Pragati Gupta

Causative Factors of Unsuccessful Dacryocystorhinostomy and the Surgical Technique of Revision External Dacryocystorhinostomy

ting the inferior portion or dividing the medial canthal tendon [3, 4] . However, the cut ends must be sutured while closing the wound [4] . Even a disinserted canthal tendon needs to be sutured to the periosteum over the nasal process of maxilla. The authors irrigated methylene blue in the lacrimal sac for identification. This does not facilitate the sac incision site over the internal common canalicular ostium and offers no advantage over visualization of the Bowman probe to ensure full-thickness incision [2] . Moreover, methylene blue spills in the surgical field following incision into the sac and interferes with subsequent tissue identification [2] . We would like to highlight the few additional operative steps routinely performed by us in revision DCRs. All the measures to prevent intraoperative bleeding are adopted. To prevent damage to the nasal mucosa, the nasal pack is removed before osteotomy and reinserted after osteotomy [2] . The ideal osteotomy includes removal of all bone between the medial wall of the sac and the nose, 3–4 mm of anterior lacrimal crest, deroofing of the upper part of the nasolacrimal canal and removal of the 5-mm bone opposite the common canaliculus opening [4] . Longitudinal incision in the sac must involve the lowest part of the sac to avoid sump syndrome. Internal punctoplasty is required We highly appreciate the article by Konuk et al. [1] . We would like to share additional findings observed in unsuccessful endonasal or external dacryocystorhinostomy (DCRs). Absent bony ostium, intact lacrimal fossa with anterior lacrimal crest and nonperforation of the sac have been encountered frequently in our practice. The osteotomy anterior to anterior lacrimal crest with intact lacrimal fossa bones was noted in 4 cases despite 1–4 previous DCRs. The bone opposite the common canaliculus had not been removed in the majority of cases. Anastomosis of lacrimal fascia flaps with nasal mucosal flaps, diverticula, fibrous membrane occluding common internal punctum and postoperative lacrimal fistula which turned out to be tubercular were other causes of failure of DCR. Surgery for unsuccessful DCR remains difficult, time consuming and challenging. The anesthetic infiltration at the medial canthus as mentioned by the authors [1] may not sustain the prolonged revision DCR surgery. We prefer infraorbital, infratrochlear and anterior ethmoidal nerve blocks, infiltration at incision site and nasal packing [2] . The authors disinserted the anterior limb of the medial canthal tendon, which may result in iatrogenic telecanthus. Exposure of the upper part of the lacrimal sac may be achieved by cutPublished online: March 16, 2011

Re: "Secondary tarsoconjunctival graft: a modification to the Cutler-Beard procedure".

Authors mention that patients developed no postoperative complications. However, contour deformity is evidently noticed in the newly constructed eyelid depicted in Figure 3. Though the convexity of the contour is partially hidden by the fold of skin in primary position, it could have been very clearly visible in the photograph in looking down position that the authors have failed to include. We believe that this contour deformity or convexity of the newly constructed eyelid margin could be due to convexity of superior border of free tarsoconjunctival graft forming the eyelid margin. We suggest that refashioning the convex upper tarsus by carefully trimming the superior tarsal border without damaging the attached conjunctiva may circumvent this problem. Authors mention that Case 2 continued to do well without entropion or eyelid retraction.1 However, as this patient had blepharoptosis, eyelid retraction would not be expected. Authors conclude that this unique technique offered 3 major advances. However, in our opinion, Yoon and McCulley’s modification appears to offer yet another advantage of reconstruction of deep superior fornix in the upper eyelid. Yoon and McCulley’s modification used a full-thickness lower eyelid flap and additionally placed a secondary tarsoconjunctival graft at the time of division of flap, whereas Hsuan and Selva reported a modified Cutler-Beard flap technique of upper eyelid reconstruction with a free tarsal graft and only a cutaneous lower eyelid advancement flap that was devoid of muscle and conjunctival layers compared with full-thickness lower eyelid flap. Thus, Yoon and McCulley’s modification provides additional conjunctiva that facilitates deep superior superior fornix.

Is it really a silicone sling assisted temporalis muscle transfer

Sir, We read an article by Gupta et al.[1] with keen interest. We wish to express following comments. Paralytic lagophthalmos remains the most serious complication of facial nerve palsy. Temporalis muscle transfer (TMT) for paralytic lagophthalmos, though a dynamic procedure, remains difficult, challenging and time-consuming surgery despite several modifications.[2,3,4] We appreciate the authors for commendable attempt to manage paralytic lagophthalmos by modified silicone sling assisted TMT.[1] Authors[1] mention that the temporalis muscle (TM) is used in dynamic procedures as it is spared in a case of facial palsy that conveys the impression as if TM is innervated by 7th nerve. The fact remains that TM is used because it is innervated by 5th nerve. Authors[1] mention that slings were advanced in the lids between the paralyzed orbicularis oculi and the skin, which in our opinion appears to be superficial. The sling is also visible through the skin. Such a superficial insertion of sling may suffer several disadvantages including extrusion. The silicone sling should have been placed submuscular between orbicularis muscle and the tarsal plate.[2,3] Postoperative day has not been mentioned in the postoperative picture.[1] However, it seems to be early postoperative picture as skin sutures are still intact. Authors[1] have failed to report long-term follow-up results after 3 months. Even postoperative photographs of the palpebral aperture in the primary position and on mastication in early and at 3 months postoperative are not presented. Moreover, authors[1] have failed to document the dynamicity of their procedure. Frey et al.[4] documented dynamic lid closure following TMT using three-dimensional video analysis system. In our opinion, the procedure described by Gupta et al.[1] is hardly any TMT, as the length of muscle shown is quite small, it fails to reach even up to the lateral canthus and is far posterior to the lateral canthus. It appears that TM is mainly acting as muscle stump for just anchoring the silicone rod. Dynamic reanimation of eyelids by TMT has not been achieved using silicone sling. Thus, it does not appear to be a silicone assisted TMT, rather it is more appropriate to call it a TM assisted silicone sling in the eyelid for management of paralytic lagophthalmos. We believe that similar postoperative results can be achieved by passing silicone sling in eyelid as described by Arion.[5] Authors[1] did not comment about postoperative patients training for chewing exercise. We believe that the patient must be educated about the need to clench the jaw in order to close eyelids voluntarily.[6] Practicing this in front of the mirror is helpful to develop a visual think-blink reflex to achieve dynamic lid closure.[6] As the silicone is a synthetic material, its integration with TM or eyelid tissues is unlikely. Moreover, in long-term with contraction of TM, silicone rod may cut through or lose its elasticity and TM may retract to its original position, resulting in recurrence. Thus, permanency of the procedure seems yet another concern.

Re: "Intralesional Tetracycline Injection for Treatment of Lower Eyelid Festoons".

154 Ophthal Plast Reconstr Surg, Vol. 32, No. 2, 2016 To the Editor: We read the article by Perry et al. with keen interest. We wish to express following comments. Festoons of the eyelids are redundant folds of lax skin and orbicularis muscle involving upper or lower eyelids that are suspended from canthus to canthus. Attenuation of orbicularis oculi and laxity of its attachments between orbicularis and deep fascia results in sagging of skin and muscle at different sites of lid and periorbital regions. Lower eyelid festoon may be pretarsal, preseptal, orbital, and malar. However, festoon most often represents malar mound with fluctuating edema and a skin fold. We appreciate the authors for reporting novel form of nonsurgical treatment of a very common problem of lower eyelid festoons by intralesional injection of 2% tetracycline.Authors mention that patients were graded on a scale of 0 (no festoon) to 4 (severe festoon). However, the authors have failed to describe the criteria of grading the festoon. Lam et al. graded malar mound as follows: grade 0: no malar mound present; grade 1: malar mound without swelling; grade 2: malar mound with variable swelling and normal overlying skin; grade 3: malar mound with fluctuating edema and a skin fold (festoon). Based on the site of occurrence of festoons in lower eyelid, it has been classified into pretarsal, preseptal, orbital, and malar festoon. Following studies by Pessa and Garza, it was found that the malar septum acts as a relatively impermeable barrier that allows tissue edema to accumulate above its cutaneous insertion. This septum defines the lower “boundary” of several clinical entities, e.g., malar mounds, malar edema, malar festoons. Based on these gradings and classification, we believe that a malar festoon itself represents severe form of festoon. Its further grading could be done according to the size of festoon. Authors injected 0.1 ml to 75 ml, 2% tetracycline into several planes of the festoon. Readers would be interested to know the basis of the concentration used and the quantity of tetracycline injected in this study. Additionally we wish to know the details of planes of intralesional injection and how much amount was injected in each plane. We believe that it would be difficult to distribute 0.1 ml in different planes. In our opinion, tetracycline should be injected in the cavity of festoon, i.e., between the orbicularis and deep fascia because that is the site where fibrosis needs to be created so that firm attachment is produced between orbicularis and deep fascia. We would be very keen to know whether 2% oxytetracycline injection could be used in place of tetracycline. In view of easy availability of commercial preparation of oxytetracycline injection, we have injected it in few cases of festoons intralesionally with good results. There was moderate edema and erythema involving lower eyelid in early postoperative period in all the patients. However, no ischemia, induration, and necrosis was encountered in any of these cases. Other important concerns which remained unanswered include 1) When was the maximum efficacy observed after the injection? 2) When to repeat intralesional injection?, and 3) What was the effect of length of follow up on the outcome? In our opinion, the maximum effect is likely to appear 3 months after the injection and repeat injection may be given after this period in case of suboptimal response or no response. Ved Prakash Gupta, M.B.B.S., M.D., D.N.B. Pragati Gupta, M.B.B.S., M.S. Rigved Gupta, M.B.B.S., M.S.

Isoamylcyanoacrylate for sutureless horizontal rectus recession surgery

Dear Editor, We read the article by Darakshan et al.[1] with keen interest. We wish to make following observations to refine this article: 1. The use of tissue adhesives as an alternative to sutures in strabismus surgery is not new.[2] Most of the studies are in experimental animals.[2-4] Only few studies of cyanoacrylate in strabismus surgery in humans are on record.[1,5,6] We congratulate the authors for reporting cyanoacrylate in rectus muscle recession for strabismus in India. However, authors[1] missed to cite the article which was the first one to describe the use of cyanoacrylate in strabismus surgeries in 10 patients.[6]

Repair of canalicular lacerations using monostent and Mini-Monoka stent.

To the Editor: We read the article by Eo et al with keen interest. We wish to express the following comments: We appreciate the authors for comparing 2 monocanalicular stents in repair of canalicular lacerations. However, the authors have used the Monostent only in 5 cases and the Mini-Monoka stent in 12 cases. Both the stents should have been used in equal numbers of cases for comparing the results, even without randomization. The authors mention that the Monostent has a larger internal diameter than the Mini-Monoka stent, which simplifies insertion by providing sufficient rigidity. However, according to the Table 1, the Monostent is softer, requiring a stylet for insertion, compared with harder MiniMonoka stent. The authors describe that, in 2 cases, saline injection through the intact opposite punctum allowed them to find the distal end. We suggest that irrigation of saline through intact canaliculus should be done after occluding the lacrimal sac, otherwise the fluid reaches the sac and throat. Additionally, we would like to share our experiences in detection of the medial cut end in deep location. Adequate retraction of wound edges, hemostasis, and application of adrenaline-soaked cottonoid at the site of a torn canaliculus under the microscope greatly facilitates the detection of the medial cut end. There should be no oozing of blood that obscures the cut end. Local adrenaline serves a dual purpose: first, it stops the bleeding, and second, it decreases soft-tissue edema and helps in the identification of the typical appearance of the cut end, which has rolled-white edges and a shiny epithelial lining. The authors used Worst pigtail probe in case 13 for detecting the lacerated canalicular end in the second exploration. We wonder how a Worst pigtail probe, with a sharp crochet hook in the tip, could be used without injury to the lumen of uninvolved canaliculus. We use a modified smooth, blunt, and round-tipped pigtail probe with a French-eye at the tip to avoid iatrogenic injury. The authors state that cut ends of canaliculus were anastomosed microscopically with 8-0 ethilon and adjacent tissue was approximated with 5-0 or 6-0 vicryl suture to reduce tension. Some surgeons believe that direct canalicular suturing is unnecessary provided the stent is in place and surrounding tissues are brought together. Leibovitch et al sutured the cut edges of the eyelid in layers while repairing canalicular lacerations with the Mini-Monoka stent. Lee et al also repaired lacerated canaliculi without mucosal anastomosis using Monoka tubes. Moreover, deep laceration in the medial canthal region requires adequate canthal tendon repair to prevent medial ectropion. The authors mention that the monostent kinked within the lacrimal sac, presumably because of its pliability. In our opinion, the length of the silicone tube in both the stents appears to be much more than the required length, that is, 15 to 20 mm. We suggest trimming the excess length to avoid complications of an unduely long stent. A case of wound opening due to increased tension caused by inappropriate length of a Mini-Monoka stent has been reported. Many surgeons suggested shortening of the Mini-Monoka stent by 20 to 25 mm. The authors have failed to address these concerns.