Lucy Clarke

PREGO (presentation of Graves’ orbitopathy) study: changes in referral patterns to European Group On Graves’ Orbitopathy (EUGOGO) centres over the period from 2000 to 2012

Background/aims The epidemiology of Graves’ orbitopathy (GO) may be changing. The aim of the study was to identify trends in presentation of GO to tertiary centres and initial management over time. Methods Prospective observational study of European Group On Graves’ Orbitopathy (EUGOGO) centres. All new referrals with a diagnosis of GO over a 4-month period in 2012 were included. Clinical and demographic characteristics, referral timelines and initial decisions about management were recorded. The data were compared with a similar EUGOGO survey performed in 2000. Results The demographic characteristics of 269 patients studied in 2012 were similar to those collected in the year 2000, including smoking rates (40.0% vs 40.2%). Mild (60.5% vs 41.2%, p<0.01) and inactive GO (63.2% vs 39.9%, p<0.01) were more prevalent in 2012. The times from diagnosis of thyroid disease to being seen in EUGOGO centres (6 vs 16 months) and from first symptoms of GO (9 vs 16 months) or from diagnosis of GO (6 vs 12 months) to first consultation in EUGOGO centres were shorter in 2012 (p<0.01). The initial management plans for GO were no different except surgical treatments for patients with mild inactive disease were more frequently offered in the 2012 cohort than in 2000 (27.3% vs 17%, p<0.05), and selenium supplements were offered only in the 2012 cohort (21.2% vs 0%, p<0.01). Conclusions These findings suggest that the clinical manifestations of patients with GO may be changing over time in Europe.

The incidence and outcome of photodynamic therapy for macular degeneration in the Northern Region of the UK

Purpose To assess the patients who have had photodynamic therapy (PDT) in the Northern region of the UK, in relation to the eligibility criteria found to benefit in the TAP study (treatment of age-related macular degeneration with photodynamic therapy study), so as to make an estimate of the number of patients who might benefit from this treatment and to present the outcome of the treatment so far.Method The records and fluorescein angiograms (FFAs) of all patients who had had PDT in the Northern region between 2001 and 2002 were reviewed for compliance with the TAP criteria of >50% classic choroidal neovascularization and >34 letters on the 2 m logMAR Early Treatment Diabetic Retinopathy Study chart. NHS funding has been available in the Northern Region since January 2001 for ‘second eye’ involvement. A review of all the angiograms performed for exudative macular degeneration in 1 year was also performed. The visual outcome of those patients 1 year from baseline was measured.Results A total of 82 ‘second eye’ patients were treated between January 2001 and December 2002. This gives an incidence of 65 per 3 million and so about 1300 in the whole of the UK (population 60 million). In all, 238 FFAs were performed on exudative macular degeneration, with 21% being found eligible for PDT. As of February 2003, 54 TAP criteria, macular degeneration patients were 1 year from initial treatment. Of these, 12 had incomplete follow-up and 13 patients had lost more than 15 letters. The responder rate defined as losing <15 letters was 42−13/42=69%. Seven of those who did not make 1-year follow-up had lost more than 15 letters when last seen, giving a responder rate of 54−20/54=63%.Conclusion There may not be as many patients eligible for PDT, using the TAP criteria, as previously hoped. The outcome of treatment appears similar to that found in the TAP study.

A 10-year review of orbital biopsy: the Newcastle Eye Centre Study

PurposeTo review the histopathological diagnoses, visual outcome, and complication rate of orbital biopsy in a UK tertiary referral centre.MethodsThis was a retrospective, clinical–pathological, interventional, consecutive case series. All orbital biopsies performed between July 2004 and June 2014 in Newcastle Eye Centre (Newcastle upon Tyne, UK) were included in this study. All relevant data collected from the local electronic database and medical records were analysed.ResultsA total of 166 orbital biopsies were identified during the study period: 86 patients (53.1%) were female and the mean age was 53.7±19.7 years. Of all the cases, orbital biopsies were performed unilaterally in 158 (97.5%) patients and bilaterally in 4 (2.5%) patients. The mean follow-up period was 2.2±2.3 years. The two most common histopathological diagnoses were non-specific inflammatory disease (62, 38.3%) and lymphoproliferative disease (40, 24.7%). None of the patients experienced ≥2-Snellen line visual loss. There were 7 (4.2%) postoperative complications noted: 1 (0.6%) orbital haemorrhage with no loss of vision, 4 (2.4%) diplopia, 1 (0.6%) short-term symblepharon, and 1 (0.6%) conjunctival granuloma. Postoperative diplopia was associated with lateral orbitotomy (P=0.044) and excisional biopsy (P=0.015).ConclusionsOrbital biopsy serves as a safe diagnostic tool in managing orbital diseases. Patient should be made aware of the risk of postoperative diplopia. Our data provides useful guidance to clinicians when counselling patients for orbital biopsy.

Lamina cribrosa displacement after optic nerve sheath fenestration in idiopathic intracranial hypertension: a new tool for monitoring changes in intracranial pressure?

Imaging in patients with idiopathic intracranial hypertension (IIH) is by definition normal but MRI may show dilatation of the subarachnoid space (SAS) around the optic nerve and a secondary flattening of the posterior sclera.1 Because of the existence of a trans-lamina cribrosa (LC) gradient, in patients with IIH the disc surface and thus the LC should be anteriorly displaced secondary to the raised intracranial pressure (ICP). In patients with glaucoma, an anterior displacement of the LC after lowering intraocular pressure (IOP) using spectral domain optical coherence tomography (SD-OCT) has been recently demonstrated.2–4 However, changes in the LC position after IIH treatment have not been reported previously. A 28-year-old woman diagnosed with IIH and treated with lumbo-peritoneal shunt presented with progressive visual loss despite well-controlled ICP. Bilateral sequential optic nerve sheath fenestration was planned and the patient underwent SD-OCT imaging using enhanced depth imaging technique3 (figure 1) of the …

A case series of anophthalmic socket cysts excised utilising fibrin sealant

ABSTRACT Anophthalmic socket cysts are challenging to remove and incomplete excision has been shown to increase the risk of recurrence. This case series describes a novel technique utilising the fibrin sealant Tisseel (Baxter AG, Vienna, Austria) to retain the socket cyst integrity during surgical removal to facilitate its complete excision. Five patients were included and followed up for a minimum of 1 year, and there were no signs of recurrence in any of the cases. The surgical technique is described and illustrated. This technique is a safe way of simplifying challenging socket cyst surgery.

A British Ophthalmological Surveillance Unit (BOSU) study into dysthyroid optic neuropathy in the United Kingdom

This prospective British Ophthalmological Surveillance Unit (BOSU) study on dysthyroid optic neuropathy (DON) determines the incidence, presenting features and management throughout the UK. New cases were identified through the BOSU yellow card and an initial questionnaire and a subsequent 9-month follow-up questionnaire were posted out. From August 2015 to August 2016 DON was reported in 49 patients with 71 eyes affected, 22 patients had bilateral DON. The most common presenting symptom was blurred vision (83%) and the most common examination finding was upgaze restriction (85%). 85% of patients were initially treated with 3 days of either 1 g or 500 mg intravenous methyl prednisolone. We received 25 follow-up questionnaires (51% of the initial cohort) with 38 eyes treated for DON and 13 bilateral cases. The average steroid dose over 9 months was 4.5 g and 47% of patients had a surgical orbital decompression. The mean visual acuity gain after 9 months of follow-up for all patients was 0.25 LogMAR. The mean visual acuity gain after just medical therapy was 0.25 LogMAR and after both medical therapy and orbital decompression it was 0.24 LogMAR. In conclusion, the incidence of DON in the UK from this study is 0.75 per million population per annum. The majority of patients are treated with initial medical therapy and almost half of all patients subsequently went on to have an orbital decompression. With either medical therapy or medical and surgical therapy, vision can improve in patients with DON.

Radiologic-pathologic correlation of orbital diseases

Heterogeneity of orbital diseases often poses a diagnostic dilemma to the ophthalmologists. With advances in imaging technology, it has become increasingly common that orbital diseases are diagnosed on clinical and radiologic findings. Herein we report a 10-year experience (April 2004 –March 2014) of radiologic-pathologic correlation of orbital diseases in our unit. The consistency between radiologic impression and histopathologic diagnosis (achieved by orbital biopsy) was defined by radiologic-pathologic correlation (RPC), which was categorised into:

Medical Management of Mild and Moderate to Severe Thyroid Eye Disease

Traditional systems of grading severity would identify the category of “mild” disease as that which does not require intervention, and the management of moderate and severe disease is often discussed together. There is increasing appreciation of the importance of assessing quality of life in the measurement of severity rather than relying entirely on physical parameters. Simple measures like lubricants and selenium supplements may be helpful in mild disease. Systemic steroids and orbital irradiation have historically been the principal nonsurgical treatments for active moderate to severe thyroid eye disease, while rehabilitative surgery has a key role in selected patients with inactive disease. Euthyroidism and abstinence from smoking are equally important therapeutic objectives.