Endonasal dacryocystorhinostomy: a report by the American Academy of Ophthalmology.

OBJECTIVE: This document describes endonasal dacryocystorhinostomy (DCR) and examines the evidence to answer key questions about the effectiveness of the procedure compared with external DCR; the relative indications, contraindications, advantages, and limitations of the procedure; and patient selection, surgical technique, postoperative care, and complications. METHODS: A literature search conducted for the years 1968 to 2000 retrieved 93 citations. The panel members reviewed 71 of these articles and selected 64 for the panel methodologist to review and rate according to the strength of evidence. A level I rating is assigned to properly conducted, well-designed, randomized clinical trials; a level II rating is assigned to well-designed cohort and case-control studies; and a level III rating is assigned to case series and poorly designed prospective and retrospective studies, including case-control studies. RESULTS: The published literature includes two reports that describe clinical trials comparing endonasal with external DCR with a 1-year follow-up. The success rate was 91% for the external DCR group in both reports and 63% and 75% for the endonasal DCR groups, defined by patency to irrigation. A longitudinal cohort study included a control group of age-matched external DCR patients who were compared with a study group of endonasal DCR patients. The reported success rate at 9 months following surgery for the endonasal cohort was 90% and was not statistically significantly different from the 94% success rate noted in the external DCR control group. Remaining data on reported success rates of primary and revision endonasal DCR were obtained from a collection of uncontrolled observational case studies with varying periods of follow-up and success rates ranging from 59% to 100%. CONCLUSIONS: It is difficult to make definite evidence-based determinations about the relative efficacy of endonasal and external DCR because of the deficiencies in the reported literature. Based on level III evidence, the available data suggest that endonasal DCR may be a viable option for the correction of acquired nasolacrimal duct obstruction and complex forms of congenital dacryostenosis in selected patients. This procedure may be indicated on a primary basis or as revisional surgery following failed external or endonasal DCR. Some studies comparing endonasal DCR with external DCR suggested lower success rates in the endonasal group; other studies yielded success rates comparable with or exceeding those of external surgery. Reported complications of endonasal DCR do not generally appear to be greater in frequency or magnitude than those associated with external DCR. Disadvantages of endonasal DCR include the preferred use of general anesthesia by many surgeons, the high cost of expensive equipment and instrumentation, and the relatively steep learning curve for this procedure. Depending on the preference of the surgeon, more postoperative care may be required for patients undergoing endonasal DCR than external DCR. Both the advantages and the limitations of endonasal DCR relative to external DCR should be carefully discussed with patients who are contemplating endonasal surgery.

Endonasal dacryocystorhinostomy in the primary treatment of acute dacryocystitis with abscess formation.

PURPOSE: To determine whether endonasal dacryocystorhinostomy may constitute effective primary treatment of acute dacryocystitis with lacrimal sac abscess formation. METHODS: This was a retrospective review of a series of 24 patients with acute dacryocystitis and lacrimal sac abscess who underwent endonasal dacryocystorhinostomy as a primary procedure. Outcome measures included resolution of signs and symptoms of acute dacryocystitis as well as intranasal ostium patency as assessed by lacrimal irrigation. RESULTS: Pain was relieved in all patients within 3 days of surgery, and swelling resolved in all patients by 9 days after surgery. Ostium patency, as defined by the absence of epiphora, and free lacrimal irrigation was achieved in 20 (83%) of 24 patients, with follow-up of 27 to 59 months (mean, 40 months). Recurrent epiphora developed in four patients; recurrent dacryocystitis developed in none. CONCLUSIONS: Endonasal dacryocystorhinostomy may be a useful option in the treatment of acute dacryocystitis with abscess formation.

A multidisciplinary approach to atypical lacrimal obstruction in childhood.

PURPOSE: This study explores the diagnosis and management of unusual anomalies involving the canaliculi, nasolacrimal duct, nasal cavity, and sinuses in childhood. METHODS: A case series of eight children with lacrimal outflow anomalies ranging from distal nasolacrimal duct cyst formation to persistent dacryocystitis following failed probing or silicone intubation were reviewed retrospectively. Diagnostic studies including intranasal endoscopy and preoperative or intraoperative dacryocystography (DCG) were of value. RESULTS: Treatment modalities included endoscopically guided resection of lacrimal cyst mucosa, endoscopic dacryocystorhinostomy (DCR), and monocanalicular or bicanalicular intubation of the lacrimal outflow system. In our series, endoscopic surgery was well tolerated by all patients with improvement in symptoms. CONCLUSIONS: This initial experience suggests that endoscopic techniques may be useful in the management of atypical lacrimal outflow obstruction in childhood.

Palpebral myiasis.

Myiasis is most prevalent in Mexico, central and south America, tropical Africa, and the southwestern United States. Although dermal myiasis is rare in most of the United States, it is a disorder that may be seen in international travelers. In the United States, external myiasis is usually caused by the cattle botfly. We report here a case of ophthalmomyiasis involving the left upper eyelid of a child. We examined a six-year-old boy who presented to the Massachusetts Eye and Ear Infirmary (MEEI) in September 1998. He complained of persistent swelling of his left upper eyelid for the previous ten days. The edema and erythema were unresponsive to warm compresses and oral antibiotics. Ocular examination revealed a mild preseptal cellulitis of the left upper eyelid with a small draining fistula. On slit-lamp examination, we found one larva protruding intermittently from the fistula site. The larva was extracted with forceps, wrapped in a moist towel and sent in a jar to the parasitology laboratory. The specimen was identified as a Cuterebra larva by a parasitologist at the Harvard School of Public Health. One week later, the patient's eyelid edema and erythema had completely resolved.

Paranasal sinus endoscopy and orbital fracture repair.

Although excellent results may be achieved in the management of many orbital floor injuries with standard transconjunctival or transcutaneous approaches, visualization of the posterior edge of the orbital floor or medial wall defect may be challenging at times. We describe our experience using endoscopic examination of the orbital floor through maxillary sinus approaches during the repair of selected orbital floor fractures. Owing to the posterosuperior angulation of the orbital floor, these approaches allow better visualization of the posterior edge of fractures involving the posterior portion of the orbital floor than do the standard transconjunctival approaches, and they facilitate confirmation that all orbital soft tissues have been elevated from the fracture site. We have used these techniques successfully in 9 patients with fractures involving either the posterior portion of the orbital floor or the medial wall or both.

The multidisciplinary management of psammomatoid ossifying fibroma of the orbit.

OBJECTIVE: To discuss the multidisciplinary management of psammomatoid ossifying fibroma (POF) of the orbit and to clarify the clinicopathologic terminology. DESIGN: The authors present a cohort of cases of POF involving the frontal and ethmoid sinuses and the orbit and discuss the nomenclature and literature. PARTICIPANTS: Three patients with POF and their treatment are discussed. INTERVENTION: Patients were worked up and treated by a multidisciplinary team using imaging studies and histopathologic analysis. Reconstruction, if necessary, was carried out at the time of excision or in a second-stage procedure. MAIN OUTCOME MEASURES: In each case, the lesion was completely excised and has not recurred. RESULTS: The diagnosis of POF was made in each case, and the patient underwent successful resection of the tumor. CONCLUSION: The authors' experience suggests that a multidisciplinary approach, including a radiologist, pathologist, neurosurgeon, otolaryngologist, craniofacial surgeon, and orbital specialist, may be useful in the evaluation and management of these lesions.

Endonasal endoscopic dacryocystorhinostomy in children.

OBJECTIVE: To describe the indications, technique, and results of endonasal endoscopic dacryocystorhinostomy in children with congenital and acquired disorders of the nasolacrimal system. DESIGN: Retrospective case series. SETTING: Tertiary care hospital. PATIENTS: Four children ranging in age from 10 months to 6 years. INTERVENTION: Primary or revision endonasal endoscopic dacryocystorhinostomy performed via a joint otolaryngologic-ophthalmologic team approach. MAIN OUTCOME MEASURES: Incidence of surgical complications and postoperative clinical status. RESULTS: The duration of follow-up was 10 to 24 months with a successful clinical outcome in all 4 children. Two procedures were complicated by nasal vestibule skin abrasions secondary to rotation of the drill shaft. CONCLUSIONS: Despite the technical challenges posed by the small anatomical dimensions of the pediatric nasal airway, the combination of proper otolaryngologic endoscopic instrumentation and ophthalmologic lacrimal sac transillumination guidance allows for the safe and successful performance of endonasal endoscopic dacryocystorhinostomy in the pediatric population.

The CO2 laser in oculoplastic surgery.

The introduction of a new generation of carbon dioxide (CO2) lasers has permitted the development of new approaches toward certain oculoplastic disorders and procedures. The high absorption of this infrared laser by tissue water assists oculoplastic surgeons in performing incisional and excisional procedures precisely and with relatively good hemostasis. The development of new scanned continuous-wave or pulsed delivery systems has facilitated controlled tissue ablation with decreased collateral thermal injury during cutaneous resurfacing procedures. The unique characteristics of the CO2 laser mandate special attention to protection of the patient and surgical team, and careful preparation and training will help the prospective laser surgeon to successfully address the learning curve associated with this new technology. Although long-term follow-up is limited, results reported to date suggest that the CO2 laser represents an important addition to the armamentarium of the oculoplastic surgeon.

The role of the integrin family of adhesion molecules in the development of tumors metastatic to the orbit.

Tumors metastatic to the orbit frequently originate from certain primary tumors such as breast, lung, prostate, and melanoma. The site-specific nature of orbital metastases, as well as that of other metastatic lesions, cannot be the result of random seeding. We present evidence from a review of the literature demonstrating that tumor cells express adhesion molecules of the integrin family, and that these receptors play a pivotal role in the development of a metastatic colony. We investigated orbital metastatic lesions from prostate carcinoma, malignant melanoma, and lobular breast carcinoma to determine the level of integrin expression by immunohistochemistry. Several integrin subunits (alpha2, alpha4, beta3) were found to have increased expression in the metastasis when compared to normal prostate tissue and normal melanocytes. The increased expression of these integrins may be responsible for the tendency of these tumors to metastasize to the orbit, as well as for the tendency of prostate tumors to metastasize to bone. The results from the staining of the breast metastasis were inconclusive.

The spectrum of orbital aspergillosis: a clinicopathological review.

Orbital aspergillosis is an uncommon but serious infection that may first present to the ophthalmologist. Usually arising from the paranasal sinuses, it may present in manifold ways within the orbit. Some presentations, such as optic nerve involvement, can respond to systemic corticosteroids, leading to delays in diagnosis and possibly iatrogenic potentiation of the infectious process. In this review, pertinent clinical and radiographic findings are discussed, and the literature is summarized. Classic approaches to therapy include local treatment, debridement, and systemic amphotericin B. We review novel approaches to treating orbital aspergillosis and detail a flow-chart for its management. Four patients from the spectrum of orbital aspergillosis are also described: initially presenting as an infection of an exenteration socket, a complex dacryocystitis, and optic nerve tumor, and post-operative periorbital swelling. Physicians should be familiar with the clinical spectrum of disease and the variable presentation of this infection, as early diagnosis and rapid institution of appropriate therapy are crucial elements in the management of invasive aspergillosis. In the neutropenic or otherwise immunocompromised patient, a high index of suspicion must be maintained as delays in diagnosis of fulminant aspergillosis may lead to overwhelming and rapidly progressive infection. Obtaining adequate diagnostic material for pathological and microbiological examination is critical. Newer methods of therapy, particularly itraconazole and liposomal amphotericin B, may be beneficial in selected patients.

Orbital lesions in the blue rubber bleb nevus syndrome.

PURPOSE: To identify ophthalmologic manifestations of the blue rubber bleb nevus syndrome, a rare cutaneovisceral hemangiomatosis. METHODS: The authors report two patients with a diagnosis of blue rubber bleb nevus syndrome with orbital hemangiomas. RESULTS: In one patient, the orbital lesion presented with signs and symptoms similar to an orbital varix and in the other with lid ecchymosis from an eyelid lesion. CONCLUSION: Patients with the blue rubber bleb nevus syndrome may have vascular orbital lesions associated with intermittent proptosis. Ophthalmologists should be familiar with the syndrome and its life-threatening complication of gastrointestinal hemorrhage.

Adjustable suture technique for levator recession.

OBJECTIVE: To determine whether an adjustable suture technique is clinically useful in levator recession surgery. DESIGN: Consecutive clinical series. SETTING: Inpatient hospital and ambulatory surgical center. PARTICIPANTS: Ten patients who were undergoing levator recession surgical procedures for correction of eyelid retraction constituted the group of subjects of this study. OUTCOME MEASURES: Outcome measures included margin-reflex distance and palpebral fissure measurements. RESULTS: Postoperative margin-reflex distance and palpebral fissure measurements were within 0.5 mm of the desired eyelid position in 10 or 14 procedures and within 1 mm of the desired position in 12 of 14 procedures. CONCLUSION: Adjustable sutures may be a useful adjunct in levator recession surgery.

Ocular toxicity following topical application of anesthetic cream to the eyelid skin.

BACKGROUND AND OBJECTIVE: The use of topical anesthetic cream in the periorbital region may be of clinical value. The potential for toxic effects from such use has not been studied in a controlled manner. This study was performed to evaluate the potential ocular toxicity of anesthetic cream topically applied to the eyelid in an animal model. MATERIALS AND METHODS: Ten rabbits underwent periorbital eutectic mixture of local anesthetics (EMLA) (2.5 percent lidocaine and 2.5 percent prilocaine) application and were observed for evidence of gross or microscopic ocular toxicity. Baseline external and anterior segment examinations were performed, including biomicroscopy and fluorescein staining, after which a standard quantity of EMLA cream (0.75 g) was applied along the upper eyelid and covered with an occlusive dressing. After 1 hour of treatment, the eyelid and anterior segment were examined for evidence of adverse reaction. The eyelids were excised and examined histopathologically. RESULTS: No significant adverse effects were noted on external lid and anterior segment examination. The histopathologic findings were within normal limits. CONCLUSIONS: This study suggests that external application of EMLA cream to the eyelid does not induce local toxicity in the rabbit model. The external application of EMLA cream may be safe in the periorbital region.

Complications of porous spherical orbital implants.

PURPOSE: To determine the complications observed with using porous spherical orbital implants (hydroxyapatite and porous polyethylene) and the factors leading to their occurrence. METHODS: A total of 101 cases of porous spherical orbital implantation by five ophthalmic surgeons were reviewed retrospectively. The demographic data, diagnosis, prior surgery, type and technique of surgery, implant characteristics and prosthesis fitting were described in patients with complications. RESULTS: Eleven of the 101 patients had implant exposure. There were six male (1 with bilateral involvement) and four female patients, ranging in age from 2 to 71 years. Preoperative diagnosis included trauma in five patients, nontrauma in five, and tumor in one. Seven had prior eye surgeries. Three patients underwent evisceration, whereas eight underwent enucleation. Eight hydroxyapatite and three porous polyethylene implants were used with diameters of 16 to 20 mm. Three were unwrapped, six were wrapped in sclera, and two were wrapped in preserved fascia. Exposures, which generally occurred within 1 year, were grouped into small (1-5 mm), medium (6-10 mm), and large (> 10 mm). One delayed case occurred after drilling. Small stable exposures were managed conservatively. Larger exposures were managed either by implant revision or replacement. All patients were fit ultimately with a prosthesis. Histopathologic findings of explanted spheres showed fibrovascularization limited to the periphery with moderate inflammatory reaction. CONCLUSION: Complications were significantly higher in cases of eviscerations than enucleations. Complications occurred in implants either unwrapped or wrapped in homologous grafts. None of the autologous wrapping had exposure. Secondary procedures may initiate exposure when fibrovascular status of implant is inadequate.

Combined dacryops with underlying benign mixed cell tumor of the lacrimal gland.

PURPOSE/METHODS: Computed tomographic scan disclosed a well-defined mass in the right lacrimal fossa of a 57-year-old woman. We excised and examined the mass. RESULTS/CONCLUSIONS: The mass was a combination of a small benign mixed cell tumor and a large ductal cyst of the lacrimal gland. It is possible that a cyst in the lacrimal duct may mask an underlying neoplasm of the lacrimal gland.

Endoscopic laser dacryocystorhinostomy.

Endoscopic laser dacryocystorhinostomy (DCR) enables an obstructed lacrimal sac to be opened through an intranasal approach, avoiding the need for a skin incision. The holmium:yttrium aluminum garnet (holmium:YAG) laser is well-suited for this procedure because of its properties of fiberoptic delivery, effective bone cutting, and precise soft-tissue coagulation. Efficient bone ablation is particularly important for primary DCR which requires removal of relatively thick bone along the lateral nasal wall to expose the lacrimal sac. Forty-six endoscopic laser DCRs were performed on 40 patients. There were no intraoperative or postoperative complications. The surgery successfully relieved lacrimal obstruction in 85% of patients. Endoscopic instrumentation allowed for the rapid identification and correction of intranasal causes of DCR failure, including ethmoid sinus disease and middle turbinate hypertrophy. Endoscopic laser DCR appears to be a safe and effective procedure which should be considered as an alternative to external DCR for the surgical treatment of nasolacrimal duct obstruction.

Holmium:YAG endonasal laser dacryocystorhinostomy.

Previously described techniques of endonasal laser-assisted dacryocystorhinostomy appear to offer several advantages over conventional external dacryocystorhinostomy, including the following: (1) decreased disruption of medial canthal anatomy, (2) enhanced hemostasis, and (3) avoidance of a cutaneous scar. Although good results were achieved, several limitations of early laser-assisted techniques have been noted, including difficulty in removal of the thick bone of the anterior lacrimal crest and inability to obtain specimens of lacrimal sac mucosa for biopsy purposes. In a series of 40 consecutive, primary endonasal dacryocystorhinostomy procedures, we used the holmium:YAG (Ho:YAG) laser for bone removal and endoscopic sinus surgical instrumentation to obtain lacrimal sac biopsy specimens. Intraoperative hemostasis was excellent and medial canthal scarring was avoided in all patients. The overall long-term ostium patency rate in our series was 82%. Several technical modifications adopted in the latter part of our series, including use of a small drill for supplemental bone removal, extensive removal of lacrimal sac mucosa, and use of a double stent, appeared to enhance this success rate.