Ji Sun Paik

Lacrimal gland fistula after cosmetic lateral canthoplasty.

BackgroundWe report a case of lacrimal gland fistula formation after cosmetic lateral canthoplasty in a young Asian woman. PatientA 34-year-old woman, who twice underwent lateral canthoplasties of both eyes with additional upper eyelid blepharoplasty, developed clear fluid discharge from a small draining tract near the lateral canthus after being operated on with cosmetic lateral canthoplasty. Assuming that lacrimal gland fistula has developed, we differentiated the tract from the lacrimal gland using a Bowman probe and performed lacrimal gland fistulectomy, which resolved the discharge, leaving no complications. ConclusionsTo our knowledge, this is the first case of lacrimal gland fistula after cosmetic lateral canthoplasty, and surgeons performing this procedure should be aware of lacrimal gland herniation and fistula tract formation, especially in patients who have undergone multiple eyelid surgeries.

Microscopic Characteristics of Lower Eyelid Retractors in Koreans

Purpose To identify the microscopic characteristics of lower eyelid retractors in Korean individuals and to elucidate age-related changes in lower eyelid retractors. Methods Eighteen Korean lower eyelids from formalin-fixed cadavers were stained with Massons trichrome. Specimens were divided into two groups based on age at death (group A, ≤65 years; group B, >65 years), and the microscopic findings were analyzed and compared by light microscopy. Results The capsulopalpebral fascia (CPF) had distinct junctions and no fusion with orbital septum in 14 eyelids (77.8%). The CPF was fused with the orbital septum in only two eyelids (11.1%). Although not significant, the inferior tarsal muscle was closer to the tarsus in group A (1.24 ± 0.71 mm) than group B (2.14 ± 1.18 mm, p = 0.07), and the tarsal height tended to be longer in group B (4.71 ± 0.55 mm) than group A (4.16 ± 1.01 mm, p = 0.20). Tarsal fatty infiltration was more evident in group B. Conclusions The CPF was rarely fused with the orbital septum in our sample of Korean lower eyelids. Although we did not identify any remarkable age-related changes in lower eyelid structures, there was a tendency for the lower retractor to loosen from the tarsus and for increased fatty infiltration in the lower eyelids from elderly individuals.

Effect of Orbital Decompression on Corneal Topography in Patients with Thyroid Ophthalmopathy

Objective To evaluate changes in corneal astigmatism in patients undergoing orbital decompression surgery. Methods This retrospective, non randomized comparative study involved 42 eyes from 21 patients with thyroid ophthalmopathy who underwent orbital decompression surgery between September 2011 and September 2014. The 42 eyes were divided into three groups: control (9 eyes), two-wall decompression (25 eyes), and three-wall decompression (8 eyes). The control group was defined as the contralateral eyes of nine patients who underwent orbital decompression surgery in only one eye. Corneal topography (Orbscan II), Hertel exophthalmometry, and intraocular pressure were measured at 1 month before and 3 months after surgery. Corneal topographic parameters analyzed were total astigmatism (TA), steepest axis (SA), central corneal thickness (CCT), and anterior chamber depth (ACD). Results Exophthalmometry values and intraocular pressure decreased significantly after the decompression surgery. The change (absolute value (|x|) of the difference) in astigmatism at the 3 mm zone was significantly different between the decompression group and the controls (p = 0.025). There was also a significant change in the steepest axis at the 3 mm zone between the decompression group and the controls (p = 0.033). An analysis of relevant changes in astigmatism showed that there was a dominant tendency for incyclotorsion of the steepest axis in eyes that underwent decompression surgery. Using Astig PLOT, the mean surgically induced astigmatism (SIA) was 0.21±0.88 D with an axis of 46±22°, suggesting that decompression surgery did change the corneal shape and induced incyclotorsion of the steepest axis. Conclusions There was a significant change in corneal astigmatism after orbital decompression surgery and this change was sufficient to affect the optical function of the cornea. Surgeons and patients should be aware of these changes.

Outcomes of levator resection in blepharoptosis patients with grafted corneas

PurposeTo present the surgical results of, and postoperative complications after, resection of the levator aponeurosis as a treatment for aponeurotic blepharoptosis in patients with grafted corneas.MethodsNine eyes with grafted corneas displaying aponeurotic blepharoptosis were investigated. Undercorrective resection of levator aponeurosis was performed on all nine patients. The margin reflex distance 1 (MRD1) values prior to the operation and at 7 days and 6 months after the operation were compared. The postoperative MRD1 values of patients with both poor and fair levator function were also evaluated. Differences in visual acuity and visual field before and after surgery were also assessed.ResultsThe MRD1 values at 7 days and 6 months after the surgery were higher than before surgery, and there was no difference between the MRD1 values of patients with poor and fair levator function at these time points. Levator function 6 months after surgery improved compared with that before surgery. Neither visual acuity nor the visual field changed after the blepharoptosis surgery. There was no preoperative corneal problem in any patient, and postoperative corneal erosion in some patients resolved with only conservative care.ConclusionsIn blepharoptosis patients with grafted corneas, the undercorrection of blepharoptosis by levator resection showed satisfactory surgical results regardless of levator function status (poor or fair), and did not adversely affect the survival of grafted corneas.

CD34 + tumours of the orbit including solitary fibrous tumours: a six-case series

BackgroundTo report six cases of CD34+ fibroblastic mesenchymal tumours, which are uncommon neoplasms in the orbit.Case presentationSix patients presenting with proptosis and palpable mass who were later diagnosed with fibrous solitary tumours, fibrous histocytoma or haemangiopericytoma in the orbit were included. All patients received radiologic examinations and surgical excision for histopathology and immunohistochemistry examinations. Five patients had no recurrence after a minimum follow-up of 12 months. One patient (case 6) experienced recurrence twice, and had debulking surgeries each time. At present, the patient still has remnant tumour in the orbit, but no growth has been detected during the past two years. The tumour size will be closely monitored.ConclusionsEven though fibroblastic tumours are rarely found in the orbit, they can present as a palpable mass with proptosis. Complete surgical excision is important for long-term prognosis, and immunohistochemical study is helpful for confirming pathologic diagnosis.

New Miyake-Apple view using a nasal endoscope.

Dear Editor, It is impossible to observe the posterior surface of the iris, ciliary body, pars plana, ora serrata, lens equator, and lens zonules of the eye using ordinary clinical tests. Until now, the Miyake-Apple view technique has been used to observe the posterior view of the anterior segment ex vivo [1–3]. With this technique, after cutting the eyeball equator, we observe the structures from behind. First, the enucleated eyeball is frozen in liquid nitrogen at −70 °C. The eyeball is cut with a knife at the equator. Glue is applied to the cut edges, and the eyeball is then attached to a transparent acrylic plate. Photographs of the posterior surface of the anterior segment are taken through the transparent plate. While this technique provides a good posterior view of the anterior segment, it is cumbersome and cannot be used in vivo. We can observe the inner structure, with minimal damage, using an endoscope such as that used in gastroscopy, colonoscopy, laparoscopy, and arthroscopy. In this letter, we present a new technique for photographing the posterior view of the anterior segment using a nasal endoscope like that commonly used in oculoplasty clinics. We performed orbital exenteration in a 78-old woman with squamous cell carcinoma in the bulbar conjunctiva and lower lid. We took photographs of the Miyake-Apple view of the eyeball using a nasal endoscope (Stryker Corporation, Kalamazoo, MI, USA) to determine whether there was any clinical sign of intraocular tumor invasion before sending the specimen to the pathology laboratory. The enucleated eyeball was placed on the table. The optic nerve was held with the left hand, while a 7 mm sclerotomy was made at the posterior pole using a #11 knife, and the endoscope probe was inserted with great care (Fig. 1-1). Cataract surgery had been performed in this eye (Fig. 1-2A). A clear one-piece intraocular lens was placed in the center of the capsular bag. The two haptics were placed symmetrically in the bag. There was no ruptured posterior capsule and there was no evidence of zonulysis. There was some remnant cortex near a haptic in the capsule (Fig. 1-2B). The equator of the lens capsule could be clearly observed in 360°. The lens equator was in contact with the ciliary processes and had an uneven margin (Fig. 1-2C). Zonules connecting the lens capsule and ciliary process were not visible. We think that the zonules were too thin and transparent for this endoscope. In an academic video on hydrodissection in cataract surgery, Miyake et al. reported that they had to use dyes to visualize the zonules [4]. The posterior surface of the iris was observed through the translucent lens capsule (Fig. 1-3A). It was brown in color, and the surface was flat. The ciliary body comprised the pars plicata and pars plana. The ciliary processes of the pars plicata showed more light color than those of the other ciliary body (Fig. 1-3B). We were able to observe the circumferential fiber of the ciliary muscle between the ciliary processes. The pars planawas dark and flat, just like its name (Fig. 1-4A). The vitreous over the peripheral retina was like fog (Fig. 1-4B). We observed an ora serrata, the border of the retina, and the spars plana (Fig. 1-4C). From iris to ciliary body and peripheral retina, we found no evidence of tumor invasion. This is consistent with the findings of the pathologist. H. S. Hwang Department of Ophthalmology, Chuncheon Sacred Heart Hospital, Hallym University, Chuncheon, South Korea

Suggestion of response evaluation criteria in patients with ocular adnexal mucosa-associated lymphoid tissue lymphoma (OAML)

Ocular adnexal mucosa-associated lymphoid tissue lymphoma (OAML) has been recognized as most common primary orbital malignancy. However, little was known about the response criteria for OAML. Our aim was to suggest response criteria for nonconjunctival OAML; the response evaluation of which using the conventional response criteria is inappropriate. A retrospective chart review of 34 eyes from 30 patients diagnosed with nonconjunctival OAML was conducted, focusing on the change in tumor size based on linear bi-dimensional and three-dimensional methods in magnetic resonance imaging (MRI) of the orbit. The maximum tumor response period of each case was investigated, and the expected optimal response period was calculated using regression analysis. In 30 evaluable patients, the median time taken for the maximum tumor response was 6xa0months (range, 3–18). More than 75xa0% of patients attained maximal tumor response in 6xa0months after initial therapy for follow-up period, the median value of which was 30xa0months (range, 15–77). Based on the regression analysis, it took 4.7xa0months for the maximum diameter (2r) of tumor to decrease by 50xa0% of initial lesion size. We cautiously suggest that optimal response could be defined as 50xa0% reduction of the maximum diameter in 6xa0months since the treatment was initiated, and that only observation without additional therapy is enough for nonconjunctival OAML, if optimal response is achieved.