Christopher T. Shah

Cranial nerve seven palsy and its influence on meibomian gland function.

Purpose: To investigate a possible relationship between cranial nerve seven (CN VII) palsy and meibomian gland dysfunction. Methods: A prospective case series of 16 patients with unilateral CN VII palsy was evaluated for meibomian gland function. Main outcome measures included the Sunnybrook Facial Grading System for CN VII palsy and a modified version of a noncontact, noninvasive meibomian gland evaluation by Arita et al.1,2 Unaffected contralateral eyes were used as the control group for comparison. Results: Sixteen affected eyes were evaluated. The mean Sunnybrook Facial Grading System composite score was 34.19 ± 24 (score = −15 to 100; maximum function = 100). A paired samples t test between affected and unaffected eyes demonstrated a significant difference between mean values for tear break-up time, eyelid abnormality, meiboscore for upper eyelid, meiboscore for lower eyelid, combined meiboscore, and digital pressure. No significant difference was found for superficial punctate keratopathy nor Schirmer’s test. A Pearson product-moment correlation coefficient found a significant negative correlation between the Sunnybrook Facial Grading System composite score and all aspects of meibomian gland function, except for the upper eyelid meiboscore, which only approached significance (p = 0.059). Conclusion: These findings suggest that a strong relationship exists between cranial nerve seven palsy and meibomian gland dysfunction. Clinical optimization of meibomian gland function may benefit cranial nerve seven palsy patients.

Asymmetric eyebrow elevation and its association with ocular dominance.

Purpose: To examine the relation between asymmetric eyebrow elevation and ocular dominance. Methods: A retrospective cohort study was performed in patients who underwent bilateral upper eyelid blepharoplasty from July 2007 to May 2009. Patients with pre- and postoperative involuntary asymmetric eyebrow elevation were selected from a surgical log database for inclusion in this study. Brow asymmetry was determined by examination of preoperative and postoperative digital photographs and was defined as a measured eyebrow-height difference in conjunction with the asymmetric recruitment of the frontalis muscle. Ocular dominance was determined by using a modified Porta test. Statistical analysis was performed by using the Fisher Exact test. Results: Forty-seven patients met inclusion criteria. Sixty-six percent (31 of 47) involuntarily, asymmetrically elevated the right eyebrow, and 34% (16 of 47), the left. Of the 31 patients with right eyebrow elevation, 87% (27 of 31) were right-eye dominant, and 13% (4 of 31) were left-eye dominant (p < 0.001). Among patients with asymmetric left eyebrow elevation, 62.5% (10 of 16) were left-eye dominant, whereas only 37.5% (6 of 16) patients were right-eye dominant (p < 0.001). Conclusion: We report for the first time that involuntary asymmetric eyebrow elevation and ocular dominance are significantly associated. The assessment of ocular dominance should be included in the pre- and postoperative evaluation of patients with asymmetric brow elevation undergoing blepharoplasty. This asymmetry and its etiology must be recognized, so that an attempt to create symmetry does not result in the overcorrection of the contralateral eyelid that may lead to complications such as lagophthalmos and exposure keratopathy.

TB Peritonitis Mistaken for Ovarian Carcinomatosis Based on an Elevated CA-125

Background. In the United States, tuberculosis (TB) is of relatively low prevalence and most newly diagnosed patients are born outside of the United States. In addition, a large percentage (20.6%) of TB cases initially present with extrapulmonary manifestations (CDC, 2010). Cases of TB peritonitis are a diagnostic challenge in women due to the nonspecific clinical features overlapping with signs of ovarian cancer. (Kosseifi et al., 2009; Rashed et al., 2007; and Xi et al., 2010). We present a 27 year-old woman thought to have ovarian carcinomatosis based on elevated levels of CA-125 who was ultimately diagnosed with TB salpingitis, endometritis, and peritonitis. Methods. This brief report is a retrospective case report. Results. This case outlines the unfortunate consequences of the misdiagnosis of what probably was an antibiotic responsive illness, resulting in an unnecessarily aggressive surgical procedure. The delay in the diagnosis of tuberculous pertitonitis resulted in an unnecessary radical resection of the patients reproductive organs. Conclusions. Patients with TB peritonitis present with non-specific signs that may be misdiagnoses as ovarian cancer. In differentiating between ovarian carcinomatosis and peritoneal TB, it is vital to consider country of origin, age, CA-125, ascitic fluid analysis, and the use of intra-operative frozen sections.

Medical Malpractice in Uveitis: A Review of Clinical Entities and Outcomes.

ABSTRACT Purpose: To guide risk management in uveitis. Methods: Retrospective review of malpractice verdicts, rulings, and settlements. Results: The WestLaw® database was reviewed for lawsuits related to uveitis in the United States from 1930–2014. Twenty-five cases met inclusion criteria, and 48% of these were infectious. Overall, 64% of outcomes favored the defendant ophthalmologist. The most common diagnoses were viral retinitis (28%), iritis (12%), syphilis (8%), and toxoplasmosis (8%). Seven suits (28%) were resolved by settlement, with mean adjusted indemnities of

Alphasphere as a Successful Ocular Implant in Primary Enucleation and Secondary Orbital Implant Exchange

724,302 (median,

Anophthalmic syndrome: a review of management.

409,390; range,

Foveal hypoplasia in autosomal recessive spastic ataxia of Charlevoix-Saguenay

127,837–2,021,887). Two cases (8%) resulted in plaintiff verdict, with adjusted awards of

Malpractice Litigation in Pediatric Ophthalmology

1,399,800 and

Modified second stage Hughes tarsoconjunctival reconstruction for lower eyelid defects

630,799. Conclusions: Despite being a rare diagnosis, viral retinitis (especially acute retinal necrosis) is the most common clinical entity associated with litigation in uveitis and should be considered early. Educating patients about potential adverse events, early testing for syphilis, and maintaining a positive relationship may also minimize risk.

Malpractice Litigation in Ocular Oncology

ABSTRACT Purpose: To describe the surgical technique for a novel poly-HEMA (2-hydroxyethyl methacralate)[PHEMA] implant (Alphasphere, Addition Technology, Des Plaines, IL) in primary enucleation and placement of secondary orbital implant. Methods: Retrospective chart review of all patients receiving an Alphasphere implant for primary enucleation or secondary implant exchange from October 2009 to 2011. Interval follow-up was performed again on January 2013. Patient demographics, indications for surgery, and post-operative complications were reviewed. Results: Twelve patients received an Alphasphere implant for primary enucleation (n = 10) or secondary exchange (n = 2), with follow-up that ranged from 2 weeks to 14 months. The study included 9 adult and 3 pediatric patients with a mean age of 40 years, range 8–82 years. The indication for enucleation included: painful blind eye (n = 9), enophthalmos with difficult prosthesis fit in cases of secondary implant exchange (n = 2), and prophylaxis for sympathetic ophthalmia (n = 1). Only one patient required removal of the implant, due to a sinus infection with subsequent extrusion of the implant. Otherwise, the only other complication experienced was slight implant migration (n = 1). Conclusion: This initial report indicates that Alphasphere can be successfully used in the management of an anophthalmic socket. The advantages of the Alphasphere implant include: it does not require tissue wrapping, extraocular muscles can be directly sutured to the implant, it maintains a smooth surface to limit risk of exposure due to conjunctival breakdown, and undergoes anterior orbital fibrovascular ingrowth which optimizes prosthesis location and socket motility.