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Background and Aims: Proxymetacaine eye drops are known to reduce subjects' blink rates' and are well tolerated compared with other topical anesthetic eye drops.' A randomized, controlled trial was performed to assess their routine use in fluorescein angiography, investigating their effect on patient comfort and image quality.Methods: One hundred patients undergoing routine fluorescein angiography were randomized to receive either proxymetacaine (0.5%) or saline eye drops to both eyes. The degree of comfort of the patient and any stinging sensation induced by the eye drops were recorded, as were the photographer's independent assessment of image quality and overall procedural ease (using standardized linear analog scales). Requests made to hold the patient's eyelids open were also noted. Results: The patients' comfort score data were not normally distributed and were negatively skewed. The comfort scores of the proxymetacaine group were significantly higher than those of the control group (proxymetacaine group: n = 50, median score 9; control group: n = 48, median 8; Mann-Whitney U test = 925, P = .044). Proxymetacaine had no significant effect on the photographer's scores for image quality and overall ease of procedure, or on the requests for eyelids to be held open. Conclusion: Although proxymetacaine use was associated with a significantly higher comfort score than in the control group, it is difficult to recommend routine use of proxymetacaine in fluorescein angiography because most patients in both groups found the procedure very tolerable. Moreover, proxymetacaine use did not significantly improve the overall ease of the procedure or the image quality, as judged by the photographer. [ABSTRACT FROM AUTHOR]

Background: In 2020, routine cataract surgery was halted in most countries due to the COVID-19 pandemic in order to reduce transmission. With a consequent lack of theatre space, we developed a safe cataract pathway in outpatient department clean rooms to minimize patient exposure and time spent in hospital using a sterile laminar air flow device. We describe our initial experiences of restarting elective cataract surgery in the UK outpatient setting, outside of the operating theatre environment., Methods: This was a prospective consecutive study of our clinical practice. A sterile air zone unit, the Toul Meditech Operio Mobile device, was used to create a sterile surgical site in three separate outpatient clean rooms from May 2020 to December 2021 in different geographical locations within Herefordshire, UK. Observations of the time spent in the department and a formal patient satisfaction survey were carried out for the initial 100 patients. All patients were followed up to assess development of post-operative complications., Results: 1269 patients were included in the study. No patients sustained post-operative infection (n = 0/1269, 0%). For the initial 100 patients, the average time spent within the department was 74.3 min (unilateral cases, range 45-115 min) and 93.1 min (bilateral, 55-135 min). Patient satisfaction was high., Conclusion: Initial results demonstrate a safe, efficient and effective cataract surgery pathway with high patient satisfaction by converting outpatient clean rooms into ophthalmic operating theatres using the Toul Meditech Operio Mobile., (© 2022. The Author(s), under exclusive licence to The Royal College of Ophthalmologists.)

Trainee involvement in cataract surgery is vital to allow proper training of the next generation of ophthalmic surgeons. However, recent changes in the UK Law, coupled with open publication of National Cataract Dataset results, lead us to conclude that the status of being a trainee is itself a material risk that now needs to be divulged to patients during the consent process. The opinions of current trainee surgeons in the UK were sampled via questionnaire and clinical negligence counsel was involved in the authorship of the paper in order to analyse the legal issues at stake. Attitudes towards consent regarding trainee involvement in UK cataract surgery need to change.

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: We report a case of a HLA-B27 negative patient presenting with severe, bilateral, idiopathic acute anterior uveitis with acute hypotony and hypotony maculopathy as their first uveitic episode., Case Presentation: Within a week of onset of her first episode of acute anterior uveitis, a 45 year-old Caucasian lady developed profound ocular hypotony with unrecordable intraocular pressures, reduced vision and choroidal folds. All investigations were negative. Uveitic hypotony responded slowly to corticosteroids--intravenous, oral and topical--with normalization of intraocular pressure and resolution of choroidal folds after two months. Anterior uveitis and hypotony have not returned with six months of follow-up., Conclusion: Bilateral, profound hypotony maculopathy may present acutely in idiopathic acute anterior uveitis, may be slow to respond to treatment and should be considered as a cause of vision loss in patients with this condition.

We report the case of a 3-year-old child, who presented with lid swelling which progressed to proptosis of the left eye. He also had systemic symptoms of fatigue and weight loss. An examination revealed hepatosplenomegaly and lymph node enlargement. Investigations showed a peripheral smear with blast cells, which were also revealed through a bone marrow biopsy. A CT scan showed a mass lesion in the left orbit that had infiltrated into the surrounding tissues. He was diagnosed with acute lymphoblastic leukaemia (ALL) with left-sided orbital mass secondary to it. Haematogenous masses in the orbit are commonly due to granulocytic sarcomas, which are usually associated with acute myelogenous leukaemia (AML), not ALL, and are rare especially when they precede systemic disease.

Aims: To report an unusual case of acute dacryocystits with fully patent nasolacrimal duct at follow-up after incision and curettage., Case Report: A 63-year-old patient with acute dacryocystitis and nasolacrimal duct abscess. CT orbits confirmed dacryocystitis without any orbital collection. Incision and drainage of the abscess was performed., Results: Postoperative syringing of nasolacrimal duct demonstrated a fully patent nasolacrimal duct, with long term relief of epiphora., Conclusion: In some patients, dacryocystorhinostomy is not required after incision and drainage of a nasolacrimal abscess; reversible causes such as dacryoliths should always be considered.

Prostaglandin analogs are commonly used in the treatment of glaucoma. They are a safe and effective treatment associated with few side effects. Common local side effects include conjunctival hyperemia, iris pigmentation, and eyelash hypertrichosis. The authors present a case of a patient using travoprost treatment for primary open-angle glaucoma, who underwent excision of a lower eyelid basal cell carcinoma and reconstruction with an upper eyelid tarsoconjunctival flap and overlying skin graft. The patient developed hypertrichosis of the skin graft attributable to prostaglandin analog use.

Purpose: To present a modified transconjunctival approach for involutional entropion repair., Methods: This study is a retrospective consecutive single surgeon case series using a transconjunctival approach for involutional lower lid entropion (ILLE) repair., Results: Eleven eyes were operated for involution entropion with 9 cases of complete resolution. Two patients required further Jones' retractor plication., Conclusion: Transconjunctival involutional lower lid entropion repair is a time-efficient, safe, and efficacious technique. The scar free technique described leads to full restoration of lower lid anatomy. In contrast to other reports we found a relatively low rate of recurrence on follow-up.

Background: Invasive fungal sinusitis is a rare condition that usually occurs in immunocompromised patients and often presents as an orbital apex syndrome. It is frequently misdiagnosed on presentation and is almost always lethal without early treatment., Design: Retrospective case series of 14 consecutive patients with biopsy-proven invasive fungal sinusitis from four tertiary hospitals., Participants: Fourteen patients (10 men and 4 women; age range 46-82 years)., Methods: Retrospective chart review of all patients presenting with invasive fungal sinusitis between 1994 and 2010 at each hospital, with a close analysis of the tempo of the disease to identify any potential window of opportunity for treatment., Main Outcome Measures: Demographic data, background medical history (including predisposing factors), symptoms, signs, radiological findings, histopathological findings, treatment approach and subsequent clinical course were recorded and analysed., Results: Only one patient was correctly diagnosed at presentation. Only two patients were not diabetic or immunocompromised. The tempo was acute in two patients, subacute in nine patients and chronic in three patients. In the subacute and chronic cases, there was about 1 week of opportunity for treatment, from the time there was a complete orbital apex syndrome, and still a chance for saving the patient, to the time there was central nervous system invasion, which was invariably fatal. Only two patients survived - both had orbital exenteration, as well as antifungal drug treatment., Conclusions: Invasive fungal sinusitis can, rarely, occur in healthy individuals and should be suspected as a possible cause of a progressive orbital apex syndrome., (© 2012 The Authors. Clinical and Experimental Ophthalmology © 2012 Royal Australian and New Zealand College of Ophthalmologists.)

Background: We present a series of patients with acute suppurative bacterial dacryoadenitis and review the clinical presentation, microbiology, treatment options and outcome., Methods: A multicentre, retrospective, case series review of patients with a clinical diagnosis of acute bacterial suppurative dacryoadenitis (ASBD). Records were examined to obtain information regarding patient demographics, presenting symptoms and signs, radiology, microbiology, management, outcomes and follow-up., Results: 11 patients (9 men, 2 women; mean age 43.9 years, range: 6-82 years) were included. Average time to presentation was 2.8 days, and predisposing conditions were found in 45% of cases. Common presenting symptoms were eyelid swelling, pain, redness and diplopia, and common signs were ptosis, discharge and restriction of eye movements. The most common causative bacteria were Staphylococcus aureus and skin flora. Lacrimal gland swelling was universally seen on CT, with globe indentation of displacement in 27% of cases. Intravenous antibiotics were used in 91% of cases, which subsequently resolved over an average period of 9.7 days. Those with abscess formation (n=2) required incision and drainage., Conclusions: ASBD is a rare condition that resolves quickly if managed appropriately. Underlying anatomical, infectious or inflammatory conditions should be investigated, and skin commensals should be covered with the instigation of antibiotic therapy.

A 37-year-old man presented with swelling under the lateral aspect of the right upper eyelid. He had sustained an alkali ocular chemical injury 10 years before resulting in persistent lateral canthal webbing. Diagnosis was made of lacrimal duct cyst (dacryops) and webbing of the lateral canthus and the findings were confirmed on computed tomography. He underwent lacrimal duct cyst marsupialisation and lateral canthoplasty with good cosmetic result, and there was no recurrence of symptoms at 2 months post-operatively. Lacrimal duct cyst is a rare clinical entity and has been postulated to result from localized inflammation or trauma to conjunctiva. To the best of our knowledge, this is the first report of dacryops following a chemical injury.

Acute dacryocystitis is a rare complication of infectious mononucleosis with only three previous reports in the English literature. We present two further children with acute dacryocystitis and clinical and laboratory features of Epstein-Barr Virus related infectious mononucleosis. Both were treated with systemic antibiotics and one child additionally required surgical drainage of a lacrimal sac abscess. Both children made a complete recovery without any lacrimal symptoms. Acute dacryocystitis is uncommon in children without a history of congenital nasolacrimal duct obstruction, and an underlying systemic condition such as infectious mononucleosis should be suspected. In such patients, dacryocystitis can be expected to resolve without symptoms of nasolacrimal duct obstruction and dacryocystorhinostomy is seldom required.

Aims: To describe the outcomes and complications for composite eyelid grafts in a large case series over a 9-year period., Method: A retrospective study of all patients who underwent a composite graft for eyelid reconstruction between January 2000 and May 2009. A composite eyelid graft involves the excision of a full thickness pentagonal wedge from the donor eyelid, which is inserted into the recipient eyelid defect. The orbicularis muscle is discarded from the composite graft. Initial diagnosis, complications, postoperative eyelid contour and colour were recorded., Results: Forty-two patients were identified in the study period; the mean age was 69 years. Reconstruction following basal cell carcinoma excision was the commonest indication for surgery. Thirty-five composite grafts were performed for lower eyelid defects and seven for upper lid defects. The average size of the grafts was 9.1 (range 7-12) mm. Five patients required two grafts to reconstruct the defect. Thirty-six (86%) patients achieved a satisfactory contour and 33 (78%) patients had good matching skin colour. Partial dehiscence occurred in five patients and three patients had bulkiness of the graft postoperatively. We had no episodes of graft failure, although two patients had skin necrosis, which resolved., Conclusion: Composite eyelid grafts when combined with mobilisation of the recipient orbicularis muscle can result in good preservation of eyelid function with satisfactory cosmesis.

Objective: The aim of this study was to report a case of Charles Bonnet syndrome secondary to eye patching following eyelid reconstruction with an unusually acute onset., Method: An observational case report was conducted., Results: The patient reported complex visual hallucinations that started less than 10 minutes after patching of her right eye (the left eye had poor vision from previous trauma). The patch was removed after 2 days, and the hallucinations gradually stopped over the subsequent 2 days., Conclusion: This case of Charles Bonnet syndrome describes an unusually acute onset of hallucinations and is only the second reported case following eye patching. Eye patching is commonly used in a number of situations, and it is important to be aware of this association, as the diagnosis of Charles Bonnet syndrome is often overlooked., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Objective: To present our experience of early endonasal DCR (endoDCR) in the treatment of acute dacryocystitis (AD). Methods. International multicenter non-comparative retrospective study., Results: 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)., Conclusions: 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.

Ptosis surgery has seen many advances in the last few decades, the most important of which have emerged as a result of better understanding of the anatomy and physiology of the eyelid and orbit. Anterior approaches such as a levator aponeurosis advancement, tarsoaponeurectomy and posterior repair involving resection of Muller's muscle have proven to be effective in most cases. The focus of this article is a discussion of the indications, operative techniques, success rates and complications of transcutaneous levator advancement in detail.

Purpose: To describe a case series of patients with anterior orbital invasion by medial canthal basal cell carcinoma (BCC) managed with non-exenterating surgery., Design: International, multicenter, retrospective, noncomparative, consecutive case series., Participants: Twenty patients identified from the individual institutions' databases with histologically confirmed orbital invasion by periocular BCC., Methods: Examination of charts, relevant imaging, and histopathologic data., Main Outcome Measures: Demographics; clinical characteristics and radiologic features; histopathologic features; surgical techniques for excision, reconstruction, and subsequent procedures; complications; visual acuity; and recurrence., Results: Twenty patients were identified. Twelve of 20 patients (60%) had recurrent BCCs, with 1 patient having had prior radiotherapy for previously incomplete excision. Eighteen of 20 patients (90%) had a palpable mass, 16 of 20 patients (80%) had clinical involvement of the nasolacrimal system, and 1 of 20 patients (5%) had limited extraocular movements. Preoperative radiologic evidence of orbital invasion was found in 10 of 20 patients (50%). Histologic evidence of orbital invasion was present in every patient, the subtypes being infiltrative (9/20, 45%), nodular (4/20, 20%), micronodular (2/20, 10%), multifocal (1/20, 5%), and mixed (4/20, 20%); extratumoral perineural invasion was present in 1 patient (5%). Final margins were clear in 18 of 20 patients (90%), positive in 1 of 20 patients (5%), and unclear in 1 of 20 patients (5%). Reconstruction was by direct closure in 1 patient and by a variety of standard oculoplastic flaps and grafts in 19 of 20 patients (95%). Twelve of 20 patients (60%) had postoperative extraocular muscle movement restriction, and 15 of 20 patients (75%) had epiphora. Subsequent revision procedures were needed in 12 of 20 patients (60%), including insertion of a lacrimal bypass tube and revision of medial canthal position. At a mean follow-up of 38 months, 18 of 20 patients (90%) were still alive (2 deaths due to other causes) with 1 recurrence (exenterated). Postoperative visual acuity was within 2 Snellen lines of preoperative visual acuity in 17 of 20 patients (85%)., Conclusions: With careful planning and margin control, conservative surgery in this highly selected group proved possible with a low rate of disease recurrence, albeit with a relatively short follow-up. Postoperative complications, such as epiphora and ophthalmoplegia, were largely expected; most patients underwent subsequent revision procedures to address these and other complications., Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article., (Copyright © 2010 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: To elucidate the insertion of the levator aponeurosis and Müller's muscle on the upper eyelid of Caucasians through cadaveric study., Methods: Sagittal full thickness sections of 11 cadaveric upper eyelids in Caucasian (7 right and 4 left; age range, 78-101 years old at death; age average, 87.7 years old) were prepared and stained with Masson's trichrome. The specimens were examined microscopically to discern the configuration of the levator aponeurosis, Müller's muscle and tarsus. Main outcome measures were the position of insertion of the levator aponeurosis and Müller's muscle onto tarsus., Results: In all 11 specimens, the levator aponeurosis inserted onto the distal tarsal plate, reaching the level of the marginal arterial arcade. The extension of Müller's muscle in 4/11 specimens (36.4%) surpassed the superior margin of the tarsal plates, but did not reach any further down the tarsus than its upper third; in the remaining seven specimens (63.6%), Müller's muscle attached to the superior aspect of the tarsal plate., Conclusions: This study from Caucasian cadavers suggests that fibres from the levator apponeurosis extends down to the distal portion of upper eyelid tarsus, with majority of Müller's muscle insertion being onto the superior aspect of the tarsal plate.

Aim: To describe air regurgitation as a complication in patients on continuous positive airway pressure (CPAP) therapy for obstructive sleep apnoea (OSA) following dacryocystorhinostomy (DCR) surgery with or without Lester-Jones tube (LJT) insertion., Methods: A retrospective review of all patients with air regurgitation on CPAP therapy who previously underwent a DCR/LJT procedure. Patient demographics, lacrimal surgical history, CPAP therapy and outcome were recorded., Results: Four male patients were identified. The mean age at presentation was 54 years. Two patients had an LJT inserted, and two patients had a DCR procedure, one was external, and one was endonasal. All four patients had resolution of their epiphora. Three patients had superficial epithelial keratopathy requiring lubricant therapy. All patients attempted using ointment to act as a barrier over the neo-ostium, which was unsuccessful. One patient had the LJT removed with resolution of the air regurgitation. Two patients changed their CPAP machines to variable, and three patients reduced the pressure of their CPAP therapy without any improvement. All three patients had persistence of air regurgitation at a mean follow-up of 18 months., Conclusions: Air regurgitation can occur following naso-lacrimal surgery in patients on CPAP therapy. Although this is an unusual complication, it should be discussed with the patient at the time of obtaining informed consent.

Purpose: To describe the clinical, immunohistochemical and prognostic features, as well as outcomes of a large series of patients with orbital and periorbital diffuse large B-cell lymphoma (DLBCL)., Design: This study is a multicentre, retrospective non-comparative consecutive case series., Methods: The setting for this study was institutional. A total of 37 consecutive patients identified from the institutions' databases with periorbital and orbital DLBCL were enrolled in the study. A retrospective chart review was used for observation. The main outcome measures were patient demographics, clinical features, imaging, immunohistochemical and histopathological data, treatments administered, and survival., Results: A total of 20 out of 37 cases (54.1%) represented localised periorbital disease (group L), 11 of 37 (29.7%) had systemic disease at presentation with periorbital disease (group S1), and 6 of 37 (16.2%) had previous history of systemic lymphoma (group S2). In all, 28 out of 30 (93.3%) patients were CD20+, 5 of 25 (20%) were CD3+, and 11 of 11 (100%) were CD79a+ (varying denominators reflect the different numbers of patients tested). A total of 25 out of 32 patients (78.1%) received chemotherapy, 14 (43.8%) received rituxmab plus chemotherapy, and 19 (59.3%) received radiotherapy. Nine deaths occurred, one in group L (not lymphoma related), six in group S1, and two in group S2. Five-year Kaplan-Meier survival estimates were 55.9% for all cases, 90.9% for group L, 36.0% for group S1, and 0% for group S2. One-year progression-free survival estimates in groups S1 and S2 combined were 58.3% for patients treated with rituximab and 28.6% for those who were not., Conclusions: To our knowledge, this report represents the largest series of patients with periorbital and orbital DLBCL in the literature. The difference in survival between groups L, S1 and S2 was striking, reflecting the grave prognosis of systemic DLBCL, but conversely the relatively optimistic outlook for patients with localised disease. Rituximab plus chemotherapy may be associated with increased survival.

Purpose: To describe 6 new cases of primary orbital liposarcoma and provide a review of the relevant literature., Design: Noncomparative consecutive case series and literature review., Participants: Six patients with primary orbital liposarcoma., Methods: Review of patient charts, imaging, and histopathology; literature review., Main Outcome Measures: Patient demographics; clinical presentations; results of radiologic imaging; histopathology; surgical techniques used and their complications; other treatment modalities; outcomes and recurrences., Results: Six cases of primary orbital liposarcoma were identified, 5 of which were primary presentations and 1 of which was a recurrence. In 4 cases, exenteration was deferred, resulting in recurrence of disease in all 4. All cases were exenterated, and 2 cases had local recurrence despite exenteration. Two cases were associated with the Li-Fraumeni syndrome and other malignancies. Literature review identified 34 other cases of primary orbital liposarcoma, which, partly because of its rarity, is frequently initially misdiagnosed. The most common subtype is myxoid (56.8%); other types are pleomorphic (10.8%) and well differentiated (29.7%). Well-differentiated tumors have the best prognosis. Non-exenterating surgery was associated with recurrence, although recurrence post-exenteration also occurred. Although radiotherapy has an established role in the treatment of nonorbital liposarcoma, the role of both radiotherapy and chemotherapy in the management of primary orbital liposarcoma is still unclear., Conclusions: Orbital liposarcoma remains a diagnostic and surgical challenge. Exenteration remains the treatment of choice, but clinicians must also be aware that liposarcoma may herald the diagnosis of the Li-Fraumeni familial cancer syndrome., (Copyright 2010 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

A 45-year-old woman presented with an 8-month history of a firm mass over the right superonasal orbital rim, followed by an episode of hemorrhage and anesthesia 5 months later. Clinical history and CT were suggestive of a venous malformation with phleboliths. Excision biopsy was performed. Histopathology revealed intravascular papillary endothelial hyperplasia with fibrotic-calcific changes. Hypoesthesia in the supra-orbital region persisted postoperatively. Although a benign lesion, intravascular papillary endothelial hyperplasia should be considered a differential diagnosis of a vascular lesion with compressive effects.

Purpose: To describe the use of a lacrimal bypass tube in the management of epiphora in patients with epiphora attributable to lacrimal pump failure in facial palsy., Design: Multicenter retrospective interventional study., Methods: Information regarding patient demographics, diagnoses, symptoms, oculoplastic interventions, dacryocystorhinostomy, and Jones tube insertion were collected from patient charts., Results: Eighteen patients were identified, in all of whom epiphora was clinically and/or radiologically assessed as being attributable to pump failure, lid laxity having been corrected. All had constant epiphora prior to Jones tube insertion. Dacryocystorhinostomy was performed in all; insertion of a Jones tube was performed simultaneously in 12, with delayed insertion in 6. Patients' subjective epiphora improved postoperatively in 15 of 18 (83.3%) and at final median follow-up of 27.5 months (range, 6 months to 31 years); symptoms were improved in 13 of 18 (72.2%). Complications occurred in 13 of 18 (72.2%), including tube extrusion and the need for repositioning., Conclusions: In this highly selected group of patients, Jones tube insertion led to symptom improvement in 83.3% postoperatively and in 72.2% at median follow-up of 27.5 months. Tube extrusion and migration were common, although such complications were not unexpected and were treatable., (Copyright 2010 Elsevier Inc. All rights reserved.)

Aim: To present the clinical features and management outcomes in a large longitudinal series of patients with craniofacial fibrous dysplasia (CFD)., Methods: Retrospective interventional consecutive case series. Main outcome measures included signs and symptoms, radiographic findings, long-term outcomes, and postoperative complications., Results: A total of 42 patients with CFD were identified. The mean age at presentation was 16.7 years; mean follow-up was 12.6 years. Out of these 42 patients, 37 (88.1%) had unilateral involvement and 5 (11.9%) had bilateral involvement, of which 3 (7.1%) had McCune-Albright syndrome. The commonest presenting symptom was facial asymmetry (36 cases, 86%). The frontal bone was the most commonly involved (27 cases, 64.3%), zfollowed by the sphenoid (24 cases, 57.1%). The most common pattern of bone involvement was monostotic (32 cases, 76.2%). Radiological optic canal involvement occurred in 18 eyes of 15 (37.5%) patients, with optic atrophy in 9 eyes (18.8%) of 7 patients (16.7%). Surgical intervention was performed in 30 (71.4%) cases for both functional and reconstructive reasons. Optic canal decompression was performed in three cases, in all of which stabilization of vision was achieved; no patient lost vision as a result of surgery., Conclusions: In this large longitudinal series of CFD, visual loss was not uncommon and occurred insidiously. The presenting clinical and radiological features, surgical interventions, and outcomes are discussed.

The gross anatomy of the lower eyelid is analogous to that of the upper eyelid, however, the lower eyelid has a more simplified structure with less dynamic movement. Common malpositions of the lower eyelid include entropion and ectropion, rehabilitative surgery of which requires a thorough understanding of lower eyelid anatomy. Furthermore, precise anatomic knowledge is a prerequisite for both reconstructive and cosmetic lower eyelid surgery in order for it to be performed appropriately. In this review, we present the clinical anatomy of the structures of the lower eyelid, as well as highlighting relevant surgical implications. Featured here are the structure of the different eyelid lamellae, the lower eyelid retractors and their relations, the orbital septum, fat pad compartments, and Lockwood ligament.

The role of intubation in routine dacryocystorhinostomy (DCR) surgery is unclear, with there being little evidence in favour of this practice, which appears to have largely come about as a result of history, anecdote and the evolution of DCR surgery. In this paper, a brief history of intubation in DCR surgery is presented and the evidence base is analysed.

Purpose: To examine the microscopic anatomic features of lower eyelid retractors in Caucasians, specifically looking for an anatomic division of the retractors into 2 layers, as is present in the Asian eyelid., Design: Experimental anatomic study., Participants: Seven Caucasian cadavers (13 lower eyelids: 7 right and 6 left)., Methods: Sagittal full-thickness sections of the cadaveric lower eyelids were prepared and stained with Masson's trichrome. The specimens were examined microscopically to discern the configuration of the lower eyelid retractors. Micrographs were obtained with a digital camera system attached to the microscope., Main Outcome Measures: Histologic findings of the lower eyelid retractors in Caucasians., Results: Although 2 specimens were excluded because anatomic details were severely disrupted during slide preparation, all the other samples demonstrated clear double layers of the lower eyelid retractors., Conclusions: The lower eyelid retractors in Caucasians consist of clear double layers. In this regard, no differences were detected between Caucasian and Asian eyelid anatomic features.

Background: To determine normal exophthalmometric values for a Sri Lankan population and investigate their demographic, physical, refractive and ocular biometric correlates., Methods: The Kandy Eye study was a population-based, cross-sectional study. By randomized cluster sampling, 1721 eligible participants, who were 40 years old and over were identified; 1375 participated. Exophthalmometry was performed with Hertel's exophthalmometer. Participants' demographics including age, gender and ethnicity were recorded. Height, weight, body mass index, non-cycloplegic refraction and ocular biometry were measured with standardized methods. Summary statistical analysis was performed for exophthalmometric values and relationships with other factors were tested using Pearson product-moment correlation coefficient analysis, standard single and multiple linear regression analysis., Results: A total of 1341 subjects were included in the analysis. Exophthalmometric values for the population had a mean of 15.82 mm, standard deviation of 2.73 mm and range of 10.46-21.28 mm. Exophthalmometric values for men were significantly higher than women. There were no significant differences between the racial groups' exophthalmometric values (Sinhalese, Tamils, Moors). Exophthalmometric values were significantly correlated with age, gender, height, weight, body mass index, base and axial length but not to refractive spherical equivalents. Only gender, weight, base and axial length were independent predictors for exophthalmometric values after adjusting for confounders., Conclusion: In this Sri Lankan population, our study provided the first reported estimates of a normal exophthalmometric range and determined gender, weight, base and axial length as its correlates. Sri Lankans are the first population to demonstrate this relationship between weight and exophthalmometric values and also showed that refraction is not a cause for pseudo-proptosis.

Purpose: To examine the microscopic structure of the upper eyelid of Caucasians, in particular looking for evidence of the presence of smooth muscle fibers and the microscopic nature of the levator aponeurosis., Methods: Full-thickness sagittal sections of central upper eyelids from 11 postmortem upper eyelids of 7 Caucasians (age range 78-101 years at death; mean age 87.7 years) were examined. The samples were stained with Masson trichrome and were microscopically examined for the presence of smooth muscle fibers and to determine whether the levator aponeurosis comprised one or more layers., Results: All of the samples contained smooth muscle fibers, which were located posteriorly. Evidence of a clear double-layer structure was found in only 1 sample; the other 10 samples demonstrated a single monolayer, which was not reflected to the orbital septum but continued distally., Conclusions: In this series of upper eyelid specimens of Caucasians, all aponeuroses contained smooth muscle fibers, the distribution of which was more concentrated posteriorly, identical to previous findings in Asian eyelids and suggestive of a possible common mechanism of eyelid tension regulation between races. Most of the levator aponeuroses examined had evidence of a single monolayer only; this represents a further absolute difference in the microanatomical structure of the upper eyelids between Caucasians and Asians.

Purpose: An unusual case of nasal-type natural killer/T-cell lymphoma (NKTL) of the orbit is reported., Methods: The clinical history, computed tomography, magnetic resonance imaging, and biopsy specimen of a 29-year-old man with a right orbital lymphoma were evaluated., Results: The patient initially presented with conjunctival injection and had flu-like symptoms before developing right proptosis and reduced vision; imaging showed a diffuse infiltrative process throughout the orbit. Orbital biopsy revealed angiodestruction with prominent necrosis, and angiocentric lymphoma growth and lymphoma cells were positively stained for CD3, CD20, CD45RO, CD56, cytotoxic molecules (granzyme B and T-cell intracellular antigen-1), and Epstein-Barr virus., Conclusions: NKTL is rare and may present acutely; the imaging findings presented serve to highlight the radiologic features of the disease.

Reactive arthritis is a well-known sequel to both dysenteric and urethritic illnesses, classically occurring in combination with conjunctivitis, arthritis, and/or a variety of dermatologic conditions. Dacryoadenitis has not been previously described as part of the spectrum of reactive arthritis. The authors describe a case of biopsy-proven bilateral dacryoadenitis, which developed in the setting of chlamydial urethritis.

Purpose: Primary orbital intraosseous hemangioma represents a rare, histopathologically benign, vascular tumor of the bony orbit. Only 41 cases have been documented in the literature to date. The authors present 4 new cases of the disease and review the relevant literature., Methods: Retrospective, multicenter case note analysis of 4 patients with histopathologically confirmed primary orbital intraosseous hemangioma and a systematic review of the English-language literature., Results: Four new cases of cavernous haemangiomata are presented with varying clinical manifestations, radiologic appearances, and treatments. Literature review (including the present 4 cases) yielded 45 cases in total. Presentation is often in the fourth and fifth decades (42% cases), the frontal bone being most commonly affected, followed by the zygoma, sphenoid, and maxilla. Intracranial extension occurred in 4 cases. Median duration of symptoms before presentation was 12 months (range, 1 month to 15 years) and the most frequent presentation was a painless mass, often on the orbital rim. The radiologic findings are reviewed. Histopathologically, the lesions were cavernous in 80%, capillary in 17%, and mixed in 3%; the capillary subtype seemed to be associated with more aggressive disease. Treatment was mainly by surgical excision and occasionally complicated by significant blood loss; preoperative embolization of lesions may reduce bleeding., Conclusions: Primary orbital intraosseous hemangioma is a rare vascular tumor that typically presents with a mass effect in the orbits of patients in the fourth and fifth decades of life. Preoperatively, it is important to be cognizant of the possible diagnosis as surgery can be complicated by life-threatening hemorrhage.

Purpose: To provide an up-to-date review of the clinical presentations, investigations, and management of orbital tuberculosis (OTB)., Methods: Systematic review of the literature concerning OTB, limiting the results to English-language peer-reviewed journals., Results: Seventy-nine patients from 39 publications were identified as cases of OTB. The condition presents in one of five forms: classical periostitis; orbital soft tissue tuberculoma or cold abscess, with no bony involvement; OTB with bony involvement; spread from the paranasal sinuses; and tuberculous dacryoadenitis. The ocular adnexa, including the nasolacrimal system and overlying skin, may also be involved., Conclusions: Diagnosis can be difficult and may necessitate an orbital biopsy, in which acid-fast bacilli (AFB) and characteristic histopathology may be seen. Growth of Mycobacterium tuberculosis (mTB) from such a specimen remains the gold standard for diagnosis. Ancillary investigations include tuberculin skin tests and chest radiography, but more recently alternatives such as whole blood interferon-gamma immunological tests and PCR-based tests of pathological specimens have proven useful. The management of OTB is complex, requiring a stringent public health strategy and high levels of patient adherence, combined with long courses of multiple anti-tuberculous medications. The interaction of the human immunodeficiency virus (HIV) with TB may further complicate management.