[Watery eyes: diagnostic and therapeutic considerations]. / Tranende ogen.

Tear complaints can arise from either an increased tear production or from a disturbed tear drainage. Increased tear production from the lacrimal gland is a neuroregulated response to a dried out or irritated ocular surface. Dryness often results from a reduced quality of the tear film, but can also be caused by eyelid malposition with increased globe exposure. Impaired tear drainage usually occurs when the lacrimal drainage system is blocked at the level of the ductus nasolacrimalis, the canaliculi or the lacrimal punctae. Anatomical knowledge of the lacrimal system is necessary to distinguish between the different causes. Using cases and illustrations, we provide insight into the diagnostic considerations for a patient with a watery eye.

The lacrimal gland in Sjögren's syndrome: can we unravel its mystery using ultrasound?

According to a recent survey of patients with the autoimmune disease primary Sjögren's syndrome (pSS), dry eye symptoms are present in 95-98% of pSS patients. As one of the most disabling symptoms mentioned by pSS patients, dry eyes have demonstrable effects on quality of their life, leading to eye dryness, itching, and pain, with some patients describing as a recurrent sensation of sand or gravel in the eyes. The symptoms are matched only in prevalence by dry mouth and chronic fatigue. In contrast to the prevalence of dry eye symptoms in pSS and their burden on pSS patients, our comprehension of dry eye disease development is minimal; specifically how function of the tear-fluid producing gland the lacrimal gland (LG), manifests. The comparison becomes stronger again when we consider what we know about dysfunction of the salivary gland (SG) in pSS, for example the appreciation of the transcriptome of 'innately activated' B cells invading the SG, their complicity in formation of lymphoepithelial lesions, and the ability of the SG epithelium to actively contribute to the inflammatory milieu. The exploration of ultrasound imaging as an additional modality to garner information about SG dysfunction in pSS has opened many doors for non-invasive, repeatable imaging in pSS. Here we summarise SG histology and ultrasound phenotype briefly and then juxtapose this with available studies examining LG pathology and ultrasound, and our understanding of LG dysfunction in pSS.

Compression of the optic chiasm is associated with reduced photoentrainment of the central biological clock.

Objective: Pituitary tumours that compress the optic chiasm are associated with long-term alterations in sleep-wake rhythm. This may result from damage to intrinsically photosensitive retinal ganglion cells (ipRGCs) projecting from the retina to the hypothalamic suprachiasmatic nucleus via the optic chiasm to ensure photoentrainment (i.e. synchronisation to the 24-h solar cycle through light). To test this hypothesis, we compared the post-illumination pupil response (PIPR), a direct indicator of ipRGC function, between hypopituitarism patients with and without a history of optic chiasm compression. Design: Observational study, comparing two predefined groups. Methods: We studied 49 patients with adequately substituted hypopituitarism: 25 patients with previous optic chiasm compression causing visual disturbances (CC+ group) and 24 patients without (CC- group). The PIPR was assessed by chromatic pupillometry and expressed as the relative change between baseline and post-blue-light stimulus pupil diameter. Objective and subjective sleep parameters were obtained using polysomnography, actigraphy, and questionnaires. Results: Post-blue-light stimulus pupillary constriction was less sustained in CC+ patients compared with CC- patients, resulting in a significantly smaller extended PIPR (mean difference: 8.1%, 95% CI: 2.2-13.9%, P = 0.008, Cohen's d = 0.78). Sleep-wake timing was consistently later in CC+ patients, without differences in sleep duration, efficiency, or other rest-activity rhythm features. Subjective sleep did not differ between groups. Conclusion: Previous optic chiasm compression due to a pituitary tumour in patients with hypopituitarism is associated with an attenuated PIPR and delayed sleep timing. Together, these data suggest that ipRGC function and consequently photoentrainment of the central biological clock is impaired in patients with a history of optic chiasm compression.

Endoscopic dacryocystorhinostomy: long-term experience and outcomes.

PURPOSE: To report our experience in endoscopic dacryocystorhinostomy in treating nasolacrimal duct obstruction over a 14-year period. METHODS: Retrospective case series carried out over a 14-year period from 1999 to 2014. A total of 624 endoscopic dacryocystorhinostomy procedures were performed in 442 patients who were diagnosed with persistent epiphora. PARTICIPANTS: In total, 624 procedures in a total of 442 patients (<18 yo: 36 and >18 yo: 406) were included. Patients' records were assessed for demographics, intra- and postoperative complications, outcome and follow-up. RESULTS: In total, 442 patients underwent an endoscopic dacryocystorhinostomy. There were 342 females (77.3%) and 100 males with a mean age of 50.2 years. All patients presented with epiphora: 33 congenital (7.5%), 357 acquired (80.7%) and 52 functional cases (11.8%). The adult dacryocystorhinostomy (n = 577) had an anatomical success of 90.1%. Children's group (<18 yo) n = 36 with a total of 47 procedures and an anatomical success of 91.5%. Functional cases (all adults - n = 52) showed a 91% benefit after operation. In 624 DCRs, we found a complication rate of 3.2%. CONCLUSION: Endoscopic dacryocystorhinostomy offers good success rates with a safety profile and efficacy equivalent to the traditional external approach is an effective treatment with good outcome results in adults and children with persistent or functional epiphora.

Comparison of intralesional corticosteroid and propranolol treatment of periorbital infantile hemangiomas: an outcome study of 61 cases.

PURPOSE: To compare intralesional corticosteroid (IC) injections with oral propranolol in children with periorbital infantile hemangioma (IH). METHODS: Children were diagnosed with IH and treated with IC (n = 29) or propranolol (n = 14). In cases in which no further improvement was seen, treatment was stopped and the outcome measured. Type, duration, and complications of treatment and supportive or additional therapies were scored, along with outcomes of visual measurements, at the start and end of therapy. RESULTS: Twenty-one of the 29 children (72%) treated with IC injections were given a second injection and 16 (55%) were given more than two. Median duration of IC therapy was 15.9 months (interquartile range (IQR) 10.28), compared with 6.5 months (IQR 4.87) for propranolol (p<0.001). The complications reported after IC injections were bleeding (n = 9) and ulceration (n = 7). No complications were noted in the propranolol group. Additional therapy consisting of oral prednisolone therapy was applied in one child from the steroid-treated group. The levels of amblyopia and the median absolute improvement did not significantly differ between the groups. CONCLUSIONS: The IC injections and oral propranolol medication equally improved amblyopia in children with IH of the periorbital and cheek region; however, propranolol was associated with fewer complications and additional or supportive treatment was not indicated. We prefer oral propranolol medication over IC injections in cases in which IH threatens to hamper visual acuity.

Ectopic brain tissue in the orbit: 5-year follow-up.

A neonate presented with a dilated pupil of the left eye. Magnetic Resonance Imaging (MRI) showed a mass in the left inferior part of the orbit. Incisional biopsy was performed. Histopathological examination revealed ectopic brain tissue. The patient had a 5-year follow-up without any growth on MRI. Ectopic brain tissue in the orbit is a rare finding in the literature, almost all involved infants or neonates. Pathogenesis is still unknown.

Direct orbital puncture of the cavernous sinus for the treatment of a carotid-cavernous dural AV fistula with a concomitant venous/lymphatic malformation.

A 37- year old male with a long history of a left orbital venous/lympathic malformation presented with ocular injection, increased proptosis and reduced left vision. Angiography demonstrated a carotid cavernous dural AV fistula combined with a concomitant venous/lymphatic malformation. After attempts at transvenous embolization, a direct uncomplicated transorbital puncture of the cavernous sinus via a lateral orbitotomy was performed with complete resolution of ocular symptoms.

Near infrared spectroscopy for the detection of desaturations in vulnerable ischemic brain tissue: a pilot study at the stroke unit bedside.

BACKGROUND AND PURPOSE: There is uncertainty whether bilateral near infrared spectroscopy (NIRS) can be used for monitoring of patients with acute stroke. METHODS: The NIRS responsiveness to systemic and stroke-related changes was studied overnight by assessing the effects of brief peripheral arterial oxygenation and mean arterial pressure alterations in the affected versus nonaffected hemisphere in 9 patients with acute stroke. RESULTS: Significantly more NIRS drops were registered in the affected compared with the nonaffected hemisphere (477 drops versus 184, P<0.001). In the affected hemispheres, nearly all peripheral arterial oxygenation drops (n=128; 96%) were detected by NIRS; in the nonaffected hemispheres only 23% (n=30; P=0.17). Only a few mean arterial pressure drops were followed by a significant NIRS drop. This was however significantly different between both hemispheres (32% versus 13%, P=0.01). CONCLUSIONS: This pilot study found good responsiveness of NIRS signal to systemic and stroke-related changes at the bedside but requires confirmation in a larger sample.