Resolution of Pityriasis rubra pilaris induced ectropion with oral dexamethasone. A case report.

An 82-year-old male presented with generalised Pityriasis rubra pilaris (PRP) managed initially by dermatology team. The patient did not respond to first- and second-line treatment, including oral acitretin, steroid creams, and methotrexate, and developed bilateral cicatricial ectropion, for which he was referred to oculoplastic team for surgical management. A head injury resulting in subacute subdural haematoma, managed with a week course of low dose oral dexamethasone, resulted in the improvement of his skin condition and complete resolution of the cicatricial ectropion within a few weeks. Thus, systemic treatment of PRP with oral dexamethasone may be considered sooner in the treatment of cicatricial ectropion in similar cases.

Prostaglandin analogues: A double-edged sword in orbital glaucoma disease management.

INTRODUCTION: The authors describe benefits of the recognised adverse effects of prostaglandin analogues on periocular structures in patients with unilateral proptosis and intraocular pressure rise. This case points to intentional consideration of prostaglandin analogue therapy in this selected cohort of patients with secondary ocular hypertension and proptosis. CASE DESCRIPTION: A 70-year-old gentleman who presented with a 1-week history of a red and painful right eye associated with tortuous and dilated episcleral blood vessels. Visual acuity was unaffected. A diagnosis of idiopathic orbital inflammatory disease was made by extraocular muscle biopsy. Two weeks later, the patient presented with worsening pain, reduced vision and raised intraocular pressure. The secondary ocular hypertension was successfully treated with topical preserved eye drops, including latanoprost, a prostaglandin analogue. Over 6 months, the patient developed drop intolerance and punctate keratopathy leading to therapy non-adherence. Interestingly, the patient reported improvement in periocular appearance related to prostaglandin-associated periorbitopathy. Ocular surface disease and intraocular pressures were subsequently managed with preservative-free eye drops. CONCLUSION: Secondary ocular hypertension is not an uncommon consequence of orbital disease. Prostaglandin analogue can act as a double-edged sword in the management of raised intraocular pressure by reducing eye pressure at the cost of developing adverse effects of prostaglandin-associated periorbitopathy. These adverse effects however can be beneficial in the aesthetic rehabilitation of proptosis and associated exposure keratopathy in patients with unilateral orbital disease and probably should be sought as first line treatment in those with proptosis and raised intraocular pressure.

Novel technique of non-surgical rejuvenation of infraorbital dark circles.

BACKGROUND: Infraorbital dark circles are a common esthetic concern which can be challenging to treat given their multifactorial nature. Under-eye dark circles are seen in all skin types, with a strong familial component in darker skin types. Other major contributing factors include soft tissue and bony changes, skin changes, lifestyle contributions, and allergies. Involutional periorbital volumetric changes cause volume loss in the tear trough, naso-jugal and palpebro-malar grove, skin and subcutaneous tissues with tethering of the eyelid skin to the tear trough ligament, giving a sunken and hollow appearance to the lower lid. Associated prolapse of the orbital fat and thin skin can worsen the appearance of a dark circle. Hyaluronic acid fillers placed in the pre-periosteal plane in the tear trough, palpebro-malar and naso-jugal grooves, give good results in patients with thick eyelid skin and negligible fat prolapse. However, in patients with thin skin and moderate fat prolapse, authors have reported worsening outcomes with risk of Tyndall (blue-gray discoloration) and contour irregularities from visible lumps. AIMS: To describe a novel technique to improve dark circles caused by a diffuse valley-type pre-septal tear trough deformity in patients with thin eyelid skin. METHODS: Retrospective case note review of 330 eyelids treated with microdroplet subdermal placement of filler in the preseptal tear trough area by a single surgeon. CONCLUSION: This novel technique shows good esthetic outcomes in patients with dark circles, with good longevity and a low risk of complications.

Awareness of management of hyaluronic acid induced visual loss: A British National Survey.

BACKGROUND: Visual loss from aesthetic hyaluronic acid filler injections is an under-reported complication. Our study surveyed British Oculoplastic consultants and Consultant members of the British Eye Emergency Care Society, on their awareness of visual vascular complications of dermal fillers and its emergency management. METHODS: A prospective survey of the members of the British Oculoplastic Society and the British Eye Emergency Society, using the Survey Monkey platform. RESULTS: There were 53 responses. Eighty five percent of responders were aware of ophthalmic artery occlusion and visual loss as a recognised complication of hyaluronic acid based fillers. Six respondents had encountered at least one case of visual loss associated with HA fillers. Approximately 27% of the respondents had some experience of the recommended appropriate management of this complication. Majority of these practitioners did not have local management guidelines for this complication (88%) nor were they aware of guidance to manage the complication (75%). CONCLUSIONS: This survey captures the current experience of British Ophthalmologists and Oculoplastic Surgeons in the management of visual vascular complication with dermal fillers. This may relate to the rarity of this complication. Although there is an awareness of visual loss as a complication from aesthetic dermal fillers, there appears to be a lack of knowledge of current management guidelines across Eye Specialists in UK. It is important for practitioners to be able to recognise and manage vascular compromise and further study recommendations are made.

Orbital abscess as a complication of Pott's puffy tumour in an adolescent male.

Pott's puffy tumour (PPT) is a known complication of frontal sinusitis. It is defined as subperiosteal abscess formation due to osteomyelitis of the frontal bone presenting as a forehead swelling. It is a life-threatening condition that can lead to intracranial and intraorbital complications. Gadolinium-enhanced MRI and contrast CT scan are the best modalities to localise and define the collection, in addition to confirming disease extension. Once confirmed by imaging and depending on disease extension, management of PPT requires a multidisciplinary team approach and depends on the local provision of surgical care. Following surgical drainage of the abscess cavity, a prolonged course of antibiotics is required postoperatively to treat the underlying osteomyelitis.

The kissing puncta: an under-reported and stubborn cause of epiphora.

BACKGROUND: 'Kissing puncta' (KP) or punctal apposition is an anatomical phenomenon sparsely reported in the English literature. We describe our experience of managing chronic epiphora in patients with punctal apposition. METHODS: A retrospective audit of five patients (nine eyes) with KP associated with epiphora. Data including: presenting symptoms, physical signs and surgical outcomes were collected. RESULTS: Five patients aged between 66 and 77 years were reviewed. Common clinical features were: chronic epiphora, involutional eyelid laxity, kissing puncta (present at all phases of the blink) and reduced upper and lower margin-reflex distances. Medial upper eyelid ptosis with orbital fat prolapse was a prominent feature. Four patients (nine eyes underwent eyelid-tightening surgery to restore normal anatomical position of the puncta. Only one of the four patients achieved improvement in epiphora at 3 months. One patient with continued epiphora underwent subsequent dacrocystorhinostomy with improvement in symptoms. The fifth patient had mild laxity and underwent dacrocystorhinostomy at first instance, with no improvement in symptoms, despite surgical success. CONCLUSIONS: The KP sign is commonly found in those with involutional eyelid changes. Epiphora is present in variable degrees in the presence of punctal apposition. Restoration of normal punctal position with eyelid-tightening surgery does not always confer an improvement in epiphora. Surgical management in the setting of KP is therefore challenging with a guarded prognosis. Symptomatic patients with KP should be counselled accordingly.

Periocular Manifestations of Afatinib Therapy.

Epidermal growth factor receptor tyrosine kinase inhibitor therapy has been increasingly employed in the treatment of a variety of tumors. The authors report the rarely documented side effect of trichiasis with the use of Afatinib in a patient with spinal chordoma and review-related literature. A 67-year-old lady was referred to the oculoplastic service with a 3-month history of ocular irritation and pain associated with blurred vision. She has a 4-year history of spinal chordoma treated with daily Afatinib 50 mg over the past 6 months. Clinical examination revealed trichomegaly and trichiasis affecting all 4 eyelids associated with blepharitis, conjunctival, and corneal abrasion on fluorescein staining. Hypertrichosis of the eyebrow bilaterally was also present. Afatinib and other epidermal growth factor receptor tyrosine kinase inhibitor-associated changes to eyelash and eyebrow hair is a result of epidermal growth factor receptor pathway activation in keratinocytes results in remodeling of the hair follicle. This results in the variation in the severity of clinical presentation of trichiasis.

The Prevalence of Lower Eyelid Fornix Fat Prolapse: A Diagnostic Measure of Involutional Entropion.

PURPOSE: In our experience, lower lid involutional entropion is commonly associated with inferior fornix fat prolapse and non-eversion of the tarsal plate. We aimed to assess the prevalence of this sign as an early diagnostic indicator of lower lid involutional entropion in symptomatic and control groups. METHODS: Prospective, comparative, observational case series. Fornix fat prolapse and failure of tarsal eversion in patients with involutional entropion were studied. Fornix fat prolapse was assessed by pulling the lower lid margin to the inferior orbital rim and comparing the meniscus of the protruding fat. The absence of tarsal eversion and lid laxity were also assessed. Patients were reassessed following correction using radiofrequency entropion surgery. RESULTS: Sixty eyes of 50 Caucasian patients with involutional entropion underwent entropion correction. Fornix fat prolapse was found preoperatively in 83.3% (50 eyes), with complete reversal of fat prolapse in 76% (38 eyes) over a mean follow-up of 18.9 months, after successful surgery (P < 0.01). None of the 100 eyes (50 patients) in the control group showed fornix fat prolapse or absence of lower lid tarsal eversion (P < 0.01). CONCLUSION: There is high prevalence of fornix fat prolapse and failure of tarsal eversion (BB sign) in involutional entropion, with reversal after successful eyelid surgery. The absence of fornix fat prolapse in normal controls suggests that this is an important, underlying anatomical etiology, with diagnostic and prognostic value.

Monocular Diplopia and Nondisplaced Inferior Rectus Muscle on Computed Tomography in a Pediatric Pure Orbital-Floor Fracture.

Trapdoor fractures are common in children because of elastic nature of the pediatric bone. Clinical signs and radiological evidence in these cases may be minimal.This study involves a 14-year-old girl who sustained blunt trauma to her left eye. Initial investigation, for pure orbital floor fracture included computerized tomography (CT scan) of the orbit, did not show any evidence of incarcerated rectus muscle. She had no limitation of extraocular movements nor enophthalmos. Following conservative treatment, she had a left persistent orbital pain and left monocular diplopia. This prompted a magnetic resonance imaging (MRI) of the orbit investigating soft tissue, which found fine partial muscle herniation through the self-sealed fracture needing surgical intervention.Although an orbital CT imaging is preferrd, in this acute setting, magnetic resonance imaging should be considered to delineate the soft tissue anatomy in relation to a trapdoor fracture, especially when there are not cardinal associated physical symptoms with a trap door fracture such as restricted eye movement and enophthalmos. Mono-ocular diplopia can be noted as an associated symptom to prompt early surgical repair.

The Nonsurgical Management of Orbital Dystopia Using Refractive Lenses and Prosthetic Shells.

Surgical rehabilitation of orbital dystopia can be challenging. The authors demonstrate the effective use of spectacle lenses to visually correct misalignments of the globe and the orbit. Presented is a retrospective review of 4 patients undergoing aesthetic rehabilitation through use of spectacle lenses and in a number patients a cosmetic shell.Two patients with neurofibromatosis presented with inferior dystopia of the globe and orbit. A base-down prismatic lens applied to the spectacles in conjunction with a prosthetic shell successfully visually corrected the facial asymmetry and improved patients' aesthetic appearance. One patient with a history of traumatic retinal detachment, who did not want any surgical intervention, a "plus" (hypermetropic) lens was used to magnify the perceived image of an enophthalmic and phthisical globe, to enhance appearance and improve symmetry. In the fourth patient, with Goldenhar syndrome, the appearance of a hypotropia and concurrent esotropia was successfully treated with a Fresnel prism and a prosthetic shell.This case series illustrates the successful role of various refractive lenses often in conjunction with prosthetic shells in patients with reduced vision and orbital dystopia to improve facial symmetry. This conservative treatment is especially useful when surgery is not a desired or not considered a suitable option for the patient.

The "reading man" flap for reconstruction of large periorbital defects.

PURPOSE: The "reading man" flap (RMF), a double advancement transposition cutaneous flap named for its appearance, has been described in the reconstruction of various circular skin defects, particularly in the malar region. We describe two cases where this flap was used to reconstruct the lower eyelid/periorbital region. METHODS: Two oculoplastic patients with lower eyelid basal cell carcinomas underwent Mohs micrographic excision resulting in a large skin defects. In both cases, reconstruction was performed using the RMF. RESULTS: At 6 months, both patients achieved good cosmetic results with no case of secondary eyelid malposition. CONCLUSION: The RMF is a useful adjunct to the armamentarium of the oculoplastic surgeon for the reconstruction of large periorbital defects.

Safety of the use of xylometazoline nasal spray in young children undergoing lacrimal surgery: an observational study.

PURPOSE: It is common practice to prepare the nasal mucosa with decongestant in children undergoing lacrimal surgery. Xylometazoline 0.05% (Otrivine) nasal spray is commonly used. It has been reported to cause cardiovascular side effects. In the absence of formal guidelines on the safety of the use of nasal decongestants in children, we reviewed our practice to answer the question: How safe is preoperative use of xylometazoline in children undergoing lacrimal surgery? To our knowledge, this is the first study to address the potential side effects of the use of xylometazoline preoperatively in children undergoing lacrimal surgery. METHODS: This was a retrospective analysis of medical notes of children undergoing lacrimal surgery with the use of preoperative intranasal xylometazoline 0.05% over a 5-year period. RESULTS: Twenty-nine children, age 1-6 years (mean 3 years), underwent lacrimal surgery under general anesthesia with preoperative use of intranasal xylometazoline. Topical intranasal 1:10,000 adrenaline was used during surgery in all patients. All children were found to have uneventful surgery and recovery from anesthesia. CONCLUSIONS: Xylometazoline 0.05% intranasal use for prelacrimal surgery was found to be effective and safe. Addition of sympathomimetic topical adrenaline (1:10,000) did not impose any risks. The type of general anesthesia may influence the cardiovascular side effects anecdotally recorded during xylometazoline use.

Aspergillus infection of supramid orbital implant and hyperostosis of orbital bone: report of a unique case.

PURPOSE: The authors report the clinical findings in a patient who developed proptosis fourteen years after an orbital floor fracture repair with a Supramid orbital implant due to hyperostosis of the orbital floor and lateral orbital wall bone secondary to aspergillus infection. METHODS: Clinical, radiological, microbiological and histological findings and the management of this patient are presented. RESULTS: A 25-year-old male was referred with proptosis and lower lid retraction, fourteen years after a traumatic orbital floor fracture repair with a Supramid implant. Orbital exploration revealed a thick irregular sheet of bone covering the orbital floor implant and extending laterally along the lateral orbital wall. Aspergillus fumigatus was grown from the Supramid implant as well as from the bone and histology showed chronic inflammatory process with reactive bone formation. Patient was treated with a course of oral Voriconazole and post-operatively the patient is asymptomatic with reduction in proptosis. CONCLUSION: To the best of our knowledge, this is the first case of Apergillus fumigatus infection secondary to a Supramid orbital floor implant, associated with hyperostosis of orbital bone.

Complications of intracanalicular plugs: a case series.

PURPOSE: Intracanalicular plugs are commonly used in the management of dry eyes. The authors report 3 cases of complications associated with intracanalicular plugs. METHODS: Clinical findings and the management of these patients are presented. RESULTS: The first patient (case 1) is a 47-year-old female with severe dry eyes. Six months after insertion of intracanalicular Form fit hydrogel plugs (OASIS Medical) she developed canaliculitis with Klebsiella oxytoca. The second patient (case 2), a 33-year-old female, who developed left canalicular abscess 5 months following the insertion of bilateral, intracanalicular Form fit hydrogel plugs (OASIS Medical). The third patient (case 3) a 33-year-old female had granulation tissue formation within the left lower canaliculus, 5 years after insertion of intracanalicular plug. The symptoms in the three patients resolved after they underwent canaliculotomy with removal of the plugs. CONCLUSION: Complications of intracanalicular plugs can sometimes outweigh their benefits. These plugs can lodge in the lacrimal outflow system and cause pyogenic granuloma formation and canaliculitis. To our knowledge, until now there have been no reports of complications associated with Form Fit hydrogel plugs (OASIS Medical) and its infective complication with Klebsiella oxytoca.