Importance This study assesses the interobserver agreement on dacryocystography (DCG) and dacryoscintigraphy (DSG) findings. Background There are no standard grading criteria to guide the interpretation of conventional DCG and DSG findings and therefore there may be a degree of subjectivity. This study evaluates the level of interobserver agreement in the interpretation of DCG and DSG findings. Design A retrospective observational study at the Royal Adelaide Hospital. Participants A total of 165 patients who presented with epiphora with 276 DCGs and 290 DSGs performed were included in this study. Methods DCG and DSG images were obtained, anonymized, randomized and interpreted by three independent oculoplastic surgeons. Standard grading criteria were set for both DCG and DSG images. Data from all observers were analysed for interobserver agreement using Kappa (κ) statistics, generated using a variation of Cohen's kappa for multiple observers. Main Outcome Measures Level of interobserver agreement (κ values) in the grading of DCG and DSG findings. Results There was an overall moderate interobserver agreement for DCG findings (κ = 0.55), with the highest agreement on interpreting canalicular obstruction (κ = 0.80), followed by proximal nasolacrimal duct obstruction (κ = 0.67) and normal patency (κ = 0.63). There was an overall fair interobserver agreement for DSG findings (κ = 0.36), with the best being moderate agreement (κ = 0.42‐0.50) for interpreting pre‐sac delay and post‐sac proximal delay. Conclusions and Relevance DCG offers good reliability in interpreting patent and obstructed systems. On the other hand, DSG has poor agreement and highlights some of the limitations in the ability to guide epiphora management.

Background/Objectives Vismodegib, a hedgehog pathway inhibitor, has been used in the management of locally advanced basal cell carcinoma (BCC) not suitable for surgery or radiation therapy. We report our experience using neoadjuvant vismodegib for locally advanced periocular BCC, followed by surgical excision. Our aim was to assess the effect on the extent of surgical excision and histological response. Subjects/Methods A retrospective case series of patients treated with neoadjuvant vismodegib, for the management of locally advanced periocular BCC prior to surgical excision, with intraoperative margin control. Patients were treated until a maximum clinical response was seen. The difference between the estimated surgical margins prior to vismodegib and the eventual margins used was compared. Fine (1 mm) vertical sections through the excised tumour were performed to assess the histological response and look for a multifocal tumour. Results Eight Caucasian patients had neoadjuvant treatment with vismodegib for a median duration of 6 months. Some clinical response was seen in all cases but was only partial in 6/8 patients. Histological evaluation of the excised specimen showed residual BCC in 6/8 cases and thus 2/8 showed complete histological regression. Two cases showed squamous differentiation. Side effects occurred in 7/8 patients all which resolved on cessation of therapy. The mean follow-up was 13.4 ± 5.2 months. Conclusions Neoadjuvant treatment of periocular BCC showed a mixed clinical and histological response. Final surgical excision achieved clear margins in all patients with no recurrence at 13 months and a reduction in predicted defect size, but possible squamous differentiation in two cases.

We report on the largest consecutive series of Caucasian patients under 16 years of age with PSUS. We have demonstrated a seasonal preponderance with presentation typically in winter or spring. We report a novel finding of corneal endotheliopathy in one of our PSUS patients. We also report on the benefit of adalimumab in the management of severe cases of PSUS; use of biologics in this particular cohort of uveitis patients has not previously been reported. With aggressive treatment our patients achieved good visual outcomes comparable to other published series.

The etiology of uveitis in this pediatric population is mixed. With close monitoring, most patients maintain good vision.

Purpose To describe a modified technique of endoscopic orbital decompression for dysthyroid optic neuropathy nonresponsive to pulsed corticosteroids. Methods Retrospective, interventional single centre case series included 17 consecutive patients with dysthyroid optic neuropathy (DON) who were refractory to pulse corticosteroids. Removal of the posteromedial floor and the orbital process of palatine bone (OPPB) was performed in addition to the endoscopic transethmoidal medial orbital wall decompression (ETMOWD), to achieve maximal orbital apex decompression. Main outcome measures were change in visual acuity (VA), color vision, degree of proptosis reduction, incidence of new-onset diplopia, and any complications. Results Seventeen eyes (100%) had a statistically significant improvement in VA from 1.0 ± 0.44 LogMAR to 0.0 ± 0.15, with an average improvement of 0.41 ± 0.30 LogMAR (p 0.05, paired t-test). Fourteen out of 16 eyes had a complete improvement in color vision and two eyes had partial recovery. Afferent pupillary defect (76.5%) resolved in all cases. Five out of 10 cases with preoperative visual field defects demonstrated no residual field defects following surgery. The range of proptosis reduction was 0-5 mm (mean 2.7 ± 1.3 mm). No patients with diplopia (12/17) had worsening or developed new-onset diplopia following surgery. Conclusion Combined removal of the posterior medial floor including the OPPB with ETMOWD may be a viable alternative in the surgical management of DON.

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Fig. 2-(A) Coronal computed tomography demonstrating opacification of the right sphenoid and ethmoid sinuses. (B) T2weighted fat-suppressed coronal magnetic resonance imaging (MRI) showing a hyperintense superior orbital lesion with central areas of hypointensity. (C) T1-weighted fat-suppressed coronal MRI showing a nonenhancing superior orbital mass.

Large cysts in the orbital lobe of the lacrimal gland are rare and are associated with Sjögren syndrome and B-cell mucosa-associated lymphoid tissue lymphoma. The authors describe 4 new cases of large orbital lobe lacrimal gland cysts. The first 2 patients, both with Sjögren syndrome, had unilateral cysts associated with chronic inflammation. Mucosa-associated lymphoid tissue lymphoma was also identified in the cyst wall of the second case and could not be completely excluded in the first case. The third patient, with a history of rheumatoid arthritis, had bilateral cysts, again associated with mucosa-associated lymphoid tissue lymphoma. The fourth patient, with no history of systemic disease, had a unilateral cyst associated with reactive lymphoid hyperplasia. Finally, the authors report the long-term outcomes of 3 previously reported cases.