin graft plus/minus lateral tarsal strip (48.3% in 2012 Vs 38% in 2007). A standardized post-operative management plan was implemented in all patients in both years, with good compliance documented in 65.5% in 2012 and 90% in 2007.

A robust Mohs reconstructive surgery pathway is provided at Royal Bolton Hospital, ensuring all patients are assessed and managed within 18 weeks. The appointment of a second oculoplastic consultant has significantly reduced surgical waiting times.

February 25, 2013 at 12:52 pm

leeteaktan@googlemail.com

Identifying orbital GPA at presentation is difficult as c-ANCA is often negative and orbital biopsy often does not demonstrate classic features of vasculitis.

The aim of this study was to compare GPA with other causes of orbital inflammation and identify the clinical and imaging features that are most likely at presentation to predict GPA.

This is a retrospective non-interventional study spanning over a 21-year period of all patients who had undergone orbital biopsy from 1988-2009 at Moorfields Eye Hospital. 470 were identified from the Institute of Ophthalmology Pathology database and 247 patients with complete clinical information were included in the study. Patients were divided into GPA and non-GPA groups based on the final clinical diagnosis and management. Clinical and imaging features were compared to determine those predictive of GPA

37 patients were assigned to the GPA group and 210 patients to the non-GPA group. Mean age for the WG group was 50.4 (range 14-87), male female ratio 15:22. Features highly suggestive of GPA were sinonasal symptoms, sinonasal involvement and bony erosion (p=0.00 respectively). Bony erosion was independent of ANCA positivity and systemic involvement. 22% had evidence of systemic involvement at presentation and no other patient with GPA developed systemic involvement during follow-up

A high index of suspicion should be maintained for GPA in the presence of sinonasal symptoms at presentation as well as sinonasal involvement and bony erosion on imaging. No patients with orbital GPA who did not have systemic involvement at presentation developed systemic progression with time suggesting that orbital GPA can remain a long term localised disease

February 25, 2013 at 3:00 pm

anuradhajayaprakasam@hotmail.com

Socket surgery should achieve good cosmetic results with minimal complication. The senior author’s practice of socket surgery is evaluated over a 14 year period.

A retrospective audit of all socket surgery (excluding congenital anophthalmos) performed by a single surgeon at Addenbrooke’s Hospital, Cambridge between 1999 and 2012.

81 patients (mean age 45, range 3-90 years) underwent socket surgery but a full dataset was available in 59. Enucleation was performed in 14 patients (24%), all with primary implantation of a porous polyethylene sphere (Medpor). 15 patients (25%) underwent evisceration with primary implantation of a Medpor sphere in all but 3 cases (endophthalmitis). Most patients (51%) were referred with complications of previous socket surgery, including post-enucleation socket syndrome (22%), exposed orbital implants (8%), implant extrusion (3%) and socket contracture (12%). They required secondary orbital implantation (22%), implant exchange (12%), dermis fat grafting 3%, mucous membrane grafts (2%), fornix deepening (8%) and patch graft (5%). Median follow-up was 2 years (range 1 month to 6 years). There were no extruded or exposed implants and only minor complications, including conjunctival inclusion cysts (8%), persistent volume deficiency (15%) and shallow fornix (3%). At the point of discharge 78% of patients were pleased with the outcome of their surgery.

Considering that most patients in our practice are referred for secondary socket surgery, there have been no cases of implant extrusion or exposure and the complication rates are low, highlighting the fact that meticulous surgical technique provides a good outcome for our patients.

February 25, 2013 at 8:30 pm

sbhag@aol.com

Melanocytic conjunctival lesions cause anxiety resulting in referral to ocular oncology services. They formed 53% of the conjunctival lesions referred in one centre, of which blue naevi formed only 0.5%. Blue naevi are rare conjunctival naevi, that may show slow progressive growth and have a low potential for malignant transformation. They may cause anxiety due to the age at recognition of naevus, their clinical location and growth pattern. We present 3 cases of conjunctival blue naevus.

Three cases of conjunctival blue naevus were identified over a period of 10 years, from the histopathology database. We reviewed the patient demographics, clinical presentation and management.

The first and third patients were in their fifth decade and the second in their second decade. All three cases presented with a pigmented conjunctival lesion increasing in size over a period of months. The naevi were located in the plica with extension into the fornix, in the bulbar conjunctiva adjacent to the limbus and at the the caruncle. The older age at presentation in the first and third cases, increase in size and location at plica with extension into the fornix were causes for concern. All three patients underwent excision biopsy, which was complete on histopathological assessment. Following the results of the biopsy the first patient was reassured and discharged. The second patient has had no further problems over a period of 6 months follow up. The third patient has defaulted from follow up, suggesting no further problems.

Blue naevus should be included in the differential diagnosis of pigmented lesions of the conjunctiva. They usually pursue a benign course and therefore all conjunctival pigmented lesions in older people should be biopsied to avoid anxiety and additional unnecessary therapy.

February 25, 2013 at 8:40 pm

sbhag@aol.com

There is no consensus on the optimal treatment for periocular MCC because of low patient numbers. Management is often based on cutaneous MCC. We present 3 cases of periocular MCC and discuss the clinical presentation, management and outcome.

Cases of MCC diagnosed and referred to our institution over a period of 8 years were identified from the histopathology database. The the clinical records of were reviewed and the patients demographics, presentation, management and outcome recorded.

Case 1

A 78year old male presented with a rapidly growing mass on the right upper lid, initially diagnosed as stye. Following biopsy confirmation of diagnosis he underwent complete excision with reconstruction followed by radical radiotherapy to involved regional lymph nodes. He has been followed up for almost 5 years with no recurrence or metastasis.

Case 2

An 85y old female presented with a rapidly growing cystic lesion under the lateral aspect of her left eyebrow. Following pathological confirmation of diagnosis she underwent radical radiotherapy of brow and regional lymph nodes as she refused further surgery. The patient died seven months later at home, cause unknown.

Case 3

A 67 year old female developed a mass on the lower lid medially 2 months following dacryocystorhinostomy surgery.. She underwent chemotherapy with little reduction in tumour size. This was followed by radical surgery and post operative radiotherapy. 5 years later she developed recurrence.

Based on these 3 cases early diagnosis with complete excision and radiotherapy appears to be a reasonable option for localised periocular MCC. Patients require long term careful follow up for late recurrences.

February 25, 2013 at 8:45 pm

sbhag@aol.com

Congenital ptosis is present at birth and associated with a dystrophic levator muscle. Surgery is indicated to prevent amblyopia, abnormal head posture or for cosmetic reasons. The choice of surgery depends on age, levator function and degree of ptosis.

We compared the outcomes of brow suspension surgery with levator advancement surgery at our centre.

A retrospective review of paediatric cases operated by one surgeon over a period of 8 years with respect to demographics, outcomes for two different surgical approaches, complications and patient / parent satisfaction.

117 eyes of 78 patients were included in the study. The average age of the patients operated was 5.45 years (range 0.5 – 14.75y). In 89.6% of the children ptosis was an isolated finding whereas in 13.9% it was associated with syndromes such as blepharophimosis. The indication for surgery was visual in 42.7% and cosmetic in 56.4%. 69.2% of the children had brow suspension surgery and 27.4% had levator advancement surgery. For brow suspension surgery, fascia lata was used in 46.9% and mersilene mesh in 50.6% of the children. The overall average palpabral aperture in the whole group improved from 5.59mm (range 2-11mm) preoperatively to 7.65mm (range 4 -14mm) post operatively. The improvement for levator resection was from a pre-operative level of 6.5mm to 8.5mm on average and for brow suspension was from 5.3mm to 7.1mm on average. 2.6% (3cases) of the patients had complication post operatively, one developed wound dehiscence, one granuloma and one recurrent upper eyelid swelling.

The right choice of surgery, brow suspension or levator resection, based on levator function gives an equally good outcome in both groups.

February 25, 2013 at 8:52 pm

INDIRAMADGULA@YAHOO.CO.UK

DCR creates a communication between the lacrimal sac and the nasal cavity, bypassing the NLD. This study was conducted to assess 5-year functional success after external vs. non-laser endoscopic DCR in a district general hospital in North-west England.

70 patients who underwent DCR surgery between Aug 2003 – Aug 2007 were sent a postal questionnaire. It had a visual analogue scale for symptoms and questions exploring their perception of outcome and success 5 years after surgery.

47 (17 M, 30 F) questionnaires were received. Of them 22 patients had external & 25 endoscopic DCR. Mean VAS score for external DCR was 9.5, 90% were asymptomatic or improved after 5 years and 90% considered the surgery a success. Mean VAS score for endoscopic DCR was 7.5, 68% were asymptomatic or improved and 72% opined surgery to be successful.

External DCR has a higher log term success compared to endoscopic DCR.

February 25, 2013 at 9:34 pm

rbourkiza@hotmail.com

The Central face is a highly visible area, yet surprisingly skin cancers still do present late. Large periocular Basal Cell Carcinomas (BCCs) cause significant and disfiguring morbidity, whilst also presenting a risk of orbital extension. We report factors associated with delayed presentation of large eyelid BCCs to a single ophthalmic centre in Essex.

Retrospective case note review of consecutive patients presenting to the Eye Unit at Queen’s Hospital from Sept 2010 to Sept 2012 with large periocular BCCs. Data was collected on age, gender, primary or recurrent lesion, site, histological subtype & size. Data on healthcare timeline (first GP presentation, referral, hospital consultation) was also recorded. A telephone questionnaire was conducted with the patients to explore possible reasons for advanced presentation.

There were 21 patients identified with large periocular BCCs during the study period, with a slight female preponderance (n=12, 57%) and a mean age of 77 years (range 51-94). The majority of lesions were primary (n=20, 95%). The most common sites affected were medial canthus (n=8, 38 %)> lower lid (n=6, 28.5%) >extended periocular areas (n=4, 19%) > lateral canthus (n=2, 9.5%) > upper lid (n= 1, 4.7%). The mean maximum diameter of the lesions was 17.9mm (range 10-30mm). The histological subtype was nodular (n=15, 71%), morphoeic (n=5, 23%), basisquamous (n=1, 5 %).

Only 15 (71.4%) patients were available for the telephone questionnaire. 73.3% (n=11) stated noticing the lesion, but not considering it serious to report initially. 73 %(n=11) lived with their partners, and only one patient (9%) was encouraged by their partner to report lesion to the GP. The main reasons for seeking medical help was lesion growth (n=6, 40%), persistence (n=2, 13.2%), bleeding (n=1, 6.6%), & previous history of skin cancer (n=2, 13.2%). Fifty three percent (n=8) saw an optician routinely after becoming aware of the lesion, none were referred to seek specialist advice. The median time between noticing the lesion and seeking medical help was 36 weeks (range 4-144 weeks). The median time between seeing the GP and referral to secondary care was 9 weeks (range 1 – 82 weeks). The median time between onward referral from secondary care to Oculoplastics was 3 weeks (range 2 – 17 weeks). The main source of referral to the Oculoplastic service was from secondary care (n=19, 90.5%), dermatology accounting for 86 % (n=18).

BCC is the most common cutaneous tumor affecting the eyelids. It usually develops in the elderly, grows slowly & painlessly, and has an extremely low metastatic potential making it an “ideal candidate” for a neglected tumor. Our study confirms previous reports of delayed presentation due to patient neglect. Our study also suggests the need for targeted education of local opticians and highlights the need to refine our current patient referral pathway, which further delays treatment of these challenging cases.

February 25, 2013 at 10:17 pm

ajb101@doctors.org.uk

To describe the clinical presentation and management of a rare case of squamous malignant transformation of a periorbital Syringocystadenoma papilliferum (SCAP) in a middle aged healthy female.

Case report with a Medline and Embase literature review of periorbital SCAP, with particular emphasis on the potential of malignant transformation.

SCAP is a rare sweat gland tumour and considered to be a benign lesion, with a very low risk of malignant transformation. It is more common in the head and neck region, typically arising from a pre-existing naevus sebaceous. Eyelid involvement has been infrequently reported. Malignant transformation is usually into Basal Cell Carcinoma (BCC). Squamous Cell Carcinoma (SCC) transformation is exceptionally rare and has been described as developing from non-periorbital SCAP only twice in the literature. This is the first reported case of periorbital malignant squamous transformation of SCAP that was treated successfully with surgical excision. The patient remains under observation and recurrence free.

As this entity is hardly known within the ophthalmic literature, this case highlights the importance of being aware of the potential malignant transformation and for ophthalmologists to remain vigilant. Prophylactic excision of the lesion should be recommended, given the rare potential of malignant transformation.

February 25, 2013 at 11:44 pm

hbs@doctors.net.uk

OCT is increasingly used in dermatology to visualise the microstructure of the skin in vivo. We investigate this technology in the imaging of periocular BCC

Fifteen consecutive patients with biopsy-proven periocular BCC were prospectively investigated with macroscopic measurement and VivoSight OCT imaging prior to surgical excision. Postoperatively, horizontal margins (x, y), and depth of invasion (z) were compared between haematoxylin and eosin-stained histology sections and the preoperative OCT images

The OCT margins correlated positively with histology (r=0.80 and 0.66 for x and y respectively) and could be identified in 3/15 (x axis) and 6/15 (y axis) cases. The correlation with depth of invasion was r=0.43, and the vertical margin could be measured accurately in 9/15 cases. Correlation of internal tumour morphology between OCT and histology included; a) internal lobules (100%), b) dilated blood vessels in the upper dermis (80%), c) overlying epidermal thinning (100%)

There was a strong positive correlation between the horizontal margins of periocular BCCs measured using in vivo OCT and histology, and a weak positive correlation with depth of invasion. OCT was also able to demonstrate characteristic features of the internal morphology of these tumours. The VivoSight OCT was easy to use, but is currently limited by its 1.8mm tissue penetration, and 5mm x 5mm horizontal field. It the future it may be possible to increase the horizontal field by modifying the probe. Although further investigation is required, our study suggests that this technology has potential to help evaluate tumour margins prior to, and possibly even during surgery

February 26, 2013 at 5:44 am

hbs@doctors.net.uk

Patients, carers and the public are central to setting the research agenda, with a key role in identifying study priorities; planning, funding, running and evaluating clinical trials; and disseminating findings. Not only does this ensure appropriate patient-focused outcomes, but the National Institute for Health Research (NIHR) has made this a prerequisite for funding. One method of encouraging engagement with research is through PPI events

The Moorfields NIHR Biomedical Research Centre, in partnership with TED charities, arranged a PPI day for TED. The event included: didactic lectures; pre- and post-event questionnaires; an exhibition with stalls, posters and an interactive ‘voting wall’ to determine research priorities; focus group sessions to evaluate how patients would like trials conducted; and one-to-one interviews to explore individual patient experiences

100 people attended the event, and 70 completed questionnaires (35 patients, 9 supporters, 4 exhibitors, 15 healthcare professionals, and 7 ‘others’). When asked whether the day had provided what they wanted, 48/52 (92%) said ‘yes’, 3/52 (6%) said ‘no’. Overall 6/52 (12%) rated it ‘good’, 28/52 (54%) ‘very good’, and 18/52 (34%) ‘excellent’. 36 patients registered to participate in further research, and identified; finding the cause for TED, improving psychological support, and achieving a better cosmetic outcome, as key research priorities. A poor understanding of TED amongst medical professionals was a common complaint

The event received very positive feedback, and achieved its key objective of encouraging patient engagement with researchers in identifying priorities and improving trial design

February 26, 2013 at 5:57 am

isabelle.larre@yahoo.fr

To compare surgical outcome and success rate of endonasal sutured flaps dacrocystorhinostomy with and without silicone intubation.

Patients with primary anatomic lacrimal duct obstruction were included in a prospective non-randomized comparative case study. During the first study year all consecutive patients had En-DCR with O’Donoghue tube placed (group A) and during the second study year all patients underwent En-DCR without tube (group B).

Patients were reviewed at 1, 3 and 6 months postoperatively. Success was assessed on criteria of patient’s satisfaction, symptoms relief and anatomic patency.

57 patients underwent En-DCR between September 2009 and September 2011. One month post operatively, success was observed in 61.3% of patients of group A vs 84.6% in patients of group B, partial success in 32.3% vs 3.8% (p< 0.013) and failure in 6.4% vs 11.5%. After 6 months, success rate based on patients’ satisfaction was 90 % in group A and 88.5% in group B with no statistical difference.

The success rate of sutured flaps En-DCR is no different with or without a lacrimal stent, but early patient post-operative satisfaction appears to be higher when no tube is used

March 1, 2013 at 11:08 am

james.neffendorf@gmail.com

Lacrimal sac tumours are rare but must be considered in the diagnosis of patients presenting with medial canthal region masses. We report a case of lacrimal sac rhabdomyosarcoma in an adult, which to our knowledge is unique, to highlight the features of lacrimal sac tumours. We review the literature available to guide diagnosis and management of such tumours.

We present the case, illustrated by means of intra-operative photography and histology, of a 31-year old man presenting to eye casualty with a 4 week history of a right medial canthal lump, accompanied by epiphora and discomfort.

An initial diagnosis of dacryocystitis was made and treatment with oral antibiotics commenced. 1 week later, following minimal clinical response, he was seen in the lacrimal clinic. In view of atypical features he was listed for exploration +/- DCR. At surgery, a firm lacrimal sac mass was found, with no fluid or evidence of acute infection and he underwent dacryocystectomy, together with biopsy of the surrounding tissues. Histological examination revealed alveolar rhabdomyosarcoma, with tumour to the excision margin. Rapid referral to the oncology service was made. Staging scans showed no evidence of metastatic disease. The patient has received three cycles of chemotherapy with a good response and remains under follow-up.

To our knowledge, there are no previously reported adult cases of lacrimal sac rhabdomyosarcoma in the peer-reviewed literature. Using this case and a review of the literature for lacrimal sac tumours we highlight the specific clinical features that should arouse suspicion of a lacrimal sac malignancy, together with their management and prognosis.

March 1, 2013 at 2:50 pm

drtomjackson@yahoo.co.uk

Intraorbital calcification is a common incidental finding in computed tomography (CT) scanning. Previous studies have reported the incidence to range between 3-16%. The purpose of this study was to investigate the prevalence of incidental orbital calcification found on CT scans in a population of patients seen in New Cross Hospital, Wolverhampton.

We reviewed 159 consecutive CT scans of the orbits undertaken between 1st April 2010 and 10th June 2011 in patients over 18 years old.

The prevalence of incidental orbital calcification was 14% and included calcification of the optic nerve head (7%), trochlea (4%) and rectus muscle insertion (4%). In two cases trochlear calcification was present with optic nerve calcification. It was a unilateral finding in 43%. 64% were male and the mean age was 65 years (range 48-88 years).

The cause of intraorbital calcification is not known. Calcification in tissues may be dystrophic or metastatic, however, an alternative hypothesis is that intraorbital calcification is a congenital variant rather than an acquired process. This would explain why trochlear calcification has been noted in such a wide range of ages and may explain the varying prevalence reported in previous studies.

The cause of this common incidental finding remains to be elucidated and it is important to include in the differential diagnosis of orbital foreign bodies.

March 3, 2013 at 11:16 am

Lbagdonaite@yahoo.com

Extrusion is the most common reason for failure after Jones tube placement. The StopLoss Jones tube (SLJT) is a new innovation in Jones tubes that incorporates a flexible silicone internal flange to resist extrusion. We present our early experience of using this new tube.

Case note review of a single surgeon consecutive series of patients having SLJT placement from Nov 2011- present.

21 SLJTs were placed in 17 eyes of 13 patients, 9 female, 4 male; age range 23-83 years, mean 60.

Follow-up ranged from 0.5-15 months.

Indications for initial SLJT placement were: previous LJT complications 9 (53%), failed canalicular-DCR surgery 6 (35%), primary placement for inoperable canalicular occlusion 2 (12%).

86% tubes (18/21) had a 4.0mm flange, 3 tubes had a 3.5mm flange (14%); the most common tube length was 11 mm, range 10-15mm.

There were no intra-operative complications.

The extrusion rate was 0%.

4 tubes were replaced: 1 was too long, 2 others had conjunctival overgrowth (at 2/12 and 12/12), 1 tube migrated medially at 3/12.

1 tube (3.5mm flange) migrated medially at 12/12 but the track remained patent and the patient was reluctant for replacement.

Patient satisfaction with the tube was: 90% fully satisfied, 5% was moderately satisfied, 5% not satisfied.

The overall final surgical success rate (defined as: patent tube, no significant watering) at last follow-up was 95%.

In this short follow-up initial study the StopLoss Jones tube appears to be effective in preventing extrusion and has a high rate of success and patient satisfaction.

March 3, 2013 at 11:35 am

pari.shams@gmail.com

To prospectively report the incidence of acute rhinosinusitis (ARS) following endoscopic dacryocystorhinostomy (DCR)

Prospective, non-randomised, non-comparative, single surgeon interventional case series including 196 consecutive patients undergoing 203 endonasal DCR with clinical and radiological evidence of nasolacrimal duct or common canalicular obstruction. Preoperative lacrimal and sinonasal clinical assessment and imaging, intraoperative endoscopic video recording, and postoperative clinical and endoscopic follow-ups were analysed for cases of ARS occurring within the first 4 weeks following DCR, surgical complications and outcomes. The minimum follow-up was 12 months. The management of ARS and a past history of chronic rhinosinusitis (CRS) and sinonasal surgery are reported.

Three patients (1.5%) developed ARS within the first 5 post operative days, none of which had experienced peri-operative complications and all had a past history of CRS. The rate of CRS in this cohort of 196 patients was 10.2% (n=20) of which 15% (n=3) developed ARS, although none had symptoms of CRS at the time of surgery; one had undergone previous sinus surgery. Presenting symptoms of ARS included facial pain, tenderness over the affected sinus and nasal discharge; all patients responded to oral antibiotic therapy.

The rate of ARS following endoscopic DCR was 1.5%. In those with a prior history of CRS it was 15% (p<0.0001). ARS developed within the first post operative week among patients with a past history of CRS, who were asymptomatic at the time of surgery, and responded to oral antibiotics. CRS may be a risk factor for the development of post-operative ARS.

March 3, 2013 at 9:08 pm

pari.shams@gmail.com

A turn-over septal flap has been reported as a spacer for levator lengthening in a single case report. This study reports the preliminary outcomes of this technique in a series of patients with upper lid retraction associated with thyroid eye disease (TED), facial nerve palsy or previous eyelid surgery causing symptomatic corneal exposure.

Retrospective, multicenter study of 22 eyelids of 20 patients who underwent transcutaneous levator lengthening using the reflected orbital septum as a spacer. Change in eyelid height and contour, position of the skin crease, symptoms of exposure keratopathy and complications associated with the use of this technique were recorded.

The average age was 57 years. Two patients were excluded where the septum was found to be too thin at the time of surgery. The palpebral aperture (PA) was reduced by an average of 2.5mm (p<0.0001) and the position of the skin crease remained unaltered in 80%. The difference in PA between the operated and contralateral eyelid was reduced from 1.8mm to 0.1mm (p<0.0001). Patients with eyelid retraction due to TED had a greater reduction in upper scleral show (p<0.05) compared to other causes of eyelid retraction. These values remained stable over the follow-up period of 12.9 months and all patients had resolution of exposure keratopathy. Complications included one case of overcorrection and another of late recurrent lateral flare.

The turn-over orbital septal flap technique may be a viable option as an autogenous spacer for the treatment of upper eyelid retraction. This technique may be possible in cases where the orbital septum has been opened by previous surgery but may not be feasible in patients where the septum is very thin.

March 3, 2013 at 9:20 pm

saulrajak@hotmail.com

Mid-facial radiotherapy can cause nasolacrimal obstruction. Lacrimal bypass surgery in the presence of fibrosis and tumour is very challenging and has high failure rates. Nasolacrimal stenting can be used to prevent canalicular or nasolacrimal duct obstruction. However, stenting and tube retrieval can be difficult. The problem can be overcome with Nunchaku bicanalicular silicon stents. These are self-retaining and do not require nasal retrieval. FCI Nunchakus is a bicanalicular silicon stent with firm metal guide wires that does not require retrieval. We report their prophylactic use prior to mid-facial radiotherapy.

Patient one had a partial excision of an olfactory neuroblastoma. Patient two had radical excision of a mucoepidermoid carcinoma of the right maxillary antrum. Both patients had Nunchaku nasolacrimal stents inserted into patent nasolacrimal systems prior to adjunctive radiotherapy (patient one bilateral, patient two unilateral, according to radiotherapy site).

Stents were left in-situ for three to four months throughout the radiotherapy. On removal the nasolacrimal systems remained patent in both patients. Long-term follow-up will continue.

This novel use of Nunchaku stents may help to avoid lacrimal bypass surgery in patients with complex nasal tumours requiring radiotherapy.

March 4, 2013 at 10:56 pm

sadie.wickwar.1@city.ac.uk

This study examined factors associated with the Quality of Life (QoL) of patients with TED seeking orbital decompression surgery.

Ninety-two adult patients with TED due to undergo orbital decompression surgery at Moorfields Eye Hospital, London were assessed on illness severity, activity and duration, the Graves Ophthalmology Quality of Life questionnaire (GO-QOL- two subscales; visual and psychosocial function), and the Hospital Anxiety and Depression Scale (HADS). Regression models were used to identify which factors were associated with QoL in this population.

Participants were 71% female, 80% white, had a mean age of 47 years and a mean disease duration of 53 months. Clinical levels of anxiety were found in 39% and clinical levels of depression in 24%. The regression model accounted for 81% of the total variance in the GO-QOL psychosocial function scores. After demographic and clinical variables were controlled, socio-cognitive processes explained the most variance (25%) in psychosocial function scores (p < 0.001). The model explained 67% of the variance in the GO-QOL visual function scores. After demographic, clinical and socio-cognitive process variables were controlled for, anxiety and depression explained 15% of the variance in GO-QOL visual function scores (p<0.001).

After accounting for clinical and demographic characteristics psychosocial variables made a large contribution in accounting for QoL. It is of note that a large proportion of this population experience clinical levels of depression and anxiety. This paper emphasises the importance that clinicians when planning surgery for TED patients, are aware of the psychosocial factors that could potentially influence outcome. Longitudinal studies would need to be conducted to explore direction of causality.

March 5, 2013 at 10:26 am

mohamad.abdullah@moorfields.nhs.uk

To evaluate the indications, techniques, outcomes and complications of the commonly used surgical approaches to the orbit in children.

Choice of the appropriate orbitotomy was made according to the location, extent and nature of the lesions. Post-operative visual acuity, cosmesis, extent of surgical resection and complications were recorded and statistically analysed.

The study included 88 children, 42 male (47.8%) and 46 female (52.2%) aged 2 months to 16 years. Average follow up period was 12.2 months. The commonest presentation was globe displacement (39.7%). Surgical intervention for aesthetic reasons was the commonest indication (32.9%), followed by visual deterioration (29.5%). Most cases were histopathologically found to be orbital dermoid cysts (36.5%). Commonest approaches included upper eyelid crease (63.6%), swinging lower eyelid approach (14.7%), lateral approach (10.2%), subciliary (5.7%) and transcranial (5.7%). Total excision of the orbital lesions was possible in 68.2% and an acceptable cosmetic outcome was achieved in 94.2% of cases. Post-operative visual acuity improved in 73.0%, partially improved in 19.2% and deteriorated in 7.6% of cases. Proptosis was improved in 82.6%. Post-operative complications included residual lymphangiomas which showed progressive post-operative proptosis, orbital cellulitis, ptosis and in one case, optic nerve glioma recurrence.

The shallow nature of the paediatric orbit lends itself to anterior orbitotomy for accessing most orbital lesions and negates the need for bone resection during the lateral approach. There is an increasing role for surgery in the successful management of visually threatening periocular haemangiomas.

March 5, 2013 at 12:26 pm

bimalk@doctors.org.uk

To establish if not intubating at the time time of endonasal DCR surgery carries any advantage over intubation

11 patients who had lacrimal sac mucocoeles were selected not to have silicone intubation at the time of endonasal DCR surgery. We looked at improvement of symptoms(epiphora), state of internal lacrimal window opening and speed/ presence of flourescein flow. This study was prospective. Patients were followed up at 3 months and 6 months post op with endoscopic examination.

Success rate at 3 months was 80% for symptom improvement and 70% for lacrimal window patency. Fluorescein flow matched lacrimal window patency.

6 month results were 71% and 57% respectively but these were difficult to inteprete due to the high DNA rate. However, successful patients at 3 months seem to remain symptom free at 6 months.

The number of patients studied is small and clinical significance of results is difficult to intepret but it would seem that the success rate in DCR cases without stenting is lower than in cases with stenting (based on our previous audit and other published literature on endonasal DCR with standard intubation).This would seem more so when one considers that the cases selected for non intubation had dilated sacs (mucocoeles) and carried a favourable prognosis.

March 5, 2013 at 12:52 pm

mrkreis@gmail.com

The lateral tarsal strip (LTS) procedure is a commonly performed operation for correction of lower eyelid malpositions. Lateral canthal granuloma formation – which can be tender for the patient and delay recovery – is a recognised complication, albeit readily treatable with corticosteroid injection.

This video highlights a straightforward addition to the standard LTS procedure that is quick and simple to perform and seems to reduce the risk of post-procedure granuloma formation

After fashioning the tarsal strip, the conjunctiva is removed via diathermy and scraping in the usual fashion, which results in a de-epithelialised strip, which can then be attached to the periosteum. However, the meibomian glands and ducts themselves still contain secretions, which, if left in situ, we believe will contribute to the granuloma formation, much as a ruptured orbital dermoid cyst leads to chronic inflammation. We therefore routinely perform a series of lateral tarsal squeezes using forceps, e.g. St Martin’s forceps, and work along the length of the fashioned strip from the medial to lateral end. As we perform this manoeuvre, copious secretions can be seen to be expressed from the meibomian orifices and are wiped away.

This lateral tarsal strip squeeze takes less than a minute to complete and therefore adds little to the total operating time. In addition, it requires no additional equipment making it economical as well.

We highly recommend this simple modification to reduce post-operative granulomas.

March 5, 2013 at 4:00 pm

mrkreis@gmail.com

Syringoid carcinoma (SC) is a rare skin tumour mainly presenting on scalp. It is a locally aggressive growing tumour with destructive pattern and frequently recurrent.

We report a case of a periocular SC of the right upper and lower lids (RUL/RLL), which was microscopically completely excised and reconstructed.

A 50-year-old man presented with a 3-year history of right eye irritation. Examination revealed a cicatrising mass at the right lateral canthus and an irregular upper and lower eyelid margin. Multiple biopsies were taken, which suggested the presence of SC. After tertiary centre pathological review, a full thickness wedge excision of the RUL confirmed the diagnosis. The entire RUL/RLL were excised, the definitive diagnosis being SC with extensive perineural and intraneural invasion and clearance being confirmed using a rapid paraffin technique. Total eyelid reconstruction was performed using a periosteal and temporalis fascial flap for the new RLL posterior lamella and a full thickness tarsal graft from the left upper lid for the RUL posterior lamella. Full thickness skin graft from the right preauricular area was used to form the new anterior lamella of the RLL as well as a skin advancement graft for the new RUL anterior lamella.

The patient showed an initial good functional result with a comfortable eye, good lid margins and viable grafts. There was minimal lagophthalmos but no corneal staining at week 3 post-op review.

SC is a rare skin tumour that is often misdiagnosed and treatment therefore delayed. In this case excision was complete but due to reported perineural growth pattern in the involved specimen frequent and on-going reviews are needed for early detection of recurrence.

March 6, 2013 at 9:30 am

dr.kenneth.chan@gmail.com

To report outcomes of periocular full-thickness skin grafting using Tisseel.

Retrospective audit of all patients receiving full-thickness grafts under care of a single surgeon in 4-year period. Early and late complications were noted, particularly hypertrophy/contracture requiring revision. Cosmetic outcomes were graded by a predetermined scheme.

59 patients underwent 63 skin grafts. Indications comprised reconstruction after Mohs’ (67%) or conventional tumour surgery (19%); cicatricial ectropion (13%) and trauma (1%). Sites included lower lid (41 cases/65%); upper lid (9 cases/14%), and medial canthus (11 cases/17%). 52% of the lid defects were larger than half of the respective lid. Tisseel was applied after suture anchoring of graft and simple dressings were maintained for 1-8 (mean: 5) days. Early complications (< 30 days) comprised wound infection (3 cases/5%), haematoma (4 cases/6%) and partial edge dehiscence (4 cases/6%). No graft failed. In the medium term 19/41 (46%) lower lid grafts developed secondary ectropion, however in 14/19 this improved after massage only, with full symptom resolution. 3/19 patients had further grafting for ectropion; 2 declined revision. Graft hypertrophy was noted in 10/63 (16%) during follow-up. In 6/10 this improved without treatment to the extent where there was no cosmetic issue; 4 were revised. Final cosmesis was deemed good or excellent in 71%, with mean follow-up of 14 +/- 13 (range: 1-44) months.

Final outcomes are similar to other reported data. Sutured bolsters are not necessary despite lid movement. Tisseel appears safe to use in the periocular region and may improve graft survival.

March 6, 2013 at 2:48 pm

dr.kenneth.chan@gmail.com

To present surgical results of island flaps used for lower eyelid reconstruction.

All island flaps used by single surgeon between Oct 2009 and Mar 2013 were reviewed. Cosmetic outcomes were graded by a predetermined scheme. Functional outcomes were also noted.

16 patients had lower lid reconstruction with island flap alone (4/16) or as part of a composite flap reconstruction (12/16). The defect was due to excision of a basal carcinoma in 75% of patients; 75% had undergone Mohs’ surgery. Total defect area was over half of the lower eyelid in 57% of patients. All patients achieved good or excellent cosmesis at final / last visit (mean: 9.2 months). Symptomatic epiphora was noted in 2 patients in the early post-operative period and 4 patients had secondary ectropion within the first six weeks of their operations, which was managed with lid massage only.

The myocutaneous V-Y (island) flap shows good cosmetic and functional outcomes in the short to medium term. It is a useful tool for lower lid reconstruction and in particular it may preclude the need for a skin graft in defects too large for purely sliding myocutaneous flaps.

March 6, 2013 at 2:51 pm

dr.kenneth.chan@gmail.com

To describe a single-staged paramedian forehead flap technique, where the base of the axial flap is safely narrowed by intraoperative identification of the artery using Doppler ultrasound.

Doppler ultrasound is used to identify the supratrochlear artery in the area of the planned flap, which is then marked. The required flap is drawn around this vessel and the base of the flap, where the pedicle will rotate, is thinned to avoid a bulky area of rotation, while the integrity of the vessel is preserved. This avoids the disfigurement of a bulky rotational area and therefore the need for a second-stage procedure to revise this area of the flap.

There was no incidence of flap necrosis in the 3 patients to date where this technique was used. All flaps were cosmetically satisfactory in the area of the nasal bridge and required no revision of this area.

We would recommend this manoeuvre in all axial flaps where it could be advantageous to narrow the rotating area of the flap.

March 6, 2013 at 2:53 pm

abdulhanifudin@gmail.com

To report our surgical experience in the treatment of Morbihan Syndrome (rosaceous lymphoedema of the eyelids)

A case series of 4 patients with Morbihan Syndrome is presented. Each patient had chronic upper and/or lower eyelid swelling which was non responsive to medical treatments. Standard upper and/or lower eyelid blepharoplasty surgery was performed in 3 patients.

Each patient initially had a satisfactory result from surgery, but in all three cases the eyelid swelling returned between 7 and 21 months later requiring further blepharoplasty surgery. Of three cases, one patient had a long term improvement after two procedures.

The treatment of Morbihan Syndrome remains a challenge. Medical treatments have not been shown to be effective and surgical results are variable. Blepharoplasty surgery can be effective in reducing eyelid oedema but the patient should be warned that whilst the initial results can be encouraging, more than one procedure may be required.

March 7, 2013 at 10:27 pm

kamransaha@doctors.org.uk

Congenital lacrimal fistulae are due to abnormal ectodermal invagination in the eyelids after day 35 in human embryogenesis. Leading to a watery eye or ‘cheek’, the true cause of such lacrimal symptoms is frequently overlooked, leading to significant diagnostic delay. We undertook a retrospective study of the management of these fistulae to determine the efficacy of primary external dacrocystorhinostomy and fistulectomy. A successful outcome measure was defined as ‘no further surgery required’ at any time during the follow up period.

Retrospective, Non-comparative case series

There are 20 patients described, of which 16 (80%) were referred from secondary ophthalmic centres. Median age at presentation was 15 years (range 4-31 years) with a male preponderance of 2:1. Presenting complaint was of ‘epiphora’ in 18 cases, and two presented with ‘sticky discharge’. Three patients had syndromic pathology (e.g. Down’s, Hay-Wells syndrome) with the remaining patients having no significant past ocular or medical history. One patient had a fistulectomy alone. All other patients underwent external dacrocystorhinostomy with fistulectomy, with a silicone stent placed in patients over the age of ten. Mean follow-up time was 13 months (range 2-28 months). During this period, no patient developed recurrent lacrimal symptoms requiring further surgery.

In this study males were more likely to present with symptomatic congenital lacrimal fistulae. Although an embryological abnormality, interestingly these patients typically did not present to this unit until their teenage years. Dacrocystorhinostomy with fistulectomy provides an excellent management option for this malformation.

March 8, 2013 at 11:48 am

d.ezra@ucl.ac.uk

One of the key pathological processes characterising Thyroid Eye Disease (TED) is the expansion of the orbital fat compartment. Adipogensis of orbital fibroblasts is known to be a key aspect of this process. orbital tissues. Mechanical environment is understood to have significant and far-reaching effects on cell transformation, proliferation and differentiation. We test the hypothesis that increased pressure drives the differentiation of orbital fibroblasts into adipocytes.

Cell lines of orbital fibroblasts were derived from 3 TED and 3 control patients. Cells were seeded in free-floating 3D collagen matrices by a process of rapid polymerisation. After integration of the cells within the gel, external pressure was applied using a custom made weight-compression system. Adipogenesis was assessed by cell counting for positive staining with Oil-Red-O and PCR for PPARG.

TED orbital fibroblasts were found to spontaneously undergo adipogenesis in a 3D culture environment (65% expression) , even without the application of external pressure. the application of external pressure increased the adipogensis response to 85% of cells. Control orbital fibroblasts were found to respond to more dramatically to externally applied pressure by inducing adipocyte differentiation which increased from 20% at baseline to 80% after the application of external pressure. These findings were confirmed by Oil-Red-O staining and PPARG gene expression.

Orbital fibroblasts respond to external pressure by differentiating into adipocytes. This novel finding may explain the the cause of adipogenesis in thyroid eye disease, which is a predominately inflammatory condition.

March 8, 2013 at 12:10 pm

d.ezra@ucl.ac.uk

The skin of the eyelid is known to scar relatively lightly. In contrast, skin of other sites (e.g. pre-sternal area) scar vigorously. Little is known about the mechanisms which mediate this difference in behaviour. The aims of their study were to compare measures of eyelid and presternal skin fibroblast contraction induced by stretch and by pro-inflammatory cytokines.

Three Cell lines of pre-sternal and upper eyelid skin were harvested from patients undergoing upper lid blepharoplasty. Cells were seeded in free-floating 3D collagen matrices by a process of rapid polymerisation. Contractile efficiency was assessed by daily serial digital photography of the gel diameter over a 7-day period. Comparisons between Presternal and Blepharoplasty skin was made was made. Matrices were incubated under several conditions: TGF-B and IL-1B, both of which are well recognised as being pro-fibrotic cytokines .Fibroblast populated collagen matrices were subjected to stretch experiments using a Culture Force Monitor (CFM) to detect the minute contractile forces exerted by cells.

Presternal skin fibroblasts were found to have a greater baseline contractility that eyelid fibroblasts in free floating collagen gels. When exposed to external stretch, these cell lines did not differ in their contractile response. Presternal skin fibroblasts increased their contraction in the presence of TGF-B in contrast to eyelid fibroblasts, which did not respond.

Eyelid skin fibroblasts differ in their fibrosis response when compared to presternal skin fibroblasts. Intrinsic differences in cell phenotype and response to inflammatory stimuli, rather than skin tension alone underlie these differences.

March 8, 2013 at 3:13 pm

d.ezra@ucl.ac.uk

Sebaceous cell carcinoma (SebCC) is a potentially lethal eyelid malignancy. There are two important clinical phenotypes for this disease: A nodular form and an invasive form which can grow spread in a pagetoid fashion. There have been no previous studies investigating gene expression patterns in these tumour types.

The aims of this study are to identify the pattern of micro-RNA(miR) in SebCC and to compare nodular and pagetoid tumours to determine which genes may be responsible for the different behaviours of these tumour subtypes.

10 SebCC specimens were identified from the pathology library at the UCL Institute of Ophthalmology. 5 of which were nodular and 5 invasive. RNA was extracted from 10um section of paraffin blocks using standard techniques. Purified RNA was subjected to microRNA array analysis Using the NanoString system. Gene expression data was analysed using GeneSpring X software. Differences in gene expression were analysed using ANOVA and validated using standard PCR.

For localised nodular tumours, only 3 dysregulated miRNAs were identified: miR- 9, miR-34a, and miR-205 (p<0.05). For invasive tumours, 19 Dysregulated miRNAs were identified, of which 17 were unique to the invasive tumour. These include miR-106b, miR-93 and miR-21 (P<0.05). These uniquely expressed miRNAs in invasive tumours are known to mediate tumour invasion and metastasis.

This study has identified important differences in the gene expression of SebCC which explain the molecular mechanisms underlying the transformation of this tumour. In addition, differences in expression between nodular and invasive tumours identify candidate genes responsible for invasive behaviour.

March 8, 2013 at 3:57 pm

konalsaha@hotmail.com

To describe a simple technique to manage the rounded lateral canthus.

Surgical Technique

1: The new eyelid margins are marked by drawing a line following the natural curve of the eyelids to the lateral orbital rim at a point intended to be the position of the new lateral canthus.

2: The lateral canthal web is split into anterior and posterior lamellae using a blade, extending the dissection to the lateral orbital rim with scissors.

3: The skin/anterior lamella is incised along the superior marking to create a skin flap based on the lower eyelid.

4: The conjunctiva, attenuated orbicularis/posterior lamella is incised along the inferior marking to create a conjunctiva lined flap based on the superior eyelid.

5: The flaps are folded over the raw edges of the newly created eyelid margins – the skin flap posteriorly and the conjunctiva lined flap anteriorly.

6: The flaps are secured with 8-0 absorbable suture.

7: The lateral canthal angle is supported with a transcanthal lateral canthopexy.

Following the procedure we encourage patients to digitally separate the newly created lateral eyelids to prevent adhesion formation.

The procedure was carried out on 7 patients, all of whom had previously undergone lower eyelid transcutaneous blepharoplasty.

Preoperative and postoperative photographs at 3 months were viewed by a blinded observer. All patients were noted to have elongation of the horizontal palpebral aperture and sharpening of the lateral canthal angle.

No significant complications were noted and no patients required reoperation.

We present a simple and effective procedure for correcting rounding of the lateral canthi.

March 8, 2013 at 7:16 pm

Limbachia1@gmail.com

To describe the use of autologous fat transfer for orbital volume augmentation in post-enucleation sunken socket syndrome in conjunction with fornicial deepening sutures

A case report

Successful orbital volume augmentation was achieved along with better cosmesis and prosthetic eye stability for the patient

Autologous fat transfer is a highly effective technique in treating patients with symptomatic post-enucleation sunken socket syndrome

March 8, 2013 at 7:19 pm

rumanahussain@hotmail.com

Acute onset ptosis demands urgent evaluation and assessment due to the potential underlying causes with significant associated morbidity and mortality.

Thus far, there have been no reports of an upper respiratory viral infection as a cause of a sudden onset isolated unilateral ptosis.

Case report

We present a case of a 42 yr old healthy Caucasian lady with a sudden onset of a marked right upper lid ptosis, a few days after suffering from a viral upper respiratory tract infection. Examination revealed a unilateral ptosis, in the absence of soft tissue swelling, ophthalmoplegia, pupillary abnormality, fatigueability or other neurological signs. There was no history of trauma and the upper lid tarsal plate and superior tarsal conjunctiva were both normal. Numerous investigations were undertaken including blood tests with inflammatory and immune markers, a CT angiogram, an MRI and EMG, all of which were normal. Spontaneous improvement was noticeable within 48 hours of admission, with complete resolution of symptoms at 4 weeks from presentation.

Viral infections in healthy young individuals are usually self limiting and neurological sequelae are rare. Ptosis has been described in the past as a presenting feature in guillian barre syndrome. However there are no reports to date of a post-viral isolated unilateral ptosis, in the absence of other significant neurologic signs. It is paramount to investigate the cause of acute ptosis; in this case, a post viral aetiology was a diagnosis of exclusion.

March 8, 2013 at 9:34 pm

sbhag@aol.com

Steven johnson syndrome (SJS) has a relatively low incidence but a high morbidity and mortality. Acute ocular complications develop in approximately 80% of hospitalised patients.

Management of the cicatricial entropion in these patients is a challenge for ophthalmologists. We present our experience of posterior lamellar advancement in three cases of cicatricial entropion presenting at varying lag times reflecting the varying severity and the progressive nature of this disorder.

A Retrospective review of three cases of cicatricial entropion secondary to steven johnson syndrome presenting at varying time intervals following the initial event. All three cases were managed with posterior lamellar advancement at 11years, 4 years and 4 months following the onset of SJS, at our center over a period of 12 years.

All three patients have had an improvement in lid margin position and improved ocular comfort with reduced need for topical lubricants. The second patient needed additional electrolysis for misdirected lashes. The third, who had the most severe reaction and required early intervention during the initial acute presentation required additional botulinium toxin injections to control blepharospasm and cryotherapy for trichiasis. Despite aggressive management he developed keratinization of conjunctiva and corneal complications.

Cicatricial entropion of varying chronicity and severity can be managed effectively in all four lids with posterior lamellar advancement, avoiding conjunctival surgery in steven johnson syndrome. Based on these three patients, the outcome of surgery appears to be related to time of onset of cicatricial entropion from the initial event.

March 9, 2013 at 8:38 am

deeparathore4@gmail.com

To evaluate the value of Dacryoscintigraphy in patients with punctal stenosis.

A retrospective case note analysis of patients who were treated with 3-snip punctoplasty from 2007-2012

100 eyes of 57 patients were reviewed. 81% were female and 19% were males. The age range was 19-89 years (mean 61 years, SD ±17 years). 76% of patients had bilateral whereas 24% had unilateral involvement. Following 3 snip-punctoplasty, 86 eyes (86%) had functional improvement in their symptoms with anatomical patency of the puncta. 5% (n= 4) of this group had cicatrization, at 6-8 weeks, which subsequently resolved after repeat 3- snip punctoplasty. 32 eyes (32%) had Dacryoscintigraphy pre-operatively (Group 1), which demonstrated pre-sac delay. Epiphora improved symptomatically in 25 eyes (78%) while 7 eyes (22%) failed to improve.68 eyes (68%) did not have Dacryoscintigrams prior to the 3-snip punctoplasty (Group 2). In this group 59 eyes (87%) improved and 9 eyes (13%) failed to improve. There was no statistically significant difference between the 2 groups in improvement of symptoms. (p=0.2) 14 eyes (14%) had persistence of epiphora despite anatomical patency of the punctae. Post-punctoplasty Dacryoscintigraphy revealed pre-sac delay in 5 eyes, post-sac delay in 7 eyes and 2 had normal drainage. Only 5 eyes have had surgical intervention so far. In the pre-sac delay subgroup (n=5), 2 had lid tightening and, 3 were not keen for surgery. In the post-sac delay subgroup (n=7), 3 had Dacryocystorhinostomy (DCR), 3 are awaiting DCR and 1 is awaiting follow up. 100% (n= 5) of the eyes who underwent subsequent surgery improved symptomatically.

Dacryoscintigraphy performed on patients with punctal stenosis prior to 3-snip punctoplasty did not seem to impact on outcome. However Dacryoscintigraphy done on patients who failed to get symptomatic relief post 3-snip punctoplasty seemed to be of some value in the choice of subsequent surgical intervention for improvement of symptoms

March 9, 2013 at 11:54 am

ahsen@doctors.org.uk

The assessment of patient satisfaction forms an important component in the evaluation of clinical outcome, although there are few tools which allow the patient or guardian to provide a visually objective demonstration of success. We introduce a tool incorporating objective criteria, for the use of a patient or guardian in the assessment of the post-operative functional and aesthetic result of congenital ptosis surgery.

Forty children who had congenital ptosis surgery by an ophthalmologist at our tertiary level unit were identified and postal PTOSIS questionnaires were sent to the home address of their parents or guardians. The survey included information on the operation performed, subjective questions on the perceived pre and post-operative experience, a visual image allowing the assessor to mark pre and post-operative lid position and a section for comments.

There was a 57.5% response rate with 23 returned surveys. Four of these surveys were completed by the child themselves. All responses demonstrated an understanding of the visual success portion of the PTOSIS questionnaire and Likert-scale responses supported an encouraging view of the service provided at our unit. Both subjective and objective portions of the questionnaire were completed thoroughly by all respondents.

Our results demonstrate that this tool can form a useful part of the operative experience for a patient and their family. Implementation of the tool from the beginning of the consultation could allow a more accurate assessment of the pre-operative lid position and the tool could therefore function throughout the period of hospital experience.

March 9, 2013 at 6:19 pm

vijaybwagh@gmail.com

To review the outcome and safety profile of ptosis surgery and compare with literature and British Oculoplastic Surgery Society (BOPSS) national audit.

We retrospectively analysed results of 30 consecutive ptosis surgeries with minimum twelve month follow up. Data were collected from Electronic patient records and patient notes.Success rate was assessed objectively and subjectively grading questionnaire using BOPSS criterion.

Mean Age of the patients was 53.8 yrs (Range 18-80 yrs) with female preponderance (18:12). Commonest etiology was involutional and majority had moderate ptosis (49%). Success rate was 84% using subjective criterion and 80% using objective criterion. Two patients had significant lagopthalmos following surgery and one patient had resurgery for reformation of upper eye lid skin crease. Comparison with previous audit shows significant improvement in our results.

We established good outcome and safety profile of Ptosis surgery at our unit and results were better than national average.

March 9, 2013 at 11:41 pm

f.kalapesi@unsw.edu.au

To examine orbital biopsies over a 10 year period, previously labelled as idiopathic orbital inflammatory disease (IOID), in order to detect any cases of undiagnosed IgG4-related disease (IgG4-RD).

IgG4-RD is a recently recognised systemic entity which has been described in the orbit. It is responsive to immunosuppressive therapy. Retrospective analysis is relevant so that the otherwise undiagnosed condition can be diagnosed, systemic associations sought and appropriate therapy, if required, can be instituted.

Adult lacrimal gland and other orbital biopsies obtained over 10 years from the Bristol Eye Hospital were used for this study. Biopsies which had previously been reported as IOID were examined, whilst those with a known tissue diagnosis such as lymphoma, sarcoid or Wegeners were excluded. Biopsies were re-examined histologically and immunochemically to define the number of plasma cells, confirm polyclonality, and quantitate the number of IgG4 positive plasma cells. IgG4-RD was diagnosed if >50 IgG4 positive plasma cells were found per high power field. Clinical features of these patients were analysed.

17 cases were studied (14 lacrimal gland; 3 other orbital). 4 were diagnosed with IgG4-RD (23.5%). All of the IgG4-RD patients were female in contrast to the whole group, in which only 59% were female. The IgG4-RD patients were on average a decade younger than the group (with 2 of these being in their twenties). Further clinical data will be presented.

Considering IgG4-RD specifically allows a diagnosis of an otherwise neglected disease. Our study further illuminates the prevalence of IgG4-RD and its clinical characteristics.

March 10, 2013 at 3:08 am

robingjones@gmail.com

We report a rare case of multifocal venous malformation (VM) with extensive periorbital involvement

Case report

A newborn male presented with a massive periorbital vascular lesion and smaller cutaneous lesions of the feet. The periorbital lesion caused gross upper lid expansion, visual axis occlusion and globe displacement. Ultrasonography (US) and magnetic resonance imaging (MRI) confirmed extensive orbital and lid involvement. Infantile haemangioma (IH) was proposed but the diagnosis was guarded as Gadolinium contrast was witheld because of the risk of renal failure. A trial of Propranolol yielded equivocal results. The lesion was complicated by profuse bleeding requiring transfusions. A further MRI with Gadolinium suggested VM. Surgical debulking allowed significant reduction of the upper lid. Histology showed VM. Prolene frontalis suspension was later performed followed by amblyopia therapy.

Vascular anomalies are divided into vascular tumours (commonest: IH) and vascular malformations. These groups differ in their biological, clinical, radiological and pathological features. Despite this, the term ‘haemangioma’ continues to be indiscriminately applied to all types of vascular anomalies leading to inappropriate management and misdirected research efforts.

Doppler US is useful for assessing the flow of a lesion but MRI with Gadolinium enhancement is the investigation of choice. It defines the extent, anatomic structures involved, and the flow characteristics of the lesion.

This case highlights the diagnostic and therapeutic challenges posed by a massive perioribital VM in a newborn. It underscores the need for correct terminology and appropriate imaging to ensure correct diagnosis and management.

March 10, 2013 at 7:23 am

robingjones@gmail.com

We report a case of a large trans-orbital foreign body missed on plain film, causing globe indentation

Case report

A 48 yr old male was thrown from his mountain bike at 20mph, striking his face against a tree stump. He retained consciousness with full recollection of events including a brief episode of epistaxis and a persistent sore throat.

Plain films were requested by ED and reported by a consultant radiologist. No fractures were seen. A right sided, 1cm infero-temporal sub-cilliary lid laceration and sub-conjunctival haemorrhage prompted referral to ophthalmology.

Eye movements were full but with pain on up-gaze. No orbital rim steps were felt and infra-orbital sensation was intact. Intraocular pressures measured 20mmHg OD and 10mmHg OS. Indirect ophthamoscopy OD showed a large equatorial, infero-temporal scleral indent.

CT imaging revealed a 10cm x 0.8cm low-density foreign body, consistent with wood. The stick passed inferior to the globe, beneath inferior rectus and through a comminuted orbital floor fracture. It then traversed the maxillary sinus, crossed the right nasal cavity and anterior nasopharynx, and came to rest in the left parapharyngeal space 12mm from the left internal carotid artery.

Systemic antibiotics were given and the stick was removed through an extension of the skin laceration under general anaesthesia with maxillo-facial surgical input. The patient was orthophoric post-operatively and was allowed home 48 hours later.

This case provides further evidence that plain films are of limited use in their ability to delineate orbital fractures, radiolucent foreign materials and soft tissue structures. Epistaxis without direct trauma to the nose and the possibility of a retained foreign body should prompt urgent CT imaging.

March 10, 2013 at 7:53 am

aruna_dharmasena@hotmail.co.uk

To discuss the previous literature on intra-ocular calcification and present a case of uniform calcification of the choroid in its entirety found during an evisceration procedure.

Literature review in English Language Literature on Sclero-Choroidal Calcification and presentation of a case.

Calcifications in the choroid can be due to systemic diseases such as pseudohypoparathyroidism or due to local pathology such as choroidal osteoma or ‘idiopathic sclerochoroidal calcification’. Although potentially dystrophic calcification could occur in any degenerated or necrotic tissue, it also usually leads to a focal or multifocal ossification of the affected tissues which can usually be detected microscopic assessment of these tissues. We report a case of uniform ‘shell like’ calcification of the entire choroid which was removed in its entirety during a evisceration procedure in a patient suffered from childhood uveitis, cataract, retinal detachment, band keratopathy and bacterial keratitis.

Although focal or multifocal choroidal calcification has previously been published as a rare finding in otherwise healthy patents, total choroidal dystrophic calcification has not been reported to our knowledge. In addition, to the best of our knowledge, this is the only case with histopathological analysis of dystrophic sclero-choroidal calcification in the literature.

March 10, 2013 at 10:38 am

olivmac9@hotmail.com

Vacuum assisted closure (VAC) was first described to assist the wound healing environment of complex wounds. Using a photographic surgical series we describe a case of orbital exenteration in which a split thickness skin graft was used to line the orbital cavity. We demonstrate how a vacuum assisted closure dressing was applied to assist with skin graft take. This is a follow on case from the original paper from our unit published in 2003.

A 69 year old man with recurrent basal cell carcinoma of the medial canthal region underwent multiple surgical excisions over the course of 8 years. The recurrent tumour became invasive of the medial orbit and exenteration was then carried out. A fenestrated split thickness skin graft was applied to the wound bed. The vacuum dressing was set at a continuous pressure of 60mmHg for 5 days.

The procedure was well tolerated by the patient and the skin graft is currently taking well. In this photo series we demonstrate the application of a vacuum assisted dressing.

The orbit is a challenging area for skin grafts as haematoma and wound fluid collection may impede skin graft from taking. We photographically demonstrate the application and advantages of vacuum assisted closure in successful skin grafting of the orbital cavity following exenteration. This is a useful method in complex wound healing.

March 10, 2013 at 11:58 am

anumaudgil@hotmail.com

To describe cases including histopathology of this rare malignant neoplasm of sweat glands in the eyelid

Case report including clinical photographs and histopathology

Photographs of surgical management and reconstruction will be shown

Apocrine adenocarcinoma is a rare neoplasm in the eyelid. This presentation therefore gives uncommon insight into it’s appearance, histopathology and management.

March 10, 2013 at 12:38 pm

anuradhajayaprakasam@hotmail.com

To examine the features and management of exenteration patients presenting to a tertiary referral centre.

A retrospective case notes review of exenteration surgery undertaken at Moorfields Eye hospitals over the 15 year period 1997 – 2012 was conducted. Patient demographics, referral sources, history, clinical features, neuro-imaging, histopathology, clearance, surgery, adjuvant therapy and outcomes including recurrence and survival were recorded and analysed.

41 exenterations (22 female), performed by 7 consultants, were identified. Mean age at exenteration was 64 years (range 13 – 87 years). The commonest presenting feature was a lump (32%), others included diplopia, enophthalmos, proptosis, bleeding, and distorted periocular anatomy. Primary tumour sites included orbital (27%), conjunctiva (22%), upper lid (20%), lower lid (17%) and lateral canthus (7%). The majority of exenterations were for recurrent tumours (61%). Pathologies included sebaceous cell carcinoma (29%), melanoma (20%), basal cell carcinoma (17%), and squamous cell carcinoma (12%). 71% of patients had lid sparing exenteration with direct closure. 1 healed by secondary intent. 12% required local skin flaps. No adjuvant therapy was required in 49% of patients, 29% had radiotherapy and 2% had chemotherapy. 5 patients (12%) had recurrence between 22 months and 7 years post exenteration. 37 (90%) patients survived at the end of their follow up period, 1 patient died 2 years post exenteration of metastatic cancer.

Exenteration was performed most commonly for tumours originating in the lids. The commonest pathology was sebaceous cell carcinoma. 71% of patients underwent lid sparing exenteration. Only 12% had recurrence occurring from 22 months to 7 years post exenteration.

March 10, 2013 at 2:54 pm

kim.z@doctors.org.uk

To determine the overall success rate of the surgical management of functional epiphora and assess the role of lacrimal scintigraphy

A retrospective review of 26 eyes (22 patients) with functional epiphora that underwent lacrimal scintigraphy (LS) and subsequent surgery was carried out. Patients with symptoms of epiphora, normal lid position, adequate puncta, no ocular surface disease, normal nasal examination, and patent lacrimal systems on syringing were included. Success was defined as patient satisfaction and resolution of symptoms.

The average follow up period was 6.7 months. LS findings were abnormal in 88%, 14/26 showed nasolacrimal duct obstruction, 9/26 showed pre-lacrimal sac delay and 3 were normal.

The overall success rate at the last follow up was 65%, 71% in the postsac delay group and 56% in the presac delay group. 7/10 in postsac group with successful outcome had DCR while in 3/10 lower lid tightening resolved their symptoms.

In 5/17 successful cases, LS suggested a different course of action compared to the procedure that was undertaken. In 8/9 unsuccessful cases the procedures undertaken based on LS reports failed. Overall, in 12/26 eyes LS findings were helpful in achieving a successful outcome, in the remainder LS reports did not contribute to the outcome.

Achieving satisfaction in patients with functional epiphora can be challenging. It is important that clinicians have an estimate of their success rate when counselling these patients for surgery. Although LS findings contributed to a successful outcome in less than 50% of the affected eyes in this study, the small number of patients and the retrospective nature of the study should be taken into account.

March 10, 2013 at 4:59 pm

nikocha@hotmail.com

To present a novel surgical technique benefiting patients with concomitant lower lid fat prolapse and post-enucleation-related sunken upper eyelid sulcus.

Observational two-case series. Two patients with moderate to severe post-enucleation hollow sulcus and coexistent lower lid fat prolapse are presented. A novel surgical technique employing autologous fat transposition from lower to upper lid is described. Surgery included a standard bilateral transconjunctival lower lid blepharoplasty with fat removal from all three fat compartments followed by transpalpebral transplantation of the autologous fat to preaponeurotic space of upper lid sulcus. Upper lid crease reformation was carried out at the end of the operation.

Initial overfilling, soft tissue oedema and ptosis improved progressively, while adequate volume enhancement and smooth eyelid contour was observed in both cases at 6 months post-op. Patients’ satisfaction was also remarkable. No severe complications were noted.

The described technique seems to provide adequate and predictable upper lid volume enhancement in anophthalmic sockets when lower lid fat-blepharoplasty is scheduled.

March 10, 2013 at 5:50 pm

AnchalKailey@aol.com

Ophthalmic surgery accounts for 7 percent of all NHS operations. With an increasing ageing population, the ophthalmic workload will continue to grow and with increasing pressure on the NHS to be more cost effective, it is vital that ophthalmic services are also as cost effective as possible. An audit was carried out to assess the extent of patient cancellation rates for oculoplastic surgical procedures and to find ways of reducing this.

A retrospective case note review was conducted for all non-attending patients to oculoplastic procedures between June and August 2011. Telephone interviews were conducted to further establish reasons for non-attendance and using a standardised proforma, data was collected and analysed.

Data collection from the retrospective cycle revealed a non-attendance rate of 3 percent. After implementing changes such as having a standby list of patients able to attend unexpected cancellation slots, a prospective collection between October and November 2012 was carried out. A cancellation rate of 8 percent was obtained, primarily due to uncontrollable factors such as, patients being unwell on the day of surgery. This difference may be attributable to the time of year the second cycle of data was collected.

Unexpected cancelled theatre slots are inevitable. Our audit identified both controllable and uncontrollable factors are responsible for non-attendance. Implementing simple practices can reduce controllable factors and therefore maximise utilisation of theatre lists. As a further recommendation, patient leaflets have been re-written to encourage patients to give as much notice as possible if they are felling unwell. A re-audit will commence to monitor the effect of these changes.

March 10, 2013 at 5:52 pm

nikocha@hotmail.com

To report a very rare case of blunt ocular trauma, involving dispersion of pressurized heavy-duty lubricants into the orbit. Diagnostic approach and surgical management are presented.

A 62-year-old man was referred to our department after a serious occupational accident. The patient sustained a blunt orbital injury caused by pressurized heavy-duty lubricants in his right eye. Visual acuity was 10/10 bilaterally. However, the patient complained of painful eye movements with aggravation of pain and evident diplopia on adduction. Apart from the blunt conjunctival trauma and the diffused injection, the anatomy of the eye remained undisturbed. Clinical examination and MRI findings were confirmatory for trans-conjunctival dispersion of the lubricant into the orbit.

The patient underwent a trans-caruncular orbitotomy with cleavage of the intraconal space and removal of the lubricant with the use of intense irrigation and suction. Medial rectus fascia was also found invaded by the same substance and dissected longitudinally. Improvement of eye movements and alleviation of pain were noted within the first post-op days. At 3 months follow-up, a complete recovery from the orbital trauma was noted.

The complexity of the forces developed in such injuries, as well as the nature of the involved substance, is considered essential for their management and outcome. Machinery lubricants have oily structure and appear to be lighter than water, and, therefore, irrigative washout is strongly recommended while patient in supine position at the operating theatre.

March 10, 2013 at 6:03 pm

Lbagdonaite@yahoo.com

Conjunctivodacryorhinostomy with insertion of a bypass Lester Jones tube is effective in treating epiphora due to canalicular failure. We report our experience of Jones tube placements over a 10 year period with comparison of plain and frosted tubes.

Case notes review of a single surgeon consecutive series of patients having Jones tubes placed in 2002-2011.

94 tubes (76 % plain, 24% frosted) were inserted in 58 eyes of 47 patients.

Mean age of patients was 59 years (range from 10- 89 y.).

24 males, 23 females.

Indications for initial LJT insertion were: canalicular obstruction 54% and patent non-functioning DCR 46%.

85% of first tube placements were secondary to prior lacrimal surgery, 15% were primary placement.

After follow-up with a mean of 24 months (range 0.5-108 months) there were no complications in 41% of all tube insertions.

Patient satisfaction was 85%.

A complication requiring at least one tube replacement occurred in 50% of eyes, the most common complications being extrusion 31%, medial tube migration 10%, and conjuctival overgrowth 7%.

The extrusion rate was similar in frosted and plain tubes (29% v 33%) but the mean interval to extrusion was shorter in frosted tubes (6 months v 11). The rates of medial migration/conjunctival overgrowth were not significantly different (19% v 18%) but the interval was shorter in frosted tubes (21 v 25 months).The mean interval to tube replacement for any cause was shorter in frosted than plain tubes (11 v 16 months).

Although patient satisfaction with LJT surgery is high, complications, especially extrusion, are frequent. Frosted tubes do not appear to protect against tube displacement and are associated with earlier complications.

March 10, 2013 at 6:09 pm

nickmaycock@yahoo.com

To assess patient reported outcomes (PRO) following ptosis surgery (anterior advancement of levator aponeurosis) at a UK district general hospital.

65 consecutive procedures were analysed via a retrospective case-note review. Demographics, pre-operative measurements, type of procedure, post-operative measurements, complications and reoperation rate were recorded. PRO’s were recorded using Glasgow Benefit Inventory (GBI) via a telephone interview. The GBI is an example of a patient-reported, questionnaire-based, post-interventional quality of life scale that has been validated for use in oculoplastic surgery.

65 ptosis operations (32 right, 33 left upper lid; 21 patients had bilateral surgery) on 41 patients (18 male; 23 female) (November 2008 – December 2010). Median age 77 years (range: 17-95). Complications: 3/65 (4.6%) lid too high x1, lid too low x1, wound dehiscence x1. Redo rate: 2/65 (3.0%). The mean total GBI score for ptosis surgery was +62.12 (range 45.83-79.16) (95% confidence interval: 59.04-64.84, P 0.05).

Patients derived significant quality of life benefits from ptosis surgery that was maintained for up to 5 years following surgery.

March 10, 2013 at 7:50 pm

lonajawaheer@doctors.org.uk

To assess parental satisfaction with outcome of ptosis surgery in children with congenital ptosis.

A postal questionnaire survey was conducted to assess the satisfaction of parents whose children had undergone ptosis correction at Royal Hospital for Sick Children (Yorkhill). Questionnaires were posted out to the parents with enclosed pre-paid envelopes. The questionnaire addressed the type of surgery and the level of satisfaction with the outcome soon after surgery and at present, using a Likert scale from 0 to 5.

88 children underwent 128 ptosis repair operations over the last 8 years. 43.2% (n=38) of the questionnaires posted out to the parents were completed and returned within 4 weeks. Of these, 73.7% had undergone surgery more than 2 years ago. 5.2% had undergone ptosis repair more than once. 57.9% of the children had brow suspension surgery and the rest had levator advancement. 44.4% of children had a chin-up/head-tilt posture prior to surgery and of these, 87.5% had a resolution of these symptoms following ptosis surgery. The percentage of parents who had a satisfaction score of more than 2.5 out of 5 was 89.5% at 6 weeks after surgery, and 86.1% at present. Mean levels of satisfaction with the outcome, both at 6 weeks after the surgery and at present, were slightly higher in the group who had had brow suspension surgery (4.0 and 3.8 respectively) than those who had had levator advancement (3.7 and 3.3 respectively).

The majority of parents noted a favorable outcome from ptosis surgery. Brow suspension surgery would seem to yield higher levels of satisfaction than levator advancement as expressed by the parents.

March 10, 2013 at 8:23 pm

taz500@hotmail.com

Most swellings at the medial canthus are lacrimal sac mucocoeles, these typically presenting below the medial canthal tendon (MCT). However, malignant tumours, which can also present in this region, often extend above the MCT.

This study reviews the histology of masses presenting at the medial canthus, and determines the sensitivity and specificity of this location for malignancy.

This retrospective study reviews, over a 10 year period in one institution, the histology of all patients undergoing biopsy for an atypical medial canthal mass (ie atypical for mucocoele). Associations were sought between the histological diagnosis and location of the lesion relative to the MCT.

29 patients were included, of which 9 (31%) presented with swelling wholly beneath the MCT (group A), and 20 (69%) with swelling extending above the MCT (group B).

In group A, pathology was benign in 5 (56%), and malignant in 4 (54%).

In group B, the figures were 7 (35%) and 13 (65%) respectively (p=0.4, Chi2; odds ratio = 4.55).

Of the 17 with malignancy, in 13 (76%) the mass extended above the MCT. Diagnoses included lymphomas (9/17), and carcinomas (transitional cell (4/17), adeno, adenoid cystic, squamous cell, & mucoepidermoid). Of the remaining 4 in whom the mass was below the MCT, 2 had significant lateral globe displacement.

These data give a sensitivity and specificity for mass location above the MCT being malignant of 76% and 42% respectively. When ALL medial canthal swellings are considered, including lacrimal mucocoeles, the odds ratio for swelling above the MCT being malignant rises to 322 (p<0.0001)

Medial canthal lesions extending above the MCT should be considered to be malignant until proven otherwise.

March 10, 2013 at 8:28 pm

dockimo@hotmail.com

To evaluate our one stop temporal artery biopsy service, which began in June 2010. It allows any clinician to book a pre-reserved slot in our day surgery theater for a temporal artery biopsy (TAB) directly through our booking clerk. A special proforma has been developed for this purpose that needs to be filled by the referring doctor.

Retrospective review of case notes of patients who were booked for TAB using this service from June 2010 till October 2012. Parameters looked for were: waiting times, department of origin, proportion of patients treated with steroids prior to biopsy, surgical details, size of biopsy specimen, complications of surgery and histopathological results of biopsy.

One hundred patients were booked and 98 had TAB in this period. We had 25 positive biopsies confirming giant cell arterits, 68 negatives, 4 reported as other pathologies and 1 non arterial biopsy.

Most common requesting department was rheumatology with 48 referrals followed by ophthalmology with 30 referrals.

The mean length of biopsies was 14.4 mm with no significant difference in length between positives and negatives.

No significant complications were encountered from the procedure.

We believe that One Stop Temporal Artery Biopsy service provides a high quality care and has many advantages for patients and clinicians alike.

March 10, 2013 at 8:32 pm

nuhaq1@gmail.com

To assess the use of botulinum toxin (Botox, Allergan Inc., Irvine, CA, U.S.A.) injections into the lacrimal gland in the treatment of symptomatic gustatory lacrimation (crocodile tears) following aberrant regeneration of the facial nerve.

We carried out a retrospective review of 20 consecutive patients undergoing botulinum toxin injections into the lacrimal gland between 1999 and 2012. All patients had symptomatic gustatory lacrimation from aberrant regeneration of the facial nerve. Patients underwent either percutaneous or transconjunctival injection of 1.25 to 5 units of botulinum toxin into the lacrimal gland. Patients were reassessed at 2 weeks for subjective effect of treatment and complications. An increased dose of a further 2.5 units was injected if there was poor initial response. Patient reported effect on symptoms, complications and duration of treatment were all assessed.

Duration of treatment ranged from 3 months to 12 years. Mean age at treatment was 64.4 years. The median initial dose was 2.5 units which was injected in 80% of patients. 13 of 20 patients (60%) reported an improvement in lacrimation at their initial follow-up visit. 60% of patients described temporary unintended local effects of botulinum toxin, most commonly mild ptosis occuring in 55% of cases.

To the best of our knowledge, this is the largest series with the longest follow-up assessing lacrimal gland botulinum toxin injections for gustatory lacrimation in the literature. Our study suggests that this is a well tolerated, effective treatment for gustatory lacrimation. We found a high degree of patient satisfaction despite a significant level of temporary unintended local effects.

March 10, 2013 at 8:55 pm

dockimo@hotmail.com

Lymphoma is also known as the great masquerader. In our case reports, we aim to highlight the fact that it can present to the clinician taking the form of other fairly common benign conditions.

Retrospective review of case notes.

We present two cases referred to the oculoplastic service at Sheffield Teaching Hospital with seemingly innocent presentations.

The first patient was referred for having bilateral upper lid dermatochalasis. On examination she was found to have significantly thickened skin of both upper lids. She underwent bilateral blepharoplasty and the excised skin sent for histopathological analysis. To our surprise it showed a cutaneous T cell lymphoma.

The second patient was referred for a unilateral lower lid entropion.

During the surgery, the surgeon noticed the presence of a firm swelling at the conjunctival side just inferior to the lower punctum. A biopsy was sent and revealed a mucosa associated lymphoid tissue (MALT) B cell lymphoma.

Common oculoplastic presentations with atypical features should raise the suspicion of the clinician. Low threshold for sending specimens for histopathological analysis is required as the diagnosis can easily be missed.

March 10, 2013 at 9:01 pm

nuhaq1@gmail.com

To assess the outcomes of orbital rehabilitation surgery augmented with lateral orbital wall advancement for severe proptosis in adults.

We assessed 16 eyes of 9 consecutive patients who underwent three-wall orbital decompression with adjunctive lateral wall advancement for severe proptosis between 2006-2012 at Leicester Royal Infirmary. Proptosis was due to either Graves’ orbitopathy or Crouzon syndrome. Indications for surgery were either sight threatening proptosis or to improve cosmesis. Lateral orbital wall advancement was performed by osteotomy, advancement of the lateral wall and osteosynthesis using the Leibinger Universal Mini Plate system (Stryker Leibinger GmbH, Freiburg Germany). The primary outcome measure was patient reported outcome of surgery. Secondary outcome measures included change in Hertel exophthalmometry, change in symptoms and complication rate.

The median age at time of surgery was 30.5yrs. All patients were female. All patients reported a high level of satisfaction with the results of surgery. The median preoperative exophthalmos was 30mm, median postoperative exophthalmos was 21mm, the mean reduction in exophthalmos was 7.7 mm (95%CI 6.1-9.3mm) with Hertel exophthalmometry. No patients reported post-operative diplopia. Three patients required revision surgery; 1 patient required revision of a migrated plate, two required removal of prominent plating screws.

Three-wall orbital decompression surgery combined with advancement of the lateral orbital wall is a useful technique in reducing apparent proptosis. Patients reported a high level of satisfaction with the outcome of surgery which also resulted in a large objective reduction in apparent proptosis.

March 10, 2013 at 9:06 pm

elizabethhawkes4@gmail.com

The OTS, defined by the United States Eye Injury Registry (USEIR), classifies ocular injuries and expected visual outcome. A score between 0-100 is calculated on the basis of visual acuity (VA) and injury severity at presentation in order to predict visual prognosis. A score of 100 has the best visual prognosis.

We wished to determine a) whether the OTS predicts visual outcome reliably b) whether individuals eventually undergoing evisceration could be identified earlier in their care pathway, based on their OTS score.

A retrospective calculation of the OTS on all penetrating eye injuries over a 10 year period was conducted at a UK District General hospital. OTS predictions and actual VA outcomes were compared and the sensitivity and specificity of the OTS was calculated.

62 patients were classified according to the OTS with the average score being 68.23. Evisceration was performed in 6.45% (4/62) of patients. Of 8 patients with the lowest OTS (category 1, raw score between 0-44), 1 had a final VA of 6/12 or better, 2 had a vision of hand-movements (HM) to perception of light and 5 resulted in no perception of light vision. None of these 8 patients underwent evisceration. The sensitivity to predict no vision (OTS:1 and VA of HM or worse) was 24%. The specificity to predict visual survival (OTS>1 and VA of HM or better) was 94%.

Our study indicates that the OTS has low sensitivity to predict visual outcome but does have high specificty. It does not accurately identify those requiring evisceration. The OTS is a useful tool to counsel patients on visual prognosis following ocular trauma and we therefore advocate its use in clinical practice.

March 10, 2013 at 9:14 pm

farhanqureshi101@hotmail.com

To compare outcomes of silicone thread versus polypropylene frontalis suspensions

Retrospective review of synthetic frontalis suspension procedures 2008-2011 at Manchester Royal Eye Hospital

35 procedures on 34 eyes in 27 patients were reviewed. There were 9 procedures in the silicone group and 25 in the polypropylene. The mean age of our silicone group was 30.6 years and polypropylene 32.2 years. The most common aetiology was congenital ptosis with 9/25 (36%) in polypropylene group and 6/9 (66.6%) of the silicone group. The mean overall follow-up period was 1.2 years (range 2 months – 4.5 years). Mean 1 month outcomes for palpebral apertures were 7.8mm in the polypropylene group and 6.25 in the silicone and upper margin-reflex distances were 2.1mm for polypropylene and 1.25 for silicone. Complications were noted in 15/33 eyes (45%). In the silicone group there were 3 (30%): 1 over-correction, 1 wound infection and one epithelial defect. In the polypropylene group there were 12 complications (48%): 5 punctate keratopathies, 4 significant droops, 2 lagophthalmos and one exposed suture. Seven patients needed repeat surgery in the silicone group (5/7 were adjustments of the silicone thread to alter the lid height). Five needed further surgery in the polypropylene group, 4 of which were redo procedures.

Patients requiring frontalis suspension have a higher risk of potential complications from surgery to correct their ptosis. The procedure has a significant complication rate. The ability to adjust a silicone thread makes it a safer procedure. Patients having silicone thread surgery had a less effective raising of their lid height after the initial procedure. They needed further surgery more often but this was mainly to make a minor adjustment to the silicone thread to improve the lid height or contour. Silicone thread frontalis suspensions had a lower rate of exposure keratopathy and other complications compared to polypropylene frontalis suspensions.

March 10, 2013 at 9:19 pm

estherpapamichael@doctors.org.uk

As Graves’ hyperthyroidism (GH) occurs before or is concomitant with Thyroid Associated Orbitopathy (TAO) in 80% of cases, it is vital for endocrinologists to identify the 10-15% of patients likely to benefit from active TAO management. Our aim was to investigate whether 1) Relevant questions are being asked to identify active and clinically severe TAO and 2) Risk factors for TAO progression were being identified during endocrinology consultations at a London District General Hospital.

Retrospective cohort review of endocrinology clinic letters of all GH patients over a 6 month period. We used the ‘Vancouver Orbitopathy Rule’ (VOR) (Mohaseb et al Orbit 2008), a validated screening questionnaire of 5 questions as the standard, and recorded the documented frequency of these symptoms.

Eighty endocrine consultations for 31 newly diagnosed GH patients were analysed. The most frequent question was whether the eyes had a staring appearance (10%). One in 3 positive responses initiated an ophthalmology referral. Questions about eye/eyelid redness (8%), eyelid swelling (6%) and blurred vision (3%) were documented. There was no enquiry regarding bags under the eyes. In 80% of consultations no VOR questions were asked. Five of the six patients referred to ophthalmology were diagnosed with TAO (16%). Endocrinologists were more likely to refer on the basis of their examination findings: restriction of eye movements (n=6, 100%) and proptosis (n=5, 83%). In 46% of GH consultations no eye examination was documented.

To increase timely ophthalmology referral of clinically severe and active TAO, we plan to introduce the VOR as a universal screening tool with our endocrinology colleagues in all thyroid clinics.

March 10, 2013 at 9:26 pm

farhanqureshi101@hotmail.com

To report the use of a BRAF kinase inhibitor along with a combined intracranial & orbital approach exenteration used to ensure complete excision of an isolated melanoma metastasis to the inferior rectus muscle.

A single case report

A 42 year old female presented with a 2 month history of diplopia and right hyperglobus. Relevant previous history included a cutaneous melanoma excised from her neck 18 years previously. A CT scan revealed a diffusely enlarged right inferior rectus muscle. Biopsy revealed a metastatic melanoma, positive for the V600E BRAF mutation. Her oncologist advised that BRAF kinase inhibitor therapy along with a complete excision of the solitary metastasis may improve her survival substantially. The patient was highly motivated to maximise her survival prospects. Six weeks pre-treatment with vemurafenib (a BRAF kinase inhibitor) resulted in a marked reduction in the metastasis. A frontal craniotomy was performed to divide the optic nerve and ophthalmic artery intracranially and to divide the contents of the superior orbital fissure in the anterior cavernous sinus. This enabled the orbital contents to be removed en-bloc via a lid-sparing orbital exenteration.

Histology confirmed complete excision of the metastasi with minimal margins so post-operative radiotherapy was advised. One further procedure was required 6 months post-op to close a skin defect and explore a benign cyst noted on a surveillance scan. There is no evidence of recurrence in the 11 months since her initial treatment.

This case illustrates how the combination of targeted therapy to reduce tumour size and increase operability, followed by radical surgery, were used to significantly increase this patient’s chance of cure.

March 10, 2013 at 9:34 pm

taz500@hotmail.com

Conjunctival sebaceous cell carcinoma (SebCC) is an aggressive malignancy which can present with solely intraepithelial disease, or as a discrete mass. Pagetoid spread is characteristic of SebCC, and describes intraepithelial tumour infiltration leading to skip lesions well beyond clinically apparent disease.

The purpose of this study is to examine histological tumour margins in SebCC exenteration specimens to identify the extent and frequency of distant pagetoid spread.

This retrospective case series includes patients undergoing exenteration for biopsy-proven SebCC over a 14 year period in one unit (MEH). The specimens were reviewed to determine the extent of tumour infiltration beyond the ocular surface.

29 patients were included, of whom 18 (62%) presented with solely intraepithelial disease and no discrete tumour mass. Of these, 5/18 (28%) had distant tumour infiltration on histological examination, with cells invading both the lacrimal gland AND lacrimal sac in 2 patients. Histology identified extensive, poorly differentiated intraepithelial SebCC with only small islands of invasive disease, indicating distant pagetoid spread. In contrast, such extensive spread was identified in only 2 of 11 patients (18%) with a discrete tumour mass.

Based on these data, over a quarter (28%) of patients presenting with solely intraepithelial SbCC can be expected to have extensive pagetoid spread extending to the lacrimal gland and/or sac. This has implications for exenteration surgery: in all cases, irrespective of the degree of surface involvement, great care should be taken to excise the exenteration specimen with the periosteum, lacrimal sac and proximal lacrimal duct intact to ensure complete tumour excision.

March 10, 2013 at 9:39 pm

tfayers1@gmail.com

To assess a range of measures of corneal pathology and corresponding sensory innervation patterns in blepharospasm patients. The identification of corneal pathology may open new avenues to treatment by modulating the sensory pathways of the abnormal blink reflex in blepharospasm.

20 blepharospasm patients and 20 gender and age-matched controls completed the standardized ocular surface disease index questionnaire and were examined for ocular surface disease, measured by tear osmolarity (Tearlab osmolarity system), Shirmer test, tear break-up time, National Eye Institute grading for assessment of ocular surface staining in dry eye, corneal sensitivity (Cochet-Bonnet aesthiometry) and confocal microscopy (Heidelberg Retina Tomograph II/Rostock Cornea Module).

The in-vivo confocal microscope was used to obtain 5 scans of central subbasal corneal nerves per eye. Three best quality images per eye were selected and they were analysed by a masked observer. The following nerve parameters were analysed: number of main nerve trunks, number of nerve branching, total number of nerves, nerve density, nerve tortuosity.

14 female and 6 male patients were recruited, with a median age of 64 years; control patients were matched within 3 years of age. Strikingly, a significant difference in aesthesiometry (p=0.01) was found between patients and controls. Abnormalities of nerve branching (p=0.03) in blepharospasm patients were identified with confocal microscopy.

This study demonstrates that abnormalities in corneal aesthesiometry and the morphology of the subepithelial corneal nerve plexus are features of blepharospasm. This is consistent with a growing appreciation that somatosensory abnormalities are part of the pathogenesis of dystonias.

March 10, 2013 at 9:45 pm

kunyin1982@yahoo.co.uk

To report our experience with anti-CD20 monoclonal antibody, Rituximab for the management of active corticosteroid-resistant severe thyroid associated orbitopathy (TAO).

A retrospective case series of patients jointly managed by the Orbital Service, Manchester Royal Eye Hospital and Endocrinology Department, Christie Hospital, Manchester. The first 5 patients receiving Rituximab were identified, followed-up post-treatment for a mean 24.2 months.

Five Caucasian patients were studied, 4 were females. The mean age was 47years. All had hyperthyroid disease, 1 was TPO Antibody positive. Four were smokers. Two patients had dysthyroid optic neuropathy.

The mean duration of TAO prior to steroid treatment was 15 months (range 0-48). The duration of corticosteroid treatment prior to Rituximab was 9.2 months (range 5-18).

The duration of TAO prior to RTX was 32 months (range 7-89).

Prior to Rituximab treatment, 2 patients’ disease progressed on corticosteroid, 3 had no clinical improvement. All received IV Methylprednisolone (3-11g), 1 had Azathioprine. Two underwent radiotherapy.

Four patients underwent surgical decompression. The mean CAS was 5.0 prior to corticosteroid treatment, increasing to 5.5 post therapy. 8 weeks after Rituximab treatment this reduced to 2.7, and at last follow-up this was 0. Three patients developed recurrent TAO symptoms during the follow-up period. One patient developed adverse reactions to Rituximab.

As a novel therapy it is difficult to comment on when Rituximab should be offered. Limited in numbers, our experience is that Rituximab offers an effective means of achieving targeted clinical improvement in patients with active severe TAO unresponsive to other therapies.

March 10, 2013 at 9:47 pm

mjsikuade@doctors.net.uk

Entropion is a common presentation in the occuloplastic clinic. The underlying aetiology of entropion is often benign. However, benign condition can sometimes mask more sinister pathology.We present two cases of lower lid entropion as a heralding sign of lymphoma and conjunctival intraepithelial neoplasia (CIN). These two cases are unusual aetiology of entropion.

A 70 year old woman and 91 year old man presented to the oculoplastics clinic with lower lid entropion. On initial assessment, both cases where consistent with involution entropion. However careful examinations revealed atypical features which prompted further investigations.

In one of the cases, thickened conjuctival tissue was noted in the inferior fornix. These changes were suspected to be inflammatory changes and biopsy of this area was taken during entropion repair surgery. Histopathology analysis of the specimen showed abnormal dysplastic epithelium consistent with conjunctival intraepithelial neoplasia. The second case had a diffuse swelling of the affected lower lid suspected to be a chalaizon. A decision was made to biopsy this swelling prior to listing for entropion repair surgery. Biopsy results showed MALT lymphoma.

This two cases show that Lymphoma and CIN can present as entropion. It also highlights the importance of careful examination to identify atypical features in seemingly benign ocular condition. Atypical features may be the only indication of more sinister pathology.

March 10, 2013 at 9:49 pm

devonshire.eye@gmail.com

This video demonstrates the fundamental photography techniques and standardized views in oculoplastic surgery outside a photographic studio.

A Canon EOS 60D digital single lens reflex (DSLR) crop sensor camera and a Canon 60mm USM macro lens were used in photographing the subject. Informed written consents were obtained from patients posing for the standardised photographs. The photographs were taken at various magnification ratios in-line with Westminster reproduction ratio.

We present a series of core views for various oculoplastic and orbital disease presentations as well as demonstrating how these photographs were taken in a busy out patient clinic.

It is possible to capture high quality standardized digital photographs in a busy clinical environment without the need for a dedicated studio.

March 10, 2013 at 10:00 pm

devonshire.eye@gmail.com

This video will introduce the types of cameras, lenses and flash system often used in oculoplastic photography. This video is for clinicians who want to take up the role of photographers but unsure what photographic equipment to buy.

The photographs of patients were taken with a Canon EOS 60D camera. Written informed consent was obtained from the patients. A calibrated Canon EF-S 60mm macro lens was used together with a Canon macro ring lite MR-14EX. The photographs were taken with at various magnification ratios in line with Westminster reproduction ratio. The camera was set to manual focus with an aperture value of f16, shutter speed of 1/200s and an ISO of 100. This camera and a Canon powershot G12 camera were used to shoot this video.

This video gives an overview of the types of digital cameras available to the consumer. The principle of standard representation photography is explained. The concept of full frame and crop sensor cameras will also be covered in detail. The lens choices, calibration of lenses, choice of lighting options and background set up will be included in this video.

The choice of photographic equipment for use in oculoplastic photography is very specific. A broad understanding of the types of camera, flash and lenses will help one choose the correct system for this purpose.

March 10, 2013 at 10:06 pm

poitelea.c@gmail.com

To describe the case of a 41 year old male who presented with 3 months history of a supero-nasal orbital mass which was subsequently diagnosed as palisaded myofbroblastoma.

Retrospective case report.Clinical and histopatological data were reviewed

The mass was excised via a skin crease incision and a yellow nodule 10x7x5mm was removed. Microscopy and immunohistochemistry testing showed the lesion to be myofibroblastoma. The histological features were similar to those of palisaded myofibroblastoma, which has been previously described in lymph nodes.

We describe the case of a palisaded myofibroblastoma which occured in the orbit. This entitiy has been described mainly in the lymph nodes and there is no orbital published case to dat, to the author’s knowledge.

March 10, 2013 at 10:24 pm

eyelidman@hotmail.com

Demonstrate effective technique for upper lid blepharoplasty

surgical technique demonstration with photos and videos

Effective pre and post op results selected from 1000 eyelids to date

The simple technique is to be recommended to an oculoplastic audience.

March 10, 2013 at 10:41 pm

onn912@gmail.com

To report our experience with paediatric endoDCR

Multicentre, retrospective, non-comparative study. Cases of paediatric endoDCR from 2006-2011 were included from 7 oculoplastic units. Patients over the age of 16 were excluded. The main outcome measures were: indication for surgery, demographics, previous interventions, intraoperative or postoperative complications, follow-up duration and success rate (defined as significant improvement of epiphora).

A total of 116 endoDCRs were performed for 103 patients. The mean follow-up period was 8 months (range 3 months-to-4 years), with 1 patient lost to follow-up. There were 48 males (mean age 5 years and 9 months) and 50 females (range of 4 months-to-16 years). There were a total of 98 cases of congenital nasolacrimal duct obstruction (84.5%) and 18 cases of acquired nasolacrimal duct obstruction (15.5%). Previous interventions included probing 75.9% (88/116), massaging 43.1% (50/116) and intubation 39.7% (46/116). There were no intraoperative complications. There was 1 case of postoperative pyogenic granuloma. There were no cases of postoperative infection and postoperative haemorrhage. 90% of procedures were considered successful. Complete symptom resolution was observed in 78% (90/116), significant improvement in 12% (14/116), partial improvement in 2% (2/116) and no improvements in 8% (9/116).

In our series, we demonstrated that endoDCR is a safe operation and has an overall success rate of 90% for paediatric NLDO.

March 10, 2013 at 10:43 pm

jonathanroos@cantab.net

To describe the preliminary results of a new surgical technique to treat intractable trichiasis.

Eight patients with intractable trichiasis were treated by a single surgeon at one centre. Following a deep lower-lid split through the grey line, a “bucket-handle” transposition of the lash line was performed. Subsequent healing of the lid margin was by secondary intention. Photographic images were obtained prior to surgery and at subsequent review appointments for comparison. Video is also available of the surgical technique.

Eight patients (3 males and 5 females, ranging in age from 46 to 80) have been followed for at least 5 months. The cosmetic and functional outcome was very satisfactory in all patients. There was no recurrence of trichiasis in this limited follow up time of up to a year, nor any other post operative complication.

To the best of our knowledge the “bucket-handle” lash line transposition described here has not been previously reported and appears suitable for cases of intractable trichiasis. This new procedure offers a number of advantages over current treatment options in that it is permanent, non-destructive, preserves lashes and does not lead to shortening of the lid margin. It can be performed using only a blade and single suture and may thus be suitable for areas of the world, including rural areas, where trichiasis may be common but resources remain limited. Towards this end, it is also relatively uncomplicated to teach and perform and may therefore be suitable for non-specialists. This procedure appears to provide a safe and effective alternative to other techniques such as rotation of terminal tarsus (Tarbut type) procedures.

March 10, 2013 at 11:03 pm

tfayers1@gmail.com

The TED-QOL has previously been validated to assess quality of life in thyroid eye disease. The aim of the current study was to assess its sensitivity to detect changes in quality of life in response to rehabilitative surgery.

Patients with thyroid eye disease undergoing rehabilitative surgery completed a pre and post-operative numerical rating scale questionnaire (the TED-QOL) enquiring about their overall quality of life, their ability to carry out activities of daily living and their satisfaction with their appearance.

38 patients with thyroid eye disease underwent 42 unilateral / bilateral operations (21 orbital decompression – 5 with concurrent lower lid raising; 6 squint; 13 mullerectomy, 1 lower lid raising, 1 blepharoplasty).

Pre- and post-operative mean scores for the three questions were 6.5 and 4.0 (paired t-test p<0.0001); 5.6 and 3.7 (p<0.0003); 7.6 and 4.3 (p<0.0001) respectively.

The TED-QOL is highly responsive to changes in quality of life resulting from rehabilitative surgery in thyroid eye disease.

March 10, 2013 at 11:16 pm

nazraoof@hotmail.com

To identify the risk factors, management options and prognosis of patients who develop eyelid involvement from invasive/ in situ conjunctival melanoma.

A retrospective review of patients treated for conjunctival melanoma at the Sheffield Ocular Oncology Centre between 1994 to date.

Nine patients with eyelid involvement from conjunctival invasive/ insitu melanoma were identified.

In 6/9 patients (67%), the conjunctival melanoma was in the medial canthal location.

7/9 had some eyelid pigmentation present at the time of diagnosis of the conjunctival lesion; 2/9 developed lid pigmentation during follow up.

5/9 patients developed invasive and 4/7 in situ melanoma of the eyelid.

2/9 patients also had concurrent involvement of the lacrimal system.

Treatment strategies will be discussed.

2/9 patients developed systemic metastasis and both had been referred with incomplete excision of eyelid and conjunctival lesion from elsewhere.

2/9 patients needed exenteration; one at diagnosis and one for an aggressive recurrence of disease 17 years after the initial presentation. Local control of disease has been achieved in the remaining 5/9 patients.

Conjunctival melanomas in the medial canthal location carry a higher risk of eyelid involvement. Eyelid changes should be specifically looked for as these may be present as non-contiguous field changes.

We recommend a low threshold for biopsy and local treatment of eyelid lesions with close monitoring while managing conjunctival melanomas.

Eyelid involvement in conjunctival melanoma denotes T3b stage (7th ed AJCC); and unless treated aggressively may carry a poor outcome and should be promptly referred to a specialist ocular oncology centre.

March 10, 2013 at 11:22 pm

docpsharmila@yahoo.com

We intended to assess the surgical outcomes of lateral tarsal strip with medial tarsoconjunctivoplasty (LTS with MTC) in lower lid involutional ectropion with lateral laxity

We prospectively studied all the patients that needed corrective procedure for lower lid ectropion at our hospital from November 2010 to October 2011. Patients with both lateral canthal tendon laxity and punctal ectropion were included in the study. LTS with MTC was performed on all these patients by three surgeons. 5-0 Ethibond or 5-0 Vicryl was used for suturing as per surgeon’s preference. Patient satisfaction was assessed up to a minimum period of one year.

Sixty two eyes of 53 patients had corrective surgery for lower lid involutional ectropion. Two patients with recurrent ectropion were excluded. Only 47 lids of 38 patients had both lateral canthal tendon laxity and punctal ectropion and so underwent LTS with MTC for correction. 20 were males and 18 were females. Mean age was 77 (range 55 to 101). Ethibond was used in 34 lids and Vicryl in 13. Three patients developed wound infection and only one of these grew Staphylococcus Aureus in the wound swab. Ethibond was used in one lid and Vicryl in the two other. All were treated successfully with a one week course of oral antibiotics. Lid position was satisfactory in all patients. No patient had lateral canthal tenderness

Lateral canthal laxity with punctal ectropion is common situation (79%) in involutional lowerlid ectropion. Lateral tarsal strip with medial tarsoconjunctivoplasty results in satisfactory lid position in these circumstances. Usage of Vicryl for suturing may increase the risk of infection.

March 10, 2013 at 11:29 pm

lindawiboe@dadlnet.dk

To present a surgical technique that addresses anterior lamella shortening causing an evertion of the lower punctum with subsequent medial epiphora.

We describe a surgical technique for punctal ectropion with minor cicatricial features and report examples.

The procedure involves a Z-plasty below the lower punctum combined with a medial retractor reinsertion and lateral canthopexy. The central limb of the Z-plasty is aligned vertically and placed directly below the punctum. The length of the central limb is tailored to the degree of anterior lamella shortening. A traditional 60⁰ angle Z-plasty results in a 75% lengthening of the central limb. The medial retractor reinsertion is performed as a medial spindle with reinsertion of the medial retractor with a Vicryl 5-0 extending out through orbicularis. Over this, the Z-plasty is closed with a Prolene 6-0.

The objective of this procedure is to lengthen the skin in the direction of traction and to release vertical cicatricial contraction at the expense of the horizontal vector.

Pre-and postoperative assessments includes evaluation of epiphora and dry eye, anterior lamella and punctum assessment. The main outcome measures include improvement of subjective and objective epiphora, position of punctum and amount of scarring.

We present an intraoperative photographic sequence together with preoperative and postoperative photos. Success was noted in terms of all of the outcome measures. No complications were recorded.

The technique described is an efficient and successful approach for patients with punctal ectropion due to minor cicatricial tension, foregoing the need for skin grafting. We believe patient selection is key in achieving success.

March 10, 2013 at 11:44 pm

brankamarjanovic@doctors.org.uk

To investigate the outcomes following a combined “one-stage” explant-implant procedure in patients presenting with orbital implant exposure following previous evisceration or enucleation surgery.

A retrospective review of patients (1992-2012) presenting with orbital implant exposure, without evidence for socket infection, who underwent “one-stage” explantation with simultaneous implant insertion procedure. The patients were managed at one institution, by two authors (GER and DHV).

Records were available for 44/48 patients. The type of original exposed implant was recorded in 41/44 cases: hydroxyapatite (18/44,41%), Castroviejo (13/44, 29%), Roper-Hall (3/44,7%), porous polyethylene (3/44,7%), and one each of a acrylic, glass sphere, nylon mesh and prosthetic bone. Despite conjunctival loss and inflammation, a replacement implant was successfully placed in all cases: acrylic ball 33/44 (75%), a merseline implant 6/44 (13%) and a medpor implant 1/44 (2%). The mean follow-up period was 39 months (range 3 to 168 months), and during this time, there were no cases of socket infection or implant extrusion. 4/44 (9%) patients required subsequent socket surgery (fornix reconstruction and orbital floor implant).

One-stage “explant/implant” surgery for exposed orbital implants would appear to be very effective and not associated with subsequent ball exposure. The principles in managing such patients are identical to those in primary surgery: that is, deep placement of the intraconal implant, without any tissue drag into the depths of the socket. Where there is inadequate residual sclera, such implants should be wrapped to reduce the risk of postoperative implant migration.

March 11, 2013 at 12:10 am

jonathanroos@cantab.net

To describe a case of lacrimal sac squamous cell carcinoma metastasing to the cavernous sinus a year after dacryocystorhinostomy and resulting in a VIth nerve palsy.

Single Case Report

A 44 year old woman had routine dacryocystorhinostomy at a district general hospital after presenting with epiphora of 1 years duration. Symptom persistence led to referral to a tertiary centre where an underlying malignancy was suspected and confirmed on excision biopsy. Subsequent MRI confirmed metastasis to lymph nodes but clear cavernous sinus. Despite radical neck dissection and 35 radiotherapy sessions to the periocular tissues the patient re-presented within eight months with a partial VIth nerve palsy. MRI revealed cavernous sinus infiltration and internal carotid artery narrowing due to compression by tumor.

Lacrimal sac tumors are rare but of those originating there more than 50% are malignant. A variety of cell types have been reported, including squamous cell carcinoma. Patients can present with painless epiphora and usually proceed to surgery without imaging. The intraoperative appearance of the sac is therefore key to establishing a diagnosis and some surgeons routinely send all excised material for histological evaluation. Failure to diagnose these tumors early can result in direct invasion of surrounding tissue as well as secondary spread to lymph nodes and intracranially. This tragic report should serve as a reminder for oculoplastic and lacrimal surgeons to maintain a low index of suspicion for requesting imaging as well as histological confirmation when treating lacrimal disease.

March 11, 2013 at 12:13 am

hughdeburg@gmail.com

Geometric staged excision of lentigo maligna melanoma and lentigo maligna is well established as a technique that provides low recurrence rates and optimal tissue preservation. The technique has been applied to peri-ocular neoplasms. We describe our experience using Johnson’s square technique.

Using illustrations and photos from a number of patients with lentigo maligna we describe this type of staged excision. Straight-sided biopsy of tissue surrounding a lesion is repeated until clearance is demonstrated on paraffin sections. The remaining central island of tissue is excised and the defect reconstructed in a single operation at a later time. We also describe pre-operative features, outcomes, and the relative merits of alternative surgical treatment options.

Case one had lentigo maligna in the upper lid, with clear margins at stage one and reconstruction with a Tenzel slide and rotation flap. Case two required two stages for clearance of margins of a lateral canthal area lentigo maligna, and had reconstruction with a Mustardé flap. Case three had a single stage excision of margins for lentigo maligna of the lower lid, with reconstruction by Hughes’ flap.

Johnson’s square technique is applicable to peri-ocular lentigo maligna and lentigo maligna melanoma, and its use in combined treatment by dermatologists and oculoplastic surgeons can lead to good cosmetic outcomes.

March 11, 2013 at 12:14 am

agoawalla@gmail.com

Exposure keratopathy and dry eye are recognised features of Graves’ orbitopathy (GO), often associated with other autoimmune diseases. However, prominence of the eye is not always obvious to a clinician who has not previously seen the patient. This presentation aims to illustrate this point, which has important implications for treatment when patients present with atypical marginal keratitis or corneal ulceration.

Four patients with varied corneal ulceration are presented. The first, an elderly lady with simultaneous dysthyroid optic neuropathy. Two of the remaining three patients developed marginal keratitis with underlying exophthalmos Both were only subsequently diagnosed with GO.

A fourth patient presented with a bacterial corneal ulcer that subsequently perforated, and corneal ulceration in the second eye. Whilst this was initially attributed to rheumatoid dry eye, she was later noted to have exophthalmos and on further review, it transpired that she had developed prominent eyes due to active GO several years previously.

Treatments required in this series included orbital decompression, lid recession and tarsorraphy, all to address corneal exposure. These cases all illustrate the important role that exophthalmos and ocular surface inflammation due to GO can play in the aetiology of ocular surface disease. A literature review revealed a long-term follow-up study of GO showing that 72% of patients had dry eyes

Exophthalmos secondary to GO does not completely resolve, particularly in moderate to severe disease. This case series highlights the need to be aware of the long term vulnerability of the cornea particularly when there is associated autoimmune and meibomian gland disease.

March 11, 2013 at 12:47 am

antigoni_koukkoulli@hotmail.com

Tisseel, a commercially available fibrin biosealant, has been used in Europe for more than 25 years and new indications are constantly being described. We wish to highlight several innovative uses of Tisseel in oculoplastic and lacrimal surgery based on what has been published in the literature to date. We also present our experiences with the fibrin glue, with pre- and post-procedure images.

Medial canthal basal cell carcinomas are often difficult to manage cosmetically due to the surface concavity in the region and can result in bow-string scars. We have found that a modified Laissez approach using Tisseel allows for better approximation of wound margins on glue contraction, provides scaffolding for re-epithelialization and acts as biological bandage.

In patients with recurrent dacryocystitis who are either unfit for or decline any major intervention, we instead flush the mucocoele with cefuroxime and pack it with Tisseel. This technique prevents further recurrence of dacryocystitis but does not address the epiphora.

When initially attaching a free full thickness skin graft to the recipient bed we use Tisseel glue prior to suturing. This reduces the formation of haematomas and seromas, and possibly results in a less ‘bulky’ scar.

Finally, we would like to present a modified version of anterior lamellar repositioning using Tisseel instead of the traditional sutures to secure the anterior lamella to the posterior lamella. It achieves a more evenly distribution of forces and smoother eyelid eversion. This new surgical technique has not been previously described and allows for an improved cosmetic outcome and reduced surgical time.

No postoperative complications were seen. In all cases, we had excellent cosmetic outcome and high patient satisfaction

Tisseel has been used in adnexal and lacrimal surgery with success and our experiences at our unit support this. Tisseel improves surgical efficiency, cosmetic outcome and patient satisfaction.

March 11, 2013 at 10:33 am

antigoni_koukkoulli@hotmail.com

Silent sinus syndrome is characterised by painless enophthalmos associated with involution of the maxillary sinus after infundibular occlusion. There is often delay in diagnosis. We present a case series of three patients, highlighting the clinical and radiological features. We also present a novel approach of restoring orbital volume and reducing enophthalmos in silent sinus syndrome, using a custom-fit titanium mesh implant for true-to-original repair of the orbital floor.

A case series of three patients with silent sinus syndrome.

A 31 year old female presented with a right apparent ptosis and deep superior sulcus. MRI showed opacification of the maxillary sinus with inward retraction of its medial wall and loss of volume. The second case was of a 49 year old female with known hyperthyroidism. Thyroid eye disease was suspected as she had what appeared to be left proptosis and lid retraction when compared to the right. MRI revealed loss of right maxillary sinus volume with inward retraction of its walls and no evidence of thyroid eye disease. Case 3 was of a 64 year old male with right enophthalmos, deep sulcus and diplopia.CT showed retraction of the roof and medial wall of the right maxillary sinus with opacification.

For case 1, stereolithographic models of the orbits were obtained from CT. This allowed to better assess the bony abnormality, to plan surgery and will subsequently be used as a template to create a custom-fit titanium mesh implant.

Silent sinus syndrome should be suspected in patients with painless enophthalmos and facial asymmetry. In two of these cases, the radiological findings were missed by the neuro-radiologists. It is imperative to give a good history on requests and to personally review the scans.

March 11, 2013 at 10:52 am

a.dev-borman@ucl.ac.uk

To ascertain the range of histopathological diagnoses made from tissues removed during ophthalmic surgical procedures over two years from one NHS Trust. During this period, joint recommendations were published by the Royal College of Pathologists (RCPath) and the Royal College of Ophthalmologists (RCOphth) regarding the referral of ophthalmic pathology specimens, stating that in order to avoid delayed or missed diagnoses, with certain exceptions, all tissues obtained from ophthalmic surgical procedures should be sent for histopathological examination. This policy was implemented locally from January 2011.

This was a retrospective case note review of the ophthalmic histopathology specimens sent between January 2010 and December 2011, at the Mid Essex Hospital Services NHS Trust. Patient demographics and histopathological diagnoses were determined for each.

Over the two-year period, 268 specimens were sent for ophthalmic histopathological examination. In 2010, 112 samples were sent, with 18 malignancies detected (16.1%). In 2011, 156 samples were sent, with 30 malignancies identified (19.2%). The most common diagnosis was basal cell carcinoma, comprising 43/48 malignancies (89.6%).

Since the local implementation of the joint guidelines from the RCPath and RCOphth, there was an increase in the number of ophthalmic histopathology specimens sent within this Trust, with a 3.1% increase in the number of malignancies detected. We believe that this improvement in detection of ocular malignancies justifies the increased burden on the histopathology service from the ophthalmology unit within this Trust.

March 11, 2013 at 11:01 am

aeritchie@doctors.org.uk

Several schedules of corticosteroid therapy have been used to treat Grave’s orbitopathy and evidence based demonstration of the optimal regime is lacking. Our aim was to evaluate the evidence base for the use of corticosteroids in Grave’s orbitopathy and highlight potential variables impacting on response rates.

The Cochrane Central Register of Controlled Trials, Medline (1946 to present), Embase (1996 to present) and Eugogo publications were searched for clinical trials into the treatment of thyroid orbitopathy with corticosteroids. Randomized clinical trials evaluating the use of corticosteroids alone or in comparison to other treatments for mild to severe thyroid orbitopathy were identified. Review articles and case series were excluded.

The response rate of patients treated for active thyroid orbitopathy with IV pulsed methylprednisolone ranged between 29% and 89% and with oral prednisolone ranged between 40% and 68%. The study design, methodology, follow-up periods, outcome measures, details of non responders and conclusions of relevant randomized clinical trials have been summarised.

Differences in severity of active Grave’s orbitopathy and its assessment, duration of disease and dose regimes appear to impact on response rates to corticosteroid therapy. Some non responders were treated successfully with another form of immunomodulatory therapy. Further prospective, randomized controlled trials are necessary to establish the optimal therapeutic regimen for corticosteroids in Grave’s orbitopathy and investigate why some patients do not respond to corticosteroids but do respond to other forms of immunomodulatory therapy.

March 11, 2013 at 11:53 am

priscilla.mathewson@gmail.com

To investigate the usefulness of full body computed tomography (CT) in patients with an orbital mass where the suspicion of underlying systemic malignancy or disease is high.

Retrospective case note review and analysis of all patients who attended the orbital service between January 2007 and January 2013 with a suspected secondary orbital mass. A subset that subsequently underwent CT thorax, abdomen (± pelvis) following their CT orbits was studied.

Over a six year period 538 CT orbits and 24 CT thorax, abdomen (± pelvis) sequences were requested by our service to investigate a suspected secondary orbital mass. Systemic pathology was revealed in 13 patients (54%); 11 on CT imaging, one on mammogram, and one onsubsequent positron emission tomography (PET). A further two patients with secondary orbital masses were included where whole body imaging was initiated elsewhere.

All 15 patients with a suspicious orbital mass and systemic disease detected on full body imaging in the last six years were included in this study. Thirteen patients had a new diagnosis of systemic disease (87%); five breast carcinomas, four lymphomas, one gastro-intestinal carcinoma, one ureteric carcinoma, one neuroendocrine tumour and one Wegner’s granulomatosis. Two patients had a previous diagnosis of breast cancer; which was not previously known to be metastatic.

Full body imaging is a useful adjuvant to orbital biopsy and should be initiated by the Ophthalmologist when patients first present to them with a high clinical suspicion of systemic pathology. If CT imaging is negative and the clinical suspicion for a systemic malignancy is high then PET imaging may be useful in facilitating diagnosis.

March 11, 2013 at 1:59 pm

saulrajak@hotmail.com

UV radiation is carcinogenic, probably through its mutational effect on the tumour-suppressor gene p531. Sunlight UV exposure is known to be a risk factor for basal cell carcinoma (BCC). Arc welding produces ultraviolet (UV) A (400-315 nm), UVB (315-280 nm) and UVC (280-100 nm) light. We present a case of peri-ocular BCC in which the patient’s occupation, as welder, may be causative.

A 42 year-old man presented to the eye department with a painless, ulcerating, right medial canthal lesion that had been present for six years and enlarging for two years. He had worked full-time as a welder from the age of 16. In his ‘welding posture’ the right side of his face is turned towards to the flame.

Biopsy of the lesion revealed a basal cell carcinoma with a nodular growth pattern. He underwent excision biopsy with a four millimetre margin, with delayed reconstruction after histological analysis of the specimen.

Skin type and personal sun exposure are well known to play a role in the development of BCC. Various occupations have also been found to be associated with BCC, including mining and quarry work. This case of a BCC in a young welder on the face side more exposed to the UV light, strongly suggests that welding is also a risk factor. Epidemiological studies are required to further investigate the risk.

March 11, 2013 at 4:00 pm

Schwarz.claude@gmail.com

To describe pictorially, the management of unusual periocular trauma related to a fall in the garden. The aims of surgery were to preserve upper eyelid vascularisation and function and to protect the ocular surface.

A 65 year old female, tripped over an edge whilst gardening. A full thickness lower and upper lid laceration, involving the lower canaliculus, extended obliquely to the zygomatic arch was sustained. The lateral canthal tendon (LCT) was ripped and upper lid vascularisation appeared to be compromised initially.

Surgically, the following steps were performed: re-attachment of posterior lamella, levator aponeurosis/retractors to tarsus, LCT re-attached, silicone bicanalicular intubation with Benger tubes, deep tissue stitched with 4/0 Vicryl and skin stitched with 6/0 Vicryl.

Immediately postoperatively, the upper lid vascularisation appeared to be improved. At one week postoperatively, there was marked lid oedema and poor levator function. One month postoperatively, the upper lid appeared to be healing well with moderate levator function in spite of moderate swelling. The ocular surface was well protected.

This presentation highlights that early surgical intervention in cases where tissue appears to have severe vascular compromise, may lead to a good anatomical and functional result.

March 11, 2013 at 6:35 pm

myathidaohn@gmail.com

We report a case of orbital MALT (mucosal associated lymphoid tissue) lymphoma that presented with the recurrence in the other orbit after four months of complete remission (CR).

Retrospective case report.

A 68 years old lady presented with a six week history of painless, enlarging swelling in the left inferior orbit. Ocular motility and optic nerve function were normal. CT scan revealed a mass in left inferior orbit. Anterior orbital biopsy showed extra-nodal marginal zone lymphoma (MALT) with a proliferation rate (Ki67) of less than 5% (low grade). A bone marrow aspirate showed approximately 40% infiltration with low grade lymphoma cells. Staging CT revealed multiple small volume lymphadenopathy above and below the diaphragm. She was enrolled onto the GALLIUM study, receiving rituximab and bendamustine and achieved CR after the six cycles.

She re-presented four months after CR with a right superior orbital mass and limitation on upgaze. Biopsy of this lesion confirmed the recurrence of Non-Hodgkin`s disease of the diffuse large B cell lymphoma type (DLBCL) with a proliferation rate of 30 to 40% (high grade). The tissue sample was negative for Chlamydia Psittaci and other micro-organisms.

MALT lymphoma was first described in 1983. Complete remission after chemotherapy in non-GI MALT is in 64% and the recurrence of disease in the opposite orbit is rare. There is also high association with Chlamydia Psittaci (80%).

Orbital MALT lymphoma usually responds to treatment but with this patient early recurrence with more aggressive disease occured in the other orbit shortly after remission. In our case, we noted bone marrow infiltration at her initial presentation.

March 11, 2013 at 6:48 pm

myathidaohn@gmail.com

We report a case who presented to us with eyelid malignant melanoma six years after the initial excision and re-excision of lentigo maligna. This case demonstrates the need for surgical margin clearance and extended follow-up of such patients.

Retrospective case report.

A 82 years old lady presented with a slightly red, slow-growing lesion on her left lower eye lid of unknown duration. It was 12mm in size. There was no tenderness or ulceration.

She had an 8mm lesion removed from the same lid six years previously. Initial histology revealed lentigo maligna without dermal invasion but positive margins. Re-excision of the involved margin (1.7 x 1.4 x 0.6 cm) at two months revealed a possible focus of microinvasive malignant melanoma. Unfortuntely she was lost to follow-up.

Biopsies at her second presentation revealed a recurrence of her invasive lentigo melanoma. She underwent excision and reconstruction with Hugh’s flap and free full thickness skin graft. Histology confirmed lentigo maligna melanoma with clearance margins of 2.2mm (circumferential) and 1.6mm (deep). Tumour thickness was 4.2mm and it was staged at pT4a (AJCC/UICC pTNM classification). She underwent further excisions 1.2cm and 1.5cm from the previously excised margin and 2.4cm of tissue deep to the original excision. All of these were negative for malignancy. No recurrence was noted after ten months follow-up. There was also no lymph node involvement.

Surgical management and follow-up of cutaneous melanoma can be challenging. 10-year survival for pT4 is low (40%). Therefore such cases require aggressive surgical resection with intensive and extended follow-up.

March 11, 2013 at 7:32 pm

yesayang@gmail.com

To evaluate outcomes and patient experience of modified open sky conjunctivo-mullerectomy (OSCM), which precludes the need of skin crease (SC) reformation with sutures.

Prospective data collection on patients undergoing modified OSCM, from Nov ‘11 to Feb ‘13. Modification in OSCM technique involved reattaching Muller’s muscle stump to tarsus and achieving conjunctival closure in layers, without full thickness SC sutures. Outcome measures included pre & postoperative (PO) upper margin reflex distance (MRD1), SC, assessment of eyelid contour, symmetry and occurrence of complications (at week 4). Patient experience data was collected at one week PO via a modified visual analogue scale survey.

There were 18 patients (27 eyelids); 5 males, 13 females with mean age of 62.1 years (range 24 -84). Median preoperative MRD1 was 0.25mm (range -2 – 2). Median PO MRD1 was 4mm (range 2-5), p value <0.01. Average PO lid height difference between right and left was 0.06mm (range 0-0.5) and all patients achieved good symmetry (n=14), excluding those with bilateral ptosis awaiting second eyelid surgery. SC was preserved in all, with a median measurement of 12mm (range 9-15), and 10mm (range 8-15) at pre and PO stages respectively, p value <0.01. Two cases (7.4%) developed superficial punctate keratopathy, which resolved by four weeks.

All patients completed a patient experience survey. Mean scores were as follows: lid swelling was 3.5(range 0-10), PO ocular pain was 2(range 0-7), overall patient satisfaction was 8.7 and friends & family test scored a mean of 8.8(2-10).

Our modification of OSCM preserves the skin crease with excellent objective surgical outcomes and a high subjective patient satisfaction score.

March 11, 2013 at 8:59 pm

pari.shams@gmail.com

The incidence of orbito-temporal involvement in type 1 neurofibromatosis is 1-22%. The clinical manifestations are a consequence of sphenoidal dysplasia, orbital invasion and proliferation of the plexiform neurofibroma. Due to the surgical challenges of managing affected patients, an expectant approach has traditionally been adopted. However, left untreated, progressive infiltration and distortion of crucial facial structures, makes reconstruction increasingly difficult.

A retrospective review of 20 patients who have undergone surgery for orbito-temporal neurofibromatosis over a 10 year period was conducted. Various factors were investigated: timing and stages of intervention; access incisions and operative technique; sphenoid wing reconstruction; aesthetic and functional outcomes and complications.

Treatment was based on the type and severity of the orbital involvement and visual function. No major surgical complications were recorded. A management algorithm based on specific patterns of disease will be presented.

We advocate early surgical intervention and radical resection under the care of a specialist multidisciplinary team.

March 11, 2013 at 9:11 pm

antigoni_koukkoulli@hotmail.com

Trauma presents problems for surgeons as they are forced to attempt a functional and cosmetic reconstruction in less than ideal and often unplanned situations. We present a case of severe facial trauma undergoing a staged reconstruction under a multidisciplinary team. During the process an unintended benefit of performing a staged reconstruction was found to have occurred.

A case report from a patient suffering severe facial trauma.

A male patient was admitted with extensive tissue loss due to dog bites. After initial resuscitation the patient was taken to theatre for a joint Ophthalmic and Max-Fax procedure.

No bony injuries or globe injury were found and a Gunderson flap was performed for corneal protection as no lid structures remained. Maxillo-facial surgeons used a combination skin grafts to cover the large defects some of which extended to the periostium. After initial healing a combination of free palatal and tarso-conjunctival grafts were used with pedicled skin grafts to begin initial reconstruction of the lid structures. At this time no attempt was made to reconstitute the naso-lacrimal system with a drainage tube.Previous evidence suggests that reconstruction without restoration of the tear drainage leads to an enclosed tear lake which can degrade reconstructive efforts through presumed enzymatic damage. An enclosed tear lake was in this case found to be beneficial as it acted as a natural tissue expander stretching the repaired lids and providing increased tissue for subsequent reconstructive efforts.

The patient is currently part way through the journey to satisfactory cosmetic and functional reconstruction of the peri-ocular and facial tissues.

March 11, 2013 at 10:41 pm

olivmac9@hotmail.com

To demonstrate a technique using an eyelid clamp to aid in peri-operative haemaostasis.

We demonstrate the multiple uses of an eyelid clamp including lid margin shave biopsies, excision of a large eyelid naevus, tarsoconjunctival diamond, excision of an eyelid vascular malformation and ectropion repair.

The procedure was well tolerated in all cases and good haemostasis was achieved aiding with ease of surgery, minimizing the need for electrocautery during the procedure and assisting in accurate excision patterns

This is a simple and useful technique that has a variety of uses in oculoplastic surgery.

March 11, 2013 at 10:42 pm

pari.shams@gmail.com

Dacryocystorhinostomy (DCR) is an effective surgical treatment for nasolacrimal duct obstruction (NLDO). However, some patients continue to experience persistent epiphora after anatomically successful DCR. There have been few reports into the management of so called “functional failure”.

Multicentre retrospective case note review of patients with persistent epiphora post external or endonasal DCR who were patent on syringing with or without endoscopic and or radiological evidence of a patent ostium. Clinical interventions and outcomes were recorded

45 patients from 4 Australian centers were recruited. Pre-operatively 35.5% had NLDO and 64.5% stenosis. 80% underwent endoscopic DCR and 89% were intubated with a silicon stent. The stent was removed an average of 12 weeks post DCR with return of epiphora at 16 weeks. Post-operatively 89% had evidence of a patent ostium and 100% were patent on syringing. 36 patients (80%) requested further intervention (5% were intubated, 37.5% were reintubated, 12.5% a Jones tube, 20% lid tightening, and 25% other procedures. Following the 1st intervention symptoms resolved in 92%; 8 (18%) underwent a 2nd intervention with 63% success and 2 (4%) had a 3rd intervention with 100% success. After an average 33 month, 2 interventional patients (4%) remained symptomatic but declined further treatment.

Successful management of epiphora following an anatomically successful DCR required 1-3 clinical interventions over 20-36 months. 18% of patients declined any further intervention, 15% required 2 and 5% 3 interventions. A significant number of patients (36%) opted to keep their lacrimal stent permanently and 18% required a JT despite patent canaliculi.

March 11, 2013 at 10:44 pm

fayemellington@hotmail.com

To report a hyperthyroid patient with blepharoptosis and vertical diplopia.

Case report

A 32 year-old West African lady presented with sudden-onset painless complete right blepharoptosis and vertical diplopia. Three weeks earlier she had been diagnosed with hyperthyroidism. On examination she had impaired right levator palpebrae and superior rectus function and only mild retraction of the fellow upper lid. Thyroid function tests revealed autoimmune hyperthyroidism. Inflammatory markers, other autoimmune, vasculitis, infection and sickle cell screens, blood pressure and biochemistry were all normal or negative. Ocular myasthenia gravis was excluded. MRI orbits was re-reviewed and on closer inspection, slight enlargement of right SR/levator complex was seen along with modest bilateral enlargement of all extraocular muscles. Myositis of the levator-superior rectus complex was diagnosed and intravenous steroids resulted in complete resolution of her ptosis and double vision within 72 hours.

She then developed a large goitre and Graves disease was diagnosed. 10 months after first presentation she developed bilateral proptosis. Repeat MRI scan orbits now showed faint increased T2-weighted signal in all recti.

Delay in diagnosis of ocular myositis was attributed primarily to minimal MRI findings, lack of pain and the need to exclude more sinister pathology namely third nerve palsy, myasthenia gravis and ophthalmoplegic migraine. Orbital myositis in the setting of Graves disease has not been reported before and is a novel cause of ptosis in such patients.

We postulate that orbital myositis may be part of a spectrum of lymphocytic infiltrative orbital conditions including thyroid eye disease. A common causal antigen may be implicated.

March 11, 2013 at 10:58 pm

giannouladis.konstantinos@gmail.com

To demonstrate our results of a superior lid crease approach to the excision of angular dermoid cysts.

Retrospective case series of angular dermoid cyst excisions with assessment of the cosmetic result from postoperative photographs and subjective impression of the parents. 11 cases were identified from 2010 to date.

All cases reported being very satisfied with post operative cosmesis. There was minimal scarring and well hidden under the upper lid crease for both laterally and medially located dermoid cysts with no adverse events or operative difficulties encountered with this approach.

The superior lid crease approach for the excision of dermoid cysts is a simple and effective technique with excellent cosmetic result and should be preferred over the standard direct incision as that may lead to visible scarring.

March 11, 2013 at 11:52 pm

ben.w@2able.co.uk

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April 12, 2013 at 3:25 pm

ben@trianglemedia.co.uk

A prospective cohort analysis was undertaken to compare junior (<20 procedures) vs. senior (>100 procedures) surgeons.

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April 12, 2013 at 3:38 pm

drnazy73@yahoo.com

To report a rare case of primary orbital angiosarcoma in an elderly with conflicts in treatment

A case report

A 60 year old Chinese man was referred for left eye proptosis of 4 years’ duration. Clinically, he presented with a unilateral left non-axial proptosis. His best corrected left visual acuity was 6/24 while his right visual acuity had no perception to light. There was a mass felt over the left upper eyelid, which was soft to firm in consistency and with ill-defined borders. The overlying skin was not inflamed, non-tender and there was no thrill or bruit. The degree of proptosis did not increase with valsalva manoeuver. There were dilated and tortuous vessels occupying the superotemporal part of the conjunctiva. He had a complicated cataract surgery done in the left eye and was pseudophakic with an anterior chamber intraocular lens implanted. Left optic disc was pink and normal but his posterior pole revealed a choroidal striae. However, he had a mature cataract with a long-standing retinal detachment in the right eye. Pattern of growth was demonstrated radiographically and histopathologically, confirming primary orbital angiosarcoma. In view of a precious eye, he refused an orbital exenteration.

Primary orbital angiosarcoma is best treated with orbital exenteration. In a complexed situation whereby exenteration is not the best solution, radiotherapy may have its role in controlling the disease. However, angiosarcoma may progress despite the therapy given due to its aggressive behaviour.

February 7, 2014 at 5:10 am

drgkaya@hotmail.com

The aim of this study was to analyze functional and anatomical success of silicone tube intubation in canalicular injury caused by blunt or penetrating trauma.

The records of 24 patients with canalicular injury, who applied to our clinic, were retrospectively analyzed. The patients were divided into two groups according to the type of injury (group 1: 12 patients with blunt injury, group 2:14 patients with penetrating injury). In all cases, silicone tube intubation was performed with a pigtail probe. The age, gender, cause of injury, affected eye, affected canalicula, time period between injury and operation, removal time of the silicone tube, and follow-up periods of the patients were recorded. An open passage with lacrimal irrigation was evaluated as anatomical success and absence of tear collection at fluorescein dye disappearance test and tearing complaint by the patients were accepted as both anatomical and functional success.

There were not significant differences between the groups by means of gender, affected canalicula, time period between injury and operation,removal time of the silicone tube, and follow-up periods (p>0.05).Two patients in group 1 and four patients in group 2 had tear collection at fluorescein dyedisappearance test and tearing complaint. In the first group, anatomic success was 95% and both anatomical and functional success was achieved in 91%of patients. In the second group, these rates were 90% and 84%, respectively. Success rates did not differ significantly between the two groups (p>0.05).

Annular silicone tube intubation may be used as a successful technique in maintaining anatomical and functional integrity of the canalicula after blunt or penetrating canalicular injury.

February 11, 2014 at 10:12 am

drgkaya@hotmail.com

Limbal dermoid is a benign congenital tumor involving the outer coat of the eye. The lesion was typically hemispheric, covered with pink skin, located in the inferior and temporal part of the cornea, and devoid of any major consequencas except cosmetic appearence of the eye.

We report cases of one limbal dermoids noticeable cosmetically, inducing little astigmatism.Limbal dermoid was excised surgically.

Patient who was treated surgically had good cosmetic results but had surgically induced astigmatism.

Surgical management of limbal dermoids gives good cosmetic results. However , improvement in refrective, astigmatism and visual status is not guaranteed. So , this procedure should be viewed more closely..

February 12, 2014 at 11:10 am

rushmiak@gmail.com

We describe a case of a 98-year old women with a chronic unilateral conjunctivitis with enlarged superior fornices from superior aponeurosis dehiscence. Symptoms were present for 2 years prior to referral.There was complete secondary lid closure; an associated superficial punctate keratitis and a visual acuity of 6/60. She did not respond to several weeks of intensive (2 hourly) treatment with topical prednisalone 1% drops and chloramphenicol. Subsequent additional regular sweeping of the fornices with cotton buds and topical medication did not improve her symptoms.

The patient then consented for sweeping of the fornices with 10% povidone iodine performed with topical anaesthesia as an outpatient procedure. Topical proxymetacaine 0.5% and tetracaine 1% was administered on cotton buds to both fornices. Cotton buds were then dipped in 10% povidone iodine and swept over the superior and inferior fornices several times. Double eversion of the upper lid was performed to ensure complete treatment of the superior fornix. Treatment was continued with topical 2 hourly prednisolone 1% and chloramphenicol for the following 4 weeks.

There was a marked improvement in lid position; reduction in discharge; an improvement in visual acuity to 6/18 and she was able to open her eye. Three iodine washings were performed over 3 months in the outpatient clinic resulting in significant improvement of symptoms and signs . Topical treatment was then tapered to cessation.

This treatment offers an effective management of GFS cases which do not respond to intensive topical corticosteroids and chloramphenicol.

February 22, 2014 at 2:29 pm

gracelimhc@hotmail.com

To investigate the neurovasculature of platysma in order to find a common “window” containing nerves and blood vessels supply which is present in every individual. This will aid the plastic surgeons to reconstruct the neurovasculature of the flap for grafting onto the eyelids.

6 fresh cadaver necks were dissected from 4 males and 2 females, aged 75-88 years old; (n=12 platysmas). 86 squared specimens (measuring 1.5cm x 1.5cm) surrounding any potential neurovascular structures were cut out, processed and analysed under high power microscope to confirm the presence of nerves and blood vessels. We also reviewed literature dated from 1999 to 2011.

From the literature reviewed, the authors concluded that PMF provided excellent functional and aesthetic outcome. In this study, we discovered a “window” flap (ranging from “2.5cm x 3cm‟ to “8cm x 10cm‟) bilaterally on each cadaver. This window is supplied by submental branch of facial artery, drained by facial vein, anterior and external jugular veins, and extensively innervated by cervical branch of facial nerve.

We strongly advocate the use of PMF “window” by plastic surgeons in dynamic eyelids reanimation.

February 28, 2014 at 1:01 am

sabah.stafanous@nhs.net

To present an audit of 46 cases who had the new ectropion procedure between2/11-5/12& show pre&post op.photos of excellent results. After conversion from lateral canthal sling to diamond excision for entropion&auditing&presenting successful 50 cases at BOPSS&ESOPRS in 2010,I modified the method for ectropion surgery which included;Lateral or medial pentagon(LP/MP)excision to shorten the eyelid,+/-3snip,retropunctal cautery(RPC)or medial diamond of tarso-conjunctiva(MD). This was prompted by the complication associated with the old method(lateral tarsal sling)including;Short&long term recurrence&sling slippage,long term tenderness,rounding of lateral canthus&change of appearance,lateral upper lash entropion&stopping antiplatelets.

Retrospective case notes review& a large number of pre&post op.photos.

between 2/11&5/12 46 eyes of 38 patients had the new method, all had LA&D/C surgery.
19whole ectropion,3lateral,14medial,3cicatricial&7physiological pump failre
34had LP=/-3S,RPC or MD,12had MP+/-MD,3S or RPC
41had 2&5had 3post op. visits.
All 46had satisfactory cosmetic&anatomical lid position
7physiological pump failure had satisfactory lid position.5complete resolution&2 with residual watering

The new ectropion procedure has excellent functional&cosmetic results
No complications like notching,gaping,trichiasis,infection&bleeding in 46 eyes
cheaper as only1-2 6/0 vicryl sutures,no cutting cautery&only reusable equipments
No rounding,tenderness,stitch granuloma or canthus disturbance as with LCS
Not expecting any recurrence as no slippage
Less no of post op. visits&no need to stop antiplatelets
excellent results I never looked back & plan future audit for long term effect.

March 4, 2014 at 4:04 pm

fiona.jazayeri@doctors.org.uk

PlayDoh is cheap, easily available and simple to use. PlayDoh models are a very effective way of demonstrating the anatomy of structures in a three-dimensional (3-D) model. The use of PlayDoh models as an educational tool for visualization of cerebral aneurysm anatomy by neurosurgery trainees has previously been published. We present a method of constructing a PlayDoh model of the upper eyelid. For several years, this has been used to teach anatomy of the eyelid at oculopastics courses run by the Royal College of Ophthalmologists.

The stages of creating a (3-D) model of the eyelid using PlayDoh are illustrated using sequential photographs and video.

PlayDoh models of eyelid anatomy are more efficient and realistic in training than simple drawings or photographs alone. No prior experience with PlayDoh is required to be able to construct the model. Different levels of anatomic detail can be illustrated depending on the audience. This educational tool has received unanimously excellent feedback from ophthalmology trainees, other surgical specialties, orthoptists and nurses at courses where it has been utilised.

PlayDoh modelling is an extremely effective way of teaching eyelid anatomy in three-dimensions and is readily available at low cost. We recommend the use of this method of teaching eyelid anatomy to others.

March 6, 2014 at 3:16 pm

thomaskersey@doctors.net.uk

Post-enucleation socket syndrome is a challenge for the oculoplastic surgeon. We sought to investigate the real-life volume of enucleated globes by examining the displacement in a large series of eyebank donor eyes.

A consecutive series of two hundred and thirty two donor eyes from the New Zealand eye bank donor service were examined by measuring the volume by displacement in BSS solution. All eyes were healthy and with no disease process that was likely to have altered the “normal” volume.

Two hundred and thirty two eyes from one hundred and sixteen donors were examined. The age range for the donors was 15-89 years with a mean of 61 years. The volume of globes ranged from 5.5 – 10.5 ml with a mean of 7.8 ml, median value 8.0 ml.

Published textbook eye volumes are quoted between 6.5 – 7.2 mls. The figure 7.2 ml equates to a theoretical volume based on a 24 mm diameter sphere. It is generally accepted that a prosthesis should be around 2 ml to generate a realistic anterior chamber depth but not larger than this to avoid weight-related complications.

In our series the mean volume of healthy eyes donor eyes is larger than the currently recognised eye volume. This probably relates to the additional material often removed during enucleation – muscles stumps and optic nerve. If we were to replace the median volume at a primary operation then we should replace 6.0 ml of orbital volume (8.0 ml – 2.0 ml) which equates to a primary implant of diameter of 22.54 mm. Where possible we believe using a greater implant volume should reduce the need for secondary socket volume-augmentation surgery after enucleation and primary implant.

March 7, 2014 at 11:49 am

ahsen@doctors.org.uk

Magnetic Resonance Elastography (MRE) is a rapidly evolving technology for the quantitative study of the mechanical properties of tissue. Current applications are well established in hepatic and skeletal muscle investigation. We sought to modify and employ the techniques to the study of extraocular muscles in-vivo.

Suitable drivers were fashioned and tested including a swimming goggle type apparatus, gel-filled eye mask and beaded mask attached to an external dynamic excitation device which propagated vibration waves. These were applied to the orbit in suitable volunteers who underwent MRI scanning with analysis of the region and shear waves through extraocular muscles. Data was processed with suitable computer algorithms already employed in other MRE applications.

All eight volunteers tolerated the procedure well with no safety concerns throughout the scanning period. Gradient-echo based MRE sequences were affected by the presence of significant air in the sinuses and therefore a spin-echo based sequence was deemed more appropriate with 150Hz vibration data collected. All drivers produced waves in the scalp area and two were found to produce waves within the eye muscles. With current techniques, it was determined that a larger motion wave would be required for data processing algorithms to provide repeatable stiffness measurements.

Our early tests have shown that the beaded gel-filled mask driver showed the best promise for this study. Further modifications including placing muscles under tension during versions has shown better signals. The technique shows promise in providing quantitative non-invasive stiffness measurements of eye muscles affected by pathology such as Grave’s Ophthalmopathy.

March 9, 2014 at 11:06 am

ahsen@doctors.org.uk

The elderly are known to have an increased risk of surgical complications, with the proportion of their population increasing. Our study aimed to compare an elderly versus younger patient group requiring ptosis surgery to investigate surgical outcomes and incidence of complications such as dry-eye.

Patients of 80 years and over comprised the elderly group, with the younger group being between 40-79 years. Our retrospective study was powered to detect a doubling of incidence of new or worsened dry-eye symptoms postoperatively with an 80% chance of detection at the 5% significance level. Categorical variables were compared between groups using a Chi-square test for independence. Continuous variables were assessed using the Wilcoxon rank-sum test.

335 consecutive patients were included in the study. 166 patients were defined as elderly (mean age 83.8) and 169 as the younger group (mean 67.4). 57% of the total cohort were female and 96.4% were Caucasian. The majority of patients underwent combined levator advancement and blepharoplasty (55.8%). MRD1 pre-op was significantly smaller (p=0.002) in the elderly group. 10.5% of patients had new/worse dry-eye at the first post-op rising to 17.3% by the second post-op. No significant difference in the incidence of new/worse dry-eye at first or second post-op (p=0.54), procedure performed, complication rate or MRD1 post-op was found between the age groups.

Ptosis surgery in the elderly requires an appreciation of the higher prevalence of dry-eye symptoms within this group. Although our study has confirmed expected differences between a younger and older patient, our data supports the notion that outcomes and complication rates for this type of surgery are similar in the elderly and younger population.

March 9, 2014 at 1:12 pm

vasilios.papastefanou@gmail.com

When periorbital tumours invade the orbit, tumour clearance is usually possible by orbital exenteration, with or without adjunctive radiotherapy, but some tumours are inoperable. Vismodegib, a hedgehog (Hh) signalling inhibitor, is effective in treating advanced and metastatic BCC. We present a case of advanced BCC with orbital invasion successfully treated with vismodegib.

An 84 year old man with a past history of BCC excision on the left upper lid many years earlier was referred with severe left proptosis, upper lid swelling, induration and ulceration. The left eye, which was barely visible, had no perception of light, significant chemosis, exposure keratopathy and total ophthalmoplegia. Previous biopsies confirmed recurrence of an infiltrative BCC of the left upper eyelid/eyebrow He was on warfarin for atrial fibrillation. CT and MRI scans confirmed extensive intraorbital tumour with no bone involvement. Exenteration of the orbit was considered but the patient declined. He underwent a palliative central tarsorrhaphy and was treated with oral vismodegib 150 mg daily.

After three months the tumour regressed dramatically. The eyelid mass/ulceration resolved and his proptosis and extraocular movement improved. MRI confirmed substantial regression of the tumour. He remains under observation 10 months later.

The Hh signalling pathway is a key regulator of cell growth and differentiation during development. A link exists between the Hh pathway signalling activation and several human cancers, including BCC. Vismodegib is an inhibitor of smoothened, a key component of the Hh pathway. It is the first licensed Hh signalling inhibitor in clinical use for treating locally advanced and metastatic BCC. This case illustrates its usefulness in clinical practice.

March 11, 2014 at 9:54 am

m.ting@nhs.net

The upper eyelid is a mobile vascular structure crucial for ocular protection and maintaining a clear visual axis. Reconstruction of large defects pose an oculoplastic challenge. Traditional reconstruction techniques involve either lid sharing that occludes or significantly diminishes the palpebral aperture (unsuitable for monocular patients) and require second stage procedures or recruitment of other anatomical units – from the forehead or lateral advancement with associated morbidity and scarring.

Three cases illustrate the utilization of the bilamellar lid structure for successful 1-stage reconstruction of medium to extensive defects within the ipsilateral or contralateral eyelid and brow unit without recruitment from other facial anatomical units or occluding the visual axis.

Case 1: A young Afrocaribbean male with traumatic loss of half of his left upper lid reconstructed with lateral cantholysis and full thickness sandwich graft from contralateral side. Case 2: A shallow defect two-third lid width post excision of upper part of a kissing naevus in a Nepalese male was reconstructed with a V to Y advancement of the ipsilateral eyelid and a contralateral tarsal graft. Case 3: Huge sebaceous gland carcinoma with 5mm resection margins and histological clearance resulting in subtotal loss of upper eyelid in a elderly Caucasian female’s only eye. This was reconstructed with a bipedicle flap from the ipsilateral brow and skin and tarsal graft from the contralateral upper lid.

These cases demonstrate that the upper eyelid and brow area is a versatile source of graft and flaps centered on the well-vascularized orbicularis muscle that can be used reconstruct large to subtotal lid defects.

March 12, 2014 at 9:44 pm

aeritchie@doctors.org.uk

To demonstrate a possible novel use of DWI MRI in monitoring treatment response in patients with active Graves’ orbitopathy

Two patients (68 and 71 years, both female) with sight threatening, active Grave’s orbitopathy but low clinical activity scores underwent MRI scans before and after intravenous corticosteroid treatment. Two MRI techniques, short term inversion recovery (STIR) and non-echoplanar diffusion weighted imaging (DWI) were used. Apparent diffusion coefficient (ADC) values were calculated.

Apparent diffusion coefficient (ADC) values reduced in Patient 1 who had successful medical treatment and remained elevated in Patient 2 who had an inadequate treatment response. In these cases, MRI findings were more useful than clinical activity score alone in evaluating treatment response.

Non-echoplanar diffusion weighted imaging provided a quantitative measure of treatment response by calculation of the apparent diffusion coefficient. The novel use of non-echoplanar diffusion weighted imaging for monitoring treatment response in Graves’ orbitopathy is illustrated.

March 13, 2014 at 9:33 pm

drchrisabela@gmail.com

The pattern of presentation in orbito-temporal type 1 neurofibromatosis is variable, ranging from cutaneous palpebral disease to orbital displacement and in the extreme: destruction of the cranial base. Surgeons have historically adopted a conservative strategy, waiting watchfully through puberty on the anecdotal premise that surgery during this period elicits pathergy. It is our unit’s philosophy that left untreated, only progressive infiltration, distortion and dysfunction of structures occurs, ultimately making reconstruction more difficult and outcomes worse.

A retrospective review was conducted to test our hypothesis. 55 consecutive patients who had undergone surgery for large craniofacial neurofibromatosis over a 13 year period were reviewed; looking at severity of aesthetic and functional presentation, timing and type of interventions, outcomes and complications.

The majority had soft tissue deformity without bony involvement. Rarely was disease bilateral. Patterning was mostly seen in trigeminal nerve territories. 25 patients had specific orbito-temporal variants. The spectrum of involvement is wide but there seemed to be a heirarchy of pathology, whereby as the cases became more severe, the disease pattern progressed more posterior. Sphenoid wing dystrophia was rarely seen and always on the same side as the pathology. Secondary effects on related structures such as facial nerve, airway and the ear canal, were all a function of tissue bulk.

Patterning of presentation facilitates communication and guides our strategies for measuring clinical outcome. We advocate early surgical intervention and radical resection under the care of a specialist multidisciplinary team.

March 14, 2014 at 1:30 pm

alishassan@live.com

To demonstrate a novel technique for lower lid anterior and posterior lamellar reconstruction for a full thickness defect following excision of a basal cell carcinoma.

A single interventional case presentation with demonstration of surgical technique with pre, intra and post-operative photographs.

An independent 84-year-old lady underwent excision of a left lower lid basal cell carcinoma; this left her with a 16mm full thickness lower lid defect. Past ophthalmic history was significant for macular degeneration particularly affecting the central vision in the right eye. Significant medical history included COPD and early dementia.

Reconstructive options were considered. Direct closure of the defect was not possible due to the size. Poor vision in the fellow eye meant a Hughes flap would cause significant visual and functional impairment.

A lassie faire approach was adopted, Vicryl sutures were used to reduce the size of the defect however these did not bring the wound edges into apposition. The sutures were placed in the posterior and anterior lamellae and served to align the lid and provide a structural “scaffold” along which healing could occur.

This technique resulted in rapid healing and an excellent structural and functional outcome. The technique avoided the use of a Hughes flap which would have caused temporary loss of independence.

March 16, 2014 at 1:18 pm

abumattar08@gmail.com

Thyroid eye disease (TED) or Graves’ ophthalmopathy (GO), in its severe form can be disfiguring and profoundly impairs the quality of life of affected individuals. Management to limit the visual and physical morbidity relies on thorough assessment and timely intervention. We propose a simple yet comprehensive proforma incorporating various standardised assessment tools and grading systems to assist data collection and decision-making in a busy clinical setting, with a view to integrating it into our electronic patient record system (EPR).

Clinical parameters based on recommendations of the EUGOGO and VISA grading system as well as a stratified treatment plan were incorporated into a single-sided A4 sheet. This proforma, alongside a mini quality of life (QOL) questionnaire was piloted in the oculoplastic clinic.

We assessed 12 patients using the proforma – consultant (25%), associate specialist (33%) and trainee (42%). Data collection on parameters predictive of clinical outcome including onset of systemic and eye disease, thyroid status, subjective and objective assessment of visual function, clinical activity, ocular motility and appearance was 100%. 8% patients received treatment, 8% resulted in discharge, 8% was brought back for review in < 3 months and 58% between 3-6 months. In 25% of patients the decision was guided by responses to the QOL questionnaire.

This user-friendly proforma which encompasses all the important parameters of history, clinical activity and management plan provides an effective, structured approach to data collection and decision-making for team members of various grades. When incorporated into our EPR, it has the potential of streamlining and simplifying the TED clinic experience.

March 16, 2014 at 10:03 pm

kim.z@doctors.org.uk

To describe our experience with the use of external weights and techniques for securing them for temporary treatment of facial paralysis

We prospectively reviewed twelve consecutive patients with unilateral facial paralysis who were fitted with external weights as a temporary measure prior to surgical upper eyelid loading. We used double-sided adhesive tape, micropore tan tape, tincture of benzoin and medical glue. Outcome measures included patient comfort, amount of artificial tear usage and any problems associated with the weight or securing technique.

Five patients used medical glue to attach the weight. They all found it simple and quick with increased comfort and decreased use of artificial tear. Six patients used double-sided adhesive tape and micropore tan tape interchangeably. Two (of six) found micropore tan tape effective in securing the weight for at least 12 hours and improving their comfort. Two (of six) found that using ocular lubricants reduced the adhesiveness of the tape and stopped using the weight. One (of six) did not find it useful. One (of six) found it too awkward to use.

We found external weights very useful in the majority of patients. Among different techniques, medical glue is a simple, quick and effective method for securing external eyelid weight. It lasts longer than the other techniques and can be used together with ocular lubricants.

March 16, 2014 at 11:08 pm

edward.casswell@nhs.net

To report a case of a 36-year-old woman who spontaneously expelled a lacrimal gland stone secondary to vomiting

Case notes review

A 36-year-old presented with a 3 day history of a red left eye associated with purulent discharge. She was initially diagnosed with dacroadenitis and started on oral co-amoxiclav. As a result of the antibiotics, the patient unfortunately suffered an episode of vomiting during which she felt something protruding from her lateral orbit. She subsequently expelled what appeared to be a hard stone from her lacrimal gland, a process she was able to capture on her smartphone. Subsequent CT orbits showed an enlarged lacrimal gland with intra-ductal gas, suggestive of an abscess. The patient completed a course of antibiotics and has now made a full recovery. Lacrimal gland stones are rare and this is the first case we are aware of in which one was seemingly spontaneously expelled rather than surgically excised.

Surgical removal of lacrimal gland stones may not always required as they could potentially be spontaneously expelled. This case also highlights the role of patients’ smartphones as a diagnostic aid.

March 17, 2014 at 12:36 pm

james.wawrzynski@cantab.net

Poor camera control during EnDCR surgery can cause inadequate visualisation of the anatomy and suboptimal surgical outcomes. It can be a difficult skill for ophthalmic trainees to master, with few structured training tools available. This study investigates the feasibility of using computer vision tracking in actual EnDCR surgery as a potential formative feedback tool

A prospective cohort analysis was undertaken to compare junior (<20 procedures) vs. senior (>100 procedures) surgeons. Speeded-Up Robust Features point detection & Kanade-Lucas-Tomasi tracking were applied to endoscopic video footage from routine EnDCR surgery: Total number of movements and camera path length in pixels were determined for each procedure. An approximate t test was used to test for significant difference at p<0.05.

18 videos from 9 juniors/9 seniors were analysed. Feasibility of our tracking system was demonstrated. Mean camera path lengths were significantly different at 121,422px (juniors) and 45,805px (seniors), p=0.0008. Mean number of movements was significantly different at 9143 (juniors) and 3840 (seniors), p=0.00009. These quantifiable differences demonstrate construct validity for computer vision endoscope tracking as a measure of surgical experience.

Computer vision tracking is a potentially useful structured & objective feedback tool to assist ophthalmic trainees in improving endoscope control. It enables juniors to examine how their pattern of endoscope control differs from that of seniors, focusing in particular on sections where they are most divergent. This study forms the basis for potential further work examining the relationship between improved endoscope control and superior instrument control.

March 17, 2014 at 8:43 pm

cchoo98@gmail.com

Many approaches have been described in lower lid epiblepharon correction, as this is a common congenital eyelid condition in Orientals. Skin reduction and debulking of orbicularis oculi, especially the pretarsal muscle, are essential in the anterior lamellar repositioning and effective correction of lash inversions. We believe an effective lash eversions could be achieved through small lower lid skin incision and minimal skin reduction to avoid larger cutaneous scar, lid retraction or overcorrection post surgically

A series of 10 lower lid epiblepharons were corrected through a small subciliary incision ( less 10mm ) with minimal skin reduction. Pretarsal orbicularis below the trichiasis were removed by subcutaneous blunt dissections. Immediate lash eversions could be observed. Anterior lamellae were repositioned with two subcutaneous tarsal 7/0 vicryl sutures. Skin wounds were closed with less than three sutures.
Skin crease formation were not necessary.

All patients had significant symptomatic relief and correction of lash-corneal touch. Postoperative swelling were minimal. No further corrections with one to six month follow up.

Through a lower lid small skin incision and minimal skin reduction but adequate pretarsal debulking, an effective lash eversions could be achieved.

March 18, 2014 at 1:44 pm

Tahrinasalam@hotmail.com

We compared the mechanical properties of synthetic materials used in brow suspension in a laboratory setting.

The mechanical properties of some commonly-used synthetic brow-suspension materials were investigated: monofilament polypropylene (Prolene®), sheathed braided polyamide (Supramid Extra® II), silicone frontalis suspension rod (Visitec® Seiff frontalis suspension set), woven polyester (Mersilene® mesh), and expanded polytetrafluoroethylene (Ptose-Up). Each material underwent a single tensile loading to the failure of the material, at three different displacement rates (1, 750 and 1500 mm/min). We also examined the materials with an electron microscope before and after the mechanical tests.

Mechanical properties of brow-suspension materials vary considerably
most exhibited near-linear mechanical behaviour with an initial linear elastic region almost up to the fracture point

Prolene® and Supramid Extra® II exhibited greater elastic modulus, UTS and work of fracture

Visitec® SFSS might be the most suitable, providing relatively long-lasting stability and desirable performance

These findings, together with other factors such as commercial availability, cost and clinical outcomes, will provide clinicians with a more rational basis for selection of brow suspension materials.

A further study is on-going with more testing including cyclic loading so that tests even-more closely reflect what the suspensory materials will experience once they are implanted in human body

March 18, 2014 at 2:46 pm

hbs@doctors.net.uk

Patients, carers and the public are central to setting the research agenda, with a key role in identifying study priorities; planning, funding, running and evaluating clinical trials; and disseminating findings. Not only does this ensure appropriate patient-focused outcomes, but the National Institute for Health Research (NIHR) has made this a prerequisite for funding. One method of encouraging engagement with research is through PPI events

The Moorfields NIHR Biomedical Research Centre, in partnership with TED charities, arranged a PPI day for TED. The event included: didactic lectures; pre- and post-event questionnaires; an exhibition with stalls, posters and an interactive ‘voting wall’ to determine research priorities; focus group sessions to evaluate how patients would like trials conducted; and one-to-one interviews to explore individual patient experiences

100 people attended the event, and 70 completed questionnaires (35 patients, 9 supporters, 4 exhibitors, 15 healthcare professionals, and 7 ‘others’). When asked whether the day had provided what they wanted, 48/52 (92%) said ‘yes’, 3/52 (6%) said ‘no’. Overall 18/52 (34%) rated it ‘excellent’, 28/52 (54%) ‘very good’, and 6/52 (12%) ‘good’. 36 patients registered to participate in further research, and identified; finding the cause for TED, improving psychological support, and achieving a better cosmetic outcome, as key research priorities. A poor understanding of TED amongst medical professionals was a common complaint

The event received very positive feedback, and achieved its key objective of encouraging patient engagement with researchers in identifying priorities and improving trial design

March 19, 2014 at 7:59 am

simranmangat5@gmail.com

To describe and illustrate the rarely performed technique of a reverse Hughes flap in a 92 year old lady who underwent excision of BCC and reconstruction of a left total upper eyelid defect as a 2 stage procedure.

Following complete excision of the upper eyelid to remove a BCC using the Slow MOHS technique, secondary eyelid reconstruction was performed. A lower eyelid grey line split was performed, the inferior tarsus was then anchored to the superior limb of the lateral canthal tendon and medial canthal tendon respectively using 6,0 polyglactin sutures. The levator aponeurois mobilised and advanced to the tarso-conjunctival flap from the lower lid. A free supraclavicular skin graft was then placed over the mobilised tarso-conjunctival flap. Intra-operative photographs were taken at each stage.

2 week results showed excellent healing of the graft and flap. Results following division of the Reverse Hughes flap will be presented.

The reverse Hughes flap is a useful technique to reconstruct total upper eyelid defects. It provides an excellent alternative to the Mustarde switch flap, the Cutler-Beard flap or a free tarso-conjunctival flap and Bucket handled flap. Function of the eyelid is maintained well with good stability of the reconstructed eyelid.

March 19, 2014 at 2:01 pm

m_edmunds@doctors.org.uk

Graves’ disease (GD) as an immune reconstitution syndrome during highly active antiretroviral therapy (HAART) for human immunodeficiency virus (HIV) is well described. However, clinical challenges associated with HIV in the context of Graves’ Orbitopathy (GO) are not as well characterised. Our aim was to: 1) determine the prevalence of HIV-GO co-pathology in our unit;
2) describe GO presentation and course in the context of HIV; 3) evaluate management difficulties and how these may be overcome.

Cross-sectional study of patients with thyroid dysfunction and HIV infection at University Hospital Birmingham (2003 – 2014). Retrospective case note review to identify GO with particular reference to HAART regimen, CD4 count, HIV viral load and GO activity and severity.

Of 4202 patients with thyroid dysfunction and 1186 patients with HIV only 11 were identified with both GD and HIV. Of these only 3 had GO (27%). Each were female Afro-Caribbean patients in their fourth decade, initially presenting with absent CD4 cells and high HIV viral loads (>200,000 copies/ml). Each went on to develop autoimmune thyrotoxicosis >3 years after commencing HAART. Each had normal CD4 count and undetectable viral load at time of GD diagnosis. In each case GD and GO onset were simultaneous and GO was active, severe and required orbital decompression surgery.

GO in the context of HIV is uncommon. In the few cases identified GO manifestations were clinically significant. Many challenges exist including safe immunosuppression and anticipating HAART drug interactions. To better understand GO in HIV, and counsel these patients most effectively, multi-centre surveillance is required.

March 19, 2014 at 2:41 pm

v.joganathan@doctors.org.uk

The clinical features, treatment and outcomes of three patients with amniotic membrane transplantation (AMT) following conjunctival excision of malignancy are discussed.

A retrospective case series

Two patients (Cases 1 and 2) with histological proven squamous cell carcinoma of the upper lid and involvement of forniceal conjuctiva and a patient with large bulbar conjunctival amelonitic melanoma (Case 3) underwent wide surgical excision and AMT. The grafts were sutured to cover the conjunctival defect. In addition, 3 cycles of topical Mitomycin 0.04% was used in patients (Cases 2 and 3). Triple thaw cyotherapy was also carried out in case three.
Good surgical healing of lid was achieved with no tumour recurrence in Cases 1 and 2. There was rejection of AMT within a year in all three cases. Case 1 and 3 required a buccal mucosa graft to allow satisfactory surgical outcome and healing.

This case series suggests that AMT might yield better outcome with smaller cojunctival defects and a better role for mucous membrane grafts in repairing larger defects, in particular involving the fornix or palpebral conjunctiva.

March 20, 2014 at 11:49 am

ahsen@doctors.org.uk

Satisfied patients are more likely to maintain relationships with their healthcare providers and comply with recommended medical care, with positive effects on health outcomes and avoidance of litigation. Evidence continues to be required that surgery delivers patient satisfaction.

A single-centre single-surgeon prospective survey study using a Patient Satisfaction Survey (PSS) which was designed and administered to patients who had undergone any combination of acquired ptosis, dermatochalasis and/or brow-ptosis surgery. The PSS includes eight questions pertaining to the patients’ perception of the improvement made to their appearance and vision after surgery, whether they considered it worthwhile and whether they would recommend the procedure. Survey scores were analysed for the global sample and a three-group comparison between the main procedures was performed.

A total of 79 PSS were administered with 76 patients participating. Ptosis surgery with blepharoplasty formed the largest group (n=35). Overall, percent favourable (score of 8 or higher) for each question ranged from 79.7% to nearly 100%. In comparative analyses, those with ptosis without blepharoplasty surgery had the lowest satisfaction with respect to improvement in appearance of the eyelids (p=0.04), and improvement in vision (p=0.03). Increased follow-up was significantly associated with lower satisfaction with appearance, vision and lower likelihood to recommend the procedure.

Our PSS has demonstrated capacity to gauge satisfaction in this group of patients with a high satisfaction rate after ptosis surgery. Particular patient experiences such as type of procedure and length of follow-up can be significantly associated with specific satisfaction markers.

March 20, 2014 at 3:17 pm

aruna_dharmasena@hotmail.co.uk

To report the outcomes of immunosupression with Azathioprine in the management of Thyroid Associated Orbitopathy (TAO).

Ten TAO patients who responded poorly to first line treatment options were included in this study. All patients were given a course of Azathioprine and the response to treatment was carefully recorded by pre and post treatment clinical activity score (CAS) along with any adverse effects.

The mean age at the commencement of azathioprine treatment was 55 ± 11years. All subjects were females. The mean CAS score improved from 4 to 0 over a mean duration of 12 months. The majority of this cohort of patients tolerated Azathioprine very well, although one patient complained of ataxia, two patients had nausea and gastro-intestinal side effects attributable to Azathioprine. One patient who developed pancreatitis while on AZA had her medication stopped 6 weeks after commencement of the treatment.

Azathioprine can be considered as an effective adjunct to conventional treatment options in patients with severe TAO refractory to these conventional treatment modalities. Patient selection is crucial for the treatment success.

March 20, 2014 at 3:18 pm

natasha.berridge@gmail.com

Following penetrating orbital trauma, wooden foreign bodies may cause the diagnostic challenge, as the entry wound may be small and self-sealing. Furthermore, it is well documented that such foreign bodies may remain quiescent for many years. Despite advances in radiologic technology, even fine-cut Computer Tomography scans may not clearly identify the offending foreign body.

We present a fascinating case of mistaken diagnosis and the unexpected retrieval of a large piece of ‘unidentified’ wood from the orbital cavity and maxillary sinus following alleged blunt trauma to the eye.

A 51 year-old man presented to the ED following ‘blunt’ trauma to the orbit during an alleged assault. The mechanism of injury was not accounted for. Examination revealed clinical signs and symptoms of traumatic RBH with a profound reduction in vision. Emergent orbital decompression by lateral canthotomy and cantholysis performed. The persistent raised intra-ocular pressure was addressed with medication for a number of days prior to definitive exploratory surgery.

The CT images identified a large orbital floor defect but did not reveal any foreign bodies or blood within the orbital cavity. Although misdiagnosed, the decision to treat initially as an acute RBH, albeit rare after the ‘reported’ blunt trauma was based entirely upon the clinical findings of a firm proptotic eye with acute reduction in visual acuity.

Our case highlights the difficulties encountered in managing orbital trauma when the mechanism of injury is unknown. We believe that in the event of absent clinical signs and a negative CT scan, consideration should be given to prompt orbital exploration and serial or alternative forms of imaging to reliably exclude a retained wooden foreign body.

March 20, 2014 at 4:49 pm

anks_raj@yahoo.co.uk

Monocanalicular stents have several advantages over bicanalicular stents for nasolacrimal duct intubation (NLDI), including reduced risk of cheese wiring, easier removal and being left in-situ indefinitely. We aimed to determine symptomatic relief in patients who underwent nasolacrimal duct intubation (NLDI), with a monocanalicular stent (monoka grande), for the treatment of epiphora secondary to nasolacrimal duct obstruction (NLDO)

Single centre, retrospective review of case notes of subjects undergoing NLDI between June 2011 and July 2013. Primary outcomes were determined to be subjective improvement of epiphora and need for further intervention. A sub-analysis of associated risk factors was performed

A total of 18 eyes of 15 patients are included. Mean follow up was 9.2 months (range 3-23 months). Functional success was achieved in 67% with no further intervention. Subjects who failed were older (mean age 67 years vs 55 years); had previous surgical intervention, excluding DCR, for epiphora (50% vs 8%); had inflamed nasal mucosa peri-operatively (66% vs 42%); and had earlier removal of tube (2.4 vs 4.7 months). The two groups did not vary in duration of symptoms. There was one case of post-operative corneal abrasion.

NLDI with a monocanalicular stent may be a suitable treatment approach for a carefully selected subset of patients with epiphora secondary to NLDO. Prophylactic treatment to reduce nasal mucosa inflammation and leaving the stent in-situ for greater duration may offer better success.

March 20, 2014 at 5:39 pm

rchaudhary@doctors.org.uk

We describe the use of ORTOPADS® in the management of floppy eyelid syndrome (FES) and to evaluate its effectiveness. ORTOPADS® are soft, hypoallergenic occlusive patches with hot melt adhesive, commonly used in the management of amblyopia in children. As the solid Cartella shield is often poorly tolerated overnight in FES we have explored the use of ORTOPADS® in the affected eye(s) to see if it is better tolerated to manage the condition conservatively or whilst the patient attempts to lose weight/ achieve a healthy BMI (Body Mass Index).

A total of 14 symptomatic FES patients were provided with standard sized ORTOPADS®. Two patients had previously undergone lateral tarsal strip surgery for FES by the same surgeon (JB). After 2 months the patients were sent an anonymous postal questionnaire. This used visual analogue scales (VAS). A scale of 1 (a significant deterioration) to 10 (a dramatic improvement) was used.

Percentage response rate for the questionnaire was 36%. The minimum trial period was 1 week. The maximum length of time that the ORTOPADS® were used was 18 months. 60% used the pads on the right eye; 40% used the pads on the left eye. 80% of patients preferred the ORTOPADS® to the eye shield. 1 patient did not like either.
Average score of 6.21 out of 10 for symptomatic improvement and the overall score for the ORTOPADS® was 6.25. 60% of patients continue to use the ORTOPADS®.

ORTOPADS® are readily available in most Orthoptic Departments, are well tolerated and relatively inexpensive. We show that ORTOPADS® are an effective way of helping to manage FES conservatively and are better tolerated than the standard eye shield. We recommend the use of ORTOPADS® to delay or prevent the need for any surgical intervention.

March 20, 2014 at 9:01 pm

rchaudhary@doctors.org.uk

The goal of evisceration and enucleation surgery should be to give the patient a comfortable socket with a functionally and cosmetically acceptable prosthesis. Long-term complications can arise some years after surgery. We audit all aspects of the surgical pathway including patient perspective.

Retrospective data collection from May 2007 to Nov 2012 gave us a total of 34 procedures performed. Data was available for 25 patients. Data collection included: procedure, indication for surgery and complications. SurveyMonkey® was used to create an automated telephone questionnaire to look at patients’ perspective.

There were 7 females and 18 males, aged between 17 and 92. 2 enucleation and 23 evisceration procedures were performed. The most common (44%) indication for surgery was trauma. There were no intraoperative, 3 early (within 6 weeks post-op) and 2 late complications.

The response rate of the questionnaire was 43.5%. 81.8% of patients wore an artificial eye. 36.4% rated their comfort as good; 45.5% had occasional discomfort; 9.1% had significant discomfort. 50.0% stated that they had complications after surgery and 30% had no complications. 50% rated function of their eye socket as good and the other 50% rated this as acceptable. Cosmetically, 50% were extremely satisfied with the results; 20% were satisfied and 30% found it acceptable.

The data is limited due to the rarity of the procedure. The results do reflect a good surgical outcome. The overall complication rate of 10% is comparable to standards in previous studies. Results reflect a discrepancy between actual documented complications and the patients’ apparent perception of complications. The complications were treated and all patients have now been discharged.

March 20, 2014 at 9:25 pm

saulrajak@hotmail.com

Necrotising fasciitis (NF) is a severe infection of the deep soft tissue including the fascia. It has high levels of morbidity and mortality. It occasionally affects the peri-ocular area (PONF). We present the largest reported case series of this condition, which elucidates some of the clinical and microbiological characteristics and the short and long term outcomes of this rare disease and identifies differences between PONF and NF elsewhere in the body.

A retrospective case series of cases of PONF managed by members of the Australia and New Zealand Society of Oculoplastic Surgeons between 2000 and 2013.

We identified 14 patients with PONF. A preceding minor trauma was recalled in 9/13 patients, two of who were assaulted by the same assailant. Systemic shock occurred in 1 patient and none died. Group A Strep was the commonest bacteria identified. Intravenous antibiotics (IV ABx) and 1 to 5 sessions of surgical debridement were required for to control the disease in 12/14 patients. Two patients were managed with IV ABx alone. Reconstructive surgery was required in 7/14 patients. The long-term visual outcomes were very good: all except one patient preserved >6/18 vision in the affected eye(s), in follow-ups ranging from 2 months to 10 years.

There are marked differences in PONF and NF elsewhere in the body. PONF is usually less severe, more controllable and has much better outcomes. In general, cases of PONF that received prompt diagnosis and treatment had better outcomes although there are exceptions.

March 20, 2014 at 11:06 pm

kim.z@doctors.org.uk

To describe the occurrence and severity of upper eyelid skin contracture in patients with facial paralysis

We carried out a cross-sectional study on patients with unilateral facial paralysis presenting to the facial palsy clinic at Queen Victoria Hospital, UK, December 2013 to March 2014. Patients with previous upper eyelid surgery or tarsorrhaphy on either side were excluded. We developed a standardised technique to measure the distance between the upper eyelid margin and the lower border of brow (LMBD). Facial paralysis was graded using the Sunnybrook grading scale.Its aetiology, duration and treatment were noted. Upper and lower marginal reflex distance, lagophthalmos and severity of brow ptosis was also noted.

Thirty-six patients (mean age 50.3, range: 10-79 years, 10 males and 26 females) were identified. The mean duration of paralysis was 65.4 (range: 2.5-348) months. Twenty- three (64%) patients showed shorter LMBD compared to the normal contralateral side. The mean contracture was 3.46mm (range: 1-12). The mean LMBD on the paralytic side in all patients was significantly smaller than the contralateral side; 30.40mm (95% CI, 29.23 to 31.82) compared to 32.61 mm (95% CI, 31.23 to 34.02), p=0.02 two-tailed t-test. Five patients showed contracture of 5mm or more, 11 showed 2-5 mm of contracture and 7 showed 1-2 mm of contracture. Contracture occurred as early as 2.5 months from the onset of paralysis.

This is the first study that quantitatively demonstrates contraction of the upper eyelid skin in facial paralysis. This finding is valuable in directing optimal management in the acute phase to minimise skin contracture and to reinforce the principles of avoiding skin excision in these patients.

March 20, 2014 at 11:18 pm

nuhaq1@gmail.com

To determine the clinical features, management and outcome of periocular and orbital amyloidosis in a tertiary UK service.

Retrospective, interventional, case series of patients treated at University Hospitals Leicester between 2004 and 2012. Casenotes of all patients diagnosed with amyloidosis were analysed. Clinical features, investigations, treatment modalities and outcomes were evaluated.

Casenotes of 5 patients (3 females and 2 males) were analysed. 3 patients presented with eyelid lesions, 2 with proptosis. The mean age at presentation was 60.6 +/- 5.1 yrs, the mean follow up was 36.6 months. 4 of 5 (80%) patients were managed in conjunction with the National Amyloidosis Centre.
4 of 5 patients had Lambda light chain disease. The mean number of imaging procedures was 2.2. 3 of 5 patients had systemic involvement; 4 of 5 patients did not have visceral involvement on SAP scintigraphy. Occult systemic disease was detected by PET-CT in 1 patient previously undetected by SAP scintigraphy.
4 of 5 patients underwent surgical resection, the mean number of operations was 1.6. 2 patients required multiple operations for progressive disease.
1 patient underwent treatment with systemic Infliximab but also required surgery for ocular disease.

Amyloidosis is a rare disorder which is often progressive and difficult to manage effectively. Surgical resection remains the mainstay of treatment for localised periocular disease. In our series, multidisciplinary management in conjunction with a specialist centre and newer imaging techniques have obviated the need for multiple invasive systemic biopsies. We advocate the use of PET-CT as a new imaging technique to detect occult systemic disease.

March 20, 2014 at 11:47 pm

Anjana@doctors.org.uk

Congenital cystic eye (CCE) is a rare condition caused by failure of invagination of the optic vesicle resulting in a persistent cyst replacing the eye. An associated optic nerve attached to the cyst is a rarely reported phenomenon that has been sparsely described histologically, with no immunohistochemistry reported previously. The authors present a case of CCE with optic nerve tissue inserting into the cyst and present the histological and immunohistochemical findings.

Interventional, clinico-pathological case report and literature review.

Congenital right anophthalmos with cyst (congenital cystic eye) was diagnosed in a 3 day-old female patient based on clinical and radiological findings. Following a period of observation and periodic assessment, surgery was performed to remove the intact cyst, and replace orbital volume with a bioceramic implant. Histological analysis confirmed the diagnosis. The optic nerve inserting into the capsule of the cyst was distorted and appeared atrophic. A normal optic nerve head was not present. Immunohistochemistry of the optic nerve showed a positive reaction with GFAP (glial fibrillary acidic protein); a reduced layer of meningeal tissue was also demonstrated adjacent to the optic nerve using EMA (epithelial membrane antigen). In previous cases of CCE reporting an optic stalk or rudimentary optic nerve, 11 were associated with optic nerve tissue and only 4 described optic nerve histology, with no immunohistochemical detail.

In conclusion the authors present the histopathology and immunohistochemistry of a CCE with an optic nerve attached. Immunohistochemical studies in future reports of this condition would enhance our understanding of early optic nerve development and its arrest.

March 21, 2014 at 1:18 pm

Anjana@doctors.org.uk

Orbital implant exposure is the most common complication of socket surgery. The purpose of this study is to demonstrate the versatility of the TPFG in orbital implant exposures of varying duration, implant types and patient age as well as for recurrent exposure. The use of TPFGs for hydroxyapatite, porous polyethylene and silicone implant exposure has been described previously. To the authors’ knowledge, this is the first description of this technique for acrylic implant exposure and paediatric patients.

Retrospective, interventional, non-comparative case series.

12 patients (13 grafts) are presented with a mean follow-up of 9.5 months. The duration of exposure prior to grafting ranged from 1-11 months occurring in bioceramic, hydroxyapatite, porous polyethylene and acrylic implant types. There were 2 graft failures (success rate 84.6%), one of which was treated with a 2nd TPFG. Both of these cases were associated with culture-proven implant infection. Two of the cases in this series were from the paediatric age group.

This study provides further supporting evidence for the safety and efficacy of the TPFG. It is a versatile graft with respect to: 1) the effectiveness for both short- and long-duration orbital implant exposures; 2) the use with different implant types; 3) its use within paediatric cases and 4) the ability to use it successively in the same patient. We would recommend meticulous socket follow-up after orbital implant surgery to look for signs of early infection and a low threshold for antibiotic treatment. Should exposure develop despite these measures, a TPFG should be considered and may avoid the need for orbital implant removal.

March 21, 2014 at 1:38 pm

ben@trianglemedia.co.uk

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March 21, 2014 at 2:24 pm

sadie.wickwar.1@city.ac.uk

Patients with TED report feeling socially isolated due to their appearance (Terwee et al, 2002). Although TED severity is expected to be associated with appearance concern and social avoidance, recent studies do not support this assumption (Moss & Rosser, 2012). Thus this study has examined the relationship between TED severity and social avoidance

Forty nine adults with TED (36 females) were assessed for severity of exophthalmos, clinical activity (CAS) and duration, the Derriford Appearance Scale (DAS24), and the Graves Ophthalmology Quality of Life questionnaire (GO-QOL). Correlations identified any relationships between clinical factors and demographic factors, and social avoidance. Regression models identified whether social avoidance predicted QoL

Participants had a median age of 45 (range 23 – 79) and median disease duration of 2.5 years (range 0.3 – 18). There were no significant differences between men and women in DAS24 scores. Men had a mean score of 48; 11 points higher than the male general population; 8 points higher than men with disfigurements to the head and neck (HN) region. Women scored on average 51; 19 points higher than the female general population; 9 points higher than women with disfigurements to the HN region. No statistically significant correlations were found between DAS24 scores and age, proptosis, activity, or duration. DAS24 scores explained 72% of the variance in GO-QOL psychosocial scores (p<0.001)

Men and women with TED reported levels of appearance concern and social avoidance higher than other populations and these psychological factors were not related to clinical or demographic factors. Social avoidance significantly predicted QoL

March 21, 2014 at 5:48 pm

subrahms@yahoo.com

To study how Thyroid associated orbitopathy(TAO) among Indians differs from that of caucasians

234 patients (128 females & 106 males) of TAO treated by me from Jan 1994to Dec 2013. Clinical evaluation included BCVA, color vision,IOP,lid signs,inflammatory score,Hertel’s, ocular motility,PBCT,Fundus examination,Visual fields,systemic evidence of thyroid disease &serological investigations like T3,T4&TSH.Imaging was performed when needed.Management included supportive,medical(Systemic Steroids: oral/pulse)and Surgeries for Orbital decompression(for optic nerve compression/cosmetic reasons),squint and for soft tissue changes.The data was compared with that of Caucasians available in the literature.

The average age of TAO presentation among males was 45.1 years and females 40.1 years, about 5 years younger than Caucasians.Though hyperthyroidism is the most common association,it is much less(61.97%)than among Caucasians.Hypothyroidism (52-22.22%) and Euthyroidism (37-15.81%)were more common among Indians.The inflammatory symptoms like pain and redness, diplopia were less common among Indians, while proptosis, lag ophthalmos and defective vision were more common. 192 had very low inflammatory score, & 12 had very severe inflammatory score.24 patients (10.26%) had compressive optic neuropathy.They were successfully managed with pulse steroids, followed by orbital decompression.18eyes of 12 patients had cosmetic orbital decompression.

TAO is mostly associated with hyperthyroidism, but the prevalence of euthyroidism and hypothyroidism is much higher among Indians.The Inflammatory scores are less among Indians. Proptosis, lag ophthalmos and Optic nerve compression are more frequent among Indians.

March 21, 2014 at 6:55 pm

adeelam@gmail.com

To illustrate two cases of orbital plexiform neurofibromas with no history of neurofibromatosis (NF) with associated interesting pathology.

Two cases of adults with biopsy proven plexiform neurofibroma with no history of NF.

Case 1: A 59yr old man presented with a thickened left upper lid. He had previously undergone an evisceration for a painful, blind, buphthalmic eye due to congenital glaucoma resulting in endophthalmitis. Evisceration histology revealed an incidental choroidal melanoma for which he was treated with radiotherapy. Post radiotherapy he underwent a wedge excision to tighten his lid, which had been stretched by his buphthalmic globe. Histological examination of the thickened lid revealed a plexiform neurofibroma and further examination of the evisceration sample revealed a prominence of ganglion cells within the choroid. As he had no history or signs of NF he was referred to the geneticist. The geneticist suggested it may represent a localized form of NF1 caused by a gene change in the left orbit. Interestingly, NF has been linked to cases of choroidal melanoma.

Case 2: A 54yr old lady presented with left proptosis noted since trauma to the eye 12 months prior. She had no signs of inflammation and normal vision. CT and MRI showed extraocular muscle and lacrimal gland enlargement, an orbital mass extending through the superior and inferior orbital fissure and a further temporal fossa mass. Orbital and lacrimal gland biopsy demonstrated a plexiform neurofibroma. She had no history of NF. On review of old photos it became obvious that she had had left proptosis for many years. She was referred for a neurology review.

Isolated plexiform neurofibromas can be found in adults with no history of NF.

March 21, 2014 at 10:50 pm

limrongxuan@gmail.com

There have been reports of BCC regression after incisional biopsies, more commonly in the trunk and extremities. This is thought to be secondary to the wound healing response following a biopsy.

We photographically documented a case of a peri-ocular BCC reducing significantly in size following a punch biopsy. This prompted us to organise a small prospective study charting the alteration in peri-ocular BCC sizes after punch biopsies.

We report our early results and hope to interest others in a multi-centre study.

All patients seen in our clinic with suspected BCCs were prospectively recruited. Lesions subsequently found not to be BCCs based on the histology reports were excluded. All lesions were photographed immediately before the punch biopsy and then again 4-12 weeks later. The area of every lesion was calculated (KLONK image measurement 2013). Pre-biopsy lesion size was compared to that post-biopsy.

10 patients were included in the study. The mean age at biopsy was 74 years old. The mean time between biopsy and follow-up visit was 42 days. 6 patients had 2mm diameter and 4 patients had 3mm diameter punch biopsies respectively. The mean surface area of the lesion pre- and post-biopsy was 0.37cm2 (standard deviation (SD)=0.39cm2) and 0.29cm2 (SD=0.22cm2). This reduction was not statistically significant (p=0.32) (2-tailed paired Student’s t-test).

We found a reduction in the average area of peri-ocular BCCs after biopsy. However this did not reach statistical significance, possibly because of the small numbers in our study. We hope to interest others in a multi-centre study to analyse a larger number of patients with peri-ocular BCCs.

March 21, 2014 at 10:59 pm

mrosabonilla@gmail.com

In 2000 the Two Week Wait Referral Pathway (2WW) was introduced into the United Kingdom in order to decrease the waiting times and improve survival rates of patients with suspected cancer. However, concerns have been raised since it was implemented on whether the measure is actually having the desired effect. In this context, we have undergone a retrospective review of patients seen in our adnexal department under the 2WW pathway to determine if the targeted waiting time is being achieved and the accuracy of the GP referrals.

Retrospective case notes review of 32 patients referred from their GPs through the 2WW pathway to the adnexal department at Moorfields Eye Hospital from March 2012 to February 2014. The date of GP referral, date of clinic appointment and diagnosis were recorded.

The mean waiting time was 8.6 days (range 2-14, SD: 2.9) with 2WW target achieved in 100% of cases. From the 32 patients only 5 (15.6%) were diagnosed as cancer, 23 (72%) had a non-cancer diagnosis, 3 (9.4%) were still under investigation when the study finalized and 1 (3.1%) did not attend to the clinic appointment. The most commonly misdiagnosed pathologies between the 28 cases that had a definitive diagnosis were blepharitis related chalazion and papilloma (42.8% altogether) that resolved appropriately after treatment.

Although our oncology unit is achieving the 2WW target, there is a marked lack of accuracy in the GP referrals. Although this might be related with the 2WW being used to expedite appointments more than a lack of knowledge, we propose continuing medical education (CME) in lid oncology as key for GPs to have a better understanding of the alarm signs related with malignancy of the lesions.

March 22, 2014 at 9:11 am

pouya.alaghband@gmail.com

We have employed an innovative and non-invasive technique to improve the definition of the features and borders of periocular skin lesions in oculoplastic practice.
There are two components to the reflected light from skin: regular reflectance (glare) and light backscatter. The regular reflectance contains visual cues to the texture of skin; whereas the backscatter light reveals the pigmentation, vascularisation, erythema, infiltration and other intra-cutaneous structures. The use of cross-polarized light separates two components of the light from tissue reflectance and is employed in devices commonly known as dermatoscopes.

We have utilized the Nikon circular polar filter (52 millimetre) as a handheld lens for use with a slit lamp. In addition, we have employed the same filter on our digital cameras to improve the quality of clinical photography in our department.
To demonstrate the value of this technique, we have selected 20 different types of common oculoplastic skin lesions. They were examined and photographed with and without circular polarization.

We have compared the details of the polarised and regular images of each lesion. There was a striking difference in the appearance of skin when it was imaged with polarised light as opposed to standard images. This method especially enhanced the internal characterisation of the tissue. Furthermore, it improved visualisation of pigmentations and borders of each lesion prior to intervention.

We encourage and advocate the further use of dermatoscopy in oculoplastic clinical practice. Potentially this will improve the diagnosis and surgical planning of periocular skin lesions. Our technique is easy to introduce and represents excellent value for money.

March 22, 2014 at 11:08 am

ahsen@doctors.org.uk

The natural history of Graves’ Ophthalmopathy (GO) is widely accepted to follow the course of a model attributed to Francis Felix Rundle. In Rundle’s own words, however this “ideal and theoretical” curve was based on “relatively few patients”. We sought to substantiate the model by studying exophthalmometry and clinically active score (CAS) readings in conservatively managed patients with GO.

A retrospective clinical notes analysis was undertaken of patients with Grave’s Ophthalmopathy who had been managed conservatively with no history of steroid use or immunomodulation. Population characteristics, CAS readings and change in exophthalmometry measurements were plotted over time and compared to Rundle’s curve.

Data were collected for 127 patients with 79.5% female and 76.3% non-smokers. Mean age at diagnosis of GO was 54.7 (SD 14.7) with mean follow-up 60 months (SD 67.7). Mathematical modeling using third-order linear regression was applied to patients who had sufficient clinical readings. Individual patient application to the model revealed close statistical significance in following Rundle’s Curve in some cases (p=0.062 at the 5% significance level). A universal model continues to be investigated to be applied to all patients in our group which would allow overall comparison to Rundle’s Curve.

Our preliminary findings indicate that Rundle’s Curve remains a useful tool in guiding clinicians and offering prognostic information to patients. Further work is underway with our data in providing statistical correlation.

March 22, 2014 at 4:34 pm

farhanqureshi101@hotmail.com

Previous retrospective studies of eyelid surgery alone have revealed very low post-operative infection rates (0.04% to 0.2%) To the best of our knowledge there is no prospective post-operative infection data available specifically for all types of oculoplastic surgery. A prospective study was conducted in 5 National Health Service (NHS) ophthalmic units to determine this.

Data was prospectively collected on all patients undergoing oculoplastic procedures under the care of 11 consultant oculoplastic surgeons in 5 hospitals over a 3 month period (1st February to 30th April 2013) on all eyelid, lacrimal, and orbital surgery performed in the operating theatre. The participating hospitals were: Aintree University Hospitals, Royal Bolton Hospital, Cheltenham General Hospital, Manchester Royal Eye Hospital & Royal Preston Hospital.

A total of 901 oculoplastic procedures were carried out over the 3 month period.
75% of cases involved eyelid surgery , 16% were lacrimal cases and 9% were orbital cases. Six (0.7%) cases of post-operative infection were reported. Five of these involved eyelid surgery alone and 1 was a lacrimal surgery case. No orbital surgery post-operative infections were reported.
Those who developed infections presented 4-12 days post-operatively with suggestive signs and symptoms starting between 0 and 7 days prior to attendance. With oral antibiotics, all infections resolved between 6 and 30 days following initiation of antibiotic treatment. One patient needed further corrective surgery due a wound dehiscence.

Surgical site infections occur in approximately 5% of patients across all types of surgery. Although oculoplastic infections are much lower this study reveals a higher rate of oculoplastic surgical site infections (0.7%) than previous retrospective studies have revealed (0.04-0.2% quoted for eyelid surgery alone). Our prospective study is likely to be more representatative of the true rate of oculoplastic surgical site infections than previous published studies which may not have captured all infections due their retrospective nature. This study provides oculoplastic surgeons with a useful and more accurate benchmark to compare their own surgical site infection rates and counsel patients and their carers pre-operatively.

March 22, 2014 at 4:50 pm

poitelea.c@gmail.com

Orbital decompression for thyroid orbitopathy (TO) helps reducing orbital congestion and to cosmetically rehabilitate a patient. TO contributes to periocular ageing changes with loss of the lid-cheek continuum, lower eyelid hollowness or prominent fat pads. We present the results of our orbital decompression surgery when combined with orbital fat grafting of excised posterior orbital fat.

A retrospective patients with TO who underwent orbital bone and fat decompression surgery combined with posterior orbital fat excision from the infero-lateral and medial orbit and re-grafting into the lower lid-cheek junction. After lower eyelid retractor recession and release of the orbito-malar ligament, excised fat was placed into the pre-periosteal space in the region of the SOOF. Age, sex, pre- and post-op. visual acuity, proptosis , diplopia, soft tissue swelling were recorded. Cosmetic appearance at 3 months was assessed via photos (assessing lid-cheek continuum, lower lid hollow , retraction and contour, and fat prominence). Outcome measures included complications, cosmesis and retroplacement.

28 orbits of 17 patients (13 females) were treated. Mean age was 47 years (26-79). There were no intraoperative complications, infection or visual loss. Postop. complications included diplopia (3 patients), caruncular granuloma (2), lower lid lump (3), fat seepage (1). The lid-cheek continuum, lower lid hollowness, height, contour and fat prominence improved in all patients Average reduction in proptosis was 3.87mm (1-6).

Conclusion

Orbital decompression combined with orbital fat grafting can lead to functional and cosmetic satisfactory outcome. Combined surgery may reduce the need for subsequent aesthetic eyelid surgery.

March 23, 2014 at 7:35 am

poitelea.c@gmail.com

Upper eyelid loading with gold or platinum is a popular and important treatment for the rehabilitation of patients with lagophthalmos due to facial palsy.

Platinum chains have fewer complications (astigmatism, migration, bulging or extrusion) and better cosmesis when compared to standard rigid gold implants. We report the use of thin, surgeon-linked 0.2g and 0.4g platinum segments (PS, Altomed) in these patients. PS combine the advantages of platinum chains whilst being cheaper and allowing for adjustment, if the desired effect is not achieved after implantation.

This was a prospective study of patients with facial palsy undergoing upper eyelid loading with PS. 0.2g and/or 0.4g PS were sutured together with 6/0 nylon to create a chain of the desired weight. The PS were sutured high on the tarsus and to the recessed levator with 6/0 Nylon. Data (patient age and sex, PS weight, marginal reflex distance, lagophthalmos) and standardised photographs (used for grading contour and prominence) was collected pre-operatively and 3 months after surgery.

10 patients (6 female) with a mean age of 53 years (range 25-68 years) took part in the study. The average weight implanted was 1.2g, comprising 3 PS on average. All demonstrated near complete resolution of their lagophthalmos, with no complications during the follow-up period. The majority of the patients had a natural upper eyelid contour and no discernable prominence of the PS at final follow-up.

New surgeon-linked platinum segments are a useful alternative for upper eyelid loading when treating lagophthalmos. They allow the option of adjustability of weight without the need for exchange.

March 23, 2014 at 7:40 am

simonrogers@doctors.org.uk

To describe a new modification to the technique of evisceration that allows for placement of a large implant, along with a double scleral layer closure without division of the posterior sclera.

After evisceration of the uveal contents, rectangular, mobile, scleral flaps still attached to the medial and lateral rectus muscles are created. A porous polyethelene implant of appropriate size is chosen to maximize orbital volume replacement. The superior and inferior scleral flaps are sewn over the implant. Then the mobilized medial and lateral scleral flaps, vascularized by their rectus muscle attachments, are overlapped by 2-3mm and sewn over the anterior surface of the implant. The superior and inferior edges of these advanced flaps are tacked down to the underlying superior and inferior scleral flaps. Tenon’s capsule and conjunctiva are sutured in separate layers. A conformer of appropriate size is inserted.

The paper will include photos and illustrations of the technique with some provisional data from cases performed. We will also discuss the potential benefits of this technique over other previously reported evisceration techniques.

We feel that the long-term success of an evisceration is dependant on three factors: (i) Adequate intraorbital volume replacement, optimally with in the area of volume loss, (ii) Low-tension coverage of a suitable orbital implant in multiple layers, (iii) Maintenance of normal orbital anatomy by utilising dissection which is as minimally-invasive as possible. In this way the aim is to preserve maximal postoperative motility. The technique described in the paper addresses all of these factors and we recommend its use when performing evisceration.

March 23, 2014 at 8:01 am

qiangk@gmail.com

Dacryocystorhinosotomy (DCR) surgery has been traditionally performed via an external approach under general anaesthetic (GA) for the treatment of primary acquired nasolacrimal duct obstruction (PANDO). Endoscopic DCR has been constantly refined, with recent studies showing success rates similar to the external method. Potential advantages of endonasal DCR, in addition to scar avoidance, include a possible increase in local anaesthetic (LA) day case procedures.
The aim of this survey is to identify the current DCR surgical practice in the UK regarding commonest surgical approach, preferred mode of anaesthesia and day case rate.

An online questionnaire was sent to 120 lacrimal surgeons in the UK listed on the British Oculoplastic Surgery Society (BOPSS) website.

62 questionnaires were returned (51.6%). Over 70% performed the majority of primary DCR surgery via external approach, with 50% almost exclusively undertaking external DCR’s. Approximately 15% most commonly used LA for external DCR’s, whereas only 6% avoided using GA for the majority of endonasal DCR’s. For external DCR cases, only 4 percent of surgeons routinely planned an inpatient stay, compared to 2% for patients having the endonasal DCR’s.

This survey shows that UK surgeons with a special interest in lacrimal surgery, currently still prefer the external approach, though there is a significant proportion (20%) routinely favouring primary endonasal DCR. The vast majority of external and endonasal DCR procedures are still performed under GA, but interestingly LA use is much commoner for external DCR. Overall there has been a switch to predominantly day case DCR surgery with the proportion of surgeons routinely requiring inpatient stays being low for both groups.

March 23, 2014 at 2:21 pm

anupmakumar@hotmail.com

To describe the surgical management of patients with periocular complications related to the use of the withdrawn dermal filler Novabel ®.

We present three patients who underwent the successful surgical excision of extensive lower lid/cheek foreign body granulomata. Data presented will include pre and postoperative clinical photographs, histology results and details of the surgical management.

Each patient had undergone lower eyelid tear trough injections with the dermal filler Novabel ®. The patients developed progressive firm, non-tender swellings in the lower eyelids and upper cheeks approximately 3 to 6 months after the initial treatment. One patient had been treated with oral steroids and two patients had undergone periocular injections of saline and steroid prior to referral. Following some initial improvement the problems had recurred.

The patients underwent surgery by a single surgeon (BL). The dermal fillers and inflammatory masses were removed successfully using a subciliary skin incision combined with primary fat grafting in one patient. Adjunctive steroid injections were required for each patient.

All dermal fillers are associated with risks and potential complications. Novabel ® is an alginate dermal filler which was withdrawn from the market in August 2010 due to reports of adverse granulomatous reactions.

These cases highlight the potential surgical strategies, which can be considered in order to manage periocular granulomatous reactions unresponsive to medical management alone.

March 23, 2014 at 2:24 pm

anupmakumar@hotmail.com

To present the audit results of a series of consecutive patients undergoing lower eyelid transconjunctival blepharoplasty with fat repositioning by a single surgeon (BL).

A retrospective case note review of all cases performed between August 2010 and March 2014. Data collected included patient demographic details, intraoperative and postoperative complications, and postoperative outcome including patient feedback.

There were 39 patients included in the audit. There were 7 males and 32 females with a mean age of 48.5 years (range 32:69 years). The surgery was performed under LA with sedation using a tranconjunctival approach. In 25.6% (n=10) of patients adjunctive treatment was performed at the time of surgery including upper eyelid blepharoplasties, brow lift surgery and Coleman fat injections. There were no intraoperative complications. One patient, a diabetic, developed a bilateral lower eyelid infection 9 days postoperatively, which required urgent surgical intervention. There were 2 cases of suture related conjunctival granulomas. One patient required topical steroid treatment and the other patient settled after removal of the conjunctival suture. No patients experienced persistent lumpiness of the transposed fat.

Patient feedback was available in all cases. In 97.4% (n=38) patients were satisfied with the outcome of their surgery.

In facial rejuvenation surgery transconjunctival blepharoplasty with fat repositioning can successfully treat appropriately selected patients with tear trough defects and eyelid fat herniation avoiding the potential stigmata often associated with a transcutaneous blepharoplasty. The overall patient satisfaction was very high using this technique.

March 23, 2014 at 2:35 pm

jonathan.norris@ouh.nhs.uk

To report the outcomes of the endoscopic DCR (En-DCR) surgery performed by oculoplastic surgical trainees and to describe factors that may improve success rates for surgeons in training.

A retrospective, comparative audit of 40 consecutive En-DCR cases carried out by 3 trainee oculoplastic surgeons at East Grinstead over a 3 year period was performed. Data including indication for surgery,intra and postoperative complications, objective/subjective success and details of revision surgery was collected.Success was defined as complete resolution of epiphora with patency on syringing and a positive functional endoscopic dye test.Written informed consent was obtained from all patients and data collection was carried out with appropriate Institutional Review Board guidance.

The success rate for each surgeon was 16/18 (89%), 8/8 (100%) and 8/14 (57%), respectively with overall 80% (32/40) success at mean follow-up 17.8±15.0 weeks. The trainee with the lowest success rate used silicone stents in only 29% of cases compared to 89% and 100% by the other 2 trainees.
In failed cases who underwent revision surgery (n=6), all were found to have closure of the soft-tissue ostium and sac requiring flap revision. Two cases required further bone removal supero-posterior to the lacrimal sac.

This study demonstrates good surgical outcomes achieved during the training period in En-DCR surgery.Failure in this audit was primarily due to closure of the soft-tissue ostium, either secondary to inadequate osteotomy and sac-marsupilisation or postoperative scarring. Intra-operative mucosal trauma is higher amongst trainees and adjuvant silicone stenting during the training period may play a role in minimising failure.

March 23, 2014 at 2:45 pm

kim.z@doctors.org.uk

To describe our experience with the use of botulinum toxin (BoNTA) for the symptomatic treatment of lacrimal outflow obstruction

We retrospectively reviewed case-notes of patients with epiphora due to lacrimal outflow obstruction who chose to have injections of botulinum toxin into the palpebral lobe of the lacrimal gland instead of surgery between 2009-2014. Epiphora was graded subjectively with Munk scores obtained before and after treatment as well as qualitative degree of improvement reported by the patients. Severity and duration of side effects were also noted.

Seventeen patients (22 eyes, mean age 70.3, 4 males and 13 females) were identified. A mean of 3.5(range 1-10) injections of BoNTA (Botox®, Allergan)(1.25-7.5 units) were given per eye. Four patients underwent more than 3 injections. Median interval between injections was 4 (range 3-6) months. The mean Munk score (3.5, range 2-4) improved significantly after treatment to 1.63 (range 0-3, p=0.0001 paired two-tailed t-test). Fourteen (88%) patients reported modest to complete improvement of their symptoms. Epiphora completely resolved in a fifth, improved by up to 60-90% in a half and only “a little better” in a further fifth. Temporary bruising and diplopia (lasting 2 weeks) was reported in 12% (2/17).

We report our outcomes for BoNTA to the palpebral lobe of the lacrimal gland in patients with lacrimal outflow obstruction epiphora seeking alternatives to surgery. This data may be of value for informed consent and for commissioning groups in funding this treatment.

March 23, 2014 at 3:12 pm

aneesanazreen@yahoo.co.uk

Radiation retinopathy is a potential long-term complication of radiation therapy to the orbit. The aim of this study was to identify the risk of developing radiation retinopathy following radiotherapy.

A retrospective review of 9 patients who developed radiation retionopathy following external beam radiation therapy for orbital diseases

There were 6 males and 3 female patients. Age of onset ranged from 40 years to 75 years with a mean age of 57 years. We had 6 patients with lymphoma, 1 with optic nerve meningioma, 1 with schwannoma and 1 with thyroid orbitopathy. Patients received external beam radiation therapy at doses between 30 and 40Gy with 15 to 20 fractions. 5 patients with radiation retinopathy had comorbidity (diabetes mellitus type 2), of which only one patient had background diabetic retinopathy before developing radiation retinopathy. The mean time between radiation and development of retinopathy was 24 months ranging from 8 months to 53 months. Visual acuity ranged from hand movements to 6/9.The other ocular complication of radiotherapy included dry eyes (10 eyes), cataract (8), optic neuropathy (2) and nasolacrimal duct obstruction (1). 2 patients had mouth ulcers following radiotherapy. There was no recurrence of lymphoma in any patients. 4 patients developed proliferative changes of which 3 patients had diabetes mellitus. 2 patients with proliferative changes received pan retinal photocoagulation, 1patient required pars plana vitrectomy and other patient refused treatment. The mean follow up was 54 months.

Radiation retinopathy is a well-known complication of radiotherapy for orbital tumors, however risk is higher if associated with vascular comorbidities. Excellent local control can be achieved with radiation doses of 20 Gy to 35 Gy. Higher doses may result in an increased risk of complications.

March 23, 2014 at 3:26 pm

aneesanazreen@yahoo.co.uk

To evaluate the efficacy, tolerability and complication of argon laser coagulation of xanthelasma lesions.

Retrospective case notes review of 33 patients who received argon photocoagulation for xanthelasma.

Sixty-three eyelids of 33 patients with xanthelasma that were flat with an average size of 35mm were treated using an argon green laser. The laser parameters were as follows: wavelength 514 nm; spot size 500 microns; energy 700 mW; the duration of the laser pulse 0.1-0.2 seconds. The procedure was done on outpatient basis under local anaesthesia. There were 23 females and 10 males, with the mean age of 48years ranging from 32 to 73 years. 91%(30) had bilateral lesions.
10% (3) had comorbid hypercholesterolemia and diabetes mellitus.
49%(16) had excellent result and required only one sitting of laser treatment. 36%(12) had two sitting, 9%(5) had three sitting of laser
treatment. There were no complication or scar formation in 97%(32); nevertheless 3%(1) had depigmentation on the laser site. The mean follow up was 6 months. To the best of our knowledge this is the largest series ever studied.

Argon laser treatment is the best alternative technique especially in case with cosmetic indications. It’s a safe, effective, fast and painless outpatient procedure with less postoperative care with the good acceptance of technique by the patient. This procedure should be considered as a first line of treatment in patients with multiple flat lesions.

March 23, 2014 at 3:29 pm

s_makuloluwe@yahoo.co.uk

Diagnostic studies such as computed tomography scans (CT) and magnetic resonance imaging (MRI) are ordered frequently in ophthalmic practice. Few studies have reported their role in confirming clinical suspicion. Our clinical accuracy in diagnosing neuro-ophthalmic and orbital disease was assessed using neuroimaging as a supportive tool.

This retrospective study included all patients that had CT scans and/or MR imaging over an 8-month period, identified from our radiological database. Clinical ophthalmic/orbital findings and indication for imaging was correlated with scan results to assess diagnostic accuracy. Imaging results were categorised as relevant (relating to clinical findings), significant other (unrelated to presentation; requiring attention), non-significant other (incidental findings without clinical significance), and normal.

133 patients were identified, each having CT or MRI imaging. 22 (16.5%) had CT (age range 32 to 92 years, mean 65.6) and 111 (83.5%) had MR (age range 3 to 94 years, mean 54.0). 44/133 scans (33.1%) yielded relevant results to support the clinical findings. 9/133 (6.8%) had significant other pathology, 29/133 (21.8%) had non-significant other findings. A few of these had cross over with their ophthalmic/orbital disease (3 in significant other group, 4 in non-significant other group). 57/133 (42.9%) had normal scans. Relevant findings are tabulated in comparison to clinical impression.

Using neuroimaging, we demonstrate a high rate of clinical diagnostic accuracy by ophthalmologists. When applied judiciously, these imaging modalities remain an important supportive and diagnostic tool.

March 23, 2014 at 3:38 pm

farihashafi@doctors.org.uk

Report outcomes of patients undergoing enucleation for retinoblastoma (RB) at Birmingham Children’s Hospital (BCH).

Retrospective consecutive case series. Patient demographics, implant characteristics, intraoperative details and postoperative complications were recorded.

239 patients (127 female, 112 male) underwent enucleation for RB between August 1992 and September 2013. Mean age was 2.3 years (range 2 months – 12 years). 4 patients underwent bilateral enucleation. Porous polyethylene (Medpor®) sphere implants were used in the majority of cases (93.6%). Most common size of implant used was 20 mm (33.3%) and 18mm (30.7%). No significant intraoperative complications were encountered. Mean duration of follow-up was 36.5 months (range 2 weeks – 13.5 years). Postoperative complications were noted in 18 eyes (7.5%). 8 patients (3.3%) developed exposure of the implant. 1 case required replacement of an exposed 18mm implant with a 14mm implant. This patient developed intolerance of the overlying prosthesis with mucopurulent discharge. 1 patient developed exposure of a magnetic implant, which was successfully replaced with a 18mm porous polyethylene implant. The remainder of patients were managed conservatively. 5 patients (2.1%) developed conjunctival prolapse and 2 patients (0.1%) developed granulation tissue in the socket. 1 patient with severe eczema developed orbital cellulitis 2 months following enucleation with a 16mm orbital implant. The patient was treated with intravenous antibiotics and the implant was removed with no further complications.

Orbital implantation with porous polyethylene implants is associated with favourable outcomes in the paediatric population following enucleation for RB.

March 23, 2014 at 3:45 pm

sabry_bridan@hotmail.com

To determine the topographic patterns, wavefront aberrations ,and quality of vision changes before and after Pterygium surgery with conjunctival autograft..

Interventional non –comparative case study, including 32 eyes of 23 patients ,with stage 3-4 pterygium (4-5.4 mm extent over the cornea),undergone pterygium surgery between 2/2011 and 11/2012 in Magrabi Aseer hospital and Cairo University hospitals. Corneal topography and wavefront aberrations were derived for a 5.0-mm pupil using a 10th order Zernike polynomial expansion using OPD Scan II. Pre- to postoperative changes were assessed for significance using analyses of variance.

Satisfactory corneal topography was available on 32 eyes (mean age 50.4±8.7 years ). The root-mean-square (RMS) of error in preoperative eyes was 2.15+/- 0.60 μm. Preoperatively, the total higher order RMS wavefront aberration(HOA) was 0.86+/-0.23 μm. All Zernike modes were elevated, with coma being the major contributor 0.40+/-0.50 μm. Pterygium excision significantly reduced wavefront aberrations across all modes and orders (1.97+/-0.35): total higher order RMS postop 0.69+/-0.45 μm. Axial map showed asymmetric orthogonal vertical bow tie with superior steepness in 11 eyes ; with corneal navigator interpreted as keratoconus suspect in 9 eyes ,pattern corrected to symmetric bow tie postoperatively in 8 eyes.12 eyes revealed astigmatism against the rule with non orthogonal symmetric bow tie pattern, 9 eyes showed truncated symmetric vertical bow tie with 10-20 degrees of skewing

Zernike polynomial fitting well describes wavefront aberrations in eyes with pterygia. Pterygia are associated with wavefront aberrations, especially coma, but these were largely eliminated by surgery. Misdiagnosis of early keratoconus may occur on cursory examination of OPD Scan ;with keratoconus suspicion on corneal navigator. Quality of vision improved after pterygium excision.

March 23, 2014 at 4:28 pm

martaperezoftalmo@gmail.com

To describe technique and outcomes of using a skin stab incision to bury the suture during medial spindle surgery

A diamond shape of conjunctiva and lower lid retractors posterior to the lacrimal punctum is excised as described for the original technique. A stab skin incision is made at the junction of the lower eyelid and cheek skin. A double-armed suture is passed through the inferior retractors and inferior tarsal plate and instead of passing the suture through the skin and into a bolster, it is knotted beneath the stab incision skin. If a 6/0 vicryl is used on a 11mm needle, it can be used to close the skin also. First follow up was at 2 months.

A retrospective review of all medial spindle operations performed from May 2011 to May 2013 by the same surgeon was undertaken. Only patients with follow-up > 6 months were analysed. No patients developed suture related complications or dimples, and incision scars were essentially invisible. Surgery was anatomically successful in 44/46 and functionally successful in 100%.

Medial spindle technique with stab incision is a successful technique for correcting medial ectropion where patients don’t have to tolerate the tender unsightly bolster and also reduces the number of visits without compromising the outcome.

March 23, 2014 at 4:44 pm

qiangk@gmail.com

Surgical dressings are commonly used in oculoplastic reconstructive surgery, not only in the periocular area but also at other sites including the periauricular, clavicular and gluteal regions. Dressings help to control postoperative bleeding, absorb exudates, ease pain and provide protection for newly formed tissue. Despite their importance doctors often have limited training in the selection or use of surgical dressings.
The purpose of this poster is to provide a useful and practical algorithm for clinicians to select the most appropriate dressing in any given clinical situation.

A single paper questionnaire was sent internally to ophthalmologists working in the oculoplastic department at East Sussex Healthcare NHS Trust.
A dressing algorithm was created in collaboration with the local wound care nurse specialist.

The questionnaire response confirmed that no clinicians reported having formal teaching in surgical dressings. All agreed that an algorithm would be useful in helping to decide which dressings to use in different situations.
A surgical dressing algorithm was created using the following as selection criteria:
• Allergies (particularly to adhesives)
• Friability of surrounding skin
• Presence of exudates or bleeding
• Suspected presence of bacterial colonisation

Appropriate surgical dressings have an important role in the promotion of healing of surgical wounds both periocularly and also from tissue donor sites. Knowledge can be limited in this area and therefore we have created a simple dressing algorithm based on certain patient and wound characteristics. The algorithm clarifies the decision making process and should be especially beneficial in the management of wound complications.

March 23, 2014 at 4:49 pm

martaperezoftalmo@gmail.com

to describe the use of both periosteal rotational flap and temporalis fascia graft in the management of complex thyroid-related upper lid surgery. The use of temporalis fascia in this contect has not previously been reported in the literature.

A 34 year-old woman diagnosed of moderate-to-severe inactive thyroid eye disease underwent bilateral orbital decompression followed by bilateral upper lid lengthening (Mullerectomy plus levator recession). The patient underwent several prior operations to both raise and lengthen the upper lids bilaterally, but the results were not symmetrical. For the redo left upper lid retraction a periosteal rotational flap was used to correct disinsertion of the lateral horn of levator palpebrae in combination with further levator muscle recession. Correction of the recurrent right ptosis requiered a temporalis fascia interposition graft to reattach the fibrosed retracted levator muscle to the tarsus.

A good eyelid contour and symmetry was achieved using two types of autologous tissue to correct complex upper lid malposition in the context of thyroid eye disease as demonstrated by pre and post operative facial photography. No complications occurred and no recurrence was found after 8 months follow up.

Both autologous periosteal and temporalis fascia can be used successfully to augment upper lid surgery in challenging cases of recurrent thyroid –related lid malposition.

March 23, 2014 at 4:52 pm

qiangk@gmail.com

We would like to present 2 cases of cranial meningiomas initially presenting to the oculoplastic clinic.

Case report

The first case is of a 45 year old with 6 month history of a sensation of fullness in her temporal fossa and blurred vision on the same side. It was noted on examination there was a proptosis and corresponding optic disc swelling. Urgent imaging revealed the presence of hyperostosis and a sphenoid ridge meningioma en plaque. Unexpectedly, there was evidence of multiple meningiomas in the occipital and parietal lobes possibly indicating an underlying systemic disorder such as neurofibromatosis.
The second case is of a 38 year old with a 3 month history of worsening vision in both eyes and an apparent change in behaviour and cognitive function. Initial examination revealed severely reduced vision and colour vision defects. Despite normal appearances of the optic disc, there was a bitemporal hemianopia. Urgent MRI reveals a large extra axial mass in the anterior cranial fossa consistent with a large bi-olfactory groove meningioma causing compression of the optic nerves, frontal lobe syndrome and anterior pituitary dysfunction. Urgent neurosurgical removal revealed a mildly atypical meningothelial meningioma.

Meningiomas are insidiously growing intracranial lesions which can result in catastrophic vision loss due to its late presentation. In addition to vision loss, there are a variety of presentations including proptosis and optic nerve dysfunction. As ophthalmologists, It is important to realise that depending on their location ocular and orbital examination may be entirely normal and other neurological symptoms may predominate.

March 23, 2014 at 4:58 pm

martaperezoftalmo@gmail.com

To highlight learning points in management of a lesion initially diagnosed as a keratoacanthoma (KA)

A 42 year-old man was referred from dermatology for a KA in his lateral left brow. The lesion was 22 mm diameter, symmetrical and keratin-plugged. It had appeared 8 weeks ago and the patient reported it was starting to regress. The lesion was excised with 4mm margins, processed conventionally, and reconstructed using a rotational temple flap

Histology showed a squamous cell carcinoma with perineural invasion (PNI) and a very narrow deep margin. Re-excision was deemed necessary and he then required 3 stages of Mohs’ micrographic surgery to achieve clearance. This was largely for lateral rather than deep tumour extension which was completely undetected by the conventional excision margin result. He finally required extensive reconstruction including a bridged segment of a paramedian forehead flap divided after several weeks, and he has since had adjuvant radiotherapy.

Keratoacanthoma is a spontaneously involuting variant of SCC but is typically a lesion of the elderly: be wary of the diagnosis in younger patients and manage accordingly, due to the risk of PNI.
Where skin is short, a bridged segment of a paramedian forehead flap is ideal for lateral brow reconstruction.

March 23, 2014 at 5:02 pm

qiangk@gmail.com

Sarcoidosis is a multisystem disorder which can manifest itself in variety of ways. We report 2 patients with unusual initial presentations of sarcoidosis to our oculoplastic clinic.

Case report

The first is a 55 year old patient who presented with a 10 day history of bilateral upper lid painful swellings associated with red eyes and blurred vision. Examination revealed severe lacrimal gland inflammation. Blood tests including serum ACE were normal but subsequent lacrimal gland biopsy revealed granulomatous inflammation with non caseating granulomas suggestive of sarcoidosis. The patient responded well to oral and topical steroids. Respiratory, cardiac and dermatological evaluation revealed no systemic involvement indicating a diagnosis of ocular sarcoid.
The second is a 53 year old patient who presented with progressive monocular vision loss over 1 week, with severe headache and retrobulbar pain. Fundoscopic examination revealed a raised subretinal lesion with overlying exudative retinal detachment. B scan revealed evidence of posterior scleritis. Serum ACE was only slightly rasied. Tapering oral steroids resulted in complete resolution of symptoms and retinal detachment. Interestingly 2 years later the patient presented with a bilateral lower limb nodular rash later diagnosed as erythema nodosum. Further evaluation revealed no systemic involvement and a diagnosis of ocular sarcoid was made.

Sarcoidosis can present in a variety of ways. Uncommonly it can present with just ocular symptoms and signs as in the 2 reported cases. It is important to realise that though initial presentation may just involve the orbit and eyes, further thorough systemic evaluation is required to avoid further untreated morbidity or even death.

March 23, 2014 at 5:03 pm

rumanahussain@hotmail.com

A good functional and cosmetic result following midfacial reconstructive surgical procedures is of paramount importance. We describe the use of a PEEK (Polyetheretherketones) implant to reconstruct the mid-face area, following extensive mutilating surgery due to an infiltrative skin tumour

Case report

A 67yr old gentleman underwent multiple and extensive surgeries to the left cheek and lower lid due to a highly aggressive metatypical basal cell carcinoma (BCC). Complete clearance of the recurrent tumour resulted in a cosmetically evident absent cheek contour and facial deformity. The PEEK implant was used to restore the bony cheek contour, with good aesthetic outcome and restoration of the facial symmetry.

Pre-operative planning with 3-dimensional CT scans allow for customization of the implant. PEEK implants have been scantily described in the peri-orbital region. The material has a very low reported morbidity and also has the advantage of improving intra-operative predictability and reducing surgical time in complex reconstructive procedures.

March 23, 2014 at 5:38 pm

h_bhutto@yahoo.co.uk

Demonstrating the technique of using a Kelly’s punch to perform punctoplasty

The video demonstrates how to perform this procedure using Kelly’s punch which fits easily into the punctum after dilating, allowing for effective and controlled surgical punctal widening.

An effective punctal widening is achieved with ease.

Punctal stenosis is a significant cause of watery eyes and can be caused by infections, injury (physical, chemical, irradiation or thermal), and certain systemic conditions. This is normally treated with a 1 snip, 2 snip or 3 snip procedure using scissors. The procedure is awkward with forceps and scissors as the tissues are delicate and slippery, and often post op the openings are not wide enough when performed by less experienced surgeons. We demonstrate the ease of technique using a Kelly’s punch which enables a significantly easier surgery to deliver an effective result.

March 23, 2014 at 5:56 pm

i.haq@me.com

Orbital exenteration is an emotionally and physically disfiguring procedure which typically involves removal of the entire contents of the orbit and surrounding periorbita for the treatment of life-threatening malignancies. The Royal Hallamshire Hospital in Sheffield is unique in that it is one of 4 specialist Ocular Oncology units in the UK, and as a result has been prolific in the rates of exenterations carried out when compared to the published literature. In this study the authors aim to review their experience with exenteration, including indications and outcomes.

A retrospective study reviewing operating department records via a computerised database to identify all patients who had undergone exenteration of the orbit from April 2008 to May 2013 inclusive, at the Royal Hallamshire Hospital in Sheffield. 

Over a five year period, 38 patients were identified. The mean age of those having undergone exenterations was 68.1 years.  Of these 21 were male and 17 female. 10 different tumours were encountered, the most common of which were melanoma (10), squamous cell carcinoma (SCC) (9) and basal cell carcinoma (5). Of the melanomas there was a 30% mortality rate, and with SCC 55%. All our patients with BCC have survived so far. 32% of our exenterations were lid sparing. 32% of our patients received adjuvant radiotherapy. There was no local recurrence. So far 50% of our patients have survived.

Malignancy requiring orbital exenteration is a complex disease, requiring specialised and aggressive management from a multidisciplinary team. Exenterations are performed with an increasing frequency at this unit, and unsurprisingly given the nature of the unit, the majority are a result of ocular melanomas referred in from elsewhere. Radical surgery is only part of a wider management for these conditions and the journey for cosmetic rehabilitation is long, with multiple hospital visits for longterm recurrence follow-up, and profound consideration of psychological effects.

March 23, 2014 at 6:52 pm

qiangk@gmail.com

To highlight an unusual case of bilateral upper and lower eyelid swelling secondary to oral Finasteride treatment taken for benign prostatic hyperplasia (BPH).

Retrospective case note analysis

A 84 year old gentleman presented with a 3 month history of bilateral upper and lower lid swelling. There were no other associated symptoms to suggest thyroid orbitopathy. Past ocular history included a blind right eye secondary to a longstanding shot gun injury and recurrent episodes of blepharoconjunctivitis. Past medical history was unremarkable except for a diagnosis of BPH. External examination revealed periorbital lid swelling and redness bilaterally, mild blepharitis and dermatochalasis. There was also a right convergent squint. Further questioning revealed that the patient had recently commenced Finasteride, a medication used in the treatment of BPH. With no other cause identified it was decided to have a trial period off this medication and the lid swelling completely resolved within a few weeks.

Finasteride is a type 2 5-alpha-reductase inhibitor that prevents the conversion of testosterone to dihydrotestosterone. It is commonly used in the treatment of benign prostatic hyperplasia and also male pattern baldness. Recognised side effects include testicular pain and generalised hypersensitivity reactions of which lip and facial swelling have been reported. Published ophthalmic case reports involving finasteride, however, have only mentioned an association with cataracts and intraoperative floppy iris syndrome. Our case has highlighted an unusual and previously unreported cause of isolated periorbital lid swelling in a patient taking Finasteride.

March 23, 2014 at 7:05 pm

i.haq@me.com

The Royal Hallamshire Hospital in Sheffield is unique in that it is one of 4 specialist Ocular Oncology units in the UK, and as a result has been prolific in the rates of exenterations carried out when compared to the published literature. The philosophy and design of ocular prosthesis and orbital implants have evolved significantly since the post World-War period, and in the last decade achievements in implant design and biomaterials have reduced complication rates prfoundly. However, for many ophthalmic professionals, the principles behind contemporary implants remains a mystery.

A retrospective study reviewing operating department records via a computerised database to identify all patients who had undergone exenteration of the orbit from April 2008 to May 2013 inclusive, at the Royal Hallamshire Hospital in Sheffield.

Over a five year period, 11 patients were identified whom had undergone a variety of aesthetic camouflages with formal prosthesis. Their experiences have been assessed in the form of a telephone questionnaire.

In this study the authors present a case series of 11 patients to delineate their techniques, experiences and pearls along the journey towards cosmetic rehabilitation, which is often long, and fraught with multiple hospital visits for longterm recurrence follow-up, and profound consideration of psychological effects. The authors will also look to discuss what accomplishments can we foresee in the next ten years.

March 23, 2014 at 7:08 pm

tristanmcmullan@gmail.com

To work out the depth of periocular BCC extension in the study population and to discuss the safe depth for the deep margin for standard surgical excision of BCC and identify variables influencing it

Retrospective analytical study involving review of medical records of histologically confirmed periocular basal cell carcinoma managed in Northampton General Hospital during the period 2008-2012. Relevant demographic, clinicopathological and histopathological data were collected.

78 BCC cases were recruited. All were managed with conventional excision. 85% were excised with 3mm peripheral surgical margin with overall clearance rate of 89.7%. Deep surgical margin was positive for tumour cells only in 1.3% (1) of primary excision specimens . In 91.67% instances tumour depth was less than 3.5mm. Only 2 patients (2.78%) had their tumour depth more than 4mm . Histologically 60% were nodular subtype and 25% were infiltrative or mix nodulo-infiltrative. During the period of follow up which ranged between 1 to 57 months (median 13 moths), there was no tumour recurrence was reported. We did not find any statistically significant association between tumour depth and demographic or tumour characteristics.

Tumour depth for periocular BCC was below the range of 3.5-4 mm, in over 90% of instances. During conventional wide margin excision, a satisfactory deep clearance rate can be achieved by adhering to the general rule of excising through subcutaneous tissue. But more precisely, if the deep surgical margin is in 1.5 – 2.0 mm depth in the subcutaneous layer ( about 3.5 to 4 mm from the surface of the tumour) , there is over 90% chance of achieving primary clearance.

March 23, 2014 at 7:39 pm

psrjnr@hotmail.com

To investigate the process of recording and coding of procedures in Oculoplastics, and the implications on payment by results.

Critically examine the process of recording and coding oculoplastic procedures in theatre and outpatients. To link this activity to the Healthcare Resource Groups (HRGs) national tariffs with examples to determine the financial implications of various coding options for certain procedures.

We demonstrate how frequently incorrectly recorded/coded procedures lead to significant underpayment. We show how correctly recorded procedures may also draw underpayment if the urgency or patients age is not accounted for. We also discovered various clinic procedures, which are not routinely accounted for. This has significant financial implications with respect to payment by results. Accurate recording is invariably linked to accurate coding and appropriate financial remuneration.

Recording and coding of oculoplastic procedures underpins a primary income stream for the clinical service. By understanding the process, tariffs and educating all stakeholders, it is possible to increase much needed revenue to Ophthalmology Departments in this current fiscal climate.

March 23, 2014 at 8:06 pm

drtomjackson@yahoo.co.uk

To report outcomes of primary punctoplasty in eyes with epiphora secondary to punctal stenosis and the role of dacryoscintigraphy

Retrospective review of all punctoplasties between Feb 2007 and Jan 2013

87 eyes of 50 patients underwent 3-snip punctoplasties during this period. 79% of eyes were female and the mean age was 64 years (range 19-89 years)

76% of eyes had an improvement in symptoms. 5% had early cicatrisation requiring repeat surgery

21 eyes had no improvement in symptoms. 12 then underwent dacryoscintigraphy (2 normal drainage, 6 post-sac delay, 4 pre-sac delay) and 4 underwent CTDCG (all showed nasolacrimal duct obstruction (NLDO)). Those with pre-sac delay had lid laxity and were offered lid tightening surgery, those with post-sac delay or NLDO were offered DCR, those with normal drainage were treated for blepharitis

The remaining 5 eyes did not undergo further imaging. 2 were treated for blepharitis and 2 were offered lid tightening. The final patient had crocodile tears associated with a previous 7th nerve palsy and underwent botulinum toxin A injection of the lacrimal gland

All eyes undergoing further treatment had resolution of symptoms

Punctoplasty is a simple procedure with a success rate of 76% in our series. Punctal stenosis is often associated with blepharitis and lid laxity and it is important to fully address these at the same time to maximise the chance of success

In patients whose symptoms fail to improve after punctoplasty, dacryoscintigraphy is useful to decide if there is pre or post-sac delay. Those with pre-sac delay may benefit from lid tightening, those with post-sac delay may benefit from DCR surgery and those with normal flow are unlikely to improve with further surgery

March 23, 2014 at 8:17 pm

drtomjackson@yahoo.co.uk

To report the relevance and outcomes of all orbital CT scans requested by the Oculoplastic service

Retrospective review of case notes of all orbital CT scans between Jan 2007 and Jan 2013

A total of 592 CT scans were performed and pathology identified in 303(51%). The common indications were thyroid eye disease (16%), an intra/extraconal masses (5%) and lacrimal gland pathology (3%)

We analysed the accuracy of the pre-scan clinical diagnosis with the radiological diagnosis. This was most accurate in conditions with clear clinical signs such as cellulitis (100%) and less accurate in conditions such as suspected lacrimal pathology (80%) or an orbital mass (73%) where the clinical signs are more subtle. Interestingly 23% of scans done as a baseline test in the absence of clinical signs were radiologically positive

22 cases with an orbital mass and suspected systemic pathology underwent a whole body CT scan prior to biopsy. This revealed systemic pathology in 11 cases (50%) and resulted in a biopsy from an alternative more accessible site in 7 cases (32%)

The accuracy of the pre-scan clinical diagnosis varies depending on the condition and was 76% in suspected orbital pathology, while 23% with positive radiological findings had no clinical signs

In cases where orbital pathology is suspected to be secondary to systemic disease, whole body CT imaging if used judiciously, can result in biopsying the most accessible & appropriate site, minimising patient morbidity

March 23, 2014 at 8:20 pm

jamespl@doctors.org.uk

To describe a novel method for large upper eyelid skin lesion excision associated with modified blepharoplasty.

A standard blepharoplasty excision site (BES) was marked on the upper eyelids of two patients. Each border of their asymmetric upper eyelid lesions (xanthelasma palpebrarum) was marked to form an elliptical lesion excision site (LES) along relaxed skin tension lines. The skin was then held under tension and callipers measured the distance ‘A’ from the upper LES border to the upper BES border along a virtual radial line lying at 90° to the upper eyelid skin crease curve. The callipers were then moved inferiorly along the same virtual line so the same distance ‘A’ could be marked from the lower LES border to a point inside the marked BES. This method was repeated so enough points were marked inside the BES to create a Virtual Template of the LES size, shape and alignment. The marked BES upper border was then modified to follow the Virtual Template, reducing the surface area of the BES by that of the LES. The LES and modified BES were excised. The LES was sutured, reforming the original BES shape before it was sutured.

Complete lesion excision, patient satisfaction, symmetry, good sulcus skin fold contour and equal skin show were achieved for all eyelids.

The Virtual Template method produces good cosmesis for large upper eyelid lesions that are separate or cross the BES upper border if the LES height is less than the BES height. Free skin grafts are not required and it reduces potential inaccuracy from making estimated LES templates before or after lesion excision.

March 23, 2014 at 8:49 pm

doana77@yahoo.com

To report a case of Kimura’s disease in the orbit and its management and to help improve the knowledge of the clinicopathological features of this disease in the orbit.

Retrospective case note analysis of clinical progression, blood investigations, imaging and treatment.
A 79 years old man presented with 6 months history of red and swollen right eye, unresponsive to previous GP medication – artificial tears. Patient had prostate cancer in remission, previously excised right cheek basal cell carcinoma, left ear squamous cell carcinoma completely excised, controlled essential hypertension, ischaemic heart disease and type2 diabetes mellitus.
Clinical examination showed soft orbits, no proptosis, erythema and firm, bulky fullness of the lower lid, right eye. MRI showed thickening and ill defined signal change involving the right eye lower lid soft tissue. There was extension of associated signal abnormality and abnormal enhancement around the right globe inferiorly – main differential from imaging point of view included lymphoma. No abnormality was shown on the left orbit.
Anterior orbital biopsy was performed and histology reports that the features found were most in keeping with Kimura’s disease- Angiolymphoid Hyperplasia with Eosinophilia ALHE.

Based on clinical presentation, on MRI results and mainly on the histology reports from the anterior orbit biopsy the diagnosis of Kimura’s disease was made and conservative treatment with local steroids was started with very good response.

Kimura’s disease is a rare and infrequently reported cause of chronic, inflammatory orbital disease and needs to be considered as a differential diagnosis.

March 23, 2014 at 9:06 pm

aruna_dharmasena@hotmail.co.uk

To review the published literature on the management of congenital anophthalmia/microphthalmia and to present our experience of the management of these challenging cases.

A literature search was performed in Medline/Cochrane Library. Thirty three English language publications were relevant and included in this review. In addition, the outcomes of 26 anophthalmic/microphthalmic sockets in a cohort of 17 subjects who were referred to us over the past 10 years (2004-2014) were retrospectively analysed.

An exponential rise in the number of microphthalmic/anophthalmic socket referrals was observed. Mean age at presentation was 5 months (95% CI, 3.4–6.6). M:F ratio was 1:1.3. There were 10 anophthalmic sockets (38%), out of which 4 patients had bilateral involvement, one had a microphthalmic fellow eye and one patient had unilateral anophthalmia. Sixteen sockets (62%) were microphthalmic. Mean follow-up was 25.7 months (95% CI, 15.4 – 36.0). Eight cases (31%) had syndromic associations such as chromosaolal translocations, CHARGE, Kabuki and Patau syndromes. After confirming absolute blindness all patients were fitted with a clear conformers. Subsequent management was tailored to the individual. Custom made cosmetic conformers, solid expanders, hemispheric hydrogel expanders and orbital implants were amongst other treatments options.

We have seen a significant increase in microphthalmic/anophthalmic cases referred to Manchester Royal Eye Hospital in recent years. We emphasizes the need for raised awareness of their management. Continuous stimulation of growth of the orbit is key to the symmetrical growth of the orbit and midface and treatment options should be tailored to the individual patient.

March 23, 2014 at 9:42 pm

fayemellington@hotmail.com

To report 2 cases of recurrent orbital cellulitis (one with persistent proptosis).

Case reports, literature review.

Both patients had had two orbital decompressions; diagnoses were meningioma and thyroid eye disease (TED). Orbital cellulitis presented 5 and 6 years after surgery. Both responded to antibiotics but cellulitis recurred on stopping treatment. Neither had pre-existing sinus disease, but CT confirmed maxillary sinus obstruction. One patient developed gradual recurrence of proptosis without evidence of reactivation of TED. Both are awaiting functional endoscopic sinus surgery.

Orbital decompression creates direct communication between the orbit and sinus cavities, allowing potential spread of sinus infection to the orbit. Late post-operative sinusitis or orbital cellulitis is rare, with no cases of recurrent disease previously described. Cases reported after endoscopic decompression involved frontal &/or ethmoidal sinuses, with no reports of orbital cellulitis secondary to maxillary sinusitis after orbital decompression. Recurrent proptosis due to maxillary sinusitis after decompression is extremely rare: this is the 3rd reported case. Patent sinus drainage drains flora away from the orbit; in our cases post-op inflammation and scarring may have compromised sinus outflow causing obstructive sinusitis, potentiating the infection. Sinus disease should be suspected in patients with recurrent proptosis or orbital cellulitis after orbital decompression. It is a differential diagnosis for reactivation of TED. In such cases, we recommend prompt referral to otolaryngology.

March 23, 2014 at 9:45 pm

fayemellington@hotmail.com

Semi-permanent eyelash extensions are one of the biggest beauty trends worldwide. The beauty industry is poorly regulated and the procedure is not without risk. We report a case of bilateral red eyes due to iatrogenic lagophthalmos and evaporative dry eye following upper lid eyelash extensions.

Case report, literature review.

A 23-year-old woman presented to Eye Casualty with bilateral sore red eyes since having upper lid eyelash extensions for the first time the previous day. Snellen visual acuities were 6/5 and 6/6 (right and left eye respectively). Examination revealed bilateral inferior bulbar conjunctival hyperaemia and epithelial erosions (worse in the right eye). She was treated with ocular lubricants (g.Systane QDS). Her symptoms fully resolved within 2 days.

In this cosmetic procedure, lower lid lashes are typically taped down before single synthetic lashes are glued to each upper lid lash root. This process can take up to one and a half hours during which distraction of the lower lid by tape may induce lagophthalmos and evaporative dry eye. Reported complications include abrasions and allergic blepharitis or keratoconjunctivitis from the lid-fixing tape or formaldehyde-containing glue. Both the beautician and patient reported that the tape did not contact the ocular surface and formaldehyde-free glue was used. This is the first case to our knowledge of this particular complication but given the numbers undergoing this treatment worldwide, greater awareness of potential complications is advocated.

March 23, 2014 at 9:56 pm

fayemellington@hotmail.com

To describe and illustrate a simplification of the Malhotra surgical technique of transconjunctival posterior approach white line advancement ptosis correction for patients with moderate to good levator function.

Illustrated description of surgical technique.

We describe a technique whereby after dissection of the Mullers-conjunctiva composite flap, the levator aponeurosis is advanced with three evenly spaced double-armed absorbable sutures passed through the white line then through the superior tarsal border (partial thickness) without bringing the sutures through to the skin. A 2mm sliver of conjunctiva is removed and the remaining conjunctiva is then draped over the superior tarsus with the aid of a squint hook as the upper lid is re-verted.

This modified and simplified revision of the Malhotra technique of white line advancement for posterior approach ptosis repair has several advantages: it involves minimal dissection and does not require per-operative adjustment and therefore allows predictable ptosis repair under heavy sedation or general anaesthetic; it leaves no visible sutures; it has a high success rate with good cosmetic outcomes. It is technically straightforward, time-efficient and easy to learn.

March 23, 2014 at 10:18 pm

khadijahbasheer@yahoo.co.uk

To highlight the use of cosmetic eyelid tape to adjust eyelid position and improve eyelid ptosis

We present a 35 year-old female with bilateral ptosis secondary to oculo-pharangeal syndrome. She previously underwent bilateral ptosis surgery with subsequent second ptosis correction to her right eye. However the patient still experienced functional impairment with reduced visual field and was unhappy with the cosmetic appearance. However clinical examination demonstrated bilateral lagophthalmos and mild corneal exposure keratopathy, she was therefore counseled against further surgery.

A solution was found by the patient using double-sided eyelid tape which is widely available on the Internet The tape is commonly used for eyelid cosmesis, often for the creation of a double eyelid appearance within Asian patients. The patient used this tape to selectively elevate her eyelid for cosmetic reasons and functionally increasing her visual field. The patient is able to remove the tape prior to sleeping or should the eye become dry. We present a series of photographs before and after use of this eyelid tape to demonstrate the tape application technique and the effect achieved.

This case highlights a novel and inexpensive way for patients to improve eyelid appearance, including ptosis. It is readily available on the Internet marketed at patients with droopy eyelids and those with wishing to create a larger palpebral aperture or a skin crease. This application could be used in the oculoplastic setting for patients who are unsuitable or hesitant to proceed with ptosis correction surgery, for patients who wish to show their surgeon how they wish to appear post-operatively or as a temporary improvement in eyelid cosmesis.

March 23, 2014 at 10:22 pm

drdenizilhan@gmail.com

To evaluate two patients presenting with ptosis in benign reactive lymphoid hyperplasia.

The medical records of two patients with unilateral ptosis who were referred to Akdeniz University Ophthalmology Department were examined.

Conjunctival hyperemia and follicular hypertopia and upper eyelid edema and mechanical ptosis were seen unilaterally in both of the patients. Incisional biopsy were performed in both patients. The lesions were characterized by polyclonal lymphoid cell infiltration and pathological diagnosis were benign lymphoid hyperplasia. Systemic steroid treatment was performed and the lesions were disappeared in two months. Systemic analysis was performed and no lymphoproliferative diseases were found. The patients were decided to be examined 6-months periodically.

Benign reactive lymphoid hyperplasia should be kept in mind in cases with acquired unilateral ptosis and careful inspection is essential for accurate diagnosis in such patients.

March 23, 2014 at 10:30 pm

vijaybwagh@gmail.com

To review the improvement in accuracy of audit measure documentation and reaudit outcome and safety profile of ptosis surgery.

We reviewed effect of newly implemented structured teaching and training on juniors and effect of audit proforma introduction which was implemented following previous review. We reaudited our results of 30 consecutive ptosis surgeries with minimum twelve month follow up. Data were collected from Electronic patient records and patient notes.Success rate was assessed objectively and subjectively grading questionnaire using BOPSS criterion.

Mean Age of the patients was 53.8 yrs (Range 18-80 yrs) with female preponderance (18:12). Commonest etiology was involutional and majority had moderate ptosis (49%). Success rate was 84% using subjective criterion and 80% using objective criterion. Two patients had significant lagopthalmos following surgery and one patient had resurgery for reformation of upper eye lid skin crease. There is significant improvement in documentations of the data (85% vs 52%). Use of proforma and photographic documentation was extremely helpful in collecting data and to confirm accuracy of the data. Comparison with previous audit shows significant improvement in our results.

We established effective implementation of structured teaching and training on juniors doctors and audit proforma introduction in measuring audit outcome. We also established good outcome and safety profile of Ptosis surgery at our unit and results were comparable to national average.

March 23, 2014 at 10:33 pm

vanissu0@me.com

To describe a case of a CSF leak encountered during lateral orbital decompression surgery due to abnormally absent of part of lateral orbital roof.

The authors present a case of a 52 year old male who presented unilateral right proptosis in the setting of quiescent thyroid eye disease. The patient was distressed by the resulting facial asymmetry and was keen on rehabilitative surgery. He was offered a unilateral lateral wall decompression.
The chosen method of decompression was an anterior rim sparring technique.

An extended lateral canthotomy and exposure of the lateral orbital rim periosteum was performed and the periosteum reflected. Further periosteum reflection was performed intraorbitally. At that stage, a CSF leak was observed in the lateral wall – roof junction. A careful examination revealed a 1 cm x 7 mm bone defect in the orbital roof with direct exposure of the dura. No obvious dural tear was noted though a slow CSF leak appeared to be filtrating through.
The on-call neurosurgeon was contacted for advice. A Surgicel® haemostat was placed on the defect and the decompression aborted.

When retrospectively reviewing the orbital CT scan, we noted an abnormally attenuated orbital roof. This was not picked up preoperatively.
A literature search regarding abnormal orbital wall anatomy as well as complications related to lateral orbital decompression was performed. No similar presentations were found.

March 23, 2014 at 10:38 pm

maria.ophth@gmail.com

This report compares the presentation, clinical features and management of two patients with a frontal sinus osteoma.

Retrospective case note analysis including orbital imaging.

A 19yr old female complained of diplopia and ptosis. Examination revealed a right axial proptosis, restricted eye movements and choroidal folds. Imaging detected a 42 x 30mm right frontal sinus osteoma which extended into the right superior orbit, compressing the right superior rectus muscle. Surgical removal was via an external frontal osteoplastic flap.

Our 16yr old female patient presented with a 9 month history of headache, upper lid fullness and a change in appearance. A bony hard swelling was palpable in the supero-nasal orbit and the globe was displaced inferiorly. A 25 x 20mm ivory osteoma extending from the right frontal sinus into the orbit was revealed on imaging. Surgical management involved removal via an external frontoethmoidectomy using a Lynch-Howarth approach.

Sino-orbital osteomas are usually small, asymptomatic incidental findings seen on radiological examination. Only approximately 5% of people with osteomas become symptomatic and require surgical intervention. Osteomas should be on the differential diagnosis for any patient, especially teenagers or young adults, presenting with signs and symptoms of orbital disease. Our cases demonstrate that the presentation and surgical management can vary depending on the location and extension of disease. Osteomas are associated with Gardner’s syndrome and patients should be screened for a chromosome 5 defect.

March 23, 2014 at 10:49 pm

aamohite3@gmail.com

To investigate whether benign lid lesions can be accurately diagnosed clinically and whether a purely nurse-led service was comparable to a doctor-led service. We also looked at the impact of grade of doctor within this service.

An interventional, retrospective case series of patients with suspected benign lid lesions who underwent excision with histological confirmation over a period of 6 years. The lid lesions were classified into seven subtypes. Clinical and histological diagnoses were analysed and retrospectively compared. Doctors were divided into six categories based on experience level. The nurse-led service was provided by a single specialist nurse.

596 lesions in 470 patients (mean age 56.0 years) were included. Overall diagnostic accuracy was 80%. Of the 20% that failed to concur with histology, 1.3% were missed malignancies, predominantly BCC’s. Missed malignancies were highest in melanocytic naevi & epidermal inclusion cysts.

Sensitivity and specificity of clinical diagnosis were as follows: Benign epithelial proliferations 95.7% and 92.2% respectively, epidermal inclusion cysts 92.2% and 88.0%, cysts of Moll 66.7% and 96.7%, naevi 39.4% and 99.8%, xanthelasma 97.5% and 100%, molluscum 20% and 99.8%, other benign lesions 50% and 99.8%. There was no difference in diagnostic accuracy amongst clinicians (p>0.05), with the specialist nurse and all doctor grades achieving comparable rates (p=0.956).

We advocate histological confirmation of all excised clinically benign lesions, with added vigilance towards melanocytic naevi and epidermal inclusion cysts. An Oculoplastic nurse-led service is safe, cost-effective and comparable to a doctor-led service.

March 23, 2014 at 10:58 pm

staceystrong@doctors.org.uk

There are currently no gold standards for the documentation of orbitofacial fractures. In 2012, a regional trauma centre audit found locally recommended documentation to be lacking. A trauma pro forma was introduced, multidisciplinary meetings established and a more robust referral system created between maxillofacial and ophthalmology departments. This audit reviewed if documentation had improved since the introduction of these changes.

Of 65 orbitofacial fracture patients presenting to A&E between 02/2012–04/2013, 43 files were located. Locally recommended documentation criteria at baseline and 2 weeks post-operative included: subjective symptoms, visual acuity, colour vision, swelling, conjunctival assessment, lid position, globe position, enophthalmos, extra ocular movements, pain on extra ocular movement, watering and diplopia. Six-month documentation criteria included enophthalmos and diplopia alone. Surgical patients achieved 100% compliance if they fulfilled all 26-point criteria. Non-surgical patients required only 14-points.

On average, surgical patients completed 9 out of 26-point criteria (34.6%). Non-surgical patients averaged 6 out of 14-points (42.9%). Nineteen patients did not attend one or more appointments and 8 patients were discharged by 4 months. Weak documentation included: watering, lid position, globe position and pain on extra ocular movement. Strong documentation included: visual acuity, extra ocular movements and diplopia

Overall documentation was found to be lacking. We propose a gold standard of 26-point (surgical) and 14-point (non-surgical) criteria. We will introduce a patient “orbital trauma” pathway booklet including these gold standards and re-audit in April-July 2014

March 23, 2014 at 11:07 pm

kierendarcy@me.com

To investigate the safety of planned two-stage excision and reconstruction of periocular basal cell carcinomas (BCC), including simultaneous further excision and reconstruction in selected cases with involved margins after the first excision. High-risk anatomy and the definition of a clear/close margin were analysed.

A retrospective case-notes review of 412 consecutive patients undergoing surgery at Bristol Eye Hospital (BEH) and Aintree University Hospital (AUH) over a five-year period.

412 patient surgical episodes in total from the two centres were identified. A two-stage surgical excision and reconstruction was planned in 332 (81%), 63 (15%) had one-stage, 16 (4%) three stage and 1 six-stage. A 2mm excision margin was used in 363 (88%); 3mm in 22 (5.3%) with 37 (9%) not documented. 73 (18%) of patients had a re-excision due to a close or involved initial surgical margin. Only 11 (15%) had tumour identified in this re-excision. All 11 had an initial positive margin. 9 of these were completely excised at this 2nd stage. 2 (0.49%) had a close or involved margin requiring a third excision. Tumour involving the margin in an initial excision increases the relative risk of finding BCC in the re-excision ten-fold. Tumour location was also a critical finding of our study with medial canthal lesions increasing the risk of incomplete surgical control by 2.5 times.

A planned two-stage procedure is a safe and effective method for treating selected periocular BCC. An involved margin increases the risk of residual tumour ten fold; conversely a close margin (>0.1mm) is relatively safer. Tumour location is also important. Greater consensus is required between surgeons and histopathologists in defining safe tumour management.

March 23, 2014 at 11:14 pm

angelsinap@hotmail.com

To report an unusual case of malignant transformation of an eyelid kissing naevus in an 8-year-old boy and to discuss the management options.

Case report.

An 8-year-old boy was referred to the Oculoplastics Department of the University Hospital Southampton for excision of a kissing naevus in the area of the right medial canthus. The kissing naevus had been present since birth with reported fleshy growth in the upper lid portion over a 6 month period. It was excised with full thickness skin grafts from both upper lids. Pathology report of the excised lesions along with cytogenetic analysis concluded a description of melanocytic tumour of uncertain malignant potential. Decision was made for further wide local excision and sentinel lymph node biopsy. Wider local excision was performed successfully (no residual melanocytic lesion was noticed) with post-auricular full thickness skin graft to the defect. Sentinel lymph node biopsy showed micrometastatic melanoma. Radical neck lymphadenectomy was undertaken showing no further melanocytic lesion.

Malignant transformation of an eyelid kissing naevus is very rare and the management plan in this case can be challenging.

March 23, 2014 at 11:14 pm

kierendarcy@me.com

To investigate the safety of planned two-stage excision and reconstruction of periocular basal cell carcinomas (BCC), including simultaneous further excision and reconstruction in selected cases with involved margins after the first excision. High-risk anatomy and the definition of a clear/close margin were analysed.

A retrospective case-notes review of consecutive patients undergoing surgery at Bristol Eye Hospital and Aintree University Hospital over a five-year period.

412 patient surgical episodes in total from the two centres were identified. A two-stage surgical excision and reconstruction was planned in 332 (81%), 63 (15%) had one-stage, 16 (4%) three stage and 1 six-stage. A 2mm excision margin was used in 363 (88%); 3mm in 22 (5.3%) with 37 (9%) not documented. 73 (18%) of patients had a re-excision due to a close or involved initial surgical margin. Only 11 (15%) had tumour identified in this re-excision. All 11 had an initial positive margin. 9 of these were completely excised at this 2nd stage. 2 (0.49%) had a close or involved margin requiring a third excision. Tumour involving the margin in an initial excision increases the relative risk of finding BCC in the re-excision ten-fold. Tumour location was also a critical finding of our study with medial canthal lesions increasing the risk of incomplete surgical control by 2.5 times.

A planned two-stage procedure is a safe and effective method for treating selected periocular BCC. An involved margin increases the risk of residual tumour ten fold; conversely a close margin (>0.1mm) is relatively safer. Tumour location is also important. Greater consensus is required between surgeons and histopathologists in defining safe tumour management.

March 23, 2014 at 11:19 pm

princetonlee@hotmail.com

To present a case of spontaneous superior ophthalmic vein thrombosis (SVOT) in an ex-intravenous drug user and the management of this rare condition.

A case discussion and literature review of the causes, investigation and management of SVOT is to be presented

A 41 year-old male prisoner presented with severe progressive headache, left retrobulbar pain & proptosis with mild visual compromise. He was found to have left superior ophthalmic vein thrombosis on CT venogram. There was no radiological or clinical evidence of orbital cellulitis. All paranasal sinuses on the contralateral side were opacified suggesting sinusitis (the ipsilateral sinuses were all clear). The white cell count and ESR were elevated but blood cultures and septic screen were negative and patient remained apyrexial. CT scan of the neck showed a left hypoplastic internal jugular vein. Thrombophilic screen were negative. Deep vein thrombosis had been ruled out on numerous occasions in the past.

He was treated with broad-spectrum intravenous antibiotics, low molecular weight heparin and a right sinus washout. His vision returned to 6/6 from 6/9.5 at presentation and the range of eye movement improved. He is receiving a six months course of warfarin anticoagulation.

We report a case of spontaneous superior venous thrombosis with no direct source of localized or systemic infection and no thrombophilic risk factors. His complex social history posed a challenge in diagnosis and clinical management.

March 23, 2014 at 11:21 pm

poitelea.c@gmail.com

The aim of our study was to evaluate the effect of active Manuka honey on wound healing following elective upper eyelid surgery.

A prospective randomised single-blinded study of 46 patients undergoing bilateral upper eyelid surgery (blepharoplasty with or without ptosis correction) over a period of 10 months was carried out. Patients were asked to apply honey twice a day to a randomly chosen eyelid and apply Vaseline to both eyelids for six weeks. A blinded assessor graded the scars at 1 week, 1 month and 4 weeks after surgery. We used Manchester scar scale, a subjective scar grading scale and a modified eyelid-specific scar grading scale developed by the investigators. Standardised photographs were also taken at each visit.

37 patients completed the trial (13 males and 24 females) without any complications. Mean age was 67 years (range 50-85). Of the 9 patients excluded, only 2 were related to honey use (1 possible infection, 1 found it too sticky). 4 months data was collected for11 patients, mainly due to patients non-attendance.The majority of patients preferred the appearance of the eyelid honey was applied to. This was true at 1 week (51% better), 1 month (40% better) and at 4 months (55%). The majority of patients also reported improved itching on the treated side. For all grading scales there was no significant difference between the two eyelids.

This is the first randomized control trial of the effect of Manuka honey on eyelid surgical wounds. It appears people believe that the use of honey improves their wound healing and relieves wound related symptoms. Despite its stickiness, it is well-tolerated by patients in the first month of surgery.

March 23, 2014 at 11:56 pm

chrismclean@nhs.net

A technique is described whereby anterior approach aponeurotic surgery is completed under topical anaesthesia.

Twelve patients underwent aponeurotic ptosis surgery. Topical anaesthesia was discussed preoperatively with patients but not recommended for those who were significantly anxious about the procedure. Those who agreed to topical anaesthesia understood that they could request additional subcutaneous local anaesthesia at any stage during the operation. An occlusive dressing was placed over the upper eyelid under which was placed EMLA anaesthetic cream. The dressing was left in situ for 45 minutes prior to surgery. Anterior approach aponeurotic surgery was then carried out by first making an 8 mm long skin crease incision. Gentle bipolar cautery was used for haemostasis. The levator aponeurosis was identified, advanced and sutured to the tarsal plate with a single 5-0 Ethibond suture and the skin incision closed with interrupted 8-0 Vicryl sutures.

All twelve patients described only mild symptoms of discomfort during the procedure. None of the patients requested additional anaesthesia in the form of a subcutaneous injection at any time during the procedure. All patients had a satisfactory eyelid height at the end of the procedure, with minimal bruising.

Topical aponeurotic ptosis surgery has the advantage of avoiding the discomfort of the initial subcutaneous local anaesthetic injection normally used for this procedure and the bruising that is associated with this. It is not suitable for anxious patients or in those cases where there is a high incidence of bleeding, as excessive use of the bipolar cautery can be uncomfortable.

March 24, 2014 at 12:34 am

mark.sigona@doctors.org.uk

Is delaying skin graft after debridement for periorbital necrotising fasciitis more beneficial than early skin graft or allowing healing by secondary intention alone?

Retrospective casenote review.

Patients were aged between 56 and 76. Two had bilateral periorbital involvement. Two were secondary to insect bites, one of whom also had sinus disease demonstrated on CT scan. One was secondary to herpes zoster ophthalmicus; one had concomitant tonsillitis and one had no obvious cause. Three of the patients were febrile, with temperatures ranging from 37.7 to 39.5 degrees C. All were admitted and treated with IV antibiotics. All patients required debridement of periorbital tissue, three requiring secondary debridement procedures.

One patient had skin graft procedures bilaterally six days after debridement. She later developed upper lid contractures with ectropion and exposure, and required a repeat skin graft four months later. In one patient, healing by secondary intention was allowed and she subsequently developed bilateral upper lid ectropion requiring skin grafts four months after debridement. The remaining patients all had planned autografts five to eight weeks after debridement with donor tissue from contralateral lids or neck. All patients with delayed skin graft made an excellent recovery.

This case series highlights the benefit of late surgical repair once patients have completely recovered from the initial infection and initial debridement. Early skin Graft, or healing by secondary intention alone, was shown to be associated with contractures leading to ectropion and exposure requiring further surgery.

March 24, 2014 at 12:34 am

aruna_dharmasena@hotmail.co.uk

Lacrimal sac/duct tumours are rare and approximately 55% tumours originating in the lacrimal sac/duct have been reported as malignant. The mortality rates from these tumours are high due to their late presentation. We present a varied series of 7 cases of lacrimal sac tumours.

A case series of seven consecutive cases and review of literature.

Seven consecutive cases of lacrimal sac tumours managed between 2009 and 2014, to Manchester Royal Eye Hospital were identified and analysed retrospectively. The age at presentation ranged from 26 – 85 years. The male: female ratio was 1: 2.5. All patients initially presented with epiphora. Histopathological analysis revealed solitary fibrous tumour (n=2), melanoma (n=1), chronic lymphocytic leukaemia(n=1), atypical lymphoid proliferation (n=1), oncocytoma (n=1), and a papilloma with focal transitional component (n=1). In 4 cases, the tumours were discovered during/after routine scheduled dacryocystorhinostomy (DCR) procedures. One patient had metastatic spread and died in spite of chemotherapy.

A large proportion of lacrimal sac tumours are malignant and prompt diagnosis requires a high degree of suspicion during the initial clinical examination. All atypical/suspicious cases should be investigated by radiological investigations of the lacrimal drainage system. Many of these patients will need complex surgical procedures in collaboration with other head and neck specialities in order to attempt histological clearance.

March 24, 2014 at 12:39 am

anupmakumar@hotmail.com

To present a case series of patients with orbital solitary fibrous tumour from a tertiary referral centre, focussing on clinical variation, diagnostic dilemmas and management challenges.

This is a non-comparative retrospective case series. A database of all orbital tumours treated since 1999 was used to identify orbital solitary fibrous tumour cases. Data collected included patient demographics, clinical presentation, histopathological features, and details of management and clinical outcome.

We identified 9 cases. There were 2 males and 7 females with a mean age of 41.6 years (range 17 – 83). The mean follow-up period was 39.3 months (range 3-156 months). The presenting symptoms included proptosis(n=6), periocular mass(n=1), foreign body sensation(n=1), and epiphora(n=1).
Integrative sequencing has demonstrated recurrent NAB2-STAT6 gene fusion in solitary fibrous tumour cases and a new STAT6 antibody for immunohistochemistry has been reported to show the presence of a STAT6 genetic mutation. The results of immunohistochemistry with the STAT6 antibody in our cases will be presented.
All cases underwent elective surgical management with complete histopathological clearance confirmed in 6 cases. One patient underwent adjuvant stereotactic radiotherapy.

This case series demonstrates the variable presentation, new immunohistochemistry features and management challenges associated with orbital solitary fibrous tumours. The surgical management of these cases remains a major challenge.

March 24, 2014 at 1:03 am

nic_johnston@yahoo.com

To present a case report of a gentleman referred with preseptal cellulitis, unresponsive to treatment who was diagnosed on histology with cutaneous angioscarcoma. To review the histology and clinical findings of this uncommon presentation to ophthalmology services

Case presentation with literature review of cutaneous angiosarcoma

87 Year old gentleman with glaucoma on combigan, referred from GP as query drop allergy, then re-referred as query cellulitis.
Hot and swollen face for four weeks, unilateral hemifacial swelling, no pain,or fever, and otherwise well. Was investigated with CT and multiple biopsies. Histology and literature review to be presented.

Cutaneous angiosarcoma of the scalp and face,is the most common form of angiosarcoma. The disease is primarily located on the head and neck of elderly persons. Most patients present with an enlarging bruise, a blue-black nodule, or an unhealed ulceration. Bleeding and pain may be present. . Initially, these lesions can be confused with cellulitis, edema, bruising, or infection, leading to a delay in diagnosis.

March 24, 2014 at 6:53 am

nic_johnston@yahoo.com

Case presentation of a patient with HZO who presented with proptosis and had unilateral enlarged orbital muscles.

Case presentation and review of literature

A gentleman presented with unilateral HZO. He was noted to be mildly proptosed and had neuroimaging.
He had unilateral orbital muscle swelling, with no clinical or biochemical evidence of TED.
He has slowly improved on systemic steroids.
We can only find one other case presented in the literature

We report an extremely uncommon case of HZO leading to unilateral orbital muscle enlargement

March 24, 2014 at 6:59 am

aruna_dharmasena@hotmail.co.uk

Adult orbital/adnexal Xanthogranuloma is poorly understood. The rarity of this disease precludes prospective investigation or meta-analysis, making the evaluation of safety and efficacy of existing and new treatment modalities extremely difficult and much of the knowledge on this rare disease entity is based on previously reported case series. In this paper the authors report another case of orbital Xanthogranulomas and discuss their experience on the management of a this previously unreported patient.

Case report and review of literature.

A 63 year old man presented with a 1 year history of left epiphora, ptosis, left upper lid skin yellow discolouration. He suffered from adult onset asthma, diet controlled type ll diabetes, angina and biopsy proven chronic prostatitis. There was a left partial ptosis, impaired upgaze, hypoglobus and a palpable mass in the left upper lid subcutaneous tissue. It extended into the supero-nasal orbit. CT scan revealed an ill-defined inflammatory stranding within the left orbit, predominantly of the anterosuperior extraconal compartment suggestive of a chronic nonspecific inflammatory process. Biopsy showed replacement of orbital adipose tissue by collagenous tissue containing extensive sheets of bland fomy macrophages and patchy lymphoid aggregates.

Given the history of adult onset asthma this case of orbital Xanthogranulomas most certainly belong to the subgroup adult onset asthma and periocular xanthogranuloma (AAPOX). Several treatments including oral/intra lesional steroids, metotrexate, cyclosporine, radiation, immunotherapy, laser application and surgery have been proposed. A high degree of clinical suspicion is required to identify this rare disease.

March 24, 2014 at 7:19 am

h_bhutto@yahoo.co.uk

Demonstrating both techniques using surgical videos.

Parallel video demonstration showing the variations in the 2 approaches to achieve the same result of creating a communication between the lacrimal sac and the nasal cavity (Dacryocystorhinostomy) for blocked nasolacrimal ducts

The video shows the techniques of endoscopic and External DCR and in parallel such that surgeons preferring one or the other technique can see how the other technique serves to achieve the similar result.

Two parallel videos demonstrate the variations between external and endoscopic DCR techniques through the surgical steps.

March 24, 2014 at 7:23 am

drtomjackson@yahoo.co.uk

To describe a simple technique for improving access in endonasal dacryocystorhinostomy

Video demonstration

Endoscopic DCR is an operation that is now performed commonly by ophthalmologists. The operation relies on good nasal access to give sufficient space for manipulating both the endoscope and secondary instruments. If access is poor due to a deviated nasal septum, it can be combined with a formal septoplasty, however, this is an operation that is unfamiliar to most ophthalmologists.

Our video will demonstrate a simple ‘finger septoplasty’ which temporarily realigns a deviated nasal septum to improve access for endoscopic DCR.

Patients are prepared in the standard way for an endoscopic DCR with general anaesthetic and nasal preparation with patties soaked in 1:10000 adrenaline. The face is cleaned and draped. The surgeon inserts their little finger into the nostril on the side of the operation and applies firm pressure directly to the septum at the point of its deviation. The cartilage is flexible and the pressure deviates the septum to the contralateral side. This very simple technique causes no damage or bleeding of the septum and significantly improves access in cases of a deviated septum.

At the end of the operation the surgeon uses their finger to reposition the septum to its original position by applying pressure from the contralateral nostril

Endoscopic DCR is technically challenging when nasal access is poor. The ‘finger septoplasty’ offers a very simple technique to improve access in cases with a deviated nasal septum

March 24, 2014 at 8:33 am

ma1604@hotmail.co.uk

Our interesting case report illustrates a double masquerade of an upper lid sebaceous cell carcinoma; as an asymmetrical
blepharitis but simultaneously as a diffuse, inflammation of lid tissue presumed to be reaction to sling material post-operatively
following a third redo silicone brow suspension, for correction of congenital ptosis.

N/A

N/A

Sebaceous cell carcinoma may exhibit diffuse, pagetoid spread, which invades the epidermis of the eyelid and epithelium of the
conjunctiva, clinically simulating a benign inflammatory process; such as blepharoconjunctivitis, which is well described.

Our case report illustrates a double masquerade as a chronic inflammatory response to the sling material in the silicone brow
suspension. Histopathology of the upper lid biopsy confirmed a sebaceous cell carcinoma with periadnexal epithelial pagetoid involvement. To our knowledge, this masquerade has not been described in the literature.

Our patient required 5mm excision margins and repair of upper lid defect with a large frontal pedicle flap and mucous membrane
graft, performed as a joint procedure with plastic surgeons.

A high clinical index of suspicion for sebaceous cell carcinoma as a masquerade should be maintained. Consideration will lead to prompt biopsy and diagnosis of this rare, aggressive tumour which demonstrates a high rate of regional and systemic metastasis. This will avoid delays in diagnosis with its associated morbidity and mortality.

March 24, 2014 at 2:51 pm

aruna_dharmasena@hotmail.co.uk

Malignant Triton Tumour is a very rare soft tissue sarcoma with rhabdomyoblastic differentiation. To our knowledge this tumour has not been reported in the human orbit previously. In this paper we review the published literature on malignant Triton tumour in humans and present a case of orbital Triton Tumour which is the only reported case within the orbit so far.

Case Presentation and review of the literature

A 47 year old male with a longstanding left blind eye due to childhood toxocara infection was referred to our Oculoplastics and Orbital surgery department due to increasing pain thought to be originating from the affected eye over a period of 9 – 10 months prior to presentation. The B-scan and the Computed topography (CT) revealed a large cystic lesion attached to the original globe. He underwent a left enucleation and complete excision of the adjoining cystic mass with a primary orbital implant. The histopathology analysis of the orbital tissues revealed highly malignant spindle cells with marked nuclear atypia. There were frequent mitotic figures as well as focal necrosis suggestive of Triton tumour. He developed an increasing orbital pain and developed rapidly progressive proptosis. The orbital implant was removed and he was treated with chemotherapy and radiotherapy promptly with very good effect. An orbital exenteration was crried out to remove the residual tumour.

The current treatment protocol of Triton tumour includes immediate surgical resection followed by radiotherapy. Unfortunately in spite of prompt treatment these tumours have a poor prognosis in general. Since this is the first reported case of Triton tumour of the orbit the long-term benefits of radical surgery such as orbital exenteration are still not known.

March 24, 2014 at 5:18 pm

s_ho2@yahoo.com

To identify the demographic data of patients who had obital tumor that was referred to Serdang Hospital, a tertiary oculoplastic referral centre in Malaysia.

Retrospective case notes review on patients who have orbital tumor biopsied or removed in Serdang Hospital from January 2011 to April 2013.

There are 60 patients in total with 33 male and 27 female. 37 tumors occurred in the right whilst 23 was found to be on the left. The age of presentation ranges from 7 to 87 (median and mean : 50, SD 20.27). 58.3% of the patients are Malay, 32% of them are Chinese and 6.7% are Indians. The most common presentation is proptosis and reduced vision. Histology diagnosis showed that lymphoid pathologies are the commonest (41.7%) with 25% of them B Cell lymphoma and 16.7% benign lymphoid hyperplasia. Primary and secondary malignant tumor attributed for 19.4% of the tumor.

We presented here the 2 ½ years data of orbital tumor presented to Serdang Hospital. Lymphoid associated pathologies are the commonest presented condition with malignant tumor constitute one fifth of the pathologies.

March 24, 2014 at 5:49 pm

umiya.agraval@nhs.net

We presented the novel use of fresh amniotic membrane graft (AMG) in management of conjunctival lesions at BOPSS 2012 where we highlighted the improved immediate post operative surgical outcomes with its use. We now present our 2 year follow up data in relation to long term local surgical outcome and survival.

11 patients who had AMG following the excision of conjunctival lesions in 2011 were prospectively followed-up for a 2 year period.

2 year follow up: 2 out of 6 conjunctival melanoma patients developed in transit conjunctival metastases requiring proton beam therapy, both deceased within a year of treatment from systemic metastases. 3 patients with conjunctival melanoma were treated with post operative Mitomycin C (MMC) eye drops with no evidence of local or systemic metastases. All 3 in situ squamous cell carcinoma patients required post operative MMC drops and are recurrence free. The lower fornix sebaceous gland carcinoma patient, refused exenteration, needed AMG along with extensive lid excision and reconstruction, requiring multiple lid procedures resulting in extensive scarring, diplopia and restriction of eye movements but is comfortable. Benign pathology patient is stable and has been discharged.

The use of fresh AMG has improved the local surgical outcomes of these patients by improving healing and reducing scarring as it allows for a wider surgical margin. We have noted that a wider, complete excision of lesions with non-touch surgical techniques reduces the risk of local recurrence and long-term survival is improved. Large conjunctival melanomas with in transit conjunctival metastases have a poorer prognosis.

March 24, 2014 at 5:54 pm

drnazy73@yahoo.com

To report three histopathologically confirmed cases of orbital schwannoma which manifest differently.

Case series.

Case 1 : A 50 year-old male with a right progressive proptosis associated with blurring of vision. Clinically, there was a right axial proptosis with positive retropulsion. Right mild RAPD was present and right optic disc was hyperaemic. Magnetic resonance imaging of the orbit revealed a right intraconal cystic lesion with fluid level, displacing the superior rectus and optic nerve.

Case 2 : A 63 year-old female with a left lower lid mass which was painless and increasing in size. An earlier incisional biopsy done elsewhere but result was unknown to her. Her left eye was hypertropic and non-seeing. Her left extraocular movement was restricted. Computed tomography of the orbit revealed a significantly large left lower lid well-defined firm mass with no bony lytic lesions

Case 3 :An 80 year-old female presented with a brief history of right eye protrusion, associated with blurring of vision. There was no history of trauma. There was a family history of colonic carcinoma. Her right eye vision was no perception to light. There was a right non-axial proptosis, marked RAPD and limited extraocular movements. Computed tomography of the orbit showed a right well-defined mass, non-enhancing and occupying the superomedial part of the orbit and extended posteriorly to involve the orbital apex.

Schwannomas are rare periorbital & orbital benign tumours with variable anatomic & pathologic features. Combination of clinical, imaging and surgical features may be helpful in making a diagnosis of schwannoma. Benign in nature, it does have the propensity to become malignant.

March 24, 2014 at 6:32 pm

btod_0407@yahoo.co.uk

Our main aim was to rule out malignancy on the base of lesion . Horny cutaneum is a clinical diagnosis referring to a conical projection above the skin that resembles a miniature horn. The base of the horn can be flat, nodular or crateriform. The horn is composed of compacted keratin. Larger sized lesion and tenderness at the base suggest favour malignancy. Malignancy is present in 16-20% of the cases, with Squamous Cell Carcinoma being the most common type. We reported a young girl with big keratin horn on the left upper lid .

Case report of 3.5 year old Chinese girl presented a history of quick ,7 monthly horny growth on left upper lid.. The local examination revealed a firm horny growth of 20 mm in length and 3 mm in diameter .Excision of the growth with an elliptical incision and primary closure was done under GA.

Histology shows a piece of skin covered with thick layer of keratotic crust. The dermis shows a granulomatous inflammatory reaction centred on empty space suggestive of lipogranulomatous reaction. The Feature is consistent with cutaneous horn and chalazion. No evidence of malignancy found.

Cutaneous horn usually appears on exposed skin areas like in our case but more often in elderly persons. Although the horns are usually benign, the important issue is to rule out malignancy at the base of horn. This case of cutaneous horn is unusually large and presented in a young patient with quick growth.

March 24, 2014 at 7:15 pm

aruna_dharmasena@hotmail.co.uk

Lymphoepithelioma (squamous cell carcinoma with a characteristic lymphoid stroma) is a poorly differentiated carcinoma primarily occuring in the nasopharynx. In contrast lymphoepithelioma-like carcinomas (LELC) are malignancies that have morphologic features similar to the nasopharyngeal Lymphoepitheliomas but arise in locations outside of the nasopharynx. LELC is a rare malignancy in the lacrimal drainage system and Only 4 cases have been reported so far. In this paper we discuss another patient with nasolacrimal sac LELC and review the previously reported cases and their treatment options and prognosis.

Case report and review of literature

A 58 year old female presented with a 2 year history of right sided epiphora and a chronic discharge suggestive of lacrimal sac mucocele and chronic dacryocystitis. Nasolacrimal duct system examination revealed an anatomical blockage distal to the common canaliculus. ENT examination was unremarkable. An external dacryocystorhinostomy (DCR)was attempted and a solid tumour within the right lacrimal sac was discovered intra-operatively. The tumour was excised from the lacrimal sac and sent for urgent histopathological analysis which confirmed the diagnosis of lymphoepithelial carcinoma (lymphoepithelioma) of the lacrimal sac. Previously reported cases had shown a good initial response to radiotherapy and taking this into account further treatment with radiotherapy was arranged.

Given the rarity of ocular adnexal LELC, the optimal therapy is unclear. Previously reported cases have had surgical debunking and radiotherapy with good effect. They have not had primary tumour recurrence (follow up of 12 – 33 months). But one patient has had developed a lymph node metastasis after 6 months.

March 24, 2014 at 7:56 pm

tharsika2408@gmail.com

Hypertelorism (HPT) can have a profound impact on appearance and social function. Skeletal correction is undertaken to achieve a favourable appearance change. We ask whether quantified orbital translocation can predict soft tissue change and thereby facilitate planning for aesthetic outcome.

Pre and post operative CT data of 18 hyperteloric patients and 30 controls treated by two surgeons at Great Ormond Street Hospital were entered into Osirix software. Inter-dacryon distance (IDD), inter-lateral orbital wall distance (ILoD), palpebral fissure width (PFW), inter-canthal distance (ICD) and palpebral fissure angle (PFA) were correlated, and assessed against osteotomy technique and canthopexy details.

PFW is unchanged postoperatively, independent of surgeon/technique, providing a constant reference value. Medial canthopexy did not increase canthal medialisation, but in combination with lateral canthopexy may improve control of the PFA. Mean preoperative ratio IDD:PFW is 1.41 reducing to 0.94 postoperatively (mean control = 0.64). Mean preoperative ratio ICD:PFW of 1.89 reduces to 1.53 (mean control = 1.16). The correlation of IDD:PFW to ICD:PFW is 0.89 preoperatively decreasing to 0.77 postoperatively, suggesting that the medial canthus and dacryon move imperfectly together.

We propose the use of the PFW as a denominator in generating patient specific ratios as the PFW does not change postoperatively. Lateral canthopexy can modify palpebral fissure angle. Surgery significantly reduces the IDD:PFW and ICD:PFW but does not reach control value. Control IDD:PFW is 0.64 – providing a novel, prospective, directly measurable target in HPT surgical planning.

March 24, 2014 at 8:06 pm

h.ajwani@doctors.org.uk

Masquerade syndromes are non-inflammatory disorders that initially present as ocular inflammation. Orbital lymphoma and lymphoma of the orbital adnexa are relatively rare however they are known to mimic ocular inflammation. We describe a case of orbital diffuse large B-cell lymphoma (DLBCL) which illustrates a number of potential pitfalls in diagnosis and management.

A 87 year-old male first presented to outpatients clinic with a painless right orbital mass in late 2009. He was started on systemic corticosteroid therapy and then referred to Moorfields Eye Hospital. The orbital mass initially demonstrated a positive therapeutic response, but eventually became refractory to steroid therapy over the period of two years. On his most recent referral in mid 2011 the mass had increased considerably in size, and orbital exenteration was required. MRI of the head and orbits confirmed the presence of an enhancing mass within the right lateral rectus with antero-medial globe displacement and medial displacement of the right optic nerve. The patient underwent eye-lid sparing exenteration, leaving the proximal third of the tumour stump at the orbital apex where the lesion entered the cranium.

DLBCL is known to demonstrate a partial response to steroid therapy alone, this type of therapeutic response can result in a diagnostic dilemma when managing patients with seemingly innocuous orbital mass lesions.

The response shown in this case demonstrates the need to maintain a high index of suspicion for malignancy at all times, even when clinical remission is achieved. In all cases of orbital mass lesions, biopsy should be sought wherever possible in order to obtain an accurate diagnosis and either confirm or exclude malignancy.

March 24, 2014 at 8:48 pm

oraladil_2000@yahoo.com

conjunctival amyloidosis is a very rare disease that present in the middle aged adults,here we report an extremely rare case of primary localised conjunctival amyloidosis in a child. A review of medical English literature revealed no previous reported
case in childhood (only one case of localised secondary conjunctival amyloidosis was reported in literature by Rodrigues in 1976,seconadry to squint surgery)

A 13 year old female was presented with 4 month history of right ptosis ,the ocular examination was unremarkable apart from mild right ptosis.The patient was listed for ptosis repair under general anaesthesia. At the start of surgery eyelid was everted only to note giant tarsal papillae/ A biopsy was taken from that area/and local steroid injected into tarsal conjunctiva and surgery was abandoned. The patient was given topical steroid to use and postoperatively the ptosis was noticed to improve.

Biopsy showed clumps of amorphous pink staining material staining orange with congo red and on polarisation there was an apple green birefringence suggestive of amyloid. Following this the patient was referred to the national amyloid centre, where the patient further assessed ,it was concluded there that the amyloidosis was a localised one with no evidence of systemic disease. An immunohistochemical staining of amyloid deposits was performed.This was suggestive of AL amyloidosis . For the next two years the patient was seen regularly in the eye clinic and gradually waned off topical steroid and the improvement of the right lid ptosis was maintained. .

It is important in cases of ptosis to evert the eyelid to check the palpebral conjunctiva as the ptosis can be mechanical
in nature

March 24, 2014 at 8:55 pm

martaperezoftalmo@gmail.com

To report ocular features of this rare condition, the associated likely stem cell deficiency; and the multi-disciplinary rehabilitation required to achieve eyelid closure including use of rib cartilage.

A boy was born in 2007 with severe eyelid deficiency, rudimentary ears, learning difficulties and failure to thrive. His neonatal management included split skin grafts to all 4 eyelids. This gave corneal protection, albeit dependent on a good Bells’ and frequent lubricants throughout his early childhood. Unfortunately he gradually developed marked corneal vascularisation unrelated to exposure, areas of conjunctival and cornea keratinisation, a left convergent squint and dense left amblyopia. His nutritional status was poor prior to PEG feeding, but he was never recorded as vitamin A deficient. More recently he has had full thickness skin grafts to both lower eyelids supported by rib cartilage grafts overlaid with bucket handle orbicularis flaps. While each eye was done separately, rib cartilage was harvested only once: the second graft was left buried subcutaneously in preparation for the second procedure to minimise harvesting risks and time.

Lagophthalmos has resolved. The corneal vascularisation is however unchanged despite topical treatments.

A rare and challenging syndrome, where the multidisciplinary approach and the use of rib cartilage proved invaluable as no ear cartilage was available. Rib cartilage provides excellent material as a spacer against gravity, and excepting donor site access appear superior to auricular cartilage regarding shape, size, pliability and ease of use.

March 24, 2014 at 9:19 pm

simranmangat5@gmail.com

To audit the results of a simplification of the Malhotra surgical technique of transconjunctival posterior approach white line advancement ptosis correction for patients with moderate to good levator function. Results compared to the BOPSS national ptosis survey.

Retrospective review of a consecutive series of 9 procedures on 8 patients with primary aponeurotic ptosis undergoing posterior approach repair using this modified method. We describe and compare our results as per criteria defined by the BOPSS national ptosis survey.

There were 8 ptosis procedures during this period. There were 2 women and 6 men. The mean age was 70 years. Pre-operative phenylephrine test was positive in 7 patients. Minimum follow-up was 3 months. All patients achieved their desired lid height. One patient had a slightly flat contour. No patients were over-corrected. No patients required re-operations. Discomfort was not a concern post-operatively. All patients were subjectively completely satisfied.

This modified and simplified revision of the Malhotra technique of white line advancement for posterior approach ptosis repair achieves results exceeding those achieved in the national ptosis survey. This modification doesn’t compromise the results of white line advancement ptosis surgery.

March 24, 2014 at 9:56 pm

Hannahtimlin@hotmail.com

To improve our anatomical knowledge of the normal healthy punctum in physiological conditions by using Optical Coherence Tomography(OCT), an imaging technique novel to the lacrimal system.

22 inferior puncta from 11 healthy volunteers had been imaged using Anterior Segment Spectral Domain OCT. Qualitative characteristics and quantitative data were analysed.

The punctum required gentle eversion by rolling a cotton bud placed inferior to the punctum.
OCT images reveal three layers of tissue presumed to be; epithelium, substantia propria and orbicularis. The epithelium extended from the surface of the lid down into the punctum showing variation in thickness from person to person with a mean of 70μm (SD 19, range 41 to 141). The second layer of tissue was hyperreflective and thicker in comparison to the epithelium. The deepest visible layer was hyporeflective compared to the middle layer with an irregular interface between the two.
The medial wall of the punctum showed a graduated, curved approach to the internal punctum suggestive of a papilla. In comparison, the lateral wall showed a more acute angled approach without evidence of a papilla.
The mean external punctal opening size was 615μm (SD 136, range 410 to 872) and the mean internal opening size was 18 μm (SD 30, range 0 to 99). At a depth of 500μm the majority of puncta were closed (64%). A fluid level was visible inside 18 puncta. It was not possible to visualise the horizontal canaliculus. Whilst an ampulla has been described in cadaveric dissections, there was no evidence of subpunctal dilation in vivo.

OCT can be used to image and measure the lacrimal punctum and the surrounding tissue layers.

March 24, 2014 at 10:29 pm

moh-yasser@hotmail.com

To report the success rate of autostable bicanaliculus intubation stent (SRS)in the management of acquired external punctal stenosis.

21 eyes of 12 patients who underwent stent implantation (18eyes used 30mm, 2 eyes used 25mm, 1 eye used 35mm) using disposable sizers. In all patients,1mm calibrated dilator supplied with the stent was performed carefully to prevent damage to the ampulla prior to the insertion of the stent, it is necessary to verify the absence of canalicular obstruction by probing and patency of the NLD by irrigation. For the management of AEPS and were prospectively evaluated regarding duration of epiphora, associated blepharitis or trachoma, and the success of treatment. Stent were removed 2 months after insertion.

There were 21 eyes of punctal stenosis, causing epiphora. The mean age of patients was 55 (±20) years. The mean interval between the onsets of epiphora and stent implantation was 18.4 (±12.7) months. Associated chronic blepharitis was detected in 4 eyes, trachoma complication in 3 eyes. The patient’s were examined at first day postoperative, 1 week, 1 month, and 2 months. Success was achieved in 19 eyes (90%). We had 4 cases of minor conjunctival irritation which were resolved in one week, and 2 cases of diminished palpebral fissure, in one case we replaced the stent. Spontaneous sent loss was noted in 5 eyes between the 1 week and 2 month follow-up. One patient suffered from residual epiphora.

SRS stent implantation for the treatment of AEPS is very effective. Careful punctum dilation should be performed and proper patient instructions to wear protective eyeglasses following procedure, to decrease spontaneous sent extrusion.

March 24, 2014 at 10:39 pm

tpatel2@nhs.net

Two unusual oculoplastic cases presenting with epiphora, which lead to diagnoses of; case 1: low grade B cell non-Hodgkin’s lymphoma and case 2: inverted papilloma.

Case reports.

Case 1: 55-year-old lady presented with an 18-month history of right epiphora. She gradually developed a poorly defined, smooth, non-tender, fleshy grey mass at the right inner canthus, with no ulceration. Probing and syringing revealed obstruction in the right eye. An MRI scan of the orbit confirmed a lacrimal sac mass involving the medial aspect of right orbit. Thereafter, right anterior orbital biopsy was performed diagnosing low grade B cell Non-Hodgkin’s Lymphoma (probable Mucosal Associated Lymphoid Tissue). The patient received a course of radiotherapy to the right eye. Staging CT elicited the lymphoma was stage 1 and limited to the right orbit.

Case 2: 51-year-old gentleman presented with a 3-year history of epiphora and swelling over the right medial canthus. On examination a right mucocele and lower lid punctual stenosis was found. The patient underwent a dacrocystorhinostomy and septoplasty and a biopsy was sent from the lacrimal sac tissue and O’Donohue silicone tubes passed. It was determined that the mass was an inverted Schneiderian papilloma with exophytic growth. There was no evidence of dysplasia or malignancy.

Epiphora is a fundamental symptom that patients commonly present with in eye clinic. Causes can include ocular irritation and inflammation or obstruction of the lacrimal system.
These two cases illustrate the importance of considering malignancy and other benign causes of epiphora. Such cases require acknowledgement, as early detection and multidisciplinary care will ensure timely management and treatment.

March 24, 2014 at 10:39 pm

dsm@doctors.org.uk

To describe a case eyelid Merkel cell carcinoma (MCC) caused by polyomavirus (MCPyV) in a patient with psoriasis. The eyelid reconstruction was complicated by auricular donor site wound inoculation from an active herpes simplex virus (HSV) keratitis.

A 55 year old lady with longstanding scalp psoriasis presented with a 3 week history of an enlarging dusky red left upper lid tumour. An incision biopsy showed a Merkel cell carcinoma. She was treated with wide local excision of the whole left upper eyelid with a clear marginal strip. The defect was repaired using a Cutler Beard flap and an interlamellar auricular cartilage graft followed by local radiotherapy.

Despite a previous history of excellent general health, this patient developed HSV infection of the cartilage donor site. She had been treated with topical acyclovir for a possible dendritic ulcer of the non-surgical right eye. After intravenous antiviral and antibiotic treatment she developed a cephalic vein thrombosis and 2 months later a left parotid recurrence of the MCC, treated with facial nerve sparing parotidectomy with cervical lymph node excision and radiotherapy.

1. Infected monocytes localizing within lesions of inflammatory diseases, such as psoriasis, may release MCPyV locally, infect Merkel cells and induce MCC.
2. Viral transfer of HSV enveloped virus from the cornea to another site might have occurred in this case. This has not been previously reported to our knowledge.
3. The presence of psoriasis and a rapidly expanding chalazion-like eyelid mass might increase the likelihood of a diagnosis of MCC, which requires urgent treatment.

March 24, 2014 at 10:44 pm

karla@karla.ch

Congenital lacrimal fistula is a rare developmental abnormality causing irritation and secretion. A review of the literature indicates few and incoherent reports of this entity. We evaluated clinical finding in two families and four unrelated patients. The aims were to structure clinical findings and define treatment procedures and prognosis.

Eight patients were examined and family history was taken. Four of eight patients underwent surgery and intraoperative findings were compared.

Four patients (two male, two female) presented with unilateral fistula located next to the inferior canaliculi and otherwise patent system. No family history was discovered. One patient had even an unaffected twin brother. In three of these four patient surgery was performed by removing the fistula which was connecting to the inferior canaliculus.
Four patients (three boys, one female) presented bilateral lacrimal fistula located low on the cheek. Puncta were missing. All patients had a family history. Two siblings presented additional minor systemic abnormalities. Two patients were operated and malformed lacrimal drainage system with missing canaliculi and missing nasolacrimal duct were fully removed.
All patients had a history of secretion since early childhood.

We introduce two new types of lacrimal fistula:
1. Unilateral lacrimal fistula located infero-nasal to the medial canthal angle connecting to the inferior or the common canaliculus. The lacrimal system is patent. Simple removal of the fistula is needed. No family history is found.
2. Bilateral lacrimal fistula located lower on the cheek, the lacrimal system is severely underdeveloped and needs to be fully removed. Family history reveals further affected family members.

March 24, 2014 at 10:48 pm

oraladil_2000@yahoo.com

To check the outcome of Quickert procedure in entropion cases

A retrospective case series study ,23 patients underwent Quickert procedure to correct age related lower eyelid entropion between October 2011 to December 2012 in Rotherham Hospital.
The change in procedure from original description was in few points
1-Full thickness eyelid resection was done in the middle of eyelid rather than in the lateral part.
2-Hooking of lower eyelid retractors:taking long vertical bites from lower part of retractors .
3-After hooking the retractors,the sutures passed through pretarsal orbicularis near lid margin and not coming out of skin below lashes as originally described.

Total of 28 Quickert procedures were performed by one surgeon.Age range of patients:63-94/mean age:78 years.Gender:12 male and 11 female.14 cases were right sided,5 cases left sided, rest bilateral. 22 Cases were operated for the first time while the remaining 6 cases were recurrent entropion.Follow up ranged from 1 to 11 month/mean follow up was 3 months.
Post operative review showed normal lid position in all the 28 cases with no post operative complications.

Quickert procedure is effective method to correct age related lower lid entropion with high success rate

March 24, 2014 at 10:49 pm

agorogiannis@gmail.com

To present an unusual case of subdural hygroma in a 13-year old male with progressive eyelid swelling and proptosis.

A 13-year old boy was referred urgently to the Ophthalmology Department with a ten-day history of swelling of his left eyelids and progressive ipsilateral proptosis. No history of head trauma was reported. Over the previous 10 weeks he had complained of migraine-type headaches, that did not improve with painkillers. In the last 5 days he complained of diplopia, blurring of vision, tinnitus on the left ear and difficulty walking. Examination revealed a left hypertropia & papilloedema.

Urgent neuro-imagining of head and orbits revealed a subdural hygroma. It was treated in the local tertiary hospital initially with burr-hole evacuation of the subdural hygroma and fenestration of the arachnoid cyst. After the first operation he deteriorated and underwent insertion of a cyst peritoneal shunt.

Subdural hygroma is a rare diagnosis especially in patients without a history of head trauma, and is an unusual cause of papilloedema. Neuro-imagining is of great importance to establish the diagnosis and plan the suitable therapeutic approach.

March 24, 2014 at 10:50 pm

anupmakumar@hotmail.com

To present the clinical details, radiological and histological features and management challenges of a patient with malignant orbital solitary fibrous tumour (SFT).

A retrospective case review.

A 68 year old female presented with marked proptosis and hypoglobus with reduced vision over the previous few months. MRI scan showed a large well-defined postero-superior extraconal orbital mass extended into the apex. CT scan showed marked thinning and deficiency of the posterior orbital roof. Old photos, clinical and radiological features were consistent with a longstanding benign orbital mass with recent progression and visual compromise.
The patient underwent neurosurgical /orbital surgery with a pterional approach. The tumour was highly friable and removed piecemeal. A small residual frill of tumour was left behind at the orbital apex to avoid optic nerve damage or superior orbital fissure syndrome. The patient made an excellent recovery with improved vision and facial symmetry.
After some debate histopathology confirmed the diagnosis of SFT with malignant features. Complete surgical excision would have necessitated extensive destructive potentially debilitating surgery. After detailed discussions with both patient and colleagues a plan to observe closely was agreed. A 6 month surveillance scan shows no progressive tumour and the patient remains well.

Reports of malignant orbital SFTs are extremely rare and these lesions seem to behave less aggressively in comparison to SFTs in other locations. They are relatively chemo and radio-resistant and so complete surgical excision is recommended. However this case highlights the need to tailor radical treatments on an individual basis.

March 24, 2014 at 10:57 pm

a-l.s@gmx.com

CTDCG assesses the anatomy of the lacrimal drainage system. The aim of this study IS to assess the value of CTDCG with lacrimal syringing for patients undergoing Endonasal Dacryocystorhinostomy(DCR).

Retrospective study of patients presenting to an Ophthalmology unit in North Wales with epiphora during 2003 to 2013. 82 patients with lacrimal duct obstruction were referred to ENT for CTDCG and DCR. Proximal obstruction = no passage of contrast past the lacrimal sac on CTDCG. Distal obstruction = contrast filling the lacrimal sac but did not enter the nose on CTDCG. Patent if saline passed to throat or contrast in nose on CTDCG.

Radiology reports, Ophthalmology and ENT notes were obtained for 28 eyes of 21 patients. Mean age 65.95 years (range 47-89), 24%male. Presenting with symptoms of epiphora for mean 38months,29% bilaterally. 10% had a change in symptoms when seeing ENT. Mean time between Ophthalmology review and DCR was 12.4months. 19% required additional surgery including septoplasty or sinus surgery. 5(24%) had sinus disease on DCG. DCG agreed with 72% of 25 eyes with a SWO obstruction. 3 further found on DCG of which 2 were operated on. DCG agreed with laterality of symptoms in 71%. Agreement between DCR side and obstruction on: SWO was 64%; 71% with DCG and 90% with presenting symptoms.
2(10%) suspicious lesions biopsied returned as no malignancy. Mean follow up 31.5months from Ophthalmology review to final follow up, 19% required revision. 10(48%) patients observed an improvement in symptoms at final follow up.

CTDCG identified 2 further obstructions compared to SWO that underwent DCR. Greatest agreement between which eye is finally operated on is with presenting symptoms.

March 24, 2014 at 11:27 pm

agorogiannis@gmail.com

To assess whether diagnoses of eyelid lesions suggested by GP’s were matched to the final diagnoses of Ophthalmologists. Also to evaluate whether these referrals were appropriate and made efficient use of a “See and Treat List”.

This audit was undertaken in the Ophthalmology Department, James Paget University Hospitals, Gorleston-on-sea, UK.
In eight clinics, 48 patients were referred to the “See and Treat List”. Of these 32 were male and 16 were female. The mean age was 56.33 ± 17.23 years; range 18-85 years). Of the 40 patients that attended the list, 7 did not arrive and 1 cancelled on the day. 80% of the patients (32 patients) were referred directly by GPs.

High accordance (25/32) between GP’s and ophthalmologists were found. In one case, a lesion that was referred as malignant was revealed to be a basal cell carcinoma. No malignant lesion was misdiagnosed by GPs and referred as benign.

All GP referrals to the “See and Treat List” were appropriate. We are also able to conclude from this audit that GPs have a good awareness of common of eyelid lesions and are able to correctly differentiate benign from malignant lesions.

March 24, 2014 at 11:28 pm

j.beare@sky.com

To look at the incidence of conjunctivalisation of the eyelid margins in different age groups.

Patients attending a general eye outpatient clinic were examined for evidence of conjunctivalisation of the lid margins. The patients age and sex and also the use of any eye drops or systemic medication were recorded in addition to the presence of other significant morbidity such as diabetes. Patients were asked about the presence of any eye irritation, stickiness or watering of the eyes. Representative photographs were taken of some patients. The information was all stored in a database to enable easy data retrieval and analysis.

100 patients were examined and the incidence of conjunctivalisation seemed to be directly related to age. Conjunctivalisation of the lid margins never occurred in normal young patients but it was almost universally present in patients over 80 but varied in degree.

Conjunctivalisation of the lid margins is perhaps an under-recognised cause of the “rheumy” sticky, red, watery irritable eyes in the elderly. Treatment is symptomatic with lubricating eyedrops.

March 24, 2014 at 11:37 pm

drlopezoliver@yahoo.com.mx

If preseptal cellulitis is not treated promptly may evolve to orbital cellulitis, which may result in blindness or even intracranial complications including cavernous sinus thrombosis and death. Management of preseptal cellulitis consists in specific antibiotic therapy. Some complicated cases do not respond, and surgical drainage or debridation is required, after surgery edema and purulent discharge, retard wounds healing, lengthening patients’ time of admittance, as well as prolonged use of antibiotics. We report the utility of Negative Pressure Wound Therapy (NPWT) as an adjuvant method in the treatment of preseptal cellulitis that requires surgical drainage.

The NPWT is a procedure in which negative pressure on a wound is distributed through a foam with the purpose of promote healing, eliminating excess exudate hindering bacterial growth, protecting the wound from the enviroment, promoting perfusion and wound edges approaching, thus providing a moisturized healing environment.(1)
OBJECTIVE
To evaluate for the first time the use of NPWT in a series of four complicated cases of preseptal orbital cellulitis, with partial response to intravenous antibiotic therapy, which required surgical treatment (drainage or debridation), as an adjyuvant method.

CASE 1
A 60 year old male with medical hystory of type 2 diabtes mellitus, and 72 hours left orbital trauma, clinical and radiologically diagnosed with left preseptal orbital cellulitis. Visual Acuity (VA) no measurable because severe lid edema, treated intravenosuly with Meropenem 1000 mg, Clindamycin 300 mg three times a day and Vancomycin 1000 mg twice a day. Eyelid surgical debridation was performed, because of necrotic tissue; edema and purulent discharge persisted; NPWT was applied with a 125 mmHg negative pressure over the left orbit wound for 48 hours three times in one week, after this edema and discharge dramatically improved. Thus patient was ready for eyelid reconstruction, at this time VA reported 20/20.
CASE 2
A 17 year old male with 48 hours clinical history of preseptal cellulitis secondary to left eyebrow piercing infection. VA was no measurable because of eyelid edema, intravenous treatment included Clindamycin 300 mg three times a day and Ceftiaxone 500 mg twice a day. Computed tomography (CT) scan reported lid abscess thus transcutaneous surgical drainage was perfomed; purulent discharge resolved but lid edema persited; NPWT was applied over the left orbit with 125 mmHg for 48 hours, three times in one week, with complete resolution of edema and the presence of granulation tissue over the surgical wound, reconstruction was not necessary, final VA reported 20/20.
CASE 3
A 58 year old male with clinical history of type 2 diabetes mellitus and 3 days left palpebral trauma, middle palpebral edema was present, VA on the left eye reported 20/30, intravenous therapy included Clindamycin 300 mg three times a day and Ciprofloxacin 500 mg twice a day, surgical debridation was performed because the presence of necrotic tissue. Palpebral edema persisted. Abundant fibrin covered wound’s bed. NPWT was applied at 125 mmHg over the left orbit 48 hours two times in one week, with improve in edema, granulation tissue over the wound, without fibrin. Final VA reported 20/20.
CASE 4
A one year old male with a 5 days clinical history of left palpebral edema, with VA not measurable because of palpebral edema, CT scan showed preseptal abscess and ethmoidal sinusitis. Treated intravenously with Clindamycin 40 mg/k/d and Ceftriaxone 100 mg/k/d, surgical drainage and NPWT transoperatively with 50 mmHg during 72 hours twice in one week. Showed edema resolution and granulation tissue proliferation. Reconstruction was not necessary. Four years follow up VA reported 20/20.

We reported 4 cases, all male (60, 58, 17 and 1 year old), diagnosed with complicated preseptal cellulitis, between 2-5 days of evolution. Two diabetic adults developed the condition secondary to trauma, while the young one was posterior a piercing infection, and the infant associated to sinusitis. All were treated with intravenous antibiotic therapy and surgical drainage showing partial improvement, and received NPWT every 48 or 72 hours for 2 or 3 times in a week. The NPWT reached 125 mmHg, except for the infant who received 50 mmHg. No ocular complications were observed.

Antibiotic and surgical therapy achieve an effective but incidious resolution of complicated preseptal orbital cellulitis. It is well proved the effectiveness of NPWT on wounds’ healing process. However the use of negative pressure has never been reported in this pathology. According to the mechanism of the NPWT, increased perfusion contributes to edema resolution and stimulates granulation tissue, thus accelerating wound healing.
The NPWT showed to be a safe and effective method to treat complicated preseptal orbital cellulitis as an adjyuvant therapy to antibiotic and surgical treatment.

March 26, 2014 at 1:03 pm

yuysal002@yahoo.com

Neuroblastoma usually occures in the period of early childhood and can metastase to the orbit. Periorbital ecchymosis and proptosis are the most common ocular findings of neuroblastoma. Some situations like trauma can cause the delay in diagnosis. Our aim is to report a similar case and to remind the similarity of ocular findings of trauma and neuroblastoma

Reviewing the medical records of patient with the diagnosis of neuroblastoma

A two-year-old boy presented with the complaint of left periorbital swelling and ecchymosis. Patient had a history of falling down and subsequent head trauma two months ago. Slight swelling had occured on the left side of head at that time. After three weeks of falling down, swelling had begun to increase and the patient was followed due to possible effect of trauma. Because of continuous increase in swelling, the patient was referred to our department. On the examination, ecchymosis on the upper eyelid bilaterally, subconjunctival hemorrhage, mild proptosis and gaze limitation on the left side were seen. After examination, possible diagnosis of neuroblastoma was made. Tomography of orbit showed a mass involving inferior temporal fossa and left orbit. There was destruction on the sphenoid and zygomatic bones.
On the left suprarenal gland, a mass was also detected. After bone marrow biopsy and biochemical investigation neuroblastoma was diagnosed. After chemotherapy, ocular findings subsided.

In conclusion, due to the similarity of ocular findings, history of trauma can cause the delay in diagnosis of neuroblastoma. This case highlights that history of trauma may mask the underlying cause of periorbital ecchymosis and swelling.

March 26, 2014 at 8:51 pm

taz500@hotmail.com

To describe a modified surgical technique for correcting very large angle exodeviations in patients with third cranial nerve palsies refractory to other treatments, and determine long term outcomes.

A consecutive series of seventeen patients with large angle, incomitant squint were operated on at Moorfields Eye Hospital between 2005-2013 using periosteal anchoring by a joint Strabismus/Adnexal team. All patients underwent anchoring of the insertion of the medial rectus (MR) muscle to the periosteum of the medial wall via a retrocaruncular approach, in conjunction with either lateral rectus recession or complete disinsertion and fixation to the lateral orbital rim connective tissue. Retrospective analysis assessed previous procedures, pre operative prism dioptre (PD) deviations and complications.

17 eyes of 17 patients were included in the study. Mean follow up was 16.9 months (range 3 to 66). Pre operative exotropia ranged from 40 to 115 PDs (median 70). At the final follow up all patients had reduced horizontal deviations ranging from -80 to +14 PDs (median 16). The mean overall reduction in deviation was 50.2 PD (range 20 to 108). None of the patients required further surgery.

Large angle incomitant divergent squints present a difficult surgical challenge. We advocate a combined bi-rectus fixation approach with traction sutures to hold the globe in the primary position

March 30, 2014 at 9:16 pm

e.obi@usa.net

Haemolacria is a rare feature of some diseases of the conjunctiva, eyelids, lacrimal gland and lacrimal sac. Although diagnosis of the source of blood in the tear film is often straight forward, it is important to be aware of rare causes.

We present a unique case of haemolacria diagnosed by clinical means when radiological investigations were non-contributory.

A 22 year old female, presented with intermittent profuse bleeding from her left eye (Fig 1) and nose, three years after an accidental glass injury to her face. A firm lump in the region of her left medial canthus had been put down to scar tissue (Fig 2) and both a plain facial radiograph and orbital MRI scan revealed no abnormality. However transillumination strongly suggested a glass foreign body (Fig 3) which during removal was found to be a long fragment of glass parallel to the left lateral wall of her nose and penetrating her lacrimal sac (Fig 4). Following removal she remains free of symptoms

Although rarely used, transillumination should not be overlooked as a useful clinical examination technique. We discuss the clinical indications for transillumination and review the literature for the causes of haemolacria.

April 1, 2014 at 12:45 am

e.obi@usa.net

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e.obi@usa.net

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April 1, 2014 at 12:47 am

e.obi@usa.net

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April 1, 2014 at 12:48 am

abhiramidevidr@gmail.com

To report a case of lacrimal sac carcinoma

CASE REPORT

A 72 year old Chinese gentleman presented with complaints of a gradually progressive swelling over the left lacrimal sac region for the past 3 years associated with epiphora.There was no history of discharge,bloody tears,epistaxis,acute dacrocystitis and sinonasal disease before or after the onset of swelling.
On Examination:
There was a palpable firm to hard mass measuring approximately 3cm x 2cm in size.It was non-tender and situated in the left lacrimal sac area.Skin overlying it was mobile and free from the underlying mass.The lesion was not extending above the medial canthal tendon and regurgitation on pressure over the lacrimal sac was negative.
On syringing,it was freely patent.There was no proptosis and restriction of extraocular muscles.
Patient had a history of biopsy of swelling done at a private hospital 3 years ago and was told it was a benign lacrimal sac tumour.
Magnetic resonance imaging (MRI) Brain/Orbit done on the 30/10/13 showed a left medial orbit lesion which was extraconal and may be related to the frontal ethmoid air cells,anterior nose or medial orbit.
Chest x-ray did not show any lung metastasis.
Initially,patient was under the Ear,Nose and Throat (ENT) follow up till December 2013.
Biopsy from the left middle meatus was done and while awaiting the histopathological report (HPE), he was referred to the Oculoplasty team.
2 months later, patient was planned for biopsy and excision of the left lacrimal sac tumour under Oculoplasty and ENT.
Intraoperatively,the left lacrimal sac tumour was found superolaterally till the floor of left orbit.Medially,it extended till the lacrimal bone and inferiorly it extended breaching the superior wall of the maxillary sinus.
The lacrimal sac tumour was identified and dissected but the capsule broke and the tumour was removed in pieces.
1 week later,histopathology report (HPE) of the left lacrimal sac biopsy showed an invasive carcinoma consistent with mixed squamous transitional cell type.
Histopathology report (HPE) of the left middle turbinate biopsy showed an inflammed benign polyp.
Currently,patient has been planned for radiotherapy with monthly follow up under Oculoplasty to rule out recurrence of the carcinoma.

It is important to consider all lacrimal sac tumours as malignant untill proven otherwise by histology.
These lesions require aggressive treatment and life long follow up in view of high chances of recurrence.

April 1, 2014 at 4:28 am

abhiramidevidr@gmail.com

To report a case of orbital cellulitis in an infant

CASE REPORT

An Indonesian baby at 29 day of life was brought by his parents to the emergency department of Universiti Malaya Medical Centre with a history of progressive left eye swelling for 1 week duration associated with intermittent low grade fever.
There was also history of another swelling at the left cubital fossa for 4 days.
History obtained from mother showed that baby was delivered at term via spontaneous vaginal delivery with no known medical illness.
The baby was active and feeding well till he was bitten by an insect over the left eye 1 week ago.Parents did not seek treatment till they noted pus discharge from the left eye since day 5 of illness.
Baby was brought to a General Practitioner and was given oral Augmentin,Paracetamol and Chloramphenicol ointment for the left eye swelling.
However,the condition was not improving and the left eye swelling was worsening.Parents revisited the General Practitioner
2 days later and was referred to Universiti Malaya Medical Centre for further management.
On Examination:
The baby was fretful,tachypnoeic with an oxygen saturation of 98% under room air.
Hydration status was fair.
Baby was unable to open the left eyelid due to the swelling.Skin overlying the swelling was erythematous and pus discharge was noted.
Immediate admission was done with referral to Ophthalmology by the Paediatric team.
Intravenous antibiotics, C-Penicillin 390 000 units BD and Cefotaxime 200 mg TDS was started.
Computed Tomography (CT) Brain/Orbit done showed a left periorbital and orbital abscess extending to the left maxillary and ethmoid sinuses with no evidence of intracranial extension.
Full Blood Count(FBC) showed a high white cell count (TWBC) of 16.9 with neutrophilic predominance of 67%.
Anterior segment examination showed moderate chemosis of conjunctiva with normal pupillary reaction.
Diagnosis of left Orbital Cellulitis was done.
Left external periorbital drainage was done on the same day (15/3/14) by the Oculoplasty team.
It was an uneventful procedure.
Intraoperatively,multiple punctate sinuses on the left upper lid and multiple loculations were noted with copious amounts of thick purulent discharge.
The pus was discharging into the superomedial fornix on pressure.Approximately,7ml of pus was removed.
Bone destruction over anterior wall of maxillary bone was noted.
2 weeks later,culture and sensitivity of the left eye swab showed Methicillin sensitive Staphylococcus Aureus and Pseudomonas Stutzeri which was sensitive to Gentamicin.
The baby was started on Intravenous Gentamicin 16mg OD and Intravenous Cloxacillin 200mg QID.
Currently,the baby is able to open the left eye spontaneously and the swelling over the left eye has resolved.

Detailed history and investigation should be performed in any child with swelling of the eye.Although controversy exists about the medical or surgical management of orbital abscesses in paediatric patients,prompt diagnosis and treatment in this baby has given excellent recovery results of this otherwise sight threatening condition.

April 1, 2014 at 6:06 am

v.joganathan@doctors.org.uk

Phantom pain has been described following amputation of various organs. Eye pain and non pain stimulus arising from an anophthalmic socket remains poorly recognised.

A retrospective case series of phantom eye syndrome (PES) and a review of the literature.

Case 1: A 40 year old man who underwent bilateral enucleation for familial exudative vitreal retinopathy. He has daily symptoms of intermittent foggy, yellow vision associated with flashing lights since his operation in both eyes. This is intermittently accompanied by a cold sensation inside both eyes. His symptoms give him immense comfort and he is happy to remain with symptoms.

Case 2: A 41 year old man who has right artificial eye following traumatic injury. For the past 30 years, he experiences intermittent, right socket numbness and desire to pinch his enucleated eye. This does not give him much discomfort or limit his daily activities. The patient attributed these sensations to be side effects of the trauma and eye surgery itself.

Case 3: A 52 year old man with left artificial eye since 2 years of age. He continues to have left dull eye pain, intermittent flashing lights and coloured patches. He had thought this was normal as doctors have never been able to explain his symptoms in the past. He reflects on these feelings being disturbing as a child.

Case 4: An 88 year old lady, who underwent enucleation of her left eye for rubeotic glaucoma, has daily dull left socket pain for two years. This limits her usual activities especially in the morning and has built coping strategies in place. Clinical examinations of her left socket, prosthesis were unremarkable.

PES remains under recognised clinically and in the published literature. Patients and doctors may lack of awareness of the disease. Clinical priority to look for structural pathology at first instance might be contributory. Patients should be informed of this disease entity before eye removal and PES should be sought of on subsequent clinical evaluation. Various non-medical, non-surgical techniques have been proposed to alleviate phantom pain symptoms.

April 1, 2014 at 9:59 am

Tahrinasalam@hotmail.com

A peculiar feature of periocular dystonias is the ability of some patients to dramatically attenuate their symptoms by sensory stimulation. This phenomenon is often described as ‘Geste Antagoniste’. The primary aim of this study is to describe the prevalence and nature of sensory tricks in benign essential blepharospasm (BEB) and hemi facial spasm (HS).
The secondary aims are to assess if the severity of the disease is associated with the presence of sensory tricks in these patients and to analyse if the patients that use sensory tricks respond differently to botulinum toxin injections than the ones that do not use the sensory tricks.

Non-interventional cross-sectional design, to study patients with facial dystonias in the adnexal department at Moorfields Eye Hospital. Questionnaire based study of 200 patients in clinic to assess the features of their dystonias and the possible relation to the sensory trick phenomenon.
A questionnaire was administered during routine appointments to all patients that match the inclusion criteria. The questionnaire was completed in 5 to 10 minutes and included different domains regarding severity of the disease (measured by Jankovic scale and Blepharospasm disability index), effect of previous botulinum toxin treatments (if administered), and the use of sensory tricks. We assessed other ocular features that could affect the severity and outcome of the spasms, such as the corneal aesthesiometry as assessed with the Cochet-Bonnet corneal aesthesiometer; and the ocular surface state using the Oxford Scheme

Inclusion criteria include adult patients with well-established diagnostic of BEB and HS, who understood the study and agree with verbal consent to participate in it.
Exclusion criteria included patients with secondary blepharospasm related to ocular surface pathology, and patients that do not understand the study and / or do not consent to participate on it.

Preliminary data shows a prevalence of sensory tricks in 53% in our patient cohort. Patients with the sensory tick had a 20% reduction in the amount of botulinum toxin required and a longer average follow up period by 6-7 weeks. The type of sensory tricks encountered were varied and included pressure application to the face, chewing, singing and dancing.
Patients with the sensory tick had a better ocular surface score that those patients without the trick, and a slight decrease in corneal sensation.

Benign essential Blepharospasm (BEB) and Hemifacial spasm (HS) are the most common movement disorders affecting the face. A distinct phenomenon in dystonia is sensory trick or geste antagoniste (GA).. A clear relation was found between the dystonia, the response to the current treatment with botulinum toxin, and the sensory tricks. Therefore a new approach with these patients could be tried using different devices to take advantage of the sensory tricks. To the best of our knowledge this is the largest study to identify the types of sensory tricks experienced and also the first study to describe a relationship between the severity of the spams and the use of sensory tricks.

April 4, 2014 at 10:21 am

tomfearnley78@gmail.com

To demonstrate a proof of concept that quantitative texture feature analysis of contrast-enhanced magnetic resonance imaging of orbital tissues can be used to produce a unique footprint for a variety of orbital disease processes as an adjunct to histology as a reference standard

We used the MaZda software program to perform quantitative texture analysis of magnetic resonance images of a variety of orbital structures to demonstrate that a unique histogram footprint is produced. MaZda is a publicly available, free software program that computes texture analysis parameters for MRI images by mathematically summarizing the signal intensity of pixels within a chosen region of interest. A number of histologically confirmed disease processes generate a characteristic histogram appearance. Such software could therefore be used as a useful noninvasive classification method for orbital disease processes when used as an adjunct to a radiological opinion and histology as the reference standard. The ready access to picture archiving and communicating systems now allows ophthalmologists to review MRI images long before a formal report has been generated. With increasing pressure on our radiology colleagues in terms of turnaround times for scan reports this software tool may facilitate more rapid active intervention. It may also prove to be useful in cases of indeterminate histology or where achieving a tissue diagnosis is technically challenging and poses a high risk of iatrogenic morbidity

The MaZda quantitative texture analysis software produces characteristic histograms for a variety of orbital pathologies. These histograms can be used with a predictive value by observers blinded to the histological diagnosis

This study shows proof of concept that classification of orbital tissue pathology is possible by applying quantitative texture analysis to contrast enhanced MRI. Further studies are needed to produce a larger reference frame of histograms in histologically confirmed disease

April 5, 2014 at 3:33 pm

nuhaq1@gmail.com

To demonstrate a small incision direct brow lift technique to address brow ptosis.

Brow ptosis causes lateral hooding of the upper lid skin and we suggest that functional correction of brow ptosis primarily necessitates elevating the lateral portion of the brow. The most common reason in limiting the use of direct brow lift surgery to elevate the brow is the potential for developing a prominent scar above the eyebrow. Strategies such as crenating the incision or performing endoscopic and pretrichial brow lift aim to prevent obvious scarring. These techniques carry their own risks mainly relating to potential numbness and muscle weakness secondary to nerve damage. We present a useful and simple technique illustrated by video demonstrating the method developed by the senior author to correct a mild, predominantly lateral brow ptosis. A step by step demonstration of the technique with audio commentary is shown. Post-operative images demonstrating the appearance of the brow and scar after healing are also included.
Informed consent with permission to film for the purposes of publication and presentation was obtained from all patients participating in the making of the video.
The video was created by the Medical Illustration department at the University Hospitals Leicester and edited by the authors.

Patients undergoing this technique reported a high level of satisfaction with the degree of brow lift with minimal visible scar.

Small incision direct brow lift is a safe technique utilising an approximately 2cm incision over the lateral brow minimising the potential for an obvious scar.

April 6, 2014 at 12:13 pm

andrea_d_z@yahoo.com

To describe a case of primary intraepithelial sebaceous gland carcinoma of the ocular surface treated topically with mitomycin C drops and imiquimod cream.

We present the case of an 81 year old man who presented with left conjunctival erythema and discomfort due to widespread cicatricial and inflammatory changes of the ocular surface. Map biopsies showed intraepithelial sebaceous gland carcinoma involving the bulbar and tarsal conjunctival surface and the skin of the upper eyelid. The patient declined any form of disfiguring surgery. His conjunctival disease was treated with a course of mitomycin C drops, followed by a course of imiquimod cream for the eyelids.

Treatment was well tolerated. Three months after the completion of treatment, there was significant improvement in patients symptoms and the appearance of the ocular surface. Further map biopsies of the conjunctiva showed clearance of the disease at 5 out of 6 biopsy sites. Biopsy of the eyelid skin showed no evidence of intraepithelial disease. A further course of mitomycin C is planned.

Mitomoycin C is a good treatment option for sebaceous cell carcinoma confined to the conjunctival epithelium in cases where local resection is not possible. This is the first documented use of imiquimod for primary intraepithelial sebaceous carcinoma affecting the eyelid skin. The treatment combination of mitomycin C and imiquimod may avoid exenteration in selected cases.

April 6, 2014 at 10:26 pm

b.udani-shah@doctors.org.uk

Surgical technique description and case presentation.

An eighty-four year old male presented to the oculoplastic service with longstanding acquired, complete lower motor neuron facial nerve paralysis. Prior mid-facial resuspension surgery and lower lid tightening had been unsuccessful. The patient now had severe mid-face descent, ectropion, lagophthalmos and exposure keratopathy, with orbicularis muscle atrophy.

A two stage procedure was performed. A vertical right nasolabial flap was raised and two weeks later rotated horizontally to provide lower eyelid support. Mid-face pre-periosteal dissection was performed and the mid face resuspended with three Mitek bone anchor sutures:

In the first stage a vertical elongated “v” shaped flap was constructed extending from just lateral to the mid-shaft of the nose to just lateral to the right corner of the lips. At this stage the flap was merely incised and loosely sutured at its origin, but not transferred. We felt that this delayed flap technique would enhance the sustainability of our flap.

In the second stage, the flap was mobilised and rotated ninety degrees clockwise to its intended position; horizontally just inferior and parallel to the right lower lid. The flap was anchored with Mitek sutures to the orbital rim, and sutured with 8.0 PDS. Additionally, a mid-face elevation and canthopexy was undertaken, as well as a frost suture placed which was removed the following morning.

Post operatively, the patient was seen to have significant elevation of his previous mid-face ptosis and improvement of his lagophthalmos. The patient reports a significant reduction in his problematic drooling and epiphoria, and aesthetically he has vastly improved symmetry of his face. The flap itself appears healthy with no signs of ischaemia.

Whilst the vast majority of patients with bells palsy can expect complete recovery of their symptoms, a minority present with longstanding effects. This patient displayed perhaps the most severe complete paralysis we had seen, and subsequently had persistent symptoms despite surgical intervention. There are many well established surgical interventions described, including insertion of an upper lid gold weight to alleviate lagophthalmos through to temporalis transfer.

Our method of constructing a nasolabial flap which is rotated and transferred just inferior to the lower eye lid is as yet undescribed in this scenario and certainly provided us with encouraging results, both functionally and cosmetically.

April 6, 2014 at 11:07 pm

mayaeiger@gmail.com

To describe a rare case of orbital infection due to Citrobacter Koseri and Achromobacter, manifested as progressive right eye ptosis following minor head trauma.

A 67 year old diabetic male with microvascular disease, approached the emergency room complaining of headache and right eye ptosis two days after minor head trauma. Eye examination was remarkable for complete right eye ptosis and mild NPDR. Pupils were reactive and normal with no eye movement restriction. Brain CT showed Pan-sinusitis without bone destruction. The next day right eye proptosis, eyelid edema and upward eye movement restriction appeared with hyperglycemia. Due to the differential diagnosis of Mucormycosis, and corresponding MRI findings, intravenous Liposomal Amphotericin B and Clindamycin were initiated and urgent FESS and orbital biopsy performed. Minimal sinus infection with no necrotic tissue were found. Orbital, sinuses and nose cultures grew Citrobacter Koseri and Achromobacter. Four days later optic neuropathy appeared. Imaging showed deterioration at the orbital apex, without orbital abscess or cavernous sinus thrombosis. Trans-nasal orbital decompression was performed, with gradual improvement in optic nerve functions.

On follow up proptosis, ptosis, movement restriction, and optic nerve functions returned to normal, except for lower visual field loss. One month after initial presentation corresponding altitudinal optic nerve head pallor was observed.

Rapidly progressing orbital infection in a diabetic patient should warrant urgent aggressive workup and treatment due to suspected Mucormycosis infection, however atypical organisms should be considered. In this unique case orbital cellulitis was caused due to irregular organisms ensued after unrelated head trauma. In the treatment course optic nerve functions deteriorated, necessitating orbital apex decompression.

April 7, 2014 at 1:34 pm

drkennyc@gmail.com

It is increasingly recognised that anatomical patency alone does not define success in dacryocystorhinostomy (DCR) surgery. The patients’ subjective perception of quality of life (QOL) is an outcome measure that is equally, if not more, important. A number of studies have investigated the perceived improvement in QOL in DCR surgery. However these are mainly for endoscopic endonasal DCR (EE-DCR) and with a retrospective questionnaire such as the Glasgow Benefit Index (GBI). This study aims to prospectively measure the QOL in patients undergoing either external DCR or EE-DCR with a QOL questionnaire both before and after surgery to demonstrate benefit.

A 14 question questionnaire with minor wording modification from the validated GO-QoL was used to assess the symptoms’ effect on patients’ QOL. Similar to the GO-QoL the questions are divided into the consequences of decreased visual acuity or visual functioning (10 questions) and the psychosocial impact (4 questions). The questions are answered on a three-point Likers scale. The answer “no, not at all limited” were given 2 points, “yes, a little limited” 1 point and “yes, seriously limited” 0 points. The total was converted to a score out of 100 with 100 being no loss of QOL.
The patients were given the questionnaire to complete at the time of consultation pre-operatively. After the surgery the same questionnaire is presented to the patients again ranging from 2 months to 1 year post operatively.

20 cases (19 patients) from November 2012 to January 2014 were prospectively recruited into the study. There were 11 external DCRs and 9 EE-DCRs. Ten cases where on male patients and ten on female patients. Patients’ age range from 42 to 82 (mean 65 years). Preoperatively the patients had a visual function QOL mean score of 51.98 (SD 24.73). This increased to 76.11 (SD 30.56) postoperatively. This represents an increase of 24.13 (p=0.001) which is statistically significant. In terms of the psychosocial QOL questions, the patients scored 47.5 (SD 26.47) preoperatively, increasing to 79.38 (SD 22.68) postoperatively. This represents an increase of 31.88 (p=0.000) which is highly significant.

This study shows that, by using a disease specific QOL questionnaire before and after DCR surgery, patients experiencing a significant improvement in QOL in both the visual function and psychosocial domains can be reliably demonstrated. This is more robust than using the GBI which is performed only postoperatively and thus is subject to biases due to memory and perception changes. Our study also demonstrates that the improvement to QOL is evident in both external DCRs and EE-DCRs.

April 7, 2014 at 2:51 pm

mail@olivia-li.com

To present the Mitek anchor device, insertion technique and oculoplastic surgical indications.

The Mitek anchor (Depuy Mitek EMEA, Rome) is a coupling device, combining rigid bone fixation and adjacent soft tissue re-approximation. Originally developed for orthopaedic surgery and used in ligament repair, Mitek device use has expanded into ENT and Maxillofacial surgery in temporo-mandibular joint surgery and hyloid suspension for sleep apnoea. Mitek anchors have also found a role with oculoplastic surgery and we wish to highlight the use of this technology to oculoplastic surgeons. The authors have no financial interest in the product.

The technique is demonstrated using a step-by-step intra-operative photograph sequence.

The Mitek anchor device consists of two suture arms attached to a bone anchor, housed within a detachable plastic implantation holder. The insertion technique: 1) The site of bone fixation is marked and pre-drilled 2) the mounted anchor is pushed into the snug drilled ostium site until a give is felt which indicates proper fixation 3) The implantation housing is detached to release the two attached sutures 4) The adjacent soft tissue is then approximated to the underlying bone using the two sutures ends. Multiple Mitek anchors may be placed according to the clinical indication.

Mitek anchors are a useful adjunct for oculoplastic surgeons in procedures requiring soft tissue fixation to bone and may offer a good alternative to periosteal soft tissue fixation. Mitek anchors may be particularly useful in mid-face elevation, especially medially, an area that is typically difficult to achieve good soft tissue support. Mitek anchors may also be successfully employed in the lateral orbital rim to provide rigid lateral canthal fixation.

April 7, 2014 at 9:19 pm

richardscawn@me.com

Mid-face elevation and re-suspension can be used to address functional deficits secondary to mid-face descent and provide anterior lamella augmentation for lower-lid reconstruction. However a paucity of evidence exists regarding the long-term effectiveness of mid-face elevation surgery.

Consecutive case series, retrospective chart review and objective digital image analysis of all patients undergoing mid-face re-suspension over a five year period in a tertiary oculoplastic and craniofacial facility.

A consecutive series of patients were identified with a minimum of 6 months follow up. The surgery was performed by four surgeons, within a single facility. Indications for surgery include congenital craniofacial abnormalities and acquired retraction secondary to trauma, neoplasia, involution, paralysis and cosmetic surgery. Fixation techniques included Mitek bone anchored sutures, endotines and drill hole fixation. Although some descent is anticipated the patients are deliberately over-corrected initially to account for this. The technique may elevate the lower lid without requiring traditional augmentation using anterior or posterior lamella grafts. (The technique is demonstrated in a series of intra-operative pictures)

Mid-facial elevation surgery is a useful technique in facial and lower lid reconstruction. Mid-facial surgery provides an alternative method of anterior lamella augmentation. A soft tissue mid-face lift is preferred in acquired cases while a sub-periosteal technique is favoured in congenital cases. This retrospective analysis provides objective photographic documentation of the effect of time on the position of the lower lid margin.

April 7, 2014 at 10:12 pm

richardscawn@me.com

To describe a surgical algorithm for Neurofibromatosis induced ptosis correction

Retrospective chart review of 65 consecutive patients with neurofibromatosis treated at a tertiary oculoplastic unit during a 20 year period.

28 patients required ptosis surgery. Three distinct ptosis distribution patterns were identified. These groups corresponded to the trigeminal nerve eyelid anatomy and resultant neurofibroma location. These groups were Supra-trochlear, supra-orbital and lacrimal. The clinical presentations and surgical management differed between these groups.
Lacrimal nerve based neurobromas produced the classic S shaped deformity while supra-orbital and supra-trochlear generated central and medial eyelid ptosis respectively.
Lacrimal neurofibromas were associated with an involved and dystrophic levator palpebral superioris while supra-trochlear and supra-orbital neurofibromas demonstrated relative sparing of the levator muscle.

Medial and central eyelid ptosis secondary to neurofibroma may be initially treated with good results by neurofibroma excision alone. However lateral, lacrimal nerve associated neurofibromas, will likely require ptosis surgery at the time of initial neurofibroma excision.

April 7, 2014 at 10:20 pm

yuysal002@yahoo.com

Epiphora due to lacrimal drainage system obstruction from metastasis occures rarely. Our aim is to present a case who has a history of colorectal adenocarcinoma and the first sign of metastasis is epiphora.

We have reviewed the medical records of a patient who complaints of epiphora due to lacrimal drainage system obstruction from colorectal carcinoma metastasis.

A 73- year-old man presented with a 3-month history of epiphora in the left eye. One week before presentation, diplopia and decrease in vision in the left eye had developed and then the patient had been sent to our department for further evaluation and treatment. On the examination, visual acuity of patient was 0.3 in the left eye and 0.8 in the right eye. Gaze restriction was noted in the left eye. Slight conjunctival hyperemia and telangiectasia on the medial part of lower eyelid were seen. There was slight edema on the medial canthal region. Computerized tomography showed medial orbital mass lesion invading lacrimal drainage system. Patient had a history of colorectal adenocarcinoma for 4 years. Histopathologic examination of material taken from this lesion was compatible with metastatic adenocarcinoma. Body images were taken and radiologic images showed renal metastasis. Radiotherapy and chemotherapy were scheduled.

Epiphora may be the first sign of lacrimal drainage system metastasis. Clinicians should consider in mind this condition during evaluation of a patient with epiphora especially in patients with history of malignancy.

April 7, 2014 at 10:31 pm

skdhani@msn.com

Floppy eye lid is a rare condition associated with various systemic conditions and can present with varied ocular symptoms and could be easily missed without proper history taking, clinical examination and further investigations to confirm the association with various systemic conditions. The purpose of this presentation is to highlight the manifestations of floppy eye lid and associated systemic disorders, diagnosis and appropriate management of Floppy Eye Lid surgically and medically.

Gathered evidence about the management of Floppy Eye Lid from Literature and applied in the appropriate management of Floppy Eye Lid both medically and surgically. In this presentation cases of typical Floppy Eye Lid were presented highlighting how they were misdiagnosed and treated as simple ptosis and surgical correction was performed to correct the ptosis ignoring the symptoms, signs and presentation of Floppy Eye Lid resulting which resulted in failure. These cases were treated with surgical procedures tailored to the patients depending on the presentation of Floppy Eye Lid and associated features like ptosis, dermatochalasis, lower lid ectropion in single step or multiple interventions resulting in satisfactory outcome both cosmetically and functionally.

With careful planning of surgical management tailored to each individual patient, good surgical outcome was achieved either by Lateral Canthal Tightening alone or staged correction by Lateral Tarsal Strip and Ptosis Correction on separate occasions. Associated lower lid ectropion or laxity is also addressed.

Though Floppy Eye Lid is a rare condition, it cannot missed with careful history taking and examination. The aim of this presentation is to diagnose the condition appropriately, analyse the systemic associated conditions and treat the condition surgically and medically to get the best results with surgical procedures suited to each individual patient.

April 7, 2014 at 11:11 pm

olivmac9@hotmail.com

To use a computer-based image-processing algorithm to establish objective evidence of changes in the curvature of the tarsus relative to the line of vision. Changes in the tarsal curvature of the upper eyelid relative to line of vision are important especially in surgical correction of paralytic lagophthalmos in which the upper lid is weight loaded with rigid or flexible implants.

After an ultrasound examination with a 7.5 MHz scanner (no-contact method) of the upper eyelid tarsus with the patient in primary, left and right gaze, a computer-aided examination of the upper eyelid tarsus was performed followed by the calculation of the radius of curvature of the tarsus relative to the line of vision in each position.

Using regression of a Taylor polynomial, the shape of the tarsus was mapped by a quadratic function, and we were able to objectively demonstrate changes in tarsal curvature relative to line of sight.

Objective evidence of changes in the tarsal curvature relative to the line of vision, may influence choice of upper lid implant, flexible versus rigid, in the treatment of paralytic lagophthalmos with upper lid loading.

April 7, 2014 at 11:49 pm

beckylouford@googlemail.com

To highlight the merits of evisceration with orbital implant, compared to enucleation, as a preferred technique for removal of severely traumatised eyes in the field hospital setting, and to encourage educated debate on this topic.

Relevant literature is reviewed in the context of military precedent.

Loss of an eye due to military trauma carries a distinct set of potentially severe psychosocial sequelae. Lack of early access to specialist services places these patients at extra risk of socket complications and poor cosmetic outcome. However, removal of severely injured eyes in war zones is often delayed due to the belief amongst military surgeons that the more complex procedure of enucleation is required to prevent sympathetic ophthalmia (SO). There is in fact no evidence to suggest that the choice of surgical technique for eye removal, rather than the nature of the trauma itself, actually impacts the risk of SO in the fellow eye. It is possible that any delay in removing highly disrupted uveal tissue may increase the risk of SO.

Evisceration is a more straightforward procedure than enucleation and can be taught to non-oculoplastic specialists. Evisceration with a simple orbital implant can be performed in a field hospital setting. The availability of a technique that can be used soon after injury to remove irretrievably traumatised eyes early may both reduce the risk of SO and improve cosmetic outcomes. Better training of personnel caring for military eye trauma and better education about the evidence regarding SO may help to improve outcomes. We wish to discuss our conclusions with the BOPSS membership before producing recommendations for military ophthalmologists and trauma surgeons.

April 8, 2014 at 12:09 am

ma1604@hotmail.co.uk

A 44 year old female patient presented with a severely painful left orbit several weeks following evisceration and insertion of acrylic 20mm orbital implant.
On clinical examination, no evidence of local orbital infection or extrusion of implant were identified. MRI orbits with contrast revealed an inferior ophthalmic vein occlusion, best visualised with fat suppression in axial and coronal planes.

N/A

N/A

The patient was initally managed conservatively, with appropriate levels of analgesia and kept under close review. Haematological investigation for infection, inflammation and pro-thrombogenic factors proved negative.

Orbital pain levels persisted, without improvement after 5 months, which led to the decision to remove the implant under a general anaesthetic. A normal acrylic implant with healthy, non-infected tissue was visualised at the time of surgical removal.

The patient’s reported pain improved following this procedure, which correlated with images from repeat MRI orbits which confirmed reduction in the calibre of inferior ophthalmic vein. (*Additional MR angiography orbits currently awaited).

To our knowledge, isolated thrombosis of inferior ophthalmic vein following insertion of acrylic orbital implant is not reported in the literature.

April 8, 2014 at 3:41 am

emma.worrell@qvh.nhs.uk

A new technique to produce hollow prostheses. A case series of patients utilised
standard methods to fabricate hollow ocular prostheses where rehabilitation had
proved difficult.

This paper describes the fabrication process and results of hollow ocular
prostheses.

Each hollow eye was significantly reduced in weight. One third lighter of
the original weight, with the exact size, shape and volume of the existing solid
prosthesis. Improvement in mucous discharge, increased comfort, wear time of prostheses and aesthetics is reported.

This simple design significantly reduced the weight of these eyes, and
revolutionised these patients’ rehabilitation. Previously the solid prostheses
overburdened the lower eyelids, causing discomfort, irritation, discharge and
reddening, whereas the new lightweight prostheses are unobtrusive, comfortable and
good aesthetically.The innovation to create a hollow medical device enhancing comfort, added functionality, utilising traditional fabrication methods is both revolutionary and cost effective as a treatment option. Being able to increase patient satisfaction by reducing irritation and discharge, increase wear, produce significantly lighter prostheses at reduced cost, will undoubtedly transform the lives of some of our most challenging patients.

January 13, 2015 at 2:00 pm

kateshirley_23@hotmail.com

Review the effectiveness of crawfords tube insertion as a management option for functional epiphora in an adult population.

A 3-year retrospective review of clinical outcomes in adult patients who underwent crawford tube insertion for functional epiphora in a regional centre.

Patient symptoms improved to some degree in 71% of patients.
64% experienced irritation from tubes in-situ.
Only 15% required subsequent DCR.

If patients are selected using strict criteria and crawfords tubes inserted for functional epiphora only, the clinical outcome is good. The majority of patients experienced improvement in their symptoms.
It is however important to council patients of the chance of irritation from the tubes.
It also avoided DCR procedure in 85% of patients.

January 16, 2015 at 7:44 pm

aoife.j.naughton@gmail.com

To establish the proportion of new patients assessed in the oculoplastic clinic with a primary concern of epiphora.
To identify the proportion of patients requiring surgical management.
To review the current clinical patient pathway from point of referral to discharge.
To determine the overall success rate in patients requiring surgical management.

We included all new patients seen at the oculoplastic/lacrimal clinics over a 6 month period from 1st January to 30th June 2013 inclusive, who were referred with epiphora. A total of 141 patients were identified, of which the health records of 127 patients were available for analysis.

Mean patient age was 60.3 years. The primary clinical diagnosis was lacrimal obstruction (35.5%), lid malposition (35.5%), ocular surface disease (21%), eyelash abnormality (2%) and other (6%). The proposed treatment modality was surgical for 70% and non-surgical for 30%. Of those offered surgery, 76% proceeded. Intervention was categorised as lacrimal 45%, lid surgery 40%, or combined 15%. Success, defined as resolution of symptoms following one surgical intervention with no major complications, was achieved in 92%. The clinical patient pathway was deemed efficient, with a high percentage of patients requiring only one pre-operative clinic visit(81%), one operation(96%) and one post-operative clinic visit(80%) prior to discharge.

53% of new patients seen in the specialist oculoplastic/lacrimal clinic over the 6 month period were assessed for epiphora.
A large proportion of patients had a surgical cause suggesting a satisfactory referral refinement pathway.
Surgery is associated with a high rate of functional success.

January 26, 2015 at 11:38 am

mehbubkadir@gmail.com

To assess the rate , characterstics, associated risk factors and management strategies of different types of eyelid malignancies in Bangladesh

Observational multicentre case series study was done from 2008 to 2013 (six years). We included all clinically evaluated eyelid malignancies. We preferred frozen section biopsy than excision biopsy with 2 mm normal tissue. Experienced pathologist reported all cases. Management strategy was setup on location, types of lesion, orbital involvement, metastasis to lymph node and distant organ. Statistical analysis was used to assess the differential distribution of variables observed in this study.

We evaluated 212 patients those who were presenting eyelid malignancies. Analysis revealed Sebaceous gland carcinoma (SGC) was 86 cases (40.56%), Basal cell carcinoma (BCC) was 83 cases (39.15%), Squamous cell carcinoma (SCC) was 39 cases (18.39%) and Malignant melanoma (MM) was 04 cases (1.88%). Among them, 4 patients presented bilateral eyelid malignancies. Male patients were 116 (54.72%) and female patients were 96 (45.28%). The mean age was 57.39, 61.52, 64.47 and 52.50 in SGC, BCC, SCC and MM respectively. Right eye was involved in 126 cases (59.4%), left eye was 82 cases (38.67%) and 4 cases (1.88%) showed involvement of both eye. Lower eyelid was more involved in BCC (79%) and upper eyelid was more involved in SGC (81%). Orbit was involved in 21 cases (10.1%) and Metastasis was found in 11 cases (5.18%). Associated riskfactors was betel leaf with /without nut chewing (76%), smoking (43%) and prolong sun exposure (31%). Frozen section was done in 104 cases (49.06%). Eyelid reconstruction was done by direct closure in 58 cases (27.35%), Semicircular flap in 37 cases (17.45%), Triangular flap in 25 cases (11.79%), Cutler beared procedure in 30 (14.15%), Hughes procedure in 34 cases (16.03%), Mustard check rotational flap in 05 cases (2.35%), Skin graft in 21 cases (10%) and Z plasty in 03 cases (1.14%). Exenteration were done in 13 cases (6.13%). Recurence were rarely observed in fraozensection biopsy (0.94%).

Sebaceous gland carcinoma of the eyelid is highest in occurrence in Bangladesh. Betel leaf and nut chewing is commonest risk factor. Early management provides minimum invasive procedure, completely cure the lesion, salvage the globe and prevents metastasis. Frozen Section is the preferred method to reduce the recurrence

January 29, 2015 at 7:21 pm

tinakhanam@hotmail.com

To compare the results of probing with and without endoscopy in cases of congenital nasolacrimal duct obstruction without prior probing.

This was a retrospective analysis on 2 non-randomized cohorts, 30 probing in the conventional method (group 1) and 30 with endoscope (group 2), between January 2008 and January 2013. Both groups were similar in age and had no previous surgery. The age of the patients studied ranged between 7 and 28 months in the first group and between 8 and 31 months in the second group.

The procedure was successful in 70% of the conventional probing group and in 96% in the endoscopy-probing group. In group 1, 20% of patients and in group 2, 18% of patients had tight inferior turbinate. Some anomaly was observed in 40% of patients undergoing endoscopy.

In our study, 96% of eyes had complete resolution of symptoms with endoscopy compared to 70% without endoscopy. Therefore, avoiding further surgeries with general anaesthesia or use of other equipment or techniques. Nasal endoscopy has the added advantage of direct intraoperative visualisation, understanding and management of congenital nasolacrimal duct obstruction. It is the only method that confirms the correct anatomic position of the catheterisation instantly, thereby reducing the rate of false passage creation.

February 9, 2015 at 1:58 pm

alishassan@live.com

Trigeminal trophic syndrome (TTS) arises when a central or peripheral nervous system lesion impairs trigeminal nerve function and denervates an area of skin. Different causes of neurological damage can cause TTS including surgical ablation of the trigeminal nerve, vascular disorders including vasculitis, brainstem infarction and acoustic neuroma. An ulcerative skin lesion results if the denervated skin is not allowed to heal, in most described cases this is due to repeated picking of skin.

A single interventional case report displaying history, examination and management.

A 59-year-old male with a background of frontal lobe stroke presented one month post varicella zoster ophthalmicus with a non-healing skin ulceration in the distribution of the right-sided ophthalmic branch of the trigeminal nerve. There was significant cicatricial upper lid ectropion with secondary exposure keratopathy and severe corneal ulceration. The patient underwent upper lid full thickness skin grafting and levator recession, however he continued to pick his skin resulting in failure of the graft. Subsequent contraction of the forehead skin resulted in gross facial distortion.

Trigeminal trophic syndrome (TTS) is a rare skin condition characterised by self-inflicted ulceration affecting a distribution of the trigeminal nerve. We describe a case in which cutaneous varicella zoster infection affecting the ophthalmic division of the trigeminal nerve resulted in severe contraction and scarring, with secondary conjunctival and corneal exposure. This case presented many challenges in management.

February 9, 2015 at 4:53 pm

oraladil_2000@yahoo.com

To assess the results of conjunctival caruncle biopsy

A retrospective review of caruncle lesion cases presented to a tertiary referral centre(Tennets institute of ophthalmology/Gartnave hospital/Glasgow) between 2003 to 2014.The demographic data reviewed together with clinical notes and histology reports.

Total of 77 patients reviewed. The majority of cases were white British ( 73 out of 77 patients)All but one case were unilateral.The mean age at presentation was 55 year(range:12 to 91 year).41 out of 77 patients were female. Right caruncle was involved in 39 cases while left side was involved in 37 cases and one case was bilateral. The clinical diagnosis (which was later on confirmed by biopsy) was correct in nearly half of cases(37 out of 78 cases).The most common lesion on caruncle excision was naevus( 23 cases) followed by papilloma(15 cases),and oncocytoma(13 cases).The remainder were as follows:5 cases sebaceous gland hyperplasia,4 cases carcinoma in situ,3 cases sebaceous adenoma,3 cases of inclusion cyst, and 2 cases each for melanoma,primary acquired melanosis and lymphoma ,one case each for:choristoma/cyst of moll/granuloma/and sebaceous cyst.This makes the total numberof cases with potential malignancy or malignant cases 10 out of 78 cases.The follow up ranged from 1 month to 53 months(mean:6.4 months)

This is one of the largest case series about caruncle lesions.The majority of lesions in caruncle are benign .It is recommended to excise caruncle lesion as some cases can be malignant and although in considerable number of cases the lesion can be diagnosed clinically but this is not possible in all cases and hence the importance of complete excision and histopathological assessment

February 9, 2015 at 10:37 pm

martaperezoftalmo@gmail.com

A novel description of the posterior displacement of the lamina cribrosa (LC) and prelaminar tissue in response to the subaracnoid space (SAS) decompression after optic nerve sheath fenestration in a patient with idiopathic intracranial hypertension (IIH) and progressive visual loss, using spectral-domain optical coherence tomography (SD-OCT).

A 28 year-old woman diagnosed with IIH and treated with lumbo-peritoneal shunt presented with progressive visual loss despite apparently well- controlled intracranial pressure (ICP). A 24-hours register showed spikes of raised ICP. A bilateral optic nerve sheath fenestration was performed using supero-nasal skin crease approach. Serial horizontal B-scan images of the optic nerve head (ONH) were obtained from each eye using enhanced depth imaging SD-OCT.

A posterior displacement of the LC and cup surface was demonstrated after optic nerve sheath fenestration and SAS decompression with improvement of the visual function.

Posterior displacement of the LC after optic nerve sheath decompression may be an indirect sign of ICP lowering. Changes in the position of the LC can be assessed non-invasively using SD-OCT and it may represent a new tool in management of patients with IIH.

February 11, 2015 at 4:39 pm

sabah.stafanous@nhs.net

To present 2 unusual cases referred for ptosis;the ptosis in one was due to previously undiagnosed metastatic breast carcinomas&the other due to secondary amyloid deposits around retinal explant.

Case 1;74ys old woman referred for L progressive ptosis for 2ys, generally healthy & no medications. O/E L marked ptosis, very rigid lid could not be everted, no levator function, elevation limitation, 2 lower lid swelling & no lymphadenopathy. Sclerosing tumour or lymphoma was suspected &subsequent lid biopsies confirmed lobular breast carcinoma, oestrogen receptor +ve. Breast surgeon found L>R breast carcinoma, fixed axillary nodes, back multiple nodules &bone metastasis every where, further biopsies confirmed same lid pathology. She was advised that it is treatable but not curable& put on Letrozole. When reviewed 3/12 later ptosis, movements &swellings were improving on letrozole.
Case 2; 72 yrs old male referred with R ptosis,had a history of retinal detachment surgery 89&bilateral phaco+IOL 2yrs ago.ptosis was sudden after a subconjuncival haemorrhage 6/12 ago. O/E he had moderate R ptosis, normal skin crease&levator function. Lid evertion revealed smooth pinkish swelling around superionasal retinal explant&extending to inferior fornix (?Salmon patch).Lymphoma was suspected but subsequent biopsy proved amyloidosis around exposed retinal explant. After biopsy lesions healed with scarring, ptosis improved &retinal implant covered&no active intervention was required.

pre&post biopsies photos will be shown.

2 unusual cases of ptosis masquerading rare conditions showed the goldstandard teaching of full history&examination&applying logical clinical judgement for the correct diagnosis.

February 12, 2015 at 1:26 pm

rohitsaxena13@yahoo.co.uk

To evaluate the epidemiology of basal cell carcinoma, including location and histological sub-types involving the eyelids of patients attending a tertiary referral centre in Northern Ireland.

This was a retrospective observational cohort study. Clinical and histopathology records of basal cell carcinoma specimens’ received between January’2008 & March’2013 were analysed. The histopathology slides were reported by a pathologist and data was collected regarding the histological type of basal cell carcinoma and the demographic profile of the patients.

During the study period, 431 patients were confirmed with a diagnosis of basal cell carcinoma. There were 218 females and 213 males. The mean age of patients was 70.34 years. Nodular subtype was the most common, being diagnosed in 323 (74.94%) patients, followed by Infiltrative in 93 (21.57%), Multifocal 13 (3.02%) and Ulcerative in 2 (0.46%) patients.

Nodular sub-type was the most common histological type of basal cell carcinoma diagnosed in Northern Ireland. The annual incidence of basal cell carcinoma appeared to be increasing.

February 22, 2015 at 5:55 pm

bmm@doctors.org.uk

Primary lacrimal gland squamous cell carcinoma (PLGSCC) is a rare but potentially life-threatening epithelial tumour accounting for fewer than 2% of primary epithelial malignancies of the lacrimal gland. Shields et al published the last major review in 2004 reporting that 10% of orbital space occupying lesions occurs in the lacrimal gland, while 20% of solid lacrimal gland masses are of epithelial origin, of which 45% are reported as malignant epithelial tumours, with 2% of squamous cell carcinoma origin. Since this, a few sporadic cases have been reported.

We present a case report of PLGSCC in a 76year old Caucasian smoker, who is otherwise fit and healthy with no previous significant medical or ophthalmic history.

This gentleman self-presented to our eye casualty clinic in August 2014, due to dissatisfaction with his GP’ diagnosis and six month management of left eye proptosis secondary to a slowly progressive painless mass in the lacrimal gland region, treated as an infection.

He was managed in the Oculoplastic clinic. Computed tomography demonstrated a laterally placed intraorbital extraconal mass with medial globe displacement. Orbital biopsy histopathological examination supported a poorly differentiated carcinoma with features of squamous cell carcinoma and possible sebaceous cell carcinoma. Staging CT neck, thorax, pelvis and abdomen ruled out primary or metastatic origin.

The patient was managed with left orbit exenteration and histopathological examination confirmed characteristic findings consistent with primary squamous cell carcinoma of the lacrimal gland, confirming the diagnosis.

February 24, 2015 at 12:34 pm

vjuniat@doctors.org.uk

To report a case of successful conservative management for eyelid and conjunctival melanoma when patient declined exenteration.

A 67-year-old lady with a chronic red left eye was diagnosed on biopsy with conjunctival primary acquired melanosis with atypia. Four months later she developed extensive biopsy confirmed lentigo maligna (LM) of the skin of the left eyelid, temple and cheek. The patient declined all treatment options at this stage. A year later she developed a new pigmented conjunctival lesion. Conjunctival and eyelid skin map biopsies found florid LM for skin and conjunctiva with invasive conjunctival melanoma extending to the deep margin. There was no lymphovascular or perineural invasion. There was no evidence of nodal or distant metastasis. The patient was offered exenteration but declined it. Topical treatments with Mitomycin 0.04% drops (2 weeks on/off X 3 cycles) and Imiquimod for the skin lesions were therefore instituted.

Skin biopsies at two-year follow-up were negative for malignancy and there was no evidence of clinical recurrence at three years. Topical Mitomycin therapies resulted in limbal stem cell failure, which will be treated with stem cell transplantation.

Exenteration is a disfiguring procedure with reconstructive challenges, associated with significant functional and psychological morbidity. This case highlights the efficacy of repeat cycles of topical Mitomycin C and Imiquimod for the treatment of conjunctival melanoma and LM in cases where patients decline surgery or are not medically fit for exenteration. Our patient in particular will need long term follow up for close monitoring of recurrence.

February 25, 2015 at 5:52 pm

dm2@sun.ac.za

A case series of inoperable eyelid basal cell carcinomas (BCC) successfully treated with intralesional bleomycin injections (IBI) is presented. Bleomycin is a glycopeptide antitumor antibiotic and antiviral drug produced by the bacterium Streptomyces verticillus and readily commercially available.

Patients were recruited from the Oculoplastics Clinic at Tygerberg Academic Hospital¸ Cape Town¸ South Africa. In all cases conventional surgical therapy was refused or contraindicated. All patients were offered IBI as alternate therapy. The number of injections per individual was determined by the biomicroscopic tumour response. Pre and post treatment photographs were taken and informed consent was obtained. A solution containing 1 international unit bleomycin per ml saline together with 2 percent lignocaine was injected intralesionally via a multipuncture technique. The injected volume was calculated to be equivalent to the estimated volume of the lesion. Retreatment was performed on a 4-8 weekly basis until satisfactory clinical endpoints were achieved.

IBI induced significant regression with marked clinical improvement and reduction in tumor size of all eyelid BCC’s treated obviating the need for further surgical intervention in most cases.

Based on our experience with the drug we propose that intra lesional bleomycin could be considered as an effective treatment modality in eyelid basal cell carcinoma cases where conventional surgical intervention is not possible.

February 26, 2015 at 10:37 am

fayemellington@hotmail.com

To provide baseline data and highlight any major deficiencies in the current level of care provided for patients with TED in the United Kingdom.

Cross-sectional study. During a 3-month period in Summer 2014, consecutive patients with TED who presented to nominated specialist eye clinics for the first time were asked (along with their examining doctor) to complete a standardized questionnaire. Completed forms were collated and data analyzed using summary statistics.

86 patients mean age 48.88 (SD 14.02, range 19-80) years were included. F:M ratio 6:1. Seven hospitals participated. Mean time since first symptoms of TED = 35.71 months. Mean time since first visit to any doctor with symptoms until TED diagnosed = 9.60 months. Mean time from referral to being seen in specialist eye clinic = 2.02 months. 13% (11/86) received radioiodine, 3 had thyroid eye disease at the time. 2 of these 3 patients had active TED and received prophylactic steroids. The third patient had inactive disease. Six patients who received radioiodine and did not have TED at the time went on to develop it. They were all female with a history of poor thyroid control and mean CAS 2.2. 60% patients were current smokers or ex-smokers. Only 64% current smokers had been offered smoking cessation advice. 30% knew that smoking increases the risk of deterioration of TED. Disease classification: 41% mild, 55% moderate-to-severe, and 4% sight-threatening disease. At first visit, mean clinical activity score 2.18.

There is a long time from presentation to diagnosis of TED and from diagnosis to referral to a specialist eye clinic. A large proportion of patients were unaware of their thyroid status. All patients with active TED should and did have steroid prophylaxis during radioiodine therapy. A significant proportion of patients (55%, 6/11) who received radioiodine therapy did not have TED at the time but went on to develop it. Not enough patients are being provided with smoking cessation advice and information on the impact of smoking on thyroid eye disease and control of thyroid function.

February 26, 2015 at 12:31 pm

e.obi@usa.net

Lacrimal surgery aims to provide a low resistance tear drainage passage. An assessment of lacrimal resistance guides decisions on surgery. We present a novel system to measure lacrimal outflow resistance.

Patients in a specialist lacrimal clinic had a full work-up to the point of tear duct syringing (SWO). The tear ducts were then assessed using a manometric system that applies a fixed, known head of fluid pressure via a cannula that seals to the punctum; fluid flow is recorded and the lacrimal resistance derived as fluid pressure/fluid flow (units cmH20secml-¹, for simplicity presented as drops per minute, dpm). Those with reduced flow also had SWO. Patient groups were: A: controls, B: external visible cause for watering (ocular surface/lid/punctum), C: no externally visible cause, D: post op DCR, E: mixed/other.

444 tear ducts were examined. Mean flows (dpm) were: A (n=19) 55; lower limit of normal 29; B (n=184) 46; C (n=145) 22: D (n=38) 52. Excluding complete obstruction (n=29), SWO only detected 48% of those with impaired manometric flow. Of those with a normal SWO test 53% had impaired manometric flow; 34% had a flow of 0 dpm. Manometric testing showed high levels of repeatability (paired t-test p=0.76). Differences in A v C and B v C were statistically significant (p<0.0001).

A new manometric system reliably measures lacrimal resistance and provides a substantial increase in sensitivity over conventional lacrimal syringing.

February 27, 2015 at 8:38 am

karnesh@doctors.org.uk

To help develop limited existing knowledge about a rare lacrimal sac tumour.

A 59 year old gentleman was referred to the Oculoplastic clinic in February 2014 with an 8 month history of a progressive left medial canthal mass extending above the canthal tendon. Orbital biopsy and lesion excision in March 2014 confirmed invasive transitional cell carcinoma. Further extensive excision and bone removal occurred in April 2014 for incomplete margins. The patient subsequently underwent orbital exenteration including medial orbital wall and medial maxillectomy in July 2014 for repeat incomplete margins.

The patient is currently tumour free at the site of primary involvement. CT thorax, and MRI and CT of the head and neck show no distant disease so far.

Transitional cell carcinoma of the lacrimal sac is a rare tumour with a high mortality rate. Preventing delay in histological diagnosis is paramount. Once confirmed, multi-disciplinary team involvement is crucial for planning management.

March 1, 2015 at 10:49 am

kateshirley_23@hotmail.com

To demonstrate a quick and effective technique for lateral tarsal strip. Enabling improved haemostasis and a clear field through the use of high temp cautery for incisions and isolating the tarsal strip.

Video presentation of surgical technique.

This video demonstrates the techniques of using the disposable cautery in an effective way to clear the tarsal plate and secure it to the orbital rim. This technique allows the common procedure of lateral tarsal strip to be carried out in a time efficient manner. The use of disposable cautery is convenient and allows the surgical field to remain relatively clear throughout.

The use of disposable high temp cautery to perform lateral tarsal strip procedures is a quick and effective technique.

March 4, 2015 at 10:21 am

jltovilla@yahoo.com

To describe a series of patients who developed severe orbital emphysema after a vitreo-retinal surgery .

This is a multiinstitutional review of 4 patients, that were referred to our institutions with a clinical and
tomographic findings of orbital emphysema after a vitreo-retinal surgery. All of these cases had a different
clinical course and a different final outcome.

In the 4 cases presented in this paper, visual acuity was severely affected, with restricted ductions. CT
demonstrated the presence of air within the superficial and deep orbital tissues. Treatment options included use
of IV antibiotics, and decongestants with a successful outcome in three patients. One patient, required multiple procedures to decompress the orbit and showed a mild improvement after hyperbaric oxygen therapy without visual acuity recovery.

We believe that the orbital emphysema in our 4 patients after a vitreoretinal procedure associated
to air tamponade, probably happened due to a small intraoperative scleral puncture that lead to leakage
of the intraocular gas into the orbital cavity, as this is not the normal behavior of C3-F8 gas used in the
vitreous cavity. Behavior of gases in the eye, might depend on the concentration, type of gas used and
also with the altitude of the city where patients live.
To the best of our knowledge this is the first case series of patients with orbital emphysema secondary to a
vitreo-retinal procedure.

March 4, 2015 at 11:14 pm

benwhile@doctors.org.uk

To show how chronic orbital abscesses can develop despite the resolution of risk factors.

A 14 year old boy with no significant past medical or ophthalmic history presented with sinusitis, right unilateral proptosis and lid swelling. A CT scan showed ethmoidal sinusitis and non-specific soft tissue changes in the superomedial area of the right orbit but no sub-periosteal or intra-orbital collection. The patient had a sinus washout and antibiotics. Lid swelling and conjunctival injection settled completely, and the patient remained systemically well however, the proptosis persisted. 3 weeks later an MRI scan identified a large new cystic cavity within the right orbit. This was drained surgically and found to contain pus.

Microscopy revealed gram +ve cocci and gram –ve bacilli. No growth on culture. Postoperatively there was resolution of the proptosis and the vision remained good.

Pushkar et. al. has described this rare presentation of chronic orbital abscesses with no disseminated orbital inflammation but had no imaging of the acute phase. The serial imaging in this case means we are now able to fully show the natural history of this condition.

March 5, 2015 at 2:13 pm

smriti_nagpal@hotmail.com

To evaluate and compare the success rate of Transcanalicular laser-assisted DCR (TLA-DCR) with endonasal augmentation, with and without intubation at 5 months, in patients suffering from primary NLD obstruction

A prospective, randomised interventional pilot study was conducted, comprising of 40 adult patients with primary acquired NLD obstruction (PANDO) divided randomly into 2 equal groups (with and without bicanalicular intubation).An osteotomy was first created using 980nm diode laser (set at 8W continuous mode) transcanalicularly and then enlarged intranasally using Blakesley’s nasal forceps, followed by bicanalicular silicon intubation in group B patients. The patients were followed-up for a total period of 5 months. The tubes were removed at the end of 8 weeks and the ostium size was assessed endoscopically after tube removal and again at the end of follow-up.A successful outcome was defined in terms of both subjective and objective parameters i.e. relief of symptoms and ostium patency on syringing and endoscopic assessment. Results were analyzed at the end of a follow up of 5 months, using the Fisher’s Exact test (p<0.05)

The mean age of the patients was 35.3±15.89 years, with 9 male and 31 female patients, the 2 groups having a similar male: female ratio. An overall success rate of 87.5% was achieved at the end of 5months with no statistically significant difference between the two groups. Postoperative complications like tube displacement and punctal injury were more in the intubated group

TCLA-DCR is an effective, scarless, daycare procedure, for treatment of PANDO with no additional advantage offered by silicone intubation

March 8, 2015 at 2:23 pm

m.ting@nhs.net

To review the ocular complications arising from ocular, periocular and facial cosmetic surgical and non-surgical interventions.

A MEDLINE search was conducted to find articles detailing complications from ocular cosmetic devices and procedures (cosmetics, eyelash and eyebrow enhancement, cosmetic contact lenses, ocular whitening, iris implants, refractive surgery), non-surgical periocular and facial interventions (laser resurfacing and chemical peels, filler injections, botulinum neurotoxin injections) and surgical periocular and facial interventions (blepharoplasty, face lift, rhinoplasty, orthognathic surgery).

Ocular complications were divided into 3 main groups: complications arising from cosmeuticals and devices, from intraocular or ocular surface cosmetic interventions (including lid margin and eyelashes) and those arising from peri-ocular and facial surgical and non–surgical interventions.

An awareness of potential complications and the evidence-based management of ocular complications is essential for safe practice.

March 8, 2015 at 11:12 pm

davidcurragh@hotmail.com

To establish efficacy of the procedure and patient satisfaction with their outcome following direct brow lift including complications.

All patients under the care of a single surgeon were identified and invited to participate with a telephone based questionnaire to establish satisfaction and complications.

There were 54 operations performed and a response rate to the questionnaire of 80% was achieved. 70% of patients rated their surgery as a success and were completely satisfied with the outcome. There was an improvement in pre-operatively described symptoms and an improvement in quality of life measures. 26% of patients reported significant scarring and 37% reported significant numbness at a mean follow-up time of 24 months.

Direct brow lif is successful in correcting brow ptosis with a high degree of satisfaction with patients reporting a complete satisfaction rate of 70%. Rates of forehead scarring and numbness are high post-operatively and surgical technique has been modified as a result. The importance of patient selection and counselling regarding these risks has also been highlighted.

March 9, 2015 at 2:52 pm

fizza.mushtaq@gmail.com

To highlight the outcomes of a one stop basal cell carcinoma excision and reconstruction service.

We carried out a retrospective case note analysis over a three year period of patients who underwent excision and reconstructions at the Heart Of England Foundation Trust. Case load and outcomes of surgery were documented.

We analysed a total of 150 excision and reconstructions; of which 139 were basal cell carcinomas. This was 93 % of the total caseload. All samples had frozen section performed on the same day as reconstruction. Of these only 6 did not have 100% clearance on first excision; therefore requiring a second frozen section. Total cost of this procedure is £2500 and the saving made is that of approximately £500 as a second theatre slot on a different day for the same patient is not required. All procedures were performed on the same day, which meant high patient satisfaction, and effective and prompt management of these lesions. There were no post operative complications in any of these patients. Higher rates of graft failure or prolonged healing were noted in patients on anti-coagulants pre operatively.

We have proposed that a one stop basal cell carcinoma excision and reconstruction service can be offered to patients on the NHS. Having a facial tumour can be a distressing experience for patients, therefore achieving full surgical clearance in one session is a desired outcome for both patient and surgeon. We have also shown that the cost effectiveness of this procedure means that an extra theatre slot for the same patient is not required and therefore the service is available for a larger patient cohort. This reduces both waiting list times and increases patient satisfaction.

March 11, 2015 at 8:04 pm

jonathan.norris@ouh.nhs.uk

The NHS is under significant financial strain placing an emphasis on clinicians to increase productivity whilst maintaining quality. We present the use of industrial models to drive efficiency in the oculoplastic minor ops clinic (OcMOPS); a service with historically long waiting times and poor satisfaction.

The principles of Lean Six Sigma (LSS) used at Toyota were employed as a framework including tools such as value stream mapping to identify and reduce waste. Retrospective data (Jan–Jun 2011) was collected from patient records to process map the service. The Takt time was calculated illustrating demand and capacity. Post-improvement data (Aug–Dec 2014) was compared assessing: cycle time (CT), referral to treatment time (RTT) and profitability. A satisfaction survey was carried out post-treatment using a Likert scale.

Prior to streamlining, a mean of 6.1 patients were treated per 4 hour session. The mean RTT was 246.3 days with a mean treatment CT of 55 minutes per patient. Examples of service reform implemented include:(1)combining the 1st review and treatment date, (2)standardisation of case-mix, (3)use of disposable instruments, (4)‘fast-track’ photography and (5)developing a tele-results system. Post-change in practice 11.9 patients were seen per clinic (97% increase). RTT fell by 24% to 186.3 days and CT improved by 62% to 21 minutes. The survey found that all patients were very satisfied with the new service. The change in practice generated an additional £50,000 / annum.

Industrial models can be successfully applied to the healthcare sector. In OcMOPS we have used the principles of LSS to eliminate waste, improve profitability and patient experience.

March 12, 2015 at 10:09 am

brentskippen@gmail.com

To report the ten year treatment outcomes of a small cohort of patients with ocular adnexal lymphoma (OAL) primarily treated with chemotherapy in a single British centre. To then compare these results with the long term treatment outcomes of other OAL treatment modalities in the literature.

A retrospective cohort study of 12 OAL patients treated primarily with chemotherapy in a single hospital is presented. The average follow up duration was 10 years from the initial treatment. The mean age at diagnosis was 57 years and 75% of the patients were female. 66% of patients had unilateral disease. The majority (66%) of cases were mucosa-associated lymphoid tissue (MALT) lymphoma and 33% had systemic involvement at the onset of disease treatment. Initial treatment consisted of chemotherapy in 75%, radiotherapy in 17% and observation in 1 patient. Initial chemotherapy regimens most commonly contained chlorambucil.

92% (11/12) of patients were still alive 10 years after initial treatment. 1 patient died, 9 years after initial treatment for MALT lymphoma, of a more aggressive form of systemic B cell lymphoma. 58% (7/12) of patients had recurrent disease, mostly local recurrence, which presented on average 6 years following initial treatment. Recurrent disease was treated mostly with systemic chemotherapy (6/7 patients) and with local radiotherapy in 1 patient. Rituximab was the most common chemotherapy agent used for treatment of recurrent disease.

Most OAL is unilateral, low grade MALT lymphoma and has a good prognosis. No specific guidelines currently exist for the management of OAL but there are many treatment options with long term results in the literature. These treatment options include several regimes for chemotherapy, radiotherapy, intralesional interferon, doxycycline and simple observation. The ideal treatment should be more efficacious than observation, have minimal side effects and be cost effective. This ideal treatment is yet to be determined.

March 13, 2015 at 8:20 am

davidcurragh@hotmail.com

To present a case series of patients presenting with neglected basal cell carcinomas highlighting their destructive nature and complex management

5 patients presented to the oculoplastic clinic with neglected periocular skin lesions present for more than one year. They were all biopsied and management options discussed

All 5 cases were proven to be basal cell carcinomas. Two cases were extensive medial canthal lesions which were excised and required extensive reconstruction. Two cases were lateral canthal lesions which invaded the lateral orbital wall and caused extensive destruction to both the upper and lower lids. One of these cases led to a exposure related corneal perforation and eventual palliative eviscertion. Both cases were not curable by surgical resection and were referred for palliative radiotherapy. Only one was suitable and the other was managed conservatively. The final case was an extensive tumour which had eroded the entire lower lid and underwent exenteration

The case series highlights the management options available in cases of extensive periocular basal cell carcinoma. The delayed presentations led to more extensive reconstructive surgery than would have likely been required if the patients had presented at an earlier stage. In some cases the lesions were inoperable. Neglected cases still occur and patients’ fears of hospitals or healthcare professionals are often a factor in patients not seeking medical attention and can be difficult to address. Education of patients and healthcare professionals is important regarding early identification and urgent referral for investigation of new periocular skin lesions

March 13, 2015 at 9:13 pm

c.murphy3@nhs.net

To describe a case of bilateral microphthalmia associated with neonatal hepatitis caused by mutations in the VSX2 gene. A literature review of previous reported cases of microphthalmia due to VSX2 mutations will highlight the systemic phenotypic variability of this genetic abnormality which has implications for genetic counselling.

Case report with details of genetic analysis and phenotype.

Our case was noted at birth to have severe microphthalmia with axial lengths of 7.1mm and 8.0mm; the baby was born to consanguineous parents of Pakistani origin. In addition to the micropthalmia the child has unexplained neonatal hepatitis- despite extensive investigations including liver biopsy. Genetic testing revealed a homozygous missense mutation (c679C>T) of VSX2 gene (visual system homeobox 2). The same genotype has been previously described in a distant family member also born to consanguineous parents; in this case the microphthalmia, was associated with profound hearing impairment, low muscle tone and severe learning difficulties. The only other reported case of this genotype is in 2 sisters of Iranian origin with microphthalmia and no extraocular features. This case highlights the systemic phenotypic variability in cases with recognized genetic mutations – this has important implications for genetic counselling.

This is the second reported case of VSX2 mutation causing bilateral severe microphthalmia and the first reported case with this constellation of systemic features.

March 17, 2015 at 5:15 pm

sabah.stafanous@nhs.net

I have done lateral canthal sling to correct horizontal lid laxity for ectropion for 10 years. I have now converted to this new method since 2010. It involve a lateral pentagon +/- medial diamond of tarso conjunctiva or 3snip & retropunctal cautery it has excellent long lasting results & I would like to share it with colleagues

I would show pre & post op. photos & if time allows a short video or steps of surgery

This method has excellent audited results with no scarring, infection, notching or trichasis. so far there have been no recurrence. patient with physiological pump failure also have symptoms resolved or improved. Compared to tmy old method of canthal sling there is minimal or no complications, cheaper in cost, less theatre time, anticoagulants do not need to be stopped and no recurrence in 5 yrs

This is an excellent method for a very common condition in our speciality, it is easy to perform with high patient satisfaction. once adopted I never looked back & would like my colleagues to try it

March 18, 2015 at 12:35 pm

andre@doctors.org.uk

People who wear an ocular prosthesis often suffer with dry eye symptoms. Up to 90% will also complain of socket discharge, many of whom on a daily basis. By improving the surface finish of the prosthesis from a standard polish to a smoother, optical quality (contact lens) polish, we hope to improve wear tolerance.

Single blind prospective randomised controlled trial. The prosthesis of participants was randomised to receive either a standard, or a smoother, optical quality polish when they attended. A questionnaire covering cleaning, lubricant use, inflammation, comfort and discharge was completed by the patient at entry to the trial, at 1 month and at 12 months. Lower scores related to a better-tolerated prosthesis. At each visit, the prosthesis was stained and photographed against a standardised background to assess deposit build up. Photographs were anonymised and used to explore the association of deposit build up to socket discharge and dry eye symptoms.

41 patients took part in the study. The median age of the prosthesis was 3 years (range 0-16 years). There was no statistically significant difference in questionnaire score between the two groups at baseline (9.05 v 9.80) or at 1 month (10.30 v 10.65). Although 12-month follow-up is not yet complete, patients treated with the new optical quality polish, appear to have benefited (2.52 v 3.74). Subjective scoring of benefit by participants seems to concur with this finding (average 2.19 v 1.50 – higher scores better).

Optical quality finish to an ocular prosthesis appears to be a relatively simple and readily available means of improving patient tolerance and reducing deposit build up.

March 18, 2015 at 1:42 pm

alasdairkennedy@nhs.net

The inward turning of the eyelid margin so that the meibomian gland orifices and lashes are directed towards the globe is called an entropion. The most common type of entropion is involutional, a combination of lid laxity, lower lid retractor weakness and orbicularis oculi override. Unfortunately, the condition can be intermittent and can go unnoticed leading to ocular surface damage. In suspected cases, clinicians can use clinical techniques to elicit the condition for example the forced closure of the eyelids, the Tetracaine Provocation Test (TPT) and the Test of Induced Entropion (TIE). We present an alternative diagnostic test: The Test of Induced Entropion Two (TIE(2)).

We selected three patients with intermittent entropion from our oculoplastic clinic in whom forced closure of the eyelids and the TPT did not induce entropion. We performed and video recorded the conventional tests for entropion and the TIE2 test on these patients.
The TIE(2) test is performed by asking the patient to look down and by holding their upper lid high. The patient is then asked to close their eyelids as tightly as possible. An entropion will then be induced.

In all three cases, conventional methods did not provoke an entropion. Following the TIE(2), in all three cases, an entropion was induced.

When there is suspicion of intermittent entropion but conventional provocation tests do not provoke one, the TIE(2) is a simple and useful diagnostic tool.

March 19, 2015 at 12:50 pm

srigore@gmail.com

The purpose of this study is to review our experience of secondary intention healing of periocular defects resulting from tumour excision, to review the current literature and provide recommendations for best use of secondary intention healing in the periocular region.

A retrospective study of periocular defects which were left to heal by secondary intention, following Mohs micrographic surgery (MMS) for tumour excision, in a 3 year period. The patients were identified from the MMS database. Review of case notes and pre and post-operative photographs were utilized to assess the functional and cosmetic results. Patient experience and satisfaction were assessed with a questionnaire.

26 patients (mean age 67 years; 17 females and 9 males) were included. The lower lid was the commonest location (69%) followed by the medial canthus (19%) and the upper lid (11%). 38% of defects were full thickness involving the lid margin. The mean follow-up period was 14.5 months (+/-9 months, range 6 weeks to 30 months).

2 patients developed lower lid ectropion. 1 patient required electrolysis for lanugo hairs and another developed mild canthal dystopia. 2 patients experienced mild ocular irritation during the healing phase. 4 out of 20 patients who replied to questionnaires felt self-conscious about the healing eyelid wound. All but 1 patient were satisfied with the cosmetic result of the healed eyelid.

‘Laissez faire’ is a very effective alternative to reconstruction for periocular defects resulting from MMS. It is particularly helpful in anxious or debilitated patients who are unsuitable for surgery, or prefer to avoid further surgery.

March 21, 2015 at 1:49 pm

Drumair216@yahoo.com

No significant allergic reaction with silicone implant has been reported before. Gentamycin is used to soak the implant for few minutes to reduce the chances of infection. Although gentamycin has been associated with contact dermatitis but very rarely has caused severe anaphylactic reaction.

We present here a case of 65 years old Caucasian lady, who we operated for right eye Evisceration due to painful blind eye, with silicone implant placement under general anaesthesia with no known drug or food allergy. Patient was stable on Propofol and Remifentanil infusion for 55 minutes, eye contents eviscerated, silicone ball (implant) soaked in Gentamycin for 3-4 minutes was implanted, suddenly started dropping her blood pressure to un-recordable. Intubated and crash teams were called. Patient had neither rash, oedema nor murmur. She had a mild global wheeze. Initially, a high suspension was pulmonary embolism thus echo heart was done immediately, which confirmed no right heart changes which are classical of pulmonary embolism. Another possibility could have been an anaphylactic shock, as patient went into shock almost 3-4 minutes after implanting silicone ball inside scleral flaps.

Consequently, silicone ball was removed and sclera was sutured. Hydrocortisone was given and normal sinus rhythm was achieved. Patient was then discharged after 20 hours.

The main reason of discussing this patient is to make our readers aware about a possible reaction and to be extra cautious about such reactions. Other alternatives to both silicone and Gentamycin should be preferred in order to prevent such incidents in future.

March 21, 2015 at 10:56 pm

senthil714@yahoo.com

To study the efficacy of ETO sterilized X-ray film Vs various autologous grafts which were
placed as an overlay over titanium mesh implant in preventing the incidence of adherence
syndromes following blowout fracture repairs using titanium mesh implants

10 patients who had large blowout fractures of the floor of the orbit which
required placement of titanium mesh implants with screw fixation were chosen for the study. ETO
sterilized X-ray film was placed over the titanium mesh to prevent direct tissue contact of the
titanium mesh with the orbital tissues in 5 patients,rib graft was placed as an overlay in 3
patients,iliac crest bone and auricular cartilage graft was placed in 2 patients.

ETO sterilized X-ray film was found to be well tolerated,inert ,easy to use and highly cost/
time effective and successful in preventing adherence syndromes associated with the use of
titanium implants in blowout fracture repairs of the orbit. One patient had implant displacement
with the use of rib cartilage which required surgical removal and another developed orbital cellulitis
which required Fess drainage.

ETO sterilized X-ray film can be placed over the titanium implant which prevents the
occurrence of Adherence syndromes following the use of titanium mesh in treating blowout
fractures of the orbit. X-ray film is inert,easily available,cheap and bio compatible and can be used as
an overlay implant.Other autologous grafts offer no significant advantages and are associated with
significant donor site morbidity and implant related complications.

March 22, 2015 at 11:18 am

drsarmi@yahoo.com

We conducted a patient satisfaction survey following LTS surgery performed by a non-consultant for lower lid malposition. The aim was to get an understanding of the patient experience to enable us to improve preoperative counselling.

A telephone questionnaire was presented to patients who underwent LTS surgery performed by a single surgeon between January 2010 and July 2012. The interview was conducted by the Oculoplastic Clinical Nurse Specialist, who asked about preoperative symptoms, postoperative improvement, cosmetic appearance and satisfaction with surgery.

36 patients were included (15 entropion and 21 ectropion), with a median follow-up of 6 months. Twelve entropion patients presented with soreness or grittiness, 3 presented with epiphora or discharge. Seventeen ectropion patients presented with epiphora, while four presented with sore or gritty eyes. Fourteen of 15 (93%) entropion patients and 20 of 21 (95%) ectropion patients reported postoperative improvement in symptoms. One patient in each group reported no change. 81% patients reported an improvement in their cosmetic appearance. 92% patients were satisfied or very satisfied with the surgery. Five patients made positive comments including requests to convey their gratitude to the surgeon. Three patients (8%) were neither satisfied nor dissatisfied with the procedure. In this group, one reported that local anaesthesia was “not pleasant”, one needed subsequent ptosis surgery and one was unable to specify.

LTS surgery resulted in excellent patient satisfaction scores, with an improvement of symptoms in over 90% of patients. Over 80% reported an improvement in cosmetic appearance. This data helps while counselling patients before LTS surgery.

March 22, 2015 at 12:19 pm

gruchi1@rediffmail.com

To evaluate the efficacy and complications of the new `Mirror tuck technique` for fixation of lacrimal bypass tube in proximal canalicular blocks in laser CDCR.

A prospective interventional study was conducted in 40 consecutive eyes of adult patients, undergoing 980 nm diode laser CDCR for proximal canalicular blocks. After creating the tract under endoscopic guidance, the tube collar was fixed to the conjunctiva with 6-0 prolene suture by `Mirror tuck technique`. First an encircling suture was tied around the neck of the tube, then a cross mesh was created on the surface of the collar; interlocking suturing was performed all around the collar by taking bites from conjunctiva adjacent to the tube and passing it from the centre of the mesh. Success was defined as absence of extrusion or tube migration at one year of follow up.

Success was achieved in 39(97.5%) cases. One patients suffering from allergic conjunctivitis, had medial migration of tube while rubbing vigorously. Heaviness was reported by 5(12.5%) patients till about 2 weeks. Conjunctival overgrowth over the tube occurred in 1(2.5%) case at 5 months which was excised and treated with application of 0.02% Mitomycin C. There were no cases of suture abcess or suture intolerance warranting tube removal.

`Mirror tuck technique` is an effective method for tube fixation( for tube without holes) in conjunctivodacryocystorhinostomy(CDCR). However it is important to position the conjunctival opening so as to leave sufficient space for passage of sutures for anchorage medially.

March 22, 2015 at 5:50 pm

simranmangat5@gmail.com

To calculate the presence of persisting tumour in second specimens following incomplete primary excision. By definition an incomplete primary excision should lend to tumour being present in a further specimen if sent. In practice this is not always the case and this study aims to establish the risk of having tumour present in second specimens if they are sent.

A 9 year retrospective study was conducted of all two stage slow Mohs’ procedures for periocular skin cancer conducted at Wolverhampton Eye Infirmary from 2006- 2014. Data collected included age, sex, site of tumour, type of tumour, onset be it de-novo or recurrence, size of margin taken, orientation of involved margin(s), any margin less than 1mm, location of second specimen if taken, presence of tumour in the second specimen, reconstruction details, recurrence of tumour, length of follow up and any post-operative complications.

66 patients were included, 24 males and 42 females. Mean age was 74. 54 cases were BCCs. 48 cases were de-novo and 18 were recurrences. 35% (n=23) of patents had an involved margin after the first stage. Further excision was undertaken in all patients with involved margins. In these second specimens, tumour was only present in 22% (n=5) and absent in 78% (n=18). There were no recurrences during the study period. Mean follow up was 14.9 months.

In our experience, in two stage procedures, the majority of second specimens taken due to an involved margin do not contain any residual tumour tissue. Our results would support a conservative degree of further excision by oculoplastic surgeons when a second specimen is required in two stage procedures.

March 24, 2015 at 9:34 pm

sun.t.michelle@gmail.com

To investigate the viscoelastic behavior of normal tarsus tissue.

Ten samples of tarsus tissue were obtained from ten patients with normal eyelid laxity undergoing various ophthalmic procedures at the Royal Adelaide Hospital. Samples were tested fresh within 2 hours of excision using a CellScale BioTester 5000 (CellScale, Waterloo, Canada). A preload of approximately 50 mN was applied for 10 minutes before the sample was subjected to uniaxial tension under linear ramp displacement control. Maximum strain was 30%, as this allowed the sample to reach the linear portion of the stress-strain response without slipping out of the clamps. Thirty dynamic cycles were performed at a strain rate of 1%/s. LabJoy 2.0 software (CellScale, Waterloo, Canada) was used to control the test parameters and collect the data at a sampling rate of 10 Hz. Images were captured at a rate of 1 Hz using the BioTester’s overhead CCD camera. The raw data were processed with MATLAB R2010b (MathWorks, Natick, USA) using a custom-written program.

The average width of samples tested was 5.51mm (SD 1.45mm) whilst average thickness was 1.6mm (SD 0.51mm). The elastic moduli ranged from 1.02-2.93 MPa with a mean of 2.00 +/- 0.71MPa. The mean extensibility was found to be 16.73% and mean phase angle 6.44%.

We found the elastic moduli of human eyelid tarsus ranged from 1.02-2.93 MPa. Our results establish a benchmark for native tarsus tissue, which can be used when evaluating tissue engineered tarsal substitutes in the future.

March 24, 2015 at 9:52 pm

sun.t.michelle@gmail.com

Orbital schwannomas are rare and despite a variety of external surgical approaches previously utilized, removal of tumours located in the deep orbital apex remains challenging. The endoscopic endonasal approach has been used increasingly for various apical tumours, but few describe this technique for orbital schwannomas. We therefore aimed to investigate the feasibility of this technique for orbital schwannomas.

We present two cases of orbital schwannoma removed using an endonasal endoscopic approach, one of which was completely removed endoscopically with the addition of medial rectus detachment to facilitate access to the medial intraconal apex.

The first patient was a 31 year-old Cantonese female who was found to have an 11x8mm right orbital apical schwannoma which was removed using a endoscopic endonasal sphenoethmoidal approach. The second patient was a 78 year-old Caucasian male who had a 28x17x18mm orbital schwannoma removed via a transcaruncular and endoscopic endonasal assisted approach. At 6 and 12 month follow-up respectively, there were no signs of recurrence or residual disease.

Our findings suggest that the use of an endonasal approach may facilitate the safe removal of selected medially located orbital schwannomas whose posterior margins involve the orbital apex.

March 24, 2015 at 10:01 pm

c.murphy3@nhs.net

Regarding enucleation, evisceration and exenteration
1. To describe the current incidence in the UK.
2. To identify changing trends nationally over the last 25 years.

The numbers of enucleation, evisceration and exenteration performed annually were obtained from all four home nations from 1989- 2013. Data were obtained from the following sources: Hospital episode statistics (England), Information services division (Scotland), Social Services and Public Safety (Northern Ireland), Patient episode database (Wales).

In 2013 the incidence of the following procedures in the United Kingdom were: enucleation 0.63/ 100,000, evisceration 0.68/100,000 and exenteration 0.13/100,000. This compares with 1.77/100,000 (enucleation), 0.42/100,000 (evisceration) and 0.12/100,000 in 1989 (exenteration). Overall from 1989 to 2013 the combined rate of all eye removal has fallen from 2.30 to 1.44/ 100,000. Despite an approximate overall 37% decrease in eye removal, rates of evisceration have increased by over 60% whilst enucleations have decreased by 66%. Rates of exenteration have stayed low.

Over the last 25 years there has been a significant decline in the number of eyes requiring surgical removal within the UK. Current rates of enucleation, evisceration and exenteration remain low and surgical practice has shifted from enucleation to evisceration. This study illustrates the impact of advances in medical and surgical treatment of advanced and end stage eye disease.

March 24, 2015 at 10:53 pm

lienhuynh@doctors.org.uk

We present a case of a one day old neonate with bilateral dacryocystoceles. Bilateral dacryocystoceles is a rare anomaly and can lead to respiratory distress and problems with feeding requiring urgent ENT involvement.

Illustrative case report and literature review.

Serial photographs demonstrate resolution of the dacryocystoceles following conservative management.

Bilateral dacryocystoceles may cause obstruction of the nasal airway and be life threatening. Urgent ENT referral is needed as surgical intervention may be required.

March 25, 2015 at 6:47 pm

james.wawrzynski@cantab.net

There are currently no routinely used imaging modalities for the proximal lacrimal system. Optical Coherence Tomography (OCT) is a safe and non-invasive method of high resolution cross-sectional imaging of tissue microstructures using infra-red radiation. In this study we investigate whether OCT may be used to image the punctum and proximal canaliculus.

A cohort of healthy asymptomatic subjects with normal ocular anatomy were invited to enrol. Spectral OCT images of the lower punctae were captured with a Topcon 3D Optical Coherence Tomography 2000 machine and the higher resolution Heidelberg Spectralis OCT machine. Measurements were made of the maximal punctal diameter, canalicular diameter and canalicular depth. Our data for depth of the vertical canaliculus was compared to the widely quoted figure of 2mm using a two-tailed t test to check for a statistically significant difference at p<0.05.

Thirty-six punctae of eighteen subjects were scanned using the Topcon machine. The punctum was recognisable on the OCT image in all cases. The mean depth, width and cross sectional area of the visualised canaliculi were 0.753mm (sd 0.216), 0.110mm (sd 0.067) and 9.49 x 10-3 mm2 respectively. The mean width of the punctum was 0.247mm (sd 0.078). Data from the Heidelberg machine are being analysed at the time of submission.

We have demonstrated the first in-vivo high resolution images of normal punctal and vertical canalicular anatomy using spectral OCT. There is currently no other practical way to accurately image punctal and proximal canalicular morphology in vivo. OCT is a convenient and readily available tool in most eye clinics with resolution ideally suited for imaging of the punctum and proximal canaliculus.

March 26, 2015 at 11:18 pm

vijaybwagh@gmail.com

To review the safety and efficacy of upper eyelid postseptal gold weight implant for lagophthalmos.

Retrospective case notes review of patients undergoing upper eyelid gold weight implantation.

Between 2009 and 2014, 33 patients (20 male; 60.6%) were identified as having undergone upper eyelid postseptal gold weight implantation (median age 65 years, range 18-92 years). All patients had lagophthalmos secondary to facial nerve dysfunction (House-Brackmann scale 4-6), primarily due to head and neck surgery (51%), infection (18%) or Bell’s palsy (15%). The mean weight of the gold implant was 1.4gms (range 1-2gms). Additional per-operative surgery included medial canthoplasty (18%), lateral tarsal strip (45%) and brow lift (9%). The mean follow-up period was 21months (range 6-48 months). There were no per-operative complications and none of the patients had postoperative infection or implant extrusion. 100% patients had an improvement in lagophthalmos, resulting in reduced keratopathy and reduced ocular discomfort. Mean lagophthalmos on gentle closure was reduced from 5.8mm to 1.6 mm and mean lagophthalmos on blink was reduced from 8mm to 2.8mm. Gold weight implants were removed in 3 patients (9%); due to possible gold allergy in two patients and discomfort in one patient. 4 (12%) patients had further surgeries including brow lift (3) and ptosis correction (1).

Upper eyelid gold weight implantation was effective in reducing lagophthalmos and exposure keratopathy in our series. Implant related complications are uncommon with our technique of postseptal gold weight implantation and patients are very satisfied with the surgical outcome.

March 27, 2015 at 11:30 am

amer.durrani@addenbrookes.nhs.uk

Aberrant Hh signalling is the key driver in BCC pathogenesis. Vismodegib is a first-in-class Hh pathway inhibitor licensed in the UK for the treatment of aBCC that is inappropriate for surgery or radiotherapy. STEVIE is an ongoing study of vismodegib in adults with aBCC. We present details from selected UK patient cases and key global interim data from STEVIE (data cutoff: 6 November 2013).

Adults with locally advanced (la) or metastatic (m) BCC received vismodegib 150 mg once daily until progressive disease, unacceptable toxicity, or withdrawal. The primary objective is safety; efficacy is a secondary endpoint.

STEVIE recruitment is complete (n=1,227, of which n=41 are from UK centres); patient treatment and follow-up are ongoing. This interim analysis included 501 patients (laBCC = 470; mBCC = 31) with potential ≥12 months’ follow-up. The most common treatment-emergent adverse events (TEAEs) were muscle spasms (63%), alopecia (61%), dysgeusia (54%), decreased weight (32%), asthenia (28%), decreased appetite (25%), ageusia (22%), diarrhoea (17%), fatigue (16%), and nausea (16%). Overall response rate in patients with measurable disease (Response Evaluation Criteria In Solid Tumors, version 1.1) was 67% (laBCC; n=302/453) and 38% (mBCC; n=11/29); median durations of response were 23 and 10 months, respectively.

This interim analysis of STEVIE, the largest study conducted in adults with aBCC, confirms the previously observed safety profile and efficacy of vismodegib. Data from UK patients further support vismodegib treatment for aBCC.

March 27, 2015 at 1:34 pm

princetonlee@hotmail.com

A standard surgical technique with combined trans-cranial and fronto-zygomatic orbitotomy approach to resect optic nerve glioma has been described. We are presenting a case with trans-cranial and orbital roof approach without orbitotomy to resect the intra-orbital and intra-cranial part of the optic nerve glioma.

A 13 year old female patient presented with a unilateral proptosis and deterioration of vision. CT and MRI demonstrated a 2 x 1.5 x 1.6 cm optic nerve mass with intracranial extension. She underwent optic nerve biopsy though medial lid crease approach which confirmed the mass to be pilocytic astrocytoma.

A coronal incision and craniotomy approach was made to excise the pre-chiasmatic portion of the optic nerve. Frozen section was done to ensure a tumour free margin. The orbital roof was removed to gain access to the optic nerve glioma. Particular attention was made to preserve the annulus of Zinn while resecting the optic nerve glioma up to the posterior globe. The intra-canalicular portion of the optic nerve was then removed while preserving the ophthalmic artery.

The orbital roof was reconstructed with titanium plate. The craniotomy was repositioned with screws and scalp closed in a standard fashion.

Histology confirmed clear margin resection of the optic nerve glioma. This patient demonstrated good recovery with minimal residual ptosis. The range of extra-ocular movement is full. The fundoscopy showed compromised retinal blood circulation.

We demonstrated an alternative approach to resect the optic nerve glioma without a froto-zygomatic orbitotomy while preserving the globe and orbital structures.

March 27, 2015 at 4:32 pm

adeelam@gmail.com

To investigate the influence of lower lid tightening in lacrimal pump failure-related functional nasolacrimal duct obstruction (FNLDO) epiphora patients, using Munk score subjective epiphora scoring and dacryoscintigraphy objective scoring, as respective outcome parameters.

Prospective evaluation of 20 eyes presenting with functional epiphora and lower lid laxity. Only the patients with anatomical patency on lacrimal syringing were retained for the study, and each asked to complete the epiphora Munk score questionnaire as a subjective parameter. At the same time dacryoscintigraphy imaging analysis was undertaken as an objective physiological baseline parameter. Patients with normal anatomical patency were referred for lateral tarsal strip surgery. Three months post-operation, these patients were again asked to complete the Munk score questionnaire, and were also subjected to a repeat objective dacryoscinitigraphy imaging.
Objective dacryoscintigraphy radiology reports, and patient subjective epiphora Munk scores both before and after the lower lid surgical tightening, were compared.

A significant improvement occurred in the subjective (Munk) score of the patients after lower lid surgery, while the physiological objective parameter remained unaltered.

Surgical correction of lower lid laxity improved patients’ subjective epiphora Munk scores, whilst objective physiological dacryoscinitigraphy was unaffected. This suggests that addressing lid laxity in patients with lacrimal pump failure-related FNLDO can be of benefit in reducing patients’ symptoms.

March 27, 2015 at 8:16 pm

limrongxuan@gmail.com

The regression of non-melanoma skin cancers has been recorded following incisional biopsy. The exact mechanism is unknown but wound healing is thought to play a role. Anecdotally, shrinkage of peri-ocular BCCs after incisional biopsy has been noted, but there are no reported studies. The aim of this study was to quantify change in size of peri-ocular tumours post punch biopsy.

Patients with suspected BCCs were prospectively recruited between December 2013 and December 2014. All lesions were photographed before the punch biopsy and then again 3-8 weeks later. In each case, a 2-3mm2 punch biopsy was performed in the centre of the tumour so as not to blur the tumour margins. The lesion size was calculated based on the photographs (KLONK image measurement 2013). A 2-tailed paired Student t-test was used for statistical analysis.

19 patients with a BCC were included, with the mean age at biopsy of 74 years. The mean time between biopsy and follow-up was 37 days.

A malignant tumour may be expected to increase in size between visits, however in this study only 7 tumours increased in surface area, by an average of 7mm2 (22 mm2 to 29 mm2). 2 tumours remained unchanged and 10 decreased by an average of 17mm2 (45 mm2 to 28 mm2).

The mean surface area of the lesion prior to biopsy was 33mm2 (standard deviation=31mm2) and at the post-biopsy visit 27mm2 (SD=19mm2). This difference was not statistically significant (p=0.17).

We found a reduction in the average surface area of peri-ocular BCCs post- biopsy, although this did not reach statistical significance. 10 of 17 tumours exhibited a reduction in tumour surface area post-biopsy.

March 27, 2015 at 10:47 pm

sonali.nagendran@gmail.com

Operating theatre utilization has become the principal measure of NHS operating theatre service performance. We analysed operating theatre utilization data from a tertiary centre to identify factors influencing theatre efficiency.

This audit used prospective data on oculoplastic surgery performed in a tertiary centre over 3 time periods in 2011, 2014 and 2015. The primary outcome measure was the operating list utilization rate, calculated as the combined value of time spent on anaesthesia and surgery (induction to surgical closure) as a percentage of the total planned session time.

An initial audit in 2011 recorded the operating list utilization rate as 81.2%. However a reaudit in 2014 recorded a drop to 64.5%, prompting an evaluation of the pathway from scheduling to surgery. Factors contributing to poor theatre utilization included inappropriate scheduling times for cases, last minute operating list changes and cancellations and delays at the list start and between cases. Changes implemented included standardised scheduling, finalising the list 48 hours in advance, reducing staggered patient arrival and enabling same day preassessment for patients to fill cancelled slots.
A reaudit in 2015 analysing the effect of these changes demonstrated that theatre utilization had increased to 78%. The theatre utilization rate was higher for all day lists (82%) compared to half day lists (76%), suggesting that these lists were more efficient.

Identifying and altering factors that influence efficiency can make a significant difference to theatre utilization, improving service delivery and maximising the use of a valuable resource.

March 28, 2015 at 10:05 am

conmalone@gmail.com

We present a case series describing the varied applications of botulinum toxin injection in extraocular muscle restriction and overaction.

We prospectively identified 10 consecutive patients with inferior rectus or medial rectus restriction or overaction: 1 inferior rectus restriction secondary to retinal detachment repair; 1 residual inferior rectus overaction secondary to 4th nerve palsy correction; 1 residual inferior rectus restriction after thyroid eye disease surgery; 1 idiopathic inferior rectus overaction; 2 inferior rectus restrictions secondary to Graves orbitopathy; 1 medial rectus overaction after 6th nerve palsy; 2 residual medial rectus overactions after strabismus surgery; 1 idiopathic medial rectus restriction.

Follow-up ranged from 1 month to 6 months. Success was measured objectively by orthoptic assessment and subjectively by patient satisfaction with appearance and decrease in diplopia. Signs and symptoms improved in 9 out of 10 patients after 1 injection. 1 patient had no improvement after 2 injections and underwent further surgical treatment. There were no complications.

Botulinum toxin injection is a safe, inexpensive, versatile and effective treatment for a variety of extraocular muscle conditions.

March 28, 2015 at 5:42 pm

gjvasuki@yahoo.com

To study the clinical features, management and visual outcome in self- mutilating eye injuries.

Case series of three patients presenting with self-inflicted eye injuries .Two of three patients had bilateral eye involvement.

Case 1 : 57 year old prisoner with delusional disorder, presented with endophthalmitis due to self inflicted injury. He had recurrent episodes of inserting sewing needles in his left orbit. Recently he inserted a needle in his right (only eye) and left orbit. As the needle in the right eye was beneath the lateral rectus and not causing damage to the optic nerve or any structures in the orbital fissure, no removal was undertaken. This decision was undertaken together with the psychiatrist, who was of the opinion that he was looking for any support to his belief that he had cancer and was likely to self harm again if we removed the needles.

Case 2: 24 year old male psychotic prisoner presented to ophthalmology with attempted bilateral auto-enucleation. He had bilateral globe rupture with extrusion of intraocular contents and underwent emergency surgery. Vision was no perception of light in both eyes and eventually had bilateral phthisis bulbi.

Case 3: 35 year old schizophrenic, in a psychiatric hospital attempted auto enucleation in his left eye with a pen which led to fulminant orbital cellulitis and foreign body close to the orbital fissure. He made excellent progress with treatment with surgical removal and debridement.

Self mutilating eye injuries occurred in male patients with psychosis and delusional disorders. All our patients had very severe injury. In a majority it led to loss of vision or eye. Management of these patients can be complex requiring appropriate input from psychiatric team and long term rehabilitation.

March 28, 2015 at 5:48 pm

gruchi1@rediffmail.com

To study the Outcome of bilateral transcanalicular laser assisted dacryocystorhinostomy (TLADCR) in a single sitting in patients suffering from bilateral nasolacrimal duct obstruction (NLDO).

A non- randomized interventional study was performed in 20 consecutive adult patients suffering from bilateral nasolacrimal duct obstruction (NLDO) who reported to the oculoplasty clinic from March 2011 to April 2013. There were 16, 8 and 16 eyes of chronic dacryocystitis, acute dacryocystitis and failed DCR respectively. All the patients underwent bilateral TLADCR using 7W continuous mode 980nm diode laser under local anaesthesia and an osteotomy of 8mm X 8mm (200.96mm2 ) was created. The patients were followed up at 1 week, 1 month, 3 months, 6 months and 1year. Syringing was performed on each visit and osteotomy size was assessed on the last visit. Anatomical success was defined as patency on syringing on final visit.

The average operative time per patient was 36.15 minutes for both eyes. The average operative times in failed DCR, chronic dacryocystitis and acute dacryocystitis was 12.5 minutes 21.62 minutes and 17.75 minutes respectively. Success was achieved in 92.5% eyes. The average osteotomy size at 1 year was 93.572mm2. One patient with bilateral failure was later diagnosed as orbital tuberculosis.

Thus bilateral TLADCR is a useful procedure in bilateral NLDO allowing early rehabilitation of the patient. It reduces the patient visits to the hospital. Revision surgeries are fastest to perform.

March 28, 2015 at 5:57 pm

matthewgillam@doctors.org.uk

Complex orbital fractures require multi-specialty input. There are no nationally agreed best practice guidelines (BAOMS Trauma Specialist Group Lead). Our study aims to track the patient pathway from injury, investigation and treatment in multiple departments in a major tertiary referral network and to document demographics, clinical findings, management and outcome to inform the formulation of guidelines for timely optimal management.

Data was collected on patients who sustained orbital trauma referred to ophthalmology between April–November 2014 (79 patients). This included timings of A+E, OMFS, ophthalmology and radiology assessment, details of orbital/ocular injuries, motility impairment and management with outcomes.

61/79 patients attended eye appointments, a 23% DNA rate. 47 patients were male, 14 female with an average age of 44 years (range 5-85). The most common mechanism of injury was assault (26 patients). Average injury-eye assessment time was 4.96 weeks, 65% were seen within 2 weeks of referral. Average injury-surgery/discharge time was 9.04 weeks (range 1.14-43.86). 87% of patients had fractures and 89% of patients underwent CT. 22% had ocular injury with 38% requiring surgery/laser. 23% of patients had enophthalmos, 16% ocular dystopia and 34% ocular motility problems. 33% had fracture surgery and 3 patients required revision surgery.

“Hub and spoke” trauma networks were formed nationally following recommendations made in 2000. Despite this, there is relatively paucity of UK orbital trauma epidemiology data. Our data is comparable to international data but with some important differences. We are liaising with the BAOMS Trauma Group to form national guidelines for ophthalmic assessment of orbital trauma.

March 28, 2015 at 6:01 pm

gjvasuki@yahoo.com

Does Temporal artery biopsy (TAB) aid in the management of patients with temporal arteritis (TA) and what is the outcome of biopsies performed by ophthalmologists?

This study was performed as a retrospective audit which includes all biopsies performed by ophthalmologists from February 2011 to May 2014. Data was obtained by review of patient notes.

Eighty two biopsies were performed by Ophthalmologists which included referrals from rheumatology and ophthalmology. 44% of temporal artery biopsies were performed by Oculoplastic consultants. 65% had visual symptoms at presentation.28% of biopsies were diagnostic of TA, normal in 53.2 %, equivocal in 11.4%, alternate diagnosis made in 3.7% and other tissue was biopsied in 3.7%.Length of biopsy specimen was 10 mm and more in 38% of cases only.The majority of patients continued on steroids despite a normal biopsy based on clinical grounds.TAB does not make a difference in management of TA in 83.6% of patients.Patients with a strong clinical diagnosis of GCA with an ACR (American College of Rheumatology) criteria>/= 3 without a biopsy, do not need a TA biopsy to confirm the same. No complications of biopsy were encountered.

The overall yield rate for biopsy of temporal artery is 96%. Oculoplastic surgeons perform a large number of TA biopsies compared to other ophthalmologists.TAB has changed management only in a very small percentage where histopathology ruled out TA or diagnosed TA. In majority of cases it does not contribute to patient management, although it is still very useful to obtain a diagnosis. Clinicians need to assess the need for biopsy based on clinical and biochemical features. The length of biopsy specimen could be improved to increase the sensitivity.

March 28, 2015 at 7:10 pm

aruna_dharmasena@hotmail.co.uk

To examine the time trends in the incidence in congenital anophthalmia, microphthalmia, congenital malformations of orbit and agenesis of lacrimal apparatus in England over the past two decades.

Children born with anophthalmia and microphthalmia from 1990 to 2011 in England were identified using linked hospital episode statistics (HES). Data for congenital malformations of orbit and agenesis of lacrimal apparatus were only available from 1998 onwards. Using the record-linked datasets the number of hospital admissions and the annual incidence of each malformation were calculated. English national population denominators were obtained from the Office for National Statistics for each calendar year. Age-standardisation in the study of trends over time was undertaken using the direct method and the European standard population.

Episode-based and person-based ‘first-ever’ rates of both anophthalmia and congenital malformations of orbit and agenesis of lacrimal apparatus showed no systematic increase or decrease over time. In contrast, rates of microphthalmia showed a subtle upward trend. In 2011, the English national incidence of anophthalmia, microphthalmia, congenital malformations of orbit and agenesis of lacrimal apparatus were 0.59 (95% CI, 0.01–1.17), 9.42 (7.12–11.73) and 0.74 (0.09–1.38) per 100 000 respectively.

National incidence of hospital/outpatient admissions related to anophthalmia, congenital malformations of orbit and agenesis of lacrimal apparatus showed no systematic rise or fall during the study period. In contrast, the national incidence of microphthalmia showed only a subtle upward trend from 1990 – 2011.

March 28, 2015 at 10:30 pm

malikkps@rediffmail.com

To compare the efficacy of pentagon resection and 5-0 prolene sling surgery for correction of lower lid involutional ectropion.

Thirty eyes of twenty patients of more than 50 years of age suffering with lower lid involutional ectropion were included in the study. Inclusion criteria included history of watering, generalized lid laxity of more than 6mm on pinch test and punctal ectropion. They were randomly divided into two equal groups, A and B. Group A underwent 5-0 prolene sling surgery and Group B underwent pentagon resection and lowerlid reconstruction. The patients were followed up at 1 week, 2 weeks, 1 month and 6 months.
Success was defined as punctal apposition and decreased laxity of less than 4mm at the end of 6 months.

Both the groups were matched in terms of severity of ectropion. Complications like lid notching and shallowing of inferior fornix were noticed in group B while in group A, one patient had suture erosion. The recovery time postoperatively was much lesser in group A (2 days), as opposed to 10-14 days in Group B patients.
A final success of 93.3% was achieved in Group A as against 100% in Group B. The difference between the groups wasn’t statistically significant.(p value=1)

While both procedures have similar success in treating mild to moderate involutional ectropion, faster postoperative recovery and lesser complications are seen with sling suture. However a larger sample size is needed for making definite recommendations.

March 29, 2015 at 6:18 am

apoorva.ag@gmail.com

To evaluate and compare the anatomical and functional success of canaliculorhinostomy and no-flap technique with Mitomycin C and bicanalicular silicone intubation in failed dacryocystorhinostomy

The study was conducted on 20 consecutive symptomatic adult patients with failed DCR having anatomical blocks beyond 10 mm. They were randomly divided into two equal groups A and B. Group A underwent canaliculorhinostomy and group B no-flap technique followed by Mitomycin C and bicanalicular silicone intubation in both the groups. The patients were followed up on day 1, day 7, every 2 weeks for 2 months and monthly till 5th month. Tube was removed after 2 months.
Anatomical success was defined as patency on syringing on final visit and functional success was Munk score ≤ 1 and subjective relief of symptoms by forced choice approach.

The age group varied from 18 to 65 years, the average duration of symptoms was 32.3 months with previous history of external DCR in 8, endonasal DCR in 11 and combination of both in 1 patient. The intraoperative findings suggestive of previous surgical failure were CCB, fibrosis of anastomosis, small osteotomy, absent osteotomy, intact sac and absent nasal mucosa.
Anatomical success was 90% in group A and 100% in group B (p = 0.305). Subjective relief of symptoms was 80% in group A and 90% in group B(p=0.355)

Both canaliculorhinostomy and no-flap technique are safe and effective procedures for distal blocks in failed dacryocystorhinostomy(DCR). Since no-flap technique has reduced operative time, requires less expertise, is safe and is reproducible, it can be practiced by general ophthalmologists

March 29, 2015 at 6:49 am

glennacefenech@gmail.com

To analyse the long-term outcome of patients having a Lester Jones tube insertion for canalicular obstruction.

Retrospective review of available clinical notes in 37 patients (49 eyes) who have undergone a Lester Jones tube insertion for canalicular obstruction between 2005 and 2014. Data collected included aetiology of lacrimal obstruction, encircling fixation procedure, post-operative complications, ongoing symptoms and follow-up.

Primary endoscopic Lester Jones tube insertion was performed in 96% of eyes using 5-0 vicryl as an encircling fixation technique. The main causes of canalicular obstruction were, previous failed DCR (40.8%), idiopathic canalicular stenosis (22.4%), chemotherapy (12.2%) and medial canthal tumour excision/trauma (12.2%).

55% of eyes developed complications at a mean of 3.2 months. 75% of these were malposition or extrusion of the tube; the other 25% were blocked tubes that couldn’t be cleared in clinic.

53.1% of eyes had at least one repositioning/reinsertion of tube. 18.4% of eyes had at least two repositioning/reinsertions, whilst 6.1% of eyes had three repositioning/reinsertions of tube.

50% of eyes with previous failed DCR, 36% of those with idiopathic canalicular stenosis, and 100% of those with previous medial canthal tumour excision/trauma required tube revision.

6 eyes developed a conjunctival granuloma that required excision. 3 patients declined a reinsertion of tube.

This report shows that 55% of primary endoscopic Lester Jones tube insertions develop tube related complications at a mean time of 3.2 months, 75% of these being malposition or extrusions. 93.5% of patients have complete resolution or significantly improved epiphora.

March 29, 2015 at 11:45 am

kim.z@doctors.org.uk

The assessment and management of the ocular complications of facial paralysis remain unstandardised since the clinicians have not yet developed a widely accepted grading scale that adequately addresses the ocular aspects of this condition. In the management of facial nerve paralysis, the important priorities for the ophthalmic surgeon are protecting the ocular surface, maintaining sight and peripheral vision as well as improving the cosmesis of periocular area. We have developed the CADS classification system based on these four disease end points: Cornea, resting Asymmetry, Dynamic function and Synkinesis.

Thirty individuals with unilateral facial paralysis were graded by two independent assessors for the four disease parameters, using the CADS classification system.

The overall interobserver agreement was 86.7% for Cornea, 93.3% for resting Asymmetry, 93.3% for Dynamic function and 86.7% for Synkinesis. The agreements reached 100% in the last fifteen patients.

This is the first ophthalmic grading scale that is comprehensive and objective as much as possible while simple, quick and easy to learn.

March 29, 2015 at 1:56 pm

rupapatel1@nhs.net

To describe a rare case of atypical carcinoid tumour metastatic to the orbit.

A 58 year old gentleman with a known history of metastatic neuroendocrine tumour presented with a 2 week history of vertical diplopia. On examination exposure keratopathy and optic neuropathy were found. MRI confirmed a mass lesion of the left orbit presumed to be metastatic from his known neuroendocrine cancer. Radiotherapy was unsuccessful and excision of the mass was carried out via a lateral orbitotomy approach.

Three months post-operatively he was symptom-free and the exposure keratopathy and neuropathy resolved.

Carcinoid tumours in general are rare and there have been only 4 reported cases of metastatic atypical carcinoid tumour to the orbit. Carcinoid can be typical or atypical depending upon histology. Atypical carcinoid is rarer and more aggressive. We report a case of successful resolution of exposure keratopathy and optic neuropathy following excision of an atypical carcinoid tumour with lateral orbitotomy.

March 29, 2015 at 2:20 pm

wefong_siah@yahoo.com

To study clinical outcomes of ruptured dermoid cysts.

A multi-centre, retrospective review of 76 cases of periorbital and orbital dermoid cysts that showed evidence of rupture histologically. Clinical presentation and outcomes were recorded.

Median age was 5.5 years (range 1–63). Location of cyst was either periorbital (n=53, 69.7%) or orbital (n=23, 30.3%). Two (2.6%) cysts were ruptured at presentation and 27 (35.5%) ruptured during surgical excision. There was no documentation of a clinically-apparent cyst rupture for the remaining 47 cases (61.8%). Overall, there were only 2 cases (2.6%) with persistent inflammation (>3 months); {Case 1: Ruptured cyst at presentation that developed persistent inflammation postop due to incomplete excision requiring further excision of the cyst remnant from the attached bone. Case 2: Orbital dermoid ruptured during early dissection with resultant persistent inflammation and was managed conservatively.} We found a 3.7% (1/27) incidence of persistent inflammation in surgically-ruptured cysts. All 6 cases (7.9%) of cysts with bony attachment in this series were associated with a clinically-apparent rupture (rupture at presentation, n=1; surgical rupture, n=5). Older age (Kruskal-Wallis, p = 0.032) and bony attachment (Fisher Exact’s Test, p = 0.002) were significant factors for cyst rupture while there was no influence from cyst location (p = 0.17).

This data confirms the low likelihood of ongoing inflammation in cases of cyst rupture during surgical excision. In contrast, ruptured cysts at presentation were associated with persistence of inflammation. Those with a clinically-apparent rupture were more likely to be of older age and had a cyst with bony attachment.

March 29, 2015 at 2:49 pm

farihashafi@doctors.org.uk

Endonasal surgical approaches to the medial intraconal orbit require great precision and care to avoid damage to important structures like the optic nerve. This is technically challenging due to limited access and structures that limit the endoscopic view of the intraconal space. We present a novel exclusively endoscopic endonasal technique, in which access to the medial intraconal orbital contents was achieved by a medial rectus sling.

The medial orbit was accessed through an endoscopic endonasal approach. The medial orbital wall was removed, periorbita divided and medial rectus slung endonasally with a suture and retracted superomedially to gain access to an apical intraconal medial orbital mass. The medial rectus sling suture was received trans-septally from the contralateral nares.

A 72-year-old Caucasian female presented with loss of vision and reduced extraocular movements in her right eye. Baseline blood tests and inflammatory markers were normal. CT scan revealed bilateral medial intraconal orbital apex masses. Biopsy of the right orbital apex lesion was performed through an exclusively endoscopic approach in which the medial rectus muscle was retracted supero-medially using a suture.

To the best of our knowledge this is the first demonstration of the use of a medial rectus sling employed via an entirely endoscopic approach in the United Kingdom. This technique allows safe and easy access to the medial intraconal space and intraorbital optic nerve with no associated adverse clinical sequelae. In addition this technique negates the need for an adjuvant transconjunctival approach.

March 29, 2015 at 3:00 pm

wefong_siah@yahoo.com

To report a series of patients requesting treatment for temple-related problems following lateral wall rim-sparing orbital decompression for thyroid-associated orbitopathy and to discuss the surgical management.

A case series of 6 patients (5F:1M, n=11 orbits) with persistent, troublesome temple-related problems of at least 3 years duration that required further corrective surgery.

Median age was 57 years (range 23-65). Temple-related problems consist of bothersome temple hollowness (n=11), masticatory oscillopsia (n=8), temple tenderness (n=4) and a “clicking” sensation (n=4). Preoperative imaging studies showed the absence of deep lateral wall in all 11 orbits and evidence of prolapse of lacrimal gland into the wall defect in 4 orbits accounting for tenderness. Surgical approaches included the repair of lateral wall defect with MEDPOR implant, medial wall and intra-/extra-conal fat decompressions. Autologous fat transfer or dermal filler was used to improve temporal hollowness. Postoperatively, there was full resolution of symptoms of masticatory oscillation, temple tenderness, “clicking” sensation and a marked improvement in temple hollowness. Two patients developed new onset diplopia necessitating strabismus surgery.

Persistent, troublesome temple-related problems following lateral wall rim-sparing orbital decompression are rare but can be surgically corrected. Reconstructive surgery to repair the lateral wall defect and/or other approaches such as balanced medial wall and intra-/extra-conal fat decompressions may mitigate the issue.

March 29, 2015 at 3:03 pm

farihashafi@doctors.org.uk

Acute orbital haemorrhage (AOH) is a rare but potentially sight-threatening emergency. Vision can be preserved by prompt intervention however the rarity of encountering AOH means staff can be unfamiliar with managing this. We describe a patient who developed blinding AOH following peribulbar block for cataract surgery. This led us to develop a management algorithm to optimise outcomes following AOH.

Case discussed at Ophthalmology and Anaesthetic clinical governance meetings. Anaesthetics is well versed in the use of algorithms for emergencies and we have followed a similar format to create a joint management algorithm. Our algorithm describes a step-by-step approach for the theatre team to follow and will be shown in the presentation.

80 year old female patient on warfarin admitted for cataract surgery. Anaesthetist administered peribulbar anaesthesia into the inferomedial and inferolateral orbit. Shortly after injection she developed taut ecchymosed eyelids with proptosis. AOH was identified and emergency lateral canthotomy and cantholysis performed. Vision was no perception of light (NPL) the next morning. Following urgent oculoplastic opinion, medical treatment with intravenous acetazolamide, mannitol and dexamethasone commenced. CT orbits showed subperiosteal bleed in the medial orbit, most likely from the anterior ethmoidal artery. Patient was offered, but declined surgery. Vision remained NPL.

Our algorithm for management of AOH provides a systematic, easy to follow protocol, defining the roles of the operating surgeon, anaesthetist and theatre staff. The algorithm will be clearly displayed in ophthalmology and trauma theatres to enable easy access and hence improve outcomes from AOH.

March 29, 2015 at 3:06 pm

farihashafi@doctors.org.uk

Laissez-faire is an alternative to surgical reconstruction of defects where wound healing occurs by secondary intention. The role of this technique in managing peri-ocular tumours has been described, but is not universally well established. We report our outcomes using laissez-faire with sutured Sorbsan for defects in the medial canthal region.

Retrospective analysis of 31 consecutive cases of medial canthal defects allowed to heal by laissez-faire following excision of tumour. Sorbsan dressing, a highly absorbent biodegradable alginate dressing derived from seaweed, was sutured into the defect. Sutures were strategically placed to dictate the direction of healing. Tumour diagnosis, size of defect, time taken to epithelialise, functional and cosmetic outcome, complications, follow-up duration and any secondary interventions required were recorded. A video demonstrating the surgical technique will be shown.

Size of initial defect ranged from 8 x 5 mm to 25 x 10 mm. Mean time taken for wound epithelialisation was 33 days. Mean duration of follow-up was 26.3 months (range 4 – 110 months). Good functional and cosmetic outcomes were achieved in all 31 patients. All patients were satisfied with their aesthetic outcomes. Further detailed review of clinical photographs showed epicanthic fold in 2 patients and 1 patient had a hypopigmented visible scar. No cases required secondary intervention and there were no cases of postoperative infection.

Laissez-faire with sutured alginate dressing in the medial canthal region alleviates the need for reconstruction, thus reducing patient morbidity and provides immediate coverage of the defect whilst providing good aesthetic outcomes even for relatively large defects.

March 29, 2015 at 3:10 pm

farihashafi@doctors.org.uk

The ideal video equipment for intraoperative extraocular imaging should offer high definition footage of surgical anatomy whilst maintaining sterility of surgical field. We report our experience of the VITOM exoscope system as an effective intraoperative video imaging and teaching modality for extraocular surgery.

VITOM (Karl Storz Endoscopy, Tuttlingen, Germany) is a specially designed exoscope mounted onto a versatile mechanical arm. It is attached to a high definition (HD) digital camera displayed on a HD video monitor and slave screen via a standard endoscopy stack. This technology has been used in other surgical subspecialties, but never in ocular or extraocular surgery. VITOM was evaluated by four surgeons during surgery for ptosis, lid malposition, periocular malignancy, and strabismus. Image quality, VITOM handling, ease of use, ability to maintain sterile field and value as teaching aid were evaluated. Theatre layout will be shown as part of the presentation along with representative videos and images from the VITOM system.

The consensus of opinion was that image quality was excellent. Surgeons found VITOM easy to use, and agreed it provided excellent still and video images of the surgery. Trainees and medical students felt that imaging aided their understanding of surgical anatomy and operative steps. Theatre staff perceived improved operation flow through better visualisation of the procedure.

VITOM is an excellent intraoperative video imaging and teaching tool allowing the entire theatre team to visualise surgical anatomy and operative steps whilst maintaining a sterile field. Videos can be edited in real-time and the system allows accurate documentation of surgery.

March 29, 2015 at 3:18 pm

sonali.nagendran@gmail.com

Patient reported outcome measures play an increasingly important role in the assessment of hospital care. The consent process is an important factor contributing to patient satisfaction with oculoplastic day case surgery. We compare the effect on patient satisfaction of consent on the day of surgery to consent in clinic prior to surgery.

Patients were given a questionnaire to complete following surgery, to rate satisfaction with various aspects of care on a scale of 1-4. The initial audit involved 46 consecutive patients who had been consented on the day of surgery, immediately prior to the start of the operating list. The re-audit involved 45 consecutive patients who were consented in clinic at the time of scheduling surgery.

In the initial audit, satisfaction with the explanation of the procedure, including benefits, risks and complications was rated on average 3.7 out of 4 (92.5%). Satisfaction with the quality of the information given was also rated 3.7 out of 4 (92.5%). In the re-audit satisfaction with the explanation of the procedure was rated on average 4 out of 4 (100%). Satisfaction with the quality of the information given was also rated 4 out of 4 (100%). Overall patient satisfaction increased from 3.7 out of 4 (92.5%) to 3.9 out of 4 (97.5%).

Our audit indicates that consenting patients in clinic at the time of scheduling surgery rather than on the day of surgery improves patient satisfaction with the consent process. GMC consent guidance specifies that patients should be given adequate time to reflect on their decision to have surgery. Consenting in clinic provides a more relaxed environment for discussion and gives patients additional time to absorb information and raise concerns prior to surgery.

March 29, 2015 at 3:45 pm

farihashafi@doctors.org.uk

Extraocular muscle enlargement (EOME) is most commonly associated with thyroid eye disease. We report our outcomes of investigating and managing non-thyroid related EOME (NTR-EOME).