Patterns of visual field changes in thyroid eye disease.

This article provides a systematic description of visual field changes in thyroid eye disease-compressive optic neuropathy (TED-CON). A retrospective, non-comparative chart review of patients with TED-CON and documented Humphrey Visual Field 24-2 or 30-2 testing was conducted with IRB approval. Ninety-six visual fields in 68 patients were classified into 7 broad categories (superior, inferior, diffuse, temporal, nasal, central/paracentral, enlarged blind spot) and 17 mutually exclusive patterns from the Ocular Hypertension Treatment Study (OHTS) or "other." Fifty-three of 96 visual fields (55%) showed an inferior defect using the broad categories, with the remaining 6 categories ranging from 2% to 14%. The five most common OHTS patterns were other (28%), partial arcuate (28%), partial peripheral rim (9%), arcuate (8%) and altitudinal (7%). Further sub-classification showed a predominance of inferior visual field defects, ranging from 33% to 93% of each category. Of the 78 visual fields in these five categories combined, 52 (67%) were inferior defects. Inferior defect is the most typical TED-CON-associated visual field change. While the OHTS categories are geared toward classification of glaucomatous patterns, the overall predominance of inferior field defects in TED-CON was clearly demonstrated. These "other" visual field changes showing central inferior defect up to but not crossing the horizontal meridian and not contiguous from blind spot to nasal meridian should be designated as "TED-CON pattern." The high proportion of visual fields falling under the "other" category, however, does demonstrate the need for a more specific and tailored visual field classification system for TED-CON.

Mullers Muscle Conjunctival Resection for Treatment of Contact Lens-Associated Ptosis.

PURPOSE: The aim of this study was to look at the surgical outcomes of posterior approach Mullers muscle conjunctival resection surgery for contact lens-related ptosis. METHODS: This was a retrospective, comparative interventional case series. All patients and controls underwent phenylephrine 10% testing and had a positive response prior to surgical intervention. RESULTS: Thirty-one eyelids with ptosis were identified in 20 contact lens wearing patients, which were matched with 27 eyelids in 15 controls. The contact lens wearing patients wore contact lenses for a mean of 20.6 ± 12.1 years. More than half (60%) wore soft contact lenses, as opposed to rigid gas-permeable contact lenses. Preoperative margin-to-reflex distance-1 was lower in patients who wore rigid contact lenses (0.8 ± 0.7 mm) as compared with patients with soft contact lenses (1.7 ± 1.1 mm) (p = 0.01). Surgical success, as defined by margin-to-reflex distance-1 ≥3 mm or symmetry of upper eyelid height (within 1 mm), was achieved in 93.5% in the contact lens group and 92.6% of controls. Postoperative margin-to-reflex distance-1 was significantly higher in the contact lens wearers (3.9 ± 1.3 mm) compared with the controls (3.2 ± 1.1 mm; p = 0.01). There was a significant correlation between the amount of tissue resected intraoperatively and the improvement in margin-to-reflex distance-1 (Pearsons correlation coefficient, r =0.36; p = 0.006). There were no surgical complications of any patients in the study. CONCLUSION: Mullers muscle conjunctival resection surgery is an effective surgical correction for contact lens-associated ptosis. Patients can achieve excellent results with minimal risk of residual ptosis or asymmetry.

Axial Globe Position Measurement: A Prospective Multicenter Study by the International Thyroid Eye Disease Society.

PURPOSE: Identify a reproducible measure of axial globe position (AGP) for multicenter studies on patients with thyroid eye disease (TED). METHODS: This is a prospective, international, multicenter, observational study in which 3 types of AGP evaluation were examined: radiologic, clinical, and photographic. In this study, CT was the modality to which all other methods were compared. CT AGP was measured from an orthogonal line between the anterior lateral orbital rims to the cornea. All CT measurements were made at a single institution by 3 individual clinicians. Clinical evaluation was performed with exophthalmometry. Three clinicians from each clinical site assessed AGP with 3 different exophthalmometers and horizontal palpebral width using a ruler. Each physician made 3 separate measurements with each type of exophthalmometer not in succession. All photographic measurements were made at a single institution. AGP was measured from lateral photographs in which a standard marker was placed at the anterior lateral orbital rim. Horizontal and vertical palpebral fissure were measured from frontal photographs. Three trained readers measured 3 separate times not in succession. Exophthalmometry and photography method validity was assessed by agreement with CT (mean differences calculation, intraclass correlation coefficients [ICCs], Bland-Altman figures). Correlation between palpebral fissure and CT AGP was assessed with Pearson correlation. Intraclinician and interclinician reliability was evaluated using ICCs. RESULTS: Sixty-eight patients from 7 centers participated. CT mean AGP was 21.37 mm (15.96-28.90 mm) right and 21.22 mm (15.87-28.70 mm) left (ICC 0.996 and 0.995). Exophthalmometry AGP fell between 18 mm and 25 mm. Intraclinician agreement across exophthalmometers was ideal (ICC 0.948-0.983). Agreement between clinicians was greater than 0.85 for all upright exophthalmometry measurements. Photographic mean AGP was 20.47 mm (10.92-30.88 mm) right and 20.30 mm (8.61-28.72 mm) left. Intrareader and interreader agreement was ideal (ICC 0.991-0.989). All exophthalmometers' mean differences from CT ranged between -0.06 mm (±1.36 mm) and 0.54 mm (±1.61 mm); 95% confidence interval fell within 1 mm. Magnitude of AGP did not affect exophthalmometry validity. Oculus best estimated CT AGP but differences from other exophthalmometers were not clinically meaningful in upright measurements. Photographic AGP (right ICC = 0.575, left ICC = 0.355) and palpebral fissure do not agree with CT. CONCLUSIONS: Upright clinical exophthalmometry accurately estimates CT AGP in TED. AGP measurement was reliably reproduced by the same clinician and between clinicians at multiple institutions using the protocol in this study. These findings allow reliable measurement of AGP that will be of considerable value in future outcome studies.

A Novel Bioresorbable Implant for Repair of Orbital Floor Fractures.

PURPOSE: To describe clinical, radiologic, and safety outcomes of orbital floor fracture repair using a novel bioresorbable polycaprolactone (PCL) mesh implant (Osteomesh™, Osteopore International, Singapore). METHODS: This is a prospective interventional case series of orbital floor fractures repaired using a novel PCL mesh implant. Clinical evaluation was conducted at presentation and postoperatively at 1, 4, 12, 24 and 48 weeks. Computed tomography (CT) of the orbits was performed 1 year postoperatively. RESULTS: A total of 20 patients were recruited. Mean follow up was 50.4 ± 31.88 weeks. The majority of the patients were male (60%) and of Chinese ethnicity (75%), and the mean age was 39.35 (range 13-69) years. The most common mechanism of injury was assault. The average fracture size was 21.9 mm (range 12-32 mm) in the anteroposterior meridian and 18.65 mm (range 6-27 mm) in the horizontal meridian. Fifty percent of the patients were classified as having a large orbital defect (horizontal width ≥20 mm). The binocular single vision (BSV) score improved from 72.1% preoperatively to 90.8% postoperatively (P < 0.05) for 17 patients who had pre and postoperative charts. BSV improvement did not differ significantly between those with large and small orbital fracture sizes. There were features of neobone formation on CT scan performed 1.5 years after implantation. CONCLUSION: This bioresorbable implant is a promising material for the repair of both small and large orbital floor fractures, giving good functional and aesthetic outcomes.

Orbital inflammatory disease in relapsing polychondritis.

We present a 73-year-old Chinese male with bilateral relapsing, remitting orbital inflammatory disease associated with relapsing polychondritis. He first presented with right orbital inflammation that did not improve despite antibiotic treatment. Computer tomography (CT) of the orbits showed a soft tissue mass along the roof of the orbit, which was biopsied, revealing acute on chronic inflammation. There was complete resolution of his orbital inflammation within 2 weeks of initiating systemic steroid treatment. He subsequently developed recurrent bouts of left orbital inflammation. One year later, he was diagnosed with relapsing polychondritis and subsequently developed multiple myeloma seven years later. Comanagement with a rheumatologist will be helpful to achieve control of the disease with judicious use of immunosuppression. Long-term follow-up of the patient will be necessary to monitor for malignant transformation of the orbital lesion, as well as the development of other hematologic malignancies.

A survey of the histopathology of lacrimal gland lesions in a tertiary referral centre.

PURPOSE: To describe the histopathological distribution of biopsied lacrimal gland lesions in a tertiary referral centre in Singapore. METHODS: This was a retrospective chart review. Clinical records of patients who underwent lacrimal gland biopsy at a tertiary referral centre in Singapore between 2000 to 2010, were reviewed. Data collated included patient demographics, clinical presentation, association with systemic disease and histopathological diagnosis. RESULTS: Sixty-nine patients were studied. Median age of presentation was 50 years. Forty patients (58%) were female and the majority (84%, n = 29) were Chinese. The mean follow-up duration was 35.0 ± 34.5 months. 30.4% (n = 21) of the patients had bilateral disease. Chronic dacryoadenitis (46%, n = 32) was the most common histopathological diagnosis, followed by lymphoproliferative disorders (38%, n = 26) and pleomorphic adenoma (10%, n = 7). The diagnoses in four other patients included adenoid cystic carcinoma, lacrimal gland hypertrophy, lacrimal duct cyst and orbital vascular malformation. CONCLUSION: Chronic dacryoadenitis and lymphoproliferative disorders are the two commonest causes of lacrimal gland lesions in our series. Although many cases remain non-specific, about 60% have a specific inflammation that may be associated with a systemic disease. As one third of our patients with lymphoproliferative disease of the lacrimal gland had an associated systemic lymphoma, patients with such lesions should be referred for investigation of possible systemic lymphoma. The results of our study can aid in providing a more targeted approach to patient management.

Long-term, multicenter evaluation of subconjunctival injection of triamcinolone for non-necrotizing, noninfectious anterior scleritis.

PURPOSE: We sought to characterize the long-term outcomes and complications of subconjunctival triamcinolone acetonide injection (STI) for non-necrotizing, noninfectious anterior scleritis. DESIGN: Retrospective, interventional, noncomparative, multicenter study. PARTICIPANTS: Sixty-eight eyes of 53 patients from 9 participating hospitals in the United States, Singapore, and Australia. Only eyes with 6 or more months of follow-up were included. INTERVENTION: Subconjunctival injection of 2 to 8 mg of triamcinolone acetonide was administered to eyes with non-necrotizing, noninfectious anterior scleritis. MAIN OUTCOME MEASURES: Resolution of signs and symptoms, time to recurrence of scleritis, and side effect profile. RESULTS: Median follow-up was 2.3 years (range, 6 months to 8.3 years). Sixty-six eyes (97.0%) experienced improvement of signs and symptoms after 1 injection. Twenty-four months after a single injection, 67.6% of eyes remained recurrence-free, whereas at 48 months, 50.2% were recurrence-free. Some 55.0% of patients who had adverse effects from systemic medications were off all systemic medications at last follow-up; 55.0% of patients who were taking systemic medications at the time of first triamcinolone acetonide injection were not taking prednisone and immunosuppressants at this time; 76.2% of patients still requiring systemic agents had associated systemic disease. Fourteen eyes (20.6%) had ocular hypertension not requiring intraocular pressure (IOP)-lowering therapy. Two eyes (2.9%) were treated with topical IOP-lowering agents alone, and 2 eyes required surgical intervention for glaucoma. None developed scleral necrosis or melt. CONCLUSIONS: This retrospective, international study carried out at 9 hospitals suggests that STI can treat non-necrotizing, noninfectious anterior scleritis with side effects limited to elevated IOP in a few patients. Although no cases of scleral melt or necrosis were observed, we cannot definitively conclude that this may not occur after STI. Intraocular pressure should be closely monitored after STI. Subconjunctival triamcinolone acetonide injection may be useful as adjuvant therapy or to decrease systemic medication burden. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

A survey of contact lens complications in Singapore.

OBJECTIVES: To describe the type of complications related to contact lens wear seen in a hospital setting in Singapore. METHODS: Data were collated over a 2-year period from April 1999 to March 2001, from all public hospitals in Singapore. A standardized clinical record form was completed by the attending doctor when a patient presented for contact lens-related complications. RESULTS: Nine hundred and fifty-three contact lens-related complications were recorded. The mean age of presentation was 26.4 years. Women made up the majority n=491 (68%). Most patients were Chinese (555, 77%). Six hundred and seventy-six (93.7%) patients were soft contact lens wearers. Most patients, 585 patients (85.2%) wore their lenses on a daily basis. Two hundred and forty-four cases (25.6%) of infective keratitis were seen, with 55 patients requiring hospital admission for management of the infection. Soft disposable contact lens wear was associated with the majority of the infective keratitis (178, 73%). Epithelial keratitis occurred in 229 patients (24.0%) with punctuate epithelial erosions being the commonest presentation in 139 (14.6%). Allergic conjunctivitis occurred in 179 (18.8%) of the cases with giant papillary conjunctivitis accounting for 147 (15.4%) of them. Dry eyes (77, 8.1%), sterile infiltrates (71, 7.5%) and neovascularization of the cornea (75, 7.9%) were the next commonest complications seen. Corneal edema, solution- and lens-related complications occurred in small numbers, accounting for less than 5% of the complications reported. CONCLUSION: Infective keratitis secondary to soft lens wear was the most common complication, followed by epithelial keratitis and allergic conjunctivitis seen in public hospitals in Singapore.

An unusual causative agent for an orbital abscess: Granulicatella Adiacens.

We present a patient who developed an orbital abscess secondary to a retained organic (wooden) foreign body after a fall. Clinically, he had a right sub brow fistula exuding purulent discharge, four millimetres of proptosis, limitation of ocular motility in all directions of gaze, but no signs of optic neuropathy. Preoperative computed tomography and magnetic resonance imaging of the orbits was performed to localise the abscess and to facilitate surgical planning. He underwent exploration, drainage of the abscess and removal of the wooden foreign body with good postoperative recovery. Cultures isolated Ganulicatella Adiacens, a nutritionally variant streptococcus. This is an unusual causative organism and to our knowledge, this is the first reported case of a posttraumatic orbital abscess associated with Granulicatella Adiacens. Clinical suspicion, isolation of the organism and appropriate microbial treatment requires a multidisciplinary approach, with input from the ophthalmologist, microbiologist and infectious disease team. This will ensure a good outcome in patient management.

Lessons of the month 2: Ocular manifestations and complications of hepatitis C infection.

We present a case of a man with hepatitis C with acute visual loss in his left eye over a 3-day period. Initial evaluation suggested a possible idiopathic orbital inflammatory syndrome as underlying cause for his symptoms. Initial response to systemic glucocorticoids and antiviral treatment were encouraging with improvement in the patient's visual acuity. After a period of loss to follow up and discontinuation of treatment, the patient re-presented with visual loss in his left eye. Re-evaluation confirmed a diagnosis of marginal zone B-cell lymphoma. This case illustrates the importance of considering the various ocular manifestations of hepatitis C.

Retained lens fragment in the anterior segment as a cause of recurrent anterioruveitis.

A 61-year-old male developed recurrent anterior uveitis over a period of 8 months after an uncomplicated phacoemulsification and posterior chamber intraocular lens implantation surgery. This was subsequently found to be due to a retained lens fragment in the anterior segment, with complete resolution following surgical extraction of the fragment. To our knowledge, this is the first report of recurrent anterior uveitis attributable to a retained lens fragment following uncomplicated cataract surgery, and the diagnosis should be considered in a pseudophakic patient presenting with recurrent episodes of anterior uveitis.

Comparison of anterior chamber depth measurements using the IOLMaster, scanning peripheral anterior chamber depth analyser, and anterior segment optical coherence tomography.

AIM: To compare anterior chamber depth measurements by three non-contact devices-the IOLMaster, scanning peripheral anterior chamber depth analyser (SPAC), and Visante anterior segment optical coherence tomography (AS-OCT) METHODS: Prospective, cross sectional study of 497 phakic subjects over 50 years of age attending a community clinic in Singapore. Anterior chamber depth of the right eye was measured using all three techniques by the same investigator. Depth measurements were made from the corneal epithelium to the anterior lens surface. The values obtained were compared using Bland-Altman analysis. RESULTS: 232 men and 265 women were examined (mean (SD) age, 63.4 (7.9) years). Mean anterior chamber depth was 3.08 (0.36) mm with IOLMaster, 3.10 (0.44) mm with SPAC, and 3.14 (0.34) mm with AS-OCT. A significant difference was present between the anterior chamber depth measurements recorded by the three devices (p<0.0001). Mean differences between the measurements were: AS-OCT v IOLMaster, 0.062 (0.007) mm (95% limits of agreement, -0.37 to 0.25 mm) (p<0.0001); AS-OCT v SPAC, 0.035 (0.011) mm (-0.44 to 0.51 mm) (p = 0.0001); SPAC v IOLMaster, 0.027 (0.012) mm (-0.57 to 0.50 mm) (p = 0.027). CONCLUSIONS: AS-OCT gave systematically deeper anterior chamber measurements than SPAC and IOL-Master. However, as the differences found were small they are unlikely to be clinically important.

Effect of upgaze on lower eyelid position in Korean patients with congenital ptosis.

PURPOSE: The purpose of this study was to demonstrate accompanying clinical features besides lid droop in congenital ptosis and to determine the effect of upgaze on lower eyelid position in patients with congenital ptosis. METHODS: Pediatric patients with congenital ptosis who visited our clinic over a 1-month period in 2014 were recruited for this study. Clinical photographs and measurements were taken prospectively in primary gaze and upgaze. Measurements taken from photographs and clinical records include inferior scleral show (ISS), vertical lower lid height (LL), and canthal tilt angle (CTA). RESULTS: There were 35 patients with congenital ptosis. There was more ISS in unilateral ptosis eyes than in the normal side in both primary gaze (p < 0.05) and upgaze (p < 0.01), with corresponding increase in ISS in upgaze (p < 0.05). There was also more ISS in unilateral ptosis eyes than in bilateral ptosis eyes in primary gaze (p < 0.05) and upgaze (p < 0.01), with accompanying increase in ISS in upgaze (p < 0.01). There was less elevation of the lower lid in unilateral ptosis eyes (0.5 ± 0.7 mm) than in the contralateral normal eyes (0.8 ± 0.7 mm) in upgaze, but this was not statistically significant (p = 0.07). CTA was lower in ptosis eyes than in normal eyes in primary gaze and upgaze (p < 0.01 and p < 0.05, respectively). CONCLUSION: ISS was larger in ptosis eyes and upgaze appears to increase ISS. Canthal tilt is lower in congenital ptosis eyes than in normal eyes in primary gaze and upgaze.

Surgical Outcomes of Porcine Acellular Dermis Graft in Anophthalmic Socket: Comparison with Oral Mucosa Graft.

PURPOSE: We describe our experience with the Permacol graft in anophthalmic socket reconstruction, and compare it to the autologous buccal mucosal graft, emphasizing the postoperative vascularization and contraction of each graft. METHODS: This was a retrospective comparative study. We measured the time necessary for the graft surface to be completely vascularized, as well as the fornix depth of the conjunctival sac in anophthalmic patients. RESULTS: Ten patients underwent Permacol graft reconstruction, with 44 undergoing buccal mucosal graft reconstruction. Seven eyelids (70%) in the Permacol group had a good outcome, with improvement in lower eyelid position and prosthesis retention. Nine out of 10 eyelids (90%) in this group showed complete vascularization of the graft at 2.6 ± 1.9 months postoperatively, while the grafted buccal mucosa was fully vascularized at 1.1 ± 0.3 months postoperatively (p < 0.01). Postoperative fornix depth in the Permacol group was 9.1 ± 2.2 mm, compared to 14.9 ± 4.5 mm in the buccal mucosal graft group (p < 0.01). Mean increases in fornix depth were 33.1% and 67.9% of the mean vertical length of the implanted graft. CONCLUSIONS: The Permacol graft can be useful as spacer graft material in anophthalmic socket patients. It takes longer to vascularize, and undergoes greater graft shrinkage with time, compared to the buccal mucosal graft.

Severity of pediatric blepharokeratoconjunctivitis in Asian eyes.

PURPOSE: To describe and evaluate the severity of pediatric blepharokeratoconjunctivitis in Asia. DESIGN: Retrospective case series. METHODS: Clinical records of patients diagnosed with pediatric blepharokeratoconjunctivitis at a tertiary referral center in Singapore from 1991 through 2010 were reviewed. Patients were graded as having mild (corneal involvement without scarring), moderate (corneal scarring), or severe (corneal scarring with thinning or perforation) disease based on recorded clinical findings. RESULTS: Fifty-one patients were diagnosed with pediatric blepharokeratoconjunctivitis. The mean age at presentation was 10.2 ± 3.6 years, most patients were female (80.4%), and the mean duration of follow-up was 58.9 ± 44.0 months. Chinese (56.9%) subjects made up most of the cases. Most subjects had moderate (56.9%), followed by severe (37.4%) and mild (5.9%), disease. Four patients (7.9%) had an associated dermatologic disease. All patients were treated with topical antibiotics, and 98% were treated with topical steroids. Nineteen (37.3%) patients received systemic antibiotic therapy, and 1 received systemic steroid therapy. Three patients required deep lamellar keratoplasty (2 tectonic and 1 optical), and 2 underwent cornea gluing alone; all 5 of them were Chinese. Patients graded as having severe disease were more likely to undergo surgical intervention (26.3%) than patients who were graded as having moderate (0%) and mild (0%) disease (P < .05). The main complication of treatment was raised intraocular pressure in 7 (13.7%) patients requiring medical therapy. Overall, best-corrected visual acuity improved by 0.10 logarithm of the minimal angle of resolution units (P < .001) after appropriate medical and surgical intervention. CONCLUSIONS: Pediatric blepharokeratoconjunctivitis patients in Asia seem to have a more severe clinical presentation and course. Early and adequate management can arrest the disease process and can minimize visual morbidity.