A case of non-lacrimal immunoglobulin G4 (IgG4)-related orbital disease with mastitis.

IgG4-related orbital disease is a recognised cause for orbital inflammation. As its awareness increases and diagnostic accuracy improves there will be an increased number of cases being identified. This unique case demonstrates for the first time, with histological evidence, a case of a non-lacrimal IgG4-related orbital disease with concurrent IgG4-related mastitis. We describe a 47 year old who presented with a supraorbital swelling and mass. This was initially successfully treated with oral steroids and was later excised on recurrence. Immunohistochemical and blood serum analysis confirmed IgG4-related orbital disease. On systemic enquiry she was found to have a mass of the breast, which was shown to be IgG4-related mastitis. She is currently asymptomatic with no sign of recurrence and is under long-term surveillance. This case highlights the importance of systemic work up in patients presenting with orbital foci of IgG4 disease.

Abscessed porous polyethylene (Medpor) orbital implant: a case report.

We report the evolution of clinical features of orbital implant infection in a 42-year-old man. Despite appropriate treatment recurrent conjunctival dehiscence could not be prevented. Explanation of the implant resulted in complete resolution of symptoms. Histopathological examination confirmed focal necrotising acute inflammation with the presence of colonies of the organism in the deep substance of the implant.

A case of lower lid ulcer secondary to reverse migration of silicone punctal plug.

Silicone punctal plugs are effective and relatively safe method of managing keratoconjunctivitis sicca. We present a case where a silicone punctal plug migrated to cause aseptic necrosis of the surrounding tissue leading to a lid ulcer.

Pseudodacryocystitis: paediatric case series of infected atypical ethmoid air cells masquerading as recurrent dacryocystitis.

PurposeTo highlight the clinical and surgical considerations in treating patients with apparent recurrent acute dacryocystitis with a patent lacrimal system.MethodsThree children referred to a tertiary unit as recurrent acute dacryocystitis were reviewed retrospectively. Imaging and subsequent surgical intervention revealed the underlying diagnosis.ResultsAll three cases presented with recurrent abscesses in the region of the lacrimal sac that failed to respond to incision and drainage. The lesions were lower and more lateral to the usual location of a sac abscess and closer to the inferior orbital rim. All three cases were found to have patent lacrimal systems on syringing, and all were found to have infected, low-lying, anteriorly placed aberrant ethmoid air cells on computed tomography and magnetic resonance imaging. These were confirmed on subsequent surgical exploration.ConclusionsInfected low-lying ethmoid air cells can mimic dacryocystitis with recurrent abcesses. In cases where a patent nasolacrimal system is demonstrated and a more inferolateral location of the swelling than would be expected in dacryocystitis is seen, imaging is warranted to ensure the appropriate intervention is undertaken. Anterior ethmoidectomy as opposed to dacryocystorhinostomy is the appropriate treatment in these cases.

Indications and outcome of carotid Doppler ultrasound: an ophthalmic perspective.

PURPOSE: The purpose of this study was to assess indications and outcome of carotid Doppler ultrasound requested by ophthalmologists from an eye hospital over a period of three years. METHODS: This retrospective study was designed to analyse data for all patients referred to have carotid Doppler ultrasound from 1999 to 2001. Colour fundus photograph was used to ascertain diagnosis of ocular condition. Detailed case note analysis was done to correlate patient details, indication, results of carotid Doppler, and status of anti-platelet treatment as well as presence of other risk factors. RESULTS: 107 patients were included in the study. 46.7% had normal internal carotid on Doppler while 53.3% patients had stenosis, 22.8% of which were significant. 15 out of 24 patients with retinal artery occlusion had internal carotid artery (ICA) stenosis. 2 out of 6 patients with migraine had significant stenosis. 12 patients had retinal vein occlusion (5 were bilateral), 9 of whom showed ICA stenosis. 14 of 15 patients with retinal emboli had stenosis of ICA. Other diagnoses included anterior ischaemic optic neuropathy, cranial nerve palsy, etc. 42 patients had 1 to 3 risk factors, and 11 patients had more than 3 risk factors. Ophthalmologists started anti-platelet management in 24 patients (42.1%) with some degree of ICA stenosis. CONCLUSIONS: Approximately 55% of our patients referred for carotid Doppler were positive for ICA stenosis with nearly a fifth of such referrals having more than 70% stenosis, which is considered to be clinically significant. Our results highlight the importance of such referrals for carotid Doppler for various ophthalmic conditions by the ophthalmologists.

Contact thermal burns of the cornea.

The records of 59 patients (66 eyes) with contact thermal burns of the cornea (unilateral in 52 cases and bilateral in 7) were reviewed to determine the causes, clinical presentation, management and complications of such injuries. Most of the injuries (90%) occurred at home. The commonest cause was splashing of boiling fluids (42% of cases), followed by contact with red-hot firecracker particles (18%) and lit match heads (17%). In 59 eyes (89%) the burn was limited to the corneal epithelium, in 5 (8%) the superficial stroma was also involved, and in 2 (3%) there was associated corneal perforation caused by mechanical impact of foreign bodies. Débridement of the coagulated epithelium with patching was the most successful treatment, healing 48 (73%) of the eyes. Postburn complications were rare, the most common being development of inferior symblepharon, in three eyes (4%).

Ocular findings in sleep apnoea patients using continuous positive airway pressure.

PURPOSE: To describe ocular findings in patients with established obstructive sleep apnoea hypopnoea syndrome (OSAHS) using continuous positive airway pressure (CPAP). METHODS: hundred and fifteen referrals investigated for OSAHS were included. Patients with OSAHS were compared with those with normal sleep study controls. Subgroup analysis for CPAP users and non-users was also carried out. RESULTS: OSAHS patients (n=89) compared with the controls (n=26) had higher ocular irritation symptoms (P<0.001), abnormal tear break-up time (P<0.05) with increased upper (P<0.001) and lower (P<0.001) lid laxity. Floppy eyelid syndrome (FES) was noted in 31.5% (28/89) OSAHS patients vs 3.8% (1/26) controls (P=0.005). Open angle glaucoma prevalence in OSAHS patients (3/89, 3.4%) was similar to the controls (1/26, 3.8%) (P=0.92). Sixty-seven (75.3%) OSAHS patients were using CPAP (average duration: 19.6+/-15.3 months). All CPAP users maintained a supine sleep posture to prevent mask edge leaks. A fifth of CPAP users (14/67) had experienced earlier episodes of conjunctivitis secondary to leaks. CPAP users had similar upper and lower lid laxity (P=0.746 and 0.633) to non-CPAP users, but a better tear film (P=0.029) and less ocular irritation (P=0.134). CONCLUSION: OSAHS patients showed increased ocular irritation, abnormal tear film, lid laxity, and FES. The prevalence of glaucoma in our series was similar to normal population data of 2%, P=0.429, and may relate to use of CPAP in majority of the patients. More stable tear film in CPAP users was probably secondary to the supine sleep postures necessarily adopted with CPAP use.

Molluscum Contagiosum-Induced Periocular Toxic Dermatitis.

This report describes an unusual case of a 9-year-old boy with a 6-month history of right lower eyelid lesion and excoriation of the adjoining skin that had not responded to topical treatment. The umbilicated lesion was electively excised and the base of the lesion was cauterized under general anesthesia, which resulted in complete resolution of the periocular dermatitis without additional treatment. It is important to consider molluscum contagiosum in the differential diagnosis in patients with periocular dermatitis, especially in the presence of an umbilicated vesicle, although it is classically taught that these lesions present with toxic conjunctivitis.

Evidence-based practice in acute ophthalmology.

AIM: To study the overall level of evidence-based practice in an accident and emergency eye unit in the UK and evaluate the extent of evidence-based practice by ophthalmologists and nurse practitioners (NPs). METHODS: The case notes of all new patients attending our accident and emergency department for a period of 1 week were reviewed prospectively. For each case, the diagnosis at presentation and its intervention was ascertained. A literature search using Medline and Cochrane library was performed to assess the level of evidence provided for each diagnosis-intervention pair. Each diagnosis-intervention pair was evaluated and graded to assess the best level of evidence provided. RESULTS: A total of 474 new patients attended the eye casualty during the study period. No diagnosis was made in 27 cases and they were excluded from the analysis. Out of 447 patients, 308 (68.9%) cases were managed by NPs and 139 (31.1%) by doctors. A total of 294 (65.8%) patient interventions were based on evidence from systematic reviews, meta-analysis and randomised-controlled trials, of which 223 were managed by NPs and 71 by ophthalmologists. This difference was statistically significant with P<0.001. One hundred and seven (23.9%) interventions were supported by evidence from prospective and retrospective trials. CONCLUSION: This study demonstrated that two-thirds of interventions were based on the highest level of evidence and was comparable to studies performed in other specialities. It also highlights the advanced role of trained NPs in acute ophthalmology.

'Fast-tracking' cancer referrals: application for periocular basal cell carcinoma.

AIM: To study the feasibility of a modified fast-track protocol for periocular basal cell carcinoma (BCC). METHODS: A modified protocol was set up with an aim to examine all periocular BCCs within 6 weeks of referral to our oculoplastic clinic. An audit of this protocol was performed over a 2-year period. RESULTS: A total of 65 patients were referred as a 'possible BCC' over the 2-year period. In all, 32 of these patients were referred by dermatologists (49%), followed by fellow consultant ophthalmologists (20 patients, 31%) and general practitioners (11 patients, 17%). The clinical suspicion in the oculoplastic clinic agreed with the referral diagnosis in 71% (46 of the 65) of patients. This figure was particularly high for referrals from dermatologists (84%). In all, 44 out of the 46 'clinically suspected BCC' underwent surgical excision. Histopathology confirmed BCC in 39 of these 44 patients, a diagnostic accuracy of 89%. Among the subgroup of patients referred by the dermatologists, the largest source of referrals, 24 out of 30 patients that underwent surgical excision had histologically proven BCC; a diagnostic accuracy of 80%. CONCLUSION: Our study shows that the modified fast-track protocol for periocular BCCs is practical and feasible. Such a practice is highly desirable since it prevents a long wait for patients who are aware of a possible malignant periocular lesion.

The consent and counselling of patients for cataract surgery: a prospective audit.

PURPOSE: The aims of ideal preoperative informed consent include educating the patient adequately to enable an autonomous decision to be made without causing undue anxiety. We study how the paternalistic and nonpaternalistic approaches meet this ideal. The influence of the new patient consent forms is also assessed. METHODS: Two cycles of a prospective clinical audit are presented. An assessment of relevant patient knowledge was performed by patient interview. Visual analogue scales were used to quantify patient anxiety. RESULTS: The first cycle, examining a paternalistic approach, demonstrated: 37% of patients understood what a cataract was and 48% understood what surgery involved. 48% misunderstood that cataract surgery was completely risk free. In total, 80% of patients undergoing second eye surgery believed that it was completely risk-free. Average anxiety visual analogue scores (VAS) for cataract surgery were low (2.89). The second cycle, examining the nonpaternalistic approach combined with the implementation of new consent forms showed that, despite more explicit repeated preoperative consent: 39% of patients understood correctly what a cataract was, 28% understood what surgery involved and 43% misunderstood that surgery was completely risk-free. All patients undergoing second eye surgery thought that it was risk-free. The average anxiety VAS for cataract surgery were moderate (5.00). CONCLUSIONS: Both paternalistic and non-paternalistic approaches to informed consent are inadequate in meeting the demands of the ideal informed consent. The new patient consent forms appear to have little effect in influencing patient knowledge about their surgery. Patients undergoing second eye surgery often have an overoptimistic view of cataract surgery.

Pyogenic granuloma following silicone punctal plugs: report of two cases.

PURPOSE: To report two cases of pyogenic granuloma following silicone punctal plugs. METHODS: Interventional case reports. RESULTS: The authors report two cases of pyogenic granuloma secondary to silicone punctal plugs and their lacrimal sequelae following surgical removal in one case and conservative treatment with removal of the plug alone in another. The former case developed no lacrimal sequelae while the second case developed punctal scarring. Spontaneous loss of plugs was common to both the cases. CONCLUSIONS: Patients with punctal plugs should be informed about plug-related problems and encouraged to report them.

Prospective survey of adverse reactions to topical antiglaucoma medications in a hospital population.

AIM: To identify the relative incidence and profile of adverse drug reaction (ADR) to various topical ocular hypotensives in a hospital setting. METHODS: All the patients presenting in outpatients clinic and accident and emergency with an ADR to topical hypotensive agent from August 2000 to January 2001 were included in the study. Details regarding the type date of commencing the treatment, the date of developing ADR, time to resolution of the ADR were noted. RESULTS: Over the period of 6 months, 66 patients presented with 73 ADRs. Brimonidine was the most frequent offending agent. In total, 23 (34.8%) presented with ADR after being commenced on treatment for more than 12 months. In all, 16 (24%) patients had IOP > 21 on presentation, eight (12%) patients underwent filtration surgery following the development of ADR. CONCLUSION: Adverse drug reaction to ocular hypotensive agents is not uncommon and can have a major impact on glaucoma management. Delayed presentation and association with raised intraocular pressure presentation emphasise the need for effective patient education to encourage prompt reporting of ADR.

Bilateral congenital posterior-capsular defects: a case report.

We report a rare case of bilateral congenital posterior-capsular defects and its successful management by the dry-aspiration technique. To our knowledge, this is the first documented case of a posterior-capsular rupture with no demonstrable cause.

Indications and Outcome of Carotid Doppler Ultrasound An Ophthalmic Perspective.

PURPOSE: The purpose of this study was to assess indications and outcome of carotid Doppler ultrasound requested by ophthalmologists from an eye hospital over a period of three years. METHODS: This retrospective study was designed to analyse data for all patients referred to have carotid Doppler ultrasound from 1999 to 2001. Colour fundus photograph was used to ascertain diagnosis of ocular condition. Detailed case note analysis was done to correlate patient details, indication, results of carotid Doppler, and status of anti-platelet treatment as well as presence of other risk factors. RESULTS: 107 patients were included in the study. 46.7% had normal internal carotid on Doppler while 53.3% patients had stenosis, 22.8% of which were significant. 15 out of 24 patients with retinal artery occlusion had internal carotid artery (ICA) stenosis. 2 out of 6 patients with migraine had significant stenosis. 12 patients had retinal vein occlusion (5 were bilateral), 9 of whom showed ICA stenosis. 14 of 15 patients with retinal emboli had stenosis of ICA. Other diagnoses included anterior ischaemic optic neuropathy, cranial nerve palsy, etc. 42 patients had 1 to 3 risk factors, and 11 patients had more than 3 risk factors. Ophthalmologists started anti-platelet management in 24 patients (42.1%) with some degree of ICA stenosis. CONCLUSIONS: Approximately 55% of our patients referred for carotid Doppler were positive for ICA stenosis with nearly a fifth of such referrals having more than 70% stenosis, which is considered to be clinically significant. Our results highlight the importance of such referrals for carotid Doppler for various ophthalmic conditions by the ophthalmologists. (Eur J Ophthalmol 2004; 14: 240-4).