Diplopia Following the Insertion of a Canalicular Bypass Tube: Etiology, Risk Factors, Management, and Outcomes.

PURPOSE: To report the etiology, management, and possible risk factors for diplopia after canalicular bypass surgery. METHODS: A multicenter retrospective, noncomparative case series of patients who developed diplopia following canalicular bypass surgery were assessed. RESULTS: Twenty-four cases of diplopia were identified across 12 institutions. Tubes were inserted as a primary procedure with external dacryocystorhinostomy (DCR) (1; 4%) or without DCR (10; 42%) or as a secondary procedure after external (8; 33%) or endonasal (5; 21%) DCR. Factors predisposing to local damage were noted in 17 (71%): these factors included preexisting autoimmune/inflammatory condition (7 cases), medial canthal tumor resection (5 cases), preoperative radiotherapy (2 cases), 2 drug treatments (topical and systemic), and 1 local surgery. Horizontal diplopia was due to restriction of abduction and first noted at a median of 3.5 months (mean: 17.8 months, range: 1 day to 112 months) and persisted in 23 (96%) cases with a mean restriction of -2, affecting primary gaze in 4 patients and activities of daily living in 13 (42%). Seventeen patients received various treatments: 10 were operated on resulting in cure in 1 and improvement in 9. A stable degree of diplopia persisted in all but one patient. CONCLUSIONS: Restriction of abduction causing horizontal diplopia is a rare complication with canalicular bypass surgery and a notably high proportion occurred after tube placement without DCR; carunculectomy was not ubiquitous. Although in some the diplopia may be improved with intervention, the chance of cure is low. This complication should probably be included during informed consent for canalicular bypass tubes.

The management of periorbital nodular fasciitis using intra-lesional triamcinolone: a case report and review of the literature.

Nodular fasciitis (NF) is a subcutaneous, nodular, pseudo-sarcomatous, fibroblastic proliferation. It is rarely reported in the periorbital region and the management approach is variable.Presented is an eight-year-old female with a three month history of a periorbital mass. Incisional biopsy histologically confirmed nodular fasciitis with a unique gene translocation. The lesion was treated primarily with one intra-lesional injection of triamcinolone acetonide. Four months post-injection, the lesion resolved completely. No recurrence was seen at 12-months follow-up post-injection. No side effects were noted.To our knowledge. this is the first reported use of intra-lesional triamcinolone acetonide as a first-line treatment in periorbital NF. We found this to be a safe and effective treatment, which can obviate the need for surgical excision in a cosmetically sensitive region.

Early low-dose rituximab for active thyroid eye disease: An effective and well-tolerated treatment.

BACKGROUND: Thyroid eye disease (TED) is an autoimmune inflammatory disease that can be disfiguring and potentially sight threatening. Suppression of inflammation in active disease can reduce the risk of visual loss and limit long-term sequelae. Current management involves inflammation suppression using glucocorticoids. The aim of this study was to evaluate the efficacy of early disease intervention with targeted immunomodulatory therapy to alter disease course. This paper reports the efficacy of low-dose rituximab in reducing clinical activity in TED in a small population. METHODS: A retrospective audit of consecutive patients with active TED managed primarily with a 100 mg rituximab infusion. Further glucocorticoid or steroid-sparing agents were prescribed if clinically indicated. Clinical activity score, VISA overall severity score and Oxford Quality of Life score were recorded at each visit as well as TSH receptor antibody levels (TRAb), B cell subsets and adverse reactions. RESULTS: Twelve patients had mean follow-up of 6.3 months. Clinical activity scores significantly decreased (mean score 5.08 to 1.58; P < 0.001), VISA overall severity scores reduced by 50% from 12 to 6, P < 0.001 and the mean cumulative dose of IV methylprednisolone was 2.3 g. 100 mg rituximab induced significant CD19+ B cell depletion (n = 8, P < 0.001). There was no significant reduction in serum TRAb (n = 8, P = 0.06). A transient infusion-related rash was the only adverse effect, n = 4. QoL scores did not differ markedly before and after treatment. CONCLUSION: Low-dose rituximab is an efficacious, well-tolerated and safe treatment for active TED; reducing disease activity and allowing reduced administration of systemic steroid.

Periocular Manifestations of Afatinib Therapy.

Epidermal growth factor receptor tyrosine kinase inhibitor therapy has been increasingly employed in the treatment of a variety of tumors. The authors report the rarely documented side effect of trichiasis with the use of Afatinib in a patient with spinal chordoma and review-related literature. A 67-year-old lady was referred to the oculoplastic service with a 3-month history of ocular irritation and pain associated with blurred vision. She has a 4-year history of spinal chordoma treated with daily Afatinib 50 mg over the past 6 months. Clinical examination revealed trichomegaly and trichiasis affecting all 4 eyelids associated with blepharitis, conjunctival, and corneal abrasion on fluorescein staining. Hypertrichosis of the eyebrow bilaterally was also present. Afatinib and other epidermal growth factor receptor tyrosine kinase inhibitor-associated changes to eyelash and eyebrow hair is a result of epidermal growth factor receptor pathway activation in keratinocytes results in remodeling of the hair follicle. This results in the variation in the severity of clinical presentation of trichiasis.

Early use of steroid-sparing agents in the inactivation of moderate-to-severe active thyroid eye disease: a step-down approach.

OBJECTIVES: The current first-line treatment for management of active thyroid eye disease (TED) is high-dose intravenous corticosteroids, which have the potential for serious adverse effects. Our aim was to evaluate the effect of steroid-sparing agents (SSAs) in patients with moderate-to-severe active TED, using methotrexate as first-line. METHODS: Presented is a retrospective, four-year, single-centre, consecutive case series of patients with moderate-to-severe TED treated using the Oxford protocol. Treatment modality, disease activity, and adverse effects are reported at presentation, 6- and 12-month follow-up. RESULTS: 104 consecutive TED patients treated by the Oxford TED team were reviewed. 24 patients with moderate-to-severe active disease were identified (mean age 46.8 years;12 female) with a mean pretreatment VISA inflammatory index score of 5.5/10 (SD = 1.98; range 1-9). Intravenous methyl-prednisolone (IVMP) and an SSA was commenced in all patients. Mean total steroid dose was 2.72 g (SD = 1.4;1.0-6.9). 38% of patients (n = 9) received ≤1.5 g of IVMP. Only two patients required >4.5 g of IVMP equating to the EUGOGO treatment protocol dose for this patient group. There was significant improvement in inflammatory index score both at the intermediate review (mean score 2.7; SD = 2.8; P < 0.001; mean follow up 25.2 weeks) and at one year or last follow-up (mean score 1.4; SD = 1.5; P < 0.001; mean follow up 48.0 weeks). No serious or long-term adverse effects were reported. CONCLUSION: This study suggests that the initiation of an SSA, using methotrexate as first-line, with limited adjuvant IVMP is an effective and safe treatment for moderate-to-severely active TED, resulting in a significant reduction in both disease activity and total steroid load.

Acute Sickle Cell Orbitopathy Masquerading as Orbital Cellulitis.

Sickle cell orbitopathy is a rare manifestation of a sickle cell crisis and can closely mimic orbital cellulitis, both clinically and radiologically. We present a case where a child presented with what was thought to be orbital cellulitis and was treated accordingly. Subtle radiologic features of sickle cell orbitopathy were initially overlooked, resulting in an incorrect diagnosis and a treatment delay for the patient. Correctly treated most cases resolve with no adverse affects, highlighting how important it is to consider acute sickle cell orbitopathy in the differential diagnosis of acute periorbital swelling in children with sickle disease.

A quality of life survey in patients with long-term silicone oil or phthisis bulbi.

AIM: The aim of this study is to determine whether there is any difference in the quality of life of patients with a blind eye with long-term silicone oil compared to without. METHOD: Patients with either long-term silicone oil in situ (N = 17), defined as a period greater than 6 months duration with no plan for future removal, or those with a phthisical, non oil-filled eye were identified (N = 13). Two validated questionnaires (NEI VFQ-25 and the FACE-Q) that cover indicators for visual function, pain and cosmesis were sent to all patients in the two cohorts. RESULTS: There was no significant difference found in quality of life outcomes between the two groups in terms of visual function, pain or cosmesis. CONCLUSION: The results of this study support a holistic approach to the consent process before vitreoretinal surgery. Patients that may need to undergo multiple vitreoretinal procedures, where the endstage result is a long-term silicone oil fill, should be informed that their functional outcome may be similar to having no surgical intervention.

The Nonsurgical Management of Orbital Dystopia Using Refractive Lenses and Prosthetic Shells.

Surgical rehabilitation of orbital dystopia can be challenging. The authors demonstrate the effective use of spectacle lenses to visually correct misalignments of the globe and the orbit. Presented is a retrospective review of 4 patients undergoing aesthetic rehabilitation through use of spectacle lenses and in a number patients a cosmetic shell.Two patients with neurofibromatosis presented with inferior dystopia of the globe and orbit. A base-down prismatic lens applied to the spectacles in conjunction with a prosthetic shell successfully visually corrected the facial asymmetry and improved patients' aesthetic appearance. One patient with a history of traumatic retinal detachment, who did not want any surgical intervention, a "plus" (hypermetropic) lens was used to magnify the perceived image of an enophthalmic and phthisical globe, to enhance appearance and improve symmetry. In the fourth patient, with Goldenhar syndrome, the appearance of a hypotropia and concurrent esotropia was successfully treated with a Fresnel prism and a prosthetic shell.This case series illustrates the successful role of various refractive lenses often in conjunction with prosthetic shells in patients with reduced vision and orbital dystopia to improve facial symmetry. This conservative treatment is especially useful when surgery is not a desired or not considered a suitable option for the patient.

Reconstruction of extensive medial canthal defects using a single V-Y, island pedicle flap.

The medial canthus represents one of the most challenging regions of the face to reconstruct due to the anatomical structures present, the concavity of the area, and the differences in skin texture. We present a case series of 11 patients whose defects were reconstructed with a single V-Y island pedicle flap running along the nasofacial sulcus. Our single-stage flap which modified and simplified a previously described technique achieves similar cosmetic and postoperative outcomes along with a high level of patient satisfaction in an area which can be reconstructed in a variety of ways, often with suboptimal results.

The "reading man" flap for reconstruction of large periorbital defects.

PURPOSE: The "reading man" flap (RMF), a double advancement transposition cutaneous flap named for its appearance, has been described in the reconstruction of various circular skin defects, particularly in the malar region. We describe two cases where this flap was used to reconstruct the lower eyelid/periorbital region. METHODS: Two oculoplastic patients with lower eyelid basal cell carcinomas underwent Mohs micrographic excision resulting in a large skin defects. In both cases, reconstruction was performed using the RMF. RESULTS: At 6 months, both patients achieved good cosmetic results with no case of secondary eyelid malposition. CONCLUSION: The RMF is a useful adjunct to the armamentarium of the oculoplastic surgeon for the reconstruction of large periorbital defects.

Ectopic orbital meningioma: Fact or fiction?

Primary intraorbital ectopic meningiomas are rare and their existence remains controversial. We present a 30-year-old female with painless, non-axial proptosis and a palpable superomedial mass. The MRI demonstrated that the mass had no optic nerve sheath or sphenoid wing involvement and was initially reported to have no intracranial extension. The patient was initially thought to have an ectopic orbital meningioma. Subsequent multidisciplinary team (MDT) consultation and further specialist review of the MRI revealed a subtle dural tail connecting to an enhancing mass in the olfactory groove. Biopsy revealed a WHO Grade 1 transitional meningioma with an infiltrative pattern. We argue that some previously reported cases of ectopic meningioma may lack the requisite imaging to discover the primary disease. Our report highlights the importance of MRI in this group of patients and the role of a skull-base MDT with specialist neuroradiology input to determine the true origin and extent of these extradural orbital meningiomas.

Key Issues When Reconstructing Extensive Upper Eyelid Defects With Description of a Dynamic, Frontalis Turnover Flap.

Reconstruction of full thickness, total upper eyelid defects represents a significant challenge in terms of recreating an upper eyelid which has acceptable cosmesis and a degree of dynamic function. Options include bridging, eyelid-sharing techniques (e.g., Cutler-Beard), or nonbridging techniques such as an anterior lamella-based flap combined with a posterior lamella free graft or a "sandwich flap." The success of these techniques depends on the size of the defect, postoperative cosmesis and whether or not the upper eyelid still has a degree of dynamic function to avoid ptosis and exposure keratopathy. The authors present an innervated frontalis turnover flap supporting anterior and posterior lamella grafts as a reconstructive solution for an extensive upper eyelid defect. This technique is cosmetically acceptable, preserves local tissues, and maintains a degree of dynamic function, which keeps the patient's eye comfortable and does not adversely affect visual acuity.

Review on surgical management of ptosis and the use of phenylephrine: A national survey of British Oculoplastic Surgery Society (BOPSS) UK Consultants.

We assess current practice using topical phenylephrine by British Oculoplastic Surgery Society (BOPSS) consultants in the surgical management of ptosis. All UK consultant BOPSS members were invited to participate in a web-based survey, consisting of 8 questions relating to the surgical management of adult primary involutional ptosis with normal levator function and the use of phenylephrine in the management of ptosis. 53 BOPSS consultants (43%) completed the survey, of which 76% perform anterior approach levator advancement as first-line surgery. Then, 40% of consultants routinely use phenylephrine unilaterally in the ptotic eye, with 90% using 2.5% as opposed to 10%. Also, 77% of consultants use topical phenylephrine to illustrate the predicted outcome of surgery for the patient's benefit and 65% modify their approach on the basis of the test. If phenylephrine raises the ptotic eyelid >2 mm, those using an anterior approach reduces to 13.6%, with majority using a posterior approach (86.4%). If phenylephrine induces no improvement, then 76% use an anterior approach. If phenylephrine induces a contralateral ptosis 79% of consultants will perform simultaneous bilateral surgery. A number of interesting trends were observed amongst BOPSS consultants in their surgical approach to ptosis based on the phenylephrine test. The majority of consultants will switch from anterior to posterior approach surgery when the phenylephrine test is strongly positive and will also perform bilateral surgery when a contralateral ptosis is induced with phenylephrine.

The Learning Curve in Endoscopic Dacryocystorhinostomy: Outcomes in Surgery Performed by Trainee Oculoplastic Surgeons.

PURPOSE: To report outcomes of endoscopic DCR (En-DCR) performed by oculoplastic trainees and describe factors to improve success rates for trainees. METHODS: Retrospective, single-centre audit of En-DCR procedures performed by three consecutive trainee oculoplastic surgeons, over a 3-year period. Trainees also completed a reflective-learning questionnaire highlighting challenging and technically difficult aspects of En-DCR surgery, with relevant tips. RESULTS: Thirty-eight consecutive independently-performed en-DCR procedures on 38 patients (mean age 58.6 ± 21.4 years) were studied. Mean time spent in the operating-theatre was 95.7 ± 27.3 minutes. Success rate for each year was 15/17(88%), 8/8(100%) and 7/13(54%), respectively, at mean follow-up 12.5 ± 12 months. The lowest success rate year coincided with use of silicone stents in 31% cases compared to 94% and 100% in the previous 2 years. In cases that failed, video-analysis highlighted inadequate superior bony rhinostomy (2 cases), incomplete retroplacement of posterior-nasal mucosal-flaps (3 cases), significant bleeding (1 case). Those who underwent revision surgery (n = 6), were found to have soft-tissue ostium and sac closure requiring flap revision. Two-cases required further bone removal supero-posterior to the lacrimal sac. Trainees-tips that helped improve their surgery related to patient positioning, instrument handling, bone removal and posture. CONCLUSION: Good surgical outcomes are achievable training in en-DCR surgery. Adequate operating time needs to be planned. Failure was primarily due to closure of the soft-tissue ostium, either secondary to inadequate osteotomy and sac-marsupialisation or postoperative scarring. Intra-operative mucosal trauma is higher amongst trainees and adjuvant silicone stenting during the training period may be of value where mucosal adhesions are anticipated.

Orbital compressed air and petroleum injury mimicking necrotizing fasciitis.

BACKGROUND: Orbital injury secondary to petroleum-based products is rare. We report the first case, to our knowledge, of a combined compressed air and chemical orbital injury, which mimicked necrotizing fasciitis. CASE REPORT: A 58-year-old man was repairing his motorcycle engine when a piston inadvertently fired, discharging compressed air and petroleum-based carburetor cleaner into his left eye. He developed surgical emphysema, skin necrosis, and a chemical cellulitis, causing an orbital compartment syndrome. He was treated initially with antibiotics and subsequently with intravenous steroid and orbital decompression surgery. There was almost complete recovery by 4 weeks postsurgery. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Petroleum-based products can cause severe skin irritation and necrosis. Compressed air injury can cause surgical emphysema. When these two mechanisms of injury are combined, the resulting orbitopathy and skin necrosis can mimic necrotizing fasciitis and cause diagnostic confusion. A favorable outcome is achievable with aggressive timely management.

Meta-analysis of the adjunctive use of mitomycin C in primary and revision, external and endonasal dacryocystorhinostomy.

PURPOSE: To determine whether application of the anti-proliferation agent, mitomycin C (MMC), to the osteotomy site during dacryocystorhinostomy (DCR) surgery increases surgical success rates. METHOD: We conducted a comprehensive meta-analysis of randomised controlled clinical studies relating to the adjunctive use of MMC in primary and revision, as well as external (EX-DCR) and endonasal DCR (EN-DCR). RESULTS: 15 studies met our inclusion criteria with a total of 850 DCR procedures. The mean concentration of MMC used was 0.3 mg/ml (range 0.02-0.75 mg/ml) and mean duration of application 18 min (range 2-30 min). MMC significantly reduced the failure rate of primary EX-DCR (risk ratio, RR, 0.51; 95% confidence interval, CI, 0.31-0.86) and revision EN-DCR (RR 0.43; 95% CI 0.21-0.89). The adjunctive use of MMC in primary EN-DCR, however, did not confer a significant reduction in failure rate compared with control (RR 0.94; 95% CI 0.44-2.04). We found a deficiency of evidence regarding the potential benefit of MMC in revision EX-DCR. Only two cases of adverse effects relating to the use of MMC were reported among the studies, both of which related to delayed wound healing. CONCLUSIONS: Application of MMC to the osteotomy site is a safe and effective way of increasing surgical success rate in primary EX-DCR and revision EN-DCR, but does not provide any significant benefit in primary EN-DCR. Further studies are required to evaluate the potential effect of MMC in revision EX-DCR.

Transcaruncular medial canthal tendon plication with lower eyelid suture sling in facial nerve palsy.

PURPOSE: To report a technique for correcting lower eyelid punctal ectropion with an inferiorly displaced or retracted medial eyelid due to facial nerve palsy, by extending a suture sling along the pre-tarsal lower eyelid when performing transcaruncular medial canthal tendon plication. METHODS: Single-centre retrospective, non-comparative review of patients with facial nerve palsy who underwent medial canthal tendon plication with lower eyelid suture sling (MCT suture sling). Outcome measures included: the presence of lower eyelid ectropion, medial eyelid height, punctal position, inferior marginal reflex distance (MRD) and inferior scleral show measured both pre-operatively and at the last follow-up visit. RESULTS: Thirty-three patients with facial nerve palsy with a mean age of 59, underwent MCT suture sling for lagophthalmos and/or ectropion. Then, 66% (21/32) of cases had punctal ectropion pre-operatively and 9% (3/32) had punctal ectropion at the last follow-up. Medial eyelid height was deemed to improve in 66% (21/32) of cases at the last follow up visit. Follow-up was mean 13.5 months. Six (18%) patients were deemed failures due to inferior MRD and inferior scleral showing worse than pre-operative measurements. DISCUSSION: We report a technique for incorporating a suture sling to transcaruncular-approach MCT plication when the medial canthus has retracted or descended thus requiring support and a posterior vector. It avoids rounding of the medial canthal angle that may occur with traditional medial canthoplasty. Transcaruncular MCT plication is well described. Incorporating a suture sling to potentially reduce single point-fixation cheese-wiring and early dehiscence is minimally invasive, non-excisional and repeatable.

Dacryoadenitis associated with linear scleroderma en coup de sabre: A case report and review of literature.

Dacryoadenitis in the setting of linear scleroderma en coup de sabre (LScs) is an association that has not previously been described in the scientific literature. The purpose of this case report is to describe the co-existence of LScs and chronic dacryoadenitis and how it was managed. We report the case of a 42-year-old woman who presented with a 4-month history of left upper eyelid swelling with radiological enlargement of the left lacrimal gland on orbital CT and MRI imaging. Clinical examination revealed a left erythematous, swollen upper eyelid with lateral conjunctival injection and a palpable left lacrimal gland. An ipsilateral band-like cutaneous depression in the fronto-temporal region was also noted, which extended to the ipsilateral upper eyelid and brow. Serology revealed nucleolar antinuclear antibodies. A further incisional biopsy of the lacrimal gland confirmed chronic inflammatory changes and fibrous tissue. Based on both the histological and clinical findings, a diagnosis of dacryoadenitis in association with LScs was made. Oral methotrexate was commenced. The patient responded well with less frequent episodes of eyelid swelling and reduced periocular pain. This case describes for the first time, the ophthalmological manifestation of chronic dacryoadenitis in association with linear scleroderma en coup de sabre.

Management and outcomes of patients with epiphora referred to a specialist ophthalmic plastic unit.

BACKGROUND: To describe the aetiology and management of the symptom epiphora presenting to a specialist ophthalmic service. DESIGN: A retrospective case series and patient postal questionnaire of all new referrals seen in a specialist unit with primary symptoms of epiphora between January 2007 and December 2008. The study was begun in 2010 to allow a 2-year follow-up for this cohort. PARTICIPANTS: Two hundred thirty-seven patients were identified, of which 192 met the inclusion criteria. Fifty-seven were male, 135 were female, with a mean age of 60.7 (range 0-95) years. METHODS: Patients were identified using a key word search of clinic letters and a search of primary care coding. MAIN OUTCOME MEASURES: Duration of symptoms, referral source, aetiology and subjective improvement of symptoms post treatment. RESULTS: At consultation, patients had experienced epiphora for a mean of 41.1 (range 0.066-360) months. A diagnosis of partial or complete nasolacrimal duct obstruction (31.8%), dry eye with secondary reflex tearing (29.2%), eyelid malposition (10.4%) and multi-factorial epiphora (28.7%) was made after follow-up and treatment. A postal questionnaire follow-up showed that 25% of patients no longer had any epiphora, with 67% reporting an improvement in their symptoms. Final follow-up was 30-54 months. CONCLUSIONS: This study highlights the protean aetiology of the symptom and sign, epiphora. Sparse data exist on the audited success in managing this common symptom and sign. This study helps introduce an example of a benchmark for evaluating the effectiveness of epiphora. The majority of patients were referred, usually by ophthalmologists for lacrimal surgery.