Robert B. Penne

Balloon catheter dilation for treatment of adults with partial nasolacrimal duct obstruction: a preliminary report.

PURPOSE The purpose of this study is to determine the efficacy and morbidity of balloon catheter dilation for treatment of partial acquired nasolacrimal duct obstruction in adults with epiphora. METHODS We performed balloon dacryocystoplasty prospectively on a series of 15 partial nasolacrimal duct obstructions in 13 adults with epiphora. Partial obstruction was diagnosed by a negative Jones-1 test and canalicular irrigation revealing simultaneous reflux through the opposing punctum and drainage into the nose. Balloon dacryocystoplasty was performed under local anesthesia using an antegrade insertion technique. Silicone intubation of the nasolacrimal system was performed immediately after balloon catheter dilation, and the tubes were removed 2 months postoperatively. RESULTS Success was measured objectively and subjectively at follow-up examinations 2 months and 6 months after the procedure. At 2 months, 11 (73%) of 15 obstructions were open on irrigation, with subjective success (Munk, grade 0 or grade 1) reported in 13 (87%) of 15 obstructions. At 6 months, 11 (73%) of 15 obstructions were open on irrigation, with subjective success (Munk, grade 0 or grade 1) reported in 9 (60%) of 15 obstructions. CONCLUSIONS Balloon dacryocystoplasty may be a satisfactory primary treatment for adults with acquired partial nasolacrimal duct obstruction who exhibit no clinical signs of chronic infection. Additional long-term observations following balloon dacryocystoplasty are required.

Optic nerve sheath meningiomas and advanced treatment options.

Purpose of review Recent trends in the management of optic nerve sheath meningiomas have shifted towards fractionated conformal external beam radiotherapy. The purpose of this paper is to review the current literature on this subject and review the clinical characteristics and natural history of optic nerve sheath meningiomas. Recent findings Articles published within the last 2 years have reported the efficacy of using fractionated radiation therapy alone. A total of 62 patients in three studies have been reported; 40.3% retained stable visual acuity, 41.2% percent had improvement in their vision, and 18.4% percent had a decrease in visual acuity. Median follow-up time ranged from 22 to 51 months in these studies. Summary Optic nerve sheath meningiomas may be safely managed with fractionated external beam radiotherapy in select patients with possible improvement or stabilization of visual acuity. This represents an enormous improvement in a disease with typically poor visual prognosis.

Wooden intraorbital foreign body injuries: clinical characteristics and outcomes of 23 patients.

Purpose: To describe the clinical characteristics, interventions, and visual outcomes of orbital injuries associated with wooden foreign bodies. Methods: A retrospective case review of orbital injuries managed at Wills Eye Institute and Massachusetts Eye and Ear Infirmary was conducted between 1992 and 2006. Results: The clinical course and management for a total of 23 intraorbital wooden foreign body injuries were reviewed. The distribution of wood included pencil (39%), tree branch/plant matter (35%), and other treated wood (26%). About half of the subjects (52%) presented with preoperative vision between 20/20 and 20/40. Almost half of the subjects with preoperative vision between 20/20 to 20/40 retained vision in that range postoperatively (48%). Time from injury to presentation was highly variable, ranging from 24 hours to 17 months (mean, 62 days; median, 3 days). Forty-three percent of subjects presented within 24 hours of injury. The site of foreign body found within the orbit was superior (26%; n = 6), medial 30% (n = 7), inferior (26%, n = 6), posterior (9%; n = 2), and lateral (4%; n = 1). Preliminary radiographic interpretation for foreign body was definite in 61% (n = 14), possible in 22% (n = 5), and absent in 13% (n = 3). Conclusions: Young men are at particularly high risk for wood intraorbital foreign body. There was a relatively equal distribution of wood type. The time from injury to presentation was variable, ranging from <1 day to over a year. Almost half of the subjects presented within 24 hours of injury. In patients with a known site of penetration, almost half occurred in the conjunctiva, notably without presence of eyelid laceration, emphasizing the need to check the conjunctiva and fornices closely. Preliminary radiographic readings often miss or are inconclusive in detecting the foreign body. The shape, location, serial examinations, and particularly the use of quantitative CT are extremely helpful in distinguishing retained wood foreign body from other low-density signals of air or fat.

Ocular motility disorders secondary to sinus surgery.

Sinus surgery has multiple potential ocular complications including visual loss, diplopia, infection, hemorrhage, and epiphora. We report six patients with ocular motility problems secondary to sinus surgery, review the literature on ocular motility disorders secondary to sinus surgery, and propose an approach for management of those ocular motility problems following sinus surgery. Intranasal sinus surgery was found to be the most common procedure resulting in injury to an extraocular muscle and the ethmoid sinus the most common structure being operated on when injury occurred. The medial rectus was the muscle most commonly injured and it had the poorest prognosis for recovery of functional vision free of diplopia. Optimal timing for repair depends on the structure injured, but early recognition and management appear to be a key to the best outcome for these injuries.

Evaluation and Management of Pediatric Orbital Fractures in a Primary Care Setting

Objective: To review and evaluate the management of white-eyed blowout fractures (WEBOF) from Emergency Department (ED) triage through surgical repair. Methods: Retrospective chart review of consecutive cases of pediatric orbital blowout fracture requiring surgical repair at a large ophthalmologic referral center. The characteristics of patients with WEBOF and those with conventional orbital blowout fractures were compared, including: mechanism of injury, clinical presentation, ED management and referral patterns, and time to definitive treatment. Results: Sixteen patients comprised the WEBOF study group, and 14 patients with conventional blowout fractures comprised the control group. All WEBOF had pain with eye movement, limited ductions and diplopia, and 75% had nausea and vomiting. These symptoms were present in significantly lower frequencies in control patients (64%, 64%, 7%, 14%, respectively). Compared to controls, WEBOF patients were younger; had injury more often resulting from sports and play; were less likely to undergo orbital imaging in the ED; were more likely to be diagnosed with concussion in the ED; were less likely to be seen urgently by an ophthalmologist; and were told to follow-up with an ophthalmologist 4–5 days later than control patients. Conclusions: WEBOF is a clinical diagnosis consisting of vertical diplopia, gaze restriction and nausea and/or vomiting in the setting of peri-orbital trauma in the pediatric and young-adult age group. The paucity of external signs of trauma may lead to initial misdiagnosis and delay in treatment. All patients who meet WEBOF criteria should undergo dedicated orbital CT as part of the ED evaluation. If WEBOF is suspected, a prompt referral to an ophthalmologist should be made.

Cicatrizing conjunctivitis as a predominant manifestation of linear IgA bullous dermatosis

Linear IgA bullous dermatosis is an uncommon mucocutaneous autoimmune disorder that is distinct from dermatitis herpetiformis and bullous pemphigoid. Two patients who had significant conjunctival involvement but minimal skin disease are described. Irreversible conjunctival scarring indistinguishable from ocular pemphigoid developed in both patients.

Giant fornix syndrome: a case series.

Purpose: To describe the demographics, characteristics, and treatment of giant fornix syndrome, a rare cause of chronic purulent conjunctivitis in the elderly. Methods: Retrospective chart review of five patients with giant fornix syndrome evaluated by the Cornea Service, Oculoplastics and Orbital Surgery Service and the Department of Pathology at the Wills Eye Institute. Results: The median age of the 5 female patients was 75 years (mean 80, range 70–95). The median duration of eye symptoms before presentation was 2 years (mean 2.4, range 1–4). Before referral, the chronic conjunctivitis was treated with topical antibiotics in all 5 cases and with additional dacryocystorhinostomy in one case. The right eye was affected in 2 cases, and the left eye was affected in the other 3 cases. Floppy eyelids were present in 2 cases. The superior fornix was involved in 4 cases, and the inferior fornix was involved in one case. Pseudomembranes and superficial punctate keratitis (SPK) were seen in 3 cases. Diagnosis of giant fornix syndrome was made in all 5 cases. Conjunctival culture grew methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas aeruginosa, and S. aureus in singular cases. Case 1 was treated with topical moxifloxacin, Case 2 was treated with topical vancomycin and repair of the upper eyelid, Case 3 was treated with topical besifloxacin, and Case 4 was treated with dacryocystorhinostomy and topical vancomycin. Case 5 was treated with reconstruction of the left upper eyelid. The median duration of follow up was 4 months (mean 21.6, range 1–84). Conclusions: Giant fornix syndrome can lead to chronic relapsing conjunctivitis in the elderly. Deep conjunctival fornices in affected patients can be a site for prolonged sequestration of bacteria causing recurrent infections. Removing the infected debris from the superior fornix and reconstruction of the upper eyelid may prevent the recurrent chronic persistent infection.

Porphyria cutanea tarda presenting as cicatricial conjunctivitis

PURPOSE To report a case of porphyria cutanea tarda presenting as cicatricial conjunctivitis. DESIGN Observational study. METHODS A 31-year-old man presented with bilateral inferior symblepharon, superior tarsal conjunctival scarring and concretions, and recurrent conjunctival and episcleral injection. RESULTS Four years after initial presentation, the patient developed hepatitis C, and 2 years later blisters on his scalp and hands. Direct immunofluorescence studies of biopsies taken from the palpebral conjunctiva of the right lower lid were negative for cicatricial pemphigoid. A twenty-four hour urine specimen analysis revealed elevated levels of uroporphyrins and polycarboxylated porphyrins, confirming the diagnosis of porphyria cutanea tarda. The patient was treated with repeated phlebotomies and oral hydroxychloroquine, which resulted in a significant decrease in the skin lesions, conjunctival injection, and concretions under the upper lids. CONCLUSIONS Cicatricial conjunctivitis may be a manifestation of porphyria cutanea tarda.

Treatment of mucous membrane pemphigoid with mycophenolate mofetil.

Purpose: To evaluate the clinical outcomes of mycophenolate mofetil (MMF) treatment of mucous membrane pemphigoid (MMP). Methods: This is a retrospective analysis of consecutive patients with clinical MMP seen in the Ocular Surface Disease Clinic at the Wills Eye Institute, between January 1, 2004, and December 31, 2010, treated with MMF. The main outcomes measured were control of inflammation and discontinuation of MMF. Results: A total of 23 MMP patients taking MMF were identified. The median age of the MMF-treated patients was 77.0 years. Eleven of the 23 patients (47.8%) had biopsy-proven MMP. All patients were at least Foster grading system stage 2, with most stage 3 or 4. Eight patients (34.8%) failed previous treatments with dapsone, methotrexate, prednisone, azathioprine, cyclophosphamide, or 6-mercaptopurine. The average duration of MMF treatment was 23.32 ± 33.17 months (range 1–124.83 months, median 7.4 months). Of the 23 patients with MMP, control of inflammation was achieved with MMF within 3 months for 56.5% [95% confidence interval (CI) 54.5–59.6], within 6 months for 69.6% (95% CI 65.2–76.6), and within 12 months for 82.6% (95% CI 75.3–92.4) of the patients. Nineteen patients (82.4%) achieved control of inflammation, with 16 of the 19 (84.2%) achieving control of inflammation with MMF as monotherapy. Fifteen patients were treated with MMF as initial therapy. Twenty-one percent of patients (5 of 23) were taken off MMF for failure of inflammatory control (4) or an allergic reaction (1). Conclusions: Treatment of MMP with MMF in this uncontrolled case series resulted in control of inflammation in the majority of patients with minimal side effects. Our data support consideration of MMF as an initial treatment option for active ocular MMP.

Extrusion of hydrogel exoplant into upper eyelid 16 years after a scleral buckle procedure.

Sixteen years after scleral buckle surgery with a hydrogel episcleral exoplant, a 43-year-old woman presented with progressive binocular diplopia, ptosis, and an expanding mass in her upper eyelid. She underwent surgical removal of the hydrogel exoplant through an anterior approach. The exoplant proved to be friable, fragmented, and encapsulated in a fibrous tissue; the exoplant was removed in its entirety. Postoperatively, the eyelid mass resolved, while her diplopia and ptosis improved slightly.