Cat N. Burkat

Lacrimal Excretory System Concretions: Canalicular and Lacrimal Sac

PURPOSE To characterize the demographics of patients with dacryolithiasis and to compare patients who have canalicular concretions with patients who have lacrimal sac and duct dacryoliths. DESIGN Comparative case series study and literature review. PARTICIPANTS A total of 327 consecutive patients undergoing external dacryocystorhinostomy (DCR) between 1998 and 2008 at the University of Wisconsin-Madison. Fifteen consecutive patients with the diagnosis of canaliculitis during this period were also included. METHODS The charts of all patients were reviewed for age, sex, laterality, duration of symptoms, history of dacryocystitis, history of lacrimal system intervention, history of smoking, examination findings, result of canalicular probing and irrigation, and histopathologic evaluation of the dacryolith or canalicular concretion. If applicable, the canaliculus involved was noted, as was any history of purulent canalicular drainage or canalicular injury. MAIN OUTCOME MEASURES Patient demographics, duration of symptoms, history of dacryocystitis, history of smoking, presence of fungi, or Actinomyces on histopathologic evaluation. Findings were compared with prior studies reported in the literature. RESULTS Of the 327 patients undergoing DCR, 22 (6.7%) had dacryoliths; 11 of 15 patients (73.3%) with canaliculitis had canalicular concretions. Patients with canalicular concretions were older than those with dacryoliths at DCR: 70.6 years versus 51.1 years (P = 0.003). Women made up the majority of both groups: 9 of 11 patients (81.8%) with canalicular concretions and 13 of 22 patients (59.1%) with dacryoliths at DCR (P = 0.26). The mean duration of symptoms was 20.2 months among patients with canalicular concretions and 30.5 months in patients with dacryoliths at DCR (P = 0.66); 1 of 11 patients (9.1%) with canalicular concretions smoked, compared with 9 of 21 patients (42.9%) with dacryoliths at DCR (P = 0.11). Actinomyces was isolated from 10 of 11 canalicular concretions (90.9%) and only 3 of 22 dacryoliths (13.6%) from DCR (P<0.001). In none of the 11 canalicular concretions were fungi identified, compared with 2 of 22 dacryoliths (9.1%) from DCR (P = 0.54). CONCLUSIONS The demographics of patients with dacryoliths and the histopathology of their concretions vary with the location of the dacryolith in the lacrimal excretory system.

Characteristics of Orbital Multiple Myeloma: A Case Report and Literature Review

Multiple myeloma is a plasma cell malignancy that destroys skeletal, renal, and neurological function. Orbital involvement is rare, but has been considered an initial presentation for the malignancy. Furthermore, an association between the subtype of multiple myeloma and the likelihood of orbital infiltration has been suggested. We present a case of an orbital mass that was a recurrence of multiple myeloma. A literature search was performed to evaluate the presentation characteristics of orbital multiple myeloma, plasmacytoma and primary (or solitary) extramedullary plasmacytoma. Past reports were analyzed for age, sex, symptoms at presentation, time from symptom onset to presentation, prior diagnosis before presentation for orbital symptoms, radiological characteristics, immunoglobulin subtype, and survival times. Less than half of published cases had orbital multiple myeloma as the primary presentation. Proptosis is the major presenting sign of orbital multiple myeloma, and radiological evaluation shows that the majority of masses originate in the superotemporal quadrant. The dominant immunoglobulin subtype was IgG.

Acquired lax eyelid syndrome: an unrecognized cause of the chronically irritated eye.

Purpose: To describe the demographics, symptoms, and findings of acquired lax eyelid syndrome and to assess the efficacy of the 4-eyelid tarsal strip–periosteal flap technique to treat horizontally lax upper and lower eyelids. Methods: A retrospective, case-series review of 80 patients (320 eyelids) evaluated from January 2000 to April 2004 for lax upper and lower eyelids causing chronic irritation was performed. Ten patients with diagnosed floppy eyelid syndrome or obstructive sleep apnea were excluded. Height and weight of all patients were recorded to calculate body mass index. Lateral tarsal strip fixation of all 4 eyelids to periosteal flaps based inside the orbital rim was performed to achieve horizontal tightening. Postoperative follow-up ranged up to 52 months. Preoperative/postoperative symptoms and examination findings of upper and lower eyelid distraction, keratopathy, and conjunctival inflammation were compared. Results: The most common presenting symptoms were epiphora (85.7%) and irritation (80%). The most common examination findings were upper and lower eyelid horizontal laxity and palpebral conjunctival injection (100% patients). Thirteen of 70 patients (18.6%) were obese, based on body mass index; 26 of 70 patients (37.1%) were mildly overweight; 29 of 70 patients (41.4%) were normal weight; and 2 of 70 patients (2.9%) were underweight. After surgery, 91% of patients had improved or resolved symptoms and signs; 2.5% of dehiscences occurred with the use of the 4-eyelid technique. Gradual continued improvement was observed for up to 1 year. Conclusions: Evaluation of patients presenting with chronically irritated eyes should include distraction of both the upper and lower eyelids and examination for conjunctival inflammation. Acquired lax eyelid syndrome is similar to floppy eyelid syndrome; however, 43.3% of patients were normal weight or underweight. The 4-eyelid tarsal strip–periosteal flap fixation is a rapid and effective technique for correction of this syndrome.

Periorbital Edema Following Hyaluronic Acid Gel Injection: A Retrospective Review

Introduction: The purpose of this study is to investigate the incidence, clinical features, and treatment of prolonged periorbital edema following the injection of hyaluronic acid gel to the infraorbital hollows. Materials and Methods: Retrospective descriptive study. The medical records of patients from 4 physician practices with prolonged (≥1 month) periorbital edema following the placement of hyaluronic acid gel to the infraorbital hollows, diagnosed between January 1, 2008 and December 31, 2011, were reviewed. Results: A total of 51 charts were reviewed, of which 12 (24%) patients were diagnosed with prolonged periorbital edema with a mean follow-up time of 7.1 ± 4.2 months (range, 1.5–15.3 months). The mean patient age was 50.4 years (range, 36.4–64.9 years), and the edema lasted an average of 5.4 months (range, 2.7–5.3 months). A minority of patients had a preprocedural history of fluid retention (17%), seasonal allergies (25%), previous lower eyelid or midface surgery (25%), or festoons on examinat...

Anatomy of the Lacrimal System

A thorough understanding of lacrimal system anatomy is essential for the successful management of the tearing patient. In this section, the embryology, osteology, nasal and paranasal sinus anatomy, and secretory and excretory components of the lacrimal system are described in detail with clinical and surgical correlates.

A Clinicopathologic Case Study of Two Patients with Pediatric Orbital IgG4-related Disease

Abstract The purpose of this report is to describe the clinical, radiographica, and histopathologic findings in two pediatric patients with orbital IgG4-related disease.

Anatomical position of hyaluronic Acid gel following injection to the infraorbital hollows.

Purpose: To examine with histology the anatomical location of hyaluronic acid gel injected to the infraorbital hollows of cadaver specimens. Methods: The authors dissected 5 fresh hemifacial cadaver specimens following preperiosteal injection of hyaluronic acid gel to the infraorbital hollows. Following tissue fixation, full-thickness soft tissue sections were obtained along the medial, central, and lateral lower eyelid/midface of each specimen. Histologic examination of the anatomical location of hyaluronic acid gel was performed using hematoxylin and eosin and Hale colloidal iron stains. Results: Histologic examination of the central and lateral lower eyelid/midface sections revealed a significant portion of hyaluronic acid gel in either a postorbicularis or a subcutaneous plane in 8 of 10 sections. Only 2 sections displayed hyaluronic acid gel solely within a preperiosteal plane. The medial sections revealed hyaluronic acid gel resting in either a preperiosteal or an intraorbicularis plane. Soft tissue structures such as deep fat compartment septa and the orbicularis oculi muscle appeared to play a significant role in influencing the resting position of hyaluronic acid gel. Conclusions: In most specimens, the location of a significant portion of hyaluronic acid gel following injection to the infraorbital hollows differed from the intended injection plane. Soft tissue structures including fat compartment septa and the orbicularis oculi muscle appear to influence the resting position of hyaluronic acid gel. Careful attention should be used to avoid overfilling the thin soft tissue layers of the medial infraorbital hollows or tear trough.

Identifying an appropriate animal model for the nasolacrimal drainage system.

Purpose: To determine a suitable animal model for further characterization of the nasolacrimal drainage system. Methods: A comprehensive Pubmed literature search was performed to locate articles pertaining to the histology or anatomy of the nasolacrimal drainage system in research animals. The histology of 2 nasolacrimal drainage systems of a cynomolgus monkey was also evaluated using hematoxylin-eosin stain. Results: Sixteen articles were identified that describe the anatomy and/or histology of the nasolacrimal drainage system in rabbits, rats, pigs, sheep, goats, horses, deer, llamas, camels, apes, dogs, and cats, with significant homology between these models. Notable exceptions were found in rat histology and rabbit anatomy. In the few experiments using animal models to investigate the nasolacrimal drainage system, the rabbit model was the most commonly used system. Light microscopy of the cynomolgus monkey nasolacrimal drainage system revealed markedly similar anatomy and histology to that of humans. Conclusions: Literature review demonstrates a great deal of similarity in the anatomy and histology of the nasolacrimal drainage systems of 12 mammalian species. Although a common ophthalmic research animal, the rat model has significant histologic differences that prevent its use for comparison with the human lacrimal excretory system. Current literature suggests that despite anatomical variation, the rabbit animal model could potentially be used for further characterization of the nasolacrimal drainage system because it pertains to clinical applications in human patients. Preliminary light microscopy suggests that the cynomolgus monkey may be a superior model for nasolacrimal drainage research, but further studies are required.

Clinical usefulness of orbital and facial Time-Resolved Imaging of Contrast KineticS (TRICKS) magnetic resonance angiography.

Purpose: The clinical usefulness of orbital and facial Time-Resolved Imaging of Contrast KineticS (TRICKS) MRI was assessed quantitatively and qualitatively. Methods: A retrospective chart review of the years 2001 to 2011 was conducted at the University of Wisconsin, Madison. Patients were selected based on tumor location (extracranial head and neck) and evaluation with TRICKS imaging at any stage of the clinical course. The TRICKS protocol presented in this article allows measurement of specific tumor characteristics including lesion morphology, vascular anatomy, flow dynamics within the lesion, rapidity and sequential nature of contrast enhancement, and lesion distensibility. Cases involving changes in diagnoses and/or management as a result of TRICKS interpretation are presented in detail. Results: The imaging records of 49 patients were reviewed. Most lesions were located in or around the orbit (32 lesions, 65%). Benign vascular tumors comprised the largest subcategory (32 lesions, 65%) in the cohort. Of the 20 cases with histopathological data, interpretation of MRI with TRICKS magnetic resonance angiography successfully predicted 17 (85%). Characteristic enhancement patterns for the most commonly encountered lesions are presented, in addition to a qualitative analysis of how TRICKS contributed to select cases. TRICKS helped clarify diagnosis and/or redirect management in 19 of the 49 cases in this series. Conclusion: To the best of the authors’ knowledge, this is the largest study to date of patients evaluated with TRICKS MRI/magnetic resonance angiography for orbital and facial tumors. MRI with TRICKS magnetic resonance angiography imaging protocol offers a minimally invasive, safe, and effective diagnostic instrument in selected patients with clinical diagnostic uncertainty and in those patients requiring high-resolution vascular mapping for management planning.

The 18-gauge needle: an innovative simple tool for frontalis sling surgery.

Purpose: The aim of this study was to introduce the use of the 18-gauge hypodermic needle as a simple and cost-effective alternative tool in frontalis silicone suspension ptosis surgery. Methods: A retrospective, interventional, noncomparative case study was performed by reviewing 64 patients (82 eyes) who underwent this technique between February 2010 and January 2011. Patients with simple, severe congenital ptosis with poor levator excursion were included in the study. Patients with prior sling and levator resection surgery were excluded. All patients underwent unilateral or bilateral frontalis sling surgery with a silicone rod placed via a closed-incision pentagonal configuration. All surgeries were performed by a single surgeon at a tertiary referral institute using the 1.5 inch hypodermic 18-gauge needle as an insertion guide for the silicone rod. Intraoperative technique, ease of surgical maneuverability, operative time, and postoperative results and complications were noted. Results: The mean patient age was 10.3 years (range: 1–28 years). Fifty-six of 64 patients (87.5%) were between the ages of 1 and 18 years (mean: 8.5 years), and 8 of 64 (12.5%) between 9 and 28 years (mean: 23 years). Forty-two of 64 (65.7 %) patients were female and 22 of 64 (34.4%) were male. Forty-six of 64 (71.9%) patients underwent unilateral frontalis sling surgery and 18 of 64 (28.1%) patients underwent bilateral surgery. Follow up ranged from 12 to 18 months. In 2 of the 82 eyes (2.4%), the sharp end of the needle cut the silicone rod while introducing the needle from the medial suprabrow stab incision to the eyelid margin end in a closed technique, requiring replacement of the silicone rod. Average surgical time was 15 minutes for unilateral cases and 30 minutes for bilateral cases. The main advantages noted intraoperatively were the small incisions that allowed for less operative time and minimal bleeding, easy maneuverability and control of the needle during tissue passage, and smooth threading of the silicone rod. Blunting of the tip is also eliminated as the needles are disposable. Conclusions: The 18-gauge hypodermic needle is a simple and cost-effective alternative to other needles used in frontalis silicone sling ptosis surgery. Its low cost and easy accessibility make it a particularly quick and useful option in community-based practices, tertiary referral centers, and large medical eye camps globally.