Quality of vision and tear film osmolarity.

SIGNIFICANCE: We evaluate the relationship between tear film osmolarity measurements and quality of vision in patients presenting for routine eye clinic appointments. We found that the hyperosmolar group (>316 mOsm/L) had a worse quality-of-vision score than the normal osmolarity group, with glare being the most problematic symptom. PURPOSE: Quality of vision is a perception and measure of real-world vision, which is not measured routinely in a clinical setting. This study aimed to evaluate the relationship between tear film osmolarity measurements and quality of vision in patients presenting for routine eye clinic appointments. METHODS: This was an observational nonrandomized study. The participants were placed in groups based on tear film osmolarity (normal, ≤316 mOsm/L; hyperosmolar, >316 mOsm/L; or a difference of >8 mOsm/L between each eye). Thirty-three participants were enrolled in the study, of whom 22 were deemed to have a hyperosmolar tear film. A 30-item questionnaire including 10 symptoms rated on scales of frequency, severity, and bothersomeness was administered to participants in both groups. The quality-of-vision score ranged from 25 to 100 points, with lower scores indicating better quality of vision. RESULTS: The hyperosmolar group had a significantly worse quality-of-vision score than the normal osmolarity group across all three scales; mean differences for frequency, severity, and bothersomeness were 12.66 ± 9.75 (p=0.003), 9.44 ± 7.45 (p=0.003), and 11.90 ± 11.14 (p=0.008), respectively. Of the 10 symptoms that were included in the questionnaire, glare was the most problematic in the hyperosmolar group. CONCLUSIONS: In this study, we demonstrated a significant relationship between tear film hyperosmolarity and quality of vision, as patients with hyperosmolar tear films had worse quality of vision.

Management of orbital conjunctival epithelial inclusion cyst using trichloroacetic acid (20%) in an outpatient setting.

Conjunctival epithelial inclusion cysts are an infrequent complication in anophthalmic sockets. The ocular prosthesis may become difficult to retain or it may cause local discomfort. Treatment options described include surgical resection, marsupialisation, and the use of injected sclerosing agents. We present a case of a 27-year-old female who developed a conjunctival epithelial inclusion cyst two years after a left eye evisceration. This invariably caused the ocular prosthesis to become cosmetically unacceptable. Trichloroacetic acid 20% (TCA) was injected intracystically as a minor procedure at the slit lamp. Four months later there was no recurrence of the cyst and the prosthesis retained an excellent position in the socket. This case highlights the successful treatment of a conjunctival epithelial inclusion cyst with TCA (20%) without the need for a surgical procedure.

Pyoderma gangrenosum affecting the eye, orbit, and adnexa. A review.

While pyoderma gangrenosum (PG) most commonly affects the skin it can also involve other organs. It rarely affects the eye, orbit, or adnexa. Its early recognition and proper management with prompt initiation of immunosuppressive therapy are essential for the preservation of the eye and, in turn, vision, in these cases. Here, we review the limited literature already published regarding ocular involvement in PG.

Orbital abscess following posterior subtenon injection of triamcinolone acetonide.

Orbital cellulitis is a serious sight threatening and potentially life threatening condition which can be complicated by orbital abscess formation. Posterior subtenon (PST) injection of corticosteroid is commonly used in the treatment of posterior segment inflammation including post-operative macular oedema. We report a case of orbital abscess formation as a late complication of PST triamcinolone acetonide and discuss the presentation, diagnosis and management.

Porous orbital implant exposure: the influence of surgical technique.

OBJECTIVES: To examine orbital implant exposure rates following enucleation and evisceration. METHODS: A retrospective chart review of all patients who underwent an evisceration or enucleation in a single centre over a 5-year period was performed. The indication for surgery, the type and size of orbital implant used, details of the surgical technique adopted and the postoperative complications observed, in particular orbital implant exposure, were recorded. RESULTS: Over a 5-year period 24 patients had enucleation and 14 had evisceration; 22 of these procedures were performed by an ophthalmic surgeon with a special interest in orbit and oculoplastics while the remaining 16 procedures were performed by 5 ophthalmic surgeons with other sub-specialty interests. Orbital implant exposure occurred in 8 cases. One case had been performed by the first of these surgeons described. Implant exposure occurred in 4% of cases performed by this surgeon. The remaining 7 cases had been performed by the group of surgeons with sub-specialty interests outside of orbit and oculoplastics. Implant exposure occurred in 48% of cases performed by this group. CONCLUSIONS: Orbital implant exposure remains a significant cause of morbidity in patients undergoing enucleation and evisceration. Rates of orbital implant exposure were significantly lower when surgery was performed by an orbital surgeon. Differences in surgical technique are the most likely explanation.

Thyroid-like ophthalmopathy in a euthyroid patient receiving Ipilimumab.

A 68-year-old lady with metastatic malignant melanoma was treated with Ipilimumab. She presented to Eye Casualty unable to move her eyes. Physical examination confirmed ophthalmoplegia and identified proptosis bilaterally. Radiological imaging showed bilateral enlargement of all the extra-ocular muscles suggestive of thyroid eye disease. Laboratory investigations found this patient to be euthyroid. A diagnosis of thyroid-like orbitopathy secondary to Ipilimumab therapy was made. Thyroid function tests should be performed for all patients prior to their commencement of Ipilimumab. Thyroid-like eye disease may develop in patients treated with Ipilimumab even if they remain euthyroid.

Recurrence rates of periocular basal cell carcinoma following intra-operative en-face frozen section margin controlled excision.

PURPOSE: To report the margin control process and rate of recurrence of periocular basal cell carcinomas (BCCs) managed by en-face, frozen section margin controlled (FSC), excision by a single surgeon with a 3-year follow-up. METHODS: A retrospective analysis of all histopathologically proven cases of periocular BCC who underwent surgical excision with intra-operative, en-face, FSC, excision by a single surgeon from 2015 to 2019 was performed. Patients with less than 3-year follow-up were offered a virtual appointment to determine possible recurrence. RESULTS: A total of 88 BCC excisions from 86 patients were reviewed. Minimum 3-year follow-up data is available for 73 patients. The most common location and histological subtype was the lower eyelid and nodular BCC, respectively (47% and 83% of cases). Primary BCC (pBCC) comprised 98% (86/88) of cases and recurrent BCC (rBCC) comprised 2% (2/88) of cases. Negative frozen section margins were achieved in 93% (82/88) of excisions on the day of surgery. The overall recurrence rate during this time was 1.4% (1/73) at minimum 3 years. CONCLUSION: Periocular BCC can be managed effectively by en-face, FSC, excision, with a high cure rate and low recurrence rate comparable to alternative excision techniques such as Moh's micrographic surgery. Advantages of en-face excision include same-day excision and reconstruction and reduced theatre time. Primary nodular BCCs with clear margins can be considered for early discharge with advice to self-monitor.

Clinical characteristics, diagnosis, and outcomes of orbital biopsies in a single Irish centre.

AIMS: To review the distribution of histopathological diagnoses and visual outcome of orbital biopsy in an Irish tertiary referral centre over a 10-year period. METHODS: This was a retrospective, clinical-histopathological case series. Clinical records of all patients who underwent orbital biopsy between January 2008 and January 2018 in the Mater Misericordiae University Hospital were reviewed using data collected from theatre logbooks and hospital-based medical records. RESULTS: A total of 83 orbital biopsies in 77 patients were included for analysis in this study. The mean age was 55.7 ± 18.41 years. The mean follow-up period was 1.87 ± 2.097 years. The most common presenting symptoms and signs were pain (22.3%) and proptosis (27.6%). Most lesions were located in the extraconal space (65%), with incisional biopsy (65%) being the most common technique used to gain a sample for histopathological diagnosis. Histopathology analysis of the biopsies revealed malignant tumours (27, 32.5%), benign tumours (7, 8.4%), inflammation (26, 31.3%), and other diagnoses (23, 27%). Excluding patients who underwent exenteration procedures, no study patients suffered visual loss following orbital biopsy. CONCLUSIONS: Orbital biopsy serves as a safe diagnostic tool in managing orbital diseases. The breakdown of diagnosis in our patients is in line with international studies. No patients in our series suffered vision loss as a result of their orbital biopsy. This emphasises its use as a safe procedure in the diagnosis and management of patients with the orbital disease. Our data provides helpful guidance to clinicians when counselling patients for orbital biopsy.

Metastatic HER2 lacrimal/salivary gland duct adenocarcinoma.

In this report, we present a case of a patient with a 30-year history of orbital asymmetry who presented with metastatic human epidermal growth factor receptor 2 (HER2) positive lacrimal/salivary gland ductal adenocarcinoma. The patient was treated with chemoradiotherapy and trastuzumab. Tumours of lacrimal gland origin are rare, and unfortunately can frequently present in late stage. There are no current guidelines on the optimal treatment of metastatic lacrimal gland tumours, in particular those with HER2 amplified malignancy. This case highlights a unique presentation of a rare disease, and the potential for targeted therapy.

Changing trends in corneal transplantation: a national review of current practices in the Republic of Ireland.

BACKGROUND: First Irish National Corneal Transplant Registry report. AIM: To report about current corneal transplantation practices in Ireland including patient demographics, indications and types of transplant performed and to compare the findings with other developed countries. METHODS: Nationwide retrospective review of the corneal transplants performed in Ireland between 2016 and 2019. RESULTS: Overall, 536 keratoplasties were carried out: 256 (47.8%) Penetrating Keratoplasties (PK), 212 (39.6%) Descemet Stripping Automated Endothelial Keratoplasties (DSAEK), 30 (5.6%) Descemet Membrane Endothelial Keratoplasties (DMEK), and 25 (4.7%) Deep Anterior Lamellar Keratoplasties (DALK). The most common indication was Keratoconus (KC, 19%), followed by Fuchs endothelial dystrophy (FED, 18.8%), and Pseudophakic bullous keratopathy (PBK, 17%). KC (34%) and re-grafting (17%) were the leading indications for PK, whereas FED and PBK were the major indications for DSAEK (38% and 33%) and DMEK (67% and 20%), respectively. During the period studied, the number of transplants increased from 11.3 to 14 grafts per month. The number of PKs remained stable, whereas Endothelial Keratoplasties, DSAEK and DMEK, increased (3.8 to 5.6 and 0.2 to 1.6 per month, respectively), becoming the most commonly performed grafts since 2018. Only a small number of DALK were performed. CONCLUSIONS: Corneal transplantation in Ireland is following international trends as endothelial procedures have become the most common approach since 2018. However, a low overall number of transplants is performed in Ireland compared with other countries suggesting that care pathways should be implemented to improve access to corneal transplantation.

Surgical management of heavy eye phenomenon.

Heavy eye phenomenon can be cosmetically unaccepted due to significant pseudoproptosis and hypotropia. We highlight the salient features of this condition, and report successful cosmetic outcome following a staged procedure comprising orbital decompression and horizontal recti surgery.

Does the timing of silicone tube removal following external dacryocystorhinostomy affect patients' symptoms?

AIMS: To investigate whether the timing of silicone tube removal after external dacryocystorhinostomy (EXT-DCR) for lacrimal outflow obstruction affects outcome. METHODS: Retrospective chart review and follow-up by telephone survey of 205 consecutive patients undergoing EXT- DCR. Long-term success was evaluated by telephone survey. RESULTS: Full data was collected in 180 out of 205 DCRs. Ninety four tubes (52.3%) were removed routinely between 2 and 4 months after surgery, 24 tubes (13.3%) were removed before the planned 2-month period and 62 tubes (34.4%) were removed after the planned 4-month period. The three groups (early, routine and late) were comparable in terms of age, gender distribution, mode of anaesthesia, proportion of repeat EXT-DCRs and seniority of surgeon. The mean follow-up period was 3 years and 10 months. One hundred and twenty-eight of the 155 patients (82.5%) were contactable by phone. In the routine tube removal group, at the time of follow-up, 65.1% experienced complete symptom resolution, 25.4% experienced partial symptom resolution, 6.3% experienced no symptom resolution and 3.2% experienced worse symptoms. In the early tube removal group, at the time of follow-up, 63% experienced complete symptom resolution, 32% experienced partial symptom resolution and 5% experienced no change in symptoms. In the late tube removal group, at the time of follow-up, 70% experienced complete symptom resolution, 21.5% experienced partial symptom resolution and 8.5% experienced no symptom resolution. There was no statistically significant difference in the outcome of the three groups. CONCLUSIONS: Our experience and this study suggest that timing of silicone tube removal does not influence surgical success in EXT-DCR regardless of the cause of early or late tube removal.

The composition of the aphid fauna (Insecta, Hemiptera) of the Royal Botanic Gardens, Kew.

At least a dozen species of aphids (Insecta, Hemiptera) of non-native origin have expanded their range in Europe, however the importance of botanic gardens in this phenomenon has not been studied previously in detail. As a case study, investigations on the species composition and host range of Aphidomorpha in the Royal Botanic Gardens, Kew, London, United Kingdom, were conducted over a period of twelve days, in June 2017. The inventory study was carried out in the collection of living plants, both in the gardens and the glasshouses and nurseries. In total, 94 taxa of Aphidomorpha are identified (one phylloxerid, one adelgid and 92 species of aphids). 20 species are regarded as alien to the European aphid fauna and among them nine are believed to be the first published records for Kew. 20 species are regarded as serious pests, capable of virus transmission. The list of host plants includes 155 taxa from 89 genera and 49 families. Ericolophium holsti (Takahashi), species of Asiatic origin associated with Rhododendron spp., was found for the first time in the field in the UK. Changes in the species composition of the aphid fauna in reference to the Eastop's studies in 1960s were discussed.

Corneal inlay implantation complicated by infectious keratitis.

BACKGROUND/AIMS: To report five cases of infectious keratitis following corneal inlay implantation for the surgical correction of presbyopia. METHODS: This was a retrospective, observational case series. Five eyes of five patients were identified consecutively in two emergency departments during a 1-year period, from November 2013 to November 2014. Patients' demographics, clinical features, treatment and outcomes are described. RESULTS: There were four female patients and one male, aged 52-64 years. Three patients had the KAMRA inlay (AcuFocus) and two had the Flexivue Microlens inlay (Presbia Coöperatief U.A.) inserted for the treatment of presbyopia and they presented from 6 days to 4 months postoperatively. Presenting uncorrected vision ranged from 6/38 to counting fingers. One patient's corneal scrapings were positive for a putatively causative organism, Corynebacterium pseudodiphtheriticum, and all patients responded to broad-spectrum fortified topical antibiotics. All patients lost vision with final uncorrected visual acuity ranging from 6/12 to 6/60 and best-corrected vision ranging from 6/7.5 to 6/12. Two patients' corneal inlays were explanted and three remained in situ at last follow-up. CONCLUSIONS: Infectious keratitis can occur at an early or late stage following corneal inlay implantation. Final visual acuity can be limited by stromal scarring; in the cases where the infiltrate was small and off the visual axis at the time of presentation, the final visual acuity was better than those patients who presented with larger lesions affecting the visual axis. Though infection may necessitate removal of the inlay, early positive response to treatment may enable the inlay to be left in situ.

Anterior surface opacification of intraocular lenses after Descemet's stripping automated endothelial keratoplasty.

Descemet's stripping automated endothelial keratoplasty (DSAEK) is today recognised as the surgical procedure of choice for corneal endothelial dysfunction. The triple procedure (either staged or combined), whereby cataract surgery can be performed at the same time as endothelial keratoplasty, is well suited for patients with Fuch's endothelial dystrophy with decreased vision due to endothelial guttata, early stromal oedema and cataract formation. Recognised complications of DSAEK include donor graft detachment/dislocation, primary graft failure and pupillary block by air. Intraocular lens (IOL) opacification is a complication that is becoming apparent in patients who have undergone DSAEK and, to date, no definitive mechanism of such opacification has been discovered. Primary postoperative optic opacification of hydrophilic acrylic IOL designs has been attributed to the formation of calcium phosphate deposits. This has led to changes in lens designs, manufacturing processes and packaging. Secondary calcification is thought to be caused by environmental factors unrelated to the IOL model, such as breakdown of the blood-aqueous barrier. In this report, four cases of IOL anterior surface opacification are described in patients who required both cataract surgery and DSAEK. Only one case had cataract surgery and DSAEK performed concurrently, with the remainder having DSAEK performed at variable timeframes after cataract surgery.