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.

The intraoperative use of polydioxanone foil to reduce the risk of sino-orbital fistula formation in orbital exenteration.

BACKGROUND: Orbital exenteration is a radical surgical procedure resulting in deformity. It involves removal of the globe, optic nerve, extra-ocular muscles, orbital fat, lacrimal gland, and peri-osteum. Sino-orbital fistula (SOF) formation is a common documented post-operative complication, usually connecting the orbit and the ethmoid sinus. SOFs can cause leaks of serous fluid, and act as an entry site for pathogens into the orbit leading to socket infection and breakdown. METHODS: This retrospective study analyzed exenterations performed over a 22-year period (1993-2015) at the National Ocular Oncology Service Centre for Scotland. PDS is a crystalline, biodegradable polyether-ester that is strong with good shape-memory and flexibility. Orbital exenterations with and without the use of PDS foil were compared in terms of SOF formation. RESULTS: A total of 30 exenterations were performed during the study period. A total of 29 were analyzed. Choroidal malignant melanoma was the most common indication for performing orbital exenteration (n = 7, 24.14%). The most common post-operative complications seen were SOF (n = 8, 27.59%). A total of 8 out 21 (38.10%) cases not using PDS developed SOFs. By contrast, none of nine patients receiving PDS plates developed SOFs (p = 0.0332). CONCLUSIONS: This is the first study to compare SOF rate in patients undergoing exenteration with and without the use of PDS foil. PDS foil is a safe material, which has effectively reduced the incidence of SOF formation.

Educational report: A case of lacrimal sac rhinosporidiosis.

This article reports a presentation of lacrimal sac rhinosporidiosis and informs the reader of this uncommon but important diagnosis. A 36-year-old man from Pakistan presented with a 3-month history of swelling at the nasal aspect of the left lower lid. This was associated with occasional crepitus and slight localised discomfort, but no epiphora. There was a palpable fullness near the left medial canthus associated with telecanthus but a normal sac washout and normal eye examination otherwise. Previous medical history included an ipsilateral nasal polypectomy and inferior meatal antrostomy around 10 years previously, whilst living in Pakistan. Various imaging modalities were useful in identifying a soft tissue mass within the left nasolacrimal duct. Following excision biopsy, histological examination confirmed the presence of rhinosporidiosis, likely caused by the organism Rhinosporidium seeberi. Rhinosporidiosis should be considered as a potential cause in any case of lacrimal sac pathology. Imaging studies may be helpful in measuring the extent of disease, although histological examination is required to confirm the diagnosis. Although rare, the complications of rhinosporidiosis can be potentially blinding or fatal. As discussed in this case, the presence of telecanthus may represent a lacrimal system tumour, either malignant or benign, and should always prompt further investigation.

A bundle improves eye care in PICU.

BACKGROUND: Intensive care patients are susceptible to developing painful corneal epithelial deficits. Provision of eye care to prevent deficits was limited in our paediatric intensive care unit (PICU) population. INTERVENTIONS: A new eye care bundle was introduced, comprising a guideline for eye care, the addition of eye lubricants to the electronic prescribing order set for new admissions to PICU and staff education on the importance of eye care. Weekly examinations over a 2-month period following implementation of the bundle evaluated eye care provision and presence of corneal epithelial deficits on ophthalmic examination. RESULTS: Provision of formal eye care improved from 19% to 96%. The incidence of deficits was lower than previously, simple eye ointment reduced the risk of deficits, even in incompletely closed eyes. CONCLUSIONS: Use of an eye care bundle, together with a multidisciplinary team approach to eye care, improves the provision of eye care in PICU.

Visual outcomes following orbital biopsy.

BACKGROUND: The risks of orbital biopsy depend on the lesion's location and relationship with surrounding structures. Complications include reduced vision, although visual outcomes following orbital biopsy are not widely reported. AIMS: To determine visual outcomes following orbital biopsy in Gartnavel General Hospital's Oculoplastic and Oncology Service. METHODS: Case note review of 50 consecutive patients undergoing orbital incision or excision biopsy between January 2006 and December 2010. Data collected included preoperative clinical examination, radiological and histological features, preoperative and postoperative corrected distance visual acuity (CDVA) and surgical complications. The main outcome measure was change in CDVA. Mean follow-up duration was 1.32 years. RESULTS: Histological diagnoses following biopsy included idiopathic orbital inflammation (n = 13) and lymphoma (n = 9). Of the radiologically defined lesions, 86.7% were extraconal (13.3% intraconal). Extraconal lesions were anterior in 59.0% (41.0% posterior). Mean preoperative LogMAR CDVA was 0.10 which was maintained at day one post-biopsy, indicating the absence of immediate sight-threatening complications such as retrobulbar haemorrhage or optic nerve compression, and there was no significant reduction at one-year follow-up (p = 0.239). Further analysis of change in CDVA showed no difference between: anterior and posterior lesions; extraconal and intraconal lesions; incision and excision biopsies; anterior and lateral surgical approaches. CONCLUSIONS: CDVA is retained for one year following orbital biopsy. Significant visual loss is a very rare complication of this procedure.

Inferior oblique recession: an efficient technique.

INTRODUCTION: We describe a novel, simple, rapid technique for inferior oblique recession. METHOD: Access to the muscle is gained through a peripheral radial conjunctival incision midway between the lateral and inferior recti. The anterior edge of the inferior oblique muscle is identified coursing parallel to the limbus on the undersurface of Tenon's capsule, at the apex of the exposure. A locking vicryl suture is placed 1 mm from the muscle insertion. The insertion is cut along the globe under direct vision and attached to the sclera 2 mm posterior and lateral to the lateral border of inferior rectus. The conjunctiva is closed with interrupted vicryl sutures. RESULTS: The technique described allows direct visualization of the muscle throughout the procedure. In addition, bleeding is usually avoided and tissue manipulation is minimized, thus ensuring good visibility throughout the procedure and minimizing the risk of scarring. CONCLUSION: Severence of the inferior oblique muscle insertion under direct vision, facilitated by good traction of the globe in the same meridian, affords a rapid minimally invasive approach to inferior oblique recession.

Combined amniotic membrane transplant and anterior stromal puncture in painful bullous keratopathy: clinical outcome and confocal microscopy.

OBJECTIVE: To report the outcomes of anterior stromal micropuncture (ASP) combined with amniotic membrane transplantation (AMT) in the management of painful bullous keratopathy (BK) with poor visual potential, and to assess amniotic membrane (AM) retention. DESIGN: Case series, retrospective review. PARTICIPANTS: Twelve eyes of 12 patients with BK causing intractable pain or discomfort and poor visual potential, treated between March 2006 and October 2008 at Gartnavel General Hospital, Glasgow. METHODS: Epithelial debridement was followed by ASP and the amniotic membrane was stabilized with a purse-string 10/0 nylon corneal suture and a bandage contact lens. During a mean follow-up of 67 weeks (range, 27-139 weeks), pain relief, epithelial healing, visual changes, confocal microscopy, and appearance of new bullae were evaluated. Success was defined as complete resolution or significant improvement in pain. RESULTS: Twelve eyes of 12 patients, mean age 61 years (range, 40-88 years), were identified. Corneal epithelial healing was complete in 11 eyes 1 month postoperatively. Pain and conjunctival inflammation resolved in 11 patients (91.67%) and improved from severe to mild in the remaining patient. Incorporation of the AMT was observed on slit-lamp biomicroscopy in all eyes and was confirmed using confocal microscopy at final follow-up. CONCLUSIONS: ASP combined with AMT is safe and effective, alleviates pain and discomfort, reduces ocular inflammation, and promotes epithelial healing and resolution of bullae in patients with BK with poor visual potential. There was long-term evidence of amniotic membrane graft retention in all eyes after the procedure, suggesting that ASP may improve the long-term retention rate of AM.

Dorsal midbrain syndrome with loss of motor fusion: a rare association.

INTRODUCTION: Dorsal midbrain syndrome (DMS) is characterized by upgaze paralysis, convergence-retraction nystagmus, and eyelid retraction. Impaired downgaze and pupillary light-near dissociation may co-exist, while less common features including exotropia and convergence paralysis have also been described. However, loss of motor fusion is not a well recognised finding in DMS. PURPOSE: To describe DMS associated with loss of motor fusion. METHODS: Retrospective case series. RESULTS: Five patients (age 21-80 years) presented with features of DMS due to severe head injury (n=1), brainstem stroke (n=3) and pinealoma (n=1). All five complained of constant diplopia with horizontal and vertical separation and had an exotropia (range 20Δ to 70Δ), absent convergence and motor fusion. Two underwent strabismus surgery and subsequently had a variable improvement in their motor fusion. The remaining three patients were managed with occlusion. CONCLUSION: This case series illustrates the complexity of ocular motility findings associated with DMS and highlights the potential difficulties in the management of patients with loss of motor fusion.

Systemic cyclosporin A in severe atopic keratoconjunctivitis.

PURPOSE: Severe atopic keratoconjunctivitis (AKC) is associated with atopic dermatitis and is often refractory to topical treatment and potentially blinding. Because T lymphocytes are central in the pathogenesis of these diseases, systemic cyclosporin A (CSA) should treat both dermatologic and ocular manifestations. We describe the successful treatment of 8 patients with severe AKC, resistant to conventional management, with systemic CSA. METHODS: This was a retrospective observational case series. The notes of patients with severe AKC were reviewed, where the disease did not respond to topical or other systemic treatment, and was treated with systemic CSA. Response to such treatment was observed and reported in 8 patients. RESULTS: Cyclosporin A was effective as a steroid-sparing agent. Systemic corticosteroids were stopped in half of the patients. Dosage varied between 50 mg and 300 mg daily (in divided doses), and duration of treatment varied between 5 months and 7 years. Papillary blepharoconjunctivitis and punctuate keratopathy completely resolved a few weeks after CSA therapy. Corneal ulcers resolved after 5 to 10 weeks of treatment. Coexistent eczema or dermatitis was brought under control with systemic immunosuppression, and flare-ups were not present during the duration of treatment. There was remission of AKC in all 8 patients with increase in visual acuity and low incidence of side effects. CONCLUSIONS: Cyclosporin A is effective in the treatment of atopic dermatitis and keratoconjunctivitis. Our case series potentiates previous smaller case series that systemic CSA can be used effectively and safely in cases that are resistant to conventional treatment to preserve vision.

Excision of granulation tissue and free conjunctival autograft in the management of necrotizing scleritis.

PURPOSE: To describe a novel use of conjunctival autograft in the management of surgically induced scleral necrosis that occurred after squint surgery. METHODS: Interventional case report. RESULTS: A 22-year-old man underwent bilateral adjustable squint surgery. Two weeks postoperatively, he developed conjunctival retraction and an area of scleral necrosis/melting with 80% thinning. The surrounding conjunctiva was markedly inflamed with raised edges. Screening for autoimmune and vasculitic conditions did not provide any positive results. The conjunctiva surrounding the area of scleral melt was excised and the area covered by a conjunctival autograft resulting in complete healing of the scleral melt within 1 month of surgery. CONCLUSION: The pathogenesis of surgically induced scleral necrosis not associated with autoimmune conditions may be the result of the products of inflammation and lytic enzymes released by the surrounding conjunctival tissue initiating the scleral melting process. This type of surgically induced scleral necrosis may be successfully managed by excision of the surrounding inflamed conjunctiva, thus removing a potential source of collagenases, and covering the exposed sclera by a conjunctival transplant obviating the need for prolonged high-dose immunosuppression.

Retinal arteriolar macroaneurysms and central retinal vein occlusion in a patient with complete pulmonary atresia.

PURPOSE: Retinopathy in cyanotic heart disease arises due to hypoxia and polycythaemia. We report the development of central retinal vein occlusion, and two arteriolar macroaneurysms in a normotensive patient with polycythaemia secondary to complete pulmonary atresia. METHOD: A 44-year-old woman with polycythaemia secondary to complete pulmonary atresia, presented with unilateral reduced vision of hand movements in the right eye. Ocular assessment and hematological investigations were performed. Management was conservative. RESULTS: Visual acuity was hand movements in the right eye, 6/5 in the left eye. Fundus assessment found right central retinal vein occlusion, and vessel tortuosity in the left eye. Hematological tests revealed an elevated red blood count, hemoglobin, heamatocrit, but normal plasma viscosity. Three months later, two arteriolar macroaneurysms developed in the left superotemporal arcade. Vision of 6/5 was retained in the left eye, hence no laser treatment was given. Subsequent follow-up revealed gradual involution of both macroaneurysms. CONCLUSION: Multiple retinal arteriolar macroaneurysms may occur in association with cyanotic heart disease such as pulmonary atresia. They appear to involute spontaneously, hence conservative management is appropriate.

Bilateral full thickness macular holes in association with serpiginous choroiditis.

PURPOSE: To report serpiginous choroiditis associated with full thickness macular holes (FTMH). DESIGN: Interventional case report. METHODS: A 58-year-old female with bilateral serpiginous choroiditis developed right-sided blurred vision and metamorphopsia. Ocular assessment, FFA, OCT, and right macular hole surgery were performed. RESULTS: Preoperative visual acuity was 6/36 right, 6/9 left. Fundus assessment found bilateral geographic chorioretinal scarring, epiretinal membranes, right FTMH, and mild vitritis. OCT revealed bilateral FTMHs. Pars plana vitrectomy, membrane peel, and gas tamponade resulted in right macular hole closure, visual acuity improvement (6/18) and resolution of metamorphopsia. CONCLUSIONS: Macular hole may be another posterior segment complication of serpiginous choroiditis.

Sequential leukemic infiltration and human herpesvirus optic neuropathy in acute lymphoblastic leukemia.

Leukemic infiltration is a common cause of optic disk swelling in a patient with acute lymphoblastic leukemia (ALL). Recurrence of optic disk swelling in a patient with previous leukemic infiltration carries a grave prognosis when it is associated with recurrent central nervous system disease. We report a case of recurrent swelling of an optic disk in a patient with T-cell ALL who had previously been treated for CNS relapse with optic nerve involvement. In this case the swelling was associated with cytomegalovirus infection and resolved following treatment with antiviral therapy.