Optic nerve sheath fenestration via a supero-medial eyelid skin crease approach for the treatment of idiopathic intracranial hypertension in a UK population.

BACKGROUND/AIMS: Optic nerve sheath fenestration (ONSF) is a surgical intervention in the management of idiopathic intracranial hypertension (IIH) infrequently performed in the United Kingdom. Numerous surgical approaches have been described, including medial transconjunctival, lateral and endoscopic. We describe our outcomes and complications from ONSF via a supero-medial eyelid skin crease incision in patients with IIH. METHODS: We performed a retrospective review of consecutive patients undergoing ONSF for IIH between January 2011 and December 2017 by a single surgeon. RESULTS: Thirty patients were included in the analysis with a median follow-up of 14.5 months. Bilateral ONSFs were undertaken in 27 (90%). The data from one eye per patient were analysed. The mean kinetic perimetry score in mean radial degrees of the I4e isopter improved from 27.3° to 35.7°, p = 0.04. After removing cases with optic atrophy, the median modified Frisén grade of papilloedema improved from 2.5 to 1.0, p = 0.007. A total of 5/30 (17%) patients had complications: two (7%) had recurrence/late failure (one managed medically and one with cerebrospinal fluid [CSF] diversion surgery), one had transient cotton wool spots post-operatively, one had transient retinal haemorrhages and one patient had a transiently oval pupil. No patients had repeat ONSF, but CSF diversion surgery was subsequently carried out in 4/30 (13%) patients. CONCLUSIONS: ONSF via a supero-medial eyelid skin crease approach is effective at improving visual function in patients with IIH. The complication rates are low when compared with CSF diversion surgery and other surgical approaches for ONSF.

Prioritising downgaze alignment in the management of vertical strabismus for thyroid eye disease: principles and outcomes.

OBJECTIVE: To evaluate outcomes of surgery for vertical strabismus in thyroid eye disease (TED) employing a set of surgical principles aimed at avoiding reversal of downgaze deviation while restoring binocular single vision (BSV). METHODS: A retrospective review of consecutive patients undergoing vertical strabismus surgery for TED using a set of surgical principles between 2008 and 2017. Principle outcome measure was the presence of BSV in primary position and downgaze 3 months postoperatively and at latest follow-up. RESULTS: Thirty five patients (29% male) with a mean age of 58 years (range 31-83 years) were included. Median follow-up was 16 months. At presentation, 17 (49%) used monocular occlusion to avoid diplopia; the remainder used a prism and/or abnormal head posture. In 12 (34%), combined horizontal and vertical muscle surgery was required. Median (inter-quartile range) preoperative vertical deviations in primary position and downgaze respectively were 20 prism dioptres (Δ) (15, 30) and 18Δ (8, 22), which improved to 1Δ (0, 3) and 1Δ (0, 3) after the first operation. BSV in primary position and downgaze, without prism, after a single surgery was achieved in 29 (83%). Second surgery was required in 5 (14%) and one patient who had reactivation of her TED required a third surgery. At final follow-up (median 16 months), 32 (91%) were diplopia free without prisms; 3 (9%) used a small prism correction (range 2-12Δ); no patients were left with intractable diplopia. CONCLUSIONS: Our management principles are characterised by prioritising downgaze alignment to avoid downgaze diplopia reversal, whilst limiting adjustable sutures and employing standard surgical dosing. They give favourable outcomes in TED associated vertical strabismus.

Orbital decompression for thyroid eye disease: methods, outcomes, and complications.

PurposeTo determine the safety and effectiveness of orbital decompression for thyroid eye disease (TED) in our unit. To put this in the context of previously published literature.Patients and methodsA retrospective case review of all patients undergoing orbital decompression for TED under the care of one orbital surgeon (SMS) between January 2009 and December 2015. A systematic literature review of orbital decompression for TED.ResultsWithin the reviewed period, 93 orbits of 55 patients underwent decompression surgery for TED. There were 61 lateral (single) wall decompressions, 17 medial one-and-a-half wall, 11 two-and-a-half wall, 2 balanced two wall, and 2 orbital fat only decompressions. For the lateral (single) wall decompressions, mean reduction in exophthalmometry (95% confidence interval (CI) was 4.2 mm (3.7-4.8), for the medial one-and-a-half walls it was 2.9 mm (2.1-3.7), and for the two-and-a-half walls it was 7.6 mm (5.8-9.4). The most common complications were temporary postoperative numbness (29% of lateral decompressions, 17% of other bony decompressions, OR 0.50, 95% CI 0.12-2.11) and new postoperative diplopia (9% of lateral decompressions, 39% of other bony decompressions, OR 6.8, 95% CI 1. 5-30.9). Systematic literature searching showed reduction in exophthalmometry for lateral wall surgery of 3.6-4.8 mm, with new diplopia 0-38% and postoperative numbness 12-50%. For other bony decompressions, reduction in exophthalmometry was 2.5-8.0 mm with new diplopia 0-45% and postoperative numbness up to 52%.ConclusionDiffering approaches to orbital decompression exist. If the correct type of surgery is chosen, then safe, adequate surgical outcomes can be achieved.

A novel, multidisciplinary clinic for complex visual problems in older people.

BACKGROUND: Visual symptoms in older people can be complex and inadequately explained by eye pathology alone. Psychological and neurodegenerative processes may manifest as complex visual symptoms, and thus some patients may be poorly served by a purely ophthalmic approach. We have developed a novel multidisciplinary clinic with input from neurology, ophthalmology, and psychiatric specialists. Here, we describe the patient population, disease prevalence, and potential impact of this new clinic. METHODS: A retrospective audit of paper and electronic records from June 2010 to February 2012 and selected case reports. RESULTS: Between June 2010 and February 2012 48 patients attended the clinic. Notes were available for 47 (98%). Mean age was 76.2 (range 48-92). The main presenting complaints were hallucinations, followed by nonspecific visual deficit, double vision, blurred vision, and visuospatial deficit. Cognitive impairment was noted in 68% (32/47) of patients, of which 16/32 (50%) were new diagnoses. We were able to give a diagnosis to 98% (46/47) of patients; of these, 74% (35/46) were new diagnoses. A total of 6% (3/47) were felt to have presentations attributable to eye pathology alone, whereas 89% (42/47) were felt to have a neuropsychiatric component. Management included referral to other clinics for continuing care in 43% (20/47) and initiation of therapy in 36% (17/47). The three case reports demonstrate cases, where our multidisciplinary approach aided diagnosis and management of patients with complex visual symptoms. CONCLUSION: A combined clinic with neurological, ophthalmic, and psychiatric input is an effective way to diagnose and manage complex visual problems in older people.

Republished review: cataract and cognitive impairment: a review of the literature.

Acquired cataract and cognitive impairment are both common age-related problems, and ophthalmologists are increasingly likely to encounter patients who have both. Patients with dementia types who display early visuoperceptual impairment may present first to ophthalmology services. When these patients have coexisting cataract, it may be difficult to distinguish visual complaints due to cataract from those due to dementia. The interaction between visual impairment due to cataract and neurodegenerative disorders affecting the central visual pathways, is not fully understood. Visual impairment due to cataract may stress impaired attentional mechanisms and cataract extraction may improve cognitive performance in some patients with early cognitive impairment; however, the benefits of cataract surgery in established dementia are less clear. In this study, the literature on this subject was reviewed and the implications for practice were considered.

Cataract and cognitive impairment: a review of the literature.

Acquired cataract and cognitive impairment are both common age-related problems, and ophthalmologists are increasingly likely to encounter patients who have both. Patients with dementia types who display early visuoperceptual impairment may present first to ophthalmology services. When these patients have coexisting cataract, it may be difficult to distinguish visual complaints due to cataract from those due to dementia. The interaction between visual impairment due to cataract and neurodegenerative disorders affecting the central visual pathways, is not fully understood. Visual impairment due to cataract may stress impaired attentional mechanisms and cataract extraction may improve cognitive performance in some patients with early cognitive impairment; however, the benefits of cataract surgery in established dementia are less clear. In this study, the literature on this subject was reviewed and the implications for practice were considered.

Use of cataract services in eastern Africa--a study from Tanzania.

PURPOSE: To establish the proportion of patients who are blind or have low vision prior to undergoing cataract surgery at tertiary referral centers in Tanzania. To assess which patient groups presenting for cataract surgery are more likely to be blind or visually impaired. METHODS: Using pre-existing computerized audit systems we gathered data on pre-operative visual status, age, gender and presentation mode (walk-in or outreach) for 3765 patients undergoing 4258 cataract operations at 2 hospitals in Tanzania. Visual status was defined based on vision in the better eye. RESULTS: 32% of operations were performed on blind patients, 37% on patients with low vision and 31% on normally sighted patients. Predictors of blindness at presentation were: female sex (OR 1.15; 95% CI 1.00-1.32); referral from a rural outreach program (OR 1.75; 95% CI 1.51-2.02) and older age (OR 1.02; 95% CI 1.01-1.02). CONCLUSIONS: It is not only the blind who present to cataract services in Tanzania. The demand for surgery amongst patients who or are normally sighted represents a positive move towards prevention, and not only cure of cataract blindness in Tanzania. However, it also highlights the need to target those left blind from cataract in order to deliver services to those most in need. Cataract programs targeting patients in rural areas and older patients are likely to increase the number of blind patients benefiting from cataract services.