Soupramanien Sandramouli

Canaliculitis: The incidence of long-term epiphora following canaliculotomy

PURPOSE To review the long-term outcome following surgical treatment for canaliculitis. METHODS All cases of canaliculitis treated surgically from January 1995 to December 2001 were identified from theatre records. Case notes were reviewed retrospectively looking specifically for delay in diagnosis (defined as two or more visits prior to diagnosis), culture RESULTS and outcome following surgical treatment. Telephonic questionnaires were used to assess the incidence of post-treatment epiphora. Symptomatic patients were offered clinic appointments for further assessment and management. results Fifteen eyes of 15 patients were identified, 13 were females and 2 males. Mean age was 69.6 years (range 45–87 years). One patient had both upper and lower canaliculitis. The remaining 14 (93.3%) had lower canaliculitis. Diagnosis was delayed in 7 of the 15 patients (46.6%). Culture results were positive in 66.6% with Staphylocococcus spp. being the most common isolate (26.6%). Actinomyces was isolated in only 2 of the 15 cases (13.3%). Conservative treatment had been tried in 5 cases (33.3%). All patients had resolution of symptoms following canaliculotomy. Epiphora was identified in four of the treated eyes on telephonic questionnaires. Of these, three eyes had preexisting lacrimal pathology. Average follow-up was 26 months (range 6–83 months). CONCLUSION Canaliculotomy is safe and efficacious in the treatment of lacrimal canaliculitis with no demonstrable risk of posttreatment epiphora.

Xanthogranulomatous variant of immunoglobulin G4 sclerosing disease presenting as ptosis, proptosis and eyelid skin plaques

A 70-year-old male was referred to the oculoplastic clinic with left-sided ptosis and floppy eyelids. During follow-up, bilateral upper lid xanthelasma developed with worsening ptosis and proptosis, which was worse on the left side. A left orbital biopsy showed xanthogranulomatous inflammation of the orbit. The patient was treated with a variety of immune modulator regimes but due to a variety of side-effects, treatment was discontinued. The left orbit was surgically debulked twice and histology revealed xanthogranulomatous inflammation, with the additional features of sclerosis, lymphoid aggregates and a prominent population of plasma cells. Around 80% of the plasma cells expressed immunoglobulin G4 (IgG4). This case report reveals an association between xanthogranulomatous inflammation of the orbit and a prominent population of IgG4-positive plasma cells. We propose that the overall disease is a novel variant of IgG4 sclerosing disease of the orbit and suggest that cases of histologically proven xanthogranulomatous inflammation should be stained for IgG4 if there is an accompanying plasma cell population.

A unique case of IgG4 sclerosing dacryocystitis.

IgG4-related ocular adnexal disease, a relatively recently described clinical entity, is important to diagnose because during the acute phase, it responds favorably to corticosteroid treatment. The diagnosis can be confirmed by simple blood tests and histology. IgG4-related dacryoadenitis and generalized orbital disease have been reported; however, this is the first report of IgG4-related disease of the lacrimal sac. We describe an 80-year-old female who presented with a painless erythematous indurated swelling in the right lacrimal sac area with complete obstruction of the right nasolacrimal system. A 9-mm lacrimal sac mass was noted on CT dacryocystogram. Blood tests revealed an elevated serum IgG4 level, and the lacrimal sac histology was characteristic of IgG4-related disease. Corticosteroid treatment was declined by the patient. She was kept under close observation for signs of progression, systemic involvement, and potential malignant transformation.

The Use of AlloDerm in the Reconstruction of Full-Thickness Eyelid Defects

Purpose: To demonstrate the potential for the use of AlloDerm as a posterior lamellar graft in the reconstruction of full-thickness lid defects. Method: In our case series, we evaluated the surgical outcome of three consecutive patients, two with an upper eyelid defect and one with a lower eyelid defect who underwent lid reconstruction using AlloDerm grafts. Results: AlloDerm was readily taken up into the wound defect, with complete coverage of its bulbar surface by conjunctiva. In all the cases, the cornea was not affected by its contact to the AlloDerm. A mucocutaneous junction formed over the margin of the AlloDerm graft with good cosmesis. Conclusion: AlloDerm has the potential to act as an effective posterior lamellar substitute in situations where there is an adequate amount of skin muscle cover available to drape over it. It is rigid enough to replace tarsus and its structure behaves as a scaffold allowing conjunctiva to readily grow over it.

Topical diclofenac gel for the management of periocular actinic keratosis.

Purpose: We sought to evaluate the efficacy of topical 3% diclofenac gel in the management of periocular actinic keratosis. Methods: Four consecutive patients with periocular actinic keratosis who were treated with topical 3% diclofenac gel twice daily for up to 4 months were included in the study. Patients were reviewed at 1 and 2 months and then as clinically required up to 13 months after treatment. Results: All 4 patients had biopsy-proven actinic keratosis. Three of the 4 patients tolerated the therapy well. In 1 patient, an adverse reaction developed, with erythema, crusting, and scaling after 2 months of therapy, which resolved within a month of discontinuing topical diclofenac. In all the patients, a visible decrease in lesion severity was seen after 1 month, and complete resolution, within 4 months. Recurrences occurred in 2 patients at 4 months and 7 months after treatment. These were successfully managed, in one patient, by excision, and in the other, with further 3% diclofenac gel followed by cryotherapy. Conclusion: The use of 3% diclofenac gel in extraocular sites has been widely described in the dermatology literature. However, no published reports exist of its use in ophthalmology. It may be a useful therapeutic option when used alone in patients with localized disease or to reduce the size of larger, more-diffuse lesions before excision or cryotherapy, leading to improved cosmesis. Furthermore, it may also be useful in patients prone to actinic keratoses, such as organ-transplant recipients, to reduce the need for multiple excision procedures or uncomfortable ablative techniques.

A Histopathologic Study of Orbital Implant Vascularization

Purpose: To histopathologically assess the extent and pattern of vascularization of explanted porous polyethylene (PP) and hyrdoxyapatite (HA) orbital implants. To compare the vascularization in PP implants harvested after enucleation versus after evisceration. Methods: This is a comparative case series of six orbital implants explanted between 11 months and 5 years and 4 months post implantation. The implants were subjected to histopathological examination with various stains, after complete decalcification. Results: There were 2 post evisceration, 3 post enucleation and 1 secondary implant. The size of the implants varied from 18 to 23 mm diameter. The reason for explantation was exposure in all the 6 cases with additional infection in 2 cases. Histopathology revealed complete vascularization up to the core of the implant in all the cases. There was evidence of chronic inflammation within all the explanted specimens. Acute inflammation was present at the site of exposure in four of the implants. Three of these implants had additional evidence of necrosis. Two cases with clinically evident infection had Gram positive cocci within the implant. Foreign-body type giant-cells, melanophages and haemosiderin laden macrophages were also observed. Eviscerated specimens showed scleral remodelling and thickening. Conclusion: All the implants were vascularized up to the core. There was histologic evidence of chronic inflammation in all the explanted implants possibly indicating the foreign nature of the implant material. The sclera did not impede vascularization of the implants in eviscerated specimens. We found no difference in the degree of vascularization of the implant in enucleated versus eviscerated implants.

Successful treatment of nasolacrimal duct obstruction secondary to fibrous dysplasia by external dacryocystorhinostomy with mitomycin C.

A 60-year-old woman developed polyostotic fibrous dysplasia involving the right zygomatic and maxillary bones, which led to swelling along the right side of her nose that was associated with constant epiphora. A sac washout revealed a blocked right nasolacrimal duct, which was confirmed by CT dacryocystography. CT also showed signs of fibrous dysplasia in the maxillary and zygomatic bones in the form of bony expansion and ground-glass bone density. The patient underwent external dacryocystorhinostomy with mitomycin C and ODonoghue tube insertion. Bone punched out while fashioning the bony nasal ostium was subjected to histopathologic examination, which confirmed the diagnosis of fibrous dysplasia. The ODonoghue tubes were removed 8 weeks later. At 15 months postoperatively, the dacryocystorhinostomy was patent and the patient was completely relieved of her symptoms.

A case of non-lacrimal immunoglobulin G4 (IgG4)-related orbital disease with mastitis

ABSTRACT IgG4-related orbital disease is a recognised cause for orbital inflammation. As its awareness increases and diagnostic accuracy improves there will be an increased number of cases being identified. This unique case demonstrates for the first time, with histological evidence, a case of a non-lacrimal IgG4-related orbital disease with concurrent IgG4-related mastitis. We describe a 47 year old who presented with a supraorbital swelling and mass. This was initially successfully treated with oral steroids and was later excised on recurrence. Immunohistochemical and blood serum analysis confirmed IgG4-related orbital disease. On systemic enquiry she was found to have a mass of the breast, which was shown to be IgG4-related mastitis. She is currently asymptomatic with no sign of recurrence and is under long-term surveillance. This case highlights the importance of systemic work up in patients presenting with orbital foci of IgG4 disease.

Caution with tissue adhesives for peri-ocular lacerations

A 3 year old boy sustained a small laceration and bruising to his right brow. He was seen by his general practitioner, who used cyanoacrylate …

Spindle Cell Lipoma of the Conjunctiva.

A 67-year-old woman presented with progressive enlargement of a long-standing mass on the surface of her OS associated with ocular surface irritation. The mass was excised en bloc. Histopathological examination showed a well-defined encapsulated tumor composed of wiry collagen containing bland spindle cells that were strongly positive for CD34 with scattered mature adipocytes. These features confirmed a diagnosis of spindle cell lipoma.