Ophthalmoplegia With Isolated Extraocular Muscle Hypertrophy.

A 60-year-old man is experiencing diplopia but no problems with visual acuity, pain, or other symptoms. A magnetic resonance image of the head shows abnormal thickening and T2 hyperintensity of the right lateral rectus muscle. What is your diagnosis?

Is there enough evidence for the routine recommendation of eyelid wipes? A systematic review of the role of eyelid wipes in the management of blepharitis.

OBJECTIVE: Eyelid wipes are routinely recommended for blepharitis, but these do not come without financial cost and potential adverse effects. This review aimed to provide a comprehensive summary of existing evidence for the efficacy and safety of eyelid wipes in the management of blepharitis. METHODS: A search of Medline and Embase was conducted to identify studies that assessed the efficacy of an eyelid wipe option. Studies that included other interventions were excluded, as well as studies that evaluated warm compresses. Risk of bias, adverse effects, cost, and availability assessments were also performed. RESULTS: After the review of 1650 search results, 16 studies were included. A variety of eyelid wipes were studied, including common household products, tea tree oil-based products, commercial solutions, and commercial wipes. Some efficacy was demonstrated for all options that were studied, and most improvements were noted within 1 or 2 months. There was not enough evidence to determine the relative efficacy of different options. There was significant heterogeneity, and all nongeneric options were limited to 1 study, which precluded meta-analysis. The risk of bias assessment revealed concerns regarding the quality of evidence, and notably, several studies were supported by the manufacturing company. CONCLUSIONS: Although some efficacy has been demonstrated for several types of eyelid wipes, including common household products, there remains a lack of robust evidence to support their routine recommendation. Long-term costs and potential adverse effects should not be overlooked. There is not enough evidence to suggest superiority of one option over others.

Accuracy of referral diagnosis to an emergency eye clinic.

OBJECTIVE: To determine the accuracy of diagnosis of ophthalmic problems from health care practitioners such as optometrists, general practitioners, and emergency physicians in and around London, Ontario, Canada. DESIGN: Retrospective review of all referrals to the Ivey Eye Institute emergency eye clinic over a period of 6 months from January to July 2011. PARTICIPANTS: During the study period, there were 1810 patient encounters, including 1134 new referrals. METHODS: For each patient encounter, information was collected regarding basic demographics, referral source, referral diagnosis, and final diagnosis. Referrals were categorized by source of referral and anatomic location of the eye problem. The accuracy of each referral was assessed by comparing the referral diagnosis to the final diagnosis. Referrals were categorized as correct, incorrect, not yet diagnosed, nonspecific, or baseline examination. RESULTS: Referral diagnoses were correct in 45% and incorrect in 28% overall. Referral diagnoses from optometrists were correct in 54%, from emergency physicians were 39% correct, and from general practitioners were 33% correct. Ophthalmologists had the highest diagnostic accuracy, with 83% of referral diagnoses being correct. Diagnoses were incorrect in 36% from optometrists, 28% from emergency physicians, and 32% from general practitioners. CONCLUSIONS: This study demonstrates the low accuracy rate of referral diagnoses of emergency eye patients from nonophthalmologists to the Ivey Eye Institute emergency eye clinic. Better training in the diagnosis of ophthalmic problems for general practitioner and emergency medicine residents would be of benefit. Optometrists may also find it helpful to have improved emergency and urgency training. Ophthalmologists should be involved in this training.

P63 Positive Mucoepidermoid Tumor of the Lacrimal Sac with Associated Papilloma.

We report a case of a 44-year-old man who presented with a left medial canthal mass and epiphora. Imaging was suggestive of a mass continuous with the nasolacrimal sac. Subsequent surgical exploration revealed a mass adherent to bone with invasion of the lacrimal system. Histological examination revealed a squamous/transitional cell papilloma overlying a low-grade mucoepidermoid carcinoma (MEC). Complete surgical resection was completed and pathology confirmed the diagnosis. This is the first case in which a MEC has been reported concurrently with an overlying papilloma, providing support for the hypothesis that MECs arise from papillomas in the lacrimal sac. Additionally, the tissue stained positive for p63, which is congruent with MEC immunoreactivity in the salivary gland. The description of these unique histopathological findings may assist in definitive diagnosis and improve our understanding of the pathophysiology underlying lacrimal sac MEC tumors.

Low-grade intraductal carcinoma of the lacrimal gland.

Intraductal carcinoma has been described in the salivary glands as a relatively benign tumour with low-grade histopathologic features. To our knowledge, this tumour has not previously been reported in the lacrimal gland. We report the first case of low-grade intraductal carcinoma occurring in the lacrimal gland. This tumour was discovered incidentally on neuro-imaging in an asymptomatic 65-year-old patient. Incisional biopsy revealed uniform, polygonal cells with eosinophilic cytoplasm and minimal nuclear atypia, arranged in solid, cribiform and micropapillary nests. The patient underwent complete surgical excision with no evidence of recurrence at 8 months of follow-up.

Image-guided transnasal endoscopic techniques in the management of orbital disease.

PURPOSE: To assess the utility of image-guided transnasal endoscopic surgery for a variety of orbital diseases requiring decompression of at least one orbital wall. METHOD: A descriptive case series of consecutive orbital procedures requiring decompression of at least one wall. All procedures were performed using a transnasal endoscopic approach and an intraoperative image-guided LandmarX system for anatomical guidance. RESULTS: A 3-year review yielded 17 cases, including 6 cases with compressive mucoceles, 4 neoplasms, 4 patients with proptosis secondary to Graves' Ophthalmopathy, 1 case of an intraorbital abscess, 1 fungal mycetoma, and 1 hemangioma. These cases all had improved postoperative clinical status without any serious complications. The LandmarX system was a valuable intraoperative tool in all 17 cases. CONCLUSIONS: The endoscopic transnasal approach to orbital decompression surgery allows for good visualization and is minimally invasive. Using this approach in conjunction with the LandmarX image-guided system allows for improved anatomical localization and provided good results in all cases.

Giant cell arteritis presenting with aortic aneurysm, normal erythrocyte sedimentation rate, and normal C-reactive protein.

CASE REPORT: We report on an extremely rare case of giant cell arteritis (GCA) presenting without elevated erythrocyte sedimentation rate or C-reactive protein level, with aortic root involvement, and in the absence of typical clinical findings. COMMENTS: The clinical signs and symptoms as well as the laboratory investigations involved in the diagnosis of GCA are discussed.