Treatment of epiphora in connection with endolacrimal surgery using trephines: new and overview data.

BACKGROUND: To provide new and to summarize published data on endolacrimal surgery with Piffaretti's trephines, in particular in patients having patent lacrimal drainage system (syringing) and epiphora resistant to medical treatments. PATIENTS AND METHODS: From two tertiary referral centers (Basel/Switzerland; Belo Horizonte/Brazil), 126 patients undergoing endolacrimal surgery with Piffaretti's trephines, combined, when clinically indicated, with other procedures known to improve epiphora (canthoplasty/pexie and/or conjunctivochalasisplasty). RESULTS: I) A study (Basel) in 17 patients showed one-year after surgery marked epiphora symptoms' improvement in 88% (15/17) of patients, 65% (11/17) being symptom-free. II) Unpublished data (Belo Horizonte) in 42 patients found 81% (34/42) symptom-free six-months after surgery. Dacryoscintigraphy illustrated postoperative tears' clearance improvement. III) Unpublished data (Belo Horizonte) in 45 patients solely undergoing endolacrimal surgery for complete ductal obstruction found symptom-free, six-months after surgery, 27% (8/30) of patients with preoperatively enlarged lacrimal sac and 80% (12/15) with none-enlarged sac (p < 0.01, Fisher's test). IV) A study (Basel) in 22 epiphora patients reported no correlation (p = 0.62, rho -0.11, Spearman) between preoperative basal Schirmer's test II (oxybuprocain-HCL 0.4%) values and one-year surgical outcome. Patients with preoperative Schirmer's test's values ≤ or > 6 mm had similar mean postoperative symptoms' improvement (82 ± 30%, n = 11 vs. 76 ± 34%, n = 11, p = 0.97, Mann-Whitney). CONCLUSIONS: Endolacrimal surgery with Piffaretti's trephines, sometimes combined, when clinically indicated, with other procedures also known to ameliorate epiphora, can in particular improve (different conditions, surgeons, centers) epiphora's symptoms resistant to medical treatments in patients with patent lacrimal drainage system, and this apparently, even when pre-operative basal Schirmer-test values are low. By enlarged lacrimal sac, outcome is poor.

Delayed reconstruction after eyelid tumor excision.

BACKGROUND: The aim of this study is to report the feasibility of one to two weeks delayed reconstruction after eyelid tumor excision. PATIENTS AND METHODS: A retrospective case-series study was designed. Fourteen consecutive outpatients referred to a tertiary referral eye center for eyelid tumor management were enrolled. The intervention imvolved eyelid tumor excision (with four millimeters surrounding clinically tumor-free tissue), compressive patching of the excised area until reconstruction (with or without a therapeutic contact lens), extensive histological work-up to assess histological tumor clearance, and reconstruction one week after excision (in a couple of patients after two weeks when further excision was necessary to achieve tumor clearance). Excision and closure were performed by a single external trained oculoplastic surgeon (IOH) with a day per week (Fridays) operating slot. As outcome we assessed whether such an approach has led before, during, or after eyelid reconstruction to unusual major adverse events (follow-up time: 18 - 36 months). RESULTS: Delaying up to one week, in some cases even two weeks, reconstruction after eyelid tumor excision was not associated with any unusual major adverse events before, during, or after surgery. CONCLUSIONS: When necessary, after eyelid tumor excision, it is possible to delay for one week or even for two weeks reconstruction, apparently without experiencing major unusual adverse events.

Improvement of chronic epiphora symptoms after surgery in patients with different preoperative schirmer-test values.

BACKGROUND: To compare improvement of epiphora symptoms after surgery between patients who had different preoperative basal Schirmer test values. DESIGN: Retrospective comparative case-series study. PARTICIPANTS: Twenty-two consecutive patients (one eye/patient) undergoing surgery for chronic epiphora symptoms resistant to ≥ 6 months of medical treatments (who incidentally had a preoperative basal [oxybuprocain-HCL 0.4 %] Schirmer-test and a postoperative one-year follow-up) were ranked according to their preoperative basal Schirmer test values and divided into two groups of equal size: group I, patients with lower (0 to 6 mm) and group II, patients with higher (7 to 25 mm) Schirmer test values. INTERVENTION: Combination of Piffaretti's endocanlicular endoscopic lacrimal drainage (22 patients), lacrimal intubation (8 patients), lacrimal punctoplasty (22 patients), lateral canthoplasty (18 patients), and/or conjunctivochalasis (8 patients) surgical procedures. OUTCOME: Subjective self-perceptions of improvement of their epiphora symptoms was made by the patients one-year after surgery. RESULTS: While between groups I and II mean (± SD) preoperative basal Schirmer test values significantly differed (4 ± 3 mm/ 5 min vs. 10 ± 6 mm/ 5 min, p ≤ 0.001, Mann-Whitney rank sum test), the mean postoperative improvement of epiphora symptoms did not (82 ± 30 % vs. 76 ± 34 %, p = 0.92) and no significant (rho = -0.11, p = 0.62, Spearman rank correlation coefficient) correlation between Schirmer test values and symptoms improvement was found. In both groups > 70 % of patients reported ≥ 70 % (satisfactory) postoperative improvement. CONCLUSIONS: In the present study, patients who had different preoperative basal Schirmer test values reported having very similar epiphora symptoms improvement one-year after surgery.

Large upper eyelid full-thickness defects reconstructed only with an anterior lamella.

BACKGROUND: The purpose of this study is to report a surgical procedure that only uses anterior lamella structures (muscle and skin) to reconstruct large upper eyelid full-thickness total defects. PATIENTS AND METHODS: The study design is a non-comparative retrospective interventional small case series. Three patients with upper eyelid full-thickness (anterior and posterior lamellae) total-defect (horizontal extent: > 3/4 length, vertical extent: > 15 mm) after tumor excision (basal cell, squamous cell, or Merkel's cell carcinoma). As intervention an eyelid reconstruction using only a rotation/advancement muscular-skin flap was used. The outcome was postoperatively an upper eyelid anatomic cosmetic-appearance and lid-closure function. RESULTS: Good anatomic cosmetic-appearance and lid-closure function were achieved soon after surgery. No remarkable ocular as well as extra-ocular side effects or complications were noted. CONCLUSIONS: In a single-stage procedure it appears possible to repair upper eyelid full-thickness total defects by reconstructing only the anterior lamella. With this procedure there is no need to reconstruct the posterior lamella and/or to use tissue from other eyelids or parts of the body.

Eyelid sebaceous gland carcinoma in a young Caucasian man.

BACKGROUND: Eyelid sebaceous gland carcinoma is rarely observed in young Caucasian men. HISTORY AND SIGNS: A 28-year-old man was referred for a recurring chalazion of the eyelid that had been operated four times in the past two years. The chalazion-like lesion of the external third of the upper left eyelid was associated with a cystic lesion. Cytology of the fluid in the cyst and histology of the lesion were compatible with a sebaceous cell carcinoma. Magnetic resonance imaging revealed that the cystic lesion associated with the eyelid tumour was extending into the orbit. THERAPY AND OUTCOME: According to current clinical practice and experience, to increase the chance of survival of the patient, an orbital exenteration was conducted to remove the sebaceous cell carcinoma in total. CONCLUSIONS: Although rare, one should be aware that an eyelid sebaceous cell carcinoma can occur in a young Caucasian man and this diagnosis should be evoked in case of a recurrent chalazion.

A surgical approach to treat chronic epiphora and/or muculopurulent discharge in patients with permeable lacrimal drainage system.

BACKGROUND: This study reports the one-year success rate of a new surgical approach to treat symptoms of chronic epiphora and/or mucopurulent discharge refractive to at least six months of medical treatment in patients with permeable lacrimal drainage system (irrigation test). DESIGN: retrospective chart review analysis. PARTICIPANTS: seventeen consecutive patients referred from a private praxis to an eye clinic to treat, by surgery, symptoms of either chronic epiphora (8/17), mucopurulent discharge (7/17), or both (2/17). INTERVENTION: Piffaretti's non-laser transpunctal endoscopic diagnostic/surgical lacrimal drainage procedure (17/17), lacrimal punctoplasty (16/17), conjunctivochalasisplasty (5/17), lateral canthoplasty (1/17), and/or both conjunctivochalasisplasty and lateral canthoplasty (3/17). In the majority of these patients (13/17) partial obstructions within the lacrimal canaliculus (3/17), the ductus nasolacrimalis (7/17), or both (3/17) were observed endoscopically and removed with Piffaretti's lacrimal trephines. MAIN OUTCOME MEASURES: patient's self-assessment of symptom improvement one year after surgery. RESULTS: One year after surgery, 88 % (15/18) of patients had a marked improvement of their symptoms, 64 % (11/17) of them even reporting as being symptom free. When conducted (14/17), irrigation always revealed a permeable lacrimal system (test not performed in a lost-to-follow-up and in two symptom-free patients). CONCLUSIONS: Surgery can be an alternative therapeutic option for patients who have a permeable lacrimal drainage system and suffer from chronic epiphora and/or mucopurulent discharge that do not respond to conventional conservative medical therapies.

Superficial conjunctiva cauterization to reduce moderate conjunctivochalasis.

AIM: We report here a simple surgical approach to reduce moderate conjunctivochalasis. PATIENTS AND METHODS: A non-comparative prospective interventional case series study of fifteen consecutive patients with moderate conjunctivochalasis was carried out. On the inferior bulbar conjunctiva 10 to 20 superficial burns were performed with an electrical bipolar cauter to reduce moderate conjunctivochalasis. Before and around a mean time of six months after surgery digital photographs of the conjunctivochalasis were taken at the slit lamp. The maximal height of the conjunctivochalasis above the lower eyelid margin measured before surgery was compared with the height of the conjunctivochalasis measured after surgery around the same location (one eye per patient). RESULTS: In each patient, gentle and superficial cauterization induced contraction of the bulbar conjunctiva and reduction of the conjunctivochalasis. No complications were noted during or after the procedure. Mean (+/- SD) maximal conjunctivochalasis height above the lower eyelid margin was higher before (2.3 +/- 0.9 mm) than after surgery (0.8 +/- 0.6 mm). Preoperative values of conjunctivochalasis height were significantly (p < 0.001) different from the postoperative ones (Wilcoxon rank signed test). CONCLUSIONS: Gentle superficial cauterization of the inferior bulbar conjunctiva can induced significant reduction of a moderate conjunctivochalasis.

[Etiology of eyelid edema]. / Häufigste Ursachen des Lidödems in der Allgemeinpraxis.

Lidedema can be a common symptom of diseases of the orbital part of the face. One can differentiate lidedema in two groups, those that are related to an inflammation and those that are not related to an inflammation. Lidedema of the eyelid can also be secondary to a systemic disease. There is also another group that is common in the ageing population that consists of blepharochalasis and dermatochalasis where the skin becomes loose with the years and forms redundant folds.

Free autologous buccal mucosal graft transplantation to treat ocular complications after toxic epidermal necrolysis: case report.

BACKGROUND: Toxic epidermal necrolysis (TEN) can lead to ocular surface scarring associated with pain, dry eye symptoms, and decreased visual acuity that often are difficult to treat. HISTORY AND SIGNS: A 34-year-old woman was referred to our department two-years after TEN induced by lamotrigin (lamictal(R)). She was complaining of severe visual acuity loss, pain, and dry eye symptoms. Visual acuity was reduced to light perception in the right eye (RE) and to 0.2 in left eye (LE). Basal Schirmer test was 2 mm in RE and 3 mm in LE. With or without therapeutic contact lenses, the patient was experiencing severe discomfort requiring tear supplementation up to 50 - 80 times/day in both eyes. THERAPY AND OUTCOME: A free autologous mucosal graft (3.5 x 2.0 cm) was transplanted from the lower lip into the upper RE fornix. Six months after surgery, with therapeutic contact lenses, the need for tear supplementation was markedly reduced to 3 - 4 times/day in RE while it remained unchanged in LE. In RE, slit-lamp examination revealed decreases in the corneal stromal edema and in the diameter of neo-vessels associated with an improvement of visual acuity (counting fingers at 30 cm). Basal Schirmer test values were unchanged. It has to be mentioned that the improvement observed after surgery was markedly dependent on wearing a therapeutic contact lens. CONCLUSIONS: Free autologous buccal graft transplantation (with its presumably accessory salivary glands) in association with the use of a therapeutic contact lens can be an efficient approach to treat ocular complication following drug-induced TEN (Lyell's syndrome).

Lid retractors desinsertion in acquired ptosis and involutional lower lid entropion: surgical implications.

BACKGROUND: An association exists between upper and/or lower lid retractors' desinsertion and acquired ptosis and/or involutional lower lid entropion. METHOD: By highlighting the similarities that exist in the anatomy of the upper and lower lid retractors a possible pathophysiological mechanism leading to acquired ptosis and involutional lower lid entropion is suggested. As a logical consequence, in case of desinsertion, it is proposed to reattach the lid retractors to the tarsus. RESULTS: With this simple "physiological" surgical approach it is possible to treat with success a great majority of acquired ptosis and/or involutional lower lid entropion. CONCLUSION: Repairing upper and/or lower lid retractors' desinsertion can cure acquired ptosis and/or involutional lower lid entropion.

Lacrimal drainage system endoscopic examination and surgery through the lacrimal punctum.

BACKGROUND: To describe an approach to restore the physiological tear passages of an obstructed lacrimal drainage system with instruments introduced through one of the lacrimal punctum. METHOD: In a first step a miniature endoscope (Ø: 0.9, 1.1, 1.3 mm) is introduced in one of the lacrimal punctum to visualize the level, the extent, and the nature of an obstruction along the lacrimal drainage system. In a second step, the miniature endoscope is replaced by a lacrimal trephine (Ø: 0.9, 1.1, 1.3 mm) that holds an optic fiber in its lumen, and the obstruction is removed under endoscopic visual control. The entire procedure is performed under local anesthesia. RESULTS: With this approach it is possible to visualize and remove partial or total fibrous obstructions along the lacrimal drainage system (lacrimal canaliculus, nasolacrimal duct). Lacrimal sac lithiasis can also be fragmented and eliminate in the nose through the nasolacrimal duct. During or after the procedure only minor, and no major, complications can sometime occur, such as hematoma or edema (after lacrimal irrigation) of the surrounding soft tissues. CONCLUSION: The approach described here is straight forward, quick, and can be performed under visual endoscopic control and in local anesthesia. With this approach partial stenosis can easily be diagnosed and cured. This procedure might potentially change our current concepts regarding surgical indications for obstructive epiphora and dacryocystitis. However, the long-term results of this type of surgery need to be challenged.

[Masquerade of sebaceous gland carcinoma as a rapidly recurring "chalazion", a case report]. / Maskerade eines Talgdrüsenkarzinoms durch ein rasch rezidivierendes "Chalazion", eine Kasuistik.

PURPOSE: Demonstration of the importance of surgical excision and histological examination in presence of an apparently harmless tumoral alteration of the eyelids. CASE PRESENTATION: We report the case of a 65 year old patient suffering from systemic lupus erythematosus who noted a tumoral lesion on his left lower eyelid. Suspecting a chalazion, his dermatologist simply performed a cauterization. Six weeks later, a recurrence of the tumor appeared at the same location, and again, cauterization was done. A few weeks later, the patient consulted our clinic with a polycyclic tumor of 5 mm in diameter, involving the lid margin of the temporal part of the lower left eyelid. The patient had only moderate signs of blepharitis. There were no palpable preauricular and cervical lymph nodes. Suspecting a malignant tumor, the entire tumoral lesion was removed surgically. HISTOPATHOLOGY: The histopathologic examination showed a highly differentiated sebaceous gland carcinoma, most probably originating from a meibomian gland. The margins of the excision were found to be tumor-free. DISCUSSION: Sebaceous cell carcinoma is a rare entity. Depending on its histological differentiation it can be highly malignant. Infiltrative, and can metastasize. The mortality may reach 30% if low differentiation is present. As illustrated in the present case, the lesion may masquerade a chalazion. Therefore, in case of atypical lesion of the eyelid region complete surgical removal followed by a histopathological examination should be performed.

Oculoplastic surgery with a contact Nd:YAG laser silica scalpel. A case report.

Baso-cellular carcinomas involving the medial canthal regions of both eyes were resected using a 10 W cw-Nd: YAG laser scalpel. The wound bed was repaired one side by a free, split-thickness graft and on the other by a frontal pedicle flap. Surgery was, for the most part, virtually bloodless. Since laser radiation immediately seals both capillaries and lymphatics, the incidence of postoperative hemorrhage and edema was significantly less than after cold scalpel surgery. Healing was uneventful. The advantages of laser-assisted surgery are worthy of consideration: not only is the operation time markedly curtailed, but the wound healing response is excellent, with only a minimal inflammatory reaction.

[Review of 114 cases of malignant tumors of the eyelids treated surgically]. / Reévue de 114 cas de tumerurs malignes des paupières traitées chirurgicalement.

The results of the surgical treatment of 114 malignant eyelid tumors, performed by one surgeon, are reported. The localization, histology and evolution of the tumors, and the significance of surgery in treatment of these lesions, are discussed.

[Congenital ptosis. A new surgical procedure]. / Kongenitale Ptose. Neue chirurgische Verfahren.

The technique described takes existing anatomic conditions and residual function into account. No resection is required. Results after four years are very good.

[Iatrogenic teflon granuloma of the eyelid. (Teflon paste, an unsuitable filling material for plastic eyelid surgery)]. / Iatrogenes Teflongranulom des Lids. (Teflon-Paste, ein untaugliches Plombenmaterial für die plastische Lidchirurgie).

A paste of granular Teflon was injected into the upper lid of a patient for remodeling the upper palpebral furrow, which had been retracted by scars. Large foreign-body granulomas developed a few weeks later, necessitating two excisions. The causes of this unsatisfactory result with a filling material which is well established in laryngeal surgery are discussed. The authors advise against using it in well vascularized loose tissue.

[Surgical treatment of senile entropion and ectropion of the lower lid (author's transl)]. / Chirurgische Behandlung des senilen Entropions und Ektropions des Unterlides.

a) Entropion: When developing or discussing a surgical technique one should try to understand how senile entropion develops. On the basis of clinical observation we can develop a suitable surgical technique from our knowledge of atonic (never spastic) entropion. The technique is described and results discussed. b) Ectropion: Clinical observations indicate two distinct causes of pathology: either elongation of the tarsus or loosening at the points of attachment. The surgical technique should be adapted on the basis of this observation. Surgical methods are discussed.

[Indication for tarsorrhaphi in lagophthalmos]. / Indikation der Tarsorrhaphie beim Lagophthalmus.

Tarsorrhaphy is at present rarely indicated in lagophthalmos surgery. Newly developed techniques give at least as much protection to the eye as tarsorrhaphy and are clearly preferable cosmetically. Tarsorrhaphy continues to be indicated in transient facial pareses.