Tim Fulcher

Thyroid-Like Ophthalmopathy in a Euthyroid Patient Receiving Ipilimumab

Abstract A 68-year-old lady with metastatic malignant melanoma was treated with Ipilimumab. She presented to Eye Casualty unable to move her eyes. Physical examination confirmed ophthalmoplegia and identified proptosis bilaterally. Radiological imaging showed bilateral enlargement of all the extra-ocular muscles suggestive of thyroid eye disease. Laboratory investigations found this patient to be euthyroid. A diagnosis of thyroid-like orbitopathy secondary to Ipilimumab therapy was made. Thyroid function tests should be performed for all patients prior to their commencement of Ipilimumab. Thyroid-like eye disease may develop in patients treated with Ipilimumab even if they remain euthyroid.

Corneal inlay implantation complicated by infectious keratitis

Background/aims To report five cases of infectious keratitis following corneal inlay implantation for the surgical correction of presbyopia. Methods This was a retrospective, observational case series. Five eyes of five patients were identified consecutively in two emergency departments during a 1-year period, from November 2013 to November 2014. Patients’ demographics, clinical features, treatment and outcomes are described. Results There were four female patients and one male, aged 52–64 years. Three patients had the KAMRA inlay (AcuFocus) and two had the Flexivue Microlens inlay (Presbia Coöperatief U.A.) inserted for the treatment of presbyopia and they presented from 6 days to 4 months postoperatively. Presenting uncorrected vision ranged from 6/38 to counting fingers. One patients corneal scrapings were positive for a putatively causative organism, Corynebacterium pseudodiphtheriticum, and all patients responded to broad-spectrum fortified topical antibiotics. All patients lost vision with final uncorrected visual acuity ranging from 6/12 to 6/60 and best-corrected vision ranging from 6/7.5 to 6/12. Two patients’ corneal inlays were explanted and three remained in situ at last follow-up. Conclusions Infectious keratitis can occur at an early or late stage following corneal inlay implantation. Final visual acuity can be limited by stromal scarring; in the cases where the infiltrate was small and off the visual axis at the time of presentation, the final visual acuity was better than those patients who presented with larger lesions affecting the visual axis. Though infection may necessitate removal of the inlay, early positive response to treatment may enable the inlay to be left in situ.

Does the Timing of Silicone Tube Removal Following External Dacryocystorhinostomy Affect Patients' Symptoms?

Aims: To investigate whether the timing of silicone tube removal after external dacryocystorhinostomy (EXT-DCR) for lacrimal outflow obstruction affects outcome. Methods: Retrospective chart review and follow-up by telephone survey of 205 consecutive patients undergoing EXT- DCR. Long-term success was evaluated by telephone survey. Results: Full data was collected in 180 out of 205 DCRs. Ninety four tubes (52.3%) were removed routinely between 2 and 4 months after surgery, 24 tubes (13.3%) were removed before the planned 2-month period and 62 tubes (34.4%) were removed after the planned 4-month period. The three groups (early, routine and late) were comparable in terms of age, gender distribution, mode of anaesthesia, proportion of repeat EXT-DCRs and seniority of surgeon. The mean follow-up period was 3 years and 10 months. One hundred and twenty-eight of the 155 patients (82.5%) were contactable by phone. In the routine tube removal group, at the time of follow-up, 65.1% experienced complete symptom resolution, 25.4% experienced partial symptom resolution, 6.3% experienced no symptom resolution and 3.2% experienced worse symptoms. In the early tube removal group, at the time of follow-up, 63% experienced complete symptom resolution, 32% experienced partial symptom resolution and 5% experienced no change in symptoms. In the late tube removal group, at the time of follow-up, 70% experienced complete symptom resolution, 21.5% experienced partial symptom resolution and 8.5% experienced no symptom resolution. There was no statistically significant difference in the outcome of the three groups. Conclusions: Our experience and this study suggest that timing of silicone tube removal does not influence surgical success in EXT-DCR regardless of the cause of early or late tube removal.

Porous Orbital Implant Exposure: The Influence of Surgical Technique

Abstract Objectives: To examine orbital implant exposure rates following enucleation and evisceration. Methods: A retrospective chart review of all patients who underwent an evisceration or enucleation in a single centre over a 5-year period was performed. The indication for surgery, the type and size of orbital implant used, details of the surgical technique adopted and the postoperative complications observed, in particular orbital implant exposure, were recorded. Results: Over a 5-year period 24 patients had enucleation and 14 had evisceration; 22 of these procedures were performed by an ophthalmic surgeon with a special interest in orbit and oculoplastics while the remaining 16 procedures were performed by 5 ophthalmic surgeons with other sub-specialty interests. Orbital implant exposure occurred in 8 cases. One case had been performed by the first of these surgeons described. Implant exposure occurred in 4% of cases performed by this surgeon. The remaining 7 cases had been performed by the group of surgeons with sub-specialty interests outside of orbit and oculoplastics. Implant exposure occurred in 48% of cases performed by this group. Conclusions: Orbital implant exposure remains a significant cause of morbidity in patients undergoing enucleation and evisceration. Rates of orbital implant exposure were significantly lower when surgery was performed by an orbital surgeon. Differences in surgical technique are the most likely explanation.

Transient, complete loss of vision secondary to posterior diffusion of an ophthalmic viscosurgical device–lidocaine solution during complicated phacoemulsification

difficult because of multiple adhesions and the eye became immediately hypotonic even before the cannula was used. The globe was ruptured by the scissors. Patients with a history of ophthalmic surgery or scleritis present thinner sclera and scar tissue. SubTenon anesthesia should be performed without resistance with blunt scissors and a cannula. Otherwise, an alternative quadrant or method of anesthesia should be considered.

Pyoderma gangrenosum affecting the eye, orbit, and adnexa. A review

ABSTRACT While pyoderma gangrenosum (PG) most commonly affects the skin it can also involve other organs. It rarely affects the eye, orbit, or adnexa. Its early recognition and proper management with prompt initiation of immunosuppressive therapy are essential for the preservation of the eye and, in turn, vision, in these cases. Here, we review the limited literature already published regarding ocular involvement in PG.

A template for reducing ophthalmology outpatient waiting times: community ophthalmic care

BackgroundThrough an Irish Health Service Executive (HSE) initiative to tackle excessive hospital outpatient waiting times, 996 patients referred to the Ophthalmology Outpatient Department (OPD) of the Mater Misericordiae University Hospital (MMUH), Eccles Street, Dublin 7, Ireland, were outsourced to a community medical eye clinic (CMEC) for consultation with specialist-registered ophthalmologists.AimsThe study aims to determine if patients referred as routine to the OPD department could be managed in a community setting.Methods996 patients were reviewed in the CMEC, and their data was collected and placed into a spreadsheet for analysis.Results61.2% of patients referred to the OPD were fully managed in the community clinic, and 34.9% required ophthalmic surgery in hospital.ConclusionsBy facilitating direct listing of some of the surgical patients to the hospital theatre list, 89.8% of the 996 referrals received treatment without needing to attend the hospital outpatients department.

Orbital abscess following posterior subtenon injection of triamcinolone acetonide

ABSTRACT Orbital cellulitis is a serious sight threatening and potentially life threatening condition which can be complicated by orbital abscess formation. Posterior subtenon (PST) injection of corticosteroid is commonly used in the treatment of posterior segment inflammation including post-operative macular oedema. We report a case of orbital abscess formation as a late complication of PST triamcinolone acetonide and discuss the presentation, diagnosis and management.

Surgical Management of Heavy Eye Phenomenon

Heavy eye phenomenon can be cosmetically unaccepted due to significant pseudoproptosis and hypotropia. We highlight the salient features of this condition, and report successful cosmetic outcome following a staged procedure comprising orbital decompression and horizontal recti surgery.