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Non-melanoma skin cancer (NMSC) is the commonest malignancy worldwide (>80% located in the head and neck area). The aim of this study was to assess risk factors predisposing to local recurrence of NMSC of the middle third of the face (MTF). This was a single-centre retrospective analysis of patients with NMSC of the MTF treated during 1995-2010. Data on epidemiological and tumour characteristics were collected. Survival analysis was performed and log-rank tests were used to compare differences in survival for each variable. A total of 531 patients with basal cell carcinoma (BCC) of the MTF were identified. Most tumours were nodular type (28.4%), located on the nose (34.3%), and confined to the dermis (75.5%). Negative margins were achieved in 91% of cases. Median follow-up time was 35 months and 15.2% of patients developed local recurrence. Incomplete excision was the only variable predisposing to local recurrence. The cohort also included 114 patients with squamous cell carcinoma (SCC). Most tumours were well differentiated (43.9%), located at the zygomatic area (49.1%), excised with negative margins (93%), and confined to the dermis (67.8%). At a median follow-up time of 42 months, local recurrence occurred in 15.7% of patients. Tumour size, depth of invasion, and prior history of head and neck SCC were risk factors for local recurrence. The variables predictive of recurrence of BCC were incomplete excision and for SCC tumour size, depth of invasion, and a prior history of head and neck SCC.

Corneal nerves are key components of the physiological system that controls ocular surface homeostasis. The cornea is primarily innervated by the ophthalmic branch of the trigeminal nerves (cranial nerve V), which distend bilaterally from the pons. The nasociliary branch (afferent) of the ophthalmic nerve is sensory for cornea, eyelid and conjunctiva. These nerve fibres play a role in sensing temperature, chemical and mechanical stimuli, and pain, whereas, branches of the facial nerve (cranial nerve VII) contain motor nerves that control blinking and autonomic (sympathetic and a paucity of parasympathetic) fibres that stimulate tear production and secretion via feedback loops between the ocular surface, lacrimal glands and brain. Disruption of these nerves with interruption of neural feedback loops between the ocular surface and lacrimal glands can lead to corneal diseases such as dry eye disease (DED) and neurotrophic keratopathy (NK). Inversely, hypersensitivity of the nerve fibres and/or dysregulation of pain-controlling nervous centres may lead to neuropathic pain. Recently, medications that specifically target regeneration of corneal nerves have started to become available - and considering the high prevalence of diseases associated with corneal nerve dysfunction, these agents promise to fulfil a hitherto important unmet need. In this review, we explore the physiology of corneal nerves, the pathology of corneal nerve diseases and how these relate to neuropathic pain, NK and DED. We also discuss what novel treatments may be useful against diseases involving corneal nerves.

Objective To describe a clinical entity of upper eyelid margin and meibomian gland inversion (MGI) sequential to meibomian gland dysfunction (MGD), in the absence of eyelash ptosis, trichiasis or manifest marginal entropion. We highlight its clinical features, surgical management and outcomes. Methods We performed a retrospective analysis of symptomatic MGI cases refractory to conservative management who underwent surgery in our centre over a 4-year period. Anatomical correction, resolution of symptoms and possible complications are reported. Results A total of 21 eyelids of 13 patients (mean age: 68.5 ± 15.4, range: 32-88 years) were analysed. Symptomatic MGI patients were operated only if they have noted immediate comfort when we corrected the lid margin position with a cotton tip. Those with refractory superior punctate corneal staining (n = 14 eyes), blink-related discomfort (n = 8) and pseudo-blepharospasm (n = 3) reported complete postoperative resolution. Milder symptoms showed partial improvement: gritty feeling (79%), sore eye (80%) and watery eye (86%). However, symptoms of dry eye disease (DED) persisted in 88% of patients. One case recurred in 6 weeks and was offered revision surgery. Median follow-up was 5 (range: 3-12) months. Conclusion Meibomian gland inversion (MGI) is a subtle clinical entity that can be easily overlooked. Symptoms are often attributed to DED or MGD alone. It is likely that MGI represents early upper lid margin anatomical changes secondary to MGD before cicatricial marginal entropion becomes clinically apparent. Recommended treatment is conservative with intensive lid hygiene and topical MGD management. However, refractory symptomatic cases who respond positively to a 'cotton-tip test' (reversal of lid margin malposition with a rolling cotton-tip) may benefit from surgical intervention with favourable anatomical and functional outcome.

Dry eye disease (DED), a multifactorial disease of the tears and ocular surface, is common and has a significant impact on quality of life. Reduced aqueous tear flow and/or increased evaporation of the aqueous tear phase leads to tear hyperosmolarity, a key step in the vicious circle of DED pathology. Tear hyperosmolarity gives rise to morphological changes such as apoptosis of cells of the conjunctiva and cornea, and triggers inflammatory cascades that contribute to further cell death, including loss of mucin-producing goblet cells. This exacerbates tear film instability and drives the cycle of events that perpetuate the condition. Traditional approaches to counteracting tear hyperosmolarity in DED include use of hypotonic tear substitutes, which have relatively short persistence in the eye. More recent attempts to counteract tear hyperosmolarity in DED have included osmoprotectants, small organic molecules that are used in many cell types throughout the natural world to restore cell volume and stabilize protein function, allowing adaptation to hyperosmolarity. There is now an expanding pool of clinical data on the efficacy of DED therapies that include osmoprotectants such as erythritol, taurine, trehalose and L-carnitine. Osmoprotectants in DED may directly protect cells against hyperosmolarity and thereby promote exit from the vicious circle of DED physiopathology.

The management of thyroid eye disease (TED) remains a therapeutic challenge. The current established therapies are unsatisfactory in one-third of the patients and have many limitations. Rituximab (RTX) is a CD20+ B-cell-depleting monoclonal antibody approved for the treatment of non-Hodgkin lymphomas, chronic lymphocytic leukemia, and rheumatoid arthritis. The early experience with RTX suggests that it is a promising alternative therapy for TED. Rituximab may compare favorably to the conventional glucocorticoid therapy and causes less collateral damage than retrobulbar orbital radiation and decompression surgery. In addition, the preliminary studies on RTX's proposed mechanism of action have revealed new insights into the pathogenic role of B-cells in TED. We summarize the current literature on the clinical application of RTX in TED and discuss its putative mechanisms of action.

Meibomian gland dysfunction (MGD) is a common and chronic disorder that has a significant adverse impact on patients' quality of life. It is a leading cause of evaporative dry eye disease (DED), as meibomian glands play an important role in providing lipids to the tear film, which helps to retard the evaporation of tears from the ocular surface. MGD is also often present in conjunction with primary aqueous-deficient DED. Obstructive MGD, the most commonly observed type of MGD, is the main focus of this article. MGD is probably caused by a combination of separate conditions: primary obstructive hyperkeratinization of the meibomian gland, abnormal meibomian gland secretion, eyelid inflammation, corneal inflammation and damage, microbiological changes, and DED. Furthermore, skin diseases such as rosacea may play a part in its pathology. Accurate diagnosis is challenging, as it is difficult to differentiate between ocular surface diseases, but is crucial when choosing treatment options. Ocular imaging has advanced in recent years, providing ophthalmologists with a better understanding of ocular diseases. This review presents a literature update on the 2011 MGD workshop and an optimized approach to accurate diagnosis of MGD using currently available methods and tests. It also outlines the emerging technologies of interferometry, non-contact meibography, keratography and in vivo confocal laser microscopy, which offer exciting possibilities for the future. Selected treatment options for MGD are also discussed.

International audience; Meibomian gland dysfunction (MGD) is the most frequent cause of dry eye disease (DED). Eyelid inflammation, microbial growth, associated skin disorders as well as potentially severe corneal complications culminate to make MGD a complex multifactorial disorder. It is probable that MGD is a heterogeneous condition arising from any combination of the following five separate pathophysiological mechanisms: eyelid inflammation, conjunctival inflammation, corneal damage, microbiological changes and DED resulting from tear film instability. The pathogenesis of both MGD and DED can be described in terms of a 'vicious circle': the underlying pathophysiological mechanisms of DED and MGD interact, resulting in a double vicious circle. The MGD vicious circle is self-stimulated by microbiological changes, which results in increased melting temperature of meibum and subsequent meibomian gland blockage, reinforcing the vicious circle of MGD. Meibomian gland blockage, dropout and inflammation directly link the two vicious circles. MGD-associated tear film instability provides an entry point into the vicious circle of DED and leads to hyperosmolarity and inflammation, which are both a cause and consequence of DED. Here we propose a new pathophysiological scheme for MGD in order to better identify the pathological mechanisms involved and to allow more efficient targeting of therapeutics. Through better understanding of this scheme, MGD may gain true disease status rather than being viewed as a mere dysfunction.

Purpose The purpose of this study was to evaluate early visual and refractive outcomes of Descemet's stripping endothelial keratoplasty (DSAEK). Method Nine eyes of 7 male and 2 female patients, mean age 73 years, were treated with DSAEK. Eight had pseudophakic bullous keratopathy and 1 had advanced Fuch's syndrome. Patients were followed up for a mean of 11.4 months (range, 4–26). The DSAEK technique consisted of stripping Descemet's membrane and endothelium from a recipient cornea and transplanting the posterior stroma and endothelium of a donor cornea using the Tan EndoGlide. The mean operating time was 61.89 minutes (standard deviation [SD], 9.3). Results The median donor diameter was 8.375 mm (range, 8.25–8.75) and the mean donor thickness was 114.4 μm (range, 98–129). Mean preoperative sphere was −2.41 that changed postoperatively in −1.21. Mean endothelial cell loss was 25% (range, 23%–45%) at 6 months after surgery. Corneal pachymetry was reduced from 796.6 μm preoperatively to 535.5 μm postoperatively. Best corrected vicual acuity (BCVA) was 20/40 or better postoperatively and exceeded the preoperative BCVA in all eyes. No graft failure was present. Two partial graft dislocations (1st and 5th postoperative day) were observed. One graft was successfully attached after reinjecting an air bubble (rebubbling) in the anterior chamber and the other graft was reattached with 4 10/0 nylon sutures after failed rebubbling. Conclusions The key to successful endothelial transplantation is the protection and preservation of as many donor endothelial cells as possible. The TAN EndoGlide is a device that consistently delivers a donor lenticule through a small incision with minimal endothelial loss, while making the insertion procedure relatively reliable and consistent, with the surgeon in full control of the donor at all stages of insertion. The endothelial cell loss during this technique is comparable (if not better) with other endothelial graft insertions systems.

Purpose To investigate the accuracy of the preoperative evaluation in identifying a membranous obstruction of the distal canaliculus and the success rate of an external dacryocystorhinostomy (DCR) when membranectomy of the canalicular obstruction is also performed. Design Retrospective, interventional case series. Methods The surgical records of the lacrimal cases operated at Moorfields Eye Hospital between January 1997 and December 1999 were reviewed. All the patients with evidence of a membranous block of the canalicular opening into the sac identified and excised during the course of a standard DCR procedure with silastic intubation and a minimum follow-up period of 12 months were selected for this study. The records were analyzed for preoperative evaluation with syringing and probing, surgical details, outcome, and complications. Results In 59 (85%) cases a functional anastomosis was established after tube removal. Additionally, 5 cases (7%) had patent system but required later ectropion repair and considered successful. Only 4 (6%) patients needed further lacrimal surgery, and one was referred to the ENT department for nasal polyps. The silastic tube was removed at a mean period of 6 weeks (SD = 4; range, 2–24 weeks), and the mean follow-up period was 13 months (SD = 3; range, 12–29 months). The preoperative evaluation failed to identify the membranous obstruction in 30 (43%) cases, which were correctly diagnosed intraoperatively. Conclusions In our series the anatomic success rate of 92% after DCR with membranectomy is comparable to the outcome of the DCR procedure. The distal canalicular membranous obstruction is an anatomic factor that may lead to surgical failure if not identified and excised.

Rigid nasal endoscopy is a reliable technique that can be used to assist in the preoperative nasal evaluation, operative tube positioning, and management after surgery. Postoperative function can be evaluated by using a passive dye test (FEDT) viewed directly, and minor interventions carried out without the need to remove the tube or do excessive probing. Endonasal endoscopy facilitates the maintenance of tube function with minimal manipulation and patient discomfort, and is fast and efficient. Its use should help improve tube retention and function. A detailed study over a number of years is necessary to provide convincing evidence for improving clinical standards. Lester T Jones wrote: The postoperative care of such a patient (having a glass bypass tube) should be in the hands of a physician who is willing to look into the nose, as inspection of the length and position of glass tube is most important. Endoscopic endonasal assistance helps the ophthalmologist to fulfill his criteria.

AIM—The aim of this study was to assess the repeatability and reproducibility by physicians of upper lid measurements and to investigate the influence of clinical experience on the learning curve effect. METHODS—Both eyes of 22 outpatients were assessed for three basic measures of ptosis: marginal reflex distance (MRD) for upper and lower lids, upper lid skin crease (SC), and levator function (LF). Patients with variable eyelid positions were excluded. The patients were measured twice by a consultant and once by each of a clinical fellow, a specialist registrar, and a senior house officer in random order. Each observer was masked to their colleagues' results and followed a standard measurement protocol. Data were analysed using Bland-Altman plots. RESULTS—Consultant repeatability was high and consistent, the median difference between measures being 0 for each of the four parameters. Clinically acceptable reproducibility was shown in all measurements for even the least experienced physician and was particularly consistent for extreme observations. There was evidence of a learning curve effect. CONCLUSIONS—These results suggest that interobserver and intraobserver variability in assessment of upper lid ptosis using a standard measurement protocol is low and clinically acceptable when the technique of assessment is standardised.

The study compares the use of Jones' retractor plication and the Wies procedure as a primary procedure for the repair of involutional lower lid entropion in the absence of horizontal lid shortening.Retrospective case series comparison.One hundred two cases with at least 6 months follow-up after primary surgery for involutional lower lid entropion performed between 1993 and 1996.Two groups were compared: Jones' retractor plication was performed in one group and the Wies procedure in the other; neither group had horizontal shortening of the lower eyelid.The rates of cure, recurrence, and overcorrection of the lower lid entropion.Jones' retractor plication was performed in 37 (36%) patients and the Wies procedure in 65 (64%). Two of the 37 (5%) Jones cases had recurrent entropion develop, both at 31 months after surgery, compared with 1 1 of 65 (17%) recurrences after the Wies procedure (P = 0.81); recurrence after Wies procedure was earlier, at a median of 6 months after surgery. There were 20 of 65 (31 %) overcorrections after the Wies procedure and 4 of 37 (11 %) after the Jones procedure (P0.02); one quarter of each group required secondary repair of the overcorrection (5 of 20 after failed Wies procedure; 25% after failed Jones procedure). Overall, there were 6 of 37 (16%) unsatisfactory results after the Jones procedure in contrast to 31 of 65 (48%) after the Wies procedure (P0.001).These data provide strong evidence (P0.001) that, in the absence of horizontal shortening of the lower eyelid, a successful outcome is more likely after Jones retractor plication than after the Wies procedure.

Background: To report the results of cryopreserved human amniotic membrane transplantation for the management of symptomatic bullous keratopathy. Methods: Prospective non-comparative interventional case series study. Consecutive cases with symptomatic bullous keratopathy for more than 12 months not amenable to conservative treatment were managed with amniotic membrane transplantation. They were recruited over a 5-year period (September 1999 to November 2004) in one referral centre. Only one eye of each patient (the worse affected eye in bilateral cases) was operated. A 360 degree conjunctival peritomy was followed by removal of the diseased corneal epithelium. Amniotic membrane was transplanted over the cornea as a patch and sutured to the free conjunctival edges. Primary outcome measures were ocular pain and epithelial defects; secondary measures were visual acuity and ocular surface inflammation. Results: Four out of 85 recruited cases did not complete the minimum observation of 12 months and were excluded from the study. The mean follow-up period for the remaining 81 cases was 21 ± 4.2 months (range 14–34 months). Seventy-one (87.6%) eyes became asymptomatic with healed epithelium, seven required repeated amniotic transplantation and three underwent penetrating keratoplasty. Visual acuity improved in 64 (79%) patients and remained unchanged in 14. No complications were recorded. Conclusions: Amniotic membrane transplantation is an efficient and safe treatment for symptomatic bullous kerato pathy, when penetrating keratoplasty is not available. It has been shown to alleviate pain, promote corneal epithelialization and reduce conjunctival inflammation whereas in some cases it may also improve visual acuity.

No real new treatment has been developed in the last decade for thyroid eye disease (TED). Glucocorticoids (GC), orbital radiotherapy (OR) or a combination of both, are most frequently used in the treatment of TED for the iv immunosuppressive effects. However, we now have novel information regarding the when and how corticosteroids should be used. In general, the iv route of GC administration is preferable to the oral use. iv GC should be used at much lower doses than previously (4.5 to 6 g cumulative dose), possibly with a small dose of oral prednisone (or equivalent) in the interpulse period and for a few weeks after completion of iv treatment. Careful assessment of patients before treatment for identification of possible risk factors of liver toxicity is mandatory. Finally, monitoring of patients, particularly for liver function, is warranted during and after treatment. Although OR's effectiveness was disputed by a study few years ago, more recent studies have reconfirmed its beneficial role in TED and shown that it still has a positive role to play in patients with active TED. Finally, although Somatostatin-analogs (SM-as) gave the impression some years ago that might represent an effective weapon for TED management and initial, mostly uncontrolled and non-randomized trials with small number of patients supported this notion, newer randomized, double-blind studies with larger number of patients have not confirmed the first optimistic results. The question after that is if SM-as should be considered as a rubber bullet in the treatment of TED and we have to forget about them. The answer should be "no yet," especially in the light that the role of SM-as may be revitalized by the use of analogs with higher affinity for all somatostatin receptors subtypes. Such analogs are now available and under investigation in different diseases with very promising results.

Background Entropion is a condition in which the eyelid margin turns in against the eyeball. Involutional or senile entropion is one of the most common lower lid malpositions in the elderly. The interventions described and currently used for the treatment of this condition are surgical in nature, although non-surgical temporary medical treatment for the early stages of entropion has also been reported. The relative effectiveness of these interventions has not yet been resolved. Objectives To examine the effect of interventions for involutional entropion and to assess whether any method is superior to any other. Search methods We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2011, Issue 10), MEDLINE (January 1950 to November 2011), EMBASE (January 1980 to November 2011), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com),ClinicalTrials.gov (http://clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). There were no date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 2 November 2011. We also searched oculoplastic textbooks, conference proceedings from the European and American Society of Ophthalmic Plastic and Reconstructive Surgery (ESOPRS, ASOPRS), European Ophthalmological Society (SOE), the Association for Recearch in Vision and Ophthalmology (ARVO) and American Academy of Ophthalmology (AAO) for the years 2000 to 2009 to identify relevant data. We attempted to contact researchers who are active in this field for information about further published or unpublished studies. Selection criteria We included randomised controlled trials (RCTs) with no restriction on date or language comparing two or more surgical methods for correction of involutional lower eyelid entropion in people older than 60 years of age with involutional lower lid entropion. Data collection and analysis Each review author independently assessed study abstracts identified from the electronic and manual searches. Author analysis was then compared and full papers for appropriate studies were obtained according to the inclusion criteria. Disagreements between the authors were resolved by discussion. Main results We identified one RCT which met our inclusion criteria and was included in this review. Sixty-three participants with primary involutional lower eyelid entropion were randomised to everting sutures alone or everting sutures with a lateral tarsal strip. Eight participants were lost to follow-up. The trial indicates that the combined procedure for horizontal and vertical eyelid tightening in the form of everting sutures and lateral tarsal strip is highly curative for involutional entropion compared to vertical tightening in the form of everting sutures alone. The superiority of the combined approach is also supported by many good quality uncontrolled studies on specific surgical procedures but these were not included in the analysis as they were not part of the inclusion criteria. Authors' conclusions A single RCT showed that the combination of horizontal and vertical eyelid tightening with everting sutures and lateral tarsal strip is highly efficient for entropion compared to vertical tightening with everting sutures alone. Retrospective case series studies also support the combined surgical repair but details from these studies on specific surgical techniques cannot be included in the analysis.Evidence from a single RCT is unlikely to change clinical practice and thus it is still our view that there is a clear need for more randomised studies comparing two or more surgical techniques for entropion surgery addressing the recurrence and complications rate.