Autogenous hard palate mucosa: the ideal lower eyelid spacer?

BACKGROUND/AIMS

Raising a displaced lower eyelid frequently involves recession of the lower eyelid retractors with interposition of a "spacer," and several materials for this purpose have been described. This study reviewed the results of autogenous palatal mucosa in the treatment of lower eyelid displacement, including assessment of any donor site morbidity.

METHODS

A retrospective case note review of consecutive patients treated at Moorfields Eye Hospital between 1993 and 1998. All patients underwent insertion of hard palate mucosa between the inferior border of the tarsus and the recessed conjunctiva and lower eyelid retractors. Parameters studied included the underlying diagnosis, measurements of lower lid displacement or retraction, related previous surgery, the experience of the operating surgeon, intraoperative and postoperative complications, surgical outcome, and length of follow up. The main outcome measure was the position of the lower eyelid relative to the globe in primary position of gaze.

RESULTS

102 lower eyelids of 68 patients were included and a satisfactory lid position was achieved in 87/102 (85%), with inadequate lengthening or significant recurrence of displacement occurring in 15 cases. Donor site haemorrhage requiring treatment in the early postoperative period occurred in seven patients (10%).

CONCLUSION

Autogenous hard palate mucosa is an effective eyelid spacer and provides good long term support for the lower eyelid. Donor site complications are the main disadvantage, but may be minimised by attention to meticulous surgical technique and appropriate postoperative management.

Retrograde intubation dacryocystorhinostomy for proximal and midcanalicular obstruction

OBJECTIVE

Retrograde intubation of canaliculi during dacryocystorhinostomy can restore canalicular patency in cases otherwise managed with bypass tubes. The surgical technique and success for this procedure are discussed.

DESIGN

A retrospective, noncomparative case series with clinic or telephone interview for long-term follow-up of patients' symptoms.

PARTICIPANTS

One hundred two patients who had undergone this particular lacrimal drainage surgery at Moorfields Eye Hospital between 1992 and 1997.

INTERVENTION

All patients underwent a dacryocystorhinostomy and retrograde canaliculostomy while under general anesthetic.

MAIN OUTCOME MEASURES

Relief or reduction of epiphora and discharge.

RESULTS

One hundred twenty-three lacrimal systems of 102 patients were included. There were 53 females and 49 males, with ages at surgery ranging from 6 to 83 years (mean, 49 years). The etiology was idiopathic (30%), herpetic canaliculitis (24%), punctal agenesis (18%), and trauma (11%); less-common causes included dacryocystitis, Stevens-Johnson syndrome, eczema, and prior radiation therapy. Both upper and lower canalicular systems were involved in the majority (73%) of patients, and in 13 (11%) systems a dacryocystorhinostomy had previously been performed. The silicone tube was placed for a mean of 2 months (range, 1 week-9 months), and the mean postoperative follow-up was 8 months (range, 2-24 months). Epiphora subjectively improved in 90 (73%) of 123 systems, of which 27 (22%) of 123 were asymptomatic. In 33 systems (27%) in which epiphora persisted, 14 (11%) have undergone closed placement of a Jones canalicular bypass tube with control of symptoms.

CONCLUSIONS

Retrograde canaliculostomy and intubation can spare a significant number of patients the long-term inconvenience of Jones tubes. Failure of this technique does not, however, compromise or complicate the future placement of a bypass tube.

Surgical management of coexisting pseudophakic bullous keratopathy and glaucoma

This technique is a 1-step surgical management approach for patients with pseudophakic bullous keratopathy, glaucoma, and an unsatisfactory intraocular lens (IOL). The outcome of 4 consecutive patients who had penetrating keratoplasty, IOL removal, vitrectomy, transscleral sutured IOL implantation, and trabeculectomy by the same surgeon were reviewed. All patients had had intracapsular cataract extraction with anterior chamber IOL implantation and were on antiglaucoma therapy. Main outcome measures were Snellen visual acuity and intraocular pressure. A 1-stage quintuple procedure can achieve relatively rapid visual rehabilitation in these high-risk eyes. The role of filtration surgery is controversial, but it was partially successful in controlling postoperative intraocular pressure.

Comparison of dacryocystography and lacrimal scintigraphy in the diagnosis of functional nasolacrimal duct obstruction

AIM

It appears from the literature that no standardised examination exists for patients with functional nasolacrimal duct obstruction. The role of dacryocystography and lacrimal scintigraphy was compared in the diagnosis and management of these patients.

METHOD

Patients who were clinically diagnosed as having unilateral or bilateral functional nasolacrimal duct obstruction were prospectively entered into the study and data collected over 12 months in Moorfields Eye Hospital and Whipps Cross Hospital, London. All cases had, on separate occasions, a standardised dacryocystogram with delayed erect films and a lacrimal drainage scintigram.

RESULTS

45 lacrimal systems of 32 patients (mean age 62 years; 59% male) fulfilled the inclusion criteria. Abnormalities were detected with dacryocystography in 93% of systems and with lacrimal drainage scintigraphy in 95% of systems. Based on the results of previous quantitative studies, the positive scintigrams were subdivided into those demonstrating prelacrimal sac delay (13%), delay at the lacrimal sac/duct junction (35%), or delay within the duct (47%). Combining the two imaging techniques increased the sensitivity to 98%.

CONCLUSIONS

Both investigations are very sensitive at detecting abnormalities in patients with a clinical diagnosis of functional nasolacrimal duct obstruction. Lacrimal drainage scintigraphy is a slightly more sensitive test, but missed an abnormality detected by dacryocystography in two (4%) systems. A combination of the two techniques gives the highest sensitivity with maximum anatomical and physiological information but, in clinical practice, it is reasonable to perform a dacryocystogram initially and proceed to scintigraphy only if contrast radiography is normal.

Vitreoretinal surgery after inadvertent globe penetration during local ocular anesthesia

OBJECTIVE

This study aimed to review visual morbidity resulting from inadvertent globe penetration during administration of local anesthetic and to identify the most appropriate management.

DESIGN

The records of 20 consecutive patients referred to a specialist vitreoretinal unit over a 2-year period were reviewed.

PARTICIPANTS

Twenty eyes of 20 consecutive patients were included.

INTERVENTION

Observations included type of local anesthetic administered (e.g., retrobulbar or peribulbar), level of training of person administering the block, type of needle used for the block, and findings at presentation to the vitreoretinal unit. The authors also observed results of B-scan ultrasound evaluation of the retina, interval between the recognition of the complication and referral, as well as nature and timing of subsequent surgical intervention.

MAIN OUTCOME MEASURES

Final visual acuity and retinal status (attached versus detached) were measured.

RESULTS

The most common presentation was vitreous hemorrhage observed from the first postoperative day. Ten eyes were found to have an associated retinal detachment on initial assessment in the vitreoretinal unit. These eyes generally had a poor visual outcome despite vitrectomy with long-acting gas or silicone oil tamponade. Seven (70%) of the remaining eyes with attached retina at the time of presentation achieved good visual recovery after vitrectomy.

CONCLUSIONS

The authors recommend prompt referral for consideration of early vitrectomy in eyes with dense vitreous hemorrhage after inadvertent globe penetration. This management may improve the overall visual prognosis by preventing subsequent retinal detachment.

Symptomatic Rathke's cleft cyst with hypophysitis

We report a case of symptomatic Rathke's cleft cyst (RCC) with associated chronic hypophysitis. Symptomatic RCCs are rare and an associated inflammatory reaction is even rarer. The clinical and pathological findings are discussed in the light of previous published reports, together with the problems involved in making a preoperative diagnosis in such cases.