Jeffrey J. Hurwitz

The Lacrimal System

This volume is designed as a multi-speciality clinical reference on the lacrimal system. The book presents a systematic approach to the evaluation and management of lacrimal disorders and critically assesses both classic techniques and newer developments, such as laser and endoscopic surgery, local anaesthesia, and same-day surgery. The first section of the book provides essential anatomic and physiological information on the lacrimal system. The second section details the methods used in investigation of lacrimal disorders, including clinical assesment, radiologic studies and endoscopy. The third section offers guidelines for management of specific disease entities and traumatic injuries. The fourth section focuses on surgical techniques and anaesthesia.

Computerized Survey of Lacrimal Surgery Patients

A computerized survey of 295 patients undergoing lacrimal drainage surgery within a three-year period where a six-month follow-up was possible was undertaken. The etiology and demographic information regarding tear duct obstruction was assessed. Dacryocystorhinostomy surgery was found to be highly successful (93%), in obstructions of the lacrimal sac and lacrimal duct. The overall success rate in patients with canalicular and common canalicular obstruction undergoing a reconstructive approach was 73%, and those cases where an attempt was made to relieve epiphora with the insertion of a Jones bypass tube had a success rate of 65% on one operation. Most of these Jones tube patients could ultimately be rendered tear-free.

COMPARATIVE STUDY OF WOUND HEALING IN PORCINE SKIN WITH CO2 LASER AND OTHER SURGICAL MODALITIES: PRELIMINARY FINDINGS

Background. The CO2 laser is a common surgical modality in dermatology. To clarify conflicting reports on the histological healing properties of CO2 laser on incisional or ablative wounds, we have applied it in a miniature hairless porcine skin model at power settings similar to those used in clinical practice.

Outcome of lacrimal surgery in older patients

BACKGROUND Performance of lacrimal surgery under neuroleptic (local) anesthesia has greatly facilitated the procedure and decreased the associated morbidity. We reviewed the outcome of lacrimal surgery in older patients to determine whether such surgery can be performed safely in the outpatient setting in this group. METHODS Review of the office and hospital charts and the surgical and anesthetic records of 120 patients (84 women and 36 men) aged 70 to 90 years who underwent lacrimal drainage procedures (dacryocystorhinostomy [DCR], canaliculodacryocystorhinostomy, DCR with insertion of a Jones tube, or a revision endonasal procedure with probing and tube insertion) at a university-affiliated hospital in Toronto in 1996. The interval between surgery and data collection ranged from 10 to 22 months. RESULTS Of the 120 patients 65 were aged 70 to 75 years, 38 were 76 to 80 years, 11 were 81 to 85 years, and 6 were 86 to 90 years. Ninety-six patients had a unilateral procedure, and 24 (22 of whom were aged 70 to 80) had a bilateral procedure. Concomitant conditions, such as hypertension and cardiac disorders, were found in 104 patients (87%). Of the 120 patients 98 (82%) (including all those aged 81 to 90) had local anesthesia, and 22 (18%) had general anesthesia. In one case anesthesia had to be changed from local to general during the procedure because of noncompliance. A total of 112 patients (93%) whose surgery was planned as a day procedure were able to leave the hospital the same day. Three additional patients were admitted to hospital for an overnight stay because of increased bleeding at the time of surgery (one patient) or a history of cardiac problems (two patients). Five patients who had planned overnight stays because of cardiac problems did well during surgery and were discharged the same day, without consequence. None of the patients had to be readmitted at a later date for bleeding or health problems. In 109 patients (91%) the presenting symptom(s) was completely relieved. Overall, 116 patients (97%) had a totally open system with no reflux on syringing. INTERPRETATION The surgical goals and techniques of lacrimal surgery in older patients were not compromised by performing the surgery in the outpatient setting and under neuroleptic anesthesia in most cases.

Buccal mucous membrane-fat graft in the management of the contracted socket

Summary A new surgical technique for reconstructing severely contracted sockets using an autogenous buccal mucous membrane-fat graft is presented. The buccal mucosa provides replacement of deficient conjunctival surface area; the fat in the underlying substantia propria of the buccal mucosa replenishes moderate volume deficiency in a single procedure. A custom-designed conformer is used in the immediate postoperative period to maintain reconstructed vertical fornices. We present four consecutive patients with contracted sockets having both a volume deficit and severe conjunctival contracture who were successfully rehabilitated using this technique.

Hertel Exophthalmometry without Orbital Rim Contact

BACKGROUND The Hertel exophthalmometer is the most widely used instrument for the measurement of globe malposition, but an absent or damaged lateral orbital rim will preclude its application. To circumvent this shortcoming, the authors have developed a fixation adapter that attaches to a standard Hertel instrument and transfers fixation to the forehead and nasion from the lateral orbit. METHODS The adapter design is presented and discussed, along with illustrative clinical cases. A study of 30 healthy patients was performed to assess the validity of the adapter with respect to the Hertel standard. The agreement was then evaluated by comparing the Hertel adapter measurements from each patient with that of the adapter. A Wilcoxon statistic was performed to assess differences in the paired values from each patient for both techniques. RESULTS Analysis on a sample (n = 30) of a healthy adult population does not show a statistical difference between the Hertel adapter and the adapter data (P > 0.05). In addition, more than 90% of the differences fall within +/- 1 mm (standard deviation = 1.02 mm) of the means for both eyes, which is within the accepted variance for the Hertel instrument. CONCLUSION The new fixation adapter promises to become useful in assessing trauma and surgical cases where the lateral orbital rim has been violated and will expand the application of Hertel exophthalmometry to these situations.

Orbital Nonchromaffin Paraganglioma: A Case Report and Review of the Literature

Nonchromaffin paraganglioma (NCP), also called glomus body tumor or chemodectoma, is rarely found in the orbit. The behavior of orbital nonchromaffin paraganglioma may potentially be more aggressive than in other head and neck locations. Diagnosis depends on electron microscopic demonstration of membrane-bound neurosecretory granules. Results of histopathologic study show a well-circumscribed lesion without a true capsule with alveolar or organoid arrangements of epithelioid cells within a reticulin framework with thin-walled blood vessels. Cells are polygonal with round or oval nuclei containing rare mitotic figures and pale-staining cytoplasm. Differential diagnosis includes alveolar soft-part sarcoma, alveolar rhabdomyosarcoma, neuroblastoma, carcinoid, and granular cell tumor. Of 29 previously reported cases of orbital NCP, 16 have been reclassified as alveolar soft-part sarcoma. The authors report a patient with an electron microscopically established orbital NCP, with the history of a contralateral glomus jugulare tumor irradiated 14 years previously.

Double stent intubations in difficult post-traumatic dacryocystorhinostomy.

Nasolacrimal obstruction following mid-facial trauma can be a difficult challenge for the lacrimal surgeon. After the initial bony repair with wires, or screws and plates, the reconstruction of the lacrimal drainage pathway can be accomplished best after at least 3 months. We describe methods of sac stent and canalicular intubation that can be used as a double stent intubation technique for severely traumatized patients.

Orbital angiolymphoid hyperplasia with eosinophilia. Presentation as chalazion.

Angiolymphoid hyperplasia with eosinophilia (ALHE) is an uncommon, benign slow-growing lesion primarily found in the head and neck region, with onset between the third and fourth decades, and a female predominance in the nonOriental population. Kimuras disease, occurring primarily in young Oriental males, is a similar lesion with peripheral blood eosinophilia, regional lymphadenopathy, and occasional nephrotic syndrome. Orbital ALHE is rare, previously reported in only nine patients. Orbital ALHE is a solitary lesion, with an older age of onset, between the fourth and eighth decades, than ALHE elsewhere. There is a male predominance, in contradistinction to ALHE elsewhere in nonOrientals. Orbital ALHE demonstrates the same histology as other locations, with exuberant capillary proliferation and an inflammatory infiltrate of eosinophils, lymphocytes, plasma cells, and mast cells. The maturity of the lesion, not necessarily the duration, determines the presence of lymphoid follicles and germinal centers. A distinctive endothelial cell lines and even extends into the vascular lumens. Peripheral blood eosinophilia occasionally occurs, and a few cases have been reported in conjunction with asthma. Therapeutic regimens for ALHE include excision, carbon dioxide and argon laser, irradiation, steroids, electrodesiccation, and cytotoxic agents. Orbital lesions have been treated successfully with excision, or biopsy with debulking, or steroids.

Quantitative evaluation of canalicular flow using lacrimal scintillography

Lacrimal scintillography is now a recognized technique for the evaluation of lacrimal excretory physiology and pathology. Computer interfacing makes it possible to measure the time required for half the radioactivity to disappear from an area (Tl/2 value). These techniques have been used by several authors to quantitate normal and abnormal lacrimal outflow (Hurwitz et al, 1975; Doucet et al., 1982).