Results of Endoscopic Dacryocystorhinostomy under Local Anesthesia with Minimal Sedation.

PURPOSE: We evaluated the tolerability and efficacy of endoscopic dacryocystorhinostomy (Endo-DCR) in patients treated in the leaning position and under local anesthesia with minimal sedation (LAS). STUDY DESIGN: Questionnaire to determine subjective success of Endo-DCR. METHODS: From May 2013 to August 2014, a total of 95 eyes with epiphora presented to the Myoung Eye Plastic Surgery Clinic in Seoul, Korea, and were treated with Endo-DCR under LAS. Three nerve blocks were administered to achieve local anesthesia. Postoperatively, the wound site was packed with Nasopore to control bleeding and promote wound healing. Outcome measures included a patient questionnaire completed on postoperative day 7 to evaluate intraoperative and postoperative pain based on the VAS (0 to 10). RESULTS: Mean intraoperative and postoperative pain scores were 1.03 and 1.64, respectively, for 95 eyes. Of the 95 eyes treated, the patients in 82 eyes (86.31%) reported that they would prefer LAS over GA for a repeat Endo-DCR. The subjective and objective surgical success rates were 90.14% and 95.77%, respectively. CONCLUSIONS: Endo-DCR carried out under LAS with the patient in the leaning position is more useful, efficient, and feasible than Endo-DCR performed under GA with the patient in the supine position.

Direct visualization of aqueous tear secretion from lacrimal gland.

PURPOSE: To introduce a new method for direct observation of tear secretion from the palpebral lobes of the main lacrimal glands and Wolfring glands using fluorescein dye. METHODS: Twenty-six patients with dry eye and 26 healthy subjects were included in the study. Fluorescein was applied to the conjunctiva overlaying the palpebral lobe of the main lacrimal glands. Under cobalt blue light, we captured tear secretion from the glands in movies. We compared the number of excretory openings, the location and tear flow rate between the dry eye and healthy-subject groups. To observe tear secretion from the Wolfring glands, we everted the upper lids and applied fluorescein dye to the upper margin of the tarsus. RESULTS: Mean number of excretory openings on the palpebral lobe was 2.5 in the dry eye group and 3.4 in the healthy-subject group (p = 0.031). Most of the openings were observed at the ridge, the most protruding portion of the palpebral lobe. Mean flow rate from the palpebral lobe was 0.45 µl/min in the dry eye group and 0.91 µl/min in the healthy-subject group (p = 0.046). Mean flow rate from the Wolfring glands was 0.007 µl/min in the dry eye group and 0.009 µl/min in the healthy-subject group (p = 0.615). CONCLUSION: This visualization method allowed us to directly observe tear secretion from the palpebral lobe of the main lacrimal glands and Wolfring glands, and to quantitatively measure the tear flow rate from the lacrimal glands.

The Effect of Topical Diquafosol Tetrasodium 3% on Dry Eye After Cataract Surgery.

PURPOSE: To evaluate the effectiveness of 3% diquafosol tetrasodium for treating dry eye after cataract surgery. METHODS: Among patients who underwent bilateral cataract surgery, 34, who met the diagnostic criteria for dry eye syndrome 1 week postoperatively, were enrolled. Patients were randomly assigned to receive 3.0% diquafosol tetrasodium ophthalmic solution in one eye and 0.9% saline in the other eye four times daily for 8 weeks. Dry eye severity was measured at 1, 5, and 9 postoperative weeks using the Schirmer 1 test (SIT), tear film breakup time (TBUT), and fluorescein corneal staining. tear meniscus height (TMH), tear meniscus depth (TMD), and tear meniscus area (TMA) measured using Fourier-domain optical coherence tomography and symptom questionnaire scores. RESULTS: TBUT and corneal staining significantly improved 8 weeks postoperatively in eyes treated with 3.0% diquafosol tetrasodium (p < 0.01, p < 0.01) and were better than normal saline-treated eyes (p < 0.01, p < 0.01). SIT did not improve (p = 0.26). TMH, TMD, and TMA did not improve at 4 and 8 weeks. All symptom questionnaire scores improved in eyes treated with 3.0% diquafosol tetrasodium (all p < 0.01). CONCLUSION: The 3.0% diquafosol tetrasodium treatment improved tear film stability and subjective symptoms of dry eye after cataract surgery. Increased mucin production as a result of diquafosol treatment may have caused these results.

Assessment of the Tear Meniscus Using Optical Coherence Tomography in Patients With Type 2 Diabetes Mellitus.

PURPOSE: To analyze tear meniscus dimensions with Fourier domain-optical coherence tomography (FD-OCT) in patients with type 2 diabetes mellitus. METHODS: Patients with type 2 diabetes without diabetic retinopathy (DR) (n = 54), with nonproliferative DR (n = 45), with proliferative DR (PDR) (n = 25), and controls (n = 45) were enrolled. Hemoglobin A1c and Early Treatment Diabetic Retinopathy Study (ETDRS) stages of DR were evaluated. Schirmer test (ST), tear breakup time test, and fluorescein corneal staining were carried out. Tear meniscus height (TMH), tear meniscus depth (TMD), and tear meniscus area (TMA) were obtained by FD-OCT. RESULTS: TMH, TMD, and TMA in the diabetes and control groups were 233 ± 79 µm, 148 ± 53 µm, and 0.026 ± 0.015 mm, and 261 ± 67 µm, 167 ± 49 µm, and 0.032 ± 0.017 mm, respectively. All parameters were lower in diabetes (all P < 0.01). And the values in PDR were 185 ± 90 µm, 117 ± 50 µm, and 0.017 ± 0.010 mm which were lower than those in control and nonproliferative DR (227 ± 71 µm, 144 ± 50 µm, and 0.023 ± 0.010 mm) (all P < 0.01). TMH, TMD, and TMA correlated with ST (P < 0.01, P = 0.02, and P < 0.01, respectively) and the corneal staining score (all P < 0.01). Patients with longer diabetes duration and a history of panretinal photocoagulation showed significantly decreased TMH, TMD, and TMA (P < 0.01). CONCLUSIONS: OCT, along with tear breakup time and ST, is an effective way to assess tear function in type 2 diabetes. Patients with PDR and a history of panretinal photocoagulation showed lower tear meniscus parameters. The decrease in tear meniscus parameters was correlated with diabetes duration.

Comparison of Tear Meniscus Height Measurements Obtained With the Keratograph and Fourier Domain Optical Coherence Tomography in Dry Eye.

PURPOSE: To study the repeatability and reproducibility of tear meniscus height (TMH) measurements obtained with a keratograph and Fourier domain optical coherence tomography (FD-OCT) and to assess their agreement in patients with dry eye. METHODS: Sixty-four eyes with dry eye were analyzed by the Schirmer test, tear breakup time test, and fluorescein corneal staining. The TMH was measured 3 times using both devices by 2 different examiners. The repeatability and reproducibility of measurements were assessed by within-subject standard deviation (Sw), repeatability (2.77 Sw), coefficient of variation (CoV), and intraclass correlation coefficient. RESULTS: The TMH measured with the keratograph and FD-OCT was 0.232 ± 0.074 mm and 0.308 ± 0.129 mm, respectively (P < 0.01). A close correlation was found between the TMH measured with the keratograph and FD-OCT (r = 0.343). There was a negative correlation between the mean TMH and differences in the TMH measured with the keratograph and FD-OCT (r = 0.359). Both measurements correlated with the Schirmer test score, tear breakup time, and corneal staining score with P < 0.01. Intraexaminer CoV, 2.77 Sw, and intraclass correlation coefficient of the TMH were <6.5%, <0.059 mm, and >0.986, respectively, and interexaminer CoV and 2.77 Sw were 5.58% and 0.039 mm, respectively. CONCLUSIONS: Although the TMH measured with the keratograph tended to be lower than that measured with FD-OCT, the TMH measured with the keratograph closely correlated with the TMH measured with FD-OCT and conventional tests and had good repeatability and reliability.

A patient with combined corneal and ingrowing conjunctival tissue tattooing by micropigmentation method.

PURPOSE: This report describes the clinical efficacy of combined corneal and conjunctival micropigment tattooing for the treatment of a corneoconjunctival opacity. CASE SUMMARY: Combined corneal and conjunctival micropigment tattooing was performed on a 39-year-old man who had a cosmetic problem due to traumatic corneoconjunctival opacity. After removal of the corneal epithelium, a 30-gauge needle filled with dye was placed into the corneal stroma. The dye was injected into the stroma and conjunctiva. The patient was followed up for 24 months postoperatively. Although some of the dye dissipated, the majority of it remained in place 24 months after surgery. The patient had no specific postoperative complications and was satisfied with the surgical results. We obtained cosmetically good results. CONCLUSIONS: Combined corneal and conjunctival micropigment tattooing can be an effective treatment for patients with a corneoconjunctival opacity.

DIY guide-needle-assisted conjunctivodacryocystorhinostomy (CDCR).

In this study, we introduce DIY guide-needle-assisted conjunctivodacryocystorhinostomy (CDCR), in which a guide needle helps in measuring the initial Jones tube length for insertion and reduces unnecessary handling for tube changes. Three CDCR procedures were conducted in which the length of the Jones tube was calculated using a 22-gauge DIY guide needle, and a prospective study of tube position change and migration, (a major cause of CDCR failure) was done. Wound healing was almost complete within 4 weeks postoperatively in the osteotomy site, but in cases of partial middle turbinectomy, a little more time was necessary. There was a slight change in Jones tube position in the nasal cavity compared with the expected position of original tube tip, but no tube migration from the caruncle fixation position had occurred by the final follow-up time. This guide-needle-assisted CDCR has multiple advantages, such as easy measurement of the proper initial tube size, utilization of the initial needle path, and easy replacement of tubes. Finally, this approach to CDCR can be readily applied because it uses materials ordinarily found in hospitals to create the devices needed for the procedure, so there is no additional cost.

Treatment for trichiasis through a combination of eyelash trephination and electrocautery.

PURPOSE: This article introduces 3-mm-deep eyelash trephination combined with electrocautery as a way to increase the success rate for treatment for trichiasis. METHOD: We have modified surgical instruments, ready-made ophthalmic microtrephine and cautery tip for a 3-mm-deep eyelash trephination and electrocautery. After eyelash trephination with microtrephine, electrocautery was added with a bended cautery tip after embedding in the trephination site. The trephined eyelids were photographed biweekly and checked for recurrence until 8 weeks after operation. RESULT: Eyelash trephination combined with electrocautery was carried out on 20 Korean patients. The number of removed cilia was 109. Of these, the number of successfully removed hair follicles was 89. During 8 weeks, the total recurring rate of eyelash trephination combined with electrocautery was 17%. In the case of hair follicle removal success with electrocautery, the recurring rate was as low as 11%, but in the case of hair follicle removal failure with electrocautery, recurring rate is 45%. We checked the depth of removed eyelash follicles, and the mean depth was 2.03 ± 0.085 mm in this study. No serious complication was found during the period of this study. CONCLUSION: The eyelash trephination combined with electrocautery for trichiasis is a method with a low recurrence rate and few complications.

Outcomes of levator resection in blepharoptosis patients with grafted corneas.

PURPOSE: To present the surgical results of, and postoperative complications after, resection of the levator aponeurosis as a treatment for aponeurotic blepharoptosis in patients with grafted corneas. METHODS: Nine eyes with grafted corneas displaying aponeurotic blepharoptosis were investigated. Undercorrective resection of levator aponeurosis was performed on all nine patients. The margin reflex distance 1 (MRD1) values prior to the operation and at 7 days and 6 months after the operation were compared. The postoperative MRD1 values of patients with both poor and fair levator function were also evaluated. Differences in visual acuity and visual field before and after surgery were also assessed. RESULTS: The MRD1 values at 7 days and 6 months after the surgery were higher than before surgery, and there was no difference between the MRD1 values of patients with poor and fair levator function at these time points. Levator function 6 months after surgery improved compared with that before surgery. Neither visual acuity nor the visual field changed after the blepharoptosis surgery. There was no preoperative corneal problem in any patient, and postoperative corneal erosion in some patients resolved with only conservative care. CONCLUSIONS: In blepharoptosis patients with grafted corneas, the undercorrection of blepharoptosis by levator resection showed satisfactory surgical results regardless of levator function status (poor or fair), and did not adversely affect the survival of grafted corneas.

Retinal ganglion cell death induced by endoplasmic reticulum stress in a chronic glaucoma model.

This study investigated whether endoplasmic reticulum (ER) stress induced retinal ganglion cell (RGC) death in chronic ocular hypertension, one of the RGC death mechanisms, using an experimental glaucoma rat model. Glaucoma was induced in adult male Sprague-Dawley rats by cauterizing three episcleral veins. The intraocular pressure (IOP) remained elevated in the cauterized eyes for the 8-week experiment, whereas it was not elevated in the contralateral control eyes. The average number of RGCs decreased significantly, and TUNEL-positive cells were detected in the ganglion cell layer. In western blotting, Bip, the phosphorylated form of PKR (p-PERK), and C/EBP-homologous protein (CHOP) were significantly expressed at 1 or 2 weeks, and this persisted throughout the 8-week experiment. Phosphorylated eukaryotic initiation factor 2 (p-eIF2alpha) began to increase at 1 week, was sustained through 4 weeks, and decreased slightly at 8 weeks. In cauterized eyes, strong p-PERK and CHOP immunoreactivity was observed in ganglion cells after 8 weeks of IOP elevation. Taken together, in the experimental chronic glaucoma model, ER stress is involved in RGC death, and the PERK-p-eIF2alpha-CHOP pathway plays a role in the RGC apoptosis associated with ER stress. This might be a good therapeutic target to protect RGCs from ER stress injury in glaucoma.