Improvement in Epiphora Using TEARS Grading Following Surgical Treatment of Meibomian Gland Inversion in Patients With Facial Nerve Palsy.

PURPOSE: To assess epiphora outcomes using the TEARS grading score in patients with concomitant meibomian gland inversion (MGI) and facial nerve palsy (FNP) undergoing correction of MGI. METHODS: Retrospective, 5-year, noncomparative, single-center study of patients with MGI and FNP, treated with MGI correction, under the supervision of a single surgeon. A validated "TEAR" score was used to assess changes in epiphora. RESULTS: Ten patients with FNP, MGI, and epiphora were analyzed from a group of 160 patients with FNP who underwent MGI surgery between 2017 and 2022. The mean age at surgery was 50 years (range, 13-76 years). T, E, and A scores significantly improved (p < 0.05). Eighty percent of patients saw a reduction in tearing frequency (T), with 60% gaining ≥ 2-grade improvement. Improvements in clinical effects (E) and activity limitation (A) were seen in 80% of patients, with 40% and 50% gaining ≥ 2-grade improvement, respectively. R scores (related to reflex tearing) improved by 60%, with 40% seeing ≥ 2-grade improvement. Nine patients (90%) improved symptomatically with an average improvement "S" score of 65% over a mean follow-up period of 30 months. All patients demonstrated restoration of the normal anatomical position of the meibomian glands. CONCLUSIONS: MGI can cause epiphora in patients with FNP and may explain cases where symptoms persist despite standard surgical intervention. This study provides proof of concept that MGI correction can improve epiphora and that identifying MGI may be considered a critical step in the treatment algorithm for epiphora in patients with FNP.

The Importance of Identifying Meibomian Gland Inversion in Patients With Floppy Eyelid Syndrome.

BACKGROUND: Floppy eyelid syndrome (FES) is a common and underdiagnosed condition characterized by eyelid hyperlaxity with reactive palpebral conjunctivitis that can cause ocular irritation. It may be associated with meibomian gland dysfunction (MGD) and secondary tarsal curling, resulting in upper eyelid meibomian gland inversion (MGI) in the absence of obvious marginal entropion. PURPOSE: To highlight the possible significance of MGI in patients with FES and report findings and outcomes in patients with concomitant MGI and FES undergoing correction of MGI with or without upper eyelid horizontal tightening. METHODS: Retrospective, 5-year, noncomparative, single-center study of patients with FES and MGI, treated with MGI correction, with or without upper eyelid horizontal tightening, under the supervision of a single surgeon. Preoperative symptoms, surgical outcomes, complication rates, and postoperative symptoms were recorded. RESULTS: A total of 13 eyes of 9 patients were treated with MGI surgery over the study period. Seven were male. Mean age at the surgery was 63 (range 42-81) years. Two OSs, 3 ODs, and 4 OUs were treated. All patients were "cotton-tip test" positive, and 77% (10/13) had MGI-related superior corneal fluorescein staining. Three patients (33%) had previous standard tightening procedures with recurrence of symptoms within 5 to 24 (mean 16) months. Repeat horizontal tightening had been considered in all these cases before referral to our unit. Mean follow-up was 20 months. Eight patients (88.9%) had improvement of symptoms (n = 3, full resolution; n = 5, partial resolution). All patients demonstrated restoration of the normal anatomical position of the meibomian glands. Superior punctate staining resolved in all eyes. CONCLUSION: This study provides a proof of concept that upper eyelid MGI can be present and symptomatic in patients with FES. It may help explain cases where symptoms persist or recur early following standard upper eyelid horizontal tightening. Where superior corneal punctate staining and a positive cotton-tip test exist, surgical correction of MGI, alongside horizontal tightening, may provide better, and longer-lasting symptomatic relief. This study provides evidence for the need for a prospective study to evaluate the contribution of MGI in patients with FES.

Ophthalmoplegia associated with anti-GQ1b antibodies: case report and review.

A 60-year-old man with longstanding bilateral asymmetrical ptosis presented with a partial third nerve palsy. His diplopia improved following an ice pack test. He did not report any symptoms related to the coronavirus disease 2019 (COVID-19), and nasopharyngeal swab was negative. Initial head imaging and blood work-up were normal except for a high titer of anti-GQ1b antibodies. The patient was subsequently diagnosed with acute ophthalmoparesis without ataxia which is part of the anti-GQ1b antibody syndrome spectrum. He made a spontaneous recovery over the following months without the need for immunotherapy. Clinical features, pathophysiology and a review of the literature are discussed herein. It is important to consider anti-GQ1b antibody syndrome in patients with symptoms of diplopia, ptosis or suspected ocular myasthenia.

Morbihan Syndrome, a UK Case Series.

PURPOSE: To describe 10 patients with Morbihan syndrome, a rare condition characterized by the slow appearance of erythema and solid edema on the upper portion of the face, and review the literature. METHODS: Retrospective case series and review. RESULTS: The majority of patients were male (80%), and the mean age at presentation was 67 years (range, 48-88 years); 60% had asymmetrical disease (affecting mainly the right side). All subjects underwent a lid biopsy to support the diagnosis of Morbihan syndrome, which showed features of inflammation and vascular dysfunction, highly suggestive of a rosacea histological picture complicated by chronic lymphoedema. A range of medical and surgical treatment were used with variable success. The most effective ones included oral isotretinoin, intralesional triamcinolone injections, and debulking surgery. CONCLUSIONS: Morbihan syndrome is a rare and chronic condition. It can be difficult to treat and may require a range of interventions.

Comparison of higher-order aberration induction between manual microkeratome and femtosecond laser flap creation.

PURPOSE: To compare the mean change in aberrations produced by a mechanical microkeratome and femtosecond laser. METHODS: This was a retrospective study of 62 consecutive near emmetropic eyes that underwent LASIK and satisfied the following criteria: negligible laser ablation (for spherical equivalent of 0.00 to +0.50 diopters and maximum meridian of +0.50 diopters), and preoperative and at least 3 months postoperative Placido-based corneal aberrometry (ATLAS; Carl Zeiss Meditec, Jena, Germany). Eyes were divided into two groups according to the method used for flap creation: mechanical microkeratome (Hansatome zero-compression microkeratome; Bausch & Lomb, Rochester, NY [mechanical microkeratome group]) or femtosecond laser (VisuMax; Carl Zeiss Meditec, Jena, Germany [femtosecond laser group]). The root mean square total and individual higher-order aberrations were compared between the two groups. RESULTS: Corneas with mechanical flaps, on average, possessed statistically significantly higher trefoil and horizontal coma (P < .001). There was no change in higher-order aberrations, except for spherical aberration in the femtosecond laser group. Average change in coma did not correlate with hinge position. Both groups showed statistically significant changes in spherical aberration (P < .001), although this was most likely due to the small hyperopic ablation performed. CONCLUSIONS: There was greater induction of specific aberrations with the microkeratome than the femtosecond laser. Hinge position did not appear to influence the induction of coma directly, contrary to previously published reports. The difference in aberrations induction between the two groups might be due to the differences in flap thickness profiles.

Outcomes of conjunctivochalasis treatment after fornix deepening with retractor recession and repositioning.

PURPOSE: To evaluate outcomes of fornix deepening with retractor recession and repositioning for conjunctivochalasis (CCh) on improvement of conjunctival folds and ocular surface symptoms, particularly epiphora. METHODS: Retrospective, single-centre, observational case series of patients with refractory CCh who underwent fornix deepening and retractor recession. CCh was graded using the Hoh classification (grades 0 to 3 depending on the number and height of folds). Epiphora, reflex tearing, and dry eye symptoms were assessed using the validated 'TEAR' score pre- and post-CCh correction. RESULTS: 18 eyes of 11 patients with CCh (average age 68, range 46-82 years) were treated with fornix deepening and retractor recession. All had shallow fornices pre-operatively with a mean CCh grade of 1.7 (typically lower than the tear meniscus). Locations of the folds were variable: diffuse/middle (n = 10), nasal (n = 4), and temporal (n = 4). At 15-month mean follow-up, conjunctival redundancy was absent in 17 of 18 eyes postoperatively, resulting in a restored tear meniscus and reservoir. 91% saw a reduction in tearing frequency (T), with 73% gaining ≥ 2-point improvement. Improvements in clinical effects (E) and activity limitation (A) were seen in 82% and 91% of patients, respectively, with 36% and 64% gaining ≥ 2-point improvement. R scores (related to reflex tearing) improved in 73%, with 64% seeing ≥ 2-point gains. (P < 0.05 for all). CONCLUSION: Restoration of the tear reservoir by inferior fornix deepening with retractor recession and repositioning can result in improvement of CCh and epiphora.

Oculoplastic Conditions in Covid-19 Patients: Case Series and Literature Review.

Purpose: To investigate oculoplastic conditions in patients diagnosed with coronavirus disease 2019 (COVID-19) seen at ophthalmology departments of three tertiary referral centers in the United Kingdom and the United States, and review of the literature. Methods: Retrospective multicenter case series studied over 18 months. Results: A total of four patients developed eyelid, orbital, or lacrimal gland pathology within four weeks of testing positive for COVID-19. All were male, and the mean age at presentation was 49 (range, 31-58 years). Suspected diagnoses included anterior idiopathic orbital inflammation, facial angioedema, dacryoadenitis, and anophthalmic socket inflammation. Three patients recovered fully and one patient recovered partially (mean 2.7 weeks) from ocular manifestations with steroids hastening recovery. Conclusion: Adnexal manifestations of COVID-19 include self-limiting orbital inflammation and eyelid lymphedema.

Caruncular lesions: A 16-year single centre review in the United Kingdom.

BACKGROUND/AIMS: To review the clinicopathological features of caruncle biopsies carried out at a district general hospital in the United Kingdom (UK), and compare with other centres where data has been published. METHODS: Retrospective, single-centre, observational case series between 2004-2020. RESULTS: A total of 31 lesions from 31 patients were analysed. 18 of 31 patients were men (58%), and the age ranged from 12 to 91 years. 13 different histopathological types of lesions were identified in our case series, including 9 melanocytic nevi (29%), 7 benign squamous papillomas (23%), 5 skin adnexal lesions (16%), 3 chronic inflammation (10%), 3 epithelial cysts (10%), 1 basal cell carcinoma (3%), 2 malignant melanomas (6%) and l lymphoproliferative disorder (3%). Pre-operative suspected diagnoses were often vague but correct in 12 of 18 cases (67%), where data was available. CONCLUSION: The uncommon nature and variety of caruncular lesions make the diagnostic process difficult. Our case series is the first reported in the UK, showing a slightly higher proportion of malignant melanomas, in keeping with the population demographics. Excisional biopsies would, therefore, be prudent in the majority of cases to rule out any possible malignancy.

Frontal sinus infection leading to sino-orbital aspergillosis: a case report.

Sino-orbital aspergillosis is an uncommon but aggressive infection. It rarely originates from the frontal sinus due to the complex anatomy of the frontal recess and anteromedial position of its ostium. An 87-year-old man of Nigerian heritage with a history of multiple myeloma, chronic kidney disease and type 2 diabetes, presented to the eye clinic with a right tense swollen eyelid and proptosis. Computed tomography (CT) and magnetic resonance imaging (MRI) scan revealed a right superomedial mass communicating with the frontal sinus and biopsy confirmed an orbital aspergilloma. The patient was successfully treated with debulking surgery and anti-fungal treatment despite developing side effects to the drugs. To improve prognosis, ophthalmologists should be aware of this distinct entity and use a multi-disciplinary approach.

Deep anterior lamellar keratoplasty: A surgeon's guide.

PURPOSE: To review and highlight important practical aspects of deep anterior lamellar keratoplasty (DALK) surgery and provide some useful tips for surgeons wishing to convert to this procedure from the conventional penetrating keratoplasty (PK) technique. METHODS: In this narrative review, the procedure of DALK is described in detail. Important pre, intra, and postoperative considerations are discussed with illustrative examples for better understanding. A comprehensive literature review was conducted in PubMed/Medline from January 1995 to July 2017 to identify original studies in English language regarding DALK. The primary endpoint of this review was the narrative description of surgical steps for DALK, its pitfalls, and management of common intraoperative complications. RESULTS: A standard DALK procedure can be successfully performed taking into consideration factors such as age, ophthalmic co-morbidities, status of the crystalline lens, retina, and intraocular pressure. Careful trephination and dissection of the host cornea employing appropriate technique (such as big bubble technique, manual dissection, visco-dissection, etc.) suitable for the specific case is important to achieve good postoperative outcomes. Prompt identification of intraoperative complications such as double bubble, micro and macroperforations, etc. are vital to change the management strategies. CONCLUSION: Although there is a steep learning curve for DALK procedure, considering details and having insight into the management of intraoperative issues facilitates learning and reduces complication rates.

Headache and transient visual loss as the only presenting symptoms of vertebral artery dissection: a case report.

BACKGROUND: Vertebral artery dissection is an important cause of stroke in the young and diagnosis is often challenging as symptoms are varied and subtle. CASE PRESENTATION: A 33-year-old, previously healthy, white male office worker was stretching his neck when he developed sudden left-sided visual loss lasting 5 minutes associated with headache. He had no other neurological symptoms or signs. He was investigated with a computed tomography angiogram, which revealed a left vertebral artery dissection with a right posterior cerebral artery vascular occlusion. CONCLUSIONS: We describe an atypical case of vertebral artery dissection presenting with sudden transient visual disturbance without neurological signs in an otherwise healthy man. This is a rare but potentially fatal condition that can result in thromboembolic infarction. A high index of suspicion is crucial to make an early diagnosis and avoid devastating neurological outcomes.

Using Stem Cells to Model Diseases of the Outer Retina.

Retinal degeneration arises from the loss of photoreceptors or retinal pigment epithelium (RPE). It is one of the leading causes of irreversible blindness worldwide with limited effective treatment options. Generation of induced pluripotent stem cell (IPSC)-derived retinal cells and tissues from individuals with retinal degeneration is a rapidly evolving technology that holds a great potential for its use in disease modelling. IPSCs provide an ideal platform to investigate normal and pathological retinogenesis, but also deliver a valuable source of retinal cell types for drug screening and cell therapy. In this review, we will provide some examples of the ways in which IPSCs have been used to model diseases of the outer retina including retinitis pigmentosa (RP), Usher syndrome (USH), Leber congenital amaurosis (LCA), gyrate atrophy (GA), juvenile neuronal ceroid lipofuscinosis (NCL), Best vitelliform macular dystrophy (BVMD) and age related macular degeneration (AMD).

How complete are our clerkings? A project aimed at improving the quality of medical records by using a standardised proforma.

Clerking a patient is the first and most important contact that any medical team has with the patient. It provides information that may not be available later in the admission if recorded improperly, such as referral letters, collateral history, dosette boxes or prescription sheets. The quality of data recorded from this encounter was examined at a busy district general hospital surgical department. Initial measurement demonstrated that less than half of certain key parameters like dosages of medication were being recorded by clerking doctors. A clerking proforma was therefore designed to combat this problem. Over three audit cycles (n = 170, 150, 174) the proforma showed statistically significant improvements in the proportion of data that was captured at initial contact with the patient. We conclude that the introduction of proformas for clerking significantly improves the collection of data that impacts patient care during their hospital stay.