Transcutaneous (External) Dacryocystorhinostomy with Reconstruction of the Ductus nasolacrimalis. / Transkutane (externe) Dakryozystorhinostomie mit Rekonstruktion des Ductus nasolacrimalis.

BACKGROUND: Dacryocystorhinostomy (DCR) is regarded as the gold standard for the treatment of chronic dacryocystitis (CDC). Different modifications of the surgical procedure have been developed over the years. METHODS: Patients with CDC due to postsaccal lacrimal stenosis and under treatment with DCR have been included in this retrospective study. Two groups of different surgical procedures were analysed: firstly DCR without reconstruction of the ductus nasolacrimalis (DNL, group 1) and secondly patients with reopening the DNL (group 2). Criteria for success were absence of permanent epiphora, absence of inflammation of the lacrimal sac (functional success), and no recurrent surgery with free patency of the lacrimal duct (anatomical success). This was obtained by questionnaire after a follow-up of at least 12 months. The impact of gender, ectasia of the lacrimal sac, dacryoliths, and prior lacrimal surgeries was analysed. RESULTS: Overall, 248 surgeries were enrolled in this trial. Mean age in group 1 was 68 years (range: 22 to 92 years) and gender ratio was 3.2 to 1 (female : male). In that group, 68 operations could be followed up. In group 2, 62 operations on patients of a mean age of 63 years (range: 24 to 89 years) and a gender ratio of 2.9 to 1 (female : male) were observed. Complete success occurred in 75.0% in group 1 and 75.8% in group 2. Recurrent operations were necessary in one case of group 2 (1.6%) and 4 cases of group 1 (5.9%). Gender (group 1 p = 1; group 2 p = 0.115; between groups p = 0.511), ectasia of the lacrimal sac (group 1 p = 0.877; group 2 p = 0.674; between groups p = 0.878), dacryolith (group 1 p = 1; group 2 p = 0.465; between groups p = 1), and prior lacrimal surgery (group 1 p = 0.092; group 2 p = 0.051; between groups p = 0.520) did not influence the success rates in each group or between groups. Significantly more dacryoliths were found during operations of group 2 (p = 0.010). CONCLUSION: Reconstruction of the DNL during DCR is a possible and easy modification, with a slightly better success rate in curing CDC. Intraoperatively, dacryoliths might not be apparent remain in the deeper parts of the lacrimal ducts. Therefore, these segments should be inspected during surgery.

Dacryolithogenesis or Dacryolithiasis-The Story So Far.

The term dacryoliths refers to the concretions found within the lacrimal system. When the term dacryoliths is unspecified, it usually refers to the noninfectious dacryoliths commonly isolated from the lacrimal sac and the nasolacrimal duct. More often, they are diagnosed incidentally during a dacryocystorhinostomy, and the reported incidence among all dacryocystorhinostomy surgeries is 5.7% to as high as 18%. Dacryolithiasis is a complex process occurring within the lacrimal system, and current evidence suggests a multifactorial etiology. The sequence of events can be summarized broadly into 4 stages: stage of susceptibility, stage of initiation/trigger, stage of development, and stage of maintenance. The triggering event is the breach of the lacrimal sac or nasolacrimal duct epithelium, resulting in microtrauma with blood leakage. The blood clots act as a nidus for subsequent sequential laying of mucopeptides, cellular debris present locally, debris washed from the ocular surface, and extraneous agents in tears. This process is aided by altered rheology and composition of the tear film. After the formation of dacryoliths, extracellular neutrophil traps usually form on the surface, which help to maintain the dacryoliths (which do not dissolve). This review highlights and discusses the possible sequence of events during dacryolithiasis.

[Congenital anomalies in lacrimal drainage]. / Angeborene Fehlbildungen der ableitenden Tränenwege.

Congenital dacryostenosis is the most common reason for ophthalmic consultation in childhood. It is most often caused by persisting of Hasner's membrane. However, congenital malformations of the lacrimal drainage system can also occur in rare cases. In the area of the proximal lacrimal drainage system, supernumerary lacrimal puncta and canaliculi can arise as well as diverticula, fistula, and atresia. The distal lacrimal drainage system can be affected by fistulas, amniotoceles, and cysts. Association of lacrimal malformations with congenital systemic diseases is reported in about 10% of cases. Depending on the severity of the symptoms, surgical rehabilitation can be performed, and endoscopic procedures and modern lacrimal drainage intubation systems may be employed.

Congenital Anomalies in Lacrimal Drainage. / Angeborene Fehlbildungen der ableitenden Tränenwege.

Congenital dacryostenosis is the most common reason for ophthalmic consultation in childhood. It is most often caused by persisting of Hasner's membrane. However, congenital malformations of the lacrimal drainage system can also occur in rare cases. In the area of the proximal lacrimal drainage system, supernumerary lacrimal puncta and canaliculi can arise as well as diverticula, fistula, and atresia. The distal lacrimal drainage system can be affected by fistulas, amniotoceles, and cysts. Association of lacrimal malformations with congenital systemic diseases is reported in about 10% of cases. Depending on the severity of the symptoms, surgical rehabilitation can be performed, and endoscopic procedures and modern lacrimal drainage intubation systems may be employed.

Rare Diseases of the Orbit. / Seltene Erkrankungen der Orbita.

This article provides an overview of rare orbital diseases. Congenital malformations, inflammatory diseases, benign and malignant neoplasias are described. Although it represents a relatively small area of the body the orbit contains multiple different tissues. Therefore, a great variety of diseases can be found within the orbital space. That is the reason, why both the completeness and the level of detail in the description of particular diseases must be somewhat limited. Nevertheless, clinical manifestations, important aspects of diagnosis, treatment strategies, and, when specific data are available, the prognosis are described. The authors tried to highlight the most characteristic aspects of the different diseases to describe their relevant aspects in spite of the brevity of the subsections.

[Management of posttraumatic ocular hypotony]. / Management der posttraumatischen Bulbushypotonie.

The posttraumatic ocular hypotony (3% after ocular contusion, 50-74% after open globe injury) can lead to severe secondary damage of the eyeball. In addition to corneal folds, ciliary body and choroidal detachment, papilledema e vacuo and macular folds, the shrinking of the eye can lead to substantial visual impairment. Subsequently, the contralateral eye may react with ocular hypertension. The cause of the hypotony must be identified and causally treated. A preservation of the globe is possible if more than 210 ° of the ciliary body are intact. One of the major causes of posttraumatic hypotony is cyclodialysis. Smaller cyclodialysis clefts respond to a cycloplegic treatment, larger clefts require a surgical approach. The direct cyclopexy can be combined with primary wound repair or pole to pole surgery. An alternative consists of silicone oil endotamponade or occlusion of Schlemm's canal. The posttraumatic ocular hypotony is complex and requires exact diagnostics to be able to differentially and specifically treat the causes of hypotony.

[Lacrimal Duct Obstruction in Adults]. / Tränenwegsstenosen im Erwachsenenalter.

The tearing eye (epiphora) is the guiding symptome of nasolacrimal duct obstruction. Depending on the localization of stenosis, mucopurulent lacrimal discharge occurs additionally. These symptoms induce alterations of the optical system and can cause severe complications such as acute phlegmonous dacryocystitis. The grade of suffering in these patients is very high. For the diagnosis, patient's history, ocular surface conditions and inspection (macro-/microscopically) as well as palpation of the lacrimal region are essential examinations. Moreover, functional and anatomical tests enable a classification of nasolacrimal duct obstruction regarding grade of stenosis (incomplete vs. complete), type (functional vs. mechanical), and localization (pre-, intra-, postsaccal). ENT consultation prior to lacrimal surgery is obligate. Through this, a purposeful therapeutic intervention is warranted. Surgical methods consist of minimally invasive transcanalicular procedures or anastomosing surgeries. Dependent on the clinical findings, these treatment options can be applied in a patient centered therapeutic concept.

[Diseases and Surgery of the Orbit]. / Erkrankungen und Chirurgie der Orbita.

Most orbital diseases are rarely diagnosed in the clinic. Because the consequences for the eye can be severe, it is important to recognize the signs of orbital disease early in order to initiate the correct diagnostic and therapeutic steps in good time. This article presents the basics of the systematics, diagnostics and therapy of orbital diseases in preparation for the specialist examination for ENT medicine. Some orbital diseases are typical manifestations of systemic diseases (e. g. Graves' disease) or typical complications of diseases in the vicinity of the orbit (e. g. orbital complications from inflammatory or tumorous sinus diseases). The diseases of the lacrimal system and the eyelids as well as their therapy are closely related to the diseases of the orbit. Basically, it can be said that the diagnosis and therapy of orbital diseases should always be carried out on an interdisciplinary basis, whereby the involvement of the ophthalmologist is of particular importance.

[Disorders of the Lacrimal Apparatus, Part 2: Basics of Therapy]. / Erkrankungen des Tränenapparats, Teil 2: Grundlagen der Therapie.

The tearing eye (epiphora) is deemed to be the leading symptome of efferent tear duct stenosis. Nevertheless, epiphora might be caused by ocular surface pathologies or even intraocular diseases. A distinguished anamnesis and sufficient clinical examination is most meaningful for the differential diagnostic distinction. Therapy is based on pathologic changes. In case of ocular surface disease, a suitable tear substitution and antiinflammatory approach is mandatory. Multifarious triggers have to be considered as well. Addressing tear film distribution, suitable oculoplastic surgery is required. Efferent tear duct stenosis necessitates surgical treatment as the level of suffering is often very high and acute exacerbations may develop. Besides recanalization, anastomosing techniques represent the available therapeutic principles. Possible surgical approaches offer a great variety and many influencing factors navigate therapy decisions. This part of the review comments on the most important therapeutic approaches for lacrimal apparatus diseases.

Electron Microscopic Features of Canalicular Concretions.

PURPOSE: The aim of this study was to examine electron microscopic features of canalicular concretions obtained from patients with canaliculiths. METHODS: Canalicular concretions were obtained from 10 patients diagnosed as canaliculiths and were immediately fixed for ultrastructural analysis. Surface structure and transmission electron microscopical sections were studied. Multiple longitudinal and transverse ultrathin sections were obtained at different levels and all were studied using standard protocols of scanning electron microscopy and transmission electron microscopy. RESULTS: Three different types of canalicular concretions were noted; predominantly coccoid and bacilloid, predominantly filamentous, and mixed varieties. The surfaces and the cut sections showed typical and distinctive features for each of the concretion types. The filamentous subtypes were common accounting for 50% (5/10) of all canalicular concretions. The surface of predominantly filamentous concretions revealed typical honeycomb patterns, the walls and base of which were formed by definitive and peculiar arrangement of Actinomyces. Transmission electron microscopy confirmed the findings of scanning electron microscopy and demonstrated typical structural features of Actinomyces and some other bacteria undergoing binary fission. The most interesting feature was the lack of immune cells and blood products within the substance of canalicular concretions as compared with the mucopeptide concretions. CONCLUSIONS: Ultrastructural features of canalicular concretions reveal 3 distinct microbial subtypes and opens up avenues toward better understanding of the etiopathogenesis of canaliculiths and possible structural resistance to host defenses or antibiotics.

[Disorders of the Lacrimal Apparatus, Part 1: Anatomy, Physiology, Diagnostics]. / Erkrankungen des Tränenapparats, Teil 1: Anatomie, Physiologie und Diagnostik.

The lacrimal apparatus is a part of the ocular adnexa preserving ocular surface homoeostasis and therefore enabling sufficiant visual functioning. Tear producting tissues, eyelids and efferent tear ducts operate as one functional unit. Pathologic changes consist of inflammatory diseases, congenital disorders, degenerations and neoplasia. Common to all these conditions is a potential impairment of the ocular integrity as well as a substantial degree of suffering for the affected patients. This review reflects basics of the anatomy, physiology, and diagnostics of the lacrimal apparatus.

[Orbital Amyloidosis - Comparison of Two Different Clinical Courses]. / Orbitale Amyloidose ­ Vergleich zweier unterschiedlicher klinischer Verläufe.

BACKGROUND: Primary localised orbital amyloidosis (PLOA) is a very rare disease. In contrast to the isolated manifestation, systemic involvement can be associated with potentially life-threatening consequences. However, the isolated involvement of the orbit can also lead to serious complications. MATERIAL AND METHODS: Two cases of PLOA are described and the necessary ophthalmic, internistic and immunohistochemical diagnostic testing are explained. RESULTS: The first case describes a 71-year-old woman with PLOA. In the clinic, a yellow-orange bumpy prominence in the nasal lower quadrant without further ophthalmological abnormalities was found. Extensive diagnostic testing found no systemic manifestation. The patient herself was free of complaints. In the follow-up over 4 years, patient showed slow progression without ocular complications. The second case is a 72-year-old male patient with similar clinical signs but localisation in the temporal superior quadrant. During the clinical course, multiple ophthalmological complications developed (ptosis, protrusio bulbi, diplopia, secondary glaucoma, perforated corneal ulcer in neurotrophic keratopathy). Perforating keratoplasty had to be performed. Fractioned radiotherapy led to stabilisation of the disease. The follow-up period was 4 years. CONCLUSION: PLOA can lead to visual and organ threatening complications. Accurate diagnosis is required for further diagnostic and therapeutic procedures and to counteract potential local and systemic complications. Interindividual differences in the course have to be considered.

[Interdisciplinary Management of Tumours of the Eyelid and Periorbital Region]. / Interdisziplinäres Management von Tumoren der Lid- und Periorbitalregion.

INTRODUCTION: Skin malignancies are typically localised in areas of the head that are exposed to the sun. Basal cell carcinomas (BCC) are the most frequent malignancies on the facial skin. Their incidence is raising - due to demographic changes. As regards strategies for resection and reconstruction, the eyelids and the periorbital region are extremely complex and have to be treated in an interdisciplinary context. The aim of the present investigation was to analyse the results of interdisciplinary treatment of periorbital and eyelid non-melanotic malignoma. MATERIALS AND METHODS: All treated non-melanotic malignancies of the eyelid/periorbital region were analysed in a pilot study from September 2017 until July 2019. Patients were treated by an ophthalmologist and a maxillofacial plastic surgeon. The clinical and pathological parameters were collected in a databank. In all interdisciplinary cases, the tumour localisation, histology, R-status and the reconstructive strategy were analysed. RESULTS: Out of 349 patients, 14 were analysed as they were treated with an interdisciplinary approach. The youngest was 12, the oldest 98 years old. There were 6 women (average age 80.3 years) and 8 men (average age 65.3 years). BCC (n = 10) were the most frequent malignancy; 3 patients suffered from squamous cell carcinoma. Actinic keratosis was diagnosed in one case. In all patients, complete resection (R0) was certified by histopathological examination. The reconstruction was performed immediately in 6 cases, and the reconstruction strategy was accomplished after definitive histology (at least two step procedures) in 8 cases. Only one patient had three resections before starting the reconstruction procedure. DISCUSSION: Surgical treatment of malignancies of the eyelid or periorbital non-melanotic malignancies can be an interdisciplinary challenge. BCC is the most frequent entity. These critically localised BCC present with extremely deep infiltration, followed by subtotal or total eyelid resection, often including bony structures. The reconstruction is extremely complex in such cases and requires the whole plastic reconstructive repertoire of both medical disciplines.

Lower eyelid ectropion as a sequela of different underlying diseases in maxillo-facial surgery: Diagnostics and treatment approaches.

PURPOSE: This study investigated the outcome of lower eyelid ectropion (LEE) treatment in patients with another primary periorbital or mid-facial pathology. MATERIALS AND METHODS: This 18-year monocentric retrospective cohort study included patients admitted for various leading mid-facial pathologies and presenting with a LEE. The primary diagnosis, surgical pretreatment, ectropion type, ectropion severity score (ESS), and surgical techniques were recorded. The primary endpoint was the postoperative ESS score. RESULTS: Overall, 40 patients (female n = 16, male n = 24, average age 70.8 years), primarily with periorbital skin cancer (n = 21, 52.5%), facial palsy (n = 7, 17%), trauma (n = 6, 15%), or other pathologies (n = 6, 15%), were included. Surgical procedures mostly addressed a correction of anterior and posterior lamellae (n = 22, 55%), with isolated anterior lamellae in only a few cases (n = 10, 25%). The ESS score significantly decreased from 4.8 ± 1.8 to 1.3 ± 1.3 (paired t-test, p < 0.001) after a mean follow-up of 23.8 months. CONCLUSION: LEE constitutes a relevant problem. Due to preexisting canthal ligament laxity in patients undergoing oncologic or traumatic midface surgery, the risk of ectropion has so far been underestimated. Bilamellar approaches in elderly patients are likely to be obligatory in any case.

Immunohistochemical Analysis of the Lacrimal Sac Mucopeptide Concretions.

PURPOSE: To investigate the presence and distribution patterns of proteins in the lacrimal sac mucopeptide concretions. METHODS: The study was performed on 10 mucopeptide concretions obtained from the lacrimal sac during an endoscopic dacryocystorhinostomy. Immunohistochemical labeling was performed for assessing the presence and distribution of von Willebrand factor, fibronectin, collagen I, collagen III, human beta-defensin 2, beta-defensin 3, lysozyme, prolactin, cytokeratin (CK)-CK4, CK7, CK18, immunoglobulin M (IgM), immunoglobulin G (IgG), psoriasin (S100-A7), and migration inhibitory factor-related protein (MRP14/S100-A9). The results were then scored as positive or negative and the distribution pattern, if any, within the sectioned concretions was assessed. RESULTS: Immunohistochemical labeling was strongly positive for von Willebrand factor and fibronectin in the core areas of the concretions. Collagen I was widely dispersed both in the peripheral and core areas whereas collagen III was mostly limited to only few areas of the core. Strong immunoreactivity was noted for lysozyme, which was abundantly distributed, whereas prolactin receptors were positive on the surface and also the dispersed cells within the concretion matrices. Very few peripheral areas of concretions showed MRP14 or S100-A9 positivity in a noncontiguous fashion. Immunoreactivity was uniformly negative for CK-18, IgM, IgG, and psoriasin. CONCLUSIONS: The presence of fibronectin and von Willebrand factor in the core of the concretions strengthens the earlier hypothesis that blood components may act as a nidus for subsequent mucopeptide deposition. The study also provides possible clues to the lacrimal defenses mounted during dacryolithiasis.Fibronectin and vWF are present in the core of the dacryoliths. Blood components may act as a nidus in the evolution of lacrimal sac mucopeptide concretions.

[Periocular metastasis as differential diagnosis of pyogenic granuloma and therapeutic marker of a systemic disease]. / Periokuläre Metastase als Differenzialdiagnose eines "pyogenen Granuloms" und Therapiemarker einer Systemerkrankung.

BACKGROUND: A pyogenic granuloma is a frequent palpebral pseudotumor. Showing a typical clinical picture after an inflammation (hordeolum, chalazion) it can be easily diagnosed and sometimes a histopathological analysis is thought to be unnecessary. METHODS: A case report of a patient suffering from a palpebral metastasis of a clear cell renal cell carcinoma (cRCC) as an atypical differential diagnosis of an inflammatory pseudotumor of the eyelid is presented. RESULTS: A 72-year-old man presented for surgical treatment of a pyogenic granuloma. The medial portion of the inferior eyelid showed a nodular and pediculate lesion of the tarsal conjunctiva. At the time of presentation the patient was receiving adjuvant systemic treatment with cabozantinib because of lymphonodal and pulmonal metastases of the cRCC. The tumor was resected and the histopathological examination revealed a sarcomatoid dedifferentiated metastasis of the cRCC. After 4 weeks the tumor showed a local recurrence and histologically a local relapse was found. Therefore, a change in the systemic therapy was initiated (nivolumab). In the follow-up of 18 months no recurrence of the palpebral tumor occurred. A stable disease condition of the cRCC was achieved. CONCLUSION: Even if the clinical aspect of an inflammatory tumor of the lids seems to be clear, a histopathological examination is still necessary. An interdisciplinary approach with reevaluation of the systemic therapy led to an improvement of the patient treatment.

[Laser membranotomy of acute subhyaloidal hemorrhage after indirect ocular trauma]. / Lasermembranotomie bei akuter subhyaloidaler Blutung nach indirektem Bulbustrauma.

INTRODUCTION: Subhyaloidal premacular hemorrhage (SPH) causes a painless acute loss of vision with central scotoma. Typically, it can be caused by vascular retinal diseases or in the context of a Valsalva retinopathy. Ocular trauma is a less common cause of SPH. METHODS: This case report describes a 54-year-old male who presented with a painless decrease of vision in the left eye after blunt frontal trauma to the forehead during a car accident. RESULTS: A car accident resulted in an abrupt deceleration of the head by hitting the windscreen. There was no direct trauma to the eyes. The initial visual acuity of the affected left eye was 0.1 and the visual acuity of the right eye was 1.0. Funduscopy verified an incomplete detachment of the posterior vitreous body with rupture of a retinal venous vessel of the temporal upper vascular arch and prominent SPH. Furthermore, a cystoid macular edema was detected. For internal drainage a neodymium-doped yttrium aluminium garnet (Nd:YAG) laser membranotomy of the posterior vitreous body was performed 1 day after the trauma. On the first postoperative day visual acuity increased to 0.32 with a complete resolution of the macular edema. During the follow-up, visual acuity was 1.0 after 3 months and 1.25 after 6 months. CONCLUSION: Acceleration and subsequent deceleration can result in a relevant transfer of force to the vitreoretinal interface as an indirect trauma. The Nd:YAG laser membranotomy is a minimally invasive treatment option for SPH after indirect ocular trauma.

[Dacryoendoscopic Surgery-Factors Influencing Postoperative Results]. / Dakryoendoskopische Tränenwegschirurgie ­ Einflussfaktoren auf das postoperative Ergebnis.

BACKGROUND: Dacryoendoscopy (DE) is an established method in lacrimal surgery. Long-term follow-up-analyses of this surgery are of great interest. Here, factors influencing postoperative success rates should be considered to elect suitable patients. METHODS: In this retrospective study, patients having had dacryoendoscopic surgery were included. Using a questionnaire, a prospective follow-up analysis was made. Pre- and intraoperative factors were correlated with treatment success, which was defined as improved epiphora, absence of a second lacrimal surgery and no signs of chronic dacryocystitis (secretion, pain at the lacrimal sac). Additionally, we asked for patient's satisfaction with the postoperative result (categorized in "very good", "good", "poor", and "bad"). RESULTS: Overall, 215 DE of 182 patients (130 women, 52 men) were studied. Mean patient age was 58 ± 17 years (range: 18 to 91 years). Follow-up was 31 to 77 months (median: 55 months). Treatment success after this time was 59.1%, in which neither patient's age nor sex showed significant influences. In comparison to complete stenosis, incomplete obstruction could be treated successfully twice as often (p = 0.02). Patients suffering from ectatic lacrimal sacs had a risk of 1.9 for failing therapy (p = 0.01). A trend concerning worse cure rates could be observed in patients with postsaccal localization of stenosis (p = 0.2) and an age of older than 49 years (p = 0.1). Surgical results evaluated by the patients were "very good" in 32.1% and "good" in 30.2%. CONCLUSION: Dacryoendoscopy with its minimally invasive approach is suitable as a first-step procedure in lacrimal surgery. The absence of a scar and the quick recovery are vitally important for the patients. Medically important is that the topographic anatomy is preserved by using dacryoendoscopy, so other surgical techniques can be performed later without limitations, if necessary. Patients with incomplete obstructions and a localization of stenosis, being pre- to intrasaccal, profit from this treatment method in particular.

Anatomic landmarks in lacrimal surgery from an ophthalmologist's point of view: Clinical findings of external dacryocystorhinostomy and dacryoendoscopy.

Epiphora is a common clinical symptom of nasolacrimal duct obstruction. However, it is present in several pathologies and can lead to decreased quality of life for patients. A careful clinical examination including a detailed patient's history and diagnostic tests such as the fluorescein dye disappearance test and diagnostic syringing of the lacrimal duct are essential. Depending on the time of presentation (congenital, primary, or secondary acquired), grade (subtotal or total) and location of the stenosis, different surgical approaches can be considered. These are subdivided into minimally invasive (transcanalicular) and anastomosing (dacryocystorhinostomy) procedures. Furthermore, the anatomical landmarks and the site of surgical intervention differentiate the surgical techniques into endoscopic or transcutaneous. Modern intubation techniques offer a large spectrum of therapeutic possibilities enabling patient care to be customized and individualized. Knowledge of the topographical anatomy is crucial for achieving greater success and a lower complication rate. Clin. Anat. 30:1034-1042, 2017. © 2017 Wiley Periodicals, Inc.