Changes in quality of life shortly after routine cataract surgery.

OBJECTIVE: To perform a pilot study to explore use of a generic patient-reported outcome measure to assess patient-perceived improvements in quality of life within 2-4 weeks of routine cataract surgery and to explore differences after first or second eye surgery. Secondary analysis explored effects of gender and ethnicity. DESIGN: Prospective observational study. PARTICIPANTS: Consecutive patients attending a weekly nurse-led postoperative clinic. METHODS: The Glasgow Benefit Inventory (GBI), a validated, postinterventional questionnaire (not specific to one particular medical or surgical intervention), was administered. Mean scores were calculated. Scores were compared when patients were grouped by first or second eye, and by gender or ethnicity (unpaired t test). Scores potentially range from +100 (maximum benefit) to -100 (maximum detriment). RESULTS: The GBI was administered 113 times to 109 patients (4 patients were seen after both first and second eye surgery). Mean overall score was +22.8 (median +19.4; SD 19.7; 95% CI +19.2 to +26.4). Mean (SD) subscores were +30.5 (25.3), +17.8 (26.7), and -3.1 (19.9) for general, social support, and physical health subdomains, respectively. Total benefit scores were not significantly different for first or second eye surgery, or across gender (p > 0.3). Scores for patients of African (including African Caribbean) ethnicity were significantly higher than those obtained from European patients (p = 0.002). CONCLUSIONS: Patients reported significant improvements in quality of life even a few weeks after cataract surgery, as assessed by the GBI. Second eye surgery appeared to confer similar benefit to first eye surgery. The significant difference in scores between ethnic groups invites further investigation.

Why do patients with nonurgent conditions present to the Emergency Department despite the availability of alternative services?

The aim of this study was to investigate why nonurgent patients present to the Emergency Department (ED) despite availability of alternative services; also to assess impact of the UK Choose Well Campaign. A convenience sample of nonurgent ED attenders was surveyed in North Wales, UK. More than half of patients sought advice from friends, family, carer or GP before attending ED. Of the one-third of patients who had not tried an alternative service before presenting to ED, reasons given included patients thinking that they might need a radiograph (46%), believing that GP would be unable to help (29%) or stating that GP was not available (19%). Twenty per cent of patients reported they would have changed their decision about attending ED if they had known more about alternatives. Only 12% were aware of Choose Well. Analysis suggests that though Choose Well effectively provides information on alternatives, it does not translate into more appropriate attendance.

Imiquimod 5% cream as an adjuvant pre-operative treatment for basal cell carcinoma of the periocular area.

Despite national guidelines in the UK, patients with low-grade periocular malignancies frequently wait a period of months for their surgery. We have devised a protocol of pre-treatment with an immune modulator in an attempt to reduce the tumour size whilst patients await surgery. We present a case series of 5 patients who used Imiquimod 5% cream (Aldara) for 4 weeks as an adjuvant treatment prior to the excision of periocular nodular basal cell carcinomas. We also assessed tolerability of the cream using a visual analogue scale and recorded adverse events. Our patients had an average 22% reduction in tumour area (range 3.31%-39.64%) whilst awaiting surgery. The medication had a good tolerability profile and there were no ocular adverse events. Due to the promising results, this pilot study demonstrates the feasibility and value of a planned multicentre, prospective research project to further explore these initial findings.

Long-term refractive changes in children following ptosis surgery: a case series and a review of the literature.

The purpose of the study was to evaluate the long-term changes in refractive error in children with congenital ptosis managed with unilateral levator resection, and to provide a brief literature review and discuss the possible mechanisms for refractive change in the post-operative period. We present a retrospective consecutive case series of children (4-11 years old) who underwent unilateral levator resection, performed by a single ophthalmic surgeon to manage congenital ptosis between 1998 and 2001 at Maidstone Hospital, Kent. Cycloplegic refraction data were obtained prior to surgery and at the last clinic visit post surgery (minimum follow-up 12 months). The refractive changes in the non-operated contralateral eye were used as age-matched controls. Data were analysed for changes in refractive sphere and cylinder. Forty-three patients underwent levator resection during this 3-year period. Complete refraction data were available for 13 patients. The mean age at the time of levator resection was 6.7 years. The refractive error was greater on the side with the ptosis (61 %). At the last clinical follow up (mean 36.3 months; SD 34 months), the mean spherical change in the operated eye was 0.41D (range 0.12-1.50D), compared to a mean change of 0.40D (range 0.25-2.00D) in the non-operated eye. The mean cylindrical change in the operated eyes was 0.38D (range 0.25-1.00D), compared to a mean of 0.21D (range 0.50-1.75D) in the non-operated eye. In conclusion, this study did not show a significant change in refractive error following levator resection surgery for congenital ptosis.

Outcomes of ptosis surgery assessed using a patient-reported outcome measure: an exploration of time effects.

AIMS: To explore effects of time following ptosis surgery on patient-reported quality-of-life outcomes. METHODS: The Glasgow Benefit Inventory (GBI), a validated, postinterventional questionnaire was administered to consecutive adults undergoing ptosis surgery on the operating list of one surgeon over a 30-month period. Patients who were not contactable or unable to provide answers were excluded. Mean scores of patients grouped by time since surgery were compared (unpaired t test and Westlake intervals to test equivalence). RESULTS: Of 63 consecutive patients, 50 (79%) were included. Mean age was 63 years. Mean time since surgery was 561 days (range 21-973). There was no significant difference in mean total scores of patients assessed less than 18 months since surgery compared with those assessed later (p=0.544). Distributions of total scores were similar. No significant differences were found for subscores or when patients were divided into three groups according to time after surgery. Multivariate logistic regression revealed no significant effect of time since surgery. Trends were seen with regard to age and type of operation, but did not reach significance. CONCLUSIONS: Patient-perceived benefit following ptosis surgery shows stability with time, as assessed using the GBI. Future studies could explore correlations with age and type of surgery.

Investigation of basal cell carcinoma using dynamic focus optical coherence tomography.

Optical coherence tomography (OCT) is becoming a popular modality for skin tumor diagnosis and assessment of tumor size and margin status. We conducted a number of imaging experiments on periocular basal cell carcinoma (BCC) specimens using an OCT configuration. This configuration employs a dynamic focus (DF) procedure where the coherence gate moves synchronously with the peak of the confocal gate, which ensures better signal strength and preservation of transversal resolution from all depths. A DF-OCT configuration is used to illustrate morphological differences between the BCC and its surrounding healthy skin in OCT images. The OCT images are correlated with the corresponding histology images. To the best of our knowledge, this is the first paper to look at DF-OCT imaging in examining periocular BCC.

Quantitative evaluation of scattering in optical coherence tomography skin images using the extended Huygens-Fresnel theorem.

An optical properties extraction algorithm is developed based on enhanced Huygens-Fresnel light propagation theorem, to extract the scattering coefficient of a specific region in an optical coherence tomography (OCT) image. The aim is to quantitatively analyze the OCT images. The algorithm is evaluated using a set of phantoms with different concentrations of scatterers, designed based on Mie theory. The algorithm is then used to analyze basal cell carcinoma and healthy eyelid tissues, demonstrating distinguishable differences in the scattering coefficient between these tissues. In this study, we have taken advantage of the simplification introduced by the utilization of a dynamic focus OCT system. This eliminates the need to deconvolve the reflectivity profile with the confocal gate profile, as the sensitivity of the OCT system is constant throughout the axial range.

Patient-reported benefit from botulinum toxin treatment for essential blepharospasm: using 2 assessment scales.

PURPOSE: To assess and compare the change in quality-of-life and function following treatment with botulinum toxin (BTX) using the Glasgow Benefit Inventory (GBI) and Blepharospasm Disability Index (BSDI) scores. METHODS: A cross-sectional study of 62 consecutive patients treated with BTX for blepharospasm conducted during a postinterventional telephone interview. Post hoc analysis converts the GBI to a score from -100 (maximum harm) through 0 (no effect) to +100 (maximum benefit). The BSDI is converted to a score on a scale from -4 (maximum harm) through 0 (no effect) to +4 (maximum benefit). A Wilcoxon signed-rank test and linear regression analysis were performed. RESULTS: A statistically significant benefit (Wilcoxon signed-rank test) from treatment of 31.36 (95% confidence interval = 26.22-36.50; p < 0.001) and 1.04 (95% confidence interval = 0.80-1.27; p < 0.001) using the GBI and BSDI scores, respectively. Regression analysis was performed demonstrating a strong positive correlation between both scales (r = 0.637). CONCLUSIONS: BTX treatment for blepharospasm is associated with significant patient-reported improvements in quality-of-life (GBI) and functional ability (BSDI) with a strong positive correlation between both scores.

Ptosis assessment spectacles: a new method of measuring lid position and movement in children.

PURPOSE: Accurate assessment of eyelid position and movement is vital in planning the surgical correction of ptosis. Conventional measurements taken using a millimeter ruler are considered the gold standard, although in young children this can be a difficult procedure. The authors have designed ptosis assessment spectacles with a measuring millimeter scale marked on the center of the lens to facilitate accurate assessment of eyelid position and function in children. The purpose of the study was to assess the accuracy and reproducibility of eyelid measurement using these ptosis assessment spectacles. METHODS: Fifty-two children aged 2-12 years were recruited in this study. Each child underwent 2 sets of measurements. The first was undertaken by an ophthalmologist in the conventional manner using a ruler, and the second set made with ptosis assessment spectacles. On each occasion the palpebral aperture, skin crease, and levator function were recorded in millimeters. A verbal analog scale was used to assess parent satisfaction with each method. RESULTS: Clinically acceptable reproducibility was shown with the ruler and the spectacles for all measurements: palpebral aperture, skin crease, and levator function. Parents significantly preferred the glasses for measurement, as compared with the ruler (p < 0.05). CONCLUSIONS: The spectacles are as accurate as conventional methods of measurement, but are easier to use. Children tolerate these spectacles well, and most parents preferred them to the ruler.

Levator function revisited: a two-phase assessment of lid movement to better identify levator-superior rectus synkinesis.

AIM: To assess a two-phase method of recording levator function in order to facilitate the identification of patients with ptosis who have a synkinesis between the levator and superior rectus muscles. METHODS: 40 consecutive patients who attended oculoplastic clinics with ptosis and 22 patients with normal lid function were recruited. In each subject, levator function was recorded by the conventional method, measuring total upper eyelid excursion between the extremes of down-gaze and up-gaze. Levator function was also assessed using our novel two-phase approach in which upper-eyelid excursion is measured separately between down-gaze and primary position (Phase 1), and between primary position and up-gaze (Phase 2). RESULTS: In normal patients and most of the patients with ptosis, the majority of lid movement and hence levator function occurs between down-gaze and the primary position (Phase1). In those patients with ptosis and levator-superior rectus synkinesis, a higher proportion of lid movement occurred on up-gaze (Phase2). CONCLUSION: The two-phase measurement of lid movement highlights levator function in differing gaze positions and facilitates the identification of those patients with levator-superior rectus synkinesis.

Ophthalmoplegia secondary to herpes zoster ophthalmicus.

An 80-year-old Caucasian woman had been diagnosed with right herpes zoster ophthalmicus 2 ½ weeks before presentation to our department. Ten days after stopping oral aciclovir, she presented with periorbital pain, visual loss, ptosis and complete ophthalmoplegia. On examination, visual acuity in her right eye was hand movements, with a relative afferent pupillary defect and 2 mm proptosis. MRI demonstrated contrast enhancement within the orbit extending into the apex, suggestive of an inflammatory process. Oral treatment was started with oral aciclovir and corticosteroids for 2 months, when she had resolution of the optic neuropathy and ophthalmoplegia. Vision recovered to 6/9 and repeat neuroimaging revealed regression of the inflammatory process.

A randomised controlled trial to compare patient satisfaction with two different types of local anaesthesia in ptosis surgery.

BACKGROUND: Ptosis surgery is performed under local anaesthetic to allow intra-operative assessment of lid positioning. Most commonly the anaesthetic is administered as a subcutaneous infiltration at the surgical site. Ptosis surgery using a regional nerve block has also been described, with reported advantages for minimising levator paralysis and disruption of the surgical landmarks. This study was designed to compare patient satisfaction with the two techniques of local anaesthetic administration. METHODS: 32 patients undergoing ptosis surgery were enrolled into a randomised controlled trial to receive local anaesthetic either by subcutaneous infiltration or by regional nerve block. Patient satisfaction was measured postoperatively with a self-administered vertical response column questionnaire, the Iowa Satisfaction with Anaesthesia Scale (ISAS). RESULTS: Of the 32 patients who were recruited 3 patients were excluded from analysis due to incomplete questionnaires or deviation from the trial protocol. Patient groups were well matched in terms of age, sex, time on waiting list, anaesthetic risk score, and operating grade of surgeon. Comparison of ISAS scores with the Mann Whitney test demonstrated an equal level of patient satisfaction with the two techniques. CONCLUSION: This randomised controlled trial found regional nerve blocks to be associated with equal levels of patient satisfaction as the more standard technique of diffuse infiltration of local anaesthetic along the upper eyelid. This result supports the use of regional nerve blocks as a valid alternative for anaesthesia in ptosis surgery.

Laissez-faire: how far can you go?

INTRODUCTION: Lid defects created by removal of tumors are conventionally repaired by lid reconstruction. An alternative to surgical repair is wound healing by secondary intention. This technique, laissez-faire, as used in the periorbital region, was first described in 1957. PURPOSE: This report considers how effective this technique is for defects of various sizes and different locations in the periorbital region. METHODS: Defects following excision of periocular tumors in 10 Caucasian patients were allowed to heal by laissez-faire. The locations of the defects were the medial canthus (n = 4), lower eyelid (n = 4), lateral canthus (n = 1), and upper lid (n = 1). The functional and cosmetic outcome of the healing process was noted. RESULTS: A good functional and cosmetic outcome were obtained after healing by laissez-faire in 8 of the 10 patients. Of the 2 remaining patients one patient had a large medial canthal and lower lid defect which extended onto the cheek, which healed with residual scarring and medial ectropion. The second patient had a lower lid defect, which healed with a cicatricial ectropion. Of the 2 patients, only one required further surgery. CONCLUSIONS: This report shows the technique of healing by laissez-faire can be extended for relatively large defects with good results. The medial canthal region and full-thickness lower lid defects remain the favored locations for healing by secondary intention. In large defects particularly with extension onto the cheek, there is a significant risk of cicatrization, and the possibility of a second corrective operation should be discussed with the patient prior to tumor excision.

A new instrument to aid the lateral tarsal sling procedure.

We describe a new surgical instrument and its use in the lateral tarsal sling procedure. We reviewed the charts of 23 cases of such surgery over 5 years and found its use to be an effective means of correcting horizontal eyelid laxity, with a low rate of complications. This approach provides a safe and effective alternative to the lateral tarsal strip procedure.