Burnstine, Michael; Greer, Christine; Lee, Diana K.; Kim, Jonathan W.
Purpose: Myopathic blepharoptoses (ptoses) is a complex group of disorders. To date, no formal categorization scheme has been developed based on associated ocular and systemic findings, genetic fingerprint, treatment, and prognosis for each ptosis in this group. We report a new classification scheme for myopathic ptoses.
Methods: Literature review and classification development.
Results: A new classification scheme of myopathic ptoses includes isolated static myopathic ptosis (congenital ptosis), static myopathic ptosis associated with aberrant innervation and those associated with periocular abnormalities, and progressive myopathic ptoses that affect the levator muscle and other muscle groups in childhood and adulthood.
Conclusions: Making the distinction of myopathic ptosis type early will maximize patient outcomes by optimizing surgical and systemic management and facilitating the recruitment of subspecialists to care for patients with these challenging conditions.
The authors present a comprehensive and effective myopathic ptosis classification scheme to optimize surgical management and facilitate subspecialty care.
Valerie Juniat, Sarju Athwal & Mona Khandwala
Hospitals in England are reimbursed via national tariffs set out by NHS England. The tariffs payable to hospitals are determined by the activity coded for each patient’s hospital visit. There are no national standards or publications within oculoplastics for coding accuracy. Our audit aimed to determine the accuracy of coding oculoplastic procedures carried out in theatres and to assess the financial implications of any discrepancies.Methods
We carried out a prospective audit of consecutive oculoplastic procedures performed at one hospital site over a 6-week period. We subsequently created a coding proforma and performed a re-audit using the same methods.
In the first cycle, clinical coding was ‘correct’ in 30.7% of cases, ‘incomplete’ for 12.9% and ‘incorrect’ for 56.5%. Of the ‘incorrect’ codes, 54.3% were coded as non-oculoplastic procedures (e.g. extraocular muscle surgery). We discussed our findings with the coding team in order to address the sources of error. We also created a ‘tick box’ coding proforma, for completion by surgeons. Our re-audit results showed an improvement of ‘correct’ coding to 85.7%.
Clinical coding is complex and vulnerable to inaccuracy. Our audit showed a high rate of coding error, which improved following collaboration with our coding team to address the sources of error and by creating a coding proforma to improve accuracy. Accurate clinical coding has financial implications for hospital trusts and consequently Clinical Commissioning Groups. In times of severe financial pressures, this could be a valuable tool, if rolled out over all specialities, to make much needed savings.
Alexina Fantato, Manoj Parulekar & John Elston
Idiopathic blepharospasm (IB) is a rare but well-characterised adult onset focal dystonia that may cause severe visual disability. The most effective treatment is with periodic injections of botulinum toxin (BTX) into the pre-tarsal and/or pre-septal orbicularis oculi muscles bilaterally. However, even with treatment, practical visual function often remains compromised. A subset of IB sufferers find that eye opening improves with a focal unilateral digital pressure usually on a specific point on the temple. This is known as a ‘sensory trick’. We have developed a spectacle mounted device (‘Pressop’) to apply continuous individually localised focal pressure on the temple to mimic the effect of finger pressure. The aim of the study was to determine if the ‘sensory trick’ could be replicated by Pressop and if the interval between BTX treatments could thereby be extended.
Study participants had three clinic visits—an initial screening assessment, a visit 2 weeks before the next injection was due when the device was fitted, and one 2 weeks later to assess the response to Pressop. A CDQ 24 and device-specific feedback questionnaire were completed and comparison photographs were taken. Repeat BTX injections were administered at the third visit.
Of 58 patients with typical IB recruited to the trial, 39 reported an effective focal finger pressure sensory trick. 56 completed the trial, more than 50% of whom reported some benefit using Pressop; 18% had substantial improvement, sustained for up to 5 years. Improvement could occur in those without an effective sensory trick, therefore there was no significant correlation between using a sensory trick and benefiting from ‘Pressop’. There was a trend towards the responders having greater improvement in CDQ24 total score than non-responders but this was not statistically significant.
We recommend a trial of this simple safe device as a means of augmenting visual function in all IB patients.
Idowu, Oluwatobi O.; Ashraf, Davin C.; Vagefi, M. Reza; Kersten, Robert C.; Winn, Bryan J.
Purpose of review To summarize the ocular and systemic associations of floppy eyelid syndrome (FES) as well as provide an up-to-date review on the pathogenesis and treatment strategies.
Recent findings Virtually all patients with FES have obstructive sleep apnea (OSA). However, a significantly lower proportion of patients with OSA have FES. Although some studies demonstrate no association between OSA and FES, almost all show at least an association with increased eyelid laxity, which may be a less severe form of FES. FES has also been associated with keratoconus (KCN) and glaucoma. Decreased corneal hysteresis has been found in FES, KCN, glaucoma, and OSA and may be related to matrix metalloproteinase (MMP) upregulation. Hypoxia–reperfusion injury, leptin resistance, and mechanical forces all may lead to increased MMP activity, contributing to elastin breakdown in the tarsus and other tissues throughout the body. Management of FES begins with investigation for OSA. Treating OSA with continuous positive airway pressure (CPAP) or surgical uvulopalatoplasty may improve FES. Surgical treatments for FES should reduce horizontal eyelid laxity while maximizing the stability of the tarsus. Collagen crosslinking may prove a helpful modality for stabilizing the tarsus in the future.
Summary FES is associated with OSA, glaucoma, and KCN. MMP upregulation and lower corneal hysteresis have been found in these conditions, pointing toward a potential common pathogenesis.
Prithvi Ramtohul, Danièle Denis
A 61-year-old man with a history of severe seasonal allergies presented with violaceous erythema of the eyelids (Fig A). Complete physical examination disclosed reddish macules of interphalangeal/metacarpophalangeal joints (Fig A, Gottron’s sign) and proximal muscle weakness. Serum creatine phosphokinase was elevated (485 U/l, normal 31-288) and muscle biopsy revealed endomysial inflammatory cell infiltration, consistent with the diagnosis of dermatomyositis (Fig B). Magnetic resonance imaging subsequently documented a prostate tumor (Fig C, red arrow), histologically identified as large-cell neuroendocrine prostate carcinoma (Fig D, positive immunohistochemical staining for chromogranin A).
Xiaodong Zheng, Tomoko Goto, Atsushi Shiraishi & Yumi Nakaoka
Purpose: To report a new method to analyze sagittal images of the upper eyelid by anterior segment optical coherence tomography (AS-OCT).
Methods: Ninety subjects equally divided into young (20–39 years), middle age (40–59 years), and elderly (60–79 years) group were studied. A sagittal image of the upper eyelid was obtained by AS-OCT (CASIA2, Tomey, Japan) and the following parameters were determined: upper eyelid thickness (UET), the distance between two parallel lines tangential to the apexes of the cornea and the upper eyelid; the upper eyelid angle (UEA) was the angle formed by a line running tangential to the apex of the cornea and a line passing from the apex of the cornea to the apex of the upper eyelid; and the cross-sectional area (CSA), the area from the edge of the eyelid to a point 6 mm above the corneal apex. All parameters were compared among groups and correlation analyses were studied between age and eyelid parameters.
Results: The UET was 2.09 ± 0.58 mm, 2.63 ± 1.04 mm and 2.83 ± 0.83 mm in the young, middle age and elderly group, respectively. The difference between the young and the elderly group was significant (P = 0.014). The elderly group had a significantly larger UEA than that of young group (P = 0.022). The elderly group also had significantly larger CSA than the other two groups (all P < 0.01). The age was significantly correlated with all eyelid parameters.
Conclusions: AS-OCT can be used as a non-invasive and quantitative method of evaluating sagittal images of the upper eyelid.
Vahdani, Kaveh; Rose, Geoffrey E.
Over a 2-year period, a 68-year-old woman suffered multiple recurrences of left giant fornix syndrome during the repeated tailing of intensive topical steroids and antibiotics; she had also undergone surgery to reduce the left upper fornix. After a further recurrence during tailing of topical therapy for bilateral disease, treatment with 4 times daily preservative-free povidone-iodine 5% eyedrops was started—with a marked improvement of symptoms and signs within a week. The patient is maintained, symptom-free, on once-daily povidone-iodine drops and dexamethasone 0.1% drops. The dramatic improvement on topical povidone-iodine therapy might suggest that, as an initial therapy, this might be more effective than the previously-recommended regime of hourly potent topical steroids and antibiotics.
Charles, Norman C.; Belinsky, Irina
A 37-year-old woman underwent excision of a congenital melanocytic nevus of the right lower eyelid margin for cosmetic reasons. She suffered from a severe dry eye syndrome which was partially alleviated with various topical eye drops. Histopathology of the excised tissue displayed flecks of calcium that were present within the immediate subepithelial conjunctival fibrous tissue but not the nevocytes or the cutaneous surface. Unlike calcinosis cutis, wherein calcium is deposited within the cutaneous dermis, calcification of the conjunctival substantia propria is rare and may be related to the dry eye state.
Parvizi, Sahar; Ong, Juling; Abou Rayyah, Yassir; Dunaway, David
Purpose: There are different techniques for medial canthoplasty in blepharophimosis syndrome where individuals have epicanthus inversus and telecanthus leading to typical facial appearances. These methods have potential problems with scarring, epistaxis, and extrusion of metal plates.
Methods: The authors describe a novel technique of medial canthal reconstruction using titanium microplates with microscrew fixation to the anterior lacrimal crest, with effective, safe, and reproducible results.
Results: Seven children with blepharophimosis syndrome underwent medial canthus reconstruction surgery at a single center with the collaboration of a pediatric oculoplastic surgeon and craniofacial plastic surgeon to improve eye opening through correction of the lid contours and telecanthus.
Conclusions: This is a safe, effective, and reproducible technique, with minimal morbidity and rapid postoperative recovery in children. It produces cosmetically acceptable scars and a strong stable reconstruction of the medial canthal insertion.
Bernardini, Francesco P.
The video (see Video, Supplemental Digital Content 1, available at https://drive.google.com/open?id=10uuVCNADWhLRWo_EE8gx5GK2nqz5mATW) demonstrates the technique previously described in the report by Cruz et al. for correction of poor levator function (<4 mm) congenital ptosis.1 Supramaximal levator resection refers to resection of the muscle above the Whitnall ligament. The amount of resection is based on the severity of the ptosis and the measured levator function: the more severe the ptosis and poorer the levator function, the more muscle resection required. The end-point of the surgery is to have the eyelid margin rest 1 to 2 mm below the super limbus with the patient under general anesthesia. In the author’s practice, supra-maximal levator resection has become the procedure of choice for unilateral, poor levator function congenital ptosis.