An individualized approach to orbital decompression in Graves' orbitopathy.

With better understanding of the various techniques available for orbital decompression, the indications for surgical decompression in Graves' orbitopathy are now less rigid. Decompressions may be performed for (1) prolonged orbital congestion and pain, (2) orbital problems resistant to steroid treatment, (3) orbital problems where there have been steroid complications, (4) severe corneal exposure that cannot be treated with lid-lengthening surgery, and (5) the standard indication--Graves' optic neuropathy. Assessment of muscle size by computed tomographic scanning and ultrasound, as well as the measurement of orbital pressure, are important advances in the assessment of these patients. The lateral approach produces less strabismus and allows for exophthalmos reduction, especially if fascia temporalis is incised and if part of that muscle is removed. The inferomedial approach is advisable in patients with severe posterior optic neuropathy caused by apical crowding of the enlarged muscles, particularly the medial rectus. The two approaches may be combined in severe cases.

Canaliculodacryocystorhinostomy in the management of unsuccessful lacrimal surgery.

Previously, the standard procedure in the treatment of patients having had unsuccessful lacrimal surgery has been Jones tube bypass, regardless of the anatomic site of obstruction. However, many of these patients may be treated by a reconstructive approach, namely, the canaliculodacryocystorhinostomy operation. Dacryocystography is helpful in determining which of these patients are amenable to this treatment modality. Success rates are encouraging and eliminate the necessity of a permanent prosthesis and long-term follow-up.

Canaliculodacryocystorhinostomy in the treatment of canalicular obstruction.

Epiphora secondary to canalicular obstruction has been a perplexing problem most often treated with Jones' tube bypass surgery, which necessitates a permanent prosthesis and long-term follow-up. There are certain cases in which these problems may be avoided by using an alternative surgical approach. The canaliculodacryocystorhinostomy, a microsurgery technique, reconstructs rather than bypasses the physiological system. We recommend this procedure in all cases of lateral common canalicular obstruction and upper and lower canalicular obstruction with greater than 8 mm of patency.

A spindle-cell myoepithelioma of the lacrimal gland.

A middle-aged woman developed unilateral, painless proptosis that increased slowly over 1 year. A clinical diagnosis of pleomorphic adenoma of the lacrimal gland was supported by computed tomographic scanning and the tumor was excised. On histological examination the tumor proved to be a benign, myxoid myoepithelioma of spindle-cell type. Although occasionally seen in the salivary glands, to our knowledge, this tumor has not previously been described in the lacrimal gland.

Mechanism of tear flow after dacryocystorhinostomy and Jones' tube surgery.

In the 42 patients (84 eyes) in this study, 32 eyes had dacryocystorhinostomy (DCR), 15 had Jones' tube insertions, and the remaining 37 were considered controls. All patients were studied using nuclear scanning with computer interfacing quantitative lacrimal scintillography to determine the effects of blinking, respiration, and gravity on their functioning. Tears flowed through DCR openings faster than through the systems of normal patients. Patients with Jones' tubes demonstrated slower flow than in normal patients. The effect of respiration on tear flow was minimal, but blinking and lid function were important. Patients with eyelid laxity may show decreased flow even if the DCR and Jones' tubes are functional.

Lacrimal scintillography: advances and functional applications.

The more precise evaluation of excretory function of the lacrimal system was made possible in 1972 with the advent of lacrimal scintillography. Two significant recent advances involving the computerization of scanning are presented. Rapid sequence display, a qualitative, dynamic method of viewing excretory function, and immediately available quantitative computerized T-1/2 values improve the interpretive abilities of lacrimal scintillography. Various clinical entities investigated in this manner have been studied with dacryocystography, and anatomical exam, to confirm scintillography's ability in identifying functional pathology. We have been able to virtually eliminate false results and we recommend its use in selected lacrimal excretory investigation.

Ultrasound biomicroscopy in the assessment of anterior scleral disease.

High-frequency ultrasound biomicroscopy is a new method of examining subsurface anterior segment structures of the eye at microscopic resolution. The sclera has a high internal reflectivity and can be differentiated from the cornea, and overlying and underlying tissue. Using this modality, we examined 18 patients with various manifestations of scleral disease. Localized anterior staphyloma could be differentiated from other causes of a black spot on the scleral surface. Episcleral thickening could be differentiated from involvement of the sclera itself. Different patterns of scleral involvement could be imaged including diffuse low-reflective mottling, low-reflective nodules extending into the scleral substance, and scleral thinning. Scleral thinning could be assessed and quantified. Underlying changes in the vitreous could be detected. Ultrasound biomicroscopy was a useful adjunct to clinical examination in the assessment of anterior scleral disease.

Radiography in functional lacrimal testing.

A functional study of the lacrimal drainage apparatus was made in 25 patients. Angiographin was instilled into the conjunctival sac and serial radiographs were taken. The films were interpreted in conjunction with the intubation macro-dacryocystograms. Although this is a useful procedure, the use of angiographin compares unfavourably with ultra-fluid Lipiodol in a similar procedure.

Quantitative lacrimal scintillography. I. Method and physiological application.

Quantitative lacrimal scintillography, using 99mTc sulphur colloid, a high resolution gamma camera, and quantification using a digital computer, is a highly effective way of assessing lacrimal physiology, and of establishing normal flow and drainage values against which pathological cases may be compared.

Quantitative lacrimal scintillography. II. Lacrimal pathology.

Quantitative lacrimal scintillography is a useful clinical procedure in assessing lacrimal drainage function in patients with epiphora. Examples are presented of patients with canalicular disease, lid abnormalities, 'functional blocks', and dysthroid disease, in which this technique was valuable. Information regarding the dynamics of a functioning and non-functioning dacryocystorhinostomy is elucidated with quantitative scintillography.

Orbital cyst of lacrimal sac derivation.

Orbital cyst from lacrimal sac epithelium is rare and thought to originate from diverticulum of the lacrimal sac. The cyst may have direct communication with the sac, or the two structures may be anatomically separate. Since these lesions most commonly present as a medial canthal mass, the differential diagnosis should include other disorders that may cause a mass in this region. A 42 year old woman presented with a two-year history of a mass in the right medial canthal region. Nasolacrimal system was patent on irrigation. Sophisticated radiological investigation utilizing dacryocystography and computed tomography combined with dacryocystography accurately localized the lesion and demonstrated its relationship to the nasolacrimal system. This tremendously facilitated surgical removal. The lesion was excised completely via anterior orbitotomy and submitted for histopathologic examination. Haematoxylin-eosin stains revealed a cystic cavity lined by pseudostratified columnar and cuboidal epithelium with interspersed goblet cells consistent with a cyst derived from lacrimal sac epithelium, located separately, but in close proximity to the lacrimal sac. The Authors present a patient with a mass in the righ medial canthal area histologically diagnosed as an orbital cyst of lacrimal sac epithelium derivation. Sophisticated radiological lacrimal investigation helps in detection, localization and in planning surgery.

Failed dacryocystorhinostomy in Paget's disease.

We describe a patient with bony closure of a DCR due to monostotic Paget's disease. The condition may exist without biochemical, radiological or radioisotope changes. The abnormal bone must be removed and a Jones glass tube placed in the rhinostomy.

Recent advances the investigation of proptosis.

Clincal assessment of the patient presenting with proptosis determines the investigations required to make the diagnosis.

Senile entropion: the importance of eyelid laxity.

In senile entropion preoperative assessment of eyelid laxity will determine whether the condition is primarily due to increased horizontal lid laxity or to disinsertion of the retractors of the lower lid, with subsequent superior migration of the orbicularis. With increased horizontal lid laxity the lid must be surgically tightened. If such laxity is not present, an operation directed at the orbicularis or at the retractors of the lower lid is advisable. This approach had an initial success rate of 97% in a series of 75 new cases and 15 cases referred for reoperation; a second operation was successful in two of the three instances of primary failure.

Tests of thyroid function important to the ophthalmologist.

The most useful tests to establish a diagnosis of endocrine exophthalmos are the following: To prove that thyroid gland activity is increased: serum T3 and T4 assays. To demonstrate immunologic abnormalities: thyroid antibody testing and the TDA test. To demonstrate an abnormal hypothalamic-pituitary-thyroid axis: the TRH test. To demonstrate enlarged ocular muscles: orbital ultrasonography and computerized tomography.

Treatment of canalicular obstructions.

Canalicular obstructions are difficult to manage. Dacryocystography helps to localize the site of obstruction. The surgical procedures used for different conditions are described in this paper. The aim of surgery is to re-establish a patent and functional mucosa-lined channel; only when this cannot be done should the canalicular system be bypassed.

New polypropylene tube to stent or bypass the lacrimal system.

A tube made of polypropylene has been used both as a stent after canalicular reconstruction or repair and as a bypass device to drain tears when the canaliculi have been destroyed. The tube comes in different sizes, can be cut to any length, can be bent to any shape and can easily be flanged at the nasal end by the surgeon. The tube has good capillarity and drains well. There is enough tissue reaction around it so that it will not extrude, yet when it is used as a stent it can easily be removed.

Congenital abnormalities of lacrimal drainage: management of difficult cases.

Various congenital anomalies of the lacrimal drainage system are described against the background of normal development and their effective management is outlined.

Lacrimal canaliculoscopy: development of the instrument.

We have developed an endoscopic device for use in the lacrimal drainage system. The device employs a flexible, small-calibre fibreoptic cable that can easily negotiate the canalicular system. The device can be used in conjunction with a video camera and monitor for simultaneous viewing. The endoscope can be used alone for the diagnosis of lacrimal disorders. Possible future applications include laser treatment of lacrimal disorders.

Management of acquired dacryocystitis.

Acquired dacryocystitis that has its onset after the first year of life is due to fibrotic obstruction within the lacrimal drainage pathways that is usually secondary to trauma or infection. Staphylococcus aureus is the most common pathogen, but attempts should be made to express or aspirate material from the lacrimal sac for culture and antibiotic sensitivity testing. When the strain is resistant to penicillin or when a culture specimen is not obtainable, cloxacillin is the antibiotic of choice. The timing of application of hot compresses is important so that the swelling can be localized to the sac but perforation will not be induced. Once the inflammation has resolved, dacryocystorhinostomy may be needed to drain residual fluid. Dacryocystography is useful to indicate whether there is persistent obstruction or stenosis; if the results are normal but symptoms persist, scintiscanning may demonstrate a delay of tear flow out of the sac or may reveal a stone.