Morbihan Syndrome, a UK Case Series.

PURPOSE: To describe 10 patients with Morbihan syndrome, a rare condition characterized by the slow appearance of erythema and solid edema on the upper portion of the face, and review the literature. METHODS: Retrospective case series and review. RESULTS: The majority of patients were male (80%), and the mean age at presentation was 67 years (range, 48-88 years); 60% had asymmetrical disease (affecting mainly the right side). All subjects underwent a lid biopsy to support the diagnosis of Morbihan syndrome, which showed features of inflammation and vascular dysfunction, highly suggestive of a rosacea histological picture complicated by chronic lymphoedema. A range of medical and surgical treatment were used with variable success. The most effective ones included oral isotretinoin, intralesional triamcinolone injections, and debulking surgery. CONCLUSIONS: Morbihan syndrome is a rare and chronic condition. It can be difficult to treat and may require a range of interventions.

Bicanalicular Silicone Stents in Endonasal Dacryocystorhinostomy: Results of a Randomized Clinical Trial.

PURPOSE: To assess whether the use of silicone lacrimal stents affects the long-term success of endonasal dacryocystorhinostomy (EN-DCR). DESIGN: Prospective, randomized, controlled, interventional trial. PARTICIPANTS: The subjects were adult patients older than 16 years undergoing primary EN-DCR for nasolacrimal duct obstruction who gave fully informed consent and who had no lid malpositions or canalicular pathology. In cases with bilateral surgery, only the right eyes were studied. Participants were randomized to receive stents (control group) or not (study group). METHODS: Standardized nonendoscopic EN-DCR was performed by the senior author in all cases. When the ostium was completed, the randomization code was revealed as to whether a lacrimal stent was placed or not. Follow-up assessments were made at 3, 6, 9, and 12 months. Stents were removed at 3 months. MAIN OUTCOME MEASURES: The primary end point was symptoms of epiphora at 12 months, reported to the surgical booking clerk as (a) resolved, (b) significantly improved, (c) partially improved, or (d) no change or worse. The secondary end point was anatomic patency based on nasolacrimal syringing and categorized as (a) fully patent, minimal, or no reflux; (b) >50% patent but some reflux; (c) some patency but >50% reflux; or (d) nonpatent, 100% reflux. Complete success was defined as having resolved or significantly improved symptoms of watering and minimal or no reflux on nasolacrimal syringing. Partial success was defined as symptoms partially improved with a combination of patency and reflux on syringing. Failure was categorized as no change or worse symptoms of watering and 50% to 100% reflux on syringing. RESULTS: A total of 300 patients completed 12 months of follow-up. A total of 152 patients received tubes, and 148 patients did not. Overall success both subjectively and objectively was 94.7% in the stented group and 87.8% in the nonstented group (P = 0.034, Pearson chi-square 1-tailed test). The most common complications of stents included canalicular cheese-wiring and tube prolapse in approximately 4% each. CONCLUSIONS: There is a statistically significantly higher success rate in EN-DCR surgery with tubes compared with no tubes. The failure rate in this study was more than twice as high when tubes were not used (12.2% vs. 5.3%).

Sensitivity and responsiveness of the patient-reported TED-QOL to rehabilitative surgery in thyroid eye disease.

We tested the sensitivity and responsiveness of the TED-QOL to rehabilitative surgery in thyroid eye disease (TED). The 3-item TED-QOL and 16-item GO-QOL, which assess quality of life (QoL) in TED, were administered to consecutive patients undergoing rehabilitative surgery. The questionnaires were completed pre-and post-operatively to assess sensitivity (ability to discriminate between different surgical groups) and responsiveness (ability to detect within patient changes over time).56 patients underwent 69 procedures for TED (29 orbital decompressions, 15 strabismus operations, 25 eyelid procedures). The differences in scores between the three types of surgery (a measure of sensitivity) were statistically significant at the 5% level pre-operatively and post-operatively for all 3 TED-QOL scales and for both GO-QOL scales, but much more so for the TED-QOL scales in each case. The within-patient changes between the pre- and post-operative scores for the same subjects (a measure of responsiveness) were statistically very highly significant for the TED-QOL overall and appearance scales for each of the surgeries. The pre- and post-operative difference for the TED-QOL functioning scale was highly statistically significant for strabismus surgery but not for decompression or lid surgery. The change between the pre- and post-operative scores for the GO-QOL was significant for the functioning scale with strabismus and lid surgery, and was highly significant for the appearance scale with lid surgery but not for strabismus surgery or decompression. The 3-item TED-QOL is sensitive and responsive to rehabilitative surgery in TED and compares favorably with the lengthier GO-QOL for these parameters.

Oscillopsia after lateral wall orbital decompression.

PURPOSE: To assess the incidence, duration, and severity of oscillopsia after lateral wall orbital decompression for thyroid eye disease. DESIGN: Retrospective telephone interview. PARTICIPANTS: A consecutive group of patients who had undergone lateral wall orbital decompression for thyroid eye disease performed by 2 consultants at Moorfields Eye Hospital between January 2008 and December 2010. METHODS: Patients were telephoned and a standardized interview related to postoperative oscillopsia was performed. The degree of preoperative and late postoperative exophthalmometry was assessed from clinical records. MAIN OUTCOME MEASURES: The presence, severity, and duration of postoperative oscillopsia and its impact on daily activities. RESULTS: Ninety-eight patients were interviewed successfully, of which 34 (35%) had noted postoperative oscillopsia that occurred upon chewing in 29 of 34 patients (85%) and upon walking in 8 of 34 patients (24%). The oscillopsia resolved within 1 year in 15 of 34 patients (44%), and 16 of 34 (47%) still had mild symptoms at 2 years or more after surgery. Fourteen patients (41% of affected patients; 14% of the entire group) initially were troubled by the symptom, but at the time of interview, only 1 person found it troublesome and 7 reported it as a minimal problem. The reduction in proptosis was similar among those with and without oscillopsia. CONCLUSIONS: The incidence of oscillopsia after lateral wall orbital decompression was 35% when patients were questioned directly, and was much higher than anticipated from extensive clinical experience (where very few patients mention the symptom). In almost all cases, the oscillopsia resolved or was not troublesome, and only 1 patient found it bothersome more than 2 years after surgery. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

The watery eye quality of life (WEQOL) questionnaire: a patient-reported outcome measure for surgically amenable epiphora.

OBJECTIVE OR PURPOSE: To develop and test a patient-reported outcome measure for assessing health-related quality of life (HRQOL) in surgically amenable epiphora. DESIGN: Questionnaire development and validation study. PARTICIPANTS: 201 patients with a cause of epiphora amenable to surgical intervention, recruited across three independent centres. METHODS, INTERVENTION OR TESTING: The watery eye quality of life (WEQOL) questionnaire was developed and refined according to defined psychometric standards. Both surgical and non-surgical participants completed WEQOL at baseline and follow-up (>3 months), along with the Lacrimal Symptom Questionnaire (Lac-Q), RAND Short Form Health Survey (SF-36) and Glasgow Benefit Inventory (GBI). Convergent validity of WEQOL was evaluated according to correlation (R > 0.40) with each of these additional tests. Responsiveness of WEQOL to intervention was evaluated according to patient-reported success. Test-retest reliability was assessed by the Bland-Altman method and intraclass correlation (ICC) in a subset of 64 participants at baseline. MAIN OUTCOME MEASURES: WEQOL construct validity, responsiveness and test-retest reliability. RESULTS: WEQOL was moderately correlated (R > 0.4) with the Lac-Q and several subscales of the SF-36 (physical role limitation, social, emotional role limitation and emotional well-being). A stronger correlation was found between the change in WEQOL at follow-up and GBI (R = 0.61). An appropriate graded response was found with a significant change in WEQOL score being observed in patients reporting successful (-28%, p < 0.0001) and partially successful surgery (-6%, p = 0.04), but not in those reporting unsuccessful surgery (+2%, p = 0.9). High test-retest reliability was observed (ICC = 0.93). CONCLUSIONS: The WEQOL questionnaire has been developed systematically according to modern psychometric standards and has been designed to evaluate the quality of life in patients with epiphora that is of a surgically amenable cause. In this study, it has demonstrated appropriate test-retest reliability, responsiveness and construct validity.

Vibration-assisted anesthesia in eyelid surgery.

PURPOSE: To investigate whether a vibrating device applied in a circular motion to the forehead reduces the pain of local anesthetic injection in upper eyelid surgery. DESIGN: Prospective, interventional, cross-over, randomized, controlled clinical trial. PARTICIPANTS: Eighty patients undergoing bilateral upper eyelid surgery under local anesthesia. INTERVENTION: A vibrating device was applied in a circular motion to participants' foreheads while local anesthetic was injected into 1 eyelid. During injection of anesthetic on the contralateral lid, the device was applied to the forehead in static fashion with the vibration switched off (placebo). The order of intervention was randomized. MAIN OUTCOME MEASURES: After both injections had been given, participants were asked to specify their pain ratings for each injection on a scale of 0 to 10, with 0 representing no pain and 10 indicating the worst pain imaginable. Participants were also asked to qualitatively compare the 2 sides. RESULTS: The mean pain scores were 3.3 for the vibration-assisted side and 4.5 for the placebo. This difference was statistically significant (P=0.0003); 73% of participants found the vibrated side to be better than the placebo, with 35% finding it a lot or quite a bit better. CONCLUSIONS: Vibration-assisted anesthesia during upper eyelid surgery has a beneficial effect that is highly statistically significant and is clinically significant in terms of patients' qualitative assessment of pain. Further research is needed to determine whether this constitutes a quantitatively clinically significant improvement in pain management. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Lacrimal surgery success after external dacryocystorhinostomy: functional and anatomical results using strict outcome criteria.

PURPOSE: To present the results of external dacryocystorhinostomy (ext-DCR) for epiphora using strict outcome criteria and provide an accurate baseline and evidence from which to compare the results of endonasal dacryocystorhinostomy. METHODS: Retrospective case notes review of 158 consecutive adult patients who underwent primary ext-DCR. Functional success was assessed according to the patients' symptoms and anatomical success was measured using objective tests of lacrimal system patency: 1) the functional endoscopic dye test and/or endoscopic endonasal inspection of the ostium; 2) syringing of the lacrimal system; and 3) the fluorescein dye retention test. Patients without complete follow-up data were recalled for clinical reevaluation. A minimum follow-up of 6 months was required. Comparison of overall functional and anatomical success was further analyzed according to etiology using logistic regression and for different grades of surgeon using the chi-squared test. RESULTS: The results for 124 of 158 ext-DCRs showed an overall functional success of 69% and anatomical success of 74%. Patients with primary acquired nasolacrimal duct obstruction (PANDO) who had surgery by the specialist lacrimal surgeon had high success: 83% functional success and 100% anatomical success. Patients with watering eyes from non-PANDO aetiology including canalicular disease who had surgery by the specialist lacrimal surgeon had moderate success: 78% functional success and 70% anatomical success. The results of all surgery by trainees were lower but only significantly so for PANDO. The mean duration of follow-up was 2.6 years (range, 6 months to 8.3 years); median follow-up was 1.9 years. CONCLUSION: This study used strict criteria to assess functional and anatomical outcomes of primary ext-DCR and thus provide baseline measures of success with a minimal follow-up of 6 months. When canalicular disease was excluded, results for PANDO were higher. Surgery performed by the specialist lacrimal surgeon had higher success rates than when performed by trainee.

Monitoring glaucomatous progression using a novel Heidelberg Retina Tomograph event analysis.

PURPOSE: To describe an event analysis (EA) for monitoring Heidelberg Retina Tomograph (HRT) progression and to establish specificity, detection rate, and agreement with visual field progression by application to longitudinal data. DESIGN: Retrospective analysis of data from a randomized controlled trial. PARTICIPANTS: One hundred ninety-eight ocular hypertensive and 21 control subjects. METHODS: Change criteria were derived from rim area (RA) repeatability coefficients for different levels of image quality. Event analysis 1 (EA1) through EA4 were applied to longitudinal series of HRT images acquired from the ocular hypertensive and the control cohorts: EA1 (change confirmed in 2 of 3 consecutive tests in 1 or more sector), EA2 (2 of 3 in 2 or more sectors), EA3 (3 of 3 in 1 or more sector), EA4 (3 of 3 in 2 or more sectors). Specificity (1 minus false positive results) was estimated by the proportions of progressing controls and significantly improving subjects. Progression rates were compared with Advanced Glaucoma Intervention Study (AGIS) visual field (VF) criteria, an HRT trend analysis, and a VF trend analysis, with specificity matched at 95%. MAIN OUTCOME MEASURES: Estimated specificity, progression rate, and agreement between progression techniques. RESULTS: Specificity estimates were 76.2% to 88.1% (EA1), 94.1% to 95.2% (EA2), 92.2% to 95.2% (EA3), and 99.1% to 100% (EA4). Of ocular hypertensive (OHT) subjects, 45.4%, 28.3%, 26.3%, and 16.2% were identified as progressing by each strategy, respectively. With specificity at 95%, 12.1% of OHT subjects progressed by both EA2 and AGIS criteria, with a median time to progression of 3.2 and 3.6 years, respectively. By EA2 alone, 16.2% progressed, and 9.6% progressed by AGIS criteria alone. The RA trend analysis identified 12% of OHT subjects as progressing. CONCLUSIONS: The HRT EA represents a simple technique, taking into account image quality. In this cohort, it had a higher detection rate of progression, at 95% specificity, than RA trend analysis and the VF progression criteria.

Detergent capsules causing ocular injuries in children.

Capsules containing liquid laundry detergent have recently become popular. We describe six children who presented with ocular surface injuries due to the bursting of such capsules.

Changes in corneal aesthesiometry and the sub-basal nerve plexus in benign essential blepharospasm.

BACKGROUND: The aetiology of blepharospasm remains unclear. There is evidence that the afferent pathway is important, but this area remains under-researched. AIM: To explore the hypothesis that the afferent arm of the blink reflex is abnormal in blepharospasm by assessing a range of measures of corneal sensory function. METHODS: In this prospective case-control study, 21 patients with blepharospasm and 21 age-matched and gender-matched controls completed the Ocular Surface Disease Index questionnaire and underwent the following assessments: tear osmolarity, Shirmer test, tear-film break up time, corneal and conjunctival vital staining, meibomian gland dysfunction, corneal aesthesiometry and confocal microscopy. RESULTS: Corneal sensitivity was significantly lower in patients with blepharospasm than in controls (right eyes p=0.009; left eyes p=0.009, paired t test). The median number of main nerve trunks was lower for patients with blepharospasm than for controls, and this was statistically significant at the 5% level (p=0.04, paired t test). Mean nerve density, median number of nerve branches and median total number of nerves were lower for blepharospasm cases than controls, but this did not reach statistical significance. Tortuosity was greater for blepharospasm cases than controls, but this was not statistically significant. CONCLUSIONS: Blepharospasm is associated with reduced corneal aesthesiometry and a tendency towards a reduced number of nerves in the sub-basal plexus, implying an impairment in corticosensory processing, possibly a defect of the sensorimotor gating mechanism resulting in a loss of inhibition of the blink reflex.

Medical student awareness of sexual health is poor.

The aim of the study was to assess sexual health knowledge of medical students. Participants from the student population of an English Medical School (University of Bristol) were asked to fill in a questionnaire on the Internet about sexual health issues. The number of correct responses to each question was analysed according to participants' gender and medical school year. While certain issues relating to sexually transmitted infections, contraception and confidentiality in HIV testing were well understood, there was poor knowledge about the failure rate of condoms, abortion rates and prevalence of chlamydia. Women knew more about the contraceptive pill than men. Although increased years of medical training had some benefit in improving the accuracy of knowledge, this effect was surprisingly small. Most medical students have inaccurate factual knowledge about certain important sexual health issues. We consider this to reflect poorly on sexual health awareness in young people in general. There is need for greater sexual health education for future doctors and for the general public.

Validity and reliability of the TED-QOL: a new three-item questionnaire to assess quality of life in thyroid eye disease.

AIM: To develop and test a user-friendly questionnaire for rapidly assessing quality of life (QOL) in thyroid eye disease (TED). METHODS: A three-item questionnaire, the TED-QOL, was designed and compared to the 16-item Graves Ophthalmopathy (GO)-QOL and the nine-item GO-Quality of Life Scale (QLS). 100 patients with TED were administered all three questionnaires on two occasions. Results were compared to clinical severity scores (Vision, Inflammation, Strabismus, Appearance (VISA) classification). Main outcomes were construct and criterion validity, test-retest reliability, duration, comprehension and completion rates. TED-QOL correlated strongly with the other questionnaires for corresponding items (Pearson correlation: appearance 0.71, 0.62; functioning 0.69, 0.66; overall QOL 0.53). Test-retest analysis demonstrated good reliability for all three questionnaires (intraclass correlations: TED-QOL 0.81, 0.74, 0.87; GO-QOL 0.81, 0.82; GO-QLS 0.74, 0.86, 0.67). TED-QOL was significantly faster to complete (1.6 min vs GO-QOL 3.1 min, GO-QLS 2.7 min, p<0.0001) and had a higher completion rate (100% vs GO-QOL 78%, GO-QLS 94%). There was only moderate correlation between items on all three questionnaires and VISA scores. CONCLUSION: The TED-QOL is rapid and easy to complete and analyse and has similar validity and reliability to longer questionnaires. All questionnaires showed only moderate correlation with disease severity, emphasising the discrepancy between objective and subjective assessments and the importance of measuring both.

Orbital teratoma: case report and management review.

We present a case of benign mature orbital teratoma in a neonatal boy that involved the chiasmal area and cavernous sinus and displaced the nasopharynx. Visual potential was deemed to be good. Because of the chiasmal involvement, complete surgical resection, which would have compromised his visual function, was considered inadvisable. A debulking procedure, mainly of the cystic parts of the tumor, was performed. The patient remains stable at 3 years of age, with no further growth of the tumor and good vision in the affected eye.

Impact of written and photographic instruction sheets on patient behavior after cataract surgery.

PURPOSE: To evaluate the extent to which patients unnecessarily restrict activities of daily living after routine cataract surgery and to test interventions to increase activity. SETTING: Day treatment center, London, United Kingdom. METHODS: In this nonrandomized interventional clinical study, consecutive patients having routine first-eye sutureless small-incision cataract surgery received 1 of 3 of the following postoperative instructions: standard discharge instructions informing patients that they could continue all activities of daily living (standard group), an additional written sheet specifying 9 activities of daily living that are safe to perform (written group), or an additional sheet with photographs of people performing safe activities of daily living (photo group). Three weeks postoperatively, patients answered a questionnaire on whether they had avoided the activities of daily living and if so, why. RESULTS: Each group comprised 50 patients. Sixty-four percent in the standard group reported avoiding 1 or more activities of daily living. The percentage was 44% in the written group (P = .07) and 30% in the photo group (P = .0013). In all groups, the decision to avoid activities was self-directed more than 50% of the time; it was based on the advice of a nurse in 17% of cases and of a doctor in 4% of cases. CONCLUSIONS: Many patients unnecessarily avoided activities of daily living after cataract surgery. Providing an additional written sheet did not significantly improve this, whereas a photograph sheet did. Better awareness of the safety and rapid rehabilitation after modern cataract surgery is needed in hospitals and primary care centers.