Jean-Louis deSousa

Sliding tarsal flap for reconstruction of large, shallow lower eyelid tarsal defects.

Purpose: To describe a novel technique for reconstructing shallow, full-thickness defects of the lower eyelid. Methods: Twelve patients with shallow, full-thickness lower eyelid defects after Mohs excision of eyelid malignancies were treated with this technique. The posterior lamella was reconstructed by obliquely incising the residual tarsus to create medial and lateral tarsal flaps. These flaps were obliquely overlapped to tighten the eyelid and reconstruct a tarsus approximating normal height. The anterior lamella defect was then reconstructed by using local flaps or free grafts in a conventional manner. Results: Eyelid defects ranged from 25 to 40 mm horizontally and 20 to 35 mm vertically, with tarsal defects ranging from 18 to 27 mm horizontally and 2 to 3.5 mm vertically. A stable eyelid margin with good aesthetic appearance was achieved in all patients. Two patients had mild eyelid retraction not requiring intervention, and one had lower eyelid entropion 9 months after surgery. Conclusions: Sliding tarsal flaps are an effective technique for reconstruction of this type of defect. The advantages of this approach are its simplicity, utilization of preserved tissue, and avoidance of the morbidity associated with more complex procedures.

Intraocular pressure and refractive changes following orbital decompression with intraconal fat excision.

The purpose of this study was to measure the changes in intraocular pressure (IOP) and refraction following orbital decompression for thyroid orbitopathy. Methods: Retrospective review of 18 eyes in 10 consecutive patients who underwent orbital decompression including intraconal fat excision for proptosis secondary to thyroid orbitopathy. IOP using tonopen, exophthalmometry, autorefraction and autokeratometry measurements were performed at 1-week, 1-month and 3-months after surgery. Results: There was no statistically significant difference between the preoperative and postoperative IOP at 3 months. There were no significant differences found between preoperative and post operative keratometry readings or automated refraction following orbital decompression. Conclusion: Our study did not find a significant change in IOP and refraction following orbital decompression with intraconal fat excision. A larger prospective study is required in order to evaluate the role of intraconal fat excision in reducing IOP due to it’s potential role in patients with concurrent glaucoma.

Endonasal dacryocystorhinostomy for nasolacrimal duct obstruction in patients with sarcoidosis.

Abstract Purpose: To evaluate the outcomes of endonasal dacryocystorhinostomy (EN-DCR) surgery in patients with sarcoidosis. Methods: Retrospective chart review of all patients with sarcoidosis undergoing EN-DCR in 6 practices from 1999–2011. Results: We included 18 procedures in 14 patients (8 female, 6 male) who underwent EN-DCR for acquired NLDO secondary to sarcoidosis. The mean age was 53.7 (range 38–82). The presenting symptom in all cases was epiphora. Eight patients (57%) complained of having additional nasal congestion. Surgery was performed using endoscopic powered-type DCR with flaps in 12/18 (67%) and non-endoscopic mechanical EN-DCR in 6/18 (33%). In 15 (83%) cases the lacrimal sac and nasal mucosa appeared abnormally yellowish, crusty, oedematous and friable. Five patients were treated with pre-operative oral steroid and overall 8 patients had oral prednisolone post operatively, 30–60 mg tapered within 10 days–8 weeks. One patient had difficulties in tapering down the oral steroids at 6 months of follow-up. All patients were free of epiphora and patent to syringing, with nasal endoscopy revealing free flow of fluorescein through the ostium at a mean follow-up of 11.3 months (median follow-up 9 months). Conclusions: All 18 cases of acquired nasolacrimal duct obstruction secondary to sarcoidosis were treated successfully with EN-DCR. An abnormal appearance of the nasal mucosa is an important sign. Nasal congestion is a frequent sign. A successful outcome may not depend on intensive long-term therapy with local or systemic steroids. Mechanical or powered EN-DCR for nasolacrimal duct obstruction secondary to sarcoidosis achieves encouraging medium-term outcomes.

Myopia and skin cancer are inversely correlated: results of the Busselton Healthy Ageing Study

TO THE EDITOR: Kerry Breen has hit the nail squarely on the head.1 The Medical Board of Australia should heed Peter Ustinov’s advice, “Don’t just do something, stand there!” And Oliver Cromwell’s plea, “think it possible you may be mistaken”. And mine: “Please think again!” It is easier (more effective and cost-effective) to move the tail of the bell curve to the right than to shift the bulk of it to the right. While every doctor’s performance could possibly be improved, there is little point and dubious costeffectiveness in improving doctors on the right of the bell curve from “good” or “very good” to “a little bit better”, when the point of the exercise is to improve the game of poor performers. Alison Reid, former Medical Director of the New South Wales Medical Board, has suggested that the focus could readily be directed at doctors about whom there are a number of complaints, and at those in the groups known to be at risk: those with an impairment, the aged, and the professionally and geographically isolated.2 It is among these groups that the evidence shows that poor performance is most likely to be found. It would seem to me that assessment of doctors in these groups, in their practices, as is done by the Royal Australasian College of Physicians in its clinical audit program,3 would be more productive and cost-effective than wholesale assessment of all practising doctors.

Progressive orbital granular cell tumour associated with medial rectus

ABSTRACT Granular cell tumour is a rare soft tissue tumour that can occur in any part of the body, but seldom in ocular adnexa. It usually behaves in a benign fashion. We report a case of a 54-year-old man with a well-demarcated, solitary, slow-growing orbital tumour which lead to significant ocular symptoms. The case was a diagnostic and therapeutic challenge due to its location and difficulty in obtaining tissue for a histological diagnosis. Surgical biopsy attempts were made but they all failed to uncover the true identity of the lesion. A definitive diagnosis was revealed with complete surgical excision of the tumour, which was challenging due to its size and close association with rectus muscle. This case has highlighted that orbital granular cell tumour may result in significant ocular symptoms. Adequate exposure to the anatomical site is the key to obtaining diagnosis and complete excision of a lesion.

Radiological Pitfalls in Patients with Inducible Dynamic Proptosis

We report two patients presenting with marked clinical unilateral enophthalmos who had positional variability and dynamic proptosis on valsalva. On orbital imaging, enophthalmos was not documented and in fact, globe proptosis of the same side was reported for one of the patients. During CT and MRI scanning patients are often instructed to hold their breath to eliminate motion artefact. This may inadvertently induce dynamic proptosis. The radiological pitfalls of imaging patients with inducible dynamic proptosis and how to identify such patients are discussed.