Paul Cauchi

Surveillance of severe chemical corneal injuries in the UK

Aim: To estimate the incidence of severe chemical corneal injuries in the UK and describe presenting clinical features and initial management. Methods: All patients with severe chemical corneal injury in the UK from December 2005 to November 2006 inclusive were prospectively identified using the British Ophthalmological Surveillance Unit. Reporting ophthalmologists provided information regarding presentation and follow-up. Results: Twelve cases were identified, giving a minimum estimated incidence in the UK of severe chemical corneal injury of 0.02 per 100 000. 66.7% of injuries were in males of working age, 50% occurred at work, and alkali was causative in 66.7%. Only one patient was wearing eye protection at the time of injury, 75% received immediate irrigation. Six patients required one or more surgical procedures, most commonly amniotic membrane graft. At 6 months’ follow-up, the best-corrected visual acuity was 6/12 or better in five patients, and worse than 6/60 in two. Conclusion: The incidence of severe chemical corneal injury in the UK is low. The cases that occur can require extended hospital treatment, with substantial ocular morbidity and visual sequelae. Current enforcement of eye protection in the workplace in the UK has probably contributed to a reduced incidence of severe ocular burns.

Incidence of periorbital necrotising fasciitis in the UK population: a BOSU study

Background Periorbital necrotising fasciitis (PNF) is a devastating infection of subcutaneous soft tissue and underlying fascia causing severe morbidity and even loss of life. Few case reports of PNF exist and there are no prospective epidemiological studies. Methods A prospective observational study was undertaken using the British Ophthalmological Surveillance Unit reporting system. Questionnaires were sent to reporting ophthalmologists in the UK seeking cases of PNF over a 2-year period. Results 30 new cases were confirmed. 16 of the reported cases followed a precipitating event, 9 cases followed trauma and 3 followed surgery. β-haemolytic Streptococcus A was the causative organism identified in 76%, either alone or with concurrent infection, and antibiotic sensitivities are discussed. Systemic complications occurred in the majority of cases (66.6%), with sepsis and death occurring in 10%. Over 50% of surviving patients had subsequent morbidity, reduced acuity (<6/18) being common. Conclusion PNF is a rare, dangerous condition. This study identified an incidence of 0.24 per 1 000 000 per annum in the UK. β-haemolytic Streptococcus A is the most common causative organism. Mortality remains a potential outcome, and survivors suffer significant morbidity. Early intravenous antibiotic management with a consensus favouring penicillin and clindamycin combined with debridement.

Histological Evidence of Tissue Reaction to Gold Weights Used for Mechanical Ptosis

Gold and platinum weights have been implanted successfully to induce mechanical ptosis for corneal surface protection, although ocular symptoms of facial paralysis can still persist. Recent satisfaction surveys suggest that patients prefer the more expensive platinum linked chain owing to improved contour and corresponding cosmesis.1 Variations in the surgical approach to pretarsal gold weight implantation have reduced associated rates of with-the-rule corneal astigmatism and extrusion.2 Tissue reaction to gold is uncommon. Herein we report 2 cases of nonextruded gold weights removed following treatment of lagophthalmos and describe the histological findings.

Socioeconomic Status and Choroidal Melanoma in Scotland

The adverse effect of socioeconomic deprivation on health and mortality is well recognized in the United Kingdom, particularly for health inequalities in Scotland.1-2 We evaluated the demographic characteristics and audited the management of our patients with choroidal melanoma at the only ocular oncology tertiary referral center in Scotland.

Use of Ruthenium-106 Brachytherapy for Iris Melanoma: The Scottish Experience

Purpose To analyse long-term outcomes of ruthenium-106 (106Ru) plaque brachytherapy for the treatment of iris melanoma. Methods We retrospectively reviewed medical records of 19 consecutive patients with pure iris melanoma treated with 106Ru plaque brachytherapy between 1998 and 2016 at the Scottish Ophthalmic Oncology Service, Glasgow. The iris melanoma was treated with a ruthenium plaque placed on the corneal surface to deliver a surface dose of 555 Gy. We analysed vision preservation, local tumour control, radiation-related complications, eye retention rates, symptomatic metastasis and melanoma-related mortality. Results The mean largest basal diameter of the lesions was 3.50±1.42 mm (range 1.6–6.5 mm), and the mean maximum height was 1.47±0.65 mm (range 0.7–2.8 mm). The tumour control and eye retention were 100% at a mean follow-up of 62 months (range 6–195 months). A 62% reduction in tumour height was observed on ultrasonography. Complications included cataract (68%), dry eye (47%), uveitis (37%) and scleral thinning (5%). At the final follow-up visit, the mean loss of Snellen visual acuity was 1.11±2.90 lines and vision of 6/9 or better was maintained in 53% of patients. None of the patients had evidence of symptomatic metastasis (non-imaged) or melanoma-related mortality. Conclusions 106Ru plaque treatment for iris melanoma was highly effective a high tumour control, no tumour recurrences and a relatively a low complication rate.

Diode laser thermotherapy for conjunctival vascular malformations.

ing the serologic surveys was normal during the state. Dark spots/patches seen on the specular microscopy after SLT has been recently reported by Ong et al. This change in the corneal endothelium may be due to oedema, subendothelial inflammatory cells or adjacent endothelial cell damage, and they are assumed to resolve after the resolution of the inflammation. The interesting fact about our case was that these changes occurred bilaterally after a unilateral SLT procedure. Bilateral effect after unilaterally applied SLT was also reported by Rhodes et al. The authors proposed a significant reduction in the intraocular pressure of the fellow untreated eye after uneventful unilateral SLT. Regina et al. have reported two cases with central corneal oedema and haze after SLT. They hypothesized that may be due to herpetic activation or residual alcohol on the goniolens or inflammatory response in the anterior chamber. Our patient has developed peripheral corneal haze and thinning, which might be due to inadvertent application of the laser, but this reaction was bilateral. Kim and Singh have introduced a case with severe iritis and choroidal effusion. Their case was also unilaterally affected in the treated eye. Our case developed severe bilateral anterior iritis and posterior synechia in the third week of SLT. It is interesting that it may be a period enough for immunization of the other eye because both eyes were affected at the same time. SLT is usually a safe procedure, but having signs of a past intra-ocular inflammation or pigment on the posterior surface of the cornea should also be considered as a relative contraindication for SLT therapy. The involvement of the untreated eye needs further investigation for any autoimmune triggering effect of SLT.

Orbital venous-lymphatic malformation.

Case report A 39-year-old roofer was seen with a 2-week history of an enlarging vascular conjunctival lesion in the medial canthal area and a diffuse swelling in the temporal area. He also reported the presence of a superonasal anterior orbital swelling since birth. His vision, ocular movements, and position of the eyeball were unaffected. A magnetic resonance imaging (MRI) scan showed a serpiginous superior orbital mass having a vascular communication to the subcutaneous soft tissue mass on

Photodynamic Therapy for Circumscribed Choroidal Haemangioma in a Scottish Cohort

Purpose: The aim of this study was to evaluate the safety and efficacy of photodynamic therapy (PDT) with verteporfin as a treatment for circumscribed choroidal haemangioma (CCH). Procedures: This is a retrospective cohort study of all treatment-naïve patients undergoing PDT with verteporfin for CCH in a single centre between April 1, 2007, and September 30, 2016. Best corrected visual acuity (BCVA; using ETDRS letter score), optical coherence tomography (OCT) measurements and a subjective measurement of visual function were recorded before treatment, at 3-month follow-up and at each annual follow-up. Results: Seventeen Caucasian patients with CCH received PDT, with a re-treatment rate of 23.5% (n = 4). Mean (±SD) follow-up was 36.5 (±32.6) months (range 2–106). Mean (±SD) pre-PDT BCVA was 58.5 (±15.5) letters, with a mean improvement from baseline of 8.2 letters at 3 months, of 13.8 letters at 1 year, of 21.1 letters at 2 years and of 19.5 letters at 3 years of follow-up. Subjective visual improvement was noted in 67% at 3 months, in 93% at 1 year, in 86% at 2 years and in 100% at 3 years of follow-up. OCT demonstrated no intraretinal/subretinal fluid in 63% at 3 months, in 77% at 1 year, in 86% at 2 years and in 100% at 3 years of follow-up. No complications of PDT were noted during the study. Conclusions: PDT is a safe and effective treatment for CCH which results in both structural and functional improvements, and these findings are particularly applicable to patients of Caucasian ethnicity. OCT provides a useful and readily available option to monitor CCH disease activity and its response to PDT.

Management of common tumors of the conjunctiva

Tumors of the conjunctiva are typically classified as congenital or acquired and as malignant, pre-malignant or benign. The acquired lesions are usually subdivided further according to the predominant cell type. Of the acquired lesions, epithelial (of which the majority are squamous cell), melanocytic, vascular and lymphoid tumors are the most common. It is important to understand the defining features of each of these subtypes. Prompt and appropriate treatment of pre-malignant and malignant disease is paramount with referral to specialist centers when necessary. Treatment has followed a trend from surgical to medical management in recent times.

Bilateral central retinal artery occlusion in a patient with primary central nervous system lymphoma

Dear Editor Primary intraocular lymphoma (PIOL), a subset of primary central nervous system lymphoma (PCNSL), is the commonest neoplastic masquerade syndrome, often leading to delay in diagnosis and poor prognosis [1]. We report a case of bilateral central retinal artery occlusion (CRAO) preceding ocular recurrence of PCNSL. A 58-year-old male had a left frontal lobe tumour debulked in September 2007. Histology showed a diffuse large B-cell lymphoma in keeping with PCNSL. Staging eye examination at the time was negative. In spite of methotrexate-based chemotherapy, the CNS lymphoma progressed, requiring total brain radiotherapy. Further scanning in February 2008 showed complete response to treatment. His concurrent medical problems included steroid-induced diabetes, hypertension and pulmonary embolism for which he was on low molecular weight heparin. He presented to the ophthalmic department with a 4-week history of right-sided painless visual loss in March 2008. Eye examination revealed no perception of light in the right eye, afferent pupillary defect, pale oedematous retina, a cherry red spot, and segmentation of blood within the retinal vessels caused by CRAO. Left visual acuity was 6/60; fundoscopy revealed background diabetic retinopathy, and age-related macular degeneration. History, clinical examination, and investigations were negative for giant cell arteritis (normal erythrocyte sedimentation rate, C-reactive protein, and blood count). The patient returned 1 month later with painful right rubeotic glaucoma, hyphaema, and vitreous haemorrhage restricting fundoscopy. B-scan ultrasonography revealed a highly reflective choroidal mass, measuring 15.9 × 18.1 mm and 4 mm in height, associated with retinal detachment (Fig. 1). Lymphomatous infiltration was suspected. A substantial vitreous biopsy was negative. Staging magnetic resonance imaging excluded intracerebral recurrence, optic nerve/sheath, and systemic involvement. Despite topical treatment the right eye remained painful and was enucleated. Histopathological examination revealed a necrotic tumour with viable peripheral rim, with sheets of lymphoid cells replacing the retina and confined to the subretinal space. Immunohistochemical staining showed the tumor cells were positive for CD20, MUM-1, BCL-2 with patchy staining for CD30, and were negative for BCL6 and CD10.The proliferation fraction with Ki-67 was high (95%). This confirmed diffuse large B-cell lymphoma identical to the original brain biopsy. A thrombus was identified within a central vessel, in keeping with CRAO. The retina was necrotic, with no vascular invasion. The optic nerve was atrophic, and free from tumour infiltration. Left vision subsequently decreased to perception of light in September 2008. Examination confirmed CRAO. Two weeks later, the retinal oedema decreased and pale retinal creamy lesions with retinal exudation and vitritis became evident, suggesting left ocular lymphoma. Further staging and lumbar puncture confirmed significant recurrent CNS lymphoma, but no evidence of optic nerve/sheath infiltration. A course of palliative left orbital irradiation was completed in November 2008. Unfortunately, the patient died in January. Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.