Intravenous methylprednisolone-induced hypokalaemic periodic paralysis in a thyrotoxic patient: a case report and literature review.

Hypokalaemic periodic paralysis (HPP) is an uncommon complication of corticosteroid therapy, which may also be seen in thyrotoxicosis. It was mostly described in the Asian population, and it is rare in other ethnic groups. We present the case of a poorly controlled thyrotoxic Caucasian male with thyroid eye disease (TED) who suffered an acute quadriplegic episode caused by severe hypokalaemia and was admitted to the intensive care unit (ITU) within 24 hours of initiating intravenous methylprednisolone (IVMP) infusion. Once his potassium blood levels were repleted, he completely recovered from the episode. Although HPP is rare in the Caucasian population, it can be precipitated in thyrotoxic patients by systemic steroids. Caution should be exercised when administering IVMP in poorly controlled thyrotoxic patients, and we suggest monitoring the potassium levels at regular intervals with ECG monitoring for at least 24 hours in at-risk individuals.

Ectopic orbital meningioma: Fact or fiction?

Primary intraorbital ectopic meningiomas are rare and their existence remains controversial. We present a 30-year-old female with painless, non-axial proptosis and a palpable superomedial mass. The MRI demonstrated that the mass had no optic nerve sheath or sphenoid wing involvement and was initially reported to have no intracranial extension. The patient was initially thought to have an ectopic orbital meningioma. Subsequent multidisciplinary team (MDT) consultation and further specialist review of the MRI revealed a subtle dural tail connecting to an enhancing mass in the olfactory groove. Biopsy revealed a WHO Grade 1 transitional meningioma with an infiltrative pattern. We argue that some previously reported cases of ectopic meningioma may lack the requisite imaging to discover the primary disease. Our report highlights the importance of MRI in this group of patients and the role of a skull-base MDT with specialist neuroradiology input to determine the true origin and extent of these extradural orbital meningiomas.

Key Issues When Reconstructing Extensive Upper Eyelid Defects With Description of a Dynamic, Frontalis Turnover Flap.

Reconstruction of full thickness, total upper eyelid defects represents a significant challenge in terms of recreating an upper eyelid which has acceptable cosmesis and a degree of dynamic function. Options include bridging, eyelid-sharing techniques (e.g., Cutler-Beard), or nonbridging techniques such as an anterior lamella-based flap combined with a posterior lamella free graft or a "sandwich flap." The success of these techniques depends on the size of the defect, postoperative cosmesis and whether or not the upper eyelid still has a degree of dynamic function to avoid ptosis and exposure keratopathy. The authors present an innervated frontalis turnover flap supporting anterior and posterior lamella grafts as a reconstructive solution for an extensive upper eyelid defect. This technique is cosmetically acceptable, preserves local tissues, and maintains a degree of dynamic function, which keeps the patient's eye comfortable and does not adversely affect visual acuity.

Clinical and Imaging Features of Lacrimal Gland Involvement in Granulomatosis with Polyangiitis.

PURPOSE: Lacrimal gland involvement in granulomatosis with polyangiitis (GPA) commonly accompanies orbital disease, but occasionally may be the sole presentation preceding any other organ manifestation or systemic disease. Diagnosis of orbital GPA, especially in patients with lacrimal involvement as the initial presentation, can be difficult because of nonspecific clinical features and lack of diagnostic specificity on histologic and antineutrophilic cytoplasmic antibody (ANCA) testing. Orbital GPA can be associated with a high morbidity from potential visual loss or rapid progression of latent systemic disease, making early diagnosis important. The purpose of this study was to describe the clinical and imaging features of patients with lacrimal gland involvement secondary to GPA and to compare them with those of other orbital inflammatory conditions in the lacrimal gland fossa. DESIGN: Retrospective, noninterventional comparative case series. PARTICIPANTS: Two hundred forty-seven patients who had undergone orbital biopsy over a 21-year period were identified from the Institute of Ophthalmology Pathology database. Sixty-nine patients were found to have orbital inflammatory disease with lacrimal gland involvement, of whom 7 had a final diagnosis of GPA. METHODS: Clinical and imaging features of patients with GPA were analyzed and compared with those of the non-GPA group. MAIN OUTCOME MEASURES: Features associated with GPA. RESULTS: The median age at presentation for GPA patients was 30 years (mean ± standard deviation, 36.7±16.7 years; range, 14-57 years). The interval from presentation to definitive diagnosis of GPA ranged from 3 to 20 months (mean, 12.1 months; median, 12 months). Sinonasal involvement was demonstrated in 43% and bony changes were demonstrated in 29% of patients with GPA. A higher proportion of patients with GPA demonstrated sinonasal involvement (P = 0.011) and bony destruction (P = 0.048) compared with non-GPA patients. CONCLUSIONS: Associated sinonasal involvement and bony changes on imaging are highly suggestive of GPA and should prompt a full diagnostic workup. A high index of suspicion should be maintained, with repeated ANCA testing, biopsy, and imaging where indicated, especially in the younger age group.

Clinical and imaging features predictive of orbital granulomatosis with polyangiitis and the risk of systemic involvement.

OBJECTIVE: Granulomatosis with polyangiitis (GPA), previously Wegener's granulomatosis, requires prompt diagnosis and systemic review to exclude life-threatening disease. However, early diagnosis of orbital GPA may be difficult because anti-neutrophil cytoplasmic antibody (ANCA) and anti-PR3 antibody screening can be negative at presentation and orbital biopsies taken for diagnosis may not show the classic features of GPA. This study was designed to compare GPA with other causes of orbital inflammation and to identify the presenting clinical and imaging features most likely to predict GPA and its systemic spread. DESIGN: Retrospective noninterventional comparative case series. PARTICIPANTS: A total of 247 patients who had undergone orbital biopsies for clinical presentations with orbital inflammation were identified from the Institute of Ophthalmology pathology database. METHODS: Patients were divided into GPA and non-GPA groups on the basis of their final clinical diagnosis. Clinical and imaging features of these 2 groups were compared to determine those predictive of GPA, and patients with GPA also had long-term evaluation for systemic involvement. MAIN OUTCOME MEASURES: A diagnosis of orbital GPA and development of systemic GPA were the main outcome measures. RESULTS: Features highly suggestive of GPA were sinonasal symptoms, sinonasal changes, or paranasal bone erosion on imaging (P < 0.001). Bony erosion was independent of ANCA status or systemic involvement. Twenty-two percent of patients (8/37) with GPA had evidence of systemic involvement at presentation, and no patient presenting with solely orbital GPA developed later systemic disease over a median follow-up of 2.7 years. CONCLUSIONS: A high index of suspicion should be maintained for GPA when a patient presents with an orbital mass and sinonasal symptoms or imaging shows sinonasal involvement or paranasal bone erosion. No patient with solely orbital GPA involvement at presentation developed systemic disease, suggesting that orbital GPA can remain localized in the long-term.

Acute glaucoma secondary to angle obstruction by triamcinolone crystals.

PURPOSE: To present a case of acute glaucoma secondary to massive transit of triamcinolone acetonide into the anterior chamber in a pseudophakic, vitrectomized eye following intravitreal injection for treatment of cystoid macular edema. SETTING: Manchester Royal Eye Hospital. METHOD: Case study. CONCLUSION: In vitrectomized eyes with open posterior capsule receiving high dose intravitreal triamcinolone, it is prudent to perform pressure check within a week of injection.

Should patients set the agenda for informed consent? A prospective survey of desire for information and discussion prior to routine cataract surgery.

PURPOSE: To ascertain the level of information relating to specific risks desired by patients prior to cataract surgery. SETTING: Dedicated cataract surgery pre-assessment clinics of 2 hospitals in South West Wales, UK. METHODS: Consecutive patients (106) were recruited prospectively. Of these, 6 were formally excluded due to deafness or disorientation. Eligible patients (100) were asked a set of preliminary questions to determine their understanding of the nature of cataract, risk perception, and level of information felt necessary prior to giving consent. Those who desired further information were guided through a standardized questionnaire, which included an audio-visual presentation giving information relating to each potential surgical complication, allowing patients to rate them for relevance to their giving of informed consent. RESULTS: Of the entire group of 100, 32 did not wish to know "anything at all" about risks and would prefer to leave decision making to their ophthalmologist; 22 were interested only in knowing their overall chance of visual improvement; and 46 welcomed a general discussion of possible complications, of whom 25 went on to enquire about specific complications. Of these 25, 18 wished to be informed of posterior capsular (PC) tearing, 17 of endophthalmitis, 16 each of dropped lens, retinal detachment and corneal clouding, and 15 of bleeding, sympathetic ophthalmia, and PC opacification. CONCLUSION: Patients differ in their desire for information prior to cataract surgery, with one significant minority favoring little or no discussion of risk and another wishing detailed consideration of specific risks. A system of consent where patients have a choice as to the level of discussion undertaken may better suit patients' wishes than a doctor-specified agenda.