Nitrous oxide cryotherapy for primary periocular basal cell carcinoma: outcome at 5 years follow-up.

AIM: To report the outcome at 5-year follow-up of a defined series of patients with primary periocular basal cell carcinoma treated by cryotherapy using a nitrous oxide probe. METHODS: A prospective, non-comparative, interventional case series. One hundred primary periocular basal cell carcinomas were treated with a double freeze-thaw cycle nitrous oxide contact cryotherapy probe. Inclusion criteria were clinically well-defined primary periocular basal cell carcinomas with maximum diameter of 8 mm. The main outcome measure was histologically proven recurrence rate at 5-year follow-up. RESULTS: Kaplan-Meier survival analysis showed a 5-year recurrence rate of 8%. Cox regression analysis revealed no correlation between tumour site, tumour size, cryotherapy freeze time and recurrence (p=0.60, p=0.86 and p=0.71, respectively). Thirty-six per cent of patients were lost to follow-up at 5 years following treatment. CONCLUSION: The results of this series suggest that nitrous oxide probe cryotherapy for primary periocular basal cell carcinomas up to 8 mm diameter has a recurrence rate of ∼8%. Cryotherapy has certain advantages over surgical removal of tumours of this size in the periocular region, but careful follow-up is advisable.

Brow lift via the direct and trans-blepharoplasty approaches.

Brow ptosis occurs as part of the aging process, and as a complication of facial nerve paresis. The article addresses the options available for correction of brow ptosis. The direct brow lift is effective for medial and central brow ptosis, and additional lift laterally may occasionally be needed. This is achieved with either a temporal external lift or an internal lift combined with blepharoplasty. The direct brow lift is suitable for any degree and pattern of brow ptosis, usually in males. It is also suitable for older females as well as male patients with facial paresis or marked involutional brow ptosis. The trans-blepharoplasty brow lift is suitable for relatively small degrees of brow ptosis affecting mainly the lateral two-thirds of the brow in any age group. It is often combined with upper lid blepharoplasty and is performed through the same incision. Complications associated with the direct brow lift include a cosmetically disturbing scar, granuloma formation due to the use of braided absorbable sutures rather than monofilament sutures, and the brow descending again. There may be temporary patches of reduced sensation in the forehead which normally recover in a few months. Complications associated with the trans-blepharoplasty brow lift include less lift than desired, and sutures causing dimpling of the skin. These two techniques are useful additions to the approaches for patients with brow ptosis.

Orbital exenteration for invasive skin tumours.

Orbital exenteration aims at local control of disease invading the orbit that is potentially fatal or relentlessly progressive. Of all exenterations presenting to ophthalmologists, 40-50% are required for tumours in the eyelid or periocular skin. 99% of these are basal cell carcinomas and 4-6% each are squamous cell carcinomas or sebaceous gland carcinomas. Orbital invasion results in progressive fixation of the tumour to bone and reduced ocular motility. Perineural invasion of branches of the trigeminal nerve leads to numbness or pain, and that the facial nerve, to weakness. Biopsy identifies the cell type and the presence of perineural invasion. CT and MRI scanning help in the assessment of tumour spread within the orbit. Management should be in collaboration with an oncologist. Exenteration may be total-the removal of all orbital contents-or lid-sparing if the tumour is placed posteriorly. The socket may be allowed to heal by granulation or lined with a split skin graft or local flap. Complications may be seen following 20-25% of exenterations and include fistulae, tissue necrosis, exposed bone, and infection. Incomplete clearance of tumours occurs in about 38% of total exenterations and 17% of subtotal. The overall 5-year survival is 55-65%, but significantly worse if there was perineural spread. Facial prostheses may be mounted on glasses or secured with tissue glue or osseointegrated implants. Excellent cosmetic results can be achieved but many patients prefer to wear a patch.

Comparison of standard eyelid margin closure using silk with a modified repair using 7/0 vicryl and a buried knot.

AIMS: To assess the efficacy and complications of eyelid margin closure with 7/0 Vicryl or Vicryl Rapide suture with a buried knot at the grey line and to compare this with standard closure using silk with an external knot. METHODS: Analysis of a prospective, non-comparative, interventional case series using 7/0 Vicryl or Vicryl Rapide with a buried grey-line knot (modified lid margin closure). Detailed assessment during the healing period was directed to (1) the lid margin profile, (2) the grey line suture and (3) the tissue reaction. Patients were seen for assessment within two days following surgery, at 14 days and at two months. A retrospective, comparative series of silk with an external knot (standard lid margin closure) and 7/0 Vicryl or Vicryl Rapide (modified lid margin closure) was also studied. An analysis was made of the hospital records of patients who had undergone direct lid margin closure with 7/0 Vicryl, Vicryl Rapide or silk. Short- and long-term complications were noted. RESULTS: The prospective series included 24 patients whose lid margin closure had been performed with the modified technique with 7/0 Vicryl or 7/0 Vicryl Rapide. All lids healed well and there was no difference between these two sutures. The retrospective series included 123 patients. Seventy-one patients had the modified technique using 7/0 Vicryl or Vicryl Rapide. Fifty-two patients had lid margin closure with the standard technique using 6/0 silk. All lids healed well. In summary, in both the prospective and retrospective groups, no significant complications were encountered and the healing was excellent. CONCLUSIONS: 7/0 Vicryl and Vicryl Rapide with a buried knot at the grey line allows excellent lid margin healing comparable with standard closure using silk. Vicryl sutures do not need to be removed.

The direct brow lift: efficacy, complications, and patient satisfaction.

BACKGROUND/AIMS: The direct brow lift operation can be used to treat brow ptosis arising from either involutional changes or facial nerve palsy. The authors reviewed their experience with this operation to establish its efficacy and complication rate in the light of concerns over poor scar cosmesis and forehead paraesthesiae in the postoperative period. METHODS: A retrospective review of patients undergoing direct brow lifting from 1989 to 2002 was conducted, and information gained on patient satisfaction by questionnaire. RESULTS: The direct brow lift operation was found to give a predictable outcome, with high levels of patient satisfaction. With careful wound closure, postoperative scars are rarely cosmetically unacceptable to the patient. Paraesthesiae are a common but well tolerated sequelae. CONCLUSIONS: The direct brow lift was found to be a reliable method for treating brow ptosis arising through involutional change or facial nerve palsy in both men and women. The postoperative scars may be more evident in younger patients so the authors reserve this technique for "rehabilitative" rather than cosmetic brow lifts in patients of middle age and beyond.

Use of 7/0 Vicryl (coated polyglactin 910) and 7/0 Vicryl-rapide (irradiated polyglactin 910) in skin closure in ophthalmic plastic surgery.

AIMS: To assess the safety and efficacy of 7/0 Vicryl and 7/0 Vicryl rapide sutures for skin closure, and without suture removal, in ophthalmic plastic surgery. METHOD: A prospective, comparative study of 40 consecutive procedures in 32 patients. Tissue reactions to the sutures, completeness of wound healing, and number of sutures remaining were observed at first dressing, 2 weeks and 2 months. RESULTS: Wound healing was excellent at 2 weeks in all but one Vicryl rapide patient whose slight wound gape was not attributable to the suture material used. No inflammatory tissue reaction attributable to the suture was seen. No visible suture marks were observed at 2 months. Transient crusting was observed around the sutures in 9/20 (45%) and 10/20 (50%) patients with Vicryl and Vicryl rapide, respectively. Only one suture out of 144 was removed. CONCLUSION: 7-0 Vicryl and 7-0 Vicryl rapide are safe and effective sutures for skin closure in ophthalmic plastic surgery.

Oculopharyngeal muscular dystrophy: phenotypic and genotypic studies in a UK population.

Oculopharyngeal muscular dystrophy (OPMD) is an autosomal dominant disorder of late onset that commonly presents with ptosis and dysphagia. The genetic basis of the condition has been identified recently as a stable trinucleotide repeat expansion in exon 1 of the poly(A) binding protein 2 gene (PABP2), in which (GCG)(6) is the normal repeat length. The prevalence of OPMD is greatest in patients of French-Canadian origin. It is not clear if expansion repeat length is a reliable test in other populations. In this study, we analysed the phenotypic and genotypic characteristics of 31 patients with OPMD in the UK. Ptosis was the first reported symptom in two-thirds of the patients, and half of the subjects studied had evidence of ophthalmoplegia. All but one family had a pathological expansion in the PABP2 gene, ranging from (GCG)(8) to (GCG)(13). In contrast to the French-Canadian population, (GCG)(10) was almost as common as (GCG)(9), evidence against a strong founder effect in the UK population. There was a weak association between repeat length and age of disease onset. Patients with longer repeat lengths, such as (GCG)(13), developed severe limb weakness early in the disease. We were unable to detect the (GCG)(7) polymorphism in over 200 normal controls, suggesting that the frequency of this expansion is lower than that found in the French-Canadian population. One family was negative for the expansion. Affected members presented with the classical features of OPMD, namely ptosis, dysphagia and cytoplasmic inclusions on muscle biopsy, although with some atypical features, such as early age of onset, high serum levels of creatine kinase and a profound ophthalmoplegia. This family is an example of a GCG expansion-negative oculopharyngeal syndrome requiring further genetic investigation. We conclude that PABP2 analysis is a reliable non-invasive diagnostic test for OPMD in the UK population.

X linked dominant congenital isolated bilateral ptosis: the definition and characterisation of a new condition.

AIMS: To characterise the inheritance of ptosis in one particular pedigree. METHODS: The pedigree was analysed clinically and genetically to assess the mode of inheritance and to ascribe a gene locus for the condition. RESULTS: Affected members of the pedigree have bilateral symmetrical congenital isolated ptosis, a condition which is linked to genetic markers on the X chromosome in this family. CONCLUSION: A pedigree with dominantly inherited congenital bilateral ptosis is presented. The pedigree exhibits X linked dominant inheritance. A new ophthalmic condition was thereby characterised-namely, X linked dominant congenital isolated bilateral ptosis.

Repeatability and reproducibility of upper eyelid measurements.

AIM: The aim of this study was to assess the repeatability and reproducibility by physicians of upper lid measurements and to investigate the influence of clinical experience on the learning curve effect. METHODS: Both eyes of 22 outpatients were assessed for three basic measures of ptosis: marginal reflex distance (MRD) for upper and lower lids, upper lid skin crease (SC), and levator function (LF). Patients with variable eyelid positions were excluded. The patients were measured twice by a consultant and once by each of a clinical fellow, a specialist registrar, and a senior house officer in random order. Each observer was masked to their colleagues' results and followed a standard measurement protocol. Data were analysed using Bland-Altman plots. RESULTS: Consultant repeatability was high and consistent, the median difference between measures being 0 for each of the four parameters. Clinically acceptable reproducibility was shown in all measurements for even the least experienced physician and was particularly consistent for extreme observations. There was evidence of a learning curve effect. CONCLUSIONS: These results suggest that interobserver and intraobserver variability in assessment of upper lid ptosis using a standard measurement protocol is low and clinically acceptable when the technique of assessment is standardised.

Outcomes of anterior levator resection in congenital blepharoptosis.

PURPOSE: To identify any consistent factors which may predict over- or undercorrection of congenital blepharoptosis treated by anterior levator resection. METHODS: A retrospective case note review of 100 consecutive patients undergoing anterior levator resection for congenital blepharoptosis was performed to identify: (1) the amount of ptosis and degree of levator function present pre-operatively and (2) the surgical outcome. For unilateral ptosis, a successful result was defined as a lid level within 1 mm of the fellow lid following a single operation. RESULTS: Seventy-six per cent of all unilateral cases had a successful outcome at 6 weeks following surgery, falling slightly to 74% by 6 months. The most common complications at 6 months were undercorrection (19%) and overcorrection (7%). All patients undercorrected at 6 months had a pre-operative levator function in the range of 4-10 mm with a mean of 6.4 mm, whereas all those overcorrected at 6 months had a levator function in the range 9-15 mm with a mean of 12.2 mm. In the whole population, the degree of levator function was a predictor of increased risk of overcorrection, with a trend towards predicting undercorrection as well. CONCLUSIONS: In this series of patients, pre-operative levator function was found to be the most significant predictor of surgical outcome for anterior levator resection.

Painful blind eye: efficacy of enucleation and evisceration in resolving ocular pain.

AIMS: To assess the effectiveness of enucleation or evisceration in relieving pain from painful blind eyes. METHODS: 24 patients with intractable ocular pain underwent enucleation or evisceration with or without an orbital implant. RESULTS: Complete pain relief was achieved in all patients at an average time of 3 months (range 1-15 months). Seven patients required further medical or surgical treatment in addition to removal of the globe. CONCLUSION: Enucleation and evisceration were effective in relieving ocular pain in all patients with a painful blind eye in our study. However, complications of surgery and orbital implants can cause recurrent pain.

A novel X-linked dominant condition: X-linked congenital isolated ptosis.

We present a large family with a previously undescribed condition: X-linked dominant congenital bilateral isolated ptosis. Linkage analysis defined a critical region between Xq24 and Xq27.1, with a maximum single-point LOD score of 2.88 at DXS1047 and DXS984. Male and female family members are equally affected, providing an example of an X-linked, truly dominant condition.

Surgical correction of entropion and excess upper eyelid skin in congenital cutis laxa: a case report.

Congenital cutis laxa is a rare generalized inherited elastosis, characterized by the appearance of premature aging and skin laxity with mild to severe systemic anomalies. Ocular manifestations include excess skin in the eyelids, ptosis and lower lid ectropion. Of the hyperelasticity syndromes - Ehlers Danlos, Pseudoxanthoma elasticum and cutis laxa - only cutis laxa has normal skin wound healing. The diagnosis must therefore be established before surgical options for treatment are considered. We report an unusual case of a 5-month-old male child with cutis laxa who presented with upper lid entropion secondary to severe redundant upper eyelid skin. An anterior lamellar repositioning procedure successfully corrected the lid margin malposition with complete relief of symptoms.

Complications of fascia lata harvesting for ptosis surgery.

AIMS/BACKGROUND: The aim of this study was to assess the morbidity associated with harvesting autogenous fascia lata for brow suspension ptosis surgery. METHODS: A retrospective study by postal questionnaire of 24 consecutive patients. RESULTS: Early postoperative problems with pain on walking (67%), limping (38%), and wound pain (57%) occurred mostly for less than 1 week. The final cosmetic appearance of the scar caused minor concern in 38% of patients. CONCLUSION: Fascia lata is the preferred material for permanent ptosis correction when a brow suspension is required. Most of the patients, following fascia lata harvest, experienced some symptoms of leg pain and limping for less than 1 week. The only long term problem was the scar. 38% of patients found the final cosmetic appearance caused minor concern.

The use of Prolene as a temporary suspensory material for brow suspension in young children.

Children with severe, unilateral congenital ptosis are at risk of developing amblyopia if the lid obscures the visual axis. In this situation, urgent repair of the ptosis is indicated. These patients generally have very poor function of the levator palpebrae superioris muscle and a brow suspension is required. The suspensory material which gives the best long-term results is autogenous fascia lata. In young children, however, there is insufficient autogenous fascia available. We reviewed 9 patients aged 4 years or less who had undergone surgery for congenital ptosis. In each case a brow suspension was performed using 4/0 Prolene (monofilament polypropylene) suture as a temporary suspensory material. All patients achieved a satisfactory result with the upper lid remaining clear of the visual axis during a mean follow-up period of 18.7 months (range 8-29 months). We suggest that Prolene suture is a readily available material which is suitable as a temporary suspensory material for brow suspension in very young children.

Do patients like day case cataract surgery?

One hundred and fifty consecutive questionnaires following day case cataract surgery showed that 87% of the patients would choose day surgery again. The questionnaires were directed at the patients' attitudes to day surgery for their cataracts. There was overwhelming acceptance of the travelling and inconvenience involved.

A case of fungal keratitis caused by Scopulariopsis brevicaulis: treatment with antifungal agents and penetrating keratoplasty.

A case of fungal keratitis caused by Scopulariopsis brevicaulis following a penetrating eye injury is described. Treatment with antifungal agents and keratoplasty resulted in a favourable outcome.

Baseball orbital implants: a review of 39 patients.

Thirty-five secondary and six primary 'baseball' implants--acrylic balls in envelopes of donor sclera--were followed up for a minimum of 24 months. 97.1% secondary and 50% primary implants were retained. Volume replacement was satisfactory in 83.8% with a single operation, and motility of the artificial eye was at least 14 degrees of horizontal gaze in 86%, at least 7 degrees of upgaze in 95%, and at least 14 degrees of downgaze in 62.6%. Ptosis associated with the procedure occurred in 22%, and 12.2% developed a shallow fornix with instability of the artificial eye.