Patient satisfaction following endoscopic endonasal dacryocystorhinostomy: a quality of life study

PURPOSE

To assess the subjective success and quality of life of adult patients post endoscopic endonasal dacryocystorhinostomy (EE-DCR) for acquired nasolacrimal duct obstruction.

DESIGN

Retrospective, questionnaire study performed at least 6 months post EE-DCR.

PARTICIPANTS

Hundred and ten of the 282 consecutive patients who underwent EE-DCR.

METHODS

A standardised questionnaire (Glasgow Benefit Inventory, GBI) was used to analyse the quality of life. The questionnaire examines four parameters, providing total, subscale, social, and physical scores.

MAIN OUTCOME MEASURES

We aimed to assess patient experience following EE-DCR surgery. Total GBI scores range from -100 to +100, the former reflecting maximal negative benefit and corresponding to subjective worsening of tearing and impact on quality of life. Any positive score reflects a satisfactory surgical outcome and +100 represents maximal positive benefit. A score of zero is no perceived benefit.

RESULTS

The average age was 62 years, 63% were female. In three of the parameters measured, there was a subjective improvement post surgery: subscale score 22.16 (95% CI: 15.23-29.09), total score 15.04 (95% CI: 9.74-20.35), and social support score 4.67 (95% CI: 0.93-8.42). Physical health scored -4.47 (95% CI: -10.25 to 1.32). Secondary analyses demonstrate no statistical significance with respect to outcome whether a trainee or consultant performed the procedure. Younger patients (under split median of 63.5) had a better total score 19.04 (95% CI: 11.35-27.74) than those older than 63.5 years (11.04, 95% CI: 3.61-18.47).

DISCUSSION

This study shows that EE-DCR gave patients improvement in quality of life, proven by a validated questionnaire. The mean total score of 15.04 found in our study compares with the 18.7 recorded by Feretis et al in 2009. Results were irrespective of the grade of surgeon, similar to the findings of Fayers et al for functional successes.

CONCLUSION

This study supports the use of EE-DCR for the improvement of quality of life in adult patients.

The lateral tarsal strip in ectropion surgery: is it effective when performed in isolation?

PURPOSE

The lateral tarsal strip (LTS) for involutional ectropion is often performed with a medial spindle (tarsoconjunctival diamond excision). We aimed to evaluate how well the LTS alone can achieve symptomatic relief.

METHODS

A retrospective, comparative case series was performed on consecutive patients undergoing LTS alone or with medial spindle for involutional ectropion. Outcomes for LTS alone were clinically derived functional success (improvement in symptoms and aesthetic appearance) and anatomical success (judged by punctal position in the tear lake, punctal movement during blinking and absence of ectropion). We verified if these outcomes compared favourably with those of the patients who had undergone an LTS with medial spindle. Procedure selection was based on pre-operative clinical examination, especially the lateral pinch and twist test (this is described). Complications were also recorded.

RESULTS

Of 67 eyes, 23 had LTS alone and 44 had LTS with a medial spindle. Of those having LTS alone the functional success rate was 87% (95% CI (66.4, 97.2%)). This did not differ significantly from a success rate of 89% (75.4, 96.2%) in LTS with a medial spindle (P=0.99). A total of 78% (56.9, 92.5%) of patients undergoing LTS had a good anatomical result compared with 82% (67.3, 91.8%) of those who had an additional medial spindle (P=0.75). Complication rates were similar between the groups.

CONCLUSION

Where the lateral pinch and twist test returns the eyelid to a good position, the LTS alone can suffice for the management of involutional ectropion.

A clinical trial of endoscopic vs external dacryocystorhinostomy for partial nasolacrimal duct obstruction

OBJECTIVE

A literature review revealed there is no outcome data for endoscopic endonasal dacryocystorhinostomy (EES-DCR) in the subgroup of patients with acquired partial nasolacrimal duct obstruction (NDO). This study aimed to compare the results of EES-DCR vs external DCR (ext-DCR) in the treatment of partial NDO.

DESIGN

This study is designed as a prospective nonrandomised comparative clinical trial.

PARTICIPANTS

In total, 46 adult patients with acquired partial NDO participated in this study.

METHODS

Partial (sometimes called 'functional') NDO (epiphora in the presence of patent syringing) was confirmed by nuclear lacrimal scintigraphy or delayed drainage on dacryocystography. Patients with 'functional' epiphora from other causes were excluded. Post-operative outcome was assessed at 6 months. Overall, 21 (46%) patients had EES-DCR and 25 patients had (54%) ext-DCR.

MAIN OUTCOME MEASURES

Subjective success was based on patient symptoms, objective success on patency with syringing and a functioning rhinostomy evaluated using the functional endoscopic dye test (FEDT).

RESULTS

In total 18 out of 21 (86%) of EES-DCR patients had marked reduction (n=11) or complete resolution (n=7) and 25 out of 25 (100%) of ext-DCR had marked reduction (n=9) or complete resolution (n=16) of epiphora. In total 17 out of 18 (94%) of the EES-DCR patients with subjective success had a positive FEDT. All 25 out of 25 (100%) ext-DCR patients with subjective success had a positive FEDT. The three failed EES-DCR patients were all blocked on syringing. Statistically, EES-DCR does not achieve the same success rate as ext-DCR in this study (P=0.09, two-tailed Fisher's exact test, 0.045 one-tailed).

CONCLUSIONS

Both endoscopic and external DCRs provide satisfactory outcomes in acquired partial NDO. The success rate is nevertheless higher in ext-DCR compared with EES-DCR.

Image guidance removal of a foreign body in the orbital apex

Retrieval of foreign bodies lodged in the orbit present a challenging surgical problem. The trans-nasal approach when combined with image-guided navigation allows clear identification of structures and increased safety. We report a case of a successful removal of a foreign body under image-guidance using a trans-nasal approach.

British Oculoplastic Surgery Society (BOPSS) National Ptosis Survey

AIM

To assess the results of primary aponeurotic ptosis surgery among UK ophthalmic oculoplastic surgeons, from both the surgeon's and patient's perspective; also to inform and encourage good clinical practice by generating outcomes for individual surgeons, units and for benchmarking purposes.

METHODS

A prospective, web-based, non-comparative, interventional study was conducted over a period of 1 year commencing January 2005 and ending December 2005. The data-entry sheet for the preoperative, operative and postoperative data was completed and submitted online via the British Oculoplastic Surgery Society website. Surgical results were assessed objectively (by the surgeon) by measuring the upper lid margin reflex distance (uMRD) and the interlid difference in: MRD, lid show, skin crease and lid contour with the outcome graded as: success, partial success or failed. Surgical results were also assessed subjectively (by the patient) with the outcome graded as: completely satisfied, significantly improved, no change or worse than before the operation.

RESULTS

Three hundred and sixty-five patients undergoing primary aponeurotic ptosis repair, from 40 different consultant-led teams with a declared oculoplastic interest and expertise, originating from 27 units across the UK were entered into the study. Using objective criteria, success was achieved in 128/223 (57%) cases, with significantly greater degrees of success seen in patients with mild ptosis and for surgeons who performed ptosis surgery more frequently. Using subjective criteria, 184/282 (65%) of patients were completely satisfied, with a further 89/282 (32%) judging themselves significantly improved. The patients' assessment of the surgery was less critical than that of the surgeons: 46/138 (33%) of patients who were completely satisfied and 37/72 (51%) of those who were significantly improved did not meet the criteria for a successful surgical outcome. The re-operation rate was 8/313 (2.6%).

CONCLUSIONS

The authors have generated a valid series of surgical outcomes both for individuals, units and the UK as a whole, expressed in both objective and subjective terms for what we regard as the signature procedure for an oculoplastic surgeon: aponeurotic ptosis surgery. Individual results have been communicated to our members, which will allow them to compare their results with true peer-group-generated figures and will aid appraisal and ultimately revalidation.

Esophageal adenocarcinoma metastatic to the orbit

A 75-year-old woman presented with orbital and ethmoidal metastases from an esophageal adenocarcinoma 6 months after diagnosis of the primary.

Masked orbital abscess in Wegener's granulomatosis

Two patients with chronic Wegener's granulomatosis presented with worsening proptosis and visual acuity. Both patients had been maintained on long-term corticosteroids, which led to masking of the signs of orbital sepsis with potentially life-threatening implications.

Autogenous temporalis fascia patch graft for porous polyethylene (Medpor) sphere orbital implant exposure

BACKGROUND

Temporalis fascia has been recommended for hydroxyapatite sphere exposure. The aim of this study was to identify potential risk factors for exposure of porous polyethylene (Medpor) sphere implants and evaluate the use of autogenous temporalis fascia as a patch graft for exposure.

METHODS

A retrospective review of consecutive cases of porous polyethylene sphere orbital implant exposure.

RESULTS

Five cases presented between May 2000 and October 2001 (three males, two females; mean age 44.5 years). Three had enucleation (two with primary implants) and two had evisceration (one with primary implant). Exposure occurred in one primary, two secondary, and two replacement implants. Orbital implant diameter was 20 mm in four cases and 16 mm in one case (contracted socket). The mean time from implantation to exposure was 23 months (range 0.7-42.6). Three patients had secondary motility peg placement before exposure. The average time from last procedure (sphere implant or peg insertion) to exposure was 3 months (range 0.7-12.6). Four patients required surgical intervention, of which three needed more than one procedure. Autogenous temporalis fascia grafting successfully closed the defect without re-exposure in three of these four patients. The grafts were left bare in three patients, with a mean time to conjunctivalise of 2.4 months (range 1.6-3.2).

CONCLUSIONS

Exposed porous polyethylene sphere implants were treated successfully with autogenous temporalis fascia graft in three of four patients. This technique is useful, the graft easy to harvest, and did not lead to prolonged socket inflammation, infection, or extrusion.

Management of Mersilene® mesh chronic eyelid complications: a systematic approach

BACKGROUND

Mersilene mesh (polyester fibre) is commonly used in ptosis surgery for frontalis suspension as it is readily available and cheap. Management of extrusion can be challenging. We report three cases of extrusion where extremely thick mesh or extremely thin tissue may have contributed to the extrusion.

METHODS

Retrospective case note study of three adult patients who developed chronic mesh extrusion.

RESULTS

Extrusion and chronic infection occurred 5-12 months after surgery. Despite systemic antibiotics, all three patients required surgical excision of mesh from the eyelid up to the brow, which was curative.

CONCLUSION

These cases illustrate the need for a systematic approach and the need in some cases to excise the mesh to prevent recurrent infection.

Functional results and complications of Mersilene mesh use for frontalis suspension ptosis surgery

AIMS

To assess the functional results and complications of Mersilene (polyester) mesh frontalis sling suspension to correct poor levator function ptosis.

METHODS

Retrospective case series. 32 eyelids of 20 patients (12 children and eight adults).

RESULTS

Follow up 1-69 months (mean 32).

CHILDREN

eight patients had bilateral and four unilateral surgery (20 eyelids). Good long term functional results were achieved in 73% (8/11 children) and 77% (14/18) eyelids. Two children had early postoperative wound infection requiring removal of mesh in one; the other was lost to follow up following medical treatment.

ADULTS

four patients had bilateral and four unilateral surgery (12 eyelids). Good long term functional results were achieved in 75% (6/8 patients, 9/12 eyelids). One postoperative wound infection and one mesh exposure were treated definitively by surgical excision of mesh.

CONCLUSION

Mersilene mesh provides good functional results but up to 20% of patients have early soft tissue complications. Other materials such as monofilament suture or autogenous fascia lata should be considered.

A consideration of the time taken to do dacryo-cystorhinostomy (DCR) surgery

PURPOSE

Comparison of surgical times for dacryocystorhinostomy (DCR) by three different approaches: (1) external, (2) endoscopic endonasal surgical (EES), and (3) endoscopic endonasal laser (EEL) using the holmium:YAG laser. The merits and limitations of each approach are considered and surgical throughput predicted.

METHODS

Prospective study of adult patients undergoing primary DCR surgery for nasolacrimal duct obstruction. Surgical times were recorded. Subjective and objective outcomes were assessed at a minimum of 6 months.

RESULTS

A total of 48 patients undergoing 51 DCR procedures were studied. The mean surgical time for primary external (n=20), EES-DCR (n=16), and EEL-DCR (n=15) was 41.1+/-10.3, 39.6+/-13.8, and 20.9+/-7.8 min, with symptomatic success achieved in 95, 88, and 60%, respectively. Follow-up was 6-36 months, mean 8 months. It was calculated that if six EEL-DCR, four EES-DCR, or three external DCRs are performed per list for 45 lists per annum, this equals a total of 270 EEL-DCR, 180 EES-DCR, and 135 external DCRs. Of these, 108 EEL-DCR, 22 EES-DCR, and seven external DCRs will fail. If 75% of these have redo surgery using the same technique, an extra 13.5 (EEL-DCR), four (EES-DCR), and two (external DCR) lists are needed.

CONCLUSIONS

There was no significant difference between the time taken to do EES-DCR compared to external DCR, and their clinical outcomes. Only EEL-DCR was significantly faster (P<0.001). However, its lower success rate negates the apparent benefit from the greater surgical throughput.

Lower eyelid medial canthal tendon laxity grading: an interobserver study of normal subjects

OBJECTIVE

To describe a simple grading system for medial canthal tendon (MCT) laxity and measure its reproducibility.

STUDY DESIGN

Observational case series and interobserver variability study.

PARTICIPANTS

Fifty subjects (100 lower eyelids) without eyelid disease. The age range was 19 to 98 years.

METHODS

Subjects without eyelid pathology or previous surgery were selected. Two ophthalmologists assessed the position of the inferior punctum in relation to the cornea with the patient in primary gaze. Two measurements were made, the first with the lower eyelid at rest and then with the lateral distraction test. Both observers were masked to the other observer's measurements.

MAIN OUTCOME MEASURES

Kappa statistics to show the strength of agreement between the two observers for the resting and lateral distraction eyelid positions.

RESULTS

High kappa values were found for resting position (agreement in 92 of 100 eyelids) and for lateral distraction testing (agreement in 85 of 100 eyelids). The range of resting positions was from position -1 to position 1. The range of laterally distracted positions was from position 0 to position 5. Overall, a very high level of agreement was achieved between observers.

CONCLUSIONS

This grading system for MCT laxity is simple, easy to learn and reproducible, easier than measuring in millimeters, and has an advantage over merely saying the tendon is "lax" or "not lax." We propose this standardized grading system in the evaluation of patients with entropion and ectropion to identify those patients who may benefit from MCT stabilization/plication.

Raising the suborbicularis oculi fat (SOOF): its role in chronic facial palsy

AIMS

To determine the adjuvant role of unilateral suborbicularis oculi fat (SOOF) lift in the periorbital rehabilitation of patients with chronic facial palsy.

METHODS

In a non-comparative prospective case series nine adult patients (seven male, two female) aged 34-90 years (mean 60.5) with chronic unrecovered facial palsy (over 1 year), who had not had any previous rehabilitative periorbital surgery, were studied. Lateral tarsal strip and adjuvant transconjunctival approach subperiosteal SOOF lift under local or general anaesthesia were performed; medial canthoplasty was performed where indicated. There was clinical observation of the long term (over 1 year) effect on the ptotic palpebral-malar sulcus and lower eyelid retraction.

RESULTS

The patients were followed up for 12-24 months (mean 16). Seven patients (77%) had sustained clinical reduction of palpebral-malar sulcus ptosis. All patients had sustained reduction of lagophthalmos. Early postoperative complications included conjunctival cheimosis in 77%. Three patients with persistent keratitis required further surgical procedures on their upper eyelid to reduce the palpebral aperture. There were no cases of infraorbital nerve anaesthesia or recurrent lower eyelid retraction.

CONCLUSIONS

The SOOF lift has an adjuvant role in chronic facial palsy with lower eyelid retraction and ptotic-palpebral malar sulcus. It supports the lower eyelid elevation and tightening achieved with the lateral tarsal strip. The best results were obtained in congenital facial palsy.

Effective small-incision surgery for involutional lower eyelid entropion

OBJECTIVE

The aim of this study was to develop an effective and minimally invasive operation to correct lower eyelid entropion that would address both the horizontal and vertical laxity.

DESIGN

A prospective, noncomparative, interventional case series.

PARTICIPANTS

Thirty-five consecutive patients with involutional entropion, aged 62 to 92 years (mean, 77.1 years), had surgery on 45 lower eyelids. Of the 45 procedures, 33 (73%) had a primary procedure and 12 (27%) were reoperations.

INTERVENTION

A lateral tarsal strip with diagonal tightening of the orbital septum and lower lid retractors to the lateral orbital rim was performed via a 1-cm lateral canthal incision.

MAIN OUTCOME MEASURES

Complications and surgical outcome were monitored clinically for between 12 and 24 months after surgery.

RESULTS

The results were analyzed from 42 eyelids (33 patients) with a mean follow-up of 17.1 months (range 12-24 months). Two patients died and one dropped out of the study 3 months after the second eyelid operation. In 36 cases (86%), the entropion was cured. Transient lateral orbital rim tenderness was noted in six cases (14%), and one patient had a wound infection. Anatomic recurrences were detected in six eyelids of six patients, and five of these (83%) were asymptomatic.

CONCLUSIONS

This surgical approach has been found effective in 86% of eyelids. Adequate clinical followup has proven essential for accurate evaluation of entropion surgery.

Diagrammatic representation of lacrimal disease

PURPOSE

To design a diagrammatic record of lacrimal disease using easily interpretable symbols.

METHODS

This diagrammatic record was developed from existing models. A simple outline for the eyelids, lacrimal drainage apparatus and nose is used. The periocular, lid, dye test, syringing and nasal findings are represented by standard symbols.

RESULTS

Examples illustrating a range of lacrimal findings, before and after surgery, are shown.

CONCLUSIONS

A diagrammatic record of lacrimal findings which can be easily understood offers a sound basis for planning and monitoring lacrimal surgery. It is not necessary to memorize each diagram, only the principles on which they are drawn.

Well-differentiated squamous cell carcinoma of the eyelid arising during a 20-year period

An 81-year-old man had a keratotic eyelid lesions for 20 years. He eventually sought treatment by ophthalmic plastic surgery. Clinically, the lesion resembled a keratoacanthoma. Findings from histologic examination of the excision biopsy specimen showed a squamous cell carcinoma. The lesion was completely excised. This case demonstrates the difficulty in making a correct clinical diagnosis of a keratotic eyelid lesion. Performing a histologic examination of nonregressed keratotic lesions is essential to exclude a squamous cell carcinoma.

Endoscopic endonasal assistance with Jones lacrimal bypass tubes

Rigid nasal endoscopy is a reliable technique that can be used to assist in the preoperative nasal evaluation, operative tube positioning, and management after surgery. Postoperative function can be evaluated by using a passive dye test (FEDT) viewed directly, and minor interventions carried out without the need to remove the tube or do excessive probing. Endonasal endoscopy facilitates the maintenance of tube function with minimal manipulation and patient discomfort, and is fast and efficient. Its use should help improve tube retention and function. A detailed study over a number of years is necessary to provide convincing evidence for improving clinical standards. Lester T Jones wrote: The postoperative care of such a patient (having a glass bypass tube) should be in the hands of a physician who is willing to look into the nose, as inspection of the length and position of glass tube is most important. Endoscopic endonasal assistance helps the ophthalmologist to fulfill his criteria.

Endoscopic endonasal management of prolapsed silicone tubes after dacryocystorhinostomy

BACKGROUND

Loss or prolapse of silicone tubes at the medial canthus may occur after dacryocystorhinostomy (DCR) surgery. Repositioning of the prolapsed tubes is often difficult and can necessitate early removal of tubes. The goal of this study was to determine the incidence of tube prolapse after DCR, review the methods used to reposition them, and identify the optimum management.

DESIGN

Retrospective, noncomparative, interventional case series.

PARTICIPANTS

A total of 205 adults patients who had DCR with intubation by a specialist lacrimal service in West London over a 3-year period.

METHODS

Patients with spontaneous tube loss or prolapse were identified from clinic attendance and case note review.

MAIN OUTCOME MEASURES

Incidence and timing of prolapse, techniques used for repositioning and success, whether prolapse recurred, and further intervention necessary.

RESULTS

Five (2.5%) had tube loss or prolapse or both, all within the first month after surgery. The tubes were repositioned initially in four patients, but prolapse recurred in two patients necessitating further intervention. Only nasal endoscopy enabled precise tube visualization and endonasal manipulation with eventual tube stability.

CONCLUSIONS

Tube prolapse is rare after DCR surgery. The tubes can be pushed back in, but prolapse may recur unless the endonasal aspect is addressed. The position of the tie or knots should be inspected endonasally and the tubes further secured if indicated. Repositioning is best managed with endoscopic assistance, which is a simple office procedure.

Conjunctival MALT lymphoma: an usual cause of red eye

We describe a patient presenting with a red eye who was found to have conjunctival non-Hodgkin's lymphoma of the mucosa-associated lymphoid tissue (MALT) type.

Sclerosing canaliculitis after 5-fluorouracil breast cancer chemotherapy

BACKGROUND

5-Fluorouracil is a pyrimidine analogue that inhibits DNA synthesis and is commonly used in the treatment of carcinomas of the breast, gastrointestinal tract and genitourinary tract. Excessive tearing that resolves on cessation of treatment is commonly described as a side effect of the drug. Permanent stenosis of the punctum and canaliculus is extremely rare, with only 12 cases reported in the world literature. We present three cases of established lacrimal outflow obstruction in patients who were treated with CMF (cyclophosphamide, methotrexate, 5-fluorouracil), a widely used regimen for metastatic breast cancer. Patient 1 had right distal stenosis of her lower canaliculus and was syringed patent during dacryocystography with resolution of epiphora. Patient 2 had proximal blockage of all canaliculi and underwent bilateral canaliculodacryocystorhinostomy with silicone tubes that temporarily relieved symptoms until tube removal. The proximal canalicular blockage recurred due to underlying extensive fibrosis. Patient 3 had right proximal common canalicular stenosis and left distal canalicular blocks but declined surgery.

CONCLUSION

With the rise in the incidence of breast carcinoma it is important that the attention of both ophthalmologists and oncologists should be drawn to the potential ocular toxicity of systemic 5-fluorouracil chemotherapy, which may lead to lacrimal canalicular fibrosis with permanent epiphora. The management of these patients is challenging as there is a continuous spectrum of canalicular involvement from focal to diffuse; therefore early referral is recommended. Moreover as no consensus has been reached as how best to manage this unique small group of patients, we review the literature and discuss the implications for treatment.

Botulinum toxin A treatment of overactive corrugator supercilii in thyroid eye disease

BACKGROUND/AIM

Patients with thyroid eye disease with upper eyelid retraction often develop overaction of the accessory muscles of eyelid closure, the glabellar muscles corrugator supercilii and procerus. The resultant glabellar furrowing (frown lines) contributes to the typical thyroid facies. The aim of this study was to evaluate the use of botulinum toxin A reversible chemodenervation of the glabellar muscles as adjunctive treatment in the rehabilitation of patients with thyroid eye disease.

METHODS

14 patients (13 females) ages 39-76 years (mean 52) with inactive thyroid eye disease and associated medial eyebrow ptosis and prominent glabellar frown lines were recruited. All patients had a history of upper eyelid retraction. Each patient was treated with a single botulinum toxin injection (Dysport 0.2 ml, 40 units) into each corrugator supercilii and sometimes procerus muscles as an outpatient procedure. The effectiveness and acceptability of the treatment was assessed clinically and from a patient questionnaire.

RESULTS

The injections were tolerated by 13/14 (93%) patients. There was resultant flattening of the glabellar region and improvement of medial eyebrow contour in all patients, with onset of paralysis within 1 week. All patients reported a subjective improvement in appearance. Side effects included one patient (7%) with reversible partial ptosis. The beneficial effect lasted 4-6 months, with a gradual return of function. Repeat treatment was indicated where there was persistent upper eyelid retraction and protractor overaction.

CONCLUSION

Botulinum toxin A chemodenervation of the glabellar muscles in these patients was effective and acceptable. Chemodenervation should be considered in the rehabilitation of patients with thyroid eye disease where there is upper eyelid retraction and overacting protractors resulting in a thyroid frown. Once the eyelid retraction has been successfully treated by surgery, the need for further glabella muscle chemodenervation is considerably reduced.

Correction of lower eyelid retraction in thyroid eye disease: a randomised controlled trial of retractor tenotomy with adjuvant antimetabolite versus scleral graft

BACKGROUND/AIMS

Lower eyelid retraction in thyroid eye disease contributes to ocular discomfort and an unsightly appearance, especially if asymmetrical. The use of donor scleral grafts is effective in lengthening the lower eyelids but carries a risk of virus transmission. Other techniques, including those which do not use grafts, need to be compared with scleral grafts. Recurrent retraction is a recognised complication of thyroid eyelid surgery; therefore, the authors investigated the use of antimetabolites to reduce postoperative fibrosis.

METHODS

In this prospective randomised controlled trial of 25 patients (35 eyelids), the use of donor sclera in 20 lower eyelids (13 patients) was compared with partial tenotomy of the anterior part of the lower eyelid retractors (ALER) with adjuvant peroperative antimetabolite in 15 lower eyelids (12 patients). A 5 minute peroperative application of either 5-fluorouracil (25 mg/ml) in nine lower eyelids (eight patients) or mitomycin C (0.2 mg/ml) in six lower eyelids (four patients) was used to focally inhibit fibroblasts. Follow up ranged from 3 to 18 months (mean 7.8).

RESULTS

One month after surgery the results of both groups were similar. However, at 3 months after surgery the results of scleral grafting were better than tenotomy with antimetabolites: 3/12 patients (25%) treated with tenotomy and adjuvant antimetabolite required subsequent surgery using grafts for correction of recurrent retraction. There were no significant complications associated with the use of antimetabolites in the eyelid in the doses used in this study.

CONCLUSIONS

This randomised prospective trial shows that donor scleral grafts were more effective in the long term than partial tenotomy with adjuvant antimetabolite in the correction of lower eyelid retraction associated with thyroid eye disease. The use of peroperative antimetabolites in the lower eyelid was safe.

'Henderson's' relief of eyelid retraction revisited

The purpose of the study was to identify those patients with thyroid eye disease and upper eyelid retraction who would benefit from Henderson's procedure (myotomy of Muller's superior tarsal muscle with graded division of levator aponeurotic fibres on the anterior tarsal plate). The clinical records of patients attending the Thyroid Clinic of Moorfields Hospital who had undergone Henderson's procedures were reviewed. Twenty-two patients (19 women, 3 men) had Henderson's procedures at age 35-69 years (mean 49.9), with a mean follow-up of 4.55 years. Eleven patients had bilateral upper eyelid surgery, 11 unilateral (33 eyelids). The pre-operative vertical palpebral apertures ranged from 11 to 19 mm (mean 13.95); the post-operative vertical palpebral apertures ranged from 8 to 15 mm (mean 11.45), a mean reduction of 2.5 mm (p < 0.001). Eight of twenty-two patients (36%) had further eyelid surgery and 3 of 22 (14%) had further surgery recommended because of persistent upper eyelid retraction, abnormal eyelid contour (lateral flare) and asymmetry. It is concluded that Henderson's procedure should be reserved for those patients with minor degrees of almost symmetrical upper eyelid retraction who do not have abnormalities of their eyelid contour.

Quantitative morphology of human retrolaminar optic nerve vasculature

PURPOSE

To quantify the variation in the blood supply of the retrolaminar optic nerve in humans. The retrolaminar anterior optic nerve is supplied by an elliptical arterial "circle" of Haller and Zinn formed by anastomoses around the optic nerve between medial and lateral paraoptic short posterior ciliary arteries (PO-SPCAs). The frequency with which complete perioptic nerve arteriolar anastomoses (PONAA) occur is unknown, yet they form the basis for many postulated pathophysiological mechanisms.

METHODS

Scanning electron microscopy was performed on 25 orbital and ocular microvascular corrosion casts (methyl methacrylate) from 20 human cadavers of subjects 21 to 97 years of age without known ocular disease.

RESULTS

Eighteen casts were examined in detail after microdissection (the analysis of seven casts was limited because of their fragility). In 15/18 (83%) casts, the PONAA were supplied by branches of a medial and lateral PO-SPCA; in 2/18, they were supplied by one (lateral) PO-SPCA; and in 1/18, they were supplied by a superior PO-SPCA and two horizontal PO-SPCAs. The PONAA had intact superior and inferior anastomoses in 8/18 (44%) casts, anastomoses with narrowed portions in 6/18 (33%), and incomplete in 4/18 (23%). Narrowed portions were not preferentially distributed to either superior or inferior anastomoses.

CONCLUSIONS

Complete PONAA was found in more than 75% of casts, including anastomoses with narrow portions in 33% of casts.

Recovery of anterior segment circulation after strabismus surgery in adult patients

The effects of vertical rectus muscle surgery on the anterior segment and iris fluorescein angiogram were documented in 43 eyes of 41 adult patients. Characteristic iris sector perfusion defects were seen in 33 of 37 eyes (89%) after primary vertical rectus muscle surgery (no previous surgery on these muscles). Although iris perfusion defects were commonly present, associated clinical signs were mild. Two patients developed permanent pupillary changes after simultaneous surgery on two rectus muscles (superior/inferior rectus muscles and contiguous inferior/medial rectus muscles). In most patients, clinical findings resolved and the iris circulation recovered during the first 2 weeks after surgery. In 3 of 8 patients with grade 3 anterior segment ischemia (pupil dysfunction and cells) or early "postoperative uveitis," recovery of iris circulation took up to 12 weeks. These findings indicate that the time course of recovery of the anterior segment circulation after vertical rectus muscle surgery may be shorter than previously assumed.

Functional anatomy of the choroidal circulation: methyl methacrylate casting of human choroid

The functional anatomy of the normal choroidal circulation in man is described from scanning electron microscopic examination of methyl methacrylate microvascular casts. Distal and para-optic short posterior ciliary arteries supply wedge-shaped areas of choroid. Regional variations in choriocapillary morphology are well recognised; the lobules are densely packed at the posterior pole with a high capillary to inter-capillary ratio. Choroidal capillaries are flattened providing a large surface area for metabolic exchange with the retinal pigment epithelium. In acute choroidal ischaemia (from a variety of systemic disease), wedge shaped choroidal lesions may correspond to occlusion of short posterior ciliary arteries and geographic or focal lesions to occlusion of choroidal arterioles or choriocapillary lobules.

Microvascular study of the retrolaminar optic nerve in man: the possible significance in anterior ischaemic optic neuropathy

The morphology of the circle of Haller and Zinn and its variations were examined using methyl-methacrylate microvascular corrosion casting of human orbits obtained at post-mortem. It was found to be an elliptical microvascular anastomosis formed by branches of the medial and lateral para-optic short posterior ciliary arteries. The ellipse was divided into superior and inferior parts by the entry points of these branches into the eye, providing an altitudinal blood supply to the retrolaminar optic nerve. Morphological variations in terms of form, position and branches existed between subjects and between eyes from the same subject. The clinical implications of an elliptical 'circle' of Haller and Zinn providing an altitudinal blood supply to the retrolaminar optic nerve are relevant to the pathogenesis of altitudinal visual field defects in anterior ischaemic optic neuropathy.

Orbital and ocular micro-vascular corrosion casting in man

The methods of preparation and examination of complete orbital and ocular vascular casts, suitable for the study of anterior segment vasculature, are described from our experience of 20 casts. The use of low viscosity methylmethacrylate produced complete vascular filling with few artefacts when injected into isolated orbital preparations from human cadavers 36-48 hours post-mortem, despite suggestions by previous authors that injection should be within 12 hours. Using scanning electron microscopy, arteries and veins are clearly distinguishable by their endothelial nuclear impressions. The vascular anatomy of the anterior segment and of other sites including the optic nerve and choroid in man can therefore be elucidated with this method.

Children presenting to an ophthalmic casualty department

A five month prospective survey of all children (0-14 years) attending an ophthalmic accident and emergency department was carried out to determine the disease profile and the primary ophthalmic health care provided. A data base was used to collect and analyse all cases. Seventy three per cent of 475 children attending had non-traumatic ophthalmic diagnoses, less than half being referred from their general practitioners. The remaining children had minor ophthalmic injuries of which less than one quarter were referred from their general practitioners. Four of the minor ophthalmic injuries were suspected of being non-accidental injury. The management of such cases is discussed. The ophthalmologist in an ophthalmic casualty department has an important role in the provision of primary ophthalmic care for children. In the management of minor ophthalmic injuries, the alerting factors for non-accidental injury should be sought, although the apparent incidence is low.

Anterior segment vascular casting

Vascular corrosion casting provides a permanent three-dimensional record of the deeper vasculature of the anterior segment whereas fluorescein angiography allows clinical examination of superficial vessels. Morphological findings on scanning electron microscopy of vascular casts of the anterior segment in sheep are presented and compared with that of man by casting techniques. Sheep illustrate the basic mammalian anterior segment vascular architecture but lack anterior ciliary arteries which connect with the deeper collateral arterial circles. The casting technique is described and its use to answer comparative anatomical, pathological and clinical questions explained. These techniques are being applied to examine changes to the anterior ciliary arteries and the deeper vessels following strabismus surgery in an animal model. Scanning electron microscopy of vascular corrosion casts has given a new dimension to micro-vascular anatomy.

The effects of strabismus surgery on anterior segment circulation

Anterior segment circulation was assessed in 35 adults one day after squint surgery by clinical observation and low-dose fluorescein iris angiography. Seventeen patients had primary vertical rectus muscle surgery and all showed angiographic evidence of ischaemia. No ischaemia was found in the 15 patients who had secondary vertical rectus muscle surgery, or any horizontal rectus muscle surgery. The staged group had intermediate findings between the above two. Age, dysthyroid eye disease and type of conjunctival incision did not correlate with fluorescein iris angiographic sector-filling delay on the first post-operative day. The time taken for the sector with delay to fill becomes less during the first two post-operative weeks. Redistribution of iris filling persists, however. This data suggest that the safe interval before further muscle surgery can be done is shorter than has previously been assumed. Since the anterior ciliary arteries do not reform into canals the probable mechanism of redistribution of blood flow is from the long posterior ciliary arteries and increased capacity of the collateral circulation.