Kenneth V. Cahill

Management of Acute Dacryocystitis in Adults

Acute dacryocystitis frequently is extremely painful and slow to resolve even with systemic antibiotic therapy. We have identified that incision, drainage, and direct application of antibiotics inside the infected sac result in almost immediate resolution of pain and rapid control of infection. This also provides optimal culture material. Twelve consecutive patients treated in this manner had rapid control of the acute infectious process. All eight patients subsequently undergoing dacryocystorhinostomy were fully cured. A total of 58.3% of the patients were infected with gram-negative rods; 50% of the isolates were resistant to most oral antibiotics.

Expression of sodium iodide symporter in the lacrimal drainage system : implication for the mechanism underlying nasolacrimal duct obstruction in ^ I-treated patients

Purpose: Nasolacrimal outflow obstruction has been associated with high-dose (>150 mCi) radioactive iodine (I131) treatment. Commonly used for thyroid cancer treatment, I131 is effectively transported in the targeted tissue by the Na+/I symporter (NIS). We hypothesized that NIS is expressed in the lacrimal sac and nasolacrimal duct and that active accumulation of I131 is responsible for the clinical observations seen in these patients Methods: Reverse transcriptase–polymerase chain reaction and immunohistochemical analyses were used to evaluate NIS expression in both archived and fresh human tissues Results: Reverse transcriptase–polymerase chain reaction analysis showed that NIS mRNA is present in the lacrimal sac. Immunohistochemical analysis indicated that NIS protein is expressed in the stratified columnar epithelial cells of the lacrimal sac and nasolacrimal duct. NIS protein was undetectable in the lacrimal gland, Wolfring and Krause glands, conjunctiva, canaliculus, and nasal mucosa. NIS-expressing columnar epithelial cells were absent and fibrosis was evident in the lacrimal sacs from I131-treated patients undergoing dacryocystorhinostomy Conclusions: NIS is present in the lacrimal sac and nasolacrimal duct of humans, correlating to the anatomic areas of clinical obstruction that develop in patients treated with greater than 150 mCi of I131. This suggests that NIS may be the vector of radiation-induced injury to the lacrimal system. To our knowledge, this is the first report of any ion transporter in the nasolacrimal outflow system and raises new questions as to the role the lacrimal sac plays in the modification of tears and in lacrimal outflow pathology.

The effect of blepharoptosis on the field of vision.

Upper eyelid position, pupillary diameter, and visual field impairment were measured in 26 eyes with adult-onset blepharoptosis. The magnitude of superior visual field impairment was inversely proportional to the distance between the upper lid margin and the pupillary aperture. The distance between the upper lid and the central corneal reflex was the most useful measurement for predicting visual field impairment. Superior visual field impairment was present when the distance between the upper lid and the central corneal reflex was <2.5 mm. Visual field impairment inferiorly, temporally, and nasally occurred when the central corneal reflex was obscured and <1.5 mm of the vertical diameter of the pupil was visible. Observation of the relationship between the upper eyelid and the pupillary aperture provides useful information for the performance of accurate diagnostic perimetry, as well as for the management of blepharoptosis.

Fibrin sealant for Müller muscle-conjunctiva resection ptosis repair.

Purpose: To determine the safety and efficacy of fibrin sealant for use in Müller muscle–conjunctiva resection ptosis repair. Methods: This was a retrospective review of a consecutive case series. All patients underwent Müller muscle–conjunctiva resection ptosis repair with fibrin sealant used for wound closure. Surgery was performed in a manner similar to a previously described technique, using fibrin tissue sealant rather that suture for wound closure. Postoperative symmetry was defined as MRD1 of each eyelid within 0.5 mm. Results: Müller muscle–conjunctiva resection ptosis repair with fibrin sealant used for wound closure was performed on 53 eyelids of 33 patients. There were 27 female patients and 6 male patients. Twenty patients underwent bilateral ptosis repair and 13 patients underwent unilateral ptosis repair. Average follow-up was 17 weeks (range, 3 to 45 weeks). Mean preoperative MRD1 was 1.22 mm (range, –1.5 to 2.5 mm) in the right upper eyelid and 1.50 mm (range, 0 to 2 mm) in the left upper eyelid. Mean postoperative MRD1 was 3.11 mm (range, 2 to 4.5 mm) in the right upper eyelid and 3.12 mm (range, 1 to 4.5 mm) in the left upper eyelid. Postoperative symmetry was found in 32 of 33 patients (97%). We found no evidence of keratopathy or other complications attributable to the fibrin sealant. Conclusions: Müller muscle–conjunctiva resection ptosis repair with fibrin sealant used for wound closure may allow for predictable results with few complications and appears to be an acceptable alternative to traditional suture techniques.

Management of epiphora in the presence of congenital punctal and canalicular atresia.

We treated ten eyes in six pediatric patients with epiphora and punctal and canalicular atresia in one or both lids. Attempted probing and irrigation had failed to improve the epiphora. Nine out of ten of the lacrimal systems had additional anomalies, such as cutaneous lacrimal fistulas (anlage ducts), small sacs, and nasolacrimal duct stenosis or obstruction. A surgical plan is described for the exploration and reconstruction of these markedly abnormal nasolacrimal drainage systems, including a new method of performing bicanalicular intubation. Four of the five eyes with at least part of one canaliculus present have had resolution of epiphora.

Age-Matched, Case-Controlled Comparison of Clinical Indicators for Development of Entropion and Ectropion

Purpose. To analyze the clinical findings associated with involutional entropion and ectropion and compare them to each other and to age-matched controls. Methods. Prospective, age-matched cohort study involving 30 lids with involutional entropion, 30 lids with involutional ectropion, and 52 age-matched control lids. Results. The statistically significant differences associated with both the entropion and ectropion groups compared to the control group were presence of a retractor dehiscence, presence of a “white line,” occurrence of orbital fat prolapse in the cul-de-sac, decreased lower lid excursion, increased lid laxity by the snapback test, and an increased lower lid distraction. Entropion also differed from the control group with an increased lid crease height and decreased lateral canthal excursion. Statistically significant differences associated with entropion compared to ectropion were presence of a retractor dehiscence, decreased lateral canthal excursion, and less laxity in the snapback test. Conclusion. Entropic and ectropic lids demonstrate clinically and statistically significant anatomical and functional differences from normal, age-matched lids. Many clinical findings associated with entropion are also present in ectropion. Entropion is more likely to develop with a pronounced retractor deficiency. Ectropion is more likely to develop with diminished elasticity as measured by the snapback test.

Comparison of fibrin sealant versus suture for wound closure in Müller muscle-conjunctiva resection ptosis repair.

Purpose: To compare fibrin sealant (Tisseel) versus suture for wound closure in Müller muscle-conjunctiva resection ptosis repair. Methods: The charts of 114 patients (211 eyelids) who had undergone Müller muscle-conjunctiva resection were retrospectively reviewed. Suture versus Tisseel were used for wound closure. Preoperative and postoperative eyelid measurements, postoperative symmetry within 0.5 mm, and complications were compared. Results: Müller muscle-conjunctiva resection ptosis repair was performed on 211 eyelids of 114 patients. Seventeen cases were unilateral and 97 cases were bilateral. Method of wound closure included suture (45 eyelids of 31 patients) versus Tisseel (166 eyelids of 83 patients). For the suture group, the mean preoperative MRD1 was 1.2 mm and the postoperative MRD1 was 3.0 mm; the difference was 1.9. For the Tisseel group, the mean preoperative MRD1 was 1.2 mm and the postoperative MRD1 was 3.0 mm; the difference was 1.8. The 2 groups did not differ statistically in preoperative (p = 0.97) or postoperative MRD1 values (p = 0.53), the difference (p = 0.63), or postoperative symmetry within 0.5 mm (p = 0.39). In the suture group, complications included moderate to severe pain (10%), suture granuloma (6%), corneal abrasion (3%), loose suture (3%), and persistent keratopathy (3%). We found no evidence of keratopathy attributable to the Tisseel (p = 0.0001). This difference in the prevalence of complications was statistically significant (p = 0.0001). Four patients in the suture group (13%) underwent subsequent procedures including suture granuloma removal (2) and suture removal (1); 1 patient (3%) required levator resection. Three patients in the Tisseel group (4%) subsequently underwent levator resection. Conclusions: Müller muscle-conjunctiva resection ptosis repair using fibrin sealant for wound closure offers comparable eyelid position results compared with suture. Use of Tisseel showed fewer postoperative complications and was associated with fewer subsequent surgical procedures.

Congenital lacrimal system anomalies mimicking recurrent acute dacryocystitis.

We describe 2 cases of congenital lacrimal system anomalies that mimicked recurrent acute dacryocystitis. Two patients with painful swelling below the medial canthal tendon who were referred for acute dacryocystitis were evaluated clinically with findings suggestive of lacrimal system anomalies. Both patients presented in adulthood and both had a history of recurrent presumed acute dacryocystitis without epiphora. Both patients had complete absence of the lower puncta on the involved side. Irrigation via the upper system showed lacrimal drainage system patency in both cases. Surgical exploration confirmed the diagnosis of lacrimal system anomalies. The first patient had a lacrimal sac diverticulum; the second patient had a fistula connected to the common canaliculus with an adjacent cyst. Both patients were successfully treated with excision of the outpouchings. Congenital lacrimal drainage system anomalies should be considered in the diagnosis of recurrent dacryocystitis in cases where the lacrimal system appears patent. The infection can involve a fistula or diverticulum.

Nasolacrimal System Aeration on Computed Tomographic Imaging: Sex and Age Variation.

Purpose: To investigate variation in aeration of the nasolacrimal drainage system between age groups and genders, and to report the reliability of repeated aeration grading and nasolacrimal canal measurements on CT. Methods: Retrospective review of CT images from 92 individuals, 60 female and 32 male, was conducted by 3 independent reviewers for the presence of air within the nasolacrimal drainage system. Diameter and area measurements were also obtained at the smallest identifiable portion of the nasolacrimal canal by 2 independent reviewers. Results: When air is present on CT, it is seen more fully throughout the nasolacrimal system in men as compared to women. Age data demonstrate that patients from the third and fourth decade have significantly more aeration than older patients. Diameter and area of the nasolacrimal duct within the canal at its narrowest point revealed no correlation with sex, age, or nasolacrimal system aeration. Inter-reviewer reliability shows strong repeatability of aeration grading and nasolacrimal duct measurements between multiple reviewers. Conclusions: The results suggest CT is reliable and repeatable modality to assess nasolacrimal system aeration and nasolacrimal duct diameter. Decreased aeration of the nasolacrimal system in females and the elderly mirrors epidemiologic trends for those at risk to develop primary acquired nasolacrimal duct obstruction. Variables in nasolacrimal drainage system anatomy, specifically nasolacrimal duct diameter and area, did not vary between sexes or age groups, suggesting aeration may be an overlooked variable in nasolacrimal system function.

Addition of dermis-fat graft to diminish cable visibility in frontalis suspension for patients with pre-existing deep superior sulci.

Purpose: To propose and demonstrate a technique modification for frontalis suspension to simultaneously address ptosis and diminish abnormalities related to deep superior sulcus defect. Methods: Six patients underwent simultaneous frontalis suspension and placement of a superior sulcus dermis-fat graft. Results: Postoperative visibility of the cables, anticipated in patients with deep superior sulci, was prevented in these 6 patients. Conclusions: Dermis-fat grafting may be added to improve cosmesis after frontalis suspension in patients at risk for postoperative cable visibility.