Dejan M. Rašić

Clinical significance of routine lacrimal sac biopsy during dacryocystorhinostomy: A comprehensive review of literature

The main purpose of this paper is to provide the information about the incidence and types of pathology of secondary acquired obstructions of the lacrimal excretory outflow system caused by primary lacrimal sac non-neoplastic and neoplastic lesions. After a thorough literature search, 17 case-control studies were found and selected, data were extracted and categorized, to evaluate specific lacrimal sac pathology mimicking inflammation. A total of 3865 histopathologically examined lacrimal sac wall biopsy specimens from 3662 patients, taken during dacryocystorhinostomy for clinically presumed primary chronic dacryocystitis, were analyzed. The most common reported histopathological finding was non-specific chronic inflammation with or without fibrosis (94.15% of cases). Lacrimal sac-specific pathologies were present in 226 (5.85%) cases. Unsuspected lacrimal sac-specific pathologies were present in 55/226 (24.34%) cases. Almost 45% of primary lacrimal sac malignant neoplasms were not suspected, preoperatively and intraoperatively. Tumor-like lesions of the lacrimal sac were the most common pathology found: (1) lacrimal stones-dacryoliths, (2) pyogenic granuloma, (3) granulation tissues, (4) reactive lymphoid hyperplasia, and (5) lacrimal sac-specific inflammation (Wegeners granulomatosis and sarcoidosis). Neoplastic pathology was found in 55/3865 (1.42%) lacrimal sac wall biopsy specimens; of those, malignant cases were 2.24 times more frequent than benign. Lymphoma was the most common preoperatively unsuspected or intraoperatively unexpected neoplastic pathology. This analysis of the relevant literature highlights the value of routine lacrimal sac biopsy during surgery for clinically presumed primary acquired nasolacrimal duct obstruction.

Comparison of postoperative pain and satisfaction after dacryocystorhinostomy in patients operated on under local and general anesthesia

Summary Background There has been only 1 study on postoperative pain after external dacryocystorhinostomy (DCR) that compared pain between 2 groups of patients; 1 group received local anesthesia and the other received general anesthesia. To further characterize the relationship between these 2 types of anesthesia and postoperative pain, we designed a study in which a single patient received these 2 different anesthesia modalities for a short interval on 2 different sides. Material/Methods There were 50 participants in this study. External DCR was performed on the same participant on both sides using local anesthesia on 1 side and general anesthesia on the other. Postoperative pain was measured using the visual analogue scale (VAS), and localization and timing of pain were reported by the participants. Postoperative nausea and vomiting (PONV) were documented if present. Results Pain levels were significantly higher with general anesthesia 3 hours post-surgery, and 6 hours post-surgery the pain remains higher following general anesthesia but is borderline insignificant (p=0.051). However, 12 hours post-surgery, there is no significant difference in the pain level (p=0.240). There was no significant difference in the localization of pain with local and general anesthesia. Postoperative nausea is significantly more frequent after general anesthesia, and vomiting only occurs with general anesthesia. Local anesthesia was preferred by 94% of the participants (47 out of 50). Conclusions The vast majority of patients in our study who have undergone both GA and LA DCR would choose LA again, providing a compelling case for use of the LA technique.

A 7-year prospective study of routine histopathological evaluation of the lacrimal sac wall incisional biopsy specimens obtained during external dacryocystorhinostomy in adults and a review of the literature.

The most common lacrimal sac pathology is chronic inflammation with or without occlusive fibrosis. However, a substantial number of lacrimal sac-specific pathologies were reported throughout the literature which may mimic chronic inflammation and be misdiagnosed. From a tertiary ophthalmic care centre in Serbia, in a single ophthalmic pathology laboratory, during a 7-year period (January 2004 to October 2010), a 599 consecutive lacrimal sac wall biopsy samples routinely obtained during external dacryocystorhinostomy in adult patients with clinically presumed primary acquired lacrimal drainage system obstruction were analysed. Although non-specific lacrimal sac pathology was present in the vast majority of cases (578 biopsy specimens; 96.49%), this report also reveals a relatively substantial number (21 biopsy specimens; 3.51%) of clinically non-suspected or intraoperatively unexpected primary lacrimal sac-specific pathology—among them, six lesions with malignant biological behaviour were identified: one microinvasive squamous cell carcinoma and five malignant lymhoproliferative lesions. Usefulness of routine lacrimal sac wall biopsy during surgery for primary acquired lacrimal drainage system obstruction is undoubtful and commensurate with the constant need for better understanding of the pathological processes that involve lacrimal drainage system.

Pain during external dacryocystorhinostomy with local anesthesia.

Summary Background External dacryocystorhinostomy (DCR) is often performed under local anesthesia (LA) without adequate knowledge of the pain experienced by the patient. Material/Methods We subdivided our surgical technique into stages easily understood by the patients (introducing cotton tipped applicators, performing parabulbar injection, creating the incision, bone cracking (opening the ostium), manipulating the nose, intubating, closing the wound, and packing with gauze). A total of 50 patients ranging in age from 31 to 83 years of age (63.64±9.64) underwent external DCR. Each patient was asked 30 minutes after surgery to indicate the intensity of pain experienced at each stage of the surgery and during intramuscular (IM) injection of an antibiotic using a visual analog scale (VAS). Results Analysis of the VAS-based pain scores indicated 3 statistically equal occurrences of pain coinciding with the opening of the ostium, and receiving both parabulbar anesthetic and IM antibiotic injections. Conclusions The level of pain experienced during the most unpleasant stage of external DCR (ostium opening) was similar to the pain experienced from an IM injection. Patients can be informed that pain during external DCR with local anesthesia is comparable to receiving an IM gluteal injection.

Recurrence of a small primary iris stromal cyst following treatment with Nd:YAG laser photodisruption in an adult

Svetlana STANOJLOVIĆ Jurija Gagarina 73 11000 Belgrade, Serbia stanojlovic.svetlana@gmail.com SUMMARY Introduction Primary acquired iris stromal cyst is rare in adults. In this group, they are generally stable lesions which require no treatment. Case outline We describe a rare case of a small primary iris cyst in a 39-year-old patient, associated with unusual signs of irritation. Ultrasound biomicroscopy demonstrated iris stromal cyst measuring 3 × 2 mm. A neodymium-doped yttrium aluminium garnet (Nd:YAG) laser cystotomy was engaged as the least invasive treatment approach. However, the cyst recurred soon after repeated laser treatment and sector iridectomy with excision of the cyst was performed. Five years after surgery there was no evidence of recurrence. Conclusion Although more benign clinical course of primary stromal iris cyst is generally assumed in adults as compared to children, complete cyst removal seems to be mandatory for preventing cyst recurrence regardless of the cyst size or patient age. To the authors’ knowledge this is the first documented report of Nd:YAG laser photodisruption of acquired primary iris stromal cyst in an adult.

The Crystalline Lens

The human crystalline lens is the second most important refracting element of the eye. The lens functions primarily in accommodative vision. The lens doubles in volume between birth and age 70. Approximately at age 40, the lens loses its ability to accommodate because of loss of pliability, and at age 70 the transparency of the lens is reduced resulting in cataract formation.

Acute post-surgical bilateral orbital gas-producing infection — a case report and literature review

The presence of visible gas on radiography, computed tomography (CT), or magnetic resonance imaging (MRI) is associated with various pathological conditions, ranging from severe infections caused by gas-producing organisms to cutaneous and subcutaneous tissue disruption that allows an interface with the air [1]. A high index of suspicion surrounds the finding of gas because of the virulence of conditions such as gas gangrene and necrotizing fasciitis [1–12]. Gas dissecting into the orbital soft tissues as a result of bacterial activity is a rapidly progressive, extremely serious, life-threatening ophthalmological emergency [1–12]. Gas gangrene (myonecrosis) and necrotizing fasciitis can cause necrosis of tissues and systemic shock with multiorgan failure, sometimes within a matter of hours [1–3, 13]. It is well known that the usual causative organisms in gas-producing infection from a contaminated wound are clostridial species: Clostridium perfringens accounts for the majority of cases (over 80 %), while most other cases are caused by other Clostridium species [1–3]. Clostridial infection is always associated with necrosis, and very often associated with poor functional and anatomical outcome [1–4]. However, a variety of other non-clostridial organisms, both aerobes and anaerobes, may also produce infections in which gas is demonstrable: Escherichia coli, Proteus species, Pseudomonas aeruginosa, Bacteroides, Klebsiela pneumoniae, Prevotella species, Staphylococcus aureus, Peptostreptococcus species, Fusobacterium species, and Streptococcus pyogenes are only the species reported most often in the literature [2]. Non-clostridial infections may take various forms, which lead to difficulties in making accurate and prompt diagnoses and are also related to the confusion between gas gangrene and various (bacterial and nonbacterial) lesions that simulate gas gangrene. Aside from the fact that non-clostridial organisms usually involve subcutaneous tissues, they may also involve muscle and simulate clostridial myonecrosis [2, 3]. However, non-clostridial gas infections accompanied by gangrene are not very common, even in immunosuppressed individuals [2, 3]. Since the initial report by Chiari (1893), which concerned a non-clostridial gas-forming infection due to a colon bacillus in the gangrenous lower limb of a diabetic patient [4], fewer than 40 cases of non-clostridial gas-forming infections have been described. Only four such cases have been described in the orbit [5–7, 12], and these are quite different from the present case. With regard to the pathogenesis of gas bubbles of clostridial or non-clostridial etiology, they are liberated by the bacterial fermentation of glucose [4]. In addition, impaired microcirculation may also contribute to gas formation [3, 4]. It is also necessary to mention the benign, non-infectious presence of gas in the orbit, which is known as orbital emphysema. Orbital emphysema is a well-known entity that can arise from nose-blowing, tumor presentation, or after fractures of the orbital floor, and may be self-induced in psychiatric patients [15]. There are no research contracts or any kind of financial support (grants) for this study. No authors have any conflicts of interest.