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BACKGROUND/OBJECTIVES: Direct closure (DC) of eyelid defects has been retrospectively shown to give excellent outcomes. We present prospective outcome data as further evidence to promote its wider use. SUBJECTS AND METHODS: A consecutive, unselected, series of patients undergoing eyelid tumour resection was studied prospectively. DC was attempted at the time of biopsy in all of them. If DC proved impossible, delayed reconstruction using other techniques was later performed. Defect size, pre- and post-operative palpebral aperture (PA) measurements and the final visit patients’ and surgeons’ satisfaction scores for function and appearance were recorded. RESULTS: Seventy-three eyelids of 70 patients were studied. Mean resected specimen width was 16.4 mm (4–26 mm) in the DC group, versus 23.9 mm (11–42 mm) for other, non-DC reconstructions. Primary DC was achieved in 74% of this cohort. Mean final post-operative PA measurements in the DC group were 0.7 mm vertically (p = 0.003) and 0.8 mm horizontally (p = 0.009) less than preoperatively, but there was no statistical difference (p = 0.1) in the final horizontal measurements between the operated and un-operated sides in the DC group. DC satisfaction scores were excellent for both eyelid function and appearance. CONCLUSIONS: DC of eyelid defects, irrespective of per-operative PA distortion, gives excellent late post-operative outcomes. We recommend that DC, aligning the closure tension parallel to the lid margin, is attempted whenever wound margin approximation is possible in preference to alternative reconstruction techniques, regardless of any temporary PA distortion and globe displacement that this may cause. Eyelid function and appearance recover to near normal within 2 months.

Background/AimsTo analyse the complications and outcomes of vitrectomy surgery for endophthalmitis.MethodsThis was a retrospective case series. All cases that underwent 23-gauge vitrectomy surgery for endophthalmitis at a tertiary centre between 1 February 2013 and 1 February 2018 were included. Main outcome measures were as follows: visual acuity (VA) at final visit and post-vitrectomy complications.Results33 patients were included in the study with 20 men and 13 women, average age 63 years. Main post-surgical causes for endophthalmitis included phacoemulsification (n=9), trabeculectomy (n=5), intravitreal injection (n=5), corneal graft (n=4), vitreoretinal surgery (n=3) and endogenous endophthalmitis (n=6). Average follow-up was 18 months (SD 14). 21/33 (64%) patients had baseline perception of light VA. Analysis of exogenous endophthalmitis cases only demonstrated: mean LogMAR VA improved significantly from 2.68 to 1.66 (p=0.001). At final follow-up, 12% had VA of 6/12 or better, and 28% had VA of 6/36 or better. Vitrectomy within 7 days resulted in improved final VA outcomes (1.49 vs 2.16 LogMAR, p=0.032). Complications included retinal detachment (24.2%), macular hole (3%), hypotony (6%), suprachoroidal haemorrhage (3%) and enucleation/evisceration (6%).ConclusionVitrectomy for endophthalmitis leads to VA gains in some cases. Surgical outcomes may be improved with early vitrectomy performed within 7 days of the initial event for exogenous endophthalmitis. Patients should be advised of the potential risk of severe complications with/and without surgery.

We report our experience with pediatric endonasal dacryocystorhinostomy (DCR). Multicenter, retrospective, noncomparative study. Cases of pediatric endonasal DCR during 2006-2011 were included from six oculoplastic units. Patients over the age of 16 years were excluded. The outcomes of pediatric endonasal DCR are presented. Indication for surgery, demographics, previous interventions, intraoperative or postoperative complications, follow-up duration, and success rate (defined as significant improvement of epiphora) were evaluated. In total, 116 endonasal DCRs were performed for 103 patients. The mean follow-up period was 8 months (range 3 months to 4 years), with 1 patient lost to follow-up. There were 48 males (mean age 5 years and 9 months) and 50 females (range of 4 months to 16 years), with a total of 98 cases of congenital nasolacrimal duct obstruction (CNLDO) (84.5%) and 18 cases of acquired nasolacrimal duct obstruction (ANLDO) (15.5%). Previous interventions included probing 75.9% (88/116), massaging 43.1% (50/116), and intubation 39.7% (46/116). There were no intraoperative complications. There was one case of postoperative pyogenic granuloma. There were no cases of postoperative infection and postoperative hemorrhage. Ninety percent of procedures were considered successful. Complete symptom resolution was observed in 78% (90/116), significant improvement in 12% (14/116), partial improvement in 2% (2/116), and no improvement in 8% (9/116). In our series, we demonstrated that endonasal DCR is a safe operation and has an overall success rate of 90% for pediatric NLDO.

Objective Ostium closure after endoscopic dacryocystorhinostomy (DCR) is the commonest cause for anatomic failure. We aimed to determine the changes in size of the DCR ostium over time and investigate the correlation of ostium size and surgical outcomes. Design A single surgeon, prospective, nonrandomized, noncomparative, interventional case series. Participants We included a consecutive series of patients who underwent powered endonasal DCR. All patients had radiologically confirmed nasolacrimal duct or canalicular obstruction. Methods Patients were operated on by 1 surgeon (D.S.) and follow-up was at 4 weeks and 12 months. Ostium sizes were measured at the end of surgery and at 4 weeks and 12 months after surgery. Main Outcome Measures Intraoperative and postoperative ostium size, correlation of ostium size, and surgical outcome. Results We included 161 patients who fulfilled the inclusion criteria. Three patients were lost to follow-up. The ostium measured 8.6 (95% confidence interval [CI], 5.0–12.2) by 13.4 (95% CI, 10.3–16.5) at the time of surgery and 5.7 (95% CI, 2.3–9.0) by 9.5 (95% CI, 6.0–13.0) at 4 weeks, and 4.8 (95% CI, 1.9–7.7) by 8.2 (95% CI, 4.5–11.9) at 12 months. There was significant ostial shrinkage from surgery to 4 weeks (mean shrinkage of 50%) and from 4 weeks to 12 months (mean shrinkage of a further 15%). The intraoperative ostium size and postoperative size were positively correlated. Ostial size was not predictive of final ostial patency and symptomatic resolution of epiphora. Conclusions After endoscopic DCR, the final ostium size on average is 35% of the original at 12 months postoperatively. The majority of the ostium shrinkage occurs within 4 weeks postoperatively with a lesser degree of shrinkage between 1 and 12 months postoperatively. Ostium size was not predictive of overall surgical outcome. Financial Disclosure(s) The authors have no proprietary or commercial interest in any of the materials discussed in this article.

The levator palpebrae superioris (LPS) muscle is the main retractor of the upper eyelid, responsible for elevating the upper eyelid and maintaining it in an open position. Sound knowledge of its anatomy and adjacent structures is essential for eyelid surgery. Work from researchers and anatomists over the years continue to enrich our understanding in the anatomy of the LPS. In this review, we present an update on the anatomy of the LPS and its surgical implications. Important adnexa such as Whitnall's ligament, intermuscular-transverse ligament and Müller's muscle are also covered.

The term 'functional block' is used to encompass the concept of lacrimal drainage dysfunction in the presence of anatomical patency. There is significant variability in the nomenclature, clinical and investigative criteria used in the literature to define this entity. This has led to confusion and lack of comparability of studies looking at this group. The clinical features, investigative findings and treatment options in this group of patients are described. In addition, the need to differentiate between nasolacrimal stenosis and 'functional block' is emphasized, as evidence suggest patients with nasolacrimal duct stenosis have better outcomes with dacryocystorhinostomy. To better define the disease entity and enable comparability of future studies, it was proposed that this entity be replaced by the term functional epiphora with no delay, pre- or post-sac delay.

Background: To estimate the proportion of cataract surgery performed at various visual acuity and lens opacity thresholds that would coincidentally treat early angle-closure disease, and to estimate the effect of this surgery on the incidence of primary angle-closure glaucoma. Design: Cross-sectional, population-based survey in Meiktila, Myanmar. Participants: Total of 2076 inhabitants, 40 years of age and over were included. Methods: Eyes with cataract-induced visual impairment, and primary angle-closure disease were identified. Analyses were stratified by various pinhole-corrected visual acuity and Lens Opacity Classification System III scores thresholds. Main Outcome Measures: The dual role of cataract surgery in primary cataract treatment and primary angle-closure glaucoma prevention was estimated. Results: Of 4153 eyes available for analysis, 261 eyes were either primary angle-closure suspect or primary angle closure; 975 eyes had a visual acuity of

The swinging eyelid procedure is a versatile technique to approach orbital and periorbital surgical fields with less visible scar. Although mainly used in orbital surgeries, this procedure can also be used to expose the zygomatic arch and periorbital areas. The swinging eyelid procedure, therefore, enables appropriate reduction of zygomaticomalar fracture under direct visualization. We used this technique for a 27 years old man with a displaced zygomaticomalar fracture that pushed on the lateral rectus muscle. Good functional and cosmetic results were obtained postoperatively without ocular motility impairment.

To present our experience of early endonasal DCR (endoDCR) in the treatment of acute dacryocystitis (AD). Methods. International multicenter non-comparative retrospective study.Eighteen patients were identified. All were treated with antibiotics prior to surgery with a median of time from referral to endoDCR surgeon to surgery of 3 days (range 1-7). Surgery was performed using mechanical powered endoDCR (MENDCR) in 15/18 (83.3%) cases; mitomycin C was used in 5/18 (27.8%) and all cases underwent bicanalicular intubation. An increase in perioperative bleeding was noted in 5/18 (27.8%), causing interference in surgical technique in one (5.6%). Resolution of AD was seen in all cases, with no recurrences. 17/18 (94.4%) cases were free of epiphora at median follow-up of 12 months (range 2-36), with nasal endoscopy revealing free flow of fluorescein through the ostium in 17/18 (94.4%) of cases. The median total length of stay was 1 night (range 0-3).EndoDCR surgery performed early in AD led to rapid resolution of the condition in all cases and was associated with subsequent anatomical and functional success in 94.4% of cases. Early endoDCR surgery in the context of AD and the potential associated health economic benefits are worth further consideration and study.

An 86-year-old man with iatrogenic eyelid-to-globe malposition had a combination of medial tarsal strip, lateral periosteal sling, and inferior tarsal support with the ear cartilage. An appropriate apposition between the globe and lower eyelid was established postoperatively with good tear meniscus and acceptable cosmetic results.

Purpose To characterize the clinical features, aetiology and management of ophthalmic symptoms in adult patients with Parinaud syndrome. Methods This is a retrospective, non-comparative observational case series. We reviewed 40 consecutive charts of adult patients with the clinical diagnosis of Parinaud syndrome at the Royal Adelaide Hospital Department of Ophthalmology in Adelaide, South Australia, between 1991 and 2016. Charts were reviewed for the following: (1) demographic information, (2) clinical presentation, (3) neuro-ophthalmology signs, (4) aetiology of Parinaud syndrome, and (5) management. Examination findings were collected at initial evaluation, throughout the course of follow-up, and at last follow-up. Results All the cases were assessed by one of the authors (JLC). The commonest presenting symptoms were diplopia (67.5%) and blurred vision (25%) followed by visual field defect (12.5%), ataxia (7.5%) and manifest squint (7.5%). The commonest presenting signs were vertical gaze palsy (100%), convergence-retraction nystagmus (87.5%) and light-near dissociation (65.0%). Only 65.0% patients had the classical triad of vertical gaze palsy, convergence-retraction nystagmus and light-near dissociation. Midbrain pathologies including haemorrhage (30.0%), infarction (20.0%) and tumour (15.0%) were the commonest aetiology. Pineal region tumours accounted for 30.0% of presentations. Symptoms were managed conservatively in 45% of cases with temporary occlusion, prisms or refractive correction, and observation in 42.5% of cases. Surgical intervention for refractory diplopia was required in 12.5% of cases, of which 80% reported symptom resolution following surgery. Conclusion Our series highlights the variable clinical presentation of Parinaud syndrome. The classic triad of conjugate upgaze paralysis, convergence-retraction nystagmus and light-near dissociation was only present in 65% of cases. Pineal neoplasms remain an important aetiological consideration; however, primary midbrain pathology including infarction and haemorrhage constituted the majority of our cases and should be considered in all patients. Conservative management approaches for ocular symptoms are sufficient in most cases although surgical treatment of upgaze palsy can be a useful option in refractory cases.

The role of assisted local anaesthetic (aLA) for both endoscopic and external dacryocystorhinostomy is a well-tolerated and established approach. However the tolerability of aLA is unclear with powered burrs used in powered endoscopic DCR (PEDCR). We aim to evaluate the acceptability of aLA for PEDCR.This is a prospective, interventional, non-randomized, non-comparative, single surgeon study. Consecutive series of patients that underwent PEDCR performed under aLA were included in the study. Tolerability was assessed by intra-operative pain score on 100 point visual analogue scale (VAS) and if patients were willing to have aLA-PEDCR again.A total of 44 PEDCR was performed on 42 patients.56% of patients reported 0 on 100 point VAS, 65.9% (29/44) reported10, 88.6% (39/44) reported20 and no patients had score of30/100. 97.7% (43/44) of patients are happy to have PEDCR performed again under aLA. The one patient unwilling to have a repeat aLA-PEDCR was not because of pain but intolerance to the sound of drilling.PEDCR with assisted local anaesthetic is well tolerated and accepted by patients.

Purpose To describe the incidence of canalicular closure with powered endonasal dacryocystorhinostomy (DCR) without canalicular intubation in primary acquired nasolacrimal duct obstruction (PANDO). Design A single-surgeon, prospective, nonrandomized, noncomparative, interventional case series. Participants Consecutive patients attending a specialist clinic of an oculoplastic surgeon (DS) with radiologically confirmed diagnosis of PANDO. Cases of canalicular disease were excluded. Methods Patients with radiologically confirmed PANDO without canalicular involvement underwent endonasal DCR without intubation. The operation was performed by 1 surgeon (DS) and follow-up was at 4 weeks and 12 months. Main Outcome Measures Outcomes were recorded as subjective symptomatic relief at 12 months and endoscopic evidence of ostium patency and canalicular patency. Results There were 132 cases that fulfilled the inclusion criteria. Three cases were lost to follow-up. Preoperatively, 96.3% of cases had Munk scores of >2. Of the 129 cases, 127 (98.5%) had endoscopic evidence of a patent ostium with a positive endoscopic dye test at the 12-month follow-up. All cases had a patent canalicular system as demonstrated by syringing and probing. Of the 129 cases, 117 (90.7%) had subjective improvement of epiphora at 12 months with 88.4% of cases reporting Munk scores of ≤1. Conclusions In this prospective series of nonintubation for PANDO, there were no cases of canalicular closure or stenosis at 12 months. Anatomic and functional success was similar to reported outcomes for DCR with intubation for PANDO. We advocate that routine intubation for the purpose of maintaining canalicular patency is not necessary when performing endonasal DCR in PANDO. Financial Disclosure(s) Proprietary or commercial disclosure may be found after the references.

The authors report a rare case of hemangiopericytoma-solitary fibrous tumor of the eyelid. A 35-year-old male presented with approximately 1-year history of a painless and slow growing mass on his right lower eyelid, which rapidly grew in size over the last few months. The size of the lesion and the location resulted in secondary mechanical ectropion at presentation. The tumor was excised and was found to be a "hemangiopericytoma-solitary fibrous tumor" based on both histopathological and immunohistochemical examinations. Immunohistochemically, the tumor was positive for CD34 and Vimentin but negative for S100 protein and smooth muscle actin. Although initial tumor removal was complete, the patient required a subsequent operation for his residual ectropion. Despite the lesion being large at presentation, surgical intervention resulted in good functional and cosmetic outcome.