Diagnosis and Treatment of Lacrimal Gland Prolapse: A Narrative Review

BACKGROUND

Lacrimal gland prolapse (LGP) is considered to be one of the causes for upper eyelid contour abnormality that should be recognized and treated properly to yield satisfactory outcomes in blepharoplasty. To describe current findings about the prevalence, pre- and intraoperative diagnosis of LGP and its treatment options.

METHODS

PubMed and Google Scholar were thoroughly searched for articles published describing the diagnosis and treatment of LGP.

RESULTS

The reported prevalence of LGP by various authors varies between 10 and 60% based on their preoperative or intraoperative reports. Techniques such as dacryoadenopexy, modified dacryoadenopexy, and dacryoplasty have been described to secure the prolapsed lacrimal gland back into its original position. Additionally, creating a Whitnall's barrier has also been suggested as a method to reposition the gland. While all these surgical procedures have shown promising immediate results, there is a lack of published data on their long-term outcomes.

CONCLUSION

Diagnosis and proper treatment of LGP could enhance the cosmetic results of upper eyelid blepharoplasty.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Assessing the success rate of treatment in simple and complex congenital nasolacrimal duct obstruction: a systematic review and meta-analysis

PURPOSE

To assess and compare the success rate (SR) of probing and intubation in patients with congenital nasolacrimal duct obstruction (CNLDO).

METHODS

We conducted a literature search for identifying relevant studies published in English using PubMed, Google Scholar, Scopus, and Web of Science databases from the date of inception to Feb 2023. After extracting data, the SR was compared between the study groups: simple and complex CNLDO. To compare the treatment outcome, the mean difference of the SR was considered as the effect size. Random effects model or fixed effects model were performed for statistical inferences.

RESULTS

A total of 21 studies were eligible to be analyzed. The pooled SR of treatment was 88% in simple, and 57% in complex CNLDO. Exerting intubation in increased the SR from 87% (SR of probing) to 92% in simple CNLDO which was not significant. However, compared to probing, intubation has a significantly higher SR in complex CNLDO (46 to 82%). While the SR of probing was significantly lower in complex CNLDO, the difference between the SR of intubation was not significant between groups. Although increasing the age does not have an adverse effect on the SR in simple CNDLO, it causes a significant decrease in the SR of complex group.

CONCLUSION

This study revealed that even though the addition of NLD intubation does not provide significant benefits beyond probing alone for patients with simple CNLDO, in children with complex CNLDO, NLD intubation should be considered as a primary treatment due to its substantial increase in surgical success rates. Delaying the treatment would increase its success in patients with complex but not the simple CNLDO.

The Prevalence of Undiagnosed Ptosis Among Candidates for Upper Eyelid Blepharoplasty

Background

Because upper eyelid blepharoplasty has become a popular aesthetic facial surgery, surgeons should be aware that age-related changes in the eyelid are not confined to skin laxity and orbital fat prolapse.

Objectives

This study was designed to assess the prevalence of undiagnosed ptosis among blepharoplasty candidates as one of the causes of unsatisfactory surgical results.

Methods

From December 2018 to December 2022, blepharoplasty candidates were meticulously assessed for their upper eyelid and eyebrow position. Patients who were aware of their ptosis were excluded, and the other patients were classified as mild, moderate, or severe ptotic based on margin reflex distance 1. The eyebrow height was also assessed in the mid-pupillary line to assess the relationship between the severity of ptosis and eyebrow asymmetry.

Results

The authors found that 13.7% of the 2530 blepharoplasty candidates in this study had undiagnosed ptosis. Most of these patients had mild ptosis (85.5%), and they were significantly older than nonptotic patients. The rate of prevalence of ptosis was significantly higher in patients with eyebrow asymmetry (75.3% vs 3.7%); however, the severity of ptosis was not associated with the severity of eyebrow asymmetry.

Conclusions

Ptosis should be cautiously looked for and addressed for treatment in candidates for upper blepharoplasty. In most patients with masked ptosis, the severity of eyelid drooping is mild and could remain undiagnosed until after the surgery and cause unsatisfactory aesthetic results. The presence of eyebrow asymmetry could be a key feature to unmask an undiagnosed ptosis.

Level of Evidence 3

A comparison between bilateral and unilateral thyroid eye disease

PURPOSE

To compare characteristics of unilateral vs. bilateral thyroid eye disease (TED).

METHODS

This retrospective analytical cross-sectional study was conducted on patients with TED who were evaluated at an academic referral center over a 6-year period. We compared demographics, activity (clinical activity score) and severity (EUGOGO classification) of TED, thyroid disease duration, TED duration, the time interval between thyroid and eye involvement, thyroid function status, and clinical signs between bilateral and unilateral TED.

RESULTS

Three hundred eighty-three patients including 213 females (55.6%), who had a mean age of 40.23 ± 13.72 years, were enrolled. Active TED was seen in 8.8% of bilateral and none of unilateral cases (P = 0.04). Bilateral TED patients had more severe disease (P = 0.001). The distribution of hyperthyroidism, hypothyroidism, and euthyroidism was significantly different between unilateral and bilateral groups (P = 0.001). Abnormal ocular motility was present in 26.3% versus 2.3% of bilateral and unilateral ones, respectively (P = 0.001). Proptosis was more prevalent in bilateral than unilateral cases (P = 0.001). We did not observe any statistically significant difference between the two groups in others variables.

CONCLUSION

Bilateral TED patients present with more severity, activity, movement abnormality, proptosis, and hyperthyroidism.

Hypo vs. hyperthyroid eye disease: is there any difference?

BACKGROUND

Thyroid-eye disease (TED) is the most common extra-thyroidal presentation of graves' disease. We performed this study to compare clinical characteristics of TED in hypothyroid vs. hyperthyroid patients.

METHODS

This was a retrospective analytical cross-sectional study in which we compared demographics, severity (EUGOGO classification) and activity (clinical activity score) of TED, thyroid disease duration, TED duration and clinical signs between hypothyroid eye disease (Ho-TED) and hyperthyroid eye disease (Hr-TED). To minimize the effect of selection bias and potential confounders, 1:1 propensity score matching (PSM) was also performed.

RESULTS

Three hundred and seventy-four patients (341 Hr-TED and 33 Ho-TED) with a female to male ratio of 1.4:1 were identified in our study. Female to male ratio was 1.3:1 in hyperthyroid and 4.5:1 in hypothyroid group (P = 0.005). The duration of thyroid disease was longer in Ho-TED (P = 0.002) while the duration of eye disease was not significantly different between the Hr-TED (mean = 24.33 ± 41.69, median = 8) and Ho-TED (mean = 19.06 ± 33.60, median = 12) (P = 0.923). Most of the patients in hypothyroid group developed eye involvement after thyroid disease (80.0% in hypo vs. 48.1% in hyper, P = 0.003). Severity (P = 0.13) and activity (P = 0.11) was not different between Hr-TED and Ho-TED patients. After PSM analysis, no clinical characteristics were significantly different between the two groups (P > 0.05).

CONCLUSION

The results of our study showed several differences between the Hr/Ho TED patients including sex, duration of thyroid disease and pattern of eye involvement. After matching the two groups with statistical methods, no clinical characteristics were different between Hr-TED and Ho-TED patients.

Father–Son COVID ‐19‐associated mucormycosis: Important role of genetic susceptibility in combination with environmental factors

In this report, a father with a history of diabetes mellitus and his son without a remarkable past medical history, both got COVID‐19‐ associated mucormycosis (CAM) as evidenced by their clinical and radiological findings. This suggests the possible role of genetics in combination with the environment in susceptibility to CAM.

The simultaneous infection of a diabetic father and his son who did not have any known risk factors for COVID‐19‐associated mucormycosis (CAM) may indicate the possible role of genetics and the environment in CAM infection.

Atypical intraorbital dermoid and epidermoid cyst: A single institution cross-sectional retrospective study

Purpose

Intraorbital epidermoid and dermoid cyst (DC) has been reported in the literature rarely. The current study evaluates clinicopathologic, radiologic, and management of intraorbital DC cases over ten years.

Methods

In this cross-sectional study, the medical records of patients with intraorbital DC treated at the academic referral center for ocular surgery were retrospectively reviewed. Data reviewed included the patient's demographic characteristics, clinical features, imaging, surgical technique, and pathology report.

Results

Nine patients with a rare presentation of intraorbital DC were reviewed within the study period in five presentations (five intraosseous, one intraconal, one dumbbell-shaped with a large part in anterior orbit, one juxta levator palpebral muscle, and one recurrent case with intracranial extension). They ranged from 8 to 53 years of age, with a median of 29 years, and five (55.6%) were female. Histopathological evaluation revealed two cysts were epidermoid.

Conclusion

The current study provides more clinical and radiologic manifestations of rare presentations of DC that highlight the importance of high clinical suspicion in the approach to atypical DC.

•

The mean age of patients with intraorbital dermoid/epidermoid cyst was higher than periocular that usually present in early infancy.

•

The most clinical signs of patients with intraorbital dermoid/epidermoid cyst were hypophthalmos, proptosis, lid puffiness, and ptosis.

•

In addition to the atypical clinical presentation of intraorbital dermoid/epidermoid cyst, the radiological investigation is doubted potentially and can be caused mixed missed cases. So histopathological evaluation is essential for confirmation of the diagnosis.

•

It may be difficult or impossible to excise a complete intraosseous dermoid/epidermoid cyst. In such cases, evacuating cyst contents allowed for easier dissection around the lesion. In addition, burring the bone is necessary in cases where there is an intimate connection of the cyst wall to the bone.

Mycophenolate Mofetil (CellCept®) in Combination With Low Dose Prednisolone in Moderate to Severe Graves' Orbitopathy

Although corticosteroids are currently the first-choice drug for thyroid eye disease (TED), in 20–30% of cases, patients show poor or non-existent responses, and when the drug is withdrawn, 10–20% of patients relapse. Thus, in this study, we aimed to investigate the efficacy of the combined use of mycophenolate mofetil (CellCept®) and low dose oral prednisolone in patients with moderate to severe Graves' orbitopathy (GO). For the first time, we investigated the relationship between TED-related parameters and proptosis reduction. In a prospective, non-randomized, interventional case series, 242 patients with moderate-to-severe GO were, assigned to receive oral prednisolone (5 mg/ d) and mycophenolate mofetil (CellCept®) (one 500 mg tablet twice per day according to the therapeutic response). The patients were monitored regularly during the 3rd, 6th, 12th, and 18th month of treatment. The main outcome measures were the clinical activity score (CAS), intraocular pressure (IOP), diplopia, proptosis and visual acuity. We also assessed the relationship between the main outcomes with proptosis changes and time to improvement (months). Adverse effects were recorded during each visit. The clinical response rate increased from 67.7% on the third month to 89.2% on the sixth month, and 94.2% on the 12th month. This therapeutic response continued until the 18th month of follow-up. The CAS responses [disease inactivation (CAS <3)] improved during our study: 70.6% on the third month, 90.0% on the sixth month, and 92.5% at 12th month. These conditions continued until the 18th month of follow-up. Proptosis improvement was 52% on the third month, 71% on the sixth month, 83% on the 12th month, and 87.1% on the 18th month. Changes in IOP and visual acuity were not significant (P = 0.568 and 0.668, respectively). The patient showed significant improvement in the Gorman score. A Shorter duration of treatment was seen in patients with earlier onset of intervention, younger age, and lack of all extraocular muscle (EOM) enlargement on computed tomography (CT) scan (p < 0.05). In addition, a better response (more reduction) in proptosis was related to: younger age at disease, earlier treatment intervention (less interval from the time the diagnosis of moderate-to-severe GO was made until medication initiation), shorter treatment time (less time to improvement), less IOP, lack of EOM enlargement on CT scan, and lack of diplopia (P < 0.05). Adverse events occurred in six patients. Findings show that mycophenolate mofetil (CellCept®) plus low-dose prednisolone can be introduced as a new optimal dosing regimen in GO due to its better effect on chronic complications such as proptosis and diplopia.

Epidemiological Status of Thyroid Eye Disease in Central Iran

Purpose

To focus on clinical manifestations and epidemiology of thyroid eye disease (TED) in Central Iran's population.

Methods

In this retrospective case study, we analyzed all patients with TED who were referred to our oculoplastic clinic from 2015 to 2019. The patients' epidemiological characteristics and clinical presentation were compared between different thyroid disease groups and genders.

Results

Overall, 383 patients (155 male; 40.5% and 228 female; 59.5%) were included. The mean age was 39.55 years (standard deviation ± 13.45, range 10-72). Most patients (89%) were hyperthyroid with the highest duration of ocular involvement among all categories (25.6 months). The most common signs on ophthalmic examinations were proptosis (80.4%), followed by eyelid retraction (72.3.0%). TED was classified as mild in 24.5%, moderate to severe in 67.6%, and sight-threatening in 7.9%. Thirty patients (7.8%) had active TED.

Conclusions

This series with a relatively more significant number of TED cases in Central Iran found similar epidemiological and clinical characteristics of TED compared to other studies from Iran. Most of our patients were hyperthyroid, with more females compared to males. Proptosis and eyelid retraction were the most common manifestations. Most TED patients were classified as moderate to severe.

Decreased Bell's phenomenon after inferior and medial orbital wall decompression in thyroid-associated ophthalmopathy: a double-edged sword in management of the patients

PURPOSE

To evaluate the changes in Bell's phenomenon after inferior and medial orbital wall decompression in patients with thyroid-associated ophthalmopathy (TAO).

METHODS

This prospective interventional study included patients with moderate to severe non-active TAO, who underwent inferior and medial wall orbital decompression. Bell's phenomenon and adjusted Bell's phenomenon were evaluated at baseline and six months after surgery. Bell's phenomenon was assessed by holding the upper lid open during forced eyelid closure. Afterwards, the upward excursion, the distance between lower eyelid margin and lower corneal limbus, was measured. Adjusted Bell's phenomenon distance is defined as the difference between margin reflex distance two (MRD2) and Bell's phenomenon distance.

RESULTS

Thirty TAO patients, including 15 males (50%), with a mean age of 43.6 ± 11.6 years, were enrolled. The distance of Bell's phenomenon significantly decreased after surgery by an average of 3.25 ± 1.57 mm (P < 0.001). In addition, the difference between pre- and post-operative distance of adjusted Bell's phenomenon was - 1.58 ± 2.13 (P < 0.001) corresponding to the worsening in the adjusted Bell's phenomenon.

CONCLUSION

The result of our study demonstrated that Bell's phenomenon decreases significantly after inferior and medial wall decompression, which could be considered a complication of this form of orbital wall decompression in TAO.

Efficacy of probing adjunctive with low-dose mitomycin-C irrigation for the treatment of epiphora in adults with nasolacrimal duct stenosis

PURPOSE:

The purpose of the study was to investigate the efficacy of adjunctive low-dose mitomycin-C (MMC) during successful lacrimal duct probing in adults with nasolacrimal ducts (NLDs) stenosis.

MATERIALS AND METHODS:

This is a prospective case–control study on patients with NLD stenosis who were randomized into two groups. All patients underwent probing without or with an application of MMC. Former group received 0.2 mg/ml MMC irrigation for 5 min. The main outcome measures were objective evaluation of patency with irrigation, as well as patients' subjective assessment of improvement.

RESULTS:

There were 73 eyes in 58 consecutive patients; patient mean age ranged from 19 to 78 years (mean 44 years). Female included larger group of patients (63%) and mean duration of the symptoms was 26.1 months (range, 2–120 months). After mean follow-up of 11 months (range, 9–14 months), 23 (60%) of the 38 eyes in the MMC groups and 8 (22%) of the 35 eyes in control group had complete response and remained symptom free. This difference was statistically significant (P = 0.005). According to the patient's satisfaction, epiphora was partially improved in 6 (17%) eyes of control group and 4 (10%) eyes in MMC group. Application of MMC has a better outcome in patients with severe stenosis (P = 0.007); patients who had symptoms more than 12 months (P = 0.02) and patients with constant epiphora were compared with intermittent symptoms (P = 0.001). No complications were detected during patients follow-up.

CONCLUSION:

This study suggests acceptable long-term results for probing adjunctive with MMC irrigation for adults with NLD stenosis that can be recommended as a simple and effective procedure for these patients.

Nonspecific orbital inflammation and thyroid eye disease, a rare comorbidity: report of two cases and review of literature

Background

To present the very rare comorbidity of developing non-specific orbital inflammation (NSOI) in two patients with histories of definite thyroid eye disease (TED).

Case presentation

Both patients complained of new-onset progressive proptosis although their thyroid disease was controlled and computed tomography scan revealed an intraorbital inflammatory mass. The pathological assessment indicated that both patients had developed fibrosing NSOI. Therefore, intravenous corticosteroids were administered. The mass regressed and the amount of proptosis was decreased in both patients.

Conclusions

We reviewed all related cases in the literature and extracted their clinical and radiological characteristics for this paper. Ophthalmologists should consider TED and NSOI in patients with a new-onset complaint of proptosis. Despite rare comorbidity of TED and NSOI, it should be considered especially in patients with refractory proptosis, and lead to its further evaluation and prompt management.

Monocanalicular intubation in children with incomplete complex congenital nasolacrimal duct obstruction older than five years of age

Purpose:

To evaluate the role of monocanalicular intubation (MCI) in congenital nasolacrimal duct obstruction (CNLDO) in children older than 5 years of age.

Methods:

A retrospective case series study was done on children over 5 years of age diagnosed with CNLDO who underwent MCI. Success rates were evaluated subjectively by asking their parents about persistent symptoms and objectively using the dye disappearance test in clinical examination.

Results:

A total of 43 eyes of 37 patients with a mean age of 7.42 ± 2.33 (range, 5–15 years of age) were included. The success rate was 60.46%, and the rate of secondary surgical intervention was 25% of all cases (61.11% of failed cases).

Conclusion:

Primary MCI maintains a reasonable success rate in incomplete complicated CNLDO regardless of age.

Extraocular Muscle Palsy in Patients with Chronic Orbital Myositis

BACKGROUND

Orbital myositis (OM) is a subgroup of idiopathic orbital inflammation. It can involve single or multiple extraocular muscles and result in restriction or paresis of extraocular muscles.

METHOD

We reported two unusual cases of extraocular muscle paresis in the fibrotic stage of chronic OM and reviewed the literature related to this finding.

RESULTS

The first case was of a 38-year-old woman with chronic OM with large-angle right eye exotropia and right medial rectus paresis. She received a botulinum A toxin injection into the right lateral rectus muscle as a first treatment, but it was unsuccessful in correcting her deviation. Subsequently, she underwent two strabismus surgeries, which successfully resolved her diplopia in primary gaze. The second case was of a 35-year-old woman with chronic OM and left lateral rectus palsy, which was managed with a botulinum A toxin injection.

CONCLUSION

OM can cause extraocular muscle palsy in the chronic fibrotic stage of the disease.

Strabismus Surgery in Thyroid-Associated Ophthalmopathy; Surgical Outcomes and Surgical Dose Responses

PURPOSE

To investigate the success rate and surgical dose responses in strabismus surgery of thyroid-associated ophthalmopathy (TAO).

METHODS

Thirty-three patients (26 men) were included in this study and underwent strabismus surgery. The mean follow-up time was 11.3 ± 6.5 months. Success was defined as the proportion of patients with a horizontal deviation of less than 10 PD, vertical deviation of less than 4 PD, and no subjective diplopia in primary and downgaze.

RESULTS

After the final follow-up visit, strabismus surgery was successful in 87.8% of patients. Pre-operative factors (age, gender, smoking, corticosteroid usage, radioactive iodine, orbital decompression, optic neuropathy, baseline deviations, extorsion, type of strabismus, TAO duration) were not statistically correlated with success. Dose responses were calculated to be 3.44 ± 0.66 PD/mm of medial rectus recession and 4.83 ± 1.48 PD/mm for vertical rectus recession. Patients with deviation ≥25 PD had significantly larger surgical dose response compared to the group with deviation<25 PD (p value = .003 for horizontal and p-value <0.05 for vertical deviations). In eyes with predominant hypotropia, we found 1.64 ± 1.37 PD decrease in esotropia for each millimeter recession of inferior rectus muscle.

CONCLUSIONS

Surgical dose responses in large deviations were significantly higher than the moderate angle of deviation. The reported mean for vertical dose responses may vary in different patients based on the laterality and involvement of superior rectus muscles. The recession of inferior rectus muscle may correct mild-to-moderate esotropia without the need for horizontal muscle surgery.

Palpebral anthrax, a rare though important condition in villagers: A case report and literature review

The aerobic Gram-positive rod Bacillus anthracis can cause potentially lethal diseases affecting different organs. Localized eyelid inflammation is a rare presentation of cutaneous anthrax. This case report involves two patients with palpebral anthrax admitted to the oculoplastic ward of Feiz Eye Hospital, Isfahan, Iran. The patients had a history of close contact with animals. Clinical presentation included palpebral swelling and necrosis of the eyelids in both cases. The patients first underwent an appropriate antibiotic regimen, and biopsy specimens were collected from their necrotic tissues. They were discharged after complete healing and followed up to manage possible complications. Cicatricial ectropion developed in both cases during healing. Reconstructive surgery was scheduled for both cases 6 months after their discharge.

Pediatric posttraumatic orbital subperiosteal hematoma

AIM

To report five children with posttraumatic orbital subperiosteal hematoma.

METHODS

In this study, five cases with posttraumatic orbital subperiosteal hematoma were studied and reviewed along with similar cases in a systematic literature review.

RESULTS

The mean age of our patients was 9.40 ± 3.51 years, ranging from 4 to 13 years, and all were male. Mechanisms of injuries were blunt trauma, falling from a building, car accident, and falling from a bicycle. All patients had unilateral involvement. Treatment options included needle aspiration, surgical drainage, and observation for spontaneous resolution. Except for one patient, positive outcomes were achieved.

CONCLUSION

The most common location for posttraumatic orbital subperiosteal hematoma is the superior orbital wall. Traumatic optic neuropathy and permanent visual loss are uncommon. Observation, surgical drainage, and aspiration are common treatment options.

Pressure ulcer following circumferential head dressing

PURPOSE

To report four patients with forehead pressure ulcer (PU) following encircling head dressing and review the literature.

METHODS

Uneventful endoscopic forehead lift procedure was performed with moderate skin elevation in three patients. Left upper eyelid crease incision was made to remove the sub-brow dermoid cyst uneventfully in one patient. All procedures were performed under general anesthesia. Mixed topical antibiotic and steroid ointments were placed on the incision sites before putting the encircling forehead dressing (using gauze and elastic bandage). The dressing was then removed on the first postoperative examination.

RESULTS

Forehead and eyebrow PUs were observed on the first follow-up visit (16-72 h) after removing the dressing. Patients were otherwise healthy. They did not have significant pain or burning postoperatively. Management included pressure release, wound debridement, daily dressing, topical antibiotic and steroid, and silicone-based anti-scar cream. None had infected ulcer and all except one ended up with atrophic scar in the last follow-up (2-14 months). External pressure and shearing forces were assumed to be the main causative factors, even though reperfusion injury could contribute in the development of PU.

CONCLUSION

Encircling head dressing can cause PU and result in scar formation in healthy immunocompetent patients. If there is a low risk of postoperative hematoma, encircling dressing should be avoided. Early loosening of the dressing and frequent examination of the skin are the best preventive and diagnostic measures. Treatment includes pressure removal, daily debridement, and topical medications.

Orbital Exenteration: A 23-year Report

PURPOSE

Orbital exenteration is a psychologically and anatomically disfiguring procedure which indicated in some patients with malignant or progressive diseases of orbital and periorbital area. In this study, we reviewed 176 patients that underwent orbital exenteration.

METHODS

This was a retrospective study of medical records from all patients who underwent orbital exenteration from March 1991 to March 2014 in oculoplastic department at an eye care center. Demographic data, diagnosis, site of primary involvement and technique of surgery were determined in patients.

RESULTS

One hundred seventy-six cases of orbital exenteration were included that had documented histopathology. The age of patients ranged from 1 to 91 years (mean age ± standard deviation, 55.43 ± 27 years). Ninety-seven (55.11%) males and 79 (44.88%) females were included. Fifteen different tumors were identified. The most common indication was patients with basal cell carcinoma 49 (28%) followed by 41 (23.5%) squamous cell carcinomas, 35 (20%) retinoblastoma, and 13 (7%) adenoid cystic carcinomas. In total, adnexal malignancies were the most common tumors, secondarily involving the orbit. Eyelids 89 (50.5%) and the globe 43 (24%) were the most frequent site of involvement. Three types of exenteration were performed, based on available data of 129 operation sheets, 46 (35.7%) subtotal, 62 (48.1%) total, and 21 (16.3%) cases of extensive exenterations. In total 97 cases were evaluated pathologically for perineural involvement, of which perineural invasion was noted in 9 (7%) reports.

CONCLUSIONS

Frequency of exenteration in our center has increased in past 3 years and the majority of cases were eyelid basal cell carcinoma. Patient education considering periocular lesions can help in earlier diagnosis of malignant lesions and therefore reducing the number of exenteration.

Levator recession and minimal lateral tarsorrhaphy for the management of lagophthalmos and corneal exposure in facial palsy

PURPOSE

Recession of levator muscle can potentially decrease the severity of corneal exposure by reducing margin-reflex distance 1. The purpose of this study is evaluation of effects of levator recession on lagophthalmos in facial palsy.

MATERIALS AND METHODS

In a non-comparative case series of consecutive patients with exposure keratopathy due to facial paralysis between 2012 and 2017, levator recession was performed through lid crease incision. Small-size (⩽3 mm) lateral tarsorrhaphy was performed on a case-by-case basis for those with moderate-to-severe keratopathy. Preoperative and postoperative measurements of margin-reflex distance 1 and lagophthalmos were compared using paired t-test.

RESULTS

Thirty-four patients (14 men and 20 women) were enrolled with an average age of 52.3 years. Mean follow-up was 13.3 months (range, 6-36 months). The most common etiology of facial paralysis was Bell's palsy (22 cases), followed by motor vehicle accident (8), parotid surgery (3), and brain tumor surgery (1). No additional procedure was performed for eight patients, while lateral tarsorrhaphy was performed in 26 cases. Mean margin-reflex distance 1 decreased from 5.0 ± 0.4 mm to 4.0 ± 0.5 mm (p < 0.001) and mean lagophthalmos decreased from 3.3 ± 0.9 mm to 1.8 ± 0.9 mm (p < 0.001). Subgroups of patients with additional lateral tarsorrhaphy and without tarsorrhaphy experienced the same amount of reduction in margin-reflex distance 1 and lagophthalmos.

CONCLUSION

Recession of levator muscle was effective in reduction of margin-reflex distance 1 and lagophthalmos in facial palsy patients. This procedure can be added to the surgical armamentarium for management of patients with facial palsy and lagophthalmos.

Lacrimal gland prolapse in upper blepharoplasty

Purpose: To report the characteristics of lacrimal gland prolapse among the patients who underwent upper blepharoplasty.Materials and Methods: In a retrospective study, consecutive upper blepharoplasty patients with significant lacrimal gland prolapse were included. The degree of prolapse was measured as anterior protrusion of lacrimal gland from the orbital rim. Reposition of the lacrimal gland was performed by using non-absorbable sutures to fixate the gland to the periosteum of lacrimal fossa. In cases with unusually large lacrimal glands, an incisional biopsy of the gland was obtained. The orbital septum was left unsutured.Results: Twenty patients (19 females and one male) out of a total of 198 patients who underwent upper blepharoplasty (10.1%) had clinically significant lacrimal gland prolapse. Mean age was 54.8 ± 9.4 years (range, 31-69). Fourteen patients (70%) were asymptomatic. Anterior protrusion of lacrimal gland was measured to be 6.4 ± 1.2 mm (range, 5-10 mm) from the orbital rim. Incisional biopsy of the lacrimal gland was obtained in 10 patients (50%). Nine biopsies showed mild chronic inflammation and one revealed only normal lacrimal gland tissue. Postoperative course was uncomplicated in 15 patients (75%), with mild symptoms in the others and only one instance of mild unilateral recurrence of lacrimal gland prolapse.Conclusions: Reposition of a prolapsed lacrimal gland is a safe and effective adjunctive procedure in upper blepharoplasty, with minimal complications and acceptable postoperative outcome. Prolapsed lacrimal glands showed mild inflammation which could be due to repetitious movements of a lax gland, although various other etiologies can be involved.

Bilateral calcinosis cutis of orbital walls in CREST syndrome

Purpose

To describe a patient with systemic sclerosis who presented with subcutaneous yellow-white nodules on her lateral orbital rims.

Methods

Case report.

Results

A 53-year-old female was referred for management of subcutaneous firm nodules on her lateral orbital rims. She was known to have CREST (calcification, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia) syndrome, a limited variant of systemic sclerosis. Her drug history included diltiazem, captopril, aspirin, and prednisolone. There were bilateral multiple immobile yellow-white subcutaneous nodules with firm consistency, a few of which were in close proximity of periorbital skin. She was scheduled for surgical resection of the lesions and following tissue dissection, the calcified foci were removed. The incisions healed with some delay but the final postoperative follow-up at third month showed satisfactory appearance.

Conclusion

Dystrophic calcinosis cutis occurs in approximately one-fourth of patients with systemic sclerosis (scleroderma), particularly in those with the limited variant or CREST syndrome. The most frequently involved sites are the extremities. Occasionally, calcinosis involves the trunk or head, but involvement of bony orbital walls is extremely rare. Surgical excision can be considered for treatment of discrete foci of calcinosis cutis.

Ophthalmologic aspects of Dermatofibrosarcoma Protuberans: A systematic review in the context of a rare case of primary orbital involvement

OBJECTIVE

To provide a systematic review on ophthalmologic presentations of dermatofibrosarcoma protuberans (DFSP) in conjunction with a case report of primary orbital involvement by this tumor.

METHODS

A thorough electronic search on PubMed, Medline, Scopus, EMBASE and web of science databases was performed. All available data from reported cases along with our described case were extracted and analyzed.

RESULTS

We describe a 66-year-old male with primary orbital DFSP who was managed by total excision of the tumor without recurrence after 18 months of follow-up. In the literature, 14 studies reporting 15 cases were identified and reviewed. Our review topics included epidemiology, clinical presentations, pathologic features, differential diagnosis, imaging, treatment and prognosis.

CONCLUSION

Rarely, but crucially, ophthalmologists may encounter DFSP in the orbital or periorbital area. They should be familiar with the pathologic nature and treatment options for this tumor. This diagnosis should be kept in mind when approaching a case with a non-tender, nodular, firm, mass or more rarely an indenting orbital mass.

Clinical characteristics, histopathology, and treatment outcomes in adult and pediatric patients with nonspecific orbital inflammation

Purpose

To evaluate the clinical characteristics, histopathology, and treatment outcomes in adult and pediatric patients with nonspecific orbital inflammation (NSOI).

Methods

This retrospective study evaluates 76 patients with NSOI. The patients were categorized in 9 groups according to the site of involvement and histopathology results. These groups included: anterior involvement, dacryoadenitis, myositis, perineural involvement, acute fat involvement, focal mass, orbital apex involvement, diffuse sclerosing form, and multiple tissue involvement. The course of the disease was categorized as acute, subacute, or chronic. The cases with symptom duration of less than 1 week were classified as acute, 1 week to 1 month as subacute, and more than 1 month as chronic.

Results

36 (47.4%) patients were males. The mean age was 41.68 ± 17.62 (6-75) years. The most common signs and symptoms were periorbital pain, periorbital edema, decreased ocular movements or diplopia, and conjunctival injection. The most common group was dacryoadenitis in 29 (38.1%) cases. The most common form of disease was the acute involvement (50% of patients). Most of the patients were treated by oral corticosteroids. Duration of follow-up was 7.17 ± 6.26 months. Recurrence occurred in 9 (11.8%) of patients during the follow-up period.

Conclusions

This study presents a new categorization in which multiple tissue involvements were separated. Some of the NSOI features differ between adults and children. In most patients, treatment especially with corticosteroids, resolves the clinical findings.

Synkinesis Between Orbicularis Oculi and Procerus Muscles: Video Presentation of an Unusual Type of Aberrant Innervation after Cosmetic Rhinoplasty

BACKGROUND

Synkinesis is a recognized complication following peripheral facial nerve paralysis. Different types of synkinesis have been described, with oral-ocular and ocular-oral synkinesis being the most common. Ocular-nasal synkinesis has been reported in two patients following cosmetic rhinoplasty. However, synkinesis between the orbicularis oculi and procerus muscles has not been reported by now.

METHODS

This is an interventional case report.

RESULTS

Two women, aged 42 and 37 years, presented with unilateral contraction of the medial eyebrow muscles (procerus) with spontaneous or voluntary blinking, 4 and 5 months after cosmetic rhinoplasty, respectively. Both were successfully treated with injection of botulinum toxin A.

CONCLUSIONS

Surgical trauma is inevitable during every procedure, including rhinoplasty, and may damage the fine structures including branches of the facial nerve innervating the muscles. Gentle tissue handling may minimize iatrogenic injury to the fine motor branches of the facial nerve and prevent subsequent aberrant innervation and synkinesis. Botulinum toxin A injection can effectively, yet temporarily, resolve the unintentional contractions and provide significant patient comfort.

LEVEL OF EVIDENCE V

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Successful Total Resection of an Orbital Epithelioid Hemangioendothelioma with the Aid of Endovascular Embolization

Hemangioendothelioma is rarely encountered in the orbit. We present a patient with a growing orbital mass for whom surgical excision was planned. Two previous attempts at removing the mass failed due to profuse bleeding. Endovascular embolization was performed before surgery to prevent massive hemorrhage. After embolization, retinal vascular accident (combined central retinal artery and vein occlusion) occurred. However, surgical excision (lateral orbitotomy and transcoronal craniotomy) was successful, and the vision improved postoperatively. Histopathologic examination and immunohistochemistry study confirmed the diagnosis of epithelioid hemangioendothelioma. The combined approach by a team of specialists, including an interventional radiologist performing preoperative embolization of the feeding vessel and joint surgery by a neurosurgeon and oculoplastic surgeon, was the key to the effective treatment of this vascular orbital neoplasm.

Unusual occurrence of orbital hemangiopericytoma in the zygomatic bone of an adolescent: a case report

Background

Hemangiopericytoma and solitary fibrous tumor are considered related variants on the same spectrum and both may essentially be the same tumor. They are infrequently encountered in the orbital region while the zygomatic bone is an extremely rare location for these neoplasms to occur.

Case presentation

A 14-year-old boy presented with complaint of deformity of left infraorbital area and a firm, regular mass in the region. Orbital CT scan revealed a well-defined round isodense intraosseous lesion in the lowermost portion of the lateral orbital wall (zygomatic bone), expanding the bone and protruding anteriorly and medially. MRI showed the mass to be heterogenous and strongly enhancing with contrast medium. Inferior transconjunctival orbitotomy was performed and the mass was removed. The histopathologic examination and immunohistochemistry staining results (positive for CD34, CD31 and smooth muscle actin, but negative for CD99, S100, B-cell lymphoma 2 (bcl-2) and desmin) confirmed the diagnosis of hemangiopericytoma. The postoperative course was uneventful, with no evidence of recurrence after 5 years follow up.

Conclusions

This case represents the second hemangiopericytoma reported in the zygomatic bone. Although extremely rare, hemangiopericytoma/solitary fibrous tumor might be considered in the differential diagnosis of intraosseous lesions of the orbital and zygomatic region.

A rare erosive orbital mass in a child: Case report of myofibroma

PURPOSE

To present the clinical, histological, and radiographic findings of a case of orbital myofibroma in an unusual location. The literature is reviewed and the clinical relevance discussed.

METHODS

A 5-year-old boy was examined with a 1.5-month history of progressive swelling in the left supraorbital region.

RESULTS

Examination revealed a firm, painless mass in the supralateral region of the left orbit with slight reddish discoloration of the overlying skin. Computerized tomography (CT) scan images showed a well demarcated, homogenous, solid mass with extension to the lacrimal gland region and adjacent to frontal bone erosion. The mass was surgically excised and was confirmed to be myofibroma in diagnostic histological studies. There has been no evidence of recurrence in the first year after surgery.

CONCLUSIONS

Clinical appearance and imaging findings are unspecific for this tumor, and histological examination still remains the definite method of diagnosis. Therefore, it is important to be able to differentiate myofibromas from other malignant tumors with a similar presentation in pediatric patients to avoid mismanagement.

Comparison of the success rate between monocanalicular and bicanalicular intubations in incomplete complex congenital nasolacrimal duct obstruction

This article compares the success rate between monocanalicular (MCI) and bicanalicular intubations (BCI) in incomplete complex congenital nasolacrimal duct obstruction (CNLDO) and evaluate the factors responsible for the success of intubation. First, 99 patients with incomplete complex CNLDO underwent MCI (Monoka) or BCI (Crawford). Therapeutic success was defined as dye disappearance test grade 0-1 and complete resolution of previous symptoms at 12 months' follow-up. The success rates were compared between two groups. In all cases, the correlation of the age, gender, history of probing, and the presence of purulent discharges with the improvement in CNLDO symptoms were evaluated. 52 cases in the MCI and 47 cases in the BCI group were included. Then, 48 patients (48.5%) had history of probing. 26 patients (26.3%) had purulent discharges. The patients in the MCI group had lower success rate (59.6%) than the patients in the BCI group (74.4%) but the difference was not significant (p = 0.11). No complication occurred in the BCI group. In 4 cases (7.6%) in the MCI group, the tubes were lost before time of planned removal. In all cases, only preoperative absence of the pus was significantly correlated with success (p = 0.09 and OR = 0.39). BCI may be a better treatment for the patients with incomplete complex CNLDO. In silicone intubation for these cases, preoperative absence of purulent discharges could increase the success rate.

Trichoblastoma of the Upper Eyelid

Purpose:

To describe a case of trichoblsatoma on the eyelid.

Case Report:

A 45-year-old woman presented with a recurring mass on her upper right eyelid. Histopathological examination revealed well-circumscribed tissue composed of an aggregation of basaloid cells. Immunohistochemistry showed positive staining for CD34 and CD10. The patient underwent total excision of the recurrent mass.

Conclusion:

Although rare, trichoblastoma should be considered in differential diagnosis of skin masses of the eyelids.

Presentation of massive orbital hidrocystoma at birth: case report and review of the literature

Background

Hidrocystoma, or sudoriferous cyst, is an eyelid tumor originating from apocrine or eccrine sweat glands. Its presence in the orbit is relatively rare.

Case presentation

A full-term female child with severe right eye extrusion was referred to our department two hours after birth. We performed cyst aspiration under ultrasonic guidance; 15 cc straw-colored fluid was obtained and proptosis resolved significantly. Orbital magnetic resonance imaging (MRI) showed a large unilocular retrobulbar mass with hypo-intensity in T1 and hyper-intensity in T2. The case underwent further daily ocular assessment until day 5; when proptosis began to worsen again. On day 6, under general anesthesia, we performed aspiration and then the cyst was completely removed with an intact wall through a trans-conjunctival incision. The diameter of the aspirated cyst was about 4 cm. In pathologic consultation, a cystic cavity lined by a layer of sweat duct like epithelium with apical snouts consistent with the diagnosis of apocrine hidrocystoma was reported.

Conclusion

To date, in the literature, six other cases of orbital hidrocystoma have been reported in childhood with protean clinical pictures; none of which presented at birth. Herein, we introduce the first case report at birth and also provide a review on the literature. Our report strongly argues against the well reputed theory of traumatic origin for orbital hidrocystoma; it has been postulated that this tumor may be the result of sweat gland cells implantation through the orbit. We thereby suggest the possible presence of choristomatous ectopic sweat gland cells in the orbit during embryogenesis.

Conjunctival bacterial flora in fellow eyes of patients with unilateral nasolacrimal duct obstruction and its changes after successful dacryocystorhinostomy surgery

PURPOSE

To evaluate the results of conjunctival culture in fellow eyes of patients with unilateral nasolacrimal duct obstruction (NLDO) and its changes after successful dacryocystorhinostomy (DCR) surgery.

METHODS

In this prospective study, 71 adult patients with unilateral NLDO and 41 age and sex-matched controls without NLDO were evaluated. The patients were divided into 2 groups based on clinical examination; group A with purulent regurgitation and group B without purulent regurgitation. They all underwent DCR. Before DCR surgery, microbiologic specimens were taken bilaterally from the conjunctiva of both eyes. Postoperative conjunctival sampling was continued weekly until the culture became negative or the colony count reached to the range of the control group.

RESULTS

There were 38 and 33 patients in groups A and B, respectively. Silicone tube was inserted for 17 patients (23.9%). The culture was positive for bacterial growth in 56 fellow eyes (79%). The conjunctival culture in the control group was positive in 17 eyes (41.4%). The mean count of colonies in a sample unit was 624.73 ± 2412.31, 195.75 ± 407.56, and 9.5 ± 1.5 for group A, group B, and controls, respectively. The mean time of normalization of specimens was 1.43 ± 0.69 weeks (range 1-4). Higher colony count at baseline and presence of silicone tube in infected eye were significantly associated with longer normalization time for fellow eye (P < 0.001 and P = 0.003 respectively).

CONCLUSIONS

This study suggests that after successful DCR surgery, a waiting period of 4 weeks is needed for conjunctival bacterial cultures to become negative or reach the level of the normal eyes, in the fellow eyes of patients with unilateral NLDO.

The predictive factors of diplopia and extraocular movement limitations in isolated pure blow-out fracture

Purpose

To evaluate the predictive factors for development of diplopia and extraocular muscle movement (EOM) limitations in the patients with isolated pure blow-out fracture.

Methods

One hundred thirty-two patients with isolated pure blow-out fracture were included. The diagnosis was done with computed tomography scan. Possible predictive factors were analyzed with logistic regression. The cases that underwent surgery were assigned in the surgical group, and other cases were assigned in the non-surgical group. Receiver operating characteristic (ROC) curve analysis was used in the surgical group to evaluate the power of time interval from trauma to the surgery to predict persistence of 6 months postoperative diplopia and EOM limitation.

Results

At the first visit, 45 of 60 cases (75%) in the surgical group and 15 of 72 cases (20.8%) in the nonsurgical group had diplopia. After 6 months follow-up, 7 cases (11.7%) in the surgical group and 1 case (1.4%) in the nonsurgical group had persistent diplopia. Type of fracture was significantly associated with first visit diplopia (P = 0.01) and EOM limitations (P = 0.06). In the surgical group, type of fracture (P = 0.02 for both) and time interval from trauma to the surgery (P = 0.006 and 0.004, respectively) were significantly associated with 1 month diplopia and EOM limitations. Only time interval from trauma to the surgery (P = 0.04) was significantly associated with 3 months EOM limitation. In the ROC curve analysis, if the surgery was done before 4.5 (sensitivity = 87.5% and specificity = 61.3%) and 7.5 (sensitivity = 87.5% and specificity = 66.9%) days, risk of 6 months postoperative diplopia and EOM limitation was reduced, respectively.

Conclusions

In the early postoperative period, a higher rate of diplopia was observed in the patients with combined inferior and medial wall fractures and longer time intervals from trauma to the surgery. The best time for blow-out fracture surgery was within 4.5 days after the trauma.

Orbicularis Oculi Myectomy as a Treatment for Blepharospasm in a Case of Schwartz Jampel Syndrome

Purpose:

To describe a patient with Schwartz Jampel vel Aberfeld syndrome (SJS) who underwent orbicularis oculi myectomy as a treatment for blepharospasm.

Case Report:

A 4-year-old child with SJS did not respond to an injection of a single dose of botulinum toxin after one month, so orbicularis myectomy was then performed under general anesthesia. During the procedure, orbicularis vermiform movements were a useful guide for the extent of myectomy that the patient needed. He responded very well to this procedure and experienced significant relief of blepharospasm documented in follow-up visits for up to 6 months.

Conclusion:

Blepharospasm in patients with SJS can be treated with orbicularis oculi myectomy as a good functional method with faster and durable response in comparison to botulinum toxin injection.

Adult Rhabdomyosarcoma of Ethmoid Sinus Recurring as an Orbital Mass

Alveolar rhabdomyosarcoma (RMS) is a primitive, malignant, round cell neoplasm derived from mesenchymal tissue that exhibits partial skeletal muscle differentiation. We describe a rare case of alveolar RMS of ethmoid sinus, recurring as an orbital mass. A 23-year-old man with the chief complaint of anosmia and mild proptosis was diagnosed with RMS of the left ethmoid sinus and orbit following an endoscopic biopsy of the mass. He was treated with chemotherapy and radiotherapy. At 12 months after diagnosis, while still on maintenance chemotherapy, he presented to our eye hospital with a large medial canthal mass and lateral globe displacement. Orbital computed tomography revealed an extraconal mass in the medial orbit of the left eye, extending posteriorly and compressing the medial rectus muscle. Notably, the ethmoid sinus was clear. Incisional biopsy was performed and the recurrence of alveolar RMS was confirmed. Alveolar RMS of the ethmoid sinus may recur as an orbital mass, even if the sinus where it originated is clear at the time of recurrence.

Transient complete visual loss after intracameral anesthetic injection in cataract surgery

Purpose

We describe a case of transient visual loss following cataract surgery with unpreserved intracameral lidocaine.

Method

A 50-year-old man with posterior polar cataract underwent phacoemulsification. Following capsulorhexis and hydrodelineation with 0.5 cc of unpreserved lidocaine 1%, a portion of fluid reached behind the crystalline lens and caused the posterior capsule rupture. Cataract extraction and anterior vitrectomy were performed. Anesthetic administration was repeated to relieve the discomfort felt by the patient. A three-piece hydrophobic acrylic intraocular lens was implanted in the ciliary sulcus.

Results

On the first postoperative morning, the patient's vision was recorded as having no light perception. The relative afferent pupillary defect (RAPD) was found to be 4+. The retina and optic nerve head appeared normal. In the afternoon, the visual acuity (VA) was improved to 3-m count-finger. On the second postoperative morning, the patient's VA was improved to 4/10. On the third postoperative day, his VA returned to normal at 20/20 without RAPD.

Conclusion

In the event of posterior capsular rupture, to reduce retinal toxicity risks, intracameral lidocaine should not be repeated.

Microbiologic spectrum of acute and chronic dacryocystitis

AIM

To report the microbiological spectrum of acute and chronic dacrocystitis.

METHODS

Retrospective study on 100 patients who presented to the ophthalmic plastic clinic of a tertiary eye care center from May 2011 and April 2013 with acute and chronic dacryocystitis was reviewed for demographic and microbiological profile. The culture results and organisms isolated were recorded.

RESULTS

Sixty patients had acute onset and the remaining 40 patients had chronic onset dacryocystitis. The female to male ratio was 1.78. The mean age of patients was 44y. Gram-positive organisms were the most commonly isolated accounting for 54%, and the commonest species isolated was S. aureus in 26%. Percentage of gram positive cultures was higher in chronic dacryocystitis than acute ones (82% vs 48% of positive cultures; P=0.003). Also in culture positive acute dacryocystitis, gram negative species were found in 52% of eyes but only in 18% of chronic dacryocystitis.

CONCLUSION

Gram negative bacteria, culture negative samples, unusual and more virulent organisms are more common in acute dacryocystitis than chronic ones. The results of this study have significant bearing on the treatment of patients with dacrocystitis.

Cherubism: report of three cases and literature review

PURPOSE

To report 3 cases of cherubism, one of whom underwent surgery for orbital manifestations, and to provide a literature review.

CASE REPORTS

Our patients were normal at birth and developed painless enlarging of the cheeks and jaws when they were 4-5 years old. Ophthalmologic examinations showed mild proptosis, superior globe displacement and inferior scleral show in all cases. Cases 2 and 3 had lower lid skin discoloration. Computed tomography (CT) scans demonstrated bilateral multicystic lesions in the maxilla and mandible with cortical thinning in all cases. In Case 3, left eye hyperglobus and anisometropic amblyopia was seen. In this case, the CT scan showed a round, well-defined and homogeneous mass, involving the anterior and superior walls of the maxillary sinus on the left side, extending into inferior orbit. Debulking of the mass was performed at the surgery. The pathologic findings were compatible with the diagnosis of giant cell reparative granuloma. He returned 1 year after surgery with recurrence of the mass.

DISCUSSION

A few cases were reported in the literature with histopathologically proven orbital cherubism. To our knowledge, lower lid skin discoloration in Cases 2 and 3 and anisometropic amblyopia in case 3 were not described elsewhere in cherubism cases. We recommend that all cases with cherubism must be examined by an ophthalmologist to diagnose and treat possible orbital manifestations.

Pulmonary artery pressure in patients with markedly deviated septum candidate for septorhinoplasty

BACKGROUND

The nasal septal deviation (NSD) is one of the major causes of nasal obstruction. This condition increases upper airway resistance. In This study we evaluated the mean pulmonary artery pressure (MPAP) in patients with markedly deviated septum.

METHODS

Sixty two patients with NSD (Age range: 26-45 years, 34 men and 28 women) were included in the study. Mean pulmonary artery pressure was measured in preoperative period by Doppler echocardiography with the assistance of an expert cardiologist.

RESULTS

The mean preoperative MPAP value (22.5 mmHg in men and 20.03 mmHg in women) of the patients in this study was higher than normal population (20 mmHg). The MPAP of nine patients (14.5%) was greater than 25 mmHg. This value was significantly higher than values for normal population.

CONCLUSION

Markedly deviated septum had improper effects in cardiovascular system due to increase in MPAP.

The prevalence of amblyogenic factors in children with persistent congenital nasolacrimal duct obstruction

BACKGROUND

To evaluate the prevalence of amblyopia risk factors in children that underwent probing for persistent congenital nasolacrimal duct obstruction (CNLDO).

METHODS

The medical records of children with CNLDO (after 1 year of age) that underwent probing were reviewed. Amblyopia risk factors, based on the American Association for Pediatric Ophthalmology and Strabismus referral criteria in 2013, were sought in the patientsʹ records before probing. The proportion of the patients with anisometropia >1.5 diopters (D) was separately calculated. In unilateral cases of CNLDO, sphere, astigmatism, and spherical equivalent of the eyes with CNLDO were compared with contralateral eyes in order to assess the effect of CNLDO on refractive error. In the follow-up examinations, the success of the probing or the need for additional procedures (Crawford intubation, Monoka intubation, or dacryocystorhinostomy) was evaluated. The prevalence of anisometropia between 'successful probing' and 'failed probing' groups was compared.

RESULTS

A total of 433 cases were included in the study. 41 cases (9.46 %) had amblyopia risk factors. Twenty-four cases (5.5 %) had anisometropia >1.5 D (spherical or cylindrical). In unilateral cases of CNLDO, the sphere and spherical equivalent of the eyes with CNLDO were significantly greater than those of the contralateral eyes (p < 0.001 for both). Thirty-nine patients (9 %) required other interventions due to failure of probing (failed probing group). There were significantly more anisometropia prevalence in this group, compared with the successful probing group, at the initial examination (p = 0.03).

CONCLUSIONS

The findings of greater prevalence of anisometropia >1.5 D (compared with the prevalence in the general population) and significantly greater sphere and spherical equivalents in the eye with CNLDO (compared with contralateral eye) in unilateral cases with CNLDO, suggested some relationships between anisometropia and long-term untreated CNLDO. The finding of more anisometropia in failed probing cases may support the theory of structural abnormality as an explanation for the possible relationship between congenital nasolacrimal duct obstruction and anisometropia.

Clinical features and surgical outcomes of isolated inferior rectus muscle paralysis

PURPOSE

To describe clinical features of patients with unilateral isolated inferior rectus (IR) muscle paralysis along with type of surgical treatment and results after surgery.

METHODS

Patients diagnosed with unilateral isolated IR muscle palsy between 2009 and 2012 that required surgical treatment were included in the study. Diagnosis of IR muscle palsy was done by hypertropia with the largest angle in depression and abduction and inferior rectus muscle underaction.

RESULTS

Twenty-two patients remained in the study; 17 patients (77.3%) had left eye involvement. IR muscle paresis was traumatic in 12 patients (54.5%), congenital in 9 patients (40.9%), and vascular in 1 patient (4.5%). Limitation of duction in the gaze of IR muscle was -2 to -3 in all cases. 3 patients, paradoxically, had contralateral compensatory head tilt (compensatory head tilt to the opposite side of IR muscle palsy). Intraoperatively, we did not detect any gross abnormalities in the IR muscles. The surgical plan at the first operation was IR muscle resection alone in 13 patients (59.1%). At the last follow-up visit, 15 patients (68%) had no deviations in primary position and downgaze. Three cases needed reoperation.

CONCLUSION

The presence of both ipsilateral and contralateral compensatory head postures in our patients showed that three-step or head-tilt test is not helpful in the diagnosis of IR muscle palsy. In comparison with other studies, more patients in our study were treated with IR muscle resection alone. Also, our reoperation rate was lower than other studies. Absence of gross abnormality in the IR muscles at the operation and partial nature of the paresis may explain these good results. Thus, a considerable number of IR muscle palsy cases with the above characteristics may be treated successfully by one muscle surgery (IR muscle resection).

Lacrimal sac empyema incision and drainage followed by early external dacryocystorhinostomy

PURPOSE

To evaluate the success of lacrimal sac empyema incision and drainage followed by early external dacryocystorhinostomy.

METHODS

Interventional consecutive case series conducted in Farabi Eye Hospital between August 2007 and November 2010. Patients with acute dacyocystitis and lacrimal sac empyema underwent incision and drainage, followed by early (less than 4 weeks) external DCR. Data collection included patient demographics, past medical history, procedure technique, culture results, and formation of a persistent cutaneous fistula.

RESULTS

A total of 32 patients were included: 87.5% had a positive history of chronic epiphora before dacryocystitis. Of these 32 cases, 55.6% had positive culture. Staphylococcus aureus was the most common organism with 8 isolates (38%). The average number of days between empyema drainage and DCR was 11.44 days. All patients had complete resolution of dacryocystitis, with no recurrence during the follow-up period. Neither of 32 patients treated with early DCR after primary empyema drainage, developed a persistent lacrimal-cutaneous fistula.

CONCLUSIONS

Incision and drainage of the lacrimal sac empyema followed by early external dacryocystorhinostomy can be an appropriate treatment strategy for acute dacryocystitis.

Lower eyelid retractor lysis versus Lockwood advancement to minimize lower eyelid retraction resulting from inferior rectus muscle recession

Inferior rectus muscle recession tends to retract the lower eyelid. Several surgical techniques have been recommended to minimize this problem. This study compared Lockwood ligament advancement with lower lid retractor lysis (capsulopalpebral fascia disinsertion) and found that the latter technique, performed simultaneously with inferior rectus recession, more effectively minimizes postoperative lower lid retraction.

Correlation of optical coherence tomography parameters with clinical and radiological progression in patients with symptomatic optic pathway gliomas

PURPOSE

To study the optical coherence tomography (OCT) characteristics in children with optic pathway glioma (OPG) to determine if OCT changes occur alongside clinical/radiological changes at diagnosis and during the second-year follow-up.

METHODS

Twenty-three patients (38 eyes) diagnosed with symptomatic OPG in a single institution were enrolled in this longitudinal observational cohort study. Complete ophthalmologic evaluation, including determination of visual acuity, visual fields, retinal nerve fiber layer ,and posterior pole retinal thickness scanning with spectral-domain optical coherence tomography, and neuroimaging was performed at the time of diagnosis and 6 months and 1 and 2 years after presentation. Patients who experienced visual decline or radioagraphic tumor enlargement of the OPG were classified as progressors. OCT data were compared between progressors and nonprogressors.

RESULTS

The average age at diagnosis was 5.8 years. All patients were followed up for 24 months. Five patients (21%) (eight eyes) had clinical or radiological progression of their OPG during follow-up and were classified as progressors. Mean changes in average nerve fiber layer and posterior pole retinal thickness were significantly higher for progressors compared with nonprogressors (P < 0.001). The area under the receiver operator characteristic curves comparing average nerve fiber layer and posterior pole retinal thinning between the progressors and nonprogressors were 0.94 and 0.95 respectively.

CONCLUSIONS

Optical coherence tomography of average nerve fiber layer and posterior pole retinal thickness may be helpful in monitoring OPG.