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Increasing number of centres are establishing sequential fast track pathways (FTP) for management of giant cell arteritis (GCA), with temporal artery ultrasound (US) replacing temporal artery biopsy (TAB) as the first investigational method. Biopsy is performed as second investigation, when US is negative/inconclusive. This study investigates the role of TAB in a sequential GCA-FTP and its utility in those with negative/inconclusive US.Prospective study of patients referred for TAB as part of Coventry sequential GCA-FTP May 2014-June 2019. Analysis included sensitivity and specificity of TAB, impact of arterial specimen length and duration of treatment with corticosteroids on sensitivity of TAB and the clinical predictors for a positive biopsy.A total of 1149 patients with suspected GCA were referred to this GCA-FTP, with 109 (9.5%) referred for TAB. Overall sensitivity of TAB was 47% (specificity: 100%) and in patients with negative/inconclusive US sensitivity was 39% (specificity:100%). Post-fixation arterial specimen length15 mm showed lower sensitivity (14%), which increased to 52% when specimen length was ≥15 mm. Sensitivity of TAB was highest in first 7 (60%) to 10 days (59%) from starting corticosteroids. Predictors of positive biopsy using univariate logistic regression analysis were jaw claudication (OR = 5.40; p = 0.0057), elevated erythrocyte sedimentation rate (OR = 5.50; p = 0.013) and elevated C-reactive protein (OR = 23.7; p = 0.0043).This is the first study to look at the role of TAB in a sequential GCA-FTP. Biopsy plays an important role in GCA-FTP, when US is negative/inconclusive. Sensitivity of TAB improved when specimen length was ≥15 mm and performed within 10 days of commencing corticosteroids.

The field experiments were conducted at the Research Farm, Punjab Agricultural University, Ludhiana, during rabi seasons of 2017-18 and 2018-19. The wheat varieties, viz. PBW-725, PBW-677, and HD-3086, were sown on 25

The spatiotemporal variability of rainfall, particularly in the context of climate change, has been imperative for examining the cropping patterns, farming sustainable crop production, and food security in rainfed areas. To that end, trend analysis was done to study the change in rainfall patterns in the mid-hills of Himachal Pradesh. The study investigated the historical rainfall data from 1971 to 2020 on a monthly, annual, seasonal, and decadal basis by using the variability analysis methods, viz., standard deviation (SD), coefficient of variance (CV), and transformed annual precipitation departure (Z). The trend analysis was also done by Mann-Kendall (MK) and Sen's slope estimator (SSE) test and linear regression model. The annual rainfall in the region was 1115.1 mm, which showed a decreasing trend (Z = - 0.79 mm/year). Based on the linear regression model, the decrease in annual rainfall was about - 2.28 mm/year. The monthly and seasonal variability of rainfall exhibited a sensitivity to change. The months of January, April, July, and September showed an increasing trend, whereas the rest of the other months showed a decreasing trend. The seasonal rainfall (summer, monsoon, and post-monsoon) showed a decreasing trend, whereas the winter season depicted an increasing trend. During the entire study period, 1988 recorded as the wettest year, with highest annual rainfall of about 2205.0 mm and monsoon rainfall of about 1653.0 mm. The highest annual (2205.0 mm) and monsoon (1653.0 mm) rainfall was recorded in the year 1988. The decadal analysis of the rainfall on an annual basis revealed a decrease in rainfall during the periods 1971-1980, 2001-2010, and 2011-2020 as compared to 1981-1990 and 1991-2000. The rainfall over the study region confirms the strength of the change in trend. Thus, the erratic rainfall pattern makes the cropping calendar shorter and affects the agricultural productivity.

Background: Giant cell arteritis (GCA) is the most common type of systemic vasculitis affecting the elderly. Ophthalmic presentations of GCA in particular can be difficult to identify prior to permanent visual loss occurring. Methods: Here, we present 3 challenging cases as a retrospective series to highlight the variable presentations of GCA with ophthalmic involvement, but GCA was not suspected due to atypical presentation. Results: Unfortunately, all 3 cases went on to develop visual loss in the affected eye due to a delay in diagnosis or treatment. The authors wish to highlight the challenges posed to the referring clinicians, when patients had systemic/ocular co-morbidities, which delayed the suspicion of GCA Conclusion with a Practical Point: Our cases highlight the variable presentations of this condition as well as the devastating ophthalmic implications that GCA can have. A high index of suspicion must be maintained; particularly in elderly patients with atypical presentations.

PURPOSE To describe a simple alternative surgical approach to treat patients with Meibomian gland inversion (MGI; posterior migration of the Meibomian gland orifices) in the upper eyelid, secondary to cicatricial Meibomian gland dysfunction (MGD) not responding to maximal medical management. METHODS This was a retrospective, noncomparative, interventional case series of all patients with MGI not responding to conservative MGD treatment who underwent anterior lamellar repositioning through a skin crease incision with or without Blepharoplasty, between July 2017 and July 2019. RESULTS Eleven eyes of 7 patients were included in the study. All patients had a diagnosis of MGD with MGI and had been treated on average for 32 months with intensive medical therapy. Treatment included lubricants, topical ciclosporin 0.1%, topical steroids, and doxycycline. Despite intensive treatment, these patients remained symptomatic with persistent superior ocular surface staining. Following surgery, on average, the patients were followed for 23 months. Ten eyes (91%) had improvement of symptoms and superior ocular surface staining. All patients (100%) demonstrated improvement in the anatomical eversion of the eyelid margin and Meibomian gland orifice. CONCLUSION A simple upper eyelid everting surgery with anterior lamellar repositioning can be effective in managing patients with MGI giving them symptomatic relief when all medical treatment fail. To the best of the authors' knowledge, this is the first case series describing this simple surgical technique in the management of this subgroup of patients.

IntroductionGiant cell arteritis (GCA) is a common form of vasculitis and can result in permanent visual loss and other complications. The advent of vascular Doppler ultrasound (US) has provided a new means for early diagnosis for these patients although it is affected by introduction of corticosteroids (CS). The Coventry multidisciplinary fast track (FTGCA) pathway was set up in 2013 in collaboration with vascular physiology and ophthalmology with a view to enabling prompt multidisciplinary assessment.ObjectivesThis study aims to assess feasibility of this novel pathway and to assess the impact of CS use on the performance of US in a real life cohort.MethodsData were collected retrospectively for patients who attended the Coventry FTGCA pathway between 1st Jan 2014 to 31st December 2017. Patients were identified from US lists and clinical details were obtained from electronic medical records. Ethical approval was obtained from Research and Development department.Results620 eligible patients were included in this study. The pathway overall performed well with significant reduction in patients needing CS. US had sensitivity of 50% which improved further to ∼56% in CS naïve patients although median duration of CS use was 2 days. US specificity was >96%, and we were able to avoid using CS completely in 451 patients (73%). CS negatively impacted on utility of US with US more likely to be false negative.ConclusionsThis novel pathway demonstrates the ability to minimise use of CS through fast track multidisciplinary assessment. US was performed promptly and had reassuring real life sensitivity and specificity in this cohort. CS naïve patients showed significantly higher sensitivity for US despite the short duration of CS use.

Background In diagnosing adenoviral conjunctivitis, polymerase chain reaction (PCR) is widely adopted as a diagnostic tool. A new antigen-based immunoassay test (AdenoPlus; Rapid Pathogen Screening Inc, Sarasota, Fla.) is commercially available as an alternative diagnostic test. To date, evidence around the role of this test in the clinical setting has been limited and contradictory. Objective To determine the sensitivity and specificity of the AdenoPlus test relative to PCR in detecting the presence of adenovirus in patients with conjunctivitis that is recurrent, refractory to treatment, or clinically of unknown etiology. Methods A prospective study of 27 patients presenting to an acute eye clinic with conjunctivitis that is recurrent (Group A), refractory to treatment (Group B), or clinically of unknown etiology (Group C). All patients underwent the AdenoPlus test and PCR analysis. Sensitivity and specificity were calculated for AdenoPlus using PCR as a reference standard. Results Of 27 patients, 7% were in Group A, 19% in Group B, and 74% in Group C. Relative to PCR, the AdenoPlus test demonstrated a sensitivity of 33.3% (95% CI 4% to 78%) and specificity was 95.2% (95% CI 76% to 100%). Positive predictive value was 66.7% (95% CI 9% to 99%); negative predictive value was 83.3% (95% CI 63% to 95%). Conclusions Due to its high specificity, AdenoPlus may be a good diagnostic test, although further study is indicated. Due to its low sensitivity, however, the test should not be used as a screening tool in patients presenting with these features of conjunctivitis.

A study was carried out on “Impact of micro-climatic variations on forest ecosystem in mid hills of Himachal Pradesh” during winter and summer seasons of 2015-16. Comparisons of below forest canopy and open sites were carried out for abiotic and biotic factors under five forest ecosystems (chir pine forest, mixed forest, ban oak forest, agriculture field and bare area) and analysed the forest influence on local winter and summer climate according to forest type, soil type, slope orientation, tree height and diameter at breast height by using RBD design. Seasonal and diurnal variations in microclimatic variables viz., air temperature, soil temperature, relative humidity, wind speed and wind direction were measured with Portable weather station (Delta T) at afternoon 2:00-4:00 PM fortnightly in each forest ecosystem and bare area during winter and summer season. Solar radiation and albedo were measured with Pyranometer (Kipp and Zonen) at 1.35 m height. A significant decrease was attained in below forest canopy and bare area data for ambient temperature (2.5-5.0 oC), soil temperature (1.5-3.6 oC) solar radiation (13.2-47.4 Wm-2), albedo (0.15-0.21) and increased relative humidity (7-18%), soil moisture (8.0-15.2%). Among different forest ecosystem, the diurnal trends in microclimatic parameters showed large variations. The ambient air temperature ranged from 02.2-16.3 oC and 14.2- 30.7 oC where as soil temperature ranged from 07.4- 16.5 oC and 15.4-32.7 oC, however relative humidity ranged from 37- 88 per cent and 14-60 per cent among different forest ecosystem during winter and summer seasons, respectively. Mico-climatic variables under Ban-Oak forest revealed significant lowest air temperature, highest relative humidity and less wind speed.

Laissez-faire following excision of peri-ocular tumours has been described, but is not universally well established. We describe our experience with laissez-faire for managing medial canthal defects following tumour excision and compare our outcomes with full thickness skin grafts. Retrospective comparative case series of 68 patients who underwent reconstruction of a medial canthal defect using laissez-faire with sutured Sorbsan (LFS) (n = 36) or a full thickness skin graft (FTSG) (n = 32) at the same centre. Tumour diagnosis, defect size, time taken to epithelialise, functional and cosmetic outcomes, complications, follow-up duration and any secondary interventions were recorded. Basal call carcinoma was the most common neoplasm excised (63/68, 93%). Defect size ranged from 7 × 5 mm to 25 × 10 mm. Mean time for wound epithelialisation in LFS group was 33 days. Mean duration of follow-up was 32 months (range 1-80 months) for LFS and 30 months (range 6-60 months) for FTSG. Good functional and cosmetic outcomes were achieved in all 68 patients. Review of clinical photographs showed epicanthic fold in 2 patients and visible scar in 1 patient in the LFS group and 3 cases of hypopigmented scar and 7 hypertrophic scars in the FTSG group. No cases required secondary intervention. There were no cases of postoperative infection. LFS in the medial canthal region is less likely to lead to hypertrophic scarring or cicatricial sequelae compared to FTSG (p = 0.02). Both techniques are associated with excellent functional and aesthetic outcomes even for larger defects.

This article compares an independent nurse-led benign lesion service with a doctor-led one, and assesses the impact of clinician seniority on diagnostic accuracy rates. Retrospective review of benign lesions referred to a teaching hospital and managed in either a doctor- or nurse-led lid service. All lesions were diagnosed clinically, excised and then sent for histological diagnosis. Lesions were categorized into subtypes. Pre-excision clinical diagnoses were compared with histological diagnoses. Sensitivity, specificity and missed malignancy rates were calculated for each subtype. Accuracy was compared between different grades of doctors and a specialist nurse. 264 and 332 lesions were managed in a doctor-led and nurse-led service, respectively. Rates of accurate sub-typing were 79.6% and 80.4% in the doctor- and nurse-led services, respectively (p > 0.05). Clinician seniority had no bearing. Missed malignancies or pre-malignancies accounted for 1.1% and 1.5% of lesions in the doctor and nurse-led services, respectively (p > 0.05). Overall, the remaining misdiagnoses were benign lesions of another subtype (13.6%) or non-specific histological findings (5.0%) and 98.6% of lesions were confirmed as benign on histology. Overall sensitivity and specificity values were: benign epithelial proliferations 95.6% and 92.2%, epidermal inclusion cysts 92.2% and 88.0%, xanthelasma 97.5% and 100.0%, cysts of Moll 66.7% and 96.6%, naevi 39.4% and 99.8% and molluscum 20.0% and 99.8%, respectively. A dedicated nurse-led service is as effective in managing a range of clinically benign lid lesions as a doctor-led one, and clinician seniority has little impact on the diagnostic accuracy of these lesions.

Purpose: Surgical approaches to the medial orbit especially within the cone of orbital muscles necessitate great precision and care to avoid damage to surrounding structures—most importantly the optic nerve. The authors present a novel technique in which access to the medial orbital contents was achieved through an entirely endoscopic approach. Methods: A 72-year-old Caucasian female presented with loss of vision in the right eye and reduced extraocular movements. Baseline blood tests were within normal limits. Inflammatory markers were slightly elevated. CT scan revealed bilateral medial orbital apex masses. Biopsy of the right orbital apex lesion was performed through an exclusively endoscopic approach in which the medial rectus muscle was retracted infero-medially. Results: This exclusively endonasal approach to the medial intraconal space provided excellent access to the orbital apex, thus allowing successful biopsy of the medial orbital apex lesion. A video of the surgical technique demonstrates its use in this patient (see Video, Supplemental Digital Content 1, available at http://links.lww.com/IOP/A123). Conclusions: Similar reports of endonasal medialization of the medial rectus for accessing intraconal orbital lesions have been previously described in the rhinological literature. The authors describe a modification that allows for a safe and less invasive approach to the medial intraconal space and intraorbital optic nerve. There is minimal trauma to the surrounding tissues and no further damage to the optic nerve along with no associated adverse clinical sequelae. In addition, this negates the need for an adjuvant external or transconjunctival approach.

There are very few published cases of periocular keratin horns that have been reported in children. This study reports 2 pediatric cases of periocular keratin horns. The authors describe a 7-year-old male child who developed a keratin horn on the right lower eyelid and a 16-year-old female who developed a caruncular keratin horn. Both cases underwent excision biopsy, and subsequent histology confirmed that there was no evidence of malignancy. However, on the basis of the current evidence in adults and the difficulty in drawing firm conclusions from the small number of reported pediatric cases, the authors suggest that these lesions should be carefully managed due to the possibility of premalignant or malignant change at the base of the lesion.

Background:A number of centres are now running fast track pathways for diagnosis and management of Giant cell arteritis with ultrasound as the first port of call for diagnosis1. Temporal artery biopsies (TABs) have become the second line of investigation, and it is unclear how useful TAB is in this setting.Objectives:This study looked at accuracy of Temporal artery biopsy (TAB) in patients with suspected Giant Cell arteritis (GCA) with negative/inconclusive ultrasound (U/S) and how duration of treatment on steroids prior to these investigations and arterial specimen size affected it.Methods:Prospective study of all patients with suspected GCA referred for TAB when U/S was negative or inconclusive, as part of the local fast-track pathway (Coventry). Database included clinical findings, serological work up, U/S and TAB results and treatment. Sensitivity and specificity of U/S and TAB was calculated and compared based on duration of treatment with steroids.Results:One hundred and nine patients were referred for TAB via Coventry fast-track-pathway. The sensitivity of U/S in this cohort of patients was 9.08% and specificity was 93.33%. After 3 days of steroid this was 0% and 100% respectively. For TAB when done within 10 days of starting steroids, this was 65% and 87.5% respectively. After 20 days of steroids this was 0 % and 100%. The sensitivity and specificity was 20% and 85% when arterial specimen size was 11-15mm and 47% and 100% when specimen size was 16 mm or more. Sensitivity and specificity of U/S of 644 suspected GCA patients was 48% and 98%.Conclusion:Our study demonstrates that TAB plays a relevant role in GCA fast-track-pathways, when U/S is negative/inconclusive. TAB was more sensitive than U/S in this cohort of patients, but overall sensitivity of U/S was higher when calculated for all patients suspected with GCA. Both remain useful tests if performed early. TAB specimen size should ideally be 16mm or more and done within 10 days of starting steroids.References:[1]Jonathan Pinnell, Carl Tiivas, Kaushik Chaudhuri, Purnima Mehta, Shirish Dubey, O38 The diagnostic performance of ultrasound Doppler in a fast-track pathway for giant cell arteritis,Rheumatology, Volume 58, Issue Supplement_3, April 2019, kez105.036,https://doi.org/10.1093/rheumatology/kez105.036Disclosure of Interests:None declared