The Use of Hyaluronidase in Aesthetic Practice: A Comparative Study of Practitioner Usage in Elective and Emergency Situations

BACKGROUND

Hyaluronic acids (HAs) continue to be the fillers of choice worldwide and their popularity is growing. Adverse events (AEs) are able to be resolved through the use of hyaluronidase (HYAL). However, routine HYAL use has been at issue due to perceived safety issues.

OBJECTIVES

There are currently no guidelines on the use of HYAL in aesthetic practice, leading to variability in storage, preparation, skin testing, and beliefs concerning AEs. This manuscript interrogated the use of this agent in daily practice.

METHODS

A 39-question survey concerning HYAL practice was completed by 264 healthcare practitioners: 244 from interrogated databases and 20 from the consensus panel. Answers from those in the database were compared to those of the consensus panel.

RESULTS

Compared to the database group, the consensus group was more confident in the preparation of HYAL, kept reconstituted HYAL for longer, and was less likely to skin test for HYAL sensitivity and more likely to treat with HYAL in an emergency, even in those with a wasp or bee sting anaphylactic history. Ninety-two percent of all respondents had never observed an acute reaction to HYAL. Just over 1% of respondents had ever observed anaphylaxis. Five percent of practitioners reported longer-term adverse effects, including 3 respondents who reported loss of deep tissues. Consent before injecting HA for the possible requirement of HYAL was always obtained by 74% of practitioners.

CONCLUSIONS

Hyaluronidase would appear to be an essential agent for anyone injecting hyaluronic acid filler. However, there is an absence of evidence-based recommendations with respect to the concentration, dosing, and treatment intervals of HYAL, and these should ideally be available.

LEVEL OF EVIDENCE: 5

Making Sense of Late Tissue Nodules Associated With Hyaluronic Acid Injections

BACKGROUND

The pathogenesis of delayed onset tissue nodules (DTNs) due to hyaluronic acid (HA) injections is uncertain.

OBJECTIVES

To formulate a rational theory for DTN development and their avoidance and treatment.

METHODS

A multi-disciplinary and multi country DTN consensus panel was established with 20 questions posed and consensus sought. Consensus was set at 75% agreement.

RESULTS

Consensus was reached in 16/20 questions regarding the pathogenesis of DTNs forming the basis of a classification and treatment guide.

CONCLUSIONS

The group believe that filler, pathogens and inflammation are all involved in DTNs and that DTNs most likely are infection initiated with a variable immune response. Injected filler may incorporate surface bacteria, either a commensal or a true pathogen if the skin barrier is altered. The initially High molecular weight HA (HMWHA) filler is degraded to Low molecular weight HA (LMWHA) at the edge of the filler. Commensals positioned within the filler bolus may be well tolerated until the filler is degraded and the commensal becomes visible to the immune system. LMWHA is particularly inflammatory in the presence of any local bacteria. Commensals may still be tolerated unless the immune system is generally heightened by viraemia, or vaccination. Systemic pathogenic bacteraemia may also interact with the filler peripheral LMWHA, activating Toll Like receptors inducing DTN formation. Given this scenario, attention to practitioner and patient hygiene and early systemic infection treatment deserve attention. Classification and treatment systems were devised by considering each of the 3 factors of filler, inflammation, and infection separately.

Comparing the outcomes of severe versus mild/moderate ptosis using closed posterior levator advancement

Traditionally, posterior eyelid surgical approaches such as Müller's muscle-conjunctival resection (MMCR) have been utilised with great success for mild cases of ptosis, with external levator approaches having been used for more severe cases of ptosis. We present a new technique which we label closed posterior levator advancement (CPLA) for the correction of all grades of ptosis. This article is a retrospective cohort study reviewing patients with mild, moderate, and severe ptosis over a 6-year period, treated by a single surgeon using CPLA. Minimum follow-up was 3 months. Patients with good levator function (levator palpebrae superioris (LPS) function >10 mm) without concomitant procedures were subdivided based on margin-to-reflex-distance-1 (MRD1) into mild-to-moderate ptosis (MRD1 > 1.5 mm) and severe ptosis (MRD1 ≤ 1.5 mm) cohorts. The outcome measures were preoperative and postoperative MRD1, lid contour, intereye symmetry, complications, and revision rates. 393 eyes of 313 patients were identified. 91 eyes in the mild-to-moderate cohort had a preoperative MRD1 of 2.38 mm, and 302 eyes in the severe cohort had a preoperative MRD1 of 0.27 mm. Postoperatively, MRD1 was 3.86 mm and 3.49 mm, respectively. There were no significant complications in both cohorts, and revision rates were 3.3% (3 of 91 eyes) in the mild-to-moderate and 2% (6 of 302 eyes) in the severe cohorts. Upper-eyelid contour was satisfactory in 98.2% of eyes, and 97.5% intereye symmetry within 1 mm was observed. Our results show an effective correction of all ptosis grades with satisfactory cosmetic outcomes and low complication and revision rates.

Revision Dacryocystorhinostomy: A Comparison of Endoscopic and External Techniques

Background

Success rates for revision dacryocystorhinostomy (DCR) are lower than primary DCR. Scarring of the sac may limit the ability of the surgeon to achieve good nasal and lacrimal mucosa apposition. This study evaluates the comparative success rates of the external and endoscopic techniques for revision DCR.

Methods

Seventeen consecutive revision endoscopic DCRs (average age, 60.9 years) and 13 revision external DCRs (average age, 65.1years) performed from January 1999 to December 2000 performed by separate surgeons were entered into the study. Patients with functional nasolacrimal and canalicular obstruction were excluded. The average follow-up was 11.1 months for the endoscopic DCR group and 10 months for the external DCR group.

Results

A successful DCR required complete relief of symptoms and an endoscopically determined anatomic patency of the nasolacrimal system. Revision endoscopic DCR surgery was successful in 76.5% of cases (13 of 17 cases) and external DCR surgery was successful in 84.6% (11 of 13 cases). This difference was not statistically significant. (p = 0.64, Fisher exact test with a two-tailed probability).

Conclusion

Revision endoscopic DCR has a success rate of 76.5%, which compares favorably with that of the revision external DCR (84.6%).

Mikulicz's Disease: A New Perspective and Literature Review

PURPOSE

To report the clinical and pathophysiologic features of two patients with Mikulicz's disease and to further characterize recommendations for diagnosis and management with a review of the literature.

METHODS

Retrospective nonrandomized consecutive case series, Jules Stein Eye Institute, David Geffen School of Medicine at UCLA.

RESULTS

Mikulicz's disease is characterized by symmetric lacrimal, parotid, and submandibular gland enlargement with associated lymphocytic infiltrations. The authors noted two cases of Mikulicz's disease. The diagnosis of Mikulicz's disease was based on the following criteria: 1) symmetric and persistent swelling of the lacrimal glands and either or both of the major salivary glands (parotid and submandibular); and 2) the exclusion of other diseases that may mimic this presentation, such as sarcoidosis, viral infection, or lymphoproliferative disorders.

CONCLUSIONS

Mikulicz's disease is a condition in which there is bilateral lacrimal and salivary gland swelling that is not associated with other systemic conditions. The condition is self-limiting and most often, the diagnosis is a clinical one. Previously, Mikulicz's disease was often considered as a subtype of Sjögren's syndrome (SS). Clinical and immunologic differences between Mikulicz's disease and SS may warrant further consideration of Mikulicz's disease as a specific autoimmune phenomenon separate from SS, and Mikulicz's disease may be amenable to different treatment modalities than those employed in patients with SS.

Association of Polymorphisms in MACRO Domain Containing 2 With Thyroid-Associated Orbitopathy

PURPOSE

Thyroid-associated orbitopathy (TO) is an autoimmune-mediated orbital inflammation that can lead to disfigurement and blindness. Multiple genetic loci have been associated with Graves' disease, but the genetic basis for TO is largely unknown. This study aimed to identify loci associated with TO in individuals with Graves' disease, using a genome-wide association scan (GWAS) for the first time to our knowledge in TO.

METHODS

Genome-wide association scan was performed on pooled DNA from an Australian Caucasian discovery cohort of 265 participants with Graves' disease and TO (cases) and 147 patients with Graves' disease without TO (controls). Top-ranked single nucleotide polymorphisms (SNPs) then were genotyped in individual DNA samples from the discovery cohort, and two replication cohorts totaling 584 cases and 367 controls.

RESULTS

In the GWAS of pooled DNA samples, several SNPs showed suggestive association with TO at genome-wide P ≤ 10-6; rs953128 located on chr10q21.1, rs2867161 on chr7q11.22, rs13360861 on chr5q12.3, rs7636326 on chr3q26.2, rs10266576 on chr 7q11.22, rs60457622 on chr3q23, and rs6110809 on chr20p12.1. However, the only SNP consistently associated with TO on individual genotyping in the discovery and replication cohorts was rs6110809, located within MACROD2 on chromosome 20p12.1. On combined analysis of discovery and replication cohorts, the minor A allele of rs6110809 was more frequent in TO than in Graves' disease controls without TO (P = 4.35 × 10-5; odds ratio [OR] = 1.77; 95% confidence interval [CI], 1.35-2.32) after adjusting for age, sex, duration of Graves' disease, and smoking.

CONCLUSIONS

In patients with Graves' disease, a common genetic variant in MACROD2 may increase susceptibility for thyroid-associated orbitopathy. This association now requires confirmation in additional independent cohorts.

Rituximab for the treatment of IgG4-related orbital disease: experience from five cases

PURPOSE

To review the clinical efficacy and safety of rituximab for treatment of IgG4-related orbital disease (IgG4-ROD).

DESIGN

Retrospective multicentre interventional case series.

METHODS

Chart review for five cases of biopsy-confirmed IgG4-ROD (IgG4+>10/HPF, ratio of IgG4+/IgG+>40%) treated with rituximab. Information retrieved included the dosing schedule, adverse events and the magnitude, temporality, and duration of the clinical response.

RESULTS

All cases of IgG4-ROD were either steroid dependent or steroid resistant. Rituximab doses for induction therapy included two doses of 1000 mg at 2-weekly intervals, and four doses at 375 mg/m(2) at weekly intervals. Two months after starting rituximab, three cases achieved complete clinical resolution and two cases achieved partial clinical resolution. Complete radiological resolution occurred in one case, and partial radiological resolution in three cases. Three cases received rituximab maintenance therapy and one case was commenced on mycophenolate. No relapse occurred during a mean follow-up of 33 months (range: 7-65 months). One disease relapse occurred when the dosing interval of rituximab maintenance therapy was extended to 6-monthly intervals; remission was swiftly achieved with rituximab reinduction therapy. The only adverse effects reported were one episode of fatigue lasting 1 week and two episodes of orbital discomfort.

CONCLUSION

Rituximab may be an effective treatment option for IgG4-ROD that is steroid dependent or steroid intolerant. Rituximab therapy resulted in swift clinical and radiological improvement, many months free of relapse, and few side effects.

Oculofacial contour asymmetries: Management of combined treatment with hyalurostructure and botulinum toxin injections

PURPOSE

To assess the long-term results of the treatment of oculofacial asymmetries using a combined injection schedule for injections of hyaluronic acid, with a specific micro cannula and botulinum toxin.

METHOD

A retrospective study was conducted from January 2009 to January 2010. Patients were treated in the Alcazar Eye Clinic and Oculoplastic Department in Princess Grace Hospital, Monaco. We selected patients complaining of asymmetrical periorbital features who received treatment with hyalurostructure and botulinum toxin injection in one or more sessions. Nine patients were selected and presented with the following symptoms: asymmetry of eyebrow position (2 patients), superior orbital hollow (2 patients), tear trough (2 patients) and orbital volume (ocular prosthesis) (3 patients). The objective was to evaluate the efficiency of combined treatment in one or more sessions on these oculofacial asymmetries. Hyaluronic acid injections were done using hyalurostructure. Hyaluronic acid gel (Restylane Lidocaine) was used with a 25 gauge reinforced micro-cannula (pix'l +, Thiebaud). This was combined with injections of botulinum toxin (azzalure*) to areas of muscular hyperaction. Follow-up was done at 1 year by clinical examination, photography and patient satisfaction. Complications of this combined treatment have been identified.

RESULTS

At 1-year follow-up, 88% of patients were satisfied or very satisfied with their results. There were no more complications secondary to both treatments in the same session. It was not noticed more hematomas and bruises than in classical injection method. The action of toxin is constant over time despite the association of hyaluronic acid injections.

CONCLUSION

Combined treatments with toxin and hyaluronic acid in oculofacial asymmetries are efficient and can be proposed in the same session. These treatments must be repeated to maintain and optimize muscle contraction and volume loss. Use of hyalurostructure and botulinum toxin treatment in the same session is effective and safe.

Endoscopic dacryocystorhinostomy in acute dacryocystitis: a multicenter case series

OBJECTIVE

To present our experience of early endonasal DCR (endoDCR) in the treatment of acute dacryocystitis (AD). Methods. International multicenter non-comparative retrospective study.

RESULTS

Eighteen patients were identified. All were treated with antibiotics prior to surgery with a median of time from referral to endoDCR surgeon to surgery of 3 days (range 1-7). Surgery was performed using mechanical powered endoDCR (MENDCR) in 15/18 (83.3%) cases; mitomycin C was used in 5/18 (27.8%) and all cases underwent bicanalicular intubation. An increase in perioperative bleeding was noted in 5/18 (27.8%), causing interference in surgical technique in one (5.6%). Resolution of AD was seen in all cases, with no recurrences. 17/18 (94.4%) cases were free of epiphora at median follow-up of 12 months (range 2-36), with nasal endoscopy revealing free flow of fluorescein through the ostium in 17/18 (94.4%) of cases. The median total length of stay was 1 night (range 0-3).

CONCLUSIONS

EndoDCR surgery performed early in AD led to rapid resolution of the condition in all cases and was associated with subsequent anatomical and functional success in 94.4% of cases. Early endoDCR surgery in the context of AD and the potential associated health economic benefits are worth further consideration and study.

Development of criteria for evaluating clinical response in thyroid eye disease using a modified Delphi technique

OBJECTIVE

To identify components of a provisional clinical response index for thyroid eye disease using a modified Delphi technique.

METHODS

The International Thyroid Eye Disease Society conducted a structured, 3-round Delphi exercise establishing consensus for a core set of measures for clinical trials in thyroid eye disease. The steering committee discussed the results in a face-to-face meeting (nominal group technique) and evaluated each criterion with respect to its feasibility, reliability, redundancy, and validity. Redundant measures were consolidated or excluded.

RESULTS

Criteria were parsed into 11 domains for the Delphi surveys. Eighty-four respondents participated in the Delphi 1 survey, providing 220 unique items. Ninety-two members (100% of the respondents from Delphi 1 plus 8 new participants) responded in Delphi 2 and rated the same 220 items. Sixty-four members (76% of participants) rated 153 criteria in Delphi 3 (67 criteria were excluded because of redundancy). Criteria with a mean greater than 6 (1 = least appropriate to 9 = most appropriate) were further evaluated by the nominal group technique and provisional core measures were chosen.

CONCLUSIONS

Using a Delphi exercise, we developed provisional core measures for assessing disease activity and severity in clinical trials of therapies for thyroid eye disease. These measures will be iteratively refined for use in multicenter clinical trials.

'The Microhand': a new concept of micro-forceps for ocular robotic surgery

PURPOSE

To test the feasibility of retinal manipulations using a new micromanipulator (Microhand) for ocular robotic microsurgery.

METHODS

Pneumatically actuated four-finger microhands were developed at UCLA with micro electromechanical systems (MEMS) technology to mimic a human hand for small object manipulation. Microhands with four 4 mm finger lengths were used for this study to lift caliper weights and fresh retinal tissue of porcine cadaver eyes to find the maximum force at a given pressure and feasibility of the microhands for retinal manipulation in real surgery.

RESULTS

A full closure of the microhand used for caliper weight lifting was achieved under 65 psi (448 kPa) of air pressure. The four-fingered microhand was able to develop about 20 mN of total lifting force and 5 mN per finger at 80 psi (551 kPa), and was strong enough to displace and lift the retina of pig eyes.

CONCLUSIONS

The microhand is able to apply calibrated forces to ocular tissues and is suitable for ocular microsurgical procedures. This new tool would be useful in the development of robotic microsurgery.

Biologic therapeutics in thyroid-associated ophthalmopathy: translating disease mechanism into therapy

Graves' disease (GD) is a systemic autoimmune disease which targets the thyroid, orbit, and skin. Thyroid-associated ophthalmopathy (TAO) refers specifically to the orbital and periorbital manifestations of GD. Several important concepts have emerged from our enhanced understanding of the molecular mechanisms of the disease. Considerable debate remains concerning the specific identity and roles of inflammatory T-cell subsets, soluble and contact-mediated signalling, and autoantigens driving TAO. However B and T lymphocytes appear central in the process through production of disease mediators including activating autoantibodies to the thyrotropin receptor and insulin-like growth factor-1 receptor; cytokines including IL-1beta, IL-6, and IL-16; and chemokines including RANTES. Many of these molecules appear central to the inflammation, accumulation of extracellular matrix macromolecules, and fibrosis in the disease. Novel therapeutics targeting other autoimmune diseases may provide an opportunity for disrupting disease pathogenesis. It is imperative that agents targeting B-and T-cell functions be further evaluated in the treatment of aggressive forms of TAO utilizing multicenter clinical trials that allow adequate statistical power and sample size.

Autologous dermis graft at the time of evisceration or enucleation

AIM

To present a new technique using autologous dermis graft at the time of enucleation or evisceration to replace the ocular surface area lost when the corneal scleral button is excised.

METHODS

A retrospective, interventional, non-comparative case series of patients who had an autologous dermis graft placed to assist in closure of Tenon's capsule and conjunctiva at the time of enucleation or evisceration. Medical records were reviewed and the following variables were recorded: age, sex, history of previous ocular surgery or radiation treatment, indication for surgery, type of surgery, laterality, type of orbital implant, size of implant, length of follow up, and complications.

RESULTS

Nine patients were identified (three male, six female) Five had enucleation with implant placement and four had evisceration with implant placement. Four individuals received unwrapped porous polyethylene spherical implants, three received silicone implants, and two received hydroxylapatite implants. Follow up ranged from 30 to 112 weeks (mean (SD), 61 (28) weeks). No operative or early complications were observed. One patient who had enucleation after two rounds of brachytherapy for uveal melanoma developed subsequent late exposure of the implant. There were no complications involving the graft donor site.

CONCLUSIONS

This small series shows that the use of a dermis graft is a safe and effective new technique to facilitate orbital rehabilitation. It is hypothesised that the extra surface area produced with a dermis graft preserves the fornices and allows a larger implant. It may also allow the implant to be placed more anteriorly which assists with both implant and prosthesis motility.

Treatment of Lower Eyelid Retraction by Expansion of the Lower Eyelid With Hyaluronic Acid Gel

PURPOSE

To report our preliminary experience utilizing a nonsurgical alternative in the treatment of lower eyelid retraction: expansion and reinforcement of the lower eyelid with hyaluronic acid gel.

METHODS

Retrospective review of patients with lower eyelid retraction treated with hyaluronic acid gel. Pretreatment, post-treatment, and follow-up photographs were digitized and overall outcomes assessed. Measurements of inferior scleral show were standardized and compared.

RESULTS

Sixty-five procedures (31 patients; 14 male; mean age 58 years, range, 33-78 years) with lower eyelid retraction of various etiologies were treated with hyaluronic acid gel. A mean change in scleral show of 1.04 mm was found when pre- and post-treatment measurements were compared. The overall mean follow-up period was 6.2 months (range, 1-12 months). During the interval from initial treatment to follow-up visit (mean 4.6 months, range, 1-12 months), the effect of the hyaluronic acid gel diminished, with a mean increase in inferior scleral show of 0.52 mm. Twelve patients underwent a second, and 6 patients underwent a third, maintenance treatment with an improvement in scleral show of 0.87 mm and 1.13 mm, respectively. Complications were minor and included swelling, redness, bruising, and tenderness at the sites of injection.

CONCLUSIONS

Based on our preliminary results, hyaluronic acid gel shows promise as a treatment modality for the management of lower eyelid retraction. Long-term follow-up will better clarify the required frequency of maintenance injections, the degree of hyaluronic acid gel retention, and the position of the lower eyelid over time.

Thiazolidinedione induced thyroid associated orbitopathy

Background

To describe an episode of thyroid associated orbitopathy (TAO) following the initiation of thiazolidinedione (TZD).

Case presentation

We report a female patient with a history of Graves' disease and stabilised thyroid associated orbitopathy for 2.5 years, who experienced rapid progression of TAO after the initiation of thiazolidinedione for glycemic control. Following the discontinuation of TZD, the patient experienced subsequent stabilisation of disease and normalization of vision. The medical history, ophthalmic findings, and clinical course are discussed.

Conclusion

Thiazolidinediones may exacerbate TAO, and this should be taken into consideration when selecting treatment for diabetic patients with a history of autoimmune thyroid disorders.

Inflammatory myofibroblastic tumour of the orbit in a 7-year-old child

Inflammatory myofibroblastic tumour (IMT) is a rare low-grade lesion in the spectrum of myofibroblastic tumours. Systemic IMT is a well-described entity, but orbital IMT is extremely uncommon. These tumours are detected incidentally or through site-specific complaints. Their presentation may clinically and radiologically mimic that of a malignant neoplasm, thus necessitating a biopsy. Even with reports of persistence, local recurrence and malignant transformation the overall prognosis remains favourable.

Robotic ocular surgery

BACKGROUND

Bimanual, three-dimensional robotic surgery has proved valuable for a variety of surgical procedures.

AIMS

To examine the use of a commercially available surgical robot for ocular microsurgery.

METHODS

Using a da Vinci surgical robot, ocular microsurgery was performed with repair of a corneal laceration in a porcine model. The experiments were performed on harvested porcine eyes placed in an anatomical position using a foam head on a standard operating room table. A video scope and two, 360 degrees -rotating, 8-mm, wrested-end effector instruments were placed over the eye with three robotic arms. The surgeon performed the actual procedures while positioned at a robotic system console that was located across the operating room suite. Each surgeon placed three 10-0 sutures, and this was documented with still and video photography.

RESULTS

Ocular microsurgery was successfully performed using the da Vinci surgical robot. The robotic system provided excellent visualisation, as well as controlled and delicate placement of the sutures at the corneal level.

CONCLUSIONS

Robotic ocular microsurgery is technically feasible in the porcine model and warrants consideration for evaluation in controlled human trials to deploy functioning remote surgical centres in areas without access to state-of-the-art surgical skill and technology.

Mechanical Endonasal Dacryocystorhinostomy with Mucosal Flaps

Mechanical endonasal dacryocystorhinostomy (DCR) involves the creation of a large rhinostomy and the preservation of lacrimal and nasal mucosa. It replicates the main advantages of the external approach to DCR using minimally invasive techniques. A thorough knowledge of intranasal anatomy and the close collaboration of a multidisciplinary team are important when converting from the external to the endonasal approach.

Standardized terminology for aesthetic ophthalmic plastic surgery

PURPOSE

To determine whether existing Systemized Nomenclature of Medicine (SNOMED) terminology adequately describes aesthetic concepts commonly encountered in the oculoplastic and facial plastic surgery setting.

METHODS

This was a noncomparative case series. A panel of three oculoplastic surgeons compiled a list of unique concepts describing specialized aesthetic terminology commonly encountered in the oculoplastic and facial plastic surgery setting, with a specific focus on anatomic structures and descriptive findings. A standard electronic browser was used to manually search for the existence of equivalent matching concepts in SNOMED. A quality of match score from 1 to 3 was used with values of (1) no match, (2) partial match, and (3) equivalent match.

RESULTS

An assessment of the existing aesthetic terminology revealed that a majority of concepts were not represented. Of 62 total concepts, 68% had no match, 13% had a partial match, and 19% had a complete match.

CONCLUSIONS

SNOMED coverage of aesthetic terminology was less than in previous studies examining content representation for other medical topics. Such findings underscore a need for further development and refinement of aesthetic content.

Thyroid associated orbitopathy following periocular surgery

PURPOSE

To descirbe a series of patients in which Thyroid Associated Orbitopathy (TAO) occurred after periocular surgery.

METHODS

A retrospective case review of patients who developed TAO in close temporal association with periocular surgical interventions and presented at the orbital clinic from 1997 to 2004. History of previous thyroid abnormality and the lack of TAO signs and symptoms before surgery were reviewed and analyzed.

RESULTS

Nine patients that developed TAO in association with periocular surgery were identified. All were women with an average age of 59.3years. (range: 45-75 years). The patients divided into two groups. Group 1 consisted of four patients who had previously been diagnosed with Graves' hyperthyroidism (GH). They ranged in age from 48 to 75 years (average: 58.8 years). The diagnosis of GH had been made an average of 50.5 months (range: 12-96 months) before presentation with TAO. Group 2 consisted of five patients who had no previous history of thyroid abnormality. They ranged in age from 45 to 74 years (average: 60.2 years). No patients had any signs or symptoms of TAO before their recent presentation.

CONCLUSIONS

Periocular surgery may lead to local inflammatory events that may contribute to the instigation of TAO in predisposed individuals.

Paediatric endoscopic endonasal dacryocystorhinostomy in congenital nasolacrimal duct obstruction

OBJECTIVES

The objectives of this study were to report a series of paediatric patients who underwent endoscopic endonasal dacryocystorhinostomy (DCR) for primary congenital nasolacrimal duct obstruction (NLDO).

METHODS

This is a retrospective, noncomparative review of all consecutive cases in two lacrimal clinics between January 1999 and October 2004. The main outcome measures were patients' demographics, previous treatments, clinical presentation, operative and postoperative complications, postoperative follow-up and resolution of epiphora.

RESULTS

Twenty-one patients (15 males) with a mean age of 6+/-3.5 years (range, 2-14 years) underwent 26 endoscopic DCR operations for congenital NLDO. Sixteen cases were unilateral, and five were bilateral. In 13 cases (50.0%), there was a history of epiphora and chronic dacryocystitis with or without a mucocele. Two cases (7.7%) presented with acute dacryocystitis, and 11 (42.3%) had only a history of epiphora. Previous procedures included probing and irrigation in 25 cases (96.2%) and insertion of Crawford tubes in 19 cases 973.1%). During a mean postoperative follow-up period of 18+/-8 months, the anatomical success rate (free flow of fluorescein sodium and patency of ostium on nasal endoscopy) was 100%, and the clinical success rate (resolution of epiphora) was 92.3%.

CONCLUSION

Endoscopic endonasal DCR is an effective treatment modality for congenital NLDO that compares favourably with the reported success rates of external DCR.

Endoscopic Approach to Orbital Apex Lesions

PURPOSE

To examine the role of transnasal and transantral endoscopic surgical approaches in the management of apical orbital lesions.

METHODS

Retrospective case series.

RESULTS

Three patients underwent combined orbital and endoscopic surgery for treatment of apical orbital lesions. In two of these patients, the orbital apex was decompressed, which resulted in visual recovery. Using endoscopic approaches to the posterior orbit and orbital apex allowed better visualization, with minimal manipulation of tissues in an area where surgical access is limited.

CONCLUSIONS

Apical orbital lesion management benefits from a multidisciplinary and individualized plan. Endoscopic approaches can be used to improve visualization and access to a difficult surgical area. They also allow extra instrumentation to be used through the relatively capacious paranasal sinuses. These advantages may obviate lateral orbitotomy in some situations. Although endoscopic techniques are useful for biopsy, debulking, and removal of orbital apex lesions, they may be more difficult to apply to an intraconal lesion at the orbital apex.

Revision dacryocystorhinostomy: a comparison of endoscopic and external techniques

BACKGROUND

Success rates for revision dacryocystorhinostomy (DCR) are lower than primary DCR. Scarring of the sac may limit the ability of the surgeon to achieve good nasal and lacrimal mucosa apposition. This study evaluates the comparative success rates of the external and endoscopic techniques for revision DCR.

METHODS

Seventeen consecutive revision endoscopic DCRs (average age, 60.9 years) and 13 revision external DCRs (average age, 65.1 years) performed from January 1999 to December 2000 performed by separate surgeons were entered into the study. Patients with functional nasolacrimal and canalicular obstruction were excluded. The average follow-up was 11.1 months for the endoscopic DCR group and 10 months for the external DCR group.

RESULTS

A successful DCR required complete relief of symptoms and an endoscopically determined anatomic patency of the nasolacrimal system. Revision endoscopic DCR surgery was successful in 76.5% of cases (13 of 17 cases) and external DCR surgery was successful in 84.6% (11 of 13 cases). This difference was not statistically significant. (p = 0.64, Fisher exact test with a two-tailed probability).

CONCLUSION

Revision endoscopic DCR has a success rate of 76.5%, which compares favorably with that of the revision external DCR (84.6%).

Investigation and endoscopic treatment for functional and anatomical obstruction of the nasolacrimal duct system

The purpose of this study was to assess the results of endonasal DCR in patients with a functional obstruction of the nasolacrimal system. The study design was a prospective non-randomized interventional case series. A prospective series of 102 consecutive endoscopic DCRs were evaluated with preoperative dacrycytography (DCG) and lacrimal scintillography. Evaluation of the DCG and scintillography allowed the patients to be classified as either having an anatomical or functional obstruction of the nasolacrimal system. The powered endoscopic DCR was performed between January 1999 and December 2001. Patients were followed up for a minimum of 12 months after surgery. In the 70 powered endoscopic DCRs for anatomical obstruction, 68 (97%) have remained asymptomatic with a free flow of fluorescein from the conjunctiva to the nose. In the patients who were classified as having a functional obstruction, 27 of 32 were asymptomatic (84%) with a free flow of fluorescein into the nose. To conclude, powered endoscopic DCR produces excellent results in patients with anatomical obstruction and good results in patients with functional obstruction of the nasolacrimal system.

Agger nasi cell mucosal autograft for lacrimal sac reconstruction during endonasal dacryocystorhinostomy

A mucosal autograft composed of agger nasi cell mucosa was used to reconstruct the lacrimal sac mucosa in a young woman with a cicatrised lacrimal sac and obstructed nasolacrimal system. The patient had undergone a previous external dacryocystorhinostomy (DCR), dacryocystectomy and revision mechanical endonasal DCR. There was persistent epiphora and at further mechanical endonasal (MEN) DCR it was noted that only a small cuff of lacrimal sac mucosa around the common canaliculus was present. To achieve a mucosal anastomosis, the agger nasi cell mucosa was removed from the cell and placed as a free mucosal graft around the common canalicular opening. Apposition with the nasal mucosa was completed with flaps from the lateral nasal wall mucosa. Postoperatively, the patient is asymptomatic with a freely draining ostium at 18 months of follow-up.

Mechanical Endonasal Dacryocystorhinostomy Versus External Dacryocystorhinostomy

PURPOSE

To compare the success rates of a new mechanical endonasal dacryocystorhinostomy (MENDCR) technique and the conventional external dacryocystorhinostomy technique (Ext-DCR).

METHODS

A prospective, nonrandomized interventional comparative case series of 31 consecutive MENDCRs and 24 Ext-DCRs performed from January 1999 to December 2000. Patients with anatomic nasolacrimal duct obstruction were included in the study; previous lacrimal surgery and functional nasolacrimal and canalicular obstruction were exclusion criteria. Two surgeons performed the MENDCRs, using a standardized operative technique, which involved creation of a large bony ostium and mucosal flaps between the lacrimal sac mucosa and nasal mucosa. One surgeon performed all Ext-DCRs.

RESULTS

Twenty-seven patients (8 men, 19 women) underwent 31 MENDCRs. The average age of the patients was 62.9 years (range, 15 to 86 years; SD, 19.1 years). In 11 cases (35.4%), a septoplasty was required at the time of surgery, and in 6 cases (19%), further endoscopic sinus surgery was performed. In the Ext-DCR group, 23 patients (7 men, 16 women) underwent 24 DCRs. The average age was 59.6 years (range, 22 to 86 years; SD, 18.5 years). No other nasal procedures were performed at the time of surgery in this group. The average follow-up time was 13 months for the MENDCR group and 12.4 months for the Ext-DCR group. Success was defined as relief of symptoms and by anatomic patency, which was assessed by history, fluorescein flow on nasal endoscopy, and lacrimal syringing. In the MENDCR group, surgery was successful in 29 of 31 DCRs (93.5%); 1 of 2 failed cases was anatomically patent but symptomatic, yielding an anatomic patency rate of 96.8%. In the Ext-DCR group, the success rate was 95.8% (23/24 DCRs); the failed case was anatomically patent but symptomatic, giving an anatomic patency rate of 100%. The differences in overall success and anatomic patency were not statistically significant (P = 0.6 and P = 0.56, 1-tailed Fisher exact test).

CONCLUSIONS

The success rate of MENDCR (93.5%) compares favorably with that of standard external DCR (95.8% in this study). MENDCR relies on the creation of a large ostium and mucosal flap apposition. A larger, randomized prospective trial is needed to fully assess the efficacy of this new technique.

Mechanical endonasal dacryocystorhinostomy with mucosal flaps

AIMS

To describe and assess the efficacy of mechanical endonasal dacryocystorhinostomy (MENDCR). This is a new technique that involves creation of a large rhinostomy and mucosal flaps. The study involved a prospective non-randomised interventional case series with short perioperative follow up.

METHOD

A prospective series of 104 consecutive endonasal DCRs performed from January 1999 to December 2001 were entered into the study. Patients included in the study had nasolacrimal duct obstruction and had not had previous lacrimal surgery. The technique involved anastomosis of nasal mucosal and lacrimal sac flaps and a large bony ostium. Surgery was performed by two surgeons (AT/PJW). Follow up assessment included nasoendoscopy as well as symptom evaluation. Success was defined as anatomical patency with fluorescein flow on nasoendoscopy and patency to lacrimal syringing. The average follow up time was 9.7 months (range 2-28, SD 6.7 months).

RESULTS

There were 104 DCRs performed on 86 patients (30 male, 56 female). The average age of the patients was 59 years (range 3-89, SD 24.1 years). Common presentations were epiphora (77%) and/or mucocele (19%). Septoplasty (SMR) was required in 48 DCRs (46%) and 13 DCRs (12.5%) needed other endoscopic surgery in conjunction with the lacrimal surgery. The surgery was successful in 93 cases (89%). Of the 11 cases that were classified as a failure six patients was anatomically patent but still symptomatic and another two had preoperative canalicular problems. The anatomical patency with this new technique was thus 95% (99 of 104 DCRs).

CONCLUSION

MENDCR involves creation of a large ostium and mucosal preservation for the construction of flaps. The anatomical success is 95% and is similar to external DCR and better then other endonasal approaches. The authors suggest that creation of a large ostium as well as mucosal flaps improves the efficacy of this endonasal technique.

Endonasal dacryocystorhinostomy with mucosal flaps

PURPOSE

To describe a new endonasal dacryocystorhinostomy (DCR) technique and assess its efficacy.

DESIGN

Prospective nonrandomized interventional case series.

METHODS

A prospective series of 44 consecutive endonasal DCRs performed from January 1999 to December 2000 was entered into the study. The new technique involved creation of a large bony ostium and mucosal flaps to create an anastamosis between the lacrimal sac mucosa and nasal mucosa. Patients presenting with naso-lacrimal duct obstruction based on symptomatic, clinical, and radiologic grounds were included in the study. Patients who had undergone previous lacrimal surgery were excluded. Surgery was performed by two surgeons (A.T., P.J.W.) using a standardized operative technique. Patient demographics, presentation, examination findings, surgical and anesthetic data, postoperative success, complications, and follow-up were evaluated. Success was defined as anatomic patency as well as relief of symptoms as assessed by fluorescein flow on nasendoscopy, lacrimal syringing, and patient examination. Intubation of the lacrimal apparatus was performed in all operations and the tubes usually removed at 4 to 6 weeks postoperatively. After removal of the tubes follow-up was 13 months (mean, 12.9 months; range, 9-28 months; standard deviation [SD], 6.1 months).

RESULTS

There were 36 patients (12 male/24 female) who underwent 44 endonasal DCRs. The average age of the patients was 62.9 years old (range, 15-86 years old; SD, 19.1 years) and the main presentation was with epiphora (93%) and/or mucocoele (33%). In 13 operations (30%) a septoplasty was required at the time of surgery, and in 10 operations (23%) further endoscopic sinus surgery was performed in conjunction with the DCR. Anatomic success with a patent nasolacrimal system was achieved in 40 of 44 operations (91%). Symptomatic and anatomic success was seen in 39 of 44 operations (89%). Five of the DCRs were classified as failures. In one DCR the patient was symptomatic despite a patent nasolacrimal system and well-healed ostium. In two DCRs preoperative medial canalicular problems were noted. In two DCRs scarring and fibrosis of ostium were noted.

CONCLUSIONS

This new technique of endonasal DCR involves creation of a large ostium and construction of nasal and lacrimal sac mucosal flaps. Its anatomic success rate (91% or 40 of 44 DCRs) compares favorably with the success rate of other techniques for endonasal DCR and is also similar to the success of external DCR. Experience in endoscopic nasal surgery is important in endonasal DCR surgery, as other ancillary procedures may be required within the nose at the time of surgery.

Secondary haemorrhage after dacryocystorhinostomy

OBJECTIVE

To describe the incidence, clinical features, possible risk factors and outcome of patients suffering secondary haemorrhage after dacryocystorhinostomy (DCR).

METHODS

Records of all patients undergoing external DCR by one surgeon (AAM) over a 6-year period were analysed retrospectively.

RESULTS

After 293 DCR operations in 260 patients, 10 patients had a secondary haemorrhage (one after bilateral DCR), usually between days 4 and 10 post-operatively (mean 6.8 days). Six of the 10 were hospitalized for 2-5 days (mean 2.8 days), all of whom had nasal packing, intravenous antibiotics and intravenous fluids; none required blood transfusion. Three patients had immune system defects, three had used non-steroidal anti-inflammatory drugs (NSAID) and four had no obvious risk factors. All 10 had a successful outcome following DCR (compared to an overall failure rate of 25/293 (8.5%): 16 anatomical and nine functional).

CONCLUSIONS

Secondary haemorrhage after DCR was found to occur after 3.8% of DCR. Risk factors include being immunocompromised and taking NSAID prior to surgery. The haemorrhage did not adversely affect surgical outcome.