Bijan Beigi

Factors affecting the success of external dacryocystorhinostomy

PURPOSE To assess the success rate of external dacryocystorhinostomy (Ext-DCR) and factors affecting it in a university hospital. MATERIALS AND METHODS In a retrospective interventional noncomparative case series, records of 276 Ext-DCRs in 274 patients in a 9-year period were reviewed. ‘Complete success’ was defined as patent system on irrigation (objective) and absence of symptoms (subjective). Patent system on irrigation with minimal postoperative symptoms was considered as partial success. The chi-square and Fisher’s exact tests with 95% confidence interval (CI) were used to analyze the data (SPSS release version 9.0, Chicago). RESULTS The age range was 3–84 years (mean: 41.5, SD: 17.7). The majority of the patients (66.7%) were female. The most common presumed etiology was primary acquired nasolacrimal duct obstruction (PANLDO) (227/276, 82.2%). A silicone tube was inserted in 111 patients (40.2%). Follow-up was from 6 to 89 months (mean: 11.5, SD: 10.4). Overall complete success rate was 89.1% (246/276). It was 92% (209/227) in PANLDO, 72.7% (16/22) in congenital NLDO (P: 0.01, 95% CI: 0.024–0.030), 71.4% (10/14) in traumatic NLDO (P: 0.001, 95% CI: 0.012–0.017), 90% (9/10) in previous failed DCR (P: 0.6, 95% CI: 1), and two out of three patients with previous nasal/sinus surgery. Gender, type of presenting symptoms, duration of preoperative symptoms, silicone tube insertion in PANLDO, and associated canalicular stenosis did not have a significant effect on the success. CONCLUSION Ext-DCR is an effective and highly successful procedure for the treatment of NLDO regardless of the etiology.

Hertel exophthalmometry: Reliability and interobserver variation

PURPOSE To quantify and analyze the interobserver variation in Hertel exophthalmomety and to evaluate the impact of experience on it. METHODS In a population-based epidemiologic study, Hertel exophthalmometry was performed on 1063 randomly selected normal subjects (stratified sampling) by an oculoplastic attending surgeon (A) and a third-year ophthalmology resident (R). Both observers were masked to the reading of the other. The Chi-square test, two-tailed paired sample t-test, and two-tailed paired independent t-test were used to analyze the data (SPSS Release 9.0, Chicago). RESULTS There were 463 (43.5%) females and 600 (56.5%) males. The age ranged from 6 to 70 years (mean ± SD = 20.3 ± 10.9). The mean right eye protrusion was 14.8mm for both ‘A’ and ‘R’. The mean left eye protrusion was 14.6mm and 14.7mm, respectively. There was good correlation (r = 0.80) and no statistically significant difference (0.1 < P < 0.6) for the ocular protrusion values (right, left, and average) measured by ‘A’ and ‘R’. However, the percentage agreement (within ±1mm limits of acceptance) was about 60%. Comparison of the first 530 subjects versus the remaining cases showed no improvement in agreement with the senior observer. CONCLUSION Hertel exophthalmometry is a reliable method for measuring the ocular protrusion. However, as with most clinical measures, there is a negligible interobserver variation that seems to be unavoidable.

Langerhans Cell Histiocytosis Mimicking Preseptal Cellulitis

A 7-year-old girl presented with signs of preseptal cellulitis that initially responded to antibiotics but then relapsed. Computed tomography scan revealed a cystic lesion in the preseptal tissues with associated soft tissue swelling and lacrimal gland inflammation. Anterior orbitotomy revealed a hemorrhagic-appearing lesion extending from the preseptal tissues subperiosteally along the roof of the orbit. The lesion was excised and histopathology and immunohistochemical staining confirmed a diagnosis of Langerhans histiocytosis. Management of this condition depends on the extent of systemic involvement, with single bony lesions usually pursuing a benign course and often spontaneously regressing or resolving following biopsy. This case serves to highlight that an underlying cause for preseptal cellulitis should be sought and if there are relapses or inadequately resolving signs of preseptal cellulitis, then prompt investigation to rule out other causes is required.

Congenital ocular motor apraxia: An inability to unlock the vestibulo-ocular reflex

The authors report ten cases of congenital ocular motor apraxia. Two patients had Cockaynes syndrome. One patient had succinic semialdehyde dehydrogenase deficiency. One patient had vermian hypoplasia of the cerebellum. Four patients had precocious head movements with abnormal limb tremor in the first two days of life.Based on their findings the authors postulate that head thrusts are the result of a failure to unlock the vestibulo-ocular reflex from the object of regard rather than a strategy to assist horizontal gaze.

Management of a broken needle during the frontalis suspension procedure.

A 19-month-old girl with bilateral congenital ptosis and abnormal head posture underwent a bilateral frontalis sling procedure. As the needle was directed through the submyocutaneous tunnel, its tip (eye) snapped. When the needle was withdrawn, the tip was missing. The problem was addressed and the procedure was completed.

Clinical research: Ragged-red fibres in the orbicularis oculi muscle and their significance

Neuropathologic examination of the orbicularis oculi muscle (OOM) obtained from patients undergoing blepharoplasty for ectropion (n=10), entropion (n=7) and biopsies taken from patients with a clinical diagnosis of chronic progressive external ophthalmoplegia (n=3) revealed ragged-red fibres (RRF) as demonstrated by increased sub-sarcolemmal staining with haematoxylin & eosin, Gomoris trichrome and reduced nicotinamide adenine dinucleotide (NADH) in all except one specimen (95%). A control group consisting of ten patients with normal eyelids underwent OOM biopsy during the course of an enucleation or cosmetic facial surgery. Similar findings were seen in 90% of these specimens, RRFS were quantified in all specimens which were more abundant in the group with eyelid abnormalities (mean 7.05%). The mean number of RRFS in the control group was 3.40%.

Endoscopy in the field of oculo-facial plastic surgery

We have been constantly coming across a couple of questions from some mentors, peers, and trainees with regard to the use of the endoscope in the field of oculo-facial plastic surgery. The first question is why it is essential to utilize an endoscope when the conventional procedures are working just as well? The second is to what extent can it be beneficial? The answer to the first question is rooted in three concepts of modern medicine: less invasiveness, rapid recovery, and better quality of life. Ophthalmologists experienced the same scenario when phacoemulsification cataract surgery was first introduced against extracapsular cataract extraction procedure, and it is clear how the story went. This editorial highlights an update on the use of the endoscope in the field of oculo-facial plastic surgery to answer the second question. Endoscopy is a minimally invasive procedure which allows the physician to observe and manipulate the target organ through a keyhole or reach inaccessible targets. The basic instrument, the endoscope, includes a light source, delivery shaft, and a lens. There are various types available which are based on the length of the shaft and the strength and angulation of the lens. The most common ones used in our field are 4 mm and 2.7 mm diameter endoscope with zero, 30, and 45degree angulation of the lens. These are utilized in the lacrimal drainage system (LDS), orbital, and cosmetic surgery.

Late reexposure after upper eyelid tarsoconjunctival flap for exposed porous orbital implant.

The records of four patients with exposed porous orbital implant treated with the upper eyelid tarsoconjunctival Hughes flap were reviewed. The tarsoconjunctival Hughes flap was fashioned for two patients with recurrent orbital porous implant exposure and two patients with primary orbital porous implant exposure (5 to 6 mm at largest dimension; mean, 5.6 mm). There were two hydroxyapatite and two high-density polyethylene implants. In all patients, reexposure (2 to 3 mm at largest dimension; mean, 2.5 mm) occurred 6 to 24 weeks (mean, 13 weeks) after the tarsoconjunctival Hughes flap procedure at the junction of the flap and the socket surface conjunctiva. Mean follow-up duration was 18.7 months (range, 7 to 27 months). Linear late reexposure is the main drawback of the upper eyelid tarsoconjunctival Hughes flap to cover an exposed orbital porous implant.