Eyelid healing after carbon dioxide laser skin resurfacing: histological analysis.

OBJECTIVE: To clarify in vivo healing of eyelid skin after carbon dioxide (CO2) laser resurfacing. DESIGN: Patients requesting upper eyelid blepharoplasty consented to undergo previous CO2 laser skin resurfacing of the upper eyelid skin segments to be excised at various time intervals. After blepharoplasty, the skin specimens were analyzed histopathologically by 2 masked pathologists. PATIENTS: Eight patients with Fitzpatrick skin types I and II. INTERVENTION: Upper eyelid CO2 laser resurfacing 1,2, 4, or 12 weeks before planned upper eyelid blepharoplasty. MAIN OUTCOME MEASURES: Epidermis: thickness, polarity, contour, and constituents. Dermis: repair zone thickness, vascular and inflammatory pattern, collagen deposition, and elastic fiber changes. RESULTS: The epidermis regenerated within 7 to 10 days. By 3 months, the epidermis revealed flattening of the rete peg pattern with restoration of polarity, keratinocytes, and melanocytes. The 3-month dermis demonstrated a fibrotic repair zone (500-700 microm), new elastic fibers, and telangiectatic capillaries. CONCLUSIONS: Eyelids heal similarly to other skin regions treated by CO2 laser resurfacing. This cutaneous healing is analogous to that previously reported with use of chemical peels. Histological changes may explain the skin smoothing and wrinkle reduction seen clinically.

The prognostic value of preoperative dacryocystography in endoscopic intranasal dacryocystorhinostomy.

Endoscopic intranasal dacryocystorhinostomy has been used as a primary treatment of lacrimal obstruction and for revision of conventional dacryocystorhinostomy. This study correlates dacryocystographic anatomy with the success of the endoscopic surgical technique. Eighteen patients with epiphora and nasolacrimal obstruction underwent operations. Preoperative dacryocystography identified 11 patients with either normal or enlarged lacrimal sacs, and seven patients with cicatrized lacrimal sacs. Patients with lacrimal sac stones and tumors were excluded. Endoscopic intranasal dacryocystorhinostomy was successful in nine of 11 (82%) patients with normal or enlarged lacrimal sacs, and in two of seven (29%) patients with cicatrized lacrimal sacs. The endoscopic technique was much more successful with normal or enlarged lacrimal sacs than with cicatrized lacrimal sacs (P = .049). Lacrimal sac anatomy as determined by preoperative dacryocystography is an important prognostic factor in technically achieving surgical success.

Histologic and clinical evaluation of combined eyelid erbium: YAG and CO2 laser resurfacing.

PURPOSE: To report the histopathologic and clinical effects of eyelid resurfacing that combines two different lasers. METHODS: A case series of 23 patients who underwent eyelid resurfacing with two passes of the Erbium:YAG laser followed by one pass of the CO2 laser. With the Student t test, we compared skin re-epithelialization time and duration of erythema with those of a previous group of 25 patients who had undergone eyelid resurfacing with only the CO2 laser (two passes). A pathologist evaluated all skin biopsy specimens. RESULTS: Combining both lasers shortened re-epithelialization time (7 vs 12 days, P = .04) and the duration of erythema (2.5 vs 7.0 weeks, P = .02). Histopathologic examination disclosed less coagulative dermal damage with the combined laser protocol. CONCLUSION: The different biophysical properties of these two lasers can be combined in a periorbital resurfacing protocol to minimize both clinical and histopathologic morbidity.

Ocular adnexal granulocytic sarcoma as the first sign of acute myelogenous leukemia relapse.

PURPOSE: To report a case of granulocytic sarcoma involving the eyelids and caruncles after bone marrow transplantation. METHODS: Case report. A 30-year-old man with acute myeloid leukemia in remission developed multiple friable eyelid and caruncular lesions in addition to two cutaneous lesions on the chest wall and right axilla approximately 3 months after a successful autologous bone marrow transplant. RESULT: Pathologic examination was consistent with granulocytic sarcoma. CONCLUSION: This condition should be considered in the differential diagnosis of cutaneous or eyelid masses in patients with a history of leukemia.

Lacrimal gland hemangiopericytoma.

PURPOSE/METHODS: A 49-year-old woman with a left orbital mass was referred to an orbital clinic. Clinical investigation suggested a lacrimal gland lesion and the patient underwent lateral orbitotomy and excisional biopsy for a suspected pleomorphic adenoma in the lacrimal gland. RESULTS/CONCLUSION: Histopathologic evaluation disclosed a hemangiopericytoma originating within the lacrimal gland. Although hemangiopericytoma does not usually occur in this location, it may be added to the differential diagnosis of lacrimal gland enlargement.

Inadequately irradiated solitary extramedullary plasmacytoma of the orbit requiring exenteration.

PURPOSE: To emphasize that solitary orbital extramedullary plasmacytoma, a rare tumor, is not invariably radiosensitive. METHOD: We examined a patient who had undergone empirical irradiation that failed to control an orbital tumor. RESULTS: After a second biopsy had secured the diagnosis of a solitary extramedullary plasmacytoma, further irradiation proved ineffective and exenteration was required. The patient was free of recurrence one year after exenteration and had satisfactory cosmesis with a prosthesis. CONCLUSION: A histologic diagnosis is essential before treatment is commenced so that the correct radiation dosage is used.

Factors affecting the success of nasolacrimal duct probing for congenital nasolacrimal duct obstruction.

PURPOSE: To ascertain the effect of certain parameters on nasolacrimal duct probing. METHODS: In a retrospective study of 142 infants and children who underwent nasolacrimal duct probing for congenital nasolacrimal duct obstruction, age at time of probing, gender, symptom severity, presence of mucous discharge, and history of probing were correlated with success of nasolacrimal probing. Success of probing was defined as complete resolution of signs and symptoms of nasolacrimal duct obstruction. Chi-square test was used to analyze covariance. RESULTS: Success of nasolacrimal duct probing was negatively correlated with increasing age: 92%, 89%, 80%, 71%, and 42% at age 12, 24, 36, 48, and 60 months, respectively (P = .001 at each interval). Increasing severity of epiphora was correlated with increased failure of nasolacrimal duct probing (P = .05). CONCLUSIONS: Although the success of nasolacrimal duct probing declines with age, probing in older children can remain the first line of treatment. Because increasing frequency of epiphora correlates with failure of nasolacrimal duct probing, children with daily epiphora should undergo early nasolacrimal duct probing.

Hard-palate mucosa graft in Stevens-Johnson syndrome.

PURPOSE: We evaluated the use of hard-palate mucosa grafts in the treatment of cicatricial entropion and trichiasis associated with Stevens-Johnson syndrome. METHODS: Six patients, two men and four women, were treated with hard-palate mucosa grafts of one or more eyelids with cicatricial entropion, trichiasis, and corneal disease. The follow-up ranged from 19 to 33 months. RESULTS: Visual acuity improved in one of nine eyes and remained stable in the rest. Corneal epithelial disease improved in eight of nine eyes, while in one eye the epithelial defect stabilized. The corneal epithelium of all three corneal transplants remained intact, although one of these patients underwent another corneal transplantation and the other two transplants opacified from rejection. Cicatricial entropion resolved and symblephara improved in all 16 eyelids. Trichiasis resolved or improved in 12 of 16 eyelids and remained stable in the other eyelids. CONCLUSIONS: The chronic relapsing nature of Stevens-Johnson syndrome requires caution in interpreting surgical intervention in the treatment of dysfunctional eyelids. However, hard-palate grafts may be considered for patients with the Stevens-Johnson syndrome and severe ocular surface disease.

Endoscopy of the lacrimal system.

BACKGROUND/AIM: Until recently, diagnosis of disorders of the lacrimal system has depended on digital dacryocystography and on clinical examinations such as the fluorescein dye test, lacrimal probing, and irrigation. The lacrimal system and its mucous membranes can now be viewed directly with a lacrimal endoscope. While the first endoscopes were rigid and limited by poor picture quality in axial illuminations, the new generation of endoscopes are a great leap forward for new diagnostic and therapeutic approaches. METHODS: 132 patients ranging in age from 8 months to 73 years with nasolacrimal obstruction were referred to the lacrimal department. Diagnostic lacrimal imaging utilising various small calibre endoscopes less than 0.5 mm in external diameter was performed. The endoscopes are coupled to specially designed lacrimal probes as well as a CCD camera and a video recorder. The imaging was performed during standard lacrimal probing and irrigation in an outpatient clinic setting in 120 of 132 patients RESULTS: All patients reported the pain of endoscopy as being similar to that of standard lacrimal probing and irrigation. No adverse effects such as bleeding or lacrimal perforation were noted. Endoscopic manipulation was not too difficult and the picture quality, depth of focus, and illumination were satisfactory in all cases. The most common site of stenosis was the nasolacrimal duct (59 patients), followed by the lacrimal sac (39 patients) and the canaliculi (34 patients). In 25 patients, partial obstruction, rather than complete stenosis, was visualised as a narrow lumen, which widened during irrigation. In 14 of 28 patients, obstruction was due to canalicular submucosal folds and was removed with laser. In addition, the colour and consistency of the lining mucosa correlated with type of obstruction. Normal mucosa is smooth and light pink in colour. Inflammatory changes manifest as thickened and reddish grey mucosa. More complete stenosis is shown as fibrotic plaques with grey white inelastic membranes. CONCLUSION: Lacrimal endoscopy is a new, non-invasive method used to view directly and localise obstructions precisely. It allows differentiation between inflammatory, partial, and complete stenosis. Endoscopy enables one to choose the appropriate surgical therapy for patients. Patients tolerated the procedure well without any adverse reactions or effects. While it may not replace standard probing and irrigation, this technique is an extremely useful adjunct in determining the proper surgical modality, ease, and tolerance of the endoscopic manipulation by patients, and obtaining sharp and clear images of the nasolacrimal outflow system anatomy and pathology. Differentiation of various types of obstruction by precise location and severity can be achieved.

Ultrasonic assessment of rhinostomy size following external dacryocystorhinostomy.

AIM: To assess the dimensions and patency of the surgical epithelial fistula after external dacryocystorhinostomy, using B mode ultrasonography to define the postoperative soft tissue anastomosis. METHODS: 12 patients undergoing 16 external dacryocystorhinostomies, with the creation of large osteotomies, were included in a prospective study. The horizontal and vertical dimensions of the bone ostium was recorded during surgery and compared with the ultrasonographic dimensions of the soft tissue anastomosis at 1 day, 2 weeks, and 6 months after surgery. Functional patency was confirmed with dye testing and irrigation. RESULTS: Compared with an osteotomy of between 100 and 380 mm2 (mean 235 mm2), the soft tissue anastomosis on the day after surgery was, in all cases, markedly smaller (72-252 mm2; mean 144 mm2, or 61% of the bone window). The soft tissue anastomosis decreased to between 8 and 208 mm2 (mean 98 mm2; 68% of immediate postoperative value) at 2 weeks and 3-208 mm2 (mean 71 mm2; 49% of immediate postoperative value) at 6 months. 14 of the 16 (88%) dacryocystorhinostomies were functional at the end of the study, the two failures being associated with marked contracture of the soft tissue anastomosis; the outcome of surgery correlated significantly with the area of the anastomosis at 2 weeks (chi 2 = 16.3; p < 0.01) and at 6 months (chi 2 = 16.0, p = 0.01). CONCLUSIONS: B mode ultrasonography provides a simple and effective method for assessing the size of the soft tissue anastomosis after external dacryocystorhinostomy and there is a significant reduction in size after surgery, to which the functional outcome of surgery appears related. As the initial soft tissue anastomosis cannot be larger than (and is, on average, about 60% of) the area of the osteotomy, this emphasises the paramount importance of a large rhinostomy to the success of lacrimal surgery.

Endolacrimal laser assisted lacrimal surgery.

AIMS: To utilise the improved optical qualities of newly developed lacrimal endoscopes and newly miniaturised laser fibres for diagnostic visualisation and laser surgery of the lacrimal system. METHODS: A KTP laser (wavelength 532 nm, 10 W energy) was used for laser assisted dacryocystorhinostomy (DCR) with endolacrimal visualisation in 26 patients. Bicanalicular silicone intubation was placed in all patients for at least 3 months. RESULTS: After 3-9 months of follow up, the silicone tube in all 21 patients who underwent KTP laser DCR are still patent, three patients have eye watering in extremely cold weather and two required a conventional DCR. CONCLUSIONS: The KTP laser generates enough power to open the bony window in DCR surgery. Precise endolacrimal visualisation via a specially designed miniendoscope is essential for surgical success.

Degradation of the 34 amino acid gastrin by rat tissue homogenates.

Extracts of rat kidney contain an enzyme (gastrinase) that is highly specific for degradation of the 34 amino acid gastrin (G34). The Michaelis constant (Km) for kidney is 0.36 +/- 0.04 microM and the Vmax is 9.5 +/- 2.4 nmol X g-1 X min-1. Extracts of liver and brain also have gastrin degrading activity but the enzymes responsible appear to be different from the kidney gastrinase. Km for the liver enzyme is 0.08 +/- 0.02 microM but its Vmax (0.10 +/- 0.02 nmol X g-1 X min-1) is only 1% of the kidney gastrinase; Km for the brain enzyme is 0.10 +/- 0.03 microM but its Vmax (0.023 +/- 0.007 nmol X g-1 X min-1) is even lower than for the liver enzyme. The liver and brain enzymes appear to be less specific than the kidney enzyme with respect to competitive inhibition by insulin and glucagon. Cholecystokinin octapeptide is less inhibitory than the other peptides even though it shares a common C-terminal pentapeptide with G34. These findings are consistent with in vivo studies which have demonstrated that the dog kidney is an important site for extraction and degradation of endogenous dog gastrin but there is little or no hepatic removal of G34.

Characterization of insulinase from mammalian and non-mammalian livers.

The Michaelis constants (Km's) and maximum reaction velocities (Vmax's) for the degradation of beef insulin by livers from frogs, guinea pigs, rats, a rabbit, a dog and a pig were determined. The Km's for mammalian livers appear to be species-dependent and range from 0.25 microM to 0.65 microM. The Km for frog liver was somewhat lower, averaging 0.13 microM. The Km is independent of animal age, but the enzyme concentrations (Vmax) were greatly reduced in the fetal guinea pig and 3 day rat compared to the adult livers. There appears to be no relation between Km and the chemical dissimilarity between beef insulin and endogenous insulin of the species, since guinea pig liver insulinase had a Km (0.50 microM) intermediate between dog (0.47 microM) and pig (0.65 microM) liver insulinase although guinea pig insulin has a markedly different amino acid sequence and biologic activity.

Prenatal diagnosis of orbital heterotopic brain tissue.

Biopsy of fetal tissues is a relatively new procedure for the diagnosis of congenital malformations. The authors report the first case in which this technique has been applied to an orbital mass, in which heterotopic brain tissue was diagnosed by prenatal biopsy and excised in infancy. The wider implications of such intrauterine procedures are discussed.

Combined erbium:YAG and carbon dioxide laser skin resurfacing.

OBJECTIVE: To compare clinical and histological results of 2 different protocols for cosmetic laser skin resurfacing. DESIGN: Masked comparison of 2 cohort groups. PATIENTS: Forty-eight carefully selected patients who met specific inclusion and exclusion criteria for cosmetic laser skin resurfacing. Age, sex, and skin type were matched in both groups. INTERVENTIONS: Twenty-five patients had undergone cosmetic skin resurfacing with 2 impacts of a carbon dioxide laser. Another 23 patients underwent a different protocol involving 2 initial impacts of an erbium:YAG laser to ablate the epidermis followed by a single impact with a carbon dioxide laser. Skin punch biopsy specimens were obtained 1 to 2 weeks after the procedure in both groups of patients. MAIN OUTCOME MEASURES: Time to reepithelialization, duration of erythema, and patient acceptance were compared among 2 patients groups via Student t test. Patients were examined daily until reepithelialization, then weekly for 6 weeks, and then monthly for 6 months. RESULTS: Mean skin reepithelialization time was 7 days (range, 4-9 days) in the combined laser group vs 12 days (range, 9-15 days) in the carbon dioxide laser-only group (P = .04). Mean duration of erythema was 2.5 weeks (range, 1.5-3 weeks) in the combined laser group vs 7 weeks (range, 5-13 weeks) in the carbon dioxide laser-only group (P = .02). All 23 patients (100%) in the combined group but only 15 (60%) of 25 in the carbon dioxide laser-only group were willing to repeat their cosmetic laser surgery (P = .04). There were greater and deeper coagulative changes in the dermis of patients in the carbon dioxide laser-only group compared with those of patients in the combined laser group. CONCLUSIONS: The combined laser protocol showed less significant clinical and histological morbidity than the carbon dioxide laser-only protocol. Patients preferred the combined protocol. Combining these 2 lasers is a safe and patient-friendly alternative to using only the carbon dioxide laser.

Unusual orbital infections.

Because of the confined nature of the orbital space, many disease processes such as cancers, infections, or inflammations present with overlapping clinical manifestations. Also, with the multitude of muscular, neurovascular, sensory, and glandular structures located close to each other in this space, precise anatomic localization of various biologic processes can be difficult. Nevertheless, the aim of this review is to highlight recent publications about unusual orbital infections. The review begins with anatomic and etiologic classification of orbital infectious diseases. It then progresses along an anatomically based scheme to discuss various bacterial and fungal infections. Because of the infrequent occurrence of many of these diseases, emphasis is placed on diagnostic rather than treatment issues. Because of advances in epidemiology, infectious diseases, antibiotic and antifungal pharmacology, and surgical techniques, the majority of orbital infections are relatively benign. This review focuses on those rare and more challenging exceptions.

Lid crease and capsulopalpebral fascia repair in congenital entropion and epiblepharon.

Forty-one eyelids of 21 patients with congenital entropion or epiblepharon underwent transcutaneous reconstruction of the eyelid crease and retractor (capsulopalpebral fascia). All of the patients demonstrated lack of cutaneous-capsulopalpebral fascia attachment. In contrast with the patients with epiblepharon, those with congenital entropion also had partial or complete absence of tarsal-capsulopalpebral fascia attachment. Surgical treatment included anastomosis of the capsulopalpebral fascia, tarsal border, and eyelid skin crease; no skin or muscle was removed. With a minimum follow up of 1 year, malposition recurred in 3 of the 33 (9%) eyelids with epiblepharon, and in none of the 8 eyelids with entropion.

Congenital and acquired blepharoptosis.

Blepharoptosis is a relatively common condition that is frequently encountered by the ophthalmic surgeon. Treatment remains somewhat unpredictable, and the choice of one of the various surgical options depends on the cause of the ptosis and the amount of levator function. Recent contributions to the literature on the classification and management of ptosis are reviewed here.