Evaluation of a nurse-led glaucoma assessment clinic for non-complex patients.

AIMS AND OBJECTIVES: The purpose of this study was to assess the safety, feasibility and effectiveness of a nurse-led glaucoma assessment clinic service. BACKGROUND: Glaucoma is a group of serious, irreversible optic neuropathies that progressively damage the optic nerve resulting in blindness. Over 64.3 million people globally are affected by glaucoma with numbers projected to increase to 111.8 million by 2040. Glaucoma is a major public health concern that requires the development of innovative models of care to meet current and future health care demands. METHODS/DESIGN: A mixed method design was used to evaluate the assessment of non-complex glaucoma patients attending a new nurse-led clinic. Under an ophthalmologist's supervision, the glaucoma nurse completed 100 hof clinical training and assessment to ensure they were competent in completing and interpreting the required glaucoma assessment protocols. Interrater reliability between the glaucoma nurse and ophthalmology doctor was undertaken. Glaucoma patient waitlist appointment data were also compared before and after the introduction of the nurse-led clinics. This study adhered to the SQUIRE checklist for the reporting of excellence with quality improvement projects. PATIENT CONTRIBUTION: Patients contributed to the evaluation of this new nurse-led service by providing follow-up feedback on their experience. RESULTS: Agreement between clinicians for appropriate follow-up appointment times was high with 93% (n = 315) agreement achieved. Furthermore in 297 (87.5%) cases, both clinicians agreed on the patient being referred to the doctor for follow-up review. Glaucoma consultations were shown to increase from 3,115 appointments in 2019/20 to 3,504 appointments in 2020/21 after the introduction of the nurse-led clinic. The nurse-led clinics accounted for 14.5% (n = 512) of clinic appointments. CONCLUSIONS: The introduction of the nurse-led glaucoma assessment clinic service allowed patients to be reviewed safely, efficiently and satisfactorily. This new service subsequently allowed for more complex glaucoma patients to be seen by the ophthalmologists. RELEVANCE TO CLINICAL PRACTICE: Findings revealed that suitably trained glaucoma nurses are able to clinically assess and safely monitor stable non-complex glaucoma patients. Highlights the need for appropriate investment in clinical training and supervision to ensure that glaucoma assessment nurses are adequately prepared to undertake this new practice role.

Analysis of Circulating Tumour Cells in Early-Stage Uveal Melanoma: Evaluation of Tumour Marker Expression to Increase Capture.

(1) Background: The stratification of uveal melanoma (UM) patients into prognostic groups is critical for patient management and for directing patients towards clinical trials. Current classification is based on clinicopathological and molecular features of the tumour. Analysis of circulating tumour cells (CTCs) has been proposed as a tool to avoid invasive biopsy of the primary tumour. However, the clinical utility of such liquid biopsy depends on the detection rate of CTCs. (2) Methods: The expression of melanoma, melanocyte, and stem cell markers was tested in a primary tissue microarray (TMA) and UM cell lines. Markers found to be highly expressed in primary UM were used to either immunomagnetically isolate or immunostain UM CTCs prior to treatment of the primary lesion. (3) Results: TMA and cell lines had heterogeneous expression of common melanoma, melanocyte, and stem cell markers. A multi-marker panel of immunomagnetic beads enabled isolation of CTCs in 37/43 (86%) patients with UM. Detection of three or more CTCs using the multi-marker panel, but not MCSP alone, was a significant predictor of shorter progression free (p = 0.040) and overall (p = 0.022) survival. (4) Conclusions: The multi-marker immunomagnetic isolation protocol enabled the detection of CTCs in most primary UM patients. Overall, our results suggest that a multi-marker approach could be a powerful tool for CTC separation for non-invasive prognostication of UM.

Progressive orbital granular cell tumour associated with medial rectus.

Granular cell tumour is a rare soft tissue tumour that can occur in any part of the body, but seldom in ocular adnexa. It usually behaves in a benign fashion. We report a case of a 54-year-old man with a well-demarcated, solitary, slow-growing orbital tumour which lead to significant ocular symptoms. The case was a diagnostic and therapeutic challenge due to its location and difficulty in obtaining tissue for a histological diagnosis. Surgical biopsy attempts were made but they all failed to uncover the true identity of the lesion. A definitive diagnosis was revealed with complete surgical excision of the tumour, which was challenging due to its size and close association with rectus muscle. This case has highlighted that orbital granular cell tumour may result in significant ocular symptoms. Adequate exposure to the anatomical site is the key to obtaining diagnosis and complete excision of a lesion.

Endonasal dacryocystorhinostomy for nasolacrimal duct obstruction in patients with sarcoidosis.

PURPOSE: To evaluate the outcomes of endonasal dacryocystorhinostomy (EN-DCR) surgery in patients with sarcoidosis. METHODS: Retrospective chart review of all patients with sarcoidosis undergoing EN-DCR in 6 practices from 1999-2011. RESULTS: We included 18 procedures in 14 patients (8 female, 6 male) who underwent EN-DCR for acquired NLDO secondary to sarcoidosis. The mean age was 53.7 (range 38-82). The presenting symptom in all cases was epiphora. Eight patients (57%) complained of having additional nasal congestion. Surgery was performed using endoscopic powered-type DCR with flaps in 12/18 (67%) and non-endoscopic mechanical EN-DCR in 6/18 (33%). In 15 (83%) cases the lacrimal sac and nasal mucosa appeared abnormally yellowish, crusty, oedematous and friable. Five patients were treated with pre-operative oral steroid and overall 8 patients had oral prednisolone post operatively, 30-60 mg tapered within 10 days-8 weeks. One patient had difficulties in tapering down the oral steroids at 6 months of follow-up. All patients were free of epiphora and patent to syringing, with nasal endoscopy revealing free flow of fluorescein through the ostium at a mean follow-up of 11.3 months (median follow-up 9 months). CONCLUSIONS: All 18 cases of acquired nasolacrimal duct obstruction secondary to sarcoidosis were treated successfully with EN-DCR. An abnormal appearance of the nasal mucosa is an important sign. Nasal congestion is a frequent sign. A successful outcome may not depend on intensive long-term therapy with local or systemic steroids. Mechanical or powered EN-DCR for nasolacrimal duct obstruction secondary to sarcoidosis achieves encouraging medium-term outcomes.

Techniques of upper eyelid reconstruction.

Reconstruction of the upper eyelid is one of the greatest challenges facing the orbitofacial surgeon. This comprehensive review outlines the principles of reconstruction and the range of techniques available. Methods of assessing upper eyelid defects are discussed, and an algorithm for reconstruction based on defect size and lamellar involvement is given. The review contains numerous detailed examples of reconstructive techniques, including secondary intention healing, local flaps, distal flaps, simple and composite grafts, occlusive and non-occlusive methods, and canthal fixation. Eyebrow and eyelash reconstruction is also covered.

Adnexal surgery in patients undergoing ocular surface stem cell transplantation.

PURPOSE: To examine the role of adnexal disease and surgery in the outcome of ocular surface stem cell transplantation. DESIGN: Retrospective, noncomparative case series. PARTICIPANTS: Twenty-two patients (23 eyes) with severe corneal stem cell deficiency undergoing ocular surface stem cell transplantation. METHODS: Consecutive cases of stem cell grafting for ocular surface disease over a 6-year period at a single institution were studied. MAIN OUTCOME MEASURES: Main outcome measures were 2-fold: (1) nature of eyelid, fornix, and lacrimal abnormalities encountered; indications for treatment; methods; and outcome of adnexal surgery; (2) stem cell allograft success with respect to underlying disease, indication for stem cell grafting, preoperative adnexal involvement, and adnexal surgery after stem cell grafting. RESULTS: Twenty-nine limbal stem cell grafts on 23 eyes of 22 patients were identified during the study. Seventeen ex vivo expanded stem cell allografts, 11 keratolimbal allografts, and 1 living-related donor limbal allograft were performed, with combined stem cell techniques used in 5 patients. Median follow-up was 26.5 months (standard deviation, 18.6 months). Overall, stem cell graft success at final review was 69%. Thirty-four percent (10/29) of cases had eyelid involvement and 41% (12/29) had fornix involvement at the time of stem cell grafting. Trichiasis and symblepharon were the most common abnormalities. Fornix involvement was associated with a 50% chance of stem cell graft failure. After stem cell grafting, 66% (19/29) of cases required adnexal surgery. This was for lagophthalmos in 11 cases (46%), eyelid malposition in 7 cases (23%), fornix shortening in 5 cases (19%), and punctal patency in 8 cases (31%). Punctal patency and lagophthalmos frequently required repeated procedures for successful correction. Epithelial healing promptly followed correction of the adnexal abnormality with surgery; however, the need for adnexal surgery was associated with a 50% chance of stem cell graft failure. CONCLUSIONS: Concurrent adnexal abnormalities are associated with worse graft outcomes after stem cell transplantation and can compromise epithelial healing if uncorrected. Surgery for eyelid malposition and closure is essential before and after transplantation for surface epithelial integrity and often requires multiple procedures. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Periosteal fixation during subperiosteal brow lift surgery.

OBJECTIVE: To report the efficacy of periosteal fixation combined with Y-to-V scalp incisions during small-incision subperiosteal forehead and brow lift. METHODS AND MATERIALS: This is a retrospective case series of 19 patients over 12 months; 16 patients underwent bilateral and 3 unilateral surgery. Unilateral surgery was performed in patients with facial nerve palsy and was augmented with cable suspension. Superior arcus marginalis release and visualization of the supraorbital nerve was achieved using an endoscope or a transblepharoplasty approach. RESULTS: All patients achieved a desirable brow lift and contour, with a mean lift of 2.4 +/- 1.0 mm. The mean follow-up was 11 months. During follow-up, there was no evidence of recurrence of brow ptosis. All patients had an improvement of the glabellar furrows. Minor complications included transient diplopia (n=1), reduced medial upper eyelid sensation (n=1), brief postoperative bleeding from one of the small-incision sites (n=1), and persistent sensory loss involving the central scalp incisions (n=2). No long-term alopecia was noted in any case. CONCLUSION: Our results suggest that with periosteal fixation combined with Y-to-V scalp incisions, bone fixation is not necessary to achieve a desirable height during small-incision subperiosteal forehead and brow lift.

Radiological pitfalls in patients with inducible dynamic proptosis.

We report two patients presenting with marked clinical unilateral enophthalmos who had positional variability and dynamic proptosis on valsalva. On orbital imaging, enophthalmos was not documented and in fact, globe proptosis of the same side was reported for one of the patients. During CT and MRI scanning patients are often instructed to hold their breath to eliminate motion artefact. This may inadvertently induce dynamic proptosis. The radiological pitfalls of imaging patients with inducible dynamic proptosis and how to identify such patients are discussed.

Intraocular pressure and refractive changes following orbital decompression with intraconal fat excision.

UNLABELLED: The purpose of this study was to measure the changes in intraocular pressure (IOP) and refraction following orbital decompression for thyroid orbitopathy. METHODS: Retrospective review of 18 eyes in 10 consecutive patients who underwent orbital decompression including intraconal fat excision for proptosis secondary to thyroid orbitopathy. IOP using tonopen, exophthalmometry, autorefraction and autokeratometry measurements were performed at 1-week, 1-month and 3-months after surgery. RESULTS: There was no statistically significant difference between the preoperative and postoperative IOP at 3 months. There were no significant differences found between preoperative and post operative keratometry readings or automated refraction following orbital decompression. CONCLUSION: Our study did not find a significant change in IOP and refraction following orbital decompression with intraconal fat excision. A larger prospective study is required in order to evaluate the role of intraconal fat excision in reducing IOP due to it's potential role in patients with concurrent glaucoma.

Techniques and outcomes of total upper and lower eyelid reconstruction.

OBJECTIVES: To describe techniques used for reconstruction of the eyelids following total loss of the upper and lower eyelids and to describe visual and functional outcomes. METHODS: Multicenter, retrospective, interventional case series of all of the patients requiring unilateral reconstruction of both the upper and lower eyelids. RESULTS: Six cases were identified, 1 following trauma and 5 following tumor excision (4 with basal cell carcinoma and 1 with melanoma). The median age was 69 years (range, 18-90 years). Primary repair using preserved tissue was carried out in the case of traumatic avulsion. Following tumor excision, bilamellar repair was performed using composite grafts for the posterior lamella and skin-muscle flaps for the anterior lamella. Graft necrosis occurred in 3 cases (50%). In all of the cases, the reconstructed eyelids were stiff and immobile. Lagophthalmos (6 cases [100%]), ptosis (3 cases [50%]), lower eyelid retraction (3 cases [50%]), and ectropion (2 cases [33%]) were common. Useful vision was retained in all of the cases. CONCLUSIONS: Total eyelid defects are rare and often unanticipated. Adequate corneal protection can be achieved using lamellar repair principles and local tissues; however, poor vascularity demands careful planning, with vascularized flaps favored over free grafts. Reconstructed eyelids have poor function in the setting of total upper and lower eyelid loss, and revision surgery is often required to improve eyelid structure and function.

Sliding tarsal flap for reconstruction of large, shallow lower eyelid tarsal defects.

PURPOSE: To describe a novel technique for reconstructing shallow, full-thickness defects of the lower eyelid. METHODS: Twelve patients with shallow, full-thickness lower eyelid defects after Mohs excision of eyelid malignancies were treated with this technique. The posterior lamella was reconstructed by obliquely incising the residual tarsus to create medial and lateral tarsal flaps. These flaps were obliquely overlapped to tighten the eyelid and reconstruct a tarsus approximating normal height. The anterior lamella defect was then reconstructed by using local flaps or free grafts in a conventional manner. RESULTS: Eyelid defects ranged from 25 to 40 mm horizontally and 20 to 35 mm vertically, with tarsal defects ranging from 18 to 27 mm horizontally and 2 to 3.5 mm vertically. A stable eyelid margin with good aesthetic appearance was achieved in all patients. Two patients had mild eyelid retraction not requiring intervention, and one had lower eyelid entropion 9 months after surgery. CONCLUSIONS: Sliding tarsal flaps are an effective technique for reconstruction of this type of defect. The advantages of this approach are its simplicity, utilization of preserved tissue, and avoidance of the morbidity associated with more complex procedures.

Benign fibrous histiocytoma of the eyelid mimicking keratoacanthoma.

We report a case of benign fibrous histiocytoma (BFH) of the medial canthus that mimicked keratoacanthoma in clinical appearance and growth. Excisional biopsy confirmed the diagnosis of the cellular subtype of benign fibrous histiocytoma. These types of BFH are typically more aggressive in growth, with a high recurrence rate and a tendency to undergo autonomous growth at other sites. The diagnosis of BFH should also be considered among those that appear typical of keratoacanthoma. Similar to other rapidly enlarging eyelid tumors, prompt excisional biopsy is recommended.

Giant cell angiofibroma of the orbit with periosteal adherence.

We report a case of orbital giant cell angiofibroma, an unusual, recently reported benign spindle cell neoplasm. Preoperative clinical assessment and radiology suggested a benign mass and early operative findings were in concordance with this. Surgical excision was however, hampered by periosteal adhesion and lack of distinct encapsulation in the posterior part of the lesion. The histology of giant cell angiofibroma and its principle pathological differential diagnoses is discussed. As with some lymphangiomas, this is another benign orbital tumour which may present difficulties in complete surgical excision that are not anticipated based on the preoperative findings.