Wegener's granulomatosis: The ocular manifestations revisited.

AIM. To investigate whether the extent of ocular morbidity had de-creased as a result of improved diagnosis, awareness and treatment of Wegener 's granulomatosis (WG). MATERIALS AND METHODS. A retrospective study of all patients with ophthalmic involvement due to WG over an 8-year period. RESULTS. Forty-nine patients were diagnosed to have WG. Of these, 28 had ocular involvement: 21 patients had focal ocular involvement (conjunctivitis, episcleritis, scleritis, keratitis, iritis, retinitis)and 7 had orbital involvement. Permanent visual loss occurred in three patients with orbital involvement, but in no patients with focal ocular disease. Up to 90% of patients had systemic involvement. Three deaths oc- curred among those with ocular involvement. CONCLUSIONS. Patients with WG have a much improved visual prog- nosis as a result of early diagnosis and intervention with systemic im- munosuppression. A combination of assays for ANCA and tissue biop-sies were needed to establish the diagnosis of WG. Treatment with immunosuppressive agents (usually prednisolone and cyclophospha- mide)led to a good response in the majority of cases.

Choroidal tuberculosis diagnosed by polymerase chain reaction. A clinicopathologic case report.

PURPOSE: To show the use of the polymerase chain reaction (PCR) in a granulomatous choroidal lesion to support a diagnosis of tuberculosis. DESIGN: Observational case report. TESTING: Nucleic acid target amplification of a choroidal specimen using PCR for detection of Mycobacterium tuberculosis was tested. MAIN OUTCOME MEASURES: Positive nucleic acid target amplification for M. tuberculosis in the ocular sample was measured. RESULTS: PCR was positive for M. tuberculosis with appropriate negative controls. CONCLUSIONS: PCR was thought to be a useful supportive technique in the diagnosis of choroidal tuberculosis.

Dacryocystorhinostomy in nasolacrimal duct obstruction secondary to sarcoidosis.

Over the past 3 years we have treated 4 patients with nasolacrimal duct obstruction secondary to sarcoidosis. These patients have had mixed outcomes following endonasal laser-assisted dacryocystorhinostomy (DCR). A literature search from 1966 to the present yielded a further 11 cases of patients thought to have sarcoid who underwent DCR. The outcome of these 15 patients indicate that while all were initially successful, the subsequent failure rate is high. These patients are older than the majority of patients with sarcoidosis and there is a female preponderance. Systemic steroids reversed obstruction in one patient. We recommend nasal examination in all patients with nasal symptoms in whom DCR is proposed to help identify sarcoidosis or other intranasal disease and/or to allow treatment of specific diseases prior to surgery.

Quality of life outcomes following dacryocystorhinostomy: external and endonasal laser techniques compared.

AIMS/BACKGROUND. Endonasal laser dacryocystorhinostomy (ELDCR) has recently become established as an alternative technique to conventional external DCR (EXDCR) for relief of epiphora. The aim of this study was to compare quality of life and symptomatic outcomes in patients treated by these two methods. METHODS. A postal questionnaire was sent to 204 ELDCR and 78 EXDCR patients who had undergone surgery under our care more than 6 months previously. The questionnaire included the validated 18-item Glasgow Benefit Inventory (GBI) and 5 further questions addressing ocular symptomatology. RESULTS. Fully completed questionnaires were received from 156 ELDCR and 50 EXDCR patients. Mean GBI scores of +16.8 (ELDCR) and +23.2 (EXDCR) were obtained (Mann-Whitney U test = NS). Ocular symptom scores were +33 (ELDCR) and +54 (EXDCR) (p=0.005). CONCLUSION. Patients undergoing either ELDCR or EXDCR experience significant benefit in their healthcare status as detected by the GBI. There is no significant difference between the scores obtained by the two groups of patients. There were improvements in ocular symptom scores in both groups, with patients who had EXDCR scoring significantly better than the ELDCR group.

Porous orbital implants and their behaviour during drilling.

The use of porous spherical orbital implants enables ocular prosthesis motility to be improved if necessary by subsequent drilling of the implant and coupling it to the prosthesis with a peg. We compared the effect of drilling at different speeds on hydroxyapatite and porous polyethylene (Medpor) spherical implants. The implants were drilled at fixed speeds of between 15 and 2000 revolutions per minute. The samples were then viewed in an electron microscope and photographed. When hydroxyapatite is drilled the porous structure of the implant is maintained although a precise hole with well-defined walls was not produced. This contrasts with porous polyethylene where the porous structure is lost although a precise drill hole is created. This drilling technique has been used successfully in patients with hydroxyapatite implants, thus making possible stable epithelialisation of the drill hole. Our results confirm that the drilling of porous polyethylene using this technique is unlikely to be successful, as loss of the porous structure would prevent stable epithelialisation of the drill hole, resulting in exposure of the implant.

Epiphora: a quick fix?

PURPOSE: To assess whether any simple, easily performed and minimally invasive procedure may help the symptoms of patients with functional nasolacrimal obstruction without recourse to elaborate investigation or major surgery. A randomised study was performed to assess the success of retropunctal cautery (RPC) and one-snip punctoplasty in this condition. METHODS: In the absence of any cause for excess lacrimation, eyelid malposition or nasolacrimal obstruction, patients underwent either syringing alone (group A, n = 15) or syringing with RPC and a one-snip punctoplasty (group B, n = 15). RESULTS: Three months after treatment, six patients in group A were improved, compared with 13 in group B (Fisher's exact test, p = 0.0096). CONCLUSIONS: We would recommend that patients who suffer from a pump or functional nasolacrimal obstruction should receive RPC and a one-snip punctoplasty following the demonstration of a patent system on syringing. These simple procedures would not impair further investigation or lacrimal surgery if required in the future.

Endonasal laser-assisted dacryocystorhinostomy.

Endonasal laser-assisted dacryocystorhinostomy allows relief of epiphora caused by nasolacrimal duct obstruction. It can be performed as a day-case procedure and has many advantages over conventional approaches. This article reviews conventional, endoscopic and laser-assisted dacryocystorhinostomy and describes the technical steps of an endonasal procedure.

A clinical algorithm for the management of facial nerve palsy from an oculoplastic perspective.

BACKGROUND/AIMS: Facial nerve palsy can be a sight-threatening complication. We have developed a flow diagram to aid in the management of these patients so that corneal complications may be avoided. This involves the recognition of a facial palsy and institution of treatment as guided by the flow chart. METHOD: Fifty-six patients suffered a facial nerve palsy following acoustic neuroma surgery. All received regular topical ocular lubrication, followed by either botulinum toxin A (BTXA)-induced ptosis (if corneal exposure developed despite conservative treatment) or definitive eyelid surgery. RESULTS: Twenty-one patients required regular lubrication only. Of these patients treated for corneal exposure, 20 received BTXA with good resulting corneal cover. Unfortunately, 9 of these suffered diplopia, although in 4 this resolved quickly. Twenty-four patients underwent a total of 64 eyelid procedures including levator recession, lateral tarsorraphy, lateral canthal sling, medical canthoplasty and gold weight insertion. All patients had good corneal cover post-operatively and were cosmetically improved. Of the 56 patients with a facial nerve palsy, 7 presented with a corneal epithelial defect or an infected corneal ulcer. These all responded to treatment with BTXA, topical antibiotics and/or lubrication, and eyelid surgery. CONCLUSIONS: Post-operative facial palsy may result in a significant ophthalmic workload. Although a proportion of patients with a facial nerve palsy manage well with regular lubrication, additional help with eyelid closure, either in the way of BTXA-induced ptosis in the short term or definitive eyelid surgery in the long term, is often required. Eyelid surgery seems to be the mainstay of treatment, for both function and cosmesis, with many patients requiring a combination of procedures.

The sphenoidal sinus in optic nerve decompression.

Surgical decompression of the orbit may be necessary in dysthyroid patients with compressive optic neuropathy. Two-wall decompression with a trans-antral or a trans-conjunctival approach is commonly used. However, in some patients the initial improvement following this surgical procedure is not maintained. Although this may be due to disease progression, a variant of orbital anatomy can contribute to sub-optimal decompression. We report three cases in which recurrence of compressive optic neuropathy occurred following two-wall decompression. The sphenoidal sinus was placed anteriorly in these patients. Further decompression which included the lateral wall of the sphenoidal sinus resulted in improvement. An endoscopic approach provides superior access and visibility for decompression of the optic nerve into the sphenoidal sinus, and this approach may be the surgical treatment of choice in these cases.

Endoscopic holmium:YAG laser dacryocystorhinostomy-safe and effective as a day-case procedure.

Endoscopic holmium laser dacryocystorhinostomy can be used safely and efficiently to relieve symptoms of distal nasolacrimal duct obstruction. It has great advantages over the conventional external approach as it can be done as a day-case procedure under local anaesthesia. The excellent ablation of bone and soft tissue using this type of laser contribute to the fact that the procedure can be performed in a mean time of 20 minutes. We report on the results of our first 50 patients and review the literature on the subject.

Endonasal laser dacryocystorhinostomy--medium term results.

BACKGROUND/AIMS: Endonasal laser dacryocystorhinostomy (ELDCR) has many potential advantages over conventional external DCR. Although the short term results of this technique have been reported, little is yet known of the long term results, and the occurrence of late rhinostomy failure. The aim of this study was to examine the results at 3 and 12 months following ELDCR. METHOD: The notes of all consecutive ELDCRs performed between November 1993 and May 1995 were retrieved. Demographic information, details of surgery, and the postoperative results were noted. RESULTS: ELDCR procedures which did not undergo lacrimal stenting showed a short term success rate of 67% at 3 months, and a further failure rate of 9% at 12 months. ELDCRs which did undergo lacrimal stenting showed a short term success rate of 82% at 3 months, and a further failure rate of 21% at 12 months. Lacrimal intubation increased the long term success rate by 8%. The success rate was lower in the presence of local risk factors for nasal mucosal scarring. CONCLUSIONS: ELDCR requires some adjunctive treatment to improve maintenance of the nasal mucosal ostia if it is to complete successfully with external DCR on grounds other than cosmesis and patient convenience.

Issues raised by a case of orbital metastatic disease.

The clinical, radiological and histopathological findings in an 81-year-old man presenting with lung carcinoma metastatic to the orbit are described. Orbital biopsy was complicated by postoperative visual loss and failed to contribute significantly to the final diagnosis. The authors believe that in cases of possible orbital metastases a primary neoplasm should be excluded by means of a complete oncological assessment before proceeding to biopsy.

Dysversion of lateral eyelashes in children: a new diagnosis.

We believe that a previously undocumented cause of recurrent red, watery, sore and itchy eyes in children is dysversion of the lateral eyelashes. Diagnosis requires a close examination of the lateral aspect of the eyelids where dysverted lashes are seen to be growing from normal follicles. The lateral lashes are fine, long and flexible. They curve inwards and rub on the conjunctiva and cornea, and cause the above symptoms. Secondary signs include skin changes, recurrent conjunctivitis, and corneal abrasions. Conservative treatment consisting of manual repositioning of the dysverted eyelashes is recommended so that surgery may be avoided. Recognition of the condition by the primary practitioner, and institution of the straightforward treatment described above, can obviate much morbidity. The inappropriate use of topical antibiotics and frequent return visits to the practitioner may also be thus avoided.

Endoscopic holmium:YAG laser dacryocystorhinostomy.

The early results of the first 50 primary endonasal laser dacryocystorhinostomies in 49 patients performed with the holmium:YAG laser are presented. Overall, 35 (70%) were successful in relieving symptoms of nasolacrimal obstruction after a mean follow-up period of 4 months. This improved to 79% in the subgroup of patients who underwent intubation of the naso-lacrimal system. These results were similar to the results of a retrospective study of 67 patients undergoing conventional dacryocystorhinostomy in our unit. Conventional surgery was performed under general anaesthesia in all but 1 case and all were treated as inpatients, with a mean hospital stay of 2.3 days, whereas all but 1 of the laser group had their surgery under local anaesthesia and 46 operations (94%) were performed as an outpatient procedure. Surgery was significantly quicker with the endonasal laser technique and 90% of patients questioned found this technique to be entirely acceptable.

Enophthalmos secondary to maxillary sinus disease: single-stage operative management.

Maxillary sinus disease can lead to dehiscence of the orbital floor. Using endoscopic sinus surgery it is possible to simultaneously reconstruct the orbital floor and to assess and treat the underlying sinus disease.

Micrographically controlled excision (Mohs' surgery) of basal cell carcinoma around the eye. Combined dermatological surgical clearance and oculoplastic surgical repair.

Periorbital infiltrative basal cell carcinomas are notoriously difficult to treat, particularly those around the medial canthus. Micrographically controlled excision with horizontal frozen sections (Mohs' surgery) allows for clearance of the tumour with minimal loss of normal tissue. Once the tumour has been completely removed, the defect can be repaired by the oculoplastic surgeon for the best functional and cosmetic result. This is the ideal treatment for tumours with a contiguous growth pattern that are liable to be seriously over or under treated by other modalities. The technique requires special training for both the operator and the Medical Laboratory Scientific Officer (MLSO). It is costly in time and manpower but in selected cases, where recurrent tumour is most dangerous and where tissue conservation is paramount, it may be invaluable. Close collaboration between dermatological and oculoplastic surgeons in such cases probably offers the patient the best treatment and outcome.

The use of Q-switched Nd:Yag laser for removal of permanent eyeliner tattoo.

We present the results of a pilot study of the use of Nd:Yag laser in the removal of permanent eyeliner tattoos. Fourteen eyelids were treated, and in all cases a reduction in pigmentation was achieved although responses were variable. The advantages of such therapy over existing techniques are described. The technique offers a useful reduction of permanent eyeliner pigmentation and is particularly suited to treatment of localized areas of imperfect application or pigment migration.

The mersilene covered intraorbital implant.

The most widely used material for covering spherical intraorbital implants is sclera. Mersilene mesh is an alternative substance combining the advantages of permanent implant cover with low rates of infection and ready availability. We describe our experiences in the use of Mersilene mesh covered intraorbital implants in 14 patients. Our findings suggest that Mersilene mesh could be considered as a possible alternative choice of material for covering intraorbital implants.

The Mersilene mesh ptosis sling.

A variety of materials are currently available for use in brow suspension ptosis surgery when an alternative to autogenous fascia lata is indicated. We describe the use of a Mersilene mesh sling, developed to overcome the problems of failure and extrusion commonly associated with substitute suspensory materials. The results and follow up in 23 cases of blepharoptosis are presented. Our findings suggest that the Mersilene mesh sling has a definite place in ptosis management; we currently use this sling for all cases in which autogenous fascia lata is considered inappropriate.