One-Stage Alternatives to the Hughes Procedure for Reconstruction of Large Lower Eyelid Defects: Surgical Techniques and Outcomes.

PURPOSE: To present the results of 1-stage surgical advancement flaps for the repair of large full thickness lower eyelid defects. These avoid the disadvantages of the 2-stage Hughes procedure and provide favorable functional and aesthetic outcomes. METHODS: A retrospective case series of 36 lower eyelid repairs performed on 31 patients by a single surgeon in Sydney, Australia is presented. The selection criterion was a horizontal defect size 10 mm or greater that could have "classically" been repaired with a 2-stage Hughes procedure. Three different 1-stage surgical repair techniques were utilized, all incorporating local advancement-type flaps: 1) a lateral-based full thickness advancement flap; 2) a vertical tarsal plate advancement flap combined with a full thickness skin graft; and 3) a vertical skin advancement flap combined with a mucosal graft. The postoperative outcomes evaluated included flap viability, lower eyelid margin position and contour, characteristics of the new eyelid margin and patient satisfaction. RESULTS: Thirty-six lower eyelid repairs were performed in 31 patients. There were no cases of flap ischemia, necrosis, or failure. There was 1 case (3%) of postoperative eyelid retraction, 1 case (3%) of eyelid entropion requiring surgical repair, 1 case (3%) of pyogenic granuloma, 2 cases (6%) of eyelid margin cyst, and 7 cases (19%) of eyelid distichiasis. In 34 cases (94%), the patient was satisfied with the aesthetic result. CONCLUSION: The techniques described provide successful alternatives to the Hughes procedure. They are 1-stage and do not render the patient temporarily monocular, or alter the upper eyelid anatomy or function. All maintained favorable long-term functional and aesthetic outcomes for the reconstructed lower eyelid.

The Role of Routine Biopsy of the Lacrimal Sac During Dacryocystorhinostomy Surgery.

PURPOSE: To assess the role of routine histopathological evaluation of the lacrimal sac wall when performing dacryocystorhinostomy (DCR) surgery. METHODS: A retrospective review was conducted of the histology findings in lacrimal sac biopsies, taken routinely, in an external-approach DCR series. This is a single surgeon (RB), single pathologist (AG) consecutive series. The histopathology reports were reviewed and collated. Each patient's medical history and risk factors for malignancy were recorded. The surgeon documented any abnormal lacrimal sac appearance at the time of surgery. RESULTS: No patient in this series of 245, in whom 254 histology specimens were taken, recorded a significant pathological result that was not anticipated from pre-operative assessment, or from the appearance of the lacrimal sac intra-operatively. CONCLUSION: The reported recommendation for routine histopathological evaluation of the lacrimal sac wall when performing DCR surgery is not supported by this consecutive series. The authors recommend histopathological evaluation only in the setting of pre-existing clinical suspicion of malignancy, or an abnormal intra-operative appearance of the lacrimal sac.

Unusual limbal lesion in neurofibromatosis type 1.

PURPOSE: To describe an unusual limbal lesion clinically resembling pterygium in a young patient with neurofibromatosis type 1. METHODS: Clinical case report with a review of the literature. RESULTS: The lesion was excised, and histopathology was performed. Histopathology disclosed conjunctival mucosa with expansion of the substantia propria by dense and loose collagenous tissue, small nerves, and thin-walled blood vessels. No skin or skin appendages were seen, although a small amount of mature adipose was present. Focally, spindle cells with wavy nuclei were seen scattered within the collagenous areas and were positive on S100 immunohistochemistry. Mast cells were readily identifiable. There was no evidence of actinic elastosis, dysplasia, or malignancy. These histopathological features most resemble heterotopia with some features of neurofibroma. CONCLUSIONS: We report an unusual limbal lesion in a patient with neurofibromatosis type 1. Histopathological features resemble a heterotopia with some neurofibroma features. We suggest that all lesions excised from patients with neurofibromatosis, no matter how characteristic in appearance, be sent for histopathological confirmation of diagnosis.

Orbital involvement in systemic mastocytosis.

A 61-year-old female presented with a 3-day history of painful and reddened right eye with painful ocular movements. She had been diagnosed as having systemic mastocytosis 4 years earlier. Ocular examination showed Best Corrected Visual acuity of 6/6 right eye and 6/6 left eye. There was marked conjunctival injection and chemosis. The posterior segment was normal. The left eye was normal. Exophthalmometry showed 2 mm of right proptosis relative to the left eye. Computed tomography (CT) scans showed an ill-defined intra-conal lesion and enlargement of the lacrimal gland in the right orbit. A diagnostic biopsy was performed; the histopathology findings were of orbital mastocytosis. We present what our literature search suggests is the first biopsy-proven case of orbital mastocytosis.

Origins of lacrimal surgery, and evolution of dacryocystorhinostomy to the present.

The creation of an alternative pathway from the lacrimal sac into the nose has been practised for over two millennia. Early historical figures who pioneered lacrimal surgery were Celsus and Galen, treating dacryocystitis by plunging a red-hot cautery iron through the lacrimal bone into the nose. Better understanding of lacrimal physiology and anatomy led to the introduction of more sophisticated techniques in the 18th century. However, despite these approaches, the technique of Celsus continued to be practised well into the eighteenth and nineteenth centuries. Modern lacrimal surgery began when the Italian otolaryngologist, Toti, described his external dacryocystorhinostomy procedure in 1904. Dupuy-Dutemps and Bourget refined Toti's procedure, and introduced the technique of anastomosing lacrimal and nasal mucosal flaps which remains the foundation of the external dacryocystorhinostomy performed today. The endonasal dacryocystorhinostomy was described before the external approach, but its popularity and success grew only in recent times.

Margins of excision and prognostic factors for cutaneous eyelid melanomas.

BACKGROUND: Guidelines for wide excision of cutaneous melanomas according to Breslow thickness are impractical when considering melanomas arising on eyelid skin. No consensus exists regarding appropriate excision margins for these tumours. This study sought to determine whether excision margins influenced locoregional recurrence, and to identify prognostic factors for survival in these patients. METHODS: Fifty-six cases of invasive cutaneous eyelid melanomas diagnosed between 1985 and 2011 were identified from the database of Melanoma Institute Australia. Clinical and pathological factors were assessed for their associations with recurrence and survival. RESULTS: Local recurrence occurred in 12 patients (21%), nodal metastasis in 6 (11%) and distant metastasis in 2 (4%). Pathological margins>2 mm from the in situ component of the tumour were associated with increased disease-free survival (P=0.029) compared with margins≤2 mm but there was no statistically significant benefit for a pathological margin>2 mm from the invasive component. Lower eyelid melanomas were found to have a significantly higher local recurrence rate than upper eyelid melanomas (P=0.044). CONCLUSIONS: This series of cutaneous eyelid melanomas is the largest yet reported. The results suggest that, as a minimum, an in vivo surgical margin of 3 mm (corresponding to a 2 mm pathological margin after tissue fixation) is desirable for eyelid melanomas. We recommend a surgical excision margin of 3 mm for eyelid melanomas≤1 mm in Breslow thickness. However, for melanomas>1 mm in thickness, the current practice of aiming to achieve 5 mm margins would seem reasonable. Patients with lower eyelid melanomas warrant particularly close follow-up given their higher local recurrence rate.

The method of en face frozen section in clearing periocular basal cell carcinoma and squamous cell carcinoma.

BACKGROUND: The senior consultants Ross Benger and Andrew Gal have been using en face frozen section histological margin control in removing cancer from the periocular region since 1985. The aim of this study was to determine the percentage of cases in which more than one resection was necessary in order to achieve clear margins. METHODS: This is a retrospective study of patients treated at Drummoyne Eye Surgical Centre in the period 1999-2007, in whom removal of the eyelid cancer was decided to be with en face frozen section histological control. A record was kept of how many resections were necessary to achieve clear margins. Paraffin sections were subsequently examined for a final histopathological diagnosis. RESULTS: Two hundred and fifty people were included in the study, of whom 204 had basal cell carcinoma (BCC) and 32 had squamous cell carcinoma (SCC). One hundred and twenty BCCs had a full-thickness eyelid "wedge" resection, of which 45% needed more than the standard two frozen sections taken to achieve clear margins. Eighty-four BCCs were removed using ring resection, of which 35.7% needed more than the standard initial resections (peripheral annulus and deep disc) to achieve clear margins. CONCLUSIONS: Our study showed that a significant percentage of BCC and SCC lesions needed further resection after the initial frozen section edge checks to achieve clear margins. Intraoperative presence of the histopathologist increased the likelihood of achieving clearance of the cancer at a single operating session.

A modified Jones test: lacrimal scintigram correlation.

PURPOSE: To determine the correlation between lacrimal scintigraphy and a modified Jones primary dye drainage test combined with the fluorescein dye disappearance test (DDT) and Jones secondary dye test, in diagnosing the cause of epiphora. METHODS: A prospective, consecutive clinical trial was conducted. All patients presenting with epiphora were considered, but those with trichiasis, corneal irritation, lower eyelid ectropion, Bell palsy, or previous lacrimal surgery were excluded. A cohort of 39 patients (65 eyes) underwent the fluorescein DDT and the senior author's (R.B.) modified Jones primary dye drainage test (Jones dye test 1 [JDT1]). For this test, an entire fluorescein 2% Minim dose was instilled in the 2 eyes, and the patient was then asked to gently blow each nostril separately in a white tissue; the degree of fluorescein staining was noted. If there was no fluorescein staining of the tissue (negative JDT1), a traditional Jones secondary dye test (Jones dye test 2) was also performed. All patients except for those testing strongly positive on modified testing or with negative DDT and JDT1 and nil drainage from the nose in Jones dye test 2, indicating anatomical obstruction, were referred for lacrimal scintigraphy. RESULTS: In total, 59 of 65 eyes (91%) showed a positive correlation between the diagnosis arrived at after dye testing using the modified primary dye test and diagnosis on lacrimal scintigraphy. The interrater reliability for the raters was found to be κ = 0.770 and 95% confidence interval = 0.594-0.945. The strength of agreement is considered to be "good." CONCLUSIONS: The authors found that in the presence of patent lacrimal drainage system dysfunction, modified Jones primary dye test, combined with the fluorescein DDT and Jones secondary dye test, correlated strongly with lacrimal scintigraphy.

The role of mucosal flaps in external dacryocystorhinostomy.

PURPOSE: To determine whether a mucosal anastomosis fashioned at the time of external dacryocystorhinostomy (DCR) influences postoperative outcome. METHODS: The clinical records of all patients who underwent external DCR at Sydney Eye Hospital between May 2000 and August 2007 were reviewed. Data were collected in regards to surgical technique, clinical outcomes and postoperative management. Chi-square statistical analysis was done to determine the significance of the different flap techniques on surgical success. RESULTS: A total of 260 medical records were reviewed. The main outcome measure was postoperative resolution of symptoms. The mean final follow-up time was 11 months. There was no statistically significant difference in outcome between patients who had both anterior and posterior flaps sutured, compared to those who had anterior flap sutures only (73% vs 79%, p = 0.51). Patients who had no sutured flaps had an overall success rate of 89% compared to those that had at least the anterior flaps sutured together (76%); this difference was not significant (p = 0.45). CONCLUSION: There was no statistical difference in symptom outcome between patients in whom both mucosal flaps were sutured, those who had only the anterior flap sutured, or those who did not have either flap sutured at the time of surgery.

External dacryocystorhinostomy: assessing factors that influence outcome.

PURPOSE: To present the experience of external dacryocystorhinostomy (DCR) at a tertiary referral center and investigate factors that may affect clinical outcomes. METHODS: The clinical records of all patients who underwent external DCR at Sydney Eye Hospital between May 2000 and August 2007 were reviewed. Data were collected in regards to patient demographics, preoperative assessment, operative details, surgical technique, postoperative management, and clinical outcomes. This information was then analyzed, with emphasis on factors that influence surgical outcomes and success. RESULTS: A total of 338 cases were reviewed. The mean age at time of surgery was 64.82 years and the majority of patients were female (65%). Epiphora was the major preoperative symptom. Assisted local anesthesia and day stay surgery were the most common surgical settings. There was a statistically significant difference in theatre time between consultant and trainee surgeons (P < 0.00001). The mean final follow-up time was 11 months. Overall, 77.3% of patients had full resolution of symptoms and 20.8% had partial resolution. Only five patients (1.9%) had no resolution of symptoms. There was no significant difference in outcomes between consultants and trainees. Patients with anatomical nasolacrimal obstruction had significantly better outcomes compared with functional obstruction (P = 0.04). The postoperative fluorescein dye disappearance test was a good predictor of clinical success (P = 0.005). Silicone intubation for greater than 6 months was associated with better outcomes (P = 0.002). CONCLUSIONS: The results at our tertiary center are comparable to results stated in the literature. In our series, only the amount of nasolacrimal obstruction and duration of postoperative intubation influenced surgical success.

Subconjunctival "ring" recurrence of Basal cell carcinoma of the globe.

Basal cell carcinoma is the most common indication for orbital exenteration. The recurrence rate of BCC removed with microscopically controlled histology sections is up to 6%. The authors describe the recurrence of a lower eyelid BCC resected with microscopic control that did not manifest itself until 15 years later as a subconjunctival lesion, encircling the globe, and without apparent skin involvement. BCC can present in any manner following surgery, and therefore, judicious follow-up is necessary even after microscopically controlled resection.

Paraffin histology sections and delayed repair in recurrent atypical fibroxanthoma of the eyelid.

We present a report of a recurrent atypical fibroxanthoma (AFX), a tumour known rarely to involve the eyelid. A 61 year-old male was referred after reappearance of a lower eyelid AFX within two months of resection. The neoplastic spindle cells at the periphery of an AFX may be difficult to differentiate from dermal fibroblasts in frozen sections. Paraffin sections provide better histological definition and thus greater accuracy in determining completeness of excision. The patient's recurrent tumour was surgically excised and overnight paraffin sections were used to obtain margin clearance, before secondary reconstruction. The tumour required re-excision on three occasions before clearance was achieved. The patient remains tumour free at 12 months' follow-up.

Lung metastases in a case of metatypical basal cell carcinoma of the eyelid: an illustrative case and literature review to heighten vigilance of its metastatic potential.

Basal cell carcinoma (BCC) is an extremely common malignancy; however, unlike other skin cancers, they very rarely metastasize. Here we present an unusual case of metatypical BCC of the eyelid which metastasized to the lung nine years after initial surgical treatment. We include a review of the literature regarding metastatic BCC and suggest that metatypical features in primary BCC should prompt careful patient monitoring and consideration of adjuvant treatment at the time of diagnosis.

Cicatricial entropion repair with hard palate mucous membrane graft: surgical technique and outcomes.

BACKGROUND: The use of a hard palate mucous membrane graft (HPMMG) has been previously described for upper and lower eyelid cicatricial entropion repair. The objective of this paper is to review the surgical technique and postoperative complications in a large series of patient who underwent hard palate grafting for the management of cicatricial entropion. METHODS: The medical records of 107 patients representing 147 eyelids undergoing surgical management of cicatricial entropion with HPMMG were reviewed. The surgical technique is described. RESULTS: 147 eyelid operations (74 upper, 73 lower) were performed on 107 patients (46 male, 61 female), with a mean age of 63 years (range 12-87). The aetiology of the cicatricial entropion included idiopathic (41%), trauma (5.6%), chronic blepharitis (16.8%), chemical injury (3.7%), ocular cicatricial pemphigoid (8.4%), trachoma (7.5%) and other (16.8%). Patients were followed postoperatively for an average of 21 months (range 6-120). Ninety-four per cent of patients noted symptomatic improvement. The postoperative complications included excess keratin (29%), recurrence of cicatricial entropion (4.1%), punctuate epithelial erosion (2.7%), graft shrinkage (0.7%) and donor site bleeding (2.0%). CONCLUSIONS: Cicatricial Entropion with hard palate mucous membrane grafting for both upper and lower eyelid surgery offers high symptomatic and anatomical cure rates. The requirement for further surgical intervention is low.

Peripunctal "anchor" suture for securing the silicone bicanalicular stent in the repair of canalicular lacerations.

We used punctal absorbable suture in 8 patients (8 eyes) for silicone stent stabilization in canalicular repair surgery to prevent the postoperative complication of "cheese-wiring." Postoperatively there was 1 case of cheese-wiring of the repaired canaliculus, and no other complication related to the bicanalicular stent. The pericanalicular "anchor" suture may reduce the incidence of cheese-wiring by silicone bicanalicular stents after repair of canalicular lacerations or resections for stenosis.

Orbital exenteration: a 15-year study of 38 cases.

PURPOSE: To determine the clinical indications and outcomes after orbital exenteration when histologic margins were reported as "clear," examining factors affecting local and systemic recurrences and mortality. METHODS: Retrospective case review of exenterations performed in Sydney Eye Hospital in Sydney, Australia, between 1990 and 2004. Reviewed data indications for exenteration, histopathologic diagnosis, and recurrences on follow-up. RESULTS: Secondary intraorbital spread of malignant adnexal tumors was the most common indication for exenteration (34 of 38). Among these, the site of the primary neoplasm was the eyelid in 19 cases and the ocular surface in 12 cases. Exenteration was total in 26 cases, subtotal in 8 cases, and extended in 4 cases. In 11 cases, a dermis-fat graft was used for socket reconstruction; 24 cases were allowed to granulate spontaneously. The average healing time was 5 months (range, 4-6 months) for spontaneous granulation, and 6 weeks (range, 4-8 weeks) for dermis-fat grafts. Perineural spread was demonstrated histopathologically in 7 specimens. During follow-up (median, 48 months), there were 9 recurrences (23.7%): 3 local and 6 systemic. Seven patients (18.4%) died of the disease during the follow-up period. CONCLUSIONS: Dermis-fat grafts for reconstruction of the exenterated socket seem to optimize the aesthetic results. The first year is the most important period for follow-up of local recurrences, but systemic examination is needed for the longer follow-up. This may have implications in terms of reconstruction and adjunctive treatment following exenteration surgery.

Techniques of periocular reconstruction.

Eyelid and periocular reconstruction is often needed in ophthalmic practice, as a result of defects created by excision of lesions or following trauma. A variety of techniques have been described for the repair of these defects. However, it is important to have a knowledge of the basic principles underlying all these techniques and the advantages and disadvantages of each, so as to ensure the selection of the optimal technique in a particular case. Different authors have popularized different techniques based on individual preferences and experiences and a brief overview of the different techniques will be helpful to compare them. The articles referenced in this manuscript were looked up through PubMed by feeding the keywords 'periocular reconstruction' and 'eyelid reconstruction' and then looking for relevant cross-references. In this review, we have discussed the various techniques available and also illustrated them diagrammatically to have a quick overview of the topic.

Management of periocular basal and squamous cell carcinoma: a series of 485 cases.

PURPOSE: To analyze the outcome of management of patients with basal cell carcinomas (BCCs) and squamous cell carcinomas (SCCs) in a tertiary referral eye center in Sydney, Australia. DESIGN: Retrospective case series. METHODS: Review of medical records of 485 consecutive cases (469 patients) with confirmed eyelid cancer. Intervention procedures: Surgical excision with 3- to 5-mm clinically clear margins and histologic confirmation of the surgical margins. Frozen section histology or Mohs' micrographic surgery (MMS) was used for incompletely excised cases, and those located in the medial canthus or close to the lacrimal drainage system. Standard reconstruction techniques were employed. MAIN OUTCOME MEASURES: Survival period free of tumor, incomplete excision, recurrences, type of closure, and complications. RESULTS: Excision was initially incomplete in 25.4% of all tumors. Morpheaform type of BCC (chi(2)P < .001), and medial canthus location BCCs (chi(2)P < .05) were associated with a higher incomplete resection rate. A 35.9% incomplete excision rate was associated with a significantly higher recurrence rate compared with complete excision (8.4% and 4.6%, respectively, chi(2)P < .05). Twenty-seven patients (5.6%) had a recurrent tumor. After incomplete excision, there was no recurrence with MMS, but 4.7% recurrence rate when frozen section technique was used (P < .05). Local postoperative complications occurred in 41 patients (8.5%). CONCLUSIONS: In the setting of a tertiary referral center, incomplete primary resection of an eyelid skin cancer is the main risk factor for recurrence. Incomplete resection is significantly associated with medial canthus location and morpheaform type of BCC and with moderately differentiated SCC. MMS is the safer technique after incomplete tumor excision.

Interferon alpha 2b treatment for residual ocular surface squamous neoplasia unresponsive to excision, cryotherapy and mitomycin-C.

Three patients had residual or recurrent tumour following excision of large ocular surface squamous neoplasia (OSSN) lesions, which did not resolve despite the use of adjunctive cryotherapy and topical mitomycin-C therapy. The residual tumour was treated with topical or subconjunctival injectable interferon alpha 2b. All three eyes had complete resolution of the OSSN lesions after an average of 6 weeks (range 4-8 weeks) of treatment with interferon alpha 2b. No regrowth was seen during the follow-up period of 22.7 +/- 32.3 months (range 5-60 months). No adverse reactions or complaints were reported during and following interferon use, and previous symptoms from mitomycin-C treatment resolved completely. In these patients subconjunctival or topical interferon was an effective and safe treatment for residual OSSN. Longer follow up is required to confirm the long-term efficacy in prevention of recurrences.