Jane M. Olver

A consideration of the time taken to do dacryo-cystorhinostomy (DCR) surgery.

AbstractPurpose Comparison of surgical times for dacryocystorhinostomy (DCR) by three different approaches: (1) external, (2) endoscopic endonasal surgical (EES), and (3) endoscopic endonasal laser (EEL) using the holmium:YAG laser. The merits and limitations of each approach are considered and surgical throughput predicted.Methods Prospective study of adult patients undergoing primary DCR surgery for nasolacrimal duct obstruction. Surgical times were recorded. Subjective and objective outcomes were assessed at a minimum of 6 months.Results A total of 48 patients undergoing 51 DCR procedures were studied. The mean surgical time for primary external (n=20), EES-DCR (n=16), and EEL-DCR (n=15) was 41.1±10.3, 39.6±13.8, and 20.9±7.8 min, with symptomatic success achieved in 95, 88, and 60%, respectively. Follow-up was 6–36 months, mean 8 months. It was calculated that if six EEL-DCR, four EES-DCR, or three external DCRs are performed per list for 45 lists per annum, this equals a total of 270 EEL-DCR, 180 EES-DCR, and 135 external DCRs. Of these, 108 EEL-DCR, 22 EES-DCR, and seven external DCRs will fail. If 75% of these have redo surgery using the same technique, an extra 13.5 (EEL-DCR), four (EES-DCR), and two (external DCR) lists are needed.Conclusions There was no significant difference between the time taken to do EES-DCR compared to external DCR, and their clinical outcomes. Only EEL-DCR was significantly faster (P<0.001). However, its lower success rate negates the apparent benefit from the greater surgical throughput.

Effective small-incision surgery for involutional lower eyelid entropion

OBJECTIVE The aim of this study was to develop an effective and minimally invasive operation to correct lower eyelid entropion that would address both the horizontal and vertical laxity. DESIGN A prospective, noncomparative, interventional case series. PARTICIPANTS Thirty-five consecutive patients with involutional entropion, aged 62 to 92 years (mean, 77.1 years), had surgery on 45 lower eyelids. Of the 45 procedures, 33 (73%) had a primary procedure and 12 (27%) were reoperations. INTERVENTION A lateral tarsal strip with diagonal tightening of the orbital septum and lower lid retractors to the lateral orbital rim was performed via a 1-cm lateral canthal incision. MAIN OUTCOME MEASURES Complications and surgical outcome were monitored clinically for between 12 and 24 months after surgery. RESULTS The results were analyzed from 42 eyelids (33 patients) with a mean follow-up of 17.1 months (range 12-24 months). Two patients died and one dropped out of the study 3 months after the second eyelid operation. In 36 cases (86%), the entropion was cured. Transient lateral orbital rim tenderness was noted in six cases (14%), and one patient had a wound infection. Anatomic recurrences were detected in six eyelids of six patients, and five of these (83%) were asymptomatic. CONCLUSIONS This surgical approach has been found effective in 86% of eyelids. Adequate clinical followup has proven essential for accurate evaluation of entropion surgery.

Lacrimal surgery success after external dacryocystorhinostomy: functional and anatomical results using strict outcome criteria.

Purpose: To present the results of external dacryocystorhinostomy (ext-DCR) for epiphora using strict outcome criteria and provide an accurate baseline and evidence from which to compare the results of endonasal dacryocystorhinostomy. Methods: Retrospective case notes review of 158 consecutive adult patients who underwent primary ext-DCR. Functional success was assessed according to the patients’ symptoms and anatomical success was measured using objective tests of lacrimal system patency: 1) the functional endoscopic dye test and/or endoscopic endonasal inspection of the ostium; 2) syringing of the lacrimal system; and 3) the fluorescein dye retention test. Patients without complete follow-up data were recalled for clinical reevaluation. A minimum follow-up of 6 months was required. Comparison of overall functional and anatomical success was further analyzed according to etiology using logistic regression and for different grades of surgeon using the chi-squared test. Results: The results for 124 of 158 ext-DCRs showed an overall functional success of 69% and anatomical success of 74%. Patients with primary acquired nasolacrimal duct obstruction (PANDO) who had surgery by the specialist lacrimal surgeon had high success: 83% functional success and 100% anatomical success. Patients with watering eyes from non-PANDO aetiology including canalicular disease who had surgery by the specialist lacrimal surgeon had moderate success: 78% functional success and 70% anatomical success. The results of all surgery by trainees were lower but only significantly so for PANDO. The mean duration of follow-up was 2.6 years (range, 6 months to 8.3 years); median follow-up was 1.9 years. Conclusion: This study used strict criteria to assess functional and anatomical outcomes of primary ext-DCR and thus provide baseline measures of success with a minimal follow-up of 6 months. When canalicular disease was excluded, results for PANDO were higher. Surgery performed by the specialist lacrimal surgeon had higher success rates than when performed by trainee.

Raising the suborbicularis oculi fat (SOOF) : its role in chronic facial palsy

AIMS To determine the adjuvant role of unilateral suborbicularis oculi fat (SOOF) lift in the periorbital rehabilitation of patients with chronic facial palsy. METHODS In a non-comparative prospective case series nine adult patients (seven male, two female) aged 34–90 years (mean 60.5) with chronic unrecovered facial palsy (over 1 year), who had not had any previous rehabilitative periorbital surgery, were studied. Lateral tarsal strip and adjuvant transconjunctival approach subperiosteal SOOF lift under local or general anaesthesia were performed; medial canthoplasty was performed where indicated. There was clinical observation of the long term (over 1 year) effect on the ptotic palpebral-malar sulcus and lower eyelid retraction. RESULTS The patients were followed up for 12–24 months (mean 16). Seven patients (77%) had sustained clinical reduction of palpebral-malar sulcus ptosis. All patients had sustained reduction of lagophthalmos. Early postoperative complications included conjunctival cheimosis in 77%. Three patients with persistent keratitis required further surgical procedures on their upper eyelid to reduce the palpebral aperture. There were no cases of infraorbital nerve anaesthesia or recurrent lower eyelid retraction. CONCLUSIONS The SOOF lift has an adjuvant role in chronic facial palsy with lower eyelid retraction and ptotic-palpebral malar sulcus. It supports the lower eyelid elevation and tightening achieved with the lateral tarsal strip. The best results were obtained in congenital facial palsy.

Autogenous temporalis fascia patch graft for porous polyethylene (Medpor) sphere orbital implant exposure

Background: Temporalis fascia has been recommended for hydroxyapatite sphere exposure. The aim of this study was to identify potential risk factors for exposure of porous polyethylene (Medpor) sphere implants and evaluate the use of autogenous temporalis fascia as a patch graft for exposure. Methods: A retrospective review of consecutive cases of porous polyethylene sphere orbital implant exposure. Results: Five cases presented between May 2000 and October 2001 (three males, two females; mean age 44.5 years). Three had enucleation (two with primary implants) and two had evisceration (one with primary implant). Exposure occurred in one primary, two secondary, and two replacement implants. Orbital implant diameter was 20 mm in four cases and 16 mm in one case (contracted socket). The mean time from implantation to exposure was 23 months (range 0.7–42.6). Three patients had secondary motility peg placement before exposure. The average time from last procedure (sphere implant or peg insertion) to exposure was 3 months (range 0.7–12.6). Four patients required surgical intervention, of which three needed more than one procedure. Autogenous temporalis fascia grafting successfully closed the defect without re-exposure in three of these four patients. The grafts were left bare in three patients, with a mean time to conjunctivalise of 2.4 months (range 1.6–3.2). Conclusions: Exposed porous polyethylene sphere implants were treated successfully with autogenous temporalis fascia graft in three of four patients. This technique is useful, the graft easy to harvest, and did not lead to prolonged socket inflammation, infection, or extrusion.

Early Cure Rates with Narrow-Margin Slow-Mohs Surgery for Periocular Malignant Melanoma

BACKGROUND Staged excision with rush-processed paraffin-embedded tissue sections (Slow-Mohs) is an effective treatment for periocular melanoma. Although there is no consensus on initial margins of excision, narrower margins in the eyelids have the functionally and cosmetically important consequence of smaller postoperative wounds. OBJECTIVES To report early cure rates for periocular melanoma using Slow-Mohs surgery with en-face margin sectioning. METHODS Retrospective, multicenter, noncomparative case series. Slow-Mohs surgery in 14 patients with periocular melanoma from 2000 to 2006. RESULTS Fourteen patients underwent 14 Slow-Mohs procedures for eight lentigo maligna, one nodular, and one superficial spreading melanoma, and four lentigo maligna, 12 primary, and two recurrent tumors. The most common site was the lower eyelid (8/14, 57.1%). Breslow thickness ranged from 0.27 to 1.70 mm, with four cases less than 0.76 mm and one case greater than 1.5 mm. Five cases were a Clark level II or greater. Complete excision was achieved with one level (6 cases) or two or three levels (8 cases), with 2- to 3-mm margins at each level in all but one case. With median follow-up of 36 months, there were two local recurrences (2/14, 14.3%). CONCLUSION Slow-Mohs with en-face sections achieves similar early cure rates to previously published margin-controlled excision techniques. Narrow margins of excision can optimize tissue preservation without compromising outcome.

Endoscopic endonasal management of prolapsed silicone tubes after dacryocystorhinostomy.

BACKGROUND Loss or prolapse of silicone tubes at the medial canthus may occur after dacryocystorhinostomy (DCR) surgery. Repositioning of the prolapsed tubes is often difficult and can necessitate early removal of tubes. The goal of this study was to determine the incidence of tube prolapse after DCR, review the methods used to reposition them, and identify the optimum management. DESIGN Retrospective, noncomparative, interventional case series. PARTICIPANTS A total of 205 adults patients who had DCR with intubation by a specialist lacrimal service in West London over a 3-year period. METHODS Patients with spontaneous tube loss or prolapse were identified from clinic attendance and case note review. MAIN OUTCOME MEASURES Incidence and timing of prolapse, techniques used for repositioning and success, whether prolapse recurred, and further intervention necessary. RESULTS Five (2.5%) had tube loss or prolapse or both, all within the first month after surgery. The tubes were repositioned initially in four patients, but prolapse recurred in two patients necessitating further intervention. Only nasal endoscopy enabled precise tube visualization and endonasal manipulation with eventual tube stability. CONCLUSIONS Tube prolapse is rare after DCR surgery. The tubes can be pushed back in, but prolapse may recur unless the endonasal aspect is addressed. The position of the tie or knots should be inspected endonasally and the tubes further secured if indicated. Repositioning is best managed with endoscopic assistance, which is a simple office procedure.

Success rates in powered endonasal revision surgery for failed dacryocystorhinostomy in a tertiary referral center.

Purpose:To evaluate the causes of failed dacryocystorhinostomy (DCR) surgery, recommend specific endoscopic endonasal techniques in revision DCR, and report postoperative success rates. Methods:Retrospective case series in a tertiary referral center of 19 consecutive, endonasal revision DCR surgeries in 17 adult patients with previous failed DCR. All cases were revised endonasally by 1 surgeon. Analysis of etiology of failure and techniques of surgery were supplemented by review of surgical video and medical records. Surgical outcomes were measured functionally by resolution of epiphora and anatomically by patency of nasolacrimal duct system on syringing and positive functional endoscopic dye test. Results:The most common cause for failed DCR was a blocked ostium due to membranous scarring (74%). Multiple causes for failure were found in 9 of 19 cases. Adjunctive procedures during revision surgery included partial middle turbinectomy (53%) and anterior ethmoidectomy (21%). The serrated oscillating blade was required in 89% cases, the high-speed diamond bur in 26%. Mean follow up was 15 months (range 7–26 months). All 19 cases had an anatomically successfully outcome. Fifteen of 19 cases (79%) had a functionally successful outcome. Conclusions:In this study, the most frequent cause of failed DCR was a scarred ostium, which is optimally visualized endonasally and precisely managed with the oscillating blade. Using the abovementioned specific endonasal techniques, the authors have demonstrated a high success rate in endonasal revision DCR surgery.

Marsupialization for lacrimal ductular cysts (dacryops): a case series.

Purpose: To present the clinicopathological features and treatment outcomes of lacrimal ductular cysts managed with marsupialization. Methods: Retrospective case review of 13 patients presenting with lacrimal ductular cysts. Results: Thirteen patients were identified, of which 7 patients with full clinical data were included in the study, 4 female, 3 male, mean age 50 years. Their main presenting symptoms were superolateral orbital swelling, feeling of pressure on the eye, and lateral ptosis. Two patients had bilateral cysts, and the remaining 5 had unilateral cysts. Six patients required surgical marsupialization, and one patient was treated conservatively because of preexisting dry eye. At surgery, one patient had multiple dacryoliths within the cyst. Histopathological analysis of the cyst lining in 5 out of 7 patients showed bilayered cuboidal epithelium with fibrous tissue. None of the patients had dry eye symptoms or signs after surgery. Follow-up ranged from 10 months to 2 years, mean 20 months Conclusion: Marsupialization is a safe and effective treatment for lacrimal ductular cysts.

Mini-monoka made easy: a simple technique for mini-monoka insertion in acquired punctal stenosis.

Purpose: To describe a simple and effective technique to insert the mini-monoka mono-canalicular stent using a nettleship dilator, without the need for a snip-procedure. Methods: Description of a surgical technique. Results: Mini-monoka stents have been shown to have a high rate of stent migration and premature loss when combined with a one-snip procedure. Our technique preserves the annular ring of the punctum and thus reduces the likelihood of these complications. Conclusion: This is a practical technique for the insertion of the mini-monoka monocanalicular stent for acquired punctual stenosis.