The Microbiological Profile of Bicanalicular Silicone Tubes Placed During External Dacryocystorhinostomy

Objectives: To identify microbiological growth on bicanalicular silicone tubes (BST) placed during dacryocystorhinostomy (DCR) surgery and to analyze the association between culture results and surgical outcomes and BST removal time. Materials and Methods: A total of 80 lacrimal drainage systems of 68 patients who had external DCR with bicanalicular silicone intubation were included the study. Twenty-five tubes (31.3%) were removed up to 8 weeks, 28 tubes (35.0%) were removed between 9 and 11 weeks, and the remaining 27 tubes (33.7%) were removed 12 weeks or more after surgery. The tubes were transferred to Stuart medium and sent for microbiologic examination. The disc diffusion method was used to determine antibiotic resistance. Results: Culture positivity was observed for 96.2% of the tubes. Among a total of 109 isolates, 63 were gram-positive bacteria (57.8%), 37 were gram-negative bacteria (34%), and 9 were fungi (8.2%). The most commonly isolated gram-positive and gram-negative bacteria were Staphylococcus aureus (66.6%) and Enterobacter spp. (29.7%), respectively. Penicillin, clindamycin, erythromycin, and tetracycline resistances were higher among gram-positive pathogens. Cephalothin, amoxicillin-clavulanic acid, and ampicillin resistances were higher among gram-negative pathogens. There was no significant difference in terms of the microbiological profile between the three groups of removed tubes. Haemophilus influenzae was isolated at a significantly higher rate in patients with surgical failure (p=0.04). Conclusion: Although a variety of agents were isolated from removed BST, gram-positive organisms were more frequent than gram-negatives and fungi. S. aureus and Enterobacter were the most common gram-positive and gram-negative isolates. Later BST removal was associated with the isolation of significantly more bacterial strains per tube. There was no correlation between multiple infections and surgical failure. H. influenzae was more common in failed DCR cases.

Viral nucleic acid analysis with PCR in lacrimal tissue and nasal swab samples of primary acquired nasolacrimal duct obstruction cases.

PURPOSE: To evaluate the role of viral infections in the pathogenesis of primary acquired nasolacrimal duct obstruction. METHODS: The study included 48 patients diagnosed with primary acquired nasolacrimal duct obstruction undergoing dacryocystorhinostomy surgery. Prior to dacryocystorhinostomy surgery, nasal swab sample was taken from the inferior meatus at the same side. During dacryocystorhinostomy, tissue biopsy sample (2 × 2 mm) was taken from the junction area of the lacrimal sac and nasolacrimal duct. Following nucleic acid extraction, polymerase chain reaction was performed. RESULTS: The patients consisted of 9 (18.8%) men and 39 (81.2%) women with a mean age of 51.0 ± 14.3 years. Qualitative polymerase chain reaction showed viral genome in the nasal swabs of 10 (20.8%) patients, including coronavirus 229E (three cases), coronavirus HKU1 (two cases), respiratory syncytial virus (two cases), coronavirus OC43 (one case), coronavirus NL63 (one case), and adenovirus (one case). In the dacryocystorhinostomy samples, viral genomes were detected in four (8.3%) cases, including respiratory syncytial virus (two cases), coronavirus HKU1 (one case), and adenovirus (one case). There was a statistically significant agreement between nasal mucosal swab and dacryocystorhinostomy biopsy samples in terms of respiratory syncytial virus positivity (kappa = 1.000, p = 0.001). CONCLUSION: Although the viral genome was detected in the samples, a direct relationship between viruses and pathogenesis of primary acquired nasolacrimal duct obstruction could not be revealed because of the low number of positive results. However, considering the profibrotic characteristics of specific viruses such as respiratory syncytial virus and adenovirus, viral infections may be one of the many predisposing factors of primary acquired nasolacrimal duct obstruction.

Bilaterally Diffuse Lacrimal Gland Involvement: Initial Presentation of Systemic Sarcoidosis.

Orbital involvement in systemic sarcoidosis is a rare condition. We report a case of orbital sarcoidosis with bilaterally huge lacrimal gland involvement as the initial manifestation of systemic sarcoidosis. A 20-year-old woman admitted the ophthalmology department with progressive bilateral upper eyelid swelling for 6 months. The only pathologic finding was the presence of bilateral, symmetrical, solid, lobular masses at the lateral upper eyelids at the location of lacrimal glands. On systemic examination, bilateral parotid and submandibular glands appeared swollen. Magnetic resonance imaging of the orbit revealed bilateral symmetrical diffuse enlargement of the lacrimal glands with maximum and minimum thickness of 11 mm and 7 mm, respectively. The biopsy findings were compatible with sarcoidosis. Although lacrimal gland involvement has been reported in different studies, we for the first time report an unusual case with bilateral diffuse huge lacrimal gland involvement. Normal lacrimal gland thickness is approximately 4-5 mm in magnetic resonance imaging, while our case had bilateral diffuse enlargement of lacrimal glands, which showed maximum and minimum thickness of 11 mm and 7 mm, respectively. Although orbital involvement is uncommon in sarcoidosis, it should be remembered in the differential diagnosis of orbital masses.

The effect of topical cyclosporine A on clinical findings and cytological grade of the disease in patients with dry eye.

PURPOSE: To compare the clinical findings and the cytological grade of the disease before and after 6 months of topical cyclosporine A treatment in patients with dry eye. SETTING: : This single-center prospective study was performed at the Department of Ophthalmology, Ankara University School of Medicine, between January 2007 and June 2008. METHOD: Forty-five patients with dry eye (with 5 mm/5 minutes or less Schirmer test) were included in the study. Patients were treated with cyclosporine A 0.005% ophthalmic emulsion (RESTASIS) twice daily in addition to lubricant eyedrops 5 times a day. Schirmer test values, tear breakup time (BUT), and impression cytology (goblet cell density, nucleus to cytoplasmic ratio, and epithelial cell morphology) were evaluated at baseline and after 6 months. RESULTS: Before and after 6 months of the treatment with topical cyclosporine A, the median Schirmer test scores were found as 3.00 and 4.00 mm, respectively. The median BUT score at baseline was 4.00 seconds, and after treatment, the median score was 5.00 seconds. There were statistically significant differences in the median Schirmer and BUT values between, before, and after 6 months of treatment (P < 0.05). The mean cytological grade according to Nelson grading system was 1.84 at baseline and 1.51 after treatment with topical cyclosporine A for 6 months. Statistically significant improvement in cytological grades after treatment was observed (P < 0.05). CONCLUSION: Treatment of patients with dry eye for 6 months with topical cyclosporine A resulted in an increase in Schirmer test results, an increase in BUT scores, and an improvement in cytological grade of the disease.

Ultrasound biomicroscopic evaluation of the efficacy of a transillumination technique for ciliary sulcus localization in transscleral fixation of posterior chamber intraocular lenses.

PURPOSE: To evaluate the efficacy of the transillumination technique for precisely locating the ciliary sulcus in transscleral fixation of posterior chamber intraocular lenses (PC IOLs) by determining the haptic positions with ultrasound biomicroscopy (UBM). SETTING: Department of Ophthalmology, Numune Training and Research Hospital, Ankara, Turkey. METHODS: Ultrasound biomicroscopy was used to determine the haptic positions in eyes with ab externo transsclerally fixated PC IOLs. Eyes were randomly assigned to a control group, in which transscleral fixation of a PC IOL was performed, or an endoilluminator-assisted group, in which transscleral fixation was combined with transillumination. RESULTS: The study evaluated 33 eyes of 28 patients ranging in age from 16 to 81 years. The control group comprised 19 eyes (17 patients) and the endoilluminator-assisted group, 14 eyes (12 patients). All haptics were easily visualized with UBM. The UBM examination showed that the rate of haptics located in the sulcus was statistically significantly higher in the endoilluminator-assisted group (64%) than in the control group (24%) (P= .001). There was no significant difference in either group in the rate of precise sulcus location between the straight needle and the 28-gauge insulin needle (P> .05). CONCLUSIONS: Ultrasound biomicroscopy showed the difficulty in reliably suturing the haptics in the ciliary sulcus, even with the use of a transillumination technique. However, the results suggest that the transillumination technique is a safe and easy procedure and helps the surgeon identify the ciliary sulcus during transscleral fixation of PC IOLs more precisely than without the use of transillumination.

The use of ultrasound biomicroscopy in the evaluation of anterior segment tumors and simulating conditions.

PURPOSE: To report the ultrasound biomicroscopy (UBM) findings of anterior segment tumors and simulating conditions. METHODS: Thirty-five patients underwent UBM. Of those, 16 had histopathologically or cytopathologically diagnosed tumors, and 19 had clinically diagnosed lesions. RESULTS: The study material comprised 13 iris pigment epithelial (IPE) cysts, 7 ciliary body melanomas, 4 iris melanomas, 4 iris nevi, 3 intraocular invasions of conjunctival squamous cell carcinoma, 2 ring melanomas of the anterior chamber angle, 1 medulloepithelioma and 1 pars plana cyst. On UBM, all IPE cysts presented as cystic lesions with a thin cyst wall and no solid components. All ciliary body melanomas showed low to medium reflectivity, with cavitation in one case and extraocular extension in another. Iris melanomas presented as anterior (stromal) iris lesions with medium to high internal reflectivity. There was irregularity and convex bowing of the posterior iris plane in iris melanomas, a feature not seen in iris nevi. Intraocular invasion of conjunctival squamous cell carcinoma was evidenced as areas of medium to high reflectivity in the ciliary body and iris, loss of the acute angle shape and highly reflective spots in the anterior chamber. CONCLUSIONS: UBM was particularly useful in the diagnosis of IPE cysts, in the visualization of small ciliary body melanomas, in the differentiation of iris melanomas from iris nevi and in the demonstration of intraocular invasion from conjunctival squamous cell carcinoma.

The results of late probing in congenital nasolacrimal duct obstruction.

PURPOSE: To evaluate the results of lacrimal probing in children at or older than 1 year of age with congenital nasolacrimal duct obstruction. MATERIALS AND METHODS: Fifty eyes of 38 children (24 males, 14 females) with congenital epiphora who underwent nasolacrimal duct probing were evaluated in a prospective study. The age of the patients was between 12 and 101 months (mean: 33 months). Success of probing was defined as complete resolution of preoperative symptoms and signs. The mean follow-up was 8 months (3-28 months). RESULTS: The success rate of probing was 88% (44/50 eyes). Residual epiphora was observed in 6 eyes of 4 patients (12%). Age of the patient, gender, the frequency of epiphora before probing and the unilaterality or bilaterality of epiphora did not correlate with the success of probing (p > 0.05). CONCLUSION: Nasolacrimal duct probing is advocated as a primary treatment in children younger than 9 years of age before proceeding to more complex treatment options. Unsuccessful probing may result from the selection of nonmembranous obstructions rather than the increased age of the patients.

Drug-induced intraocular lens movement and near visual acuity after AcrySof intraocular lens implantation.

PURPOSE: To evaluate the factors influencing AcrySof intraocular lens (IOL) (Alcon Laboratories) movement and near visual acuity after cyclopentolate 1% and pilocarpine 2%. SETTING: Department of Ophthalmology, University of Ankara, Ankara, Turkey. METHODS: Thirty eyes of 22 patients with AcrySof IOL implantation were included in this prospective study. Near visual acuity (Jaeger) at 35 cm through best distance correction without an add and pupil diameter were measured and correlated with anterior chamber depth (ACD) measured with ultrasound biomicroscopy (UBM) after application of cyclopentolate 1% and pilocarpine 2%, respectively. The magnitude of the change in the ACD was correlated with the accommodation amplitude, patient age, time interval between surgery and imaging, preoperative axial length, capsulorhexis diameter, ACD during cycloplegia, IOL diameter, and presence of posterior capsule opacification (PCO). RESULTS: Near visual acuity significantly decreased after application of cyclopentolate 1% and increased after application of pilocarpine 2% (P < .001) in all eyes. The IOL moved anteriorly in 8 (26%) eyes and posteriorly in 22 (74%) eyes after pilocarpine 2%. There was no correlation between the ACD and near visual acuity under cyclopentolate 1% (r = 0.06, P > .05) or pilocarpine 2% (r = 0.04, P > .05). There was a moderate correlation between the anterior IOL movement and accommodation amplitude (P < .05, r = 0.42). There was no correlation between the magnitude of the IOL movement and patient age, time interval between surgery and imaging, the preoperative axial length, capsulorhexis diameter, ACD during cycloplegia, IOL diameter, and the presence of PCO (P > .05). CONCLUSIONS: There was better near visual acuity in all eyes with the AcrySof MAIOL, although most IOLs move slightly backward after of pilocarpine 2%. This points out pseudoaccommodation rather than pseudophakic accommodation. Ultrasound biomicroscopy is useful in determining the ACD and the relation between the IOL and the surrounding tissues after cataract surgery.

Ultrasound biomicroscopy of the levator aponeurosis in congenital and aponeurotic blepharoptosis.

PURPOSE: To evaluate and measure the thickness of the levator aponeurosis by ultrasound biomicroscopy in congenital dysmyogenic and aponeurotic blepharoptosis. METHODS: Forty-four upper eyelids of 22 patients who had unilateral blepharoptosis were evaluated by ultrasound biomicroscopy. The patients ranged in age from 13 to 69 years (mean, 35.4 +/- 20.2 years). Fourteen patients were male and 8 patients were female. Seven patients had congenital dysmyogenic blepharoptosis and 15 patients had aponeurotic blepharoptosis. Imaging was performed with a 50-MHz transducer. The thickness of the levator aponeurosis was measured centrally at the upper border of the tarsus. RESULTS: The levator aponeurosis was imaged in all eyelids except for one eyelid with aponeurotic blepharoptosis. The mean thickness of the levator aponeurosis was 0.39 +/- 0.10 mm in the ptotic eyelid and 0.42 +/- 0.09 mm in the control eyelid of the patients with congenital dysmyogenic blepharoptosis (p = 0.043). The mean thickness of the levator aponeurosis was 0.26 +/- 0.05 mm in the ptotic eyelid and 0.36 +/- 0.04 mm in the control eyelid of the patients with aponeurotic blepharoptosis (p = 0.001). The thickness of the levator aponeurosis was correlated with the palpebral fissure height (p = 0.013, r = 0.644) in aponeurotic blepharoptosis. The thickness of the levator aponeurosis was correlated with the levator function (p = 0.033, r = 0.795) in congenital dysmyogenic blepharoptosis. CONCLUSIONS: The thickness of the levator aponeurosis can be measured with ultrasound biomicroscopy. The most common pathology in aponeurotic blepharoptosis is thinned-out aponeurosis. The levator aponeurosis of the ptotic eyelid is thinner than the normal eyelid in congenital ptosis.

Congenital ptosis and associated congenital malformations.

We report a case of unilateral congenital ptosis which is associated with ocular and systemic congenital malformations including mild microphthalmia, microcornea, cataract, iris and chorioretinal coloboma, ectopic kidney, and ventricular septal defect. An inciting factor, acting during the second month of gestation, may affect the development of the eye, heart, and abdomen and may lead to congenital malformations. Although congenital ptosis rarely presents with ocular and systemic congenital malformations, ophthalmologists should be alert for the possibility of coexisting structural defects. Congenital ptosis is a muscular dystrophy demonstrated by various degrees of muscular degeneration and it may rarely be associated with ocular and systemic congenital malformation. Here, we report a case of congenital ptosis associated with more than one ocular and systemic malformation.

Diplopia and enophthalmos after surgical repair of blowout fracture.

PURPOSE: To evaluate the incidence of residual diplopia and enophthalmos and the possible risk factors leading to their occurrence in patients who had orbital blowout fracture repair. METHODS: Forty-two patients with pure orbital blowout fracture who had at least 6 months postoperative follow-up were included in the study group. Nineteen (45.2%) patients had orbital floor, two (4.8%) patients had medial orbital wall and 21 (50%) patients had a combination of orbital floor and medial orbital wall fractures. The fracture was reconstructed with porous polyethylene (Medpore) in 22, supramide in 12 and gelatin (Gelfilm) in 8 orbits. Mean postoperative follow-up was 11 months. RESULTS: Preoperatively, 35 patients (83%) had diplopia and 13 patients (30.9%) had enophthalmos greater than 2 mm. Of 35 patients who had preoperative diplopia, only 7 (17%) patients experienced diplopia postoperatively. Diplopia improved 1 to 4 weeks (mean, 3 weeks) following surgery in 28 patients. Timing of surgery and age of the patient were significant for the development of postoperative diplopia (p < 0.05). Sex, location of the blowout fracture and the alloplast material were not found to be significant for the development of postoperative diplopia (p > 0.05). Enophthalmos persisted in three (7%) patients postoperatively. CONCLUSION: Old patients were more likely to have residual postoperative diplopia. Surgical repair of blowout fractures within two weeks of trauma decreases the incidence of residual diplopia.

Risk factors for secondary membrane formation after removal of pediatric cataract.

PURPOSE: To evaluate the incidence of secondary membrane formation, factors that lead to its development, and the frequency of procedures to treat these membranes in children after cataract surgery. SETTING: Department of Pediatric Ophthalmology, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA. METHODS: Clinical records of 152 patients (190 eyes) who had cataract extraction between January 1986 and 1996 were reviewed retrospectively. The mean follow-up was 6 years (range 2 to 13 years). Cataract surgery was performed through a limbal incision in all cases. Twenty-eight eyes had a primary posterior capsulectomy, and 120 eyes had posterior capsulectomy combined with an anterior vitrectomy. In 42 eyes, the posterior capsule was left intact. Nineteen eyes received a primary intraocular lens (IOL), 15 eyes received a secondary IOL, and 156 eyes were rehabilitated with spectacles or contact lenses. RESULTS: Seventy-two eyes (37.9%) developed secondary membrane a mean of 8.9 months postoperatively (range 3 weeks to 53 months). Membranes occurred in 78.6% of eyes with an intact posterior capsule, 42.9% with posterior capsulectomy, and 22.5% with combined posterior capsulectomy and anterior vitrectomy. Secondary membrane formation was associated with not performing a posterior capsulectomy with anterior vitrectomy (P < .001) and the presence of a primary IOL (P < .001). Younger age at surgery increased the chance of secondary membrane formation in patients who had posterior capsulectomy and anterior vitrectomy (P < .01). CONCLUSIONS: The younger the child at cataract surgery, the greater the risk of secondary membrane. Primary posterior capsulectomy combined with an anterior vitrectomy decreased but did not eliminate the incidence of secondary membrane.

The role of Tc-99m polyclonal human immunoglobulin G scintigraphy in Graves' ophthalmopathy.

OBJECTIVE: The aim of this study was to clarify whether Tc-99m HIG (Polyclonal Human Immunoglobulin G) can image and determine the severity of orbital involvement in patients with Graves' ophthalmopathy. MATERIALS AND METHODS: Twenty-six patients between 19 and 56 years old with Graves' ophthalmopathy were examined. All patients received approximately 370 MBq Tc-99m HIG by i.v. injection. Planar and SPECT examination were performed 4 hours after the injection. Visual and semiquantitative evaluations were performed for both orbits by two independent observers, RESULTS: Clinically active ophthalmopathy patients had noticeably increased orbital accumulation of Tc-99m HIG. In patients with inactive disease, and 14 of 19 had no uptake, whereas 5 patients had orbital radioactivity accumulation. The duration of Graves' ophthalmopathy did not correlate with the presence of active ophthalmopathy and Tc-99m HIG grade. There was no correlation between clinical classification and clinical activity (r = 278). There was a good correlation between clinical activity and the radioactivity grade with r = 0.666 (p = 0.01). The clinical classification closely correlated with Tc-99m HIG grade (r = 0.423, p = 0.05). CONCLUSION: Tc-99m HIG scan can clearly identified clinically active patients, and subclinicial inflammation can be shown by this scintigraphic evaluation. The current preliminary results suggested that Tc-99m HIG SPECT might be useful for the assessment of disease activity in Graves' ophthalmopathy.

Surgical treatment of cicatricial ectropion in lamellar ichthyosis.

BACKGROUND. Lamellar ichthyosis is a skin disorder that is frequently associated with cicatricial ectropion and lagophthalmos. The authors present the surgical management of cicatricial ectropion in a case with lamellar ichthyosis. PATIENT AND METHODS. A 2-year-old male presented with bilateral cicatricial ectropion of the upper and lower eyelids. He had lagophthalmos and corneal punctuate staining. His skin was totally involved with the disease process except his prepuce. The patient was circumcised, and after the correction of horizontal eyelid laxity, the penile skin graft was sutured into the defects in all four eyelids. RESULTS. 18 months following surgery the patient had no lagophthalmos or corneal exposure, but had slight ectropion at the temporal side of the left lower eyelid. He had no complications from the circumcision. CONCLUSION. Prepuce is an alternative donor tissue in male patients with no other available donor site. To our knowledge, this is the second report of cicatricial ectropion corrected with a penile skin graft.

The role of enophthalmos in the development of involutional ectropion.

PURPOSE: This prospective study was performed to evaluate whether there is an association between enophthalmos and involutional ectropion. METHODS: Hertel exophthalmometric measurements were obtained from 31 patients with involutional ectropion and from 30 control patients who were age- and sex-matched. RESULTS: Eighteen patients had bilateral ectropion and 13 patients had unilateral ectropion. The mean of the exophthalmometric measurements of the eyes with ectropion was 12.67 +/- 2.48 (SD) mm. The mean of the exophthalmometric measurements of the control patients was 12.80 +/- 2.87 (SD) mm in the right eye and 12.83 +/- 2.93 (SD) mm in the left eye. The difference between the eyes of the patients and the controls was not statistically significant (p>0.05). In the affected eyes of the patients with unilateral ectropion, the mean exophthalmometric value was 13.15 +/- 2.51 (SD) mm, and in the unaffected eyes of the patients, the mean exophthalmometric value was 13.07 +/- 2.56 (SD) mm. This difference was not statistically significant either (p>0.05). CONCLUSION: Patients with involutional ectropion do not have more enophthalmos than the age- and sex-matched normal population. This study does not suggest an association between enophthalmos and involutional ectropion.