Impact of sphenoid trigone size and extraocular muscle thickness on the outcome of lateral wall orbital decompression for thyroid eye disease

BACKGROUND

To retrospectively review lateral wall orbital decompression for thyroid eye disease (TED) and to evaluate pre-operative CT scans to analyse the variation in proptosis reduction.

METHODS

Consecutive lateral wall orbital decompressions performed by a single surgeon were retrospectively reviewed. Pre-operative CT scan features and post-operative proptosis reduction were analysed. The sphenoid trigone cross-sectional areas were summed and multiplied by the slice thickness to yield bone volume. Cumulative extraocular muscle thickness was calculated by combining the maximum thickness of the four recti. "Trigone volume" and "cumulative muscle thickness" were correlated with proptosis reduction at 3 months post-surgery.

RESULTS

Out of 73 consecutive lateral wall orbital decompressions, 17 orbits had prior endonasal medial wall orbital decompression. In the remaining 56 orbits, the mean pre-operative and post-operative proptosis were 24.3 ± 1.6 mm and 20.9 ± 2.3 mm respectively. The proptosis reduction ranged from 1 to 7 mm (mean of 3.5 mm ± 1.3 (p < 0.001)). Mean sphenoid trigone volume was 895 ± 434.4 mm3. The mean cumulative muscle thickness was 20.4 ± 5 mm. The correlation coefficient between muscle thickness and proptosis reduction was - 0.3 and was statistically significant (p = 0.043). The correlation coefficient between sphenoidal trigone volume and proptosis reduction was 0.2 (p = 0.068). With a multivariate analysis, the coefficient of efficient of regression for muscle thickness was - 0.007 (p = 0.42) and the coefficient of regression for trigone volume was 0.0 (p = 0.046).

CONCLUSION

Proptosis reduction following lateral wall orbital decompression can be variable. Extraocular muscle thickness had a significant correlation with the outcome, with greater proptosis reduction in orbits with thin muscles. The sphenoidal trigone size had a weak correlation with decompression outcome.

Lower Eyelid Blepharoplasty: Minimizing Complications and Correction of Lower Eyelid Malposition

Lid retraction is a feared complication of lower blepharoplasty. Anatomical variations like negative orbital vector, horizontal lid laxity, and preexisting lid retraction are more prone to lid malpositions. Meticulous and precise execution of a series of surgical steps is key to preventing complications. This includes minimizing surgical trauma, meticulous hemostasis, preserving innervation to the medial lid and pretarsal orbicularis, safe method of fat excision, septal tightening while maintaining lid traction, and conservative and titrated skin excision. Canthal fixation addresses lid laxity and maintains the lid stretched vertically while postoperative healing and fibrosis are taking place. Post-blepharoplasty lid retraction may occur due to failure to address lid laxity and the occurrence of middle lamellar fibrosis. Excessive skin excision may also result in anterior lamellar deficiency. The "sag and drag" concept is useful to evaluate the post-blepharoplasty retracted lid. The treatment of the retracted lid includes lid massage, replacing the anterior lamella, or releasing the middle lamellar fibrosis or a combination of techniques. In conclusion, understanding the mechanisms of lid retraction, careful preoperative assessment, and surgical precision will help surgeons to prevent and manage this complication.

EP-94 To see or not to see: A case of complex multidisciplinary surgical reconstruction

A 4 year-old child suffered catastrophic 60% total body surface area burn injuries affecting head and neck, trunk and limbs following sulphuric acid burns. He underwent limited treatment in his country consisting of first aid and debridement and grafting in upper and lower limbs and trunk, but no treatment to the facial and ocular areas.

He was referred for assessment and reconstruction in the United Kingdom. Even though there were widespread burn scar contractures, his most severe injuries involved both eyes and adnexal structures with evidence of severe bilateral cicatricial ectropion and threat to vision.

He required multidisciplinary plastic surgery and ophthalmic complex bilateral eyelid reconstruction in two separate procedures to restore anatomical and cosmetic integrity to both eyes.

The initial procedure involved examination under anaesthesia of both eyes, release of the left upper and lower eyelids burns scar ectropion and resurfacing of the resulting defect with full thickness grafts from the left clavicular area. The grafts had full take with no evidence of infection and excellent cosmesis.

A similar procedure was performed to reconstruct the right eyelids 6 weeks later. The vision of this eye was beyond salvage but the need for cosmetic eyelid symmetry was considered as an appropriate indication to proceed to reconstruction. This was found to be successful with excellent graft take and parental satisfaction.

This case required coordination, expert holistic approach, complex surgery and extra efforts from the team to ensure compliance, communication and positive outcomes and highlights the importance of multidisciplinary team effort.

Bilateral simultaneous non-arteritic ischaemic optic neuropathy: a rare complication of idiopathic systemic capillary leak syndrome (SCLS)

We report a case of bilateral symmetrical superior visual field defects in a 72-year-old man first reported during the recovery from systemic capillary leak syndrome (SCLS). During the acute illness, he required extensive and prolonged fluid replacement and mechanical ventilation for severe hypotension, shock and multiorgan dysfunction. His visual field defect and optic nerve changes were consistent with a diagnosis of ischaemic optic neuropathy. These remained unchanged over 3 years and he retained excellent 6/7.5 visual acuity bilaterally. We hypothesised the mechanism of bilateral segmental infarction of the optic nerve head to be caused by the hypercoagulable and hypovolaemic state, in addition to pre-existing vascular disease and hypertension. This case highlights the importance of including optic nerve examination in the management plan of SCLS, particularly in individuals with underlying vascular risk factors.

Stratified glucocorticoid monotherapy is safe and effective for most cases of giant cell arteritis

Objectives

High-dose glucocorticoids anchor standard care in GCA but are associated with significant toxicity. We aimed to evaluate the safety and effectiveness of a stratified approach to glucocorticoid tapering. The strategy aggressively reduced glucocorticoid doses in those manifesting an adequate early response to treatment, with a view to minimizing glucocorticoid complications.

Methods

A retrospective, population-based study of GCA was performed. All cases were confirmed by temporal artery biopsy between November 2010 and November 2015. Baseline and outcome data were extracted from secondary and primary care records at diagnosis and 1 year follow-up. The primary outcome was loss of vision. Secondary outcomes included remission and relapse rates and CS-related complications.

Results

The cohort consisted of 73 patients (76% female; mean age 73.5 years, s.d. 7.6 years). At presentation, a reduction in visual acuity was recorded in 17 patients (22.3%). The median CRP at diagnosis was 69.5 mg/l [interquartile range (IQR) 40.5–101 mg/l], with a median ESR of 80 mm/h (IQR 60–91 mm/h). At 1 year, remission was achieved in 64 patients (87.7%), whereas 10 patients (13.7%) relapsed. A single patient sustained visual loss after initiation of therapy. The median CRP at 1 year was 4 mg/l (IQR 4–9.5 mg/l) and the mean prednisolone dose was 5.4 mg (0–15 mg). CS-related complications were observed in 10 patients (13.7%).

Conclusion

A stratified approach to CS tapering appeared safe and effective in GCA. It was associated with a high rate of remission and promisingly low rates of relapse at 1 year follow-up. These real-world data indicate that glucocorticoid exposure can be minimized safely in some patients with GCA.

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.