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Background: Ptosis may result in increased anxiety, appearance-related distress and social avoidance, and impacts visual function. Previous work demonstrates the benefits of ptosis surgery for health-related quality of life, but there is a paucity of research comparing such outcomes before and after surgery. The aim of this study was to determine potential patient benefits in health-related quality of life, social dysfunction and anxiety following successful ptosis surgery using validated measures., Methods: Adult ptosis correction surgery patients completed validated measures of appearance-related social anxiety and avoidance, anxiety and depression, and fear of negative evaluation pre-surgery. Following successful surgery, these measures were repeated post-discharge in addition to another health-related quality of life measure., Results: Of 61 patients recruited, follow-up measures were sent to 33 and completed by 23. Paired samples t-tests demonstrated positive significant changes in appearance-related social distress pre-op m = 30.94, post-op m = 23.67 (t(17) = 3.46, 95% CI 2.84-11.72, p = 0.003), anxiety pre-op m = 7.6, post-op m = 4.9 (t(19) = 4.27, 95% CI 1.38-4.02, p < 0.001) and fear of negative evaluation pre-op m = 34.79, post-op m = 31.26 (t(18) = 2.47, 95% CI 0.52-6.53, p = 0.024). There was no significant difference in depression scores pre-op m = 3.6; post-op m = 3.2 (t(19) = 0.672, 65% CL -0.85 to 1.65, p = 0.510). In total, 85% of patients reported positive benefit to well-being following surgery., Conclusion: Increasingly, evidence suggests ptosis surgery may benefit patient's well-being, appearance-related social anxiety and avoidance, as well as improving visual function. These psychosocial benefits should be considered alongside functional benefits in the provision of ptosis surgery., (© 2021. The Author(s).)

Thyroid eye disease is an auto-immune condition characterised by an acute inflammatory phase followed by a fibrotic phase, which sometimes leads to restricted eye movements and diplopia. Medical treatment with systemic steroids with or without orbital radiotherapy and immunosuppression can control the inflammatory response. Strabismus surgery should be carried out only after the inflammation is no longer active and after any decompression surgery. Surgery comprises recession of tight muscles using adjustable sutures so as to maximise the area of binocular single vision. There is debate as to whether adjustable sutures should be used for the inferior rectus muscle. Patients should be encouraged to have realistic expectations, as binocular single vision may not be achievable in all directions of gaze and lid retraction may be made worse by surgery.

Purpose: Ptosis affects both the function and appearance of the eyes and face, because of drooping of the eyelids. Previous research has focused on functional impairment; however, similar appearance altering eye conditions have been demonstrated to have major impacts on psychosocial functioning., Methods: This study examines the psychological well-being and appearance concerns of patients presenting with ptosis recruited from Bristol Eye Hospital using validated questionnaires focusing on demographics and psychosocial factors before surgery., Results: Patients reported higher levels of anxiety, depression, and appearance concern than population norms, with scores comparable to previous research examining the impact of other disfiguring eye conditions. Gender differences were observed, with almost half of females experiencing significant psychosocial issues related to appearance concern about their ptosis compared with 20% of males. Linear regressions revealed that the main predictor of poor adjustment to the appearance of ptosis was the level of concern an individual had regarding the negative perceptions of other people. These results implicate psychosocial factors and demographics as predictors of the development of appearance-related distress and compromised psychological well-being for patients with ptosis who are currently seeking surgery., Conclusions: This study provides clinicians with a greater understanding of the concerns of affected patients, and treatment motivations. The findings may also inform the development of patient reported outcome measures and support for patients, which targets the psychosocial impact of the condition.

Purpose: Orbicularis weakness is commonly associated with seventh nerve palsy or neuromuscular and myopathic conditions such as myotonic dystrophy and myasethenia gravis. We report four cases of idiopathic isolated orbicularis weakness., Methods: All four cases were female and the presenting symptoms of ocular irritation and epiphora had been present for over 7 years in three patients. All patients had lagophthalmos and three had ectropion. Three patients underwent full investigations which excluded known causes of orbicularis weakness. Two patients underwent oribularis oculi muscle biopsy and histological confirmation of orbicularis atrophy., Results: All patients underwent surgery to specifically address the orbicularis weakness with satisfactory outcomes and alleviation of symptoms in all cases. Isolated orbicularis weakness may be a relatively common entity that is frequently overlooked., Conclusion: Early recognition of this condition may lead to better management and prevent patients undergoing unnecessary surgical procedures.

Aims: This study aimed to determine the psychosocial and appearance-related concerns of a sample of ophthalmic patients by measuring a range of psychological, social, and demographic factors., Methods: Standardized psychological measures including anxiety, depression, appearance-related distress, self-discrepancy, appearance salience and valence were administered to 98 participants attending ophthalmic outpatient clinics in either London, Bristol, Sheffield or Bradford. Differences between groups were explored using t-tests and ANOVA, relationships between all variables were investigated using Pearson's correlation coefficient., Results: Although mean scores for psychological adjustment were within the normal range, some participants were experiencing considerable levels of generalized anxiety. Being older, male, and married or living with a partner was related to significantly better adjustment. Better adjustment was also related to a less visible area of concern, greater disguisability of the affected area, a more positive evaluation of their own appearance, less engagement in comparing themselves with others, greater feelings of being accepted by others, appearance being less important to their self-concept, and a smaller discrepancy between the persons ideal and actual appearance., Conclusions: A majority of ophthalmic patients adjust positively to the demands placed on them. By identifying the variables that are associated with successful adaptation, the specific psychological interventions and appropriate systems of support can be put in place to help those who are adversely affected.

Aims: To highlight the long-lasting benefit of 2-0 Prolene brow suspension for congenital ptosis., Methods: Retrospective case review of 38 paediatric cases at two centres in the United Kingdom., Results: Six cases continue to have a successful functional and cosmetic result ranging from 6 to 10 years., Conclusions: Brow suspension with 2-0 Prolene can be long-lasting in some patients.

Aims: The objective of this study was to determine the extent that psychosocial and clinical variables influence parental compliance with occlusion therapy (eye patching) in children with amblyopia., Methods: Children (n = 151) receiving occlusion therapy (eye patching) for the treatment of amblyopia were recruited from five orthoptic clinics in Bristol, UK. Parents completed a questionnaire based on Rogers' (1983) Protection Motivation Theory (PMT). The parents (n = 105) were also followed up 2 months later. Clinical data, including measures of visual acuity, were also recorded. Compliance with eye patching was assessed through self-report accounts of parents. Stepwise regression analyses were used to determine the factors predictive of compliance with eye patching., Results: Self-reported compliance with eye patching at study entry revealed that only 54% of parents were achieving orthoptists' recommendations to patch their child. Perceived self-efficacy was positively associated with compliance and perceived prohibition of the child's activities were negatively associated with compliance. At follow-up, past behaviour accounted for the largest proportion of explained variance in patching behaviour followed by response efficacy, and prohibition of the child's activities., Conclusion: The present findings may serve to inform interventions aimed at enhancing current orthoptic practice to improve compliance in amblyopic children. The importance of 'self-efficacy' and past behaviour suggests that consultations with parents exhibiting higher levels of success with patching may elicit strategies that could be shared with parents experiencing difficulties with patching their children. In addition, it is possible that the perceived efficacy of the treatment could be enhanced if orthoptists emphasised evidence of improvements in visual acuity which may, in turn, foster the maintenance of eye patching.

Currently, all lesions diagnosed clinically as basal cell carcinoma (BCC) are treated by the excision of the lesion with 3-4 mm margins followed by histopathological examination to assess clearance and confirm the diagnosis. We present the findings of surgical incisional and excisional biopsy of three young patients diagnosed on clinical examination as having BCC, who were found on histological examination to have trichoepithelioma. Whilst it may be possible to distinguish the features of trichoepithelioma in incisional biopsy specimens on morphological grounds alone it is often difficult, and immunohistochemical staining, to delineate the features of the basement membrane, provides useful additional information in the histological diagnosis. As trichoepithelioma is more common in the young it should be considered in the differential diagnosis in young patients presenting with BCC-like lesions of the periocular tissues. This subgroup of patients should have incisional biopsy carried out, and if the diagnosis of trichoepithelioma is confirmed the lesion may be excised with a small margin of healthy tissue, thereby facilitating surgical repair.

Although systemic steroids or orbital radiotherapy are effective in limiting the inflammatory response in thyroid eye disease (TED), there are reports of over 70% of treated patients requiring subsequent rehabilitative surgery: either orbital decompression or strabismus correction. This study investigated whether combined immunosuppression with primary orbital radiotherapy together with azathioprine and low-dose prednisolone, applied early in the active disease state, was more effective in treating TED. Forty consecutive patients with active TED were recruited. Orbital MRI (STIR sequence) was used to assess disease activity. Median duration of symptoms was 1.0 year. Subjects were treated with bilateral orbital radiotherapy (20 Gy in 10 fractions) and oral prednisolone and azathioprine. Pre- and post-treatment activity was measured clinically, including uniocular field of fixation, Mourits score and total eye score, until TED became inactive off all treatment. Before treatment, 15 subjects had signs of dysthyroid optic neuropathy, 35 had significant motility restriction and 38 had marked soft tissue signs. On average TED became inactive after 1.2 years (SD 0.7) of immunosuppression, and treatment was well tolerated. One patient required subsequent cosmetic orbital decompression, 6 had successful strabismus surgery and 13 required minor cosmetic lid surgery. Compared with previously reported treatment regimes we think that combined orbital radiotherapy and medical immunosuppression is far more effective than either treatment alone in the management of active TED, and led to fewer side effects of high-dose steroids. In particular there was more than a four-fold reduction in the requirement for orbital decompression and strabismus surgery.

Purpose: A prospective study was designed to evaluate the use of botulinum toxin as a temporary treatment in patients awaiting surgical repair for involutional entropion and to compare its use with lid taping., Methods: Botulinum toxin was administered to 30 patients with involutional entropion (35 eyelids). These patients had all previously been using lid taping and lubricant ointment as a temporary measure whilst awaiting lid surgery. Patients' symptoms and signs were assessed before and after toxin injection. The date of entropion recurrence was recorded. Eyelid tissue from 8 patients treated with toxin and 3 control patients who had not been given toxin was obtained after surgical entropion repair and examined histologically to ensure the botulinum toxin had no potential detrimental effects on the results of surgery., Results: The toxin was simple and quick to administer. Anatomical success was achieved in 33 of the 35 eyelids with significant improvements in symptoms and signs. The mean duration of action of the toxin was 12.5 weeks. Lower lid laxity was inversely correlated with duration of toxin action. There were no consistent changes in orbicularis oculi morphology after toxin injection., Conclusion: Botulinum toxin is a highly effective temporary treatment for involutional entropion with few complications and no adverse effects on the results of surgical entropion repair.

In amblyopia the visual input from the amblyopic eye is suppressed. The difference in contrast sensitivity between the two eyes can lead to suppression of the amblyopic eye through dichoptic masking in anisometropic amblyopia and small angle strabismus. Binocular cells in the visual cortex may also be instrumental in bringing about suppression in small angle strabismus through fusional suppression and disparity-dependent suppression. In large angle strabismus without amblyopia suppression is very powerful and is probably a modified form of binocular rivalry suppression. Which particular mechanism is operating is dependent on the pathogenesis of the amblyopia, the depth of the amblyopia and, in strabismic amblyopia, the angle of strabismus. In any given subject more than one mechanism may be operating in the different areas of the field.

We examined 25 patients with thyroid eye disease, using both the STIR (Short Tau Inversion Recovery) sequence and cine MRI techniques. A number of characteristic features can be seen on the cine MRI. There is muscle enlargement with restriction of movement and, in the burnt-out phase of the disease, reduced elasticity of the muscles is manifest as their failure to stretch on eye movement. This is in contrast to the active phase of the disease, where although the muscles are enlarged, muscle stretching is clearly visible. The STIR sequence gives an assessment of muscle water content, and hence a high signal is seen in active disease. Combining these techniques is useful in assessing the level of disease activity in thyroid eye disease, and helps in planning further management.

Immunosuppressive therapy is well established in the treatment of thyroid eye disease (TED). The best response has been observed in those with active (wet phase) disease of short duration. A prospective study was designed to observe the effects of orbital radiotherapy and oral immunosuppression on patients with TED, and to assess whether any pre-treatment parameters were predictive of the outcome. Significant improvements in uniocular fields of fixation (UFOF) and in the Mourits' disease activity scale were seen after treatment. The degree of improvement in UFOF was positively correlated with the level of initial disease activity. The use and technique of UFOF in assessing disease phase and activity are discussed.

Nineteen patients with thyroid eye disease were examined with magnetic resonance imaging using the Short Tau Inversion Recovery (STIR) sequence and compared with normal controls. The Signal Intensity Ratio (SIR) of each of the four recti was obtained by comparison with the signal intensity of the adjacent temporalis muscle. The SIR was compared with disease activity assessed using Werner's grading system, a clinical inflammatory score, and the range of extraocular movements. Results show that a high SIR is associated with a high index of disease activity. This technique is likely to prove useful in assessing disease activity and planning the management of thyroid eye disease, particularly with respect to immunosuppression.

We questioned 104 consecutive eye casualty patients about any visual disturbance experienced while wearing an eye patch as part of their treatment. Many (31%) reported momentary loss of vision in the uncovered eye. Some experienced this while driving. It was more common (p < 0.0008) if the 'dominant eye' had been patched (47%) rather than the 'non-dominant eye' (16%). In a separate experiment, a number of co-operative subjects were provided with a translucent-coloured occluder to be worn over each eye in turn. They reported a recurring coloured interference in the uncovered eye sparing the monocular crescent. We propose that the loss of vision in the unpatched eye is due to binocular rivalry suppression by the patched eye. This visual disturbance may be a cause of anxiety or risk for the patient. Patched patients should be warned this may occur, and advised to avoid driving or operating machinery.

A prospective study was carried out to test the null hypothesis that there is no additional benefit to be gained from second eye cataract extraction. Twenty-nine patients with unilateral cataract but contralateral pseudophakia completed a questionnaire enquiring into their visual disability and underwent testing of monocular and binocular visual acuity, contrast sensitivity, glare disability, fusion and stereopsis. These tests were repeated 4 months after second eye cataract extraction and lens implantation. Patients universally considered their vision to have been improved by second eye surgery and the prevalence of all symptoms were significantly reduced by this procedure. Normal binocular summation and stereopsis were restored following second eye cataract extraction. Symptomatic patients may benefit from second eye cataract extraction with lens implantation.

Symptoms and signs of orbital inflammation may be prominent features in the presentation of choroidal malignant melanoma, even when the tumour is solely intraocular. Three cases with this clinical presentation are described.

Cine magnetic resonance imaging (MRI) is a technique in which multiple sequential static orbital MRI films are taken while the patient fixates a series of targets across the visual field. These are then sequenced to give a graphic animation to the eyes. The excellent soft tissue differentiation of MRI, combined with the dynamic imaging, allows rapid visualisation, and functional assessment of the extraocular muscles. Good assessment of contractility can be obtained, but the technique does not allow study of saccadic or pursuit eye movements. We have used this technique in 36 patients with a range of ocular motility disorders, including thyroid-related ophthalmopathy, blow-out fracture, post-operative lost or slipped muscle, and Duane's syndrome.

Seventeen per cent of 216 cases of simple congenital ptosis developed amblyopia and 19% had a squint. Of those patients with amblyopia, 14% had amblyopia attributable to stimulus deprivation, 21% had anisometropic amblyopia and 51% had strabismic amblyopia. Early refraction, orthoptic assessment and treatment and, where the pupillary axis is occluded, surgery to prevent stimulus deprivation amblyopia are recommended.