Telemedicine in Oculoplastics: The Real-Life Application of Video Consultation Clinics.

PURPOSE: Our oculoplastic service piloted a new video consultation (VC) clinic in response to the COVID-19 pandemic. Data were collected to determine whether specific patients are better suited to VC, and to quantify the true benefit of VC in patients that successfully attended. METHODS: Data were collected prospectively on predetermined data collection forms, including consultation duration, diagnosis, management plan, and issues that arose. RESULTS: 37.8% of new referrals and 60.9% of return patients were vetted as suitable for VC. Of those invited to attend, 83.4% agreed to a VC appointment. Of the patients appointed to a VC clinic, 71.7% (new)/75% (return) successfully completed VC, 14.9%/15.8% attempted a VC which ultimately failed, and 13.4%/9.2% did not attend. VC successfully prevented face-to-face consultation in 81.3% of new cases and 91.1% of returns. Ectropion, entropion and dermatochalasis (new referrals), and postoperative follow-up (return patients) were well suited to VC, while patients with "watery eye" (new), and lid or conjunctival lesions (return), often required face-to-face consultation. Problems (most common issues with patients connecting to the consultation, video quality, and audio quality) were encountered during 50.3% of calls, although 82.6% of attempted calls were ultimately successful. Age was not associated with the proportion of calls that were successful. CONCLUSIONS: VC is a useful tool for oculoplastic patients, irrespective of age, as long as the patient's notes/referrals are carefully vetted to determine suitability. Patients with ectropion, entropion and dermatochalasis, and postoperative reviews are better suited to VC than those with "watery eye," lid lesions, and conjunctival lesions.

Surgical intervention for paediatric blepharoptosis: a 6-year case series.

PURPOSE: To present our experience of paediatric blepharoptosis in a tertiary referral centre and evaluate the effectiveness of surgical intervention. METHODS: A retrospective cohort study of all children receiving surgical blepharoptosis correction between 1/1/10 and 29/2/16. Children with pre-operative levator function (LF) ≥ 7 mm received levator resection, those with LF ≤ 4 mm received brow suspension, and in those children with LF of 5-6 mm, either levator resection or brow suspension was chosen depending on the degree of frontalis recruitment. RESULTS: Ninety-five children (109 eyes, 64 boys) underwent blepharoptosis surgery within the study period. Mean (range) age at surgery was 5.9 (1.2-12.5) years. Seventy-nine (83.2%) had simple levator maldevelopment. Fifteen children were excluded due to inadequate follow-up. Of the remaining 80 children, 41 (51.2%) underwent levator resection, 27 (33.8%) underwent fascia lata brow suspension, and twelve (15.0%) underwent mersilene mesh brow suspension. Margin reflex distance-1 was greatest at 6-week follow-up with a small "lid drop" by 6-month follow-up in both the levator resection (0.9 mm pre-operatively, 3.1 mm at 6-week follow-up, 2.6 mm at 6-month follow-up) and fascia lata brow suspension (0.3 mm, 2.5 mm, 2.2 mm) groups. No immediate complications, and only two serious post-operative complications, were noted. One case of residual blepharoptosis was re-operated (fascia lata brow suspension). CONCLUSIONS: Surgical correction of paediatric blepharoptosis is safe and, after an observed lid drop between 6-week and 6-month follow-up (not seen in the mersilene mesh brow suspension group), effect appears to be maintained to 6 months and beyond. Readily accessible orthoptic assessment would help identify children at risk of amblyopia, both pre-operatively and post-operatively.

Combined immunosuppression and radiotherapy in thyroid eye disease (CIRTED): a multicentre, 2 × 2 factorial, double-blind, randomised controlled trial.

BACKGROUND: Standard treatment for thyroid eye disease is with systemic corticosteroids. We aimed to establish whether orbital radiotherapy or antiproliferative immunosuppression would confer any additional benefit. METHODS: CIRTED was a multicentre, double-blind, randomised controlled trial with a 2 × 2 factorial design done at six centres in the UK. Adults with active moderate-to-severe thyroid eye disease associated with proptosis or ocular motility restriction were recruited to the trial. Patients all received a 24 week course of oral prednisolone (80 mg per day, reduced to 20 mg per day by 6 weeks, 10 mg per day by 15 weeks, and 5 mg per day by 21 weeks) and were randomly assigned via remote computerised randomisation to receive either radiotherapy or sham radiotherapy and azathioprine or placebo in a 2 × 2 factorial design. Randomisation included minimisation to reduce baseline disparities in potential confounding variables between trial interventions. Patients and data analysts were masked to assignment, whereas trial coordinators (who monitored blood results), pharmacists, and radiographers were not. The radiotherapy dose was 20 Gy administered to the retrobulbar orbit in ten to 12 fractions over 2 to 3 weeks. Azathioprine treatment was provided for 48 weeks at 100-200 mg per day (dispensed as 50 mg tablets), depending on bodyweight (100 mg for <50 kg, 150 mg 50-79 kg, 200 mg for ≥80 kg). The primary outcomes were a binary composite clinical outcome score and an ophthalmopathy index at 48 weeks, and a clinical activity score at 12 weeks. The primary analysis was based on the intention-to-treat allocation and safety was assessed in all participants. This study is registered with ISRCTN, number 22471573. FINDINGS: Between Feb 15, 2006, and Oct 3, 2013, 126 patients were recruited and randomly assigned to groups: 31 patients to radiotherapy plus azathioprine, 31 to sham radiotherapy and azathioprine, 32 to radiotherapy and placebo, and 32 to sham radiotherapy and placebo. Outcome data were available for 103 patients (54 for sham radiotherapy vs 49 for radiotherapy and 53 for placebo vs 50 for azathioprine), of whom 84 completed their allocated treatment of radiotherapy or sham radiotherapy and 57 continued to take azathioprine or placebo up to 48 weeks. There was no interaction betweeen azathioprine and radiotherapy (pinteraction=0·86). The adjusted odds ratio (ORadj) for improvement in the binary clinical composite outcome measure was 2·56 (95% CI 0·98-6·66, p=0·054) for azathioprine and 0·89 (0·36-2·23, p=0·80) for radiotherapy. In a post-hoc analysis of patients who completed their allocated therapy the ORadj for improvement was 6·83 (1·66-28·1, p=0·008) for azathioprine and 1·32 (0·30-4·84, p=0·67) for radiotherapy. The ophthalmopathy index, clinical activity score, and numbers of adverse events (161 with azathioprine and 156 with radiotherapy) did not differ between treatment groups. In both groups, the most common adverse events were mild infections. No patients died during the study. INTERPRETATION: In patients receiving oral prednisolone for 24 weeks, radiotherapy did not have added benefit. We also did not find added benefit for addition of azathioprine in the primary analysis; however, our conclusions are limited by the high number of patients who withdrew from treatment. Results of post-hoc analysis of those who completed the assigned treatment suggest improved clinical outcome at 48 weeks with azathioprine treatment. FUNDING: National Eye Research Centre, Above and Beyond, and Moorfields Eye Charity.

Pleomorphic adenomas of the lower eyelid: a case series.

Pleomorphic adenomas are well-recognized tumors usually arising within the main lacrimal gland. Their occurrence, however, is not limited to the main lacrimal gland. There have been cases reported in the eyebrow, upper eyelid, lateral lower eyelid, lacrimal sac, and even intraocularly. The medial aspect of the lower eyelid is a very rare site of occurrence because it is largely devoid of accessory lacrimal glands. We describe 2 cases of pleomorphic adenomas arising in the medial aspect and 1 case arising in the middle of the lower eyelid, respectively. The likely origin of these tumors at this location is from ectopic lacrimal gland.

Corneal perforation due to limbal involvement in Sézary syndrome.

BACKGROUND: The majority of lymphomas involving the eye and ocular adnexa are B-cell lymphomas. Ocular involvement by T-cell lymphoma is rare. We report a case of corneal perforation due to direct involvement of the corneal limbus by lymphoma in a patient with Sézary syndrome. METHODS: A 58-year-old male with cutaneous T-cell lymphoma presented with painful, left-sided corneal ulceration, a dense infiltrate, severe epitheliopathy, hypopyon and a diffuse confluent dermatitis involving the lids. He had a history of Sézary syndrome. Despite maximal treatment, this severe ulcerative keratitis progressed to central corneal perforation. The eye was subsequently enucleated and submitted for histopathological examination. RESULTS: Histopathological examination confirmed corneal ulceration with perforation. There was an infiltrate of large atypical cells at the limbus, with tropism for the overlying epithelium. Immunohistochemical staining of these cells was positive for CD2, CD3, CD5, CD4 and CD7. Staining for CD8, CD30 and CD56 was negative. The appearances were those of an epitheliotrophic T-cell lymphoma, and were considered to represent spread from the patient's underlying Sézary syndrome. The patient died 2 months later from bronchopneumonia. CONCLUSIONS: Ocular involvement by cutaneous T-cell lymphoma usually occurs in advanced disease, and carries a poor prognosis. This patient was immunocompromised due to advanced malignancy, and there was a high suspicion of infection as the primary cause of corneal ulceration. This case highlights that it is important to consider direct tumour infiltration as an initiating or contributing factor for corneal ulceration in such patients.

Chiasmal compression misdiagnosed as normal-tension glaucoma: can we avoid the pitfalls?

Routine neuroimaging for patients with presumed normal-tension glaucoma (NTG) is a contentious issue and it has been suggested that it may be unnecessary due to the low yield for detecting intracranial pathology. However, it has also been reported that 8% of patients diagnosed with NTG have associated compressive lesions of the anterior visual pathways. We present three patients in whom the initial diagnosis of NTG was eventually revealed to be chiasmal compression secondary to a pituitary tumour. Case 1: a 79-year-old woman was treated for NTG for several months before a bitemporal haemianopia developed and imaging showed a pituitary tumour. Case 2: an 83-year-old man was treated for NTG while a magnetic resonance imaging (MRI) scan was requested routinely. This subsequently revealed a pituitary tumour. Case 3: a 52-year-old man with left inferior arcuate visual field loss plus disc pallor was treated for NTG. His visual field deteriorated over 8 years, despite his intraocular pressure (IOP) being well controlled. An MRI was eventually requested, which revealed a pituitary tumour. All of our patients had signs that, with hindsight, should have raised suspicions about the presumptive diagnosis of NTG and initiated neuroimaging at an earlier stage. Whilst compression of the anterior visual pathways is an uncommon finding in patients thought to have NTG, features such as bitemporal field loss, optic disc pallor, poor colour vision and, particularly, poor disc/field correlation should alert the clinician to the possibility of an intracranial mass lesion.

Successful medical treatment of blepharochalasis: a case series.

INTRODUCTION: Blepharochalasis describes recurrent attacks of idiopathic transient painless oedema in the adnexal tissue of the orbit with the most severe reaction in the skin and orbicularis region. This may produce permanent tissue changes associated with thinning of the eyelid skin. Previous reviews have concentrated on surgical correction of the excess skin and orbicularis created by the condition. There has, as yet, been no report of successful medical management. PATIENTS AND METHODS: We report here on 4 males and 2 females aged between 37 and 78 years. Systemic acetazolamide (initially 250 mg SR OD), was used in combination with a topical steroid (hydrocortisone cream). RESULTS: All 6 patients achieved relief of their symptoms, with decreased incidence of occurrence and duration of episode if not complete resolution. CONCLUSION: Oral Acetazolamide in combination with topical hydrocortisone provides effective relief of the periorbital oedema associated with blepharochalasis. In our short series, the cases were improved either with medical therapy alone or in combination with surgery. Relapses following surgery were diminished as a result of prior medical therapy.

Simultanagnosia following perinatal hypoxia: a possible pediatric variant of Balint syndrome.

A 7-year-old boy with a history of low birth weight and perinatal hypoxia presented with symptoms of a spatial disorder of attention (simultanagnosia) and defective foot movements under visual control (optic ataxia), similar to a complex known as Balint's syndrome. Imaging revealed mature areas of ischemic damage in the posterior parietal and superior occipital lobes consistent with the diagnosis. Balint's syndrome in children is rarely reported and is important to recognize to allow adequate rehabilitation and environmental adaptation.

Chlamydial conjunctivitis presenting as pre septal cellulitis.

Chlamydia conjuctivitis results from infection by chlamydia trachomatis, the commonest treatable sexually transmitted infection in Europe. Its clinical manifestations involve the conjunctiva and the cornea. The inflammation under the upper eyelid may be sufficient to present as ptosis, however previously it has not been documented to cause a preseptal cellulitis. We present such a case. A 15-year-old girl was diagnosed with a left viral conjunctivitis. Five days later, she returned with marked oedema of the left upper and lower lids accompanied by erythema. The tarsal conjunctiva revealed follicles and large papillae and extra ocular movements revealed discomfort on elevation. A secondary diagnosis of bacterial pre septal cellulitis was made and the treatment was changed a broad spectrum oral antibiotic. On review at two days, the patient now complained of a large amount of purulent discharge in association with the marked pre septal swelling. As previous bacteriology and virology had been negative, the patient was re swabbed for chlamydia. This proved positive and her symptoms completely resolved following administration of Azithromycin. In this particular case recognition of the pathogen is important to alert the patient to the likelihood of unknown genital infestation. In all cases of positive culture, the patient should be counselled to attend a genitourinary clinic and to alert any sexual partners to the need to do likewise.

Churg-Strauss syndrome presenting with conjunctival nodules in association with Candida albicans and ankylosing spondylitis.

Churg-Strauss syndrome is a rare diffuse vasculitis of which the ocular manifestations have been well documented. However, reports of conjunctival involvement in Churg-Strauss syndrome are scarce. Such a presentation is described in a man with Candida albicans infection as well as ankylosing spondylitis, and a possible aetiological linkage is established amongst all three.