Success rate of late primary probing in congenital nasolacrimal duct obstruction.

PURPOSE: To investigate the clinical outcomes of late primary probing in congenital nasolacrimal duct (NLD) obstruction. METHODS: A prospective interventional study was designed to recruit children older than 24 months who presented with clinical manifestations of NLD obstruction since February 2008 to Farabi Eye Hospital, Tehran, Iran. No prior surgical intervention for NLD obstruction was performed on these patients; they underwent probing of the nasolacrimal system and irrigation under general anesthesia by oculoplastic surgeons. The outcome of the procedure was assessed 2 to 3 months postoperatively. Data of the patients until February 2013 were considered for analysis. RESULTS: The total number of patients during the 5-year study was 343. The total success rate considering all of the age groups was 75.8%. The success rate was 85% in those who were 2 to 3 years old, 63% in those who were 3 to 4 years old, and 50% in those who were 4 to 5 years old. In patients with chronic dacryocystitis with mucopurulent discharge, 83% had successful probing and irrigation. In patients with epiphora with no mucopurulent discharge, 59% had successful results with probing. CONCLUSIONS: In the cases of congenital NLD obstruction, primary probing before 2 years of age has a high success rate; there is a high overall success rate (75.8%) in the 2- to 5-years age group, but when older than 5 years, further procedures such as intubation and dacryocystorhinostomy would be needed because of the high failure rate of probing.

Surgical waiting times for ocular and periocular cancer patients in Toronto.

BACKGROUND: The purpose of this study was to evaluate surgical waiting times experienced by intraocular and periocular cancer patients in Toronto and to assess the period of greatest delay between certain stages of ocular cancer care. METHODS: A retrospective chart review was performed on cases of adult patients who underwent surgery between January 2002 and December 2004 for malignant or premalignant tumours of the eye and ocular adnexa. Waiting time intervals were calculated between 5 time points: initial presentation to referring physician or optometrist, date of referral to oculoplastics or ocular oncology, initial assessment, consent date, and surgery date. Total surgical waiting time was the period between the initial presentation and surgery date. RESULTS: The mean total surgical waiting time was 85.93 (standard error [SE] 212.70) days. The 5% trimmed mean total waiting time was 51.07 days. The longest mean total waiting time averaged 94.16 (SE 18.69) days for patients with orbital or lacrimal tumours. For all patients, the interval of greatest delay was between initial assessment and consent (according to means) or between referral and initial assessment (according to 5% trimmed means). For patients with lid, brow, or conjunctival tumours the interval of greatest delay was between referral and initial assessment, and for those with orbital, lacrimal, or intraocular tumours it was between initial assessment and consent. INTERPRETATION: By measuring the period between consent and surgery, the Ontario government is not measuring the interval of greatest delay in ocular cancer care. The wait-time registry may benefit from including data from patients with periocular tumours.

Identification of retained intracanalicular plugs with ultrasound biomicroscopy.

BACKGROUND: Punctal plugs may be associated with complications, the most common being secondary epiphora due to canalicular obstruction. Simple lacrimal irrigation will diagnose an obstruction within the canaliculus but will not determine whether the plug is still present at the site of the obstruction. We performed a study to determine the feasibility of imaging retained intracanalicular plugs with ultrasound biomicroscopy (UBM). METHODS: We performed in vitro evaluation of an EagleVision punctal plug and a Herrick intracanalicular plug to obtain information about the UBM characteristics of the two plugs. We then performed UBM in two patients with suspected intracanalicular plugs, one with prolapse of an EagleVision punctal plug into the canaliculus and one with bilateral epiphora secondary to inserted intracanalicular Herrick plugs. RESULTS: In both cases, UBM enabled location of the plugs within the canalicular system at the level of obstruction. INTERPRETATION: UBM is a useful diagnostic tool in determining the presence and location of a presumed retained intracanalicular plug, either placed directly within the canaliculus or prolapsed into the canaliculus from a punctal position.

A new, wider-diameter Crawford tube for stenting in the lacrimal drainage system.

PURPOSE: To determine whether technology is available to secure a larger-diameter Crawford tube swedged onto the metal Crawford introducer and to use the system in a closed intubation to treat a failed dacryocystorhinostomy. METHODS: A metal ferrule has been developed to swedge a larger-diameter Crawford tube onto the standard Crawford probe. Seven patients with failed dacryocystorhinostomy procedures were treated with probing and intubation with the use of this larger-tube Crawford system. RESULTS: Six of the 7 patients had patent lacrimal systems after the tubes were removed, a result comparable to open revision after a failed dacryocystorhinostomy. In each case, on insertion, the tube remained firmly attached to the Crawford probe and did not dislodge. CONCLUSIONS: The technology of using a metal ferrule at the junction of the standard Crawford probe and a larger silicone tube was successful in creating a Crawford system with greater dilation capability than the standard Crawford system. The technique of probing and intubation with this larger Crawford system may be a simple alternative to open revision of a failed dacryocystorhinostomy procedure.

The surgical management of thyroid ophthalmopathy

It is mandatory to determine whether the patient with thyroid eye disease is in the acute, sub-acute (inflammatory) phrase or the chronic (burnt out) phrase. Patients in the inflammatory phrase are best treated with either anti-flammatory drugs (steroids, immunosuppressives), or radiotherapy. Patients in the burnt-out (fibrotic) phrase are best treated with surgery if required. There are three types of surgery in thyroid eye disease: 1. Eye lid surgery (lid lengthening, blepharoplasty, tarsorrhaphy) which may be performed for cosmetic purposes, or, more frequently, to protect the cornea. 2. Strabismus surgery, mainly recessions of the inferior rectus and/or medial rectus muscles, if the patient is unhappy with prisms. 3. Orbital decompression either via the trans-ethmoidal route for unremitting optic neuropathy, or the lateral route for exophthalmos without optic neuropathy.(AU)

Management of orbital and adnexal trauma

Ocular adnexal trauma involve the eyelids, orbit, or lachrymal system. Management of complex orbital and ocular adnexal trauma should involve a multidiscplinary approach. Life-and-sight-threatening injuries must be recognised and treated appropriately. Adherence to the fundamentals of trauma management and a stepwise, systemic approach to ocular and adnexal examination reduce the likelihood that serious injuries will be missed. After all injuries have been identified, they should be repaired appropriately to optimize both functional and cosmetic outcomes.(AU)

The correlation of clinical lacrimal bone density and thickness, established at the time of DCR surgery, with systemic bone mineral densitometry testing.

BACKGROUND. Due to a growing concern with regard to the relationship between osteoporosis and fractures, we wished to examine the correlation of systemic bone density with lacrimal bone characteristics (thickness and density), as measured at the time of dacryocystorhinostomy (DCR). Significant correlation would suggest that oculoplastic surgeons may screen for osteoporosis during DCR. METHODS. A prospective study of the bone mineral density in patients (n=32) undergoing DCR was conducted. During DCR, the lacrimal bone thickness and density were estimated clinically. Postoperatively, the systemic bone density was measured by dual-energy x-ray absorptiometry (DEXA) scanning. The data were analyzed using Student's t-test, Pearson correlation and Pearson chi-square methods. RESULTS. Analyzed in a bivariate arrangement, significant correlation (p<0.05) was detected between the systemic bone density (as measured at two sites, the femoral head and lumbar spine) and the lacrimal bone characteristics (thickness and density). Therefore, the lower the lacrimal bone thickness or density, the lower the systemic bone density. INTERPRETATION. With the finding of significant correlation between lacrimal bone thickness and density and systemic bone density, oculoplastic surgeons can screen for osteoporosis during DCR. If low-density thin bone is encountered during DCR, the patient's general practitioner should be alerted.

Needlestick injury and human immunodeficiency virus (HIV): a surgeon's personal story

With increasing numbers of HIV positive patients worldwide, the oculoplastic surgeon will come into greater contact with them. This increases the chances of accidental occupational exposure and the risk of self-inoculation with HIV. This presentation describes an oculoplastic surgeon's personal experience with a needle stick injury in a known HIV positive patient. The surgeon must be fully educated as to the "2-hour window" after the injury in which the decision must be made with respect to post-exposure anti-retroviral prophylaxis, and initiation of treatment in an attempt to prevent seroconversion. This presentation also outlines the important medical and legal issues of informed consent, ramifications of seroconversion, and the important issues of antiretroviral drug toxicity and compliance. The surgeon will describe the success of the post-exposure prophylaxis regimen in preventing seroconversion for the prescribed six-month follow-up period, and will discuss the tremendous anxiety until the final negative test result was available (AU)

Proximal canalicular imaging utilizing ultrasound biomicroscopy A: Normal canaliculi.

The proximal canaliculi are the most difficult structures within the lacrimal drainage pathways to be imaged. Dacryocystography has been the most useful method for imaging the canaliculi, but it cannot demonstrate the canaliculi distal to an obstruction, nor can it demonstrate the walls or tissue surrounding the walls of the canaliculi. Ultrasound biomicroscopy utilizing a high-resolution subsurface imaging technique is able to image the proximal canaliculi in the cadaver model.

Proximal canalicular imaging utilizing ultrasound biomicroscopy B: Canaliculitis.

The proximal canaliculi can be imaged in patients with canaliculitis utilizing ultrasound biomicroscopy. The caliber of the proximal canalicular lumina, dilated by the disease process, can be evaluated. In addition, stones, debris and tissue fluid may be visualized within the system, without the need to inject a viscous material. This technique may prove to be of value in patients with mild or subclinical canaliculitis from the perspective of diagnosis. Outlining the extent of the disease process within the canaliculus may have some therapeutic value as well.

Proximal canalicular imaging utilizing ultrasound biomicroscopy C Experimental balloon catheter dilatation.

If proximal canalicular obstruction is to be treated by balloon catheter dilatation, a technique must be available to measure the short-term and long-term effects of the dilatation. Ultrasound biomicroscopy can image the pre-dilated and post-dilated proximal canaliculus in vivo. Further in vivo studies will determine the potential of this technique in the clinical setting.