Orbital Implant Infection after Drilling Procedure

PURPOSE: To report the severity of orbital implant infection related to a drilling procedure and to provide a foundation for reevaluating this procedure. METHODS: We investigated retrospectively 17 patients who were suspected of orbital implant infection and whose infected implants were ultimately removed. In these patients, increased mucopurulent eye discharge and implant exposure after the drilling procedure were observed. We attempted to treat them with topical and systemic antibiotics, but the discharge and implant exposure did not improve. RESULTS: Of the 17 removed implants, 13 were hydroxyapatite and 4 were Medpor(R). The pegs used were plastic pegs in 12 cases and titanium pegs in 5 cases. The average duration from the first orbital implant insertion to drilling was 10.2+/-5.3 months. The average duration from drilling to severe infection symptoms was 37.0+/-30.0 months. The average duration from the onset of symptoms to implant removal was 12.9+/-12.6 months. The mean follow-up period after final surgery was 15.4 months. In most cases, the deep portions of the removed implants were fragile, malodorous, and filled with pus. Acute and chronic inflammatory cell infiltrations were observed in the pathological examinations, and H. influenzae, S. aureus, S. viridans were identified. They did not receive any drilling procedure thereafter and no infection or inflammatory sign was subsequently observed. CONCLUSIONS: Drilling and pegging can cause unexpected, severe complications such as orbital implant infection, in which the infected implant has to be removed to be cured. Therefore, before performing a drilling procedure doctors should carefully consider the patient's preferences and urgent needs.

Anophthalmic Conjunctival Sac Reconstruction using Acellular Dermal Allograft

PURPOSE: To investigate the clinical results and safety of the acellular dermal allograft (SureDerm(R), Hans Biomed co., Korea) as a new spacer graft in anophthalmic socket contracture. METHODS: We grafted SureDerm(R) as the replacing spacer in 8 patients for the treatment of anophthalmic socket contracture. Under local anesthesia, SureDerm(R) was sutured at the levator aponeurosis and upper margin of the tarsus using 6-0 Vicryl in the upper lid. In the lower lid, SureDerm(R) was sutured at the tarsal conjunctiva and lower margin of the incised conjunctiva. The patients were followed-up individually for 6 to 15 months. RESULTS Surgical results in all 8 eyelids (6 lower lids, 2 upper lids) were satisfactory. The grafted SureDerm(R) survived in all patients with little contracture. There were no other complications such as infection, rejection, or exposure. CONCLUSIONS: We consider SureDerm(R) a good replacing spacer material for the treatment of anophthalmic socket contracture.

A Case of Orbital Abscess Secondary to Dacryocystitis

PURPOSE: We report a case of orbital abscess secondary to acute dacryocystitis in which the patient had been cared for chronic dacryocystitis. METHODS: A 59-year-old woman presented to our clinic with a history of chronic sinusitis from childhood and right chronic dacryocystitis treated for 6 years. She had sufferred from influenza 2 weeks previously and complained of painful lid swelling, limitation of ocular movement, exophthalmos, chemosis, and decreased vision of the right eye for 2 weeks. An orbital CT scan was taken and bacterial culture and sensitivity tests were done from the discharge. RESULTS: CT scan showed inflammation and abscess formation around the right nasolacrimal duct orifice which was swollen and widened. Some of the inflammation tissues extended into the retrobulbar portion. Streptococcus pyogenous was cultured. Lid swelling, pain, exophthalmos, and visual acuity improved after external dacryocystorhinostomy, and surgical drainage. CONCLUSIONS: We should be careful in a case of acute dacryocystitis underlying chronic dacryocystitis as it easily causes complications, and in such a case early surgical management as well as antibiotics therapy is more effective.

A Korean Case of Cornelia de Lange Syndrome

PURPOSE: Cornelia de Lange syndrome is a rare disease showing characteristic facial appearance, developmental delay, growth retardation, low birth weight, skeletal formation anomaly, hirsutism and various ophthalmologic problems. METHODS: We experienced a case of an 18-year-old female with Cornelia de Lange syndrome showing superficial keratitis with entropion, ptosis, high myopia, lacrimal cutaneous fistula and characteristic facial appearance. She was born with low birth weight, operated for cleft palate and diagnosed with ventricular septal defect. In addition, she showed psychological lag and developmental impairment. RESULTS: We performed entropion correction surgery, administered medical therapy for superficial keratitis and prescribed glasses for her myopia. CONCLUSIONS: This is the first case report on the successful correction of entropion with Cornelia de Lange syndrome in Korea.

A Case of Nasal Endoscopic Treatment for Paranasal Mucocele

PURPOSE: We report a case of sphenoid and ethmoid mucocele causing orbital apex syndrome, which was successfully treated with drainage under nasal endoscopy. METHODS: A 82-year-old female visited the hospital complaining of decreased visual acuity in her left eye for 15days. Visual acuity of the left eye was hand motion . She also complained of left ocular pain and headache. In ophthalmologic examination, exophthalmos, mild ptosis, extraocular muscle movement limitation and RAPD (relative afferent pupillary defect) of the left eye were found. Orbital CT showed a 3.3 X 2.9 X 4.1 cm sized well-demarcated cystic lesion involving the left sphenoid sinus, left ethmoid sinus, and posterior portion of the right ethmoid sinus. The ethmoid air cell was remodeled by this cystic mass. The medial wall of the left orbit was protruded outward. So, the medial rectus muscle and optic nerve in the left orbit were compressed. We found a bulging yellowish cystic mass supero-posterior to the middle turbinate under nasal endoscopy. We performed incision and drainage under nasal endoscopy. RESULTS: At post-operative 2days, orbit CT showed the removed large mucocele in the sphenoid and ethmoid sinuses. At post-operative 2weeks, corrected visual acuity of the left eye was 0.6. There was no exophthalmos, ptosis, or extraocular muscle movement limitation. CONCLUSIONS: Endoscopic surgery in the treatment of paranasal mucocele can be performed during a short time under local anesthesia and anatomical change of the paranasal sinus can be minimized. We therefore suggest that drainage through nasal endoscopy is effective method in the treatment of paranasal sinus mucocele.

Result of Partial Nasolacrimal Duct Obstruction After Silicone Tube Intubation

PURPOSE: In a preliminary series of 36 eyes with partial nasolacrimal duct obstruction, the types of dacryoscintigraphy result were classified and the results of silicone tube intubation were analysed. METHODS: The results of dacryoscintigraphy, performed in 36 eyes of 29 patients with partial nasolacrimal duct obstruction, were classified into the following 3 types: pre-lacrimal sac type, proximal nasolacrimal duct type and distal nasolacrimal duct type. Punctoplasty accompanied by silicone tube intubation was conducted selectively. RESULTS: In dacryoscintigraphy, symptoms improved in 6 eyes among 6 in distal nasolacrimal duct type (100%), 14 eyes among 18 in proximal nasolacrimal duct type (77.8%) and 8 eyes among 12 in pre-lacrimal sac type (66.7%). CONCLUSIONS: We conclude that dacryoscintigraphy predicts the results of silicone tube intubation. Furthermore, silicone tube intubation was effective in proximal nasolacrimal duct type and distal nasolacrimal duct type, but less effective in pre-lacrimal sac type of partial nasolacrimal duct obstruction.

The Effect of Revision Endoscopic Dacryorhinostomy (EDCR)

PURPOSE: The purpose of this study was to evaluate the effects of revision endoscopic endonasal dacryocystorhinostomy (EDCR) and the causes of postoperative failure after primary endoscopic DCR in patients with nasolacrimal duct obstruction. METHODS: This prospective study enrolled 32 patients (32 eyes) who had undergone revision of endoscopic DCR with the diagnosis of obstruction of nasolacrimal system after primary EDCR between October 1997 and February 2003. RESULTS: The most common cause of revision operation after primary EDCR was granuloma, followed by membranous obstruction and common canalicular obstruction. The success rate of the cases with granuloma was 69.2%, and that with membranous obstruction was 100%. CONCLUSIONS: Revision EDCR success rate can be improved by reducing the frequency of granuloma as this was the most common factor for revision EDCR. The effect of antimetabolites in revision EDCR success rate is to be further evaluated.

The Effect of Vascular Endothelial Growth Factor on Vascularization in Porous Polyethylene Orbital Implant (Medpor(R))

PURPOSE: We investigated the effect of VEGF usage and the method of surgery on the vascularization rate of the porous orbital implant (Medpor(R)). METHODS: Thirty six Newzealand white rabbits were randomized into 2 groups according to the method of surgery (evisceration and intrascleral implantation and evisceration and retroscleral implantation). Each group was subdivided into two groups, a group treated with VEGF, and the other without VEGF treatment. The degree of vascularization was observed in the four groups at 1, 2, 4 weeks by using cryofilm transfer kit (Finetec, Tokyo, Japan). The implant was sliced at the equator with cryomicrotome and stained with Hematoxylin and Eosin, Masson's trichrome and reticulin. The sample was observed to assay the degree of fibrovascular ingrowth with light microscope. RESULTS: The group in which VEGF was used and the implant was inserted retrosclerally (n=9) showed significantly higher vascularization rate than the other three groups (P0.05). CONCLUSIONS: After using VEGF or inserting the implant retrosclerally, the vascularization of the implant was significantly incresed.

A Survey of Post-Operative Satisfaction in Patients with Canalicular Obstruction after Jones Tube Intubation

PURPOSE: This study was devised to evaluate the post-operative satisfaction and daily life behavior in the patient who underwent Jone tube intubation. METHODS: 60 patients who underwent Jones tube intubation replied to the questionaire consisted of twenty questions. The questionare consisted of six groups: Basic statistical informations, past medical history, post operative satisfaction, post operative complications, questions about anesthesia, patients compliance. RESULTS: 28 (46.7%) patients were satisfied with outcomes of Jones tube intubation. 9 (15.0%) patients replied acceptable, and 23 (38.3%) patients were dissatisfied. Age, sex were not significantly associated with the post operative satisfaction (P-value>0.05). Air blowing in the eye was the most frequent complications (41.6%) and other concerning ocular symptoms are regurgitation of nasal discharge (35.0%), persistent tearing (35.0%), fogging of eyeglasses (18.3%) and etc. 23 patients (46.0%) refused to receive bilateral surgery because of post operative complications, old age, economic problems. CONCLUSIONS: Post operative satisfaction after Jones tube intubation is not associated with its functional success rate due to numerous postoperative complications.

A Case of Ocular Sparganosis in Korea

PURPOSE: Ocular sparganosis has not been reported in Korea and 5 cases have been reported sporadically worldwide. Among these, 2 cases were found under the conjunctiva. We reported the first Korean case of ocular sparganosis manifesting as a subconjunctival mass. CASE: A 29-year-old man was presented to remove sunconjunctival mass in his left eye for cosmetic purpose. His ocular findings were normal except 0.5 x 0.5 mm sized subconjunctival mass. The surgically excised mass was suspected to have a parasite grossly. Sparganum was identified under microscopic examination after hematoxylin-eosin staining. CONCLUSIONS: The morphologic state of mumified parasite under microscope was plerocercoid phase of spargaum. His ocular movement and visual acuity remained normal after excision of the mass.

The Capsulopalpebral Fascia Repair for Senile Entropion

PURPOSE: We report that simple capsulopalpebral fascia (CPF) repairs were effective when patients diagnosed as senile entropion had the disinsertion lines of the CPF on everted lower conjunctivas (demarcation line). METHODS: Twenty patients (27 eyes) who had demarcation lines and showed no severe horizontal lid laxity were operated for senile entropion during the period March 1, 1996 to July 30, 2001. After subciliary skin incision, the disinserted CPF was identified and repaired by reattaching the superior edge of the CPF to the inferior edge of the lower tarsus. RESULTS: This procedure was performed on 27 eyes of 20 patients (women 11, men 9, average age 68.6 years). We followed up the patients from 3 to 30 months after surgeries (average 7.8 months). Two patients showed complications, one was conjunctival prolapse and the other was recurrence of entropion. CONCLUSIONS: Simple capsulopalpebral fascia (CPF) repairs gave good results in patients with senile entropion who had disinsertion lines of the CPF on everted lower conjunctiva (demarcation line) without severe horizontal lid laxity. Moreover this procedure had shorter operation and recovery times compared with other combined surgeries.

Blepharoptosis after Ocular Surgery and Aponeurosis Repair

PURPOSE: We retrospectively investigated the etiological factors and evaluated the surgical results of aponeurosis repair for blepharoptosis after ocular surgery. METHODS: We investigated the types of ocular surgery, anesthesia, and other etiological factors related with postoperative blepharoptosis for 20 eyes of 20 patients and evaluated MRD1 (Margin Reflex Distance 1), IPF (Interpalpebral Fissure) and levator function preoperatively and after levator aponeurosis repair surgery. RESULTS: Types of previous ocular surgery were cataract surgery (15 eyes), penetrating keratoplasty (2 eyes), retinal surgery (2 eyes) and panretinal photocoagulation using gonioscopic lens (1 eyes). 18 eyes had received ocular surgery with rigid type eye speculum and 18 eyes with retrobulbar anesthesia. Mean levator function measured preoperatively was good (12 mm). We found dehiscence or detachment of levator aponeurosis in surgical field and performed aponeurosis repair or advancement with correction 2 mm more than MRD1 of normal contralateral eye. Mean IPF and MRD1 were improved 6 months after aponeurosis repair (from 4 mm, -0.5 mm to 7 mm, 2 mm respectively). CONCLUSIONS: This study indicates that blepharoptosis after ocular surgery can be induced by rigid type eye speculum, local anesthesia and various causes. Surgical findings of blepharoptosis after ocular surgery were dehiscence or detachment of levator aponeurosis and could be corrected by aponeurosis repair effectively.

Success Rate of Endonasal Dacryocystorhinostomy Based on the Location of the Lacrimal Sac

PURPOSE: We studied whether the illumination had an influence on the identification of the location of the lacrimal sac and the success rate of endoscopic endonasal dacryocystorhinostomy (DCR). METHODS: Endoscopic endonasal DCR was performed on 85 eyes of 80 patients who had obstruction of nasolacrimal system without illumination. RESULTS: In all patients, identification of the location of the lacrimal sac by detecting the probe tip or the lacrimo-maxillary suture line was accomplished, without illumination. Final success rate was 87.1% in illuminator non-using group. CONCLUSIONS: We considered that endoscopic endonasal DCR without illumination, in the knowledge of lacrimal sac, ethmoid anatomy, and anatomical variations, was a non-invasive, efficient, and satisfactory method.

The transconjunctival approach to a large retrobulbar cavernous hemangioma of the orbit

Cavernous hemangiomas are one of the most common benign tumors of the orbit in adults. We report a case of a longstanding retrobulbar hemangioma that was removed successfully through a temporal transconjunctival approach combined with lateral canthotomy. A 45-year-old female patient, with a 15-year history of slowly progressive proptosis and decreased visual acuity of the left eye, had a corrected visual acuity of finger count at 50 cm OS, compared with 1.0 OD. Exophthalmometry by the Nagle's method measured 15 mm OD by 26 mm OS. Magnetic resonance imaging (MRI) revealed a well-encapsulated retrobulbar main mass, 2.3 x 3.0 x 3.7 cm in size along with multiple small satellite nodules that were displacing the optic nerve and globe superiorly. The tumors were removed through a superotemporal transconjunctival approach combined with lateral canthotomy. Pathological examination revealed an intraorbital cavernous hemangioma. The patient was free of visible scars, proptosis and any other noticeable complications at her last follow-up, 6 months after surgery.

Intranasal Endoscopic Diagnosis and Treatment in Congenital Nasolacrimal Duct Obstruction

This study is to demonstrate the effectiveness of intranasal endoscopy during silicone tube insertion in children with congenital nasolacrimal duct obstruction. Participants were 10 children with symptoms of epiphora since birth. They underwent silicone tube insertion during the period of July 1998 to November 1999. Three were female and seven male. Mean age was 25.8 months, ranging from 15 to 44 months. Probing had been failed in five of them, once in two children and twice in the other three. Silicone tube insertion was done after identifying the cause of probing failure by observing the probe tip with intranasal endoscopy. The cause of tearing confirmed by intranasal endoscopic examination were mucosal obstruction in 5 cases, submucosal passing of the probe in 4 cases and obstruction due to pus collection in one case. In 4 cases in which the probe had passed into submucosal space, probing succeeded in three cases by placing the probe tip medially(nasal direction). There was accompanying abnormal bony structure in the other one case and we had to bend the probe tip with ethmoid forceps into nasal cavity to form the lacrimal pathway. When probing fails or is difficult to do due to poor cooperation, identifying the cause of failure with intranasal endoscopic examination and inserting silicone tube under direct visualization can minimize intranasal trauma and will lead to good outcome.

Usefulness of 99m Tc-MDP Bone Scintigraphy for Assessing Vascular Ingrowth on Hydrox yapatite Ocular Implant

This study was to evaluate the clinical usefulness of 99m Tc-MDP bone scintigraphy for assessing vascular ingrowth into the ocular implants after enucleation and evisceration. Twenty four patients(M:F=7:17, mean age:36), with a coralline hydroxyapatite after uncomplicated enucleation or evisceration surgery were studied. Uptake ratio was also calculated by measuring the implants activity(H)and contralateral orbit activity(N). Grading score and uptake ratio were compared with clinical outcome of vascularization. Additionally, we also analyzed the vascularization status as time lapse between primary surgery and scintigraphic study and surgical methods. The degree of grade and uptake ratio were inversely correlated with vascular ingrowth. Higher than grade 2 or greater than 1.56 in H/N ratio seemed to be an indicator for better prognosis. 99m Tc-MDP bone scintigraphy can be a useful method to evaluate the vascularized status of implants. Adequate time for 99m Tc-MDP bone scintigraphy after enucleation and evisceration was 11~20 weeks.

A Case of Fibrous Histiocytoma in Orbit

Fibrous histiocytoma is a slow-growing mesenchymal tumor that most commonly occurs in soft tissue and retroperitoneum, with an occasional occurrence in the orbit. This mesenchymal tumor should be included in the differential diagnosis of orbital mass in adults because this tumor is radioresistant and prone to recurrences and malignant potential if incompletely excised. So complete excision is the treatment of choice. A case report of a healthy 27-year-old woman with a gradually increasing, non tender superonasal mass and proptosis in the left orbit. She also developed diplopia. CT scan and MRI showed a well-marginated and encapsulated homo-geneous 2 x3 cmsized mass in the superonasal portion of the left orbit. The tumor was totally excised under the impression of carvenous hemangioma. In H-E stain, tumor cell revealed a marked cellularity, storiform arrangement of ovoid to spindle cells but there was little nuclear polymorphism, atypism and absent mitosis. Results of immunohistochemical study showed positive cytoplasmic immunoreactivity to alpha-1-ntitrypsin antibody but negative to S-100 protein, smooth muscle actin, Neuron specific enolase. Masson-Trichrome stain showed positive. The final diagnosis of a benign fibrous histiocytoma invading the orbit was confirmed by histopathological examination. There was no recurrence for more than 14 months after complete surgical excision. We present the above case with a brief review of literature.

Subconjunctival Orbital Fat Prolapse

Subconjuctival orbital fat prolapse is a disease, which can be diagnosed by clinical manifestations and treated with simple procedure. Intraconal fat prolapses through weakened tenon and protrudes into subconjunctival space. The mass shows convex anterior margin and places at superotemoral region. The mass shrinks when indented and enlarges by putting pressure on the globe. It is frequently seen on males over 60 years old. It usually occurs bilaterally, and does not seem to be in association with obesity. Computer tomography and magnetic resonance image of the orbit show the mass contiguous to intraconal fat. Partial excision with careful hemostasis is sufficient for treatment.

A Case of Myoepithelial Carcinoma Arising in the Lacrimal Gland

The vast majority of epithelial neoplasms of the lacrimal gland are pleomorphic adenomas, which comprise slightly more than 50%of epithelial tumors of this anatomic location.Other types of primary epithelial neoplasm of the lacrimal gland include adenoid cystic carcinoma, adenocarcinoma, mucoepidermoid carcinoma, and malignant mixoid tumors. Myoepitheliomas are rare tumors, most frequently reported in the salivary glands. A 61-year-old woman had painless proptosis of the right eye for 5 months. The orbit CT scan showed a lacrimal tumor involving adjacent frontoparietal bone.Histopathologically it was proved as myoepithelial carcinoma of the lacrimal gland.The patient underwent a right orbital exenteration and radiation therapy.We report this unusual case with literature review.

The Relation between Nasal Cavity Size and Success Rate in Endonasal Dacryocystorhinostomy

We studied whether the structure and size of nasal cavity around osteotomy site had an influence on the success rate of endoscopic endonasal dacryocystorhinostomy [DCR]. Endoscopic endonasal DCR was performed on 80 eyes of 72 patients who had obstruction of nasolacrimal system.We graded nasal cavity around osteotomy site according to the diameter of drill which could pass[grade I:7 mmdrill can pass, grade II:5 mmdrill can pass, grade III:3 mmdrill can pass, grade IV:3 mmdrill cannot pass].The primary success rate is 70%[56 eyes] and final success rate is 81.3%[65 eyes]after secondary operation was perfomed on 14 eyes of 24 failed eyes in primary operation.Primary success rate was 78.8%[41/52 eyes]and 53.6%[15/28 eyes]in grade I-II and grade III-IV, respectively.Final success rate was 86.5%[45/52 eyes]and 71.4%[20/28 eyes]in grade I-II and grade III-IV, respectively.The difference of success rates according to nasal cavity size is stastically significant[P<0.05] and the relation of nasal septum deviation to small nasal cavity is stastically significant[P<0.05].We found canalicular obstruciton in 5 of 14 eyes during secondary operation which was not found in primary speration, and it was suspected to have been caused by mechanical trauma to canalicular system during operation.