Ophthalmic presentation of undiagnosed sinonasal masses
K Vahdani and G Rose
Ophthalmic Plast Reconstr Surg vol 37:5 (2021)
Review: This is a retrospective chart review for patients seen at Moorfields Eye Hospital between 1969-2020 to evaluate clinical features of patients with an ophthalmic presentation of underlying, undiagnosed sinonasal pathology.
Of 448 patients, 56% were male and the average age of presentation was 47 years (range 3-92 years). The commonest presenting symptoms were proptosis (34%), orbital ache/pain (31%), periorbital swelling (29%) and diplopia (22%). Non-axial displacement of the globe was recorded in 74% (particularly inferolateral, lateral or upward), ocular movements were reduced in 56%, corrected visual acuity of 6/18 or worse was found in 20%, 16% had an ipsilateral relative afferent pupillary defect and an orbital mass was palpable in 49%. There was 2.3mm relative exophthalmos (range 0-17mm) in patients with unilateral disease. Abnormalities of the disc and fundus were seen in 15%.
The commonest pathologies were sinus mucocoeles at 38% (predominantly frontal/ethmoidal), 11% had undiagnosed chronic sinus inflammatory disease (mostly granulomatous with polyangiitis) and one-third were tumours (13% benign and 20% malignant). Of these, carcinomas of the ethmoid or maxilla were commonest, and 2/3 of malignancies were found in male patients. The average age for presentation of malignant tumours was 54 years (15 years older than patients with benign tumours). Multivariate regression analysis of mass lesions identified periorbital pain (odds ratio, 6.0; 95% confidence interval, 1.7-21.5; P=0.005) and reduced ocular motility (odds ratio, 3.2; 95% confidence interval, 1.1-9.0; P=0.03) as features most predictive for undiagnosed sinonasal malignancy.
Comment: Sinonasal tumours may grow insidiously within air-filled spaces and often present late with orbital or cranial invasion. Beware the late-middle-aged male with periorbital pain and reduced ocular movements.
Lower eyelid involutional entropion following cataract surgery
Schulz C et al
Eye (2022) vol 36
Review: A retrospective cohort study to determine whether cataract surgery is associated with an increased risk of subsequent lower eyelid entropion and to evaluate potential associated factors. The population included consecutive patients undergoing first eye cataract surgery (having never had previous adnexal surgery) over a 10-year period at a single institution (n=14,574), with the fellow phakic eye serving as a control (thus matched for age, sex and follow-up duration), and end-points being second eye cataract surgery, or any other intraocular or adnexal surgery.
There is a well-established association between cataract surgery and post-operative eyelid malposition, with upper eyelid ptosis being the most recognised1. However, it has also been noted that a relatively higher proportion of pseudophakic patients also undergo lower lid entropion repair and there might be an association between cataract surgery and the development of lower lid entropion2.
The relative risk of undergoing subsequent entropion repair after cataract surgery was calculated by comparing the rate of entropion surgery between the exposed (pseudophakic) group, and their matched control (phakic) eyes. This overall relative risk was 4.0 (95% confidence interval 1.6-9.8; P <0.001). Median time from cataract surgery to ipsilateral entropion repair was 58 months (range 3-124, n=24).
Comment: The fourfold increase in the risk of entropion repair appears to be delayed some months after cataract surgery. The authors suggest this might be due to the surgery accelerating involutional change. They discuss possible mechanisms of damage, which are not fully established. However, they do highlight the importance of oculoplastic assessment both pre- and post-operatively, and mindfulness of the periocular tissue intra-operatively.
- Wang Y et al. Incidence and risk of ptosis following ocular surgery: a systematic review and meta-analysis. Graefes Arch Clin Exp Ophthalmol. 2019; 257:397-404
- Hurwitz JJ et al. Association of entropion with cataract surgery. Ophthal Plast Reconstr Surg. 1990; 6:25-7.
Nicotinamide and nonmelanoma skin cancers
A Jamison and R Malhotra
Ophthalmic Plast Reconstr Surg. Published online 15 February 2022
Review: This is a perspective piece discussing the potential benefit of oral nicotinamide (an amide derivative of vitamin B3) to reduce the incidence of non-melanoma skin cancers (NMSC).
There has been extensive discussion in the dermatology literature about the efficacy of oral nicotinamide supplementation in reducing the incidence of skin cancers such as basal and squamous cell carcinomas. A precursor of nicotinamide adenine dinucleotide (NAD+), which is crucial to the production of ATP, nicotinamide can protect against reducing ATP levels, maintaining the energy levels required to sustain DNA repair and reduce UV radiation-induced immunosuppression.
The article discusses early literature showing protective effects in murine models and a randomised controlled trial (RCT) showing a 23% reduction in NMSC at 12 months, with 500mg twice daily dosing. Some criticism of the statistical analysis of the RCT, as well as it having a composite primary endpoint, tempers the widespread acceptance of that degree of benefit of supplementation. Given the underlying pathophysiology, it is felt that nicotinamide is likely to have a preventative effect on NMSC, but a higher standard of evidence will be required to prove it.
Comment: Oral nicotinamide has a good side-effect profile and is available over the counter. Given its potential to reduce the incidence of NMSC (even though currently unproven), it would be worth mentioning it to our high-risk patients with previous adnexal skin cancers. Certainly, it’s worth watching this space.
Dr Catherine McMurray is an ophthalmologist serving the communities of South and Central Auckland and an honorary lecturer in the Department of Ophthalmology, University of Auckland. She consults at Counties Manukau and Auckland DHBs, specialising in oculoplastic surgery.