John J. Woog

Holmium: YAG Endonasal Laser Dacryocystorhinostomy

Previously described techniques of endonasal laser-assisted dacryocystorhinostomy appear to offer several advantages over conventional external dacryocystorhinostomy, including the following: (1) decreased disruption of medial canthal anatomy, (2) enhanced hemostasis, and (3) avoidance of a cutaneous scar. Although good results were achieved, several limitations of early laser-assisted techniques have been noted, including difficulty in removal of the thick bone of the anterior lacrimal crest and inability to obtain specimens of lacrimal sac mucosa for biopsy purposes. In a series of 40 consecutive, primary endonasal dacryocystorhinostomy procedures, we used the holmium:YAG (Ho:YAG) laser for bone removal and endoscopic sinus surgical instrumentation to obtain lacrimal sac biopsy specimens. Intraoperative hemostasis was excellent and medial canthal scarring was avoided in all patients. The overall long-term ostium patency rate in our series was 82%. Several technical modifications adopted in the latter part of our series, including use of a small drill for supplemental bone removal, extensive removal of lacrimal sac mucosa, and use of a double stent, appeared to enhance this success rate.

Endoscopic laser dacryocystorhinostomy

Endoscopic laser dacryocystorhinostomy (DCR) enables an obstructed lacrimal sac to be opened through an intranasal approach, avoiding the need for a skin incision. The holmiumtyttrium aluminum garnet (holmium:YAG) laser is well‐suited for this procedure because of its properties of fiberoptic delivery, effective bone cutting, and precise soft‐tissue coagulation. Efficient bone ablation is particularly important for primary DCR which requires removal of relatively thick bone along the lateral nasal wall to expose the lacrimal sac. Forty‐six endoscopic laser DCRs were performed on 40 patients. There were no intraoperative or postoperative complications. The surgery successfully relieved lacrimal obstruction in 85% of patients. Endoscopic instrumentation allowed for the rapid identification and correction of intranasal causes of DCR failure, including ethmoid sinus disease and middle turbinate hypertrophy. Endoscopic laser DCR appears to be a safe and effective procedure which should be considered as an alternative to external DCR for the surgical treatment of nasolacrimal duct obstruction.

Orbital implants in enucleation surgery: A report by the american academy of ophthalmology☆

OBJECTIVE To compare prosthetic and implant motility and the incidence of complications associated with porous and nonporous enucleation implants. METHODS Literature searches conducted in January 2002 for 1985 to 2001 and May 2002 for October 2001 to 2002 retrieved relevant citations. The searches were conducted in MEDLINE and limited to articles published in English with abstracts. Panel members reviewed the articles for relevance to the assessment questions, and those considered relevant were rated according to the strength of the evidence. RESULTS A randomized clinical trial and a longitudinal cohort study detected no difference in implant or prosthetic movement between nonpegged hydroxyapatite porous and spherical alloplastic nonporous implants. No controlled studies were retrieved that investigated whether pegging porous implants improves prosthetic movement. Several case series indicate that patients with pegged hydroxyapatite implants have some degree of improved prosthetic motility. Longitudinal cohort studies show that sclera-covered hydroxyapatite implants have higher exposure rates than sclera-covered silicone implants, and unwrapped porous polyethylene implants have higher exposure rates than unwrapped acrylic implants. There are numerous case series that document a wide range of implant exposure rates in patients with various enucleation implants. It is difficult to compare complication rates among implant types because patient populations vary, surgical techniques differ, and follow-up periods are often limited. CONCLUSIONS Based on one randomized clinical trial, spherical alloplastic nonporous and nonpegged porous enucleation implants provide similar implant and prosthetic motility when they are implanted using similar surgical techniques. Coupling the prosthesis to a porous implant with a motility peg or post appears to improve prosthetic motility, but there are few available data in the literature that document the degree of the improvement. There is a widely variable incidence of porous implant exposure, but certain surgical techniques and the type of wrapping material seem to reduce the exposure rate. Additional research is needed to document the long-term incidence of complications related to porous enucleation implants and associated surgical techniques. This includes the use of wrapping materials and what procedural modifications, both surgical and prosthetic, are most effective in reducing these complications.

Endonasal dacryocystorhinostomy in the primary treatment of acute dacryocystitis with abscess formation

Purpose To determine whether endonasal dacryocystorhinostomy may constitute effective primary treatment of acute dacryocystitis with lacrimal sac abscess formation. Methods This was a retrospective review of a series of 24 patients with acute dacryocystitis and lacrimal sac abscess who underwent endonasal dacryocystorhinostomy as a primary procedure. Outcome measures included resolution of signs and symptoms of acute dacryocystitis as well as intranasal ostium patency as assessed by lacrimal irrigation. Results Pain was relieved in all patients within 3 days of surgery, and swelling resolved in all patients by 9 days after surgery. Ostium patency, as defined by the absence of epiphora, and free lacrimal irrigation was achieved in 20 (83%) of 24 patients, with follow-up of 27 to 59 months (mean, 40 months). Recurrent epiphora developed in four patients; recurrent dacryocystitis developed in none. Conclusions Endonasal dacryocystorhinostomy may be a useful option in the treatment of acute dacryocystitis with abscess formation.

Orbital Lesions in the Blue Rubber Bleb Nevus Syndrome

PURPOSE To identify ophthalmologic manifestations of the blue rubber bleb nevus syndrome, a rare cutaneovisceral hemangiomatosis. METHODS The authors report two patients with a diagnosis of blue rubber bleb nevus syndrome with orbital hemangiomas. RESULTS In one patient, the orbital lesion presented with signs and symptoms similar to an orbital varix and in the other with lid ecchymosis from an eyelid lesion. CONCLUSION Patients with the blue rubber bleb nevus syndrome may have vascular orbital lesions associated with intermittent proptosis. Ophthalmologists should be familiar with the syndrome and its life-threatening complication of gastrointestinal hemorrhage.

The role of the integrin family of adhesion molecules in the development of Tumors metastatic to the orbit

Summary Tumors metastatic to the orbit frequently originate from certain primary tumors such as breast, lung, prostate, and melanoma. The site-specific nature of orbital metastases, as well as that of other metastatic lesions, cannot be the result of random seeding. We present evidence from a review of the literature demonstrating that tumor cells express adhesion molecules of the integrin family, and that these receptors play a pivotal role in the development of a metastatic colony. We investigated orbital metastatic lesions from prostate carcinoma, malignant melanoma, and lobular breast carcinoma to determine the level of integrin expression by immunohistochemistry. Several integrin subunits (α2, α4, β3) were found to have increased expression in the metastasis when compared to normal prostate tissue and normal melanocytes. The increased expression of these integrins may be responsible for the tendency of these tumors to metastasize to the orbit, as well as for the tendency of prostate tumors to metastasize to bone. The results from the staining of the breast metastasis were inconclusive.

Combined Dacryops With Underlying Benign Mixed Cell Tumor of the Lacrimal Gland

PURPOSE/METHODS Computed tomographic scan disclosed a well-defined mass in the right lacrimal fossa of a 57-year-old woman. We excised and examined the mass. RESULTS/CONCLUSIONS The mass was a combination of a small benign mixed cell tumor and a large ductal cyst of the lacrimal gland. It is possible that a cyst in the lacrimal duct may mask an underlying neoplasm of the lacrimal gland.

Ocular Toxicity Following Topical Application of Anesthetic Cream to the Eyelid Skin

BACKGROUND AND OBJECTIVE The use of topical anesthetic cream in the periorbital region may be of clinical value. The potential for toxic effects from such use has not been studied in a controlled manner. This study was performed to evaluate the potential ocular toxicity of anesthetic cream topically applied to the eyelid in an animal model. MATERIALS AND METHODS Ten rabbits underwent periorbital eutectic mixture of local anesthetics (EMLA) (2.5 percent lidocaine and 2.5 percent prilocaine) application and were observed for evidence of gross or microscopic ocular toxicity. Baseline external and anterior segment examinations were performed, including biomicroscopy and fluorescein staining, after which a standard quantity of EMLA cream (0.75 g) was applied along the upper eyelid and covered with an occlusive dressing. After 1 hour of treatment, the eyelid and anterior segment were examined for evidence of adverse reaction. The eyelids were excised and examined histopathologically. RESULTS No significant adverse effects were noted on external lid and anterior segment examination. The histopathologic findings were within normal limits. CONCLUSIONS This study suggests that external application of EMLA cream to the eyelid does not induce local toxicity in the rabbit model. The external application of EMLA cream may be safe in the periorbital region.

Comparison of automated and manual perimetry in patients with blepharoptosis.

Purpose: To compare Goldmann manual perimetry and Humphrey automated perimetry for sensitivity in detecting visual field loss, efficiency, and patient preference. Methods: This prospective study compared Goldmann manual perimetry and Humphrey automated perimetry testing techniques in 20 consecutive preoperative blepharoptosis patients with unilateral or bilateral blepharoptosis with a marginal reflex distance of ⩽+2.5 mm, no dermatochalasis overhanging the eyelid margin, and no superior visual field defects due to glaucoma, neurologic disease, or other causes. Main outcome measures included efficiency, patient preference, and sensitivity in detecting visual field loss. Institutional review board approval was obtained prior to the start of the study. Results: Goldmann perimetry had significantly shorter examination times (−&Dgr;6.4 minutes, 95% confidence interval: 4.5–8.3, p < 0.001) and was preferred by most patients (70%). There was no statistically significant difference between the 2 techniques in detecting superior visual field loss at 90° meridian. Conclusions: Goldmann manual perimetry for assessing visual field loss in blepharoptosis patients is more efficient than Humphrey automated perimetry and is preferred by patients. Both techniques are sensitive in detecting ptosis-related visual field loss.