The role of nasal endoscopy in repeat pediatric nasolacrimal duct probings.

PURPOSE: To determine whether pediatric nasal endoscopy improves treatment success in recurrent nasolacrimal duct obstruction. METHODS: A retrospective analysis was carried out on 2 nonrandomized cohorts of consecutively treated patients who had one failed nasolacrimal duct probing at the Hospital for Sick Children, University of Toronto. The first cohort of 24 consecutive patients (32 eyes), group A, was treated with Crawford silicone tube intubation by one ophthalmologist (R.C.P.). The second cohort of 23 consecutive patients (33 eyes), group B, was treated with repeat probing by a second ophthalmologist (A.V.L.) in conjunction with nasal endoscopy by one otolaryngologist (V.F.). Abnormalities found on endoscopy were treated accordingly, and no tubes were inserted. Follow-up, through phone interviews or office visits, was conducted to assess the patients' symptoms. RESULTS: Group A patients were older at both the first probing (P = .048) and the second procedure (P = .012). No significant difference in the failure rates was found, with treatment failing in 3 eyes (2 patients) in group A and in 5 eyes (4 patients) in group B (P = .479). Interestingly, 17 of the 32 tubes in group A were extruded in 1 month or less. Also, 28 of 33 eyes in group B had abnormalities on endoscopy-some, multiple. Twenty-two eyes underwent inferior turbinate infracture: 5 had redundant mucosa, which was removed, and 6 had abnormal openings of the inferior meatus. CONCLUSIONS: We were unable to show any benefit of nasal endoscopy over intubation of the nasolacrimal system with silicone tubes in the treatment of failed probings despite the identification and treatment of abnormalities. The study was limited by its low power to detect differences because of the small number of patients and the high success rate of the traditional treatments for congenital nasolacrimal duct obstruction.

Distribution of adrenergic receptor subtypes in the retractor muscles of the upper eyelid.

PURPOSE: To identify adrenergic receptor subtypes and their relative distribution in the retractor muscles of the upper eyelid, the levator palpebrae superioris, and the Müller muscle. The pattern of distribution of these receptors in the Müller muscle was further compared in patients with dysthyroid eyelid retraction and in normal subjects. METHODS: Müller muscle specimens were collected from 19 patients undergoing ptosis correction and from 8 patients undergoing repair of dysthyroid eyelid retraction. Immunohistochemical staining for alpha 1-, alpha 2-, beta 1-, and beta 2-adrenergic receptors was performed using antihuman rabbit polyclonal antibodies. RESULTS: alpha 2-Adrenergic receptors were the predominant subtype in the Müller muscle, and beta 1-adrenergic receptors were the predominant subtype in the levator muscle. There was no significant difference in the staining pattern between specimens collected from patients with dysthyroid eyelid retraction and those from normal subjects. CONCLUSIONS: The interaction between the alpha 2 and beta 1 receptors in the upper eyelid retractor muscles may be important in the control of the upper eyelid position and may contribute to the development of dysthyroid eyelid retraction. Specific alpha 2 antagonists could be developed and may be effective pharmacologic agents for the treatment of eyelid retraction.

Long-term results of frontalis suspension using irradiated, banked fascia lata.

This study was undertaken to study the long-term rate of recurrence of ptosis and other postoperative complications after frontalis suspension using banked irradiated fascia lata. One hundred thirty-two lids of 72 patients underwent frontalis suspension between 1980 and 1989. The preoperative diagnoses included severe congenital ptosis (83%), blepharophimosis (10%), third nerve palsy (4%), and chronic progressive external ophthalmoplegia (3%). The age at the time of surgery ranged from 5 months to 19 years, with an average of 3 years and 5 months. In 46 patients (64%), surgery was done before age 3 years. The follow-up time ranged from 6 to 15 years, with a mean and median of 10 years. Good to excellent lid height was achieved immediately after surgery in all but three patients. Recurrence of ptosis occurred in 20 cases (28%), and 28 lids (21%). The time to reoperation ranged from 1 to 7 years, with an average of 3 years. Sixteen patients (80%) with recurrence were younger than 3 years of age. Reaction to donor fascia lata occurred in only two patients (3%). Only one patient suffered from excessive exposure keratopathy and required revision of the sling. Banked fascia lata is easy to use and should be considered as an alternative suspensory material in children younger than 3 years of age with congenital ptosis. The long-term reoperation rate in this cohort of patients was higher than the 5% rate reported for autogenous fascia, but lower than that previously reported for banked fascia lata (50% at 8 years).

Sensitivity and specificity of the diagnosis of periocular lesions by oculoplastic surgeons.

BACKGROUND: A few studies have assessed the sensitivity of ophthalmologists in diagnosing periocular lesions. However, no study has assessed their diagnostic specificity or the degree to which they overdiagnose various lesions. We performed a study to determine the sensitivity and specificity of oculoplastic surgeons' preoperative diagnoses of common and uncommon periocular lesions. METHODS: Using the patient records of four oculoplastic ophthalmologists, we reviewed all charts documenting periocular surgery in which lesions were excised and sent for biopsy. For each of 358 cases we recorded the preoperative diagnosis as listed by the surgeon and the postoperative diagnosis as reported by the pathologist. Each preoperative diagnosis was then scored as correct or incorrect. The relative number of each type of lesion was determined, and the ophthalmologists' sensitivity and specificity were calculated. RESULTS: The sensitivity and specificity for the eight most frequently lesions were (in order of frequency) basal cell carcinoma 92.1% and 81.6% respectively, papilloma 81.6% and 66.0%, cyst 66.7% and 69.7%, nevus 53.6% and 75.0%, seborrheic keratosis 27.8% and 71.4%, chalazion 93.3% and 100.0%, squamous cell carcinoma 33.3% and 55.6%, and xanthelasma 100.0% and 76.9%. The values for melanoma were 50.0% and 28.6%, for sebaceous gland carcinoma 0.0% and 100.0%, and for uncommon lesions (nonspecific inflammation, actinic keratosis, granuloma, cavernous hemangioma, folliculitis, benign sweat gland tumour, eccrine hidrocystoma and collagenous tissue) 27.8% and 57.1%. The overall accuracy in lesion identification was 70.0%. INTERPRETATION: Although ophthalmologists have excellent diagnostic sensitivity and specificity for some types of lesion, such as basal cell carcinoma and chalazion, the identification of other lesion types, such as cyst, squamous cell carcinoma and possibly melanoma and sebaceous gland carcinoma, is less optimal.

Management of congenital dacryocystocoele.

Congenital dacryocystocoele occurs when the nasolacrimal drainage apparatus in the newborn has concomitant blocks at the level of the junction of the common canaliculus with the lacrimal sac and at the distal end of the nasolacrimal duct. This results in a typical pink or blue swelling in the region of the medial canthus. Spontaneous resolution is common, although dacryocystitis may supervene. Treatment should be conservative unless dacryocystitis occurs, or intranasal extension coexists. A series of seven consecutive cases is presented and a management plan for the neonate with congenital dacryocystocoele is proposed.

The surgical management of congenital lacrimal fistulae.

Congenital lacrimal fistulae are developmental anomalies of the lacrimal apparatus that are usually symptomatic, frequently causing epiphora and occasionally causing fistulitis or dacryocystitis. They may be associated with other abnormalities of the lacrimal system or with systemic anomalies. Complete excision alone, or in combination with nasolacrimal intubation and/or dacryocystorhinostomy is recommended for treatment.

Eyelid and fornix reconstruction in bilateral abortive cryptophthalmos (Fraser syndrome).

Cryptophthalmos refers to a group of uncommon congenital anomalies of eyelid formation that can occur alone or in combination with multiple congenital anomalies as part of the Fraser syndrome. We present a case of bilateral abortive cryptophthalmos in a child with Fraser syndrome and discuss the problems of surgical management. A brief discussion of isolated and syndromic cryptophthalmos, including normal eyelid development, the pathogenesis of cryptophthalmos, and the management options follows.

Clinical anophthalmos.

We report on 15 patients (10 boys, 5 girls) with clinical anophthalmos. Two of them had bilateral anophthalmos, 10 had systemic anomalies, and six had abnormalities of their remaining eye. Only two appeared to have an associated underlying aetiology. Fourteen patients underwent orbital reconstruction or socket enlargement with varying degrees of success. Our own experience suggests that unnecessary lid procedures should be avoided, but we recommend early prosthetic fittings. We feel that a multidisciplinary approach is necessary to attain useful rehabilitation.

The orbicularis stripping operation for intractable blepharospasm: surgical results in eighteen patients.

The orbicularis stripping operation may be the only method of relieving the symptoms of essential blepharospasm when medical means and botulinum toxin injections fail.

Silicone tube intubation of the lacrimal drainage system.

We report 158 silicone tubes placed in the lacrimal drainage systems in 150 patients. Intubation is indicated in the following: congenital nasolacrimal duct obstruction, fresh canalicular lacerations, primary canalicular disease, complicated dacryocystorhinostomies, canaliculorhinostomies, and failed dacryocystorhinostomies. The procedure may be useful prophylactically before surgery or radiation of the medial canthal region.

An analysis of corneal transplantation: II--postoperative astigmatism.

An analysis of 153 penetrating keratoplasties was undertaken. The same surgical technique was used in all cases. Three factors had a statistically significant effect on postoperative astigmatism, as measured by keratometry. (1) Astigmatism decreased with increasing follow-up time (P less than 0.05). (2) Vitreous loss at the time of the keratoplasty increased the amount of postoperative astigmatism (P less than 0.05). (3) Females had more postoperative astigmatism than males (P less than 0.05), but this was probably related to a tendency for females to have a greater incidence of postoperative anterior synechiae (P just greater than 0.05), and the fact that all 6 cases of vitreous loss were in females. There was an almost significant trend toward postoperative anterior synechiae being associated with increased astigmatism (P just greater than 0.05), and there was also a trend toward the division of these synechiae reducing the amount of astigmatism. Fifteen of the 153 penetrating grafts were done in cases of herpes simplex. These were compared with 11 lamellar grafts done for herpes simplex, and there was a statistically insignificant trend toward more postoperative astigmatism in penetrating grafts.

An analysis of corneal transplantation: I--graft clarity.

A retrospective review has been undertaken of the clarity results of 378 keratoplasties performed by 6 Toronto corneal surgeons between January 1970 and December 1974. Lamellar keratoplasties were included in the data related to herpes simplex only. In herpes simplex penetrating grafts gave better vision than lamellar grafts. The following factors were statistically important with respect to graft clarity: age of recipient, type of corneal disease, peroperative corneal vessels, first or subsequent graft, pre- and/or postoperative glaucoma, postoperative anterior synechiae, combined procedure, vitreous loss, previous cataract surgery, and follow-up time. The following factors were statistically unimportant with respect to graft clarity: donor age, time from death to enucleation (median 2.8 hours), time from enucleation to use (median 24 hours), sex of donor and recipient, interrupted or running suture, use of microscope, penetrating or lamellar graft in herpes simplex, postoperative astigmatism, and division of postoperative anterior synechiae. Silk (compared with nylon), larger grafts and combined procedures all increased the incidence of graft rejection. Repeat grafts were associated with more preoperative corneal vascularization.

Prediction of graft fate from cytopathology of recipient button.

We wished to know whether the fate of human corneal grafts could be predicted from the cytological study of recipient's corneal buttons removed at operation. We counted the number of different inflammatory cells in 168 full-thickness corneal buttons, and related the findings to the operative results retrospectively. If inflammatory cells, particularly polymorphonuclear cells are present in significant numbers in the corneal button the chance of a successful graft is reduced by about 20 per cent (P less than 0.05).

Eye injuries in Canadian hockey.

Increasing public concern led the Canadian Ophthalmological Society, in January 1974, to form a committee to study the incidence, types and causes of hockey eye injuries and to devise means of reducing such injuries. Retrospective and current studies were undertaken, and face protectors were tested. In both pilot studies, sticks were the commonest cause and the highest number of eye injuries was in players 11-15 years old. An average of 15% of all injured eyes were rendered legally blind. Cooperation with hockey authorities has resulted in changed rules and their sticter enforcement, and formulation of standards for face protection approved by the Canadian Standards Association. In this interim report the committee recommends that all amateur hockey players wear eye protectors and urges ophthalmologists to participate in efforts to improve the design of protective equipment.

Photographic assessment of the optic disc.

Increasing the sensitivity of methods of examining the visual field may merely increase subjective errors already inherent in this test. The optic disc can be examined quite objectively and subtle changes are best assessed by photography. A method, evolved through trial and error, is outlined for obtaining high quality colour transparencies and Polaroid Land Prints of the optic disc for follow up. Routine disc photography should be an important part of a glaucoma record.