Prevalence, indications and demographic characteristics of Botulinum neurotoxin use in a tertiary oculoplastic centre.

OBJECTIVES: Over the past 40 years, Botulinum Neurotoxin (BoNT) treatment has been used in many presentations to the hospital eye service. There is little published on its practice in an ophthalmology setting. We aim to report on the prevalence of BoNT use, indications for treatment, age, gender, socioeconomic and ethnic variations observed, and dosages used. METHODS: We performed a retrospective cross sectional observation study on the use of botulinum neurotoxin treatment in the oculoplastic department of a busy tertiary centre in the University Hospitals of Leicester, United Kingdom. RESULTS: The prevalence of BoNT in the service was 13.7 per 100,000 people. Of the 145 cases identified, the commonest indications for treatment were hemifacial spasm (62% of cases) and blepharospasm (29% of cases). Proportionally, twice as many females than males received BoNT (χ2 = 17.3, p < 0.0001). For those >30 years of age, the prevalence increased with age with those >90 years having a seven times higher prevalence than the mean. Overall, no significant differences were found in ethnicity and median index of multiple deprivation rank between those with treatment and the general population although specific district council variations were noted. CONCLUSIONS: These findings would assist commissioners in providing adequate resources to meet demand based on the demographics of their local population. Further qualitative and quantitative research is required to enhance our understanding of some of these trends.

Emergency canthotomy and cantholysis - Factors affecting confidence among ophthalmic trainees in the United Kingdom.

PURPOSE: Retrobulbar hemorrhage from trauma is the most common cause of orbital compartment syndrome. Emergency canthotomy and cantholysis is a vision-saving procedure. We sought to identify confidence among ophthalmic trainees in this procedure as well as any relevant factors that have any impact. METHODS: An online, confidential anonymous questionnaire was distributed to ophthalmology training groups in the UK. Questions explored the participant's stage of training and grade and confidence in this area as well as their ophthalmic experience in terms of training courses attended and elective versions of the procedure performed. RESULTS: We received 45 completed responses from the survey. 20/23 (87%) of junior trainees had not performed an emergency canthotomy/cantholysis to date, whereas 19/22 (86%) of senior trainees had performed between 1 and 5 such procedures. 15/23 (65%) of junior trainees had not performed an elective canthotomy compared to only 3/22 (14%) of the senior trainees. We found that the main factors that were associated with increased confidence level were the higher numbers of emergency and elective cases performed, training courses, and previous oculoplastic surgery rotation (P = 0.0001). CONCLUSION: From our survey, we found low confidence levels among junior trainees due to limited exposure. Confidence appeared to be linked to both elective and emergency surgical experience of the procedure as well as training course and having worked in an oculoplastic surgery firm. Changes to training portfolio requirements for junior trainees to incorporate early oculoplastic experience may help to achieve this on a national scale.

Acute Painful Ptosis Secondary to IgG4 Dacryoadenitis.

A 48-year-old lorry driver presented with 3 weeks of blurred vision, pain and diplopia. There was a right upper lid ptosis with some restriction of eye movements. A CT revealed an enlarged lacrimal gland and lacrimal gland biopsy showed IgG4-positive plasma cells. The patient responded to oral prednisolone and fully recovered. As a condition which mimics a number of diseases, an IgG4-related disease presents a diagnostic challenge and ought to be considered in both acute and chronic presentations.

The Use of a Polyetheretherketone (PEEK) Implant to Reconstruct the Midface Region.

A good functional and cosmetic result after midfacial reconstructive surgical procedures is of paramount importance. We describe the use of a Polyetheretherketone (PEEK) implant to reconstruct the midface area, after extensive mutilating surgery due to an infiltrative skin tumor. A 67-year-old male patient underwent multiple and extensive surgeries to the left cheek and lower lid because of a highly aggressive metatypical basal cell carcinoma. Complete resection of the recurrent tumor resulted in a cosmetically evident absent cheek contour and facial deformity. The PEEK implant was used to restore the bony cheek contour, with good aesthetic outcome and restoration of the facial symmetry. Preoperative planning with 3-dimensional CT scans allow for customization of the implant. PEEK implants have been scantily described in the periorbital region. The material has a very low reported morbidity and also has the advantage of improving intraoperative predictability and reducing surgical time in complex reconstructive procedures.

Inverting sutures for tarsal ectropion (the leicester modified suture technique).

PURPOSE: To describe a simple technique to correct tarsal lower eyelid ectropion with or without marked eyelid laxity (The Leicester Modified Suture technique). METHODS: A retrospective interventional case series of patients undergoing correction of tarsal ectropion with inverting sutures. The study adhered to the principles of the Declaration of Helsinki. RESULTS: Twenty patients (25 eyelids) met the inclusion criteria. The success of the procedure was assessed by improvement of symptoms, eyelid position, and the need for reoperation. The mean postoperative follow up was 3.6 months (range 2-15 months). Eighteen patients (90%) had a successful outcome, while in 2 patients (10%) the outcome was satisfactory, as there was mild residual eversion of the eyelids. None of the patients required reoperation. CONCLUSIONS: Tarsal lower eyelid ectropion can be surgically challenging to correct via the transconjunctival plication or subciliary reattachment of retractors. This method is simple to use, resulting in an excellent outcome with no tissue dissection. This technique is easy to learn and implement for oculoplastic surgeons at all levels of experience.

Idiopathic orbital inflammation: a new dimension with the discovery of immunoglobulin G4-related disease.

PURPOSE OF REVIEW: To review idiopathic orbital inflammation, with particular reference to the evolving entity of ocular adnexal immunoglobulin G4 (IgG4) disease. RECENT FINDINGS: Emerging evidence suggests that sclerosing idiopathic orbital inflammation can be an IgG4-related disease and discovery of this link has further reduced the subset of 'idiopathic orbital inflammation'. Ocular adnexal IgG4 disease should especially be considered if the orbital disease is bilateral or where there is systemic involvement. New reports are linking the possibility of lymphoma arising from a background of IgG4-positive inflammation in both the orbit and in other organs, and both the physician and the patient should be aware of this long-term risk. SUMMARY: Although the diagnosis of IgG4-related orbital disease continues to be challenging, there is a growing understanding of the pathophysiology and this is likely to be key to developing a clinical strategy for the diagnosis and effective treatment of this condition.

Alfentanil sedation for oculoplastic surgery: the patient experience.

PURPOSE: A number of agents have previously been reported to be safe and effective for sedation and analgesia in ophthalmic surgery under local anaesthesia, but there has been no previous patient-focused assessment of this form of conscious sedation. We present a patient satisfaction survey, including a validated pain score, for patients undergoing oculoplastic procedures under local anaesthesia with alfentanil sedation. METHODS: A prospective, non-randomized, questionnaire-based study of the experience, satisfaction and pain scores of consecutive patients undergoing oculoplastic procedures under local anaesthesia with alfentanil sedation at University Hospital, Coventry, UK, under the care of one Consultant Oculoplastic Surgeon between 2006 and 2009. RESULTS: Three hundred and sixty-seven patients were surveyed over the 3-year period. Overall, 52% were female and 89% of Caucasian ethnic origin. Mean duration of surgical procedures was 34 minutes (range 2-120 minutes). Over 90% of patients described a low pain score, both during the local anaesthetic injection and per-operatively, and 98% stated that they were happy to have this sedation technique for further oculoplastic surgery in future. Side effects related to sedation were reported in 5% of patients. There were no conversions to general anaesthesia and no day-case patients required an overnight in-patient stay. CONCLUSION: Conscious sedation with alfentanil for oculoplastic procedures under local anaesthesia results in low pain scores and high patient satisfaction with minimal complications.

Megalocornea and bilateral developmental cataracts.

We present the case of a 9-year-old boy with megalocornea and juvenile cataracts. Bilateral lens aspiration and acrylic intraocular lens (IOL) implantation were performed under general anesthesia. After the surgery, both IOLs gradually decentered. Posterior capsule opacification was a further complication, necessitating bilateral neodymium:YAG (Nd:YAG) capsulotomy under local anesthesia. Five years after the Nd:YAG capsulotomy, the decentered IOLs remained in the same position and the vision remained stable with glasses. Cataract extraction in megalocornea is difficult, and complications are frequent. The type of IOL, IOL size, and need for surgery should be carefully considered.

Simple surgery for severe trichiasis.

PURPOSE: To describe a simple surgical technique for the definitive treatment of severe trichiasis, where the eyelid position is adequate. METHODS: Five anterior lamellar excision procedures are reported, with wounds left to heal by the laissez-faire technique. RESULTS: Postoperatively, all patients were symptom free. No recurrences have been seen with a mean follow-up of 17 months. CONCLUSIONS: Wound healing by secondary intention for periocular defects is not commonly described. Combined anterior lamellar excision and laissez-faire technique shows promising results for trichiasis.

An arteriovenous malformation masquerading as a carotid-cavernous sinus fistula.

PURPOSE: To describe a case of an occipital arteriovenous malformation (AVM) presenting with unilateral signs mimicking a carotid-cavernous sinus fistula (CCF). DESIGN: Interventional case report. METHODS: A 67-year-old normotensive male presented with loss of vision, pain, and proptosis of the right eye. Best-corrected visual acuity was right eye 6/36 and left eye 6/5. Examination of the right eye revealed orbital congestion with arteriolization of the episcleral vessels and an intra-ocular pressure of 44 mm Hg which was refractory to medical treatment. RESULTS: Computed tomography (CT) angiogram and cerebral angiography found an occipital AVM draining into the right sphenoparietal sinus and thereafter the right ophthalmic vein, bypassing the cavernous sinus. Embolization followed by excision of the AVM resulted in recovery of vision, reversal of proptosis, and normalization of intraocular pressure. CONCLUSIONS: Rapid diagnosis and immediate intervention resulted in a rewarding visual recovery despite a persisting left homonymous hemianopia.