Suresh Sagili

The Learning Curve in Endoscopic Dacryocystorhinostomy: Outcomes in Surgery Performed by Trainee Oculoplastic Surgeons.

Abstract Purpose: To report outcomes of endoscopic DCR (En-DCR) performed by oculoplastic trainees and describe factors to improve success rates for trainees. Methods: Retrospective, single-centre audit of En-DCR procedures performed by three consecutive trainee oculoplastic surgeons, over a 3-year period. Trainees also completed a reflective-learning questionnaire highlighting challenging and technically difficult aspects of En-DCR surgery, with relevant tips. Results: Thirty-eight consecutive independently-performed en-DCR procedures on 38 patients (mean age 58.6 ± 21.4 years) were studied. Mean time spent in the operating-theatre was 95.7 ± 27.3 minutes. Success rate for each year was 15/17(88%), 8/8(100%) and 7/13(54%), respectively, at mean follow-up 12.5 ± 12 months. The lowest success rate year coincided with use of silicone stents in 31% cases compared to 94% and 100% in the previous 2 years. In cases that failed, video-analysis highlighted inadequate superior bony rhinostomy (2 cases), incomplete retroplacement of posterior-nasal mucosal-flaps (3 cases), significant bleeding (1 case). Those who underwent revision surgery (n = 6), were found to have soft-tissue ostium and sac closure requiring flap revision. Two-cases required further bone removal supero-posterior to the lacrimal sac. Trainees-tips that helped improve their surgery related to patient positioning, instrument handling, bone removal and posture. Conclusion: Good surgical outcomes are achievable training in en-DCR surgery. Adequate operating time needs to be planned. Failure was primarily due to closure of the soft-tissue ostium, either secondary to inadequate osteotomy and sac-marsupialisation or postoperative scarring. Intra-operative mucosal trauma is higher amongst trainees and adjuvant silicone stenting during the training period may be of value where mucosal adhesions are anticipated.

Outcomes of posterior-approach 'levatorpexy' in congenital ptosis repair.

Purpose We describe a minimally invasive technique and report our experience of posterior approach levator plication (‘levatorpexy’) for congenital ptosis. Study design Retrospective review. Participants Consecutive series of 16 patients. Materials and methods Posterior approach levatorpexy was performed for congenital ptosis under general anaesthesia. This surgical procedure involves exposing the posterior surface of the levator muscle through a transconjunctival approach. The levator muscle is advanced and plicated using a suture passed through its posterior surface, partial-thickness, to tarsal plate and tied on the skin. No tissue (conjunctiva, Mullers muscle, levator) are excised during this procedure. Main outcome measures Data collected included margin reflex distance (MRD1), symmetry of eyelid height, contour and complications. Surgery was considered successful if the following three criteria were simultaneously met: A postoperative MRD1 of ≥2 mm and ≤4.5 mm, inter-eyelid height asymmetry of ≤1 mm, and satisfactory eyelid contour. Results Mean age was 9.1 years (range 3–26 years). Mean postoperative follow-up was 8.1 months (4–24 months). Preoperative phenylephrine test was positive in 81% of patients. Mean levator function was 11 mm (5–15 mm). Mean preoperative MRD1 was 1.5 mm and the mean postoperative MRD1 was 2.6 mm. Fourteen patients (87%) achieved the desired eyelid height and fulfilled our criteria set for success. Conclusions Posterior approach levatorpexy appears to be a safe and effective procedure for correction of congenital ptosis particularly with moderate or better levator function.

Lacrimal Scintigraphy: “Interpretation More Art than Science”

Lacrimal scintigraphy (LS) or dacryoscintigraphy can demonstrate abnormalities in 80%–95% of patients with symptoms of epiphora and a patent lacrimal system on syringing and up to 40% asymptomatic individuals. Precise localization of the site of delay may not always be possible due to lack of anatomic detail on LS. LS is considered useful in patients with epiphora with delayed tear clearance and patency to syringing and suspected to have either nasolacrimal duct (NLD) stenosis or lacrimal pump failure. It remains unclear, however, as to whether LS can reliably distinguish between the two. The literature reports considerable variation in the technique, normative data, analysis, and interpretation of LS. Qualitative or visual analysis is simpler to perform and to our knowledge used more frequently in comparison to quantitative analysis. There is little extra information to be gained from LS in cases with complete NLD obstruction or severe NLD stenosis on syringing.

Intraocular pressure and refractive changes following orbital decompression with intraconal fat excision.

The purpose of this study was to measure the changes in intraocular pressure (IOP) and refraction following orbital decompression for thyroid orbitopathy. Methods: Retrospective review of 18 eyes in 10 consecutive patients who underwent orbital decompression including intraconal fat excision for proptosis secondary to thyroid orbitopathy. IOP using tonopen, exophthalmometry, autorefraction and autokeratometry measurements were performed at 1-week, 1-month and 3-months after surgery. Results: There was no statistically significant difference between the preoperative and postoperative IOP at 3 months. There were no significant differences found between preoperative and post operative keratometry readings or automated refraction following orbital decompression. Conclusion: Our study did not find a significant change in IOP and refraction following orbital decompression with intraconal fat excision. A larger prospective study is required in order to evaluate the role of intraconal fat excision in reducing IOP due to it’s potential role in patients with concurrent glaucoma.

Anterior Approach White-Line Advancement: A Hybrid Technique for Ptosis Correction.

Purpose: To describe the technique of anterior approach white-line advancement for correction of ptosis. Methods: Retrospective review of consecutive cases that underwent anterior approach white-line advancement for correction of aponeurotic ptosis. In this technique, the posterior surface of the levator aponeurosis (white line) is accessed through a skin crease incision (anterior approach) and advanced toward the tarsal plate. Surgery was considered successful if the following 3 criteria were simultaneously met: postoperative upper margin reflex distance of ≥2 and ⩽4.5 mm, inter-eyelid height asymmetry of ⩽1 mm, and satisfactory eyelid contour. Written informed consent was obtained from all the patients and the study was HIPPA compliant. Results: Twenty patients (29 eyelids) were included in this study. Mean postoperative follow up was 1.25 months (1 to 6 months). Mean preoperative margin reflex distance was 0.38 mm (−1 to 2 mm) and the mean postoperative margin reflex distance was 3.16 mm (2 to 4 mm). Eighteen patients (90%) fulfilled the criteria set for success. The patients rated the outcome of surgery as follows: 80% completely satisfied and 20% significantly improved. Conclusion: Anterior approach white-line advancement is a hybrid technique that incorporates the principles of both anterior and posterior approach ptosis correction techniques. The posterior surface of levator aponeurosis (white line) is exposed and advanced toward the superior border of tarsal plate with minimal disruption of eyelid anatomy including the orbital septum and preaponeurotic fat pad. Hence, this technique can achieve superior cosmetic results similar to a posterior approach procedure, without the need for a conjunctival incision.

Platinum segments: a new platinum chain for adjustable upper eyelid loading

Purpose Prospective study evaluating outcomes of individually sutured platinum segment chains in upper eyelid loading. Methods Single-centre, single-surgeon, prospective study. Upper eyelid loading with 0.4 and 0.2 g platinum segment chains for lagophthalmos. Segments were sutured to create a desired weight and attached to superior tarsus and distal levator aponeurosis following levator recession. Primary outcome measures: improvement in lagophthalmos and complications. Secondary outcome measures: cosmesis of eyelid margin contour and implant prominence. Minimum 3-month follow-up. Results Eighteen eyelids of 17 patients received segment chains (mean weight 1.2 g, range 0.8–1.6 g) and 3 for exchange of pre-existing gold weights. Median follow-up was 10 (range 6–17) months. Mean blink lagophthalmos improved from 7 (3–10) mm to 3 (0–6) mm (p<0.0001), and gentle closure from 3.2 (0–8) mm to 1.1 (0–4.9) mm (p=0.0004). Twelve patients (71%) reported no prominence, and the remainder, mild prominence only. The chain was graded as having no prominence in 78% (14/18) eyelids. Two required segment adjustments with removal of a single 0.2 g segment at 11 months and transfer of 0.4 g segment to the contralateral eyelid at 16 months, respectively. One complication (posterior, trans-conjunctival exposure above the superior border of the tarsal plate) was seen 12 months post surgery, requiring repositioning. Conclusions Platinum segment chains provide benefits of platinum chains with additional advantages of postoperative adjustibility. They can be used as an addition to pre-existing in situ weights or chains. Trial registration number REC reference: 13/SW/0146. IRAS project ID: 119022.

Facial palsy-induced blepharospasm relieved by a Bangerter foil

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Acquired lacrimal sac fistula mimicking basal cell carcinoma

Background Lacrimal sac fistulae can arise after an episode of dacryocystitis, usually forming below the medial canthus. Preceding symptoms of a watery eye with mucous discharge and a history or signs of inflammation are typical.

Excision of periocular basal cell carcinoma guided by en face frozen section

We describe a technique for monitoring excision margins in periocular basal cell carcinoma (BCC) using en face frozen sections and report outcomes. We excised periocular BCC with 3mm margins. An outer 1mm sliver of the perimeter of the specimen was mapped and sent for evaluation by en face frozen section. The central tumour mass was processed using routine paraffin sections. A further 3mm level was excised at the site of any affected margin and the outer 1mm sliver was again evaluated by frozen section. We identified 78 patients from November 2003 to July 2009; 67 had primary tumours and 11 (14%) had recurrent BCC of which 52 (66%) were located on the lower eyelid. Growth patterns were nodular (n=34, 43%), infiltrative (n=25, 32%), micronodular (n=12, 16%), and superficial (n=7, 9%). A third of BCC with a clinically nodular appearance showed additional histological patterns including infiltrative and micronodular growth patterns. Of 30 clinically nodular carcinomas, 29 were excised completely with one level, and one required 2 levels of excision for clearance after evaluation by frozen section. Mean follow-up was 23 months (range 2-60). There was one recurrence (1%). Excision of margins guided by en face frozen section is justified by the low rates of recurrence, and it can easily be taught or imported into hospital practice. Clinically nodular BCC have subclinical extensions that can be missed on bread loaf sectioning, which makes the sampling of margins a standard for periocular BCC.

Orbital exenteration: indications, techniques and complications

ABSTRACT Introduction: Orbital exenteration is defined as removal of all the orbital contents including the periorbita and eyelids. Although a disfiguring procedure, orbital exenteration can provide a cure in certain locally invasive tumors including basal and squamous cell carcinoma. Areas covered: This review details the indications and surgical technique of orbital exenteration. This article also elaborates the surgical and non-surgical options for reconstruction and rehabilitation following orbital exenteration. A literature-search was conducted on terms orbital exenteration, indications, technique and reconstruction. All relevant peer-reviewed articles were analyzed. Expert commentary: Orbital exenteration is a radical excision procedure indicated for tumors invading the orbit where a conservative excision is unlikely to achieve complete clearance. However, conservative excision options such as globe-sparing orbital excisions are increasingly being considered and outcomes of this continue to emerge in the literature. Continued improvements in managing periocular skin malignancies, including techniques of margin-controlled should continue to reduce the incidence of cases presenting with orbital invasion and hence the need for orbital exenteration.