Rapid Rehabilitation With Skin-Muscle Sparing Orbital Exenteration: A Single-Center Series.

AIMS: To examine the features and clinical management of patients who underwent skin-muscle sparing orbital exenteration in a tertiary referral center. PATIENTS AND METHOD: Retrospective case-note review for patients undergoing skin-muscle sparing orbital exenteration at Moorfields Eye Hospital between 1997 and 2012. Patient demographics, clinical features, histopathology, clearance, surgery, adjuvant therapy, and outcomes were analyzed. RESULTS: Seventy-four patients (33 male; 45%) had skin-muscle sparing orbital exenteration at a median age of 63.8 years (median 65.5, range 13-96 years) for malignancies primarily arising in the eyelids (34 cases; 46%), orbit (25 cases; 34%) or conjunctiva (15 cases; 20%). The commonest pathologies were sebaceous carcinoma (20 cases; 27%), melanoma (19 cases; 26%), squamous cell carcinoma (12 cases; 16%), and basal cell carcinoma (9 cases; 12%). The patients had very rapid rehabilitation with primary closure of skin-muscle flaps over the cavity, either directly (63/74 patients; 85%), or with addition of local flaps. Local radiotherapy had been given before exenteration to 18 (24%) patients, was administered after exenteration in 19 (26%) patients, and both before and after surgery in 5 (7%); those having postoperative radiotherapy were referred at 2-3 weeks after exenteration, and the initial prosthetics fitting was started at 3-6 weeks after surgery. Thirty-eight (51%) patients died during a follow-up of 1-164 months (mean 55, median 47 months); 20/38 (53%) died from metastases-although 9/20 had known metastatic disease prior to palliative exenteration. Three patients were alive with apparently inactive metastases at 30, 39, and 140 months after surgery. CONCLUSION: Direct closure of skin-and-muscle flaps is achievable in almost all undergoing orbital exenteration. In contrast to skin-grafting, free myocutaneous flaps or secondary intention healing, this allows early referral if adjunctive orbital radiotherapy is needed, and the initial fitting of prosthetics can be within weeks of surgery. The technique also avoids the much greater donor-site morbidity of other reconstructive techniques, such as local or free myocutaneous flaps.

The first UK national blepharospasm patient and public involvement day; identifying priorities.

PURPOSE: We describe the planning and outcomes of the first 'Blepharospasm Day' in the UK. Blepharospasm is a distressing condition for patients and carers. Our 'patient and public involvement' event aimed to: cultivate a more informed patient group via active dialogue, help clinicians more effectively prioritise research and to facilitate peer-to-peer support for affected patients and public. DESIGN: A national one-day event was organised by the oculoplastics department at Moorfields Eye Hospital. The event was divided into informative lectures delivered by professionals and a patient panel, during which patients shared their experiences and expectations. METHODS: Data were collected from a variety of sources including: an interactive voting "LiveWall" poster, a pre-event questionnaire; "living with Blepharospasm", transcripts from patient panel discussions; and a feedback questionnaire. RESULTS: The event was well-received with 100% of respondents rating it good or excellent. Four research themes were identified: "aetiology", "alternative treatments", "faster, more accurate diagnosis", and "symptom control". Delegates' self-reported knowledge of blepharospasm increased significantly after the event. Limitations of the BdSI severity-assessment tool were noted with 22% of respondents failing to utilise it appropriately. CONCLUSION: Through our innovative "Blepharospasm Day", patient's priorities for research were identified, delegates understanding of blepharospasm increased and an independent blepharospasm patients-representatives' group was established; a first in the UK. Furthermore, short-fallings identified in the BdSI tool highlight the need for better severity-assessment tools. We demonstrate the benefits of the 'patient and public involvement' approach in the management of complex conditions such as blepharospasm. ABBREVIATIONS: PPI: Patient and public involvement; SLV-PSP: sight loss and vision sector - priority setting partnership; BRC: Biomedical Research Centre; NIHR: National Institute for Health Research; BsDI: Blepharospasm Disability Index.

Upper eyelid levator-recession and anterior lamella repositioning through the grey-line: Avoiding a skin-crease incision.

PURPOSE: This study aims to report a case series of upper eyelid cicatricial margin entropion with retraction, corrected through a grey-line approach only. We remind readers of the grey-line approach to levator recession (LR) and lamellar repositioning surgery. METHODS: A retrospective review of clinic notes and photographs of patients who underwent grey-line split (GLS), LR, release of orbital septum, recession of levator, advancement of posterior lamella and anterior lamellar repositioning without a skin crease incision, from December 2015 to December 2016. Indications for surgery included mild-to-moderate cicatricial margin upper eyelid entropion, tarsal curling, and meibomian gland inversion. Patients requiring spacer interposition to lengthen the posterior lamella were excluded from the study. Parameters of the study included lid margin position, lid height, ocular surface health and symptom improvement. RESULTS: Eleven eyelids of eight patients were included in the study, and underwent the procedure described. Lid margin position measured as the marginal reflex distance lowered (improved) in 72.7% of patients. Lid margin eversion was achieved in all eyes (100%). Corneal punctate epithelial erosions markedly improved, being present in 72.7% of patients preoperatively, and only 9.1% of patients postoperatively. Eight of eleven eyes showed symptomatic improvement, with six (54.5%) being completely asymptomatic and two achieving partial relief. An added observation was a pretarsal show asymmetry in some patients which improved in 36.4% of surgeries postoperatively. CONCLUSION: Upper eyelid LR with GLS and anterior lamella repositioning can all be performed through the plane of the split, avoiding a skin incision. Normal lid margin apposition was achieved in all eyes with 91% demonstrating a clear cornea and 72% having symptomatic improvement.

A benign or malignant eyelid lump--can you tell? An unusual collision tumour highlighting the difficulty differentiating a hidrocystoma from a basal cell carcinoma.

Hidrocystoma and basal cell carcinoma (BCC) are common eyelid lesions. The former is benign while the latter is malignant and can cause significant destruction of the adnexal structures, orbital invasion and visual loss. The authors describe a case of a 76-year-old female with a slow growing right upper lid lesion which was diagnosed as a hidrocystoma but excision biopsy revealed a collision tumour comprised of a BCC abutting a hidrocystoma in the same lesion. Cystic BCC can masquerade as hidrocystoma but there are no previous case reports of BCC coexisting with hidrocystoma in the same lesion. This case highlights the fact that apparently benign lesions, such as hidrocystomas, may actually be malignant or coexist with malignant pathology. Clinicians should have a low threshold for appropriate excision biopsy and histological examination of such lesions, especially if there are sinister features, such as lash loss, induration, pigmentation or a pearly appearance.

Valsalva retinopathy in pregnancy: SD-OCT features during and after Nd:YAG laser hyaloidotomy.

Valsalva retinopathy can present as a sudden, dramatic loss of central vision due to the premacular location of the resultant subhyaloid hemorrhage. Certain vascular conditions predispose to the condition and occasional reports exist of Valsalva retinopathy in pregnancy. The authors describe a case of Valsalva retinopathy in a pregnant patient in terms of the physical features present that led to making the decision to treat by Nd:YAG laser hyaloidotomy as opposed to conservative management. Spectral-domain optical coherence tomography (SD-OCT) was able to demonstrate the physical features of the lesion prior to, immediately after, and weeks after treatment, and showed not only the dispersion of hemorrhage into the vitreous cavity from the subhyaloid space, but also that the subhyaloid cavity dimensions were unchanged despite release of the hemorrhage. SD-OCT visualized the actual hyaloidotomy site and its subsequent closure, which has not previously been reported in the literature.

Periorbital fat atrophy - an unfamiliar side effect of prostaglandin analogues.

Prostaglandin F2 alpha (PGF2a) analogues including bimatoprost and travoprost are used worldwide, often as first line topical treatments for glaucoma. We present 2 cases of a newly described side effect of both these topical agents in terms of periorbital fat atrophy. This visually noticeable side effect had features demonstrable on MRI scanning. The periorbital fat atrophy is most apparent with uniocular use and both doctors and patients need to be aware of this side effect before commencing treatment. The effects, however, appear to be reversible with treatment cessation.

Comparison of assessments of severity and quality of life in cutaneous disease.

Clinicians are, by profession, capable assessors of severity of disease. Whether from severity they can deduce a patient's Quality of Life (QoL) is debatable. This study compared scores for physician-assessed severity with the corresponding scores for patient QoL, as assessed using Dermatology Life Quality Index (DLQI) questionnaires in 57 dermatological out-patients. Although there was some degree of correlation between the two measures (r = 0.56), interpretation of QoL from disease severity is clinically unreliable. Thus a physician's assessment of QoL requires formal assessment using a tool such as the DLQI.