Gary J. Lelli

Ophthalmic cyclosporine use in ocular GVHD

Purpose: To evaluate the safety and efficacy of topical ophthalmic cyclosporine in patients with dry eyes secondary to graft-versus-host disease (GVHD). Methods: Records of consecutive patients with ocular GVHD treated with topical cyclosporine were reviewed. Results: Thirty-two eyes of 16 patients were included with a mean follow-up of 90 days. Dry eye symptoms improved in 10 patients (62.5%), and corneal fluorescein staining improved in all eyes (P = 0.0039). Global physician impression was favorable in 12 patients (75%). Ocular burning or irritation was noted in 3 patients (19%), which improved with either continuation of cyclosporine at the current dosing regimen or reduction in dose and/or concentration of cyclosporine. Conclusion: Ophthalmic cyclosporine seems to be safe and may be beneficial for patients with ocular GVHD, particularly those with more severe dry eyes.

Ocular adnexal lymphoma staging and treatment: American Joint Committee on Cancer versus Ann Arbor

Purpose To evaluate the prognostic utility of the American Joint Committee on Cancer (AJCC) staging system for ocular adnexal lymphoma (OAL). Methods A multicenter, consecutive case series of patients with biopsy-proven conjunctival, orbit, eyelid, or lacrimal gland/sac lymphoma was performed. The electronic pathology and clinical records were reviewed for new or recurrent cases of ocular adnexal lymphoma. The main outcome measures included pathology and clinical staging (AJCC and Ann Arbor systems), treatment, and recurrence (local and systemic). Statistical analysis included demographic evaluations and the Kaplan-Meier survival probability method. Results Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue were the most common (n=60/83, 72%). The most common Ann Arbor clinical stages were IE (76%) followed by IIE (17%) and IIIE (7%). Pathology identified 13 cases (15%) that were upstaged to group IV (p=0.017). Similarly, AJCC clinical stages were cT1NOMO (21.7%), cT2NOMO (44.6%), cT3N0M0 (5%), and cT4NOMO (2.4%). Local control was achieved in 75% of treated patients. There were 19 local recurrences from which 14 (74%) belonged to the non–radiation treatment groups. Lower-risk groups (T1 and T2 without lymph node involvement or metastatic disease of AJCC and IE of Ann Arbor) had longer disease-free survival than the higher-risk groups (AJCC T1, T2 with nodal involvement or metastatic disease, T3, and T4 as well as Ann Arbor II, III, and IV). The overall mean follow-up was 43.3 months (range 6–274). Conclusions Regardless of stage, recurrence and disease-free survival were more closely related to treatment and histopathology rather than tumor size or site-specific location.

Current preferences and reported success rates in dacryocystorhinostomy amongst ASOPRS members.

ABSTRACT Purpose: Success rates for endoscopic and external dacryocystorhinostomy vary widely (external 70–95%; endonasal 59–99%). We investigated surgical preferences and reported success rates in dacryocystorhinostomy amongst American Society of Ophthalmic Plastic and Reconstructive Surgery members. Methods: This retrospective study utilized a questionnaire sent to American Society of Ophthalmic Plastic and Reconstructive Surgery members. Information culled included number of cases performed, surgical approach, and results. Results: 214 (38% response rate) surveys were completed, representing over 7,054 cases in one year. 93.9% of respondents offer external dacryocystorhinostomy; 63.1% offer endonasal. Surgeons report an increased rate of post-operative tearing with endonasal versus external (35.6% versus 5.8%, p < 0.001) and post-operative dacryocystitis with endonasal versus external (13.2% versus 1.0%, p < 0.001). The top reasons for choosing endoscopic DCR were patient preference, no visible scar, and prior failed DCR. The top reasons for choosing external DCR were higher success rate, physician preference, and more long-term data on outcome. The majority of members use bicanalicular Crawford tubes (76%). Tubes were most commonly removed during post-operative months 2 (34.6%) and 3 (36.4%). Conclusions: Despite papers reporting equivalent success rates between external and endonasal dacryocystorhinostomy, more American Society of Ophthalmic Plastic and Reconstructive Surgery members perform greater numbers of external dacryocystorhinostomy, prefer external dacryocystorhinostomy, and report a higher success rate with this approach.

Outcomes in silicone rod frontalis suspension surgery for high-risk noncongenital blepharoptosis.

Purpose: To evaluate the outcomes of silicone rod frontalis suspension for complicated cases of ptosis with poor levator function. Methods: A retrospective interventional case series of consecutive patients undergoing silicone rod frontalis suspension by 2 surgeons over 20 years generated records of 51 eyelids (33 patients) with ptosis secondary to cranial nerve III palsy, myasthenia gravis, chronic progressive external ophthalmoplegia, or oculopharyngeal dystrophy. Outcome measures included postoperative change in eyelid height, lagophthalmos, and corneal fluorescein staining; need for reoperation; patient and physician satisfaction; grading of postoperative photographs; and interobserver agreement. Results: Forty-five percent of patients had preoperative corneal staining. Surgery resulted in a significant increase in eyelid height (+2.8 mm; p < 0.0001), lagophthalmos (+0.4 mm, p < 0.0001), and corneal staining grade (+0.3 units; p = 0.02). Most patients achieved a subjectively acceptable result. Patient and physician agreement with outcome assessment was good (&kgr; = 0.65, p < 0.0001). Twenty eyelids (39%) required revision of the silicone sling, most often for adjustment of eyelid height. Survival analysis differed by diagnosis (p = 0.0154) and was most favorable for patients with myasthenia gravis. Interobserver agreement on postoperative photographs was marginal. Conclusions: Silicone rod frontalis suspension surgery increases the eyelid height in complicated blepharoptosis patients with minimal eyelid excursion. Patients and physicians concur closely regarding satisfaction; masked assessment of photographic outcome parameters by observers yields marginal agreement. Because most patients undergoing this procedure have a narrow window for appropriate postoperative eyelid height, a relatively high proportion of patients required revision. Silicone rod frontalis suspension surgery is chosen in these challenging cases for the ease of adjustment.

Bilateral Lacrimal Gland Disease: Clinical Features of 97 Cases

OBJECTIVE Bilateral lacrimal gland (LG) disease is a unique presentation that can result from varied causes. We reviewed the diagnoses, clinical features, and outcomes of 97 patients with this entity. DESIGN Case series. PARTICIPANTS Ninety-seven patients with bilateral LG disease. METHODS Retrospective review and statistical analysis using analysis of variance and the Fisher exact test. MAIN OUTCOME MEASURES Patient demographics, clinical features, diagnostic testing, diagnosis, and treatment. RESULTS Patient age ranging from 8 to 84 years (mean, 46 years). The predominant gender was female (77%), and race included black (49%), white (38%), and Hispanic (12%) patients. Diagnoses fell into 4 categories: inflammatory (n = 51; 53%), structural (n = 20; 21%), lymphoproliferative (n = 19; 20%), and uncommon (n = 7; 7%) entities. The most common diagnoses included idiopathic orbital inflammation (IOI; n = 29; 30%), sarcoidosis (n = 19; 20%), prolapsed LG (n = 15; 15%), lymphoma (n = 11; 11%), lymphoid hyperplasia (n = 8; 8%), and dacryops (n = 5; 5%). Inflammatory conditions were more likely in younger patients (P<0.05) and in those with pain (P<0.001) and mechanical blepharoptosis (P<0.01) at presentation, whereas lymphoma was more common in older patients (P<0.001) without active signs of inflammation at presentation. Black patients were more likely to have sarcoidosis (P<0.01). Laboratory results showed high angiotensin converting enzyme level being significantly more likely in patients with sarcoidosis (P<0.05). However, sensitivity was limited to 45%, with 25% of patients diagnosed with IOI also demonstrating positive results. Corticosteroid therapy was the treatment of choice in 38 cases, corresponding to resolution of symptoms in 29% and improvement in an additional 32%. Overall, chronic underlying disease was found in 71% of patients, among whom 26% achieved a disease-free state, whereas 3% succumbed to their underlying disease. CONCLUSIONS The cause of bilateral lacrimal gland disease most commonly was inflammatory, followed by structural and lymphoproliferative. Patient characteristics and clinical presentations were key features distinguishing between competing possibilities. Despite local control with corticosteroids or radiotherapy, underlying disease continued in 71% of patients and led to death in 3%.

Histopathologic changes in punctal stenosis.

Purpose: To describe the pathologic changes in punctal stenosis by reporting the histopathologic findings in a series of punctoplasty specimens. Methods: Observational retrospective chart review. Electronic health records of all patients having punctoplasty over a 2-year period at an academic oculoplastic practice were examined. All patients whose records included pathology reports were entered into a database. Results: Twenty-four patients, representing 30 eyes, had pathology records in the electronic health records. Patients were 75% women and had an average age of 65 (19–88) years. Associated conditions included blepharitis (71%), dry eye syndrome, or Meibomian gland dysfunction (63%). Histopathologic examination demonstrated chronic inflammation in 11 eyes (36.7%), fibrosis in 7 eyes (23.3%), chronic inflammation and fibrosis in 4 eyes (13.3%), squamous metaplasia in 3 eyes (10%), normal conjunctival mucosa in 3 eyes (10%), and Actinomyces israelii canaliculitis in 2 eyes (6.7%). Conclusions: Nearly all histopathologic specimens revealed findings consistent with inflammation, fibrosis, or both. These findings provide evidence to support the hypothesis that the many etiologic causes of punctal stenosis are linked by a common pathophysiologic mechanism involving inflammation.

Evaluation of the canalicular entrance into the lacrimal sac: an anatomical study.

Purpose: The purpose of this study was to investigate the prevalence of a common canalicular entrance in the lacrimal sac and to investigate the anatomy of the canalicular/lacrimal sac junction with direct visualization using a novel cadaveric dissection technique. Methods: Preserved cadavers were dissected to allow direct visualization of the canalicular entrance(s) to the lumen of the lacrimal sac. The prevalence of a common canaliculus and the anatomical variations of the canalicular/lacrimal sac mucosal fold of tissue were recorded. Results: One hundred twenty-four lacrimal systems (95 cadavers; 43 female, 52 male) were included in the study analysis. Overall, 123 lacrimal systems demonstrated a common canaliculus entering the lacrimal sac. Only one demonstrated 2 separate orifices (right orbit; male) in the sac (0.08%; 95% confidence interval, 0.1%–4.4%). Seventy-four lacrimal systems had some variation of a canalicular/lacrimal sac mucosal fold (59.7%). The remaining 50 (40.3%) had no visible canalicular/lacrimal sac mucosal fold. Conclusions: This study provides direct anatomical evidence that the prevalence of separate canalicular orifices in the lacrimal sac is lower than previously reported (<1%). Additionally, the presence of a valve-like structure at the canalicular/lacrimal sac junction is common. These observations can potentially play a role in evaluating and treating lacrimal system pathology.

Evaluation and Treatment of Perioperative Corneal Abrasions

Purpose. To evaluate perioperative risk factors for corneal abrasion (CA) and to determine current care for perioperative CA in a tertiary care setting. Methods. Hospital-based, cross-sectional study. In Operating Room and Post-Anesthesia Care Units patients, a comparison of cases and controls was evaluated to elucidate risk factors, time to treatment, and most common treatments prescribed for corneal abrasions. Results. 86 cases of corneal abrasion and 89 controls were identified from the 78,542 surgical procedures performed over 2 years. Statistically significant risk factors were age (P = 0.0037), general anesthesia (P < 0.001), greater average estimated blood loss (P < 0.001), eyes taped during surgery (P < 0.001), prone position (P < 0.001), trendelenburg position (P < 0.001), and supplemental oxygen en route to and in the Post-Anesthesia Care Units (P < 0.001). Average time to complaint was 129 minutes. 94% of cases had an inpatient ophthalmology consult, with an average time to consult of 164 minutes. The most common treatment was artificial tears alone (40%), followed by combination treatment of antibiotic ointment and artificial tears (35.3%). Conclusions. Trendelenburg positioning is a novel risk factor for CA. Diagnosis and treatment of perioperative corneal abrasions by an ophthalmologist typically require three hours in the tertiary care setting.

Early postoperative adjustment of the Fasanella-Servat procedure: review of 102 consecutive cases.

Purpose: To describe and evaluate an office-based technique to adjust the Fasanella-Servat procedure in the first postoperative week. Methods: This retrospective case series reviewed all consecutive eyelids undergoing the Fasanella-Servat procedure between July 1, 2006, and July 1, 2007, by a single surgeon (R.D.L.). Charts were reviewed to determine the frequency, timing, safety, and efficacy of postoperative adjustment. Postadjustment photographs were reviewed by a blinded ophthalmic plastic surgeon for eyelid contour, height, symmetry, overall cosmesis, and picture quality as excellent, satisfactory, or poor. Results: The Fasanella-Servat procedure was performed on a total of 102 eyelids in 54 patients over the 12-month interval. Postoperative adjustments at the time of suture removal were performed to improve mild eyelid asymmetries for 22 eyelids (22%) in 19 patients. Postadjustment photographs, available for 17 patients, showed excellent eyelid contour (53%), height (88%), symmetry (82%), and cosmesis (65%). Satisfactory results were obtained in all remaining photographed eyelids. Conclusions: The Fasanella-Servat procedure should be viewed as an adjustable ptosis correction with the adjustment as a standard component of postoperative suture removal. This manipulation takes only a few moments with minimal to no patient discomfort. It allows for improvements in eyelid height and contour. This series demonstrates a procedure that is simple, highly successful, and safe.

Three-dimensional volumetric assessment of the nasolacrimal duct in patients with obstruction.

Purpose: The purpose of this study was to determine if a significant difference exists in the nasolacrimal duct volume of subjects with primary nasolacrimal duct obstruction compared with that of controls. Methods: This was a retrospective, case–control study of 70 subjects with prior maxillofacial CT scans, including 35 subjects with obstruction and 35 controls. Volume measurements of the nasolacrimal duct were made on a GE Advantage Workstation using volume viewer software, and measurements were compared using an unpaired Student t test. Interrater and intrarater reliabilities were calculated. Results: There was no significant difference in the nasolacrimal duct volume of patients (0.411 ± 0.18 cm3) compared with that of controls (0.380 ± 0.13 cm3) (p = 0.23). Women had smaller volume ducts (0.356 ± 0.11 cm3) than that of men (0.482 ± 0.19 cm3) (p < 0.001). Male patients had smaller volume ducts (0.470 ± 0.23 cm3) than that of male controls (0.493 ± 0.14 cm3) (p = 0.70), while female patients (0.384 ± 0.13 cm3) had significantly larger volume ducts than that of female controls (0.328 ± 0.08 cm3) (p = 0.01). There was excellent interrater and intrarater reliabilities. Conclusions: CT 3-dimensional volumetric software can be used to accurately measure the nasolacrimal duct volume in patients with obstruction. Both the absence of a significant difference in patient’s and control’s nasolacrimal duct volumes and the overlap in range between the 2 groups imply that the volume of the tear duct is likely not related to the etiology of obstruction. The increase in volume seen in females with obstruction may be due to expansion of the bony canal during the postmenopausal years. The exact etiology of primary nasolacrimal duct obstruction requires further investigation.