Assessment and management of proximal and incomplete symptomatic obstruction of the lacrimal drainage system

Epiphora is a common complaint of patients who present to an Ophthalmology Clinic. In many cases, epiphora is due to an obstruction in the lacrimal drainage system. However, a subgroup of symptomatic patients with epiphora has a patent lacrimal drainage system. Such cases are usually termed 'functional obstruction' and / or 'stenosis of the lacrimal drainage system'. Various etiologies and diagnostic and therapeutic approaches have been described in literature, which implies the lack of a standardized approach. This article will review the evolving diagnostic and therapeutic approaches in literature, and in the end, propose a paradigm in approaching this group of patients

Lacrimal gland fistula after upper eyelid blepharoplasty

To report the first case of lacrimal gland fistula after upper eyelid blepharoplasty for blepharochalasis. Standard upper blepharoplasty and the hooding excision were performed in a female with blepharochalasis. The patient developed a fistulous tract with tearing from the incision few days after hooding excision. Fistula excision and lacrimal gland repositioning were performed. There were no complications after the repositioning procedure [6 months follow up]. Prolapsed lacrimal gland and fistula formation can occur after upper blepharoplasty hooding excision

Thyroid-associated ophthalmopathy in Iranian patients

We determined the frequency of clinical thyroid ophthalmopathy in Iranian patients. This crosssectional study was performed at the Endocrinology Institute of Tehran University of Medical Sciences. All patients with documented thyroid disorders from September 2003 to July 2005 were recruited. Eye examinations included evaluation of soft tissue changes, measurement of proptosis, lid width, lagophthalmos, evaluation of eye muscle function, and determination of visual acuity. The activity of ophthalmopathy was scored according to the NOSPECS scale. Among 851 visited patients, 303 cases had thyroid eye disease [TED]. The nature of the ophthalmopathy breaks down as follows: 53.4% were hypothyroid [9.3% Hashimoto disease], 5.5% euthyroid and 41.1% had Graves' disease. The prevalence of TED in males was 60% which was nearly 2 times the prevalence of TED in females. There was a significant relationship between presentation of TED and active smoking of the patients [P<0.0001] while no significant relationship with passive smoking was obtained [P=0.181]. The most common clinical sign of TED in descending order respectively were proptosis with 63.4%, soft tissue involvement [40.9%], extraocular muscle involvement [22.1%], corneal involvement [12.9%] and optic nerve dysfunction [6.3%]. Myasthenia gravis occurred in only 2 patients. In the logistic regression, occurrence of TED was influenced by cardiovascular disease [OR=5.346], Graves' disease [OR=47.507], radioiodine therapy [OR=2.590], and anti-thyroid medications [OR=0.650]. Thyroid ophtalmopathy [orbitopathy] is a matter of important health concern among patients with thyroid disorder. Since TED occurred with a high prevalence in all thyroid states, a close collaboration between endocrinologists and ophthalmologists along with timely referrals of patients with any eye complaint is deemed necessary. Also smoking was the most important risk factor for developing TED. Therefore, it is advisable to raise awareness and to strongly encourage smokers with thyroid disorders to quit smoking

Change in quality of life after medical and surgical treatment of Graves' ophthalmopathy

To assess the changes in quality of life [QOL] of patients after treatment of their Graves' ophthalmopathy [GO]. In this prospective, cross-sectional study, the GO-QOL questionnaire was completed by 67 subjects before and at least 6 months after steroid treatment [61 subjects, group 1] or optic neuropathy orbital decompression [6 subjects, group 2]. Visual, psychosocial, education and counseling scores [higher score = better health], GO severity and clinical activity scores and minimal clinically important difference [MCID] were recorded and analyzed for correlation and statistical significance. A P-value <0.05 was considered statistically significant. The mean age of patient enrolled in the study was 38.3 years, with 43 females [64.2%]. The mean duration of thyroid dysfunction and GO were 40.1 and 26.5 months, respectively. Two treatment groups were similar for all the variables [0.06 < P < 0.9], except for higher mean age in the orbital decompression group [45.2 versus 37.7 years] [P = 0.03]. Mean severity, activity, visual function and psychosocial function scores significantly improved in group 1 [steroid group] [P < 0.05, all cases]. A significant improvement in clinical activity score and psychosocial scores occurred in group 2 [decompression group] [P < 0.05]. MCID was achieved in two-thirds of the patients, with no significant difference between groups [P > 0.05]. There was no significant effect of duration of thyroid disease and GO and severity and activity of GO on QOL scores either before or after treatment [P > 0.05, all cases]. Steroid treatment and orbital decompression significantly improve the QOL in GO. Duration, severity and activity of GO did not have a significant impact on the QOL

Quality of life in patients with thyroid eye disease

To evaluate quality of life [QOL] before and after corticosteroid therapy for thyroid eye disease [TED] and to determine the impact of the disease on QOL. A modified TED-QOL questionnaire was completed by consecutive patients before and at least 6 months after steroid therapy. All patients were clinically and biochemically euthyroid during the course of the study. QOL was assessed in subscales of visual function, psychosocial, and educational/counseling; TED was classified by severity score [NOSPECS] and Mourits' clinical activity score. Overall, 61 patients including 18 [29.5%] male and 43 [70.5%] female subjects with mean age of 37.3 +/- 13.7 [range, 18-33] years were enrolled. Mean duration of thyroid dysfunction and TED were 40.1 +/- 44.8 and 26.5 +/- 38.2 months, respectively. Mean disease severity and activity significantly decreased, and visual and psychosocial function scores significantly improved following corticosteroid therapy for TED. Psychosocial score was significantly worse than visual function score before but not after steroid treatment. Linear regression analysis and Spearman correlation test showed no significant correlation between duration of thyroid dysfunction, duration of TED, disease severity and activity on one hand, and QOL scores on the other hand, before or after treatment. TED seems to adversely affect psychosocial activity more than visual function. Corticosteroid therapy significantly improves QOL. No significant correlation seems to exist between QOL scores and the severity or activity of TED

Plaque radiotherapy in recurrent or incomplete-excised conjunctival squamous cell carcinoma and melanoma

To assess the results of brachytherapy in patients with recurrent or incomplete excised conjunctival squamous cell carcinoma [SCC] and malignant melanoma. Three patients underwent brachytherapy of one eye and one patient underwent brachytherapy of both eyes with ruthenium-106 [RU-106] plaques, all of them had a history of incomplete resection or recurrence of the tumor after surgery. All patients were male with an average age at diagnosis of 54 years [range, 34-76 years].The shape and the size of plaques were determined based on location and size of the suspected area. The plaque was inserted to deliver a target dose of 80-100 Gy in the region of conjunctival malignancy. The diagnosis was squamous cell carcinoma in three eyes and conjunctival melanoma in two eyes. All patients had surgical history of one to three previous excisions with or without cryotherapy before brachytherapy. There were microscopic residual tumors after excision in 2 eyes and recurrent lesion was evident in 3 other eyes. A mean dose of 95 Gy was delivered to the tumor bed. Complete tumor regression without any evidence of recurrent lesion was obtained in all five eyes. The patients were followed for 32 months on average [range, 18-42 months]. No radiation related complication was detected, with an exception of a dry eye in the last follow up. Brachytherapy with RU-106 plaque is an alternative method for treatment of selected patients with recurrent or residual conjunctival SCC and melanoma

novel technique of small incision fascia lata harvesting without a faciatome for frontalis suspension procedure

To introduce a small incision technique of fascia lata [FL] harvesting for frontalis suspension blepharoptosis procedure. A skin incision was made in a line between the lateral condyle of the tibia and the anterior superior iliac crest, starting 4- 5 cm above the knee and extending upward 2- 2.5 cm. Approximately 8 cm superior to the first incision, a second skin incision was made with the same length. The FL was dissected from subcutaneous tissue from 1 cm superior to superior border of upper incision to 1 cm inferior to inferior border of lower incision. A 15 mm x 5- 10 mm strip of FL was excised. The fascial defect was left open. Subcutaneous and deep layers were closed with three 4-0 plain catgut sutures and the skin with subcuticular 5-0 prolene sutures. The technique was used in 22 patients from 4 to 47 years of age [Mean: 18.29 +/- 14.20] for 34 frontalis sling procedures. Mean follow-up time was 6.17 +/- 3.21 [3-16] months. Wound hematoma [1/22, 4.5%], wound discharge [2/22, 9%], pain at rest [100%, up to 4 days], pain on walking [20/22, 90%; up to 3 weeks], limping [13/22, 59.1%; up to 7 days] were the main postoperative complications. No significant skin scar was observed and none of the patients needed scar revision. Small incision FL harvesting procedure is a good alternative method when the FL stripper is not available