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.

Electrical stimulation as a therapeutic option to improve eyelid function in chronic facial nerve disorders.

PURPOSE: To establish whether it is possible to improve orbicularis oculi muscle function in the eyelids of patients with a chronic seventh cranial nerve palsy by using transcutaneous electrical stimulation to the point at which electrical stimulation induces a functional blink. METHODS: Ten subjects (one woman, nine men) aged 36 to 76 with chronic, moderate to severe facial nerve palsy were recruited into the study. Voluntary and spontaneous eyelid movements were assessed, using an optical measuring system, before, during, and after a 3-month treatment period. Voluntary and spontaneous lid velocities were also measured and compared with eyelid kinematic data in normal subjects (12 women, 18 men; age range, 22-56 years). RESULTS: Therapeutic electrical stimulation applied over 3 months produced improvement in eyelid movement (>2 mm) in 8 of 10 patients during voluntary eyelid closure. However, there was no significant improvement recorded in spontaneous blink amplitudes or peak downward-phase velocity of the upper eyelid. This regimen of stimulation failed to recover function well enough that a functional blink could be induced in the paretic eyelid by electrical stimulation. CONCLUSIONS: Electrical stimulation using transcutaneous electrical nerve stimulators units can improve voluntary eye closure, apparently because of a reduction in stiffness of eyelid mechanics, rather than an improvement of muscle function. Investigation of alternative stimulation regimens is warranted.

A line imaging system for measurement of eyelid movements.

A line scan imaging system which provides a facility for comprehensive measurement and analysis of eyelid motion in human subjects is described. The device obtains parasagittal line images of the eye and eyelids by focusing an image of the eye onto a linear 256-element CCD array. Line images are acquired and digitized at a rate of 200 per second and stored in a buffer memory. The stored data are subsequently analysed on a PC to give measurements of eyelid displacement and velocity. Measurements of eyelid displacement and velocity during normal blinks in five subjects were comparable with published results from other measurement techniques.

Glaucoma screening clinic in general practice: prevalence of occult disease, and resource implications.

BACKGROUND: Previous studies have shown that for every known case of glaucoma there is another case of occult disease. Most cases of glaucoma are detected by optometrists. AIM: This study set out to determine the prevalence of occult glaucoma in a practice population and assess the likely resource implications of introducing a glaucoma screening programme into a general practice setting. METHOD: The 1153 patients registered with one practice in Leicester who were aged 55-69 years on 1 January 1992 and who were not known to have glaucoma prior to screening were invited to a screening clinic. Prior to screening there were 11 known cases of glaucoma in this age group. Screening was carried out by a practice nurse. Patients who failed the screening tests were referred according to the study protocol to the ophthalmology department of the Leicester Royal Infirmary and examined by one ophthalmologist. The number of cases of occult glaucoma and other eye disease detected, the cost per case screened and case detected, and the number of referrals generated were evaluated. RESULTS: Nine hundred and fifty people (82%) accepted the invitation and attended for glaucoma screening. Of those screened 115 (12%) were referred for ophthalmic assessment. Glaucoma was confirmed in 14 of the referred patients (12%) while a further 15 (13%) were found to have ocular hypertension. All but one of those people diagnosed as having glaucoma recalled having been examined by their optician within the last five years; for 50% the period was less than two years. Nineteen of the patients referred (17%) had other ocular pathology detected by the ophthalmologist and no abnormality was detected in 65 patients referred (57%). The estimated cost to the practice (excluding hospital outpatient costs) per case screened using the study protocol was 6 pounds and the cost per case detected was 408 pounds. CONCLUSION: Glaucoma screening may be successfully undertaken in a general practice setting by non-ophthalmically trained staff who have received tuition in the use of the equipment. It is well received by the population served but the capital cost of equipment is likely to be too high for most practices to afford. The reaffirmation of at least one occult case of glaucoma for every known case is particularly alarming in the absence of a national screening programme and the asymptomatic course of this treatable, blinding disease. Closer cooperation between general practitioners and optometrists will be the practical way ahead for most practices.

An analysis of referral routes and diagnostic accuracy in cases of suspected glaucoma.

Over a nine-month period two hundred and thirteen referrals to the Department of Ophthalmology of the Leicester Royal Infirmary, England, for suspicion of glaucoma were examined by a single ophthalmologist. Ninety-nine percent of referrals resulted from the findings at an optometric visit. Despite this, less than 32% were confirmed as having glaucoma and less than 23% had ocular hypertension. Twenty-nine percent showed no abnormality. Of those with glaucoma 19% showed advanced field loss in their worse eye. The guidelines relating to referral practices as a result of optometric examinations need to be reviewed and agreed upon by ophthalmologists, optometrists and general practitioners.

Management of ophthalmic disease in general practice.

A study was undertaken to investigate the management of ophthalmic conditions in general practice in order to identify areas requiring education and training input. Management of patients with eye disease presenting to 17 Nottingham general practitioners was examined over a 12-month period. Of all patients registered with the participating doctors, 4% presented with eye problems, accounting for 1.5% of all general practice consultations. Children under five years of age had the highest consultation rates, female patients having higher consultation rates than male patients in all age groups. Infective conjunctivitis was responsible for 41% of consultations about eye problems and allergic conjunctivitis for a further 13%; 70% of consultations resulted in a prescription. Corticosteroids were prescribed in 3% of consultations for eye problems; this was considered inappropriate by the study ophthalmologist in over a third of these cases. Patients were referred for further management following 16% of consultations. Thirty nine per cent of referrals to the hospital ophthalmic service were either to an eye casualty department or requested an urgent clinic appointment. While most eye problems are managed solely by general practitioners there is clearly a need for ophthalmic services that can rapidly provide a specialist opinion. However, most eye disease seen in general practice involves the external eye or anterior segment, and the diagnosis may be confidently made using basic ophthalmic history taking and examination skills with non-specialist equipment. The acquisition of these skills should be emphasized at undergraduate level and built upon in later years in postgraduate training.

Demand incidence and episode rates of ophthalmic disease in a defined urban population.

OBJECTIVES: To estimate demand incidence and episode rates of ophthalmic disease in a defined urban population over one year. DESIGN: Study of patients presenting with eye problems to general practice and eye casualty department. SETTING: General practice and ophthalmic services in west Nottingham. SUBJECTS: 36,018 people from the combined practice lists of 17 Nottingham general practitioners. MAIN OUTCOME MEASURES: Ophthalmic disorder, age and sex of patient, and where presented. RESULTS: 587 consultations were recorded for ophthalmic problems, 1771 with general practitioners and 816 with eye casualty. Most consultations to general practice were by females (1066 (60%)), whereas men aged 15-44 accounted for most work in eye casualty. These men commonly presented with trauma. Infective conjunctivitis, the commonest condition, had an episode rate of 13.5/1000 population/year. Demand incidence for cataracts was 1.9/1000 population/year. Demand incidence for chronic conditions increased with age. CONCLUSIONS: As the average age of the population increases demand for ophthalmic services will rise. Planning and provision of resources to meet this increased demand should be considered now.

Study of diagnostic accord between general practitioners and an ophthalmologist.

OBJECTIVES: To identify diagnostic accord and disagreement between general practitioners and an ophthalmologist and thereby determine how undergraduate and non-specialist postgraduate ophthalmic training could be improved. DESIGN: Comparison of diagnosis of presenting conditions by general practitioners and one ophthalmologist in patients consulting general practitioners for ophthalmic problems during March 1989 to February 1990. SETTING: 12 general practices in west Nottingham. PATIENTS: 1474 patients presenting to the study general practitioners with new ophthalmic conditions or new episodes of recurrent conditions. MAIN OUTCOME MEASURES: Diagnoses of general practitioners and ophthalmologist. RESULTS: 1121 (76%) of patients with eye problems agreed to see the ophthalmologist and most were seen within three days. Sufficient data for comparison were available on 1103 patients. Diagnostic agreement was found in 638 cases (58%), but potentially serious misdiagnosis was found in only 15 cases; management in three of these cases would have ensured later identification. Most commonly confused conditions were infective and allergic conjunctivitis, blepharitis, and dry eyes. General practitioners assessed visual acuity in only 114 cases yet eight of the 15 patients seriously misdiagnosed had reduced acuity, an important diagnostic sign. CONCLUSIONS: Most ophthalmic disease seen in general practice does not require specialised equipment for diagnosis. Most cases of misdiagnosis have no serious consequences for the patient. Undergraduate and postgraduate training in ophthalmology should ensure that common conditions can be easily differentiated and more serious conditions identified and referred.

The development of cataract following trabeculectomy.

OBJECTIVE: To determine the risk of cataract development following trabeculectomy. DESIGN: A prospective follow-up study of patients seen pre-operatively and at one, three, six and 12 months following surgery and subsequently at yearly intervals. SETTING: Ophthalmology Department of Nottingham University Hospital. PATIENTS: Fifty-seven patients with primary open angle glaucoma, including pseudoexfoliation, undergoing trabeculectomy. MAIN OUTCOME MEASURES: Increases in lens opacity measured by the Lens Opacity Meter 701, the Keeler Projectoscopy and clinical grading. RESULTS: Of 35 patients seen at six months post-operatively, none had lost two Snellen lines of visual acuity due to lens opacity, although three patients showed evidence of increasing lens opacity on all three parameters. CONCLUSION: There is no evidence of visually significant lens opacity occurring at six months post-operative follow-up.