Hunter K. Yuen

Subconjunctival Mycetoma as an Unusual Cause of Tears With Black Deposits

Author Affiliations: Research Center for Inflammation and Regenerative Medicine, Faculty of Life and Medical Sciences, Doshisha University (Dr Ueta) and Department of Ophthalmology, Kyoto Prefectural University of Medicine (Drs Ueta, Sotozono, Yokoi, Inatomi, and Kinoshita), Kyoto, Japan. Correspondence: Dr Ueta, Department of Ophthalmology, Kyoto Prefectural University of Medicine, 465 Kajiicho, Hirokoji, Kawaramachi, Kamigyoku, Kyoto 6020841, Japan (mueta@koto.kpu-m.ac.jp). Financial Disclosure: None reported. Funding/Support: This work was supported in part by grants-in-aid for scientific research from the Japanese Ministry of Health, Labour, and Welfare (Research on Intractable Diseases), the Japanese Ministry of Education, Culture, Sports, Science, and Technology, a research grant from the Kyoto Foundation for the Promotion of Medical Science, the Intramural Research Fund of Kyoto Prefectural University of Medicine, a Shiseido Female Researcher Science Grant, and a research grant from the Japan Allergy Foundation. Additional Contributions: Chikako Endo provided technical assistance.

Fat-removal orbital decompression for disfiguring proptosis associated with Graves’ ophthalmopathy: safety, efficacy and predictability of outcomes

The objective of this study was to analyse clinical outcomes of patient who underwent fat-removal orbital decompression (FROD) for disfiguring proptosis associated with Graves’ ophthalmopathy. This is a retrospective review of 21 eyes of 11 patients who have received transforniceal FROD for disfiguring Graves’ exophthalmos at the Hong Kong Eye Hospital from January 2009 to March 2012. The amount of orbital fat removed and proptosis reduction in terms of Hertel value and complications were evaluated. The mean volume of orbital fat removed was 4.0xa0±xa01.1xa0ml (range 1.6–5.5xa0ml), and the mean change of Hertel value was 4.2xa0±xa01.3 (range 1–6, pxa0<xa00.000). None has visual loss or new-onset diplopia at primary gaze after FROD. No complications such as retrobulbar haemorrhage, meningitis, sinusitis, tissue necrosis, infraorbital paraesthesia or unsightly scar were observed. FROD could achieve reasonable proptosis reduction. It had a good safety profile, and results were predictable.

Long-term outcomes of punch punctoplasty with Kelly punch and review of literature.

PurposeTo report long-term outcomes of punch punctoplasty utilizing the Kelly punch and to compare the results with other described methods of punctoplasty in literature.Patients and methodsA retrospective, non-comparative interventional case series of patients who underwent punch punctoplasty at the Hong Kong Eye Hospital over an 8-year period. A standard Kelly Descemet’s membrane punch was utilized for punctal enlargement in all cases. Patient records and their operative records were reviewed. Anatomical success was defined by well-patent puncta on follow-up. Functional success was considered complete if tearing resolved completely postop and partial if residual tearing remained despite patent puncta and nasolacrimal drainage system. An OVID MEDLINE review was performed to compare success rates of various punctoplasty surgeries in literature.ResultsIn all, 101 punch punctoplasties from 50 patients were performed between January 2008 to January 2016. At a mean follow-up of 34 months (range: 6–86 months), the anatomical success rate was 94% (95 out of 101 puncta), whereas functional success was 92% (54 out of 59 eyes). Two cases experienced postop dry eyes; otherwise no major complication was observed.ConclusionPunch punctoplasty via the readily available Kelly punch is a simple, minimally invasive procedure that demonstrates high anatomical and functional success as a sole primary treatment for simple punctal stenosis.

Safety and efficacy of adjunctive intranasal mitomycin C and triamcinolone in endonasal endoscopic dacryocystorhinostomy.

AbstractnOne of the common causes of failure in dacryocystorhinostomy for nasolacrimal duct obstruction (NLDO) is mucosal scarring and fibrosis around the ostium. Steroid and mitomycin C (MMC) can potentially reduce scarring by their action on the inflammatory and proliferative phase of wound healing, respectively. The purpose of this study is to evaluate the safety and efficacy of combined usage of adjunctive MMC and intranasal triamcinolone (TA) in endonasal endoscopic dacryocystorhinostomy (EE-DCR). This is a retrospective interventional case series. All patients underwent mechanical EE-DCR in two regional hospitals in Hong Kong from January 2005 to December 2006 were included. All received intraoperative MMC application for 5xa0min and gelfoam soaked with TA onto the ostium. Main outcome measures include the anatomical and functional success rate at follow-up at least 6xa0months after operation. Other outcomes include complications occurred during and after operation. A total of 73 EE-DCR were performed in 69 patients. Three patients had simultaneous bilateral DCR; one had sequential DCRs for both sides. At the last follow-up, anatomical success was achieved in 68 cases (93xa0%) and both anatomical with functional success in 67 cases (92xa0%). No major complication was observed. Minor complications included asymptomatic mucosal adhesion between the nasal septum and lateral nasal wall in one patient and moderate secondary hemorrhage in another. EE-DCR with adjunctive MMC and TA is a safe and successful procedure for the treatment of NLDO.

Lymphoproliferative Disease of the Orbit.

AbstractLymphoproliferative diseases of the orbit account for majority of orbital tumors. The pathologies range from reactive lymphoid hyperplasia to specific IgG4-related inflammation to malignant lymphomas. This review summarizes current concepts regarding pathology, clinical presentation, diagnosis, staging, and treatment strategies of major orbital lymphoproliferative diseases based on updated and relevant bibliography.

Epidemiology of Open-Globe Injuries in Hong Kong.

PURPOSEnThe aim of this study was to review the epidemiology and clinical outcomes of open-globe injuries (OGIs) in Hong Kong over a 10-year period.nnnDESIGNnRetrospective case-review.nnnMETHODSnThis study included patients with OGI who presented to Hong Kong Eye Hospital and Queen Elizabeth Hospital from 1999 to 2008. Patient demographics, causes and mechanisms of injury, visual acuity (VA) at presentation, clinical features, and final VA were collected. Univariate and multivariate analyses using logistic regression were performed to identify poor prognostic factors.nnnRESULTSnA total of 122 eyes of 121 patients were included. More than half (63%) were male, and the mean age was 54 years. Workplace injuries (36%) ranked first, followed by fall (32%) and assault (13%). The majority (66%) presented with VA less than 5/200. Common associations included hyphema, lens damage, uveal prolapse, and vitreous hemorrhage. Overall, about half (46%) sustained profound visual loss (final VA <5/200). Twelve eyes underwent evisceration or enucleation. Only 1 eye developed endophthalmitis. Univariate analysis suggested that profound visual loss was associated with poor initial VA, relative afferent pupillary defect, and posterior scleral involvement (P < 0.05). Multivariate analysis showed that poor initial VA and posterior involvement were independent poor prognostic factors.nnnCONCLUSIONSnProfound visual loss was common after OGIs, especially in cases with poor vision at presentation and involvement of the posterior sclera. Identifying poor prognostic factors helps guide clinical management and facilitates counseling for patients. Early medical and surgical treatment may help to reduce the risk of endophthalmitis.PURPOSEnThe aim of this study was to review the epidemiology and clinical outcomes of open-globe injuries (OGIs) in Hong Kong over a 10-year period.nnnDESIGNnRetrospective case-review.nnnMETHODSnThis study included patients with OGI who presented to Hong Kong Eye Hospital and Queen Elizabeth Hospital from 1999 to 2008. Patient demographics, causes and mechanisms of injury, visual acuity (VA) at presentation, clinical features, and final VA were collected. Univariate and multivariate analyses using logistic regression were performed to identify poor prognostic factors.nnnRESULTSnA total of 122 eyes of 121 patients were included. More than half (63%) were male, and the mean age was 54 years. Workplace injuries (36%) ranked first, followed by fall (32%) and assault (13%). The majority (66%) presented with VA less than 5/200. Common associations included hyphema, lens damage, uveal prolapse, and vitreous hemorrhage. Overall, about half (46%) sustained profound visual loss (final VA < 5/200). Twelve eyes underwent evisceration or enucleation. Only 1 eye developed endophthalmitis. Univariate analysis suggested that profound visual loss was associated with poor initial VA, relative afferent pupillary defect, and posterior scleral involvement (P < 0.05). Multivariate analysis showed that poor initial VA and posterior involvement were independent poor prognostic factors.nnnCONCLUSIONSnProfound visual loss was common after OGIs, especially in cases with poor vision at presentation and involvement of the posterior sclera. Identifying poor prognostic factors helps guide clinical management and facilitates counseling for patients. Early medical and surgical treatment may help to reduce the risk of endophthalmitis.

Primary vs Secondary Endoscopic Dacryocystorhinostomy for Acute Dacryocystitis With Lacrimal Sac Abscess Formation: A Randomized Clinical Trial

Importance Endoscopic dacryocystorhinostomy (EN-DCR) is emerging as the preferred procedure in the management of nasolacrimal duct obstructions. However, its safety and long-term efficacy in the setting of acute dacryocystitis with lacrimal sac abscess have not been well studied. Objective To compare outcomes of EN-DCR as primary treatment with EN-DCR as a secondary treatment after percutaneous drainage of lacrimal sac abscess in acute dacryocystitis. Design, Setting, and Participants This randomized clinical trial was conducted from October 1, 2012, to October 31, 2015, at a tertiary ophthalmic center. The assessors of success at postoperative year 1 were masked to the procedures received by the participants. All surgical procedures were performed by 2 oculoplastic surgeons with different levels of EN-DCR experience. Eligible participants had acute dacryocystitis and lacrimal sac abscess presenting within 2 weeks of onset, who were 18 to 90 years of age. Analysis was of the intention-to-treat population. Interventions Patients were allocated by block randomization to receive either percutaneous drainage of lacrimal sac abscess followed by EN-DCR after the acute episode subsided (control group) or primary EN-DCR within 2 weeks of presentation (intervention group). Both groups received a course of empirical systemic antibiotics (amoxicillin and clavulanic acid, 375 mg, to be taken 3 times a day for 1 week). Main Outcomes and Measures Primary outcomes were time from presentation to documentation of symptom resolution and recurrence within 3 months. Results Thirty-two patients were randomized equally into 2 treatment arms (control and intervention). The mean (SD) age of patients was 61 (13) years, and there was a predominance of women (27 [84%]). The mean (SD) time to symptom resolution was 13.8 (5.8) days in the intervention group compared with 31.7 (27.1) days in the control group (mean difference, 17.9; 95% CI, 3.71-32.01; Pu2009=u2009.02). The mean (SD) time to surgery in the intervention group was shorter at 11.9 (6.3) days compared with 45.6 (30.1) days in the control group (mean difference, 33.6; 95% CI, 17.92-49.33; Pu2009<u2009.001). Recurrences occurred once in the control group and did not occur in the intervention group. No differences in operation time and complications between the 2 groups were identified. The anatomical and functional success was 87.5% (14 of 16 cases) in both groups at postoperative year 1. Conclusions and Relevance Primary EN-DCR in acute dacryocystitis with lacrimal sac abscess results in faster resolution compared with secondary treatment. No differences in recurrence, safety, or outcomes at postoperative year 1 were noted between the 2 treatment groups. Trial Registration http://www2.ccrb.cuhk.edu.hk/web Identifier: CUHK_CCT00350

Hybrid procedure for orbital venous malformation in the endovascular operation room

PurposeTo describe a hybrid procedure for orbital venous malformation in the endovascular operating room (EVOR).MethodsFive consecutive patients with venous malformation in the periocular and orbital region were included. All patients received a one-stage direct puncture venogram, image-guided glue injection, and surgical resection in the EVOR equipped with a biplane digital subtraction angiography system (BDSAS).ResultsThe mean age at the time of operation was 37.4 years (range, 22–69 years). The mean operative time was 193u2009min (range, 138–324u2009min). No intraoperative complications were noted. The mean follow-up duration was 18.8 months (range, 10–24 months). Three patients had complete removal of the vascular lesions. At the latest follow-up, no recurrence of symptoms related to the lesions was noted. All patients had an uneventful recovery and satisfactory outcome.ConclusionsThe hybrid procedure of orbital venous malformation in the EVOR is a novel application in ophthalmology. It is a safe and well-controlled procedure with real-time high-quality BDSAS surveillance to facilitate surgical resection. Its success requires collaboration between the interventional radiologist, the surgeon, and the ophthalmologist.

Response to ‘Functional and anatomical outcomes of punctoplasty with Kelly punch’

Acquired punctal stenosis represents a common cause of epiphora due to partial or complete lacrimal outflow obstruction. A variety of surgical procedures have been described involving punctal dilatation or surgical enlargement, sometimes augmented with lacrimal stenting or perforated punctal plugs. We read with interest the article by Wong et al1 regarding the long-term outcomes of punch punctoplasty with Kelly Descemet’s membrane punch. In this report the successful anatomical and functional rates were 94% and 92%, respectively. The authors would like to add the results of our 86 consecutive case series of Kelly punch punctoplasty performed on 65 patients (21 bilateral cases) with symptomatic punctal stenosis. The average follow-up was 6 months. At the last follow-up, 95% (82/86) achieved anatomical success, compared to 90% (78/86) functional success rate. Three puncta (3.4%) were noted to be re-stenosed at last visit. No significant complications were recorded. In terms of surgical technique, Wong et al1 describe an extended ampullectomy up to 2–3 mm beyond the vertical component of the canaliculus, by partially deroofing and marsupializing the lower canaliculus, aiming to counteract the postoperative scarring and contracture of the punctal opening. However, in our experience a posterior ampullectomy involving only the vertical component of the canaliculus, with two to three bites, was sufficient for achieving adequate punctal opening enlargement in majority of the cases. In cases of short or stenosed vertical component, this can be slightly extended by (~1mm). Postoperatively, patients were prescribed a topical antibiotic solely (typically g. chloramphenicol 0.5%). Our series provides further support for punctoplasty using Kelly Descemet’s membrane punch as a simple, effective, and minimally invasive procedure for patients with symptomatic punctal stenosis. Satisfactory outcomes can be achieved with minimal tissue removal, potentially with less alteration of the lacrimal pump system.

Combined (Hybrid) Operations for Orbital Venous Malformations

Hybrid procedure or hybrid operation refers to those operative procedures combining conventional open surgeries with an interventional part using catheter-based radiological diagnostic and interventional procedures at the same setting. Such procedures are carried out at hybrid operating theater or endovascular operating room (EVOR) and are being widely practiced in cardiovascular surgery, neurosurgery, and various specialties. Hybrid operations of orbital vascular lesions involve embolization of vascular malformation with N-butyl cyanoacrylate glue followed by surgical resection in the same setting at the EVOR. Prior studies have confirmed the efficacy of preoperative embolization before surgical excision. Reduced intraoperative blood loss and better delineation of resection margin both enhance a more complete excision of the malformation. Simultaneous radiological and surgical intervention in the setting of combined operating theater and angiography suite provides further advantages of real-time imaging surveillance, one-stop operation without the need of patient transfer under anesthesia, and extended multidisciplinary collaboration for management of complex lesions and complications. Hybrid procedure is safe and demonstrates excellent surgical and cosmetic outcome with minimal complications in suitable cases.