Are ethnicity, social grade, and social deprivation associated with severity of thyroid-associated ophthalmopathy?

PURPOSE: Previous studies have extensively investigated the pathophysiology, genetics, and lifestyle risk factors of thyroid-associated ophthalmopathy (TAO). The aim of this study was to investigate the independent contribution of ethnic origin, social grade, and level of social deprivation to TAO severity in a large, multiethnic, and urban population. METHODS: Retrospective case note review of all TAO patients seen at Birmingham and Midland Eye Centre, United Kingdom over a 14-year period. Ethnicity (White, Asian, or Black) was recorded, and residence postcode was used to determine social grade (National Readership Survey classification) and level of social deprivation (Index of Multiple Deprivation 2007). TAO severity was defined by European Group on Graves' Orbitopathy criteria. Moderate-to-severe: necessity for TAO treatment with oral or intravenous steroid, long-term immunosuppressants, or orbital radiotherapy. Sight-threatening: presence of dysthyroid optic neuropathy (DON) or need for urgent orbital decompression surgery. Multivariable logistic regression was performed to measure the independent influence of ethnicity, social grade, and social deprivation on indicators of severe TAO. RESULTS: Lower social grade was significantly associated with increased odds ratio (OR) of TAO patients having severe TAO, including treatment with oral (OR: 2.3 (95% CI 1.1-5.1) p = 0.03) and intravenous steroid (OR: 2.6 (95% CI 1.0-7.0) p = 0.04) and DON (OR: 4.0 (95% CI 1.2-12.7) p = 0.02), compared with those of highest social grade. Similar results were observed for social deprivation. Ethnicity had no independent association with any measure of TAO severity. CONCLUSIONS: In this cohort, lower social grade and higher social deprivation, but not ethnicity, had independent, statistically significant association with more severe TAO.

Postoperative infection rate after dacryocystorhinostomy without the use of systemic antibiotic prophylaxis.

PURPOSE: To evaluate the postoperative infection rate after external dacryocystorhinostomy (DCR) without routine systemic antibiotic prophylaxis. METHODS: Retrospective review of case notes, including eye casualty attendances, of 77 patients undergoing 82 consecutive external DCR procedures between 22 December 2006 and 31st December 2009 performed by one of the authors (O. M. Durrani) at a single centre (The Birmingham and Midland Eye Centre, United Kingdom). Patients were given topical Maxitrol eye drops (dexamethasone 0.1%, neomycin 3.5 mg and polymixin B sulphate 10,000 units) three times a day for 1 week postoperatively but no systemic antibiotics. RESULTS: Postoperative infection occurred in one of 82 cases (1.2%, 95% confidence interval 0.03-6.6%). The one case of infection consisted of superficial wound infection only and was managed with oral antibiotics and resolved with a successful outcome. Thirteen out of 87 cases were performed in patients with recurrent dacryocystitis or mucocoeles; none of these cases were complicated by postoperative infection. CONCLUSIONS: Postoperative infection after external DCR without the use of systemic antibiotics is uncommon. Assuming that oral antibiotics are 80% effective at treating postoperative infection, for routine prophylaxis, the number needed to treat to prevent one infection would be 104. Taking the upper confidence limit of 6.6%, the lower limit of the number needed to treat would be 19. The one case of infection was treated successfully with oral antibiotics and resolved with a successful outcome. These results suggest that the routine use of systemic antibiotic prophylaxis in external DCR may not be justified.

TIRAP Ser180Leu polymorphism is associated with Behcet's disease.

OBJECTIVES: The initiating cause of Behçet's disease (BD) is unknown, but an aberrant response to infection has been suggested. In this study, single nucleotide polymorphisms in Toll-like receptors (TLRs) and associated molecules that have a sentinel function at mucosal surfaces were analysed in patients with BD. METHODS: TLR expression was determined by immunohistochemistry in buccal mucosal tissue from patients with BD, in tissue from patients with lichen planus (LP) or pyogenic granuloma (PG) as disease controls, or from healthy individuals. Using SSP-PCR we analysed SNP in CD14, TLR2, TLR4 and TIRAP (TIR domain-containing adaptor protein) in patients with BD from different geographical regions. RESULTS: TLR expression was increased in buccal lesions from patients with BD compared with healthy controls; however, a similar increase was seen in lesion tissue from patients with LP or PG, suggesting that this was a generalized inflammatory response as opposed to a BD-specific response. SNP analysis showed no association between CD14, TLR2 or TLR4 polymorphisms. However, TIRAP 180Leu was significantly associated with BD in UK, but not Middle Eastern, patients. CONCLUSION: TLR expression showed no difference in tissue from patients with BD compared with either disease or healthy controls. Likewise, SNPs in TLR genes were no different from healthy controls. The association with the increased function variant of TIRAP suggests that encounter with a pathogen at mucosal sites will lead to increased cytokine production and tissue damage with persistence of mucosal lesions.

Outcome of deep lateral wall rim-sparing orbital decompression in thyroid-associated orbitopathy: a new technique and results of a case series.

PURPOSE: To describe a new technique for deep lateral (single) wall orbital decompression surgery, developed by Mr. Geoffrey Rose, for proptosis in patients with thyroid-associated orbitopathy and to analyse the results achieved in our series. METHODS: The study is an interventional, retrospective, non-comparative case series. Twenty-one eyes of seventeen patients underwent the described technique of deep lateral wall orbital decompression for thyroid-associated orbitopathy. All patients had controlled thyroid functions and underwent surgery for cosmetic rehabilitation, with analysis of the reduction in proptosis, changes in visual acuity and post-operative complications. The surgery involved removing the lateral orbital wall whilst preserving the lateral rim, the lateral wall being approached through a horizontal skin incision placed lateral to the lateral canthus. After reflecting the periosteum, most of the bone (deep lateral wall) between the skull base and inferior orbital fissure is removed. RESULTS: A mean reduction in proptosis of 4.81 mm ± 1.23 (SD) (p < 0.0001) with a median of 5.0 mm (range 3-7 mm) was achieved and the best-corrected visual acuity was maintained in all patients. There were no complications during surgery, and post-operative complications included worsening of pre-existing diplopia in one patient (6%) and transient cheek/temple numbness seen in three patients (18%). CONCLUSIONS: This technique of deep lateral wall orbital decompression developed by Mr. Rose is a safe and effective procedure for patients with mild to moderate proptosis. It carries a low risk of morbidity and avoids complications associated with decompressing the floor and medial wall, including new onset of motility disorders.

Angiomatous meningioma of orbit mimicking as malignant neoplasm: a case report and literature review.

Angiomatous meningioma is a rare and distinct meningioma variant characterised with predominance of microvascularcomponent.There are few reported cases in literature with limited information on ophthalmic manifestations and radiological findings. There is no consistent feature reported so far of this neoplasm to aid in its diagnosis. Authors report an interesting case of Angiomatous Meningioma presenting as an aggressively expanding orbital mass lesion with adjacent bony destruction mimicking a malignant neoplasm.

High rate of incomplete resection after primary excision of eyelid BCC: multi-staged resection rarely needs more than two procedures.

PURPOSE: Small, well-demarcated, biopsy-proven periocular basal cell carcinomas (BCC) are often excised in a single stage with immediate reconstruction when histology or location is considered low-risk. We investigated margin clearance in patients undergoing primary excision and immediate reconstruction (PER) versus multi-staged fast paraffin excision (MSE) and reviewed risk factors for incomplete excision. METHODS: Retrospective, interventional, comparative case series of periocular BCCs excised over a 3-year period (2006-2008). RESULTS: Ninety consecutive patients with periocular BCC (average age 77 ± 10.1 years, 60% females) were included. 39% (35/90) underwent PER with the remainder managed by MSE (55/90, 61%). Patients undergoing MSE had larger lesions (38% > 10 mm versus 23% PER) which were more likely to involve the medial canthus (25 versus 11% PER). Incomplete histological clearance was noted in 34% (12/35) patients after PER. Only 3/55 (5%) needed third stage of excision in the MSE group with final incomplete excision in two cases (3.6%) that did not undergo a third stage excision. No significant risk factors were found likely to predict residual BCC overall, after first excision stage. Subgroup analysis for patients undergoing PER showed multiple lesions as the only statistically significant factor for incomplete excision. CONCLUSION: This study shows an unacceptably high rate of incomplete resection with primary excision and repair using a standard 3 mm margin. The majority of lesions undergoing multi-stage excision required no more than two stages for complete removal. Multi-stage excision with histological confirmation of clear margins prior to reconstruction is recommended for routine management of all periocular BCC.

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.

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.

Optic nerve sheath meningioma in a patient with choroidal malignant melanoma: a case report of a complex neurocristopathy.

PURPOSE: To describe the clinical findings in a patient who had developed choroidal melanoma and was incidentally found to have meningioma of the optic nerve in the same side. METHODS: Clinical and histopathological findings of the case are reviewed and presented. RESULTS: The patient had a choroidal melanoma of the left eye for which she had initially declined surgery and 2 years later when she underwent an examination, an optic nerve sheath meningioma was incidentally found histologic examination. Both tumours are derived from neural crest cells. CONCLUSION: Complex neurocristopathy, a disorder resulting from aberrations in the growth and development of neural crest derived structures has been very rarely described in the eye and orbit. To the best of our knowledge there has been only one previous case report of a combination of neurofibroma in the right upper lid, meningioma in the right middle cranial fossa and uveal malignant melanoma in the left eye. (However in this patient the tumours were at 3 different sites.).

Incidence of endophthalmitis following vitreoretinal surgery.

AIM: The purpose of this study was to investigate the incidence of postvitreoretinal surgery endophthalmitis in a UK tertiary referral centre. METHODS: Two cases that met the clinical criteria of endophthalmitis following conventional 20-gauge vitreoretinal surgery were included in this retrospective, noncomparative, consecutive case series. RESULTS: The incidence of endophthalmitis between 1 April 1997 and 30 November 2004 was 0.038% (n = 2/5,278). CONCLUSION: The incidence of endophthalmitis following pars plana vitrectomy remains low.

Bicanalicular obstruction in lichen planus: a characteristic pattern of disease.

PURPOSE: Lichen planus, an idiopathic mucocutaneous inflammatory disease, has only once been reported to cause lacrimal drainage obstruction. The authors present a series of patients with epiphora resulting from systemic lichen planus and describe the characteristic pattern of lacrimal canalicular blockage. DESIGN: Retrospective noninterventional case series. PARTICIPANTS: Eight patients (5 women, 3 men) with a median presenting age of 49 years (range, 39-60 years). METHODS: A retrospective review of case notes for patients attending the lacrimal clinic between 1998 and 2005 was performed to identify patients with nontraumatic lacrimal canalicular obstruction. In addition to demographic information, the data collected included a history of periocular herpetic infection, administration of systemic 5-fluorouracil, other causes of canalicular obstruction, the extent of proximal and distal canalicular obstruction (noted during surgery), the type of surgery, and the surgical outcomes. MAIN OUTCOME MEASURES: Identification of patients with biopsy-proven systemic lichen planus who had conjunctival and canalicular disease and documentation of the extent and severity of canalicular obstruction. RESULTS: Of the 184 patients with canalicular obstruction identified during the study period, 8 had lichen planus. Bilateral, bicanalicular involvement was present in 7 of 8 lichen planus patients, with 3 of 8 patients having completely obstructed canaliculi. Primary dacryocystorhinostomy (DCR) with retrograde canaliculostomy was performed in 4 of 8 patients, but all required secondary placement of Lester Jones canalicular bypass tubes. The other 4 patients had either primary DCR alone (both eyes in 1 patient, with solely canalicular stenosis) or DCR with primary placement of Jones tubes (6 eyes in 3 patients). Histologic examination of pericanalicular tissues in 2 patients showed features consistent with lichen planus. CONCLUSIONS: Lacrimal involvement in lichen planus is characterized by severe bilateral bicanalicular occlusion involving most of the length of affected canaliculi, and placement of a Jones canalicular bypass tube is generally required to control symptoms.

Characterisation of 11beta-hydroxysteroid dehydrogenase 1 in human orbital adipose tissue: a comparison with subcutaneous and omental fat.

Glucocorticoids (GCs) have a profound effect on adipose biology increasing tissue mass causing central obesity. The pre-receptor regulation of GCs by 11beta-hydroxysteroid dehydrogenase type 1 (11beta-HSD1) that activates cortisol from cortisone has been postulated as a fundamental mechanism underlying the metabolic syndrome mediating adipocyte hyperplasia and hypertrophy in the omental (OM) depot. Orbital adipose tissue (OF) is the site of intense inflammation and tissue remodelling in several orbital inflammatory disease states. In this study, we describe features of the GC metabolic pathways in normal human OF depot and compare it with subcutaneous (SC) and OM depots. Using an automated histological characterisation technique, OF adipocytes were found to be significantly smaller (parameters: area, maximum diameter and perimeter) than OM and SC adipocytes (P<0 x 001). Although immunohistochemical analyses demonstrated resident CD68+ cells in all three whole tissue adipose depots, OF CD68 mRNA and protein expression exceeded that of OM and SC (mRNA, P<0 x 05; protein, P<0 x 001). In addition, there was higher expression of glucocorticoid receptor (GR)alpha mRNA in the OF whole tissue depot (P<0 x 05). Conversely, 11beta-HSD1 mRNA together with the markers of late adipocyte differentiation (FABP4 and G3PDH) were significantly lower in OF. Primary cultures of OF preadipocytes demonstrated predominant 11beta-HSD1 oxo-reductase activity with minimal dehydrogenase activity. Orbital adipocytes are smaller, less differentiated, and express low levels of 11beta-HSD1 but abundant GRalpha compared with SC and OM. OF harbours a large CD68+ population. These characteristics define an orbital microenvironment that has the potential to respond to sight-threatening orbital inflammatory disease.

Postcataract endophthalmitis: incidence and microbial isolates in a United Kingdom region from 1996 through 2004.

PURPOSE: To investigate the incidence of endophthalmitis after cataract surgery, analyze the microbiologic spectrum of infecting organisms, and assess the diagnostic utility of an anterior chamber paracentesis and vitreous biopsy. SETTING: United Kingdom tertiary referral center used by 13 operating suites. METHODS: A retrospective noncomparative consecutive series comprised 105 postcataract endophthalmitis cases. RESULTS: The annual mean incidence of endophthalmitis over the study period was 0.099% (101/101 920) [corrected] and there was no significant increase in the incidence during the study. The culture-positive rate was 58.1% (61/105). Gram-positive microbes were isolated in 93.4% of cases (57/61), with coagulase-negative staphylococci accounting for 62.3% (38/61). Anterior chamber taps yielded positive cultures in 25.7% of cases, and vitreous biopsy was positive in 53.4%. CONCLUSIONS: The incidence of endophthalmitis in this region of the United Kingdom remained stable, with gram-positive microbes accounting for 93.4% of the isolates. A combination of anterior chamber tap and vitreous biopsy should be performed in suspected cases of endophthalmitis.

Analysis of stone disease in morbidly obese patients undergoing gastric bypass surgery.

BACKGROUND AND PURPOSE: Recent studies have demonstrated a higher incidence of nephrolithiasis in the morbidly obese. Nephrolithiasis also has been described as a potential outcome after gastric bypass surgery. This is the first study to our knowledge that examines the incidence of nephrolithiasis in the morbidly obese in the setting of gastric bypass surgery at a tertiary referral center. PATIENTS AND METHODS: We retrospectively reviewed the records of patients undergoing laparoscopic gastric Roux-en-Y bypass surgery for morbid obesity at our institution for the incidence of nephrolithiasis preoperatively, de novo stones postoperatively, and both preoperative and postoperative stone formation. RESULTS: Of the 972 patients who underwent a laparoscopic gastric bypass for the treatment of morbid obesity between 1990 and the present, 85 (8.8%) were found to have upper urinary-tract calculi preoperatively, and 32 (3.2%) had de novo stones postoperatively. Of those 85 who had stones preoperatively, 26 (31.4%) developed recurrent stones postoperatively. CONCLUSIONS: These results support findings in the current literature that nephrolithiasis has a higher incidence in the morbidly obese population. The combination of preoperative stone history and gastric bypass surgery may place patients at a higher risk of future stone formation. This latter group of patients should be screened for postoperative stone formation.

Fronto-orbital mucocele and orbital involvement in occult obstructive frontal sinus disease.

AIMS: To describe the clinical features of orbital involvement arising from occult obstructive frontal sinus disease and to highlight key features to aid diagnosis. METHODS: A retrospective review of the case notes of 15 patients who presented to three regional oculoplastics units over a 7-year period were reviewed. Patient demographics, clinical characteristics, relevant medical history, microbiology results, imaging, management and outcomes were assessed. RESULTS: The mean age of our patients was 55 years. Pain was the presenting feature in 8 patients while 14 presented with upper lid swelling and redness. This swelling was medial in 60% and diffuse in 40% of patients. Proptosis was noted in 11 patients. The correct diagnosis was suspected in only 53% of patients at the time of first presentation to an ophthalmologist. The mean time from onset of symptoms to the time of correct diagnosis was 53 weeks (median 3 weeks). On direct questioning, eight patients reported a previous history of intermittent upper lid swelling and eight patients had a past history of sinusitis or frontal sinus trauma. CONCLUSIONS: We present a large series of patients with occult sinus disease presenting with orbital involvement. As patients with this potentially life-threatening condition are often misdiagnosed, we hope this paper draws the ophthalmologist's attention to key pearls in the history and examination to make a prompt diagnosis.

Multiplex bead immunoassay analysis of aqueous humor reveals distinct cytokine profiles in uveitis.

PURPOSE: To extensively characterize the complex network of cytokines present in uveitis aqueous humor (AqH), and the relationships between cytokines and the cellular infiltrate. METHODS: AqH from noninflammatory control subjects and patients with idiopathic, Fuchs' heterochromic cyclitis (FHC), and herpes-viral or Behçet's uveitis were analyzed for IL-1beta, -2, -4, -5, -7, -8, -10, -12, -13, -15, TNFalpha, IFNgamma, CCL2 (MCP-1), CCL5 (RANTES), CCL11 (Eotaxin), TGFbeta2, and CXCL12 (SDF-1), using multiplex bead immunoassays. The cellular infiltrate was also determined for each sample. RESULTS: Idiopathic uveitis AqH, compared with noninflammatory controls, was characterized by high levels of IL-6, IL-8, CCL2 and IFNgamma, the levels of which correlated with each other. For IL-6 and IL-8 these levels were proportional to the number of neutrophils present. By contrast, the levels of both TGFbeta2 and CXCL12 decreased in idiopathic uveitis AqH with increasing inflammation. Cluster analysis showed a degree of segregation between noninflammatory and idiopathic uveitis AqH. Further examination using random forest analysis yielded a complete distinction between these two groups. The minimum cytokines required for this classification were IL-6, IL-8, CCL2, IL-13, TNFalpha, and IL-2. CONCLUSIONS: Application of multiplex bead immunoassays has allowed us to identify distinct patterns of cytokines that relate to both clinical disease and the cellular infiltrates present. Bioinformatics analysis allowed identification of cytokines that differentiate idiopathic uveitis from noninflammatory control AqH and are likely to be important for the pathogenesis of uveitis.

Hand-assisted laparoscopic nephroureterectomy with open cystotomy for removal of the distal ureter and bladder cuff.

BACKGROUND AND PURPOSE: While performing laparoscopic nephroureterectomy, different techniques are used for removal of the distal ureter and bladder cuff. We present a series of patients with urothelial carcinoma of the renal pelvis or ureter who underwent hand-assisted laparoscopic nephroureterectomy (HALNU) with open cystotomy for removal of the distal ureter and bladder cuff. PATIENTS AND METHODS: From January 2000 to August 2004, 34 patients underwent HALNU. The hand-port device was placed in a lower-midline infraumbilical incision in all cases. After laparoscopic removal of the kidney and ureter down to the bladder, the hand port incision was extended caudally to allow open cystotomy. Intravesical dissection was performed at the ureteral orifice, and the bladder cuff and distal ureter were removed in a traditional open fashion. RESULTS: The mean operative time was 317 +/- 150 (SD) minutes, but the median operative time was 247 minutes. The mean estimated blood loss was 252 +/- 146 mL. The mean length of stay was 7.6 +/- 6.0 days, but the median stay was 5 days postoperatively (range 3-25). The mean morphine equivalent required postoperatively was 33 +/- 22 mg. The time of Foley catheter removal ranged from 3 to 15 days (mean 6.1 +/- 3.8 days), with no cases of extravasation by cystography at removal. Within a mean follow-up of 13.9 months, no recurrence of urothelial carcinoma was seen at the site of the excised ureteral orifice. CONCLUSION: A HALNU utilizing an open cystotomy for removal of the entire distal ureter with a bladder cuff provides excellent oncologic control while not adding significantly to the operative time or the morbidity of the procedure.

Primary anti-phospholipid antibody syndrome (APS): current concepts.

Primary anti-phospholipid syndrome (APS) is a thrombophilic state characterized by recurrent arterial and venous thrombosis, recurrent pregnancy loss, and the presence of circulating anti-phospholipid antibodies that may be responsible for thrombophilia and pregnancy morbidity. Ophthalmologic features are present in 15-88% of the patients with primary APS, thus ophthalmologists are one of the first physicians to whom the patient will present. An accurate diagnosis may save the patient from recurrent, potentially life-threatening thrombosis. In the U.S.A., an estimated 35,000 new cases of APS-related venous thrombosis occur each year in a population that is several decades younger than the patient population typically affected by thrombosis. Clinical features, such as chorea, transverse myelitis, cardiac valvular lesions, and accelerated atherosclerosis, are hypothesized to be due to a direct tissue-antibody interaction and cannot be explained purely by thrombosis. The use of recently proposed, well-defined diagnostic criteria, and better standardization of laboratory assays for the anti-phospholipid antibodies should help enable epidemiological surveys to establish the prevalence of these antibodies in patients with thrombosis and in the general population. Diagnosis of APS should be considered in all patients with recurrent systemic or ocular thrombosis in the absence of known risk factors. Several well-designed prospective studies show an increased risk of thrombosis in the presence of medium to high antibody level. With ocular involvement in as many as 88% of APS patients, an ophthalmic assessment should be an integral part of the clinical work-up of any patient with suspected or confirmed APS. The presence of isolated ocular thrombophilia with persistently elevated anti-phospholipid antibodies or lupus coagulant should confirm the diagnosis of APS. Management of these patients must be a multi-disciplinary effort with either a rheumatologist or a hematologist having the overall responsibility for coordinating treatment and monitoring the patient's immune status and anticoagulation. Treatment of isolated ocular thrombophilia in the presence of moderate to high titers of antiphospholipid antibodies should be on the same principles as patients with APS to prevent recurrent ocular or cerebral thrombosis.

The danger of wearing an anorak.

Campaigns to reduce road traffic accidents have paid little attention to the way headgear could interfere with vision. Binocular visual field measurement was undertaken in six healthy volunteers wearing four different types of anorak. All four anoraks greatly reduced the horizontal and superior field of vision. The anorak producing the worst reduction resulted in a width of vision of 99 degrees and only 15 degrees of vision above eye level, versus 167 degrees and 52 degrees respectively without an anorak. Anorak wearers should turn their heads to look sideways before crossing the road.

Patient information in Graves' disease and thyroid-associated ophthalmopathy: readability assessment of online resources.

BACKGROUND: The Internet is a vital source of information for patients hoping to learn more about their disease. Health literacy of the general population is known to be poor, with the U.S. Department of Health and Human Services (USDHHS) recommending that patient-oriented literature be written at a fourth- to sixth-grade reading level to optimize comprehensibility. In this study we assessed the readability of online literature specifically for Graves' disease (GD) and thyroid-associated ophthalmopathy (TAO). METHODS: Readability of the content of the top 20 English-language GD patient-oriented online resources and top 30 of the equivalent TAO resources returned by Google search was analyzed. Web pages were identified using the Google search terms "Graves' disease" and "Thyroid-Associated Ophthalmopathy," respectively. Extraneous text (e.g., hyperlinks, affiliations, disclaimers) was removed. Relevant text proceeded to readability analysis using four validated measures: Flesch Reading Ease Score, Flesch-Kincaid Grade Level, Simple Measure of Gobbledygook, and Gunning-Fog Index. Readability was compared with USDHHS standards. RESULTS: Overall, median word count (with interquartile range [IQR] and range) was 990 (IQR 846, 195-3867), with a median of 18 words per sentence (IQR 4.0, 7.5-28). Median Flesch Reading Ease Score was 46 (IQR 13, 24-64), Flesch-Kincaid Grade Level 11 (IQR 3.0, 7.2-17), Simple Measure of Gobbledygook 13 (IQR 2.0, 9.6-17), and Gunning-Fog Index 13 (IQR 3.0, 9.2-19), each equivalent to a reading level of >11th grade and "difficult" on the USDHHS classification. None of the web pages evaluated had readability scores in accordance with published guidelines. There was no significant difference with the country of origin of each web page, website commercial status, or with pages predominantly focused on GD or TAO. CONCLUSIONS: Readability scores for online GD and TAO patient-focused materials are inferior to those recommended. Screening of this online material, as well as subsequent revision, is crucial to increase future patient knowledge, satisfaction, and compliance.