Modified cheek advancement flap for medial lower eyelid, nasal sidewall and infraorbital cheek reconstruction: a case series.

Aim: To describe and evaluate surgical outcomes of the Modified Cheek Advancement Flap (MCAF) to reconstruct defects involving medial lower eyelid, nasal sidewall and infraorbital cheek following Mohs micrographic surgery for basal cell carcinoma (BCC).Materials and Methods: All patients who underwent MCAF between 2012 and 2018 under the care of a single surgeon (LCA) were identified. The technique described in this report is a significant modification of the traditional cheek advancement flap. The MCAF was undertaken without subciliary or infraorbital incisions, less extensive dissection and use of flap advancement rather than rotation. A retrospective chart review was completed using a pro-forma which included risk factors for flap failure, early and late complications and additional reconstructive procedures. Patient satisfaction was rated using a five-point Likert-type scale.Results: 42 patients underwent the MCAF. Mean follow up was 28.4 months (±19.9 months). Early complications were found in 11.9% of the patients and resolved completely within the first four post-operative weeks. There were no long term complications secondary to the reconstruction. No lower eyelid ectropion was noted. 78.6% of the patients cited they were 'extremely satisfied' with the final cosmetic outcome.Conclusion: The MCAF proves a valuable and safe option in periocular reconstructive surgery with excellent cosmetic results and no post-operative ectropion. The necessity for eyelid tightening as part of the reconstructive process should encourage oculoplastic surgeons to use the MCAF when reconstructing defects involving medial lower eyelid, infraorbital cheek and nasal sidewall.

Development of decellularized conjunctiva as a substrate for the ex vivo expansion of conjunctival epithelium.

This study was performed to develop a method to decellularize human conjunctiva and to characterize the tissue in terms of its deoxyribose nucleic acid (DNA) content, tensile strength, collagen denaturation, basement membrane, extracellular matrix components and its potential to support conjunctival epithelial growth. Human conjunctival tissues were subjected to a decellularization process involving hypotonic detergent and nuclease buffers. Variations in sodium dodecyl sulfate concentration (0.05-0.5%, w/v) were tested to determine the appropriate concentration of detergent buffer. DNA quantification, collagen denaturation, cytotoxicity and tensile strength were investigated. Human conjunctival cell growth by explant culture on the decellularized tissue substrate was assessed after 28 days in culture. Samples were fixed and paraffin embedded for immunohistochemistry including conjunctival epithelial cell markers and extracellular matrix proteins. Conjunctival tissue from 20 eyes of 10 donors (age range 65-92 years) was used. Decellularization of human conjunctiva was achieved to 99% or greater DNA removal (p < 0.001) with absence of nuclear staining. This was reproducible at the lowest concentration of sodium dodecyl sulfate (0.05% w/v). No collagen denaturation (p = 0.74) and no difference in tensile strength parameters was demonstrated following decellularization. No significant difference was noted in the immunolocalization of collagen IV, laminin and fibronectin, or in the appearance of periodic acid-Schiff-stained basement membranes following decellularization. The decellularized tissue did not exhibit any cytotoxicity and explant culture resulted in the growth of stratified conjunctival epithelium. Allogeneic decellularized human conjunctiva can be successfully decellularized using the described protocol. It represents a novel substrate to support the expansion of conjunctival epithelium for ocular surface cellular replacement therapies. Copyright © 2017 John Wiley & Sons, Ltd.

Corneal transplant surgery for keratoconus and the effect of surgeon experience on deep anterior lamellar keratoplasty outcomes.

PURPOSE: To investigate graft survival and surgical experience on clinical outcome following deep anterior lamellar keratoplasty (DALK). DESIGN: Multicenter cohort study. METHODS: The United Kingdom Transplant Database was used to identify patients who had undergone a first DALK or penetrating keratoplasty (PKP) for keratoconus. Data were collected at the time of surgery and at 1, 2, and 5 years postoperatively. Graft survival, best-corrected visual acuity, and refractive error were analyzed for 3 consecutive time periods. DALK outcomes were analyzed according to surgeon experience. RESULTS: A total of 4521 patients were included. Graft survival was 92% (95% CI: 90-92) for PKP and 90% (95% CI: 88-92) for DALK (P = .09). For corneal transplants undertaken in the periods 1999-2002, 2002-2005, and 2005-2007, graft survival was 90%, 92%, and 88% following DALK, and 93%, 91%, and 92% following PKP, respectively. There was no evidence of a difference between surgeons in terms of case mix (P = .4) or outcome (P = .2). Surgeon experience, in terms of the number of previous DALK undertaken, had no significant effect on outcome. A donor recipient trephine size disparity of 0.5 mm was associated with an increased risk of graft failure for both DALK (P = .03) and PKP (P = .002), whereas ocular surface disease was a significant risk factor for DALK (P = .04) but not PKP. CONCLUSIONS: There has been little change in graft survival for DALK and PKP over the past decade. Ocular surface disease is an important risk factor for graft failure following DALK. A surgical learning curve for DALK could not be demonstrated in terms of clinical outcome.

Clinical outcomes of triamcinolone-assisted anterior vitrectomy after phacoemulsification complicated by posterior capsule rupture.

PURPOSE: To compare the clinical outcomes in patients who had triamcinolone acetate-assisted anterior vitrectomy and patients who had anterior vitrectomy without triamcinolone acetate after phacoemulsification complicated by posterior capsule rupture and vitreous loss. SETTING: Arrowe Park Hospital, Wirral, United Kingdom. DESIGN: Retrospective consecutive case note review. METHODS: Consecutive case notes of patients who had anterior vitrectomy assisted by triamcinolone acetonide (triamcinolone group) or without triamcinolone acetate (no-triamcinolone group) after posterior capsule rupture between January 2007 and January 2011 were identified and examined. Data recorded at the clinic visit preoperatively and 1 day and 3 months postoperatively were collated. Information recorded on the pro forma included visual acuity, ocular comorbidities, intraocular pressure (IOP), vitreous strands in the anterior chamber, and other adverse events. RESULTS: No statistically significant difference was found in the visual acuity or IOP between 17 patients in the triamcinolone group and 34 patients in the no-triamcinolone group at any time point. Vitreous strands in the anterior chamber were noted in 1 patient in the triamcinolone group and 7 patients in the no-triamcinolone group. Cystoid macular edema (CME) was present in 3 patients in the no-triamcinolone group, including 1 patient with vitreomacular traction. CONCLUSIONS: There was no significant increase in IOP after triamcinolone acetate-assisted anterior vitrectomy. Higher rates of CME and residual anterior chamber vitreous strands in the no-triamcinolone acetate group support the clinical use of triamcinolone acetate.

Corneal endothelial dysfunction in Pearson syndrome.

Mitochondrial disorders are associated with well recognized ocular manifestations. Pearson syndrome is an often fatal, multisystem, mitochondrial disorder that causes variable bone marrow, hepatic, renal and pancreatic exocrine dysfunction. Phenotypic progression of ocular disease in a 12-year-old male with Pearson syndrome is described. This case illustrates phenotypic drift from Pearson syndrome to Kearns-Sayre syndrome given the patient's longevity. Persistent corneal endothelial failure was noted in addition to ptosis, chronic external ophthalmoplegia and mid-peripheral pigmentary retinopathy. We propose that corneal edema resulting from corneal endothelial metabolic pump failure occurs within a spectrum of mitochondrial disorders.

The effect of scleral exoplant removal on strabismus following retinal detachment repair.

PURPOSE: Scleral buckling for retinal detachment is a well-reported cause of secondary strabismus. We analyzed the effects on motility of removal of the exoplant alone to determine whether this is warranted as a separate step in the surgical management of these patients. METHODS: A retrospective case series of patients who underwent scleral exoplant removal due to symptomatic strabismus development following retinal detachment repair from 2007 to 2009 was conducted. Manifest horizontal and vertical deviations were treated as vectors of a single combined deviation (|dev|). Pre- and postoperative manifest |dev| in the primary position (|dev|(pp)) and in the gaze position of maximal deviation (|dev|(max)) were analyzed. RESULTS: Five patients were identified, all with symptomatic, binocular diplopia in the primary position prior to exoplant removal. Median |dev|(pp) prior to exoplant removal was 21(Δ) and following removal was 21(Δ) (P = 0.81). The median |dev|(max) prior to exoplant removal was 33(Δ) and following removal, 22(Δ) (P = 0.82). Median follow-up was 8 months. There were no cases of retinal redetachment following the exoplant removal. No patient reported any subjective improvement of their diplopia. All 5 patients went on to have strabismus surgery as a separate procedure. CONCLUSIONS: Median primary position deviation was unchanged by scleral buckle removal, and Exoplant removal has minimal long-term benefit on the strabismus following scleral buckling procedures.

Chronic carbon monoxide poisoning resulting in bilateral cataracts and a cystic globus pallidus lesion.

The authors describe a case of a 43-year-old lady who developed bilateral cataracts, seizures and a unilateral cystic lesion of the basal ganglia following low-dose carbon monoxide (CO) exposure over 7 years. Cataract formation may result from sustained oxidative stress as a result of chronic environmental CO exposure.

The value of the Duke Activity Status Index (DASI) in predicting ischaemia in myocardial perfusion scintigraphy - a prospective study.

BACKGROUND: Functional capacity assessment may be a useful tool to stratify patients according to risk of coronary artery disease (CAD). The Duke Activity Status Index (DASI) is a functional assessment based on activities of daily living and cardiovascular fitness, assessed using a self-administered questionnaire. MATERIAL AND METHODS: We assessed the relationship between established clinical risk factors for CAD and the DASI with results of myocardial perfusion scintigraphy (MPS). The MPS results used in the analysis were the presence of reversible ischaemia and the resting left ventricular ejection fraction (LVEF). A DASI self-administered questionnaire was completed by 117 consecutive participants, and a patient history was taken to ascertain established risk factors. All participants underwent a stress test, and myocardial perfusion scintigraphy was performed. Statistical analysis consisted of logistic and linear regression using a statistical software package. RESULTS: The DASI was the only factor that correlated significantly with reversible ischaemia on MPS. None of the previously established risk factors had a significant association with reversible ischaemia within the model. Our study found a potential relationship between the DASI score and the left ventricular ejection fraction (LVEF) although this was not statistically significant. CONCLUSIONS: Our study findings suggest that the DASI may represent a powerful tool for risk stratification prior to investigation of CAD. A further study with a larger sample size will be required to investigate the predictive value of the DASI and the association with LVEF.