Botulinum toxin type a for dysthyroid upper eyelid retraction.

PURPOSE: To evaluate the safety and efficacy of botulinum toxin type A for treatment of eyelid retraction resulting from thyroid eye disease (TED) during the inflammatory phase of the condition. METHODS: In this prospective, nonrandomized case series, 18 patients with inflammatory eyelid retraction caused by active TED received botulinum toxin type A injection (10, 5, or 2.5 U) for treatment of upper eyelid retraction. Botulinum toxin type A (Allergan, Irvine, CA, U.S.A.) was injected transconjunctivally just above the superior tarsal border in the elevator complex of the upper eyelid. RESULTS: Seventeen of 18 patients (94%) demonstrated a reduced marginal reflex distance (MRD1) after botulinum toxin injection. The average change in MRD1 of the treated eyelid after injection was -2.35 mm (range, 0 to -8.0 mm). Of the 27 eyelids injected, 33% had a 0- to 1-mm drop in eyelid height, 30% had a 1.5- to 2-mm decrease, 22% had a 2.5- to 3-mm decrease, and 15% had a greater than 3-mm decrease in eyelid height. None of the treated eyelids were noted to increase in height. One patient showed no alteration inafter treatment. One patient had clinically MRD1 significant ptosis and one patient reported worsening of preexisting diplopia after injection. Three patients undergoing unilateral injection had relative contralateral eyelid elevation. All untoward effects resolved spontaneously without sequelae. CONCLUSIONS: : Botulinum toxin type A may be used in the inflammatory stage of thyroid eye disease to improve upper eyelid retraction. Individual response to treatment is variable, but this modality should be considered as a temporizing measure until stability for surgery is reached.

Nasolacrimal obstruction secondary to I(131) therapy.

PURPOSE: To report the finding of nasolacrimal drainage system obstruction associated with I(131) therapy for thyroid carcinoma from an updated and expanded cohort. METHODS: Patients with a history of epithelial derived thyroid carcinoma who had tearing were offered referral for evaluation by an oculoplastic surgeon. Patients underwent nasolacrimal probing and irrigation procedures with localization of their nasolacrimal obstruction. Therapy for the site of obstruction was instituted. RESULTS: Clinically significant tearing was identified in 26 patients, all of whom had previously undergone I(131) therapy (n = 563). Nineteen patients were evaluated and confirmed to have nasolacrimal drainage system obstruction; 7 have yet to be formally evaluated. Areas of obstruction included nasolacrimal duct, common canaliculus, and, rarely, distal upper and lower canaliculi. Patients were treated with a variety of modalities including silicone intubation, balloon dacryoplasty, dacryocystorhinostomy, and conjunctival dacryocystorhinostomy. CONCLUSIONS: The use of I(131) for thyroid carcinoma is associated with a 3.4% incidence of documented nasolacrimal drainage obstruction and an overall 4.6% incidence of documented or suspected obstruction. The true incidence may be higher, since - I(131) treated individuals were neither systematically evaluated nor questioned about tearing. It has yet to be established if the obstructions result from local toxicity caused by the passive flow of radioactive iodine containing tears through these tissues or the active uptake and concentration of I(131) in lacrimal drainage system tissues through the sodium/iodide supporter.

Hemorrhagic ocular complications associated with the use of systemic thrombolytic agents.

OBJECTIVE: This study aimed to report three patients with hemorrhagic ocular and orbital complications associated with the use of systemic thrombolytic agents. DESIGN: The study design was a retrospective small case series. PARTICIPANTS: Three eyes of three patients were studied. INTERVENTION: Surgical procedures to reduce intraocular pressure or relieve optic nerve compression were performed. MAIN OUTCOME MEASURES: Visual acuity and intraocular pressure were measured. RESULTS: Three patients received an intravenous thrombolytic agent on diagnosis of an acute myocardial infarction. One patient had a spontaneous suprachoroidal hemorrhage develop with secondary acute angle closure glaucoma shortly after receiving tissue plasminogen activator. Another patient had an orbital hemorrhage develop on receiving tissue plasminogen activator 4 days after an uncomplicated cataract extraction. The third patient experienced an orbital hemorrhage while receiving streptokinase 1 day after undergoing an external levator resection. Two patients suffered significant visual loss due to glaucoma or compressive optic neuropathy. CONCLUSIONS: The onset of eye pain or visual loss after the administration of a systemic thrombolytic agent should alert the physician to the possibility of an ocular or adnexal hemorrhage. Prompt diagnosis and treatment can improve the likelihood of a favorable visual outcome.

Intraorbital injection of amphotericin B for palliative treatment of Aspergillus orbital abscess.

We report successful palliative treatment of an Aspergillus fumigatus orbital mass in a patient with acquired immunodeficiency syndrome by direct injection of amphotericin B into the abscess cavity. This case presents intraorbital injection of amphotericin B as an alternative to surgical debridement of Aspergillus orbital infection. In patients who are unable or unwilling to undergo more aggressive treatment, this procedure appears to limit morbidity while still providing effective palliative therapy.

Management of acute dacryocystitis in adults.

Acute dacryocystitis frequently is extremely painful and slow to resolve even with systemic antibiotic therapy. We have identified that incision, drainage, and direct application of antibiotics inside the infected sac result in almost immediate resolution of pain and rapid control of infection. This also provides optimal culture material. Twelve consecutive patients treated in this manner had rapid control of the acute infectious process. All eight patients subsequently undergoing dacryocystorhinostomy were fully cured. A total of 58.3% of the patients were infected with gram-negative rods; 50% of the isolates were resistant to most oral antibiotics.

Benign eyelid lesions.

BACKGROUND: Benign eyelid lesions include a diverse group of tumors, infections, and degenerative lesions that require specialized care for identification and treatment. OBJECTIVE: Diagnosis of benign eyelid lesions based on their clinical characteristics with pathological confirmation by biopsy where indicated. METHODS: Clinical evaluation, biopsy, and treatment with medication, surgery, and laser surgery are utilized. RESULTS: Improvement or complete resolution of these eyelid lesions is possible. CONCLUSION: Special care is necessary to avoid ocular complications that could compromise vision, comfort, and cosmesis.

Management of epiphora in the presence of congenital punctal and canalicular atresia.

We treated ten eyes in six pediatric patients with epiphora and punctal and canalicular atresia in one or both lids. Attempted probing and irrigation had failed to improve the epiphora. Nine out of ten of the lacrimal systems had additional anomalies, such as cutaneous lacrimal fistulas (anlage ducts), small sacs, and nasolacrimal duct stenosis or obstruction. A surgical plan is described for the exploration and reconstruction of these markedly abnormal nasolacrimal drainage systems, including a new method of performing bicanalicular intubation. Four of the five eyes with at least part of one canaliculus present have had resolution of epiphora.

Volume augmentation of the anophthalmic orbit with cross-linked collagen (Zyplast).

Injectable glutaraldehyde cross-linked collagen (Zyplast) has been used to augment the soft-tissue volume of the anophthalmic sockets of five patients. Follow-up of more than 1 year has demonstrated that this material can be used safely with long-lasting results. Enophthalmos and pseudoptosis were treated by injecting Zyplast transconjunctivally into the muscle cone. Superior sulcus deepening was treated by injecting Zyplast transcutaneously into the superior extraconal fat posterior to the orbital septum ("preaponeurotic fat pad"). In some cases the size of the ocular prosthesis required can be decreased. Surgical volume augmentation of the socket and superior sulcus was averted in all five patients.

A soft stent for dacryocystorhinostomy surgery.

In 516 consecutive dacryocystorhinostomies, a soft stent of 0.25 in. Penrose drain tubing was utilized. The Penrose drain remained in place for approximately 1 month to enhance ostium patency. Ostium patency and alleviation of epiphora were achieved in 99.4% of these cases. Patient comfort, simplicity of follow-up, success rate of ostium patency, and the low incidence of complications suggest that Penrose drain tubing is an excellent material to use when the surgeon feels that an ostium stent is indicated.

The effect of blepharoptosis on the field of vision.

Upper eyelid position, pupillary diameter, and visual field impairment were measured in 26 eyes with adult-onset blepharoptosis. The magnitude of superior visual field impairment was inversely proportional to the distance between the upper lid margin and the pupillary aperture. The distance between the upper lid and the central corneal reflex was the most useful measurement for predicting visual field impairment. Superior visual field impairment was present when the distance between the upper lid and the central corneal reflex was less than 2.5 mm. Visual field impairment inferiorly, temporally, and nasally occurred when the central corneal reflex was obscured and less than 1.5 mm of the vertical diameter of the pupil was visible. Observation of the relationship between the upper eyelid and the pupillary aperture provides useful information for the performance of accurate diagnostic perimetry, as well as for the management of blepharoptosis.

Long-term dislocation of a hard contact lens.

A 48-year-old female was fitted with hard contact lenses and lost the right lens the next day. She was asymptomatic for 62 months but then presented with a painful mass in the right superonasal orbital quadrant. Surgical exploration was non-diagnostic. Five months later the contact lens was found in the right upper fornix. This case emphasizes the importance of a thorough ocular examination, including double eversion of the lids and sweeping the fornices of patients with unidentified periocular masses or pain.

Ptosis associated with fatty infiltration of Müller's muscle and levator muscle.

Prominent fatty infiltration of Müller's muscle and the anterior levator muscle was noted at the time of surgery in nine of 115 patients undergoing external levator resection for ptosis. This distribution of adipose tissue was confirmed by light microscopy. Fatty infiltration appeared to be a degenerative change found in adults with congenital and acquired ptosis. Preoperatively these patients exhibited moderate to severe ptosis, fair to good levator function, and no elevation of the lid crease. The desired postoperative results were achieved with standard external levator resection and advancement techniques. The fatty appearance may lead to difficulty in identifying customary anatomical landmarks during surgery. With the exception of Horner's syndrome, abnormalities of Müller's muscle have not previously been described in association with ptosis, to these authors' knowledge.

Modified Kinosian dacryocystorhinostomy: a review of 122 cases.

A consecutive series of 122 dacryocystorhinostomies is reviewed, and a surgical technique which preserves the anterior lacrimal crest and eliminates the need to create mucosal flaps is described. The success rate of this simplified technique is 89%. The success rate rises to 94% following secondary revisions. This is comparable to more complicated procedures. Canalicular and common punctal stenosis are not found to be contraindications to dacryocystorhinostomy for obstruction of the nasolacrimal duct but do lower the success rate. Eighty-one percent of patients with concomitant canalicular disease and nasolacrimal duct obstruction were cured by dacryocystorhinostomy with silicone intubation. A success rate of 98% was achieved in patients without preoperative canalicular disease.

The wrinkle sign in tear duct obstruction.

We describe here a skin configuration present during tear duct probing in cases of canalicular and common internal punctal obstruction which we term the "wrinkle sign." The technique for eliciting the sign and the significance of its presence is described. Observation of the "wrinkle sign" is a useful adjunct to the standard technique of tear duct probing.

Unilateral eyelid retraction secondary to contralateral ptosis in dysthyroid ophthalmopathy.

A patient with dysthyroid eye disease presented with unilateral lid retraction secondary to a contralateral ptosis. While others have reported similar findings in various underlying disease processes, to the best of our knowledge this is the first case in the literature with dysthyroid ophthalmopathy, and the first where the results of surgical management are presented. The importance of testing for secondary lid retraction by manual elevation of the ptotic partner is stressed.

Orbital fine-needle aspiration biopsy in patients with cavernous sinus syndrome.

The authors report their experience with five patients presenting with cavernous sinus syndrome who, on computerized tomography (CT) studies, were shown to have a lesion simultaneously involving the cavernous sinus and a portion of the orbit. All patients underwent an orbital fine-needle aspiration biopsy (FNAB). A specific cytological diagnosis was made in three of the five patients. To obtain pathological diagnosis in the case of cavernous sinus tumors, invasive diagnostic procedures are sometimes necessary. Extension of lesions from the cavernous sinus into adjacent areas should be carefully looked for on CT scans. In the specific subset of patients with cavernous sinus tumors and simultaneous orbital involvement, orbital FNAB may provide a simple alternative to more invasive procedures. The limitations of the procedure are discussed.