Ian C. Francis

Ocular adnexal lymphoproliferative disease: a series of 73 cases

Background: This study involved 73 patients with lymphoproliferative lesions of the ocular adnexa. The lesions were categorized using the Revised European American Lymphoma classification of lymphoid tissues and analysed to determine the frequency and prognostic impact of tumour type, location, stage and patients age and sex.

Perineural Spread of Cutaneous Squamous Cell Carcinoma via the Orbit: Clinical Features and Outcome in 21 Cases

OBJECTIVE To describe the clinical features, treatment, and outcome of a series of patients with perineural spread (PNS) of cutaneous squamous cell carcinoma (SCC) via the orbit. DESIGN A cohort study. PARTICIPANTS Twenty-one patients identified with PNS of cutaneous SCC via the orbit. INTERVENTION Patients were treated with various combinations of conservative or radical surgery, external beam radiation therapy, and chemotherapy. RESULTS Of 21 cases, 17 (81%) were male. Age at presentation with PNS ranged from 38 to 82 years (median, 66 years). The forehead and eyebrow were the most common site of the primary lesion. All but one had altered or decreased sensation, but only nine presented with pain. Fourteen (67%) had ophthalmoplegia at presentation, and 14 (67%) had evidence of PNS involving branches of the facial nerve. Despite combinations of radical surgery, conservative surgery, and radiation therapy, no method of treatment appeared more effective, and 14 patients died from 9 months to 5 years after presentation with PNS (median, 3 years), usually from local and intracranial disease. Two survived to 14 and 18 years, one is alive at 3 years with recurrent local and distant disease, and four are alive without evidence of disease at 2, 3, 4 and 12 months after radiation therapy. CONCLUSIONS Perineural spread of cutaneous SCC via the orbit carries a poor prognosis. Early radiation therapy may offer the best form of palliation. The role of radical surgery probably is limited once orbital involvement is apparent, as the cavernous sinus and facial nerve branches usually are involved.

Primary phacoemulsification for uncontrolled angle-closure glaucoma

PURPOSE To report the results of primary phacoemulsification to treat uncontrolled angle-closure glaucoma. SETTING Private practice and teaching hospital department. METHODS This retrospective interventional case series assessed 3 patients having phacoemulsification and posterior chamber intraocular lens implantation for uncontrolled intraocular pressure (IOP) after acute primary angle-closure glaucoma. RESULTS Intraocular pressure control was achieved in all patients postoperatively. CONCLUSIONS Primary phacoemulsification with the option of future trabeculectomy should be considered in selected patients with persistent appositional angle closure and uncontrolled IOP after angle-closure glaucoma.

Intraoperative complications of 1000 phacoemulsification procedures: A prospective study

Purpose: To determine the frequency and nature of intraoperatlve complications of endocapsular phacoemulsification cataract surgery. Setting: Dalcross Private Hospital and the Departments of Ophthalmology, Concord Hospital and Prince of Wales Hospital, Sydney, Australia. Methods: This prospective study included the first 1000 cases of planned endocapsular phacoemulsification cataract surgery performed by an experienced surgeon. A standardized proforma was completed at the time of surgery. Data recorded included pre‐existing ocular abnormalities, duration of surgery, nuclear sclerosis grade, and intraoperative complications. Results: Major complications comprised posterior capsule tears with vitreous loss (1.4%), isolated posterior capsule tears (0.7%), and zonulysis (0.1%). Minor complications included anterior capsule tears (3.8%), iris prolapse (0.6%), and ciliary body incision (0.2%). There was a significant trend toward complications as the nuclear sclerosis grade increased. The incidence of major complications was 9.3% in the first 150 cases and 0.9% in the last 850. This represents a relative risk of 9.9 (95% confidence interval 4.2 to 23.0) of a major complication occurring in the first 150 compared with the later 850 cases. Conclusion: The frequency of major and minor complications fell sharply after the first 150 operations and was maintained. This study may provide a guide for beginning phacoemulsification surgeons and a basis for experienced surgeons to compare their performance outcomes.

Australasian orbital and adnexal Wegener’s granulomatosis

OBJECTIVE To report a retrospective case series of 29 Australian and New Zealand patients with orbital and adnexal Wegeners granulomatosis (WG). DESIGN Retrospective case series. PARTICIPANTS Twenty-nine cases of orbital and adnexal WG were identified. METHODS A number of oculoplastic surgeons and other clinicians in Australia and New Zealand was asked about their experience with orbital and adnexal WG. Clinical data regarding these cases were conveyed by means of a questionnaire. Cases of ophthalmic WG without features of orbital or adnexal disease were excluded. MAIN OUTCOME MEASURES Data obtained from the questionnaire includes age, gender, limited or generalized disease, antineutrophil cytoplasmic antibody (ANCA) status, symptoms and signs: nasolacrimal obstruction, sinusitis, fistula/orbital bone erosion, orbital mass/proptosis, extraocular muscle/diplopia, visual acuity reduction caused by optic nerve compression, orbital pain, lid edema/erythema, biopsy status, and treatment status. RESULTS Twenty-nine patients with orbital and adnexal WG were identified and described. Symptoms included awareness of an orbital mass, epiphora, orbital pain and diplopia. Signs included an orbital mass or proptosis (69%), nasolacrimal duct obstruction (52%), limited ocular rotations (52%), lid erythema and edema (31%), bony destruction (21%), and reduced visual acuity (17%). Two patients had a persistent nasolacrimocanthal fistula. Cytoplasmic pattern antineutrophil cytoplasmic antibodies (c-ANCA) were present in 52% of patients, and in 9 of 10 patients with generalized disease. However, c-ANCA was positive in only 32% (6 of 19) of patients with limited WG. Perinuclear pattern antineutrophil cytoplasmic antibodies (p-ANCA) was positive in 10% of cases. CONCLUSIONS To diagnose and treat ophthalmic WG effectively, the clinician must be aware of its protean orbital and adnexal manifestations. WG may occur with or without systemic involvement, and c-ANCA was negative in approximately half our cases. Our cases also demonstrated two orbital fistulae, an observation previously believed to be rare.

Acute haptic-induced pigmentary glaucoma with an AcrySof intraocular lens

A 49-year-old man had uneventful endocapsular phacoemulsification with in-the-bag implantation of an AcrySof SA60AT single-piece intraocular lens (IOL) (Alcon) in the right eye. Twenty-seven days postoperatively, he presented with ocular pain, intraocular pressure of 48 mm Hg, 360 degrees of hyperpigmentation of the trabecular meshwork, and iris pigment epithelial atrophy in the region of the upper temporal haptic, which had dislocated into the sulcus. The patient made an excellent recovery following IOL removal and exchange. Scanning electron microscopy of the explanted IOL demonstrated that the haptic had a rough lateral surface and anterolateral edge. We do not think this IOL should be implanted in the sulcus placement of the heptics. In this article, we report the case of a patient with an AcrySof SA60ATIOL (Alcon) who developed acute pigmentary glaucoma when the inferior haptic slipped out of the bag and came into contact with the pigmented iris and ciliary body.

The spectrum of presentation of silent sinus syndrome.

The general clinical, ophthalmologic, and radiologic features of three patients with silent sinus syndrome are presented. All three patients were treated surgically. The cases of these patients illustrate the spectrum of presentation of silent sinus syndrome, including enophthalmos, hypophthalmos, transient vertical diplopia, lid retraction, lagophthalmos, and blurred vision. All patients had sinus disease, and all patients improved after surgery using functional endoscopic sinus surgery techniques. The protean manifestations of silent sinus syndrome can be identified, thereby allowing appropriate management.

Computed tomography of the lacrimal drainage system : retrospective study of 107 cases of dacryostenosis

PURPOSE To evaluate the role of computed tomography in patients with dacryostenosis. METHODS One hundred seven cases of dacryostenosis (94 patients) were assessed by thorough clinical and lacrimal history and examination, and lacrimal region computerized tomography (CT). The lacrimal drainage system examination included the state and position of the puncta; Jones testing; lacrimal syringing; and, in the latter half of the study, telescopic nasal endoscopy. The patients were drawn from the hospital outpatients and private office of the operating lacrimal surgeon in this series (I.C.F.). Of the 107 cases, 79 either underwent dacryocystorhinostomy surgery or had this planned. RESULTS In 14 of the 107 cases (12 patients), preoperative CT led to an alteration of patient management, usually referral to an otolaryngologist for further evaluation or treatment. In addition to the detection of two tumors extrinsic to the sac, conditions such as ethmoiditis, lacrimal sac mucoceles, soft tissue opacity in the nasolacrimal duct, gross nasal polyposis, fungal sinusitis, and a dacryolith were observed by CT. CONCLUSION Similar to the role of functional endoscopic sinus surgery in otolaryngology, CT imaging will become increasingly important in the assessment of many patients with symptoms of lacrimal drainage obstruction.

Zoledronic Acid Infusion and Orbital Inflammatory Disease

A 57-year-old man presented with a 4-day history of increasing orbital pain and swelling in the right eye. A diagnosis of orbital inflammatory disease due to bisphosphonate infusion was made.

Neuro-ophthalmology of invasive fungal sinusitis: 14 consecutive patients and a review of the literature

Invasive fungal sinusitis is a rare condition that usually occurs in immunocompromised patients and often presents as an orbital apex syndrome. It is frequently misdiagnosed on presentation and is almost always lethal without early treatment.