Clinical Implication of Dacryoendoscopy in the Patients with Tearing: A Systematic Review

Purpose@#A systematic review of the literature on diagnostic and therapeutic indications, techniques, and complications of dacryoendoscopy (DE) was performed. @*Methods@#The authors performed a PubMed search of articles published in English on DE. Data were collected and classified according to the categories of the disease. The clinical outcomes and limitations were particularly analyzed. @*Results@#The lacrimal drainage system from the canaliculus to the inferior meatus could be examined based on the specific anatomical features by DE. The canalicular mucosa is smooth and brightly colored, the lacrimal sac shows covering mucosa with good vascularization and the nasolacrimal duct is lined with bright tubular mucosal folds. DE allows direct visualization of the detailed internal condition of the lacrimal disorders, to directly diagnose the site of obstruction with accuracy and address the causes and recanalize the lacrimal drainage system using assisted micro lacrimal surgical instruments in the tearing patients. @*Conclusions@#Better visualization of the lacrimal canal with DE improves the understanding of physiology and precise identification of the obstructing lesions, both of which are the key to a comprehensive management for the tearing patients.

Clinical Results of Punch Biopsy for Various Eyelid Disorders in the Office Setting

Purpose@#To introduce punch biopsy, which can be easily performed in an outpatient setting, and to evaluate its clinical usefulness. @*Methods@#A retrospective study was performed in 33 patients with atypical eyelid disorders who underwent punch biopsy. @*Results@#This study included 33 eyes (33 patients; male:female = 12:21) with a mean age of 57.27 ± 19.12 years. There were 19 (57.6%) right eye, 14 (42.4%) left eye, 15 (45.5%) upper eyelid, and 18 (54.5%) lower eyelid lesions. The biopsy approaches were percutaneous and transconjunctival in 24 (72.7%) and nine (27.3%) eyes, respectively. Benign and malignant lesions were found in 21 (63.6%) and 12 (36.4%) eyes, respectively. The benign lesions included chalazion (52.4%), acute and chronic inflammation (23.8%), acanthosis (4.8%), and ectopic cillia (4.8%), and were treated conservatively by intralesional steroid injections or incision and drainage. The malignant lesions included sebaceous carcinomas (33.3%), squamous cell carcinomas (25%), and basal cell carcinomas (16.7%), with various treatments, including surgical resections, chemotherapy, and radiation therapy. @*Conclusions@#Punch biopsy is a safe and quick procedure that can easily be performed in the office setting for patients who require a pathologic diagnosis for eyelid diseases, including malignancies. It may be useful for diagnosis and treatment planning.

Binocular Visual Rehabilitation in Paralytic Strabismus by Botulinum A Toxin Chemodenervation

Purpose@#To investigate the effect of botulinum A toxin (BTXA) chemodenervation in paralytic strabismus patients without surgical correction. @*Methods@#A retrospective chart review of 51 patients who were diagnosed as paralytic strabismus and underwent BTXA chemodenervation was performed. The patients were divided into four groups according to the cause of paralytic strabismus of vasculopathy, neoplasm, trauma, and idiopathic. They were also divided into two groups of early and late treatment according to the initiation time of BTXA chemodenervation after the onset of strabismus (3 months), and of the initial strabismus type of exotropia and esotropia. We investigated the changes of angle of deviation and diplopia after BTXA chemodenervation. @*Results@#The average deviation of angles decreased by 25.2 prism diopter (PD) (35.1 to 9.9 PD) in total patients, and the overall success rate was 64.7% (33 by 51), and the there was no statistically significant difference in success rate between each group divided by the cause of paralytic strabismus. According to the treatment timing, the deviation of the angle decreased by 28.0 PD (36.8 to 8.8 PD) in the early treatment group, and 21.3 PD (33.5 to 12.2 PD) in late treatment group at the time of the last postinjective follow-up. According to the initial strabismus type, the average angle of deviation decreased by 20.3 PD (35.6 to 15.3 PD) in exotropia group by cranial nerve 3 palsy, and 24.4 PD (32.5 to 8.1 PD) in esotropia by cranial nerve 6 palsy. @*Conclusions@#BTXA chemodenervation reduced the angle of deviation and the number of patients with diplopia regardless of the cause of paralytic strabismus. Early BTXA chemodenervation can be considered as the first treatment of choice in paralytic strabismus, especially in esotropia patients.

Diplopia after Isolated Inferior Orbital Wall Fracture According to the Computed Tomography Findings

Purpose@#To investigate the postoperative changes in diplopia and evaluate factors that affect diplopia after isolated inferior orbital wall fracture. @*Methods@#A retrospective study was conducted on 200 patients who underwent reconstruction surgery for isolated inferior orbital wall fracture between March 2001 and December 2020. Diplopia was categorized into peripheral, central, and full-degree types based on the history and binocular single vision. The natural course of diplopia was analyzed pre-operatively and at 1 day, 6 weeks, and 6 months postoperatively. We analyzed the orbital computed tomography images to determine fracture size (small, medium, or large), fracture site (anterior, middle, posterior, or mixed), extraocular muscle (EOM) size (swelling or deformity), EOM site (incarcerated or prolapsed), and EOM tenting. @*Results@#Diplopia was seen in 144 out of 200 patients (72.0%) before surgery; peripheral diplopia was seen in 57 patients (39.6%), central diplopia in 46 (24.3%), and full-degree diplopia in 20 (13.9%). Pre-operative diplopia differed according to the pre-operative limitation of range of motion (LOM) (p < 0.001) and EOM site (p = 0.022). Pre-operative diplopia type differed according to the LOM direction (p = 0.018) and EOM size (p = 0.020). Diplopia persisted in 33 patients (16.5%) 6 months after the surgery. Recovery was faster in patients with peripheral diplopia compared to those with central or full-degree diplopia. @*Conclusions@#The presence of diplopia was associated with the pre-operative LOM and EOM site but the type of diplopia was associated with LOM direction and EOM size. These factors can be used to predict the progression of diplopia in patients with isolated inferior orbital wall fracture.

Tube Position and Culture in the Nasal Cavities of Patients Treated with Silicone Tube Intubation

Purpose@#To evaluate the relationship between the position and direction of a silicone tube in the nasal cavity after silicone tube intubation and clinical features. @*Methods@#This study included 70 eyes of 52 patients who were diagnosed with nasolacrimal duct obstruction and had silicone intubation surgery. The position and direction of the silicone tube were compared after tube intubation and before extubation. An intranasal swap culture was performed before tube intubation, and the removed silicone tubes were cultured. @*Results@#The length of the silicone tube decreased from 8.7 ± 3.1 mm after intubation to 7.3 ± 3.1 mm before extubation, and the direction of the tube moved backward in the nasal cavity (p < 0.05). The bacterial culture rate changed from 94.3% before intubation to 75.7% before extubation. The most common Gram-positive bacteria (both preoperative and postoperative) was coagulase- negative Staphylococcus aureus. The most common Gram-negative bacteria were converted from Klebsiella aerogenes to Stenotrophomonas maltophilia. The fungal culture rate changed from 7.1% to 51.4%, and the culture rate increased when the silicone tube direction was moved backward (p < 0.05). The length and direction of the silicone tubes were not correlated with clinical symptoms or changes in eyelid height. @*Conclusions@#The length of the silicone tube in the nasal cavity decreased, and the tube tended to move in a posterior direction after silicone tube intubation. Considering the increase in the intra-nasal fungal culture rate, it is better to place the silicone tube in the anterior part of the nasal cavity from the inferior meatus. To clarify further the fungal infection and its clinical findings, a study of cultures with respect to location in the lacrimal system would be required.

Efficacy and Safety of Letibotulinum Toxin A for the Treatment of Essential Blepharospasm

PURPOSE: To evaluate the efficacy and safety of BOTULAX® in subjects with essential blepharospasm.METHODS: In this study, a total of 250 subjects with essential blepharospasm were enrolled at 15 investigational sites and a total of 220 subjects completed the study. The efficacy and safety were evaluated at weeks 4 and 16 after treatment compared with baseline. In total, 240 subjects were enrolled, treated with the investigational product, and evaluable for the primary efficacy assessment at week 4 after treatment; these subjects were included in the intention-to-treat (ITT) population. With the ITT set as the main efficacy set, efficacy assessment included Jankovic rating scale (JRS), functional disability score, investigator evaluation of global response and quality of life. Safety assessment including the incidence of adverse events was also performed.RESULTS: In terms of the primary efficacy endpoint (i.e., change in JRS total score at week 4 after treatment from baseline [ITT set]), mean change indicated a statistically significant reduction (p < 0.0001) and demonstrated the non-inferiority of the test drug to similar drugs. In terms of the secondary efficacy endpoints, mean change in JRS total score at week 16 after treatment and mean change in functional disability score at weeks 4 and 16 after treatment both exhibited a statistically significant reduction compared with baseline (p < 0.0001 for all). Among the 249 subjects treated with the investigational product in this study, 44 (17.67%) experienced 76 treatment emergent adverse events but no serious adverse events were observed.CONCLUSIONS: Based on the study results, BOTULAX® is considered to be an effective and safe treatment for essential blepharospasm.

Postoperative Stereopsis Changes in Various Types of Strabismus Patients Over 10 Years of Age

Purpose@#To evaluate the postoperative stereopsis changes in strabismus patients over 10 years of age after surgical correction. @*Methods@#We reviewed, retrospectively, the medical records of 193 patients (99 men and 94 women) who underwent strabismus surgery from March 2002 to August 2019 at our hospital. Patients were classified into an exotropia group, an esotropia group, or a combined strabismus group (having horizontal and vertical strabismus simultaneously), according to their strabismus type. These groups were further divided into three groups based on pre-operative stereopsis findings classified as poor (above 4,000 seconds [s] of arc), fair (between 4,000 to 100 s of arc), or good (below 100 s of arc). The stereopsis conditions before and after surgery were compared. @*Results@#Overall, the stereopsis of patients over 10 years of age who underwent surgery improved from 2.45 ± 0.69 logarcsec to 2.85 ± 0.58 logarcsec (p < 0.001) after surgery regardless of strabismus type. Stereopsis in exotropia patients was 2.33 ± 0.71 logarcsec before surgery and improved to 2.15 ± 0.56 logarcsec (p < 0.001) after surgery. Stereopsis in esotropia patients was 0.85 ± 0.58 logarcsec before surgery and 2.48 ± 0.11 logarcsec after surgery (p = 0.002). Stereopsis of combined strabismus patients was 2.44 ± 0.76 logarcsec before surgery versus 2.20 ± 0.54 logarcsec after surgery (p = 0.133). The degree of stereopsis improvement was highest for the esotropia, group followed by the combined strabismus, and exotropia groups. @*Conclusions@#Surgical correction of various types of strabismus may be helpful for binocular function in patients over 10 years of age.

Postoperative Stereopsis Changes in Various Types of Strabismus Patients Over 10 Years of Age

Purpose@#To evaluate the postoperative stereopsis changes in strabismus patients over 10 years of age after surgical correction. @*Methods@#We reviewed, retrospectively, the medical records of 193 patients (99 men and 94 women) who underwent strabismus surgery from March 2002 to August 2019 at our hospital. Patients were classified into an exotropia group, an esotropia group, or a combined strabismus group (having horizontal and vertical strabismus simultaneously), according to their strabismus type. These groups were further divided into three groups based on pre-operative stereopsis findings classified as poor (above 4,000 seconds [s] of arc), fair (between 4,000 to 100 s of arc), or good (below 100 s of arc). The stereopsis conditions before and after surgery were compared. @*Results@#Overall, the stereopsis of patients over 10 years of age who underwent surgery improved from 2.45 ± 0.69 logarcsec to 2.85 ± 0.58 logarcsec (p < 0.001) after surgery regardless of strabismus type. Stereopsis in exotropia patients was 2.33 ± 0.71 logarcsec before surgery and improved to 2.15 ± 0.56 logarcsec (p < 0.001) after surgery. Stereopsis in esotropia patients was 0.85 ± 0.58 logarcsec before surgery and 2.48 ± 0.11 logarcsec after surgery (p = 0.002). Stereopsis of combined strabismus patients was 2.44 ± 0.76 logarcsec before surgery versus 2.20 ± 0.54 logarcsec after surgery (p = 0.133). The degree of stereopsis improvement was highest for the esotropia, group followed by the combined strabismus, and exotropia groups. @*Conclusions@#Surgical correction of various types of strabismus may be helpful for binocular function in patients over 10 years of age.

Ophthalmologic Clinical Features of Facial Nerve Palsy Patients

PURPOSE: To understand the ophthalmic clinical features and outcomes of facial nerve palsy patients who were referred to an ophthalmic clinic for various conditions like Bell's palsy, trauma, and brain tumor. METHODS: A retrospective study was conducted of 34 eyes from 31 facial nerve palsy patients who visited a clinic between August 2007 and July 2017. The clinical signs, management, and prognosis were analyzed. RESULTS: The average disease period was 51.1 ± 20.6 months, and the average follow-up duration was 24.0 ± 37.5 months. The causes of facial palsy were as follows: Bell's palsy, 13 cases; trauma, six cases; brain tumor, five cases; and cerebrovascular disease, four cases. The clinical signs were as follows: lagophthalmos, 24 eyes; corneal epithelial defect, 20 eyes; conjunctival injection, 19 eyes; ptosis, 15 eyes; and tearing, 12 eyes. Paralytic strabismus was found in seven eyes of patients with another cranial nerve palsy (including the third, fifth, or sixth cranial nerve). Conservative treatments (like ophthalmic ointment or eyelid taping) were conducted along with invasive procedures (like levator resection, tarsorrhaphy, or botulinum neurotoxin type A injection) in 17 eyes (50.0%). Over 60% of the patients with symptomatic improvement were treated using invasive treatment. At the time of last following, signs had improved in 70.8% of patients with lagophthalmos, 90% with corneal epithelium defect, 58.3% with tearing, and 72.7% with ptosis. The rate of improvement for all signs was high in patients suffering from facial nerve palsy without combined cranial nerve palsy. CONCLUSIONS: The ophthalmic clinical features of facial nerve palsy were mainly corneal lesion and eyelid malposition, and their clinical course improved after invasive procedures. When palsy of the third, fifth, or sixty cranial nerve was involved, the prognosis and ophthalmic signs were worse than in cases of simple facial palsy. Understanding these differences will help the ophthalmologist take care of patients with facial nerve palsy.

Evaluation of Tear Film Lipid Layer Thickness Measurements Obtained Using an Ocular Surface Interferometer in Nasolacrimal Duct Obstruction Patients

PURPOSE: To compare the tear film lipid layer thickness (LLT) between patients with incomplete nasolacrimal duct obstruction (NLDO) and normal controls and to analyze the changes in tear film LLT and blinking pattern after silicone tube intubation in NLDO patients. METHODS: We reviewed the medical records of 68 eyes in 52 incomplete NLDO patients who underwent silicone tube intubation from January 2017 to July 2017. The LLT, blinking pattern, and Meibomian gland image were measured with the LipiView II ocular surface interferometer. The Meibomian gland drop-out ratio was measured using the polygon selection tool in the Image J program. Tear meniscus height, which is the other lacrimal indicator, was assessed with spectral-domain optical coherence tomography. RESULTS: Tear meniscus height was significantly decreased after silicone tube intubation (p < 0.01). Preoperative minimum, maximum, and average LLT values were 62.4 ± 24.0, 86.7 ± 17.9, and 71.7 ± 23.3 nm, respectively. Significant changes in the minimum, maximum, and average LLT (74.8 ± 23.6, 98.8 ± 11.0, and 91.6 ± 16.1 nm, respectively) were observed after silicone tube intubation (p < 0.001, p = 0.001, and p < 0.001). The partial blinking/total blinking ratio in 20 seconds and the Meibomian gland drop-out ratio showed no significant change after silicone tube intubation. CONCLUSIONS: Overall, the LLT was increased after silicone tube intubation. Silicone tube intubation may be helpful in maintaining LLT with a normalized of amount of tears.

Changes in Tear Meniscus Height Following Lower Blepharoplasty as Measured by Optical Coherence Tomography

PURPOSE: The lower eyelid serves important roles in tear distribution and drainage. The purpose of this study was to measure the tear meniscus height (TMH) with anterior segment optical coherence tomography after lower blepharoplasty. METHODS: A total of 52 eyes from 26 patients treated between July 2012 and June 2015 were included in the study. A transcutaneous or transconjunctival approach was performed, depending on whether (1) the supportive lower lid orbicularis oculi muscle was tightened, (2) the middle lamella was elongated, (3) minimal fat was removed or transpositioned, and (4) lateral canthal support was established. Marginal reflex distance 2 and marginal nose distance were analyzed with Image J software. TMH was measured with anterior segment optical coherence tomography. A paired t-test and Wilcoxon signed-rank test were used for statistical comparisons. RESULTS: Marginal reflex distance 2 decreased and marginal nose distance increased with both surgical techniques. TMH decreased from 337.3 ± 117.9 to 289.3 ± 69.1 µm (p = 0.024) in patients who had transcutaneous lower blepharoplasty, but increased from 186.5 ± 35.5 to 274.8 ± 58.3 µm (p = 0.000) in patients who had transconjunctival lower blepharoplasty. Medial and lateral TMHs decreased significantly from 228.8 ± 80.7 to 152.7 ± 42.1 µm (p = 0.008) in patients with transcutaneous lower blepharoplasty. TMH was significantly restored after lower blepharoplasty with either approach. CONCLUSIONS: Enhancing the lower eyelid position combined with orbicularis muscle tightening and lateral canthal support can normalize the TMH following lower eyelid blepharoplasty.

Clinical Efficacy of Lacrimal Endoscopy Assisted Silicone Tube Intubation in Patients with Nasolacrimal Duct Obstruction

PURPOSE: We evaluated the clinical efficacy of lacrimal endoscopy-assisted silicone tube intubation in patients with a nasolacrimal duct obstruction. METHODS: We conducted a retrospective chart review of 86 eyes of 67 patients who underwent lacrimal endoscopy (RUIDO fiberscope; Fibertechco, Tokyo, Japan)-assisted silicone tube intubation from December 2014 to March 2017. We compared clinical characteristics, irrigation test results, and dacryocystographic and lacrimal endoscopic findings, and analyzed factors related to surgical success. RESULTS: In total, 86 eyes of 67 patients underwent lacrimal endoscopy-assisted silicone tube intubation. The success rate was 87.2%. There was a significantly lower preoperative tear meniscus height (420.5 ± 198.1 µm vs. 639.0 ± 224.3 µm, p < 0.001). In the surgically successful group, narrowing was frequently observed (29.0% vs. 0%, p = 0.030). Dacryolith findings were associated with surgical failure (10% vs. 29%, p = 0.043). CONCLUSIONS: Lacrimal endoscopy-assisted silicone tube intubation is considered an effective and successful operative procedure and enables the observation of real-time findings inside the lacrimal drainage passage for the treatment of pathological lesions. Narrowing observed during lacrimal endoscopy indicated successful treatment as opposed to dacryolith findings, which were associated with a failed outcome.

IgG4-related Ophthalmic Disease Associated with Adult Xanthogranulomatous Disease

PURPOSE: To report a case of immunoglobulin G4 (IgG4)-related ophthalmic disease associated with adult xanthogranulomatous disease. CASE SUMMARY: A 38-year-old male with a history of cholecystectomy visited our clinic for bilateral periorbital swelling. Histopathology of the orbital biopsy showed diffuse infiltration of foamy histiocytes with Touton giant cells and lymphoid follicles, with a diagnosis of adult-onset xanthogranuloma. After excisional biopsy, he was treated with azathioprine and prednisolone. Four years after treatment, he again visited the clinic due to bilateral, yellowish eyelid masses. Serological examinations were all nonspecific findings, except for elevation of IgG and IgG4 levels. Magnetic resonance imaging showed bilateral symmetric soft tissue enlargement with slightly heterogeneous T1/T2 isosignal intensity, with contrast enhancement at the superolateral aspect of extraconal spaces. Excisional biopsy and blepharoplasty were performed. Immunohistochemical sections showed that the IgG4+/IgG plasma cell ratio was 10–20% and the IgG4 plasma cell count was 22/high power field (HPF). His past sections of 2013 from the pathology department were again stained and showed that the IgG4+/IgG plasma cell ratio was 40–50% and the IgG4 plasma cell count was 59/HPF. Thus, he was definitely diagnosed with IgG4-related ophthalmic disease. CONCLUSIONS: If there is recurrent eyelid swelling, IgG4-related ophthalmic disease should be considered as a differential diagnosis. And the patient with adult xanthogranulomatous disease can be diagnosed with IgG4-related ophthalmic disease.

Long-term Efficacy of Botulinum Neurotoxin-A Treatment for Essential Blepharospasm

PURPOSE: In the present study, we investigated the treatment efficacy and clinical outcomes of botulinum neurotoxin-A (BoNT-A) administered for longer than 5 years to patients with essential blepharospasm. METHODS: We retrospectively reviewed 19 patients (male : female = 8 : 11) diagnosed with essential blepharospasm between March 2006 and July 2016 who underwent BoNT-A injections for over 5 years and were followed. Efficacy of 297 injections of Botox (n = 162), Meditoxin (n = 75), Hugel-tox (n = 40), or Dysport (n = 20) was based on the symptom improvement score at the final injection (−1, worse; 0, same; 1, better). Injection dose (botox unit), duration of efficacy (months), and adverse events were also investigated. RESULTS: Based on product type, significant differences in patient age (59.3 ± 9.8 years), disease period (5.0 ± 5.4 years), number of botulinum neurotoxin injections before visiting our clinic (1.6 ± 2.6), and follow-up period (7.2 ± 1.6 years) were not observed. Treatment efficacy score and injection dose of repetitive injections were 0.1 ± 0.5 and 39.1 ± 4.0 units, respectively, and did not show significant differences with repeated injections. Duration of response was 5.9 ± 5.4 months, but this significantly decreased as the injections were repeated (p < 0.01). Among the 297 injections, adverse events occurred 12 times (4.0%) with no severe sequelae. CONCLUSIONS: In this study, we showed that repetitive, long-term BoNT-A injections are considered a stable and effective treatment for essential blepharospasm in terms of consistent injection dose and maintenance of treatment efficacy. However, the duration of long-term efficacy could be decreased in patients injected repetitively.

Infraorbital Nerve Hypesthesia after Inferior Orbital Wall Fracture and Reconstruction Surgery

PURPOSE: To report the incidence of infraorbital nerve hypesthesia after inferior orbital wall fracture and reconstruction surgery and analyze the duration and factors to influence the occurence of the infraorbital nerve hypesthesia. METHODS: From March, 2001 to March, 2016, the medical records of 171 patients with isolated orbital floor fracture reconstructed with porous polyethylene or titanium mesh was analyzed retrospectively. Injury mechanism, fracture type, time interval to surgery, fracture size, type and thickness of implant were analyzed. Orbit computed tomography scan was performed at preoperative and postoperative 6 weeks. RESULTS: Mean age was 30.4 years (male:female = 130:41). The mean time interval to surgery was 9.5 days. Incidence of infraorbital hypesthesia was 9.9% preoperatively, 38% in a week of surgery, 13.5% in 6 weeks and 5.8% in 6 months. Infraorbital hypesthesia lasts 20.5 weeks and the length of infraorbital canal was the only risk factor of persistent infraorbital hypesthesia. CONCLUSIONS: Postoperative infraorbital nerve hypesthesia presents in a week in most patients. It last about 20.5 weeks, then mostly recovers in 6 months. This study will be useful to predict the clinical course of the patients with infraorbital nerve hypesthesia. Therefore, full explanation about the facial sense change is necessary for the patients with inferior orbital wall fracture.

Eyelid Contour Analysis Following Müller's Muscle-conjunctival Resection and Levator Aponeurosis Advancement in Mild to Moderate Belpharoptosis

PURPOSE: To analyze both the effects and the eyelid contour of Müller's muscle-conjunctival resection and levator aponeurosis advancement in patients with mild to moderate belpharoptosis. METHODS: We conducted a retrospective cross-sectional study including 20 eyes of 16 patients who underwent Müller's muscle-conjunctival resection and 25 eyes of 17 patients who underwent levator aponeurosis advancement from January 2012 to December 2015, where each patient was followed up for at least 6 months. Surgical success was defined as either a marginal reflex distance 1 (MRD₁) elevation greater than 2.5 mm postoperatively or a bilateral MRD₁ difference less than 0.5 mm. Both the conventional and 12 oblique mid-pupil lid distances were measured every 15 degrees using custom software developed in the MATLAB program (MathWorks, Natick, MA, USA). RESULTS: The average correction of Müller's muscle-conjunctival resection was 1.1 mm, while that of levator aponeurosis advancement was 0.9 mm. There was no significant difference in MRD₁, MRD₂, function of levator palpebrae muscle, or lid contour in the preoperative status between the Müller's muscle-conjunctival resection group and the levator aponeurosis advancement group. The surgical success rate was 85% in the Müller's muscle-conjunctival resection group and 84% in the levator aponeurosis advancement group, but this difference was not significant. The postoperative lid contour (superomedial side, 15°) was more effective in the Müller's muscle-conjunctival resection group (p < 0.05). CONCLUSIONS: Overall, both types of blepharoptosis surgery were effective at correcting mild to moderate blepharoptosis. The correction of mild to moderate blepharoptosis using Müller's muscle-conjunctival resection is an effective technique for elevating the eyelid and normalizing the eyelid contour.

Clinical Efficacy of Lacrimal Endoscopy in Patients with Epiphora

PURPOSE: To evaluate the clinical efficacy of lacrimal endoscopy in patients with nasolacrimal duct obstruction (NLDO) and to compare the dacryocystography (DCG) and lacrimal endoscopic findings between patients with epiphora. METHODS: We conducted a retrospective chart review of 31 eyes of 23 patients who underwent an irrigation test, DCG, and lacrimal endoscopy from December 2014 to February 2016. We compared the clinical characteristics, and dacryocystographic findings, and lacrimal endoscopic findings of the patients, and analyzed whether or not these findings agree. RESULTS: Thirty-one eyes showed complete obstruction (13 eyes, 41.9%), partial obstruction (7 eyes, 22.6%), or patency (11 eyes, 35.5%) on irrigation test. Thirteen eyes with complete obstruction on irrigation test presented with complete obstruction (11 eyes, 84.6%) or secondary dilation (2 eyes, 15.4%) of the lacrimal sac at DCG. In terms of the level of obstruction, there was no difference between the two examinations. However, twelve eyes with complete obstruction at DCG; showed narrowing (4 eyes, 33%), granulation tissue (3 eye, 25%), mucus occlusion (2 eyes, 17%), stones (1 eye, 8%), or mucosal edema (2 eyes, 17%) on lacrimal endoscopy. Nineteen eyes with partial obstruction at DCG showed narrowing (6 eyes, 32%), mucus (5 eye, 26%), granulation tissue (4 eyes, 21%), or stones (4 eyes, 21%) on lacrimal endoscopy. CONCLUSIONS: Lacrimal endoscopy allowed real-time observation inside the lacrimal passage that cannot be detected using DCG. Both methods provide comprehensive investigations of the nasolacrimal passage system, and these methods are complementary to understand the pathophysiology of nasolacrimal duct obstruction as well as planning treatment. Lacrimal endoscopy is very useful in investigating the lacrimal drainage passage in patients with NLDO, and this method is comparable to DCG.

A Case of Ectrodactyly-ectodermal Dysplasia-cleft Syndrome with Bilateral Epiphora

PURPOSE: In the present study, a case of recurrent nasolacrimal duct obstruction as ectrodactyly-ectodermal dysplasia-cleft syndrome is reported. CASE SUMMARY: An 18-year-old male complained of epiphora in both eyes. By the age of 1, he was diagnosed with nasolacrimal duct obstruction and received left side dacryocystotomy, both sides silicone tube insertion and, right side endoscopic dacryocystorhinostomy. The general findings showed microdontia and, bilateral ectrodactyly. An irrigation test showed ‘regurgitation without pus’ and Jones test showed ‘negative’ in both sides. Complete obstruction was observed on dacryocystography and the patient underwent endoscopic conjunctivodacryocystorhinostomy with Jones tube at right side and endoscopic dacryocystorhinostomy at left side. The chromosome test showed normal findings. CONCLUSIONS: Nasolacrimal duct obstruction in ectrodactyly-ectodermal dysplasia-cleft syndrome is usually caused by dysplasia of the nasolacrimal duct and accompanied by dysplasia of lacrimal punctum and canaliculus. Providing proper care for nasolacrimal duct obstruction in ectrodactyly-ectodermal dysplasia-cleft syndrome is important. Furthermore, the high failure rate should be considered.

Customized Orbital Decompression Surgery Combined with Eyelid Surgery or Strabismus Surgery in Mild to Moderate Thyroid-associated Ophthalmopathy

PURPOSE: To evaluate the efficacy and safety of customized orbital decompression surgery combined with eyelid surgery or strabismus surgery for mild to moderate thyroid-associated ophthalmopathy (TAO). METHODS: Twenty-seven consecutive subjects who were treated surgically for proptosis with disfigurement or diplopia after medical therapy from September 2009 to July 2012 were included in the analysis. Customized orbital decompression surgery with correction of eyelid retraction and extraocular movement disorders was simultaneously performed. The patients had a minimum preoperative period of 3 months of stable range of ocular motility and eyelid position. All patients had inactive TAO and were euthyroid at the time of operation. Preoperative and postoperative examinations, including vision, margin reflex distance, Hertel exophthalmometry, ocular motility, visual fields, Goldmann perimetry, and subject assessment of the procedure, were performed in all patients. Data were analyzed using paired t-test (PASW Statistics ver. 18.0). RESULTS: Forty-nine decompressions were performed on 27 subjects (16 females, 11 males; mean age, 36.6 +/- 11.6 years). Twenty-two patients underwent bilateral operations; five required only unilateral orbital decompression. An average proptosis of 15.6 +/- 2.2 mm (p = 0.00) was achieved, with a mean preoperative Hertel measurement of 17.6 +/- 2.2 mm. Ocular motility was corrected through recession of the extraocular muscle in three cases, and no new-onset diplopia or aggravated diplopia was noted. The binocular single vision field increased in all patients. Eyelid retraction correction surgery was simultaneously performed in the same surgical session in 10 of 49 cases, and strabismus and eyelid retraction surgery were performed in the same surgical session in two cases. Margin reflex distance decreased from a preoperative average of 4.3 +/- 0.8 to 3.8 +/- 0.5 mm postoperatively. CONCLUSIONS: The customized orbital decompression procedure decreased proptosis and improved diplopia, in a range comparable to those achieved through more stepwise techniques, and had favorable cosmetic results when combined with eyelid surgery or strabismus surgery for mild to moderate TAO.

Clinicopathological Study of Lacrimal Sac Dacryolith in Patients Treated for Nasolacrimal Duct Obstruction

PURPOSE: To evaluate the correlation between clinical manifestation of patients with nasolacrimal duct obstruction and pathological characteristics of lacrimal sac and dacryolith found during endoscopic dacryocystorhinostomy. METHODS: This retrospective study included 158 patients (189 eyes) who received endoscopic dacryocystorhinostomy. We defined lacrimal dacryolith by gross discovery in the lacrimal sac during surgery or findings during pathological examination as dacryolith or calcification, including size and distribution in pathology slides. We correlated the relationship between the patients' clinical manifestations, surgical results, lacrimal sac's pathological findings including calcification, inflammation and fibrosis, and pathological findings of lacrimal sac dacryolith. RESULTS: Dacryolith was found in 61 eyes (32.3%) and among them, grossly found in 13 eyes (6.9%). Dacryolith's filling defect on dacryocystography was found in 17 eyes (9.0%) and based on grossly found dacryolith, dacryocystography's sensitivity and specificity were 58.8% and 1.7%, respectively. The average size of dacryolith was 0.3 +/- 0.8 mm2 with an average distribution of 20.1 +/- 17.9%. Distribution of dacryolith and the proportions of inflammatory cells and fibrosis in the lacrimal sac were negatively correlated (p < 0.05). The size of dacryolith and the proportions of fibrosis in the lacrimal sac were also negatively correlated (p = 0.008). In cases where the proportion of calcification in pathology slides was over 50%, the duration of symptoms in the calcification-dominant group was shorter than in other groups (p = 0.006). The success rates of endoscopic dacryocystorhinostomy with dacryolith and without dacryolith were 91.8% and 80.5%, respectively (p = 0.046). CONCLUSIONS: The patients with lacrimal sac dacryolith in nasolacrimal duct obstruction showed shorter duration of symptoms, lower fibrosis of lacrimal sac, and higher surgical success rates than the other cases. Therefore, additional research may be necessary to determine the mechanism of dacryolith formation and early treatment in nasolacrimal duct obstruction with lacrimal sac dacryolith.