Cause and Management of Patients With Failed Endonasal Dacryocystorhinostomy

OBJECTIVES: Endonasal dacryocystorhinostomy (DCR) is a well-established treatment method in patients with nasolacrimal duct obstruction. However, there are a few reports about the overall management of failed endonasal DCR. We investigated the causes and management strategies of failed endonasal DCR. METHODS: This retrospective review included 61 patients (61 eyes) who had undergone revision surgery by the same surgeon after failed endonasal DCR between January 2008 and December 2012. The appropriate revision method was determined after analysis of the etiology of failure by the fluorescein dye disappearance test, nasal endoscopy, lacrimal irrigation, and probing. The criteria for success of the revision surgery were defined by the passage of fluid without resistance upon lacrimal irrigation and normalization of the tear meniscus height. RESULTS: The mean duration between the primary endonasal DCR and revision surgery was 15.3 months. The average follow-up period after revision surgery was 12.2 months. The most common cause of endoscopic revision surgery was membranous obstruction. Endoscopic revision surgery was performed in 48 patients, while lacrimal silicone tube intubation under endoscopy was performed in 13 patients. The most common indication for lacrimal silicone tube intubation was functional epiphora. The overall success rate of the revision surgery was 89%. CONCLUSION: The most common cause of failed endonasal DCR was membranous obstruction. When patients with failed endonasal DCR presented at the clinic, it is important to identify the cause of the failure. Revision surgery could increase the final success rate of endonasal DCR.

Causes and Surgical Outcomes of Lower Eyelid Retraction

PURPOSE: To investigate the causes of lower eyelid retraction and evaluate the outcomes of various surgical procedures. METHODS: We conducted a retrospective medical record review of patients who underwent lower eyelid retraction surgery performed by a single surgeon at Kim's Eye Hospital between 2006 and 2013. We investigated the causes of lower eyelid retraction, clinical history, characteristics, treatment, and surgical outcomes. Preoperative and postoperative margin reflex distance 2 and inferior scleral show were measured for each eyelid. Success was defined as a positive eyelid elevation and a decrease in inferior scleral show. RESULTS: A total of 19 lower eyelids were treated in 14 patients with lower eyelid retraction. For cosmetic reasons, surgical correction for congenital lower eyelid retraction was performed on seven eyelids (36.8%). Ten eyelids (52.6%) exhibited secondary lower eyelid retraction after surgery. One eyelid (5.3%) was affected by facial palsy and one eyelid (5.3%) exhibited exophthalmos of an unknown origin. We adopted a selective approach based on lower eyelid retraction severity. Spacer grafting via a subconjunctival approach was the most commonly performed surgical technique (13 eyelids, 68.4%). The lateral tarsal strip procedure was used to horizontally tighten three eyelids (15.8%). At the time of the procedure, one of these eyelids (5.3%) also received an adjuvant suborbicularis oculi fat lift. Autogenous dermis fat grafting was performed on two lower eyelids (10.5%), whose retraction was caused by fat and soft tissue loss. Cosmetic outcomes were satisfactory in all cases. CONCLUSIONS: To achieve satisfactory surgical outcomes, surgeons should adopt an approach based on the severity of lower eyelid retraction. Mild lower eyelid retraction can be corrected without grafts. When retraction is severe and exceeds 2 mm, spacer grafts that push the lower eyelid margin upwards and support it from below are required.

Comparison of the Efficacies of 0.94 mm and Double Silicone Tubes for Treatment of Canalicular Obstruction

PURPOSE: To compare the clinical effects of the single wide-diameter bicanalicular silicone tube and the double bicanalicular silicone tube in endonasal dacryocystorhinostomy (DCR) with canalicular trephinization for canalicular obstruction. METHODS: We retrospectively reviewed the records of 121 patients with monocanalicular or common canalicular obstruction who had undergone endonasal DCR with random bicanalicular insertion of either double silicone tubes (insertion of two tubes into each canaliculus) or a single wide-diameter (0.94 mm) silicone tube. The tubes were removed at around 3 months after surgery. RESULTS: This study included 79 eyes of 61 patients in the double-tube intubation group and 68 eyes of 60 patients in the single wide-diameter tube intubation group. Anatomical success, evaluated by syringing, was achieved in 72 of the 79 eyes (91.1%) in the double-tube intubation group and 60 of the 68 eyes (88.2%) in the single wide-diameter tube intubation group. Functional success was achieved in 65 of the 79 eyes (82.3%) in the double-tube intubation group and 61 of the 68 (89.7%) eyes in the single wide-diameter tube intubation group. There were no significant differences in the success rates of surgery between the two groups. One patient in the double-tube intubation group underwent conjunctivodacryocystorhinostomy (CDCR) and two in the wide-diameter tube intubation group underwent CDCR or reintubation to treat recurrence. CONCLUSIONS: Intubation using a single wide-diameter tube during endonasal DCR is as effective as double-tube intubation for the treatment of canalicular obstruction, with a lower rate of complications such as inflammation or patient discomfort.

Preoperative Computed Tomography Findings for Patients with Nasolacrimal Duct Obstruction or Stenosis

PURPOSE: To identify and analyze the role of preoperative computed tomography (CT) in patients with tearing symptoms with nasolacrimal duct obstruction (NLDO). METHODS: We retrospectively reviewed the medical records and CT results on 218 patients who complained of tearing symptoms with NLDO between January 2014 and December 2014. All patients were recruited from Kim's Eye Hospital's outpatient clinic and assessed by clinical history, examination, and CT to evaluate periocular pathology and nasolacrimal drainage system. Patients with abnormal findings assessed by preoperative CT were further reviewed. RESULTS: CT was performed on 218 patients (average age, 58.2 ± 11.9 years). Of these, 196 (89.9%) had endonasal dacryocystorhinostomy, 14 (6.4%) declined surgery, and 8 (3.7%) were inoperable due to abnormal CT findings. Soft tissue opacity was the most common finding which 243 cases (85.9%) of 283 obstructed nasolacrimal duct and 89 cases (81.7%) of 109 non-obstructed nasolacrimal duct showed it. Thirty-nine (17.8%) of 218 patients showed either maxillary sinusitis or ethmoidal sinusitis and 32 (14.7%) of 218 patients presented with periocular inflammation. Other abnormal CT findings included septal deviations, previous fractures, masses, and structural abnormalities of nasal cavity. CONCLUSIONS: Preoperative CT imaging is useful in the assessment of both nasolacrimal drainage and nearby anatomical structures. This information will be helpful in planning surgical interventions and management of NLDO.

Predictors of Silicone Tube Intubation Success in Patients with Lacrimal Drainage System Stenosis

PURPOSE: To evaluate prognostic factors affecting silicone tube intubation outcomes in Asian patients with lacrimal drainage system stenosis. METHODS: A retrospective review was conducted on the medical records of 822 patients (1,118 eyes) who had undergone silicone tube intubation to treat lacrimal drainage system stenosis between January 2011 and December 2012. Patients were divided into two groups: a success group and a failure group. Success was defined as the disappearance of epiphora symptoms, normalization of tear meniscus height, and the easy passage of fluid without resistance on the postoperative syringing test. Patient and ocular parameters were compared between the success and failure groups. RESULTS: A total of 994 eyes of 727 patients were included in analyses. Patients had a mean follow-up period of 34.11 ± 18.70 weeks. Silicone tube intubation was successful in 67.2% of participants. Significant differences between the success and failure groups were found for age (p < 0.001), history of ipsilateral facial palsy (p = 0.028), follow-up period (p < 0.001), and degree of passage on the preoperative syringing test (p = 0.001). Only age (p < 0.001) and degree of passage on the preoperative syringing test (p = 0.002) remained significantly associated with silicone tube intubation success in multivariate analysis. CONCLUSIONS: Age was negatively associated with silicone tube intubation success in patients with lacrimal drainage system stenosis. The success rate was higher in patients who showed easy passage of fluid without resistance on the preoperative syringing test. These factors should be considered by surgeons planning silicone tube intubation in patients with lacrimal drainage system stenosis.

Three-dimensional assessment of condylar surface changes and remodeling after orthognathic surgery

PURPOSE: This study was performed to evaluate condylar surface changes and remodeling after orthognathic surgery using three-dimensional computed tomography (3D CT) imaging, including comparisons between the right and left sides and between the sexes. MATERIALS AND METHODS: Forty patients (20 males and 20 females) who underwent multi-detector CT examinations before and after surgery were selected. Three-dimensional images comprising thousands of points on the condylar surface were obtained before and after surgery. For the quantitative assessment of condylar surface changes, point-to-point (preoperative-to-postoperative) distances were calculated using D processing software. These point-to-point distances were converted to a color map. In order to evaluate the types of condylar remodeling, the condylar head was divided into six areas (anteromedial, anteromiddle, anterolateral, posteromedial, posteromiddle, and posterolateral areas) and each area was classified into three types of condylar remodeling (bone formation, no change, and bone resorption) based on the color map. Additionally, comparative analyses were performed between the right and left sides and according to sex. RESULTS: The mean of the average point-to-point distances on condylar surface was 0.11±0.03 mm. Bone resorption occurred more frequently than other types of condylar remodeling, especially in the lateral areas. However, bone formation in the anteromedial area was particularly prominent. No significant difference was found between the right and left condyles, but condylar surface changes in males were significantly larger than in females. CONCLUSION: This study revealed that condylar remodeling exhibited a tendency towards bone resorption, especially in the lateral areas. Condylar surface changes occurred, but were small.

Primary Squamous Cell Carcinoma of the Orbit

PURPOSE: Normal squamous cells do not exist in the orbit. Therefore squamous cell carcinoma of the orbit is rare and usually arises as a secondary tumor from distant metastasis or local invasion. The authors herein describe the first case of primary squamous cell carcinoma of the orbit in Korea. CASE SUMMARY: A 74-year-old female presented with a 2-month history of left upper eyelid swelling and ocular pain. On physical examination, a round, firm, fixed and tender mass was palpable in the superomedial side of the left orbit. Magnetic resonance imaging (MRI) showed 21 mm x 15 mm x 20 mm-sized irregular soft tissue mass with indistinct margin and peripheral enhancement in the superomedial portion of the left orbit, and incisional biopsy of the mass was performed. Histopathological examination showed clusters of squamous cells with polymorphic nuclei and interspersed keratin pearls, consistent with findings of well-differentiated squamous cell carcinoma. Despite extensive systemic work-up, there was no sign of extraorbital malignancy. The patient received left exenteration and adjuvant radiation therapy. Ten months after enucleation, a 12 mm x 14 mm sized firm mass developed on the left forehead, and excisional biopsy and frontalis rotational flap reconstruction were performed. Histopathological examination of the mass was consistent with well-differentiated squamous cell carcinoma. The patient remained alive 17 months after diagnosis without evidence of local recurrence or distant metastasis. CONCLUSIONS: Primary squamous cell carcinoma should be considered in the differential diagnosis of acutely progressing tumors of the orbit.

Causes and Treatments of Entropion and Ectropion in Adults

PURPOSE: To evaluate the causes and treatments of entropion and ectropion in adults. METHODS: A retrospective review was performed of 397 patients (490 eyes) with entropion and 109 patients (138 eyes) with ectropion who underwent corrective surgery at Kim's Eye Hospital from January 2009 to December 2012. RESULTS: The surgical correction of entropion was 3.5 times greater than that of ectropion. The causes of entropion were classified as senile (98.4%), cicatricial (1.4%) and spastic (0.2%). The causes of ectropion were classified as cicatricial (60.1%), paralytic (23.2%) and senile (16.7%). CONCLUSIONS: The main causes of entropion and ectropion were senile and cicatricial, respectively. Specifically, senile entropion was more common than senile ectropion, which is considered to be related to the lid anatomy of Asian patients.

Bilateral postoperative maxillary cysts after orthognathic surgery: A case report

Postoperative maxillary cysts are locally aggressive lesions, usually developing as delayed complications many years after radical antral surgery. This report describes a case of bilateral postoperative maxillary cysts following orthognathic surgery performed approximately 21 years previously. The patient complained of stinging pain on her right cheek. Radiographic examination revealed low-attenuation lesions on both maxillary sinuses with discontinuously corticated margins without distinct expansion or bone destruction. The cysts were enucleated with the removal of metal plates and screws for pain relief. Histopathological examination confirmed the diagnosis of postoperative maxillary cysts lined by ciliated, pseudostratified columnar cells. The patient has remained asymptomatic thus far, and there was no evidence of local recurrence at 21 months of postoperative follow-up.

Eccrine Ductal Carcinoma Arising in the Eyelid

PURPOSE: Eccrine ductal carcinoma is an extremely rare tumor that arises in the eccrine sweat glands. The authors of the present study describe a case of an eyelid mass diagnosed as eccrine ductal carcinoma. CASE SUMMARY: A 74-year-old woman visited our institute with a 3-month history of a mass in the left medial canthus. The lesion appeared as a solitary nodule with central ulceration. A magnetic resonance imaging (MRI) of the orbit showed a relatively well enhanced 0.8 cm x 0.8 cm-sized ovoid soft tissue mass. A mass excision was performed under frozen section control. The tumor was completely excised with margin clearance and medial canthal reconstruction was performed. Histopathological examination revealed a tumor composed of numerous duct-like structures lined with pleomorphic cuboidal epithelium that was diagnosed as eccrine ductal carcinoma of the eyelid. CONCLUSIONS: This is the first description of eccrine ductal carcinoma in a patient in Korea. The possibility of the eccrine ductal carcinoma should be considered in the differential diagnosis in an elderly patient with an eyelid mass.

Ankyloblepharon Filiforme Adnatum : a Case Report

PURPOSE: To report a case of ankyloblepharon filiforme adnatum in a newborn male. CASE SUMMARY: A 4-day-old male was referred for fused right eyelids with unremarkable other pediatric examinations. Ocular examination under general anesthesia revealed partial fusion of his right upper and lower eyelids by a 4 mm-wide band of tissue which arose from the skin of the upper and lower eyelids. The adhesion was separated by sharp scissors and no other ocular abnormalities were revealed. CONCLUSIONS: Ankyloblepharon filiforme adnatum is a rare congenital malformation. In this case, the band of tissue connecting the upper and lower eyelids arose not from the eyelid margin but from the eyelid skin, which is even rarer, thus supporting the theory that this condition is due to the fusion of eyelids at abnormal positions, and not due to problems during the separation of eyelids.

Dacryocystographic Findings in Unilateral Epiphora with Patent Lacrimal Drainage System

PURPOSE: To evaluate the morphologic change in the lacrimal drainage system using dacryocystography in patients with unilateral epiphora with patent lacrimal drainage system. METHODS: Clinical records of patients referred to our clinic for epiphora between October 2007 and August 2011 were reviewed. The study group included 38 patients who had symptoms of unilateral epiphora with patent lacrimal drainage system. The studied patients included 10 males and 28 females with ages varying between 24 and 72 years. RESULTS: Abnormal dacryocystographic findings in the tearing eye were 78.9% and abnormal dacryocystographic findings in the asymptomatic eye were 47.4%. Common abnormal findings included distal nasolacrimal duct stenosis, distal nasolacrimal duct dilatation and nasolacrimal sac dilatation. CONCLUSIONS: In many cases, morphologic change in the lacrimal drainage system was observed in patients with unilateral epiphora with patent lacrimal drainage system. Dacryocystographic findings may contribute in devising a treatment plan for these patients.

A Novel Decorin Gene Mutation in Congenital Hereditary Stromal Dystrophy: A Korean Family

A 43-year-old man developed decreased vision in the right eye that had persisted for seven years. Under slit lamp examination, corneal clouding was noted with normal endothelium and ocular structure. From the clinical evidence, we suspected that the patient had congenital hereditary stromal dystrophy (CHSD). He and his family underwent a genetic analysis. Penetrating keratoplasty was conducted, and the corneal button was investigated for histopathologic confirmation via both light and electron microscopy. The histopathologic results revealed mildly loosened stromal structures, which exhibited an almost normal arrangement and differed slightly from the previous findings of CHSD cases. With regard to the genetic aspects, the patient and his mother harbored a novel point mutation of the decorin gene. This genetic mutation is also distinct from previously described deletion mutations of the decorin gene. This case involved delayed penetration of mild clinical symptoms with the histological feature of a loosened fiber arrangement in the corneal stroma. We concluded that this condition was a mild form of CHSD. However, from another perspective, this case could be considered as "decorin gene-associated corneal dystrophy," which is distinct from CHSD. Further evaluation will be required for appropriate clinical, histopathologic and genetic approaches for such cases.

Predictable Factors of Postoperative Pain Following LASEK

PURPOSE: To determine predictable factors of postoperative pain and cut-off values following LASEK eye surgery. METHODS: Thirty-three eyes of 17 patients who underwent LASEK from May to December 2008 were reviewed. For evaluation of predictive factors, patients' anxiety level was converted to APAIS, HADS, STAI, and VAS preoperatively. Substance P and prostaglandin E2 levels in tears, blood pressure, heart rate, and history of any previous surgery were determined before the procedure. Thirty minutes and 1 day after LASEK, the subjective degree of pain was scored. RESULTS: Patients with high Amsterdam preoperative anxiety scale (APAIS) and Visual analogue scale (VAS) scores showed more postoperative pain (p=0.04, p<0.001). Higher substance P and prostaglandin E2 levels were significantly related with more severe pain after LASEK (p<0.001, p<0.001). Postoperative pain increased significantly, according to cut-off values (p<0.05), APAIS and VAS scores greater than 6, substance P greater than 631.84 pg/ml, and prostaglandin E2 greater than 783.90 pg/ml. CONCLUSIONS: The level of pain after LASEK surgery varies individually, and many factors, including physical and psychological variances, can affect the pain. With higher APAIS/VAS scores and higher concentrations of substance P, prostaglandin E2 portends more severe pain following LASEK.