The failed probing

The management of failed probing for congenital nasolacrimal duct obstruction is given by a panel of authors. Treatment options examined are repeat probing, inferiorturbinate infracture, closed lacrimal intubation and dacryocystorhinostomy. There is considerable variation as to the timing of these interventional techniques.

Iatrogenic complications related to the use of Herrick Lacrimal Plugs

PURPOSE

To report a series of lacrimal complications associated with a specific type of lacrimal plug (Herrick Lacrimal Plug; Lacrimedics Incorporated, Rialto, CA.)

DESIGN

Retrospective, noncomparative case series and survey.

METHODS

Members of the American Society of Ophthalmic Plastic and Reconstructive Surgery were asked to submit personally treated cases of patients referred for treatment of complications after placement of a Herrick Lacrimal Plug.

MAIN OUTCOME MEASURES

Failure of the device to be removed by simple lacrimal irrigation.

RESULTS

The clinical courses of 41 patients were analyzed. Patients ranged in age from 19 to 81 years, and all had symptomatic epiphora related to the presence of the lacrimal plug. Several interventions were used to treat lacrimal obstruction. Nasolacrimal duct probing with irrigation was used in 15 lacrimal systems, whereas six systems were probed and subsequently stented with silicone tubing. Eyelid margin cutdown was used in eight cases. Balloon dacryoplasty was performed in three systems, dacryocystorhinostomy in 18 instances, and conjunctivodacryocystorhinostomy in two patients.

CONCLUSIONS

The Herrick lacrimal occlusion device sometimes cannot be removed by simple irrigation and is capable of inducing permanent, irreversible, symptomatic lacrimal drainage system obstruction.

Congenital intraocular teratoma associated with eyelid coloboma

PURPOSE

To describe the first case of intraocular teratoma associated with eyelid coloboma and the second reported case of intraocular teratoma.

DESIGN

Interventional case report.

METHODS

A left intraocular tumor was surgically resected from a 2-day-old female with an associated lower eyelid coloboma.

RESULTS

Pathologic evaluation revealed a completely intraocular tumor comprising derivatives of all three germ cell layers giving a diagnosis of intraocular teratoma. The eyelid coloboma was repaired, and a scleral-wrapped hydoxyapatite-integrated orbital implant was placed.

CONCLUSION

To our knowledge, this is the second reported instance of teratoma originating within the globe and the only reported case of teratoma associated with eyelid coloboma. Although exceedingly rare, intraocular teratoma should be added to the differential diagnosis of congenital intraocular tumors.

Primary temporal fossa dermoid cysts. Characterization and surgical management

OBJECTIVE

To detail the characteristics and management of rarely reported and incompletely described dermoid cysts originating in the temporal fossa.

DESIGN

Retrospective case series.

PARTICIPANTS

Five patients ranging from 2 to 38 years of age with a mass in the temporal region (posterior to the lateral orbital rim) participated.

INTERVENTION

Computed tomography (CT) and excisional biopsy were performed.

MAIN OUTCOME MEASURES

Clinical and CT characteristics and surgical outcomes were measured.

RESULTS

Computed tomography showed cystic lesions, originating from the region anterior to the confluence of the greater wing of the sphenoid, frontal, and zygomatic bones. Displacement of the anteriormost portion of the temporalis muscle was common. Three cysts were isolated to the temporalis fossa, while two showed more extensive bony erosion and extension into the cranial and orbit cavities. At surgical excision, gross rupture of the cysts was noted in two cases, and two were completely liquefied. Histopathology showed variable inflammation surrounding all of the dermoid cysts. All patients did well after surgery.

CONCLUSIONS

Dermoid cysts may infrequently occur "primarily" in the temporal fossa. Bone involvement and anterior temporalis muscle displacement are common. An origin from the area anterior to the confluence of the greater wing of the sphenoid, frontal, and zygomatic bones is seen. A coronal approach facilitates wide exposure and excision. When dural extension is suggested on CT, neurosurgical assistance may be required.

Axial myopia in congenital ptosis: an animal model

Congenital ptosis in humans has been associated with anisometropia, myopia, astigmatism, and amblyopia. Scientific evidence has shown that visual deprivation causes axial myopia in animals. This study using chicks was undertaken to investigate an animal model of congenital ptosis and the effects of lid position on ocular development. Eyelid ptosis was surgically induced in one eye each of white leghorn chickens within 48 hours after hatching. The chicks were raised under natural diurnal lighting. Thirty days after inducing ptosis, the chicks were killed and their eyes enucleated and photographed in a sagittal view. Computerized image analysis was used to measure the size of the globe along five axes. Globe size was significantly greater in the superior part of eyes with ptosis compared with control eyes. No other measurement differences were significant (p < 0.01). Thus, this study demonstrates that regional axial myopia is induced by eyelid ptosis in chicks.

Ritleng intubation system for treatment of congenital nasolacrimal duct obstruction

Twenty-eight patients (34 eyes) with congenital nasolacrimal duct obstruction underwent silicone intubation with the Ritleng lacrimal intubation system. The technique involves introduction of a Prolene (Ethicon Inc, Somerville, NJ) monofilament guide thread, securely fastened to the silicone tubing, into a tubular metal probe that opens into the inferior meatus. The outcome was evaluated in terms of ease of intubation and objective success rate. Thirty-two (94%) of the 34 lacrimal systems were successfully intubated with the Ritleng system. Difficulty passing the Prolene thread through the probe and out the tip, necessitating conversion to a Crawford intubation system, was encountered in only 2 eyes (6%). The Prolene spontaneously emerged from the nose in 24 (75%) of 32 eyes, making retrieval simple and uncomplicated. The success rate for relieving signs and symptoms of obstruction was 97% (31/32) for the eyes with the Ritleng system and 100% (2/2) for the eyes with the Crawford system. Bicanalicular silicone intubation with the Ritleng intubation system is an easy and effective technique for treatment of congenital nasolacrimal duct obstruction.

A new physical finding in floppy eyelid syndrome

OBJECTIVE

The authors noted that many of their patients with the floppy eyelid syndrome had a unique finding of eyelash ptosis and lashes that curled in many directions. The purpose of this study was to determine how many of these patients had this physical finding.

DESIGN

Case series.

PARTICIPANTS

The authors retrospectively reviewed the charts and photographs of eight consecutive patients with the floppy eyelid syndrome. They also examined four new patients with floppy eyelid syndrome.

INTERVENTION

Surgical tightening of 13 upper lids was performed in 9 patients.

MAIN OUTCOME MEASURES

Relief of symptoms and normalization of eyelash position.

RESULTS

All of the 12 consecutive patients with floppy eyelid syndrome demonstrated eyelash ptosis with loss of eyelash parallelism. All patients treated with surgical shortening of the affected eyelid were asymptomatic at follow-up.

CONCLUSIONS

The authors have identified a new physical finding in the floppy eyelid syndrome: eyelash ptosis with loss of eyelash parallelism. The authors believe that this new physical finding is characteristic of the floppy eyelid syndrome, and will aid in the timely diagnosis and treatment of this sometimes obscure syndrome.

The perils of permanent punctal plugs

PURPOSE

To describe previously unreported complications associated with permanent lacrimal punctal plugs.

METHOD

Five oculoplastic practices reviewed patients referred to them over the preceding 2 years for permanent lacrimal punctal plug complications.

RESULTS

In 12 patients, 14 lacrimal punctal plugs migrated distally within the lacrimal drainage system, causing symptoms and necessitating surgical removal.

CONCLUSION

Luxation of permanent punctal plugs into the distal lacrimal drainage system can occur, sometimes requiring complex surgical intervention.

The anatomy of the common canaliculus

BACKGROUND

The functional valve between the common canaliculus and the lacrimal sac has traditionally been attributed to the valve of Rosenmüller, although this anatomical structure has never been rigorously documented.

OBJECTIVE

To define the anatomy of the canaliculus-sac junction.

METHODS

Twelve rigid plastic casts of the lacrimal outflow systems were obtained in human cadaver specimens using a well-known biologic casting material (partially polkymerized monomer to which a catalyst and promoter were added).

RESULTS

A consistent pattern of angulation within the canalicular system was documented. The canaliculi bend posteriorly behind the medial canthal tendon, then anteriorly to enter the sac at an acute mean angle of 58 degrees to the lateral wall of the sac.

CONCLUSIONS

This consistent configuration at the canaliculus-sac junction has not been previously described and may contribute to the 1-way valve phenomenon seen in some lacrimal disorders.

Malignant melanoma of the lacrimal sac

Although malignancies of the lacrimal sac are rare, malignant melanoma of the lacrimal sac is an exceedingly rare occurrence. Patients with abnormalities of the nasolacrimal system may come to otolaryngologists for evaluation. Treatment of lacrimal sac malignancies will necessitate consultation of a head and neck surgeon. The triad of symptoms commonly found in these patients includes epiphora, bloody reflux from the lacrimal punctum, and a medial canthal mass. Early local recurrence occurs frequently. Radical surgical treatment, including wide-field en bloc resection of the entire nasolacrimal system, affords the best protection against local recurrence and provides the best opportunity for enhanced patient survival. Adjunctive therapy in this disorder remains controversial.

Measurement of the resistance to fluid flow within the lacrimal outflow system

BACKGROUND

Although the presence of complete obstruction within the human lacrimal drainage system can be easily determined with diagnostic techniques currently available, it is not possible to quantitate degrees of partial obstruction. The authors have developed a new instrument that directly measures pressures associated with fluid flow, allowing the calculation (pressure : flow) of resistance within the tear drainage system. The authors believe that the ability to measure the degree of partial lacrimal stenosis quantitatively will be clinically useful, allowing the diagnosis of lacrimal disease before complete obstruction. Of course, it is first necessary to establish normal values, which was the goal of the study.

METHODS

A constant flow rate of distilled water was irrigated into the lacrimal system through the lower canaliculus, and pressure was measured continuously. Resistance then was calculated as the differential of pressure to flow rate (pressure : flow). In the first stage of a two-part study the authors determined the resistance to fluid flow in 43 tear ducts of 24 healthy patients. In this group, the resistance within the entire lacrimal system was obtained. In the second stage of this study, the authors measured the resistance in 28 tear ducts of 26 patients after successful lacrimal bypass surgery (dacryocystorhinostomy). Because dacryocystorhinostomy byasses the lower drainage system (sac and nasolacrimal duct), the resistance measured in this group of patients was determined only by the upper (canalicular) system.

RESULTS

The mean resistance within the normal lacrimal system is 49.5 +/- 17.0 mmHg.seconds/ml. Just more than half of the resistance, 26.8 +/- 13.1 mmHg.seconds/ ml (54%), comes from the canaliculi, leaving 22.7 mmHg.seconds/ml (46%) attributable to the lower system. The authors comment on comparisons between these values and theoretical values calculated using information on average dimensions obtained from casts of the lacrimal drainage system.

CONCLUSION

The authors have developed a new instrument to measure the resistance to fluid flow within the human lacrimal outflow system, and resistance values in control subjects have been documented.

Evisceration with hydroxyapatite implant. Surgical technique and review of 31 case reports

PURPOSE

To evaluate the use of hydroxyapatite (HA) as an orbital implant with evisceration.

BACKGROUND

Although several reports have documented good success with HA orbital implants and their use with enucleation, only a few reports mention HA with evisceration. These few reports are less favorable, with exposure rates as high as 67%. In contrast, the authors have had good success with evisceration and HA implants with no major complications and a low exposure rate.

METHODS

A retrospective analysis of all eviscerations with HA implant performed between January 1989 and July 1993 was completed (n = 31). Patients underwent evisceration with scleral modification, including anterior relaxing incisions and posterior sclerotomies to accommodate a large sphere without tension on the wound. Patient records were reviewed for demographic data, surgical indication, sphere size, clinical outcome, complications, and follow-up interval. The surgical technique is described.

RESULTS

All 31 patients underwent successful surgery with complications limited to exposure (6%), mild superior sulcus deficit (6%), and a conjunctival cyst (3%). No patient required further socket reconstruction, and no patient required peg placement to enhance motility. The average follow-up interval was 13.3 months.

CONCLUSIONS

The authors have had good success using HA orbital implants for evisceration without major complications. Primary evisceration with HA implantation after posterior sclerotomies is a safe and effective method for treating patients with a blind, painful eye.

Selective loss of blue cones and rods in human retinal detachment

OBJECTIVE

To determine if there are histopathologic changes in the outer retina that could explain the blue-yellow color confusion previously described following rhegmatogenous retinal detachment in humans.

METHODS

Ten eyes with traumatic retinal detachments were studied. Eight of the eyes were removed from 2 1/2 to 11 days following trauma. In the remaining two eyes, the retinas were successfully reattached. Enzyme histochemical studies for carbonic anhydrase and immunochemical studies for S antigen were performed to distinguish blue cones from red/green cones.

RESULTS

With the 2 1/2- to 4-day-old detachments, nearly all of the carbonic anhydrase-negative (blue-sensitive) cones and many of the rods were seen to have signs of irreversible necrosis, including extreme swelling of the inner segments and mitochondria, loss of the outer segments, and pyknotic and displaced nuclei. In the 6- and 11-day-old detachments, almost all of the carbonic anhydrase-negative cones and many rods were missing. Blue cones were essentially absent from the reattached retinas, and there were only about half the normal number of rods.

CONCLUSIONS

Rhegmatogenous retinal detachment results in rapid and almost total loss of the blue cones. Significant rod loss also occurs in this type of detachment but the red/green cones are comparatively resistant to damage. These findings could explain the observed blue-yellow color confusion in such patients. We discuss other clinical implications.

Vascular anatomy of the eyelids

PURPOSE

The eyelids have a rich vascular supply, and bleeding may compromise both surgical technique and postoperative results. Generally, it is known that the eyelids contain a marginal and peripheral arcade, but detailed anatomic information is not available. This study therefore was undertaken to determine the detailed anatomy of eyelid vascularity.

METHOD

The common carotid arteries of six fresh cadaver heads were injected with a compound consisting of a partially polymerized monomer, to which a catalyst and promoter were added to cause hardening. The soft tissue was then digested, using 40% potassium hydroxide, to obtain detailed casts of the eyelid arteries, arterioles, and capillaries.

RESULTS

The authors describe the eyelid vascularity and anastomotic network with average distance measurements from clinically relevant soft tissue landmarks in the 12 cadaver eyelids.

CONCLUSIONS

Consistent patterns of eyelid vascularity were observed. A better understanding of the eyelid vascularity should allow modification of surgical techniques and reduce postoperative complications after eyelid surgery.

The silent sinus syndrome. A cause of spontaneous enophthalmos

PURPOSE

Spontaneous enophthalmos and hypoglobus, in the absence of other symptoms and unrelated to trauma or surgery, may be alarming to both physician and patient. The authors describe the clinicopathologic features of a benign syndrome ("silent sinus syndrome") with this constellation of features and discuss the possible pathophysiology.

METHODS

A multicenter retrospective search for similar clinical cases was performed. All clinical records, computed tomographs, and pathology reports for each case were reviewed at one center. A literature search for similar cases also was conducted.

RESULTS

Nineteen cases of a new syndrome are presented. This syndrome affects individuals at approximately the fourth decade of life (average age, 36 years; range, 29-46 years); is characterized by bone resorption and remodeling of the orbital floor due to otherwise asymptomatic maxillary sinus disease; is associated with ipsilateral maxillary sinus hypoplasia; and is not fully explained by any previously described, classic cystic lesion of the maxillary antrum.

CONCLUSION

Enophthalmos and hypoglobus unassociated with prior trauma, surgery, or other symptoms may represent "silent sinus syndrome," which is ipsilateral maxillary sinus hypoplasia and orbital floor resorption.

Relapsing polychondritis, another cause for a "salmon patch"

We present the case of a patient with long-standing relapsing polychondritis and, first, an orbital mass and, then, a "salmon patch" conjunctival mass. The histologic pathologic findings were similar on both occasions, showing an inflammatory process with reactive lymphoid hyperplasia. In both situations, the masses responded to a short course of systemic corticosteroids. Although ocular inflammatory changes from relapsing polychondritis have been well described, to our knowledge, there have been no previous reports of conjunctival changes in the form of a salmon patch lesion, as described here. Relapsing polychondritis may be added to the differential diagnosis of a conjunctival salmon patch lesion.

Foreshortening of the Inferior Conjunctival Fornix Associated with Chronic Glaucoma Medications

The authors designed a device to measure the depth of the inferior conjunctival fornix at the slit lamp using topical anesthesia. The fornices of 179 glaucoma patients receiving topical medications for glaucoma and 420 control subjects who had no history of ocular disease were measured. These measurements were age-stratified by decade. A significant foreshortening of the inferior conjunctival fornix was found with aging (P less than 0.01). Patients in their sixth through ninth decades using miotics for 3 years or longer and patients using nonmiotic agents for 3 years or longer exhibited significant foreshortening of the inferior fornix when compared with age-stratified (by decade) control subjects (P less than 0.01). These observations suggest that increasing age and topical medications for glaucoma, or the preservatives, used for 3 years or longer, are independently associated with conjunctival shrinkage.

Anatomy of the orbital septum and associated eyelid connective tissues. Implications for ptosis surgery

The anatomy of the orbital septum and associated eyelid connective tissues was examined using cadaver dissection, histologic sections, surgical observations, and special radiologic imaging. The embryologic development of the eyelid connective tissues was also reviewed. Examination revealed a distinct layer of fibroadipose tissue in the eyelid and eyebrow posterior to the orbicularis and frontalis muscles, and anterior to the orbital septum. Fibrous septa within the submuscular fibroadipose tissue become contiguous with more compact lamellae of the orbital septum posteriorly imparting a multilayered quality to the orbital septum. Fat within the fibroadipose layer anterior to the orbital septum may be mistaken for the preaponeurotic fat pad by the unwary surgeon and may lead to surgical error. The orbital septum and the levator aponeurosis were found to join 2 to 5 mm above the superior tarsal border (average, 3.4 mm). Recommendations for ptosis surgery based on these anatomic principles are given.

Outpatient dacryocystorhinostomy

We report 105 dacryocystorhinostomy procedures in 87 patients performed on an outpatient basis. Seventy-six patients received local, and 29 received general, anesthesia. The patients left the hospital an average of 2.6 hours after surgery, but 14 were admitted after surgery--9 immediately, and 5 after some delay, primarily for epistaxis. There were no serious complications related to the outpatient nature of the surgery. The success rate was 94%. We conclude that outpatient dacryocystorhinostomy is successful, well accepted by patients, and safe, provided that inpatient care facilities are readily available should they be needed.

Comparison of nonabsorbable and absorbable sutures for use in oculoplastic surgery

Nonabsorbable sutures are often recommended for use in oculoplastic surgery. This study compares the in vivo performance of nonabsorbable and absorbable sutures in an animal model and attempts to determine if one suture type is clearly superior for subcutaneous wound closure. The performance of each suture was evaluated using three surgical techniques. Comparison of results revealed that different techniques produce profoundly different results, independent of suture choice. Clinically, all suture types behaved similarly when used with the same surgical technique. Thus, absorbable and nonabsorbable sutures are equally effective under the conditions of these experiments.

Anterior ethmoid anatomy facilitates dacryocystorhinostomy

The ethmoid air cell labyrinth lies adjacent to the medial orbital wall, extending even beyond the sutures of the ethmoid bone. Its anatomic relationship to the lacrimal sac fossa is important in lacrimal surgery. We evaluated computed tomographic scans of 190 orbits with normal ethmoid anatomy to define the anatomic relationship of anterior ethmoid air cells to the lacrimal sac fossa. In 93% of the orbits, the cells extended anterior to the posterior lacrimal crest, with 40% entering the frontal process of the maxilla. This anatomic relationship may be used to facilitate the osteotomy during dacryocystorhinostomy. During a 10-year period (310 cases), one of us routinely entered the anterior ethmoid air cells to initiate the osteotomy during dacryocystorhinostomy. This technique has helped to avoid lacerations of the nasal mucosa.

Iontophoresis for eyelid anesthesia

Local anesthesia is appropriate for eyelid surgery, but patients fear the pain of injections. We evaluated iontophoresis of lidocaine for eyelid skin anesthesia to pinprick pain sensation in normal subjects, and prior to regional infiltration of the anesthetic agent in patients undergoing eyelid surgery. After iontophoresis of lidocaine hydrochloride 4% solution to one randomly chosen eyelid, pinprick skin sensation was tested in a double-masked manner. Subjective pain scores of 10 subjects were significantly less (P less than .008) on the iontophoresis treated eyelids (0.25) than on the untreated eyelids (2.55). Nine patients undergoing bilateral upper eyelid surgery had iontophoresis applied to one randomly chosen eyelid prior to the usual anesthetic injections. In this double-masked evaluation, patients reported significantly less pain (P less than .02) on the treated eyelids (1.4) than on the untreated eyelids (4.7). We conclude that iontophoresis is effective for achieving short-term, superficial anesthesia of eyelid skin.

Assessment of tear drainage after canalicular obstruction using fluorescein dye disappearance

Assessment of tear drainage impairment after monocanalicular obstruction can be difficult. The authors used fluorescein dye disappearance to evaluate tear drainage after experimental obstruction of upper, lower, neither, or both canaliculi in 20 subjects. Marked impairment was noted in all subjects when both canaliculi were occluded (P less than 0.004). Monocanalicular obstruction (either upper or lower) generally resulted in minimal or no impairment, though 10% of subjects showed marked impairment. Fluorescein dye disappearance proved a reliable, rapid method for assessing tear drainage and detecting lacrimal obstruction.

The anophthalmic socket and the prosthetic eye. A clinical and bacteriologic study

Culture samples were obtained from the anophthalmic sockets of 40 consecutive patients using a prosthetic eye. We found an increased prevalence of bacteria in the conjunctivae of anophthalmic sockets. No significant differences in bacterial flora were observed between symptomatic and asymptomatic patients, suggesting that symptoms of irritation are not usually related to abnormal bacterial flora. Patients who frequently manipulated their prosthesis had a significantly higher proportion of gram-negative bacteria, suggesting that manipulation of the prosthesis should be avoided.

Factitious "calcification" in the lacrimal gland fossa

Computed tomographic (CT) scans are valuable in the evaluation of lacrimal gland fossa masses. Calcification in this region is considered a sign of malignancy. Silicone implants are widely used in orbital surgery and may give the appearance of calcification on CT scan. These must be distinguished from true calcification by the proper choice of the CT scan window.

Quantitating the superior visual field loss associated with ptosis

The effect of blepharoptosis on the superior visual field was assessed using a series of specially designed contact lenses to simulate ptosis in normal subjects. We found a progressive decrease in the superior visual field at the 90 degree vertical meridian, which was proportional to the degree of simulated ptosis. Our results were in close agreement with both a theoretical model and previous clinical observations. These results are important in evaluating patients contemplating ptosis surgery, as well as in visual field testing for neuro-ophthalmic disorders.

Adult vernier thresholds do not increase with age; vernier bias does

Vernier acuity and vernier bias were examined in persons aged 20 to 79 years using a method of adjustments. Vernier bias (mean error) showed a sharp increase between 35 and 45. Vernier acuity (standard deviation or precision of alignment) did not vary significantly with age. These different results indicate the importance of separate evaluation of acuity and bias. Vernier acuity is little affected by minor optical changes that occur with age. Therefore, normal vernier acuity in older persons suggests that the neural substrates which underlie fine-grain discrimination of object location are unaffected by aging over the range investigated.

Aponeurotic ptosis repair under local anesthesia. Prediction of results from operative lid height

The unpredictability of acquired ptosis repair is a difficult problem. Aponeurotic ptosis repair may be performed under local anesthesia, and past reports have suggested that operative lid position may be used to predict the final result. The authors prospectively studied 20 aponeurotic repairs under local anesthesia for patients with acquired ptosis and normal levator function. Photographs were taken during surgery, 1 week after surgery, and 3 months after surgery. Statistical analysis of vertical lid fissure measurements demonstrated a linear relationship between operative lid position and the 3-month result. When operative lid height was significantly greater than 10 mm, then a slight postoperative rise was observed, but when operative lid height was significantly less than 10 mm, then a slight postoperative fall was observed. Lid position at 1 week proved to be an excellent predictor of the 3-month result, establishing a reasonable basis for intervention in cases of overcorrection or undercorrection.

Symptoms of canalicular obstruction

The need for surgical repair of monocanalicular lacerations is controversial. The authors used temporary punctal plugs of hydroxypropyl cellulose to assess the symptoms associated with upper and lower monocanalicular obstruction in 18 normal eyes. Fifty percent of those experimental obstructions resulted in mild intermittent symptoms of epiphora, increased tear film, discomfort, or blurred vision. Constant epiphora was not reported. The results suggest that a single upper or lower canaliculus is sufficient for drainage of minimally stimulated tear secretion but may not completely drain reflex tear secretion. This information may help patients and ophthalmologists reach an informed decision as to the need for surgical repair of a severed canaliculus.

Recovery after loss of an eye

Recovery after loss of one eye requires an adjustment to monocular vision and resolution of a significant, serious emotional trauma. The impact on everyday life is not well documented. We surveyed 125 monocular patients by questionnaire regarding their recovery. Eighty-five of 125 respondents reported that loss of one eye had not changed their life in any permanent way. Only seven reported persistent visual problems, whereas 12 described problems in employment and 21 had anxiety or poor self-image. Among 49 adults who had suddenly lost a sighted eye, 50% reported that their adjustment period for driving, work, recreation, home activities, or walking was less than 1 month. Ninety-three percent thought that their adjustment was completed by 1 year. In conclusion, most patients were able to resume everyday activities after a short period of adjustment. Problems with employment and self-image were frequent, but visual problems were unusual.

Histopathology of nasolacrimal duct obstruction compatible with localized sarcoidosis

We report a case of nasolacrimal duct obstruction with histopathology compatible with localized sarcoidosis, in a patient with no evidence of systemic disease. Excisional biopsy of the nasolacrimal duct revealed multiple noncaseating granulomas. Previously reported cases of sarcoidosis involving the lacrimal drainage system all had systemic disease, and these case are reviewed. Our case illustrates the potential value of nasolacrimal duct biopsy during dacryocystorhinostomy.

The anatomy of the lateral canthal tendon

This report documents the anatomy of the lateral canthus using gross dissection, histologic examination, computed tomography, magnetic resonance imaging, and clinical measurement. Lateral canthal dissections of 16 cadaver orbits demonstrated a well-defined attachment of the tarsal plates to the orbital rim, averaging 10.6 mm in length and 10.2 mm in width at their insertion on Whitnall's tubercle, 1.5 mm behind the orbital rim and 9.7 mm inferior to the frontozygomatic suture. Histologic examination showed a band of dense fibrous tissue attached to the tarsal plates, with intermingled muscle fibers from the pretarsal orbicularis oculi muscle. A small pocket of fat was identified posterior to the orbital septum and anterior to the lateral canthal tendon. Clinical measurements of normal adults revealed 2 mm of lateral movement of the canthal angle during abduction, apparently caused by posterior fibrous attachments to the check ligament of the lateral rectus muscle.

Metastatic disease first presenting as eyelid tumors: a report of two cases and review of the literature

We present two unusual cases in which an eyelid tumor was the first sign of metastatic disease. The first involved a 53-year-old man with pulmonary carcinoma and the second a 71-year-old man with malignant lymphoma. Fifteen similar cases from the literature are reviewed. The most frequent primary lesion is breast carcinoma in women, which appears as a diffuse lesion of one or two eyelids. Metastatic lung carcinoma in men appears as solitary nodules, representing the second-most common type of lesion. The questions of left- or right-side predominance, age and sex of patients, types of tumors, and prognosis are discussed.

Ptosis following radial keratotomy. Performed using a rigid eyelid speculum

Seven patients with acquired ptosis and normal levator function following anterior radial keratotomy are presented. Five of these patients then elected to undergo radial keratotomy of the opposite eye, and four had symmetrical lid fissures (mild bilateral ptosis) after bilateral surgery. Ptosis is a well-known complication of cataract extraction, but has not been reported following radial keratotomy. Unlike cataract extraction, radial keratotomy does not require anesthetic injections, bridle sutures, or conjunctival flaps. The rigid Knapp eyelid speculum used in these cases remains as the only apparent cause of eyelid trauma and subsequent ptosis. During radial keratotomy, the speculum was opened widely in order to provide good corneal exposure and avoid contact with the diamond knife. Contraction of the orbicularis oculi muscle against the rigid speculum may have traumatized the lid, resulting in a levator aponeurosis disinsertion and subsequent ptosis.

Primary acquired nasolacrimal duct obstruction. A clinicopathologic report and biopsy technique

Primary acquired nasolacrimal duct obstruction (PANDO) of adults is a clinical syndrome of unknown cause, and the histopathology of the nasolacrimal duct has not been substantially studied. A technique of excisional biopsy of the soft tissue contents within the nasolacrimal canal during external dacryocystorhinostomy (DCR) is presented. No complications were associated with the biopsy technique in 14 cases. Two cases of lacrimal obstruction secondary to sarcoidosis and leukemia were discovered in biopsies of patients with the clinical syndrome of PANDO, demonstrating the value of routine biopsy during DCR. Biopsies revealed a spectrum of changes that correlated with duration of symptoms. Early cases revealed active chronic inflammation along the entire length of the narrowed nasolacrimal duct. Intermediate cases revealed focal resolution of the inflammatory process with fibrosis, while late cases showed fibrous obliteration of the entire duct. Although the first event in primary acquired nasolacrimal duct obstruction remains uncertain, clinicopathologic correlation suggests that compression of the duct by inflammatory infiltrates and edema precedes clinical chronic dacryocystitis.

Control of lacrimal secretion after sphenopalatine ganglion block

Tear secretion with topical anesthesia ("Basal secretion") was measured in 10 normal subjects using Schirmer's tear strips before and after a sphenopalatine ganglion block. In an additional three normal subjects, tear turnover was determined with an objective fluorophotometer both before and after sphenopalatine ganglion block. The sphenopalatine ganglion block was obtained by the injection of the lidocaine (2%) into the sphenopalatine fossa. Topical anesthesia (proparacaine 0.5%) was used prior to all measurements. Tear secretion with topical ocular anesthesia was reduced substantially by sphenopalatine block, as measured by either Schirmer's strips or objective fluorophotometry. The more exact fluorophotometric method recorded a complete cessation of tear turnover flow following ganglion block. These findings support other reports, suggesting that all tear secretion is under neurologic control and dependent on reflex stimulation.

Preserved irradiated homologous cartilage implants in canine eyelids

Preserved irradiated homologous costal cartilage implants were placed in six canine lower lids for a period of 7-12 weeks. The three implants placed under a covering of conjunctiva simulating current clinical technique were well tolerated and demonstrated little change. Exposed implants produced obvious clinical inflammation and two of three exposed grafts disappeared during the 4- to 5-week interval. The single exposed implant that was retained demonstrated partial epithelialization but suffered extensive absorption and remodeling.

Study of intranasal ostium external dacryocystorhinostomy

A rigid endoscope was used to directly examine, measure, and photograph the intranasal ostium created by an external dacryocystorhinostomy (DCR). This technique was used to examine 19 patients who underwent 22 standard external DCRs. All patients had clinically successful results, documented by a positive Jone I dye test following surgery. The dimension of the bony opening created at surgery was measured and averaged 11.84 mm in diameter. The average diameter of the healed intranasal ostium was only 1.80 mm. No statistically valid correlation between the size of the bony opening and the final size of the healed intranasal ostium could be established. Thus, a large surgical anastomosis did not necessarily result in a large healed intranasal ostium. Excellent functional results were obtained even when the intranasal ostium was quite small. Other indications for the use of this technique are discussed.

Orbital emphysema complicated by acute central retinal artery occlusion: case report and treatment

Orbital emphysema is a well-known clinical entity that has been considered benign and requiring no treatment. A case of marked orbital emphysema with simultaneous central retinal artery occlusion is described. The prompt relief of this occlusion following aspiration of air from the orbit suggests that orbital emphysema is an unreported cause of central retinal artery occlusion.

External dacryocystorhinostomy. A prospective study comparing the size of the operative and healed ostium

This study compares the size of the operative anastomosis with the size of the healed intranasal ostium resulting from 22 external dacryocystorhinostomies. The area of the healed intranasal ostium was approximately 2% of the area of the surgical anastomosis. No correlation was found between the size of the surgical anastomosis and the size of the healed ostium. In all cases, excellent functional results were obtained, regardless of the size of the healed ostium. This study suggests the size of the surgical anastomosis is not directly related to the success of the procedure, although it must be large enough to technically perform the procedure.

Transorbital decompression. Indications and results

In a few patients with Graves' disease, visual loss related to an optic neuropathy develops. Clinical and radiologic evidence suggests that the mechanism of visual loss is optic nerve compression in the orbital apex. Steroids may offer improvement, but often the condition recurs unless high doses are maintained. Orbital decompression provides dramatic visual and cosmetic improvement in most cases. A transorbital approach suitable to the experienced orbital surgeon for decompression of the orbital floor and medial wall has been presented in a companion article. Results of this approach in 12 eyes with visual loss unmanageable by steroid therapy indicate a gratifying improvement in vision. Strabismus is the most frequent complication. Results with follow-up ranging from six to 18 months are encouraging and comparable to the results obtained with other methods of surgical decompression.

Transorbital approach to decompression in Graves' disease

Patients with Graves' disease have an increased volume of orbital tissue that sometimes results in serious functional and cosmetic problems. Visual loss may result from optic nerve compression in the orbital apex. Surgical decompression provides space for expansion of orbital tissues and often results in dramatic improvement. A transorbital approach to decompression of the orbit, appropriate for the ophthalmologist with adequate orbital experience, is presented. A lower eyelid incision is used in the manner of exploring a blow-out fracture. The majority of the orbital floor and the entire ethmoidal complex are removed. Removal of bone to the orbital apex is emphasized in cases of optic neuropathy. A comparative study of the indications, results, and complications of this procedure vs other techniques of decompression for Graves' disease is presented in a companion article.