Can preoperative lacrimal endoscopic evaluation change the paradigm of conventional lacrimal surgery?

PURPOSE: To evaluate the effectiveness of preoperative lacrimal endoscopic evaluation (LEE) of lacrimal duct system (LDS). DESIGN: Retrospective comparative case series METHODS: From March 2016 to February 2020, the charts of patients chosen to undergo endoscopic dacryocystorhinostomy (EDCR) or silicone tube intubation (STI) were reviewed retrospectively. Group 1 included patients that underwent EDCR, and group 2 included patients that underwent STI. Preoperative LEE was performed for all patients. In group 1, we compared the functional success rate for patients who had been converted to STI with the patients who had undergone EDCR. In group 2, we compared the functional success rate of STI with those who had had STI without LEE. RESULTS: In group 1, 19 (54.3%) eyes were converted to STI following LEE, and the functional success rate was 84.2%, which is not significantly different from that of the EDCR group following LEE (p = 0.608). The functional success rate of EDCR without LEE was not different from that of STI following LEE (p = 1.000). In group 2, five eyes (26.3%) were converted to EDCR following LEE. The group undergoing STI following LEE showed a significantly higher functional success rate (95.7%) than the group without LEE (66.6%, p = 0.023). CONCLUSION: Preoperative LEE enables direct visualization of the LDS and helps to obtain more accurate diagnosis. This allows for the best surgical option based on LEE findings, which can contribute to better results. Therefore, LEE would be expected to change the paradigm of the classical management of LDS.

Outcomes of Single Suture Mueller's Muscle Conjunctival Resection: Ethnic Considerations.

PURPOSE: To compare outcomes of Mueller's Muscle Conjunctival Resection (MMCR) between 2 groups of patients with different anatomy due to ethnic heritage. METHODS: The medical records of patients who underwent MMCR between 2013 and 2018 were retrospectively reviewed. Patients who underwent additional procedures, such as upper blepharoplasty and browplasty, were excluded from the study. Patients were divided in 2 groups based on self-identified ethnic groups (Asian and Caucasian). Image J software was used to calculate MRD1 from digital images. The improvement of MRD1 (net MRD1) after surgery was evaluated and compared between 2 groups. RESULTS: Eighty-three eyes of 68 patients were included in this study. The Asian group consisted of 41 eyelids from 28 patients. The Caucasian group consisted of 42 eyelids from 40 patients. The average age was 52.18 (SD 20.176) in the Asian group compared with the 66.45 years (SD 9.22, p < 0.005) in the Caucasian group. The mean improvement of MRD1 was 1.96 ± 0.75 mm in Asian group and 2.05 ± 0.72 mm in Caucasian group, which was not statistically significant (p = 0.62). The incidence of ptosis overcorrection and undercorrection between the groups was also not statistically significant. CONCLUSIONS: There was no statistically significant difference in the surgical outcomes among the 2 study groups. Despite differences in the anatomy of Caucasian and Asian eyelids, MMCR is a successful procedure in patients self-identified from both ethnic groups.

Is It Really Safe to Discontinue Anticoagulant Treatment Before Ptosis Surgery From Serious Bleeding?

PURPOSE: To evaluate the effects of discontinuing anticoagulants (ACs)/antiplatelets (APs) preoperatively on surgery for blepharoptosis. METHOD: A retrospective analysis included patients with acquired blepharoptosis who underwent surgical correction, and were followed for more than 1 month. Patients were classified into 2 groups depending on AC/AP treatment or otherwise. All patients taking AC/AP discontinued with the treatment 1 week prior to surgery in accordance with our clinical guidelines. Preoperative and postoperative marginal reflex distance 1 (MRD1) and ecchymosis grade were evaluated and compared. RESULTS: Group 1 (AC/AP treatment cessation) included 47 patients with 93 eyelids, and group 2 (control) included 51 patients with 98 eyelids. The preoperative MRD1 showed no significant difference between groups. Group 1 showed a significantly higher rate of severe ecchymosis (41.8 versus 22.4%, P = 0.004) at 1 week of surgery as well as persistent ecchymosis (58.8 versus 7.3%, P = 0.000) compared with group 2 postoperatively at 1 month. Postoperative MRD1 was significantly lower in group 1 at 1 week (P = 0.019). However, the MRD1 and degree of improvement in lid height (postoperative MRD1 "preoperative MRD1) was not significantly different between the 2 groups (P = 0.499, P = 0.058) at 1 month postoperatively. CONCLUSIONS: Postoperative ecchymosis was more severe in group 1 at 1 month after ptosis surgery even though the ACs/APs were discontinued. Surgeons should be careful about this before operation. THE SYNOPSIS: Significant ecchymosis could occur even after discontinuation of antithrombotic agents in patients with a history of taking medication in ptosis surgery. Surgeons should be careful about this before operation.

Factor Influencing Postoperative Enophthalmos After Reconstruction of Orbital Wall Fracture.

PURPOSE: To determine factors influencing postoperative enophthalmos after reconstruction of orbital wall fracture. METHOD: Data of consecutive patients who were diagnosed with unilateral medial or inferior orbital wall fracture from March 2013 to February 2020 were retrospectively reviewed. Forty-three patients were included in this study (24 with medial orbital wall fracture and 19 with inferior orbital wall fracture). Their medical records including Hertel exophthalmometry, preoperative computed tomography (CT) scan, and postoperative CT scan were reviewed. The degree of enophthalmos developed was calculated by measuring exophthalmos before surgery and at 6 months after surgery. Patients were classified into 2 groups depending on whether reduction was good after surgery or not. Data (eg, age, gender, onset, fracture size, and so on) were then compared between these 2 groups. RESULTS: A total of 43 patients were included in the study. Their mean age was 40.1 years. There were 34 (79.1%) males. The mean onset from trauma to surgery was 8.1 days. Insufficient soft tissue reduction was found in 9 patients through postoperative CT scan. Preoperative mean enophthalmos was - 1.70 mm. Postoperative mean enophthalmos was -0.45 mm after 6 months. The mean fracture size was 213.74 mm2. There was no statistically significant difference in enophthalmos at 6 months after surgery regardless whether the reduction was good or not. Enophthalmos at 6 months after surgery was associated with preoperative fracture size and onset. CONCLUSIONS: Postoperative enophthalmos development might be associated with preoperative fracture size and onset. Delayed operation in case of large orbital wall fracture might lead to undesired result. Thus, surgeons should keep that in mind.

Does Intraoperative Ketorolac Increase Bleeding in Oculoplastic Surgery?

PURPOSE: To report adverse hemorrhagic outcomes in patients who received intravenous (IV) ketorolac during oculofacial plastic surgical procedures. METHODS: The medical records of 111 consecutive patients who underwent lacrimal or orbital surgery, between the years 2016 and 2018, performed by a single surgeon under general anesthesia were retrospectively reviewed. Patients were excluded if they had history of a bleeding coagulopathy, anticoagulant use prior to surgery, or insufficient follow up. Patients were divided into 2 groups based on whether they received intravenous ketorolac. The primary outcome measure was the occurrence of a major postoperative bleeding event, and the secondary outcome measures were the evaluation of postoperative ecchymosis graded at 1 week after surgery and the incidence of persistent ecchymosis beyond 4 weeks. RESULTS: A total of 111 patients were analyzed further, including 31 patients who received intraoperative IV ketorolac and 80 control patients who did not. The demographic characteristics between the 2 groups were similar. No major bleeding events occurred in either group. And there was no statistically significant difference between the 2 groups in terms of ecchymosis grade and the incidence of development of persistent ecchymosis. Comparing the subgroups of lacrimal and orbital cases, there was also no significance difference between these groups. CONCLUSIONS: This study suggests that intraoperative ketorolac use does not increase the risk of postoperative bleeding complications in oculofacial procedures. This alternative to opioids may assist with pain control and lessen the narcotic burden.

Usefulness of the dacryoscintigraphy in patients with nasolacrimal duct obstruction prior to endoscopic dacryocystorhinostomy.

PURPOSE: To evaluate the clinical usefulness of the dacryoscintigraphy in patients with nasolacrimal duct obstruction prior to endoscopic dacryocystorhinostomy. METHODS: One hundred thirty-five lacrimal views of endoscopic dacryocystorhinostomy (DCR) with a single surgeon for primary nasolacrimal duct obstruction (PANDO) were included. These were assigned into three groups according to the type of dacryoscintigraphy. Group 1 was a pre-sac obstruction pattern. Group 2 was an intra-sac obstruction pattern. Group 3 was post-sac obstruction pattern. Each group was evaluated for an anatomical and functional surgical success, presence of complications including granuloma, synechiae, and tube-induced inflammation at least 12 months after the surgery. RESULTS: Both anatomical and functional success rate showed no significant difference among the three groups (P = .297 and .472 linear by linear association). Functional failure rate (functional failure/total failure) also showed no clinically significant differences between groups. Logistic regression analysis was performed to determine the factors associated with functional success. There were no statistically significant factors in age, sex, scintigraphy type, pre-operative endoscopic grade, post-operative granuloma, and synechiae. CONCLUSION: In patients with nasolacrimal duct obstruction, preoperative evaluation of obstruction level using dacryoscintigraphy may be not useful for predicting the functional success of the endoscopic dacryocystorhinostomy.

Species-specific characteristics of the biofilm generated in silicone tube: an in vitro study.

BACKGROUND: To investigate characteristics of biofilm which is usually found in silicone tube for nasolacrimal duct surgery and can be the root of chronic bacterial infections eventually resulted in surgical failure. METHODS: To form a biofilm, sterile silicone tube was placed in culture media of Staphylococcus aureus, Corynebacterium matruchotii, Pseudomonas aeruginosa, or Streptococcus pneumonia. Biofilms formed on these silicone tubes were fixed with 95% ethanol and stained with 0.1% crystal violet. After staining, the optical densities of biofilms were measured using spectrophotometer on a weekly basis for 12 weeks. RESULTS: Staphylococcus aureus group and Pseudomonas aeruginosa group formed significantly more amounts of biofilms compared to the control group. The maximum optical densities of the two groups were found on week 3-4 followed by a tendency of decrease afterwards. However, the amounts of biofilms formed in other groups of silicone tubes were not statistically significant from that of the control group. CONCLUSIONS: Bacterial species that could form biofilm on silicone tube included Staphylococcus aureus (week 3) and Pseudomonas aeruginosa (Week 4). It is important to first consider that the cause of infection around 1 month after silicone tube intubation can be Staphylococcus aureus and Pseudomonas aeruginosa.

Clinical Significance of Biofilm on Silicone Tubes Removed From Patients With Nasolacrimal Duct Stenosis.

PURPOSE: To determine the relationship between the optical density of biofilms on silicone tubes and surgical outcomes. METHODS: A total of 43 silicone tubes from 33 patients with nasolacrimal duct stenosis were enrolled at 6 months after bicanalicular silicone tube intubation. The removed silicone tubes were divided into 2 segments. One segment of silicone tube was cultured while the other segment was used to measure optical density of biofilm. Each segment was divided into 3 pieces according to average normal human nasolacrimal anatomy. The first piece was located from puncta to lacrimal sac. The second piece was inside the nasolacrimal duct. The third piece was in the nasal cavity. Surgical outcome was evaluated at postoperative 12 months based on Munk score and fluorescein dye disappearance test. RESULTS: A total of 31 (72.1%) patients were surgically successful while 12 (27.9%) patients had surgical failure with persistent epiphora. In the second piece of silicone tube, the mean optical density of biofilm was 0.2654 nm in the surgical success group and 0.4472 nm in the surgical failure group. These results showed statistically significant (P < 0.01) difference. The most frequently isolated organism was Staphylococcus aureus in the surgical success group (7 of 31 patients, 22.6%). It was Pseudomonas aeruginosa in the surgical failure group (6 of 12 patients, 50%). CONCLUSION: This is the first study that determines the relationship between biofilm on silicone tube and surgical outcome. Biofilm formed on silicone tubes in nasolacrimal duct might cause surgical failure.

Eyelid Fat Atrophy and Depigmentation After an Intralesional Injection of Triamcinolone Acetonide to Treat Chalazion.

Two patients with depigmentation and fat atrophy after an intralesional injection of triamcinolone acetonide (TA) to treat chalazion are reported. A 2-year-old girl with chalazion in her right lower eyelid received a subconjunctival injection of TA and developed fat atrophy and depigmentation around the injected area. These changes subsided after 7 months. The second patient was a 5-year-old boy who received a triamcinolone injection into a chalazion through the eyelid skin and also developed fat atrophy and depigmentation but these changes improved after 1 year.

Reconstruction of Large Orbital Posterior Floor Wall Fracture Considering Orbital Floor Slope Using Endoscope.

PURPOSE: Reconstruction of a large orbital fracture extending to the posterior wall of the maxillary sinus is difficult and challenging. In this study, the authors present transconjunctival or transcaruncular approach using endoscopy and layered porous polyethylene barrier sheets to manage large orbital floor wall fracture. METHODS: A retrospective review of all patients who underwent reconstruction of large orbital floor wall fractures between June 2009 and July 2015 was conducted. Patient demographics, degree of enophthalmos, ocular motility and diplopia test results, and surgical complications were reviewed. RESULTS: This study included 53 eyes of 53 patients. The mean time from trauma to surgery was 34.1 days (range, 1-360 days). The average postoperative follow-up period was 6.1 months (range, 3-14 months). The degrees of enophthalmos preoperatively, and 1 week, 1 month, and 3 months postoperatively were -1.98 mm (range, -1.5 to -3 mm), 0.13 mm (range, -1.0 to +1.5 mm), -0.09 mm (range, -2.0 to +1.5 mm), and -0.43 mm (range, -2.0 to +1.0 mm), respectively. The mean improvement in enophthalmos at 3 months postoperation was 1.55 mm (P < 0.001). There was only 1 patient with residual 2 mm enophthalmos at 3 months postoperation. There were no definite surgical complications in any patient. CONCLUSION: Sufficient dissection to the posterior extent of the fracture and reconstruction of the orbital floor slope are the most important surgical factors to prevent residual enophthalmos. The authors believe using an endoscope and layered porous polyethylene are effective techniques in challenging patients with large orbital wall fracture.

Using the Endoscopic Transconjunctival and Transcaruncular Approach to Repair Combined Orbital Floor and Medial Wall Blowout Fractures.

PURPOSE: To demonstrate the effectiveness of the endoscopic transcaruncular and transconjunctival approach in the repair of combined medial and inferior orbital wall fractures. METHODS: A retrospective chart review was conducted on 160 patients with combined medial and inferior orbital wall fractures. All patients underwent surgery via an endoscopic transcaruncular and transconjunctival approach without lateral canthotomy, performed by a single surgeon. Porous polyethylene sheets (1.0 mm in thickness) were implanted to cover the orbital defects. The minimal postoperative follow-up period was 6 months. The authors evaluated enophthalmos, diplopia, and ocular motility pre and postoperatively and report surgical complications. RESULTS: A total of 160 patients were included, comprising 121 men and 39 women. The mean patient age was 33.9 ±â€Š14.1 years, and the mean postoperative follow-up period was 12 months. The average enophthalmos was 3.20 mm preoperatively, and the mean improvement at 6 months after surgery was 2.82 mm. One patient suffered a canalicular laceration after surgery, and another retrobulbar hemorrhage; however, both of these complications resolved with appropriate management. Otherwise, there were no significant surgical complications including newly developed diplopia, decreased visual acuity, or cerebrospinal fluid leakage. CONCLUSIONS: The endoscopic transcaruncular and transconjunctival approach is a useful and promising technique to repair combined medial and inferior orbital wall fractures.

Efficacy of postoperative mitomycin-C eye drops on the clinical outcome in endoscopic dacryocystorhinostomy.

PURPOSE: To evaluate the effect of postoperative topical mitomycin-C (MMC) eye drops in endoscopic (dacryocystorhinostomy) DCR and compare them with intraoperative MMC soaking. DESIGN: Retrospective, nonrandomized, interventional case series. METHODS: One hundred and sixty cases of endoscopic DCR with a single surgeon for primary nasolacrimal duct obstruction (NLDO) were included. Cases were divided into three groups. Group 1 was treated with intraoperative application of 0.02 % MMC for 5 min. Group 2 was treated with 0.02 % MMC eye drops for 5 days after surgery, without intraoperative application of MMC. Group 3 was the control group of cases without the use of MMC. Each group was evaluated for surgical success, presence of complications including granuloma, synechiae, and tube-induced inflammation, and the adverse effect of the MMC at least 6 months after the surgery. RESULTS: The success rate showed no significant difference among the three groups (P = .122, chi-square analysis). In the analysis between the two groups, although the success rate of Group 2 appeared not to be statistically different compared with that of Group 1 (P = .419, chi-square analysis), Group 2 had a statistically higher success rate for surgery than Group 3 (P = .041, chi-square analysis). The presence of granuloma was significantly lower in Group 1 than in the other two groups (P = .022, chi-square analysis). Synechiae and silicone tube-induced inflammation were not significantly different (P = .308, P = .881, chi-square analysis). There were no adverse effects associated with intraoperative or postoperative MMC application. CONCLUSION: Use of postoperative topical 0.02 % MMC is a safe and effective adjunctive modality to increase the success rate of endoscopic DCR.

The effect of Vaccinium uliginosum extract on tablet computer-induced asthenopia: randomized placebo-controlled study.

BACKGROUND: To investigate the alleviation effect of Vaccinium uliginosum extract (DA9301) on tablet computer-induced asthenopia. METHODS: This was a randomized, placebo-controlled, double-blind and parallel study (Trial registration number: 2013-95). A total 60 volunteers were randomized into DA9301 (n = 30) and control (n = 30) groups. The DA9301 group received DA9301 oral pill (1000 mg/day) for 4 weeks and the control group received placebo. Asthenopia was evaluated by administering a questionnaire containing 10 questions (responses were scored on a scales of 0-6; total score: 60) regarding ocular symptoms before (baseline) and 4 weeks after receiving pills (DA9301 or placebo). The participants completed the questionnaire before and after tablet computer (iPad Air, Apple Inc.) watching at each visit. The change in total asthenopia score (TAS) was calculated and compared between the groups RESULTS: TAS increased significantly after tablet computer watching at baseline in DA9301 group. (from 20.35 to 23.88; p = 0.031) However, after receiving DA9301 for 4 weeks, TAS remained stable after tablet computer watching. In the control group, TAS changes induced by tablet computer watching were not significant both at baseline and at 4 weeks after receiving placebo. Further analysis revealed the scores for "tired eyes" (p = 0.001), "sore/aching eyes" (p = 0.038), "irritated eyes" (p = 0.010), "watery eyes" (p = 0.005), "dry eyes" (p = 0.003), "eye strain" (p = 0.006), "blurred vision" (p = 0.034), and "visual discomfort" (p = 0.018) significantly improved in the DA9301 group. CONCLUSIONS: We found that oral intake of DA9301 (1000 mg/day for 4 weeks) was effective in alleviating asthenopia symptoms induced by tablet computer watching. TRIAL REGISTRATION: The study is registered at www.clinicaltrials.gov (registration number: NCT02641470, date of registration December 30, 2015).

Clinical Results of Modified Frontalis Suspension Technique Using Preserved Fascia Lata for Congenital Ptosis.

PURPOSE: The purpose of this study was to evaluate the clinical results of modified frontalis suspension technique with preserved fascia lata and to analyze the results according to age and preoperative ptosis degree. METHODS: This study involved a retrospective review of the electronic medical records of congenital ptosis patients who underwent unilateral or bilateral frontalis sling surgery using preserved fascia lata between March 1, 2004 and December 31, 2012. RESULTS: Seventy-seven patients (99 eyes) were included in the study. The mean age of the patients at the time of surgery was 6.2 ±â€Š6.7 years. Mean follow-up time was 5.4 ±â€Š3.2 years. Among 77 patients, 22 patients (28.5%) had a mild degree of ptosis, 39 (50.6%) had moderate, and 16 (20.7%) had a severe degree of ptosis. A satisfactory result (good and fair) was achieved in 65 of the 77 patients (84.4%) and a poor result was recorded in 12 patients (15.5%). Preoperative ptosis degree had no effect on the surgical success rate (19/22 [86.3%] in the mild group versus 34/39 [87.1%] in the moderate group versus 12/16 [75%] in the severe group, P = 0.243). There was no significant difference in surgical success rate between the unilateral and bilateral ptosis groups (45/55 [81.8%] versus 20/22 [90.9%], P = 0.479 respectively), between sexes (41/46 [89.1%] in male versus 24/31 [77.4%] in female, P = 0.271), or age groups (52/60 [86.6%] in younger group versus 13/17 [76.4%] in elder group, P = 0.526). Recurrence of ptosis did not differ according to the preoperative ptosis degree (3/22 [13.6%] in the mild group, 5/39 [12.8%] in the moderate group, and 2/16 [12.5%] in the severe group, P = 0.994). Age also had no influence on the ptosis recurrence. The preoperative marginal reflex distance 1 of 0.41 ±â€Š1.06 mm increased to 1.67 ±â€Š0.80 mm postoperatively (P = 0.000). CONCLUSIONS: The authors identified the long-term efficacy of preserved fascia lata in frontalis sling surgery with a modified frontalis suspension method for all age groups of patients. There was a small rate of recurrence (12.9%) over a maximum of 9 years of follow-up, which was corrected with additional surgery.

Endoscopic Reconstruction of Isolated Orbital Floor Wall Fracture Considering Orbital Floor Slope.

PURPOSE: To present a surgical technique for the reconstruction of the orbital floor slope in patients of isolated orbital floor fracture and to evaluate the effectiveness of this technique. METHODS: The authors conducted a retrospective review of all patients who underwent reconstruction of isolated orbital floor wall fracture between June 2010 and July 2015. The authors reviewed patient demographics, degree of enophthalmos, ocular motility and diplopia test results, and surgical complications. RESULTS: This study included 33 eyes from 33 patients. The mean time interval from trauma to surgery was 24.9 days (range, 5-360 days). The average postoperative follow-up period was 7.4 months (range, 3-28 months). The degree of enophthalmos preoperatively and 1 week, 1 month, and 3 months postoperatively was -1.55 mm (range, -3 to -0.5 mm), 0.22 mm (range, -0.5 to +1.0 mm), -0.06 mm (range, -1.0 to +1.0 mm), and -0.13 mm (range, -0.5 to +0.5 mm), respectively. The mean improvement in enophthalmos at postoperative 3 months was 1.41 mm compared with that in the preoperative data (P value <0.001). There were no patients with residual enophthalmos greater than 1 mm after reconstruction. CONCLUSION: Endoscopic orbital floor slope reconstruction in isolated orbital floor wall fracture using a layered porous polyethylene barrier implant is a very useful surgical technique for safely identifying the posterior margin of a fracture and easily reconstructing the orbital floor slope. The demonstration of slight exophthalmos of the corrected side about 1 to 2 mm at the end of the operation was also necessary.

Secondary Reconstruction of Residual Enophthalmos Using an Endoscope and Considering the Orbital Floor and Medial Wall Slope.

PURPOSE: To present a transconjunctival and transcaruncular endoscopy approach involving layered porous polyethylene barrier implants to manage residual posttraumatic enophthalmos and to evaluate the effectiveness of this technique. METHODS: The authors performed a retrospective review of all patients who underwent secondary reconstruction of orbital wall fractures because of residual enophthalmos between June 2008 and July 2015. Patients' demographics, degree of enophthalmos, ocular motility, diplopia test results, and surgical complications were reviewed. RESULTS: This study included 16 eyes (4 right eyes and 12 left eyes) of 16 patients (14 males and 2 females). The mean time interval from trauma to surgery was 7.1 months (range, 1-18 months). The average postoperative follow-up period was 6.4 months (range, 3-18 months). The degree of enophthalmos preoperatively and at 1 week, 1 month, and 3 months postoperatively was -2.47 mm (range, -2 to -3 mm), 0.5 mm (range, -0.5 to +2.5 mm), -0.06 mm (range, -0.5 to +1.5 mm), and -0.44 mm (range, -1.5 to +1.0 mm), respectively. There were no definite surgical complications in any patients. CONCLUSION: Dissection to the posterior margin of the fracture and reconstruction of the orbital floor slope are the most important surgical factors to prevent residual enophthalmos and scarring with recurrent diplopia. Demonstration of slight exophthalmos of the corrected side of about 1 to 2 mm at the end of the operation is also necessary. The authors believe that surgery using an endoscope and layered porous polyethylene is very useful for secondary reconstruction.

Association of rhinostomy shape and surgical outcome after endoscopic endonasal dacryocystorhinostomy.

PURPOSE: The purpose of this study was to investigate surgical outcomes and complications after endoscopic endonasal dacryocystorhinostomy (EDCR) in relation to rhinostomy shape. METHODS: A retrospective electronic medical record review of patients who underwent EDCR for primary acquired nasolacrimal duct obstruction (PANDO) was performed. Surgical success rates and postoperative complications were compared among three groups of patients in relation to rhinostomy shape (alcove, cavern, or concealed cavern). RESULTS: A total of 280 patients (358 eyes) were included in the study. Of the 358 eyes, 194 rhinostomies were alcove-shaped, 157 were cavern-shaped, and 7 were concealed cavern-shaped. There were no patients with flat-shaped rhinostomies. The nasal cavity was wider in patients in the alcove group than those in the cavern and concealed cavern groups (p = 0.012). The mean time to tube removal was longest in the concealed cavern group (p = 0.029). There were no significant differences in anatomical success rates among the three groups (p = 0.338). With regard to functional success for patients with anatomically patent DCR, the cavern and concealed cavern groups had significantly poorer results than the alcove group (p = 0.001). Functional success rates were 91.6 %, 84.8 %, and 57.1 % for the alcove, cavern, and concealed cavern groups, respectively. Development of postoperative granuloma was more frequent in the concealed cavern group (85.7 %) than in the alcove (29.3 %) or cavern groups (26.1 %) (p= 0.003). Multiple logistic regression models for surgical outcome showed that rates of functional failure after EDCR were influenced by patient age and rhinostomy shape (odds ratio 1.824, p = 0.045 for age; odds ratio = 9.605, p = 0.000 for rhinostomy shape) (Table 5). CONCLUSIONS: The incidence rate of symptomatic epiphora after EDCR was approximately 12 %, and this result may have been associated with cavernous and concealed rhinostomy shapes. For patients with persistent epiphora and anatomically patent DCR, it is important to identify rhinostomy shape by endoscopy in order to differentiate causes of functional failure.

Clinical Characteristics and Effectiveness of the Lateral Tarsal Strip and Medial Spindle Procedure.

This study was undertaken to evaluate the clinical characteristics and efficacy of the lateral tarsal strip (TS) and medial spindle procedure (MS). We conducted a retrospective chart review of the patients who underwent TS and MS between September 2008 and July 2011 by a single surgeon (S.H.B.). Data were collected on patient age, sex, laterality, diagnosis, procedures performed simultaneously, follow-up duration, postoperative complications, and surgical outcomes. One hundred eleven eyelids of 74 patients who underwent TS and 41 eyelids of 29 patients who underwent MS were included in this study. Patients' mean age was 61.5 years (range, 24-82) in the TS group and 68.2 years (range, 45-89) in the MS group. The most common diagnoses were lower lid laxity (54.1%) and involutional entropion (26.1%) in the TS group, and punctal ectropion in the MS group (95.1%). The percentage of patients who underwent an additional simultaneous procedure was 86.5% of the TS group and 92.7% of the MS group. Endoscopic dacryocystorhinostomy was the most commonly performed simultaneous procedure in both TS and MS groups (28.1% and 65.8%, respectively). Success rates were 96.4% in the TS group and 97.6% in the MS group. In the TS group, 3 eyelids (2.7%) required reoperation. The most common complication was chemosis in both TS and MS groups (51.4% and 50%, respectively). TS and MS are commonly performed simultaneously with other surgical procedures. These procedures aim to resolve lower lid laxity and punctal ectropion as well as relieve the symptoms of epiphora by stabilizing medial and lateral lid laxity. This review of the clinical features and effectiveness of MS and TS procedures provides useful information for clinicians.

The functional and histopathologic change in the levator palpebrae superioris and Müller muscle after subconjunctival injection of triamcinolone acetonide.

AIMS: The aim of this study was to evaluate the functional and histopathologic changes in the levator palpebrae superioris and Müller muscles after subconjunctival injection of triamcinolone acetonide (TA) in rabbits. METHODS: Twenty-four white New Zealand rabbits were divided into 2 groups. In group A, a subconjunctival injection of 0.5 mL TA (40 mg/mL) was administered to the right eye, whereas a normal saline injection of the same volume was administered to the left eye. In group B, the same procedures were done with a 1.0-mL injection of TA or normal saline into each eyelid. Follow-up was done to evaluate the histopathologic changes in the levator and Müller muscles, changes in the mean transectional area of Müller muscle, and changes in upper-lid height (marginal reflex distance 1) at 1, 2, 4, and 6 weeks after injection. Western blot analyses were used to determine the levels of myosin light chain phosphorylation and α-smooth muscle actin, which are related to the contractility of Müller muscle. RESULTS: No specific changes in marginal reflex distance 1 were noted in either group A or B. No significant histopathologic changes were found in the levator muscles. However, significant thinning of Müller muscle were found, and myosin light chain phosphorylation and α-smooth muscle actin levels were decreased. This was consistent with the histologic changes of Müller muscle observed in rabbits that received a TA injection. These changes were reversible and influenced by the volume of the injection. CONCLUSIONS: Subconjunctival injection of TA into the upper eyelids appears to be temporally influential on both the functional and histopathologic changes of Müller muscle in rabbits. This may be explained by the effect of improvement in lid retraction regardless of the minimal specific change observed in the levator muscle.

The Paradoxical Predominance of Medial Wall Injuries in Blowout Fracture.

PURPOSE: To evaluate the type and cause of orbital blowout fractures in Korea. DESIGN: Retrospective, observational case series. METHODS: Patients who underwent reconstruction for blowout fracture from March 2004 to April 2013 at Korea University Guro and Ansan Hospitals were included in this study. Patient demographics and orbital computed tomography (CT) scans were reviewed. On CT, ethmoid air cell septa, blowout fracture type, and other combined fractures were analyzed. Blowout fracture was classified as affecting up to 4 areas: the floor lateral to the infraorbital canal, the floor medial to the canal, the maxilla-ethmoidal strut ("inferomedial" strut), and the medial wall. Furthermore, trauma type and associated injury were reviewed. The results of adolescent patients and adult patients were compared, as were those of males and females. RESULTS: The study included 659 eyes of 659 patients; mean patient age was 31.01 ±â€Š14.27 years. In total, 513 (77.85%) patients were male and 146 (22.15%) were female. The most common blowout fracture type was medial wall fracture, followed by floor wall, floor and medial wall without inferomedial strut, and floor and medial wall fracture with inferomedial strut, in that order. Interestingly, patients with floor wall blowout fracture were younger (26.87 ±â€Š12.90 y) than other groups: medial wall fracture (32.35 ±â€Š14.64 y, P < 0.0001), floor and medial wall fracture (35.22 ±â€Š14.49 y, P < 0.0001), and floor and medial wall fracture involving the maxillaethmoidal strut (32.62 ±â€Š13.75 y, P = 0.002). The number of ethmoidal air cell septa was lowest in the medial wall fracture group (3.62 ±â€Š0.67): floor wall fracture (4.07 ±â€Š0.69, P < 0.0001), floor and medial wall fracture (3.90 ±â€Š0.78, P < 0.0001), and floor and medial wall fracture involving the maxilla-ethmoidal strut (4.05 ±â€Š0.72, P = 0.001). CONCLUSIONS: Our study demonstrated that the blowout fracture type distribution in Korea varied from the results of many other studies. Medial wall fracture is the most common among the 4 types, and anatomic variance, such as number of ethmoid air cell septa, could influence blowout fracture type, especially in medial wall fracture.