The UK National Artificial Eye Questionnaire Study: predictors of artificial eye wearers' experience Part 2 - visual function and quality of life.

OBJECTIVES: To report associations with visual function and quality of life (QOL) in artificial eye wearers. METHODS: Multicentre, observational, cross-sectional, nationwide study, within the National Health Service England. Items were adopted from the National Eye Institute Visual Function Questionnaire, and incorporated in the National Artificial Eye Questionnaire (NAEQ). The NAEQ was completed by 951 respondents. Multiple regressions assessed associations between the QOL scores and the experiences of artificial eye wearers, their routine management, changes over time, baseline and demographic parameters. RESULTS: Parameters predictive of a better QOL composite score included longer artificial eye wear (ß = 0.18, p < 0.001), better appearance (ß = 0.17, p < 0.001), better comfort (ß = 0.14, p = 0.001), tumour-related anophthalmia (ß = 0.13, p = 0.003), male gender (ß = 0.13, p < 0.001), shorter period of adjustment to monocular vision (ß = 0.12, p < 0.001) and use of soap for cleaning (ß = 0.09, p = 0.046). The composite score continued to improve beyond 10 years of prosthesis wear (≤2 years mean 72.80 ± 1.65 versus >10 years mean 79.45 ± 0.70; p = 0.001). Both better prosthesis appearance (ß = 0.14, p = 0.022) and improved motility (ß = 0.13, p = 0.042) predicted a better dependency score. Use of lubricating ointment predicted a worse dependency score (ß = 0.23, p = 0.003). Neither the frequency of removal, nor the cleaning frequency of the artificial eye correlated with QOL scales. CONCLUSIONS: Multiple factors in the artificial eye experience were found to predict visual function and QOL aspects. This study underscores the need to generate a dedicated QOL questionnaire for use in anophthalmic patients.

The UK National Artificial Eye Questionnaire study: predictors of artificial eye wearers' experience part 1-comfort and satisfaction.

OBJECTIVES: To report associations with comfort and with appearance satisfaction in artificial eye wearers. METHODS: Multicentre, observational, cross-sectional study, nationwide within the National Health Service England. The National Artificial Eye Questionnaire (NAEQ) was completed by 951 respondents. Multiple regressions assessed associations between the experiences of artificial eye wearers, routine management, changes over time, baseline and demographic parameters and their reported comfort, satisfaction with appearance and prosthesis motility. RESULTS: Better comfort levels were associated with needing less lubrication (ß = 0.24, p < 0.001), older age (ß = 0.17, p = 0.014), less discharge (ß = 0.16, p < 0.001), less frequent cleaning (ß = 0.16, p = 0.043), and male gender (ß = 0.06, p = 0.047). Greater satisfaction with the appearance of the artificial eye was associated with better perceived motility (ß = 0.57, p < 0.001). Black ethnic origin predicted a lower satisfaction with the appearance (ß = -0.17, p = 0.001). Greater satisfaction with the motility was associated with a better appearance rating (ß = 0.51, p < 0.001), longer time of having an artificial eye (ß = 0.13, p < 0.001), older age (ß = 0.11, p = 0.042), and a shorter adjustment time (ß = -0.07, p = 0.016). Of the testimonials concerning appearance aspects, the majority (21/45, 46.7%) were related to the effect on social interactions. CONCLUSIONS: The results suggest that more attention should be given to the "dry anophthalmic socket syndrome" as a key cause of discomfort. Young patients are concerned particularly about the motility of the artificial eye. Over time satisfaction with the artificial eye movement is likely to improve.

Meibomian gland inversion: under-recognized entity.

OBJECTIVE: To describe a clinical entity of upper eyelid margin and meibomian gland inversion (MGI) sequential to meibomian gland dysfunction (MGD), in the absence of eyelash ptosis, trichiasis or manifest marginal entropion. We highlight its clinical features, surgical management and outcomes. METHODS: We performed a retrospective analysis of symptomatic MGI cases refractory to conservative management who underwent surgery in our centre over a 4-year period. Anatomical correction, resolution of symptoms and possible complications are reported. RESULTS: A total of 21 eyelids of 13 patients (mean age: 68.5 ± 15.4, range: 32-88 years) were analysed. Symptomatic MGI patients were operated only if they have noted immediate comfort when we corrected the lid margin position with a cotton tip. Those with refractory superior punctate corneal staining (n = 14 eyes), blink-related discomfort (n = 8) and pseudo-blepharospasm (n = 3) reported complete postoperative resolution. Milder symptoms showed partial improvement: gritty feeling (79%), sore eye (80%) and watery eye (86%). However, symptoms of dry eye disease (DED) persisted in 88% of patients. One case recurred in 6 weeks and was offered revision surgery. Median follow-up was 5 (range: 3-12) months. CONCLUSION: Meibomian gland inversion (MGI) is a subtle clinical entity that can be easily overlooked. Symptoms are often attributed to DED or MGD alone. It is likely that MGI represents early upper lid margin anatomical changes secondary to MGD before cicatricial marginal entropion becomes clinically apparent. Recommended treatment is conservative with intensive lid hygiene and topical MGD management. However, refractory symptomatic cases who respond positively to a 'cotton-tip test' (reversal of lid margin malposition with a rolling cotton-tip) may benefit from surgical intervention with favourable anatomical and functional outcome.

Late outcomes of gold weights and platinum chains for upper eyelid loading.

AIM: To identify late outcomes of gold weights (GWs) and platinum chains (PCs) for upper eyelid loading in the management of lagophthalmos. METHODS: A retrospective case series of upper eyelid GWs and PCs at a single centre over a 10-year period (2004-2013). Two independent, blinded assessors graded standard photographs for any weight-related morbidity (poor upper eyelid contour, weight prominence and migration). RESULTS: Primary upper eyelid loading (high-tarsal technique) was performed in 154 eyelids of 136 patients (facial nerve palsy, n=99; non-paralytic, n=37). A total of 127 eyelids of 110 patients had primary GW insertion. Of these, 40.9% (52/127) had revision surgery: exchange of GW for PC (58%), GW repositioning (25%) and removal of GW (17%). Only 22.2% (6/27 eyelids) with primary PCs required revision surgery. In those not requiring revision surgery, photograph grading showed that both GWs and PCs had weight-related morbidity at late follow-up (median=37.5 months, range 12-110 vs median=33.5 month, range 15-106). GWs had significantly higher rate of weight prominence (p=0.001) and migration (p<0.001) compared with PCs. All PC revisions required one procedure only compared with 10% of GWs revisions requiring two or more procedures. Incidence of gold allergy was 7% (8/110 patients). There was no association between the choice of weight material, physical weight or suture material and eyelid morbidities. CONCLUSION: GWs were found to be associated with higher complications and twice more likely to require long-term revision surgery compared with PCs. Despite weight fixation at a high-tarsal location, prominence of PCs can still occur.

Can We Improve the Tolerance of an Ocular Prosthesis by Enhancing Its Surface Finish?

PURPOSE: Patients who wear an ocular prosthesis frequently suffer with dry eye symptoms and socket discharge, often on a daily basis. The aim of the study was to determine whether a smoother, optical quality polish of the prosthesis' surface could improve symptoms and wear tolerance. The study was designed as single-center, single-masked, prospective randomized controlled trial. Eighty-eight consecutive patients undergoing annual ocular prosthesis maintenance review were approached from the prosthesis clinic. Forty-one out of 49 eligible patients were recruited. METHODS: Participants were randomized to either a standard or a higher "optical quality" polish of their prosthesis. At entry to the trial, at 1 month, and 12 months they completed a questionnaire covering cleaning, lubricant use, inflammation, discomfort, and discharge. Lower scores indicated better tolerance of the prosthesis. At each visit, the prosthesis was stained and photographed against a standard background to assess deposit build up. Primary outcome measures were 1) a subjective questionnaire score and 2) an objective assessment of surface deposit build-up on prosthetic eyes by standardized photographic grading. RESULTS: Forty-one patients participated in the study. The median age of their prosthesis was 36 months (range 9 months-40 years). There was no statistically significant difference in questionnaire scores or deposit build up between the 2 groups at baseline. By 12-months, the higher optical quality polish showed a statistically significant reduction in symptoms and frequency of discharge (2.19 vs. 3.85; p = 0.05-lower scores better). Scoring of the prosthesis' deposit build-up showed a significant difference at 1 month, but this was not sustained at 12 months. CONCLUSIONS: Creating an optical quality finish to an ocular prosthesis reduces deposit build up on artificial eyes. The authors found this modification improved patient tolerance at 12 months.

Complications and outcomes of grafting of posterior orbital fat into the lower lid-cheek junction during orbital decompression.

PURPOSE: To report the complications of grafting of excised posterior orbital fat into the lower lid-cheek junction at the time of orbital decompression surgery. METHODS: Retrospective review of consecutive patients undergoing orbital decompression combined with grafting of posterior orbital fat to the pre-malar and lateral canthal area (FG). A second group of consecutive patients undergoing orbital decompression but no orbital fat grafting (NoFG) were also studied as a form of comparative control. Standard patient data, including age, sex, visual acuity, degree of proptosis, operative details, diplopia or any other complications was collected. Independent assessment of pre- and post-operative photographs graded the lower lid-cheek junction. RESULTS: Thirty-four orbits of 29 patients, of which 21 orbits underwent orbital decompression with orbital fat grafting (FG). There were no intraoperative complications, postoperative infections, or visual loss. Complications relating to fat grafting included prolonged swelling in 3 (17%) patients at 3 months, in 1 case lasting 6 months, lower lid lumps in 3 (17%), and fat seepage in 1 (6%). The FG group achieved a greater improvement in the appearance of the lower-lid-cheek junction at 12 months in comparison to NoFG. Mean grade improvement 1.24 ± 1.09 vs 0 ± 0.82 (p = 0.025). Median follow-up was 20 months (range 6-30 months). CONCLUSION: Grafting of excised orbital fat during orbital decompression can improve the appearance of the lower lid-cheek junction in patients being treated for thyroid orbitopathy. However, 24% of patients will experience swelling and/or lumpiness requiring several months to settle or further fat excision.

Periorbital Autologous Fat Grafting in Facial Nerve Palsy.

PURPOSE: To report outcomes and complications of periorbital autologous fat grafting (AFG) in improving volume loss-related symmetry and function in facial nerve palsy patients and to assess patient satisfaction. METHODS: A retrospective, noncomparative review of all facial nerve palsy patients who underwent periorbital AFG at single center over a 4-year period. Two independent graders objectively assessed standard photographs for any change in volume loss and symmetry: pre- and postoperative periods (early, 0-2 months; intermediate, 3-9 months; and late, >10 months). Any adverse outcomes were recorded. Patient satisfaction was assessed by questionnaire survey. RESULTS: A total of 18 facial nerve palsy patients (13 females) underwent periorbital AFG between February 2011 and 2015. Mean age was 51.9 ± 15.3 years (range, 26-76). Mean follow up was 6.8 ± 4.6 (range, 0.5-15) months. Photographs of 14 patients were eligible for evaluation. Tear trough visibility (p < 0.01), infraorbital rim visibility (p = 0.03), and lower eyelid-cheek junction symmetry (p < 0.01) improved in the early postoperative period with persistence of improvement in the latter parameter at intermediate postoperative period (p < 0.01). Lagophthalmos significantly improved (p = 0.03) in the early postoperative period. Two patients developed cheek cellulitis and 4 had persistent malar edema (3 had existing edema). Questionnaire survey showed a reduction in daytime ocular lubricants and an improvement in nocturnal-lagophthalmos symptoms. CONCLUSION: Periorbital AFG is a useful adjunct in improving symmetry and lagophthalmos in facial nerve palsy patients where volume loss is a contributory factor but effects were not long lasting. Patient satisfaction is high. Those with preexisting malar bags are at higher risk of developing persistent malar edema following periorbital AFG.

Blepharoptosis surgery in patients with myasthenia gravis.

BACKGROUND/AIMS: To review our approach of cautious surgical correction of blepharoptosis in patients with myasthenia gravis (MG) to minimise risk of exposure complications. METHODS: Retrospective case note review of 30 patients with symptomatic eyelid concerns despite appropriate medical treatment, who underwent eyelid surgery. The mean age at diagnosis was 47 years. 13/30 patients had systemic MG, 14/30 ocular MG and 3/30 congenital MG. The main outcome measures were improvement in eyelid height and/or position, duration of a successful postoperative result, need for further surgical intervention, and intraoperative or postoperative complications. RESULTS: 38 blepharoptosis procedures were performed on 23 patients. Mean age at time of surgery was 62 years, with an average follow-up of 29 months. 10 patients (16 eyelids) underwent anterior approach levator advancement, 4 patients (5 eyelids) posterior approach surgery and 8 patients (15 eyelids) brow suspension. One patient (2 eyelids) had tarsal switch surgery. An average improvement in eyelid height of 1.9 mm was achieved. Postoperative symptoms or signs of exposure keratopathy occurred in 17% of patients. This necessitated lid lowering in one eyelid of one patient. During follow-up, 37% of eyelids required further surgical intervention to improve the upper eyelid height, after an average of 19 months (range 0.5-49 months). CONCLUSIONS: Over a third of patients in our series required repeat surgery, which would be expected when the initial aim was to under-correct this group. In contrast to previous commentaries, the amount of eyelid excursion was not the main factor used to guide the surgical approach.

Two new cases of metastatic basal cell carcinoma from the eyelids.

BACKGROUND: Basal cell carcinoma (BCC) is an extremely common malignancy. Unlike other skin cancers, it very rarely metastasises. METHODS: We present two cases of advanced BCC on the eyelids that metastasized to the parotid region after local excision. DISCUSSION: We include a review of patients with metastatic BCC originating from the eyelids. CONCLUSION: Metastatic BCC from the eyelids is rare, but appears to occur in an older age group with a shorter time before metastasis when compared to metastatic BCC as a whole.

The international forum of ophthalmic simulation: developing a virtual reality training curriculum for ophthalmology.

BACKGROUND: To investigate the effect of a structured, supervised, cataract simulation programme on ophthalmic surgeons in their first year of training, and to evaluate the level of skill transfer. METHODS: Trainees with minimal intraocular and simulator experience in their first year of ophthalmology undertook a structured, sequential, customised, virtual reality (VR) cataract training programme developed through the International Forum of Ophthalmic Simulation. A set of one-handed, bimanual, static and dynamic tasks were evaluated before and after the course and scores obtained. Statistical significance was evaluated with the Wilcoxon sign-rank test. RESULTS: The median precourse score of 101.50/400 (IQR 58.75-145.75) was significantly improved after completing the training programme ((postcourse score: 302/400, range: 266.25-343), p<0.001). While improvement was evident and found to be statistically significant in all parameters, greatest improvements were found for capsulorhexis and antitremor training ((Capsulorhexis: precourse score=0/100, range 0-4.5; postcourse score=81/100, range 13-87.75; p=0.002), (antitremor training: precourse score=0/100, range 0-0; postcourse score=80/100, range 60.25-91.50; p=0.001)). CONCLUSIONS: Structured and supervised VR training can offer a significant level of skills transfer to novice ophthalmic surgeons. VR training at the earliest stage of ophthalmic surgical training may, therefore, be of benefit.

Management of periocular basal cell carcinoma by Mohs micrographic surgery.

BACKGROUND/AIMS: To determine the success of Mohs micrographic surgery (MMS) for periocular basal cell carcinoma (BCC) at a tertiary referral centre in the UK. DESIGN: A retrospective interventional case series covering 5 years of practice. METHODS: Review of medical records of 104 consecutive patients who underwent MMS for confirmed periocular BCC. The main outcome measure was biopsy-proven recurrence of BCC at the same anatomical location after MMS. Secondary outcome measures included tumour site, histological subtype and length of follow-up. RESULTS: 104 patients underwent MMS for periocular BCC from January 2003 to July 2008. 63 (62%) of the surgeries were for primary BCC and 25 procedures (25%) were for recurrent or residual BCC. 64% of tumours were nodular BCC. The mean follow-up was 28 months (range 1-85 months). Six recurrences were identified in total. The recurrence rate following MMS for primary BCC was 1.6% (1 patient) compared to 20% (5 patients) in the patient group treated for residual or recurrent tumours. The mean time to recurrence was 39 months (range 16-71 months). CONCLUSIONS: MMS for primary BCC has a very high success rate but the recurrence rate increases significantly in cases of recurrent or residual tumours.

Tear film osmolarity in epiphora.

PURPOSE: To examine whether patients complaining of epiphora have tears of a lower osmolarity. METHODS: Sixty-three eyes of 39 patients attending an oculoplastic clinic with a primary complaint of epiphora, had their tear osmolarity recorded. Subjects were excluded if they had current or recent topical eye therapy, active ocular infection or allergy, ocular surface scarring, evidence of dry eye, previous laser eye surgery, or a contact lens worn within the previous 12 hours. Patients were divided into 2 groups. The first included those whose primary complaint was of epiphora due to either punctal stenosis, nasolacrimal duct obstruction (partial or complete), or eyelid laxity (without evidence of frank ectropion or entropion). The second group formed the controls, and consisted of the second eye of some of the above patients, or those attending the clinic for other oculoplastic procedures not related to epiphora. Testing of tear osmolarity was performed in the clinic using the TearLab osmometer. RESULTS: Sixty-three readings were obtained, of which 32 were from patients with a primary complaint of epiphora and 31 were allocated to the control group. Patients with epiphora had a mean tear osmolarity of 291.8 mOsms/l (range, 269-324, standard deviation 16.6), compared with the control group mean of 303.7 mOsms/l (range, 269-354, standard deviation 24.1). This difference was found to be statistically significant (p = 0.025). CONCLUSION: Patients complaining of epiphora in the absence of other ocular surface pathology have a significantly lower tear osmolarity.

Perioperative spontaneous bilateral suprachoroidal hemorrhage.

Suprachoroidal hemorrhage is a rare condition, occurring most commonly in the perioperative period, although cases of unilateral spontaneous hemorrhages have been reported. We report a case of bilateral spontaneous suprachoroidal hemorrhage and discuss the potential causative factors.

Monocanalicular versus bicanalicular intubation in external dacryocystorhinostomy for primary acquired nasolacrimal duct obstruction.

PURPOSE: Monocanalicular intubation offers potential advantages over bicanalicular intubation including ease of removal and use of only one canaliculus. Recent reports suggest equal outcomes with both types of tubes for nasolacrimal intubation. This study aimed to evaluate the outcome of monocanalicular intubation during external dacryocystorhinostomy. METHODS: Fifty-seven lacrimal systems of 54 adults with primary acquired nasolacrimal duct obstruction were prospectively randomized into two cohorts for either bicanalicular intubation (n = 29) or monocanalicular intubation (n = 28) during external dacryocystorhinostomy. All subjects had their symptoms evaluated subjectively according to a modified Munk scale and objectively by the dye disappearance test along with probing and irrigation, pre- and post-operatively. Complete success was defined as a total disappearance of symptoms, partial success as an improvement with some residual symptoms, and failure as an absence of improvement or worsening of symptoms at the last follow-up. Patients with concurrent lid or ocular pathology were excluded. RESULTS: Bicanalicular subjects had a significantly higher complete success rate (21/29, 72.4%) compared to the monocanalicular group (12/28, 42.9%) (p = 0.03). Complications included 3 slit punctuae and 2 early tube removals with bicanalicular intubation; 6 temporary superficial punctate keratopathies, 1 punctal stenosis and 4 premature tube losses occurred with monocanalicular intubation. CONCLUSIONS: Patients with monocanalicular intubation during external dacryocystorhinostomy had a significantly lower success rate than patients with bicanalicular intubation in the treatment of nasolacrimal duct obstruction.

Glare and halo with refractive correction.

BACKGROUND: The aim of this investigation was to compare glare and halo with various methods of refractive correction. METHODS: Ninety-eight eyes of healthy pre-presbyopes were analysed for the presence of glare and halo using computer-generated stimuli. Subjects were divided into three groups: emmetropes without correction, single vision plastic lens spectacle wearers (with clean and dirty lenses) or single-vision soft contact lens wearers. RESULTS: No significant difference in glare was found among groups. Significant differences were noted in halos between emmetropes and both contact lens (p<0.001) and uncleaned spectacle groups (p<0.05) but not with cleaned spectacles. The reduction in halo size after cleaning the lenses was significant (p<0.0187). CONCLUSIONS: Contact lens and unclean spectacle wearers both have significantly larger halos than emmetropes and those wearing cleaned spectacle lenses. Unclean spectacles may affect the accuracy of results in psychophysical and clinical testing.