Michael Assouline

Systematic unciformectomy for a standardized endonasal dacryocystorhinostomy.

PURPOSE To describe a standardized osteotomy method for endonasal dacryocystorhinostomy (en-DCR) and the results obtained. DESIGN Prospective nonrandomized, noncomparative, interventional case series study. PARTICIPANTS One hundred consecutive adult patients (81 females, 19 males) underwent en-DCR performed by the same team of oculoplastic and rhinologic surgeons. METHODS A standardized procedure was used in all cases. This included endoscopic assessment of the surgical site from the nasal aspect, diaphanoscopy of the common canaliculus, and endonasal osteotomy. Anterior unciformectomy was followed by resection of the lacrimal bone and protected drilling of the maxillary bone of the lacrimal fossa to expose the entire medial aspect of the lacrimal sac. The middle turbinate was preserved whenever atraumatic dissection of the nasal mucosa was possible or when it was resected partially before osteotomy. MAIN OUTCOME MEASURES Rate of direct localization of the lacrimal fossa, rate of turbinectomy/septoplasty, rate of residual postoperative tearing, rate and nature of complications RESULTS Transillumination of the common canaliculus was obtained directly in 94% of cases; transillumination, required the opening of an ethmoidal cell in 2%, partial resection of the middle turbinate in 3%, and unciformectomy in 1%. Access to the surgical site required partial resection of the middle turbinate in 21% of cases, but no septoplasty. Osteotomy was initiated in 90% of cases by cleavage of the anterior insertion of the uncinate process, and in 5% by cleavage of the first, overdeveloped ethmoidal cell. The cleavage opened directly to the medial aspect of the lacrimal fossa in these 95 cases. Osteotomy was achieved by drilling alone in only five cases. Perioperative complications were limited to significant bleeding in six cases. Postoperative complications included one case of resolved frontal sinusitis on day 3, and one case of inferior lid hematoma with emphysema. CONCLUSIONS The authors suggest that anterior resection of the uncinate process is the most important surgical step to expose the medial aspect of the lacrimal fossa during endonasal DCR, whereas partial resection of the middle turbinate can be considered optional.

Recombinant human basic fibroblast growth factor (Rh-bFGF) in three different wound models in rabbits: Corneal wound healing effect and pharmacology

Prior to a clinical trial in humans, we studied the effect and pharmacological distribution of recombinant human basic fibroblast growth-factor (Rh-bFGF) in vivo. Healing experiments on de-epithelialized rabbits corneas (n = 24 animals) compared the efficacy of three bFGF doses to controls and revealed a significantly increased healing rate for both 200 ng and 500 ng per application Rh-bFGF treatment groups compared to the control groups. To assess possible side effects of Rh-bFGF (500 ng topically applied for up to 7 days, twice daily), ten rabbits were involved in a model of an anterior keratectomy wound (performed with Draegers roto-keratome to a depth of 0.15 mm). Light microscopy of thin sections of treated corneas showed an increased fibrogenesis in the anterior stroma with a more pronounced activation of keratocytes. No evidence for abnormal neovascularization or inflammation was observed when compared to control corneas. Ocular penetration and systemic distribution of topically applied labelled 125I FGF was assessed in three models (iodine vapour epithelial burn, anterior keratectomy and penetrating autokeratoplasty) in 24 rabbits. No intraocular penetration of bFGF occurred as shown by direct gamma counting. Macroautoradiography showed a selective labelling of epithelial basement membrane when denuded and intact, as previously described. Evidence for systemic absorption of breakdown products was confirmed by heparin-sepharose chromatography of blood and urine samples. Under these conditions, we suggest that topical Rh-bFGF promotes corneal wound healing without morphological adverse reaction or intraocular and systemic penetration.

A Prospective Randomized Trial of Topical Soluble 0.1% Indomethacin Versus 0.1% Diclofenac Versus Placebo for the Control of Pain Following Excimer Laser Photorefractive Keratectomy

BACKGROUND AND OBJECTIVE To compare the safety and efficacy of topical nonsteroidal antiinflammatory drugs (NSAIDs) for the control of pain after excimer laser photorefractive keratectomy (PRK). PATIENTS AND METHODS One hundred twenty informed patients were enrolled in a double-masked, randomized, comparative study and assigned to either 0.1% indomethacin, 0.1% diclofenac, or placebo treatment. Subjective postoperative pain, symptoms, re-epithelialization rate, and systemic medications were monitored for 2 days following photoablation. RESULTS Compared with the placebo, 0.1% indomethacin solution significantly reduced pain on the day of surgery (D0) (P < .05), whereas 0.1% diclofenac did not reach a significant level (P = .46). At D0, analgesic intake by the oral route was significantly greater in the placebo group (P < .05). Severe photophobia was significantly less frequent in the group treated with 0.1% indomethacin (P < .05). Corneal wound healing was significantly delayed in the patients treated with 0.1% diclofenac at D2 as compared with other groups (P = .04). CONCLUSION Topical 0.1% indomethacin solution helps control the pain induced by excimer laser photoablation of the cornea without any detrimental effect to the corneal epithelial wound healing.

Silicone punctal plug extrusion resulting from spontaneous dissection of canalicular mucosa: A clinical and histopathologic report.

PURPOSE To report on an uncommon, previously unidentified, progressive silicone punctal plug extrusion. DESIGN Small, retrospective case series. PARTICIPANTS Five cases of punctal plug extrusion were identified among a series of 424 consecutive implantations. Histopathologic analysis was obtained in one case. One additional referred case was included in this report. RESULTS The plugs were completely extruded from the punctal lumen 6 to 14 months after insertion after an otherwise uncomplicated postoperative course. All plugs were retained at the punctal margin by an encircling band of vascularized mucosal tissue originating from the canalicular lumen. The band consisted of connective tissue of canalicular mucosal origin, attached just below the junction of the punctal and canalicular epithelium. Mild mononuclear infiltration was present in the connective tissue component of the punctal region. There was no cytologic or architectural evidence of abnormal epithelium or connective tissue or of pyogenic granuloma. CONCLUSIONS These observations suggest that progressive lacrimal punctal plug extrusion may relate to mucosal dissection by the plug edges. We speculate that mechanical stress induced by eyelid closure on an improperly sized or placed implant may result in plug tilt. Subsequent epithelial hyperplasia further enhances the tilt, and the sharper edge of the conical bulb promotes separation of the canalicular mucosa from its distal luminal aspect. At the completion of the extrusion, the mucosal surface is separated from its connective tissue base, at a proximal subpunctal level, causing formation of an encircling tissue band.

In Vivo Binding of Topically Applied Human bFGF on Rabbit Corneal Epithelial Wound

We present the results of the first evaluation of human placenta extracted basic fibroblast growth factor (bFGF) in a rabbit corneal epithelium wound-healing model. Healing dose-response experiments after selective epithelial wounding with iodine vapors demonstrated that bFGF accelerated the repair process in a saturable manner. Corneal binding of topically applied 125I-labeled bFGF was investigated using radioassay and autoradiographic techniques. Basic FGF was shown to bind specifically to denuded epithelial basement membrane in a very stable fashion and not to the intact epithelium. No transfer of the topical bFGF to the aqueous humor or any intraocular structure could be observed. The stability of this interaction was further demonstrated by reextracting and characterizing the labeled factor from treated corneas. The specificity of the fixation was documented by in vivo topical competition with unlabeled bFGF or heparin. We propose that bFGF-basement membrane interactions play a role in corneal wound healing.

Bicanalicular versus monocanalicular silicone intubation for nasolacrimal duct impatency in children: A comparative study

The authors conducted a retrospective study on 120 consecutive cases of nasolacrimal duct obstructions (NLDO) in 85 children, operated on by a single surgeon (BF) from January 1988 to July 1992. Mean age at the time of surgery was 5.4 years (1 to 11 years). Seventy-seven bicanaliculo-nasal intubations (BCNI) and 43 monocanaliculo-nasal intubations (MCNI) were performed. MCNI were performed using the Fayet-Bernard ‘MonoKa’ tubing material (FCI, Paris, France). This device permits monocanalicular intubation with meatic fixation by a punctum-plug-like extremity. Among MCNI, 39 were placed into the superior canaliculus. Nine MCNI were indicated because of a true monocanalicular agenesis (inferior canaliculus agenesis in five cases and superior canaliculus agenesis in four cases).Mean follow-up was ten months. Average duration of intubation was seven months for BCNI and 5.1 months for MCNI. BCNI and MCNI resulted in complete resolution of the epiphora in 62.2 and 67.6% of cases respectively.Intermittent tearin...