A difficult diagnosis: severe Graves' ophthalmolopathy.

An 81-year-old woman with atrial fibrillation, on warfarin, with known hyperthyroidism, was admitted to hospital following a fall with proptosis and severely restricted movements in her left eye. Medics initially thought the presentation was related to an intracranial pathology but through subsequent tests and examination, ophthalmologists diagnosed a severe case of thyroid eye disease with intense inflammation. The patient responded well to systemic steroid treatment. This case report highlights a severe rapidly progressing case of thyroid eye disease with diagnostic difficulties arising from multiple comorbidities in an elderly patient.

Alleviating Pain in Oculoplastic Procedures by Reducing the Rate of Injection of Local Anaesthetic.

PURPOSE: To investigate whether the rate of infiltration of local anaesthetic influences the pain or efficacy of local anaesthesia in oculoplastic surgery. METHODS: A prospective observational study on consecutive patients undergoing a variety of oculoplastic procedures under local anaesthesia. An observer recorded the rate of injection of local anaesthetic during each procedure. The same mixture of local anaesthetic and the same needle gauge was used in all cases. Patients were asked to rate the pain of both the injection and the surgery using a visual analog scale (VAS). RESULTS: 77 consecutive patients were observed, 39/77 (50.6%) patients were female and the average age was 63.5 years (range 31-94). A statistically significant correlation was found between the rate of injection and the VAS score from the injection (p<0.0001, r=0.42). There was no significant correlation between the injection rate and the VAS score from the procedure itself (p=0.25, r=0.13). Additionally, a significant correlation was found between the injection VAS score and the procedure VAS score (p=0.0002, r=0.42). CONCLUSION: The slower the rate of injection of local anaesthetic, the less pain was reported by the patient from the injection itself. Indeed the perception of pain from the surgery overall was significantly related to the pain felt during the injection, highlighting the importance of minimising pain during the injection of the local anaesthetic. We conclude that slowing the rate of injection is an effective way of alleviating pain from administration of the anaesthetic.

A prospective, multicentre study of malignant and premalignant lesions at the base of periocular cutaneous horns.

PURPOSE: The primary objective of the study was to determine the incidence of the various pathological conditions present at the base of the periocular cutaneous horns. The secondary objective was to study the presentation of these cutaneous horns with a view to finding any clinical indicators for premalignant, malignant and benign lesions at the base. METHODS: Prospective multicentre study of patients presenting with cutaneous horns. Informed consent followed by excision biopsy of the base lesion was performed in all the cases included for the study. The biopsy specimens were examined histologically and results analysed. RESULTS: Twenty-six patients presented with cutaneous horns in the periocular region over a period of 2 years, of these two patients presented with more than one cutaneous horn. 23 patients underwent excision biopsy. There were a total of 25 specimens. Of the base lesions 2/25 (8%) were malignant, 7/25 (28%) were pre-malignant and the remaining 16/25 (64%) were benign. Analysis of the findings on clinical presentation revealed no clinical indicators to correlate with the final histology. CONCLUSION: The incidence of malignant and pre-malignant lesions present at the base of periocular cutaneous horns was 36% with 8% of them being malignant. It is important to perform an excision biopsy with histological diagnosis of the base of the cutaneous horn as there are no definite clinical features that point towards a potential for malignancy.

A case of ectopic cilia in nail-patella syndrome.

Both ectopic cilia and nail-patella syndrome (NPS) are rare entities. To our knowledge we report the first case of the two anomalies coexisting in one patient. We present the case of a 2-year-old girl, with no other ophthalmic complication of NPS, who had an excellent cosmetic outcome and no lesion recurrence following surgical excision of ectopic cilia.

Administration of hyoscine- n-butylbromide during colonoscopy: a survey of current UK practice.

OBJECTIVE: Current British Society of Gastroenterology (BSG) guidelines suggest that hyoscine-n-butylbromide (Buscopan) should be avoided during colonoscopy in patients with a history of angle-closure glaucoma. Angle-closure glaucoma, however, is not very common, is asymptomatic before onset and is treated definitively by a single laser treatment (if spotted early). Open-angle glaucoma is not affected by hyoscine. The aim of this study was to assess the use of hyoscine among colonoscopists, with particular reference to glaucoma. DESIGN AND SETTING: Following BSG endoscopy subcommittee approval, a short questionnaire was electronically administered to members of the BSG and the Association of Coloproctology of Great Britain and Ireland. MAIN OUTCOME MEASURES: Hyoscine use among colonoscopists, and effect of glaucoma history upon prescribing practice. RESULTS: 188 colonoscopists responded to some or all of the questions. 123/183 (67.2%) of respondents claimed they were aware of the BSG guidelines. 160/187 (85.6%) sometimes or always use hyoscine, while 27/187 (14.4%) never do. 137/177 (77.4%) always enquire about glaucoma history prior to administration, although 147/176 (83.0%) make no differentiation between open-angle or angle-closure forms. 126/178 (70.8%) would (incorrectly) withhold hyoscine if the patient declares a history of any form of glaucoma. 140/179 (78.2%) do not substitute glucagon as an antispasmodic. 4/180 (2.2%) had encountered ophthalmic complications post-administration. CONCLUSIONS: Current BSG guidelines pertaining to hyoscine use and glaucoma are inappropriate; the authors recommend revision. Patients undergoing colonoscopy who have received hyoscine should, instead, be advised to seek urgent medical advice if they develop ophthalmic symptoms.

Local anesthesia: A feasible option for pediatric frontalis sling surgery.

The purpose of this study was to demonstrate the suitability of local anesthesia in the pediatric age group for oculoplastic procedures. The authors present a case of frontalis sling surgery performed under local anesthesia in a 15-year-old boy with bilateral congenital ptosis. No significant technical difficulties were encountered during the procedure. Optimal intraoperative eyelid placement was facilitated by the patient's comfort and cooperation. For some selected children, local anesthesia is a good alternative to general anesthesia to obtain the best outcome.

The role of 11beta-hydroxysteroid dehydrogenase 1 in adipogenesis in thyroid-associated ophthalmopathy.

CONTEXT: Thyroid-associated ophthalmopathy (TAO) is a sight-threatening autoimmune disease in which de novo adipogenesis has been identified as a fundamental pathogenic mechanism. 11beta-Hydroxysteroid dehydrogenase 1 (11beta-HSD1) increases cortisol bioavailability and is pivotal in mediating glucocorticoid responses in adipose tissue and inflammation. OBJECTIVE: In this study we characterize 11beta-HSD1 as a determinant of the adipogenic and inflammatory pathways in TAO orbital fat (OF) compared with normal OF. PATIENTS AND METHODS: OF was harvested from 46 TAO and 44 control patients undergoing orbital surgery. Samples were examined by a combination of immunohistochemistry, real-time RT-PCR, primary cell culture, specific enzyme assays, colorimetric proliferation assays, and bead-based ELISA. RESULTS: Glucocorticoid (glucocorticoid receptor-alpha,11beta-HSD1, hexose-6-phosphate dehydrogenase) and inflammatory cytokines (IL-1beta, IL-1 receptor, IL-6, TNF-alpha, TNF-alpha inductible protein, TGF-beta2) target genes together with markers of late adipocyte differentiation (fatty-acid-binding-protein-4, glycerol-6-phosphate-dehydrogenase) were highly expressed in TAO whole OF (P < 0.05) compared with controls. Primary cultures of TAO OF stromal cells demonstrated greater 11beta-HSD1 oxoreductase activity (P < 0.05), which was regulated by cytokines, most notably TNF-alpha (P < 0.01), compared with controls. Activity increased across differentiation, and this was most marked in TAO cells (P < 0.01). Similarly, stromal cell proliferation was limited by incubation with cortisol in TAO cells only. Furthermore, cortisone decreased IL-6 (P < 0.005), IL-8 (P < 0.05), and macrophage chemoattractant protein-1 (P < 0.05) production by cultured TAO cells only, an effect that was abrogated by inhibition of 11beta-HSD1. CONCLUSIONS: Induction of 11beta-HSD1 activity and expression by inflammatory cytokines (TNF-alpha, IL-6) may enhance orbital adipocyte differentiation (adipogenesis) and limit proliferation in TAO. 11beta-HSD1 may also have a role in regulating the local orbital inflammatory response.

Characterisation of 11beta-hydroxysteroid dehydrogenase 1 in human orbital adipose tissue: a comparison with subcutaneous and omental fat.

Glucocorticoids (GCs) have a profound effect on adipose biology increasing tissue mass causing central obesity. The pre-receptor regulation of GCs by 11beta-hydroxysteroid dehydrogenase type 1 (11beta-HSD1) that activates cortisol from cortisone has been postulated as a fundamental mechanism underlying the metabolic syndrome mediating adipocyte hyperplasia and hypertrophy in the omental (OM) depot. Orbital adipose tissue (OF) is the site of intense inflammation and tissue remodelling in several orbital inflammatory disease states. In this study, we describe features of the GC metabolic pathways in normal human OF depot and compare it with subcutaneous (SC) and OM depots. Using an automated histological characterisation technique, OF adipocytes were found to be significantly smaller (parameters: area, maximum diameter and perimeter) than OM and SC adipocytes (P<0 x 001). Although immunohistochemical analyses demonstrated resident CD68+ cells in all three whole tissue adipose depots, OF CD68 mRNA and protein expression exceeded that of OM and SC (mRNA, P<0 x 05; protein, P<0 x 001). In addition, there was higher expression of glucocorticoid receptor (GR)alpha mRNA in the OF whole tissue depot (P<0 x 05). Conversely, 11beta-HSD1 mRNA together with the markers of late adipocyte differentiation (FABP4 and G3PDH) were significantly lower in OF. Primary cultures of OF preadipocytes demonstrated predominant 11beta-HSD1 oxo-reductase activity with minimal dehydrogenase activity. Orbital adipocytes are smaller, less differentiated, and express low levels of 11beta-HSD1 but abundant GRalpha compared with SC and OM. OF harbours a large CD68+ population. These characteristics define an orbital microenvironment that has the potential to respond to sight-threatening orbital inflammatory disease.

Use of a novel topical hemostatic sealant in lacrimal surgery: a prospective, comparative study.

PURPOSE: FloSeal Matrix is a new, two-component (collagen granules and thrombin), topical hemostatic sealant. We prospectively evaluated the role of FloSeal Matrix in achieving hemostasis in dacryocystorhinostomy (DCR) surgery and its intraoperative characteristics (ease of use). We hypothesize that FloSeal will efficiently control bleeding in patients and eliminate the need for postoperative intranasal dressing. METHODS: FloSeal was used during surgery in 10 consecutive patients undergoing DCR. A further 10 consecutive patients (comparative group) had DCR without FloSeal; nasal packing was performed to control postoperative bleeding. The severity of postoperative bleeding and patient comfort were compared between the two groups at three time points (immediately after surgery, 12 hours after surgery, and 24 hours after surgery). RESULTS: All patients in the comparative group had some degree of postoperative bleeding (minimal to severe), whereas the nine patients in the FloSeal group had none or minimal bleeding. The difference was statistically significant at all three measured time points (p = 0.047, 0.006, 0.05). The FloSeal group also had less postoperative discomfort (p = 0.0001). CONCLUSIONS: FloSeal Matrix is an effective hemostasis adjunct in patients undergoing lacrimal surgery. It has the added benefits of high patient satisfaction and ease of use.

Lateral tarsal strip and quickert sutures for lower eyelid entropion.

PURPOSE: To evaluate the long-term outcome of involutional entropion repair by means of a combined procedure of lateral tarsal strip and Quickert everting sutures. METHODS: Noncomparative interventional case series of patients who underwent a combined procedure of lateral tarsal strip and Quickert sutures for treatment of involutional entropion between September 1999 and September 2002. Of 75 patients who underwent surgery, 36 were followed for at least 2 years. At the 2-year clinical examination, patient comfort, complications, recurrence rates, overcorrection, and cosmetic appearance were assessed. RESULTS: The average age of the 36 patients was 76.67 years. There were 5 bilateral cases, for a total of 41 eyelids. Nine eyelids underwent the procedure to correct recurrent entropion. The recurrence rate was 0% at 1 month after surgery, 2 of 41(4.9%) at 6 months, and 5 of 41 (12.2%) at 2 years. The recurrence rate after a primary procedure was 3 of 32 (9.4%), and, after a failed previous procedure, 2 of 9 (22.2%). There were no cases of secondary ectropion, and all patients were happy with their cosmetic appearance. CONCLUSIONS: A combined lateral tarsal strip and Quickert sutures procedure is effective, simple, and addresses all of the factors that contribute to involutional entropion formation, with a good long-term success rate and cosmetic outcome.

A conjunctival leiomyoma.

PURPOSE: To report a conjunctival leiomyoma. DESIGN: Observational case report. METHODS: A 35-year-old man was referred to us for evaluation of a lesion in his left eye. The lesion had been present for 1 year but had recently caused irritation. Ophthalmologic examination revealed an elevated mass in the episclera. There was no associated conjunctival/episcleral injection. Ocular examination was otherwise entirely normal. An excisional biopsy was performed. RESULTS: The histopathologic and immunohistochemistry examinations established the diagnosis of a conjunctival leiomyoma. CONCLUSION: This case represents the first report, known to date, describing the occurrence of a conjunctival leiomyoma.

Diagnosis and management of thyroid eye disease.

Recent advances are helping elucidate the pathogenesis and improve the management of thyroid eye disease. While biochemical investigations and imaging may be supportive, ophthalmological and medical clinical assessments remain the key to the diagnosis and management of this sight-threatening disorder.