Allister S. Lee, Princeton W. Y. Lee, Anthony Allworth, Tai Smith & Timothy J. Sullivan
To report the spectrum of fungal infections involving the orbit encountered in an Australian subtropical population with respect to presentation, host risk factors, involved pathogens, treatment and outcomes.
A retrospective chart review was performed on all adult patients with orbital mycosis treated by the senior author (TJS) from 1986 to 2017 in a tertiary setting.
Thirty cases of fungal infection involving the orbit were included in this case series. Of these, 26 patients had invasive disease and four patients had non-invasive disease. Causative organisms included mucormycosis (16), aspergillus (8) and other fungi (7). Common risk factors included haematological disorders or malignancy, neutropenia, corticosteroid use and diabetes mellitus. Mucormycosis in three immunocompetent patients was caused by Apophysomyces elegans. Orbital apex syndrome was observed in approximately one third of patients at initial ophthalmological assessment. Amphotericin B was used in most cases of mucormycosis, while there was a more varied spectrum of anti-fungal use in other fungal infections. Seven patients with mucormycosis proceeded to orbital exenteration with a survival rate of 43%. No patients with other orbital fungal infections were exenterated.
Orbital mycoses are not only opportunistic but true pathogenic infections. While initial symptoms may be varied, the development of orbital apex syndrome should raise suspicion for this condition, regardless of patient immune status or age. Survival and visual outcomes are often poor with invasive disease. Multidisciplinary team management with early orbital specialist involvement is essential.
Farzad Pakdel, Mohammad Soleimani, Abolfazl Kasaei, Kambiz Ameli, Niloofar Pirmarzdashti, Ali Sadeghi Tari, Mehrbod Ghasempour & Ali Banafsheafshan
We aimed to show the outcome of very early endoscopic dacryocystorhinostomy (VE-EDCR) in a routine pool of patients with acute dacryocystitis (AD) and abscess formation compared with the standard late external dacryocystorhinostomy L-ExDCR.
This was a prospective nonrandomized comparative study conducted from June 2013 to March 2016. Patients with AD and abscess formation were referred to our oculo-facial clinic in a university-based hospital. All patients received systemic antibiotics and were assigned to either of treatment groups. Patients in group 1 underwent late external transcutaneous DCR (L-ExDCR) and group 2 underwent EDCR within 3 days after first visit, named VE-EDCR. Primary outcome measure was success of surgery.
Forty-one eyes of 41 patients with acute suppurative AD, were included from June 2013 to March 2016. Twenty-two patients underwent VE-EDCR and 19 underwent L-ExDCR. Mean age of patients was 43.41 (SD = 19.84, range 14–98) years. Mean follow-up was 14 (SD = 2.4) months. Anatomic, functional, and overall success in L-ExDCR and VE-EDCR groups were (89.5 and 86.4%, p = 0.99) (89.5% and 86.4%, p = 0.99) (89.5% and 81.8%, p = 0.66) respectively. Mean duration of cellulitis in VE-EDCR and L-ExDCR were 8.00 (SD = 4.63) and 16.11 (SD = 11.58) days, respectively (p = 0.027). No remarkable adverse event was found.
Success of very early endonasal endoscopic DCR is comparable with the traditional late external DCR. Duration of cellulitis is shorter in VE-EDCR. This therapeutic approach can be considered in patients with acute suppurative dacryocystitis.
Vickie Lee, Parizad Avari, Ben Williams, Petros Perros, Colin Dayan
The Royal College of Physicians (RCP) and Thyroid Eye Disease Amsterdam Declaration Implementation Group (TEAMeD-5) have the common goal of improving access to high quality care for thyroid eye disease (TED). The TEAMeD-5 programme recommends all patients with moderate-to-severe TED should have access to multidisciplinary clinics (MDT) with combined Ophthalmology and Endocrinology expertise.
The British Oculoplastic Surgery Society represents oculoplastic surgeons who usually lead TED care in the UK. A two-stage survey of the membership was conducted to ascertain current practice of existing resources.
Seventy percent (45/65) of respondents in Survey 1 were aware of current RCP guidance, but only 49% (22/45) rated it as a good means of improving access to comprehensive TED service. Sixty percent (39/65) of respondents are working in a multidisciplinary TED clinic with co-location of ophthalmologists and endocrinologists. Care for TED appears not to be provided in a multidisciplinary context in up to 31% (20/65). Thirty five (54%) of the respondents rated their relationship with endocrinology colleagues as good. Best practice guidelines recommend routine quality of life assessments but only 6/28 (21%) of respondents use this modality in current practice. Six percent (4/65) of areas appear not to be using intravenous steroids. In many areas (25%, 16/65), second-line immunosuppression is provided in a different trust and in 8% (5/65), it appears not to be used at all.
This survey is a ‘snapshot’ of current TED management in the UK and findings suggest scope for improvement. We recommend a framework for more robust collaboration across specialties and propose standards endorsed by multidisciplinary stakeholder societies.
Huw Oliphant, Tom Oliphant, Lucy Clarke, Colin Vize & Saul Rajak
Periocular malignancy is common and in most cases will undergo excision with pre-determined margins and subsequent histological examination. Intraoperative margin control (IOMC) modalities such as fast frozen section (FFS), fast paraffin (FP) and Mohs micrographic surgery (MMS) are being increasingly widely used, though there is a lack of information regarding utility. The aim of this study was to survey members of the British Oculoplastic Surgery Society (BOPSS) to determine attitudes and access to different modalities of IOMC.
A 12-question online survey was disseminated via an e-mail to full members of the BOPSS. The survey was hosted using Qualtrics software via the University of Sussex.
The overall response rate was 64 of 165 (38.8%). MMS was readily available in a neighbouring trust to 23 of 64 respondents (35.9%). Seven respondents (10.9%) reported no regional access to MMS. Twenty-nine members had readily available access to FFS (45.3%) and 37 of 64 to FP (57.8%) in their own institution. There is variation in what tumour types would be considered appropriate for IOMC, though most thought clinically ill-defined (morphoeic) basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) should undergo one form of IOMC (90.6% and 81.3%, respectively).
This study highlights variation in availability and utilisation of IOMC amongst oculoplastic surgeons and in different regions of the UK. While the exact place of IOMC in periocular tumour excision is debated, there is a consistent view that it should be available for some tumours. Greater consistency in provision may improve patient outcomes.
Aylin Garip Kuebler, Caroline Wiecha, Lukas Reznicek, Annemarie Klingenstein, Kathrin Halfter, Siegfried Priglinger & Christoph Hintschich
To evaluate the effectiveness of steroid-pulse therapy and three-wall orbital decompression in patients with dysthyroid optic neuropathy (DON).
Twenty-five patients (46 eyes) with a diagnosis of DON between 2008 and 2015 were included in the study. The first group (7 patients, 16 eyes) consisted of patients with a steroid-pulse treatment only and the second group (18 patients, 30 eyes) included patients with medical and surgical decompression.
Twenty patients were female; five patients were male. After the diagnosis of DON, all patients were treated with steroid-pulse treatment (intravenous 500 mg prednisolon twice/week for 4 weeks, 250 mg twice/week for 2 weeks) as a first-line treatment (medical decompression). In 30 eyes (18 patients) out of 46 eyes, (25 patients) an orbital decompression was needed to preserve the optic nerve function. In those therapy-resistant cases (surgical decompression group), the orbital decompression led to statistically significant improvements in best-corrected visual acuity (BCVA), protan and tritan value of the color vision (p = 0.007, p < 0.0001, p = 0.019, respectively, comparison of first visit to last visit).
According to our data, the mild cases of DON with better initial visual acuity (in our case series mean: 0.3 logMAR) seem to respond well to steroid treatment. However, therapy-resistant cases with an impaired initial BCVA (in our case series, mean: 0.6 logMAR) seem to need the surgery to preserve the optic nerve function. In conclusion, this retrospective study confirms the effectiveness of surgical decompression in therapy-resistant cases of DON.
Lindsay A. McGrath, Zanna I. Currie, Hardeep Singh Mudhar, Jennifer H. Y. Tan & Sachin M. Salvi
To evaluate the incidence and management of recurrent periocular sebaceous gland carcinoma at a tertiary ocular oncology service in the United Kingdom.
This was a retrospective cohort study of 62 patients with sebaceous gland carcinoma treated between 2004 and 2017. A total of 10 eyes were treated for local recurrence. The following variables were recorded: age and sex of patient; tumour location, histological subtype; recurrence type; treatment and outcome.
Of the 62 cases with eyelid SGC, 10 (16%) had recurrences during the study period and satisfied inclusion criteria. There were six (60%) females and four males in the recurrent group. The mean time interval between initial excision and tumour recurrence was 37 months (median 23 months; range 4 to 84 months). Four patients received cryotherapy to the lids and conjunctiva to control recurrent disease and two patients were treated with topical or intralesional chemotherapy. Four patients (40%) underwent orbital exenteration during the study period. Metastasis occurred in 20% over a mean follow-up of 113 months (median 106; range 47–184 months).
The risk factors for local recurrence of SGC after wide excision with paraffin section control were reported, and an approach to these recurrent lesions was proposed. The results of this study will help guide surgeons dealing with the medical and surgical conundrum of recurrent disease. The risk of recurrence is highest in the first 2 years after initial excision.
Bum-Joo Cho, Youn Joo Choi, Min Chul Shin, Suk-Woo Yang & Min Joung Lee
Childhood blepharoptosis may cause cosmetic and functional problems in children, but there is a paucity of studies about its epidemiology. This study aimed to investigate the prevalence of childhood blepharoptosis and associated risk factors in a representative Korean population.
This cross-sectional nation-wide study analysed the data set acquired from the Korea National Health and Nutrition Examination Survey 2008–2012. A total of 8218 children aged 3–18 years were included. The prevalence of childhood blepharoptosis, defined as a margin reflex distance (MRD) of < 2 mm in either eye, was estimated, and the risk factors were identified using multivariate logistic regression analysis.
The mean age of participants was 11.3 ± 0.1 years, and 52.8 ± 0.6% were boys. The overall prevalence of childhood blepharoptosis in Korea was 8.0% (95% CI, 6.9–9.1%). Boys exhibited a higher prevalence of blepharoptosis than girls at most of ages. Levator function increased with age in the normal general population. The proportion of subjects exhibiting MRD1 ≥ 4.0 mm also increased significantly with age (p < 0.001). Male gender, higher body mass index, and urban residency were significantly associated with childhood blepharoptosis.
The prevalence of childhood blepharoptosis is higher in urban obese boys. The increase of levator function with age should be considered in evaluations of childhood ptosis.