Geoffrey A. Wilcsek

Australasian orbital and adnexal Wegener’s granulomatosis

OBJECTIVE To report a retrospective case series of 29 Australian and New Zealand patients with orbital and adnexal Wegeners granulomatosis (WG). DESIGN Retrospective case series. PARTICIPANTS Twenty-nine cases of orbital and adnexal WG were identified. METHODS A number of oculoplastic surgeons and other clinicians in Australia and New Zealand was asked about their experience with orbital and adnexal WG. Clinical data regarding these cases were conveyed by means of a questionnaire. Cases of ophthalmic WG without features of orbital or adnexal disease were excluded. MAIN OUTCOME MEASURES Data obtained from the questionnaire includes age, gender, limited or generalized disease, antineutrophil cytoplasmic antibody (ANCA) status, symptoms and signs: nasolacrimal obstruction, sinusitis, fistula/orbital bone erosion, orbital mass/proptosis, extraocular muscle/diplopia, visual acuity reduction caused by optic nerve compression, orbital pain, lid edema/erythema, biopsy status, and treatment status. RESULTS Twenty-nine patients with orbital and adnexal WG were identified and described. Symptoms included awareness of an orbital mass, epiphora, orbital pain and diplopia. Signs included an orbital mass or proptosis (69%), nasolacrimal duct obstruction (52%), limited ocular rotations (52%), lid erythema and edema (31%), bony destruction (21%), and reduced visual acuity (17%). Two patients had a persistent nasolacrimocanthal fistula. Cytoplasmic pattern antineutrophil cytoplasmic antibodies (c-ANCA) were present in 52% of patients, and in 9 of 10 patients with generalized disease. However, c-ANCA was positive in only 32% (6 of 19) of patients with limited WG. Perinuclear pattern antineutrophil cytoplasmic antibodies (p-ANCA) was positive in 10% of cases. CONCLUSIONS To diagnose and treat ophthalmic WG effectively, the clinician must be aware of its protean orbital and adnexal manifestations. WG may occur with or without systemic involvement, and c-ANCA was negative in approximately half our cases. Our cases also demonstrated two orbital fistulae, an observation previously believed to be rare.

Symptom assessment in patients with functional and primary acquired nasolacrimal duct obstruction before and after successful dacryocystorhinostomy surgery: a prospective study

Aim: To evaluate symptoms in patients with functional (FNLDO) and primary acquired (PANDO) nasolacrimal duct obstruction, evaluated prospectively before and after successful dacryocystorhinostomy (DCR) surgery. Design: A questionnaire delivered by interview, pre- and postintervention. Methods: Consecutive patients with either FNLDO or PANDO were derived from a tertiary referral clinic and private practice of two surgeons (GW and ICF). The preoperative cohort consisted of 33 FNLDO patients and 28 PANDO patients. Of these, only 31 patients elected to proceed to DCR surgery. There were 12 FLNDO patients and 19 PANDO patients in the postoperative cohorts, all with definitive surgical success. Successful DCR surgery was indicated by positive endoscopic Jones 1 testing. Symptoms in relation to the patient’s vision, reading, driving, mood, work and embarrassment were assessed. The severity of these symptoms was also graded. Results: Vision and reading in particular were affected in both preoperative cohorts, and patients suffered significantly from embarrassment. Of the postoperative cohorts, the FNLDO cohort had a reduced percentage of patients suffering each symptom type, whereas the PANDO group had a reduction in percentage of patients reporting each symptom in some but not all areas. However, the overall severity was reduced in both groups, and embarrassment was significantly reduced in both groups. Conclusion: In both FNLDO and PANDO populations, symptoms bother patients significantly, and successful DCR surgery has a positive effect on the patient’s physical and psychological well-being.

Use of the pericranial flap in medial canthal reconstruction: another application for this versatile flap.

Purpose: To describe the use and outcomes of a versatile surgical technique in the reconstruction of deep soft tissue and bony defects of the medial canthus. Methods: A retrospective review of consecutive cases requiring reconstruction of medial canthal defects involving loss of periosteum or bone by a median forehead pericranial flap and full-thickness skin grafting in a tertiary referral hospital setting. Two techniques were used: an open technique, using a midline forehead incision; and an endoscopic technique, using 2 incisions behind the hairline. Results: Twenty-one cases were identified: 19 open and 2 endoscopic. The average length of follow-up was 13 months (range, 6–50 months). Ten cases required additional oculoplastic procedures including local periosteal flaps and mucous membrane grafts. Two cases (10%) had complete flap failure; one of these was caused by infection. Five (24%) had partial (<50%) skin graft necrosis. Two cases (10%) have required further surgery. Conclusions: Our experience shows the pericranial flap to be versatile, robust, and easy to manipulate, offering advantages over alternative techniques when used for the repair of deep medial canthal defects. It is a valuable reconstructive technique that can yield good cosmetic and functional results.

Frequency of simultaneous nasal procedures in endoscopic dacryocystorhinostomy.

Purpose: To assess the frequency of simultaneous nasal procedures in powered endoscopic dacryocystorhinostomy performed by oculoplastic surgeons. Design of Study: Retrospective, multicenter study. Methods: Demographic, clinical, and surgical data of consecutive endoscopic dacryocystorhinostomy cases at 3 oculoplastic centers, over periods of 6, 4, and 2.2 years, respectively, were reviewed. The rates of simultaneous nasal procedures (septoplasty, turbinectomy, and polypectomy) were studied. Complication rates in the patients who had simultaneous endonasal procedures were analyzed. Results: Five hundred seventy-six cases (mean age: 63.2 years [16.2–94 years], women: 67.3%). Of the total cohort of patients, 14.1% required a simultaneous endonasal procedure during endoscopic dacryocystorhinostomy, 11.9% (range among surgeons: 5.2%–15%) required septoplasty, 1.5% required middle turbinate surgery, and 0.34% required polypectomy. Of the 81 patients with concomitant procedures, 1 had postoperative epistaxis, and 1 had an asymptomatic septal adhesion. The anatomical and functional success rates for the entire cohort were 95.6% and 87.8%, respectively. Conclusions: A significant proportion of patients undergoing endoscopic dacryocystorhinostomy may require concomitant endonasal procedures. Hence, endonasal lacrimal surgeons using techniques that aim to marsupialize the entire lacrimal sac may benefit from expertize in the management of concomitant nasal pathologic study.

Transcaruncular medial orbitotomy for stabilization of the posterior limb of the medial canthal tendon

Purpose: A method to stabilize the posterior limb of the medial canthal tendon (MCT), using a transcaruncular medial orbitotomy (TMO) approach, is described in a stepwise fashion. The technique described is a modified version of procedures published by Ritleng, Crawford and Collin, and Fante and Elner.

Expect the unexpected.

Primary lymphoma of the lacrimal sac Primary lymphomas of the lacrimal sac (PLLS) are rare, but are a genuine cause of secondary acquired nasolacrimal duct obstruction.1 The aim of the article on PLLS by Sjo et al 2 in this issue of the BJO (p 1004) was to define their clinical and histopathological characteristics. Their report on 15 cases of PLLS studied more than seven times the number of cases than the next largest publications defining this subject. The authors, within the limits of a multinational (seven European nations), multicentre, retrospective, chart based study have achieved an excellent outcome in defining the histopathological features of the 15 cases of PLLS. The authors presumably assembled all the cases of PLLS they had on record, or could recall, from the two European pathology institutes that are named in their article. They were able to retrieve the relevant blocks, and to subject the specimens to a battery of stains with haematoxylin and eosin and an immunohistochemical panel with multiple antibodies. No less than five experienced pathologists examined each section, and in difficult cases a consensus diagnosis was reached. This is a superb approach to a rare clinical problem. The authors demonstrated convincingly that B cell lymphomas were exclusive in this study. Five each of the 15 (33%) were diffuse large B cell lymphoma (DLBCL) and extranodal marginal zone B cell lymphoma of mucosa associated lymphoid tissue (MALT lymphoma). The authors found three “transitional MALT” lymphomas, and two unclassified B cell lymphomas, the latter so named because of an inadequate volume of tissue. As the authors point out, there have been fewer than 50 cases of PLLS reported in the past 30 …

Acute angle closure glaucoma following the use of intranasal cocaine during dacryocystorhinostomy

Many thousands of dacryocystorhinostomies (DCRs) are performed by ophthalmologists routinely without problems. Postoperative pain and nausea may wrongly be attributed to wound pain and post-anaesthetic nausea. Medical and nursing staff need to be aware of the potential for intranasal cocaine to precipitate acute angle closure glaucoma (AACG). We report two cases of AACG following the use of intranasal cocaine and subcutaneous lignocaine (lidocaine) with adrenaline during DCR surgery. We believe this to be the second report of such cases. Two women, a 67 year old and a 75 year old, developed right sided AACG immediately after ipsilateral DCR surgery. Both patients were treated successfully for AACG. Cocaine is a known mydriatic and can induce angle closure glaucoma in predisposed individuals. Adrenaline in the local anaesthetic solution and intravenous atropine sometimes used during general anaesthesia are also known mydriatics. We performed right sided external DCR surgery under general anaesthesia on both females. Regional preparation included a cocaine nasal pack (5% solution) and infiltration with lignocaine and adrenaline 1:200 000 at the proposed incision site subcutaneously. Preoperative intraocular pressures were within normal limits and there was no history of …

Cavernous haemangioma in the orbital apex: stereotactic-guided transcranial cryoextraction.

A 55‐year‐old Caucasian woman presented with an orbital cavernous haemangioma superior to the optic nerve in the orbital apex. Preoperative imaging demonstrated a mass involving the superomedial and superolateral quadrants of the posterior orbit. A stereotactic fronto‐orbital approach was performed by the neurosurgical team, and cryoextraction of the lesion was accomplished by the ocular plastic surgical team.

Management of acute surgical orbital haemorrhage: an otorhinolaryngological and ophthalmological perspective.

This retrospective report describes the management and outcome of seven patients who suffered an acute surgical orbital haemorrhage (ASOH), secondary to a surgical procedure performed on either the sinuses, orbits or eyelids. All patients but one recovered their pre-operative vision. A management plan is outlined on how to assess and tackle this complication, so that the ENT surgeon may be better prepared to meet such an acute surgical emergency, should it arise.

Selective embolization and resection of a large noninvoluting congenital hemangioma of the lower eyelid.

Purpose: To present a combined interventional radiologic and resection technique for the management of a large amblyogenic, highly vascular lesion of the lower eyelid associated with severe mechanical ectropion, conjunctival pyogenic granuloma, and recurrent, spontaneous conjunctival bleeding. Methods: Preoperative selective embolization and coil placement were followed by resection of the tumor. Results: Embolization, coil placement, and resection were uneventful with cosmetic and functional visual improvement obtained. Pathology indicated a noninvoluting congenital hemangioma. Conclusions: To the authors’ knowledge, this is the first surgical technique reported in the ophthalmic literature for the selective embolization of a noninvoluting congenital hemangioma prior to its resection. Such a technique should be considered in the management of large lesions of this type.