Dacryocystorhinostomy for Acquired Nasolacrimal Duct Stenosis in the Elderly (≥80 Years of Age).

PURPOSE: The incidence of acquired nasolacrimal duct obstruction (NLDO) increases with age. Dacryocystorhinostomy, the definitive treatment for NLDO, has a high success rate (80%-100%) with a low complication rate (1%-6%), but surgical outcomes have not been reported previously specifically for an elderly population, in which there may be increased risk for intraoperative and postoperative complications. The purpose of this study was to examine surgical outcomes and complication rates of dacryocystorhinostomy in an elderly population. DESIGN: Retrospective cohort study. PARTICIPANTS: Patients 80 years of age or older undergoing external dacryocystorhinostomy at the Mayo Clinic between January 1, 1990, and December 31, 2010, were compared with a matched control group of younger patients (40-79 years of age) undergoing external dacryocystorhinostomy by the same surgeons. METHODS: We reviewed the medical charts for patients as described above. Data abstracted from patient medical records included symptomatic relief and complications such as tube protrusion, infection, persistent bleeding, and return to operating room. Statistical analysis included a 2-sample t test to compare continuous variables, chi-square testing for categorical comparisons, and the generalized estimating equation model to control for nonindependence. MAIN OUTCOME MEASURES: Primary end point was symptomatic improvement at last follow-up. Secondary end points included anatomic patency, adverse event rate, and return to operating room within 1 month of surgery. RESULTS: Forty-two dacryocystorhinostomies (32 patients) were performed in the elderly group. The control group comprised 73 dacryocystorhinostomies in 63 patients. Resolution of symptom rate at last follow-up was 64% in the elderly group versus 86% in the younger cohort (P = 0.02). Although there was no difference between groups with respect to common postoperative complications, there was a higher rate of predefined serious complications in the elderly group (5 events vs. 1 event; P = 0.01). There was no difference between groups regarding need for additional eyelid surgery (P = 0.30). CONCLUSIONS: Although most elderly patients experience symptom resolution after dacryocystorhinostomy, the rate of symptom resolution was lower than that of younger patients. The risk of routine complications was similar between the groups. The risk of serious complications was higher in the elderly group.

Comparison of automated and manual perimetry in patients with blepharoptosis.

PURPOSE: To compare Goldmann manual perimetry and Humphrey automated perimetry for sensitivity in detecting visual field loss, efficiency, and patient preference. METHODS: This prospective study compared Goldmann manual perimetry and Humphrey automated perimetry testing techniques in 20 consecutive preoperative blepharoptosis patients with unilateral or bilateral blepharoptosis with a marginal reflex distance of ≤+2.5 mm, no dermatochalasis overhanging the eyelid margin, and no superior visual field defects due to glaucoma, neurologic disease, or other causes. Main outcome measures included efficiency, patient preference, and sensitivity in detecting visual field loss. Institutional review board approval was obtained prior to the start of the study. RESULTS: Goldmann perimetry had significantly shorter examination times (-Δ6.4 minutes, 95% confidence interval: 4.5-8.3, p < 0.001) and was preferred by most patients (70%). There was no statistically significant difference between the 2 techniques in detecting superior visual field loss at 90° meridian. CONCLUSIONS: Goldmann manual perimetry for assessing visual field loss in blepharoptosis patients is more efficient than Humphrey automated perimetry and is preferred by patients. Both techniques are sensitive in detecting ptosis-related visual field loss.

A rabbit model of lower eyelid fibrosis.

PURPOSE: To create and validate a new model of lower eyelid fibrosis in Dutch-belted rabbits. METHODS: Five Dutch-belted rabbits were injected with a transcutaneous 1-ml injection of standard 95% ethanol alcohol just inferior to the eyelid margin of one lower eyelid. A control injection of 1 ml of balanced saline solution was given to the opposite eyelid. A small tattoo was placed on the skin overlying the inferior orbital rim and used as a measuring point of reference in relation to the lower eyelid margin. Analysis was twofold: eyelid measurements were made over 8 weeks to determine the presence of eyelid shortening, and a histopathologic analysis was performed. RESULTS: Mean lower eyelid shortening was greater in the ethanol alcohol intervention eyelids than the control group (-3.4 mm +/- 1.67 mm vs. 0.5 mm +/- 0.71 mm, p = 0.01). Histopathologic analysis revealed extensive fibrosis in the ethanol alcohol invention eyelids compared with the control group. CONCLUSIONS: Ethanol alcohol induces eyelid fibrosis and lower eyelid shortening. This may be a useful model in the future testing of novel surgical or pharmacologic treatments.

Transcanalicular approach to adult lacrimal duct obstruction: a review of instruments and methods.

Developments in fiberoptic technology and increasing interest in minimally invasive surgery have fueled advances in transcanalicular surgery. This article presents a review of instruments and methods for diagnostic and therapeutic approaches to adult lacrimal drainage obstruction. Available endocanalicular probes, microendoscopes, lasers, microdrills, trephines, and antegrade lacrimal balloon catheters are discussed and compared. Developments in microendoscopy, laser transcanalicular dacryocystorhinostomy, laser canaliculoplasty, transcanalicular drilling and trephination, and transcanalicular balloon dacryoplasty are also discussed in detail. Transcanalicular surgery provides a minimally invasive approach to adult lacrimal drainage obstruction that may also address the pathology causing the obstruction. Long-term success rates of transcanalicular dacryocystorhinostomy appear to be improving, but cost and a paucity of data on long-term results continue to limit the use of transcanalicular surgery.

Rhino-orbital-cerebral mucormycosis: a lethal complication of body dysmorphic disorder.

Young diabetics can sometimes have difficulty with insulin compliance for various reasons. This can be exacerbated if associated with body dysmorphic disorder or other eating disorders. The manipulation of insulin to lose weight can have devastating consequences. The authors describe a fatal case of rhino-orbital-cerebral mucormycosis secondary to insulin manipulation for the purpose of weight loss.

Orbital radiation for graves ophthalmopathy: a report by the American Academy of Ophthalmology.

OBJECTIVE: To investigate whether orbital radiation offers effective and safe treatment for Graves ophthalmopathy. METHODS: Medical literature databases were searched to identify all published reports relating to orbital radiation treatment for Graves ophthalmopathy. To be included in the technology assessment, reports had to provide original data, to report on a case series or uncontrolled trial of at least 100 subjects or a randomized clinical trial of any size, to focus on orbital radiation for the treatment of Graves ophthalmopathy, and to follow-up patients for at least 3 months. Abstracted data included study characteristics, patient characteristics, treatment response, and safety information. RESULTS: Fourteen studies were included in the technology assessment: 5 observational studies and 9 randomized controlled trials. Three of the observational studies report on treatment response, with overall favorable outcomes for 40% to 97% of patients. Three of the observational studies provided intermediate-term safety data. The risk of definite radiation retinopathy is 1% to 2% within 10 years after treatment. Patients treated with orbital radiation did not have an increased risk of secondary malignancy or premature death. The 9 randomized trials were qualitatively heterogeneous. Patients with optic neuropathy generally were excluded from participating in the randomized trials. Three of the randomized trials were sham controlled. None of these studies showed that orbital radiation was more efficacious than sham irradiation for improving proptosis, lid fissure, or soft tissue changes such as eyelid swelling. Two of the 3 sham-controlled randomized trials demonstrated improved vertical range of motion in radiation-treated subjects compared with controls. CONCLUSIONS: Systematic review of the effect of orbital radiation on Graves ophthalmopathy is limited by the lack of standardization and variable quality of published reports. Extraocular motility impairment may improve with radiotherapy, although the evidence of a treatment effect is mixed in clinical trials. Future studies are needed to determine if a potentially beneficial motility effect results in improved patient function and quality of life. Level I evidence indicates that proptosis, eyelid retraction, and soft tissue changes do not improve with radiation treatment. The efficacy of orbital radiation for compressive optic neuropathy resulting from Graves ophthalmopathy has not been investigated in clinical trials and merits further study. Radiation retinopathy, although rare, is a risk of orbital radiation, even in patients without diabetes who receive appropriate radiation dose and delivery.

Randomized, double-blind, placebo-controlled trial of long-acting release octreotide for treatment of Graves' ophthalmopathy.

CONTEXT: Despite a strong rationale for trials of somatostatin analogs in the treatment of Graves' ophthalmopathy (GO), recent studies have provided conflicting results. OBJECTIVE: The objective of the study was to determine whether octreotide long-acting release (LAR) is effective treatment for active GO. DESIGN: This was a prospective, randomized, double-blind, placebo-controlled study. SETTING: The setting was a single tertiary referral center. PATIENTS: Twenty-nine consecutive euthyroid patients with active GO [clinical activity score (CAS) >or= 3] were enrolled; 25 completed the study. INTERVENTION: Patients received four monthly doses of either octreotide LAR (20 mg) or saline by im injections. MAIN OUTCOME MEASURES: Primary measure was a change in CAS; the secondary measure was changes in retrobulbar tissue volume, proptosis, lid fissure width, range of motion, and diplopia fields. RESULTS: Median (range) CAS change was 2.5 (1, 5) in the treatment and 1.0 (0, 7) in the placebo group (P = 0.02). Median lid fissure width improved in the treatment group, (decreased 1 mm on the right and 0.5 mm on the left), compared with the placebo group (no change on the right, P < 0.01; increased 1 mm on the left, P < 0.01). No other significant differences between groups were identified. CONCLUSIONS: CAS improved to a greater extent in octreotide-LAR-treated patients than the control group. However, this finding may not represent clinical benefit because patients with higher baseline CAS were overrepresented in the treatment group, and the control group was small. In contrast, treatment-related improvement in eyelid fissure width was noted, suggesting that octreotide LAR may be useful in the treatment of a subgroup of active GO patients with significant lid retraction.

Localized orbital amyloidosis involving the lacrimal sac and nasolacrimal duct.

PURPOSE: To report the case of a 70-year-old man who presented with tearing in his left eye and a firm palpable lump in the area overlying his left lacrimal sac. DESIGN: Retrospective interventional case report. METHODS: Noninvasive diagnostic evaluation followed by external dacryocystorhinostomy, histopathologic studies, and systemic evaluation. RESULTS: The patient was found to have idiopathic localized amyloidosis limited to the lacrimal sac and nasolacrimal duct. CONCLUSION: The localized form of amyloidosis is rare, typically involves the head and neck without systemic manifestations, and carries an excellent prognosis. Previous reports of orbital amyloidosis have described involvement of the lacrimal gland, extraocular muscles, and the cranial nerves. To our knowledge, this is the first report of a patient with nasolacrimal duct obstruction secondary to amyloid deposition in the lacrimal sac and fossa.

Evaluation of the National Eye Institute visual function questionnaire in Graves' ophthalmopathy.

PURPOSE: To determine the potential suitability of the 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25) for measuring health-related quality of life (HRQL) in patients with Graves' ophthalmopathy. DESIGN: Cross-sectional study. PARTICIPANTS: Thirty adult patients with mild to severe Graves' ophthalmopathy. METHODS: Participants self-administered the NEI VFQ-25 and completed a semistructured interview to provide feedback about the questionnaire. The percentage of responses at the maximum and minimum value was calculated to assess ceiling and floor effects, respectively, for the 12 subscales of the NEI VFQ-25. The NEI VFQ-25 scores were compared for Graves' ophthalmopathy patients who reported symptomatic diplopia and those who did not report diplopia using univariate and multivariate linear regression models. MAIN OUTCOME MEASURES: The NEI VFQ-25 subscale and composite scores. RESULTS: Health-related quality of life in those with Graves' ophthalmopathy was moderately impaired, with median composite score of 69. The greatest impairment was measured in the Mental Health (median, 50) and the Role Difficulties (median, 50) subscales. Significant ceiling effects were seen in 7 of the 12 subscales. More than two thirds of Graves' ophthalmopathy patients perceived that the NEI VFQ-25 lacked items relevant to their disease. The NEI VFQ-25 scores were lower for those with diplopia symptoms (composite score, 61) compared with those without diplopia (composite score, 90). Comparing these 2 groups, the largest differences were measured in the Driving and Peripheral Vision subscales. CONCLUSIONS: The NEI VFQ-25 includes many items that are applicable to Graves' ophthalmopathy patients. However, it shows significant ceiling effects in more than half of the subscales and it lacks items on issues that are important to Graves' ophthalmopathy patients, such as altered appearance and ocular discomfort. Efforts to develop an HRQL instrument that adds Graves' ophthalmopathy-specific items to relevant aspects of the NEI VFQ-25 are warranted.

Prevalence of floppy eyelid syndrome in obstructive sleep apnea-hypopnea syndrome.

OBJECTIVES: To determine the prevalence of floppy eyelid syndrome (FES) in obstructive sleep apnea-hypopnea syndrome (OSAHS) and to develop a method to measure eyelid laxity. DESIGN: Masked cross-sectional (prevalence) study examining patients referred to the Mayo Sleep Disorders Center. PARTICIPANTS AND/OR CONTROLS: Fifty-nine subjects were examined before undergoing polysomnography. Forty-four subjects had OSAHS, and 15 did not have it. TESTING: Subjects underwent slit-lamp examination and eyelid laxity measurements, followed by polysomnography. MAIN OUTCOME MEASURES: Presence of FES as defined by subjectively easy eyelid eversion, tarsal papillary conjunctivitis, and lash ptosis; force required to displace the upper lid 5 mm, as measured by a strain gauge device; number of apnea or hypopnea episodes per hour (apnea-hypopnea index [AHI]); presence of OSAHS, as defined by an AHI of > or =5; and abnormalities on electrocardiography. RESULTS: One patient with OSAHS was found to have FES, yielding a prevalence of 2.3% (95% confidence interval [CI]: 0.1%-12.0%). One patient was referred to the Sleep Disorders Center due to a diagnosis of FES; if this patient were included, the prevalence would be 4.5% (95% CI: 0.5%-15.1%). Subjectively easy lid eversion was more common in OSAHS patients than in non-OSAHS patients. When adjusted for age and body mass index, there was a trend for association between subjectively easy lid eversion and OSAHS, but this did not reach statistical significance. Subjectively easy lid eversion was associated with AHI. Force required to displace the upper lid 5 mm was lower in lids with subjectively easy eversion, but was not associated with OSAHS or AHI. Intraclass correlation among 3 strain gauge measurements was good for both right (82%) and left (83%) lids. There were no statistically significant differences in frequency of electrocardiographic abnormalities among the various groups. CONCLUSIONS: The prevalence of FES among OSAHS patients is low. Patients with subjectively easy upper lid eversion are at risk for OSAHS. By recognizing the potential for OSAHS in these patients, the ophthalmologist may play an important role in initiating their evaluation and treatment.

Natural killer/T-cell lymphoma with ocular and adnexal involvement.

PURPOSE: To review the clinical, radiological, and histopathologic features in 8 patients with natural killer/T-cell lymphoma (NKTL) involving the orbit and/or ocular adnexa, and to describe the responses of these patients to various treatment regimens. DESIGN: Retrospective observational case series. PARTICIPANTS: Eight patients (5 male, 3 female) with NKTL involving the orbit and/or ocular adnexa were identified from 1999 through 2005. The mean age at presentation was 45 years (range, 26-65). METHODS: We retrospectively identified patients with NKTL of the ocular adnexa treated in the authors' medical centers from 1999 through 2004 using computerized diagnostic index retrieval. The clinical records and radiologic studies were analyzed to define modes of presentation and progression, response to therapy, and areas of anatomic involvement. Histopathologic findings, including the presence of CD3, CD56, and Epstein-Barr virus-encoded mRNA in each patient, were reviewed. MAIN OUTCOME MEASUREMENTS: Time of survival from presentation to last known follow-up and tumor-related death. RESULTS: Four of the 8 patients (50%) with NKTL involving the orbit or ocular adnexa had systemic involvement at presentation. Five of the 8 patients (62.5%) had concurrent sinonasal involvement, whereas 3 (37.5%) had orbital involvement alone. All lesions demonstrated CD3, CD56, and/or Epstein-Barr virus positivity on immunopathology studies. Therapy consisted of various chemotherapeutic regimens typically employed in the treatment of non-Hodgkins lymphoma, steroids, surgical intervention, and radiation. Seven (87.5%) patients died 5 weeks to 13 months after presentation, and 1 (12.5%) is alive without disease (5-year follow-up). CONCLUSIONS: Natural killer/T-cell orbital lymphoma is a rare Epstein-Barr virus-associated neoplasm that may occur with or without associated sinonasal involvement. Our series, the largest cohort reported to date, demonstrates the high lethality of this condition despite aggressive conventional therapy, suggesting that new treatment options should be considered early in the course of treatment of patients with this disorder.

The role of high-resolution computed tomography and magnetic resonance imaging in the evaluation of isolated orbital neurofibromas.

PURPOSE: To analyze the imaging findings in patients diagnosed with isolated orbital neurofibromas. DESIGN: Retrospective observational case series. METHODS: Computed tomographic (CT) and magnetic resonance imaging (MRI) findings were reviewed in five patients with orbital neurofibromas in the absence of systemic neurofibromatosis in this multicenter study. The main outcome measures were bony and soft tissue abnormalities involving the orbit and surrounding anatomic spaces. RESULTS: Patient age ranged from 36 to 43 years (mean, 41 years); three patients were men and two were women. Duration of symptoms ranged from three to 20 years. Radiologic findings included intraconal and extraconal soft tissue masses in all patients, bony orbital abnormalities in three patients, and intracranial extension in two patients. In addition, MRI studies in one patient revealed the previously unreported presence of neurofibromas involving extraocular muscle. CONCLUSIONS: Isolated orbital neurofibromas may present with differing radiologic appearances. The combined use of high-resolution CT and MRI may be of benefit in the preoperative diagnosis of these uncommon orbital tumors.

Endoscopic dacryocystorhinostomy and conjunctivodacryocystorhinostomy.

Intranasal approaches to the correction of lacrimal outflow obstruction initially were described more than 100 years ago, but they have gained renewed popularity with the recent development of the field of endoscopic sinus surgery. Endoscopic dacryocystorhinostomy (EDCR) surgery may be considered in many patients who have lacrimal outflow obstruction. It may be particularly advantageous in patients who have concomitant sinonasal disease, patients with a history of radiation therapy, pediatric patients, and in revision procedures. Advantages of the endoscopic technique include excellent visualization, the ability to evaluate the location and size of the rhinostomy site thoroughly, and the avoidance of a facial scar. Recent studies suggest that the success rates of EDCR are comparable to those achieved through traditional external dacryocystorhinostomy.

Evaluation and management of congenital nasolacrimal duct obstruction.

Congenital nasolacrimal obstruction is a common disorder in infants that results in persistent tearing and may lead to infections, such as dacryocystitis, orbital cellulitis, and bacterial conjunctivitis. The true incidence of this disorder in healthy newborns remains controversial. The most frequently quoted number of 6% comes from a study of 200 consecutive live births in the 1940s in which nasolacrimal patency was assessed by the presence or absence of discharge on compression of the lacrimal sac. Estimates from other studies, which often use different criteria for diagnosis, vary considerably from 1.2% to 30%. The incidence of the disorder is higher in children who have craniofacial disorders and Down's syndrome. This article reviews the causes and treatment of congenital nasolacrimal obstruction.

Office evaluation of lacrimal and orbital disease.

This article describes a stepwise system for evaluating the function of the lacrimal system. It discusses evaluation of the orbit with particular attention to thyroid eye disease and orbital fractures.

Evaluation and management of Graves' orbitopathy.

Graves' orbitopathy, also known as Graves' ophthalmopathy or thyroid eye disease, is a potentially progressive but generally self-limited autoimmune process associated with hyperthyroidism. It is the most common cause of proptosis and the most common orbital inflammatory disorder in adults.

Cosmetic oculofacial applications of botulinum toxin: a report by the American Academy of Ophthalmology.

OBJECTIVE: To determine the safety and effectiveness of botulinum toxin for cosmetic oculofacial use. METHODS: Literature searches for relevant citations were conducted in October 2003 for the years 1965 to 2003. The panel reviewed and rated the articles for study design, methods, and results. RESULTS: Randomized double-masked controlled studies showed statistically significant improvement in glabellar, frontal, and lateral canthal rhytids (wrinkles) when injected with botulinum toxin. Standardized documentation using photographs and masked grading by the patient and physician support the efficacy of botulinum toxin for treatment of dynamic rhytids in the glabellar region, forehead, and lateral canthal area. Complications and adverse effects associated with treatment are infrequent and short lived. CONCLUSIONS: Botulinum toxin is safe in the short term and effective in the temporary treatment of glabellar, frontal, and lateral canthal rhytids. Potential functional complications should be discussed with patients who are seeking cosmetic rejuvenation of the periocular and facial region. Further research is needed to determine the ideal effective dose for particular anatomic areas, ideal concentration, applicable doses across the different serotypes of botulinum toxin, duration of effect, changes in efficacy (if any) over extended periods of treatment, and long-term safety.

The smooth surface tunnel porous polyethylene enucleation implant.

BACKGROUND AND OBJECTIVE: To describe early clinical results with the porous polyethylene smooth surface tunnel (SST) enucleation implant. PATIENTS AND METHODS: Uncontrolled, prospective interventional case series of patients undergoing enucleation with placement of the SST implant. This implant consists of a porous polyethylene sphere with a smooth anterior surface containing pre-drilled tunnels to facilitate direct suturing of the rectus muscles to the implant without use of an implant wrap. Postoperatively, socket healing was assessed, and prosthesis and socket motility were evaluated by the surgeon using an ordinal scale (0 = no motility to 4 = excellent motility). RESULTS: Thirty patients received the SST implant, with a mean follow-up of more than 23 months. Two cases of exposure occurred and were managed surgically without the need for explantation. Mean socket motility was 3.1 on a 0 to 4 ordinal scale, with mean prosthesis motility of 2.8. CONCLUSION: The SST implant provides satisfactory socket motility and is generally well tolerated in the anophthalmic socket without the need for wrapping material.