Lacrimal drainage obstruction and dacryocystorhinostomy in children.

PURPOSE: To determine the outcome of dacryocystorhinostomy (DCR) for nasolacrimal duct obstruction (NLDO) in children. METHODS: A review of medical records of 104 cases (82 patients) of paediatric DCR who underwent DCR at the Sydney Eye Hospital from 1995 to 2004. The main outcome measures included post-operative symptomatic relief of presenting symptoms, complications, subjective visibility of any scar, and general satisfaction. Statistical methods included chi(2) tests, and Student's t-tests for the comparison of variables among groups. RESULTS: Ninety-four external, 10 endoscopic primary procedures, and five revision procedures were included. Fifty-six of the cases were primary NLDO, and 48 were secondary NLDO. The mean follow-up was 1.44 years. Average age at surgery was 6.6+/-4.2 years (mean+/-SD). Ninety-one eyes needed DCR for the involvement of the lower lacrimal outflow system, and 13 eyes were NLDO associated with congenital punctual/canalicular dysgenesis.Most of the complications of external DCR were related to Jones tube placement. Five cases (4.8%) needed DCR revision. There was a significantly higher incidence of revision surgery in the non-stented group (P<0.01), and the Jones tube group (P<0.001) as compared with the silicone intubation stent group. CONCLUSIONS: External DCRs have acceptable long-term clinical and cosmetic results, and low post-operative complication rate. Cases with punctal stenosis or those requiring Jones tube insertion are associated with a higher complication rate. Silicone intubation is associated with a lower need for operative revision.

Merkel cell tumour: case reports and review.

Merkel cell carcinoma, a small-cell undifferentiated/neuroendocrine carcinoma, is a highly invasive primary malignant neoplasm of the skin that may arise from Merkel cells or an epithelial precursor cell. One tenth of all cases affect the eyelids and periocular region, typically in the elderly population. The presentation is generally as a painless erythematous nodule with telangiectatic blood vessels and often intact overlying skin. The rarity of Merkel cell carcinoma of the eyelid can lead to delay in diagnosis and treatment of this tumour. In the present paper, the authors illustrate the aggressive nature of Merkel cell carcinoma, and the importance of early and wide surgical treatment and close follow-up. They discuss the role of rapid paraffin histology compared to frozen section. METHODS: Three cases are described, discussing the clinical presentation, diagnosis and treatment, with a review of the pathology. RESULTS: All three patients were female, presenting with rapidly growing upper eyelid tumours 20 mm in size; one case had paraffin sections suggesting incomplete clearance when frozen section had appeared clear; exenteration was required. The other two cases had lymph node involvement at one and two months post wide local excision. All patients remain alive at follow-up of 6, 4.6, and 2 years, respectively. DISCUSSION: The cases illustrate the aggressive nature of the tumour, the unusual tarsal involvement and the typical pathology. Sampling errors associated with limited frozen section control of excision may be avoidable by the use of rapid paraffin histology. The highly invasive nature of this tumour requires close follow-up following resection.

Involutional lower lid entropion: to shorten or not to shorten?

OBJECTIVE: Involutional entropion of the lower eyelid is a common problem in the aging population, and manifest horizontal laxity is often present. The authors therefore examined the cure rate, dependent on whether the lid had been shortened horizontally. DESIGN: A retrospective case series. PARTICIPANTS: Five hundred eighty-three surgical records of entropion surgery at Moorfields Eye Hospital over a 4-year period (1993-1996, inclusive) were examined, and those patients with involutional entropion and adequate follow-up data were selected. INTERVENTION: One hundred eighty of the 313 primary procedures included horizontal shortening, as did 28 of the 47 reoperations for recurrent entropion or consecutive ectropion. MAIN OUTCOME MEASURES: Surgical success was analyzed after primary correction or after reoperation, and the groups were compared with respect to age, gender, and length of follow-up. RESULTS: A cure after primary surgery was achieved in 178 (99%) of 180 patients in whom the lower eyelid was shortened compared with 104 (78%) of 133 patients in whom the eyelid was not shortened (P < 0.001). Reoperation for recurrent eyelid malposition cured 28 (100%) of 28 patients if the eyelid was shortened and 12 (63%) of 19 patients if the eyelid was not shortened (P < 0.001). CONCLUSIONS: Recurrent malposition of the eyelid was significantly more likely when horizontal eyelid shortening was not included at either primary repair or at reoperation for recurrence or overcorrection. As horizontal laxity is probably the main pathogenic factor for age-related entropion, it is doubtful whether surgical correction without horizontal shortening of the eyelid has any role in the treatment of this condition.

Flashing lights in thyroid eye disease: a new symptom described and (possibly) explained.

BACKGROUND/AIMS: Some patients with restrictive thyroid ophthalmopathy, referred for consideration of extraocular muscle surgery, complained of flashing lights in the superior visual field on upgaze. The frequency was assessed and the pathogenesis of this previously unreported symptom explored. METHODS: 30 patients were recruited, all of whom had tight inferior recti and were in the burnt out phase of thyroid eye disease. They were directly questioned regarding any symptoms of photopsia and their records were examined with respect to disease status and treatment, ocular motility, intraocular pressure, retinal status, and surgical intervention. Magnetic resonance imaging (MRI) and cine MRI scans were reviewed for evidence of globe compression. The frequency of symptoms was compared with an age and sex matched control group. RESULTS: Three patients spontaneously complained of flashing lights. A further nine patients had this symptom when directly questioned. 18 patients had no symptoms. None of the 33 control patients had symptoms on direct questioning. Sagittal MRI and cine MRI failed to demonstrate globe compression by the inferior rectus muscle even in cases that showed an intraocular pressure rise in upgaze. CONCLUSION: A new symptom of flashing lights in upgaze has been identified in thyroid eye disease patients with tight inferior recti. It is suggested that the lights are likely to be phosphenes as a result of either compression of the globe by a tight inferior rectus or traction on the insertion of the inferior rectus. The small amount of globe compression required to produce phosphenes seems to be beyond the resolution limit of MRI.