Lacrimal drainage obstruction and dacryocystorhinostomy in children.

PURPOSE: To determine the outcome of dacryocystorhinostomy (DCR) for nasolacrimal duct obstruction (NLDO) in children. METHODS: A review of medical records of 104 cases (82 patients) of paediatric DCR who underwent DCR at the Sydney Eye Hospital from 1995 to 2004. The main outcome measures included post-operative symptomatic relief of presenting symptoms, complications, subjective visibility of any scar, and general satisfaction. Statistical methods included chi(2) tests, and Student's t-tests for the comparison of variables among groups. RESULTS: Ninety-four external, 10 endoscopic primary procedures, and five revision procedures were included. Fifty-six of the cases were primary NLDO, and 48 were secondary NLDO. The mean follow-up was 1.44 years. Average age at surgery was 6.6+/-4.2 years (mean+/-SD). Ninety-one eyes needed DCR for the involvement of the lower lacrimal outflow system, and 13 eyes were NLDO associated with congenital punctual/canalicular dysgenesis.Most of the complications of external DCR were related to Jones tube placement. Five cases (4.8%) needed DCR revision. There was a significantly higher incidence of revision surgery in the non-stented group (P<0.01), and the Jones tube group (P<0.001) as compared with the silicone intubation stent group. CONCLUSIONS: External DCRs have acceptable long-term clinical and cosmetic results, and low post-operative complication rate. Cases with punctal stenosis or those requiring Jones tube insertion are associated with a higher complication rate. Silicone intubation is associated with a lower need for operative revision.

Idiopathic orbital inflammatory syndrome: clinical features and treatment outcomes.

AIM: To characterise the clinical and pathological features of 24 patients with biopsy proven Idiopathic Orbital Inflammatory Syndrome (IOIS). METHODS: Retrospective case series. RESULTS: The study included 14 men and 10 female patients, ranging in age from 14 to 75 years. The presenting symptoms and signs included pain (14/24), swelling/mass (19/24), diplopia (9/24), proptosis (15/24), extraocular muscle restriction (13/24), decreased vision (5/24) and ptosis (4/24). Histopathology was varied and included classical orbital pseudotumour (9/24), sclerosing orbital pseudotumour (13/24), vasculitic orbital pseudotumour (1/24) and granulomatous orbital pseudotumour (1/24). Treatments included oral steroids (19/24), intravenous steroids (1/24), methotrexate, azathioprine, mycophenalate and ciclosporin. Forty-two per cent of the patients had recurring episodes during the follow-up period, with 29% of patients requiring two or more treatment regimens to maintain remission. Two-thirds of patients (16/24) had complete resolution of their symptoms and signs. There was no correlation between the histopathological subtype, relapse rate or symptoms and resolution of signs. CONCLUSION: Idiopathic Orbital Inflammatory Syndrome has variable clinical and pathological features. Although, in some patients, symptoms and signs resolve spontaneously, most require treatment with oral steroids and additional immunosuppressant drugs or radiotherapy. The clinical and pathological features do not correlate with treatment outcomes.

A prospective randomized study comparing division of the pedicle of modified hughes flaps at two or four weeks.

PURPOSE: To compare the incidence of upper and lower eyelid malposition or other complications when the pedicle in modified Hughes flap repair of the lower eyelid is divided at 2 versus 4 weeks. METHODS: A prospective randomized study. Data were collected on patient age and sex, horizontal tumor dimension, upper and lower eyelid position before surgery and 3 months after division of the pedicle, and any complications. RESULTS: Complete data from 60 patients were collected, with 32 patients in the 2-week group and 28 patients in the 4-week group. The two groups were not significantly different in terms of sex, age, or tumor dimensions. In the 2-week group, the upper eyelid was within 1 mm of its preoperative position at 3 months in 25 of 32 patients (78.1%) and in 26 of 28 (92.8%) in the 4-week group. The lower eyelid was within 1 mm of its normal position in 27 of 32 patients in the 2-week group (84.4%) versus 25 of 28 (89.3%) in the 4-week group. Statistical analysis showed no significant difference between the 2- and 4-week groups for upper and lower eyelid position at 3 months. Other complications were uncommon and evenly spread between the two groups. CONCLUSIONS: A modified Hughes flap pedicle may be divided at 2 weeks with no increased incidence in upper or lower eyelid malposition or other complication.

Perineural spread of cutaneous squamous cell carcinoma via the orbit. Clinical features and outcome in 21 cases.

OBJECTIVE: To describe the clinical features, treatment, and outcome of a series of patients with perineural spread (PNS) of cutaneous squamous cell carcinoma (SCC) via the orbit. DESIGN: A cohort study. PARTICIPANTS: Twenty-one patients identified with PNS of cutaneous SCC via the orbit. INTERVENTION: Patients were treated with various combinations of conservative or radical surgery, external beam radiation therapy, and chemotherapy. RESULTS: Of 21 cases, 17 (81%) were male. Age at presentation with PNS ranged from 38 to 82 years (median, 66 years). The forehead and eyebrow were the most common site of the primary lesion. All but one had altered or decreased sensation, but only nine presented with pain. Fourteen (67%) had ophthalmoplegia at presentation, and 14 (67%) had evidence of PNS involving branches of the facial nerve. Despite combinations of radical surgery, conservative surgery, and radiation therapy, no method of treatment appeared more effective, and 14 patients died from 9 months to 5 years after presentation with PNS (median, 3 years), usually from local and intracranial disease. Two survived to 14 and 18 years, one is alive at 3 years with recurrent local and distant disease, and four are alive without evidence of disease at 2, 3, 4 and 12 months after radiation therapy. CONCLUSIONS: Perineural spread of cutaneous SCC via the orbit carries a poor prognosis. Early radiation therapy may offer the best form of palliation. The role of radical surgery probably is limited once orbital involvement is apparent, as the cavernous sinus and facial nerve branches usually are involved.

Endonasal dacryocystorhinostomy--primary and secondary.

An endonasal approach was used to restore lacrimal drainage in both primary and secondary obstructions. Patients in the primary group had a history of keloid scar formation, or wished to avoid a scar and declined to have surgery performed via an external approach. Patients in the secondary group had undergone one or more previous unsuccessful lacrimal drainage repairs. A fibreoptic endonasal telescope, linked to a video monitor, and appropriate nasal and lacrimal instruments, were used. The approach proved highly successful, in both anatomical and functional terms, in each group. In the secondary group, the endonasal approach allowed direct visualisation and repair of both nasal and lacrimal causes of failure; this approach is our preference in this group. In the primary group, endonasal instrumentation had no advantage over a conventional external operation, other than avoiding a scar. The application of laser technology may make the endonasal approach a realistic option in primary DCRs as well.

Monostotic fibrous dysplasia of the orbit: an unusual lacrimal fossa mass.

A case of monostotic fibrous dysplasia involving the orbit, presenting with a short history of painful, progressive proptosis and a lacrimal fossa mass is reported. There were no clinical or radiological clues to the diagnosis which was made on frozen section at the time of open surgical biopsy. The features of orbital fibrous dysplasia are reviewed and a possible mechanism for this rare clinical presentation of fibrous dysplasia is discussed.

Day-surgery external dacryocystorhinostomy.

A retrospective study of patients undergoing day-surgery external dacryocystorhinostomy (DCR) over five years is presented. The patients were medically fit for day-surgery, preferred outpatient to inpatient care, and had appropriate domiciliary support. There was a high success rate with minimal morbidity, similar to findings in an inpatient setting. Patient satisfaction was uniformly high. The author believes that external DCR can be performed on a day-surgery basis safely and successfully.

Metastatic breast carcinoma of the orbit.

Two Caucasian females in whom an orbital mass was the first sign of metastasis from a breast carcinoma are described. Each subject had undergone a radical mastectomy to treat a primary breast carcinoma, one six years and the other eight years previously. Each presented with ipsilateral proptosis, and restricted upper eyelid action; one had altered ocular motility. In each subject an open biopsy of the orbital mass via an eyelid crease incision revealed metastatic scirrhous adenocarcinoma of the breast. The clinical features, investigations, and treatment of orbital metastases from breast carcinoma are discussed.

A comparative study of eyelid parameters in involutional entropion.

A comparative study of eyelid parameters reported to be important in involutional entropion was made. Males and females aged greater than or equal to 65 years with normal eyelids, acute involutional entropion (history less than 6 weeks), and chronic involutional entropion (history greater than or equal to 6 weeks) were entered into the study. Significant findings were increased vertical laxity in each entropion group and increased horizontal laxity in the chronic entropion group. The upper eyelid action had an essential role in the turning in of affected lower eyelids. The degree of pretarsal overriding in the lower eyelid was not a significant differentiating feature when the groups were compared. The findings of this comparative study provide the basis for suggesting the pathophysiology of involutional entropion.

Surgical management of the lacrimal drainage system.

The physiology of normal tear drainage has been better defined in recent years. Some of the refined techniques developed in the fields of anaesthesia and surgery have been applied to the lacrimal drainage system. The combination of these advances has resulted in more rational and successful treatment of lacrimal drainage abnormalities. A review of these advances is presented with a discussion on the treatment of lacrimal drainage abnormalities.

An upper eyelid cyst from migration of a hard corneal contact lens.

A migrated polymethylmethacrylate contact lens in the upper eyelid presented as a mass of unknown etiology. The lens had been unknowingly retained in the eyelid for seven years, after it had migrated through the conjunctiva of the superior fornix, and then moved in front of the levator aponeurosis and upper tarsal plate, where it lay encysted by conjunctiva. We believe that having sequestered conjunctival epithelium around the lens explains the minimal nature of the inflammatory and secretory responses necessary to allow such a protracted period of retention.

Lacrimal drainage obstruction from lacrimal sac infiltration by lymphocytic neoplasia.

In two patients, a 52-year-old woman with chronic lymphocytic leukemia and a 71-year-old woman with malignant lymphoma, lymphocytic neoplasia infiltrated the lacrimal sac, obstructed the lacrimal drainage system, and resulted in acute or chronic dacryocystitis. The prognosis of lymphocytic neoplasia is sufficiently good that definitive treatment is usually warranted. Both patients benefitted from dacryocystorhinostomy with placement of silicone tubing in concert with management of the neoplasia and hemoglobin level.

The watery eye--management and results.

The physiology of tear drainage has been clarified by the use of lacrimal scintillography, introduced within the last decade. During the same time, anatomical depiction of the drainage pathways has been enhanced by utilisation of refined contrast-medium radiology. The results of surgery from the Unit of Ophthalmic Plastic and Reconstructive Surgery, Sydney Eye Hospital, 1973-1977, in patients with a chronically wet eye, and evaluated preoperatively on a clinical basis only, are reviewed, and the potential benefit of X-rays and scintigrams appraised in retrospect. Of 150 wet eyes undergoing D.C.R. +/- some form of intubation, 89% achieved success with the first operation, and 7% achieved subsequent procedure. The success rates at first operation within the three groups were: DCR 92%, DCR + canalicular intubation 81%, DCR + Jones conjunctivorhinostomy tube 90%. An apparent selection error of 1.3% was elicited which accurate X-ray and scintigram conceivably could have avoided.