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.

Success rates in powered endonasal revision surgery for failed dacryocystorhinostomy in a tertiary referral center.

PURPOSE: To evaluate the causes of failed dacryocystorhinostomy (DCR) surgery, recommend specific endoscopic endonasal techniques in revision DCR, and report postoperative success rates. METHODS: Retrospective case series in a tertiary referral center of 19 consecutive, endonasal revision DCR surgeries in 17 adult patients with previous failed DCR. All cases were revised endonasally by 1 surgeon. Analysis of etiology of failure and techniques of surgery were supplemented by review of surgical video and medical records. Surgical outcomes were measured functionally by resolution of epiphora and anatomically by patency of nasolacrimal duct system on syringing and positive functional endoscopic dye test. RESULTS: The most common cause for failed DCR was a blocked ostium due to membranous scarring (74%). Multiple causes for failure were found in 9 of 19 cases. Adjunctive procedures during revision surgery included partial middle turbinectomy (53%) and anterior ethmoidectomy (21%). The serrated oscillating blade was required in 89% cases, the high-speed diamond bur in 26%. Mean follow up was 15 months (range 7-26 months). All 19 cases had an anatomically successfully outcome. Fifteen of 19 cases (79%) had a functionally successful outcome. CONCLUSIONS: In this study, the most frequent cause of failed DCR was a scarred ostium, which is optimally visualized endonasally and precisely managed with the oscillating blade. Using the abovementioned specific endonasal techniques, the authors have demonstrated a high success rate in endonasal revision DCR surgery.

Endonasal endoscopic retrieval of lodged silicone punctal plugs: a case report.

We present the case of a 59-year-old woman whose silicone punctal plugs migrated distally causing lacrimal obstruction. The plugs were removed from the lacrimal sac during endoscopic endonasal dacrocystorhinostomy and is illustrated by endoscopic photographs and videos taken at the time of surgery. This case highlights the potential complications of punctal plugs and the difficulties posed in retrieving them.

Eyelid necrotizing fasciitis: what were the early signs?

BACKGROUND: Necrotizing fasciitis is a rare, life-threatening subcutaneous soft tissue infection that causes massive tissue destruction. OBJECTIVES: To illustrate the warning signs of this condition by reporting a rare case of eyelid necrotizing fasciitis. CASE REPORT: A previously healthy 22-year-old man presented with a preseptal eyelid infection that spread rapidly despite prompt treatment with several intravenous antibiotics. He developed the characteristic clinical and radiologic features of necrotizing fasciitis, and required surgical debridement to cure the infection. Histology confirmed the diagnosis. CONCLUSION: In this article, we suggest the indicators that may enable physicians to think of the development of necrotizing fasciitis in patients with infections of the skin and subcutis.

Maxillary mucocele with orbital floor remodelling.

A 79-year-old man presents with signs of an orbital mass. A CT scan revealed a large maxillary mucocele eroding through the orbital floor. Surgical drainage of the mucocele and conservative postoperative care, returned all ophthalmic signs to normal and bony remodelling of the orbital floor was demonstrated. Maxillary mucoceles should be assessed by both ENT and Ophthalmic surgeons. Postoperative remodelling of the orbital floor can be illustrated with serial CT Scans.

The use of a pleated strip of autogenous temporalis fascia graft for frontalis suspension in recurrent poor levator function ptosis in adult patients.

PURPOSE: Poor levator function (LF) blepharoptosis can be corrected surgically using frontalis muscle suspension with a variety of materials. Autogenous grafts such as fascia lata are commonly used. The need for a remote surgical site and the risk of an unattractive leg scar makes the use of an autogenous temporalis fascia (ATF) graft appealing as the scar is concealed in the hair. We describe the use of a pleated, lengthened ATF graft that is easy to prepare and insert, and provides a cosmetically acceptable outcome. METHODS: Prospective case series describing six patients with previous multiple failed lid surgeries and recurrent poor (≤ 5 mm) LF (mean 2.87 ± 1.72 mm) ptosis. The pleated graft technique was used to yield a strip of ATF up to 18-cm long from a short 2-cm temporal incision. Eight eyelids then underwent ATF graft frontalis suspension surgery using the modified Fox pentagon technique. Outcomes included eyelid measurements with 4.5-year follow-up. RESULTS: All patients achieved good functional and esthetic outcome. The mean central palpebral aperture 6 weeks postsurgery was 7.14 ± 1.67 mm, equating to a mean increase of 3.27 mm (p < 0.05 using the paired t-test). The improvement in eyelid height was maintained at the 4.5-year follow-up in all patients, except one who died of unrelated cause. CONCLUSION: A pleated strip of ATF graft provides a simpler alternative to fascia lata grafting for frontalis suspension in poor LF ptosis in adult patients with good long-term results.

Marsupialization for lacrimal ductular cysts (dacryops): a case series.

PURPOSE: To present the clinicopathological features and treatment outcomes of lacrimal ductular cysts managed with marsupialization. METHODS: Retrospective case review of 13 patients presenting with lacrimal ductular cysts. RESULTS: Thirteen patients were identified, of which 7 patients with full clinical data were included in the study, 4 female, 3 male, mean age 50 years. Their main presenting symptoms were superolateral orbital swelling, feeling of pressure on the eye, and lateral ptosis. Two patients had bilateral cysts, and the remaining 5 had unilateral cysts. Six patients required surgical marsupialization, and one patient was treated conservatively because of preexisting dry eye. At surgery, one patient had multiple dacryoliths within the cyst. Histopathological analysis of the cyst lining in 5 out of 7 patients showed bilayered cuboidal epithelium with fibrous tissue. None of the patients had dry eye symptoms or signs after surgery. Follow-up ranged from 10 months to 2 years, mean 20 months CONCLUSION: Marsupialization is a safe and effective treatment for lacrimal ductular cysts.

Endoscopic endonasal retrieval of a nasolacrimal duct stone via the valve of Hasner in the inferior meatus.

A 37 year old man presented with a 6 month history of a right epiphora with associated mucus discharge. Lacrimal irrigation demonstrated right unilateral partial nasolacrimal duct obstruction, confirmed with lacrimal scintigraphy. Nasal endoscopy showed a pale elevation in the right inferior meatus. Endoscopic endonasal examination revealed a yellow-white nasolacrimal duct stone emerging from the valve of Hasner in the inferior meatus. The distal nasolacrimal duct in the lateral wall of the inferior meatus was marsupialised and the stone removed. At 12 months follow-up the patient maintained complete resolution of symptoms.

Mini-monoka made easy: a simple technique for mini-monoka insertion in acquired punctal stenosis.

PURPOSE: To describe a simple and effective technique to insert the mini-monoka mono-canalicular stent using a nettleship dilator, without the need for a snip-procedure. METHODS: Description of a surgical technique. RESULTS: Mini-monoka stents have been shown to have a high rate of stent migration and premature loss when combined with a one-snip procedure. Our technique preserves the annular ring of the punctum and thus reduces the likelihood of these complications. CONCLUSION: This is a practical technique for the insertion of the mini-monoka monocanalicular stent for acquired punctual stenosis.

A very rare case of bloody tears with enigmatic epistaxis and haematuria.

BACKGROUND: Bloody tears are a rare symptom that can be caused by local or systemic pathology. METHODS: We describe a very rare case of bloody tears that resulted from hyperthyroidism. RESULTS: A 15-year-old female patient presented with a 6-month history of bloody tears and epistaxis. Examination excluded local ocular and nasal pathology, including neoplasm and coagulopathy. Systemic investigations identified elevated thyroid function and following treatment her symptoms resolved. We discuss the mechanism by which hyperthyroidism may induce haemostatic dysfunction. CONCLUSION: We present the first case of bloody tears secondary to thyroid dysfunction.

Treatment of a lacrimal pneumocele with punctal plug insertion.

A 37-year-old man presented with symptoms of air and mucus reflux from the right medial canthus on blowing his nose. Examination showed crepitus in the region overlying the right lacrimal sac, and he was able to produce bubbles in his conjunctival lake on instillation of topical 2% fluorescein. Dacryoscintigraphy showed symmetrical slow passage of tracer from the lacrimal sac in the nasolacrimal duct indicating delay at the postsac level. Dacryocystography showed that the right lacrimal system contained round filling defects, suggesting the presence of soft tissue tumors. However, a CT scan showed an enlarged right lacrimal fossa with air in the nasolacrimal duct and no evidence of a mass. Following lower punctal plug occlusive canaliculoplasty on the right, using a preloaded silicone plug, the patient noted an immediate resolution of reflux symptoms.

Two cases of drug-induced orbital inflammatory disease.

Orbital inflammatory disease (OID) includes all inflammatory processes affecting the orbit. Although several aetiologies are recognised, a cause may not be elucidated. We describe 2 cases in which drugs (hyaluronidase and zoledronic acid) were the cause of OID. In patients with a clinical picture of OID simulating an orbital cellulitis, the recent drug history should be considered as a possible aetiology, and treatment with steroids with or without a biopsy should be considered after an infection has been excluded.

Orbital floor abscess secondary to sinusitis in an immunocompromised patient.

A 65-year-old man with a history of renal transplantation presented with facial pain, purulent nasal discharge, and periorbital swelling. Signs of optic nerve compromise developed and persisted despite medial orbital wall decompression. Further imaging revealed an orbital floor abscess secondary to direct communication of a maxillary pseudomonal sinusitis. Full recovery was achieved after further surgical drainage via an endoscopic endonasal approach. Failure to improve after surgical decompression is an indication for repeat imaging. Immunocompromised patients can present atypically. Orbital floor abscess secondary to sinusitis without an underlying odontogenic or traumatic cause has not previously been reported. The authors highlight the importance of clinical vigilance, serial imaging, microbiological investigations, and early surgical intervention in high-risk patients.

Hypertrichosis of the upper cheek area associated with travoprost treatment of glaucoma.

Travoprost is a prostaglandin analog used in the treatment of open-angle glaucoma. This drug is safe and efficacious and has a low incidence of systemic and local side effects. Common local side effects are conjunctival hyperemia, iris pigmentation, and hypertrichosis of the eyelashes. The authors present a case of a patient who developed marked hypertrichosis of the cheek vellus 3 months after starting treatment with travoprost.

Adjunctive use of hyaluronic acid gel (Restylane Sub-Q) in anophthalmic volume deficient sockets and phthisical eyes.

PURPOSE: This study aims to present the use of Restylane Sub-Q for orbital volume augmentation in patients with secondary volume deficiency either postenucleation or postevisceration or those with phthisical eyes. METHODS: This prospective case series reviews clinical, photographic, and radiologic records of 16 patients with anophthalmic or enophthalmic orbits who underwent volume augmentation by injection with hyaluronic acid gel in the intraconal and extraconal posterior orbit. The technique is discussed in detail. RESULTS: The volume of hyaluronic acid gel injected ranged from 2 to 4 ml (mean volume, 2.3 ml) per orbit, with a mean reduction of enophthalmos of 3.7 mm (71.4%) at 1 week, 2.8 mm (59.9%) at 6 months, and 2.5 (51.3%) at 12 months, with follow-up of 94.1%, 68.8%, and 50% of the patient group, respectively. Follow-up after 12 months consisted of subjective feedback from the patient. With the exception of one patient, the mean subjective follow-up period was 14.7 months (maximum, 22.4 months; minimum, 1.6 months). The procedure was well tolerated by 15 of the 16 patients who all experienced an improvement in cosmetic appearance. There was one possible complication of orbital cellulitis (although not examined by our clinic); this patient did not attend further follow-ups. One patient had full correction of her enophthalmos, which was maintained over 12 months. CONCLUSIONS: Hyaluronic acid gel injections in patients with enophthalmic sockets appear to be a safe, tolerable, and minimally invasive alternative for orbital volume augmentation in the outpatient setting. However, as predicted, its affects are temporary, and volume does begin to decrease within 12 months of injection.

A randomized controlled trial comparing everting sutures with everting sutures and a lateral tarsal strip for involutional entropion.

OBJECTIVE: To determine whether there is a statistically significant difference in the surgical outcome of everting sutures (ES) alone versus everting sutures with a lateral tarsal strip (ES+LTS) in the treatment of involutional entropion. DESIGN: Prospective randomized comparative trial. PARTICIPANTS: Sixty-three patients with primary involutional lower eyelid entropion were enrolled in the study. The age range was 54 to 94 years, with a mean age of 77 years. Baseline characteristics of the comparative groups were similar. METHODS: Patients requiring primary surgical repair for involutional entropion were selected, and those providing informed consent were randomized for surgery. Thirty-six patients were randomized to ES alone, and 27 patients were randomized to ES+LTS. Patients were evaluated at 3 weeks and 6, 12, and 18 months postoperatively. MAIN OUTCOME MEASURES: Successful surgery was defined as a normal eyelid position at rest and inability to induce entropion on tetracaine provocation testing at or before the 18-month follow-up visit. RESULTS: Eight patients were lost to follow-up (7 had ES alone). Of the 55 patients with complete follow-up data, there were 6 failed procedures in the patients who underwent ES alone and no failed procedures in the patients who underwent ES+LTS (P = 0.02). CONCLUSIONS: These data provide strong evidence that success rates at 18 months are higher in patients treated with ES+LTS procedure compared with ES alone.

Lacrimal surgery success after external dacryocystorhinostomy: functional and anatomical results using strict outcome criteria.

PURPOSE: To present the results of external dacryocystorhinostomy (ext-DCR) for epiphora using strict outcome criteria and provide an accurate baseline and evidence from which to compare the results of endonasal dacryocystorhinostomy. METHODS: Retrospective case notes review of 158 consecutive adult patients who underwent primary ext-DCR. Functional success was assessed according to the patients' symptoms and anatomical success was measured using objective tests of lacrimal system patency: 1) the functional endoscopic dye test and/or endoscopic endonasal inspection of the ostium; 2) syringing of the lacrimal system; and 3) the fluorescein dye retention test. Patients without complete follow-up data were recalled for clinical reevaluation. A minimum follow-up of 6 months was required. Comparison of overall functional and anatomical success was further analyzed according to etiology using logistic regression and for different grades of surgeon using the chi-squared test. RESULTS: The results for 124 of 158 ext-DCRs showed an overall functional success of 69% and anatomical success of 74%. Patients with primary acquired nasolacrimal duct obstruction (PANDO) who had surgery by the specialist lacrimal surgeon had high success: 83% functional success and 100% anatomical success. Patients with watering eyes from non-PANDO aetiology including canalicular disease who had surgery by the specialist lacrimal surgeon had moderate success: 78% functional success and 70% anatomical success. The results of all surgery by trainees were lower but only significantly so for PANDO. The mean duration of follow-up was 2.6 years (range, 6 months to 8.3 years); median follow-up was 1.9 years. CONCLUSION: This study used strict criteria to assess functional and anatomical outcomes of primary ext-DCR and thus provide baseline measures of success with a minimal follow-up of 6 months. When canalicular disease was excluded, results for PANDO were higher. Surgery performed by the specialist lacrimal surgeon had higher success rates than when performed by trainee.

Medpor lower eyelid spacer: does it biointegrate?

PURPOSE: To report the histopathologic findings of explanted Medpor lower eyelid spacers (LES) in complicated cases. MATERIALS AND METHODS: Four cases of lower eyelid retraction due to thyroid orbitopathy (n = 2), facial nerve palsy (n = 1), and post-enucleation socket syndrome (n = 1) were treated with Medpor LES. RESULTS: All implants were removed between 6 months to 2 years following their original insertion due to exposure, poor stability, or contour. Histopathology of the implants showed fibrosis and vascularization although clinically, at the time of removal, did not appear vascularized. In addition, immunohistochemistry was positive for Factor VIII related antigen and CD34, thus highlighting the presence of vessels in the pores and around the implant. CONCLUSION: To our knowledge, we are the first to report histopathologic findings of explanted high-density porous polyethylene implants from the lower eyelid in humans. Although this study shows that Medpor LES does biointegrate, we advocate using it sparingly due to associated complications such as exposure, poor stability, and contour.