Eyelid basal cell carcinoma: non-Mohs excision, repair, and outcome.

AIM: To analyse the outcome of basal cell carcinoma (BCC) excision in a subregional (non-Mohs) oculoplastic service. METHODS: A single surgeon retrospective series, medical record review of 223 consecutive cases with histologically confirmed eyelid BCC (between 1987 and 2004). Tumour recurrence rate was derived from the 69 patients with a minimum 5 year follow up. RESULTS: Of the total 223 patients, the surviving 162 were included in this study. The follow up for the whole cohort ranged from 2 months to 120 months. All cases underwent excisional biopsy. 4 mm excision margins were taken in 83% of cases. The pathology revealed 84% complete primary excision. Of those reported incompletely excised 53% contained no tumour at re-excision. 70% of lid defects were treated by primary direct closure. Following confirmed histological clearance the remainder underwent delayed direct closure (2%), full thickness skin or tarsal grafts (13%), local skin and muscle flaps (11%), and spontaneous granulation (laissez faire) (4%). No major complications were noted. There were no recurrences for non-infiltrative BCCs. The overall 5 year and over recurrence rate including previously recurrent BCCs was 4.35%, only one of which was in the primary BCC group (1.6%). All recurrences were in infiltrative BCCs. CONCLUSIONS: Non-infiltrative BCC excision with 4 mm margins gave a zero recurrence rate. Long term follow up of such patients may be unnecessary. Infiltrative BCCs should be followed up indefinitely. Previous recurrence and infiltrative histology have predictive value for recurrence. We achieved one of the lowest recurrence rates reported in non-Mohs surgical excision. Direct closure was applicable in 72% of cases.

A new grading system for assessing orbicularis muscle function.

PURPOSE: To establish an objective parameter (orbicularis function) to measure the efficacy of botulinum toxin treatment in weakening the orbicularis of blepharospasm and hemifacial spasm sufferers. METHODS: The following scale has been used by one of the authors (VTT) in his botulinum clinic for several years: Grade 0: Incomplete eyelid closure.Grade 1: Lids just closing, minimal resistance to overcome.Grade 2: Closing well, some resistance, easily overcome.Grade 3: Strong closure, can be overcome with difficulty.Grade 4: Very strong closure, cannot be overcome or overcome with extreme difficulty. In order to establish the interobserver agreement, one consultant ophthalmologist, three ophthalmologists in training, and one nurse practitioner evaluated the same 65 patients, undergoing treatment with botulinum toxin for essential blepharospasm and hemifacial spasm. Observers assessed orbicularis function by asking each patient to close both eyes forcefully, while the observer tried to open them manually. The measure of agreement across the observers was estimated by kappa statistics. RESULTS: Overall interobserver agreement (kappa=0.54) was satisfactory. We used Kruskal-Wallis nonparametric test to determine agreement between the observers. The P-values for both right and left eyes were well above 0.05, indicating good consistency between the observers when using this grading system. CONCLUSIONS: A simple, new, five-point, clinical grading system for orbicularis muscle function is presented. Medical staff with different levels of experience can use it reliably.

Bleb-limiting conjunctivoplasty for symptomatic circumferential trabeculectomy blebs.

PURPOSE: To describe a new surgical technique for limiting symptomatic circumferential conjunctival blebs, an uncommon complication after trabeculectomy. METHODS: Four eyes of 2 patients underwent conjunctivoplasty to limit the extent of symptomatic circumferential blebs. An 8/0 virgin silk corneal traction suture was used to allow better exposure of the conjunctiva. Radial conjunctival and Tenon incisions were made down to bare sclera in approximately the 10:30 and 1:30 clock hour positions. The conjunctival incisions were sutured, tacking down to the sclera. RESULTS: Immediate flattening of the interpalpebral bulbar conjunctiva was noted on the first postoperative day and there was no elevation of intraocular pressure or loss of bleb function. Both patients experienced a rapid improvement in their symptoms and no complications of the procedure were noted. Recurrence of bleb extension occurred in 1 eye 4 months postoperatively, and was treated with a repeat limiting conjunctivoplasty incision with a good result. CONCLUSIONS: Early results show that bleb-limiting conjunctivoplasty is an effective means of treating symptomatic circumferential trabeculectomy blebs.

Spontaneous eyelid expansion after full thickness eyelid resection and direct closure.

BACKGROUND/AIMS: Direct closure of eyelid defects gives excellent functional results but is usually restricted to defects measuring less than a quarter of the eyelid length for fear of distorting the palpebral aperture and compromising lid function. The authors have used direct closure in larger defects. The aim of this study was to establish the effects of direct closure of full thickness eyelid margin defects under tension on the palpebral aperture dimensions. METHODS: A consecutive series of patients who had undergone one eyelid, full thickness lid resection repaired by direct closure were identified and invited to have both eyes photographed. The palpebral apertures of both eyes were measured from the photographs by a masked observer. The amount of eyelid resected was recorded from the operation notes. The unoperated palpebral aperture was used as the control. The result were analysed using a paired samples t test. RESULTS: The photographs of 18 patients were included in the analysis. The mean width of excised full thickness lid tissue was 15 mm (range 7-26 mm). The mean vertical palpebral aperture height was 9.2 (SD 1.4) mm in the operated eye as opposed to 9.3 (SD 1.2) mm in the non-operated eye. The mean horizontal palpebral aperture width was 26.1 (SD 1.9) mm in the operated eye as opposed to 26.4 (SD 1.8) mm in the non-operated eye. There was no statistically significant difference between the operated and unoperated horizontal and vertical palpebral measurements. CONCLUSIONS: Direct closure of large full thickness eyelid defects is possible in selected patients with excellent functional and cosmetic results. Eyelid tissue expansion occurs spontaneously following direct eyelid defect closure under tension, restoring the palpebral aperture dimensions.

The effect of pre-operative topical flurbiprofen or diclofenac on pupil dilatation.

PURPOSE: To assess the clinical benefit and relative efficacy of pre-operative diclofenac and flurbiprofen drops in routine cataract surgery. METHODS: Fifty-two patients undergoing extracapsular cataract extraction with lens implantation were randomised in a double-masked study to compare the efficacy of diclofenac, flurbiprofen and placebo drops in maintaining per-operative mydriasis and reducing post-operative inflammation. Balanced salt solution containing adrenaline was used in all patients. Pupil size was measured prior to the corneal section and after the completion of the operation. The degree of pain, redness, flare and cells in the anterior chamber and intraocular pressure were recorded on the day after surgery. The three groups were analysed with respect to change in pupil size, intraocular pressure and degree of inflammation. RESULTS: The change in pupil size was significantly different among the three groups (p = 0.01), there being a smaller decrease in the treatment groups compared with the placebo group and in the diclofenac treatment group compared with the flurbiprofen treatment group. Significantly less post-operative redness was recorded in the diclofenac treatment group compared with the other groups (p = 0.001). No significant difference was found between the groups as regards anterior chamber cells, flare or intraocular pressure change. CONCLUSIONS: Pre-operative diclofenac and flurbiprofen drops are effective in maintaining intraoperative mydriasis. Diclofenac reduces post-operative redness on day 1. These effects are of debatable clinical benefit.

National survey of corneal abrasion treatment.

PURPOSE: To survey the different methods used in the management of corneal abrasions (including iatrongenic cases) nationally. METHOD: A questionnaire survey of all 162 ophthalmic units in the UK was carried out in 1997. RESULTS: The response rate was 134 of 162 (83%). The majority of units do not have an established policy for the treatment of corneal abrasions. Topical antibiotic alone and antibiotic together with a cycloplegic are the commonest immediate treatments, whilst the most common treatment course is topical antibiotic. Padding and patient follow-up is practised some of the time by most units and all of the time by the remaining minority. Use of a soft bandage contact lens is uncommon. There is no statistically significant difference (p > 0.05) between the policy-holders and non-policy-holders in their use of the various topical regimes, padding and soft bandage contact lens. CONCLUSION: The traditional trio of topical antibiotic, cycloplegic and padding is still the mainstay of corneal abrasion treatment amongst units nation-wide. However, there is a lack of reproducible scientific evidence to support this treatment. Larger randomised trials looking at the efficacy of the different treatment options are needed.

Enucleation volume measurement.

The enucleation volume of a series of 17 eyes was measured by water displacement and found to be 1-2 ml in excess of the 7 ml usually quoted. This is relevant to the development of postenucleation socket syndrome in patients who have had orbital implants of a conventional size. Enucleation volumes should be measured routinely and the implant volumes selected accordingly.

Lid melanoma and parkinsonism.

This is a case report of a patient with parkinsonism on levodopa therapy who developed a lid margin melanoma. The possible association is discussed.

Oncocytoma of the eyelid: a case report.

Oncocytic tumours of the eyelids are rare, only one previous case having been reported. This paper describes a second such lid tumour affecting the medial upper lid. We present the clinical features, surgical management, and histology of the lesion.

Thyroid lid surgery.

A retrospective study of 58 thyroid patients undergoing eyelid surgery for thyroid related lid malposition is reported. A treatment strategy is suggested, based on the results of this experience. The following points are stressed: (1) The importance of recognising and relieving the inferior rectus tethering component of upper lid retraction when present. (2) The usefulness of a scleral graft in lower lid retractor recession. (3) The inadequacy of lateral tarsorrhaphy in relieving lid retraction but its value in camouflage.

Indirect funduscopy in a gas filled eye: an observation.

It has been observed that a vitrectomised, gas filled, phakic eye can produce a real, inverted, aerial image of the fundus anterior to the cornea. The optics of this phenomenon are discussed.