Plasma exosomes from patients with active thyroid-associated orbitopathy induce inflammation and fibrosis in orbital fibroblasts.

BACKGROUND: The pathogenesis of thyroid-associated orbitopathy (TAO) remains incompletely understand. The interaction between immunocytes and orbital fibroblasts (OFs) play a critical role in orbital inflammatory and fibrosis. Accumulating reports indicate that a significant portion of plasma exosomes (Pla-Exos) are derived from immune cells; however, their impact upon OFs function is unclear. METHODS: OFs were primary cultured from inactive TAO patients. Exosomes isolated from plasma samples of patients with active TAO and healthy controls (HCs) were utilized for functional and RNA cargo analysis. Functional analysis in thymocyte differentiation antigen-1+ (Thy-1+) OFs measured expression of inflammatory and fibrotic markers (mRNAs and proteins) and cell activity in response to Pla-Exos. RNA cargo analysis was performed by RNA sequencing and RT-qPCR. Thy-1+ OFs were transfected with miR-144-3p mimics/inhibitors to evaluate its regulation of inflammation, fibrosis, and proliferation. RESULTS: Pla-Exos derived from active TAO patients (Pla-ExosTAO-A) induced stronger production of inflammatory cytokines and hyaluronic acid (HA) in Thy-1+ OFs while inhibiting their proliferation. Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analysis and single sample gene set enrichment analysis (ssGSEA) suggested that the difference in mRNA expression levels between Pla-ExosTAO-A and Pla-ExosHC was closely related to immune cells. Differential expression analysis revealed that 62 upregulated and 45 downregulated miRNAs in Pla-ExosTAO-A, with the elevation of miR-144-3p in both Pla-Exos and PBMCs in active TAO group. KEGG analysis revealed that the target genes of differentially expressed miRNA and miR-144-3p enriched in immune-related signaling pathways. Overexpression of the miR-144-3p mimic significantly upregulated the secretion of inflammatory cytokines and HA in Thy-1+ OFs while inhibiting their proliferation. CONCLUSION: Pla-Exos derived from patients with active TAO were immune-active, which may be a long-term stimulus casual for inflammatory and fibrotic progression of TAO. Our finding suggests that Pla-Exos could be used as biomarkers or treatment targets in TAO patients.

Death associated protein like 1 acts as a novel tumor suppressor in melanoma by increasing the stability of P21 protein.

Melanoma is a primary malignant tumor with high lethality, which occurs in the skin and eye tissues, while the molecular mechanisms of melanomagenesis remain largely unknown. Here, we show that death-associated protein-like 1 (DAPL1) expression is lower in melanoma tissues than in paracancerous tissues or nevus tissues, and Uveal melanoma patients with lower DAPL1 expression have a poorer survival rate than those with higher expression of DAPL1. Overexpression of DAPL1 inhibits proliferation of cultured melanoma cells, whereas knockdown of DAPL1 increases cell proliferation. Tumor transplantation experiment results also demonstrate that DAPL1 inhibits tumorigenesis of melanoma cells both in subretinal and subcutaneous tissues of nude mice in vivo. Finally, DAPL1 inhibits proliferation of melanoma cells by increasing the protein level of P21 via decreasing the ubiquitin mediated degradation of P21 and promoting its stability. Conversely, knockdown of P21 neutralizes the effects of inhibition of DAPL1 on melanoma cell proliferation and enhances the severity of melanoma tumorigenesis. These results suggest that DAPL1 is a novel melanoma tumor suppressor gene and thus a potential therapeutic target for melanoma.

Abnormal Functional Connectivity Density in Patients with Dysthyroid Optic Neuropathy.

OBJECTIVE: Functional connectivity density (FCD) mapping was used to investigate abnormalities and factors related to brain functional connectivity in cortical regions of patients with dysthyroid optic neuropathy (DON) and to analyze the pathogenesis of DON further. METHODS: Patients diagnosed with thyroid-associated opthalmology (TAO) in the Eye Hospital were enrolled. All patients underwent comprehensive eye examinations and best-corrected visual acuity, visual field (VF) test. MRI data collection and analysis were completed in the 2nd Affiliated Hospital of Wenzhou Medical University. The patients were divided into 2 groups: the DON group, with an average VF, mean deviation (MD) of both eyes < -5 dB, and the non-DON group (nDON group), with an average VF MD of both eyes ≥ -2 dB. RESULTS: A total of 30 TAO patients (14 men, 16 women) with complete data who met the experimental requirements were enrolled. The average age was 48.79 (40-57) years. There were 16 patients in the DON group and 14 patients in the nDON group. No significant differences in age, gender, education level, and the maximum horizontal diameter of either medial rectus muscle were found between the 2 groups. The difference of brain FCD between the 2 groups showed significant abnormal connectivity in the right orbital gyri of the frontal lobe (Frontal_Inf_Orb_R) and the left precuneus in the DON group compared with the nDON group. As demonstrated by decreased FCD values in the right inferior frontal gyrus/orbital part, the relevant brain regions were the left middle temporal gyrus, left precuneus, left middle frontal gyrus, right postcentral gyrus, and brain gyri (excluding the supramarginal gyrus and angular gyrus) below the left parietal bone. The FCD associated with the left precuneus was increased, and the relevant brain areas were the left middle temporal gyrus, right cuneus, superior occipital gyrus, and right fusiform gyrus. A significant correlation was identified between the MD of the binocular VF and brain FCD. CONCLUSION: The abnormal FCD in the cortex of DON patients suggests that a central nervous system mechanism may be related to the pathogenesis of the DON.

Navigation-guided nasal endoscopic surgery for acute vision loss caused by fibrous dysplasia: a case report and review of literatures.

BACKGROUND: Bone fibrous dysplasia is a benign disease of bone tissue dysplasia. Vision impairment is the commonest neurological complication of craniofacial fibrous dysplasia. Most of the vision loss caused by craniofacial fibrous dysplasia is usually a gradual process. Very few present with acute visual impairment as described in our case. CASE PRESENTATION: We report a patient with fibrous dysplasia presenting rapidly progressive visual loss in the left eye secondary to bone cyst formation. Transnasal endoscopic surgery guided by navigation with drainage and curettage of this bone cyst and orbital decompression resulted in progressive improvement in visual acuity that returned to normal 1 month post-operatively. CONCLUSIONS: In cases with acute visual loss due to fibrous dysplasia, emergency surgical treatment should be considered to preserve vision. In the surgical approach, navigation-guided nasal endoscopic surgery may be preferred because of its advantages.

Orbital Infection Due to Medial Wall Fracture: Three Cases of Orbital Complications Caused by Paranasal Sinusitis Secondary to Medial Orbital Wall Fracture.

PURPOSE: The aim of this study was to report 3 cases of orbital complications in patients with secondary sinusitis due to medial orbital wall fracture. We believe that sinusitis can be secondary to the fracture of the medial orbital wall when the sinus drainage orifice is blocked due to some fracture pieces or other blocking factors. We precisely show the direct evidence of the blocking factors through radiology. DESIGN: Retrospective, noncomparative, interventional case series. PARTICIPANTS: All patients had intraorbital complications and a history of traumatic orbital medial fracture as well as imaging findings of sinusitis. METHODS: A medical record review of clinical history, imaging studies, and surgical and treatment outcomes were performed. MAIN OUTCOME MEASURES: Postoperative visual acuity, appearance, eye movement, surgical and imaging findings. RESULTS: Three patients (2 males and 1 female; average age 38.33 years [range, 11-65]) received endoscopic surgery for orbital complications related to sinusitis. All patients had evidence of paranasal sinusitis after the orbital injury. Two patients were treated with antibiotics before the operation, but there was no significant improvement. All patients underwent transnasal endoscopic sinotomy. Two patients received orbital abscess incision and drainage surgery and 1 patient underwent a cyst excision operation. The visual acuity of the 3 patients was improved after the operation, and the clinical examination was significantly improved. CONCLUSIONS: The anatomy of the orbit is closely related to the nasal cavity. The fracture of the medial orbital wall often causes abnormal anatomy of the sinus outflow tract. For the 3 of our patients, the blocking factors of sinus orifices were fracture fragment, orbital bone deformation, and the formation of giant nasal intraorbital mucocele. Sinusitis possibly occurs when drainage is not smooth. Infections develop due to the secretions retaining and accumulation of microorganisms. Inflammation from the sinus can be spread into the orbit in various ways. Our 3 patients indicate that a fracture of the inner orbital wall may cause sinusitis. When the patient is injured again or sneezing or in other conditions when the pressure in the nasal cavity increases, inflammation of the sinuses enters the orbit, causing serious intraorbital complications. It is necessary to carefully follow-up on the medical history, combined with imaging examination, to prevent the misdiagnosis of intraorbital hemorrhage or hematoma from affecting the treatment.In recent years, more and more cases of intraorbital complications caused by sinusitis have been reported.1,2 Severe intraorbital inflammation can pose a threat to vision and even life. With the great tool of the endoscope, nasal-orbital problems can be well solved. For our 3 patients, we opened the paranasal sinus and removed the occlusion of the sinus orifice through transnasal endoscopy. All patients achieved good surgical and clinical results.

Self-Cross-Linked Hyaluronic Acid Hydrogel in Endonasal Endoscopic Dacryocystorhinostomy: A Randomized, Controlled Trial.

PURPOSE: To investigate whether self-cross-linked HA hydrogel fill stimulates wound mucosal regeneration and its epithelialization around the ostia to improve long-term ostial patency in endonasal endoscopic dacryocystorhinostomy (En-DCR). METHODS: One hundred and ninety-two patients with unilateral primary chronic dacryocystitis (PCD) were randomized divided into 2 groups: group A (the HA hydrogel group) and group B (the control group). All patients underwent En-DCR. The HA hydrogel group received HA hydrogel filling the ostium at the end of the surgery and the control group received no treatment. The mucosal epithelialization of the wound, the formation of granulation, the formation of scars, and the success rate of ostial patency were compared. RESULTS: Our study included 82 patients in group A and 79 patients in group B. At the 2-week follow up, 74 patients (90.2%) in the group A had a healed ostium with a lining of intact epithelial mucosa. It was higher when compared with 56 patients (70.9%) in group B (X2 = 9.698, P < 0.05). At the 12-month follow up, Granulation were present in 7.3% of patients in group A which was significantly lower than the 19.0% of patients in group B (X2 = 4.831, P < 0.05). No statistical difference was found with scars formation between 2 groups (X2 = 1.607, P = 0.205). The success rate of ostial patency was 89.0% (73/82) in group A and 77.2% (61/79) in group B. The success rate was much higher in group A than group B (X2 = 4.02, P < 0.05). CONCLUSION: Self-cross-linked HA hydrogel may enhance the success rate of En-DCR for PCD by promoting mucosal epithelial healing and preventing excessive granulation.

Ethmoid Sinus Mucosal and Lacrimal Sac Flap Anastomosing in Patients With Failed Dacryocystorhinostomy.

PURPOSE: The aim of this work is to demonstrate the outcomes of endonasal dacryocystorhinostomy (En-DCR) with anterior ethmoid sinus mucosal and posterior lacrimal sac flap anastomosing in patients with previous failed DCR. METHODS: The clinical data of patients who suffered from recurrent epiphora after failed DCR between September 2014 and March 2018 were reviewed retrospectively. Among them, those who received the second En-DCR procedure were enrolled in this study. During the surgery, anterior ethmoidectomy was performed. Posterior lacrimal sac flap was apposed closely to the mucosal of anterior ethmoid sinus instead of nasal flap at end of the surgery. Patients were followed up more than 12 months were included, the success rate and complications were recorded. RESULTS: Sixty-one eyes of 61 patients were enrolled in the study. The success rate of our modified En-DCR was 83.6% (51/61). Among 10 eyes with postoperative obstruction, 4 eyes caused by granuloma, 2 eyes caused by scar synechia, 2 eyes caused by membranous obstruction, and 2 eyes caused by common canalicular stenosis. No serious complications such as orbital fat prolapse, cerebrospinal fluid leak, sinusitis, or visual impairment were occurred in this study. CONCLUSION: Endoscopic approach with anterior ethmoid sinus mucosal and posterior lacrimal sac flap anastomosing is a good choice for patients with recurrent epiphora after previous failed DCR.

Relationship between the 24-h variability of blood pressure, ocular perfusion pressure, intraocular pressure, and visual field defect in thyroid associated orbitopathy.

PURPOSE: To evaluate the relationship between the 24-h variability of blood pressure (BP), ocular perfusion pressure (OPP), intraocular pressure (IOP), and visual field (VF) defect in thyroid-associated orbitopathy (TAO). METHODS: Thirty patients (60 eyes) with TAO were clinically examined in the Eye Hospital of Wenzhou Medical University. Patients were divided into two groups: one with VF defect (A) and the other without (B). Clinical parameters measured include 24-h IOP, 24-h blood pressure, orbital computed tomography (CT) scan, optical coherence tomography (OCT), and VFs. The pulse pressure (PP), mean arterial pressure (MAP), mean ocular perfusion pressure (MOPP), and 24-h fluctuations were calculated by formula. RESULTS: The MOPP and MAP fluctuation were greater in group A than B (p < 0.05) and had significant negative correlation to mean deviation (MD) of VF (R = - 0.434 P = 0.001*). There was no statistical difference in the muscle index, medial rectus muscle thickness, and blood pressure between two groups. Although there were no significant differences in the mean IOP and IOP fluctuation between two groups, the incidence of IOP abnormalities has higher trend in group A. Patients with 24-h IOP fluctuation ≥8 mmHg and the mean IOP > 21 mmHg in the group A were more than group B. CONCLUSIONS: Dysthyroid optic neuropathy (DON) might have multiple pathogenic mechanisms. In this study, 24-h MOPP fluctuation and medial rectus maximal diameter were all the risk factors for DON. Higher mean IOP and 24-h IOP fluctuation might be risk factors for DON.

Endoscopic Transethmosphenoid Optic Canal and Orbital Apex Decompression for Patients With Traumatic Orbital Apex Syndrome.

PURPOSE: The aim of this study was to evaluate the efficacy, feasibility, and safety of the endoscopic optic canal and orbital apex decompression for patients with traumatic orbital apex syndrome. DESIGN: Retrospective, noncomparative case series. METHOD: Thirty-one patients (31 eyes) with traumatic orbital apex syndrome underwent endoscopic transethmosphenoid optic canal and orbital apex decompression at the Eye Hospital of Wenzhou Medical University from May 1st, 2012 to May 1st, 2018. In each case, the indication of surgery was that patient with traumatic orbital apex syndrome failed to respond to corticosteroids. Patients were followed up to 6 months after surgery. Best corrected visual acuity, visual field, ptosis, ophthalmoplegia, hypoesthesia, and pupil before and after surgery were compared. RESULT: All patients presented visual decline (including 5 patients with no light perception), ptosis, ophthalmoplegia, diplopia, pupil dysfunction, and visual field defect, and 20 of them also presented hypoesthesia. Nineteen of 31 (61.3%) patients gained improvement of best-corrected visual acuity after surgery, 7 of them gained 20/20 BCVA, and visual field showed improvement in 20 patients. Ptosis and ophthalmoplegia of all patients recovered in various degree; diplopia also relieved relatively. The function of the pupil was also improved in most patients (27/31, 87.1%). The improvement of hypoesthesia was also observed in most patients. No serious complications occurred. CONCLUSION: Endoscopic transethmosphenoid optic canal and orbital apex decompression seems to be a feasible, efficient, and safe approach for traumatic orbital apex syndrome patients.

Endoscopic Endonasal Dacryocystorhinostomy With a Novel Lacrimal Ostium Stent in Chronic Dacryocystitis Cases With Small Lacrimal Sac.

PURPOSE: To investigate feasibility of endoscopic endonasal dacryocystorhinostomy (EE-DCR) with an novel lacrimal ostium stent (LOS) intubation for patients with chronic dacryocystitis with small lacrimal sac. METHODS: Patients diagnosed as chronic dacryocystitis with small lacrimal sac who preferred to surgery treatment between March 1st, 2012 and May 1st, 2015. All included subjects were randomly divided into 2 groups (Group A and Group B). Cases in group A were performed EE-DCR with LOS intubation while cases in group B were underwent EE-DCR without LOS intubation. Demographic data of each cases were collected. The success rate and the surgical outcomes of 2 groups were compared. RESULTS: The success rate was much higher in group A than group B. At 3 months follow up, 61.6% of patients in group A exhibited scarring and/or granulation tissues around the ostium, which was significantly higher than the 36.4% of patients in group B. Of these patients with scars and/or granulation tissues, no statistical difference was found between 2 groups. Granuloma alone and scars with granuloma were observed in 10 patients and 2 patients, in group A and group B, respectively, resulting in a statistical significant difference for this outcome between the groups. At 9 months follow up and 12 months follow up, no significant statistical difference were found in the rate of scarring and/or granulation tissues, scars alone, granuloma alone and scars with granuloma between 2 groups. CONCLUSIONS: EE-DCR with novel LOS may be an effective procedure to manage chronic dacryocystitis with small lacrimal sac.

Disrupted Regional Spontaneous Neural Activity in Mild Cognitive Impairment Patients with Depressive Symptoms: A Resting-State fMRI Study.

Depressive symptoms are common in individuals with mild cognitive impairment (MCI) who have an increased risk of dementia. It is currently unclear whether the pattern of spontaneous brain activity in patients with MCI differs between subjects with and without depressive symptoms. The current study sought to investigate the features of spontaneous brain activity in MCI patients with depressive symptoms (D-MCI) using coherence regional homogeneity (CReHo) analysis with resting-state functional magnetic resonance imaging (rsfMRI). We obtained rsfMRI data in 16 MCI patients with depressive symptoms and 18 nondepressed MCI patients (nD-MCI) using a 3 T scanner. Statistical analyses were performed to determine the regions in which ReHo differed between the two groups in specific frequency bands, slow-4 (0.027-0.073 Hz) and slow-5 (0.010-0.027 Hz), and typical bands (0.01-0.08 Hz). Correlation analyses were performed between the CReHo index of these regions and clinical variables to evaluate the relationship between CReHo and pathophysiological measures in the two groups. Our results showed that D-MCI patients exhibited significantly higher CReHo in the left Heschl's gyrus and left thalamus and lower CReHo in the left postcentral gyrus in the typical frequency band. In the slow-4 frequency band, D-MCI patients showed significantly higher CReHo in the left Heschl's gyrus and left thalamus. In the slow-5 frequency band, D-MCI patients exhibited significantly lower CReHo in the superior medial prefrontal gyrus. In addition, the results revealed that CReHo values in the left thalamus were positively correlated with Hamilton Depression Rating Scale (HAMD) scores in D-MCI patients. These results suggest that the sensorimotor network may be one of the main pathophysiological factors in D-MCI.

Outcome of endoscopic trans-ethmosphenoid optic canal decompression for indirect traumatic optic neuropathy in children.

BACKGROUND: To evaluate the safety and outcomes of endoscopic trans-ethmosphenoid optic canal decompression (ETOCD) for children with indirect traumatic optic neuropathy (ITON). METHODS: From July 1st, 2008 to July 1st, 2015, 62 children diagnosed with ITON who underwent ETOCD were reviewed. Main outcome measure was improvement in visual acuity after treatment. RESULTS: Altogether 62 children (62 eyes) with a mean age of 11.26 ± 4.14 years were included. Thirty-three (53.2%) of them had residual vision before surgery while 29 (46.8%) had no light perception (NLP). The overall visual acuity improvement rate after surgery was 54.84%. The improvement rate of patients with residual vision (69.70%) was significant higher than that of patients with no light perception (NLP) (37.9%) (P = 0.012). However, no significant difference was shown among patients with different residual vision (P = 0.630). Presence of orbital and/ or optic canal fracture and hemorrhage within the post-ethmoid and/or sphenoid sinus resulted in poor postoperative visual acuity, duration of presenting complaints did not affect final visual acuity or did not effect outcomes. Intervention performed in children presenting even after 7 days from the injury did not influence the final visual outcome. Three patients developed cerebrospinal fluid rhinorrhea and one encountered cavernous sinus hemorrhage during surgery. No other severe complications were observed. CONCLUSION: Children with residual vision had better postoperative visual prognosis and benefited more from ETOCD than children with NLP. Intervention performed in children presenting even after 7 days from the injury did not influence the final visual outcome, however, this needs to be reassessed in children presenting long after the injury.Treatment should still be recommended even for cases of delayed presentation to hospital.

Combined External, Endoscopic, Endonasal-Assisted En Bloc Resection of Malignant Tumors From the Lacrimal Drainage System.

PURPOSE: The aim of this study is to describe a minimally invasive technique of en bloc resection of malignant tumors from lacrimal drainage system (LDS). METHODS: This was a noncomparative, retrospective chart review of the clinical and pathologic findings of patients presenting with a LDS malignant tumor who underwent endoscopic prelacrimal recess approach with a small external incision for en bloc excision of the LDS. RESULTS: A total of 12 patients from April 2010 to July 2017 were reviewed in this study. Of the 12 patients, 7 were males. The mean age was 51 years (range, 38-66 years), and all cases were unilateral. Histopathology revealed 3 adenoid cystic carcinomas, 2 squamous cell carcinomas, 2 melanomas, and 1 each of papilloma with carcinoma, papillary squamous cell carcinoma, mucoepidermoid carcinoma, B-cell lymphoma, and natural killer/T-cell lymphoma. Epiphora and a mass were the most common presentations. Adjuvant radiotherapy was given in 6 cases after surgery. Eleven patients remain alive and mean disease-free survival time was 25 months (range, 3-78 months). Two cases with malignant melanoma showed recurrence and 1 patient died of metastatic involvement. CONCLUSION: Endoscopic endonasal approach combined with a small external incision is efficient method for the management of tumors arising from the LDS.

Endoscopic Endonasal-Assisted Resection of Orbital Schwannoma.

Orbital schwannomas are rare and despite a variety of external surgical approaches previously utilized, removal of tumors located in the deep orbital apex remains challenging. The endoscopic endonasal approach has been used increasingly for various apical tumours, but few describe this technique for orbital schwannomas. The authors describe 2 cases of orbital schwannoma removed via an endoscopic endonasal assisted approach. The first patient was a 31-year-old Cantonese female who was found to have an 11 × 8 × 8 mm right orbital apical schwannoma which was removed using an endoscopic endonasal sphenoethmoidal approach. The second patient was a 78-year-old white male who had a 28 × 17 × 18 mm orbital schwannoma removed via a transcaruncular and endoscopic endonasal-assisted approach. These findings suggest that the use of an endonasal approach may facilitate the safe removal of selected medially located orbital schwannomas whose posterior margins involve the orbital apex.

Endoscopic Transretracaruncular-Middle Meteas Tract for Insertion of a Porous Polyethylene-Coated Jones Tube.

PURPOSE: The purpose of this article is to describe a modified lacrimal bypass with a porous polyethylene-coated Jones tube. METHODS: A total of 180 patients (180 eyes) with a nonreconstructable lacrimal obstruction underwent lacrimal bypass with a porous polyethylene-coated Jones tube through a retrocaruncular-middle meatus tract approach with endoscopic assistance. All patients were followed up at least for 24 months. Success rate of lacrimal bypass was analyzed and complications were recorded. RESULTS: A total of 174 patients were finally included. Duration of surgery ranged from 28 to 47 minutes (mean 37.2 ±â€Š4.2 minutes). The mean duration of follow-up was 30.0 ±â€Š6.4 months (range 24-48 months). The mean tube length was 23.2 ±â€Š1.9 mm (range 20-28 mm). At the final review, complete success was achieved in 138 (79.3%) patients. Moderate success was achieved in 23 (13.2%) patients, and 13 (7.5%) patients failed. Of the 161 patients successfully treated, 24 patients underwent revision surgery to excise granulomas (15 patients) or adjust tube position (9 patients). The complications included granuloma proliferation around the openings of the tube (28 eyes), downward displacement of the tube (17 eyes), and ocular discomfort (15 eyes). The majority of downward tube migration occurred in patients who had a prior history of dacryocystorhinostomy. The treatment failed for 5 patients because of repeated granulomas covering the nasal tube openings, and the treatment failed for 8 patients because of downward displacement of the tube. CONCLUSIONS: Our procedure appears to be an effective method for closed insertion of a porous polyethylene-coated Jones.

A Lacrimal Sump Syndrome With a Large Intranasal Ostium.

Lacrimal sump syndrome is an uncommon cause of failed dacryocystorhinostomy. Small osteotomy was reported as the major cause of this syndrome. Here, the authors described the first case of a lacrimal sump syndrome with a large intranasal ostium following endoscopic endonasal dacryocystorhinostomy (EE-DCR). A 51-year-old women patient suffered recurrence of epiphora and dacryocystitis for 8 months following an EE-DCR. Examination showed a large intranasal ostium with a lot of purulent discharge and patent lacrimal irrigation. Lacrimal sump syndrome was diagnosed after passing a probe into the residual lacrimal sac under the aid of an endoscope. The residual sac was reopened and merogel was packed around the wound. The clinical symptoms disappeared after the surgery. It is indicated that lacrimal sump syndrome does happen not only in a small intranasal ostium, but also in a large intranasal ostium. Existing residual sac with bacterial infection may be related to this particular case.

Image-Guided Endoscopic Combined With Deep Lateral Orbitotomy Removal of a Small Foreign Body at the Deep Lateral Orbital Apex.

To remove a small foreign body located at the deep orbit apex presents an extremely challenging problem. Small foreign bodies located in shallow lateral orbital and nasal orbital apex have been reported successfully removing in endoscopic surgery with the help of surgical navigation system. Here, the authors first describe successfully removal of a small foreign body at the deep lateral orbital apex with the help of image-guided endoscopic. A 56-year-old man presented with blurred vision and eye movement pain of the left eye while grinding metal 4 days prior to admission. A computed tomography scan showed a small metallic foreign body lodged in the deep lateral orbital apex. The foreign body was smoothly removed without any complications by endoscopic surgery under the help of surgical navigation system combined with deep lateral orbitotomy. Eye movement pain was disappeared and visual acuity was improved after surgery.

Retinal perfusion related to visual field within the same asymmetric thyroid-associated ophthalmopathy.

PURPOSE: To quantify interocular differences in the retinal microvasculature between disparate eyes and explore associations between the retinal microvasculature and visual field abnormalities within the same asymmetric thyroid-associated ophthalmopathy (TAO) patients. METHODS: Within the same asymmetric TAO eye, the eye with a severer visual field abnormality (based on the mean deviation [MD]) was considered a severe eye, and the fellow eye was considered mild. The densities of radial peripapillary capillary (RPC) and superficial retinal capillary plexuses (SRCP) were determined using optical coherence tomography angiography. Interocular differences in RPC and SRCP densities were analyzed. A generalized estimating equation (GEE) was used to form a predictive model for visual field abnormalities. Pearson's correlation was used to show the correlation between MD and the densities of RPC and SRCP. RESULTS: In 57 asymmetric TAO patients, the global RPC density in severe eyes was lower than that in mild eyes (P < 0.001), but there was no significant difference in SRCP density between the two groups (P = 0.114). In a multivariate GEE model with MD as the outcome, MD was associated only with global RPC density (coefficient ß=0.327, P < 0.001). The global RPC density was correlated with MD (r = 0.360, P = 0.003) in severe eyes, but not in mild eyes (r = 0.179, P = 0.092). No significant correlation was observed between global SRCP density and MD in either group (Both P > 0.05). CONCLUSIONS: RPC density decreased significantly and correlated with visual field abnormalities in severe eyes of TAO patients. Alterations in RPC density may contribute to visual field abnormalities in TAO eyes.

Endoscopic transcaruncular repair of large medial orbital wall fractures near the orbital apex.

PURPOSE: To study the suitability of an endoscopic transcaruncular approach (ETA) for repair of large medial orbital wall fractures (MOWFs) near the orbital apex. DESIGN: A retrospective, noncomparative case series with description of the surgical technique. PARTICIPANTS: Ninety-three consecutive patients (93 orbits) with large isolated MOWFs near the orbital apex. METHODS: The isolated MOWFs were determined by computed tomography (CT) scans of the orbit in all patients. All patients underwent fracture repair by an ETA, and the vertical and horizontal dimensions of the defects were measured during surgery. Porous polyethylene sheets (1.0 mm thick) were used to repair the bony defects. Patients were followed for 6 to 15 months. MAIN OUTCOME MEASURES: Size of vertical and horizontal fracture defects, rate of complete repair of the fracture defects, correction of enophthalmos, resolution of diplopia, and complications 6 months after surgery. RESULTS: All surgeries were completed uneventfully. The mean postoperative follow-up time was 9.7 ± 3.0 months. Under direct endoscopic visualization, all entrapped and herniated orbital contents were released and reposited, the entire boundary of the fractures were exposed adequately, and the implants were placed to overlie all edges of the fracture stably in all cases. The vertical and horizontal fracture defects measured during surgeries ranged from 16 to 30 mm and from 25 to 34 mm, respectively. Six months after surgery, complete reconstruction of the bony defects was demonstrated by orbital CT scans, and symmetry of the both eyes was acquired in 92 of 93 patients (98.9%). Of 30 patients with significant preoperative enophthalmos of more than 2 mm, 29 (96.7%) were corrected, with a mean improvement of 3.37 ± 0.77 mm. Diplopia within the 30° visual field of the gaze was resolved in 40 of 43 patients (93.0%). Three patients (7.0%) had residual diplopia on medial gaze because of presumed paralysis of the medial rectus muscle. Intraorbital hemorrhage occurred in 1 patient the day after surgery and resolved with conservative treatment. CONCLUSIONS: The ETA seems to be a useful method for recovery of the normal anatomic features of the orbits for patients with large MOWFs near the orbital apex.

A prospective study comparing mini-invasive and conventional canaliculotomy of punctum-sparing canaliculotomy for primary canaliculitis treatment.

PURPOSE: To compare outcomes of mini-invasive canaliculotomy with those of conventional canaliculotomy conducted using the punctum-sparing approach for the treatment of primary canaliculitis. METHODS: A prospective, comparative, and interventional case series study was conducted on 118 individuals with unilateral inferior primary canaliculitis. These patients were randomly divided into two groups, each with 59 cases. Group A underwent mini-invasive canaliculotomy (minor incision ~3 mm), whereas group B received conventional canaliculotomy (long incision ~6-8 mm). Punctum-sparing and canaliculus-reconstructing procedure was used to treat all patients. Both groups had silicone tube intubations and were retained in the lacrimal passages for one month. Both groups' surgical success rates and postoperative complications were measured at the last follow-up of 12 months after surgery. RESULTS: A total of 108 patients were finally included in the study, 53 in group A and 55 in group B. There were 79 females and 29 males with a median age of 57 ± 13.4 years. The anatomical success rates for groups A and B were 96.2% and 92.7% (P = 0.679), respectively. Functional success rate was accomplished by considerably more patients in group A (50/53, 94.3%) compared to group B (45/55, 81.8%) (P = 0.046). No recurrences were seen during follow-up visits in any of the participants. CONCLUSIONS: The two procedures employed in this study to treat primary canaliculitis achieves excellent clinical effects with no incidence of recurrence. The mini-invasive canaliculotomy is worthy to be recommended for its higher functional success rate with mini-invasion of canaliculus and intact lacrimal punctum.