Eyelid Skin Grafting in Young Patients with Facial Nerve Palsy.

Background: The aim of this study is to report outcomes of eyelid full-thickness skin grafting augmentation in facial nerve palsy (FNP) patients younger than 50 years of age. Methods: In a retrospective, consecutive case series, nine eyelid skin grafts performed on eight FNP patients with skin contraction (five females; median age 42 years [range, 17-47]) are presented. In most cases, upper eyelid skin grafting was combined with levator recession and anterior lamellar repositioning. Lower eyelid skin grafting was combined with lower retractors recession in all cases. Functional and cosmetic outcomes were measured preoperatively and at early (1-3 months), intermediate (3-6 months), and late (≥12 months) follow-up. Results: The corneal score improved at early follow-up (p = 0.03) and remained improved at late follow-up (p = 0.042). The gentle closure lagophthalmos was improved at late follow-up (p = 0.042). (p = 0.048). The grades of graft color, edge/skin interface, and size improved at 3-6 months post-grafting and remained improved at late follow-up (p < 0.05). Over the follow-up, four patients (50%) were recommended to have further surgical procedures. Conclusions: The preliminary results from this small cohort suggest that eyelid skin grafting is a viable option for young patients prioritizing cosmesis. This technique warrants consideration for its functional benefits.

Pneumatization of the Greater Wing of Sphenoid Utilization for Lateral Wall Decompression.

The goal of orbital decompression for thyroid orbitopathy is to expand the orbital space for the contents with various techniques described. Deep lateral wall decompression is a procedure that expands the orbit by removing bone from the greater wing of sphenoid however its effectiveness is dependent on the volume of bone removed. Pneumatization of the greater wing of sphenoid is defined as an extension of the sinus beyond the VR line (a straight line crossing the medial edges of the vidian canal and the foramen rotundum) which is a demarcation between the sphenoid body and the lateral parts of the sphenoid bone, including the greater wings and pterygoid process. We present a case of complete pneumatization of the greater wing of sphenoid affording a greater volume of bony decompression in a patient with significant proptosis and globe subluxation as a result of thyroid eye disease.

Acute Leukemia Presenting in the Pediatric Orbit.

We present a case series to evaluate the clinical features of acute leukemia presenting with primary orbital manifestations. We undertook a retrospective case review of primary orbital presentations of acute myeloid leukemia (AML) and acute lymphocytic leukemia (ALL) over a 10-year period at two hospital sites (Hereford County Hospital and Leicester Royal Infirmary). Our case series included four patients - two with AML and two with ALL. Patients were young (mean age of four years and five months) at presentation, all with unilateral disease, and presented with orbital signs. Although there was some confusion with the diagnosis at the time of referral, a suspicion of malignancy was made rapidly once ophthalmic review was initiated. All four cases were diagnosed with the assistance of peripheral blood film and bone marrow biopsy, without the need for orbital biopsy. All four cases had resolution of the orbital mass and remain disease-free.

Do Prostaglandin Analogue Lash Lengtheners Cause Eyelid Fat and Volume Loss?

BACKGROUND: Prostaglandin analogues (PGAs; a first-line antiglaucoma treatment) have been remarketed as popular eyelash-lengthening serums due to their lash-lengthening and lash-thickening side effects. Periorbital volume loss is now a well-established side effect of topical PGAs used to treat glaucoma (prostaglandin-associated periorbitopathy) but has not, to date, been listed as a potential side effect of lash-lengthening serums containing PGAs. OBJECTIVES: The aim of this study was to identify whether periorbital fat/volume loss is seen in users of PGA lash lengtheners. METHODS: This investigation comprised a case report and an informal randomized controlled study comparing "before-and-after" color photographs displayed on the websites of manufacturers of PGA-containing lash lengtheners (PGALLs) (ie, containing bimatoprost, norbimatoprost, isopropyl cloprostenate, dechloro-dihydroxy-difluoro-ethylcloprostenolamide, or methylamido-dihydro-noralfaprostal) vs 2 control groups: non-PGALLs (NPGALL) and false eyelashes (FLs). Expert and layperson blinded graders used a purpose-designed grading system to identify subtle signs of periorbital fat/volume loss over time. RESULTS: A 35-year-old female developed thin, wrinkled, darker skin, and periorbital hollowing after 10 months of treatment with Lash Boost (Rodan & Fields, San Francisco, CA), containing isopropyl cloprostenate, which reversed 6 months after discontinuation. Fifteen "before-and-after" pairs of photographs (PGALL, n = 10; NPGALL, n = 3; FL, n = 2) were graded by 5 graders (3 expert, 2 layperson). Mean grading score was 8.2 (of 19) in the PGALL group, 2.3 in the NPGALL group, and 3.2 in the FL group. PGALL scores were significantly higher than scores in the NPGALL (P < 0.001) and FL (P = 0.017) groups. CONCLUSIONS: Review of commercial "before-and-after" photographs suggests that PGALL users develop changes compatible with prostaglandin-associated periorbitopathy. Consumers must be aware of the possibility of periorbital volume loss prior to commencing treatment with PGALLs. Often the customer-facing product ingredient list contains no mention of PGAs.

Metastatic testicular choriocarcinoma presenting as eyelid swelling and ptosis.

A 34-year-old man presented with an 8-day history of swelling and ptosis affecting the right upper eyelid. An MRI scan showed right superior rectus enlargement. Histology of an incisional biopsy of the muscle demonstrated metastatic choriocarcinoma to the orbit, positive for pan-cytokeratins, beta-HCG and GATA3. Possible primary sites included testis. An ultrasound of the testes identified bilateral testicular masses, highly suspicious for primary testicular malignancy. A CT scan of the chest, abdomen and pelvis identified disseminated metastatic disease conferring a poor prognostic germ cell tumour. The overall interpretation was of disseminated testicular choriocarcinoma and the patient is currently undergoing intensive chemotherapy.

Tear Trough Malar Implant Penetrating Lacrimal Sac Causing Lacrimal Obstruction and Epiphora: Case Report and Review.

Tear trough implantation may be associated with a number of well-reported complications. To our knowledge, penetration of the lacrimal sac has never been reported as a complication of malar or tear trough implants. We report a case of lacrimal sac penetration discovered at the time of endoscopic dacryocystorhinostomy surgery in a patient who developed epiphora soon after the tear trough implant was placed.

Orbital involvement of Sitosterolemia.

Sitosterolemia is a rare inherited condition in which plant sterols are stored and deposited in the tissues. Described in 1974 by Battacharyya and Connor, it is characterized by tendon and tuberous xanthomas and a propensity to premature coronary atherosclerosis. We present the first reported case of the disease being manifest in the periorbital region. A 44-year-old man presented with a six-month history of swelling below the left eyebrow overlying the orbital rim, but without displacement of the globe. Magnetic resonance imaging identified a soft tissue mass within the orbit, with subsequent biopsy confirming a xanthogranulomatous process consistent with the diagnosis of sitosterolemia. Management of sitosterolemia aims to reduce plasma plant sterol concentrations which subsequently lowers serum cholesterol reducing the xanthomas and atherosclerotic cardiovascular diseases. This report highlights a rare, under-recognised condition (and indeed the first reporting periocular disease), and the potential dangers if misdiagnosed as hypercholesterolemia.

Allogenic dehydrated human pericardium patch graft (Tutoplast): A novel use for reconstruction in orbital implant exposure.

PURPOSE: Exposure of orbital implant post enucleation or evisceration remains one of the common complications irrespective of the type of implant used. Dermis fat graft and temporalis fascia have been used to repair the implant exposure in anophthalmic sockets. Tutoplast® pericardium, gamma sterilised dehydrated human pericardium, has been used as a scleral patch graft for glaucoma drainage device exposure and scleral thinning post squint surgery. We report the novel use of Tutoplast® patch graft to repair orbital implant exposure in this case series. METHODS: The case notes of three patients who received Tutoplast® pericardium patch graft to repair implant exposure were reviewed. Data regarding presenting symptoms, implant type, time to exposure from primary surgery, post-operative complications and length of follow up post Tutoplast® pericardium patch graft were collected. RESULTS: Three patients presented with implant exposure following evisceration. The presenting symptoms were recurrent infection, discharging socket and discomfort in all three patients. One patient had a Medpore implant, two had silicone implants. Total follow-up ranged from 9 to 22 months. In all three cases, there was relief from symptoms and the graft had incorporated fully into the surrounding orbital tissue with no recurrent exposure noted during the follow-up period. CONCLUSION: Tutoplast® pericardium has demonstrated a good safety profile and is a suitable material to use as a patch graft for orbital implant exposure.

Impact of COVID-19 pandemic and lockdown on eye emergencies.

BACKGROUND: To characterise and compare ocular pathologies presenting to an emergency eye department (EED) during the COVID-19 pandemic in 2020 against an equivalent period in 2019. METHODS: Electronic patient records of 852 patients in 2020 and 1818 patients in 2019, attending the EED at a tertiary eye centre (University Hospitals of Leicester, UK) were analysed. Data was extracted over a 31-day period during: (study period 1 (SP1)) COVID-19 pandemic lockdown in UK (24th March 2020-23rd April 2020) and (study period 2 (SP2)) the equivalent 2019 period (24th March 2019-23rd April 2019). RESULTS: A 53% reduction in EED attendance was noted during lockdown. The top three pathologies accounting for >30% of the caseload were trauma-related, keratitis and uveitis in SP1 in comparison to conjunctivitis, trauma-related and blepharitis in SP2. The overall number of retinal tears and retinal detachments (RD) were lower in SP1, the proportion of macula-off RD's (84.6%) was significantly (p = 0.0099) higher in SP1 (vs 42.9% in SP2). CONCLUSION: COVID-19 pandemic related lockdown has had a significant impact on the range of presenting conditions to the EED. Measures to stop spread of COVID-19 such as awareness of hand hygiene practices, social distancing measures and school closures could have an indirect role in reducing spread of infective conjunctivitis. The higher proportion of macula-off RD and lower number of retinal tears raises possibility of delayed presentation in these cases. Going forward, we anticipate additional pressures on EED and other subspecialty services due to complications and associated morbidity from delayed presentations.

Oedipism: An unusual case of auto-enucleation including mechanism of avulsion.

INTRODUCTION: Self-inflicted enucleation, also known as auto-enucleation (AE) or Oedipism, is an uncommon and severe form of ocular injury which presents as an ophthalmic and psychiatric emergency. Usually known to occur with untreated psychosis, this case is a rare report which demonstrates AE as a result of a subsequently diagnosed drug induced psychosis. We report the clinical presentation, management and for the first time a detailed speculative account about the mechanism of AE, based on our clinicopathologic findings. CASE REPORT: A 53-year old Afro-Caribbean patient was arrested following an altercation and was incarcerated awaiting arraignment. The patient had no previous psychiatric history but tested positive for cannabis, opiates and cocaine as well as admitting to illicit drug use in the community. Whilst in custody, the patient self-enucleated his right eye. The patient declined consent to eye examination and was subsequently admitted under section 2 of the Mental Health Act. After full work-up including Goldmann visual fields and magnetic resonance imaging, he underwent right orbital exploration under anesthetic where AE was confirmed whilst the left eye showed evidence of attempted enucleation. The residual tenons and conjunctiva was subsequently repaired without placement of an orbital implant in the right orbit. The globe was sent for histology which revealed clues to the potential mechanism of auto-enucleation. CONCLUSION: This case is unique as it offers an alternative presentation to those most commonly reported in the current literature, highlights the sparsity of literature detailing the mechanism of AE and stimulates discussion around various potential systemic etiological differential diagnoses, management strategies and complications of AE.

Tubulointerstitial nephritis and uveitis (TINU) syndrome: a systematic review of its epidemiology, demographics and risk factors.

Tubulointerstitial nephritis and uveitis (TINU) syndrome is a rare oculorenal inflammatory condition that was first described in 1975. In 2001 a major review identified 133 cases in the world literature and proposed key diagnostic criteria for the condition. Although acknowledged as rare, the limited data available prevented reliable estimates of the prevalence of the condition, and hampered elucidation of the relationship between genetic and environmental factors that contribute to its pathogenesis.In this review we have performed a systematic search on the epidemiology, demographics and proposed risk factors for TINU. Estimates of prevalence based on studies that explicitly report TINU cases suggest that it is diagnosed in 0.2-2% of patients attending specialist uveitis services, with variation reflecting a number of factors including level of diagnostic certainty required. The prevalence of uveitis in patients with tubulointerstitial nephritis (TIN) may be higher than currently recognised, particularly in the paediatric population.The prevalence of TINU is higher in younger age groups and there is a female preponderance although this gender effect appears weaker than suggested by early studies. Although important genetic contributions have been proposed, the small size of studies and variation between reports currently preclude identification of a 'pro-TINU' haplotype. Drugs and infections have been proposed as the leading acquired risk factors for the development of TINU; whilst the small size of TINU cohorts and issues of study design limit interpretation of many studies. Larger datasets from the renal literature suggest that the majority of these cases are precipitated by a drug-induced hypersensitivity reaction; however in many ophthalmic cases no clear precipitant is identified.

Hypolipidemic effects of lactic acid bacteria fermented cereal in rats.

BACKGROUND: The objectives of the present study were to investigate the efficacy of the mixed culture of Lactobacillus acidophilus (DSM 20242), Bifidobacterium bifidum (DSM 20082) and Lactobacillus helveticus (CK60) in the fermentation of maize and the evaluation of the effect of the fermented meal on the lipid profile of rats. METHODS: Rats were randomly assigned to 3 groups and each group placed on a Diet A (high fat diet into which a maize meal fermented with a mixed culture of Lb acidophilus (DSM 20242), B bifidum (DSM 20082) and Lb helveticus (CK 60) was incorporated), B (unfermented high fat diet) or C (commercial rat chow) respectively after the first group of 7 rats randomly selected were sacrificed to obtain the baseline data. Thereafter 7 rats each from the experimental and control groups were sacrificed weekly for 4 weeks and the plasma, erythrocytes, lipoproteins and organs of the rats were assessed for cholesterol, triglyceride and phospholipids. RESULTS: Our results revealed that the mixed culture of Lb acidophilus (DSM 20242), B bifidum (DSM 20082) and Lb helveticus (CK 60) were able to grow and ferment maize meal into 'ogi' of acceptable flavour. In addition to plasma and hepatic hypercholesterolemia and hypertriglyceridemia, phospholipidosis in plasma, as well as cholesterogenesis, triglyceride constipation and phospholipidosis in extra-hepatic tissues characterized the consumption of unfermented hyperlipidemic diets. However, feeding the animals with the fermented maize diet reversed the dyslipidemia. CONCLUSION: The findings of this study indicate that consumption of mixed culture lactic acid bacteria (Lb acidophilus (DSM 20242), Bifidobacterium bifidum (DSM 20082) and Lb helveticus (CK 60) fermented food results in the inhibition of fat absorption. It also inhibits the activity of HMG CoA reductase. This inhibition may be by feedback inhibition or repression of the transcription of the gene encoding the enzyme via activation of the sterol regulatory element binding protein (SREBP) transcription factor. It is also possible that consumption of fermented food enhances conversion of cholesterol to bile acids by activating cholesterol-7α-hydroxylase.