Combined neurosurgical and orbital intervention for spheno-orbital meningiomas - the Manchester experience.

PURPOSE: Surgical resection of spheno-orbital meningioma (SOM) is challenging, requiring a multidisciplinary surgical approach. We present our experience of the surgical management of patients with SOM. METHODS: A retrospective analysis of patients with SOM who underwent joint neurosurgical and orbital surgical procedures between January 2000 and June 2017. Pre-operative clinical signs, indication for surgery, surgical complications and post-operative outcomes were recorded. RESULTS: Twenty-four operations were performed. Mean age was 49.5 years. Ninety-two percent of patients were female. Pre-operatively mean Snellen acuity vision was 6/12; 13 (54%) had an RAPD; 12 (50%) had reduced colour vision; 16 (67%) had a visual field defect. The majority (21 patients, 88%) had proptosis (average 4.5 mm ± 2.8 mm). The indication for surgery was evidence of visual dysfunction in 17 (71%), the remaining 7 (29%) had high risk of visual loss clinically or radiologically. Three-months post operatively, vision was stable in 13 (58%), improved in 6 (21%) and worse in 5 (17%). Average long-term follow-up was 82 months (1-220). Fourteen (58%) maintain improved or stable visual function. Four (17%) had reduced vision due to regrowth of the tumour at an average of 24 months. CONCLUSION: SOMs are very challenging to treat surgically. In this cohort the patients were predominantly young females with aggressive disease. Visual function was improved or stabilised in 79% of the patients.

Our experience using primary oral antibiotics in the management of orbital cellulitis in a tertiary referral centre.

AIMS/PURPOSE: Orbital cellulitis is conventionally managed by intravenous (i.v.) antibiotic therapy, followed by oral antibiotics once the infection shows signs of significant improvement. We report 4 years of experience using primary oral ciprofloxacin and clindamycin in cases of orbital cellulitis. Oral ciprofloxacin and clindamycin have a similar bioavailability to the i.v. preparations and provide an appropriate spectrum of antibiotic cover for the pathogens responsible for orbital cellulitis. METHODS: A retrospective review was performed that identified all patients with orbital cellulitis and treated with primary oral antibiotic therapy admitted to the Manchester Royal Eye Hospital between March 2003 and March 2007. Age, stage of disease, surgical intervention, hospital duration, and complications were obtained. A comparison was made with patients admitted to our unit with orbital cellulitis and treated with primary i.v. antibiotics between March 2000 and March 2003. RESULTS: Nineteen patients were included in the review for the period March 2003 to March 2007, which comprised of 7 children and 12 adults. Five patients required surgical intervention. All patients responded to the oral regimen, 18 patients had no change to their oral antibiotic therapy. Mean hospital stay was 4.4 days. There were no complications. DISCUSSION: Empirical oral ciprofloxacin and clindamycin combination may be as safe and effective as i.v. therapy in the management of orbital cellulitis. Oral treatment can offer the advantages of rapid delivery of the first antibiotic dose, fewer interruptions in treatment, and simplified delivery of medication particularly in children.

'Fast-track' cataract services and diagnostic and treatment centre: impact on surgical training.

AIMS: To evaluate the impact of 'Action on Cataracts' and the development of Diagnostic and Treatment Centre (DTC) on cataract surgery training in the Central Manchester and Manchester Children's University Hospital's Trust. METHODS: We compared all cataract extractions undertaken from April to September 2005 with the same 6-month time period over the preceding 5 years. Surgery was performed on one of four types of lists: Manchester Royal Eye Hospital standard lists (MREH), Cataract Services list, Waiting List Initiative list (WLI), and Diagnostic and Treatment Centre list (DTC). Surgeons were identified by their specific codes and divided into grades. RESULTS: The total number of cataract operations undertaken on the standard MREH lists has declined significantly over the years (P<0.001 chi(2) test for trend). The number of cataract operations performed by both Specialist Registrars (SpRs) and Senior House Officers (SHOs) demonstrated a statistically significant decline over the years (P<0.001 for both cases, chi(2) test for trend), with the SHOs number dropping dramatically over the last 2 years. When comparing the number of operations performed by junior SpRs and senior SpRs, shift in the balance can be seen towards the senior surgeons. The proportion of operations performed by junior SpRs declined from 50% in 2000 to 28.2% in 2005. CONCLUSION: Recent changes in cataract care provision have had a significant impact on training. Our results document for the first time that both higher and basic surgical trainees were affected. Future care of our patients could be comprised owing to lack of training.

Long term results of diode laser cycloablation in complex glaucoma using the Zeiss Visulas II system.

AIM: To investigate the safety and efficacy of the Zeiss Visulas II diode laser system in the reduction of intraocular pressure (IOP) in patients with complex glaucoma. METHODS: The authors analysed the medical records of patients who underwent trans-scleral diode laser cycloablation (TDC) at the Manchester Royal Eye Hospital during a 34 month period. 55 eyes of 53 patients with complex glaucoma were followed up for a period of 12-52 months (mean 23.1 months) after initial treatment with the Zeiss Visulas II diode laser system. RESULTS: Mean pretreatment IOP was 35.8 mm Hg (range 22-64 mm Hg). At the last examination, mean IOP was 17.3 mm Hg (range 0-40 mm Hg). After treatment, 45 eyes (82%) had an IOP between 5 and 22 mm Hg; in 46 eyes (84%) the preoperative IOP had been reduced by 30% or more. The mean number of treatment sessions was 1.7 (range 1-6). At the last follow up appointment, the mean number of glaucoma medications was reduced from 2.1 to 1.6 (p<0.05). In 10 eyes (18%), post-treatment visual acuity (VA) was worse than pretreatment VA by 2 or more lines. CONCLUSIONS: Treatment with the Zeiss Visulas II diode laser system can be safely repeated in order to achieve the target IOP. Treatment outcomes in this study were similar to those from previously published work using the Iris Medical Oculight SLx laser.

Missed orbital wall blow-out fracture as a cause of post-enucleation socket syndrome.

BACKGROUND: Post-enucleation socket syndrome (PESS: deep upper lid sulcus, ptosis or upper lid retraction, enophthalmos and lower lid laxity) is a well-recognised complication of a volume-deficient anophthalmic socket. A patient requiring enucleation following severe ocular trauma may have an underlying orbital wall blow-out fracture which if overlooked can cause severe volume deficit with poor cosmesis and limited prosthesis motility. PURPOSE: To establish the prevalence of an undiagnosed blow-out fracture in patients with PESS and a history of relevant trauma. METHODS: Medical records and orbital computed tomography (CT) scans were reviewed for all patients presenting with PESS and a history of relevant trauma. RESULTS: Undiagnosed blow-out fractures were found in 15 (33%) of 45 patients presenting between August 1993 and December 1996. These were significant enough to warrant surgical repair in 13 (29%) patients. CONCLUSIONS: We suggest that any patient presenting with PESS and a history of relevant trauma should be considered to have an orbital wall blow-out fracture until proven otherwise by CT scanning of the orbit. Similarly any patient requiring enucleation following severe ocular trauma should undergo CT scanning to rule out a coexisting blow-out fracture which could be repaired at the time of enucleation.

Tenascin-cytotactin (TN-C) variants in pseudophakic/aphakic bullous keratopathy corneas.

PURPOSE: To examine pseudophakic/aphakic bullous keratopathy (PBK/ABK) human corneas for patterns of expression of tenascincytotactin (TN-C) variants known to mediate specific cellular functions, viz. anti-adhesion (high molecular mass (M(r))) and adhesion (low/intermediate M(r)). METHODS: PBK/ABK corneas were selected to encompass only those with bullae and without inflammation, scarring or neovascularisation. Serial sections from these and normal corneas were labelled with antibodies BC-4 (recognising all TN-C variants) and BC-2 (specific for the high M(r) TN-C variant). Bound antibody was revealed with an avidin-biotin peroxidase technique. In a given pair of corneal sections, positivity with BC-4 but not BC-2 indicates localisation of low/ intermediate M(r) TN-C variants and absence of the high M(r) TN-C variant. BC-2 identifies the high M(r) variant. RESULTS: There was no immunostaining with either BC-2 or BC-4 in normal corneas except at the corneoscleral interface, where both BC-2 and BC-4 were immunolocalised. In PBK/ABK corneas, BC-2 staining was seen in 5 of 13 corneas and was restricted mainly to epithelial basement membrane (BM) overlying bullae. BC-2 did not label the stroma. BC-4 immunostaining was present in all PBK/ABK corneas and was localised in epithelial BM, both epithelial and stromal borders of bullae, pannus, endothelial BM and in oedematous stromal regions. CONCLUSIONS: TN-C variants are differentially expressed in PBK/ABK corneas. The high M(r) variant is restricted mainly to epithelial BM overlying bullae, while low/intermediate M(r) variants occur in epithelial BM, both epithelial and stromal borders of bullae, and in pannus. Given the in vitro functions of TN-C, a role for promoting epithelial dehiscence and reattachment to the substratum in PBK/ABK corneas by high and low/intermediate M(r) variants respectively is likely.