BACKGROUND:Standard treatment for thyroid eye disease is with systemic corticosteroids. We aimed to establish whether orbital radiotherapy or antiproliferative immunosuppression would confer any additional benefit. METHODS:CIRTED was a multicentre, double-blind, randomised controlled trial with a 2 × 2 factorial design done at six centres in the UK. Adults with active moderate-to-severe thyroid eye disease associated with proptosis or ocular motility restriction were recruited to the trial. Patients all received a 24 week course of oral prednisolone (80 mg per day, reduced to 20 mg per day by 6 weeks, 10 mg per day by 15 weeks, and 5 mg per day by 21 weeks) and were randomly assigned via remote computerised randomisation to receive either radiotherapy or sham radiotherapy and azathioprine or placebo in a 2 × 2 factorial design. Randomisation included minimisation to reduce baseline disparities in potential confounding variables between trial interventions. Patients and data analysts were masked to assignment, whereas trial coordinators (who monitored blood results), pharmacists, and radiographers were not. The radiotherapy dose was 20 Gy administered to the retrobulbar orbit in ten to 12 fractions over 2 to 3 weeks. Azathioprine treatment was provided for 48 weeks at 100-200 mg per day (dispensed as 50 mg tablets), depending on bodyweight (100 mg for <50 kg, 150 mg 50-79 kg, 200 mg for ≥80 kg). The primary outcomes were a binary composite clinical outcome score and an ophthalmopathy index at 48 weeks, and a clinical activity score at 12 weeks. The primary analysis was based on the intention-to-treat allocation and safety was assessed in all participants. This study is registered with ISRCTN, number 22471573. FINDINGS:Between Feb 15, 2006, and Oct 3, 2013, 126 patients were recruited and randomly assigned to groups: 31 patients to radiotherapy plus azathioprine, 31 to sham radiotherapy and azathioprine, 32 to radiotherapy and placebo, and 32 to sham radiotherapy and placebo. Outcome data were available for 103 patients (54 for sham radiotherapy vs 49 for radiotherapy and 53 for placebo vs 50 for azathioprine), of whom 84 completed their allocated treatment of radiotherapy or sham radiotherapy and 57 continued to take azathioprine or placebo up to 48 weeks. There was no interaction betweeen azathioprine and radiotherapy (pinteraction=0·86). The adjusted odds ratio (ORadj) for improvement in the binary clinical composite outcome measure was 2·56 (95% CI 0·98-6·66, p=0·054) for azathioprine and 0·89 (0·36-2·23, p=0·80) for radiotherapy. In a post-hoc analysis of patients who completed their allocated therapy the ORadj for improvement was 6·83 (1·66-28·1, p=0·008) for azathioprine and 1·32 (0·30-4·84, p=0·67) for radiotherapy. The ophthalmopathy index, clinical activity score, and numbers of adverse events (161 with azathioprine and 156 with radiotherapy) did not differ between treatment groups. In both groups, the most common adverse events were mild infections. No patients died during the study. INTERPRETATION:In patients receiving oral prednisolone for 24 weeks, radiotherapy did not have added benefit. We also did not find added benefit for addition of azathioprine in the primary analysis; however, our conclusions are limited by the high number of patients who withdrew from treatment. Results of post-hoc analysis of those who completed the assigned treatment suggest improved clinical outcome at 48 weeks with azathioprine treatment. FUNDING:National Eye Research Centre, Above and Beyond, and Moorfields Eye Charity.

Purpose To assess the subjective success and quality of life of adult patients post endoscopic endonasal dacryocystorhinostomy (EE-DCR) for acquired nasolacrimal duct obstruction.Design Retrospective, questionnaire study performed at least 6 months post EE-DCR. Participants Hundred and ten of the 282 consecutive patients who underwent EE-DCR.Methods A standardised questionnaire (Glasgow Benefit Inventory, GBI) was used to analyse the quality of life. The questionnaire examines four parameters, providing total, subscale, social, and physical scores. Main outcome measures We aimed to assess patient experience following EE-DCR surgery. Total GBI scores range from -100 to +100, the former reflecting maximal negative benefit and corresponding to subjective worsening of tearing and impact on quality of life. Any positive score reflects a satisfactory surgical outcome and +100 represents maximal positive benefit. A score of zero is no perceived benefit.Results The average age was 62 years, 63% were female. In three of the parameters measured, there was a subjective improvement post surgery: subscale score 22.16 (95% CI: 15.23-29.09), total score 15.04 (95% CI: 9.74-20.35), and social support score 4.67 (95% CI: 0.93-8.42). Physical health scored -4.47 (95% CI: -10.25 to 1.32). Secondary analyses demonstrate no statistical significance with respect to outcome whether a trainee or consultant performed the procedure. Younger patients (under split median of 63.5) had a better total score 19.04 (95% CI: 11.35-27.74) than those older than 63.5 years (11.04, 95% CI: 3.61-18.47). Discussion This study shows that EE-DCR gave patients improvement in quality of life, proven by a validated questionnaire. The mean total score of 15.04 found in our study compares with the 18.7 recorded by Feretis et al in 2009. Results were irrespective of the grade of surgeon, similar to the findings of Fayers et al for functional successes.Conclusion This study supports the use of EE-DCR for the improvement of quality of life in adult patients.

Purpose: To evaluate the causes of failed dacryocystorhinostomy (DCR) surgery, recommend specific endoscopic endonasal techniques in revision DCR, and report postoperative success rates.Methods: Retrospective case series in a tertiary referral center of 19 consecutive, endonasal revision DCR surgeries in 17 adult patients with previous failed DCR. All cases were revised endonasally by 1 surgeon. Analysis of etiology of failure and techniques of surgery were supplemented by review of surgical video and medical records. Surgical outcomes were measured functionally by resolution of epiphora and anatomically by patency of nasolacrimal duct system on syringing and positive functional endoscopic dye test.Results: The most common cause for failed DCR was a blocked ostium due to membranous scarring (74%). Multiple causes for failure were found in 9 of 19 cases. Adjunctive procedures during revision surgery included partial middle turbinectomy (53%) and anterior ethmoidectomy (21%). The serrated oscillating blade was required in 89% cases, the high-speed diamond bur in 26%. Mean follow up was 15 months (range 7-26 months). All 19 cases had an anatomically successfully outcome. Fifteen of 19 cases (79%) had a functionally successful outcome.Conclusions: In this study, the most frequent cause of failed DCR was a scarred ostium, which is optimally visualized endonasally and precisely managed with the oscillating blade. Using the abovementioned specific endonasal techniques, the authors have demonstrated a high success rate in endonasal revision DCR surgery.

Background: Necrotizing fasciitis is a rare, life-threatening subcutaneous soft tissue infection that causes massive tissue destruction. Objectives: To illustrate the warning signs of this condition by reporting a rare case of eyelid necrotizing fasciitis. Case Report: A previously healthy 22-year-old man presented with a preseptal eyelid infection that spread rapidly despite prompt treatment with several intravenous antibiotics. He developed the characteristic clinical and radiologic features of necrotizing fasciitis, and required surgical debridement to cure the infection. Histology confirmed the diagnosis. Conclusion: In this article, we suggest the indicators that may enable physicians to think of the development of necrotizing fasciitis in patients with infections of the skin and subcutis. (c) 2013 Elsevier Inc.

We present the case of a 59-year-old woman whose silicone punctal plugs migrated distally causing lacrimal obstruction. The plugs were removed from the lacrimal sac during endoscopic endonasal dacrocystorhinostomy and is illustrated by endoscopic photographs and videos taken at the time of surgery. This case highlights the potential complications of punctal plugs and the difficulties posed in retrieving them.

A 37 year old man presented with a 6 month history of a right epiphora with associated mucus discharge. Lacrimal irrigation demonstrated right unilateral partial nasolacrimal duct obstruction, confirmed with lacrimal scintigraphy. Nasal endoscopy showed a pale elevation in the right inferior meatus. Endoscopic endonasal examination revealed a yellow-white nasolacrimal duct stone emerging from the valve of Hasner in the inferior meatus. The distal nasolacrimal duct in the lateral wall of the inferior meatus was marsupialised and the stone removed. At 12 months follow-up the patient maintained complete resolution of symptoms.

Purpose The lateral tarsal strip (LTS) for involutional ectropion is often performed with a medial spindle (tarsoconjunctival diamond excision). We aimed to evaluate how well the LTS alone can achieve symptomatic relief. Methods A retrospective, comparative case series was performed on consecutive patients undergoing LTS alone or with medial spindle for involutional ectropion. Outcomes for LTS alone were clinically derived functional success (improvement in symptoms and aesthetic appearance) and anatomical success (judged by punctal position in the tear lake, punctal movement during blinking and absence of ectropion). We verified if these outcomes compared favourably with those of the patients who had undergone an LTS with medial spindle. Procedure selection was based on pre-operative clinical examination, especially the lateral pinch and twist test (this is described). Complications were also recorded. Results Of 67 eyes, 23 had LTS alone and 44 had LTS with a medial spindle. Of those having LTS alone the functional success rate was 87% (95% CI (66.4, 97.2%)). This did not differ significantly from a success rate of 89% (75.4, 96.2%) in LTS with a medial spindle ( P =0.99). A total of 78% (56.9, 92.5%) of patients undergoing LTS had a good anatomical result compared with 82% (67.3, 91.8%) of those who had an additional medial spindle ( P =0.75). Complication rates were similar between the groups. Conclusion Where the lateral pinch and twist test returns the eyelid to a good position, the LTS alone can suffice for the management of involutional ectropion.

Purpose: Poor levator function (LF) blepharoptosis can be corrected surgically using frontalis muscle suspension with a variety of materials. Autogenous grafts such as fascia lata are commonly used. The need for a remote surgical site and the risk of an unattractive leg scar makes the use of an autogenous temporalis fascia (ATF) graft appealing as the scar is concealed in the hair. We describe the use of a pleated, lengthened ATF graft that is easy to prepare and insert, and provides a cosmetically acceptable outcome.Methods: Prospective case series describing six patients with previous multiple failed lid surgeries and recurrent poor (<= 5 mm) LF (mean 2.87 +/- 1.72 mm) ptosis. The pleated graft technique was used to yield a strip of ATF up to 18-cm long from a short 2-cm temporal incision. Eight eyelids then underwent ATF graft frontalis suspension surgery using the modified Fox pentagon technique. Outcomes included eyelid measurements with 4.5-year follow-up.Results: All patients achieved good functional and esthetic outcome. The mean central palpebral aperture 6 weeks postsurgery was 7.14 +/- 1.67 mm, equating to a mean increase of 3.27 mm (p < 0.05 using the paired t-test). The improvement in eyelid height was maintained at the 4.5-year follow-up in all patients, except one who died of unrelated cause.Conclusion: A pleated strip of ATF graft provides a simpler alternative to fascia lata grafting for frontalis suspension in poor LF ptosis in adult patients with good long-term results.

A 79-year-old man presents with signs of an orbital mass. A CT scan revealed a large maxillary mucocele eroding through the orbital floor. Surgical drainage of the mucocele and conservative postoperative care, returned all ophthalmic signs to normal and bony remodelling of the orbital floor was demonstrated. Maxillary mucoceles should be assessed by both ENT and Ophthalmic surgeons. Postoperative remodelling of the orbital floor can be illustrated with serial CT Scans.

A 37-year-old man presented with symptoms of air and mucus reflux from the right medial canthus on blowing his nose. Examination showed crepitus in the region overlying the right lacrimal sac, and he was able to produce bubbles in his conjunctival lake on instillation of topical 2% fluorescein. Dacryoscintigraphy showed symmetrical slow passage of tracer from the lacrimal sac in the nasolacrimal duct indicating delay at the postsac level. Dacryocystography showed that the right lacrimal system contained round filling defects, suggesting the presence of soft tissue tumors. However, a CT scan showed an enlarged right lacrimal fossa with air in the nasolacrimal duct and no evidence of a mass. Following lower punctal plug occlusive canaliculoplasty on the right, using a preloaded silicone plug, the patient noted an immediate resolution of reflux symptoms.

Orbital inflammatory disease (OID) includes all inflammatory processes affecting the orbit. Although several aetiologies are recognised, a cause may not be elucidated. We describe 2 cases in which drugs (hyaluronidase and zoledronic acid) were the cause of OID. In patients with a clinical picture of OID simulating an orbital cellulitis, the recent drug history should be considered as a possible aetiology, and treatment with steroids with or without a biopsy should be considered after an infection has been excluded.

PURPOSE:To describe a simple and effective technique to insert the mini-monoka mono-canalicular stent using a nettleship dilator, without the need for a snip-procedure.METHODS:Description of a surgical technique.RESULTS:Mini-monoka stents have been shown to have a high rate of stent migration and premature loss when combined with a one-snip procedure. Our technique preserves the annular ring of the punctum and thus reduces the likelihood of these complications.CONCLUSION:This is a practical technique for the insertion of the mini-monoka monocanalicular stent for acquired punctual stenosis.

PURPOSE:To present the clinicopathological features and treatment outcomes of lacrimal ductular cysts managed with marsupialization.METHODS:Retrospective case review of 13 patients presenting with lacrimal ductular cysts.RESULTS:Thirteen patients were identified, of which 7 patients with full clinical data were included in the study, 4 female, 3 male, mean age 50 years. Their main presenting symptoms were superolateral orbital swelling, feeling of pressure on the eye, and lateral ptosis. Two patients had bilateral cysts, and the remaining 5 had unilateral cysts. Six patients required surgical marsupialization, and one patient was treated conservatively because of preexisting dry eye. At surgery, one patient had multiple dacryoliths within the cyst. Histopathological analysis of the cyst lining in 5 out of 7 patients showed bilayered cuboidal epithelium with fibrous tissue. None of the patients had dry eye symptoms or signs after surgery. Follow-up ranged from 10 months to 2 years, mean 20 monthsCONCLUSION:Marsupialization is a safe and effective treatment for lacrimal ductular cysts.

A 65-year-old man with a history of renal transplantation presented with facial pain, purulent nasal discharge, and periorbital swelling. Signs of optic nerve compromise developed and persisted despite medial orbital wall decompression. Further imaging revealed an orbital floor abscess secondary to direct communication of a maxillary pseudomonal sinusitis. Full recovery was achieved after further surgical drainage via an endoscopic endonasal approach. Failure to improve after surgical decompression is an indication for repeat imaging. Immunocompromised patients can present atypically. Orbital floor abscess secondary to sinusitis without an underlying odontogenic or traumatic cause has not previously been reported. The authors highlight the importance of clinical vigilance, serial imaging, microbiological investigations, and early surgical intervention in high-risk patients.