Treatment of periocular lentigo maligna with topical 5% Imiquimod: a review.

Lentigo Maligna is a benign subtype of melanoma in situ and can progress to lentigo maligna melanoma, which is invasive. Complete surgical excision is the gold standard of treatment but requires large margins. If affecting the peri-ocular region, surgical excision leads to extensive defects, complex reconstructions, and functional impairment of the protection of the ocular surface. Here we review the reported literature about the use of Imiquimod 5% topical cream for lentigo maligna of the eyelid, the treatment outcomes, side effects and tolerance. In addition, the side effects of imiquimod treatment of non-LM lesions are described to help better inform the decision-making process. Treatment for peri-ocular Lentigo maligna showed a 56-86% complete treatment response and a 90% tolerability rate. However, reported treatment protocols vary and histopathological confirmation of clearance was only obtained in 56%. Further studies are required to determine the optimal treatment protocol to maximise clearance rates. Overall, Imiquimod was well tolerated in the peri-ocular area.

Day-Case Admission for External Dacryocystorhinostomy in Preschool Children.

PURPOSE: Epistaxis during or after dacryocystorhinostomy may present a risk of circulatory compromise, particularly in young children. In view of this concern, we reviewed the outcome and complications of external dacryocystorhinostomy in preschool children, aged less than 4½ years. DESIGN: Retrospective noncomparative series. PATIENTS AND METHODS: A case-note review for a series of preschool children undergoing external dacryocystorhinostomy as a day-case admission at Moorfields Eye Hospital between 1992 and 2018; all surgery was consultant-led. Details were taken of the type of surgery, any intraoperative or postoperative complications (surgical or anesthetic), any unplanned admissions after surgery, and the functional outcome. To assess the veracity of the medical records, the parents for a sample of 67 children were contacted to check whether there had been any unrecorded events or concerns. OUTCOME MEASURES: Anesthetic or surgical complications, unplanned admissions, and postoperative events. RESULTS: One-hundred and eighty-seven children (117 boys; 63%) underwent 228 external dacryocystorhinostomies during 201 admissions, the average admission age being 36.8 months (median, 37.5; range, 5.5-53.5 months). Forty-one children (20%) underwent bilateral dacryocystorhinostomy: the 27 having simultaneous bilateral surgery dacryocystorhinostomy were operated at a mean age of 38.2 months (median, 37.5; range, 15.5-53.5 months), this being significantly different from the average age at first operation in 14 children undergoing sequential admission for bilateral dacryocystorhinostomy (mean, 24.9 months; median, 27.0; range, 5.5-42.5) (p = 0.0023). No adverse anesthetic events were recorded, 2 children (2 dacryocystorhinostomies) required temporary nasal packing at the end of surgery for epistaxis, and one further child was admitted for overnight observation because of persistent mild epistaxis after bilateral dacryocystorhinostomy. Three children (3 dacryocystorhinostomies) had a mild, self-limiting secondary epistaxis, and there were no unplanned emergency admissions. The telephone survey did not reveal any disparity in the medical records. CONCLUSION: With experienced surgeons and anesthetists in a suitable specialist hospital, external dacryocystorhinostomy in preschool children would appear to be a safe and effective procedure, with few and minor complications. Although facilities for overnight observation should be available, the surgery can typically be planned as a day-case admission, and simultaneous bilateral surgery is also possible in this age-group.

Rituximab for remission induction in elderly patients with ANCA-associated vasculitis.

OBJECTIVES: Advancing age is a risk factor for treatment-related side effects and mortality in AAV patients treated with cyclophosphamide (CYC) and glucocorticoids (GC) for remission induction. The efficacy and safety of rituximab (RTX) in elderly AAV patients has not been well described. METHODS: We performed a single center retrospective review of 31 consecutive AAV patients aged 60 or more at the time of RTX use for remission induction. All patients received RTX with GC for remission induction. Four patients received concomitant CYC for a mean duration of 52 days. We evaluated clinical and laboratory variables at diagnosis, rates of complete remission defined as Birmingham Vasculitis Activity Score/Wegener's Granulomatosis (BVAS/WG) = 0 and patient survival, renal survival, infections requiring hospitalization, and vasculitis relapse 24 months following RTX use. RESULTS: Of the 31 patients, 77% were Caucasian, 68% female, mean age was 71 ± 6 years, 58% were MPO ANCA positive, and 42% had relapsing disease. The mean BVAS/WG score entry was 4.4 ± 1.5, 71% had glomerulonephritis (GN) and 10% had alveolar hemorrhage. The mean baseline e-GFR was 40 ± 28ml/min/1.73m(2). Thirty patients achieved remission with a mean time to remission of 57 ± 27 days. The single patient with refractory vasculitis responded to CYC. The mean prednisone dose at 6 months was 5.6 ± 4mg. Remission maintenance therapy was started within 12 months of RTX induction in 6 patients (4 with RTX, 1 with azathioprine, and 1 with mycophenolate mofetil). One patient suffered a limited relapse 10 months post RTX use. Among the 22 patients with GN at baseline, 1 developed ESRD. One-year patient survival among 25 patients with at least 1 year of follow-up was 100%. There were no episodes of infusion reaction or leukopenia. There were 3 episodes of bacterial pneumonia, 1 episode of candida pneumonia, and 1 episode of disseminated cutaneous zoster. CONCLUSIONS: This study demonstrates that rituximab is effective for remission induction in elderly patients with AAV. Furthermore, we observed a high incidence of infectious complications. Our experience was limited by its retrospective design, and further studies are needed to evaluate the efficacy and safety of RTX in elderly AAV patients.

The accuracy of the Edinburgh Red Eye Diagnostic Algorithm.

PURPOSE: To assess the diagnostic accuracy of the Edinburgh Red Eye Algorithm. METHODS: This was a prospective study. A questionnaire was designed and made available to clinicians referring patients to the acute ophthalmology service within Edinburgh. The questionnaire involved them using the algorithm to reach a diagnosis in patients presenting with red eye(s). Patients were then referred to the emergency eye clinic and the questionnaire faxed to the clinic or sent with the patients. Patients were then examined by an experienced ophthalmologist (not blinded) to reach a 'gold standard' diagnosis. The concordance between the 'algorithm assisted' diagnosis and the 'gold standard' was then assessed. RESULTS: All patients presenting with red eye(s) were eligible for inclusion. Forty-one questionnaires were completed, two were excluded. The algorithm assisted diagnosis was correct 72% (28/39) of the time. It correctly diagnosed: acute angle closure glaucoma in 100% of cases (4/4); iritis in 82% (9/11); stromal keratitis in 63% (5/8); epithelial keratitis in 70% (7/10); and infective conjunctivitis in 50% (3/6). DISCUSSION: The diagnostic accuracy of The Edinburgh Red Eye Diagnostic Algorithm is 72, rising to 76% when only the most serious red eye(s) causes are included. The diagnostic accuracy of non-ophthalmologists when assessing patients presenting with red eye(s) is greater when the algorithm is used. We hope that the use of this algorithm will prevent delayed presentations of certain serious eye conditions and reduce the morbidity from delayed treatment.

Transient ischemic attack and stroke in systemic lupus erythematosus.

Ischemic stroke is increased in systemic lupus erythematosus (SLE) patients. The differential diagnosis of stroke in SLE is complex. Transient ischemic attack and ischemic stroke share pathophysiologic mechanisms, but prognosis may vary depending on severity and cause, and definitions are dependent on the timing and extent of the diagnostic evaluation. In SLE patients with a history of transient ischemic attacks, stroke occurred in 57%. Cerebrovascular events account for 20% to 30% of deaths in patients with SLE. In SLE, both disease-specific and traditional stroke risk factors are important.

Acquired lacrimal sac fistula mimicking basal cell carcinoma.

BACKGROUND: Lacrimal sac fistulae can arise after an episode of dacryocystitis, usually forming below the medial canthus. Preceding symptoms of a watery eye with mucous discharge and a history or signs of inflammation are typical. OBJECTIVES: To highlight the features of lacrimal sac fistulae and encourage readers to consider this in the differential diagnosis of apparently ulcerative medial canthal skin lesions. METHODS: We describe three patients with inferior-medial canthal ulcerative skin lesions, all referred to ophthalmic plastic surgeons either by dermatologists or plastic surgeons, presumed clinically to have basal cell carcinoma (BCC). RESULTS: All three were in fact due to acquired lacrimal sac fistulae, and syringing of the nasolacrimal system confirmed the presence of a fistula. CONCLUSIONS: These cases illustrate the importance of questioning patients about their previous ocular symptoms when dealing with less familiar periocular lesions.

Urgent in-patient coronary angiography: a comparison of centres with and without cardiac catheter facilities.

OBJECTIVES: To review the referral of patients to a tertiary centre for urgent angiography and to determine if there are differences in invasive treatment strategies for patients with acute coronary syndrome (ACS). METHODS: There were 2 parts to the study, a retrospective part over 3.5 years from a computerised cardiac laboratory booking data base and a prospective part over 3 months. RESULTS: There were 1190 urgent in-patient angiograms performed with 499 (42%) admitted initially to the tertiary centre while the remaining 691 (58%) were admitted to district general hospitals (DGH), with no on-site access to a cardiac laboratory, and subsequently transferred to the tertiary centre. Once referred, DGH patients waited longer for their angiogram (2.7 +/- 3.2 vs 2.0 +/- 2.8 days, p < 0.0001). Interestingly, DGH patients appear to spend an average of 4 days in hospital prior to referral for angiography. DGH patients were more likely to have a higher Thrombosis in Myocardial Infarction (TIMI) risk score at presentation and following angiography were more likely to have coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI) and less likely to have angiographically normal arteries. CONCLUSIONS: Our findings are consistent with previous studies demonstrating that access to coronary angiography varies considerably between hospitals. However, we have demonstrated that patients in DGHs wait on average 4 days before referral for coronary angiography suggesting that there may be triage based on initial responses to medical therapy. Further research is needed to determine whether this has a direct effect on outcomes.