Long-term outcomes of margin-controlled excision for eyelid melanoma.

OBJECTIVES: To provide evidence for long-term outcomes for margin-controlled excision of eyelid melanoma. METHODS: Retrospective single-centre observational case series of patients treated for eyelid melanoma between 2007 and 2016, with a minimum of 5-year follow-up. Tumour excision involved rush-paraffin en face horizontal sections and delayed repair (Slow Mohs; SM). RESULTS: Twenty-two cases were seen with a survival of 91% (two deaths from nodular and lentigo maligna melanoma) and seven with melanoma in situ (MIS). Invasive melanoma includes eight lentigo maligna melanoma, four nodular, two amelanotic and one desmoplastic. Mean Breslow thickness was 6 mm for invasive (range 0.5-26). Mean excision margin for MIS was 3 mm (range 2-5 mm) and for invasive was 5 mm (range 2-10). Further excisions were performed in nine (41%); two went on to recur. Local recurrence was 36%; six invasive (27%) at a mean of 24 months (range 1.5-5 years) and two for MIS at a mean of 15 months (range 1-1.5 years). Imaging occurred for suspected advanced disease. Sentinel node biopsy was not performed. Advanced melanoma therapy was performed in two cases. No vitamin D testing occurred. CONCLUSIONS: Survival rates are in line with 90% overall survival in the UK. Prescriptive excision margins are not applicable in the periocular region and margin-controlled excision with a delayed repair is recommended, but patients need to know further excision may be needed to obtain clearance. Evidence recommending vitamin D therapy needs to be put into clinical practice. In addition, upstaging of MIS occurred advocating excision rather than observation of MIS. More studies are needed to determine the best management of eyelid melanoma.

The UK National Artificial Eye Questionnaire Study: comparisons between cosmetic shell and artificial eye users. Part 2: maintenance, management and quality of life.

AIMS: To compare the unique experiences related to artificial eye (AE) versus cosmetic shell (CS) wear. METHODS: In this observational, cross-sectional study, the National Artificial Eye Questionnaire was employed nationwide within the National Health Service England. This second part of the study assesses daily management and care experiences, as well as visual function and quality of life aspects. RESULTS: Overall, 951 respondents wore an AE, while 238 wore a CS. Both AE and CS respondents rated a relatively high score for a beneficial effect of prosthesis polishing, with an average score of 80.08±0.87 versus 77.17±1.73 (p=0.13, respectively). CS respondents removed and cleaned their prosthesis more frequently than AE respondents (p<0.0001, p=0.002, respectively). CS respondents instilled lubrication more frequently than AE respondents (p=0.022) with 33.3% versus 43.7% of AE and CS wearers, respectively, lubricating on at least a daily basis. The overall QOL composite score was similar in both AE and CS groups (approximately 77%, p=0.74). Social functioning was similar, and relatively high in both groups (approximately 86%, p=0.77). CONCLUSIONS: This study characterises unique aspects of CSs versus AEs in a large national cohort. The results should provide reinforcement to the gain in popularity of CSs.

The UK National Artificial Eye Questionnaire Study: predictors of artificial eye wearers' experience Part 2 - visual function and quality of life.

OBJECTIVES: To report associations with visual function and quality of life (QOL) in artificial eye wearers. METHODS: Multicentre, observational, cross-sectional, nationwide study, within the National Health Service England. Items were adopted from the National Eye Institute Visual Function Questionnaire, and incorporated in the National Artificial Eye Questionnaire (NAEQ). The NAEQ was completed by 951 respondents. Multiple regressions assessed associations between the QOL scores and the experiences of artificial eye wearers, their routine management, changes over time, baseline and demographic parameters. RESULTS: Parameters predictive of a better QOL composite score included longer artificial eye wear (ß = 0.18, p < 0.001), better appearance (ß = 0.17, p < 0.001), better comfort (ß = 0.14, p = 0.001), tumour-related anophthalmia (ß = 0.13, p = 0.003), male gender (ß = 0.13, p < 0.001), shorter period of adjustment to monocular vision (ß = 0.12, p < 0.001) and use of soap for cleaning (ß = 0.09, p = 0.046). The composite score continued to improve beyond 10 years of prosthesis wear (≤2 years mean 72.80 ± 1.65 versus >10 years mean 79.45 ± 0.70; p = 0.001). Both better prosthesis appearance (ß = 0.14, p = 0.022) and improved motility (ß = 0.13, p = 0.042) predicted a better dependency score. Use of lubricating ointment predicted a worse dependency score (ß = 0.23, p = 0.003). Neither the frequency of removal, nor the cleaning frequency of the artificial eye correlated with QOL scales. CONCLUSIONS: Multiple factors in the artificial eye experience were found to predict visual function and QOL aspects. This study underscores the need to generate a dedicated QOL questionnaire for use in anophthalmic patients.

Does lagophthalmos change on lying supine after upper eyelid platinum segment chain loading?

BACKGROUND: Facial nerve palsy (FNP) often significantly affects blink. Platinum segment chains (PSC) improve lagophthalmos, however, debate exists as to the effectiveness of weights when the patient lies supine. METHODS: Prospective case series of patients with FNP following PSC insertion. Lagophthalmos on blink, gentle and forced closure was observed in the seated position, lying flat supine at 0 degrees, lying supine with one pillow underneath the head and lying on the side, with the non-facial palsy side to the pillow. This side was chosen to account for the effect that the pillow may have on lagophthalmos. RESULTS: Twenty eyes with PSC for facial palsy related lagophthalmos were assessed in 19 patients. Clinically, 12 out of the 20 eyes had no change in lagophthalmos on gentle closure when sitting up compared to supine (no pillow). The remaining 8 eyes had an increase of lagophthalmos of mean 2.3 mm (range 1-6 mm) when supine. There was no statistical difference in the amount of lagophthalmos between sitting up and lying flat with no pillow on gentle closure (P value = .0804) and blink (P value = .1567). About 50% of patients have ongoing requirements for evening lubricating ointment application but only one patient in our cohort experienced morning ocular symptoms. No patient was taping their eyelids. CONCLUSION: In our study, the prevalence of lagophthalmos increasing on gentle closure when supine is 40%. Statistically, there is no difference between gentle closure in the sitting and supine position.

UK National Artificial Eye Questionnaire study: comparisons between cosmetic shell and artificial eye users. Part 1: demographics, comfort and satisfaction.

AIMS: To compare the unique experiences related to artificial eye (AE) versus cosmetic shell (CS) wear. METHODS: In this observational, cross-sectional study, the National Artificial Eye Questionnaire (NAEQ) was employed nationwide within the National Health Service England. The proportions or mean values of the aetiology of sight or eye loss, demographics, length of prosthesis wear, reported adjustment time to the prosthesis, comfort, discharge and satisfaction of appearance were compared between AE and CS respondents. RESULTS: Overall, 951 respondents wore an AE, while 238 wore a CS. In both, trauma was the leading cause for the prosthesis (47.6% and 44.1%, respectively); however, these groups differed in the proportions of the other aetiologies (p<0.0001). AE respondents were generally older (p=0.002) and had longer overall prosthesis wear (p<0.0001) compared with CS respondents. The overall comfort score was similarly, relatively high in both AE and CS respondents (80.4±0.73 vs 81.41±1.45; p=0.51). The discharge-related patient satisfaction ranking was relatively low, in both groups, with a small trend towards worse discharge scores among AE wearers (59.41±0.76 vs 62.26±1.52, p=0.094). Self-reported length of time that has taken to adjust to wearing the prosthesis was not significantly different (p=0.17). Appearance of the eye (p=0.032) and motility of the prosthesis (p<0.0001) were ranked superior by CS respondents compared with AE. CONCLUSIONS: This study characterises unique aspects of CS versus AE in a large national cohort. The results should provide reinforcement to the gain in popularity of CS.

The UK National Artificial Eye Questionnaire study: predictors of artificial eye wearers' experience part 1-comfort and satisfaction.

OBJECTIVES: To report associations with comfort and with appearance satisfaction in artificial eye wearers. METHODS: Multicentre, observational, cross-sectional study, nationwide within the National Health Service England. The National Artificial Eye Questionnaire (NAEQ) was completed by 951 respondents. Multiple regressions assessed associations between the experiences of artificial eye wearers, routine management, changes over time, baseline and demographic parameters and their reported comfort, satisfaction with appearance and prosthesis motility. RESULTS: Better comfort levels were associated with needing less lubrication (ß = 0.24, p < 0.001), older age (ß = 0.17, p = 0.014), less discharge (ß = 0.16, p < 0.001), less frequent cleaning (ß = 0.16, p = 0.043), and male gender (ß = 0.06, p = 0.047). Greater satisfaction with the appearance of the artificial eye was associated with better perceived motility (ß = 0.57, p < 0.001). Black ethnic origin predicted a lower satisfaction with the appearance (ß = -0.17, p = 0.001). Greater satisfaction with the motility was associated with a better appearance rating (ß = 0.51, p < 0.001), longer time of having an artificial eye (ß = 0.13, p < 0.001), older age (ß = 0.11, p = 0.042), and a shorter adjustment time (ß = -0.07, p = 0.016). Of the testimonials concerning appearance aspects, the majority (21/45, 46.7%) were related to the effect on social interactions. CONCLUSIONS: The results suggest that more attention should be given to the "dry anophthalmic socket syndrome" as a key cause of discomfort. Young patients are concerned particularly about the motility of the artificial eye. Over time satisfaction with the artificial eye movement is likely to improve.

Switchover study of onabotulinumtoxinA to incobotulinumtoxinA for facial dystonia.

IMPORTANCE: When making a cost-saving it is important to ensure there is no loss of efficacy. BACKGROUND: Clinical effectiveness and efficiency of incobotulinumtoxinA compared to onabotulinumtoxinA in facial dystonia is unclear. Our aim is to evaluate switching from onabotulinumtoxinA to incobotulinumtoxinA in the treatment of essential blepharospasm (EB), hemifacial spasm (HFS) and aberrant facial nerve regeneration (AFR). DESIGN: A retrospective study of a prospective, single-masked switchover audit from onabotulinumtoxinA to incobotulinumtoxinA. PARTICIPANTS: Twenty essential EB, 12 HFS and six AFR patients. METHODS: A switchover from stable onabotulinumtoxinA to incobotulinumtoxinA using a 1:1 unit ratio and contemporaneous efficacy measures. Two nurse injectors performed the injections over a period of 6 years. Each masked patient received three onabotulinumtoxinA and three incobotulinumtoxinA over a minimum of 2 years. MAIN OUTCOME METHODS: At each visit, a blepharospasm disability score (BDS), Jankovic score (JS), subjective improvement (SI), duration of maximum effect (DME) and complications were recorded. A cost comparison per unit dose was made. RESULTS: Twenty EB, 12 HFS and six AFR received 114 onabotulinumtoxinA and 114 incobotulinumtoxinA treatments. Both brands had similar efficacy, but SI (P < .01) and DME (P < .05) were higher in the HFS group with incobotulinumtoxinA. Complications included bruising (two onabotulinumtoxinA, one incobotulinumtoxinA) and ptosis (three onabotulinumtoxinA, zero incobotulinumtoxinA). OnabotulinumtoxinA was 33% pricier. CONCLUSION AND RELEVANCE: Switching from onabotulinumtoxinA to incobotulinumtoxinA did not result in an inferior outcome for the treatment of facial dystonia and led to a cost-saving for the department.

Meibomian gland inversion: under-recognized entity.

OBJECTIVE: To describe a clinical entity of upper eyelid margin and meibomian gland inversion (MGI) sequential to meibomian gland dysfunction (MGD), in the absence of eyelash ptosis, trichiasis or manifest marginal entropion. We highlight its clinical features, surgical management and outcomes. METHODS: We performed a retrospective analysis of symptomatic MGI cases refractory to conservative management who underwent surgery in our centre over a 4-year period. Anatomical correction, resolution of symptoms and possible complications are reported. RESULTS: A total of 21 eyelids of 13 patients (mean age: 68.5 ± 15.4, range: 32-88 years) were analysed. Symptomatic MGI patients were operated only if they have noted immediate comfort when we corrected the lid margin position with a cotton tip. Those with refractory superior punctate corneal staining (n = 14 eyes), blink-related discomfort (n = 8) and pseudo-blepharospasm (n = 3) reported complete postoperative resolution. Milder symptoms showed partial improvement: gritty feeling (79%), sore eye (80%) and watery eye (86%). However, symptoms of dry eye disease (DED) persisted in 88% of patients. One case recurred in 6 weeks and was offered revision surgery. Median follow-up was 5 (range: 3-12) months. CONCLUSION: Meibomian gland inversion (MGI) is a subtle clinical entity that can be easily overlooked. Symptoms are often attributed to DED or MGD alone. It is likely that MGI represents early upper lid margin anatomical changes secondary to MGD before cicatricial marginal entropion becomes clinically apparent. Recommended treatment is conservative with intensive lid hygiene and topical MGD management. However, refractory symptomatic cases who respond positively to a 'cotton-tip test' (reversal of lid margin malposition with a rolling cotton-tip) may benefit from surgical intervention with favourable anatomical and functional outcome.

Long-term outcome of flexible onabotulinum toxin A treatment in facial dystonia.

PURPOSE: The purpose of this study was to assess the long-term outcome of onabotulinum used to treat facial dystonia and compare a flexible and fixed treatment regimen. METHODS: This was a retrospective comparative study looking at benign essential blepharospasm (BEB), hemifacial spasm (HFS) and aberrant facial nerve regeneration synkinesis (AFR) treatment with onabotulinum toxin A (Botox®) over a minimum of 10 years. Fifty-one patients were recruited into the study, with each dystonia subgroup having 17 patients. Blepharospasm disability score (BDS), subjective improvement score (SIS), duration of maximal effect (DME) and complications were recorded at each visit. RESULTS: The mean age was 63 years and gender predominately female. Thirty-seven patients underwent flexible treatment intervals compared to 14 fixed treatment intervals, averaging 3.4 and 4 per annum, respectively. Mean BDS significantly improved from 6 to 3 at last review across all 3 groups, with the highest effect on BEB. BDS improvement was greater in flexible intervals. SIS remained similar for all three conditions during follow-up, but in those undergoing flexible intervals, SIS increased by a small margin compared to fixed interval. Mean DME was 10.5 weeks across all dystonias, but increased progressively only in the flexible interval group. Complications included ptosis (30%), dry eye (14%) and lagophthalmos (8%). CONCLUSION: Flexible onabotulinum provided better long-term relief on BDS for facial dystonia than a fixed regimen. Flexible interval treatment may also provide better patient satisfaction and longer DME compared to fixed treatment. Both have similar complication rates. With flexible treatment however, fewer injections were required over 10 years, leading to cost saving.

Dry eye after Lester Jones tube insertion for epiphora.

Purpose: To report the occurrence of dry eye after Lester Jones tube (LJT) insertion. Methods: Retrospective case series from a single unit. The dacrocystorhinostomy (DCR) was carried out using both endoscopic and external approachs; however, insertion of LJT used the same method as either a primary or secondary procedure. Dry eye as an outcome measure was only confirmed after three separate visits using the presence of both patient symptoms and dry eye signs with none preceding tube insertion. Results: Fifty-four patients underwent consecutive LJT insertion over a 5-year period. Mean age was 52.6 (range 25-73 years). The majority were female 39 (72%). Revision surgery was required in 15 (27%) with 3 or more occurring in 6 (11%). In total, 9 patients developed dry eyes (17%). Mean age was 60 (range 47-73) years, 5 females and 4 males. Four of the dry eye individuals had undergone primary LJT insertion and the remaining five received their first LJT 6-24 (mean 15) months post-DCR. Two dry eye patients had previously undergone LASIK and radiotherapy. Conclusion: A risk of dry eye following LJT placement is higher than the literature suggests. This should be considered and counseled, especially in those who have underlying pre-disposing factors. Ease of removal may be a desirable attribute in such cases.

Complications and outcomes of grafting of posterior orbital fat into the lower lid-cheek junction during orbital decompression.

PURPOSE: To report the complications of grafting of excised posterior orbital fat into the lower lid-cheek junction at the time of orbital decompression surgery. METHODS: Retrospective review of consecutive patients undergoing orbital decompression combined with grafting of posterior orbital fat to the pre-malar and lateral canthal area (FG). A second group of consecutive patients undergoing orbital decompression but no orbital fat grafting (NoFG) were also studied as a form of comparative control. Standard patient data, including age, sex, visual acuity, degree of proptosis, operative details, diplopia or any other complications was collected. Independent assessment of pre- and post-operative photographs graded the lower lid-cheek junction. RESULTS: Thirty-four orbits of 29 patients, of which 21 orbits underwent orbital decompression with orbital fat grafting (FG). There were no intraoperative complications, postoperative infections, or visual loss. Complications relating to fat grafting included prolonged swelling in 3 (17%) patients at 3 months, in 1 case lasting 6 months, lower lid lumps in 3 (17%), and fat seepage in 1 (6%). The FG group achieved a greater improvement in the appearance of the lower-lid-cheek junction at 12 months in comparison to NoFG. Mean grade improvement 1.24 ± 1.09 vs 0 ± 0.82 (p = 0.025). Median follow-up was 20 months (range 6-30 months). CONCLUSION: Grafting of excised orbital fat during orbital decompression can improve the appearance of the lower lid-cheek junction in patients being treated for thyroid orbitopathy. However, 24% of patients will experience swelling and/or lumpiness requiring several months to settle or further fat excision.

Can We Improve the Tolerance of an Ocular Prosthesis by Enhancing Its Surface Finish?

PURPOSE: Patients who wear an ocular prosthesis frequently suffer with dry eye symptoms and socket discharge, often on a daily basis. The aim of the study was to determine whether a smoother, optical quality polish of the prosthesis' surface could improve symptoms and wear tolerance. The study was designed as single-center, single-masked, prospective randomized controlled trial. Eighty-eight consecutive patients undergoing annual ocular prosthesis maintenance review were approached from the prosthesis clinic. Forty-one out of 49 eligible patients were recruited. METHODS: Participants were randomized to either a standard or a higher "optical quality" polish of their prosthesis. At entry to the trial, at 1 month, and 12 months they completed a questionnaire covering cleaning, lubricant use, inflammation, discomfort, and discharge. Lower scores indicated better tolerance of the prosthesis. At each visit, the prosthesis was stained and photographed against a standard background to assess deposit build up. Primary outcome measures were 1) a subjective questionnaire score and 2) an objective assessment of surface deposit build-up on prosthetic eyes by standardized photographic grading. RESULTS: Forty-one patients participated in the study. The median age of their prosthesis was 36 months (range 9 months-40 years). There was no statistically significant difference in questionnaire scores or deposit build up between the 2 groups at baseline. By 12-months, the higher optical quality polish showed a statistically significant reduction in symptoms and frequency of discharge (2.19 vs. 3.85; p = 0.05-lower scores better). Scoring of the prosthesis' deposit build-up showed a significant difference at 1 month, but this was not sustained at 12 months. CONCLUSIONS: Creating an optical quality finish to an ocular prosthesis reduces deposit build up on artificial eyes. The authors found this modification improved patient tolerance at 12 months.

Late outcomes of gold weights and platinum chains for upper eyelid loading.

AIM: To identify late outcomes of gold weights (GWs) and platinum chains (PCs) for upper eyelid loading in the management of lagophthalmos. METHODS: A retrospective case series of upper eyelid GWs and PCs at a single centre over a 10-year period (2004-2013). Two independent, blinded assessors graded standard photographs for any weight-related morbidity (poor upper eyelid contour, weight prominence and migration). RESULTS: Primary upper eyelid loading (high-tarsal technique) was performed in 154 eyelids of 136 patients (facial nerve palsy, n=99; non-paralytic, n=37). A total of 127 eyelids of 110 patients had primary GW insertion. Of these, 40.9% (52/127) had revision surgery: exchange of GW for PC (58%), GW repositioning (25%) and removal of GW (17%). Only 22.2% (6/27 eyelids) with primary PCs required revision surgery. In those not requiring revision surgery, photograph grading showed that both GWs and PCs had weight-related morbidity at late follow-up (median=37.5 months, range 12-110 vs median=33.5 month, range 15-106). GWs had significantly higher rate of weight prominence (p=0.001) and migration (p<0.001) compared with PCs. All PC revisions required one procedure only compared with 10% of GWs revisions requiring two or more procedures. Incidence of gold allergy was 7% (8/110 patients). There was no association between the choice of weight material, physical weight or suture material and eyelid morbidities. CONCLUSION: GWs were found to be associated with higher complications and twice more likely to require long-term revision surgery compared with PCs. Despite weight fixation at a high-tarsal location, prominence of PCs can still occur.

Periorbital Autologous Fat Grafting in Facial Nerve Palsy.

PURPOSE: To report outcomes and complications of periorbital autologous fat grafting (AFG) in improving volume loss-related symmetry and function in facial nerve palsy patients and to assess patient satisfaction. METHODS: A retrospective, noncomparative review of all facial nerve palsy patients who underwent periorbital AFG at single center over a 4-year period. Two independent graders objectively assessed standard photographs for any change in volume loss and symmetry: pre- and postoperative periods (early, 0-2 months; intermediate, 3-9 months; and late, >10 months). Any adverse outcomes were recorded. Patient satisfaction was assessed by questionnaire survey. RESULTS: A total of 18 facial nerve palsy patients (13 females) underwent periorbital AFG between February 2011 and 2015. Mean age was 51.9 ± 15.3 years (range, 26-76). Mean follow up was 6.8 ± 4.6 (range, 0.5-15) months. Photographs of 14 patients were eligible for evaluation. Tear trough visibility (p < 0.01), infraorbital rim visibility (p = 0.03), and lower eyelid-cheek junction symmetry (p < 0.01) improved in the early postoperative period with persistence of improvement in the latter parameter at intermediate postoperative period (p < 0.01). Lagophthalmos significantly improved (p = 0.03) in the early postoperative period. Two patients developed cheek cellulitis and 4 had persistent malar edema (3 had existing edema). Questionnaire survey showed a reduction in daytime ocular lubricants and an improvement in nocturnal-lagophthalmos symptoms. CONCLUSION: Periorbital AFG is a useful adjunct in improving symmetry and lagophthalmos in facial nerve palsy patients where volume loss is a contributory factor but effects were not long lasting. Patient satisfaction is high. Those with preexisting malar bags are at higher risk of developing persistent malar edema following periorbital AFG.

Effect of Manuka Honey on Eyelid Wound Healing: A Randomized Controlled Trial.

PURPOSE: To report outcomes of a randomized trial on the role of "active" Manuka honey on eyelid surgical wound healing. METHOD: Prospective, randomized, single-blinded study was performed for patients undergoing bilateral upper blepharoplasty. Vaseline was applied 4 times a day to both sides for 6 weeks and in addition, one eyelid was randomized to receive Manuka honey twice daily. Postoperative wounds were graded by a masked observer at 1 week, 1 month, and 4 months using Manchester scar scale and a modified eyelid scar grading scale. Patients scored symptoms, expressed preferred side, and of any problems they experienced using honey. Standard photographs were graded by 2 independent assessors. RESULTS: Fifty-five patients were randomized. One week after surgery, 46 (29 women, 17 men, mean age 68 years, median 69, range 49-85) were available for analysis. There was a trend toward distortion of the surrounding skin being less (1.6 vs. 1.8, p = 0.07) and the scar being less palpable (1.8 vs. 2.0, p = 0.08) on the Manuka-treated side. Patients reported the scar on the Manuka side to have less stiffness (1.3 vs. 1.6, p = 0.058). At 1 month, all 3 grading scales showed no difference between the 2 sides. At 4 months, scar grading scales showed no differences; however, patients reported scar pain to be significantly less on the Manuka-treated side than control (0.48 vs. 1.9, p = 0.005). Thirty-one of 46 patients believed the scars were similar on both sides, 11 preferred the honey-treated side, and 4 preferred the control. CONCLUSION: Upper eyelid scars treated with or without Manuka honey heal well, without significant difference when assessed by validated scar grading scales; however, honey may provide subjective benefits early, postoperatively.

How can we maximize the use of our operating lists? An analysis of factors influencing theatre efficiency in oculoplastic day surgery.

Operating theatre utilization has become the principal measure of NHS operating theatre service performance. We analysed data from oculoplastic theatres in a tertiary centre to identify factors influencing theatre efficiency. We conducted three audits on operating theatre utilization in 2011, 2014 and 2015. Data was collected from real time information entered into the hospital database, including time of arrival, induction, first cut and close of operation. The primary outcome measure was the operating list utilization rate, a combined value of anaesthetic and surgical time as a proportion of the total planned session time. The initial 2011 audit recorded an operating list utilization rate of 81.2%. However, this dropped to 64.5% in 2014 following new management and a move to a new theatre suite. Analysis of the factors contributing to poor theatre efficiency led to changes that streamlined the patient pathway, including standardized case scheduling and reducing staggered patient arrival. A 2015 reaudit analyzing the effects of these changes demonstrated an increase in the operating list utilization rate to 78%. It was significantly higher (p < 0.01) for whole-day lists (85%) compared to half-day lists (75%), suggesting that whole-day lists were more efficient. Operating theatres are a valuable resource and the factors affecting theatre efficiency within our unit are common and will be relevant to units elsewhere. Correcting them can lead to significant improvements in patient care. Data from this study may provide a benchmark for other units in the United Kingdom.

CADS grading scale: towards better grading of ophthalmic involvement in facial nerve paralysis.

INTRODUCTION: Ophthalmologists lack a facial nerve grading instrument (FNGI) that comprehensively encompasses the ophthalmic sequelae of facial nerve paralysis (FNP). Assessment and management of ophthalmic sequelae remains inconsistent, and outcomes of clinical studies are incomparable. We have developed and successfully adopted an FNGI based on four aspects of periorbital involvement: cornea, asymmetry, dynamic function and synkinesis. This CADS classification is specific for periorbital involvement, with objective and subjective parameters, to standardise grading. We present this classification and the results of a validation study in clinical practice. METHODS: A cross-sectional, validation study. Two clinicians independently assessed and graded each patient on the same day, blinded to each other's grading. Each grader assigned a score to each of four parameters: C (0-3, ±a), A (0-2), D (0-3), S (0-2). RESULTS: Thirty patients (19 females, mean age 60, range 30-84 years) with unilateral facial paralysis were graded. A total of 60 assessments were conducted. CADS scores ranged from C0A0D1S1 to C3aA2D3S0. In the first 30 assessments (of the first 15 patients), the two assessors disagreed over the corneal grading in four patients. The last 30 assessments of 15 patients showed complete agreement in all four parameters of the grading scale. The overall inter-observer agreement was 86.7% for cornea, 93.3% for resting asymmetry, 93.3% for dynamic function and 86.7% for synkinesis. After the first six patients, Cohen's κ reached 1 for all but synkinesis that ranged between 0.9 and 1. CONCLUSIONS: We present a validation study of an FNGI specifically designed for ophthalmic involvement of FNP. Objective and subjective parameters helped standardise grading and management planning.

Platinum segments: a new platinum chain for adjustable upper eyelid loading.

PURPOSE: Prospective study evaluating outcomes of individually sutured platinum segment chains in upper eyelid loading. METHODS: Single-centre, single-surgeon, prospective study. Upper eyelid loading with 0.4 and 0.2 g platinum segment chains for lagophthalmos. Segments were sutured to create a desired weight and attached to superior tarsus and distal levator aponeurosis following levator recession. PRIMARY OUTCOME MEASURES: improvement in lagophthalmos and complications. SECONDARY OUTCOME MEASURES: cosmesis of eyelid margin contour and implant prominence. Minimum 3-month follow-up. RESULTS: Eighteen eyelids of 17 patients received segment chains (mean weight 1.2 g, range 0.8-1.6 g) and 3 for exchange of pre-existing gold weights. Median follow-up was 10 (range 6-17) months. Mean blink lagophthalmos improved from 7 (3-10) mm to 3 (0-6) mm (p<0.0001), and gentle closure from 3.2 (0-8) mm to 1.1 (0-4.9) mm (p=0.0004). Twelve patients (71%) reported no prominence, and the remainder, mild prominence only. The chain was graded as having no prominence in 78% (14/18) eyelids. Two required segment adjustments with removal of a single 0.2 g segment at 11 months and transfer of 0.4 g segment to the contralateral eyelid at 16 months, respectively. One complication (posterior, trans-conjunctival exposure above the superior border of the tarsal plate) was seen 12 months post surgery, requiring repositioning. CONCLUSIONS: Platinum segment chains provide benefits of platinum chains with additional advantages of postoperative adjustibility. They can be used as an addition to pre-existing in situ weights or chains. TRIAL REGISTRATION NUMBER: REC reference: 13/SW/0146. IRAS project ID: 119022.