Corneal Complications Secondary to Involutional Entropion at Presentation.

PURPOSE: To determine the frequency and significance of corneal complications at presentation of involutional entropion in an Australian population. Patient demographics and duration of symptoms were collated to assess how these factors related to presentations. METHODS: Case records were retrospectively interrogated at an Oculoplastic Ophthalmology practice over a 15-year period to identify patients with lower eyelid involutional entropion. All patients had ophthalmic examination by an ophthalmologist. Patients meeting inclusion criteria had data collected including detailed assessment of corneal examination findings. RESULTS: The final cohort included 203 patients of which 50.7% were male. The mean age was 75.1 years. Cornea findings at presentation included superficial punctate keratopathy (69%), no change (25.6%), corneal ulcer (4%), and other (1%). One percent of patients had vision loss attributable to complications of entropion. Range of duration of symptoms was 2 weeks to 6 years with a mean of 11.5 months. CONCLUSIONS: At presentation, involutional entropion has mild corneal findings with 95.1% of patients demonstrating superficial punctate keratopathy or normal corneal epithelium. Vision loss is a rare complication and was observed in 1% of patients in this study, all with preexisting corneal pathology.

Idiopathic Acquired Lacrimal Canalicular Obstruction.

PURPOSE: Acquired lacrimal canalicular obstruction has a variety of causes. In a small proportion of patients, no cause can be identified. This article describes a cohort of 27 patients with idiopathic acquired lacrimal canalicular obstruction encountered over a 28-year period. METHODS: The diagnostic database of the senior author was analyzed to identify all cases of idiopathic acquired lacrimal canalicular obstruction seen from 1990 to 2017. Demographic, clinical, and treatment details were analyzed. Patients with primary lacrimal punctal stenosis or closure were excluded from the analysis. RESULTS: The authors encountered 27 patients with idiopathic acquired lacrimal canalicular obstruction (17 female, 63%) aged 34 to 91 years (median: 65 years). The level of canalicular obstruction ranged from 1 to 10 mm from the punctum. Canalicular obstruction involved 1 canaliculus in 4 patients, 2 in 14 (ipsilateral in all except one), 3 in 3, and all 4 in 6. One patient who presented with ipsilateral upper and lower canalicular obstructions developed contralateral upper and lower obstructions several years later, and another patient redeveloped obstructions after initial successful surgical repair. In all cases, there were no features on history or examination to suggest a cause for the canalicular obstruction. Follow up ranged from 1 to 260 months (mean: 39 months). Sixteen patients underwent surgical repair, 11 with a dacryocystorhinostomy and placement of a Lester Jones glass bypass tube, 2 had a canaliculo-dacryocystorhinostomy (anastomosis of the canaliculus to the nose), 2 had dacryocystorhinostomy and trephination of the canalicular obstruction with silicone intubation, and 1 had a dacryocystorhinostomy alone to try and improve drainage through a single patent canaliculus. CONCLUSION: Idiopathic acquired lacrimal canalicular obstruction is uncommon and occurs more frequently in older women. The condition may be slowly progressive and can affect one or more canaliculi at any level. Treatment is the same as for any other cause of acquired lacrimal canalicular obstruction.

Combined use of bulbar conjunctival pedicle flap and labial mucous membrane graft for porous orbital implant exposure: Long-term outcome.

Implant exposure is the most common serious complication of porous orbital implants, and often requires surgical repair. This study aims to describe a new repair technique using a bulbar conjunctival pedicle flap and a labial mucous membrane patch graft, as well as to report its long-term results. A retrospective chart review was performed on all patients whose porous orbital implant exposures were repaired using this technique from 1995 to 2014. Twenty-three patients were included. The maximal defect dimension ranged from 2 to 18 mm. Sixteen patients (70%) also received a banked human scleral patch graft during their repair. The mean follow-up was 130 months (range 29-267 months). Eighteen patients (78%) were successfully treated with one repair surgery. At the final follow-up, 21 patients (91%) could comfortably wear a prosthetic eye, and 18 patients (78%) reported satisfactory cosmesis. Two patients (9%) developed small conjunctival cysts that were successfully excised. The combination of a bulbar conjunctival pedicle flap and a labial mucous membrane patch graft is a simple but effective technique in salvaging exposed porous orbital implants. Its long-term results are promising.

Enophthalmos and Hemifacial Skeletal Atrophy After Trigeminal Nerve Injury.

A 60-year-old woman presented with several years increasing right upper eyelid ptosis. She had undergone surgical decompression of the right trigeminal nerve in the posterior cranial fossa 15 years earlier for trigeminal neuralgia. This left her with permanent numbness in the second and third divisions of the trigeminal nerve. In addition to the ptosis, she was found to have right enophthalmos and a smaller right face. CT scans showed a smaller midfacial skeleton on the right and a depressed orbital floor. The changes were different to those seen in silent sinus syndrome. Photographs taken over many years showed the facial changes were acquired and came on gradually many years after the trigeminal nerve injury. It is possible that trigeminal nerve injury may lead to trophic changes in the facial skeleton, but these have not been previously reported.

Comparison of lateral orbital decompression with and without rim repositioning in thyroid eye disease.

PURPOSE: Rim-off lateral wall decompression may be associated with functional and cosmetic deficit. Our objective, therefore, was to describe the functional and cosmetic results of deep lateral orbital decompression with and without anterior rim repositioning for thyroid eye disease. METHODS: In this retrospective comparative case series all consecutive thyroid eye disease patients who underwent deep lateral wall decompression at the Royal Victorian Eye and Ear Hospital between 1990-2007 and the Goldschleger Eye Institute, Sheba Medical Center between 2008-2011 were included. Patients were divided into two groups: the "rim-on" group in which the anterior lateral orbital rim was repositioned and the "rim-off" group in which it was left off. Main outcome measures were: proptosis reduction, postoperative oscillopsia and diplopia, presence of visible or palpable lateral orbit depression. RESULTS: One hundred and twelve patients who underwent 186 orbital decompressions were included in the final analysis. The average proptosis reduction for two- and three-wall decompressions ranged between 4.6-4.9 mm in the rim-on and 4.6-5.7 mm in the rim-off group respectively. The prevalence of postoperative oscillopsia was similar in both groups. The preoperative diplopia worsened in 17 patients (32.1 %) in the rim-on group and in seven patients (12.3 %) in the rim-off group (P = .02, chi-square test). None of the patients developed visible or palpable lateral orbit depression. CONCLUSIONS: Deep lateral orbital decompression without anterior rim repositioning may be an effective approach to enhance functional and cosmetic outcomes in thyroid eye disease patients without increasing the risk of lateral wall depression or postoperative oscillopsia.

Conjunctival cicatrizing disease presenting with lacrimal obstruction.

Patients with conjunctival cicatrizing disease may develop lacrimal obstruction. Little is published on lacrimal obstruction as the presenting feature of otherwise asymptomatic cicatrizing conjunctival disease. The records of all patients presenting between 1994 and 2015 with lacrimal obstruction found to have cicatrizing conjunctival disease were reviewed. Demographic details, clinical findings, disease progression and treatment were analyzed. Thirty-five patients (25 female), aged 43-91 years (median 74, mean 71.3 years) had epiphora and a mild conjunctival cicatrizing process. Nine patients had onset of epiphora after cataract surgery. All except one patient had obstruction of the proximal lacrimal system (punctum and/or canaliculus). In 14 cases, the obstruction was unilateral (both puncta or canaliculi), with one progressing to bilateral obstruction after 11 years. In 19, all 4 puncta or canaliculi were obstructed. Two patients had unilateral nasolacrimal duct obstruction; one developed contralateral canalicular obstruction 2 years later. Conjunctival biopsies were obtained in 19 of 35 cases (54%), and OCP immunohistochemistry was positive in 7/19 (37%). All other biopsies showed chronic inflammation. Two patients had lichen planus. In follow-up (range 0.1-11 years, mean 3.2 years), 2 patients' conjunctival disease progressed mildly, and 3 progressed moderately, with 2 of these 5 having positive OCP immunohistochemistry, and 1 having lichen planus. Patients with conjunctival cicatrization may present with lacrimal obstruction, usually punctal or canalicular. Conjunctival disease is usually mild and non-progressive, but patients should be monitored for disease progression.

Malignant melanoma of the lacrimal drainage apparatus complicating conjunctival melanoma.

PURPOSE: Melanoma of the conjunctiva may occasionally involve the lacrimal drainage apparatus (LDA). This makes clinical management difficult. The authors describe 5 cases of conjunctival melanoma with LDA disease and make recommendations about its management. METHODS: Retrospective review of case notes and histopathology reports. RESULTS: Five cases of LDA melanoma arising in patients with conjunctival melanoma are described. All 5 had orbital exenteration as part of their treatment. Melanoma of the LDA was clinically present at the time of exenteration in 1 case, found unexpectedly in 2 cases, and developed subsequent to exenteration in 2 cases. One patient died within 8 months of exenteration from metastatic melanoma. Two patients were disease free 3 and 5 years after exenteration. One patient developed metastasis in the parotid gland 4 years after exenteration but remained disease free 7 years after exenteration. One more patient has had a local recurrence in the maxilla and lateral nasal wall 4 years after exenteration, and after resection of that lesion and radiotherapy is disease free after 18 months. Seventeen patients underwent orbital exenteration for conjunctival melanoma over the period 1996-2013 at the authors'institution, with 5 having or developing LDA disease (29%). In the same period, there were 52 patients with conjunctival melanoma overall, with LDA involvement occurring in 5 of 52 patients (9.6%). CONCLUSIONS: Melanoma of the LDA may complicate conjunctival melanoma in a significant percentage of cases having orbital exenteration. The surgical technique for orbital exenteration in patients with conjunctival melanoma should take this into account by intentionally removing the lacrimal sac and upper nasolacrimal duct as well as the lacrimal canaliculi. If melanoma is found in the LDA, consideration should be given to wider en bloc excision of the LDA.

Isolated traumatic neurogenic ptosis with delayed recovery.

PURPOSE: To describe the entity of isolated neurogenic ptosis due to presumed tractional injury to the nerve of innervation of the levator palpebrae superioris, with recovery occurring over a period up to 6 months. METHODS: Retrospective case review. RESULTS: Three cases of presumed neurapraxic injury to the nerve of innervation to the levator palpebrae superioris are described. Two cases had a clear history of traction to the upper eyelid. There was no evidence of damage to other extraocular muscles or their nerves of innervation in 2 cases and mild transient superior rectus underaction in 1. Maximal recovery occurred over a period of up to 6 months. CONCLUSIONS: Traumatic neurapraxic injury to the nerve of innervation to the levator palpebrae superioris may occur in certain types of upper eyelid injury, most notably when there is significant forward traction applied to the upper eyelid. Although recovery may occur within weeks, as previously described, this series illustrates that recovery may take up to 6 months.

Transorbital puncture for the treatment of cavernous sinus dural arteriovenous fistulas.

BACKGROUND: Endovascular embolization of carotid-cavernous sinus dural arteriovenous fistulas (CCFs) is most commonly performed via a transfemoral-transvenous approach. Surgical cut-down of the superior ophthalmic vein is an alternative, well-described route. When these prove inaccessible, a transorbital approach can be used to reach the fistula. METHODS: We describe the recent experience- including indications, surgical technique, radiological findings and post-operative outcomes- in Melbourne of a series of patients in whom a percutaneous, transorbital direct puncture of the cavernous sinus enabled successful embolization of dural arteriovenous fistulas. RESULTS: Each of three patients achieved successful embolization of their CCFs via a transorbital puncture. Post-operatively, all patients experienced symptomatic relief with complete resolution of clinical signs secondary to their CCFs. CONCLUSION: When angioarchitecture does not allow endovascular access, transorbital puncture of carotid-cavernous sinus dural arteriovenous fistulas can be a safe and effective technique. This report supports its success and low complication rate.

Orbicularis oculi: morphological changes mimicking mitochondrial cytopathy in a series of control normal muscles.

INTRODUCTION: Orbicularis oculi (OO) muscle has recently proposed as a suitable muscle for biopsy to diagnose mitochondrial cyopathy: METHODS: Enzyme histochemical and immunohistochemical studies were performed on OO muscle obtained from 18 patients aged 37-87 years (median 64 years), 6 males, 12 females, who were undergoing routine upper blepharoplasty surgery. RESULTS: We confirmed the marked type II fibre (fast myosin heavy chain) predominance (89%) but also noted a different proportion and distribution of mitochondria in these fibres with occasional pseudo-'ragged-red' fibres with prominent subsarcolemmal and cytoplasmic aggregation of mitochondria. Cytochrome oxidase-negative fibres and true 'ragged-red' fibres were found at all ages over 40 years at levels that approach those used for diagnosis of mitochondrial cytopathy in peripheral or limb skeletal muscles. CONCLUSION: We would therefore urge caution in the use of OO as muscle biopsy for diagnosis of mitochondrial cytopathy and advise concomitant biopsy of limb skeletal muscle and/or supplementary genetic studies.

Bilateral lacrimal gland disease: clinical features and outcomes.

BACKGROUND: Patients with bilateral lacrimal gland disease are a unique subset of patients where there is a paucity of literature. This presentation often represents systemic disease or malignancy and can cause diagnostic difficulties. We aim to describe the diagnoses and features of bilateral lacrimal gland disease. METHOD: Retrospective multi-centre case series involving 115 patients with bilateral lacrimal gland disease from 1995 to 2020. RESULTS: 115 patients were included. Their ages ranged from 9 to 85 (mean 47.3 years) with a female predominance (73, 63.5%). The most common category of diagnosis was inflammatory (69, 60%) followed by lymphoproliferative (23, 20%), structural (17, 14.8%) and other conditions (6, 5.2%). The five most common specific diagnoses were IgG4 related disease (20, 17.4%) and idiopathic orbital inflammatory disease (20, 17.4%), lymphoma (16, 13.9%), lacrimal gland prolapse (13, 11.3%), and sarcoidosis (11, 9.6%). Corticosteroid treatment was used most commonly (29, 25.2%) followed by observation (25, 21.7%). At last follow up, the majority of patients had complete resolution, significant improvement with mild residual disease or stable disease without further progression (104, 90.4%). CONCLUSION: Bilateral lacrimal disease may be due to a range of aetiologies, most of which are systemic. The most common are inflammatory and lymphoproliferative conditions. Due to the wide range of aetiologies of bilateral lacrimal gland disease, it is extremely difficult to accurately determine a cause based on clinical findings alone, highlighting the vital role of lacrimal gland biopsy in patients presenting with bilateral lacrimal gland disease.

Recurrent lacrimal gland pleomorphic adenoma: clinical and computed tomography features.

OBJECTIVE: To report the clinical and computed tomography (CT) features of recurrent lacrimal gland pleomorphic adenoma (LGPA). DESIGN: Retrospective observational case series. PARTICIPANTS: Five patients with recurrent LGPA. METHODS: Clinical records and CT findings in 5 patients with recurrent LGPA were reviewed. MAIN OUTCOME MEASURES: Clinical and CT features, malignant transformation, and disease-free survival. RESULTS: Five patients presented at intervals of 9 to 19 years after initial surgery for LGPA with symptoms and signs of recurrent tumor centered on the lacrimal gland fossa. Four patients underwent surgery to remove recurrent tumor, and 1 patient declined surgical intervention. One of the 4 operated patients was found to have malignant transformation and required craniofacial resection for tumor clearance. One patient had benign recurrence in a previously exenterated orbit and also required a craniofacial resection. Two patients with benign but multifocal recurrence had en bloc resection of tumor, but remain at risk of further recurrence. Computed tomography in all 5 patients revealed irregular bone erosion and remodeling in relation to nodules of recurrent tumor, despite only 1 of these patients having confirmed malignant transformation. Four patients were free of disease at their last follow-up at intervals of 9 months to 18 years, including the patient with malignant transformation (14 years follow-up). One patient who declined treatment has been lost to follow-up. CONCLUSIONS: Recurrent LGPA tends to develop multifocally and may be widespread in the operative field. Computed tomography shows recurrent tumor nodules that are often associated with irregular bony erosion and remodeling despite these recurrences being usually benign. Repeated recurrence requiring further surgery with potential significant morbidity remains a lifelong risk, and malignant transformation in recurrent LGPA may also occur. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Double lacrimal puncta: clinical presentation and potential mechanisms of epiphora.

PURPOSE: Congenital supernumerary lacrimal puncta and canaliculi are rarely reported. Our purpose is to present the largest series of patients with supernumerary puncta and to describe the clinical presentation and associated lacrimal anomalies. DESIGN: Observational retrospective case series. PARTICIPANTS: All patients diagnosed with supernumerary puncta by a single surgeon between 1988 and 2008. METHODS: Retrospective case note review. MAIN OUTCOME MEASURES: Patient demographics, clinical presentation, lacrimal and systemic examination findings, management, and surgical outcomes. RESULTS: Twenty-three patients (12 female, 11 male) with a median presenting age of 54 years (range, 1-88 years) had unilateral double lower lid puncta. In 5 patients the presence of a double punctum was an incidental examination finding. Eighteen patients had unilateral tearing on the same side as the double punctum. In 6 children presenting with tearing, associated congenital lacrimal anomalies included nasolacrimal duct obstruction, a lacrimal fistula, a lacrimal sac diverticulum, and absence of the upper canaliculus. Associated systemic findings in 3 children included Down syndrome (1 patient) and preauricular sinuses (2 patients). Of 12 adult patients presenting with ipsilateral tearing, 5 had complete nasolacrimal duct obstruction and 6 had either partial nasolacrimal duct obstruction or functional epiphora. Dacryocystorhinostomy was performed in 12 patients and resulted in improvement or resolution of symptoms in 11 patients (92%). CONCLUSIONS: Double lower lacrimal puncta may be associated with epiphora. In younger patients, tearing may be due to associated congenital anomalies of the nasolacrimal system. A proportion of patients presenting with onset of tearing in adulthood have patent lacrimal systems and otherwise normal adnexal examination results, suggesting that the presence of double puncta may be associated with compromised canalicular function. Reflux of tears through the accessory canaliculus is a potential mechanism and would be consistent with a recently proposed 2-compartment model of lacrimal canalicular drainage. FINANCIAL DISCLOSURE(S): The authors have no proprietary or commercial interest in any materials discussed in this article.

Orbital decompression in the treatment of proptosis due to high axial myopia.

PURPOSE: To report the results of orbital decompression surgery for proptosis due to high axial myopia. METHODS: The clinical records and imaging of 8 consecutive patients with high axial myopia who underwent orbital decompression surgery to treat disfiguring proptosis were reviewed. Data collected included preoperative and postoperative best-corrected visual acuity, Hertel exophthalmometry, ocular motility examination findings, and surgical complications. RESULTS: Eight patients (6 women) with a median presenting age of 53 years (range, 41-78 years) underwent unilateral bony orbital decompression surgery to treat proptosis due to unilateral or asymmetric high axial myopia. Indications for surgery were disfigurement in all patients and exposure keratopathy in 4 patients. All patients had more than 12 diopters of myopia on the operated side and axial lengths between 27.5 and 34.7 mm. Preoperative visual acuity was reduced in all patients owing to amblyopia and/or myopic retinal degeneration. In addition, 2 patients had mild symmetrical thyroid-related orbitopathy. After orbital decompression surgery, Hertel exophthalmometry measurements on the operated side were within 2 mm of the other side in all patients. The mean reduction in proptosis was 2.3 mm after deep lateral orbital wall decompression (3 patients), 4.3 mm after medial and lateral wall decompression (3 patients), and 5 mm after 3-wall decompression (2 patients). Five patients had a hypotropia on the operated side, and inferior rectus recession was performed in 4. Two patients underwent additional eyelid procedures. No surgical complications were observed. CONCLUSIONS: Orbital decompression to reduce proptosis in patients with unilateral or asymmetric high axial myopia can improve cosmesis with low morbidity.

Lacrimal obstruction in inflammatory bowel disease.

PURPOSE: To report lacrimal drainage obstruction in association with inflammatory bowel disease (IBD) in 9 patients. METHODS: The clinical records of 461 consecutive adult patients treated for acquired lacrimal obstruction by dacryocystorhinostomy were reviewed. Patients with IBD were identified. Additional data collected included known secondary causes of lacrimal obstruction, a history of sinonasal disease, complications following lacrimal surgery, and demographic information. RESULTS: Nine patients (7 women, 2 men) with a median presenting age of 61 years (range, 38-70 years) had IBD. Five patients had Crohn disease, and 4 patients had ulcerative colitis. Seven patients had nasolacrimal duct stenosis or obstruction, and 2 patients had lacrimal canalicular obstruction. Six patients (67%) reported symptoms of sinonasal disease. One patient reported intermittent tearing and nasal obstructive symptoms during flare-ups of bowel disease. All 9 patients were being treated with long-term oral 5-aminosalicylate agents prior to the onset of lacrimal symptoms. One patient had recurrent lacrimal obstruction, 1 year after initially successful surgery. No other surgical complications were observed. Excluding 1 patient with herpetic canalicular obstruction and Crohn disease, the proportion of patients undergoing dacryocystorhinostomy surgery identified to have IBD (1.7%) was significantly higher than the estimated prevalence of IBD in the Australian population (0.3%) (p < 0.0001). CONCLUSIONS: In a large cohort of patients surgically treated for acquired lacrimal obstruction, the authors found an increased rate of IBD compared with the estimated population prevalence. To investigate this association further, the authors recommend obtaining lacrimal sac biopsies from patients with IBD who undergo dacryocystorhinostomy surgery.

Transorbital puncture of the cavernous sinus to treat a dural carotid-cavernous sinus fistula.

A 35-year old woman presented with left ocular injection, proptosis, and reduced vision. Cerebral angiography demonstrated a dural carotid-cavernous fistula supplied by internal and external carotid branches. Following endovascular embolization, the external carotid supply was obliterated. A residual fistula supplied by a branch of the ophthalmic artery and draining by the ophthalmic veins resulted in progressive glaucoma. Compartmentalization of the cavernous sinus precluded access to the fistula via the cerebral venous sinuses. Attempted transarterial embolization via the ophthalmic artery was not achieved. The superior ophthalmic vein was partially thrombosed and an attempt at its surgical isolation was unsuccessful. In this patient, transorbital puncture of the cavernous sinus allowed complete obliteration of the fistula and resulted in prompt resolution of symptoms.

Periocular necrotising fasciitis: a multicentre case series.

INTRODUCTION: Necrotising fasciitis (NF) is a severe infection of deep subcutaneous soft tissues with high morbidity and mortality. Periocular necrotising fasciitis (PONF) is a very rare condition with many unanswered questions about the presentation and management. We present a retrospective case series of patients with PONF from three centres in Australia and two in the UK to investigate the clinical and microbiological characteristics and outcomes and report on patients treated with antibiotics alone. RESULTS: Twenty-nine patients (20 men; 69%) with PONF were identified and followed up for between 2 months and 10 years (median 57, mean 52.6 months) between 1990 and 2013. Conditions associated with chronic immunocompromise were present in 16/29 (55%). Twenty-one (75%) recalled minor periocular trauma or an infected lesion, two having been assaulted by the same assailant. Systemic shock occurred in 6/29 (21%) patients and 1 died. Group A, ß-haemolytic Streptococcus was the most common bacterium identified (25/29, 86%). Intravenous antibiotics were used in all patients, and up to five tissue debridements were required to control the disease in 23/29 (74%); reconstructive surgery was required in 12/29 (41%) patients. One patient died from the disease and visual loss occurred in four eyes of four patients (14%). CONCLUSIONS: PONF has a better prognosis than disease elsewhere in the body, but is still associated with significant risk of visual loss and a small risk of death. Intravenous antibiotic treatment with cautious observation may be reasonable in selected patients with a low threshold for debridement.