Pediatric preseptal and orbital cellulitis - a 6 year experience from a London tertiary centre.

PURPOSE: This study reports the experience of pediatric preseptal and orbital cellulitis at a London tertiary centre during a 6-year period and highlights the role of orbital surgeons in the management of subperiosteal abscess (SPA). METHODS: A retrospective review was conducted of all pediatric patients hospitalised for preseptal and orbital cellulitis. RESULTS: A total of 201 children including 152 cases of preseptal cellulitis and 49 cases of orbital cellulitis were admitted at a London tertiary centre over the study period. Patients with orbital cellulitis and especially those managed surgically had higher rates of fever, higher presenting white cell count and C-reactive protein level compared to cases of preseptal cellulitis. 77.6% of patients with orbital cellulitis had SPA. 81.6% of SPA had a medial component, while 28.9% had superior component. 61.2% of orbital cellulitis cases were managed surgically. Surgical intervention was carried out by otorhinolaryngologists (ENT) in 76.7% of cases, jointly between ENT and orbital surgeons in 16.7% of cases and by orbital surgeons alone in 6.7% of cases. Of the 11 SPA involving the orbital roof, all were surgically managed and orbital surgeons were involved in 54.5% of cases. When SPA involved the medial wall, orbital surgeons were only involved in 6.5% of cases. CONCLUSIONS: We recommend all patients with superior SPA be treated at a centre with both ENT and orbital surgeons as these may not be amenable to drainage by ENT alone.

Combined upper lid skin crease and endoscopic approach to frontal sinus mucocoeles.

PURPOSE: This case series describes the ophthalmic manifestations of frontal sinus mucoceles and reports the long-term surgical outcomes of a combined endoscopic and upper-lid skin crease drainage approach carried out jointly with otorhinolaryngology. METHODS: We present a retrospective case review of 18 orbits and 15 patients presenting with frontal sinus mucocoeles, all of whom underwent drainage via an adapted anterior orbitotomy approach between January 2015 and July 2023. Data collection included preoperative and postoperative examination findings (visual acuity, extraocular motility, lid retraction, and lagophthalmos), mucocoele recurrence, cosmetic satisfaction, and surgical complications. Patients were followed up for an average of 22 months. RESULTS: All patients underwent successful frontal mucocoele drainage via a modified anterior orbitotomy and simultaneous endonasal approach. At presentation, three (20%) had extraocular restriction leading to diplopia, and six (40%) had proptosis in the eye adjacent to the mucocoele. One patient presented acutely with no light perception in the affected eye due to compressive optic neuropathy. All patients who had reduced extraocular motility before surgery regained full motility post-operatively. Treatment was successful in all cases, and there was no documented mucocoele recurrence during follow-up. Satisfactory aesthetic outcomes were achieved in all cases. Reported complications included temporary forehead numbness and ptosis of the affected eyelid, which resolved without intervention. CONCLUSION: The modified anterior orbitotomy approach to frontal mucocoeles allows optimal frontal sinus access and mucocoele treatment while preserving cosmesis.

A multidisciplinary approach to frontal sinus mucocoeles using an upper lid skin crease incision combined with endoscopic drainage allows full access to the frontal sinus and treatment of the mucocoele while preserving cosmesis.

Horizontal eyelid shortening alone versus combined procedures for the correction of involutional lower eyelid entropion.

BACKGROUND: Conventionally, management of involutional entropion involves correcting both vertical and horizontal laxity, however the optimal surgical approach is debated. OBJECTIVE: To compare the recurrence rate of horizontal lower eyelid shortening alone with combined surgical approaches for correction of involutional lower eyelid entropion. METHODS AND MATERIAL: A retrospective, comparative, consecutive case series of patients undergoing surgery for involutional lower eyelid entropion with both horizontal and vertical laxity. Patients were categorized based on the procedure as: Group 1, horizontal shortening alone, Group 2, horizontal shortening with everting sutures), and Group 3, horizontal shortening with retractor plication. RESULTS: Of the 249 procedures (31 bilateral) performed on 218 patients, 54 (22%) involved horizontal eyelid shortening alone (Group 1), while 80 (32%) had this combined with everting sutures (Group 2), and 115 (46%) with retractor plication (Group 3). The anatomical success rates for Groups 1, 2, and 3 were 93, 94, and 90% (P = 0.69), respectively. Similarly, reported symptom improvements were 94, 93, and 93% for these groups (P = 0.91). After an average follow-up of 15.7 months (median 10; range 6-81), Group 1 (eyelid shortening alone) had a 7% (4/54) recurrence, compared to 8% (16/195) in Groups 2 and 3 (combined procedures) (P = 1.0). Complications were minor, with no significant difference between groups. CONCLUSION: Eyelid shortening alone appears to be as effective as combined techniques for involutional entropion with both horizontal and vertical eyelid laxity. Nevertheless, procedure selection should consider primary pathogenic factors.

Canalicular obstruction associated with dupilumab.

PURPOSE: Dupilumab is a novel treatment for severe atopic dermatitis and is associated with a range of ocular complications such as blepharoconjunctivitis, keratitis, cicatricial ectropion and punctal stenosis. METHODS: We report 4 patients with canalicular obstruction in association with dupilumab therapy, and we describe their treatment and outcomes in each case. RESULTS: Canalicular obstruction was diagnosed by an oculoplastic consultant between 3 years and 3 months and 4 years and 9 months after the commencement of dupilumab therapy. Case 1 underwent nasolacrimal intubation, case 2 was treated conservatively, and case 4 underwent endonasal dacryocystorhinostomy and these patients' symptoms resolved. Unfortunately, in case 3 despite endonasal dacryocystorhinostomy with stenting they remained symptomatic. CONCLUSION: This case series adds to the growing number of ocular complications associated with dupilumab therapy, and there is yet an optimal treatment strategy to mitigate these complications. It is possible that simple conservative measures such as discontinuation of dupilumab and topical treatments with steroids can eventually lead to some form of recovery and recanalisation of the canalicular system. Early referral to an ophthalmologist prior to the development of canalicular obstruction to control the inflammatory ocular surface could reduce the risks of cicatricial sequelae from dupilumab, and temporary stenting of the canalicular system could be attempted as a method to keep the canalicular system patent, whilst the patient remained on treatment.