Jonathan H. Norris

Managing antiplatelet and anticoagulant drugs in patients undergoing elective ophthalmic surgery

The management of antiplatelet and anticoagulant treatment can be challenging for the ophthalmic surgeon with the risk of impaired surgical view or potentially sight-threatening haemorrhage. With the advent of newer medications and the expanding usage of these drugs, there is a need for up-to-date guidance on the subject. This paper describes the current use of modern antiplatelet and anticoagulant drugs in the UK, and reviews the evidence of such treatments in the context of ophthalmic surgery. A multidisciplinary approach has been used to develop a guideline for the management of antiplatelet and anticoagulation treatment in elective ophthalmic surgery. Specifically, guidance is provided on when and how to stop antiplatelet and anticoagulant treatment and, importantly, when to seek specialist medical advice.

The Learning Curve in Endoscopic Dacryocystorhinostomy: Outcomes in Surgery Performed by Trainee Oculoplastic Surgeons.

Abstract Purpose: To report outcomes of endoscopic DCR (En-DCR) performed by oculoplastic trainees and describe factors to improve success rates for trainees. Methods: Retrospective, single-centre audit of En-DCR procedures performed by three consecutive trainee oculoplastic surgeons, over a 3-year period. Trainees also completed a reflective-learning questionnaire highlighting challenging and technically difficult aspects of En-DCR surgery, with relevant tips. Results: Thirty-eight consecutive independently-performed en-DCR procedures on 38 patients (mean age 58.6 ± 21.4 years) were studied. Mean time spent in the operating-theatre was 95.7 ± 27.3 minutes. Success rate for each year was 15/17(88%), 8/8(100%) and 7/13(54%), respectively, at mean follow-up 12.5 ± 12 months. The lowest success rate year coincided with use of silicone stents in 31% cases compared to 94% and 100% in the previous 2 years. In cases that failed, video-analysis highlighted inadequate superior bony rhinostomy (2 cases), incomplete retroplacement of posterior-nasal mucosal-flaps (3 cases), significant bleeding (1 case). Those who underwent revision surgery (n = 6), were found to have soft-tissue ostium and sac closure requiring flap revision. Two-cases required further bone removal supero-posterior to the lacrimal sac. Trainees-tips that helped improve their surgery related to patient positioning, instrument handling, bone removal and posture. Conclusion: Good surgical outcomes are achievable training in en-DCR surgery. Adequate operating time needs to be planned. Failure was primarily due to closure of the soft-tissue ostium, either secondary to inadequate osteotomy and sac-marsupialisation or postoperative scarring. Intra-operative mucosal trauma is higher amongst trainees and adjuvant silicone stenting during the training period may be of value where mucosal adhesions are anticipated.

Meta-analysis of the Adjunctive Use of Mitomycin C in Primary and Revision, External and Endonasal Dacryocystorhinostomy

Abstract Purpose: To determine whether application of the anti-proliferation agent, mitomycin C (MMC), to the osteotomy site during dacryocystorhinostomy (DCR) surgery increases surgical success rates. Method: We conducted a comprehensive meta-analysis of randomised controlled clinical studies relating to the adjunctive use of MMC in primary and revision, as well as external (EX-DCR) and endonasal DCR (EN-DCR). Results: 15 studies met our inclusion criteria with a total of 850 DCR procedures. The mean concentration of MMC used was 0.3 mg/ml (range 0.02–0.75 mg/ml) and mean duration of application 18 min (range 2–30 min). MMC significantly reduced the failure rate of primary EX-DCR (risk ratio, RR, 0.51; 95% confidence interval, CI, 0.31–0.86) and revision EN-DCR (RR 0.43; 95% CI 0.21–0.89). The adjunctive use of MMC in primary EN-DCR, however, did not confer a significant reduction in failure rate compared with control (RR 0.94; 95% CI 0.44–2.04). We found a deficiency of evidence regarding the potential benefit of MMC in revision EX-DCR. Only two cases of adverse effects relating to the use of MMC were reported among the studies, both of which related to delayed wound healing. Conclusions: Application of MMC to the osteotomy site is a safe and effective way of increasing surgical success rate in primary EX-DCR and revision EN-DCR, but does not provide any significant benefit in primary EN-DCR. Further studies are required to evaluate the potential effect of MMC in revision EX-DCR.

Transcaruncular Medial Canthal Tendon Plication with Lower Eyelid Suture Sling in Facial Nerve Palsy

Abstract Purpose: To report a technique for correcting lower eyelid punctal ectropion with an inferiorly displaced or retracted medial eyelid due to facial nerve palsy, by extending a suture sling along the pre-tarsal lower eyelid when performing transcaruncular medial canthal tendon plication. Methods: Single-centre retrospective, non-comparative review of patients with facial nerve palsy who underwent medial canthal tendon plication with lower eyelid suture sling (MCT suture sling). Outcome measures included: the presence of lower eyelid ectropion, medial eyelid height, punctal position, inferior marginal reflex distance (MRD) and inferior scleral show measured both pre-operatively and at the last follow-up visit. Results: Thirty-three patients with facial nerve palsy with a mean age of 59, underwent MCT suture sling for lagophthalmos and/or ectropion. Then, 66% (21/32) of cases had punctal ectropion pre-operatively and 9% (3/32) had punctal ectropion at the last follow-up. Medial eyelid height was deemed to improve in 66% (21/32) of cases at the last follow up visit. Follow-up was mean 13.5 months. Six (18%) patients were deemed failures due to inferior MRD and inferior scleral showing worse than pre-operative measurements. Discussion: We report a technique for incorporating a suture sling to transcaruncular-approach MCT plication when the medial canthus has retracted or descended thus requiring support and a posterior vector. It avoids rounding of the medial canthal angle that may occur with traditional medial canthoplasty. Transcaruncular MCT plication is well described. Incorporating a suture sling to potentially reduce single point-fixation cheese-wiring and early dehiscence is minimally invasive, non-excisional and repeatable.

ORBITAL COMPRESSED AIR AND PETROLEUM INJURY MIMICKING NECROTIZING FASCIITIS

BACKGROUND Orbital injury secondary to petroleum-based products is rare. We report the first case, to our knowledge, of a combined compressed air and chemical orbital injury, which mimicked necrotizing fasciitis. CASE REPORT A 58-year-old man was repairing his motorcycle engine when a piston inadvertently fired, discharging compressed air and petroleum-based carburetor cleaner into his left eye. He developed surgical emphysema, skin necrosis, and a chemical cellulitis, causing an orbital compartment syndrome. He was treated initially with antibiotics and subsequently with intravenous steroid and orbital decompression surgery. There was almost complete recovery by 4 weeks postsurgery. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Petroleum-based products can cause severe skin irritation and necrosis. Compressed air injury can cause surgical emphysema. When these two mechanisms of injury are combined, the resulting orbitopathy and skin necrosis can mimic necrotizing fasciitis and cause diagnostic confusion. A favorable outcome is achievable with aggressive timely management.

Development of a New Module of the FACE-Q for Children and Young Adults with Diverse Conditions Associated with Visible and/or Functional Facial Differences

Abstract Appearance and facial function are concepts not well addressed in current pediatric patient‐reported outcome measures (PROM) for facial conditions. We aimed to develop a new module of the FACE‐Q for children/young adults with facial conditions that include ear anomalies, facial paralysis, skeletal conditions, and soft tissue conditions. Semi‐structured and cognitive interviews were conducted with patients aged 8‐29 years recruited from craniofacial centers in Canada, USA, UK, and Australia. Interviews were used to elicit new concepts and to obtain feedback on CLEFT‐Q scales hypothesized to be relevant to other facial conditions. Interview data were recorded, transcribed, and coded. Experts were emailed and invited to provide feedback via Research Electronic Data Capture (REDCap). Eighty‐four participants and 43 experts contributed. Analysis led to the development of a conceptual framework and 14 new scales that measure appearance, facial function, health‐related quality of life, and adverse effects of treatment. In addition, 12 CLEFT‐Q scales were determined to have content validity for use with other facial conditions. Expert input led to minor changes to scales and items. This new FACE‐Q module for children/young adults is being field‐tested internationally. Once finalized, we anticipate this PROM will be used to inform clinical practice and research studies.

IgG4-related disease presenting as posterior scleritis and vitritis, progressing to multifocal orbital involvement

IgG4-related disease (IgG4-RD) is a rare, chronic inflammatory condition that may involve nearly every organ system. Originally identified as a cause of autoimmune pancreatitis, its characteristic histological and clinical features have been found in a wide variety of inflammatory presentations, including the eye and orbit. Here we describe an example of a case of IgG4-RD initially presenting as scleritis and vitritis, with further progression to multifocal bilateral orbital involvement. Tissue biopsy of an orbital mass was highly characteristic of IgG4-RD histology and a rapid clinical response to corticosteroids was observed. This case highlights IgG4-RD as a rare cause of intraocular inflammation that may progress to involve the orbit.

Bronchial artery aneurysm: a rare, undescribed cause of Horner syndrome

Bronchial artery aneurysms are a rare and asymptomatic but potentially fatal condition. We present the first described case in the literature of an acute onset Horner syndrome secondary to a bronchial artery aneurysm. A 65-year-old man was referred for a new rightsided ptosis, which had occurred in the last 3months. Hewas otherwise asymptomatic, had not suffered any trauma previously and had no medical comorbidities. On examination, best-corrected visual acuity was 6/6 right and 6/6 left. A 1-mm right ptosis (compared with left side) was noted (Fig. 1). Levator function and ocular motility were normal. Anisocoria was seen with no associated iris heterochromia. The right pupil was miotic when compared with the left (Fig. 1), and this was accentuated in the dark. Apraclonidine 1% (Alcon, Surrey, UK) was used to pharmacologically confirm a suspected right Horner syndrome. Thirty minutes post-instillation in both eyes, there was reversal of the anisocoria, which confirmed the diagnosis (Fig. 2). A CT-angiogram (CTA) (aortic arch/carotid protocol) demonstrated a torturous right bronchial artery with an irregular lumen, which represented a small, partially thrombosed aneurysm. This was at the level of the T4 vertebra, immediately anterior to the right sympathetic chain (Figs 3, 1). The patient underwent an endovascular procedure to have the aneurysm treated shortly after the diagnosis was made. Horner syndrome or ‘oculosympathoparesis’, was first described by Johann Horner in 1929. It classically presents with ipsilateral blepharoptosis and pupillary miosis. The sympathetic supply to the eye is a threeneuron chain that follows a long and circuitous route. First-order neurons originate centrally in the thalamus and descend to synapse at the level of C8 to T2 in the interomediolateral spinal cord. Second-order neurons then emerge in the upper thoracic ventral nerve roots (mainly T1) to join the sympathetic chain and ascend to synapse in the superior cervical ganglion. There is a degree of variation at the thoracic level where the second-order neurons emerge from to enter the sympathetic chain. The bronchial arteries are located anteriorly adjacent to the sympathetic chain in the upper thoracic levels. Third-order neurons exit the superior cervical ganglion and form a plexus surrounding the internal carotid artery (ICA) to ascend to the eye. Causes of Horner syndrome are classified as first order (central), second order (pre-ganglionic) and third order (post-ganglionic) and can cause serious

Reconstruction of extensive medial canthal defects using a single V-Y, island pedicle flap

ABSTRACT The medial canthus represents one of the most challenging regions of the face to reconstruct due to the anatomical structures present, the concavity of the area, and the differences in skin texture. We present a case series of 11 patients whose defects were reconstructed with a single V-Y island pedicle flap running along the nasofacial sulcus. Our single-stage flap which modified and simplified a previously described technique achieves similar cosmetic and postoperative outcomes along with a high level of patient satisfaction in an area which can be reconstructed in a variety of ways, often with suboptimal results.

The “reading man” flap for reconstruction of large periorbital defects

ABSTRACT Purpose: The “reading man” flap (RMF), a double advancement transposition cutaneous flap named for its appearance, has been described in the reconstruction of various circular skin defects, particularly in the malar region. We describe two cases where this flap was used to reconstruct the lower eyelid/periorbital region. Methods: Two oculoplastic patients with lower eyelid basal cell carcinomas underwent Mohs micrographic excision resulting in a large skin defects. In both cases, reconstruction was performed using the RMF. Results: At 6 months, both patients achieved good cosmetic results with no case of secondary eyelid malposition. Conclusion: The RMF is a useful adjunct to the armamentarium of the oculoplastic surgeon for the reconstruction of large periorbital defects.