John V. Linberg

PRIMARY ACQUIRED NASOLACRIMAL DUCT OBSTRUCTION. A CLINICOPATHOLOGIC REPORT AND BIOPSY TECHNIQUE

Primary acquired nasolacrimal duct obstruction (PANDO) of adults is a clinical syndrome of unknown cause, and the histopathology of the nasolacrimal duct has not been substantially studied. A technique of excisional biopsy of the soft tissue contents within the nasolacrimal canal during external dacryocystorhinostomy (DCR) is presented. No complications were associated with the biopsy technique in 14 cases. Two cases of lacrimal obstruction secondary to sarcoidosis and leukemia were discovered in biopsies of patients with the clinical syndrome of PANDO, demonstrating the value of routine biopsy during DCR. Biopsies revealed a spectrum of changes that correlated with duration of symptoms. Early cases revealed active chronic inflammation along the entire length of the narrowed nasolacrimal duct. Intermediate cases revealed focal resolution of the inflammatory process with fibrosis, while late cases showed fibrous obliteration of the entire duct. Although the first event in primary acquired nasolacrimal duct obstruction remains uncertain, clinicopathologic correlation suggests that compression of the duct by inflammatory infiltrates and edema precedes clinical chronic dacryocystitis.

Foreshortening of the Inferior Conjunctival Fornix Associated with Chronic Glaucoma Medications

The authors designed a device to measure the depth of the inferior conjunctival fornix at the slit lamp using topical anesthesia. The fornices of 179 glaucoma patients receiving topical medications for glaucoma and 420 control subjects who had no history of ocular disease were measured. These measurements were age-stratified by decade. A significant foreshortening of the inferior conjunctival fornix was found with aging (P less than 0.01). Patients in their sixth through ninth decades using miotics for 3 years or longer and patients using nonmiotic agents for 3 years or longer exhibited significant foreshortening of the inferior fornix when compared with age-stratified (by decade) control subjects (P less than 0.01). These observations suggest that increasing age and topical medications for glaucoma, or the preservatives, used for 3 years or longer, are independently associated with conjunctival shrinkage.

Anatomy of the orbital septum and associated eyelid connective tissues : Implications for ptosis surgery

The anatomy of the orbital septum and associated eyelid connective tissues was examined using cadaver dissection, histologie sections, surgical observations, and special radiologie imaging. The embryologie development of the eyelid connective tissues was also reviewed. Examination revealed a distinct layer of fibroadipose tissue in the eyelid and eyebrow posterior to the orbicularis and frontalis muscles, and anterior to the orbital septum. Fibrous septa within the submuscular fibroadipose tissue become contiguous with more compact lamellae of the orbital septum posteriorly imparting a multilayered quality to the orbital septum. Fat within the fibroadipose layer anterior to the orbital septum may be mistaken for the preaponeurotic fat pad by the unwary surgeon and may lead to surgical error. The orbital septum and the levator aponeurosis were found to join 2 to 5 mm above the superior tarsal border (average, 3.4 mm). Recommendations for ptosis surgery based on these anatomic principles are given.

Evisceration with Hydroxyapatite Implant: Surgical Technique and Review of 31 Case Reports

PURPOSE To evaluate the use of hydroxyapatite (HA) as an orbital implant with evisceration. BACKGROUND Although several reports have documented good success with HA orbital implants and their use with enucleation, only a few reports mention HA with evisceration. These few reports are less favorable, with exposure rates as high as 67%. In contrast, the authors have had good success with evisceration and HA implants with no major complications and a low exposure rate. METHODS A retrospective analysis of all eviscerations with HA implant performed between January 1989 and July 1993 was completed (n = 31). Patients underwent evisceration with scleral modification, including anterior relaxing incisions and posterior sclerotomies to accommodate a large sphere without tension on the wound. Patient records were reviewed for demographic data, surgical indication, sphere size, clinical outcome, complications, and follow-up interval. The surgical technique is described. RESULTS All 31 patients underwent successful surgery with complications limited to exposure (6%), mild superior sulcus deficit (6%), and a conjunctival cyst (3%). No patient required further socket reconstruction, and no patient required peg placement to enhance motility. The average follow-up interval was 13.3 months. CONCLUSIONS The authors have had good success using HA orbital implants for evisceration without major complications. Primary evisceration with HA implantation after posterior sclerotomies is a safe and effective method for treating patients with a blind, painful eye.

Comparison of orbital fracture repair performed within 14 days versus 15 to 29 days after trauma.

Purpose: To examine whether orbital floor and/or medial wall fracture repair delayed for 15 to 29 days is as effective as early surgery. Methods: A retrospective review is reported comparing outcomes of early fracture repairs (performed 1–14 days after trauma) to delayed fracture repairs (performed 15–29 days after trauma). Ocular motility, diplopia, and time to resolution of diplopia postoperatively are the main endpoints. Results: Fifty-eight patients were included in the study: 36 underwent early fracture repair (average 9 days after trauma) and 22 underwent delayed fracture repair (average 19 days after trauma). Ocular motility was equivalent in both groups, both before and after surgery. Patient reports of diplopia and frequency of strabisumus surgery were also equivalent in both groups. The time to resolution or stability of diplopia postoperatively is independent of the time to surgery within the first 29 days after trauma. Conclusions: Although 14 days after trauma is commonly cited as a timeline target for orbital blowout repair, these data show that effective fracture repair can be performed up to 29 days after trauma. Patients with improving diplopia and at low risk for enophthalmos can therefore be observed for 3 to 4 weeks prior to undergoing surgery. This may help prevent unnecessary surgery in some cases. Fourteen days need not be considered a deadline for orbital floor and/or medial wall fracture repair.

Aponeurotic Ptosis Repair under Local Anesthesia: Prediction of Results from Operative Lid Height

The unpredictability of acquired ptosis repair is a difficult problem. Aponeurotic ptosis repair may be performed under local anesthesia, and past reports have suggested that operative lid position may be used to predict the final result. The authors prospectively studied 20 aponeurotic repairs under local anesthesia for patients with acquired ptosis and normal levator function. Photographs were taken during surgery, 1 week after surgery, and 3 months after surgery. Statistical analysis of vertical lid fissure measurements demonstrated a linear relationship between operative lid position and the 3-month result. When operative lid height was significantly greater than 10 mm, then a slight postoperative rise was observed, but when operative lid height was significantly less than 10 mm, then a slight postoperative fall was observed. Lid position at 1 week proved to be an excellent predictor of the 3-month result, establishing a reasonable basis for intervention in cases of overcorrection or undercorrection.

Symptoms of Canalicular Obstruction

The need for surgical repair of monocanalicular lacerations is controversial. The authors used temporary punctal plugs of hydroxypropyl cellulose to assess the symptoms associated with upper and lower monocanalicular obstruction in 18 normal eyes. Fifty percent of those experimental obstructions resulted in mild intermittent symptoms of epiphora, increased tear film, discomfort, or blurred vision. Constant epiphora was not reported. The results suggest that a single upper or lower canaliculus is sufficient for drainage of minimally stimulated tear secretion but may not completely drain reflex tear secretion. This information may help patients and ophthalmologists reach an informed decision as to the need for surgical repair of a severed canaliculus.

The Perils of Permanent Punctal Plugs

PURPOSE To describe previously unreported complications associated with permanent lacrimal punctal plugs. METHOD Five oculoplastic practices reviewed patients referred to them over the preceding 2 years for permanent lacrimal punctal plug complications. RESULTS In 12 patients, 14 lacrimal punctal plugs migrated distally within the lacrimal drainage system, causing symptoms and necessitating surgical removal. CONCLUSION Luxation of permanent punctal plugs into the distal lacrimal drainage system can occur, sometimes requiring complex surgical intervention.

A new physical finding in floppy eyelid syndrome

OBJECTIVE The authors noted that many of their patients with the floppy eyelid syndrome had a unique finding of eyelash ptosis and lashes that curled in many directions. The purpose of this study was to determine how many of these patients had this physical finding. DESIGN Case series. PARTICIPANTS The authors retrospectively reviewed the charts and photographs of eight consecutive patients with the floppy eyelid syndrome. They also examined four new patients with floppy eyelid syndrome. INTERVENTION Surgical tightening of 13 upper lids was performed in 9 patients. MAIN OUTCOME MEASURES Relief of symptoms and normalization of eyelash position. RESULTS All of the 12 consecutive patients with floppy eyelid syndrome demonstrated eyelash ptosis with loss of eyelash parallelism. All patients treated with surgical shortening of the affected eyelid were asymptomatic at follow-up. CONCLUSIONS The authors have identified a new physical finding in the floppy eyelid syndrome: eyelash ptosis with loss of eyelash parallelism. The authors believe that this new physical finding is characteristic of the floppy eyelid syndrome, and will aid in the timely diagnosis and treatment of this sometimes obscure syndrome.

Vascular Anatomy of the Eyelids

PURPOSE The eyelids have a rich vascular supply, and bleeding may compromise both surgical technique and postoperative results. Generally, it is known that the eyelids contain a marginal and peripheral arcade, but detailed anatomic information is not available. This study therefore was undertaken to determine the detailed anatomy of eyelid vascularity. METHOD The common carotid arteries of six fresh cadaver heads were injected with a compound consisting of a partially polymerized monomer, to which a catalyst and promoter were added to cause hardening. The soft tissue was then digested, using 40% potassium hydroxide, to obtain detailed casts of the eyelid arteries, arterioles, and capillaries. RESULTS The authors describe the eyelid vascularity and anastomotic network with average distance measurements from clinically relevant soft tissue landmarks in the 12 cadaver eyelids. CONCLUSIONS Consistent patterns of eyelid vascularity were observed. A better understanding of the eyelid vascularity should allow modification of surgical techniques and reduce postoperative complications after eyelid surgery.