A prospective outcome study of membranous and solid distal common canalicular obstructions.

PURPOSE: To prospectively evaluate the surgical outcomes of membranous and solid distal common canalicular obstructions (CCOs) following endoscopic dacryocystorhinostomy (EnDCR) and lacrimal intubation combined with either membranotomy or trephination. METHODS: This was a prospective, non-randomized, consecutive interventional case series. Inclusion criteria included patients undergoing EnDCR with evidence of a membranous block or more solid obstruction of the distal common canaliculus, treated with membranotomy or canalicular trephination. Complete CCO was confirmed pre-operatively using dacryocystography and dacryoscintigraphy. All patients received bicanalicular intubation for 3 months with a minimum follow-up of 12 months. Functional and anatomical success was assessed at 4 weeks, 3 months, and 12 months following surgery. Functional success was defined as subjective improvement of epiphora and anatomical success as the presence of a patent ostium and a positive dye test on nasal endoscopy. RESULTS: Twenty-nine patients were included in the study with a mean age of 58 years. Twenty-one patients (72%) received a membranotomy and eight (28%) required trephination. At 12 months, the functional and anatomical success rate in the membranotomy group was 90% (19/21) and 100% (21/21), respectively, and in trephination group the functional and anatomical success rate was 63% (5/8). There were no intra-operative or lacrimal stent-related complications. CONCLUSIONS: Identifying and excising distal CCOs in association with EnDCR and lacrimal intubation is associated with a high degree of functional (83%) and anatomical (90%) success. The success of membranous obstructions appear be superior to outcomes for solid obstructions of the distal common canaliculus that require trephination.

Paroxysmal raised intracranial pressure associated with spinal meningeal cysts.

Raised intracranial pressure in association with spinal meningeal cysts has rarely been reported. We describe four patients in whom evidence of paroxysmal raised intracranial pressure was found in association with spinal meningeal cysts. Cerebrospinal fluid diversion procedures have previously been shown to relieve local symptoms due to spinal cysts. In our patients symptoms of paroxysmal headache were alleviated by this method, suggesting a causal relationship with the raised pressure. This association may be an under diagnosed cause of paroxysmal headaches. We review the medical literature on the classification of spinal meningeal cysts, evaluate the theories of their origin and offer suggestions on the pathogenesis of the abnormal CSF dynamics that may allow an interplay between raised intracranial pressure and spinal meningeal cysts to produce paroxysmal symptoms.

Acute post-operative rhinosinusitis following endonasal dacryocystorhinostomy.

PURPOSE: To investigate the incidence and risk factors for acute rhinosinusitis (ARS) following endoscopic dacryocystorhinostomy (EnDCR). METHODS: Retrospective 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. Pre-operative lacrimal and sinonasal clinical assessment and imaging, intraoperative endoscopic video recording, and post-operative clinical and endoscopic findings were analysed for cases of ARS occurring within the first 4 weeks following DCR among patients with and without a past history of chronic rhinosinusitis (CRS). Surgical complications and outcomes at 12 months and management of ARS are reported. RESULTS: 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. DISCUSSION: The rate of ARS following EnDCR was 1.5%. In those with a prior history of CRS, it was 15% (P=0.009). 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.

Turn-over orbital septal flap and levator recession for upper-eyelid retraction secondary to thyroid eye disease.

BACKGROUND: 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 (ULR) associated with thyroid eye disease (TED) causing symptomatic exposure keratopathy (EK). METHODS: Retrospective, multicenter study of 12 eyelids of 10 patients with TED undergoing a transcutaneous levator-lengthening technique using the reflected orbital septum (OS) as a spacer. Change in palpebral aperture (PA) and contour, position of the skin crease (SC), symptoms of EK, and complications were recorded. RESULTS: The average age was 47.5 years. Two patients were excluded, as their septa were found to be very thin at surgery. At an average of 13 months postoperatively, the PA was reduced by 2.5 mm on average (P<0.001) and was within 1 mm of the contralateral eyelid in 11 cases (92%); the position of the SC was within 1 mm of the desired position in all cases. EK resolved in all cases. Complications included one case of overcorrection and one case of recurrent lateral flare. CONCLUSIONS: The turn-over orbital septal flap technique may be a viable option as an autogenous spacer for the treatment of ULR in TED. This technique may be possible in cases where the OS has been opened by previous surgery but may not be feasible in patients in whom the septum is very thin.

Patient-reported benefit from oculoplastic surgery.

PURPOSE: It is vital that surgeons undertaking oculoplastic procedures are able to show that the surgery they perform is of benefit to their patients. Not only is this fundamental to patient-centred medicine but it is also important in demonstrating cost effectiveness. There are several ways in which benefit can be measured, including clinical scales, functional ability scales, and global quality-of-life scales. The Glasgow benefit inventory (GBI) is an example of a patient-reported, questionnaire-based, post-interventional quality-of-life scale that can be used to compare a range of different treatments for a variety of conditions. METHODS: A cross-sectional study was undertaken using the GBI to score patient benefit from four commonly performed oculoplastic procedures. It was completed for 66 entropion repairs, 50 ptosis repairs, 41 ectropion repairs, and 41 external dacryocystorhinostomies (DCR). The GBI generates a scale from -100 (maximal detriment) through zero (no change) to +100 (maximal benefit). RESULTS: The total GBI scores of patients undergoing surgery for entropion, ptosis, ectropion, and external DCR were: +25.25 (95% CI 20.00-30.50, P<0.001), +24.89 (95% CI 20.04-29.73, P<0.001), +17.68 (95% CI 9.46-25.91, P<0.001), and +32.25 (95% CI 21.47-43.03, P<0.001), respectively, demonstrating a statistically significant benefit from all procedures. CONCLUSION: Patients derived significant quality-of-life benefits from the four most commonly performed oculoplastic procedures.

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.

Optic neuritis: a review.

Acute demyelinating optic neuritis (ON) is the initial presentation in approximately 20% of cases of multiple sclerosis (MS) and is characterized by unilateral, subacute, painful visual loss without systemic or neurological symptoms. The Optic Neuritis Treatment Trial (ONTT) has provided valuable insights into both the natural history and clinical course of demyelinating ON with respect to treatment. Visual function improves spontaneously over weeks and within 12 months 93% have recovered to a visual acuity of at least 20/40. Treatment with high-dose corticosteroids may accelerate visual recovery, but has little impact on long-term visual outcome. In the ONTT the 10-year risk of recurrence of demyelinating ON was 35%. The presence of white matter lesions on the initial magnetic resonance image of the brain has been identified as the strongest predictor for the development of MS. The 15-year risk of developing MS in the ONTT was 25% with no lesions, but 75% with one or more lesions. Since there is evidence of early axonal damage in acute demyelinating ON, disease-modifying drugs should be considered in patients at high risk of developing MS in the future as prophylaxis against permanent neurological impairment.

Age-related changes in the normal sagittal relationship between globe and orbit.

PURPOSE: To establish the pattern of change in globe protrusion with advancing age. The findings contribute to our understanding of orbital ageing, and are useful in the longitudinal assessment of patients with orbital disease, craniofacial abnormalities and trauma. METHODS: Ocular protrusion from the lateral orbital rim to the corneal apex was measured in 653 Caucasians aged 21-80 years. Healthy subjects only were included in the study excluding those with ocular or orbital diseases. Measurements were taken using a single instrument and observer. Data were analysed for both sexes and each eye separately. RESULTS: The mean exophthalmometry reading in both sexes (318 female and 335 male) was 19+/-2mm. Ninety-eight percent of readings between the two eyes were within 1mm of each other and no subject had greater than 2mm of asymmetry. In all groups there was a negative linear correlation between ocular protrusion and age. This correlation was found to be highly statistically significant in all groups (r=0.56-0.65, p<0.0001). There was no statistically significant difference between change in ocular protrusion with age between the left and right eye for females or males. This study demonstrates a strong association between ocular protrusion and age in a Caucasian population. This association is an almost linear reduction in ocular protrusion with increasing age between the ages of 31 and 80. Asymmetry in ocular protrusion between the two eyes does not develop with increasing age.

B Cell lymphoma of the brain stem masquerading as myasthenia.

A 54 year old man is described with signs compatible with ocular myasthenia gravis and an apparent excellent response to pyridostigmine. Subsequent clinical progression and further investigation suggested the presence of an inflammatory brain stem lesion, which responded to corticosteroid therapy. Clinical relapse, including the development of central neurogenic hyperventilation, led to a brain stem biopsy, confirming a diagnosis of B cell lymphoma. This case illustrates the propensity of primary CNS lymphoma (PCNSL) to mimic other conditions. Brain MRI is mandatory in presumed "test negative" ocular myasthenia with atypical clinical findings. Spontaneous regression of PCNSL or response to corticosteroids is common and should not mitigate against the diagnosis. Histopathological confirmation should ideally be made before starting therapy, as this may obscure or delay the correct diagnosis. Although PCNSL is rare, it must be considered in all patients with brain stem syndromes, and in all patients 50 years or older with contrast enhancing focal lesions.

Ataxia in the setting of complicated enteropathy: double jeopardy.

The differential diagnosis of subacute onset ataxia in the setting of enteropathy is wide. A 54 year old patient with a pancerebellar syndrome and known ulcerative jejunoileitis is described. Small bowel biopsy showed evidence of enteropathy associated T cell lymphoma and subsequent neuropathological analysis and immunophenotyping confirmed metastasis of this tumour to the cerebellum. The presence of anti-gliadin antibodies and MRI evidence of a more longstanding process suggested additional immunologically mediated cerebellar dysfunction. Lymphomatous involvement of the CNS is rare in patients with complicated enteropathies, and has not been previously reported to involve the cerebellar parenchyma. This diagnostic possibility should be borne in mind before attributing cerebellar dysfunction in patients with the coeliac related enteropathies to nutritional compromise or immunological dysfunction (gluten ataxia) alone.