Developmental Cysts of the Orbit With Mixed Conjunctival and Cutaneous Epithelial Phenotypes.

AIM: To describe the characteristics of patients presenting with congenital orbital cysts containing epithelia of both cutaneous phenotype-that is, epidermis with or without keratin, and at least one dermal structure (sweat gland or pilosebaceous unit)-and conjunctival phenotype (with goblet cells); these cysts with mixed lining are termed "dermo-conjunctival" cysts. PATIENTS AND METHODS: Review of clinical records for patients having dermo-conjunctival cysts that were treated between 1997 and 2017; patients with cysts of solely conjunctival or solely cutaneous origin were omitted. Data recorded included gender, age at presentation, laterality, orbital location, ophthalmic features, surgical and radiological data, and light microscopic findings. RESULTS: Of 241 patients with congenital orbital cysts, 22 (9%) contained both cutaneous and conjunctival epithelium; unlike the relatively common congenital cysts lined with solely cutaneous epithelia, these dermo-conjunctival cysts typically occupied the superonasal or nasal quadrants of the orbit (p < 0.000001). Fifteen (68%) of the 22 patients were male, and the group presented at a median age of 22 years (range 8-51 years), with symptoms for a median duration of 5 years (range 1 month-33 years). Fourteen (64%) had noted an orbital mass, 3 (14%) had inflammatory pain, and 1/22 (4%) had reduced acuity. Globe displacement was axial in 7 patients (32%) and nonaxial in 13 (59%), and ocular motility was restricted in 4/22 (18%). Of 17 patients with imaging, 9 (53%) had bone expansion, and the cyst was intimately related to the trochlea in 10 (59%). By definition, all cysts contained conjunctival epithelium with goblet cells: hair shafts were present in 13/22 (59%) specimens, sebaceous units in 18 (82%), sweat glands in 6 (27%), and keratinized epithelium was present in 8 (36%). Fourteen (63%) of cysts had mild chronic inflammation within the cyst wall, and granulomas were present in 8 (36%). CONCLUSION: Congenital dermo-conjunctival orbital cysts are rare and favor a medial location-this suggesting an origin from sequestered caruncular tissues, the only postseptal source of both dermal and conjunctival structures. Unlike pure cutaneous cysts that typically present as superficial masses in childhood, dermo-conjunctival cysts are often postseptal and present in adults.

Disruptive behavior in a high-power distance culture and a three-dimensional framework for curbing it.

BACKGROUND: Disruptive behavior can harm high-quality care and is prevalent in many Western public health systems despite increasing spotlight on it. Comparatively less knowledge about it is available in Asia, a region commonly associated with high-power distance, which may limit its effectiveness in addressing disruptive behavior. PURPOSE: The aim of this study was to develop a comprehensive framework for tackling disruptive behavior among health care professionals in a public health system. METHODOLOGY: A nationwide cross-sectional study relying on the Nurse-Physician Relationship Survey was conducted in Singapore. Four hundred eighty-six public health care professionals responded. RESULTS: Two hundred ninety-eight doctors (95.5%) and 163 nurses (93.7%) had witnessed a form of disruptive behavior. Doctors observed disruptive behavior committed by other doctors and nurses much more frequently than did nurses. Doctors made stronger associations between disruptive behavior and negative employee outcomes and between disruptive behavior and negative patient outcomes. Qualitative analyses of participants' open-ended answers produced a multipronged three-dimensional approach for tackling disruptive behavior: (a) deterrent measures, (b) development of knowledge and skills, and (c) demonstration of organizational commitment through proper norms, empathizing with staff, and structural reforms. PRACTICE IMPLICATIONS: Disruptive behavior is a multifaceted problem requiring a multipronged approach. Our three-dimensional framework is a comprehensive approach for giving health care professionals the capability, opportunity, and motivation to address disruptive behavior effectively.

Visual recovery after small incision lenticule extraction (SMILE) in relation to pre-operative spherical equivalent.

PURPOSE: To assess visual recovery after small incision lenticule extraction (SMILE) in relation to pre-operative spherical equivalent. METHODS: Two hundred fourteen eyes of 107 patients were enrolled. Following surgery, patients were examined pre-operatively, 1 day, 2 weeks, 1 month and 3 months later. High myopia was defined as pre-operative spherical equivalent ≤ - 5 D. A linear mixed-effects model was used. RESULTS: Mean ± standard deviation pre-operative spherical equivalent was - 5.30 ± 1.36 D that reduced significantly to 0.04 ± 0.70 D (p < 0.001) at 1 month and - 0.02 ± 0.66 D (p < 0.001) at 3 months. Mean pre-operative LogMAR uncorrected distance visual acuity ± SD was 0.97 ± 0.09 that improved significantly to 0.04 ± 0.06 at 2 weeks (p < 0.001), 0.01 ± 0.04 at 1 month (p < 0.001) and 0.01 ± 0.04 at 3 months (p < 0.001). Eighty-eight eyes (41.2%) had uncorrected distance visual acuities of 0.0 at 1 day, 154 eyes (72.0%) at 2 weeks,194 eyes (90.7%) at 1 month and 199 eyes (93.0%) at 3 months. Significantly more eyes with low myopia (> - 5 D) achieved acuities of 0.0 at 1 day and 2 weeks (p = 0.041 and p < 0.001). Post-operative acuities were not associated with refractive targets, laser cut energy settings or other variables. Two hundred nine eyes (97.7%) were within ± 0.5 D of target and 213 eyes (99.5%) were within ± 1 D. CONCLUSIONS: SMILE for low myopia had faster visual recovery in the early post-operative period with no significant differences between groups detected by 1 and 3 months.

Small incision lenticule extraction (SMILE) lenticule thickness readout compared to change in axial length measurements with the IOLMaster.

PURPOSE: To compare theoretical values from the small incision lenticule extraction (SMILE) lenticule thickness readout with change in axial length measurements taken with the IOLMaster. METHODS: We prospectively studied 214 eyes from 107 patients undergoing bilateral SMILE surgery for myopia or myopic astigmatism between December 2014 and May 2017 at an ophthalmological practice in Singapore. All eyes were examined pre-operatively and 1 and 3 months post-operatively with the IOLMaster following SMILE surgery. Achieved lenticule thickness was taken as the change in axial length after surgery. A linear mixed-effects model was used to examine changes in axial length, spherical equivalent and acuity over time. The relationships between change in axial length and theoretical lenticule thickness and spherical equivalent were examined with multiple linear regression analyses, and model prediction was assessed with adjusted R2 statistics. RESULTS: Mean (95% confidence interval [CI]) spherical equivalent pre-operatively was - 5.25 (95% CI - 5.38 to - 5.12) diopters (D), at 1 month was 0.04 (95% CI - 0.09 to 0.17) D (p < 0.001), and at 3 months was - 0.02 (95% CI - 0.15 to 0.11) D (p < 0.001). Mean (95% CI) pre-operative axial length was 27,726 (95% CI 25,595 to 25,857) µm. Post-operative axial length at 1 month was significantly shorter at 25,595 (95% CI 25,464 to 25,726) µm (p < 0.001) with no change thereafter (p = 0.647). Pre-operative mean ± standard deviation (SD) refractive target was 0.24 (± 0.3) D, and mean difference between target and post-operative spherical equivalent at 1 month was 0.20 D (95% CI 0.16 to 0.25 D, p < 0.001). Multiple regression analysis showed that change in axial length at 1 month was, on average, 5% lower than theoretical lenticule thickness, indicating an average difference of 5.4 µm (95% CI 5.2 to 5.6 µm). Preoperative spherical equivalent predicted negative association with change in axial length at 1 month (ß = - 14.8, 95% CI - 18.2 to - 11.3, adjusted R2 = 0.457, p < 0.001). CONCLUSIONS: Calculated lenticule thickness values were less than expected, and post-operative refractive outcomes at 1 month showed a slight under-correction. Further research in this area is needed to validate these findings.

Congenital respiratory epithelial cysts of the orbit: a rare cause of major orbital impairment.

Congenital respiratory epithelial cysts of the orbit are rare lesions with few reported cases. Extensive disease may cause an orbital apex syndrome, resulting in significant visual loss. Two such cases were described, the risk factors associated with surgical morbidity were identified, and the embryological origins of these cysts were reviewed.

Assessment of axial length before and after myopic LASIK with the IOLMaster.

PURPOSE: To assess the relationship between theoretical ablation depth and axial length change after LASIK with the IOLMaster (Carl Zeiss Meditec, Dublin, CA). METHODS: Ninety-nine eyes were examined preoperatively and 1 and 3 months after LASIK. RESULTS: Mean ± standard deviation (SD) spherical equivalent before LASIK was -4.06 ± 1.91 diopters (D). Mean ± SD ablation depth was 83.13 ± 30.31 µm. Mean ± SD postoperative axial length of 25.11 ± 0.14 mm at 1 month was significantly shorter than mean ± SD preoperative axial length of 25.20 ± 0.14 mm (P < .001) with no subsequent change thereafter (P = .450). An increase in ablation depth of 1 µm led to a decrease in axial length of 0.00118 ± 0.00005 mm. Ablation depth correlated strongly with change in axial length (adjusted R(2) = 0.9039). CONCLUSIONS: The IOLMaster showed a decrease in axial length after LASIK that correlated well with theoretical ablation depth.

The Behavioral Factors That Influence Person-Centered Social Care: A Literature Review and Conceptual Framework.

The last decade has seen numerous policy reforms to emplace person-centered social care. Consequently, the public has been given more information, choice, and autonomy to decide how best they want to be cared for later in life. Despite this, adults generally fail to plan or prepare effectively for their future care needs. Understanding the behavioral antecedents of person-centered decision-making is thus critical for addressing key gaps in the provision of quality social care. To this end, we conducted a literature review of the psychological and health sciences with the aim of identifying the aspects that influence person-centered decision-making in social care. Using an established theoretical framework, we distilled nine behavioral factors-knowledge, competency, health, goal clarity, time discounting, familiarity, cognitive biases, cognitive overload, and emotion-associated with "Capability," "Opportunity," "Motivation," and "Behavior" that explained person-centered decision-making in social care. These factors exist to different degrees and change as a person ages, gradually impacting their ability to obtain the care they want. We discuss the role of carers and the promise of shared decision-making and conclude by advocating a shift from personal autonomy to one that is shared with carers in the delivery of quality social care.

The Schizophrenia Cognition Rating Scale: validation of an interview-based assessment of cognitive functioning in Asian patients with schizophrenia.

Growing interest in cognitive deficits associated with schizophrenia has led to the need for a clinician-friendly cognitive instrument. The Schizophrenia Cognition Rating Scale (SCoRS), recognized for its brevity and ease of administration, has proven to be a valid and reliable measure of overall cognition in schizophrenia patients. However, there has been no such validation in an Asian context. This SCoRS validation study involved 103 patient and 48 control subjects within an Asian population. Test-retest reliability, sensitivity of the instrument to cognitive differences between patients with schizophrenia and healthy controls as well as validity by comparing with a standardised performance-based cognitive battery, the Brief Assessment of Cognition in Schizophrenia (BACS) were assessed. Our findings indicated that SCoRS is highly reliable (ICC=0.984) and sensitive to cognitive dysfunction. SCoRS is significantly correlated with BACS composite scores and predicted functional outcomes as measured by Global Assessment of Functioning (GAF) and World Health Organisation-Quality of Life (WHO QOL) within an Asian population. SCoRS represents a clinician-friendly cognitive assessment tool that incorporates third-party feedback and might be employed in clinical practice to better evaluate and manage schizophrenia.

Recurrence of treated ciliary body melanoma following trabeculectomy.

A 69-year-old man was treated for a right ciliary body melanoma with plaque radiotherapy. One year later, he had uncomplicated cataract extraction but developed prolonged postoperative inflammation and secondary glaucoma. The tumour remained unchanged on yearly ultrasound B scans but intraocular pressures became uncontrolled despite maximal medical therapy. After radiotherapy, he underwent trabeculectomy with 5-fluorouracil and revision with mitomycin C 2 years later. The melanoma recurred with extrascleral extension under the trabeculectomy bleb 14 years after plaque radiotherapy and 5 years after trabeculectomy surgery. Enucleation was performed and histological analysis showed a ring melanoma involving the root of the iris, filling the trabecular meshwork and extending into the anterior chamber. The predominant cell type was epithelioid with large nuclei and prominent nucleoli. Trabeculectomy surgery may increase the risk of extrascleral extension of ciliary body melanoma even after apparently successful plaque radiotherapy and long-term local tumour control.

Lacrimal surgery success after external dacryocystorhinostomy: functional and anatomical results using strict outcome criteria.

PURPOSE: To present the results of external dacryocystorhinostomy (ext-DCR) for epiphora using strict outcome criteria and provide an accurate baseline and evidence from which to compare the results of endonasal dacryocystorhinostomy. METHODS: Retrospective case notes review of 158 consecutive adult patients who underwent primary ext-DCR. Functional success was assessed according to the patients' symptoms and anatomical success was measured using objective tests of lacrimal system patency: 1) the functional endoscopic dye test and/or endoscopic endonasal inspection of the ostium; 2) syringing of the lacrimal system; and 3) the fluorescein dye retention test. Patients without complete follow-up data were recalled for clinical reevaluation. A minimum follow-up of 6 months was required. Comparison of overall functional and anatomical success was further analyzed according to etiology using logistic regression and for different grades of surgeon using the chi-squared test. RESULTS: The results for 124 of 158 ext-DCRs showed an overall functional success of 69% and anatomical success of 74%. Patients with primary acquired nasolacrimal duct obstruction (PANDO) who had surgery by the specialist lacrimal surgeon had high success: 83% functional success and 100% anatomical success. Patients with watering eyes from non-PANDO aetiology including canalicular disease who had surgery by the specialist lacrimal surgeon had moderate success: 78% functional success and 70% anatomical success. The results of all surgery by trainees were lower but only significantly so for PANDO. The mean duration of follow-up was 2.6 years (range, 6 months to 8.3 years); median follow-up was 1.9 years. CONCLUSION: This study used strict criteria to assess functional and anatomical outcomes of primary ext-DCR and thus provide baseline measures of success with a minimal follow-up of 6 months. When canalicular disease was excluded, results for PANDO were higher. Surgery performed by the specialist lacrimal surgeon had higher success rates than when performed by trainee.

Schwannomas of the lacrimal gland fossa.

PURPOSE: Schwannomas are rare benign nerve sheath tumours that account for 1% of orbital tumours and, although sometimes associated with neurofibromatosis, most occur as isolated lesions and arise from branches of the ciliary or trigeminal nerves. METHODS: Two rare cases of Schwannoma arising within the lacrimal gland fossa are presented, these tumours being managed with intact surgical excision. RESULTS: A 66-year-old Caucasian female was referred with 6 months of progressive left painless proptosis and intermittent diplopia. Restriction of left upgaze was associated with 3 mm relative proptosis. On a presumptive preoperative diagnosis of pleomorphic adenoma, the patient underwent a bone-swinging lateral orbitotomy with intact excision of a moderately-firm, lobulated lesion which proved to be a Schwannoma. A 30-year-old White female was referred with a 4-year history of slowly progressive right supratemporal periocular lump. There was 2 mm of right relative proptosis and slight restriction of right extraocular movements. Although lacrimal gland remnants were present at the edge of both specimens, at surgery it was evident that the tumours completely occupied the lacrimal gland fossa and any normal orbital lobe of the lacrimal gland had undergone atrophy. CONCLUSIONS: Two very rare cases of Schwannoma arising within the lacrimal gland fossa are presented, the tumours causing complete atrophy of the normal orbital lobe of the lacrimal gland.

Idiopathic orbital inflammation with extensive intra- and extracranial extension presenting as 6th nerve palsy--a case report and literature review.

INTRODUCTION: To report a case of idiopathic orbital inflammation with extensive extraorbital involvement presenting as 6th nerve palsy. MATERIALS AND METHODS: The patient presented with right periorbital pain, headache, and diplopia. Orthoptic examination revealed 6th nerve palsy. Investigations, including imaging (CT, MRI, MRA, chest x-ray), lumbar puncture, and screening blood tests (autoimmune disease and TB), were normal. He was lost to follow-up but presented again with no perception of light in the right eye with almost complete ophthalmoplegia and 3 mm of proptosis four months later. RESULTS: Repeat imaging showed a poorly defined mass involving the extraocular muscles in the posterior right orbit extending into the cavernous sinus and infratemporal fossa. Histopathologic examination showed a fibro-inflammatory infiltration of lymphocytes, plasma cells, and histiocytes, with widespread collagen deposition. No granulomas, vasculitis, or necrosis were seen. A tuberculosis screen (Mantoux) and lumbar puncture were negative. Idiopathic orbital inflammation (IOI) was diagnosed, and 60 mg of oral prednisolone and 300 mg of isoniazid were commenced. Fourteen months later, the patient remained blind, but ocular motility had returned to normal and no proptosis was evident. CONCLUSIONS: IOI can present in an atypical fashion and early disease may be undetectable radiologically.

Subretinal abscess after scleral buckling surgery: a rare risk of retinal surgery.

CASE REPORT: Intraocular infections after scleral buckling surgery for retinal detachment are very rare. COMMENTS: We document, on ultrasound B-scan, a rare case of subretinal abscess after scleral buckling surgery.

Making in-roads across the youth mental health landscape in Singapore: the Community Health Assessment Team (CHAT).

AIM: Adolescence and early adulthood is marked by physical, emotional and psychological changes, and is the peak onset of mental disorders. Internationally, one-fifth of children and adolescents have serious mental health problems, yet services catering to them are scarce. Locally, traditional mental health services are associated with much stigma. In 2009, the Community Health Assessment Team (CHAT), a youth-focused outreach and assessment service, was set up to address service gaps and care barriers. METHODS: CHAT's key offering is a free and confidential mental health assessment service to facilitate help-seeking individuals between the ages of 16 and 30 gain access to early treatment. Young persons' profile and assessment outcomes were collected and entered into a database. RESULTS: Between May 2009 and March 2013, CHAT received 601 referrals: 40.1% (241/601) from young persons themselves and 40.9% (246/601) from school or community counsellors. 79.2% (313/395) of those assessed had mental health issues. 61.5% (243/395) were referred to specialist clinics and 28.6% (113/395) to school or community counsellors. CONCLUSION: There is a steady increase in our referrals; majority are self-referred or referred from school and community counsellors. This attests to the success of our general outreach and targeted capacity-building efforts. Cognizant of young persons' distress, CHAT continues to work with downstream services for continuity of care, which also presents opportunities to consolidate and expand our network of specialist and community partners. Future directions seek to address current challenges: having a mobile platform to complement our face-to-face assessments, and building collaborations to provide holistic services for young persons.

Optic disk ovality as an index of tilt and its relationship to myopia and perimetry.

PURPOSE: To examine the association of optic disk ovality with myopic refractive error, axial length, and the visual field. DESIGN: Prospective observational case series. METHODS: The study included 150 randomly recruited male subjects with myopia. In all cases, one eye was randomly selected, and subjective refraction, slit-lamp examination, applanation tonometry, gonioscopy, A-scan ultrasonography, funduscopy, and color optic disk stereo photography were performed. Disk ovality was assessed using the ratio of minimum to maximum disk diameter (index of tilt). A ratio of < or = 0.8 was considered as significant disk tilt. Visual fields were tested using static automated threshold perimetry with two methods of optical correction: trial lenses and contact lenses. RESULTS: Of the total sample, 137 subjects completed the study. Mean age was 21.2 +/- 1.1 year, and mean spherical equivalent was -6.36 +/- 3.56 diopters. Mean ovality ratio was 0.83 +/- 0.09; 55 subjects (40.2%) had significant tilted optic disks. Greater optic disk ovality (tilt) correlated with greater myopia (P = .009) and longer axial length (P = .009); 95.6% of subjects had normal visual fields with both methods of optical correction. Using multiple linear regression analysis, greater tilt was independently related to a higher mean defect on testing with trial lenses (P < .01). CONCLUSIONS: Increased optic disk tilt was associated with higher myopia and reduced sensitivity on field testing. These factors are important in the assessment of glaucoma in patients with myopia.

Refractive lenticule extraction flap and stromal bed morphology assessment with anterior segment optical coherence tomography.

PURPOSE: To evaluate the flap and stromal bed after refractive lenticule extraction using optical coherence tomography (OCT). SETTING: Singapore National Eye Centre, Singapore. DESIGN: Longitudinal case series. METHODS: Horizontal scans (RTVue) were taken preoperatively and after refractive lenticule extraction. Two procedures were performed: femtosecond lenticule extraction and small-incision femtosecond lenticule extraction. Flap and bed thicknesses were measured at the center (0.0 mm) and 1.5 mm and 3.0 mm to either side. RESULTS: At 1 week, the mean flap at 0.0 mm was borderline thicker (P=.056) and at +3.0 mm significantly thicker after femtosecond lenticule extraction than after small-incision femtosecond lenticule extraction (P=.003). The mean bed at 0.0 mm was thinner after femtosecond lenticule extraction (P=.03). The flap at -3.0 mm showed thinning between 1 week and 3 months after small-incision femtosecond lenticule extraction (P=.018). The flap at +3.0 mm thinned between 1 week and 1 month after femtosecond lenticule extraction (P=.009). After femtosecond lenticule extraction, there were increases in bed (P=.027) and total corneal (P=.013) thicknesses at 0.0 mm between 1 week and 3 months, remaining stable thereafter (3 months: P=.842 and P=.508, respectively). The mean spherical equivalent decreased and the uncorrected acuity improved after both procedures (P<.001), with stabilization of both variables at 3 months. CONCLUSION: A significant difference in stromal bed thickness between femtosecond lenticule extraction and small-incision femtosecond lenticule extraction was detectable by AS-OCT 1 week postoperatively.

Estimation of corneal power after myopic laser refractive surgery: comparison of methods against back-calculated corneal power.

PURPOSE: To compare methods of corneal power estimation after myopic laser refractive surgery with back-calculated corneal power (K). SETTING: Private practice, Edmonton, Alberta, Canada. DESIGN: Case series. METHODS: Patients with previous myopic laser surgery followed by cataract extraction were studied. Back-calculated K obtained with the Holladay IOL Consultant was compared with that obtained by the clinical history method (CHM), the modified Maloney method, an adaptation of the Maloney method using individualized Orbscan IIz-derived posterior corneal power values, Orbscan IIz quantitative area topography, and the Gaussian optics formula. A mixed effects linear model was used for analysis. RESULTS: The mean spherical equivalent (SE) before laser treatment was -6.43 diopters (D) ± 3.52 (SD). The estimated means of all methods except those obtained with the CHM, modified Maloney method, 2.0 mm total axial map, 1.5 mm total mean map, and 1.5 mm total optical map were significantly different from the mean of the back-calculated K. Estimates from the 1.5 mm total mean map were generally 0.06 D higher. The 2.0 mm total axial map, modified Maloney method, 1.5 mm total optical map, and CHM underestimated corneal power by 0.11 D, 0.13 D, 0.22 D, and 0.26 D, respectively. Unit increases in optical zone and pre-laser myopic SE were associated with decreases in corneal power of 1.58 D (P = .047) and 0.55 D (P = .0001), respectively. CONCLUSION: The modified Maloney method, 2.0 mm total axial map, 1.5 mm total mean map and 1.5 mm total optical map of the Orbscan IIz may provide estimates closer to the back-calculated K than the CHM. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.