Khami Satchi & Alan A. McNab
Patients with conjunctival cicatrizing disease may develop lacrimal obstruction. Little is published on lacrimal obstruction as the presenting feature of otherwise asymptomatic cicatrizing conjunctival disease. The records of all patients presenting between 1994 and 2015 with lacrimal obstruction found to have cicatrizing conjunctival disease were reviewed. Demographic details, clinical findings, disease progression and treatment were analyzed. Thirty-five patients (25 female), aged 43–91 years (median 74, mean 71.3 years) had epiphora and a mild conjunctival cicatrizing process. Nine patients had onset of epiphora after cataract surgery. All except one patient had obstruction of the proximal lacrimal system (punctum and/or canaliculus). In 14 cases, the obstruction was unilateral (both puncta or canaliculi), with one progressing to bilateral obstruction after 11 years. In 19, all 4 puncta or canaliculi were obstructed. Two patients had unilateral nasolacrimal duct obstruction; one developed contralateral canalicular obstruction 2 years later. Conjunctival biopsies were obtained in 19 of 35 cases (54%), and OCP immunohistochemistry was positive in 7/19 (37%). All other biopsies showed chronic inflammation. Two patients had lichen planus. In follow-up (range 0.1–11 years, mean 3.2 years), 2 patients’ conjunctival disease progressed mildly, and 3 progressed moderately, with 2 of these 5 having positive OCP immunohistochemistry, and 1 having lichen planus. Patients with conjunctival cicatrization may present with lacrimal obstruction, usually punctal or canalicular. Conjunctival disease is usually mild and non-progressive, but patients should be monitored for disease progression.
Andrea Papp, Clemence Vasserot-Merle, Guido Dorner & Dion Paridaens
This article reports on two cases of severe pediatric Graves orbitopathy (GO) in two adolescents of African origin. Two black male adolescents presented with highly active GO and signs of beginning compressive optic neuropathy. Neither of them were smokers nor had a family history of GO. Besides urgent referral to pediatric endocrinologists, intravenous methylprednisolon pulse therapy was initiated. In spite of the fluctuating thyroid hormone levels in the initial phase of antithyroid therapy, intravenous steroid administration stopped the progression of malignant GO rapidly in both of our patients without any considerable side effects. Although the course of GO during childhood is considered to be mild, severe, sight threatening GO—requiring immunosuppression—may occur at young age, as in the reported adolescent patients of African descent.
Antony George Francis Thottian, Rony Benson, Seema Kashyap, K. P. Haresh, Subhash Gupta, Dayanand Sharma & Goura Kishor Rath
Second cancers in survivors of hereditary retinoblastoma occur much more commonly than in the general population. This can be attributed both to the germline mutation of the RB gene and chemoradiation used for treatment of this paediatric cancer. Medulloepithelioma is an uncommon tumor of neuroectodermal origin, seen largely in the paediatric population and rarely reported in adults. Though the incidence of second malignancies is common in retinoblastoma, medulloepithelioma as a second malignancy in retinoblastoma survivors is rare, with only one case reported so far. Herein, we present a case of a 29-year-old patient presenting with medulloepithelioma of the right orbit, arising in the radiation field of previously treated retinoblastoma. This case was also peculiar in that though the origin of tumor was in the eyeball it had a very aggressive clinical course.
Sonali T. Nagendran, We Fong Siah, Andre Litwin, Christine Barbosa, Jan Jayatilake & Raman Malhotra
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.
Fabian N Fries, Pamela Youssef, Paul Anthony Irwin, R. Isaiah Tubbs, Mariaos Loukas, R Shane
We compare, on left and right side of human skulls, the length of Whitnall’s tubercle as a relevant landmark and anchor point for the lateral retinaculum. Twenty human skulls were used in this study. A caliper was used to measure the length of Whitnall’s tubercle, the distance from Whitnall’s tubercle to the frontozygomatic suture and the height of the orbit. An overall mean for these three parameters was calculated using the data obtained. There were no significant differences between left and the right sides. The combined mean length of Whitnall’s tubercle was 4.9 mm ± 23%. The combined mean distance from the frontozygomatic suture was 7.8 mm ± 25%. The orbital height was found to be the measurement with the highest congruence between the two sides having a combined mean of 32.3 mm ± 7%. Although 6 out of 20 skulls were found to have no tubercle, five out of twenty skulls had a tubercle only on one side. Even though human skulls develop from bilateral symmetric osteogenesis, surgeons should always be aware of possible asymmetry and possible absence of Whitnall’s tubercle between sides or among individuals. The frontozygomatic suture was found to be a useful landmark in identifying the position of Whitnall’s tubercle in the majority of specimens. Such information will be useful in realigning the lateral retinaculum following surgery.