The failed probing.

The management of failed probing for congenital nasolacrimal duct obstruction is given by a panel of authors. Treatment options examined are repeat probing, inferiorturbinate infracture, closed lacrimal intubation and dacryocystorhinostomy. There is considerable variation as to the timing of these interventional techniques.

Eyelid retractor surgery as an adjunct to cicatricial ectropion repair.

PURPOSE: To evaluate the effectiveness of eyelid retractor repair in cicatricial ectropion of the lower eyelid. METHODS: The study design was a prospective case series. One hundred and twenty eight eyelids were operated on in 100 consecutive patients with cicatricial ectropion. All patients underwent lower eyelid retractor repair via a conjunctival approach combined with skin replacement to the anterior lamella with or without a horizontal lid tightening procedure. When only medial ectropion was present, a medial-based transpositional skin flap was used to repair the anterior lamella (26 eyelids). The remaining eyelids with ectropion involving all or most of the eyelid underwent upper-to-lower eyelid lateral-based transpositional skin flap repair (92 eyelids), or full thickness free skin grafting (10 eyelids). Horizontal lid tightening was performed by lateral canthoplasty in 123 eyelids. RESULTS: Relief of cicatricial ectropion symptoms was reported in 90% of patients overall. A normal punctum position was achieved in 70% of eyelids, overall, and was highest (88%) with a medial-based transpositional skin flap. CONCLUSIONS: Eyelid retractor repair combined with skin replacement and horizontal lid shortening is an effective procedure for cicatricial ectropion.

Unusual presentations of pleomorphic adenoma and adenoid cystic carcinoma of the lacrimal gland.

PURPOSE: To report two atypical cases of pleomorphic adenoma and adenoid cystic tumours of the lacrimal gland. METHODS: Two case reports are presented. The first is of a 65-year-old female with a long history of right hypoglobus with sudden recent worsening. Computed tomography (CT) showed a round, well-defined lesion in the fossa for the lacrimal gland with an anterior hypodense extension suggestive of possible malignancy in a pleomorphic adenoma. The tumour in the second case, a 35-year-old male, was diagnosed after presentation following a relatively minor periorbital injury. The smooth rounded mass on CT scan was suggestive of a benign lacrimal gland tumour. RESULTS: The lesion in case 1 was excised with a diagnosis of haemorrhage within a pleomorphic adenoma. The lesion in case 2 was excised with a diagnosis of adenoid cystic carcinoma of the lacrimal gland with pseudocapsule. CONCLUSIONS: Haemorrhagic cyst developing beneath the pseudocapsule of a pleomorphic adenoma should be considered in the differential diagnosis of secondary development of malignancy in a pleomorphic adenoma. Adenoid cystic tumours of the lacrimal gland can present with a pseudocapsule.

Congenital orbital cysts associated with the common sheath of superior rectus and levator palpebrae superioris muscles.

PURPOSE: To review the clinical and operative features of a subgroup of superior congenital orbital cysts that intimately are associated with the common sheath of the superior rectus and levator palpebrae superioris muscles. METHODS: Records from four eligible patients were reviewed retrospectively. RESULTS: All four patients had ptosis or lid swelling at initial presentation and were found at surgery to have large cysts within the common tendon sheath of the superior rectus and levator palpebrae superioris muscles. The lining of these cysts resembled that of conjunctiva. There was no precedent conjunctival disease or surgery. CONCLUSIONS: The authors propose that these cysts are congenital and arise as misdirected cleavage of mesoderm during formation of the superior fornix. As such, this type of cyst has not been described previously and may represent a third group of congenital orbital cysts distinct from both conjunctival inclusion and dermoid cysts. Particular caution is required in their excision.

Adjustable sutures in eyelid surgery for ptosis and lid retraction.

New techniques are described and illustrated for ptosis and lid retraction surgery in which the sutures holding the upper eyelid position are adjustable postoperatively. In the anterior approach, the sutures pass from the levator muscle through the anterior surface of the tarsal plate at the position of the skin crease and are tied at the skin crease incision. In the posterior approach, the sutures pass from the levator muscle through the cut upper edge of the tarsal plate and are tied at the position of the desired skin crease. The techniques allow the lid height to be adjusted for over and undercorrection medially, centrally, laterally, or overall if required, thereby achieving the optimal surgical result without altering the position of the skin crease. Suture adjustment is a simple procedure and is recommended at 24 hours.

Congenital lower eyelid deformity with trichiasis (epiblepharon and entropion).

A series of 43 patients with congenital lower eyelid malposition and trichiasis (epiblepharon and entropion) is presented with clinical findings, family history, approach to management and results of treatment. The average age of patients was 9.3 years. A family history was present in 21%, and 30% had at least one parent of Oriental extraction. Thirty-nine patients underwent surgery for persistent symptoms due to chronic eyelash-globe contact. The surgical procedures performed were a modified Hotz procedure, Quickert sutures, and Jones-type retractor plication. Surgery was effective in at least 90% of all procedures.

Distichiasis: management with cryotherapy to the posterior lamella.

Distichiasis is the congenital condition of partial or complete accessory rows of eyelashes which exit from the posterior lid margin at or near the meibomian gland orifices. A series of 24 patients with distichiasis is presented with clinical features and results of treatment. The treatment modes of epilation, lid margin cryotherapy, or eyelid splitting cryotherapy to the posterior lamella are evaluated. The latter was found to effectively relieve symptoms without retreatment in 87% patients. Keratinisation of the lid margin was found at long term follow up in a few cases and retinoic acid has been used successfully in the treatment of this. Two previously unreported associations of distichiasis are Pierre Robin syndrome and idiopathic eyelid oedema. A family history of distichiasis was found in 50% patients, and of distichiasis with lymphoedema in 30%.

The clinical features and associations of retinal emboli.

A series of 207 patients with retinal emboli is presented with the ocular findings and systemic associations examined. Emboli were most frequently single, unilateral, crystalline and involved the left eye. Emboli were most frequently observed at the major retinal vascular temporal arcades and posterior pole arterioles, with 40% seen at a bifurcation and 10% at an arteriovenous crossing. Non-crystalline emboli were more likely to be associated with retinal pathology, such as retinal artery or vein occlusion. Carotid ultrasound was performed in 74 patients: 18% of asymptomatic subjects had internal or common carotid stenosis greater than 75%; 21% of symptomatic patients had stenosis greater than 75%. In 70%, the stenosis was worse on the side of the embolus. In symptomatic patients, significant stenosis is more likely to be unilateral.

Intraocular lacrimal gland choristoma.

There have been nine previously reported cases of intraocular lacrimal gland choristoma. This case report is of an infant with an intraocular lacrimal gland choristoma which was managed conservatively for a 19-month period until the onset of glaucoma. Tumour biopsy was initially performed because until this time the tumour's behaviour suggested it was not malignant. The latter was confirmed on biopsy, however hypotony resulted following the surgical intervention.