Histological Progress Observation of Conjunctival MALToma

PURPOSE: We report six cases of histologically diagnosed conjunctival MALT (mucosa-associated lymphoid tissue)oma. Presenting symptoms were eyelid swelling, foreign body sensation, lid mass, injection and itching sensation. PATIENTS AND METHODS: Six patients with conjunctival MALToma were followed. Clinical progress and biopsy result were reviewed periodically. RESULTS: The conjunctival MALToma seemed to be localized and slowly progressive. Although the conjunctival MALToma is known to be well responsive to radiotherapy, two of three patients who received radiotherapy revealed to have remnant lymphoma cells histologically in conjunctival biopsy. In addition, chemotherapy did not have curative effect in any of the patients. CONCLUSIONS: Therefore, we are doubtful for the necessity of active treatment in MALTomas of the conjunctiva.

Resistance of Fluid Flow within the Nasolacrimal Duct

The presence of complete obstruction within the human lacrimal drainage system can be easily found. The partial obstruction within the lacrimal drainage system can be diagnosed with Jones dye test and radiologic test. However, above tests can't determine the degree of partial obstruction as qualitative methods. Authors designed the instrument that measures the resistance to constant fluid flow within the nasolacrimal duct. Author measured the resistance to 5 ml/min flow rate with stainless steel canula (internal diameter, 0.395 mm) within the nasolacrimal duct in 194 people (388 eyes) without epiphora. The means of the resistance in all cases are 187.64+/-42.37 mmHg.seconds/ml. There are no statistical significances in both eyes and sex groups. But in age groups between teens and 20s, 30s and 40s, 60s and over 70s, there are statistically significant. Between the age and the resistance the coefficiency of correlation(r) is 0.56 in right eye, 0.64 in left eye, 0.60 in both eyes and as a result of regression, statistical significance showed (p-value<0.01). Authors suggested the normal value of the resistance in age and sex groups quantitatively. On the basis of this measurement, it is possible to make the early diagnosis and the proper plan of treatment in the partial obstruction of the nasolacrimal duct, the differential diagnosis between epiphora from the partial obstruction within the nasolacrimal duct and from other causes.

Draining Capacity of the Nasolacrimal Duct in Normal Korean Adults

The presence of abnormality within the human lacrimal drainage system can be determined with syringing, probing, fluorescein dye disappearance test, and Jones test.But the degree of partial obstruction cannot be determined with these qualitative tests.For quantitative measurement of drainage capacity of nasolacrimal duct, authors designed an instrument that measures the fluid flow within the nasolacrimal duct from distilled water at constant height. We measured the drainage capacity with a stainless steel canula in 109 persons (218 eyes)without epiphora and impaired drainage system.The means of the drainage capacity in all cases are 4.42 +/-0.87 ml/min in right eye and 4.28 +/-0.83 ml/min in left eye.And the means of the drainage capacity in all cases are 4.46 +/-0.89 ml/min in male and 4.25 +/-0.92 ml/min in females.There are no statistic significances in laterality and sex. Normal values of drainage capacity of nasolacrimal ducts in Korean adults were suggested quantitatively according to age and sex.These values obtained in this study might help us to make early diagnosis and a proper plan of treatment in the partial obstruction of nasolacrimal duct, the differential diagnosis between epiphora from the partial obstruction within the nasolacrimal duct and those from other causes.

Epicanthus as a Cause of Pruritis

According to the ophthalmic literature, the lack of epicanthus and termi-nal hairs at the medial side of punctum are unique features in most non-Asian eyelids.We wanted to examine the presence of terminal hairs at the medial side of punctum in Asian.A study was designed to examine 416 eyes of 208 patients who had visited our hospital between March 1999 and Sep-tember 1999.Physical examination included the presence of epicanthus, terminal hairs at the medial side of punctum, upper eyelid crease and pruritus in medial canthal area.The mean age of the patients was 56.5 years.Epi-canthus was seen in 256 eyes of 416 eyes (61.5%).The upper lid creases were detected in 242 eyes of 416 eyes (58.2%)and classified mostly as the medial tapering and lateral flaring type (83.5%).There were 250 eyes of 416 eyes (60.1%)who had terminal hairs at the medial side of punctum.Sixty eyes of 416 eyes (14.4%)complained of itching sensation in medial canthal area and had experienced once or two times per week (70.0%).They com-posed of 44 eyes of 60 eyes (73.3%)with epicanthus and terminal hairs, 10eyes of 60 eyes (16.7%)with only terminal hairs, and 6 eyes of 60eyes (10.0%)with only epicanthus.In our study, we found many patients had terminal hairs at the medial side of punctum in Asian and the presence of epicanthus and terminal hairs caused itching sensation at medial canthal area.

Decreased Basal Tear Production Associated with General Anesthesia

Two types of tear secretion, basic and reflex, have been postulated. Basic secretion is thought to be a constant,slow secretion by the accessory lacrimal glands. Reflex secretion was defined as an increased rate of secretion caused by neural stimulation and thought to be secreted by the main lacrimal gland. The purpose of the present study is to measure the effect of general anesthesia and atropine on basal tear secretion in order to elucidate the association between basal tear secretion and autonomic nervous system. We studied the 84 cases of general operations that were performed between March 1998 and June 1998. Basal tear measurements were made before premedication, 5 minutes after injection of atropine, 10 minutes after general anesthesia and 1 hour after general anesthesia. Basal tear secretion was lower at 5 minutes after injection of atropine than before premedication and markedly decreased after induction of general anesthesia. Therefore, we think that basal tear secretion is closely related to the autonomic nervous system.

Treatment of Conjunctivochalasis Using Bipolar Cautery

Conjunctivochalasis cause epiphora because abnormal redundant conjunctival tissue obstruct the punctum and block the tear outflow. The surgical resection of the redundant conjunctial tussue with scissors has been performed but it has caused such problems as difficult control of bleeding, long surgical time, high incidence of subconjunctival hemorrhage and cosmetic dissatisfaction. Therefore, the authors performed the operation of conjunctivochalasis with bipolar cautery instead of scissors and evalunted the efficacy of this new method. The authors prospectively studied 9 patients(16 eyes) of conjunctivochalasis who complained of epiphora and were found to have redundancy of conjunctival tissue around the punctal area on slit-lamp examination. They have neither lacrimal pathway insufficiency and obstruction, nor facial falsy or lid laxity that impair the lacrimal pump action, and also no anatomical anomaly of the punta was noted. After marking of redundant conjunctival tissue with gentian Violet under the operationg microscope and topiacal anethesia wint 4% lidocaine, redundant conjunctival tissue was removed by bipolar cautery. We also cauterized exposed Tenon`s capsule to contract the wound. Suture was not performed or three interrupted suture were placed. Epiphora was improved after simple cauterization of redundant conjunctiva in 15 eyes out of 16 eyes during at least 2 months of follow-up period. Removal of redundant lower incidence of subconjunctival hemorrhage than resection technique using scissore. We expect that this surgical technique will substitute for established technique with scissors beause bipolar cautery method was simple and showed lower incidence of complications.

A Clinical Experience of Postoperative Double Elevator Palsy after Surgical Removal of Schwannoma in Orbit and Cavernous Sinus

A patient who had been complaining of slowly progressive proptosis for two months came to the authors`hospital. Brain MRI was taken promptly to show an intraorbital lesion highly suspicious of schwannoma. We performed an operation in concert with neurosurgeons in which the intraorbital mass was totally resected through orbitozygomatic and extradural approach. After the surgery, ptosis of right upper eyelid and right hypertropia of 22 prism developed as a complication. Another operation was performed 7 months after the initial resection of the mass, in which right inferior rectus muscle was recessed and a silicone sleave was inserted for right frontalis sling. No further complication developed thereafter. Presently, the patient has right hypotropia of 8 prism and only a few creases on right upper eyelid. Orbital schwannoma is a rare disease and comprises approximately 1 percent of all orbital tumors. The authors experienced postoperative double elevator palsy as well as sinus and intraorbital schwannoma. We report this case with review of the literature.

Orbital Metastasis of Hepatocellular Carcinoma

Recently elongation of life in cancer patients by modern treatment modalities is thought to be attributed to the increase in the frequency of metastatic tumors in the orbit. The characteristic feature of metastatic orbital tumors is rapid progression associated with motor and sensory symptoms. The authors experienced orbital metastais of hepatocellular carcinoma in a 45-year-old male patient, proven histopathologically. As far as we know, only three histologically proven cases been reported in the literature. Besides, no orbital metastasis of hepatoma has been reproted in Korea, where heaptitis and hepatoma are highly prevalent. Because metastatic hepatoma has highly developed vasculature, surgeons should be aware that intractable bleeding may obstruct the further progression of the palliative surgery, as in our case.

Conjunctivochalasis as a Cause of Epiphora and its Histopathological Findings

When examining in the patients with epiphora, it is common to evaluate only the insufficiency or obstruction of lacrimal pathway by irrigation or dacryocystography and to over look the conjunctival conditions near the punctum in most cases. Authors found marked redundancy of conjunctival tissue around the punctal area in 8 patients(12 eyes) who complained of epiphora. They have neither lacrimal pathway insufficiency and obstruction, nor facial palsy or lid laxity that can impass the lacrimal pump action, and also no anatomical anomaly of the puncta. In fluorescein dye dissappearence test of these patients, the clearance of dye was markedly delayed on the lesion site(Grade 3 to 4). Epiphora was dramatically improved after simple resection of redundant conjunctiva under surgical microscope. The Hematoxylin-Eosin and Toluidine-Blue staining of resected conjunctiva revealed infiltration of many inflammatory cells and increase of metachromatic cells in the conjunctival stroma.

The Effect of Palpebral Spring in Lagophthalmos caused by Nerve Palsy

Facial palsy produces asymmetry of the face and lagophthalmos, incomplete eyelid closure. Exposure keratitis and eyeball pain can be induced by prolonged lagophthalmos, and the vision can be treatened at last. Therefore, the correc tion of lagophthalmos is important to preserve the proper visual function. Tarsorrhaphy has been the classic method of providing corneal protection in lagophthalmos caused by facial nerve palsy, but it produces a cosmetic problem and limits vision, so it should be reserved only to comatous patients. Since Morel-Fatio and Lalardrie implanted a palpebral spring in 1964 first time, several modifications have been reported to maximize the effect of spring in lagophthalmos. The authors experienced the dynamic eyelid animation with papebral spring, custom-made by authors with orthodontic wire in four patients who sufferd from exposed keratitis and eyeball pain due to lagophthalmos, which were intractable to medical therapy. Eyeball pain and keratitis were completely subsided in all patients with good lid closure. One patient was removed the palpebral spring due to recovery of facial nerve function at postoperative 6 months, other three patinets are well with implanted pa.lpebral spring.

Orbital Lymphocytic Tumor Gradually Progressed to More Malignant Form during 4 Years

Primary lymphocytic tumor of the orbit is known as a relatively uncommon condition and difficult to diagnose in their types exactly even with microscopic examination. The authors experienced a reactive lymphoid hyperplasia patient, 42 years old male, which was progressed to atypical lymphoid hyperplasia during 4 years, confirmed by immunoperoxidase staining. In this case, steroid therapy was of no use and it shows resistance to combined chernotherapy.

Clinical Experience of Monocanaliculonasal Stent in Canalicular Laceration

Repairing of canalicular laceration has some controversies on the golden timing of surgery, the suture method, the materials of stent, and the need of repairing the upper canaliculus in case of involving upper canaliculus. Until recently, reconstruction of the canaliculus with a bicanalicular silicone stent has been accepted as the most reasonable method. But the bicanalicular stent has some disadvantages including cosmetic problem and the possibility of injuries to the normal canaliculus during intubation. The authors used newly developed monocanaliculonasal stents in nine patients with traumatic canalicular laceration and it showed the absence of epiphora the cosmetically superiority, and the simplicity of intubation, compared with bicanalicualr silicone stent.

Treatment of Blow-out Fracture Located in the Posterior Portion of the Orbital Floor

Until now, there has been many papers about orbital blow-out fracture, but reports regarding the treatment and the prognosis of fractures located in the posterior portion of the orbital floor have been limited. The most common fracture site of the orbital floor is the medial portion of the infraorbital groove and repairing of the floor fracture located in the anterior portion of the floor is relative easy and has minimal complications. But when the fracture is located in the posterior portion of the floor, the possibility of the optic nerve injury is anticipated by surgical manipulation itself and the implanted silastic sheet Authors reconstructed posterior portion of the orbital floor fracture through conjunctival approach combined with Caldwell-Luc procedure in 5 patients, confirmed posterior orbital floor fracture on CT scan from July 1993 to November 1994. The results were satisfactory with no residual diplopia. Complications including prolonged maxillary sinusitis and lateral canthal deformity were encountered in each patient, but cured with ENT treatment and lateral canthoplasty. In reconstruction of orbital floor fracture, Caldwell-Luc approach was seldom used because of several reasons including the poor predictability, bleeding problrm, and the high incidence of sinus infection. But recently, Caldwell-Luc approach is reanimated by some endoscopic surgeons because of good visualization and less traumatic. In case of posterior floor fracture, our surgical method can reduce the possibility of injury to optic nerve and vital tissues around the orbital apex in spite of enlarging surgical field.