Outcomes of Anterior-Side Rectangular 4-Snip Punctoplasty for Patients with Punctal Stenosis

PURPOSE: To evaluate the efficacy of anterior-side rectangular 4-snip punctoplasty, a modification of posterior ampullectomy that is currently used in patients with punctal stenosis. METHODS: We performed a retrospective chart review of patients with punctal stenosis who underwent anterior-side rectangular 4-snip punctoplasty at our hospital. Fluorescein dye disappearance test (FDT) and questionnaire on tearing symptoms and tear meniscus height (TMH) based on spectral-domain optical coherence tomography (SD-OCT) were evaluated in preoperative and postoperative follow-up examinations of the patients. Anatomical success was defined as punctum without re-stenosis at last visit; functional success was defined as FDT grade of 0 or 1, or tearing symptom score of 2 or less. RESULTS: A total of 44 anterior-side 4-snip punctoplasty procedures were performed in 27 patients. The average age of all subjects was 56.0 +/- 11.0 years (range, 39 to 82 years). The mean follow-up period was 9.4 months (range, 6 to 20 months). FDT, tearing symptom score (p < 0.01, Wilcoxon signed-rank test), and TMH (p < 0.01, paired t-test) were significantly decreased after surgery. Anatomical success was 40/44 cases (90.9%) and functional success was 38/44 cases (86.4%). There were no complications such as skin defect or cosmetic problems. CONCLUSIONS: Anterior-side rectangular 4-snip punctoplasty is an effective surgical procedure for patients with punctal stenosis, maintaining functions of the lacrimal drainage system without re-stenosis of punctum.

The Effects of Intralesional Steroid Injection for Chalazion According to the Concentrations of Triamcinolone Acetonide

PURPOSE: To compare the efficacy of an intralesional steroid injection in the treatment of chalazion according to triamcinolone acetonide (TA) concentrations. METHODS: A total of 108 patients with 120 chalazia received an intralesional injection of TA. Patients were divided into 3 groups according to the concentrations of TA: 5 mg/ml, 10 mg/ml, and 40 mg/ml. A regular follow-up was performed and the size of lesion and recurrence were evaluated. RESULTS: Success was defined as a minimum of 80% decrease in size with no recurrence. The success rate was 78.1% in the 5 mg/ml group, 76.2% in the 10 mg/ml group, and 78.4% in the 40 mg/ml group. These results were not statistically significant (p = 0.999, Fisher's exact test). Yellow deposits developed in 4 out of 37 lesions in the 40mg/ml group, and in 1 out of 42 lesions in the 10 mg/ml group. Skin depigmentation was observed in 1 case in the 5 mg/ml group. CONCLUSIONS: Intralesional TA injection is an effective treatment for chalazion. There is no significant difference in success rates according to the concentrations of TA. However, caution is advised in cases of high injection concentrations of TA to prevent yellow deposits.

Treatment of the Lacrimal Fistula with Punctal Plug

PURPOSE: To evaluate the results and complications of the punctal plug insertion through lacrimal fistula. METHODS: Four patients diagnosed with congenital lacrimal fistula had a punctual plug inserted through the lacrimal fistula without anesthesia from January to May 2005. RESULTS: Mean follow-up period was 6.8 months. In two pediatric patients whose mean age was 5.0 years, the fistula was not associated with nasolacrimal duct. In two adult patients, it was associated nasolacrimal duct obstruction, whose mean age was 49.0 years. In all cases epiphora improved. There was a puncal plug prolapse in one case and no other complications. CONCLUSIONS: Punctal plug insertion is considered a simple and useful technique for lacrimal fistula without congenital nasolacrimal obstruction in children especially whose parents refuse general anesthesia. Punctal plug insertion can be useful to reduce scarring in adult patients that receive endoscopic dacryocystorhinostomy with nasolacrimal obstruction.

Modified Simple Excision for Epicanthal Folds

PURPOSE: To evaluate the effect of modified simple excision for epicanthal folds. METHODS: Eight patients with the epicanthal folds were treated using a modified simple excision method from June to December 2005. After medial traction of the epicanthal fold to expose the medial canthus, parabola-shaped marking was done near mucocutaneous junction. Under local anesthesia, incision of skin, dissection of subcutaneous tissue and excision of subcutaneous fibrous tissue and orbicularis oculi muscle were done. After marking the medial canthus on the skin, a wedge-shaped excision of the extra skin was done. Fixation sutures to the medial canthal tendon and skin sutures were then performed. RESULTS: Eight participants were evaluated (four males and four females) with a mean age of 16.71+/-8.34 years. The mean follow-up period was 42.86+/-5.80 days. After the operation, the skin scar was not visible due to its deep position, and no complication, such as damage to the lacrimal canaliculus or sac, was observed. CONCLUSIONS: Modified simple excision for epicanthal folds is an effective method that does not leave a visible scar.

Length Indicator of Lacrimal Pathway in Probing with Congenital Nasolacrimal Duct Obstruction

PURPOSE: To differentiate complex obstruction from the nasal cavity floor when performing probing in congenital nasolacrimal obstruction. METHODS: Twenty-five eyes of 23 patients with congenital nasolacrimal duct obstruction were treated by probing from January to December 2003. We measured the length between the medial canthus and nasal ala and between the punctum and nasal floor after positioning the probe in the nasal cavity and compared the two lengths. RESULTS: There were 15 males and 10 females. Their mean age was 11.48+/-4.32 months. The mean length between the lower punctum and nasal floor was 3.28+/-0.34 cm, and the mean length between the medial canthus and nasal ala was 2.82+/-0.26 cm. The length between the punctum and nasal floor was longer than that between the medial canthus and nasal ala (p<0.01). There was a positive relationship between two lengths (r=0.805, p<0.01). CONCLUSIONS: Measuring the length between the medial canthus and nasal ala before probing in patients with congenital nasolacrimal obstruction is helpful to distinguish the nasal floor from complex nasolacrimal obstruction when a hard stop is encountered.

Comparison of Photorefractive Keratectomy and Laser Epithelial Keratomileusis for Low to Moderate Myopia

PURPOSE: To compare the efficacy and safety of photorefractive keratectomy with laser epithelial keratomileusis, for low to moderate myopia. METHODS: Patients with a manifest refraction less than -6.0 diopters were enrolled in this study. Patients were treated with photorefractive keratectomy (47 eyes) or laser epithelial keratomileusis (42 eyes). Preoperative and postoperative uncorrected visual acuity, refractive errors, keratometry, residual central corneal thickness, epithelial healing time, and corneal haze were evaluated for a 1 year follow-up period. RESULTS: There were no significant differences between photorefractive keratectomy and laser epithelial keratomileusis in uncorrected visual acuity, refractive errors or correction of refractive errors. Residual central corneal thickness increased until 6 months postoperative and thereafter in both photorefractive keratectomy and laser epithelial keratomileusis groups. There were no significant changes in keratometry after postoperative 1 month. Epithelial healing time of photorefractive keratectomy was shorter than that of laser epithelial keratomileusis. Corneal haze score had a peak at 1 month postoperative and then decreased rapidly until 3 months postoperative, it was stable after 6 months. Corneal haze score at 1 month was less than 0.5 in both groups and did not disturb visual acuity. CONCLUSIONS: Photorefractive keratectomy and laser epithelial keratomileusis have an equal effect in correction of visual acuity and refractive errors. They have equivalent levels of safety as measured by postoperative residual central corneal thickness and corneal haze. Both procedures are effective methods to correct low to moderate myopia.

Effect of Mitomycin C to Inhibit Corneal Haze Formation after Photorefractive Keratectomy for High Myopia

PURPOSE: To evaluate the safety and results of the prophylactic use of 0.02% mitomycin C (MMC) to inhibit haze formation after excimer laser photorefractive keratectomy (PRK) for high myopia in eyes that were not good candidates for laser in situ keratomileusis (LASIK) because of inadequate corneal thickness. METHODS: On thirty eyes with high myopia (-6.0 to -10.13 diopters), PRK with intraoperative topical 0.02% MMC application was performed. Visual acuity, refraction, keratometry, corneal haze, central corneal thickness, corneal endothelium, repair of corneal epithelium, and other complications were evaluated for 1 year. RESULTS No eyes showed any BCVA loss, and some even presented a BCVA increase, except in one case: one eye had lost a line 1 year after PRK. At 1 year after surgery, the spherical equivalent was within +/-0.5 D of the desired refraction in 73.33% of the cases, and 86.67% were within +/-1.0 D of the intended refraction. At 3 months after surgery, the mean corneal haze scale stabilized at about 0.22, and decreased further thereafter. Central corneal thickness increased steadily postoperatively, whereas endothelial density decreased significantly, however, the percentage of hexagonal cells and coefficient of variation in cell area showed no change. Epithelial regeneration was complete within 4 days, and there were no other complications. CONCLUSIONS: The prophylactic use of a 0.02% MMC applied intraoperatively after PRK produced lower haze rates and a better visual outcome. But, due to the decrease in endothelial cell density, the safety of MMC can be determined only after long-term observation.

New Incision Line for Epiblepharon Repair

PURPOSE: To evaluate the clinical efficacy of a procedure using a new incision line in cases of epiblepharon. METHODS: This study comprises 199 eyes of 105 patients (56 males, 49 females) clinically diagnosed with epiblepharon. The mean period of follow-up was 4.42 months. After marking the punctal position, the medial limit of the incision line was determined so as not to exceed the medial canthus, and the lateral limit was determined so as not to touch the cilia. The lower incision line was a folded line of skin formed after pulling the upper skin of the medial canthal area or after a downward gaze of the patient. The upper incision line was parallel to the lid margin from the medial limit and met the lower incision line at the lateral limit. RESULTS: Recurrence happened in three eyes, but only one of them underwent re-operation. The other 2 eyes showed weak touching not to need operation. There were no postoperative complications. CONCLUSIONS: This procedure with a newly designed incision line for cases of epiblepharon showed a low recurrence rate and good cosmetic results, with a reduced operation time.

Effect of Mitomycin C to Inhibit Corneal Haze Formation after Photorefractive Keratectomy for High Myopia

PURPOSE: To evaluate the safety and results of the prophylactic use of 0.02% mitomycin C (MMC) to inhibit haze formation after excimer laser photorefractive keratectomy (PRK) for high myopia in eyes that were not good candidates for laser in situ keratomileusis (LASIK) because of inadequate corneal thickness. METHODS: On thirty eyes with high myopia (-6.0 to -10.13 diopters), PRK with intraoperative topical 0.02% MMC application was performed. Visual acuity, refraction, keratometry, corneal haze, central corneal thickness, corneal endothelium, repair of corneal epithelium, and other complications were evaluated for 1 year. RESULTS No eyes showed any BCVA loss, and some even presented a BCVA increase, except in one case: one eye had lost a line 1 year after PRK. At 1 year after surgery, the spherical equivalent was within +/-0.5 D of the desired refraction in 73.33% of the cases, and 86.67% were within +/-1.0 D of the intended refraction. At 3 months after surgery, the mean corneal haze scale stabilized at about 0.22, and decreased further thereafter. Central corneal thickness increased steadily postoperatively, whereas endothelial density decreased significantly, however, the percentage of hexagonal cells and coefficient of variation in cell area showed no change. Epithelial regeneration was complete within 4 days, and there were no other complications. CONCLUSIONS: The prophylactic use of a 0.02% MMC applied intraoperatively after PRK produced lower haze rates and a better visual outcome. But, due to the decrease in endothelial cell density, the safety of MMC can be determined only after long-term observation.

The Long-Term Effects of Soft Contact Lens Wear on Corneal Thickness, Curvature and Endothelium

PURPOSE: To investigate the effects of long-term contact lens (CL) wearing on corneal thickness, curvature, and endothelium. METHODS: Using ultrasonic pachymetry, Orbscan topography and specular microscopy, we evaluated the cornea of 53 subjects who had used soft CL for more than 5 years compared with 47 controls who had never used CL. RESULTS: There was a significant decrease of central corneal thickness in CL wearers. The difference of central corneal thickness between the two groups was 16.39 micrometer. The percentage of central corneal thickness less than 500 micrometer was 24.5% in the CL wearers and 12.2% in the controls. The mean corneal thickness of the CL wearers in the center and eight peripheral areas, as measured with Orbscan topography, was significantly reduced by about 7.28 to 17.87 micrometer compared with that of the controls. The corneal curvature and elevation were significantly steeper in the CL wearers than in the controls but no difference in the mean corneal astigmatism was found between the two groups. Endothelial density and percentage of hexagonal cells were decreased and the coefficient of cell area variation was increased in the CL wearers compared to the controls. The percentage of endothelial cell densities less than 2500 cells/mm2 was 24.5% in the CL wearers and 4.25% in the controls. CONCLUSIONS: Long-term soft contact lens use may have a significant effect on corneal thickness, curvatures and endothelial morphology.

Triamcinolone Regurgitation into Anterior Chamber after Intravitreal Triamcinolone Injection

PURPOSE: To report triamcinolone regurgitation into the anterior chamber after intravitreal triamcinolone injection for macular edema. METHODS: A total of 402 eyes (432 cases) received intravitreal injection of triamcinolone acetonide for macular edema from November 2002 to December 2004. A retrospective review included the medical records of all patients who showed regurgitation into the anterior chamber after intravitreal triamcinolone injection. The clinical outcome and any complications were analyzed. RESULTS: Regurgitation was observed in 9 of 402 eyes (11 of 432 cases, 2.55%) after intravitreal triamcinolone acetonide injection. All were phakic eyes. Pseudohypopyon was observed during the follow-up period but resolved gradually without any significant complications. Intravitreal injection of triamcinolone acetonide results in increased visual acuity (p<0.01) and decreased macular thickness (p<0.01) after 2 weeks of injection. CONCLUSIONS: Triamcinolone particles that regurgitated into the anterior chamber gradually resolved without any significant complications. These can, however, mask symptoms of endophthalmitis and delay accurate diagnosis, so careful follow-up examination is imperaive.

Treatment of Conjunctival Nevus with Argon Laser

PURPOSE: To evaluate the clinical efficacy of Argon laser photocoagulation in patients with conjunctival nevus. METHODS: Twenty-seven patients (27 eyes) who were clinically diagnosed with conjunctival nevus from January to September 2003 were included in this study. The conjunctival nevus was eliminated by Argon laser after topical anesthesia with proparacaine. The power density varied between 200 and 400 mW and the spot size ranged from 100 to 300 microgram. The duration of argon laser was 0.15~0.2 sec. The spot count was varied according to the size and degree of pigment density of conjunctival nevus. The mean follow-up period was 7.0 months. RESULTS: The wounds after Argon laser treatment were completely healed within 1 week. Twenty-three eyes were treated completely with only one laser treatment but 4 needed an additional laser treatment for more satisfactory cosmetic results. There were no postoperative complications such as infections, conjunctival degeneration or recurrence. CONCLUSIONS: Argon laser treatment for conjunctival nevus has benefits such as no intraoperative hemorrhage, low recurrence rate, easier method and good cosmetic results.