Suzana Matayoshi

Comparative study of Botox ® injection treatment for upper eyelid retraction with 6-month follow-up in patients with thyroid eye disease in the congestive or fibrotic stage

AimTo compare morphometric data of the eyelid fissure and the levator muscle function (LF) before and up to 6 months after transcutaneous injection with five units of Botox® in patients with upper lid retraction (ULR) from congestive or fibrotic thyroid eye disease (TED).MethodsTwenty-four patients with ULR from TED were submitted to transcutaneous injection of 5 units (0.1 ml) of Botox in one eye only. Patients were divided into two groups: 12 with congestive-stage TED (CG), and 12 with fibrotic-stage TED (FG). Bilateral lid fissure measurements using digital imaging and computer-aided analysis were taken at baseline and at regular intervals 2 weeks, 1 month, 3 months and 6 months after unilateral Botox injection. Mean values taken at different follow-up points were compared for the two groups.ResultsMost patients experienced marked improvement in ULR, with a mean reduction of 3.81 mm in FG and 3.05 mm in CG. The upper eyelid margin reflex distance, fissure height and total area of exposed interpalpebral fissure were significantly smaller during 1 month in CG and during 3 months in FG. Reduction in LF and in the difference between lateral and medial lid fissure measurements was observed in both groups. The treatment lasted significantly longer in FG than in CG.ConclusionsA single 5-unit Botox injection improved ULR, reduced LF and produced an adequate lid contour in patients with congestive or fibrotic TED. The effect lasts longer in patients with fibrotic orbitopathy than in patients with congestive orbitopathy.

Chronic dacryocystitis in American mucocutaneous leishmaniasis.

Purpose This study describes lacrimal tract involvement and surgical outcome in patients with mucocutaneous leishmaniasis. Methods Four patients, ages 20 to 75 years, had nasal lesions resulting from mucocutaneous leishmaniasis and sought treatment for chronic dacryocystitis. Each patient had had lacrimal symptoms since childhood or early adulthood, concomitantly with the development of upper airway lesions. Dacryocystography showed nasolacrimal duct stenosis in all cases on the affected side. Three patients underwent dacryocystorhinostomy (one bilaterally), and one patient had bilateral dacryocystectomy. Results Two patients had surgical fistula closure soon after surgery. A sequential endoscopic operation for remotion of a synechia between the fistula and the middle turbinate was successful in one of these patients. Histopathologic analysis of lacrimal sacs and nasal mucous membranes close to the anastomotic site revealed chronic nonspecific inflammatory process and negative immunohistochemistry for Leishmania. Conclusions Dacryocystitis may result from nasal mucocutaneous leishmaniasis. The surgical outcome was unsatisfactory in one of the four patients.

Efeitos adversos associados à aplicação de toxina botulínica na face: revisão sistemática com meta-análise

PURPOSE: To estimate the occurrence of adverse effects associated with the use of botulinum toxin by performing a systematic review and meta-analysis. METHODS: A systematic literature search of MEDLINE and Cochrane Library was conducted until September 2007. The occurrence of the adverse effects was estimated of the relative frequency for case report and of the relative risk for randomized trials. Heterogeneity was evaluated with the Q test and I2 index. Eggers significance test was used to identify the publication bias. Sensitivity analysis was performed to evaluate the effect of the publication biases. RESULTS: Eight randomized trials and thirteen case reports filled the inclusion criteria. In the systematic review of case reports, 1,003 subjects were studied and 182 (18.14%) showed adverse effects. Eyelid ptosis was the most frequent adverse effect, presenting in 34 (3.39%) patients of the case reports. In the meta-analysis of randomized trials, the overall relative risk for adverse effects as headache, eyelid ptosis, local reaction and infection was respectively: 1.07, 3.25, 0.99 and 0.94. For all comparisons, P values were greater than 0.05. CONCLUSION: Ptosis was the most frequent adverse effect and showed the higher relative risk associated with botulinum toxin. It is necessary to perform a pattern of adverse effects related for better understanding the relationship between adverse effects and use of botulinum toxin.

Obstrução de vias lacrimais associada ao tratamento radioiodoterápico de carcinoma de tireoide

PURPOSE: To report the finding of nasolacrimal drainage system obstruction associated with radio iodine therapy and to review clinical data and the surgical treatment outcome of this rare complication. METHODS: We retrospectively analyzed ophthalmological data of patients with history of thyroid carcinoma that underwent radioactive iodine I-131 therapy and were referred to lacrimal surgery. RESULTS: 17 patients with thyroid cancer treated with thyroidectomy and radioactive iodine I-131 therapy presented symptomatic nasolacrimal duct obstruction after 13.2 months following cancer treatment. 11 patients presented bilateral epiphora, 8 had lacrimal sac mucocele. Age range was 30 to 80 years, 10 patients had less than or equal to 49 years. The mean cumulative dose of radioiodine was 571mCi (range: 200-1200 mCi). Nasal obstruction symptoms and increased salivary glands were also present in 53% of patients. All subjects underwent dacryocystorhinostomy. Dilation of the lacrimal sac and increased intraoperative bleeding was also observed in 3 younger patients. Complete epiphora and dacryocystitis resolution after surgery occurred in 82.4%, and partial in 17.6% (3 patients that still presented unilateral relapse after correction of bilateral obstruction). Mean follow-up was 6 months (range: 2-24 months). CONCLUSIONS: Cumulative high dose of radioidine, nasal and salivary gland dysfunction are associated with lacrimal drainage obstruction. We observed a great percentage of younger patients presenting dacryocystitis when compared to the idiopathic dacryostenosis. Radioactive iodine uptake by nasolacrimal duct mucosa with subsequent inflammation, edema and fibrosis seems to have a relationship to lacrimal duct obstruction. The knowledge of this complication is important for the study and proper management of these patients.

Dacryocystectomy: indications and results

BACKGROUND After the advent of dacryocystorhinostomy (DCR), dacryocystectomy (DCT) was regarded as mutilant surgery and reserved for lacrimal sac tumors. PURPOSE To present current indications for dacryocystectomy. METHODS Eighteen eyes from 11 patients subjected to DCT were reviewed retrospectively. Nine patients had chronic dacryocystitis confirmed by dacryocystography and two patients had lacrimal sac tumors. RESULTS The indications for DCT were: three patients with systemic medical problems, three patients with dry eye, two cases of lacrimal sac tumors, two cases of traumatic dacryocystitis and one case of cutaneous leishmaniasis. Dacryocystitis was resolved in 17 of 18 eyes; the two cases of tumor evolved without epiphora. One patient (traumatic dacryocystitis) had recurrence of dacryocystitis. CONCLUSIONS DCT is mainly performed when a lacrimal sac tumor is suspected but, since it avoids the intra- and postoperative complications related to dacryocystorhinostomy, it can be indicated in cases of dacryocystitis with significant lacrimal discharge and an enlarged or altered lacrimal sac.

Avaliacao do filme lacrimal de pacientes com distonia facial durante tratamento com toxina botulínica tipo A

PURPOSE: To determine the effect of botulinum toxin injection in the eyelid on lacrimal film in patients with facial dystonia. METHODS: Twenty-four patients with essential blepharospasm and hemifacial spasm were submitted to botulinum toxin injection and lacrimal film tests were performed before the application and after seven and thirty days. RESULTS: There was improvement in symptoms of dry eye and rose bengal test, however, the breakup time and Schirmers test did not show significant variation between pretreatment and after 1 month of follow-up. CONCLUSION: The dry eye symptoms in patients with facial dystonia may be attenuated by botulinum toxin due to its possible inhibitory effect on the orbicular muscle leading to a decrease in lacrimal pump.

Criptococose palpebral: relato de caso

Relata-se o caso de uma paciente portadora de sindrome da imunodeficiencia adquirida empiricamente tratada com esquema triplice para tuberculose miliar. Durante a evolucao clinica a paciente cursou com lesoes comprometendo a palpebra e conjuntiva tarsal a direita. A hipotese diagnostica inicial foi de tuberculose ocular com comprometimento conjuntival e palpebral. A biopsia da lesao conjuntival mostrou presenca do Criptococcus neoformans. Apos o inicio do tratamento especifico com anfotericina B, a paciente apresentou melhora das lesoes cutâneas.

Síndrome de Down e alterações de vias lacrimais

PURPOSE: To identify the alterations of the lacrimal system in patients with Down syndrome. METHODS: A descriptive and retrospective survey covering eleven eyes in eight patients, diagnosed as Down syndrome, attended in the period from 1995 to 2001. RESULTS: All patients had chronic dacryocystitis with obstruction of the nasolacrimal duct. One patient also presented canaliculitis by Streptococcus sp and congenital absence of the lower lacrimal punctum was observed in another patient. Five patients were submitted to dacryocystorhinostomy, probing and intubation was performed in three patients. The complaints of epiphora were solved in four eyes. CONCLUSIONS: There are few accounts about lacrimal system disorders in patients with Down syndrome. The identification and surgical resolution of lacrimal obstruction is important, since it interferes with the quality of life of these patients. In the present study, it was verified that the lacrimal obstruction occurred in the nasolacrimal duct, like that which occurs in adults. The surgical prognosis was bad in 83.4% of intubations and in 57.2% of dacryocystorhinostomies. The reasons for the unsuccessful surgery may be related to a greater postoperative fibrosis in these patients, and the difficulty of obtaining their collaboration after surgery. Further studies are necessary to support the present observation.

Implante de peso de ouro: complicações precoces e tardias

PURPOSE To evaluate the indications, the results and the complications seen in the patients submitted to gold weight implantation to correct paralytic lagophthalmos. METHODS Charts of 20 patients with lagophthalmos secondary to facial nerve palsy of diverse etiologies, which were submitted to gold weight implantation in the upper eyelid of the affected side, were retrospectively examined. RESULTS The most frequent cause of paralytic lagophthalmos was acoustic neurinoma after surgery (40%). Early and late complications occurred in 40% of the implants. Four patients (20%) presented a local inflammatory reaction in the first 3 months after surgery. Two patients (10%) presented skin and orbicular muscle thinness over the gold weight 4 and 7 years after the implant, respectively. One patient (5%) presented gold weight displacement after 3 years and another patient (5%) had late gold weight extrusion after 10 years. CONCLUSIONS In this series, the complication rate of gold weight implantation was high (40%). The complications were divided into early, possibly related to the material impurity and the late, due to the evolution of the facial nerve palsy that presented a decrease in muscle tonus.

Ophthalmomyiasis as a cause of canalicular lesion

OBJECTIVE Myiasis is the invasion of human tissues by Diptera larvae. Ocular involvement is uncommon. Trauma is the major cause of lacrimal apparatus lesions. However, it is rarely associated with parasitic infestation. The objective of this paper is to report a case of canalicular laceration caused by Dermatobia hominis larva. DESCRIPTION An eight-year-old girl presented preseptal cellulitis that was refractive to antibiotics. A Dermatobia hominis larva was observed inside the lacrimal sac. Surgical extraction was performed and laceration of the lacrimal drainage system was noted. COMMENTS Parasitic infection of the lacrimal apparatus is rare. Surgical extraction is the treatment of choice in such cases. Despite being uncommon, ophthalmomyiasis should be considered as a possible diagnosis when cellulitis is not responsive to antibiotics, especially in endemic areas. This is the first description of lacrimal drainage system injury by Dermatobia hominis larva.