Paediatric blepharoptosis: a 10-year review.

PURPOSE: To examine the characteristics of blepharoptosis and the success of surgical intervention in a large group of children presenting to a specialist at paediatric ophthalmology center. METHODS: Ten-year retrospective case notes review of patients presenting to the Birmingham Children's Hospital for blepharoptosis surgery. Resultant database was interrogated for aetiology of ptosis; severity; surgical correction; outcome; complications and need for reoperation. RESULTS: One hundred and fifty five children (186 eyes) underwent blepharoptosis surgery. Hundred and ten patients (71%) were treated with a levator resection procedure, 28 (18%) underwent a brow suspension using Mersilene mesh, 15 (10%) with Fasanella Servat procedure and 2 (1%) with La Mange procedure. The mean post-operative follow-up was 30.82 months with 84 children completing a minimum of 12 months follow-up. Overall, 70.97% lids were successfully corrected with a single operation. In 9.14% lids, the results were fair but no further surgery was carried out. Reoperation was required in 19.89% of lids with the mean time to second surgery being 32.69 months. Amblyopia was found in 26.45% (41 children); in 3 patients, their amblyopia became manifest after the ptosis surgery. A concomitant squint was present in 14.19%, and 18.70% had a significant refractive error requiring spectacles prescription, with anisometropia present in more than 72% of these patients. CONCLUSIONS: Early referral to an ophthalmologist is necessary even though surgical correction may be delayed. Children with congenital ptosis need to be monitored for amblyopia both pre- and post-operatively, as the incidence of strabismus and refractive errors is much higher than the general population and these may develop even after ptosis surgery.

Primary extrasac orbital lymphoma presenting as nasolacrimal obstruction.

Primary orbital lymphoma is an unusual cause of epiphora in the elderly population. Lymphomas that give rise to nasolacrimal duct obstruction usually arise from within the lacrimal sac. Epiphora is a common presenting complaint that may be easily disregarded as a minor debilitating symptom. This case describes a 58-year-old Caucasian man presenting with epiphora due to primary extrasac orbital lymphoma, causing external mechanical compression on the nasolacrimal duct system. Although a rare presentation, it highlights the need for a thorough examination in patients presenting with epiphora. Nasolacrimal duct obstruction could well be the initial manifestation that leads to the diagnosis of a more serious underlying systemic disease, and lymphoma needs to be included in the differential diagnosis of secondary nasolacrimal duct obstruction.

Three different consecutive manifestations of morphoeic BCC in the same patient: presenting first as ectropion, then entropion, and finally medial canthal dystopia with epicanthus inversus.

Morpheaform basal cell carcinoma (BCC) can cause diagnostic difficulty due to an atypical clinical presentation. Successful treatment requires a high index of clinical suspicion together with an early confirmatory biopsy. We present the case of an 81-year-old lady with a delayed diagnosis of morphoeic BCC due to an unusual presentation of evolving lid malposition, and we highlight the limitations of a punch biopsy in diagnosing atypical lesions. An appropriate biopsy technique is vital, with consideration for repeat biopsies when necessary, especially if the clinical picture is changing over time.

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.