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AimsTo compare the unique experiences related to artificial eye (AE) versus cosmetic shell (CS) wear.MethodsIn this observational, cross-sectional study, the National Artificial Eye Questionnaire was employed nationwide within the National Health Service England. This second part of the study assesses daily management and care experiences, as well as visual function and quality of life aspects.ResultsOverall, 951 respondents wore an AE, while 238 wore a CS. Both AE and CS respondents rated a relatively high score for a beneficial effect of prosthesis polishing, with an average score of 80.08±0.87 versus 77.17±1.73 (p=0.13, respectively). CS respondents removed and cleaned their prosthesis more frequently than AE respondents (pConclusionsThis study characterises unique aspects of CSs versus AEs in a large national cohort. The results should provide reinforcement to the gain in popularity of CSs.

AimsTo compare the unique experiences related to artificial eye (AE) versus cosmetic shell (CS) wear.MethodsIn this observational, cross-sectional study, the National Artificial Eye Questionnaire (NAEQ) was employed nationwide within the National Health Service England. The proportions or mean values of the aetiology of sight or eye loss, demographics, length of prosthesis wear, reported adjustment time to the prosthesis, comfort, discharge and satisfaction of appearance were compared between AE and CS respondents.ResultsOverall, 951 respondents wore an AE, while 238 wore a CS. In both, trauma was the leading cause for the prosthesis (47.6% and 44.1%, respectively); however, these groups differed in the proportions of the other aetiologies (pConclusionsThis study characterises unique aspects of CS versus AE in a large national cohort. The results should provide reinforcement to the gain in popularity of CS.

AimTo identify late outcomes of gold weights (GWs) and platinum chains (PCs) for upper eyelid loading in the management of lagophthalmos.MethodsA retrospective case series of upper eyelid GWs and PCs at a single centre over a 10-year period (2004–2013). Two independent, blinded assessors graded standard photographs for any weight-related morbidity (poor upper eyelid contour, weight prominence and migration).ResultsPrimary upper eyelid loading (high-tarsal technique) was performed in 154 eyelids of 136 patients (facial nerve palsy, n=99; non-paralytic, n=37). A total of 127 eyelids of 110 patients had primary GW insertion. Of these, 40.9% (52/127) had revision surgery: exchange of GW for PC (58%), GW repositioning (25%) and removal of GW (17%). Only 22.2% (6/27 eyelids) with primary PCs required revision surgery. In those not requiring revision surgery, photograph grading showed that both GWs and PCs had weight-related morbidity at late follow-up (median=37.5 months, range 12–110 vs median=33.5 month, range 15–106). GWs had significantly higher rate of weight prominence (p=0.001) and migration (pConclusionGWs were found to be associated with higher complications and twice more likely to require long-term revision surgery compared with PCs. Despite weight fixation at a high-tarsal location, prominence of PCs can still occur.

Introduction Ophthalmologists lack a facial nerve grading instrument (FNGI) that comprehensively encompasses the ophthalmic sequelae of facial nerve paralysis (FNP). Assessment and management of ophthalmic sequelae remains inconsistent, and outcomes of clinical studies are incomparable. We have developed and successfully adopted an FNGI based on four aspects of periorbital involvement: cornea, asymmetry, dynamic function and synkinesis. This CADS classification is specific for periorbital involvement, with objective and subjective parameters, to standardise grading. We present this classification and the results of a validation study in clinical practice. Methods A cross-sectional, validation study. Two clinicians independently assessed and graded each patient on the same day, blinded to each other9s grading. Each grader assigned a score to each of four parameters: C (0–3, ±a), A (0–2), D (0–3), S (0–2). Results Thirty patients (19 females, mean age 60, range 30–84 years) with unilateral facial paralysis were graded. A total of 60 assessments were conducted. CADS scores ranged from C 0 A 0 D 1 S 1 to C 3 aA 2 D 3 S 0 . In the first 30 assessments (of the first 15 patients), the two assessors disagreed over the corneal grading in four patients. The last 30 assessments of 15 patients showed complete agreement in all four parameters of the grading scale. The overall inter-observer agreement was 86.7% for cornea, 93.3% for resting asymmetry, 93.3% for dynamic function and 86.7% for synkinesis. After the first six patients, Cohen9s κ reached 1 for all but synkinesis that ranged between 0.9 and 1. Conclusions We present a validation study of an FNGI specifically designed for ophthalmic involvement of FNP. Objective and subjective parameters helped standardise grading and management planning.

Purpose Prospective study evaluating outcomes of individually sutured platinum segment chains in upper eyelid loading. Methods Single-centre, single-surgeon, prospective study. Upper eyelid loading with 0.4 and 0.2 g platinum segment chains for lagophthalmos. Segments were sutured to create a desired weight and attached to superior tarsus and distal levator aponeurosis following levator recession. Primary outcome measures: improvement in lagophthalmos and complications. Secondary outcome measures: cosmesis of eyelid margin contour and implant prominence. Minimum 3-month follow-up. Results Eighteen eyelids of 17 patients received segment chains (mean weight 1.2 g, range 0.8–1.6 g) and 3 for exchange of pre-existing gold weights. Median follow-up was 10 (range 6–17) months. Mean blink lagophthalmos improved from 7 (3–10) mm to 3 (0–6) mm (p no prominence, and the remainder, mild prominence only. The chain was graded as having no prominence in 78% (14/18) eyelids. Two required segment adjustments with removal of a single 0.2 g segment at 11 months and transfer of 0.4 g segment to the contralateral eyelid at 16 months, respectively. One complication (posterior, trans-conjunctival exposure above the superior border of the tarsal plate) was seen 12 months post surgery, requiring repositioning. Conclusions Platinum segment chains provide benefits of platinum chains with additional advantages of postoperative adjustibility. They can be used as an addition to pre-existing in situ weights or chains. Trial registration number REC reference: 13/SW/0146. IRAS project ID: 119022.

Background/aims To review our approach of cautious surgical correction of blepharoptosis in patients with myasthenia gravis (MG) to minimise risk of exposure complications. Methods Retrospective case note review of 30 patients with symptomatic eyelid concerns despite appropriate medical treatment, who underwent eyelid surgery. The mean age at diagnosis was 47 years. 13/30 patients had systemic MG, 14/30 ocular MG and 3/30 congenital MG. The main outcome measures were improvement in eyelid height and/or position, duration of a successful postoperative result, need for further surgical intervention, and intraoperative or postoperative complications. Results 38 blepharoptosis procedures were performed on 23 patients. Mean age at time of surgery was 62 years, with an average follow-up of 29 months. 10 patients (16 eyelids) underwent anterior approach levator advancement, 4 patients (5 eyelids) posterior approach surgery and 8 patients (15 eyelids) brow suspension. One patient (2 eyelids) had tarsal switch surgery. An average improvement in eyelid height of 1.9 mm was achieved. Postoperative symptoms or signs of exposure keratopathy occurred in 17% of patients. This necessitated lid lowering in one eyelid of one patient. During follow-up, 37% of eyelids required further surgical intervention to improve the upper eyelid height, after an average of 19 months (range 0.5–49 months). Conclusions Over a third of patients in our series required repeat surgery, which would be expected when the initial aim was to under-correct this group. In contrast to previous commentaries, the amount of eyelid excursion was not the main factor used to guide the surgical approach.

Several treatable ophthalmic conditions were missing from the differential diagnoses of cluster headache in the article by Nesbitt and Goadsby.1 For example, scleritis, uveitis, orbital inflammatory disease (including dacryoadenitis and sino-orbital disease), and intermittent angle closure glaucoma may present with recurrent pain, lacrimation, conjunctival injection, periorbital oedema, ptosis, …