The VITOM® exoscope in oculoplastic surgery: the 5 year Coventry experience.

BACKGROUND: Intraoperative imaging is a desirable tool in oculoplastic surgery; however, there are few modalities which allow surgeons to capture and edit the images in real time without compromising the sterility of the surgical field. We describe the set-up of the VITOM® exoscope system based on our 5 years' experience of using it as an effective intraoperative video imaging and teaching modality for extraocular surgery. METHODS: The VITOM® is a specially designed exoscope mounted onto a versatile mechanical arm. It is attached to a high definition (HD) digital camera displayed on the HD video monitor of a standard endoscopy stack. This technology has been utilised in other surgical subspecialties, but there is no documented use within extraocular surgery. RESULTS: The exoscope was simple to set-up and allowed real-time recording and editing with an HD image display system. The theatre team were able to view the precise surgical steps, contributing to improved theatre flow. Trainees reported that the VITOM® images significantly improved their visualisation and understanding of key surgical anatomy and steps. CONCLUSIONS: Our experience showed that the VITOM® exoscope is an excellent intraoperative video imaging and teaching aid, as it allows real-time capture and editing of open surgery and seems to improve theatre flow. With newer models using 3D stereoscopic vision, it could be further evaluated as a heads-up viewing system within extraocular and oculoplastic surgery.

The enlarged extraocular muscle: to relax, reflect or refer?

PurposeExtraocular muscle enlargement (EOME) is most commonly associated with thyroid eye disease, but there are other causes. We report our outcomes of investigating and managing non-thyroid-related EOME (NTR-EOME).MethodsRetrospective consecutive case series. Sixteen patients identified by clinical features and orbital imaging. Patient demographics, radiological features, and adjuvant tests including biopsy and final diagnosis were recorded.ResultsMean age at presentation 59.3 years (range 24-89 years). Mean follow-up 3.2 years (range 3 months to 5.5 years). Superior rectus (SR) was most commonly involved muscle (8/16 cases) followed by lateral rectus (4/16). Of the 16 cases, 14 were associated with underlying systemic neoplasia (5 lymphoma, 5 metastatic carcinoma, and 4 presumed paraneoplastic syndrome). All SR enlargement was associated with underlying neoplasia. All patients underwent orbital imaging followed by systemic imaging based on clinical index of suspicion (14/16 patients (13 full body CT (FBCT), 1 mammography)). Positive systemic radiological findings were detected in 12/14 cases. Of the remaining 2 patients, 1 underwent full body positron emission tomography-computed tomography (FBPET-CT), which detected thyroid carcinoma, and the second patient underwent FBCT for staging following orbital biopsy showing lymphoma. Four patients (25%) died within 3 years of follow-up due to disseminated systemic malignancy.ConclusionsAll cases of NTR-EOME should be viewed with a high level of clinical suspicion for systemic neoplasia, especially when the SR is involved. FBCT can help to identify a primary systemic cause. FBPET-CT is best reserved for cases negative on FBCT or for staging and monitoring systemic disease. NTR-EOME can be associated with significant mortality (25%), hence warrants prompt and thorough systemic investigation.

Upper lid entropion post ptosis correction: is tarsal buckling the cause?

PURPOSE: To report two cases of the rare complication of entropion following involutional ptosis surgery and its successful management. METHODS: Clinical findings and management of the patients are presented. RESULTS: Case 1: An 89-year-old female underwent aponeurosis advancement surgery for left involutional ptosis. Post-operatively she achieved good lid height, but had developed entropion of the upper lid which resulted in a persistent corneal epithelial defect. The patient underwent repeat surgery during which the aponeurosis was found to be inserted into the lower part of middle one third of tarsus with the tarsus itself being extremely thin. The aponeurosis was reinserted into upper third of tarsus, followed by greyline split with anterior lamellar repositioning. Post-operatively the patient achieved good lid height with correction of the entropion.Case 2: A 70-year-old male who had previously undergone bilateral brow lift and ptosis correction two years ago, was referred with right upper lid entropion. During surgery the aponeurosis was found to be inserted into the lower part of middle one third of tarsus, with a very thin tarsus. This patient was also managed by reinserting aponeurosis into upper third of tarsus with grey line split and anterior lamellar repositioning following which he achieved good lid height and correction of the entropion. COMMENT: Entropion has rarely been reported as a complication of ptosis surgery. This case series highlights the importance of taking special care when advancing the aponeurosis, in cases where the tarsus is thin, as it may result in vertical buckling of the tarsus.

Cancer incidence in Malaysia.

No population-based cancer registry exists in Malaysia; thus our main sources of incidence data were biopsy series. We determined the frequency of cancers by body site, sex, and ethnic group from biopsy records of the Division of Pathology of the Institute for Medical Research in Kuala Lumpur for the years 1969-71. We then made comparisons of leading sites with data from the Singapore Cancer Registry. Relative risk values for 21 sites indicated significant differences among ethnic groups for cancers of the nasopharynx, larynx, lung, bone, skin, cervix, ovary, prostate, and penis and for lymphomas.