Exploring beliefs and distress in patients with facial palsies.

Evidence suggests that people with facial palsy may experience higher levels of distress, but the reasons for this are yet to be explored. This study aimed to explore people's illness beliefs, emotions, and behaviours in relation to their facial palsy and understand how distress is experienced by this group. Semi-structured individual interviews were conducted in the UK with adults with facial palsy. Interview questions were theoretically informed by the Common-Sense Self-Regulatory Model (CS-SRM). Thematic Analysis was conducted following a combined inductive and deductive approach. Twenty people with facial palsy participated (70% female; aged 29-84). Patient distress was accounted for by illness beliefs (symptoms, cause, control and treatment, timeline and consequences), and four additional themes (coping behaviours, social support, identity and health service provision). Experiences of anxiety, depression, and anger were widespread, and some participants experienced suicidal ideation. The burden of managing a long-term condition, altered self-perception, and social anxiety and isolation were key drivers of distress. There is a need for more integrated psychological support for patients with facial palsy. Within clinical consultations, patient's beliefs about facial palsy should be identified and systematically addressed. Service development should include appropriate referral to specialist psychological support via an established care pathway.

Psychological distress and coping following eye removal surgery.

Purpose: Psychological distress is reasonably well documented in people with facial disfigurement; however, in patients following eye removal surgery this has not been studied adequately. We hypothesised that lower distress levels would be associated with age and more adaptive coping strategies and that women would be more likely to report higher levels of distress and, therefore, use maladaptive coping strategies.Methods: This exploratory, cross-sectional study measured distress and coping in a sample of 56 post enucleation or evisceration patients. The Hospital Anxiety and Depression Scale and the Brief COPE measured distress and coping strategies.Results: In all, 25.5% and 10.9% of the sample had high levels of anxiety and depression, respectively. Significant associations were found between levels of distress, coping strategies and demographic variables (p < .05). There were significant differences in coping strategies between those with higher and lower levels of distress (p < .05). Females reported higher levels of anxiety (U = 202.5, p < .01) and depression (U = 229, p < .05) than males. Those who experienced enucleation or evisceration aged between 20 and 39 years reported significantly higher levels of depression compared with other age groups (U = 68.5, p < .01).Conclusions: There was a relatively low level of distress across the whole sample, but we found high levels of distress in a considerable proportion (18.18%) of participants. Participants' coping strategies and levels of distress were correlated. Females and participants aged between 20 and 39 years at time of eye removal were particularly vulnerable to distress.

Cerebrospinal fluid derived from progressive multiple sclerosis patients promotes neuronal and oligodendroglial differentiation of human neural precursor cells in vitro.

In the adult CNS, tissue-specific germinal niches, such as the subventricular zone of the lateral ventricles and the subgranular zone of the dentate gyrus of the hippocampus, contain multipotent neural precursor cells (NPCs) with the capacity to self-renew and differentiate into functional brain cells (i.e. neurons, astrocytes or oligodendrocytes). Due to their intrinsic plasticity, NPCs can be considered an essential part of the cellular mechanism(s) by which the CNS tries to repair itself after an injury. In inflammatory CNS disorders, such as multiple sclerosis (MS), neurogenesis and gliogenesis occur as part of an 'intrinsic' self-repair process. However, full and long-lasting repair in progressive MS is not achieved. Recent data suggest that endogenous NPCs, while trying to repair the damaged CNS in MS, may become the target of the disease itself. It is possible that factors produced during MS, like CNS-infiltrating blood-borne inflammatory mononuclear cells, reactive CNS-resident cells, and humoral mediators, can alter the physiological properties of NPCs, ultimately impairing their ability to promote neural regeneration. Here, we investigate the effect of cerebrospinal fluid (CSF) derived from primary progressive (PPMS) and secondary progressive (SPMS) MS patients (CSF-MS) on the survival, proliferation, and differentiation of commercially available human embryonic-derived NPCs named ENStem-A. We found that PPMS derived CSF markedly reduced the proliferation of ENStem-A and increased their differentiation toward neuronal and oligodendroglial cells, compared to control CSF. Similar but less striking results were seen when ENstem-A were treated with SPMS derived CSF. Our findings suggest that in both SPMS and PPMS the CNS milieu, as determined by extrapolation from CSF findings, may stimulate the endogenous pool of NPCs to differentiate into neurons and oligodendrocytes.

Botulinum toxin to improve lower facial symmetry in facial nerve palsy.

INTRODUCTION: In long-standing facial palsy, muscles on the normal side overcontract causing difficulty in articulation, eating, drinking, cosmetic embarrassment, and psychological effects as patients lack confidence in public. METHODS: We injected botulinum toxin A (BTXA) into the normal contralateral smile muscles to weaken them and restore symmetry to both active and passive movements by neutralising these overacting muscles. RESULTS: A total of 14 patients received BTXA (79% women, median age 47 years, average length of palsy 8 years). They were all difficult cases graded between 2 and 6 (average grade 3 House-Brackmann). All 14 patients reported improved facial symmetry with BTXA (dose altered in some to achieve maximum benefit). Average dose was 30 units, but varied from 10 to 80 units. Average time to peak effect was 6 days; average duration of effect was 11 weeks. Three patients had increased drooling (resolved within a few days). CONCLUSION: The improvement in symmetry was observed by both patient and examining doctor. Patients commented on increased confidence, being more likely to allow photographs taken of themselves, and families reported improved legibility of speech. Younger patients have more muscle tone than older patients; the effect is more noticeable and the benefit greater for them. BTXA improves symmetry in patients with facial palsy, is simple and acceptable, and provides approximately 4 months of benefit. The site of injection depends on the dynamics of the muscles in each individual patient.

Psychological distress in people with disfigurement from facial palsy.

AIMS: Psychological distress is well documented in people with facial disfigurement. However, the prevalence of psychological distress in patients with facial palsy has not been studied. This study aims to establish the prevalence of psychological distress and the extent of anxiety and depression in a sample of facial palsy patients from the Northwest of England. METHOD: A total of 103 participants with facial palsy completed a questionnaire pack comprising the Illness Perception Questionnaire-Revised (IPQ-R), a demographic questionnaire, and the Hospital Anxiety and Depression Scale (HADS). The severity of participants' facial palsy was measured by the House-Brackmann scale. RESULTS: In all, 32.7 and 31.3% of the sample had significant levels of anxiety and depression, respectively. The mean age of participants was 59, and 35.9% had grade 6 facial palsy. Significant associations were found between participants' perception of consequences, duration, timeline, and the level of distress. No significant associations were found between clinical severity of facial palsy and levels of distress. Females had significantly higher levels of anxiety compared with males. CONCLUSIONS: There was a significant level of distress in this study group. The levels of psychological distress were higher than the levels found in other outpatient attenders. There were significant associations between participants' illness perceptions and their level of distress.

Effectiveness of a multidisciplinary facial function clinic.

OBJECTIVES: To analyse the usefulness of a multidisciplinary facial function clinic (FFC). DESIGN: Retrospective case-note review. SETTING: The FFC was established in July 2006 at the Manchester Royal Eye Hospital with attending consultants from Ophthalmology, Skull-Base Otolaryngology, Plastic Surgery, and Physiotherapy. PARTICIPANTS: We retrospectively reviewed the case notes for 59 consecutive patients seen at the FFC from July 2006 to February 2009. MAIN OUTCOME MEASURES: We documented demographic data, including distance travelled and average journey time. RESULTS: The 59 patients (mean age 46 years) made a total of 106 clinical visits (mean 1.8). The mean distance travelled by a patient was 31.9 miles with an estimated journey time of 47 min, each way. At presentation the average House-Brackmann grade of facial nerve weakness was IV. Ophthalmologist's advice was needed for 58 (98.3%), otolaryngologist's for 57 (96.6%), plastic surgeon for 49 (83.0%), physiotherapist for 58 (98.3%), and 4 (6.8%) were referred for psychological counselling. In all, 47 (79.7%) of our patients needed input from all four consultants during their visit at the FFC. By combining the presence of several consultants in one clinic, we saved an average of 5.1 visits (325.4 miles; 8 h travel time) for each patient. CONCLUSION: We and our patients feel our multidisciplinary facial function clinic has been an effective service and has continued to work.

Non-union of the humeral shaft treated by internal fixation.

We reviewed 40 cases with non-union of the humeral shaft. There were 31 men and nine women patients with an average age of 38.5 (35-65) years. Thirty-four non-unions were of the atrophic type. Non-union was most often found at the transition of the middle third to the lower third of the humeral shaft. Six fractures were classified as open at the time of the initial injury. All patients were treated by open reduction and internal fixation with a dynamic compression plate (DCP). Cancellous bone graft was used in all atrophic non-unions. In one patient an additional fibular graft was used. The average follow-up was 13 (6-18) months. Final results were available for 34 patients. Thirty-one fractures (91%) healed in an average of 4.5 (3-9) months. Main complications were temporary radial nerve palsy in two patients and deep infection in one.

Wegener's granulomatosis: The ocular manifestations revisited.

AIM. To investigate whether the extent of ocular morbidity had de-creased as a result of improved diagnosis, awareness and treatment of Wegener 's granulomatosis (WG). MATERIALS AND METHODS. A retrospective study of all patients with ophthalmic involvement due to WG over an 8-year period. RESULTS. Forty-nine patients were diagnosed to have WG. Of these, 28 had ocular involvement: 21 patients had focal ocular involvement (conjunctivitis, episcleritis, scleritis, keratitis, iritis, retinitis)and 7 had orbital involvement. Permanent visual loss occurred in three patients with orbital involvement, but in no patients with focal ocular disease. Up to 90% of patients had systemic involvement. Three deaths oc- curred among those with ocular involvement. CONCLUSIONS. Patients with WG have a much improved visual prog- nosis as a result of early diagnosis and intervention with systemic im- munosuppression. A combination of assays for ANCA and tissue biop-sies were needed to establish the diagnosis of WG. Treatment with immunosuppressive agents (usually prednisolone and cyclophospha- mide)led to a good response in the majority of cases.

Transient quadriparesis after electric shock.

A case of acute transient flaccid quadriparesis after a low voltage electric shock is reported. The patient recovered completely with in three days.

The visual results and changes in retinopathy in diabetic patients following cataract surgery.

INTRODUCTION: A study was designed to investigate the visual improvement and incidence of progression of retinopathy in diabetic patients following extracapsular cataract extraction or phacoemulsification. They were compared to a matched group of non-diabetic patients. METHODS: A retrospective analysis of all diabetic patients (118) undergoing ECCE (90) or phacoemulsification (28) in 1995. These patients were operation and age matched with 118 non-diabetic patients who underwent surgery during the same year. RESULTS: There was no statistically significant difference in complications following ECCE in diabetic and non-diabetic patients (p = 0.2). Complications were however more common in non-diabetic patients undergoing phacoemulsification compared to diabetics undergoing the same procedure (p = 0.046). Although consultants performed 42% of the surgery in diabetics compared to 31% in non-diabetics, there was no significant difference in the rate of complications between consultants and residents (p = 0.8). Overall the visual improvement in non-diabetics was better than diabetic patients (p = 0.006). This was due to a better improvement amongst non-diabetic patients undergoing phacoemulsification (p = 0.02). Overall, cataract surgery was found to lead to a worsening in retinopathy in 19 operated eyes (15 had no retinopathy preoperatively) compared to a worsening in 8 fellow eyes. This was statistically significant (p = 0.04). However, ECCE was no more likely to cause worsening of retinopathy than phacoemulsification (p = 0.87). CONCLUSIONS: Diabetic patients due to undergo cataract surgery a) have a good chance of visual improvement but to a level less than if they were not diabetic, b) have a greater chance of visual loss, c) surgery may initiate or worsen any pre-existing retinopathy and this may affect their vision in the future.

Leber's hereditary optic neuropathy mitochondrial DNA mutations at nucleotides 11778 and 3460 in multiple sclerosis.

OBJECTIVES: Leber's hereditary optic neuropathy (LHON) can be difficult to distinguish from optic neuritis seen in multiple sclerosis (MS). About half of the LHON patients harbor a mutation at nucleotide (nt) 11778 in the mitochondrial (mt) DNA. In addition, mutations at nt-3460 and nt-14484 have been associated with LHON. An association of LHON and MS has been suspected for decades, and, recently, the LHON nt-11778 and nt-3460 mtDNA mutations have been found in several patients with MS or MS-like disease. We attempted to determine which MS patients should be evaluated further for LHON mutations. METHODS: We screened 103 clinically definite MS patients (age range from 18 to 72 years, 27 men and 76 women) for the LHON nt-11778 and nt-3460 mtDNA mutations. RESULTS: Neither mutation was identified in the patients. CONCLUSIONS: Our findings confirm previous reports which found that both LHON mutations are rare in unselected MS patients. The reports to date suggest that MS patients with peripapillary teleangiectasia typical of LHON, with relatives harboring LHON or with early severe bilateral optic neuropathy, particularly if female, should be further evaluated for LHON mutations.

Porous orbital implants and their behaviour during drilling.

The use of porous spherical orbital implants enables ocular prosthesis motility to be improved if necessary by subsequent drilling of the implant and coupling it to the prosthesis with a peg. We compared the effect of drilling at different speeds on hydroxyapatite and porous polyethylene (Medpor) spherical implants. The implants were drilled at fixed speeds of between 15 and 2000 revolutions per minute. The samples were then viewed in an electron microscope and photographed. When hydroxyapatite is drilled the porous structure of the implant is maintained although a precise hole with well-defined walls was not produced. This contrasts with porous polyethylene where the porous structure is lost although a precise drill hole is created. This drilling technique has been used successfully in patients with hydroxyapatite implants, thus making possible stable epithelialisation of the drill hole. Our results confirm that the drilling of porous polyethylene using this technique is unlikely to be successful, as loss of the porous structure would prevent stable epithelialisation of the drill hole, resulting in exposure of the implant.

The effect of timolol drops on respiratory function.

PURPOSE: Recently, attention has been focused on the adverse drug reactions of topical timolol, especially with regard to respiratory function in the elderly. This study was designed to assess whether timolol causes an alteration in lung function in patients without pre-existing respiratory disease and who have not suffered the impact of long-term beta 2 blockade. METHODS: A placebo-controlled randomised, double-masked, cross-over study was carried out on 20 ocular hypertensive patients with intraocular pressures over 21 mmHg, normal optic discs and full visual fields by Humphrey perimetry. Subjects received single-dose units of timolol maleate 0.5% drops or normal saline drops. Both were instilled in one eye or systemically (sublingually). The peak expiratory flow rate (PFR), forced expiratory volume (FEV), vital capacity (VC) and FEV/VC (%) ratio were all measured both before and after each type of drop and route of administration. RESULTS: Two hours after instillation of timolol there was no change in PFR (p = 0.67) or VC (p = 0.40), but there was a fall in FEV (p = 0.038) and the FEV/VC (%) ratio (p = 0.041). The fall was greatest after topical administration. CONCLUSIONS: Our results show that in our group of patients there was a tendency towards mild bronchial obstruction after topical timolol, although this was not clinically significant.

Epiphora: a quick fix?

PURPOSE: To assess whether any simple, easily performed and minimally invasive procedure may help the symptoms of patients with functional nasolacrimal obstruction without recourse to elaborate investigation or major surgery. A randomised study was performed to assess the success of retropunctal cautery (RPC) and one-snip punctoplasty in this condition. METHODS: In the absence of any cause for excess lacrimation, eyelid malposition or nasolacrimal obstruction, patients underwent either syringing alone (group A, n = 15) or syringing with RPC and a one-snip punctoplasty (group B, n = 15). RESULTS: Three months after treatment, six patients in group A were improved, compared with 13 in group B (Fisher's exact test, p = 0.0096). CONCLUSIONS: We would recommend that patients who suffer from a pump or functional nasolacrimal obstruction should receive RPC and a one-snip punctoplasty following the demonstration of a patent system on syringing. These simple procedures would not impair further investigation or lacrimal surgery if required in the future.

Evaluation of contamination of used disposable contact lenses by Acanthamoeba.

PURPOSE: The purpose of this study was to evaluate the contamination of used disposable soft contact lenses with Acanthamoeba. METHODS: We evaluated 51 consecutive disposable soft contact lens wearers in a prospective study. Before their check-up visits, patients were offered a free new contact lens in exchange for donating their old one. The used contact lenses (n = 102) were then removed and placed in culture medium for Acanthamoeba. We subsequently investigated patterns of wear and hygiene habits. RESULTS: The mean age of this population was 32.6 +/- 11.0 years. The average time of disposable soft contact lens wear was 13.7 hours per day. The contact lenses were disinfected daily with commercial solutions. Twenty-five (49.0%) subjects did not clean their lens cases properly. Acanthamoeba was not isolated from any of the 102 lenses. CONCLUSIONS: There were no cases of Acanthamoeba contamination in a small population of disposable soft contact lens wearers who regularly disinfected their lenses with standard commercially available contact lens solutions.

A clinical algorithm for the management of facial nerve palsy from an oculoplastic perspective.

BACKGROUND/AIMS: Facial nerve palsy can be a sight-threatening complication. We have developed a flow diagram to aid in the management of these patients so that corneal complications may be avoided. This involves the recognition of a facial palsy and institution of treatment as guided by the flow chart. METHOD: Fifty-six patients suffered a facial nerve palsy following acoustic neuroma surgery. All received regular topical ocular lubrication, followed by either botulinum toxin A (BTXA)-induced ptosis (if corneal exposure developed despite conservative treatment) or definitive eyelid surgery. RESULTS: Twenty-one patients required regular lubrication only. Of these patients treated for corneal exposure, 20 received BTXA with good resulting corneal cover. Unfortunately, 9 of these suffered diplopia, although in 4 this resolved quickly. Twenty-four patients underwent a total of 64 eyelid procedures including levator recession, lateral tarsorraphy, lateral canthal sling, medical canthoplasty and gold weight insertion. All patients had good corneal cover post-operatively and were cosmetically improved. Of the 56 patients with a facial nerve palsy, 7 presented with a corneal epithelial defect or an infected corneal ulcer. These all responded to treatment with BTXA, topical antibiotics and/or lubrication, and eyelid surgery. CONCLUSIONS: Post-operative facial palsy may result in a significant ophthalmic workload. Although a proportion of patients with a facial nerve palsy manage well with regular lubrication, additional help with eyelid closure, either in the way of BTXA-induced ptosis in the short term or definitive eyelid surgery in the long term, is often required. Eyelid surgery seems to be the mainstay of treatment, for both function and cosmesis, with many patients requiring a combination of procedures.

Use of indomethacin for pain relief following scleral buckling surgery.

BACKGROUND/AIMS: Patients undergoing scleral buckling and cryotherapy suffer from mild to moderate postoperative pain. As good pain relief facilitates post-operative ocular examination, as well as patient comfort and recovery, the authors designed a prospective randomised double masked trial to evaluate the efficacy of indomethacin as a satisfactory analgesic for such patients. METHOD: Patients with a primary uncomplicated rhegmatogenous retinal detachment requiring scleral buckling and cryotherapy were randomly allocated to receive either indomethacin or placebo. A rectal suppository was administered 2 hours before surgery, followed by two capsules twice daily for 10 days. Pain relief was assessed with a linear graphic rating scale at the end of each day. Supplementary analgesia was allowed and recorded. RESULTS: 12 patients received indomethacin (group A) and 16 received placebo (group B). The extent of surgery was similar in both groups. One patient in group A, and two in group B withdrew after 3 days. The pain scores were converted to changes from the baseline (score on day 1), and the area under the curve calculated for each patient. The means of the areas were analysed with the Mann-Whitney test and showed that indomethacin caused a statistically significant reduction in pain score, both at 3 days (p = 0.04) and at 10 days (p = 0.014). There was no statistically significant difference in extra analgesic requirements between the two groups (p = 0.2). CONCLUSIONS: Indomethacin is recommended for short to medium term pain relief following scleral buckling and cryotherapy.

The effect of heparin-coated intraocular lenses on intraocular pressure following combined trabeculectomy and cataract surgery.

PURPOSE: To review the effects on intraocular pressure control of the use of standard and heparin-coated intraocular lenses (IOLs) following combined cataract and glaucoma surgery after a minimum period of 2 years. METHODS: Case note review of all patients with glaucoma who required cataract extraction combined with trabeculectomy and who were randomized to either of the two IOL types. The number of ocular hypotensive medications and the intraocular pressures were recorded pre-operatively and at 3, 6, 18 and 24 months following surgery. RESULTS: The two groups (9 receiving standard IOLs and 10 heparin-coated IOLs) were comparable for age, sex and follow-up, as were the pre-operative intraocular pressures and number of treatments. Post-operatively, all patients achieved an intraocular pressure < 21 mmHg at the final visit, with only one patient in each group requiring topical medication, but the standard lens group had a higher intraocular pressure at 2 years (p<0.05). The magnitude of the fall from the pre-operative values was greater in the heparin-coated lens group at 2 years after surgery (p<0.02). The presence of a visible drainage bleb occurred equally frequently in the two groups. CONCLUSIONS: Use of a heparin-coated IOL does not adversely affect the intraocular pressure control following combined cataract and drainage surgery. The greater fall in intraocular pressure at 2 years in those receiving a heparin-coated IOL may have occurred by chance.