Charles Diaper

Dry Eye Diagnosis

PURPOSE To determine the most effective objective tests, applied singly or in combination in the diagnosis of dry eye disease. METHODS Two groups of subjects--41 with dry eye and 32 with no ocular surface disease--had symptoms, tear film quality, evaporation, tear turnover rate (TTR), volume and osmolarity, and meibomian gland dropout score assessed. RESULTS The subjects with dry eye had TTR, tear evaporation, and osmolarity significantly different from that of healthy normal subjects. Cutoff values between the groups were determined from distribution curves for each aspect of tear physiology, and the effectiveness of the cutoff was determined from receiver operator characteristic (ROC) curves. Values of 12%/min for TTR, 33 g/m(-2)/h for evaporation, and 317 mOsmol/L for osmolarity were found to give sensitivities, specificities, and overall accuracies of 80%, 72%, and 77%; 51%, 96%, and 67%; and 78, 78%, and 79%, respectively when applied singly as diagnostic criteria in dry eye. In combination, they yielded sensitivities, specificities, and overall accuracy of 100%, 66%, and 86% (in parallel) and 38%, 100%, and 63% (in series), respectively. Discriminant function analysis incorporating these three factors in an equation allowed diagnosis with a sensitivity of 93%, specificity of 88%, and overall accuracy of 89%. CONCLUSIONS Tear osmolarity is the best single test for the diagnosis of dry eye, whereas a battery of tests employing a weighted comparison of TTR, evaporation, and osmolarity measurements derived from discriminant function analysis is the most effective.

Tear physiology of aqueous deficiency and evaporative dry eye

Purpose. To determine the differences in tear physiology between aqueous deficiency dry eye (ADDE) and evaporative dry eye (EDE), and evaluate their utility in diagnosis. Methods. Fifty-six dry eye patients were classified into 30 ADDE and 26 EDE according to the recently published Dry Eye Workshop criteria. A range of tear physiology measures comprising of tear evaporation, turnover rate (TTR), distribution, volume and osmolarity, and meibomian gland dropout were measured in these patients. The effectiveness of the tests, singly and in combinations, in differentiating between the dry eye subtypes was evaluated by retrospective allocation into groups and by Receiver Operative Characteristics (ROC) curve analysis. Results. Statistically significant differences were seen for TTR and tear evaporation (with lower values for ADDE) between ADDE and EDE, but no significant differences were seen for tear osmolarity, volume, distribution, and meibomian gland dropout scores. Differentiation of ADDE and EDE by a cut-off value of 11%/min for TTR was found to have a sensitivity of 86%, specificity of 75%, positive predictive value 89%, negative predictive value 69%, and overall accuracy 83%. The area under the curve on the ROC curve was 0.83. For tear evaporation, a cut-off of 60 g/m2h was found to have a sensitivity of 77%, specificity of 55%, positive predictive value 38%, negative predictive value 80%, and overall accuracy 58% in subtype differentiation. The area under the curve was 0.59 on the ROC curve. The distribution curve of the evaporation rates for ADDE and EDE, showed an overlap coefficient of 0.76 indicating that tear evaporation is within a similar range in these two dry eye subtypes. Conclusions. Tear turnover is significantly lower in ADDE than EDE, but there is considerable overlap of tear evaporation between the two dry eye subtypes. Tear osmolarity and turn over tests can be conducted sequentially to effectively diagnose dry eye and its subtypes.

Tear and meibomian gland function in blepharitis and normals.

Purpose: To determine the differential features of tear physiology and meibomian gland function in blepharitics for ascertaining the diagnostic potential of a number of clinical tests. Methods: Two groups of subjects, 15 with clinically diagnosed blepharitis (11 women and 5 men mol/L; age 60.9 ± 12.5; range 41–79) and 15 age- and sex-matched controls (11 women and 5 men mol/L; age 60.7 ± 12.6; range 40–78), were included in the study. Tear physiology was assessed by evaporimetry and interferometry and the meibomian glands by expression and meibography. Results: Tear evaporation rate was significantly higher (P<0.001) in blepharitics (46.3 ± 22.9 g/m2/hr) than that in normals (18.0 ± 10.7 g/m2/hr). The lipid pattern was found to be significantly less stable (P=0.001) in the blepharitic group compared with that in the normal group. By meibography, meibomian gland dropout was scored and found to be significantly greater (P=0.001) in blepharitics in both the upper eyelids (blepharitis 1.0 ± 0.8; normal 0.1 ± 0.3) and lower eyelids (blepharitis 2.1 ± 8.3; normal 1.0 ± 0.8). The dropout score was the same or greater for the lower lids than for the upper lids, in all cases. A significant difference (P=0.000) in meibomian gland expression was found between blepharitics and normals; meibum was significantly thicker and more opaque in blepharitics in both the upper (blepharitis 2.2 ± 0.7; normal 1.0 ± 0.2) and lower (blepharitis 2.6 ± 0.7; normal 1.3 ± 0.4) eyelids. Conclusions: There are significant differences in tear physiology and meibomian gland function in patients with blepharitis when compared with those without. All the tests employed would be useful as single tests in the diagnosis of blepharitis, with meibomian gland dropout of the lower eyelid offering the greatest effectiveness as a single measure.

Mohs surgery vs primary excision for eyelid BCCs.

Introduction: The aims of management of basal cell carcinoma are for complete excision, and minimise damage to the surrounding tissues. Our aim is to compare the proposed defect of a primary excision biopsy with the actual defect following Mohs micrographic surgery on the same lesions. Materials and Methods: A cohort of 23 patients about to undergo Mohs micrographic surgery for eyelid basal cell carcinomas was recruited. The lesions were assessed regarding size and location. A digital photograph of the lesions pre Mohs excision and the defects post Mohs excision for analysis on the Photoshop Adobe package using the caliper function to measure the eyelid lesion, and defects and to calculate the area. Results: All 18 patients had solitary basal cell carcinomas; 9 (50%); 10 of the 18 cases having a larger proposed primary excision defect and the remaining 8 cases a larger post-Mohs micrographic surgery defect area. Discussion: Basal cell carcinoma is the most common non-melanoma malignant eyelid tumour. The results supported basal cell carcinomas, particularly morphoeic types, are difficult to examine, and location is a poor predictor of recurrence. We did not find that Mohs micrographic surgery universally reduces the size of the defects area. However, if the primary aim of the surgery is to cure the patient and prevent recurrence, Mohs is still the best choice.

The Pulfrich phenomenon; clumsiness and collisions which can be ameliorated

The Pulfrich phenomenon has been described many times but usually just as an interesting academic issue with only diagnostic significance. The phenomenon is due to the fact that patients with unilateral optic neuropathy due to ischaemia, facial injury or multiple sclerosis may have delayed transmission of retinal responses to light from one eye to the brain. This leads to an altered and incorrect interpretation of the pathway and direction of moving targets. Clinicians should be aware of the unique symptomatology of the Pulfrich phenomenon because it is often difficult for patients to describe their symptoms which can be both unpleasant and troublesome. An appropriate tint in either a spectacle or contact lens over the normal eye delays retinal conduction, so re-establishing visual processing symmetry and ameliorating the symptoms.

Periocular steroids in conjunctival reactive lymphoid hyperplasia, a new approach?

Evidence is scarce regarding appropriate treatment of conjunctival reactive lymphoid hyperplasia. Biological therapies and immune modulators have shown promising results but are not without side effects. We report a case of conjunctival benign lymphoid hyperplasia treated with one subconjunctival triamcinolone injection. This achieved complete regression and no recurrence in three and half years of follow up. A 70-year-old woman was referred with an irritating conjunctival lesion of her right eye with no visual symptoms. To our knowledge there is no past ocular or medical history of note. Visual acuity was 6/6 in both eyes. Anterior segment examination revealed a conjunctival salmon patch (Fig. 1a) in her right eye. Lesion diameter was 8 mm ¥ 5 mm with approximately 1 mm thickness, the posterior

Caliber persistent artery of the eyelid.

BackgroundTo report three cases of caliber persistent artery presenting in the eyelid.MethodsA case series describing three patients with vascular lesions of the eyelid that were biopsied. One case was bilateral.ResultsAll three patients presented with a painless red lesion on the eyelid. These were on the lower eyelid in two patients and the upper eyelid in one patient. For the bilateral case, the lesions were both on the lower eyelid. Histological examination of all four biopsies showed a large caliber artery within the dermis extending almost at right angles to the skin surface and consistent with caliber persistent artery.ConclusionsThese are the first reports of caliber persistent artery of the eyelids, an entity that is most commonly recognized on the lips. Clinicians should consider this entity in the differential diagnosis of patients presenting with a painless, vascular lesion of the eyelid.

Chlamydial conjunctivitis presenting as pre septal cellulitis.

Chlamydia conjuctivitis results from infection by chlamydia trachomatis, the commonest treatable sexually transmitted infection in Europe. Its clinical manifestations involve the conjunctiva and the cornea. The inflammation under the upper eyelid may be sufficient to present as ptosis, however previously it has not been documented to cause a preseptal cellulitis. We present such a case.A 15-year-old girl was diagnosed with a left viral conjunctivitis. Five days later, she returned with marked oedema of the left upper and lower lids accompanied by erythema. The tarsal conjunctiva revealed follicles and large papillae and extra ocular movements revealed discomfort on elevation. A secondary diagnosis of bacterial pre septal cellulitis was made and the treatment was changed a broad spectrum oral antibiotic. On review at two days, the patient now complained of a large amount of purulent discharge in association with the marked pre septal swelling. As previous bacteriology and virology had been negative, the patient was re swabbed for chlamydia. This proved positive and her symptoms completely resolved following administration of Azithromycin.In this particular case recognition of the pathogen is important to alert the patient to the likelihood of unknown genital infestation. In all cases of positive culture, the patient should be counselled to attend a genitourinary clinic and to alert any sexual partners to the need to do likewise.

The effect of socio-economic status on severity of periocular basal cell carcinoma at presentation

Purpose: To evaluate the influence of socio-economic factors on size of periocular basal cell carcinoma at presentation. Methods: All periocular basal cell carcinoma cases receiving treatment from the oculoplastics team in South Glasgow Hospitals NHS Trust, Glasgow, between 1999 and 2009, were identified retrospectively. Information collected included demographic details of patients, side and site of lesions, type of lesions, and size of lesions. The size of lesion was defined as small for any dimension not exceeding 5 mm, medium for dimensions between 6 mm and 10 mm, and large for dimensions exceeding 11 mm. Home address was used to determine the Scottish Index of Multiple Deprivation rank. The demographics, size of lesion, and Scottish Index of Multiple Deprivation rank were investigated using the general linear regression modelling. Results: Of the 67 cases, 24 were men and 43 were women. The mean age was 71.5 years. There were a total of 67 identified cases, of which 38 presented with small-size lesions, 24 with medium-size lesions, and 5 with large-size lesions. Scottish Index of Multiple Deprivation is related to the presenting incidence of basal cell carcinoma, with the lower ranks presenting more frequently. Conclusions: Socio-economic deprivation is associated with larger and more frequent presentation of periocular basal cell carcinoma. This highlights the importance of raising awareness among populations of the more deprived areas of the significance of lumps and bumps within the periocular regions.

Retained soft contact lens masquerading as a chalazion: A case report

A misplaced contact lens is a common ocular emergency presenting to the eye casualty. We report a case of lost soft contact lens which migrated in the lid and presented 13 years later with symptomatic eye lid swelling. Authors in the past have reported migration and subsequent retention of lost hard lenses in locations such as the superior fornix and eyelid. To the best of our knowledge, misplaced soft contact lens masquerading as a chalazion has not been reported in the literature. Consideration should be given to the possibility of a retained contact lens in a patient with a history of a lost or misplaced lens, and examination of the ocular surface with double eversion of the upper lid should be performed.