The association between nocturia, hormonal symptoms and bladder parameters in women: an observational study.

OBJECTIVE: Postmenopausal nocturia is poorly understood. This study aimed to identify hormonal and lifestyle factors associated with nocturia and to understand the relative contribution of altered urine production and bladder storage dysfunction in women. DESIGN, SETTING, POPULATION AND METHODS: Women ≥40 years presenting to public continence services were enrolled in a cross-sectional study. A total of 153 participants completed a hormone status questionnaire, a validated nocturia causality screening tool and a 3-day bladder diary. Descriptive statistics and logistic regression models for nocturia severity and bladder diary parameters were computed. RESULTS: Overall, 91.5% reported nocturia, 55% ≥2 /night. There was a difference of 167.5 ml (P < 0.001) in nocturnal urine volume between women with nocturia ≥2 (median 736 ml) versus less often (517 ml). Significant predictors of self-reported disruptive nocturia were age (odds ratio [OR] 1.04, 95% CI 1.002-1.073) and vitamin D supplementation (OR 2.33, 95% CI 1.11-4.91). Nocturnal polyuria was significantly more common with nocturia ≥2 compared with less frequent nocturia (P < 0.002). Exercise for 150 minutes a week was protective for nocturnal polyuria (OR 0.22, P = 0.001). Nocturia index >1.3 was significantly predicted by age (OR 1.07, P < 0.001), regular exercise (OR 0.41, P = 0.036), day flushes (OR 4.00, P = 0.013) and use of vitamin D (OR 2.34, P = 0.043). Maximum voided volumes were significantly lower with nocturia ≥2 versus less often (night: 268 ml versus 350 ml; day: 200 ml versus 290 ml). CONCLUSIONS: Bothersome nocturia in postmenopausal women is associated with changes to both nocturnal diuresis and bladder storage. Regular physical activity, prolapse reduction and oestrogen replacement may be adjunctive in managing bothersome nocturia in women.

Management of thyroid eye disease in the United Kingdom: A multi-centre thyroid eye disease audit.

This article aims to provide baseline data and highlight any major deficiencies in the current level of care provided for adult patients with thyroid eye disease (TED). We undertook a prospective, nonrandomized cross-sectional multicenter observational study. During a 3-month period June-August 2014, consecutive adult patients with TED who presented to nominated specialist eye clinics in the United Kingdom, completed a standardized questionnaire. Main outcome measures were: demographics, time from diagnosis to referral to tertiary centre, time from referral to review in specialist eye clinic, management of thyroid dysfunction, radioiodine and provision of steroid prophylaxis, smoking, and TED classification. 91 patients (mean age 47.88 years) were included. Female-to-male ratio was 6:1. Mean time since first symptoms of TED = 27.92 (73.71) months; from first visit to any doctor with symptoms to diagnosis = 9.37 (26.03) months; from hyperthyroidism diagnosis to euthyroidism 12.45 (16.81) months. First, 13% had received radioiodine. All those with active TED received prophylactic steroids. Seven patients who received radioiodine and did not have TED at the time went on to develop it. Then, 60% patients were current or ex-smokers. 63% current smokers had been offered smoking cessation advice. 65% patients had active TED; 4% had sight-threatening TED. A large proportion of patients (54%) were unaware of their thyroid status. Not enough patients are being provided with smoking cessation advice and information on the impact of smoking on TED and control of thyroid function.

Spontaneous silent sinus syndrome (imploding antrum syndrome): case series of 16 patients.

INTRODUCTION: Silent sinus syndrome (SSS) is a rare idiopathic collapse of the maxillary sinus and orbital floor. We present the second largest series of sixteen patients with SSS and describe their management. METHODS: A cohort of 16 patients with spontaneous SSS between 1999 and 2009 were reviewed at the Royal National Throat Nose and Ear Hospital. All patients were initially referred from a postgraduate ophthalmic hospital, Moorfields Hospital. RESULTS: Fourteen patients required endoscopic sinus surgery to re-establish maxillary sinus drainage and the remaining two settled with intranasal medical therapy consisting of steroids and decongestions. Follow- up ranged from 6 months to 4 years with a mean of 2.6 years. An improvement in enophthalmos and was seen in all surgically treated patients with a mean improvement of 2.2mm and range 0.5-4mm. DISCUSSION: SSS arises from congestion of the ostiomeatal complex resulting in negative pressure within the maxillary sinus and a gradual implosion of the antral cavity. Endoscopic sinus surgery successfully re-establishes maxillary aeration in our series and leads to clinical and aesthetic improvement in the degree of enophthalmos and has avoided the need for orbital floor repair in all but two cases.

Lateral canthotomy orbitotomy: a rapid approach to the orbit.

PurposeThe lateral compartment of the orbit can readily be accessed through a horizontal lateral canthotomy without the need to swing the lid or remove bone. In this paper the technique, accessible orbital territory, and duration of surgery are presented.Patients and methodsRetrospective, non-interventional descriptive case series for patients who underwent a lateral canthotomy to access pathology within the lateral orbit.ResultsA series of 18 patients are included, all presenting with pathology lateral to, or within, the optic nerve. Pathologies included amyloidosis (1), lymphoma (4), metastatic adenocarcinoma within the optic nerve (1), idiopathic lateral rectus muscle mysositis (4), meningothelial meningioma of the optic nerve (1), intraconal orbital meningioma (1), reactive lymphoid hyperplasia (1), optic nerve glioma (3), optic nerve meningioma (1), and cavernous haemangioma (1). The median surgical time was 36 min (range 23-75 min). No patient required detachment of the lower lid, the technique leaving both upper and lower 'arms' of the lateral canthal tendon attached to Whitnall's tubercle.ConclusionsThe lateral canthotomy approach orbitotomy is a rapid, safe, and minimally disruptive approach for accessing pathology in the lateral orbit and optic nerve. The lateral canthal tendon is split along the horizontal raphe without detachment of either limb from Whitnall's tubercle, no bone is removed, and the post-operative recovery is rapid with minimal associated inflammation or chemosis. This approach is also flexible, permitting the clinician to increase exposure to the orbit peroperatively by swinging the lower lid if required.

Can Lester Jones tubes be tolerated for decades?

PurposeLester Jones described canalicular bypass tubes 50 years ago. We present a cohort of patients with Jones' tubes first placed between 1969 and 1989, and who were reviewed within the last 15 years.Patients and methodsRetrospective case-note review for living patients identified as having had Jones' tube placement prior to 1990. The duration of Jones' tube usage was noted and the number of replacements recorded.ResultsTwenty-nine patients (33 eyes) had maintenance of their Jones' tube(s) within the last 15 years, and had first tube placement before 1990. The average follow-up was 29.5 years (median 28.8 years, range 17-45.7 years). The original tube was present in 8/33 (24%) of eyes, at a mean survival of 34 years (33.3 years; range 29.4-44.4 years). The number of tube replacements during follow-up ranged from 0 to 9 (mean 1.7; median 1). When considering the initially placed tube in all 33 eyes, however, the survival ranged between 18 days and 44.4 years (mean 13.6 years; median 6.9 years). At last follow-up, 11/33 (33%) of eyes had lost their tubes, with 9 having minimal or no symptoms.ConclusionsThese patients with Jones' tube placement before 1990 provides the first recorded evidence that the device can be tolerated for at least four decades, and that some patients will-with appropriate outpatient maintenance-retain their originally placed tube. This information may be useful in counselling patients about the lifetime expectation for bypass tubes.

Which factors are associated with quality of life in patients with Graves' orbitopathy presenting for orbital decompression surgery?

PURPOSE: Graves' orbitopathy (GO) is associated with changes in the appearance of the eyes and visual dysfunction. Patients report feeling socially isolated and unable to continue with day-to-day activities. This study aimed at investigating the demographic, clinical, and psychosocial factors associated with quality of life in patients presenting for orbital decompression surgery. METHODS: One-hundred and twenty-three adults with GO due for orbital decompression at Moorfields Eye Hospital London were recruited prospectively. Clinical measures including treatment history, exophthalmos, optic neuropathy, and diplopia were taken by an ophthalmologist. Participants completed psychosocial questionnaires, including the Graves' Ophthalmopathy Quality of Life Scale (GO-QOL), the Hospital Anxiety and Depression Scale, and the Derriford Appearance Scale. Hierarchical multiple regression analyses were used to identify predictors of quality of life. RESULTS: Higher levels of potential cases of clinical anxiety (37%) and depression (26%) were found in this study sample than in patients with other chronic diseases or facial disfigurements. A total of 55% of the variance in GO-QOL visual function scores was explained by the regression model; age, asymmetrical GO and depressed mood were significant unique contributors. In all, 75% of the variance in GO-QOL appearance scores was explained by the regression model; gender, appearance-related cognitions and depressed mood were significant unique contributors. CONCLUSION: Appearance-related quality of life and mood were particularly affected in this sample. Predominantly psychosocial characteristics were associated with quality of life. It is important when planning surgery for patients that clinicians be aware of factors that could potentially influence outcomes.

Lacrimal gland hemangiopericytoma.

PURPOSE/METHODS: A 49-year-old woman with a left orbital mass was referred to an orbital clinic. Clinical investigation suggested a lacrimal gland lesion and the patient underwent lateral orbitotomy and excisional biopsy for a suspected pleomorphic adenoma in the lacrimal gland. RESULTS/CONCLUSION: Histopathologic evaluation disclosed a hemangiopericytoma originating within the lacrimal gland. Although hemangiopericytoma does not usually occur in this location, it may be added to the differential diagnosis of lacrimal gland enlargement.

Inadequately irradiated solitary extramedullary plasmacytoma of the orbit requiring exenteration.

PURPOSE: To emphasize that solitary orbital extramedullary plasmacytoma, a rare tumor, is not invariably radiosensitive. METHOD: We examined a patient who had undergone empirical irradiation that failed to control an orbital tumor. RESULTS: After a second biopsy had secured the diagnosis of a solitary extramedullary plasmacytoma, further irradiation proved ineffective and exenteration was required. The patient was free of recurrence one year after exenteration and had satisfactory cosmesis with a prosthesis. CONCLUSION: A histologic diagnosis is essential before treatment is commenced so that the correct radiation dosage is used.

Factors affecting the success of nasolacrimal duct probing for congenital nasolacrimal duct obstruction.

PURPOSE: To ascertain the effect of certain parameters on nasolacrimal duct probing. METHODS: In a retrospective study of 142 infants and children who underwent nasolacrimal duct probing for congenital nasolacrimal duct obstruction, age at time of probing, gender, symptom severity, presence of mucous discharge, and history of probing were correlated with success of nasolacrimal probing. Success of probing was defined as complete resolution of signs and symptoms of nasolacrimal duct obstruction. Chi-square test was used to analyze covariance. RESULTS: Success of nasolacrimal duct probing was negatively correlated with increasing age: 92%, 89%, 80%, 71%, and 42% at age 12, 24, 36, 48, and 60 months, respectively (P = .001 at each interval). Increasing severity of epiphora was correlated with increased failure of nasolacrimal duct probing (P = .05). CONCLUSIONS: Although the success of nasolacrimal duct probing declines with age, probing in older children can remain the first line of treatment. Because increasing frequency of epiphora correlates with failure of nasolacrimal duct probing, children with daily epiphora should undergo early nasolacrimal duct probing.

Clinical assessment of corneal endothelial cell density: an original system of grading using a slit-lamp biomicroscope.

An original system of grading of the corneal endothelial specular reflection, as assessed with a Haag-Streit 900 slit-lamp biomicroscope, has been shown to have a very highly significant relation to the endothelial cell density measured by contact specular photomicroscopy. The grading, though subjective and therefore not a substitute for the detailed record of photomicroscopy, is readily applicable to clinical practice and is a useful method of comparing and recording endothelial cell densities when assessed by the same observer. The intraobserver, but not the interobserver, variability has been examined, and the theoretical aspects of the grading system and a clinically applicable interpretation of the grading are presented.

Clinical assessment of retinal elevations: a review of methods and a novel clinical technique.

A new clinical test for the detection of retinal elevation is described. The test, based on alterations of retinal surface light reflexes during indirect ophthalmoscopy, is extremely sensitive to very shallow detachments. The optics, the degree of sensitivity, and the limitations of the new clinical technique are examined and other clinical methods are reviewed.

Factors affecting the success rate of open lacrimal surgery.

Postoperative soft tissue infection may predispose to failure of open lacrimal surgical procedures. Using a retrospective analysis of 413 cases, the failure rates for primary and repeat surgery were 12.0% and 8.9% respectively (0.25 < p < 0.5). Postoperative soft tissue infection is associated with an increased risk of failure (p < 0.005); antibiotics decrease the rate of postoperative infection and may thus decrease the failure rate. Furthermore, antibiotic therapy decreases the rate of failure in cases after previous facial trauma. Curative antibiotic therapy for established postoperative infection is less effective than preventative therapy at improving the success rate after surgery. Previous trauma is also associated with a greater rate of failure (p < 0.02), possibly owing to the frequent canalicular problems in such patients. Silicone tubes appear to increase neither the rate of infection nor failure (p > 0.5). Trauma, acute dacryocystitis, and silicone tubes appear to act on outcome independently of each other.

Trigeminal sensory loss in orbital disease.

A study was undertaken to estimate the incidence of periorbital trigeminal sensory loss with different types of orbital disease and to determine whether the area of loss is related to the location or nature of the underlying condition. A retrospective review was carried out of the clinical case notes of patients identified from the orbital diagnostic database held at Moorfields Eye Hospital. A total of 103 patients (51 male, 52 female), aged between 11 and 84 years (median 51 years), had signs of periorbital trigeminal sensory loss at the time of investigation for orbital disease and in 14/103 (13%) this sensory loss was symptomatic. Sensory loss was due to trauma in eight cases (8%), benign orbital disease in 54 (52%), and malignant disease in 41 cases (40%). The relative frequency of recorded sensory changes is about 9% for malignant tumours, 5% for benign tumours, 4% after orbital trauma, 3% for orbital inflammatory disease, and less than 1% for orbital structural anomalies. Relative corneal hypoaesthesia occurred in 40/103 (39%) cases. Periorbital sensory loss was recorded in about 3% of patients with orbital disease and, in contrast with commonly held views, malignancy was not the most common cause of sensory loss. The affected dermatome is a useful guide to the location of orbital disease, but a poor indication of underlying pathology. Relative corneal hypoaesthesia appears unrelated to the type of disease or to its location within the orbit.

Exenteration for benign orbital disease.

Exenteration, or removal of the globe with part or all of the surrounding orbital contents, is generally reserved for malignancy. The procedure may, however, be of value in the management of some benign orbital diseases. The indications for exenteration in management of benign orbital disease are threefold. Firstly, patients in whom diffuse disease, such as idiopathic inflammation, has resulted in an irretrievable situation of visual loss and clinically uncontrollable pain or disfigurement; in many such cases we consider exenteration to be preferable to the (often severe) side effects of prolonged and inadequate medical therapy. The second group are those patients with grossly disfiguring orbital abnormalities, such as teratomas, extensive varices, or massive optic nerve tumours. The last group comprises patients with tumours that, while histologically benign, may have malignant potential or show a tendency to diffuse or persistent infiltration of orbital soft tissues. Sixteen illustrative cases of full or partial exenteration for benign disease are described.

Anisocoria in unilateral ophthalmic disease.

Pupillary diameters in the affected and unaffected eyes of 327 patients with uniocular red eye were assessed during fixation of a distant target. The mean pupillary diameters were similar in the unaffected eyes in each of eight diagnostic groups, but were significantly different (F = 3.84, p less than 0.001) in the diseased eyes. With corneal abrasions (p less than 0.001), marginal keratitis (p less than 0.05), and acute anterior uveitis (p less than 0.001) the mean pupillary diameter for the affected eye was significantly smaller than that of the unaffected eye. The observed differences of pupillary diameter probably reflect the role of neuronal and autocoid mechanisms in the unilateral control of pupillary size.

Pleomorphic adenoma of the lacrimal gland.

To reduce the risk of recurrence and malignant transformation, pleomorphic adenomas of the lacrimal gland should be removed intact, without prior biopsy. Seventy one of the 78 patients in this series were referred without previous surgery, and, on clinical or radiological evidence, 63 (89%) tumours were correctly diagnosed and totally excised, with preservation of a margin of the surrounding normal tissue. Sixty three patients had tumour within the body of the gland and 55 (84%) had radiological signs or satisfied clinical criteria for pleomorphic adenoma that we suggested previously; that is, over 1 year of symptoms and absence of pain. Eight (16%) orbital lobe tumours were misdiagnosed preoperatively and biopsied; in all these patients symptoms had been present for less than 1 year, and four patients had pain. Eight patients with tumours arising in the palpebral lobe had a short history of an upper lid mass, and their tumours were excised without biopsy. With the surgical techniques described in this paper, there has been no recurrence of tumour in patients with follow-up as long as 21 years. A modification of surgical technique, with preservation of the palpebral lobe of the gland, has reduced the incidence of postoperative dry eye and distortion of the upper eyelid.

Dermofat grafts to the extraconal orbital space.

Dermofat grafts were placed in the upper or lower lid sulci in 35 subjects, aged from 11 to 59 years, to improve the cosmesis of volume deficient sockets or prevent tissue adhesion. Volume enhancement and cosmetic improvement were achieved in 31 patients, in whom useful vision was present in 13/22 after previous trauma, in 4/4 with facial clefting, and in 3/3 with orbital or facial fat atrophy. Grafts were used successfully in nine patients to prevent scar formation after division of adhesions between the eyelids or levator muscle and the orbital margins. A reduction of the bulk of upper-lid grafts was required in three cases; histopathology of the excised fat showed relatively minor degrees of inflammation, atrophy, and fibrosis.

Lacrimal drainage surgery in Wegener's granulomatosis.

AIM: To examine the results of open lacrimal surgery in patients with Wegener's granulomatosis. METHODS: A retrospective review of patients with Wegener's granulomatosis who underwent lacrimal surgery over a 17 year period. RESULTS: 11 patients were identified and a total of 14 primary dacryocystorhinostomies (DCR) and one revisional DCR were performed; symptomatic relief was achieved in 13/14 operations and one patient required revisional surgery for persistent symptoms. There were no intraoperative and few postoperative complications. CONCLUSIONS: In contrast with some previous reports, open DCR appears to be a safe procedure and it is recommended as a treatment for lacrimal obstruction in patients with Wegener's granulomatosis, but an increase of perioperative immunosuppression is recommended in certain cases.

Primary malignant neoplasms of the lacrimal gland.

The clinical characteristics and outcome of 50 primary malignant neoplasms of the lacrimal gland are reviewed: 38 (76%) adenoid cystic carcinomas, six (12%) carcinomas arising in pleomorphic adenoma, and six (12%) adenocarcinomas or other types of carcinoma. Most patients presented with a short history and pain, though pain tended to occur less often and later with adenocarcinoma than with adenoid cystic carcinoma. Pain was unrelated to the duration of symptoms, invasion of bone, loss of trigeminal nerve function, or the frequency and time of tumour recurrence. The estimated disease-free survival for patients with adenoid cystic carcinoma was significantly (p less than 0.01) reduced where half or more of the biopsy specimen showed basaloid differentiation. Eleven patients underwent extended cranio-orbital resection, and the others received a combination of total dacryoadenectomy adenectomy and/or radiotherapy. Survival after adenoid cystic carcinomas appears to be significantly (p less than 0.05) greater when tumour resection is combined with radiotherapy than after radiotherapy alone. At present, however, the rate of disease-free survival after treatment of adenoid cystic carcinoma appears unaltered by cranio-orbital resection, though these latter patients form a relatively greater proportion of those surviving for more than 10 years. Further long-term follow-up is needed to see if this technique does influence survival.

Open lacrimal surgery: a comparison of admission outcome and complications after planned day case or inpatient management.

AIMS: To assess the outcome, in terms of completion of admission and complication rates, for two series of patients undergoing open lacrimal surgery, one group planned for a day case admission and the other planned for inpatient stay. METHODS: A retrospective analysis of case notes was performed for 200 patients planned to have day case admission (for 209 open lacrimal operations) and the details compared with those for 200 inpatient admissions (for 228 lacrimal procedures) during the same period of study. The success rates for surgery were not examined. RESULTS: 9% of planned day cases required overnight admission, 5.5% for medical reasons and 3.5% for social or administrative reasons. There was a similar incidence of postoperative complications in planned day cases and inpatients, although 6% of day case patients developed postoperative cellulitis, compared with 1.3% of the inpatients (p = 0.01). Overall, the incidence of cellulitis was greater in cases complicated by intraoperative haemorrhage (p < 0.05) or the use of absorbable nasal packing (p < 0.0001). A similar number of patients in each group attended the accident and emergency department before the planned first postoperative clinic visit. CONCLUSION: Patients undergoing open lacrimal surgery can be safely managed as day cases if carefully selected for suitability on social and medical criteria. The use of general anaesthesia is not, in itself, a contraindication to day case lacrimal surgery.