Purpose: To describe our experience with the use of botulinum toxin (BoNTA) for the symptomatic treatment of lacrimal outflow obstruction. Methods: We retrospectively reviewed the case notes of patients with epiphora due to lacrimal outflow obstruction who chose to have injections of botulinum toxin into the palpebral lobe of the lacrimal gland instead of surgery between 2009 and 2014. Epiphora was graded subjectively with Munk scores obtained before and after treatment as well as qualitative degree of improvement reported by the patients. Severity and duration of side effects were also noted. Results: Seventeen patients (22 eyes, mean age 70.3, 4 males and 13 females) were identified. A mean of 3.5 (range; 1-10) injections of BoNTA (Botox, Allergan; 1.25-7.5 units) were given per eye. The mean interval between injections was 3.9 months (range 3-6). The mean Munk score (3.4, range 2-4) improved significantly after treatment to 1.6 (range: 0-3, P = 0.0001 paired two-tailed t-test). Epiphora completely resolved in a fifth, improved by up to 60-90% in a half and only 'a little better' in a further fifth. Temporary bruising and diplopia (lasting 2 weeks) was reported in 12% (2/17). Conclusion: We report our outcomes for BoNTA to the palpebral lobe of the lacrimal gland in patients with lacrimal outflow obstruction epiphora seeking alternatives to surgery. This data provide further evidence for informed consent and for commissioning organisations considering the funding of this treatment.

The overall numbers of patients with endophthalmitis following intravitreal injections has risen dramatically over the past years. In contrast to earlier reports of multicentre studies, outcome of patients is relatively poor in the current treatment settings. We did not find clinical features useful in identifying cases with negative culture.

Purpose To describe the occurrence and severity of upper eyelid skin contracture in facial nerve palsy (FNP). Methods We enroled consecutive patients with unilateral FNP into this study. Patients with previous upper eyelid surgery for either side were excluded. We developed a standardised technique to measure the distance between the upper eyelid margin and the lower border of brow (LMBD). FNP was graded using the Sunnybrook grading scale. Its aetiology, duration, and treatment were noted. Upper and lower marginal reflex distance and lagophthalmos were also noted. Results Sixty-six patients (mean age 51 years) were included. FNP was owing to a variety of aetiologies. LMBD on the paralytic side was shorter than the normal contralateral side in 47 (71%), equal in 15 (23%), and larger in four (6%) patients. The mean contracture was 3.4 mm (median: 3, range: 1-12) with 11 (17%) patients showing 5 mm or more of skin contracture. The mean LMBD on the paralytic side in all patients was significantly smaller than the contralateral side; 30 ± 3.7 (median: 30; 95% CI 29-31) compared with 32 ± 3.7 (median: 32; 95% CI 32-33), respectively, Po0.0001, two-tailed paired t-test. Conclusion To our knowledge, this is the first study that quantitatively demonstrates contraction of the upper eyelid skin in FNP. This finding is valuable in directing optimal early management to minimise skin contracture and to caution surgeons against unnecessary upper eyelid skin excision.

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.

patients with scleritis develop bilateral disease, 50% of whom have delayed onset in the fellow eye, mostly of the same type of scleritis. 8 A high index of suspicion may uncover this sight-threatening but treatable condition. Occasionally a patient with medical training will experience the symptoms of a disorder that may provide a unique opportunity to determine the exact nature of the symptom. This has occurred in the past with lightning flashes from posterior vitreous detachment (PVD) because Moore published the findings of his own photopsia in 1947. 1 We describe an ophthalmologist colleague who suffered bilateral PVD with specific symptoms of black flashes for a brief period before the onset of the typical lightning flashes. One of the authors (LW) a 51-year-old female ophthalmologist with À5.5 D right eye and À6.0 D left developed acute PVD in the left eye. The first symptoms she noticed were black coloured flashes in the inferotemporal periphery. These were momentary, vertically orientated and occurred in a flickering pattern before subsiding and then returning again. After 6 h, they were replaced by white flashes and floaters. She was examined by THW and found to have a PVD with Weis ring. Seven years later, she developed in the right eye a similar pattern of black flashes for 2 h before they were replaced by white flashes and floaters from PVD (confirmed by THW). We suspect that many patients forget or disregard this initial symptom because these flashes are soon replaced by white lightning flashes. Since the presentation by LW, we have on specific questioning found black flashes to be present in other individuals with PVD. The symptom may be due to traction on the axons of the surface of the optic nerve by the vitreous as the PVD process creates the Weis ring thus interrupting the signal from the retina. The fact that the PVD has not yet occurred is suggested by the appearance of floaters and white lightning flashes only after the black flashes have disappeared. Evidence that the PVD process can be traumatic to the optic nerve head can be seen in some patients who develop haemorrhages on the surface of the optic nerve head after PVD. 2,3 This is the first description of black photopsia in PVD that we are aware of. References