Joseph A. Mauriello

CLINICOPATHOLOGIC STUDY OF LACRIMAL SAC AND NASAL MUCOSA IN 44 PATIENTS WITH COMPLETE ACQUIRED NASOLACRIMAL DUCT OBSTRUCTION

We studied 44 patients who had dacryocystorhinostomy for primary acquired complete nasolacrimal duct obstruction. The lacrimal sac and nasal mucosa adjacent to the osteotomy were examined histologically. The lacrimal sac had chronic inflammatory changes in 33 of 37 patients with varying degrees of fibrosis in 34 of 37. Focal ulceration of the lacrimal sac epithelium was present in 15 cases. Goblet cells, present in 11 specimens, were not identified in 26 specimens. Moderate or severe chronic inflammation was found in 14 of 44 nasal mucosal specimens and marked fibrosis in 22. The pathology of the lacrimal sac and nasal mucosa is similar to that of the nasolacrimal duct in complete nasolacrimal duct obstruction. The nasal inflammation may have resulted from dacryocystitis or alternatively contributed to the dacryocystitis.

Use of BotuIinum Toxin in the Treatment of One Hundred Patients with Facial Dyskinesias

One hundred patients with involuntary eyelid and facial spasms resulting from essential blepharospasm, Meige syndrome, and hemifacial spasm continued to respond to repeated injections of botulinum toxin at expected time intervals during a 30-month period. This series of more than 372 injections done by one of us (JAM) supports the finding of earlier, smaller series that tolerance to the toxin does not develop. The drug had a greater duration of effect in patients with hemifacial spasm than in patients with blepharospasm; the duration of effect was 17.25 weeks in the former group and 12.6 weeks in the latter. Eighteen percent of patients required a higher than standard dose for a therapeutic response. Fourteen of 15 patients with lower facial spasms and one patient with torticollis had significant relief. Dry eye may be managed by titrating the lower lid dose.

Management of traumatic optic neuropathy--a study of 23 patients.

Twenty three patients with traumatic optic neuropathy were managed by medical and surgical treatment as follows. High dose intravenous steroids were initiated in all patients. If visions did not improve significantly after 24 to 48 hours decompression of an optic nerve sheath haematoma by medial orbitotomy and neurosurgical decompression of the optic canal were considered based on computed tomographic scan findings. Nine of 16 patients who received steroids only showed significant improvement. One of three showed improvement on optic nerve decompression after steroid failure; three or four showed improvement on optic nerve decompression after steroid failure; three or four showed improvement with combined optic nerve sheath decompression by the medial orbitotomy and decompression of the optic canal by frontal craniotomy. A lucid interval of vision after injury and an enlarged optic nerve sheath were associated with an improved prognosis. Five of the 23 patients had a lucid interval and all five had a final improved vision, while only five of 18 patients without a lucid interval improved. Similarly seven of the nine with an enlarged optic nerve sheath showed improvement while only three of 10 patients (three bilateral cases) who presented with no light perception improved with medical and surgical treatment. While a prospective controlled study of the management of traumatic optic neuropathy is necessary this preliminary study suggests that treatment of traumatic optic nerve sheath haematoma by optic nerve sheath decompression should be considered in selected patients.

Treatment choices of 119 patients with hemifacial spasm over 11 years

A retrospective study of patients with hemifacial spasm (HFS) was performed in order to determine long-term treatment choices: local botulinum toxin, type A, injections, oral pharmacologic agents, and surgery (neurosurgical decompression of the seventh nerve at the brainstem level and upper eyelid blepharoplasty). Of 119 patients with diagnosed hemifacial spasm in the Oculoplastics Division of the Department of UMD-New Jersey Medical School, Newark, NJ from September, 1983, to June 1, 1994, 108 were initially treated with 735 botulinum toxin injections. Forty-seven of the 108 patients (43.5%) initially treated at our institution received 459 injections for a median treatment period of 59 months per patient. Eight patients (7.4%) continued treated elsewhere and four other patients were injected at our institution until their death from other causes. Twenty-two patients (20.4%) were lost to followup after receiving 117 injections. Five patients (4.6%) had spontaneous resolution of their condition after botulinum toxin therapy and nine patients (8.3%) chose not to receive any additional injections or other treatment. Thirteen patients (12.0%) did not respond adequately to botulinum injections and 10 such patients obtained relief from treatments other than botulinum toxin: oral pharmacologic agents (two patients), neurosurgical decompression of the seventh nerve (two patients), and upper eyelid blepharoplasty (one patient). In addition to botulinum injections, 15 patients required adjunctive minor tranquilizers and/or antiseizure medications. Botulinum A toxin is an excellent long-term treatment of hemifacial spasm. This condition may occasionally spontaneously resolve after botulinum therapy.

Management of Visual Loss after Optic Nerve Sheath Decompression in Patients with Pseudotumor Cerebri

Purpose: To determine the appropriate management of patients with pseudotumor Cerebri with early, progressive visual loss after optic nerve sheath decompression (ONSD). Methods: The records of all patients with pseudotumor Cerebri who underwent ONSD were reviewed retrospectively. Patients who showed visual loss within 1 month of surgery were studied. Results: Five patients with pseudotumor Cerebri, including two with renal failure and hypertension, had visual loss within 1 month of ONSD. The first patient had an abrupt decrease in vision 6 days after ONSD. In this patient, a vessel on the nerve sheath bled into the surgical site. At the time of ONSD, this patient had a visual acuity of 20/20 1 day after surgery. Six days later, visual acuity decreased to 20/200. After high-dose intravenous corticosteroids failed to improve vision, emergency lumboperitoneal shunt resulted in full visual recovery. An apparent infectious optic neuropathy developed in the second patient 3 days after surgery. After 72 hours of intravenous antibiotics, visual acuity improved from 20/600 to 20/15. The other three patients had gradual visual loss after ONSD, which stabilized after lumboperitoneal shunts. Conclusions: Avoidance of bleeding during ONSD may prevent fibrous occlusion of the surgical site. Patients with no identifiable cause for visual loss after ONSD, who do not respond to intravenous corticosteroids, should be evaluated for emergency lumboperitoneal shunting. Postoperative infectious optic neuropathy should be considered in the differential diagnosis of abrupt visual loss after ONSD.

Use of Vicryl (polyglactin-910) mesh implant for repair of orbital floor fracture causing diplopia: a study of 28 patients over 5 years.

Over the past 5 years, Vicryl mesh (polyglactin-910) implants were used successfully to reconstruct the orbital floor in 28 patients with significant preoperative diplopia due to orbital floor fractures. The layered mesh is available in 26.5 χ 24 cm sheets, each of which is folded onto itself into 24 layers and packaged; 24 layers are approximately 4 mm thick. Appropriately sized implants varying in thickness from 6 to 56 layers were used to cover and fill the orbital floor defect. Absorbable Vicryl mesh is well-tolerated by orbital tissues; since it is soft and pliable, it is unlikely to compress orbital structures such as the optic nerve, lacrimal sac, or extraocular muscles. A second surgical site necessary for autogenous implants is avoided. The Vicryl mesh implant is technically easy to insert and does not require fixation in the orbit. Because Vicryl mesh is absorbable, the risks associated with permanent alloplastic implants are reduced. Similarly, there is no potential spread of communicable disease with homologous tissue implants. Follow-up ranged from 1 month to 2 years (median, 13 months). None of the patients had late complications. The only complication was transient, low-grade eyelid inflammation in four patients.

Inferior rectus muscle entrapped by Teflon implant after orbital floor fracture repair.

A patient with a tripod fracture had entrapment of the inferior rectus muscle after reconstruction of an orbital floor defect with an alloplastic implant. Prior to insertion of the implant, the operating surgeon reported no motility disturbance. An orbital computed tomography scan suggested that the implant impinged on the inferior rectus muscle. Because of persistent diplopia, the orbit was reexplored. An intraoperative forced duction test prior to removal of the implant was positive in the field of action of the inferior rectus muscle. An intraoperative forced duction test after removal of the implant was negative in the field of action of the inferior rectus muscle. Motility was markedly improved after removal of the implant. These findings confirm that the implant was the cause of the entrapment. The surgical technique utilized to minimize complications after orbital floor reconstruction with the implant is outlined in this article.

Modified corncrib (inverted T) procedure with Quickert suture for repair of involutional entropion.

PURPOSE The purpose of the study was to determine long-term results of involutional entropion repair by a modified corncrib (inverted T) procedure with a Quickert suture. METHODS A retrospective review of consecutive patients with involutional entropion who underwent repair by a modified corncrib procedure from January 1986 to July 1994 was performed. A full-thickness basedown triangle (corncrib) excised at the lateral limbus corrects horizontal laxity and everts the eyelid margin. The stem of the T is represented by the vertical closure of the eyelid margin and the tarsus. The top of the T is represented by the horizontal wound at the lower tarsal border after excision of an ellipse of skin and preseptal orbicularis muscle medial and lateral. The resultant horizontal scar prevents overriding of preseptal over pretarsal orbicularis oculi muscle. A translid double-armed Quickert suture preplaced 2 to 3 mm lateral to the punctum plicates the dehisced lower eyelid retractors and also prevents overriding of preseptal over the pretarsal orbicularis muscle. This suture pierces the conjunctival cul-de-sac and exits the skin just anterior to the lashes. RESULTS In 63 eyelids of 59 patients (4 bilateral cases), there were no failures with a median follow-up of 49.3 months. Complications were minimal. CONCLUSIONS The modified corncrib (inverted T) procedure is performed through a single surgical wound, requires minimal surgical dissection, and provides excellent long-term results.

Use of Split-Thickness Dermal Graft in the Surgical Treatment of Corneal and Scleral Defects

We used split-thickness dermal grafts for the surgical treatment of corneal and scleral perforations in two patients and obtained excellent results. Patient 1 had severe lye burns and bilateral corneal perforations and Patient 2 had scleromalacia perforans. The dermal graft self-epithelializes and, thus, does not need to be covered by conjunctiva; is supple, without the bulkiness of other materials, particularly cartilage and periosteum; is hearty and flourishes on avascular surfaces such as cornea and sclera; has good tensile strength; and is autogenous.

Adenoid squamous carcinoma of the conjunctiva—a clinicopathological study of 14 cases

AIMS In order to determine the clinicopathological features and optimum management of a series of patients with adenoid squamous cell carcinoma of the conjunctiva, all cases of squamous cell carcinoma (SCC) of the conjunctiva and cornea on file in the registry of the ophthalmic pathology at the Armed Forces Institute of Pathology were reviewed. METHODS On histopathological examination, a predominant adenoid or pseudoglandular pattern due to islands of neoplastic squamous or epidermoid cells surrounded by acantholytic cells was necessary for inclusion in the study. Histochemical and transmission electron microscopic studies (TEM) were performed. Clinical features of all the patients were extracted from the charts. RESULTS The anatomical location of the 14 tumours was corneoscleral limbus (seven patients) and bulbar conjunctiva (seven patients). Eight patients presented with inflammatory signs and irritation (red eye, tearing, foreign body sensation), while six patients developed a slowly growing, painless mass. Histochemical and TEM studies showed extracellular hyaluronic acid and no intracellular mucin. Of the two patients initially treated by enucleation, one was free of disease after 2 years while the second patient had recurrence in the socket and died of brain metastases despite wide orbital excision and radiotherapy. All five patients with recurrent tumours initially had irritated red eyes and two required enucleation. One such patient, after orbital exenteration and radiotherapy, died of unrelated disease. CONCLUSION The study demonstrates that adenoid SCC of the conjunctiva often presents with inflammatory signs. The tumour is locally aggressive and may metastasise and should, therefore, be histopathologically differentiated from the less aggressive conventional squamous cell carcinoma. Optimum treatment includes wide excision with documented histological clear margins of resection on permanent sections and frequent follow up.