Floppy eyelid syndrome: the coventry experience.

PURPOSE: Floppy eyelid syndrome is a condition that is difficult to identify and diagnose and with no clear guidelines on its management. We propose a method of reliably grading this syndrome and have proposed a management algorithm based on the grading. MATERIALS AND METHODS: Retrospective data collection of patients diagnosed with Floppy eyelid syndrome and treated under the care of a single oculoplastic surgeon over a 9 year period. RESULTS: First, 102 patients were included and were classified into 3 groups. Grade 1 (F1) 7.5%, Grade 2 (F2) 36.5% and Grade 3 (F3) 56%. Only 12% of our cohort required surgery, and 92% of these patients demonstrated improvement in their symptoms. DISCUSSION: Clinical grading of Floppy eyelid syndrome patients will help determine patient's management plan. In our experience, operating on both upper and lower eyelids at the same time where indicated helps to maintain the normal anatomical relationship and improve epiphora.

Alfentanil sedation for oculoplastic surgery: the patient experience.

PURPOSE: A number of agents have previously been reported to be safe and effective for sedation and analgesia in ophthalmic surgery under local anaesthesia, but there has been no previous patient-focused assessment of this form of conscious sedation. We present a patient satisfaction survey, including a validated pain score, for patients undergoing oculoplastic procedures under local anaesthesia with alfentanil sedation. METHODS: A prospective, non-randomized, questionnaire-based study of the experience, satisfaction and pain scores of consecutive patients undergoing oculoplastic procedures under local anaesthesia with alfentanil sedation at University Hospital, Coventry, UK, under the care of one Consultant Oculoplastic Surgeon between 2006 and 2009. RESULTS: Three hundred and sixty-seven patients were surveyed over the 3-year period. Overall, 52% were female and 89% of Caucasian ethnic origin. Mean duration of surgical procedures was 34 minutes (range 2-120 minutes). Over 90% of patients described a low pain score, both during the local anaesthetic injection and per-operatively, and 98% stated that they were happy to have this sedation technique for further oculoplastic surgery in future. Side effects related to sedation were reported in 5% of patients. There were no conversions to general anaesthesia and no day-case patients required an overnight in-patient stay. CONCLUSION: Conscious sedation with alfentanil for oculoplastic procedures under local anaesthesia results in low pain scores and high patient satisfaction with minimal complications.

Periorbital Masson's tumor: a case series.

Intravascular papillary endothelial hyperplasia (IPEH) or Masson's tumor is an unusual variety of benign vascular tumor. Involvement of periorbital area is uncommon. We report 2 cases of periorbital IPEH and review relevant literature.

Vitreous loss during phacoemulsification in glaucoma patients: long-term intraocular pressure control.

PURPOSE: To assess the long-term effect of vitreous loss during phacoemulsification on intraocular pressure (IOP) control in glaucoma patients. SETTING: Birmingham and Midland Eye Centre, City Hospital, Birmingham, United Kingdom. METHODS: In this study, 26 glaucoma cases with vitreous loss during phacoemulsification were identified from operative room records. The cases were performed from January 1999 to December 2001. Minimum follow-up was 12 months. Postoperative IOP control in eyes with vitreous loss (Group 1) was assessed and compared with that in stable fellow eyes (Group 2), which served as controls. Another control group (Group 3) comprised patients with primary open-angle glaucoma who had successful phacoemulsification. Case notes of 22 patients from the same period fulfilled these criteria. RESULTS: The 3 groups were comparable in age, sex, laterality, ethnicity, mean IOP, and mean number of medications preoperatively. Twelve months after surgery, 43.2% in Group 1, 23.1% in Group 2 (P<.05) and 4.5% in Group 3 had significantly worse IOP; the differences between Group 1 and Groups 2 and 3 were statistically significant (P<.05). Intraocular pressure control was significantly better in Group 3 than in Group 2 (P<.05). CONCLUSIONS: Vitreous loss during cataract surgery in glaucoma patients adversely affected IOP control in the long term. Results suggest that uneventful cataract surgery in glaucoma patients improves IOP control.

Rapidly progressing bilateral cataracts in a patient with beta thalassemia and pellagra.

Soon after the diagnosis of pellagra in a 20-year-old patient with beta thalassemia, bilateral intumescent cataracts rapidly developed. We believe the patient's crystalline lenses were at an increased oxidative state due to iron overload from the thalassemia. Depletion of the lens epithelial cells of an important antioxidative agent (glutathione) as a result of niacin (vitamin B3) deficiency due to pellagra reduced the antioxidative capacity of the lenses. The oxidative damage led to rapid development of cataracts.

Reversible visual loss in a patient with rheumatoid arthritis and the role of vascular imaging.

Spontaneous vertebral artery dissection is a condition that can have lethal consequences. The condition should be considered in young male patients who present with a stroke. At presentation, headaches, cerebral ischaemic episodes and oculosympathetic paresis are the most commonly encountered manifestations. The diagnosis is confirmed with angiography. Here, we present a middle-aged male gardener with rheumatoid arthritis and signs of vertebral artery dissection to highlight the importance of diagnosis and discuss the controversies in management.

Anterior scleritis, scleral thinning, and intraocular pressure measurement.

We report a case of unilateral glaucoma with falsely low intraocular pressure reading as a result of scleral thinning from anterior scleritis.

Referral patterns in paediatric orbital cellulitis.

OBJECTIVES: Orbital cellulitis in children may result in severe visual morbidity and even mortality if not managed appropriately. The definitive management of orbital cellulitis is in the realms of the otolaryngologist, as the underlying pathology is associated with sinus disease in more than 90% of cases. Our observations suggest that there is a tendency for patients with suspected orbital cellulitis not to be referred promptly for otolaryngological opinion and management, which may result in adverse outcomes. The aim of this study was to determine the initial management by establishing general practitioners' attitudes to the referral and management of suspected orbital cellulitis. METHODS: Anonymous questionnaires were sent to general practitioners to ascertain details on their initial treatment modalities and preferred specialist referral. General practitioners in Worcestershire and North Staffordshire, two major regions in the West Midlands, UK, were targeted. RESULTS: The majority of general practitioners initially commenced patients on oral antibiotics, and referred patients primarily to ophthalmologists for further assessment, although significant variations in referral patterns were found. CONCLUSION: Better education for primary care physicians is needed regarding the initial management and referral of paediatric patients with suspected orbital cellulitis. They should be referred promptly for hospital admission. A good multidisciplinary approach with quick involvement of the three specialities (ear, nose and throat, ophthalmology and paediatrics) would avoid delays in the definitive management and ensure optimal outcomes.

Long-term results of trabeculectomy with mitomycin C applied under the scleral flap.

PURPOSE: The objective of this study was to look at the long-term safety, and the effectiveness on intraocular pressure, of trabeculectomy and mitomycin C (MMC) applied under the scleral flap. METHODS: All patients undergoing trabeculectomy and MMC application during the period June 1992-August 1995 were included. Data on 30 eyes of 25 patients were reviewed. We looked at sociodemographic variables, intraocular pressure (IOP) control, visual acuities and bleb morphology. Bleb-related and other complications were also noted. Statistical analysis was performed with Student's paired t-test, and Kaplan-Meier life table analysis was utilised for IOP control. RESULTS: The mean age of patients (12 male and 13 female) was 56 years (range 7-79 years), with a mean follow-up period of 8.7 years (range 5-11 years). There was one eye with blebitis/endophthalmitis at 4 years, and one eye developed hypotonous maculopathy. Ten eyes were noted to have poor bleb morphology due to long-standing fibrosis, and the majority of these underwent further surgical intervention with 5-fluorouracil (5FU) needling. The IOP control showed good results, with mean IOP falling from a preoperative level of 24.8-15.2 mmHg at the last visit, with good probability of maintenance in the longer term. The main reason for reduced vision was pre-existing co-morbidity and development of lenticular opacities. CONCLUSION: In the series with the longest follow-up period our study showed that trabeculectomy augmented with MMC under the scleral flap in these difficult cases can achieve good long-term IOP control and is associated with minimal long-term complications.

A comparative study of referral patterns and management of patients with malignant brain tumours in Birmingham, UK, and Toronto, Canada.

The management of malignant brain tumours comprises a huge financial burden to any health care system. The referral pattern and initial management of this condition has not been widely investigated. Our main aim was to investigate and compare the referral patterns between two tertiary referral centres in Birmingham, UK, and Toronto, Canada, which have similar health care provision structures, but different financial resources, in order to examine whether there are any significant delays in the pathway of either system. The investigation consisted of a retrospective analysis of case records of patients identified as having malignant brain tumours who had been operated on at the two centres during the period 1997-1998. Data were collected on patient demographics, symptomatology at presentation, referral pattern, and time intervals between presentation, investigations, neurosurgical consultation and operation. Mann-Whitney U-tests of statistical significance were used to compare the two centres. Sixty-eight and 100 patients in Birmingham and Toronto, respectively, were identified from the registers following exclusion of patients with benign or low-grade tumours. Both centres were found to be similar with respect to sociodemographic factors of patients with malignant brain tumours. Referral patterns were analysed for presenting symptoms of neurological deficit and seizure, and found to be similar for both centres. Time intervals from presentation to investigation and from investigation to neurosurgical consultation were not significantly different between the two centres. Significant differences were found from neurosurgical consultation to operation (Birmingham, 3 days, and Toronto, 6 days, p = 0.006), and the duration of stay in hospital (Birmingham, 11 days, and Toronto, 2 days, p < 0.001). Although there are differences in the financial resources of the two tertiary centres our study reveals no significant differences in the referral pathway to operation.