Surgical considerations in skin of colour: minimizing pathological scars.

In most surgeries, the primary aim, for both surgeons and patients, is the success of the operation being undertaken. A secondary aim is for optimal wound healing with minimal scar formation. The normal wound-healing process involves four distinct but overlapping stages: haemostasis, inflammation, proliferation and remodelling. In some patients, the cellular process involved in the proliferation and remodelling stages can be deranged, resulting in the formation of hypertrophic or keloid scars, a phenomenon more frequently seen in skin of colour. The first report of excessive scarring is thought to be the Smith papyrus about 1700 BC. In the 20th century, both Mancini and Quaife (in 1962) and Peacock et al. (in 1970) classified excessive scarring into hypertrophic and keloid scar formation. Clinicians can minimize the risk of these pathological scars developing by using good preoperative, perioperative/intraoperative and postoperative surgical practices. This paper reviews the wound-healing processes in association with good surgical principles and practice, discusses how implementing these principles in practice helps in this prevention and management of pathological surgical scars such as hypertrophic scars and keloid scars. and offers a practical step-by-step clinical guide that can be used by any clinician.

Comparison of a manometric tear duct irrigation test with dacryoscintigraphy in the investigation of epiphora.

PURPOSE: Assessment of lacrimal resistance in patients with patent lacrimal systems is important in determining whether dacryocystorhinostomy (DCR) surgery is appropriate. Current techniques, including lacrimal syringing and dacryoscintigraphy (DSG), can be unreliable. We compare the results of a manometric tear duct test (mTDT) irrigation technique with DSG in these patients. METHODS: All symptomatic patients in a specialist lacrimal clinic had full work-up apart from syringing. Lacrimal resistance was assessed using mTDT which applies a fixed head of fluid pressure via a cannula sealed to punctum. Conventional syringing was also performed in cases with abnormal mTDT. Symptomatic patients with delayed tear clearance, no external cause for watering and patent lacrimal systems had DSG. MTDT and DSG results were compared, including in asymptomatic fellow eyes. RESULTS: 105 tear ducts were examined, 85 symptomatic. Symptomatic eyes had a significantly higher mean mTDT resistance (p = .0003) and more had abnormal mTDT (52%) compared to asymptomatic eyes (10%). Although mean tear duct resistance was higher in those with nasolacrimal duct stenosis (NLDS) than freely patent (FP) on syringing (8.5 vs 10.8 dpm), this was not significant (p = .6). High proportions of both FP and NLDS groups had no flow at all on mTDT (60% and 53%, respectively). DSG showed no significant difference in the symptomatic versus asymptomatic eyes (p = .36), nor between those with a normal or abnormal mTDT (p = .25), nor between FP and NLDS groups (p = .25). CONCLUSIONS: In contrast to DSG, the mTDT provides valuable, objective information on lacrimal resistance that can guide a decision to DCR surgery.

Assessment of lacrimal resistance using a manometric tear duct irrigation system.

Lacrimal surgery aims to provide a low-resistance tear drainage passage. An assessment of lacrimal resistance guides decisions on surgery. We present results of a modified tear duct irrigation system that reliably measures lacrimal outflow resistance. Patients in a specialist lacrimal clinic had a full work-up to the point of tear duct syringing. The tear ducts were irrigated using a manometric system, which applied a fixed, known head of fluid pressure to a lacrimal cannula. Fluid flow is recorded and the lacrimal resistance derived as fluid pressure/fluid flow (units cmH20 secml-1, for simplicity presented as drops per minute, dpm). Patient groups were: A: Asymptomatic, A1: subgroup where the fellow symptomatic eye had a visible cause for watering, B: external visible cause for watering (ocular surface/lid/punctum), C: no externally visible cause, D: post op DCR, E: post syringing and probing, F: mixed/other. 444 tear ducts were examined. Mean flows (dpm) were: A1 (n = 19) 55; B (n = 183) 46; C (n = 142) 22: D (n = 38) 52. Excluding complete obstruction (n = 29), tear duct syringing only detected 48% of those with impaired manometric flow. Of those with a normal tear duct syringing, 53% had impaired manometric flow; 34% had a flow of 0 dpm. Differences in A1 versus C; B versus C and pre versus post dacryocystorhinostomy were all statistically significant (p < 0.05). The manometric system presented reliably measures lacrimal resistance and provides a substantial increase in sensitivity and specificity over conventional lacrimal syringing.

Pleomorphic adenomas of the lower eyelid: a case series.

Pleomorphic adenomas are well-recognized tumors usually arising within the main lacrimal gland. Their occurrence, however, is not limited to the main lacrimal gland. There have been cases reported in the eyebrow, upper eyelid, lateral lower eyelid, lacrimal sac, and even intraocularly. The medial aspect of the lower eyelid is a very rare site of occurrence because it is largely devoid of accessory lacrimal glands. We describe 2 cases of pleomorphic adenomas arising in the medial aspect and 1 case arising in the middle of the lower eyelid, respectively. The likely origin of these tumors at this location is from ectopic lacrimal gland.

Lacrimal gland biopsies-results from a tertiary centre in the UK.

PURPOSE: To report the histopathological results of lacrimal gland biopsies over a 21-year period in a tertiary referral centre in the United Kingdom. To the best of our knowledge, this represents the largest series to be published in the United Kingdom. METHODS: A retrospective observational review was carried out for patients who underwent lacrimal gland biopsies in a tertiary referral centre at the University Hospitals of Leicester, United Kingdom between the years of 2000 and 2021. RESULTS: Lacrimal gland biopsies were performed on 248 patients during the specified 21-year period. They comprised 157 (63.3%) females and 91 (36.7%) males. The mean age at presentation was 50.8 years (range 15-94 years). The majority of patients were Caucasian (69.4%, n = 172) followed by Asians (25.0%, n = 62), African/Afro-Caribbean (4.8%, n = 12) and other ethnicities (0.8%, n = 2). The most common histopathological diagnosis was chronic inflammation dacryoadenitis (69.0%, n = 171) followed by lymphomas (15.3%, n = 38). CONCLUSION: Our study shows that chronic inflammation accounts for the majority of histopathological diagnosis followed by lymphoproliferative disorders.

A bilateral cicatricial ectropion and bilateral upper lid shortening caused by 5-fluorouracil toxicity in a patient with dihydropyrimidine dehydrogenase deficiency.

CONTEXT: Well-known causes of a cicatrizing ectropion are chemical/thermal injuries, dermatitis, cutaneous diseases, malignancies, and trauma. We add to this preceding list a systemic cause of a cicatrizing ectropion as a result of a rare side effect of 5-fluorouracil (5-FU), a common and frequently used chemotherapeutic agent. METHODS: A case report demonstrating the clinical presentation of a cicatricial ectropion caused by (5-FU) chemotherapy toxicity in a patient with dihydropyrimidine dehydrogenase deficiency. We also describe the subsequent investigations and management of this case. RESULTS: A bilateral cicatrizing lower lid ectropion, bilateral upper lid shortening, cicatrizing and sclerosing facial skin changes occurred in an 80-year-old male, undergoing preoperative chemoradiotherapy, incorporating Capecitabine, an oral 5-FU prodrug for a locally advanced rectal carcinoma. Severe 5-FU toxicity ultimately proved fatal but in addition to typical 5-FU related adverse effects, the patient developed bilateral incomplete lid closure, secondary corneal exposure and keratopathy. Due to the patient's extreme ill health, he was managed conservatively with a moist chamber. CONCLUSION: 5-fluorouracil chemotherapy in patients with dihydropyrimidine dehydrogenase deficiency, can give rise to ocular and cutaneous toxicity. We also present the complex management problems that have to be anticipated in treating such systemically compromised patients.

Fronto-orbital mucocele and orbital involvement in occult obstructive frontal sinus disease.

AIMS: To describe the clinical features of orbital involvement arising from occult obstructive frontal sinus disease and to highlight key features to aid diagnosis. METHODS: A retrospective review of the case notes of 15 patients who presented to three regional oculoplastics units over a 7-year period were reviewed. Patient demographics, clinical characteristics, relevant medical history, microbiology results, imaging, management and outcomes were assessed. RESULTS: The mean age of our patients was 55 years. Pain was the presenting feature in 8 patients while 14 presented with upper lid swelling and redness. This swelling was medial in 60% and diffuse in 40% of patients. Proptosis was noted in 11 patients. The correct diagnosis was suspected in only 53% of patients at the time of first presentation to an ophthalmologist. The mean time from onset of symptoms to the time of correct diagnosis was 53 weeks (median 3 weeks). On direct questioning, eight patients reported a previous history of intermittent upper lid swelling and eight patients had a past history of sinusitis or frontal sinus trauma. CONCLUSIONS: We present a large series of patients with occult sinus disease presenting with orbital involvement. As patients with this potentially life-threatening condition are often misdiagnosed, we hope this paper draws the ophthalmologist's attention to key pearls in the history and examination to make a prompt diagnosis.

Optic nerve sheath fenestration for idiopathic intracranial hypertension: a seven year review of visual outcomes in a tertiary centre.

PURPOSE: To determine visual outcomes of patients with Idiopathic intracranial hypertension (IIH), who underwent optic nerve sheath fenestration (ONSF), utilising the two most commonly used tools for monitoring visual function (visual acuity and visual fields) and a third less commonly used tool, colour vision. METHODS: A retrospective study of ONSF patients from 2004 to 2011. Patients' symptoms, body mass index, CSF opening pressure, and visual outcomes were analysed. RESULTS: ONSF's were carried out on 31 eyes of 14 patients. 64% were female and 36% were male. The most predominant symptom was a headache (93%). 71% of patients had a BMI>30. The average CSF opening pressure was 36mmHg (range 22-64). Post ONSF, visual acuity (VA) improved in 24.1%, remained stable in 62.1% and worsened in 13.8% of operated eyes. 6% were lost to follow up. Visual fields (VF) were reliable in 48% of operated eyes. Of these 33.4% improved, 53.3% remained the same and 13.3% worsened. Colour vision (CV) improved or remained stable in 87%, and worsened in 13% of operated eyes. 4 patients had tertiary procedures (LP or VP shunts). ONSF resulted in statistically significant improvement/stabilisation in visual acuity, visual fields and colour vision. Most importantly, this was not dependent on the body mass index. CONCLUSION: ONSF is a safe procedure in experienced hands. It predominantly stabilises visual function in majority of maximally medicated patients but also offers improved visual function to some patients. Colour vision monitoring is a useful adjunct in patient with unreliable visual fields. Unfortunately patients whose visual function deteriorated despite maximal medical and surgical treatment were often those who presented late or had a delay in their clinical diagnosis.

Management and clinical outcome of penetrating keratoplasty for long-term corneal changes in sympathetic ophthalmia.

Purpose. To report the visual outcome of penetrating keratoplasty performed on the sympathizing eye in three cases of sympathetic ophthalmitis. Methods. Interventional case series of three patients, diagnosed with sympathetic ophthalmitis, with corneal changes in the form of band keratopathy and decompensation underwent penetrating keratoplasty to the sympathizing eye. They had each sustained penetrating trauma as a child and had undergone previous cataract surgery and superficial keratectomy. Two patients had undergone lamellar keratoplasty prior to this procedure. One patient had undergone trabeculectomy for glaucoma, and she was on antiglaucoma medication. The preoperative visual acuity was 1/60 in the affected eye of each patient. Penetrating keratoplasty was performed in the sympathizing eye and the donor graft size was 7.50 mm, and the host graft size was 7.25 mm. Our patients were immunosuppressed prior to the procedure to help prevent graft rejection. Result. At one year follow-up, a BCVA of 6/36 or better was achieved in all three patients. Postoperative examination of the fundus showed peripheral chorioretinal atrophy with pigmentary changes at the macula, accounting for the limited vision. The grafts remain clear to date, and there has been no recurrence of uveitis or rejection. Conclusion. Penetrating keratoplasty can be considered as a surgical option to restore useful vision in a stable sympathizing eye in sympathetic ophthalmitis, and this depends on the extent of the pathology. However, these cases require treatment with immunosuppressives to prevent graft rejection and to prolong graft survival.