Telemedicine in Oculoplastics: The Real-Life Application of Video Consultation Clinics.

PURPOSE: Our oculoplastic service piloted a new video consultation (VC) clinic in response to the COVID-19 pandemic. Data were collected to determine whether specific patients are better suited to VC, and to quantify the true benefit of VC in patients that successfully attended. METHODS: Data were collected prospectively on predetermined data collection forms, including consultation duration, diagnosis, management plan, and issues that arose. RESULTS: 37.8% of new referrals and 60.9% of return patients were vetted as suitable for VC. Of those invited to attend, 83.4% agreed to a VC appointment. Of the patients appointed to a VC clinic, 71.7% (new)/75% (return) successfully completed VC, 14.9%/15.8% attempted a VC which ultimately failed, and 13.4%/9.2% did not attend. VC successfully prevented face-to-face consultation in 81.3% of new cases and 91.1% of returns. Ectropion, entropion and dermatochalasis (new referrals), and postoperative follow-up (return patients) were well suited to VC, while patients with "watery eye" (new), and lid or conjunctival lesions (return), often required face-to-face consultation. Problems (most common issues with patients connecting to the consultation, video quality, and audio quality) were encountered during 50.3% of calls, although 82.6% of attempted calls were ultimately successful. Age was not associated with the proportion of calls that were successful. CONCLUSIONS: VC is a useful tool for oculoplastic patients, irrespective of age, as long as the patient's notes/referrals are carefully vetted to determine suitability. Patients with ectropion, entropion and dermatochalasis, and postoperative reviews are better suited to VC than those with "watery eye," lid lesions, and conjunctival lesions.

A non-surgical alternative to the management of myopathic ptosis.

Oculopharyngeal Muscular Dystrophy (OPMD) is a systemic progressive autosomal dominant myopathy which results in ptosis due to levator weakness. Surgical correction can be complicated by corneal exposure and a non-surgical alternative, such as ptosis props, can be uncomfortable in patients with preserved orbicularis function. We describe a case of a 57-year-old gentleman with OPMD, who declined surgical intervention, and self-manages his ptosis with cosmetic glue.

Cataract surgery refractive outcomes: representative standards in a National Health Service setting.

BACKGROUND/AIMS: To report refractive outcomes from an National Health Service (NHS) cataract surgery service and assess if results meet suggested benchmark standard. METHODS: Details of all patients undergoing cataract surgery in the Southern General and New Victoria hospitals in Glasgow, UK, between November 2006 and December 2016 were prospectively entered into an electronic database. Patients were reviewed 4 weeks postoperatively in the eye clinic and underwent refraction at their local optometrist prior to this appointment. Surgically uncomplicated cases with in the bag' non-toric intraocular lens implantation were included. Patients with previous laser refractive procedures or failing to achieve 6/12 acuity or better postoperatively were excluded. Proximity to targeted postoperative refraction was documented. RESULTS: Over this 10-year period, 11 083 eyes underwent cataract surgery. Of these, 8943 eyes of 6936 patients (80.69%) met the inclusion criteria and had both target and postoperative outcome refraction recorded. The mean difference between the targeted and outcome refraction was -0.07 D (SD 0.67). The mean absolute error was 0.50 D. Postoperative refraction was within 1 D of target refraction for 7938 eyes (88.76%) and within 0.50 D for 5577 eyes (62.36%). CONCLUSION: Refractive outcomes following routine cataract surgery reported here are well within the targets recommended by the Royal College of Ophthalmologists and European guidelines, but suggest that higher cataract refractive outcome benchmark standards may not yet be a realistic expectation for all NHS units with current biometry practice.

The Effect of Socio-Economic Status on Severity of Periocular Basal Cell Carcinoma at Presentation.

PURPOSE: To evaluate the influence of socio-economic factors on size of periocular basal cell carcinoma at presentation. METHODS: All periocular basal cell carcinoma cases receiving treatment from the oculoplastics team in South Glasgow Hospitals NHS Trust, Glasgow, between 1999 and 2009, were identified retrospectively. Information collected included demographic details of patients, side and site of lesions, type of lesions, and size of lesions. The size of lesion was defined as small for any dimension not exceeding 5 mm, medium for dimensions between 6 mm and 10 mm, and large for dimensions exceeding 11 mm. Home address was used to determine the Scottish Index of Multiple Deprivation rank. The demographics, size of lesion, and Scottish Index of Multiple Deprivation rank were investigated using the general linear regression modelling. RESULTS: Of the 67 cases, 24 were men and 43 were women. The mean age was 71.5 years. There were a total of 67 identified cases, of which 38 presented with small-size lesions, 24 with medium-size lesions, and 5 with large-size lesions. Scottish Index of Multiple Deprivation is related to the presenting incidence of basal cell carcinoma, with the lower ranks presenting more frequently. CONCLUSIONS: Socio-economic deprivation is associated with larger and more frequent presentation of periocular basal cell carcinoma. This highlights the importance of raising awareness among populations of the more deprived areas of the significance of lumps and bumps within the periocular regions.

Retained soft contact lens masquerading as a chalazion: a case report.

A misplaced contact lens is a common ocular emergency presenting to the eye casualty. We report a case of lost soft contact lens which migrated in the lid and presented 13 years later with symptomatic eye lid swelling. Authors in the past have reported migration and subsequent retention of lost hard lenses in locations such as the superior fornix and eyelid. To the best of our knowledge, misplaced soft contact lens masquerading as a chalazion has not been reported in the literature. Consideration should be given to the possibility of a retained contact lens in a patient with a history of a lost or misplaced lens, and examination of the ocular surface with double eversion of the upper lid should be performed.

The Pulfrich phenomenon; clumsiness and collisions which can be ameliorated.

The Pulfrich phenomenon has been described many times but usually just as an interesting academic issue with only diagnostic significance. The phenomenon is due to the fact that patients with unilateral optic neuropathy due to ischaemia, facial injury or multiple sclerosis may have delayed transmission of retinal responses to light from one eye to the brain. This leads to an altered and incorrect interpretation of the pathway and direction of moving targets. Clinicians should be aware of the unique symptomatology of the Pulfrich phenomenon because it is often difficult for patients to describe their symptoms which can be both unpleasant and troublesome. An appropriate tint in either a spectacle or contact lens over the normal eye delays retinal conduction, so re-establishing visual processing symmetry and ameliorating the symptoms.

Caliber persistent artery of the eyelid.

BACKGROUND: To report three cases of caliber persistent artery presenting in the eyelid. METHODS: A case series describing three patients with vascular lesions of the eyelid that were biopsied. One case was bilateral. RESULTS: All three patients presented with a painless red lesion on the eyelid. These were on the lower eyelid in two patients and the upper eyelid in one patient. For the bilateral case, the lesions were both on the lower eyelid. Histological examination of all four biopsies showed a large caliber artery within the dermis extending almost at right angles to the skin surface and consistent with caliber persistent artery. CONCLUSIONS: These are the first reports of caliber persistent artery of the eyelids, an entity that is most commonly recognized on the lips. Clinicians should consider this entity in the differential diagnosis of patients presenting with a painless, vascular lesion of the eyelid.

Mohs surgery vs primary excision for eyelid BCCs.

INTRODUCTION: The aims of management of basal cell carcinoma are for complete excision, and minimise damage to the surrounding tissues. Our aim is to compare the proposed defect of a primary excision biopsy with the actual defect following Mohs micrographic surgery on the same lesions. MATERIALS AND METHODS: A cohort of 23 patients about to undergo Mohs micrographic surgery for eyelid basal cell carcinomas was recruited. The lesions were assessed regarding size and location. A digital photograph of the lesions pre Mohs excision and the defects post Mohs excision for analysis on the Photoshop Adobe package using the caliper function to measure the eyelid lesion, and defects and to calculate the area. RESULTS: All 18 patients had solitary basal cell carcinomas; 9 (50%); 10 of the 18 cases having a larger proposed primary excision defect and the remaining 8 cases a larger post-Mohs micrographic surgery defect area. DISCUSSION: Basal cell carcinoma is the most common non-melanoma malignant eyelid tumour. The results supported basal cell carcinomas, particularly morphoeic types, are difficult to examine, and location is a poor predictor of recurrence. We did not find that Mohs micrographic surgery universally reduces the size of the defects area. However, if the primary aim of the surgery is to cure the patient and prevent recurrence, Mohs is still the best choice.

Tear physiology of aqueous deficiency and evaporative dry eye.

PURPOSE: To determine the differences in tear physiology between aqueous deficiency dry eye (ADDE) and evaporative dry eye (EDE), and evaluate their utility in diagnosis. METHODS: Fifty-six dry eye patients were classified into 30 ADDE and 26 EDE according to the recently published Dry Eye Workshop criteria. A range of tear physiology measures comprising of tear evaporation, turnover rate (TTR), distribution, volume and osmolarity, and meibomian gland dropout were measured in these patients. The effectiveness of the tests, singly and in combinations, in differentiating between the dry eye subtypes was evaluated by retrospective allocation into groups and by Receiver Operative Characteristics (ROC) curve analysis. RESULTS: Statistically significant differences were seen for TTR and tear evaporation (with lower values for ADDE) between ADDE and EDE, but no significant differences were seen for tear osmolarity, volume, distribution, and meibomian gland dropout scores. Differentiation of ADDE and EDE by a cut-off value of 11%/min for TTR was found to have a sensitivity of 86%, specificity of 75%, positive predictive value 89%, negative predictive value 69%, and overall accuracy 83%. The area under the curve on the ROC curve was 0.83. For tear evaporation, a cut-off of 60 g/mh was found to have a sensitivity of 77%, specificity of 55%, positive predictive value 38%, negative predictive value 80%, and overall accuracy 58% in subtype differentiation. The area under the curve was 0.59 on the ROC curve. The distribution curve of the evaporation rates for ADDE and EDE, showed an overlap coefficient of 0.76 indicating that tear evaporation is within a similar range in these two dry eye subtypes. CONCLUSIONS: Tear turnover is significantly lower in ADDE than EDE, but there is considerable overlap of tear evaporation between the two dry eye subtypes. Tear osmolarity and turn over tests can be conducted sequentially to effectively diagnose dry eye and its subtypes.

Tear and meibomian gland function in blepharitis and normals.

PURPOSE: To determine the differential features of tear physiology and meibomian gland function in blepharitics for ascertaining the diagnostic potential of a number of clinical tests. METHODS: Two groups of subjects, 15 with clinically diagnosed blepharitis (11 women and 5 men mol/L; age 60.9 +/- 12.5; range 41-79) and 15 age- and sex-matched controls (11 women and 5 men mol/L; age 60.7 +/- 12.6; range 40-78), were included in the study. Tear physiology was assessed by evaporimetry and interferometry and the meibomian glands by expression and meibography. RESULTS: Tear evaporation rate was significantly higher (P<0.001) in blepharitics (46.3 +/- 22.9 g/m/hr) than that in normals (18.0 +/- 10.7 g/m/hr). The lipid pattern was found to be significantly less stable (P=0.001) in the blepharitic group compared with that in the normal group. By meibography, meibomian gland dropout was scored and found to be significantly greater (P=0.001) in blepharitics in both the upper eyelids (blepharitis 1.0 +/- 0.8; normal 0.1 +/- 0.3) and lower eyelids (blepharitis 2.1 +/- 8.3; normal 1.0 +/- 0.8). The dropout score was the same or greater for the lower lids than for the upper lids, in all cases. A significant difference (P=0.000) in meibomian gland expression was found between blepharitics and normals; meibum was significantly thicker and more opaque in blepharitics in both the upper (blepharitis 2.2 +/- 0.7; normal 1.0 +/- 0.2) and lower (blepharitis 2.6 +/- 0.7; normal 1.3 +/- 0.4) eyelids. CONCLUSIONS: There are significant differences in tear physiology and meibomian gland function in patients with blepharitis when compared with those without. All the tests employed would be useful as single tests in the diagnosis of blepharitis, with meibomian gland dropout of the lower eyelid offering the greatest effectiveness as a single measure.

Dry eye diagnosis.

PURPOSE: To determine the most effective objective tests, applied singly or in combination in the diagnosis of dry eye disease. METHODS: Two groups of subjects--41 with dry eye and 32 with no ocular surface disease--had symptoms, tear film quality, evaporation, tear turnover rate (TTR), volume and osmolarity, and meibomian gland dropout score assessed. RESULTS: The subjects with dry eye had TTR, tear evaporation, and osmolarity significantly different from that of healthy normal subjects. Cutoff values between the groups were determined from distribution curves for each aspect of tear physiology, and the effectiveness of the cutoff was determined from receiver operator characteristic (ROC) curves. Values of 12%/min for TTR, 33 g/m(-2)/h for evaporation, and 317 mOsmol/L for osmolarity were found to give sensitivities, specificities, and overall accuracies of 80%, 72%, and 77%; 51%, 96%, and 67%; and 78, 78%, and 79%, respectively when applied singly as diagnostic criteria in dry eye. In combination, they yielded sensitivities, specificities, and overall accuracy of 100%, 66%, and 86% (in parallel) and 38%, 100%, and 63% (in series), respectively. Discriminant function analysis incorporating these three factors in an equation allowed diagnosis with a sensitivity of 93%, specificity of 88%, and overall accuracy of 89%. CONCLUSIONS: Tear osmolarity is the best single test for the diagnosis of dry eye, whereas a battery of tests employing a weighted comparison of TTR, evaporation, and osmolarity measurements derived from discriminant function analysis is the most effective.

Spontaneous intraocular lens extrusion in a patient with scleromalacia secondary to herpes zoster ophthalmicus.

We report a case of spontaneous intraocular lens (IOL) extrusion in association with scleromalacia 10 years after uneventful endocapsular surgery. The patient had a history of iridocyclitis secondary to herpes zoster ophthalmicus in the affected eye. A minimally invasive approach involving repositioning the IOL and closure with a conjunctival flap resulted in restoration of visual acuity.

Chlamydial conjunctivitis presenting as pre septal cellulitis.

Chlamydia conjuctivitis results from infection by chlamydia trachomatis, the commonest treatable sexually transmitted infection in Europe. Its clinical manifestations involve the conjunctiva and the cornea. The inflammation under the upper eyelid may be sufficient to present as ptosis, however previously it has not been documented to cause a preseptal cellulitis. We present such a case. A 15-year-old girl was diagnosed with a left viral conjunctivitis. Five days later, she returned with marked oedema of the left upper and lower lids accompanied by erythema. The tarsal conjunctiva revealed follicles and large papillae and extra ocular movements revealed discomfort on elevation. A secondary diagnosis of bacterial pre septal cellulitis was made and the treatment was changed a broad spectrum oral antibiotic. On review at two days, the patient now complained of a large amount of purulent discharge in association with the marked pre septal swelling. As previous bacteriology and virology had been negative, the patient was re swabbed for chlamydia. This proved positive and her symptoms completely resolved following administration of Azithromycin. In this particular case recognition of the pathogen is important to alert the patient to the likelihood of unknown genital infestation. In all cases of positive culture, the patient should be counselled to attend a genitourinary clinic and to alert any sexual partners to the need to do likewise.

Tear film osmolarity: determination of a referent for dry eye diagnosis.

PURPOSE: To determine new referents, or cutoff levels for tear film hyperosmolarity in the diagnosis of keratoconjunctivitis sicca (KCS) and to assess their effectiveness in independent patient groups. METHOD: A meta-analysis was performed on published data for tear osmolarity in samples of normal eyes and various subtypes of dry eye, and pooled estimates of the mean and standard deviations for normal and (all) dry eye subjects were determined. Diagnostic referents were derived from the intercept between the distributions of osmolarity in the two samples and from receiver operator characteristic (ROC) curves. This referent was tested for effectiveness of diagnosis in independent groups with normal and dry eyes. RESULTS: An osmolarity referent of 315.6 mOsmol/L was derived from the intercept of the distribution curves, and 316 mOsmol/L from the ROC curve. When applied to independent groups of normal and dry eye subjects a value of 316 mOsmol/L was found to yield sensitivity of 59%, specificity of 94%, and an overall predictive accuracy of 89% for the diagnosis of dry eye syndrome. CONCLUSIONS: Tear hyperosmolarity, defined by a referent of 316 mOsmol/L, was superior in overall accuracy to any other single test for dry eye diagnosis (Lactoplate, Schirmer test, and Rose Bengal staining), even when the other test measures were applied to a diagnosis within the sample groups from which they were derived. For overall accuracy in the diagnosis of dry eye, the osmolarity test was found to be comparable with the results of combined (in parallel or series) tests.

Correction of the Pulfrich phenomenon by surgery and laser.

We describe 2 patients who presented with asymmetrical media changes and a spontaneous Pulfrich phenomenon. In the first case, the phenomenon was due to cataract formation and an interocular latency difference of 1.49 ms +/-0.07 (SD) was found. After cataract surgery, the symptoms resolved and no interocular latency difference could be measured. In the second case, the phenomenon was caused by posterior capsule opacification and an interocular latency difference of 1.16 +/- 0.08 ms was found. The symptoms were alleviated and no interocular latency difference could be measured after a neodymium:YAG laser capsulotomy was performed. The symptomatology of the Pulfrich phenomenon is often difficult for patients to explain. Clinicians should be aware of the phenomenon with cataract patients.