Adam S. Hassan

Management of submacular hemorrhage with intravitreous tissue plasminogen activator injection and pneumatic displacement

OBJECTIVE To investigate the efficacy and safety of treating thick submacular hemorrhages with intravitreous tissue plasminogen activator (tPA) and pneumatic displacement. DESIGN Retrospective, noncomparative case series. PARTICIPANTS From 5 participating centers, 15 eligible patients had acute (<3 weeks) thick subretinal hemorrhage involving the center of the macula in eyes with pre-existing good visual acuity. Hemorrhages were secondary to age-related macular degeneration in 13 eyes and macroaneurysm and trauma in 1 eye each. METHODS The authors reviewed the medical records of 15 consecutive patients who received intravitreous injection of commercial tPA solution (25-100 microg in 0.1-0.2 ml) and expansile gas (0.3-0.4 ml of perfluoropropane or sulfur hexafluoride) for thrombolysis and displacement of submacular hemorrhage. After surgery, patients maintained prone positioning for 1 to 5 days (typically, 24 hours). MAIN OUTCOME MEASURES Degree of blood displacement from under the fovea, best postoperative visual acuity, final postoperative visual acuity, and surgical complications. RESULTS In 15 (100%) of 15 eyes, the procedure resulted in complete displacement of thick submacular hemorrhage out of the foveal area. Best postprocedure visual acuity improved by 2 lines or greater in 14 (93%) of 15 eyes. After a mean follow-up of 10.5 months (range, 4-19 months), final visual acuity improved by 2 lines or greater in 10 (67%) of 15 eyes and measured 20/80 or better in 6 (40%) of 15 eyes. Complications included breakthrough vitreous hemorrhage in three eyes and endophthalmitis in one eye. Four eyes developed recurrent hemorrhage 1 to 3 months after treatment, three of which were retreated with the same procedure. CONCLUSIONS Intravitreous injection of tPA and gas followed by brief prone positioning is effective in displacing thick submacular blood and facilitating visual improvement in most patients. The rate of serious complications appears low. Final visual outcomes are limited by progression of the underlying macular disease in many patients.

Local corticosteroid treatment of eyelid and orbital xanthogranuloma

Purpose: To demonstrate the efficacy of local corticosteroid therapy for the treatment of eyelid and orbital xanthogranuloma in adults. Methods: The authors performed a retrospective chart review of 6 patients receiving local triamcinolone acetonide (40 mg/ml) injections for the treatment of eyelid and orbital xanthogranuloma at the University of Michigan. All patients underwent diagnostic biopsy before treatment. The effects of this therapy on symptoms and signs of the disease were assessed. Results: All 6 patients had eyelid swelling or nodularity and 5 had yellow discoloration of their eyelids. All lesions involved the eyelids and anterior orbit and 5 were present bilaterally. Biopsy revealed necrobiotic xanthogranuloma in 4 patients and adult-onset xanthogranuloma in 2 patients. Triamcinolone acetonide was administered intralesionally as series of 2 to 25 injections. Local control was obtained in all 6 cases, with the reduction of symptoms and signs of the disease in 5 cases. Two patients with necrobiotic xanthogranuloma had development of non-Hodgkin lymphoma. Average follow-up of patients whose treatment was not truncated by systemic chemotherapy was 52 months (range, 30 to 86 months). No complications occurred as a result of this treatment. Conclusions: Intralesional injection of triamcinolone acetonide is an effective, safe treatment for orbital xanthogranuloma in adults. This modality avoids the side effects associated with systemic corticosteroid or cytotoxic agent therapy.

Graded full-thickness anterior blepharotomy for correction of upper eyelid retraction not associated with thyroid eye disease

Purpose: To evaluate the efficacy of graded full-thickness anterior blepharotomy for upper eyelid retraction of various causes not associated with Graves eye disease. Methods: Twenty-one eyelids of 18 patients with upper eyelid retraction not caused by Graves eye disease were treated with graded full-thickness anterior blepharotomy. Preoperative and postoperative symptoms, midpupil to upper eyelid distance, lagophthalmos, and superficial punctuate keratopathy were evaluated. Results: Upper eyelid retraction was due to facial nerve palsy in 4 patients (22%), overcorrected ptosis in 5 patients (28%), and cicatrix after trauma in 6 patients (33%). One patient each (6% each) had retraction from graft-versus-host disease, after blepharoplasty, and after orbicularis oculi myectomy for blepharospasm. At a mean of 10 months follow-up, presenting symptoms resolved or improved in 17 patients (94%) and remained unchanged in 1 patient (6%). Midpupil to upper eyelid distance, lagophthalmos, and superficial punctuate keratopathy all improved significantly (all p < 0.001). No surgical complications occurred. Conclusions: Graded full-thickness anterior blepharotomy is a safe, effective, and rapid technique for patients with symptomatic upper eyelid retraction due to etiologies other than Graves eye disease. This technique improves symptoms and signs of ocular exposure while addressing relative upper eyelid height symmetry and contour.

Linear magnetic resonance enhancement and optic neuropathy in primary angiitis of the central nervous system.

A 38-year-old woman developed incoherent mentation, tremor, ataxia, and bilateral optic disc edema with mildly depressed visual acuity, nerve fiber bundle defects, and a left afferent pupillary defect. Magnetic resonance imaging of the brain disclosed striking linear contrast enhancement radiating from the ventricular borders. Lumbar puncture showed a normal opening pressure with a lymphocytic pleocytosis and elevated protein. On the basis of these findings, the initial diagnosis was viral or post-viral meningoencephalitis and the patient was not treated. During the next 4 weeks, her condition worsened. A brain and meningeal biopsy disclosed findings typical of primary angiitis of the central nervous system. With aggressive treatment, her neurologic status and magnetic resonance imaging normalized and her optic neuropathy improved markedly. Optic neuropathy and linear magnetic resonance imaging enhancement should be recognized as features of primary angiitis of the central nervous system.

Cranial nerve seven palsy and its influence on meibomian gland function.

Purpose: To investigate a possible relationship between cranial nerve seven (CN VII) palsy and meibomian gland dysfunction. Methods: A prospective case series of 16 patients with unilateral CN VII palsy was evaluated for meibomian gland function. Main outcome measures included the Sunnybrook Facial Grading System for CN VII palsy and a modified version of a noncontact, noninvasive meibomian gland evaluation by Arita et al.1,2 Unaffected contralateral eyes were used as the control group for comparison. Results: Sixteen affected eyes were evaluated. The mean Sunnybrook Facial Grading System composite score was 34.19 ± 24 (score = −15 to 100; maximum function = 100). A paired samples t test between affected and unaffected eyes demonstrated a significant difference between mean values for tear break-up time, eyelid abnormality, meiboscore for upper eyelid, meiboscore for lower eyelid, combined meiboscore, and digital pressure. No significant difference was found for superficial punctate keratopathy nor Schirmer’s test. A Pearson product-moment correlation coefficient found a significant negative correlation between the Sunnybrook Facial Grading System composite score and all aspects of meibomian gland function, except for the upper eyelid meiboscore, which only approached significance (p = 0.059). Conclusion: These findings suggest that a strong relationship exists between cranial nerve seven palsy and meibomian gland dysfunction. Clinical optimization of meibomian gland function may benefit cranial nerve seven palsy patients.

Horizontal eyelid movement on eyelid closure

Purpose: When performing ptosis surgery, a suture is placed between the levator and the tarsal plate at the point of the desired peak. This placement is done while the patient’s eye is closed, but its effects are observed with the patient’s eye open. Unaccounted-for horizontal eyelid movement on eyelid closing may therefore adversely affect the desired outcome. The purpose of this study was to characterize the horizontal translation of the eyelid on closing the eyes. Methods: In this experimental case series study, a randomly selected upper eyelid of normal subjects, subjects with ptosis, and subjects with exophthalmos, ages 21 through 70, was studied to determine the horizontal eyelid movement on closing the eyes by videotape analysis of the movement of dots placed above the eyelid margin and on the eyelid crease above the center of the pupil. Results: The eyelid translation on closing the eye is medial and varies among subjects from 0.1 mm to 3.5 mm. The movement is usually greater at the eyelid margin than at the eyelid crease. Conclusions: The amount of horizontal eyelid translation on closing the eyes is clinically significant in many people. The clinical impact of this finding should affect how ptosis surgery is performed. The desired point of peaking of the eyelid should be marked at the beginning of the case with the eyes open and the mark used as a guideline for placing the suture that will determine the peak.

Double silicone intubation as treatment for persistent congenital nasolacrimal duct obstruction.

Purpose The great majority of children with nasolacrimal duct (NLD) obstruction are successfully treated with probing or conventional silicone tube intubation. A small percentage of patients fail to have their NLD obstruction resolved with these procedures and require dacryocystorhinostomy (DCR). This study was conducted to assess the effectiveness of double bicanalicular silicone intubation with placement of two loops of silicone tubing through the NLD for treatment of persistent NLD obstruction in children as an alternative to DCR. Methods Ten eyes of 9 patients with nasolacrimal duct obstruction who had failed conventional therapies and were to otherwise undergo DCR were instead treated with double bicanalicular silicone tube intubation. Resolution of preoperative symptoms and signs of NLD obstruction were assessed. Results At an average follow-up of 40 ± 5.6 months, all patients had improvement in symptoms and signs. The mean patient age was 31 ± 3.2 months. The average duration of intubation was 15 ± 0.73 months. Eight of 10 eyes had complete resolution of NLD obstruction symptoms. Two of 10 treated eyes had occasional symptoms of mattering with upper respiratory infection and exposure to wind or cold but required no further treatment. Nine of 10 eyes were treated for congenital NLD obstruction. The remaining patient had failed conventional bicanalicular intubation after repair of a traumatic common canalicular avulsion. Conclusions Double bicanalicular silicone tube intubation is an effective alternative to DCR in selected children who have failed conventional therapies for NLD obstruction. This treatment obviated DCR in all patients in this study.

Giant peptic ulcer: A surgical or medical disease?

BACKGROUND Medical management of giant peptic ulcers has traditionally been associated with significant morbidity and mortality rates, dictating the need for surgical intervention. METHODS To determine if recent advances in therapy has reduced the number of patients who require surgical procedures, we reviewed the medical records of all patients with peptic ulcers of 2 cm or more at our institution from January 1991 to August 1996. RESULTS We identified 75 patients with giant ulcers who were followed for a mean duration of 36 months. Sixty-three patients (84%) were managed without operation with a good outcome, documented by healing on repeat esophagogastroduodenoscopy and/or resolution of symptoms. Medical management included treatment of Helicobacter pylori infection, stopping nonsteroidal anti-inflammatory drugs, and potent acid suppression. Endoscopic intervention to control bleeding was successful in 7 patients (9%), and 2 patients (3%) were treated successfully with angiographic embolization. Only 12 patients (16%) required surgical intervention: 6 as the result of bleeding, 2 as the result of perforation, 1 as the result of obstruction, and 3 with intractable disease. CONCLUSIONS In this series of patients with giant peptic ulcers, most patients (84%) were managed without surgical treatment. Our data suggest that improvements in medical therapy have obviated the need for eventual surgical intervention in most patients with giant ulcers.

Asymmetric eyebrow elevation and its association with ocular dominance.

Purpose: To examine the relation between asymmetric eyebrow elevation and ocular dominance. Methods: A retrospective cohort study was performed in patients who underwent bilateral upper eyelid blepharoplasty from July 2007 to May 2009. Patients with pre- and postoperative involuntary asymmetric eyebrow elevation were selected from a surgical log database for inclusion in this study. Brow asymmetry was determined by examination of preoperative and postoperative digital photographs and was defined as a measured eyebrow-height difference in conjunction with the asymmetric recruitment of the frontalis muscle. Ocular dominance was determined by using a modified Porta test. Statistical analysis was performed by using the Fisher Exact test. Results: Forty-seven patients met inclusion criteria. Sixty-six percent (31 of 47) involuntarily, asymmetrically elevated the right eyebrow, and 34% (16 of 47), the left. Of the 31 patients with right eyebrow elevation, 87% (27 of 31) were right-eye dominant, and 13% (4 of 31) were left-eye dominant (p < 0.001). Among patients with asymmetric left eyebrow elevation, 62.5% (10 of 16) were left-eye dominant, whereas only 37.5% (6 of 16) patients were right-eye dominant (p < 0.001). Conclusion: We report for the first time that involuntary asymmetric eyebrow elevation and ocular dominance are significantly associated. The assessment of ocular dominance should be included in the pre- and postoperative evaluation of patients with asymmetric brow elevation undergoing blepharoplasty. This asymmetry and its etiology must be recognized, so that an attempt to create symmetry does not result in the overcorrection of the contralateral eyelid that may lead to complications such as lagophthalmos and exposure keratopathy.

Comprehensive, combined anterior and transcaruncular orbital approach to medial canthal ligament plication.

Purpose: To assess the efficacy of a comprehensive technique for correction of severe punctal and medial lower eyelid ectropion and lower eyelid retraction associated with medial canthal ligament (MCL) laxity. Methods: A comprehensive technique that plicates the anterior and posterior crura of the MCL was performed on 8 eyelids of 6 patients with punctal ectropion and MCL laxity. Preoperative and postoperative symptoms, punctal ectropion, medial lower eyelid ectropion, lower eyelid retraction, lagophthalmos, and exposure keratopathy were evaluated. Results: At an average of 13 months (range, 8–17 months), preoperative symptoms of epiphora and discomfort improved or resolved in all eyes. Punctal ectropion improved in all eyes and completely resolved in 75% of eyes. Medial lower eyelid ectropion was corrected in all eyes, when present. Lower eyelid retraction, lagophthalmos, and exposure keratopathy improved in all eyes. In 1 case, edema of the caruncle and semilunar fold persisted for 6 months. Conclusions: Combined anterior and transcaruncular MCL plication is an effective and safe procedure for addressing severe punctal and medial lower eyelid ectropion that accompanies MCL laxity and is difficult to correct by other methods. This procedure provides stable, 3-dimensional support to the medial lower eyelid and punctum.