Endocanalicular laser dacryocystorhinostomy with mucosal flaps.

PURPOSE: To describe the technique of endocanalicular laser dacryocystorhinostomy with mucosal flap creation and to report the outcomes of this technique. METHODS: Prospective noncomparative case series of 7 patients with primary acquired nasolacrimal duct obstruction undergoing endocanalicular laser dacryocystorhinostomy with mucosal flap. The mucosal flap was created using an endoscopic endonasal approach. An endocanalicular approach was used to fashion the lacrimal sac opening and the osteotomy of the lacrimal sac fossa. RESULTS: Nine procedures were performed in 7 female patients. Average patient age was 68±15 years. Intraoperative complications included bleeding during the creation of the mucosal flap in 1 patient. The procedure was associated with no pain to moderate pain in all cases. Anatomical success was achieved in 89% of procedures and symptomatic relief was achieved in 89% of surgeries for an average follow up of 10 ± 5 months. Only 1 patient required an external dacryocystorhinostomy revision because of postoperative restenosis. CONCLUSIONS: Endocanalicular laser dacryocystorhinostomy provides a minimally invasive approach to epiphora with a good success rate. The addition of a nasal mucosal flap to this technique may aid in proper fistulization and should be studied in larger prospective trials.

Acute orbital inflammatory syndrome secondary to an ANCA-positive small-vessel vasculitis: a case report and review of the literature.

A 61-year-old man presents with sequential painful bilateral proptosis within 36 h and orbital compartment syndrome resulting in complete loss of vision bilaterally. Sequential urgent lateral canthotomy and cantholysis were performed to reverse the compartment syndrome. Orbital imaging showed non-specific orbital inflammation. Biopsies showed necrotizing inflammation and bloodwork was positive for c-ANCA. The patient was therefore treated with prednisone and cyclophosphomide and showed good recovery of vision in one eye, and had no recurrence of orbital inflammation. ANCA-associated orbital vasculitides are rare, but must be kept in mind in the differential diagnosis of acute orbital inflammatory syndromes.

Guidelines for vismodegib in the management of periocular basal cell carcinoma.

OBJECTIVE: The management of advanced basal cell carcinoma (BCC) in the periocular region remains a clinical challenge. Vismodegib (ErivedgeTM) has been approved in 2013 by Health Canada for adult patients with "histologically confirmed metastatic BCC or locally advanced BCC inappropriate for surgery or radiation." An expert consensus was sought to create a standardised approach in the use of this novel treatment. METHODS: Fourteen practicing oculoplastic surgeons across Canada were involved in formulating and reviewing guidelines until consensus was reached. A consultancy meeting was followed by further ratification of guidelines over email. Two voting surveys were performed of the group to objectively assess agreement over each statement within the guidelines. Ratification continued until at least two-thirds of the group agreed on every guideline statement. RESULTS: The guidelines summarize 21 statements in a major and minor criteria format. A multidisciplinary team review is suggested for each patient with the involvement of recommended specialists. The internal survey revealed 100% agreement over 9 statements, 91.7% agreement over 8 statements, 83.3% agreement over 4 statements, and 2 statements had 66.7% and 58.7% agreement each. All statements with less than 91.7% agreement were surveyed again, and they were kept, modified, or removed on the basis of a consensus of over 66.7%. CONCLUSIONS: These guidelines serve to act as a framework for physicians considering vismodegib for the medical management of patients with advanced or metastatic periocular BCC. Future applications, including neoadjuvant uses of the drug, may become apparent through further research.

Eye Popping Disease: Common Characteristics and Management of Spontaneous Globe Subluxation.

PURPOSE: The objective of this study was to describe the clinical features, predisposing factors, and management of 8 new cases of spontaneous globe subluxation (SGS) and provide a review of the relevant literature. DESIGN: Patient demographics, clinical presentations, investigations, management, complications, and outcomes were measured. METHODS: This was a retrospective, case-note analysis of 8 patients with SGS and a major review of the English-language literature. RESULTS: Eight new cases of spontaneous globe subluxation were identified with varying clinical manifestations and treatments. Literature review has shown less than 50 cases. Space-occupying lesions such as thyroid eye disease, shallow orbits, and floppy eyelids were major contributors to predisposition to SGS. CONCLUSIONS: Orbital congestion, shallow orbits, and floppy eyelids can all play a role in predisposing patients to SGS. Successful surgical management of SGS, when required, should be tailored to the individual patient profile for best results.