Mohs Surgery for Periocular Basal Cell Carcinoma Without a Mohs Surgeon: The First Series in Hong Kong.

Purpose To report the first series of Mohs micrographic surgery (MMS) in Hong Kong, where the roles of a Mohs surgeon were shared and coordinated by a "mobile" surgeon. METHODS DESIGN: Prospective non-comparative interventional case series. SUBJECTS: 20 consecutive Chinese patients (10 male, age 78.5+10.4 years, range 55-91 years) with primary periocular basal cell carcinoma (pBCC) referred to the university oculoplastic unit between October 2007 and August 2013. INTERVENTION: MMS were conducted according to a streamlined standard operating procedure emphasizing surgeon-driven mapping, specimen orientation, and on-site clinico-histological correlation with the dermatopathologist at the frozen-section laboratory. MAIN OUTCOME MEASURES: Clinical and histological characteristics of tumors, layers of Mohs procedures, complications, and biopsy-confirmed recurrence at the same location. Results All 20 patients received MMS as planned. Sixteen pBCCs (80%) were diffusely pigmented, and three (15%) were focally pigmented. Sixteen were also nodular. The average tumor diameter was 7+3 (3-15) mm. Seven (35%) were within 2 mm of the punctum. Histologically, 11 (55%) were nodules, and four (20%) were superficial. An average of 1.8+0.8 Mohs levels were performed. Apart from the initial two patients, who required four and three levels, respectively, seven (35%) patients were cleared after the first level of MMS using a 1mm clinical margin. The remaining 11 patients required two levels with an additional 1-2mm margin, but only focally as guided histologically. Defects in 16 patients (80%) were reconstructed by local flaps, two by direct closure, and two with pentagon closure. Among the seven patients with pericanalicular BCC, three patients had their remaining canaliculi successfully intubated, while two developed stenotic upper and two lower punctae postoperatively. One patient had prolonged wound healing. Three patients had lid margin notching, two had medial ectropion, one had medial canthal rounding, and two had lateral canthal dystopia. No recurrence was detected at a mean follow-up of 80+23 months (43 to 113 months) in all patients. Conclusions MMS was successfully introduced in Hong Kong without a Mohs surgeon. Providing complete microscopic margin control and preserving tissues, it was proven to be a valuable treatment option for pBCC. Our multidisciplinary protocol demonstrated that these merits are possible and warrant validation in other resource-limited healthcare settings.

Efficacy and Safety of 6-Weekly versus 12-Weekly Intravenous Methylprednisolone in Moderate-to-Severe Active Thyroid-Associated Ophthalmopathy.

PURPOSE: To compare the efficacy and safety of 6-weekly and 12-weekly intravenous methylprednisolone (IVMP) regimens in moderate-to-severe, active thyroid-associated orbitopathy (TAO) patients. BASIC PROCEDURES: Retrospective comparative study of patients who received IVMP between January 2011 and July 2021 at the Thyroid Eye Clinic, the Chinese University of Hong Kong. Outcome measures included the 7-item clinical activity score (CAS), exophthalmos, extraocular muscle motility (EOMy), marginal reflex distance (MRD), best corrected visual acuity (BCVA), intraocular pressure (IOP), the requirement of additional treatment, and complications. MAIN FINDINGS: A total of 65 (63% (41/65) females) moderate-to-severe, active TAO patients aged 50 ± 13 (25-74) years received 6-weekly (n = 22) or 12-weekly (n = 43) IVMP. Sex, age, smoking status, and Graves' disease status were comparable in the two groups (all p > 0.05). CAS at week 6 (p = 0.0279), 12 (p = 0.00228), and 52 (p = 0.0228) were lower at each time for the 12-weekly group. Exophthalmos improved more at week 6 (p = 0.0453) and 12 (p = 0.0347) in the 12-weekly group. The improvement of diplopia, MRD1, MRD2, and EOMy were comparable between the two groups. More patients in the 6-weekly group (p = 0.00169) required additional treatments including IVMP+/-ORT. Patients in the 6-weekly group who did not require additional treatment had a lower presenting CAS (p = 0.0193) than those who required additional treatment. The total numbers of adverse events were comparable between the two groups.

Combined high-dose sub-tenon triamcinolone, intravitreal bevacizumab, and laser photocoagulation for refractory diabetic macular edema: a pilot study.

PURPOSE: To study the efficacy and safety of triple therapy (sub-Tenon triamcinolone [∼70 mg], intravitreal bevacizumab [1.25 mg], and focal/grid laser) for refractory diabetic macular edema. METHOD: Twenty-nine eyes of 29 patients who received triple therapy were monitored for central foveal thickness, best-corrected visual acuity (BCVA), and side effects over a 1-year period. Their results were compared with a focal/grid laser historical control group of 18 eyes (18 patients). RESULTS: In the triple therapy group, mean central foveal thickness significantly reduced from baseline value of 441 µm to 298 µm at Month 12 (P < 0.001), but there was no significant change of BCVA. In the control group, there were no sustained significant changes of central foveal thickness or BCVA. A subgroup analysis of 7 eyes in the triple therapy group with baseline BCVA of ≤20/100 showed significant BCVA improvements from 4 weeks to 9 months. The maximum improvement was achieved at 6 months, when the mean BCVA improved by 9.5 Early Treatment Diabetic Retinopathy Study letters from baseline. Intraocular pressure rise (31.0%), partial ptosis (17.2%), and significant cataractogenesis (8.7%) were encountered in the triple therapy group but not in the control group. CONCLUSION: Sustained reduction of central foveal thickness was achieved with triple therapy over the 1-year study period. Significant visual improvement was seen only in patients with worse baseline BCVA, but not in the triple therapy group as a whole. Significant side effects of intraocular pressure rise, ptosis, and cataractogenesis were encountered in the triple therapy group.

Efficacy of 1.25 MG versus 2.5 MG intravitreal bevacizumab for diabetic macular edema: six-month results of a randomized controlled trial.

PURPOSE: To evaluate the efficacy of intravitreal injections of two different dosages of bevacizumab (Avastin) for treating diffuse diabetic macular edema. METHODS: Fifty-two eyes of 52 patients with diabetic macular edema were randomized to receive three monthly intravitreal injections of 1.25 mg or 2.5 mg bevacizumab. Patients were observed for 6 months and optical coherence tomography central foveal thickness, logMAR best-corrected visual acuity (BCVA), and adverse events were assessed. RESULTS: Forty-eight eyes of 48 patients completed the 6-month follow-up and were analyzed. Significant mean central foveal thickness reductions were observed in both groups at all follow-up visits (P < 0.013). Significant improvements between baseline and 6-month mean logMAR BCVAs were seen, with the mean logMAR BCVA improved from 0.63 to 0.52 in the 1.25 mg group and 0.60 to 0.47 in the 2.5 mg group. No significant difference in BCVA was observed between the two groups at any time point (P > 0.56). Subgroup analysis showed that intravitreal bevacizumab seemed to be more effective in eyes without any previous diabetic macular edema treatment. CONCLUSIONS: Three monthly intravitreal bevacizumab injections resulted in significant reduction in central foveal thickness and improvements in BCVA in diabetic macular edema patients. Both 1.25 mg and 2.5 mg seemed to have similar treatment efficacy.

Central serous chorioretinopathy after sequential argon-neodymium: YAG laser iridotomies.

Laser peripheral iridotomy is the standard treatment for acute angle-closure glaucoma. A patient with acute angle-closure glaucoma who developed central serous chorioretinopathy after uneventful laser iridotomies is described. Central serous chorioretinopathy occurring after sequential argon-neodymium:YAG laser peripheral iridotomy is a novel complication in the English literature and is related to the stress induced by both the initial disease and the subsequent procedure, particularly in psychologically susceptible individuals.

Retrocapsular lens matter in uneventful phacoemulsification: does it really exist?

PURPOSE: To have the first cytopathological evaluation of any lens matter fragments within retrocapsular anterior vitreous in those patients undergone uneventful phacoemulsification in Prince of Wales Hospital, Department of Ophthalmology and Visual Sciences, the Chinese University of Hong Kong, Hong Kong. METHODS: Thirty patients with cataracts and various vitreoretinal conditions that required combined surgery were recruited. After the uneventful clear corneal phacoemulsification, three sclerotomies including infusion port were created with cautions against any inadvertent leakage of vitreal content. The anterior vitreous at retrocapsular space was harvested by a special 'round-the-clock' dry vitrectomy into a special specimen reservoir hub and syringe. The aspirate was immediately fixed in 50% ethanol and together with a masked positive control sent for cytocentrifugation processing. The microscope slides of the anterior vitreal content and control were stained with haematoxylin and eosin and papanicolaou. Positive controls were collected from the effluent fluid of the phaco cassettes right after the phacoemulsification. The samples were masked and examined by an experienced pathologist for any cytopathological evidence of lens matter. RESULTS: Out of 30 patients, three suspicious cases of retrocapsular lens fragment were noted by retroillumination on the operating table. However, all the anterior vitreous specimens were negative for lens matter whereas all the controls were positive after cytopathological verification. CONCLUSIONS: This is the first cytopathological study objectively indicating low likelihood of the postulation that retrocapsular lens matter occurred after uneventful phacoemulsification.

Prospective Randomized Comparative Study of the Effect of Pupil Dilation or Miosis in Intraocular Lens Pupillary Capture After Combined Phacoemulsification and Vitrectomy With Intraocular Tamponade.

PURPOSE: The objective of the study was to compare the safety and efficacy of postoperative pharmacological pupil dilation, miosis, and alternate-day pupil dilation and miosis after combined phacoemulsification (phaco), intraocular lens (IOL) implantation, and pars plana vitrectomy (PPV) with intraocular tamponade. DESIGN: This was a prospective, randomized controlled clinical trial. METHODS: Patients who were indicated for phaco with IOL implantation, PPV, and intraocular tamponade were randomly assigned into 3 different groups: (1) pupil dilation using 4% homatropine (dilation group), (2) pupil miosis using 1% pilocarpine (miosis group), and (3) alternate-day pupil miosis and dilation starting with 1% pilocarpine on the first day postoperatively and switched to 4% homatropine thereafter on alternate days (alternate-day group). The main outcome measured was the rate of IOL capture postoperatively. The secondary measurable outcomes were the complication rates, visual acuity, and ease of fundal examination with binocular indirect ophthalmoscopy. RESULTS: Twenty-two, 21, and 20 eyes were allocated to the dilation, miosis, and alternate-day groups, respectively. Intraocular lens capture was found in 7 (11.1%) of 63 eyes. Intraocular lens was captured in 6 (27.3%) of 22 eyes in the dilation, 1 (4.5%) of 21 eyes in the miosis, and none in the alternate-day groups (P = 0.0133). The difference of the visual acuity among the 3 groups was not statistically significant (P = 0.650). Anterior chamber reaction of more than +1 cell in the first week was found in 6 (27.3%) of 22, 13 (61.9%) of 21, and 10 (50%) of 20 eyes in the dilation, miosis, and alternate-day groups, respectively (P = 0.074). Although more eyes were found with posterior synechia in the miosis group, the difference was not statistically significant (P = 0.478). The number of eyes that had suboptimal binocular indirect ophthalmoscopy view was 3 (13.6%) of 22, 12 (57.1%) of 21, and 6 (30%) of 20 in the dilation, miosis, and alternate-day groups, respectively (P = 0.01). CONCLUSIONS: Pupil dilation after combined phaco with IOL implantation, PPV, and intraocular tamponade could lead to a higher chance of IOL capture. Pupil miosis may lead to more anterior chamber inflammation. The regimen of alternate pupil dilation and miosis may cause less chance of IOL capture.

Central retinal vein occlusion associated with clomiphene-induced ovulation.

OBJECTIVE: To report a case of central retinal vein occlusion associated with clomiphene citrate (CC). DESIGN: Case study. SETTING: Ophthalmology clinic of an academic hospital. PATIENT(S): A 36-year-old woman referred from the infertility clinic for blurred vision. INTERVENTION(S): Ophthalmic examination after CC therapy. MAIN OUTCOME MEASURE(S): Central retinal vein occlusion after ovulation induction with CC. RESULT(S): A 36-year-old Chinese woman developed central retinal vein occlusion after eight courses of CC. A search of the literature on the thromboembolic complications of CC does not include this severe ophthalmic complication, although mild visual disturbance after CC intake is not uncommon. CONCLUSION(S): This is the first reported case of central retinal vein occlusion after treatment with CC. Extra caution is warranted in treating infertility patients with CC, and patients should be well informed of this side effect before commencement of therapy.