The association between nocturia, hormonal symptoms and bladder parameters in women: an observational study.

OBJECTIVE: Postmenopausal nocturia is poorly understood. This study aimed to identify hormonal and lifestyle factors associated with nocturia and to understand the relative contribution of altered urine production and bladder storage dysfunction in women. DESIGN, SETTING, POPULATION AND METHODS: Women ≥40 years presenting to public continence services were enrolled in a cross-sectional study. A total of 153 participants completed a hormone status questionnaire, a validated nocturia causality screening tool and a 3-day bladder diary. Descriptive statistics and logistic regression models for nocturia severity and bladder diary parameters were computed. RESULTS: Overall, 91.5% reported nocturia, 55% ≥2 /night. There was a difference of 167.5 ml (P < 0.001) in nocturnal urine volume between women with nocturia ≥2 (median 736 ml) versus less often (517 ml). Significant predictors of self-reported disruptive nocturia were age (odds ratio [OR] 1.04, 95% CI 1.002-1.073) and vitamin D supplementation (OR 2.33, 95% CI 1.11-4.91). Nocturnal polyuria was significantly more common with nocturia ≥2 compared with less frequent nocturia (P < 0.002). Exercise for 150 minutes a week was protective for nocturnal polyuria (OR 0.22, P = 0.001). Nocturia index >1.3 was significantly predicted by age (OR 1.07, P < 0.001), regular exercise (OR 0.41, P = 0.036), day flushes (OR 4.00, P = 0.013) and use of vitamin D (OR 2.34, P = 0.043). Maximum voided volumes were significantly lower with nocturia ≥2 versus less often (night: 268 ml versus 350 ml; day: 200 ml versus 290 ml). CONCLUSIONS: Bothersome nocturia in postmenopausal women is associated with changes to both nocturnal diuresis and bladder storage. Regular physical activity, prolapse reduction and oestrogen replacement may be adjunctive in managing bothersome nocturia in women.

Lateral canthotomy orbitotomy: a rapid approach to the orbit.

PurposeThe lateral compartment of the orbit can readily be accessed through a horizontal lateral canthotomy without the need to swing the lid or remove bone. In this paper the technique, accessible orbital territory, and duration of surgery are presented.Patients and methodsRetrospective, non-interventional descriptive case series for patients who underwent a lateral canthotomy to access pathology within the lateral orbit.ResultsA series of 18 patients are included, all presenting with pathology lateral to, or within, the optic nerve. Pathologies included amyloidosis (1), lymphoma (4), metastatic adenocarcinoma within the optic nerve (1), idiopathic lateral rectus muscle mysositis (4), meningothelial meningioma of the optic nerve (1), intraconal orbital meningioma (1), reactive lymphoid hyperplasia (1), optic nerve glioma (3), optic nerve meningioma (1), and cavernous haemangioma (1). The median surgical time was 36 min (range 23-75 min). No patient required detachment of the lower lid, the technique leaving both upper and lower 'arms' of the lateral canthal tendon attached to Whitnall's tubercle.ConclusionsThe lateral canthotomy approach orbitotomy is a rapid, safe, and minimally disruptive approach for accessing pathology in the lateral orbit and optic nerve. The lateral canthal tendon is split along the horizontal raphe without detachment of either limb from Whitnall's tubercle, no bone is removed, and the post-operative recovery is rapid with minimal associated inflammation or chemosis. This approach is also flexible, permitting the clinician to increase exposure to the orbit peroperatively by swinging the lower lid if required.

Can Lester Jones tubes be tolerated for decades?

PurposeLester Jones described canalicular bypass tubes 50 years ago. We present a cohort of patients with Jones' tubes first placed between 1969 and 1989, and who were reviewed within the last 15 years.Patients and methodsRetrospective case-note review for living patients identified as having had Jones' tube placement prior to 1990. The duration of Jones' tube usage was noted and the number of replacements recorded.ResultsTwenty-nine patients (33 eyes) had maintenance of their Jones' tube(s) within the last 15 years, and had first tube placement before 1990. The average follow-up was 29.5 years (median 28.8 years, range 17-45.7 years). The original tube was present in 8/33 (24%) of eyes, at a mean survival of 34 years (33.3 years; range 29.4-44.4 years). The number of tube replacements during follow-up ranged from 0 to 9 (mean 1.7; median 1). When considering the initially placed tube in all 33 eyes, however, the survival ranged between 18 days and 44.4 years (mean 13.6 years; median 6.9 years). At last follow-up, 11/33 (33%) of eyes had lost their tubes, with 9 having minimal or no symptoms.ConclusionsThese patients with Jones' tube placement before 1990 provides the first recorded evidence that the device can be tolerated for at least four decades, and that some patients will-with appropriate outpatient maintenance-retain their originally placed tube. This information may be useful in counselling patients about the lifetime expectation for bypass tubes.

Management of thyroid eye disease in the United Kingdom: A multi-centre thyroid eye disease audit.

This article aims to provide baseline data and highlight any major deficiencies in the current level of care provided for adult patients with thyroid eye disease (TED). We undertook a prospective, nonrandomized cross-sectional multicenter observational study. During a 3-month period June-August 2014, consecutive adult patients with TED who presented to nominated specialist eye clinics in the United Kingdom, completed a standardized questionnaire. Main outcome measures were: demographics, time from diagnosis to referral to tertiary centre, time from referral to review in specialist eye clinic, management of thyroid dysfunction, radioiodine and provision of steroid prophylaxis, smoking, and TED classification. 91 patients (mean age 47.88 years) were included. Female-to-male ratio was 6:1. Mean time since first symptoms of TED = 27.92 (73.71) months; from first visit to any doctor with symptoms to diagnosis = 9.37 (26.03) months; from hyperthyroidism diagnosis to euthyroidism 12.45 (16.81) months. First, 13% had received radioiodine. All those with active TED received prophylactic steroids. Seven patients who received radioiodine and did not have TED at the time went on to develop it. Then, 60% patients were current or ex-smokers. 63% current smokers had been offered smoking cessation advice. 65% patients had active TED; 4% had sight-threatening TED. A large proportion of patients (54%) were unaware of their thyroid status. Not enough patients are being provided with smoking cessation advice and information on the impact of smoking on TED and control of thyroid function.

Which factors are associated with quality of life in patients with Graves' orbitopathy presenting for orbital decompression surgery?

PURPOSE: Graves' orbitopathy (GO) is associated with changes in the appearance of the eyes and visual dysfunction. Patients report feeling socially isolated and unable to continue with day-to-day activities. This study aimed at investigating the demographic, clinical, and psychosocial factors associated with quality of life in patients presenting for orbital decompression surgery. METHODS: One-hundred and twenty-three adults with GO due for orbital decompression at Moorfields Eye Hospital London were recruited prospectively. Clinical measures including treatment history, exophthalmos, optic neuropathy, and diplopia were taken by an ophthalmologist. Participants completed psychosocial questionnaires, including the Graves' Ophthalmopathy Quality of Life Scale (GO-QOL), the Hospital Anxiety and Depression Scale, and the Derriford Appearance Scale. Hierarchical multiple regression analyses were used to identify predictors of quality of life. RESULTS: Higher levels of potential cases of clinical anxiety (37%) and depression (26%) were found in this study sample than in patients with other chronic diseases or facial disfigurements. A total of 55% of the variance in GO-QOL visual function scores was explained by the regression model; age, asymmetrical GO and depressed mood were significant unique contributors. In all, 75% of the variance in GO-QOL appearance scores was explained by the regression model; gender, appearance-related cognitions and depressed mood were significant unique contributors. CONCLUSION: Appearance-related quality of life and mood were particularly affected in this sample. Predominantly psychosocial characteristics were associated with quality of life. It is important when planning surgery for patients that clinicians be aware of factors that could potentially influence outcomes.

Periocular implantation cysts: a late complication of ophthalmic surgery.

PURPOSE: To describe the clinical characteristics for a group of patients presenting with acquired implantation cysts following periocular surgery. METHODS: Retrospective, non-comparative series of patients who underwent surgery at Moorfields Eye Hospital for orbital implantation cysts, with review of clinical case notes and imaging. RESULTS: Twenty-three patients (13 male; 57%) were treated between 1997 and 2011 with cystic lesions that presented at an average interval of 22.7 years after previous periocular surgery. The age at presentation ranged from 14 to 76 years (mean 45.3; median 46 years). Five patients had a history of prior enucleation or evisceration (with ball implantation in 4/5 cases) and six had undergone orbital fracture repair with either a silicone or titanium plate. Eight patients had prior strabismus surgery, three had retinal detachment repair with either a scleral buckle or vitrectomy, and one patient had repair of a conjunctival laceration in childhood. All but one patient underwent either wide marsupialisation or complete excision of the implantation cysts, with no record of recurrence. Visual acuity improved after surgery in a half of the patients, whereas remaining unchanged in the remainder. CONCLUSION: Orbital implantation cysts constitute a relatively rare complication of periocular surgery and can present decades after the causative procedure.

Cranio-orbital primary intraosseous haemangioma.

PURPOSE: Primary intraosseous haemangioma (IOH) is a rare benign neoplasm presenting in the fourth and fifth decades of life. The spine and skull are the most commonly involved, orbital involvement is extremely rare. We describe six patients with cranio-orbital IOH, the largest case series to date. PATIENTS AND METHODS: Retrospective review of six patients with histologically confirmed primary IOH involving the orbit. Clinical characteristics, imaging features, approach to management, and histopathological findings are described. RESULTS: Five patients were male with a median age of 56. Pain and diplopia were the most common presenting features. A characteristic 'honeycomb' pattern on CT imaging was demonstrated in three of the cases. Complete surgical excision was performed in all cases with presurgical embolisation carried out in one case. In all the cases, histological studies identified cavernous vascular spaces within the bony tissue. These channels were lined by single layer of cytologically normal endothelial cells. DISCUSSION: IOCH of the cranio-orbital region is rare; in the absence of typical imaging features, the differential diagnosis includes chondroma, chondrosarcoma, bony metastasis, and lymphoma. Surgical excision may be necessary to exclude more sinister pathology. Intraoperative haemorrhage can be severe and may be reduced by preoperative embolisation.

'Stalled' periocular necrotising fasciitis: early effective treatment or host genetic determinants?

BACKGROUND: Necrotising fasciitis (NF) is a devastating disease with considerable mortality and morbidity, and early aggressive surgical debridement of devitalised necrotic tissues has traditionally been advocated. METHODS: We describe three patients who were referred from other units several weeks after developing periocular necrotising fasciitis; in all the three, the disease had been managed medically without surgical debridement, with apparent 'stalling' of the inflammatory process despite persistent necrotic periocular tissue. RESULTS: Following 'elective debridement' of the devitalised tissues and reconstruction with local flaps, all achieved a satisfactory aesthetic result. DISCUSSION: The role of host genetic determinants, polarised cytokine responses, and early, effective medical treatment in patients with atypical 'disease phenotypes' in NF are discussed.

Acute thyroid eye disease (TED): principles of medical and surgical management.

The active inflammatory phase of thyroid eye disease (TED) is mediated by the innate immune system, and management is aimed at aborting this self-limited period of autoimmune activity. In most patients with TED, ocular and adnexal changes are mild and management involves controlling thyroid dysfunction, cessation of smoking, and addressing ocular surface inflammation and exposure. In patients with acute moderate disease, this being sufficient to impair orbital functions, immunosuppression reduces the long-term sequelae of acute inflammation, and adjunctive fractionated low-dose orbital radiotherapy is used as a steroid-sparing measure. Elective surgery is often required following moderate TED, be it for proptosis, diplopia, lid retraction, or to debulk the eyelid, and this should be delayed until the disease is quiescent, with the patient stable and weaned off all immunosuppression. Thus, surgical intervention during the active phase of moderate disease is rarely indicated, although clinical experience suggests that, where there is significant orbital congestion, early orbital decompression can limit progression to more severe disease. Acute severe TED poses a major risk of irreversible loss of vision due to marked exposure keratopathy, 'hydraulic' orbital congestion, or compressive optic neuropathy. If performed promptly, retractor recession with or without a suture tarsorrhaphy protects the ocular surface from severe exposure and, in patients not responding to high-dose corticosteroid treatment, decompression of the deep medial orbital wall and floor can rapidly relieve compressive optic neuropathy, as well as alleviate the inflammatory and congestive features of raised orbital pressure.

Acute presentation of vascular disease within the orbit-a descriptive synopsis of mechanisms.

Vascular events in the orbit can present with an acute onset of symptoms, and, if untreated, raised orbital pressure and reduced arterial perfusion can lead to loss of orbital functions. Such events are commonly due to haemorrhage, but can also be due to arterio-venous shunts and very rarely arise from intraorbital vascular occlusion. The likely diagnosis is often evident on taking a thorough history and examination and in most cases, after appropriate imaging, the process can be monitored for progression. Visual failure is usually due to high pressure at the orbital apex, resulting in ischaemic optic neuropathy, and any evidence of a persistent significant visual impairment should prompt intervention.

Discoid lupus erythematosus of the periorbita: clinical dilemmas, diagnostic delays.

PURPOSE: Untreated periocular discoid lupus erythematosus (DLE), though very rare, may lead to significant morbidity with lid deformities, trichiasis, and symblepharon formation. We present the largest reported cohort of patients with biopsy-proven DLE solely affecting the periorbital region. METHODS: Observational case series of patients managed over a 7-year period (2004-10). RESULTS: Seven patients (one male) presented to the Adnexal Service at Moorfields Eye Hospital at a median age of 47 years (range 23-71 years); median interval from symptom onset to biopsy-proven diagnosis was 38 months (range 6-86 months). Changes in peripheral skin were present in 1 patient (occurring after the initial eyelid presentation) and the presenting periocular features were dissimilar across the group, these included: chronic blepharo-conjunctivitis, madarosis, atypical chalazia, depigmentation of the eyelid margin, or marked, persistent periocular oedema with dacryoadenitis.Two cases settled spontaneously, but five required systemic hydroxychloroquine or intralesional corticosteroid injections. CONCLUSION: Periorbital DLE is rare and very varied in its presentation, the protean manifestations often resulting in significant diagnostic delay. All patients with unusual periocular skin disease and those with a refractory inflammatory dermopathy, should undergo biopsy of involved tissue(s), thus leading to earlier diagnosis and prevention of permanent cicatricial periocular changes.

Orbital decompression for Graves' orbitopathy in England.

AIMS: The purpose of this study was to obtain data on orbital decompression procedures performed in England, classed by hospital and locality, to evaluate regional variation in care. METHODS: Data on orbital decompression taking place in England over a 2-year period between 2007 and 2009 were derived from CHKS Ltd and analysed by the hospital and primary care trust. RESULTS AND CONCLUSIONS: In all, 44% of these operations took place in hospitals with an annual workload of 10 or fewer procedures. Analysis of the same data by primary care trust suggests an almost 30-fold variance in the rates of decompression performed per unit population. Expertise available to patients with Graves' orbitopathy and rates of referral for specialist care in England appears to vary significantly by geographic location. These data, along with other outcome measures, will provide a baseline by which progress can be judged.

Spontaneous silent sinus syndrome (imploding antrum syndrome): case series of 16 patients.

INTRODUCTION: Silent sinus syndrome (SSS) is a rare idiopathic collapse of the maxillary sinus and orbital floor. We present the second largest series of sixteen patients with SSS and describe their management. METHODS: A cohort of 16 patients with spontaneous SSS between 1999 and 2009 were reviewed at the Royal National Throat Nose and Ear Hospital. All patients were initially referred from a postgraduate ophthalmic hospital, Moorfields Hospital. RESULTS: Fourteen patients required endoscopic sinus surgery to re-establish maxillary sinus drainage and the remaining two settled with intranasal medical therapy consisting of steroids and decongestions. Follow- up ranged from 6 months to 4 years with a mean of 2.6 years. An improvement in enophthalmos and was seen in all surgically treated patients with a mean improvement of 2.2mm and range 0.5-4mm. DISCUSSION: SSS arises from congestion of the ostiomeatal complex resulting in negative pressure within the maxillary sinus and a gradual implosion of the antral cavity. Endoscopic sinus surgery successfully re-establishes maxillary aeration in our series and leads to clinical and aesthetic improvement in the degree of enophthalmos and has avoided the need for orbital floor repair in all but two cases.

An unusual eyelid lump: unsuspected embedded contact lens for up to 40 years. Two cases and literature review.

The purpose of this study is to report two patients with retained rigid gas-permeable contact lenses (RCLs) that had become integrated into the upper eyelid tissues, to provide a brief literature review and to discuss possible aetiologies. The methods used in this study are as follows: retrospective review of clinical records and review of the literature. Two contact lens wearers presented with an upper eyelid mass, one after previous loss of a lens and the other 40 years after a failed trial of RCL wear; this latter case appears to be the longest delay in diagnosis reported in the ophthalmic literature. Although extremely rare, the presence of an upper tarsal lump in a RCL wearer should raise possibility of an embedded contact lens, particularly where the contour is suggestive in size or shape. Ultrasonography or magnetic resonance imaging may show characteristic changes. It is probable that RCL migration into periocular tissues occurs by entrapment above the upper tarsal border and integration, by local tissue necrosis, into the tarsus or pretarsal space.

The management of patients with thyroid eye disease after bilateral orbital 3 wall decompression.

INTRODUCTION: Thyroid eye disease is the most common cause of unilateral and bilateral proptosis in adults. Orbital decompression surgery may cause and/or worsen a pre-existing ocular motility disorder. METHODS: A retrospective review was carried out of all bilateral 3 wall orbital decompressions for severe thyroid eye disease performed between January 2002 and December 2004 by one surgeon. Subsequent surgeries were recorded. RESULTS: Seventy-four patients were identified, 59 (80%) females and 15 (20%) males. Mean age at the time of decompression was 46 years. Fifteen (20%) patients complained of diplopia due to strabismus prior to decompression surgery and 20 (27%) developed new diplopia postsurgery. Twenty patients (27%) required no further intervention following decompression surgery; the remainder underwent an average of 2.5 procedures. Strabismus surgery was performed in 32 (43%) patients. The mean time from the decompression to first strabismus surgery was 12 months. Forty-three (58%) patients underwent lid surgery. The mean time from decompression to first lid surgery was 16 months. CONCLUSION: This study demonstrates how this group of complex patients required multiple surgical procedures within an extended timescale, therefore requiring several in- and outpatient visits.

Natural history of flexed knee gait in diplegic cerebral palsy evaluated by gait analysis in children who have not had surgery.

Eighteen children with diplegic cerebral palsy and no history of orthopaedic surgery had two gait analyses a mean of 6.3 years apart to analyse the effects of time on their gait. The mean age of the children at first analysis was 7.7 years (range 4.4-13.3 years). The data was analysed as a whole group (18 children) and as two sub-groups of nine children: those with a shorter follow-up (mean 5.0 years) and those with a longer follow-up (mean 7.5 years) between analyses. The following significant bilateral changes were seen in the whole group and longer follow-up sub-group: deterioration in the range of knee flexion, mid-stance knee flexion, peak knee extension in stance and hamstring length and an improvement in mean and maximum hip rotation. Temporal data showed no significant changes once normalised. There were no bilateral significant changes in data from children evaluated at a mean of 5 years follow-up. GMFCS scores generally improved over time despite the significant increase in flexed knee gait. There was no significant change in gait deviation index in any group over time. There was an increase in body mass index in 16 children but there was no correlation between this and the degree of mid-stance knee flexion. These findings may have implications for longer term follow-up of children with cerebral palsy into adulthood.

Lacrimal drainage surgery in patients with rare nasal diseases.

AIM: To examine the results of open lacrimal drainage surgery in patients with rare nasal diseases. METHOD: A retrospective review of a group of patients with rare nasal disease who underwent open lacrimal surgery over a 15-year period at Moorfields Eye Hospital. Three main groups of disease were identified: (I) patients with treated mid-face tumours; (II) patients with prior major midfacial injury or surgery; and (III) patients with congenital nasal anomalies, including nasal aplasia. The more common systemic conditions of Wegener's granulomatosis and sarcoidosis were specifically excluded. RESULTS: Eighty-six patients (43 men; 50%) were identified with an age range between 1 and 82 years at the time of surgery. A total of 100 primary procedures were performed in 85 patients and symptomatic relief was achieved in 83/100 (83%) eyes, with 18/100 eyes (18%) requiring two or more lacrimal procedures. Lacrimal reconstructive surgery was considered impractical in two further patients. There were no intraoperative and few postoperative complications. CONCLUSION: With adequate experience, open lacrimal surgery appears to be a safe and effective procedure in the majority of patients with rare nasal diseases or major nasofacial anomalies.