The differential diagnosis of subacute onset ataxia in the setting of enteropathy is wide. A 54 y... more The differential diagnosis of subacute onset ataxia in the setting of enteropathy is wide. A 54 year old patient with a pancerebellar syndrome and known ulcerative jejunoileitis is described. Small bowel biopsy showed evidence of enteropathy associated T cell lymphoma and subsequent neuropathological analysis and immunophenotyping confirmed metastasis of this tumour to the cerebellum. The presence of anti-gliadin antibodies and MRI evidence of a more longstanding process suggested additional immunologically mediated cerebellar dysfunction. Lymphomatous involvement of the CNS is rare in patients with complicated enteropathies, and has not been previously reported to involve the cerebellar parenchyma. This diagnostic possibility should be borne in mind before attributing cerebellar dysfunction in patients with the coeliac related enteropathies to nutritional compromise or immunological dysfunction (gluten ataxia) alone.
Acute demyelinating optic neuritis (ON) is the initial presentation in approximately 20% of cases... more Acute demyelinating optic neuritis (ON) is the initial presentation in approximately 20% of cases of multiple sclerosis (MS) and is characterized by unilateral, subacute, painful visual loss without systemic or neurological symptoms. The Optic Neuritis Treatment Trial (ONTT) has provided valuable insights into both the natural history and clinical course of demyelinating ON with respect to treatment. Visual function improves spontaneously over weeks and within 12 months 93% have recovered to a visual acuity of at least 20/40. Treatment with high-dose corticosteroids may accelerate visual recovery, but has little impact on long-term visual outcome. In the ONTT the 10-year risk of recurrence of demyelinating ON was 35%. The presence of white matter lesions on the initial magnetic resonance image of the brain has been identified as the strongest predictor for the development of MS. The 15-year risk of developing MS in the ONTT was 25% with no lesions, but 75% with one or more lesions. Since there is evidence of early axonal damage in acute demyelinating ON, disease-modifying drugs should be considered in patients at high risk of developing MS in the future as prophylaxis against permanent neurological impairment.
ABSTRACT A 78-year-old woman with dementia presented with functional visual loss secondary to bil... more ABSTRACT A 78-year-old woman with dementia presented with functional visual loss secondary to bilateral chronic purulent dacryocystitis. A right external dacryocystorhinostomy (DCR) under local anaesthesia and sedation (LAS) was performed which failed after one month. Wound care was problematic as the patient removed all dressings and picked at the incision resulting in dehiscence and wound infection. She then underwent bilateral dacryocystectomy (DCT) under LAS and cauterisation of the common canaliculus via an endoscopic endonasal approach. Post-operatively her symptoms fully resolved. An endoscopic approach to lacrimal sac excision may be feasible in selected cases where a skin incision may not be desirable.
To report the outcome of orbital implant removal and dermis fat graft (DFG) implantation in patie... more To report the outcome of orbital implant removal and dermis fat graft (DFG) implantation in patients with chronic anophthalmic socket pain (ASP), in whom all detectable causes of pain had been ruled out and medical management had failed. Retrospective, multicentre case series. A review of all cases undergoing orbital implant replacement with DFG between 2007 and 2013 was conducted at the University of Iowa Hospitals and Clinics (UIHC), USA, and St. Erik Eye Hospital, Sweden. Inclusion criteria included (1) chronic ASP >2 years and unresponsive to treatment, (2) absence of pathological or structural cause for pain established by socket examination and orbital imaging, and (3) minimum 12-month post-surgical follow-up. Six cases with chronic ASP were identified, four were post-enucleation and two were eviscerated at an average age of 45 years. The incidence of chronic ASP among enucleations at UIHC over a 6-year period was 0.7%. Indications for enucleation and evisceration included tumours and glaucoma. Intractable ASP had been present for an average of 11 years and persisted despite medical management. All patients were free of pain within 3 months of implant removal and DFG placement and remained pain free at an average 24 months following surgery. Orbital implant replacement with DFG was effective at relieving chronic ASP, and pain resolution was sustained in all cases. This surgical intervention may be a useful management option for patients in whom all detectable causes of chronic pain have been excluded and have failed medical pain management.
Ophthalmic Plastic and Reconstructive Surgery, May 1, 2016
To describe and evaluate 1) the quantitated internal suture browpexy (ISB), which combines the ad... more To describe and evaluate 1) the quantitated internal suture browpexy (ISB), which combines the advantages of a browpexy and "brassiere suture," 2) the endoscopic Endotine browplasty, and 3) to compare these two techniques in patients undergoing simultaneous upper blepharoplasty. Retrospective review of patients undergoing bilateral upper blepharoplasty alone, bilateral ISB with upper blepharoplasty, and bilateral Endotine (MicroAire, Charlottesville, VA, U.S.A.) browplasty with upper blepharoplasty by one surgeon was performed. ImageJ 1.47v software (Wayne Rasband, National Institutes of Health, Bethesda, MD, U.S.A.) and standardized photographs were used to measure pre- and postoperative brow position at three positions (central, medial, lateral). Statistical analysis was performed using Sigmaplot version 12.5 for Windows (Systat Software, Inc., San Jose, CA, U.S.A.). Thirty-three patients undergoing ISB with blepharoplasty, 33 undergoing Endotine browplasty with blepharoplasty, and 30 patients undergoing blepharoplasty alone were included. The 3 groups were matched for age and gender. Patients undergoing upper blepharoplasty alone showed statistically significant brow descent at all three brow positions (mean: -1.7 mm [p ≤ 0.04]). The quantitated ISB prevented brow descent but provided minimal brow elevation (mean lateral elevation: right eye (OD) +1.3 mm [p = 0.03]; OS +0.9 mm [p = 0.08]). Endotine browplasty with upper blepharoplasty provided significant brow elevation at all brow positions, particularly laterally (OD +4.0 mm [p < 0.001]; OS +3.5 mm [p < 0.001]). There were no complications. Upper blepharoplasty alone is associated with brow descent; performing ISB simultaneously effectively prevents this descent. Endotine browplasty with upper blepharoplasty achieves significant brow elevation. Quantitation of the browpexy allows reproducible placement of the suture thereby producing consistent and symmetrical results.
An accurate understanding of the anatomy of the lateral nasal wall is key to achieving complete e... more An accurate understanding of the anatomy of the lateral nasal wall is key to achieving complete exposure of the lacrimal sac during endonasal dacryocystorhinostomy (EnDCR) and the avoidance of complications such as basal skull fracture and orbital fat prolapse. This review provides a comprehensive summary of the clinical and cadaveric anatomical studies of the lateral nasal wall to date and their application to endonasal lacrimal surgery. The maxillary line and the axilla of the middle turbinate are the major landmarks commonly utilized by lacrimal surgeons to localize the lacrimal sac. Numerous clinical, cadaveric and radiologic studies have attempted to define the relationship of these and other important anatomical landmarks, closely related to the lacrimal sac and routinely encountered during endonasal surgery, such as the frontal process of the maxilla, the agger nasi air cell and the uncinate process. A greater understanding of the relevant endonasal anatomy over time has led to safer and more effective surgical techniques. Greater insights into the precise anatomical relationship of the lacrimal sac to other structures on the lateral nasal wall has enabled lacrimal surgeons to perform EnDCR surgery in a more accurate, efficient and well tolerated manner, matching its success to that of the external approach.
The differential diagnosis of subacute onset ataxia in the setting of enteropathy is wide. A 54 y... more The differential diagnosis of subacute onset ataxia in the setting of enteropathy is wide. A 54 year old patient with a pancerebellar syndrome and known ulcerative jejunoileitis is described. Small bowel biopsy showed evidence of enteropathy associated T cell lymphoma and subsequent neuropathological analysis and immunophenotyping confirmed metastasis of this tumour to the cerebellum. The presence of anti-gliadin antibodies and MRI evidence of a more longstanding process suggested additional immunologically mediated cerebellar dysfunction. Lymphomatous involvement of the CNS is rare in patients with complicated enteropathies, and has not been previously reported to involve the cerebellar parenchyma. This diagnostic possibility should be borne in mind before attributing cerebellar dysfunction in patients with the coeliac related enteropathies to nutritional compromise or immunological dysfunction (gluten ataxia) alone.
Acute demyelinating optic neuritis (ON) is the initial presentation in approximately 20% of cases... more Acute demyelinating optic neuritis (ON) is the initial presentation in approximately 20% of cases of multiple sclerosis (MS) and is characterized by unilateral, subacute, painful visual loss without systemic or neurological symptoms. The Optic Neuritis Treatment Trial (ONTT) has provided valuable insights into both the natural history and clinical course of demyelinating ON with respect to treatment. Visual function improves spontaneously over weeks and within 12 months 93% have recovered to a visual acuity of at least 20/40. Treatment with high-dose corticosteroids may accelerate visual recovery, but has little impact on long-term visual outcome. In the ONTT the 10-year risk of recurrence of demyelinating ON was 35%. The presence of white matter lesions on the initial magnetic resonance image of the brain has been identified as the strongest predictor for the development of MS. The 15-year risk of developing MS in the ONTT was 25% with no lesions, but 75% with one or more lesions. Since there is evidence of early axonal damage in acute demyelinating ON, disease-modifying drugs should be considered in patients at high risk of developing MS in the future as prophylaxis against permanent neurological impairment.
ABSTRACT A 78-year-old woman with dementia presented with functional visual loss secondary to bil... more ABSTRACT A 78-year-old woman with dementia presented with functional visual loss secondary to bilateral chronic purulent dacryocystitis. A right external dacryocystorhinostomy (DCR) under local anaesthesia and sedation (LAS) was performed which failed after one month. Wound care was problematic as the patient removed all dressings and picked at the incision resulting in dehiscence and wound infection. She then underwent bilateral dacryocystectomy (DCT) under LAS and cauterisation of the common canaliculus via an endoscopic endonasal approach. Post-operatively her symptoms fully resolved. An endoscopic approach to lacrimal sac excision may be feasible in selected cases where a skin incision may not be desirable.
To report the outcome of orbital implant removal and dermis fat graft (DFG) implantation in patie... more To report the outcome of orbital implant removal and dermis fat graft (DFG) implantation in patients with chronic anophthalmic socket pain (ASP), in whom all detectable causes of pain had been ruled out and medical management had failed. Retrospective, multicentre case series. A review of all cases undergoing orbital implant replacement with DFG between 2007 and 2013 was conducted at the University of Iowa Hospitals and Clinics (UIHC), USA, and St. Erik Eye Hospital, Sweden. Inclusion criteria included (1) chronic ASP >2 years and unresponsive to treatment, (2) absence of pathological or structural cause for pain established by socket examination and orbital imaging, and (3) minimum 12-month post-surgical follow-up. Six cases with chronic ASP were identified, four were post-enucleation and two were eviscerated at an average age of 45 years. The incidence of chronic ASP among enucleations at UIHC over a 6-year period was 0.7%. Indications for enucleation and evisceration included tumours and glaucoma. Intractable ASP had been present for an average of 11 years and persisted despite medical management. All patients were free of pain within 3 months of implant removal and DFG placement and remained pain free at an average 24 months following surgery. Orbital implant replacement with DFG was effective at relieving chronic ASP, and pain resolution was sustained in all cases. This surgical intervention may be a useful management option for patients in whom all detectable causes of chronic pain have been excluded and have failed medical pain management.
Ophthalmic Plastic and Reconstructive Surgery, May 1, 2016
To describe and evaluate 1) the quantitated internal suture browpexy (ISB), which combines the ad... more To describe and evaluate 1) the quantitated internal suture browpexy (ISB), which combines the advantages of a browpexy and "brassiere suture," 2) the endoscopic Endotine browplasty, and 3) to compare these two techniques in patients undergoing simultaneous upper blepharoplasty. Retrospective review of patients undergoing bilateral upper blepharoplasty alone, bilateral ISB with upper blepharoplasty, and bilateral Endotine (MicroAire, Charlottesville, VA, U.S.A.) browplasty with upper blepharoplasty by one surgeon was performed. ImageJ 1.47v software (Wayne Rasband, National Institutes of Health, Bethesda, MD, U.S.A.) and standardized photographs were used to measure pre- and postoperative brow position at three positions (central, medial, lateral). Statistical analysis was performed using Sigmaplot version 12.5 for Windows (Systat Software, Inc., San Jose, CA, U.S.A.). Thirty-three patients undergoing ISB with blepharoplasty, 33 undergoing Endotine browplasty with blepharoplasty, and 30 patients undergoing blepharoplasty alone were included. The 3 groups were matched for age and gender. Patients undergoing upper blepharoplasty alone showed statistically significant brow descent at all three brow positions (mean: -1.7 mm [p ≤ 0.04]). The quantitated ISB prevented brow descent but provided minimal brow elevation (mean lateral elevation: right eye (OD) +1.3 mm [p = 0.03]; OS +0.9 mm [p = 0.08]). Endotine browplasty with upper blepharoplasty provided significant brow elevation at all brow positions, particularly laterally (OD +4.0 mm [p < 0.001]; OS +3.5 mm [p < 0.001]). There were no complications. Upper blepharoplasty alone is associated with brow descent; performing ISB simultaneously effectively prevents this descent. Endotine browplasty with upper blepharoplasty achieves significant brow elevation. Quantitation of the browpexy allows reproducible placement of the suture thereby producing consistent and symmetrical results.
An accurate understanding of the anatomy of the lateral nasal wall is key to achieving complete e... more An accurate understanding of the anatomy of the lateral nasal wall is key to achieving complete exposure of the lacrimal sac during endonasal dacryocystorhinostomy (EnDCR) and the avoidance of complications such as basal skull fracture and orbital fat prolapse. This review provides a comprehensive summary of the clinical and cadaveric anatomical studies of the lateral nasal wall to date and their application to endonasal lacrimal surgery. The maxillary line and the axilla of the middle turbinate are the major landmarks commonly utilized by lacrimal surgeons to localize the lacrimal sac. Numerous clinical, cadaveric and radiologic studies have attempted to define the relationship of these and other important anatomical landmarks, closely related to the lacrimal sac and routinely encountered during endonasal surgery, such as the frontal process of the maxilla, the agger nasi air cell and the uncinate process. A greater understanding of the relevant endonasal anatomy over time has led to safer and more effective surgical techniques. Greater insights into the precise anatomical relationship of the lacrimal sac to other structures on the lateral nasal wall has enabled lacrimal surgeons to perform EnDCR surgery in a more accurate, efficient and well tolerated manner, matching its success to that of the external approach.
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