Balanced (endoscopic medial and transcutaneous lateral) orbital decompression in Graves' orbitopathy.

BACKGROUND: To determine the clinical outcomes and morbidity of endoscopic medial wall combined with transcutaneous lateral orbital wall decompression in Graves' orbitopathy. METHODOLOGY: A retrospective noncomparative case series of patients who underwent surgical decompression for Graves' orbitopathy at Hospital Universitario de Fuenlabrada between 2004 and 2014 was performed. We reviewed the patients' charts and analyzed before and after the decompression, the visual acuity (Snellen chart), optic nerve compression (fundoscopy and optic coherence tomography), exophthalmometry (Hertel measurement), ocular motility, diplopia, eyelid surgery needed after decompression and its possible complications. RESULTS: A total of 20 patients (36 orbits) were operated. The mean follow-up was 44 months (range 18-84). Vision improved dramatically in all compressive optic neuropathy cases (5 cases). Hertel measurements improved on average 3.5 mm (range 1.5-4.5). Diplopia was cured in eight patients (40%) and nine patients with severe preoperative diplopia required strabismus surgery after decompression. Eyelid surgery was further needed in 13 patients. Hyaluronic acid injection was the most used technique for the treatment of eyelid retraction (6 out of 13 patients). Only two major complications were observed: one case had a major post-operative epistaxis and another a cerebrospinal fluid leak. Both were resolved without further sequelae. CONCLUSIONS: These results suggest that endoscopic medial wall combined with transcutaneous lateral wall orbital decompression is an effective and safe treatment for the symptomatic dysthyroid eye disease with important proptosis or compressive optic neuropathy.

Surgical treatment of familial dacryocystocele and lacrimal puncta agenesis.

Bilateral agenesis of the lacrimal puncta and enlargement of the nasolacrimal canal are rare anatomic variants. The authors present 2 familial cases: a 39-year-old woman with bilateral dacryocystocele and lacrimal puncta agenesis and her 46-year-old brother, who had a long history of epiphora and recurrent dacryocystitis, and also had bilateral lacrimal puncta agenesis and a left dacryocystocoele. The authors report the endoscopic, CT, and MRI findings, and describe the surgical treatments, by endoscopic dacryocystorhinostomy in the first case, and conjunctivodacryocystorhinostomy with Jones tube in the second case. At 24 months after surgery, both patients' symptoms were improved.

Resolution of epiphora with nasolacrimal stents: results of long-term follow-up in a multicenter prospective study.

PURPOSE: To evaluate in a prospective, multicenter setting the long-term effectiveness of polyurethane stents in the percutaneous management of epiphora. MATERIALS AND METHODS: Patients (n = 426; age range, 19-88 years, mean, 48; 91 men, 335 women) with severe epiphora had stents (470 eyes/496 stents) inserted to treat unilateral or bilateral and complete or partial obstruction of the nasolacrimal system. The etiology of the obstruction was idiopathic in 280 cases (59.5%) and chronic dacryocystitis in 190 (40.4%). The stent set designed by Song was used in all patients, and the original technique was slightly modified by us and conducted on an outpatient basis. RESULTS: The initial technical success rate of stent placement was 95%. The average time of the procedure was 6 minutes (range, 3-70). Resolution of epiphora was complete in 452 eyes and partial in 18. On follow-up (mean, 24 months; range, 1 week to 67 months), 340 of 496 stents remained patent (68.5%). Segregating primary patency by year of follow-up, the rates were 75.6%, 68.4%, 64.8%, 60.1%, and 59.2% in the first, second, third, fourth, and the current (67 months) years, respectively. Minor complications such as moderate pain (21 cases), epistaxis (75 cases), palpebral edema and hematoma (31 cases), and headache (four cases) and two acute dacryocystitis events were recorded. Of the 156 obstructed stents, 114 were withdrawn, and 49 of these patients remained asymptomatic for a mean of 27 months (secondary patency, 31.4%). After stent removal, the sac configuration was unchanged in 93 (81.5%), contracted in 11 (9.6%), and widened in 10 (8.8%) cases. CONCLUSIONS: The procedure is simple and safe, both in stent insertion and in withdrawal when occluded. The success rate was >75% in the short term and >55% in the long term. Although not totally without concerns, the technique is attractive for most patients who prefer not to undergo surgery or are unsuitable surgical candidates. Stent failure does not preclude subsequent treatment options and is an excellent first-line treatment of epiphora.

Severe keratomycosis secondary to Scedosporium apiospermum.

PURPOSE: To report an unusual case of severe keratomycosis caused by Scedosporium apiospermum without any known previous ocular injury, that resulted in a corneal perforation, which was treated with an emergency penetrating tectonic keratoplasty and later with phacoemulsification and astigmatic keratotomy to restore good visual function. METHODS: A 45-year-old woman with a history of multiple sclerosis presented with a severe and refractory corneal abscess in her right eye without any known prior injury. Corneal scrapings were obtained and stained for microscopic evaluation. The samples were sent for aerobic and anaerobic bacterial and fungal cultures. RESULTS: Microbiologic examination of the corneal scraping showed Scedosporium apiospermum micelle. The fungal culture was sensitive to miconazole, itraconazole and voriconazole. Partial clinical improvement was achieved with hourly topical natamycin, amphotericin B, and systemic itraconazole application, although in vitro sensitivity tests showed resistance to the topical antifungal agents used. A corneal paracentral perforation occurred despite aggressive treatment. An emergency eccentric penetrating keratoplasty was performed with satisfactory results. Subsequent phacoemulsification and astigmatic keratotomy restored a good visual function. CONCLUSION: A fungal etiology should be suspected in a progressive and refractory corneal abscess. This report highlights the utility of microbiologic investigation to perform an early and accurate diagnosis. Aggressive medical treatment and even therapeutic penetrating keratoplasty to remove infected tissue could result in the maintenance of useful visual function. In view of the poor prognosis of this specific fungus, a closer observation and early keratoplasty might be required to preserve the ocular globe.