Progressive Necrotizing Ocular Surface Disease, Despite Immunosuppression.

A 60-year-old man was referred with 2 years of left conjunctivitis that persisted despite antibiotic and systemic corticosteroid therapy. The severity and extent of surface disease had increased slowly after prior dacryocystorhinostomy. Subsequent conjunctival biopsies demonstrated granulomas with patchy necrosis but no evidence of malignancy or organisms; systemic screening for sarcoidosis and tuberculosis was negative. A markedly thickened and inflamed left ocular surface was present on referral, with areas of conjunctival ischemia and patchy white slough on the tarsi. Further ocular surface biopsy did not reveal malignancy, and therefore mycobacterial infection was considered a possible cause. Mycobacterium tuberculosis was cultured, albeit only after repeated conjunctival swabs and biopsies. Appropriate treatment led to a very rapid resolution of ocular surface disease. Localized periocular tuberculosis is extremely rare outside developing nations, and its rarity may cause this differential diagnosis for persistent severe ocular surface disease to be overlooked in industrialized nations.

A Novel Simulation Model Significantly Improves Confidence in Canthotomy and Cantholysis Among Ophthalmology and Emergency Medicine Trainees.

BACKGROUND: Orbital compartment syndrome is a potentially blinding eye condition. Timely diagnosis and treatment are paramount to optimize visual outcomes. Lateral canthotomy and cantholysis is the definitive management and a required competency for emergency physicians and ophthalmologists. Lack of confidence in the procedure can result in delayed treatment and poor outcomes. OBJECTIVES: Our aim was to create a low-cost, realistic, simulation model to ensure trainees were confident in performing lateral canthotomy and cantholysis. METHODS: A model was created using equipment found in the emergency department. This model's efficacy was assessed using pre- and post-teaching questionnaires measuring learner's self-perceived confidence. RESULTS: Forty-seven emergency medicine and 18 ophthalmology registrars rated their confidence in the procedure using a 5-point Likert scale (1 = not very confident, 5 = extremely confident); 42% (n = 27) of participants felt 'quite confident' (4 on Likert scale) in carrying out the procedure unsupervised out of hours after the teaching session, compared with 9.23% (n = 6) before (p < 0.01). Our model resulted in significant increases in all three measures of confidence (diagnosing orbital compartment syndrome, locating the necessary equipment and performing canthotomy and cantholysis) and was rated as 4.35 (1 = not at all helpful, 5 = extremely helpful) in understanding the anatomy of the region. Sixty-six percent (n = 43) of participants stated they would like further simulation teaching. CONCLUSIONS: Our model is low cost, easy to assemble, and anatomically correct. The user can 'strum' the inferior canthal tendon without cutting the lower lid, appreciating the difference between canthotomy and cantholysis. Use of this model significantly increased the number of learners who felt "quite confident" with performing the procedure. Use of this model should be considered for trainees in ophthalmology and emergency medicine.

Introducing the 'Benign Eyelid Lesion Pathway': 1 year experience of synchronous tele-oculoplastics in a tertiary hospital.

BACKGROUND: Patients with benign eyelid lesions make up a large proportion of referrals to the oculoplastic service and lend themselves well to telemedicine with assessments heavily reliant on history, observation-based examination and photographs to enable management decision-making. Our tertiary unit set up tele-oculoplastics clinics for all new patients referred for benign eyelid lesions comprising tele-consultation with antecedent patient photograph: Benign Eyelid Lesion Pathway (BELP). One year on, we describe a retrospective analysis of 974 patients looking at distinct parameters of effectiveness. METHODS: We retrospectively collected data from electronic patient records (EPR) for BELP patients from July 2020 to August 2021 (n = 974). We analysed time efficiency (referral time to treatment plan, consultation duration in minutes, average waiting times, number of patients seen per clinician and DNA rate), accessibility, safety (via video surveillance clinic) and theatre utilisation. RESULTS: 57.3% (n = 558) were listed for a surgical procedure direct from tele-consultation with 94.9% (n = 513) of these proceeding to surgery; 22.8% (n = 222) were discharged, 10.7% (n = 104) had further video follow-up and 6.7% (n = 65) required face-to-face follow-up. Our results showed efficient referral-to-treatment times, waiting times, consultation times and non-attendance rate. There was only a 2.57% non-attendance rate. There was no missed diagnosis of a malignancy of a presumed benign lesion. CONCLUSION: Tele-oculoplastics provides a streamlined, safe, effective, and logistically convenient way to review benign eyelid lesions. With the increased waiting times for referral to biopsy of eyelid lesions, this clinic shows it is imperative to provide digital accessibility for patient assessment and booking to operating theatre.

Blood-stained tears-a red flag for malignancy?

BACKGROUND: Blood-stained tears can indicate occult malignancy of the lacrimal drainage apparatus. This study reviews data on patients presenting with blood in their tears and the underlying cause for this rare symptom. METHODS: Patients presenting with blood in their tears, identified over a 20-year period, were retrospectively collected from a single tertiary ophthalmic hospital's database and analysed. RESULTS: 51 patients were identified, the majority female (58%) with a mean age of 55 years. Most cases were unilateral (96%) with blood originating from the nasolacrimal drainage system in 53%. The most common diagnosis for blood-stained tears was a lacrimal sac mucocele (n = 16) followed by a conjunctival vascular lesion (n = 4). Three patients had systemic haematological disorders. The rate of malignancy was 8% (n = 4), with 2 patients having lacrimal sac transitional cell carcinomas, one with a lacrimal sac plasmacytoma and the other with chronic lymphocytic leukaemia and bilateral orbital infiltration (with bilateral bloody tears). One patient had a lacrimal sac inverted papilloma, a premalignant lesion. Four patients had benign papillomas (of the lacrimal sac, conjunctiva and caruncle). CONCLUSION: Haemolacria was a red flag for malignancy in 8% of patients (and tumours in 18% of patients). A thorough clinical examination including lid eversion identified a conjunctival, caruncle, eyelid or canalicular cause in 27% of cases.

Creating a secure clinical 'Bring Your Own Device' BYOD photography service to document and monitor suspicious lesions in the lid oncology clinic.

BACKGROUND: Ophthalmic examinations are mostly documented using sketches and written descriptions. Improvements in app security and IT infrastructure mean that high-quality anterior segment photographs can be routinely collected with smartphones alone. The lid oncology team relied on pre-operative formal slit-lamp imaging in the one-stop biopsy clinic, a lengthy process with capacity limitations, that risked delays to care. METHODS: A Bring Your Own Device (BYOD) photography service was developed through a series of iterations and collaborations. Healthcare Assistants took photographs on iPhone SE with Quikvue lens attachments in Pando app. Lesions requiring a slit lamp were photographed by the doctor. Images were uploaded to the patient record twice weekly. The service was evaluated using time-motion studies, imaging quality and utility grading, and patient feedback. RESULTS: BYOD photography saved lid oncology patients 41 min (one-third of total appointment time) and reduced delays to treatment to zero. A patient survey reflected the acceptability of the service, with 100% feeling photography was important at every visit. In terms of utility, 97.5% of smartphone images were suitable for monitoring lesions and making management decisions. The management plan based on the smartphone photographs was consistent with the management plan formulated face-to-face in clinic in 92.5% images. CONCLUSION: BYOD photography has replaced formal slit-lamp imaging in the lid oncology service. This sustainable, cost-effective BYOD solution requires little training and can be adapted, reproduced, and scaled globally. BYOD photography can offer detailed records to monitor progress, contribute to remote care models, improve patient experience, and reducing medical error.

Recurrent epiphora after dacryocystorhinostomy surgery: Structural abnormalities identified with dacryocystography and long term outcomes of revision surgery : Success rates of further surgery following failed dacryocystorhinostomy surgery.

BACKGROUND: To investigate the aetiopathology of recurrent epiphora or stickiness after dacryocystorhinostomy (DCR) surgery, identifiable on dacryocystography (DCG), and to assess the success rates of secondary corrective surgeries. METHODS: Consecutive post-DCR DCG images from patients with recurrent symptoms were reviewed between 2012 and 2015. RESULTS: One hundred fifty-nine eyes of 137 patients were evaluated. Fifty-eight DCGs showed normal postoperative findings, 4 an upper/lower canalicular block, 13 a common canalicular block, 31 a completely closed anastomosis, 50 a narrow anastomosis, and 3 an anastomosis draining into a nasal sinus. The most successful corrective procedures for each failure category were: Lester Jones Tube (LJT) for a normal post-operative DCG (17/18 success), Sisler trephination with tubes for upper/lower canalicular block (1/2 success), redo-DCR with tube for common canalicular blockage (5/6 success), redo-DCR +/- tube for completely closed anastomosis (12/16 success), LJT followed by redo-DCR +/- tube for narrow surgical anastomosis (1/1 and 17/27 success respectively), and redo-external-DCR with tube for anastomosis into a nasal sinus (1/1 success). Redo-DCR was ineffective in patients who had good post-DCR anatomical patency (22% success). CONCLUSION: This is the first study to report success rates of redo-DCR surgery according to anatomical findings confirmed by DCG. The outcome flow diagram help clinicians recommend procedures that are most likely to be successful for their patient's specific anatomical abnormality. It also provides a visual tool for the shared decision-making process. Notably, symptomatic patients with a normal DCG post DCR are unlikely to benefit from redo-DCR, with a LJT being the recommended next step.

Impact of Upper Eyelid Surgery on Symptom Severity and Frequency in Benign Essential Blepharospasm.

OBJECTIVE: To assess the impact of periocular surgery, other than orbicularis stripping, on the severity and frequency of blepharospasm symptoms. METHODS: Consecutive patients with benign essential blepharospasm (BEB) who underwent eyelid/eyebrow surgery with the aim of improving symptoms were retrospectively reviewed over a 5-year period. Patients who had completed the Jankovic Rating Scale (JRS) and Blepharospasm Disability Index (BDI) pre- and at least 3 months postoperatively were included. RESULTS: Twenty-four patients were included. JRS scores significantly improved from 7.0 preoperatively to 4.1 postoperatively (p < 0.001), and BDI scores significantly improved from 18.4 preoperatively to 12.7 postoperatively (p < 0.001); the mean percentage improvements were 41% and 30%, respectively. Patients were followed for a median of 24 months postoperatively. CONCLUSION: Periocular surgery significantly reduced BEB symptoms in the majority (83%) of patients by an average of 33% and may therefore be offered for suitable patients. An important minority (17%) of patients experienced symptom worsening.

Long-Term Outcomes of StopLoss Jones Tubes for Epiphora in Patients With Early or Multiple Loss of Lester Jones Tubes.

PURPOSE: Extrusion is the most common cause of failure in conventional Lester Jones tubes (LJTs). StopLoss Jones tubes (SLJTs) with distal flange are designed to reduce this complication. This study compared the survival of SLJTs with their prior LJTs and control patients with LJTs-only. METHODS: Retrospective review of consecutive LJT or SLJT insertion between January 2014 and December 2016. RESULTS: Twenty-eight eyes of 23 patients had 31 SLJTs. Before their SLJTs, these patients had 116 cumulative failed LJTs. Forty-seven eyes of 34 patients had 59 LJTs only. Fifty-two percent of SLJT group and 18% of LJT-only group had complex medial canthal conditions (p = 0.003). Compared to their previous LJTs, the SLJTs were less likely to extrude (3% SLJT vs. 64% prior LJT, p < 0.0001); there was no statistical difference in rates of sinking in (26% SLJT vs. 13% prior LJT, p = 0.0964). The median survival of LJTs in those who went on to have a SLJT was 3.5 months. SLJT insertion significantly lengthened the median survival to 26 months (p < 0.0001), comparable to the LJT-only group (25.5 months, p = 0.45). While extrusion was also the most common complication in the LJT-only group, this occurred only in 20% of eyes; tube failure from sink-in occurred in 14% of eyes. CONCLUSIONS: SLJTs, in patients prone to multiple or early prior LJT losses, can be used to rescue this group and allow them to regain a similar survival curve to the less complicated LJT-only group. Rates of tube extrusion are significantly reduced with the use of SLJT.

Characterizing Congenital Double Punctum Anomalies: Clinical, Endoscopic, and Imaging Findings.

PURPOSE: To characterize the anatomical anomaly of congenital double puncta, identify factors contributing to epiphora and its treatment. METHODS: Retrospective review of patients presenting with epiphora and a double lacrimal punctum over a 6-month period. RESULTS: Five consecutive patients (3 female) were identified. The median age was 50 years (range 34-76). Investigations included punctum optical coherence tomography, dacryocystography, and canalicular endoscopy. The medial punctum was more morphologically abnormal when compared with healthy puncta, with optical coherence tomography showing no vertical canalicular component in 80% (4/5) of patients, and a more superficial than usual horizontal canaliculus in 80% (4/5). Dacryocystography and canalicular endoscopy showed the junction of the 2 inferior canaliculi, which was very proximal in 1, mid canalicular in 2, and at the level of the common canaliculus in 2. In 1 patient, the only abnormality identified was the double lower punctum, with a high tear meniscus and delayed fluorescence dye disappearance test. They underwent endonasal dacryocystorhinostomy with improvement of epiphora. In the other 4 patients, causes of epiphora were nasolacrimal duct stenosis with mucocoele, punctal stenosis, common canalicular stenosis with nasolacrimal duct stenosis, upper canaliculitis, and blepharitis. Their treatments included endonasal dacryocystorhinostomy, punctoplasty, canaliculotomy, and blepharitis treatment. All had improvement of epiphora following treatment. CONCLUSIONS: These findings suggest that the underlying canalicular anomalies are varied and that the clinical manifestation is also heterogenous. Optical coherence tomography imaging suggests that the medial of the 2 puncta is the more morphologically abnormal one, with dacryocystography and canalicular endoscopy demonstrating different accessory canaliculi lengths.Double puncta coexist with a range of other nasolacrimal pathologies. OCT suggests that the medial of the 2 double puncta is the abnormal one, with DCG and endoscopy demonstrating a range of accessory canaliculus lengths.

Characterizing the Occluded Lacrimal Punctum Using Anterior Segment Optical Coherence Tomography.

PURPOSE: Epiphora is sometimes associated with an absent or occluded lacrimal drainage punctum (or puncta). This study uses noninvasive "enhanced depth" anterior segment optical coherence tomography (OCT) to give improved characterization and understanding of absent or fully occluded puncta and the underlying canaliculus. METHODS: Anterior segment spectral domain OCT images were collected prospectively from 9 lower puncta of 6 patients with epiphora and absent or fully occluded puncta, not amenable to dilation in clinic, to see if a canaliculus was visible on OCT imaging below the occluded punctum. RESULTS: An epithelial lined canalicular lumen was visible on OCT in 4 lower eyelid puncta from 2 patients and OCT identified 80% (4/5) of the canaliculi that were located on microscope-assisted punctal exploration. These lumens were seen within 580 µm depth from the eyelid margin surface. A half of the eyes in which a canaliculus was identified on OCT (the 2 eyes in a single patient) had resolution of epiphora following punctoplasty, and the other patient was found to have coexisting nasolacrimal duct stenosis and required later dacryocystorhinostomy. The positive predictive value for identifying a canaliculus on lower eyelid punctal exploration in acquired complete punctal occlusion (excluding the congenital case) was 1, with a negative predictive value of 1. CONCLUSIONS: This study demonstrates that canaliculi can be imaged with OCT where formal access is precluded by an occluded punctum. This noninvasive investigation might help predict the likelihood of successful retrieval of a canaliculus at surgical exploration.

Corneal perforation from peripheral ulcerative keratopathy in patients with rheumatoid arthritis: epidemiological findings of the British Ophthalmological Surveillance Unit.

BACKGROUND/AIMS: This study quantifies the threat to vision and the survival in patients presenting with peripheral ulcerative keratopathy (PUK) corneal perforation associated with rheumatoid arthritis (RA) in the UK. METHODS: New cases of corneal perforation from PUK in patients with RA were prospectively collected from the UK via the British Ophthalmological Surveillance Unit from July 2012 to June 2014. An initial questionnaire collected data on presentation and the first 2 weeks' management, and a follow-up questionnaire collected 1-year data on ocular morbidity and mortality. RESULTS: 30 eyes of 28 patients were identified over 2 years, estimating a UK incidence of 0.234/million/year. 20/27 (74%) were female, with a median age of 68 years (range 41-84). The most common initial management was cyanoacrylate glue with a bandage contact lens, oral steroids, topical and oral antibiotics, and lubricants. Long-term management included corneal grafting in 12/20 (60%) eyes of patients living at 1 year. The 1-year all-cause mortality was 6/25 (24%), which increased to 1/2 (50%) if both eyes had perforated. In the remaining patients alive at 1-year follow-up, there was a 13/20 (65%) poor visual outcome of less than or equal to counting fingers. 8/25 (40%) patients had bilateral PUK, with 2/25 (8%) having bilateral perforation. 5/19 (26%) patients alive at 1-year follow-up were eligible for sight impairment registration. CONCLUSION: This study highlights the serious ocular morbidity and high mortality associated with corneal perforation from PUK in patients with RA despite treatment. The mortality doubled if both eyes perforated, which should serve as a harbinger of impending serious medical problems.

The Application of Infrared Imaging and Optical Coherence Tomography of the Lacrimal Punctum in Patients Undergoing Punctoplasty for Epiphora.

PURPOSE: To determine the application of imaging the stenotic lacrimal punctum with infrared photographs and optical coherence tomography (OCT) and to identify characteristics of the lacrimal punctum in patients who benefit from punctoplasty. DESIGN: Case-control study. PARTICIPANTS: Twenty patients with epiphora who were listed for punctoplasty and 20 healthy controls. METHODS: Prospectively, 20 patients listed for punctoplasty were asked to rate their epiphora, using the Munk score, before and after punctoplasty. They also underwent preoperative OCT and infrared imaging of the affected punctum. They were divided into 2 groups, depending on whether the epiphora improved, and were compared with 20 healthy controls. MAIN OUTCOME MEASURES: Measurements of puncta from infrared and OCT images were obtained along with Munk scores of patient epiphora. RESULTS: The infrared image measurements were significantly smaller in those patients whose epiphora improved compared with those whose did not in both the area of the punctal aperture and in the maximum punctal diameter. Additionally, those patients with improvement in epiphora had a significantly smaller preoperative punctal diameter at 100 µm depth on OCT compared with healthy controls; this was not observed in patients whose epiphora failed to improve. There was no significant difference in the punctum diameter among the 3 groups at the punctum surface entrance or at 500 µm depth. Patients with epiphora had a higher tear meniscus within the punctum compared with healthy controls. CONCLUSIONS: Lacrimal punctum infrared and OCT imaging may be helpful in predicting patients more likely to benefit symptomatically from punctoplasty, with patients with smaller puncta having greater symptomatic improvement. However, the results suggest that inner punctum diameter (not readily measurable by slit-lamp examination), rather than the surface diameter, is correlated with outcome. Additionally, OCT measurements of the tear meniscus height within the punctum may be related to the degree of epiphora.

Characterizing the lacrimal punctal region using anterior segment optical coherence tomography.

PURPOSE: Abnormalities of lacrimal punctum size and morphology probably contribute to excess tearing, with significant effects on quality-of-life for affected individuals. Our current understanding of normal punctal morphology originates from ex vivo studies, which are unlikely to capture the true nature of the living punctum. This study used enhanced depth anterior segment optical coherence tomography (OCT) to give improved characterization and understanding of lacrimal punctal structure. METHODS: Qualitative and quantitative assessments were performed on spectral domain OCT images collected prospectively from 40 lower puncta of 20 healthy volunteers. RESULTS: The average external lower lid punctal diameter was 0.646 mm (SD 150 µm) on OCT imaging, measured at the largest diameter, which was in parallel to the mucocutaneous junction. Fifty-five per cent of puncta appeared closed, whilst the eyelids were open. Fluid menisci were visible within 73% of puncta. A postpunctal 'ampulla' was visible within three systems, one of which was imaged through the conjunctival surface. Ampullary dilatation occurred laterally, rather than at the medial wall. CONCLUSION: Optical coherence tomography provides quick and non-invasive assessment of the lacrimal punctum and its neighbouring tissue layers. This assessment of punctal size and morphology has the potential for further investigation of punctal physiology, for aiding diagnosis, and for monitoring the results of treatment. The average external diameter of the punctal opening measured in this study is greater than that recorded in anatomical textbooks.

CD4+ and CD8+ T-lymphocyte scores cannot reliably predict progression in patients with benign prostatic hyperplasia.

OBJECTIVE: To determine whether the density of CD4(+) and CD8(+) T-lymphocytes in a transrectal ultrasonography (TRUS) biopsy of the prostate can be used to predict the progression of lower urinary tract symptoms (LUTS) in benign prostatic hyperplasia (BPH). PATIENTS AND METHODS: In total, 100 patients were randomly selected from a pool of patients with histologically proven, benign TRUS biopsy specimens. There were seven full years of follow-up available. Clinical data were recorded, including prostate volume, International Prostate Symptom Score (IPSS), prostate-specific antigen, urine flow rate, postvoid residual urine volume and previous prostate surgery. Markers of disease progression included the subsequent development of acute urinary retention (AUR), ≥4 point rise in IPSS, prescription of medical therapy (α-blocker or 5-α-reductase inhibitor) and bladder outlet surgery. Four patients' specimens were unsuitable for analysis. Biopsy sections from 96 patients were immunohistochemically stained for the presence of CD4(+) and CD8(+) T-lymphocytes and the density of infiltrate was assessed using random field sampling and point counting. RESULTS: Some 29% of patients (28/96) did not have BPH at the time of biopsy. Of all patients, 41% (39/96) progressed, 10% of whom (4/39) did not have BPH at the time of biopsy. A further 10% (10/96) developed AUR, 7% (7/96) had a ≥4 point rise in IPSS, 33% (32/96) required medical therapy for BPH and 11% (11/96) required bladder outlet surgery. There was low correlation between CD4(+) and CD8(+) densities in paired sections. CD4(+) and CD8(+) densities did not provide any significant predictive function in the progression of BPH, nor was their any predictive association noted between CD4(+) and CD8(+) scores and the development of prostate cancer. Sub-analysis did show that a threshold mean of ≥1.35 CD8(+) cells per field predicted progression to AUR with a sensitivity of 60% (95% confidence interval, CI, 26.2-87.8), specificity of 73.3% (95% CI 62.6-82.2) but a positive predictive value of 20.6% (95% CI 8.0-39.7). CD4(+) infiltrate density suggested a trend to general progression but without statistical significance. CONCLUSION: The present study, despite certain trends, shows no evidence for an association between CD4(+) and CD8(+) T-lymphocytes and the progression of LUTS in BPH.

Randomized, controlled study of long-acting local anesthetic (levobupivacaine) in femoral artery sheath management during and after percutaneous coronary intervention.

OBJECTIVE: To assess the effect of long-acting local anesthetic (levobupivacaine) in addition to lidocaine for the management of femoral artery sheaths during and after percutaneous coronary intervention (PCI). BACKGROUND: Femoral artery sheaths are commonly used during PCI. Sheath removal is often delayed after the procedure by which time short-acting local anesthetic agents may no longer be effective. METHODS: Sixty patients were randomized to either usual care or the administration of local levobupivacaine after PCI. Patients were asked to report their pain experienced on a visual analogue score. RESULTS: Thirty patients received additional levobupivacaine (0.5%) and 30 received standard care. There were no procedural differences between the groups, except that more patients in the control group received intravenous (IV) morphine at the time of sheath removal. There was no difference between the control group and levobupivacaine group in pain scores at the time of sheath insertion. (2.0 +/- 0.4 versus 1.8 +/- 0.3; p = 0.80). Both groups recorded low pain scores while waiting for sheath removal, and the score was slightly (but not significantly) lower in the levobupivacaine group (1.3 +/- 0.2 versus 0.8 +/- 0.2; p = 0.09). Pain scores were lower in the levobupivacaine group during sheath removal 2.2 +/- 0.4 versus 1.1 +/- 0.2; p = 0.02). There were no differences in terms of blood pressure between the groups at any time point. CONCLUSIONS: Levobupivacaine reduced the need for IV opiate and provided better analgesia than lidocaine alone in patients undergoing PCI.