Impact of sphenoid trigone size and extraocular muscle thickness on the outcome of lateral wall orbital decompression for thyroid eye disease.

BACKGROUND: To retrospectively review lateral wall orbital decompression for thyroid eye disease (TED) and to evaluate pre-operative CT scans to analyse the variation in proptosis reduction. METHODS: Consecutive lateral wall orbital decompressions performed by a single surgeon were retrospectively reviewed. Pre-operative CT scan features and post-operative proptosis reduction were analysed. The sphenoid trigone cross-sectional areas were summed and multiplied by the slice thickness to yield bone volume. Cumulative extraocular muscle thickness was calculated by combining the maximum thickness of the four recti. "Trigone volume" and "cumulative muscle thickness" were correlated with proptosis reduction at 3 months post-surgery. RESULTS: Out of 73 consecutive lateral wall orbital decompressions, 17 orbits had prior endonasal medial wall orbital decompression. In the remaining 56 orbits, the mean pre-operative and post-operative proptosis were 24.3 ± 1.6 mm and 20.9 ± 2.3 mm respectively. The proptosis reduction ranged from 1 to 7 mm (mean of 3.5 mm ± 1.3 (p < 0.001)). Mean sphenoid trigone volume was 895 ± 434.4 mm3. The mean cumulative muscle thickness was 20.4 ± 5 mm. The correlation coefficient between muscle thickness and proptosis reduction was - 0.3 and was statistically significant (p = 0.043). The correlation coefficient between sphenoidal trigone volume and proptosis reduction was 0.2 (p = 0.068). With a multivariate analysis, the coefficient of efficient of regression for muscle thickness was - 0.007 (p = 0.42) and the coefficient of regression for trigone volume was 0.0 (p = 0.046). CONCLUSION: Proptosis reduction following lateral wall orbital decompression can be variable. Extraocular muscle thickness had a significant correlation with the outcome, with greater proptosis reduction in orbits with thin muscles. The sphenoidal trigone size had a weak correlation with decompression outcome.

Radioactive iodine treatment for Graves' hyperthyroidism: incidence of Graves orbitopathy.

PURPOSE: There are limited recent data on the effect of radioactive iodine (RAI) for Graves' disease on Graves' orbitopathy (GO) development or reactivation. This audit investigates the GO incidence in patients with Graves' disease after RAI treatment, and explores risk factors present, and steroid prophylaxis use. METHODS: A retrospective audit of Graves' disease patients treated with RAI over a 5-year period. Data collected: smoking status, thyroid-stimulating hormone receptor antibody (TRAb) status, GO history, Graves' disease duration, eye features pre- and post-treatment, prophylactic corticosteroids, RAI dose given, post-RAI thyroid status, duration until hypothyroid. RESULTS: One hundred one patients were included, with a median Graves' disease duration 36 months. 34/101 (33.7%) were active/ex-smokers, 86/101 (85.1%) were TRAb-positive, 11/101 (10.9%) had a GO history; 32 (31.7%) had eye features present. Median RAI dose given was 596MBq. 8/101 (7.9%) patients received prophylactic corticosteroid; 89/101 (88.1%) achieved hypothyroid state in the year after RAI. GO developed in 5/101 (5.0%), of which 4/5 (80%) were de novo in high-risk individuals who did not receive steroids. One was a GO reactivation despite steroids. Two required intravenous steroids with/without orbital radiotherapy, one completed oral steroid taper; the remainder were treated conservatively. CONCLUSION: Our cohort had a lower GO incidence in patients with Graves' disease receiving RAI, with majority arising de novo . It is essential that all patients are assessed for Graves orbitopathy risk factors and counselled adequately prior to RAI. The decision to initiate steroids should be undertaken in a multi-disciplinary setting involving endocrinologists and ophthalmologists.

Lower Eyelid Blepharoplasty: Minimizing Complications and Correction of Lower Eyelid Malposition.

Lid retraction is a feared complication of lower blepharoplasty. Anatomical variations like negative orbital vector, horizontal lid laxity, and preexisting lid retraction are more prone to lid malpositions. Meticulous and precise execution of a series of surgical steps is key to preventing complications. This includes minimizing surgical trauma, meticulous hemostasis, preserving innervation to the medial lid and pretarsal orbicularis, safe method of fat excision, septal tightening while maintaining lid traction, and conservative and titrated skin excision. Canthal fixation addresses lid laxity and maintains the lid stretched vertically while postoperative healing and fibrosis are taking place. Post-blepharoplasty lid retraction may occur due to failure to address lid laxity and the occurrence of middle lamellar fibrosis. Excessive skin excision may also result in anterior lamellar deficiency. The "sag and drag" concept is useful to evaluate the post-blepharoplasty retracted lid. The treatment of the retracted lid includes lid massage, replacing the anterior lamella, or releasing the middle lamellar fibrosis or a combination of techniques. In conclusion, understanding the mechanisms of lid retraction, careful preoperative assessment, and surgical precision will help surgeons to prevent and manage this complication.

Bilateral simultaneous non-arteritic ischaemic optic neuropathy: a rare complication of idiopathic systemic capillary leak syndrome (SCLS).

We report a case of bilateral symmetrical superior visual field defects in a 72-year-old man first reported during the recovery from systemic capillary leak syndrome (SCLS). During the acute illness, he required extensive and prolonged fluid replacement and mechanical ventilation for severe hypotension, shock and multiorgan dysfunction. His visual field defect and optic nerve changes were consistent with a diagnosis of ischaemic optic neuropathy. These remained unchanged over 3 years and he retained excellent 6/7.5 visual acuity bilaterally. We hypothesised the mechanism of bilateral segmental infarction of the optic nerve head to be caused by the hypercoagulable and hypovolaemic state, in addition to pre-existing vascular disease and hypertension. This case highlights the importance of including optic nerve examination in the management plan of SCLS, particularly in individuals with underlying vascular risk factors.

Outcomes following Notched Ruthenium-106 Plaque Brachytherapy for Juxtapapillary Choroidal Melanomas.

PURPOSE: This study aimed to evaluate the outcomes of juxtapapillary choroidal melanomas treated with notched ruthenium-106 plaques. METHODS: Juxtapapillary choroidal melanomas (tumours within 2 disc diameters from the optic disc) treated with notched ruthenium-106 plaques (Eckert & Ziegler, BEBIG, Berlin, Germany) at the Scottish Ocular Oncology Service between 2009 and 2015 were retrospectively reviewed. The data were analysed with respect to various outcome measures including recurrence, complications, vision, and eye preservation. RESULTS: We reviewed 40 patients with a median tumour diameter of 8.4 mm (range 5-17 mm) and a median thickness of 2.5 mm (range 1.1-6 mm). AJCC tumour category distribution was 62.5% T1, 32.5% T2, and 5% T3 tumours. The mean presenting vision was 0.3 logMAR, and the mean final vision was 0.7 logMAR, with 62.5% retaining >1.0 logMAR and 50% retaining >0.3 logMAR at the final follow-up. The median follow-up was 51 months (14-100 months). Over the maximum follow-up time, 13 tumours (32.5%) recurred. Six of these were treated with salvage proton beam therapy (PBT), 2 with transpupillary thermotherapy followed by PBT, and 5 with enucleation. The final eye retention rate was 87.5%. Complications included maculopathy (10%), retinal detachment (5%), neovascular glaucoma (2.5%), and diplopia (2.5%). The observed risk of recurrence over 5 years was 31% (95% CI: 14.1%, 47.8%), and the risk of enucleation over 5 years was 11.5% (95% CI: 0.9%, 21.8%). CONCLUSION: Juxtapapillary choroidal melanomas treated with notched ruthenium plaques have a high recurrence rate and frequently need salvage treatment with PBT for tumour control. This has led to a change in our practice toward offering PBT as the first-line treatment for these patients.

Stratified glucocorticoid monotherapy is safe and effective for most cases of giant cell arteritis.

OBJECTIVES: High-dose glucocorticoids anchor standard care in GCA but are associated with significant toxicity. We aimed to evaluate the safety and effectiveness of a stratified approach to glucocorticoid tapering. The strategy aggressively reduced glucocorticoid doses in those manifesting an adequate early response to treatment, with a view to minimizing glucocorticoid complications. METHODS: A retrospective, population-based study of GCA was performed. All cases were confirmed by temporal artery biopsy between November 2010 and November 2015. Baseline and outcome data were extracted from secondary and primary care records at diagnosis and 1 year follow-up. The primary outcome was loss of vision. Secondary outcomes included remission and relapse rates and CS-related complications. RESULTS: The cohort consisted of 73 patients (76% female; mean age 73.5 years, s.d. 7.6 years). At presentation, a reduction in visual acuity was recorded in 17 patients (22.3%). The median CRP at diagnosis was 69.5 mg/l [interquartile range (IQR) 40.5-101 mg/l], with a median ESR of 80 mm/h (IQR 60-91 mm/h). At 1 year, remission was achieved in 64 patients (87.7%), whereas 10 patients (13.7%) relapsed. A single patient sustained visual loss after initiation of therapy. The median CRP at 1 year was 4 mg/l (IQR 4-9.5 mg/l) and the mean prednisolone dose was 5.4 mg (0-15 mg). CS-related complications were observed in 10 patients (13.7%). CONCLUSION: A stratified approach to CS tapering appeared safe and effective in GCA. It was associated with a high rate of remission and promisingly low rates of relapse at 1 year follow-up. These real-world data indicate that glucocorticoid exposure can be minimized safely in some patients with GCA.

Unwrapped hydroxyapatite orbital implants: our experience in 347 cases.

OBJECTIVES: To report the results of a large case series of enucleations with primary insertion of an unwrapped hydroxyapatite (HA) orbital implant. METHODS: We retrospectively reviewed consecutive enucleations with primary orbital (HA) implant insertion performed at the Scottish Ocular Oncology Service, Glasgow between 1990 and 2014. The unwrapped hydroxyapatite orbital implant was placed in the posterior portion of the socket and recti muscles sutured end-to-end over the implant. RESULTS: Out of 347 consecutive enucleations, the indication for enucleation was tumour-related pathology in 59.7% and painful blind eye in 40.3%. Majority (70%) received an implant of 22-mm diameter. At an average follow-up of 3.5 years, complications included post-enucleation socket syndrome (11.5%), chronic discharge (9.2%), chronic pain (4.3%), recurrent conjunctival infection (2.3%),conjunctival cysts (2%), contracted socket (1.4%), implant exposure (1.2%), haematoma (0.6%) and ill-fitting prosthesis (0.6%). Implant exposure (1.2%, n = 4) occurred at a mean of 4.5 months post surgery and was managed by temporalis fascia graft (n = 1), tarsoconjunctival flap (n = 1), implant removal (n = 1) and observation (n = 1). Overall, 9.8% of patients needed further surgery including lower lid tightening (4.3%), ptosis repair (2.3%), conjunctival cyst excision (1.2%), fornix reconstruction (1.2%), graft/flap for exposure (0.6%) and implant removal (0.3%). CONCLUSIONS: A low rate of implant exposure indicates that absence of wrapping material around hydroxyapatite orbital implants does not compromise surgical outcomes and has the added benefit of reduced surgical time and avoidance of complications from wrapping materials. Posterior implant placement and end-to-end recti suturing contribute to the success of the procedure.

Uveal melanoma-associated survival in Scotland.

BACKGROUND/OBJECTIVES: The Scottish Ocular Oncology Service (SOOS) manages all patients with uveal melanoma (UM) in Scotland. Our aim was to determine the long-term all-cause and cause-specific survival of patients with UM, irrespective of treatment modality. SUBJECTS/METHODS: A retrospective single-centre cohort study including all patients diagnosed with UM by the SOOS between 1/1/1998 and 31/12/2002. Data from the SOOS database were correlated with death records held by National Records of Scotland, which provided date, and all listed causes, of death for all deceased patients. RESULTS: Two hundred and eighteen patients were newly diagnosed with UM between 1/1/1998 and 31/12/2002. One hundred and fifteen (52.8%) were female. The mean (median) age at diagnosis was 63(65) years (range: 16-89). Of 179 choroidal melanomas, melanoma-specific survival was 92.3%, 87.4% and 83.8% at 5, 10 and 15 years, respectively. Cancer-specific survival was 85.8%, 71.8% and 62.3%. All-cause survival was 81.6% (146/179), 62.0% (111/179) and 46.7% (computed, fraction inexpressible). Of 26 ciliary body melanomas, melanoma-specific survival was 87.2%, 81.3% and 81.3% at 5, 10 and 15 years. Cancer-specific survival was 62.9%, 40.6% and 40.6%. All-cause survival was 61.5% (16/26), 38.5% (10/26) and 26.9% (7/26). Of 13 iris melanomas, at all three timepoints (5/10/15 years), melanoma-specific survival was 100%, cancer-specific survival was 92.3%, and all-cause survival was 76.9% (10/13). CONCLUSIONS: Correlation of SOOS and national records survival data confirms 15-year melanoma-specific survival of 83.8%, 81.3% and 100% for choroidal, ciliary body and iris melanomas, respectively. We can now provide accurate survival data to our patients in Scotland.

Use of Ruthenium-106 Brachytherapy for Iris Melanoma: The Scottish Experience.

PURPOSE: To analyse long-term outcomes of ruthenium-106 (106Ru) plaque brachytherapy for the treatment of iris melanoma. METHODS: We retrospectively reviewed medical records of 19 consecutive patients with pure iris melanoma treated with 106Ru plaque brachytherapy between 1998 and 2016 at the Scottish Ophthalmic Oncology Service, Glasgow. The iris melanoma was treated with a ruthenium plaque placed on the corneal surface to deliver a surface dose of 555 Gy. We analysed vision preservation, local tumour control, radiation-related complications, eye retention rates, symptomatic metastasis and melanoma-related mortality. RESULTS: The mean largest basal diameter of the lesions was 3.50±1.42 mm (range 1.6-6.5 mm), and the mean maximum height was 1.47±0.65 mm (range 0.7-2.8 mm). The tumour control and eye retention were 100% at a mean follow-up of 62 months (range 6-195 months). A 62% reduction in tumour height was observed on ultrasonography. Complications included cataract (68%), dry eye (47%), uveitis (37%) and scleral thinning (5%). At the final follow-up visit, the mean loss of Snellen visual acuity was 1.11±2.90 lines and vision of 6/9 or better was maintained in 53% of patients. None of the patients had evidence of symptomatic metastasis (non-imaged) or melanoma-related mortality. CONCLUSIONS: 106Ru plaque treatment for iris melanoma was highly effective a high tumour control, no tumour recurrences and a relatively a low complication rate.