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.

LESCs: Lateralizing Eyelid Sleep Compression Study.

PURPOSE: To study the hypothesis that in normal patients, changes in eyelid elasticity may occur asymmetrically and in relation to the side on which the individual sleeps. DESIGN: Prospective, consecutive, single-center study within a large, tertiary-referral ophthalmology department within a university hospital. METHODS: This prospective study was carried out consecutively on 262 normal patients. The 3 inclusion criteria were 1) age≥55 years, 2) absence of facial nerve palsy, and 3) absence of eyelid trauma or surgery. Immediately before the ocular plastic surgeon assessed the patient, each patient was questioned in a separate consulting room by the attending orthoptist as to his or her customary side of sleeping. After detailed explanation, the "history-masked" ocular plastic surgeon then assessed the patient's upper eyelid laxity, the main outcome measurement. This was performed by asking the seated patient to look down and then gently grasping the upper eyelids close to the eyelid margin, just medial to the lateral commissure. The ocular plastic surgeon, with thumbs pronated, simultaneously distracted both upper eyelids superiorly, laterally, and anteriorly. The measured separation of the upper eyelid from the globe conjunctiva was obtained using calipers. Eyelid laxity grading was designated as grade 1: 0 to 1.9 mm; grade 2: 2.0 to 3.9 mm; grade 3: 4 to 9 mm; and grade 4: floppy. RESULTS: Two hundred sixty-two patients (58% females) who consecutively satisfied the selection criteria were evaluated, of which 70.22% (183/262) patients had significantly greater laxity of the upper eyelid that corresponded to the side on which they customarily slept. An unpaired t test used to compare the eyelid laxity between the sleeping side and nonsleeping side was statistically significant (p<0.001). CONCLUSION: Normal patients demonstrate a correlation between the side on which they historically or customarily sleep and the laxity of their ipsilateral upper eyelid.

Apocrine adenocarcinoma of the eyelid: case series and review.

PURPOSE: To report 2 patients with apocrine adenocarcinoma of the eyelid and review the literature. DESIGN: Noncomparative, retrospective case series and review. PARTICIPANTS: Clinical data of 2 patients with histopathologic diagnoses of apocrine adenocarcinoma of the eyelid were obtained from medical records. The histopathology and immunohistochemistry data for the 2 cases were studied. A retrospective review was performed on all reported cases of eyelid apocrine carcinoma. MAIN OUTCOME MEASURES: Clinical features, histopathology, immunohistochemistry, and clinical course following treatment are reported. The results of a retrospective review of clinical presentations, local and systemic spread, treatment method, and prognosis from published case reports on eyelid apocrine adenocarcinoma are discussed. RESULTS: One patient had orbital invasion at presentation. This patient had radiotherapy alone and had no systemic or local recurrence at 2 years. One patient underwent a 4-mm margin wide surgical excision. This patient had no local or systemic recurrences at 1 year. A review of the literature suggests that the prognosis of adnexal apocrine tumors is indeterminate and variable. Most patients have successful outcomes following local surgical excision. Radiotherapy has been used as an adjunctive treatment for local metastatic disease. CONCLUSIONS: Apocrine adenocarcinoma is a rare adnexal tumor of the eyelid, which may present with orbital invasion.

Microwash or macrowash technique to maintain a clear cornea during cataract surgery.

We describe a technique of irrigating and thereby rapidly and effectively clearing the cornea of relatively large amounts of surface contaminants that reduce surgical visibility and may contribute to endophthalmitis. This technique is referred to as "macrowash." If the technique is required, it is usually at the commencement of cataract surgery, immediately after placement of the surgical drape. The technique not only saves time, but also reduces the volume of irrigating solution required by the "microwash" technique, which is traditionally carried out by the scrub nurse/surgical assistant using a Rycroft cannula attached to a 15 mL container of irrigating solution.

Epiphora in the presence of a simulated mucocele secondary to nasal polyposis in a patient with samter triad.

A 69-year-old man was referred with epiphora and soft-tissue swelling in the left nasolacrimal sac region. Ipsilateral Jones 1 and 2 tests were negative. On attempting sac "wash out" via the left lower canaliculus, there was fluid reflux from the left upper canaliculus. CT revealed bony erosion of the lacrimal and frontal process of the maxillary bone by nasal polyposis. T2-weighted axial MRI demonstrated severe bilateral intranasal polyposis with those on the left pushing the lacrimal sac laterally and simulating a mucocele. Transnasal polypectomy re-established physiologic tear drainage and relieved the swelling in the region of the lacrimal fossa. This case emphasises the importance of routine nasal endoscopy as part of the assessment of the lacrimal system.

Granulation tissue in the eyelid margin and conjunctiva in junctional epidermolysis bullosa with features of laryngo-onycho-cutaneous syndrome.

Eye and adnexal involvement in epidermolysis bullosa can range from symptoms of mild irritation resulting from conjunctival involvement to severe cicatrization of the ocular surface and adnexa. We describe a unique case of granulation tissue in the eyelid margin and conjunctiva in a patient with junctional epidermolysis bullosa. The eyelid granulation tissue resembled granulomas that seen in laryngo-onycho-cutaneous syndrome, which is caused by a mutation in an isoform of the LAMA3 gene, LAMA3a. On investigation, our patient had a combination of a unique mutation in LAMA3 and the mutation I17N in LAMA3a, providing further evidence that laryngo-onycho-cutaneous syndrome is a variant of junctional EB.

The phenotype of limbal epithelial stem cells.

PURPOSE: The purpose of this study was to identify phenotypic markers of human limbal stem cells in fetal and adult corneas. METHODS: RNA from microscopically dissected superficial limbal and central fetal (18 weeks) corneas was amplified and used to generate P(32)-labeled, reverse-transcribed antisense RNA that was linearly amplified and hybridized to a focused stem cell cDNA microarray. Differential gene expression of fetal limbus was compared with the expression of central cornea. Microarray differential expression experiments were performed on P63-expressing primary cultured limbal epithelial cells (passage 1; Pa1) and primary cells passaged 5 times (Pa5). Semiquantitative RT-PCR assay and immunohistochemistry were performed on fetal and adult corneas and cultured primary limbal epithelial cells, to confirm the results of the microarray experiments. Slow-cycling (pulsed bromodeoxyuridine label-retaining) limbal epithelium in corneal organ culture was studied for the expression of four selected upregulated limbal genes. RESULTS: Of the 266 genes tested, 33 were differentially overexpressed (more than twofold) in the fetal limbus (compared with central cornea) and primary cultured limbal epithelium compared with primary cells after 5 passages. Cytokeratin 15 (CK15) and cytokeratin 14 (CK14) are expressed in limbal basal epithelium and P-cadherin (CDH3) and Wnt-4 expression was restricted to basal and immediate parabasal limbal epithelium of both the adult and fetal corneas). Bromodeoxyuridine label retaining epithelium in corneal organ culture (slow-cycling cells) expressed the four selected limbal upregulated genes. CONCLUSIONS: For the first time, a focused stem cell pathway microarray analysis has been performed on fetal cornea and cultured limbal explant epithelium. CK15, CK14, CDH3, and Wnt-4 are expressed in the basal limbal epithelial cells.

Intraorbital glass foreign body missed on CT imaging.

A 36-year-old woman presented with a 7-week history of foreign body sensation in the superior right orbit after orbital trauma sustained during an accidental face-down fall onto a broken drinking glass. CT identified a 10.35 x 3.91-mm radiopaque foreign body in the right orbit superolateral to the globe. Orbital exploration superficial to the levator palpebrae superioris aponeurosis in close proximity to the site occupied by the CT-identified foreign body revealed an additional glass intraorbital foreign body, 4.0 x 2.5 x 0.25 mm in dimension. The second glass foreign body was entirely missed on the preoperative, 1-mm axial scans combined with sagittal and coronal reconstructed images and plain radiography.