Endonasal dacryocystorhinostomy: a report by the American Academy of Ophthalmology.

OBJECTIVE: This document describes endonasal dacryocystorhinostomy (DCR) and examines the evidence to answer key questions about the effectiveness of the procedure compared with external DCR; the relative indications, contraindications, advantages, and limitations of the procedure; and patient selection, surgical technique, postoperative care, and complications. METHODS: A literature search conducted for the years 1968 to 2000 retrieved 93 citations. The panel members reviewed 71 of these articles and selected 64 for the panel methodologist to review and rate according to the strength of evidence. A level I rating is assigned to properly conducted, well-designed, randomized clinical trials; a level II rating is assigned to well-designed cohort and case-control studies; and a level III rating is assigned to case series and poorly designed prospective and retrospective studies, including case-control studies. RESULTS: The published literature includes two reports that describe clinical trials comparing endonasal with external DCR with a 1-year follow-up. The success rate was 91% for the external DCR group in both reports and 63% and 75% for the endonasal DCR groups, defined by patency to irrigation. A longitudinal cohort study included a control group of age-matched external DCR patients who were compared with a study group of endonasal DCR patients. The reported success rate at 9 months following surgery for the endonasal cohort was 90% and was not statistically significantly different from the 94% success rate noted in the external DCR control group. Remaining data on reported success rates of primary and revision endonasal DCR were obtained from a collection of uncontrolled observational case studies with varying periods of follow-up and success rates ranging from 59% to 100%. CONCLUSIONS: It is difficult to make definite evidence-based determinations about the relative efficacy of endonasal and external DCR because of the deficiencies in the reported literature. Based on level III evidence, the available data suggest that endonasal DCR may be a viable option for the correction of acquired nasolacrimal duct obstruction and complex forms of congenital dacryostenosis in selected patients. This procedure may be indicated on a primary basis or as revisional surgery following failed external or endonasal DCR. Some studies comparing endonasal DCR with external DCR suggested lower success rates in the endonasal group; other studies yielded success rates comparable with or exceeding those of external surgery. Reported complications of endonasal DCR do not generally appear to be greater in frequency or magnitude than those associated with external DCR. Disadvantages of endonasal DCR include the preferred use of general anesthesia by many surgeons, the high cost of expensive equipment and instrumentation, and the relatively steep learning curve for this procedure. Depending on the preference of the surgeon, more postoperative care may be required for patients undergoing endonasal DCR than external DCR. Both the advantages and the limitations of endonasal DCR relative to external DCR should be carefully discussed with patients who are contemplating endonasal surgery.

Orbital lipogranulomatous inflammation harboring Mycobacterium abscessus.

PURPOSE: A case of iatrogenic Mycobacterium abscessus orbital infection is presented to call attention to its distinct histopathologic appearance, mechanism of organism, virulence, and clinical management. METHODS: Clinicopathologic analysis of an orbital infection caused by M. abscessus is described. Detailed histologic analysis is performed to provide insight into the mechanism of infection and correlate the features of the orbital infection with that of atypical mycobacteriosis at other body sites. RESULTS: A 71-year-old woman had an orbital mass in the supranasal orbit after a blepharoplasty. The mass consisted of a dimorphic inflammatory reaction with a superficial purulent reaction and a deeper granulomatous process consisting of epithelioid tubercles, each centered about a lipid vacuole. Acid-fast bacilli were found in the lipid vacuoles but not elsewhere in the specimen. Each tubercle was surrounded by a zone of lymphocytes and a desmoplastic reaction. Microbiologic culture studies identified M. abscessus. A combination of surgical intervention and antibiotic therapy for 4 weeks eliminated the infection. CONCLUSIONS: Acid-fast stains should be performed on any orbital lesion showing an apparent lipogranulomatous reaction. Although clinical management of orbital atypical microbacteriosis is difficult, the combination of surgical and specific antimicrobial intervention is effective. Our study contributes to an evolving understanding of the mechanism of human infectivity of these low-virulence organisms by suggesting that the orbital fat is a source of lipid material that can harbor the organisms, allowing them to escape host immunosurveillance.

Pediatric enucleation: analysis of volume replacement.

OBJECTIVES: To determine the percent volume replacement by an implant and prosthesis, the long-term sequelae of poor volume replacement, and specific guidelines for volume replacement in pediatric patients. METHODS: A retrospective observational study of 16 pediatric patients who underwent enucleation (group 1) and 31 adult patients enucleated in childhood (group 2) was performed. The total volume replacement and the volume replacement by the implant were determined. The incidence of secondary surgical procedures for superior sulcus deformity, enophthalmos, ptosis, ectropion, and socket contraction was determined. RESULTS: The average percent volume replaced by the implants in group 1 patients was 68%. The average percent volume replaced by the implants in group 2 patients was 21%. Seventy-one percent of patients in group 2 underwent secondary implant surgery to augment volume and eliminate superior sulcus deformity and enophthalmos. CONCLUSIONS: The placement of an adequately sized implant in pediatric patients may obviate the need for secondary augmentation of socket volume in adulthood. The authors suggest an implant 2 mm less in diameter than the axial length of the eye in pediatric patients.

The ideal ocular prosthesis: analysis of prosthetic volume.

PURPOSE: An ocular prosthesis should complement the volume of the intraconal implant to achieve complete replacement of the volume that is removed by enucleation. This study investigates the limitations on the prosthetic volume in achieving this goal. METHODS: Prosthetic volume and thickness were measured in 70 patients who underwent enucleation. Patients in group 1 (n = 17) were adults enucleated in childhood, and patients in group 2 (n = 53) were enucleated as adults. Clinical problems after enucleation were documented to determine problems potentially related to prosthetic volume. RESULTS: None of the ocular prostheses in this patient series was greater in volume than 4.2 ml (range, 0.75-4.2 ml). The average prosthetic volume for patients with implant diameters of 14 mm to 22 mm was 2.2 ml. A prosthetic volume > or =1.8 ml provided an anterior to posterior dimension of 7 mm. Anterior malposition of the implant and the presence of severe socket contraction were noted in patients with the smallest and the thinnest prostheses. In group 2, larger prostheses were associated with ptosis and lower eyelid laxity (p < 0.05; p < 0.01). CONCLUSIONS: One should not depend on the ocular prosthesis to supply more than 4.2 ml of volume in the anterior compartment of the socket. Adult patients with normal bony development, noncontracted sockets, and an average axial length should not receive implant sizes <20 mm, if one intends to achieve complete replacement of the volume removed by enucleation. Children should receive the largest implant possible.

Lichen simplex chronicus of the eyelid.

Lichen simplex chronicus is a common dermatosis that rarely affects the eyelids. We report the clinical and pathologic features in the case of a middle-aged man who had lichen simplex chronicus of both lower eyelids. The clinical features suggested the presence of basal cell carcinoma.

Predicting the ideal implant size before enucleation.

PURPOSE: This study of volume replacement in anophthalmic sockets compares the volume replaced by the implant and prosthesis with the volume removed from the socket and evaluates A-scan ultrasonography as a tool to predict an ideal implant size before enucleation. METHODS: In this retrospective study of 59 anophthalmic patients, the volume replaced by the implant and the prosthesis was compared with the volume of the enucleated eye. The volume removed was estimated by calculating the volume of the fellow eye using A-scan ultrasonography. Enophthalmos and superior sulcus deformity were measured and correlated with the percent volume replacement in the anophthalmic sockets. RESULTS: Greater enophthalmos and superior sulcus deformity were found in patients with less than 100% volume replacement compared with those with 100% or more volume replacement. The axial length determined by A-scan ultrasonography of the fellow eye suggested that a larger implant size should have been placed in 76.3% of those patients with less than 100% volume replacement. Sixty-three percent of adult patients could have received an implant more than 22 mm in diameter to fill 80% of the volume removed at enucleation. CONCLUSIONS: A-scan ultrasonography of the fellow eye provides a useful tool for predicting the implant size before surgery for optimal volume replacement.

Sebaceous carcinoma. Tumor progression through mutational inactivation of p53.

BACKGROUND: Sebaceous carcinoma may masquerade for years as an inflammatory condition. In many cases, this may be because of the presence of longstanding intraepithelial disease (e.g., dysplasia or carcinoma in situ), which eventually progresses to invasive carcinoma recognized through tumefaction and a worsening clinical presentation. The mechanism for this tumor progression is unknown. In the Far East, human papilloma virus (HPV) has been suggested to play a role in the development of sebaceous carcinoma by inactivating tumor suppressor gene p53. Here, the authors explore the molecular basis of the progression of ocular sebaceous carcinoma. METHODS: Cases of sebaceous carcinoma seen at the University of Virginia, Department of Ophthalmology, during the period from 1989 to 1996 were analyzed for HPV infection by in situ hybridization and polymerase chain reaction. The expression of p53, p21WAF-1, Bcl-2, and epithelial membrane antigen was examined by immunohistochemistry. In one of the cases, frozen tumor was available, allowing exons 5 through 9 of the p53 gene to be sequenced. RESULTS: Seven cases were identified, all of which were from women. All were negative for HPV. In cases in which disease was restricted to dysplasia (carcinoma in situ), p53 but not p21WAF-1 was negative. In contrast, cases that contained a component of invasive or metastatic carcinoma showed striking hyperexpression of nuclear p53 in all of the malignant cells. In one of these cases, a G:C-->T:A transversion was found in the p53 gene. This mutation, characteristic of bulky carcinogens, substituted phenylalanine for cysteine 277, a residue that participates in hydrogen bonding to the p53 DNA binding consensus sequence. CONCLUSIONS: Mutational inactivation of p53 may be involved in the progression of sebaceous carcinoma.

Prevention and management of complications associated with the hydroxyapatite implant.

The hydroxyapatite orbital implant offers many advantages compared to conventional implants; however, its use is not entirely free of complications. The objectives of this study are to review the complications encountered with the hydroxyapatite orbital implant, suggest mechanisms contributing to the development of these complications, and emphasize aspects of surgical technique that will minimize the risk of the most frequent complication, implant exposure. Preoperative, operative, and postoperative records of 154 patients receiving primary and secondary hydroxyapatite implants were studied retrospectively. Three clinical types of exposure defects were observed; dehiscences along the horizontal suture line, defects over holes in the hydroxyapatite, and a defect adjacent to the site of radiation plaque therapy. Most small exposures healed spontaneously. Medium and large defects were associated with anteriorly malpositioned implants, most often required surgical intervention, and were successfully managed with one or a combination of techniques including flaps, mucous membrane grafts, or repositioning of the implant more posteriorly. Placing the hydroxyapatite implant as far posteriorly as possible and advancing the extraocular muscles 3-5 mm from the apex of the implant will prevent most exposures. Unlike other types of implants, the hydroxyapatite implant does not migrate or extrude, and when exposed, usually does not require removal.

Primary nonkeratinized epithelial ('conjunctival') orbital cysts.

The types of orbital cysts that are most familiar to ophthalmologists are epidermoid and dermoid cysts, both of which are lined by keratinized stratified squamous epithelium. We studied six patients who had orbital cysts lined by nonkeratinized epithelium that resembled normal conjunctiva. Compared with epidermoid and dermoid cysts, these primary nonkeratinized cysts tend to cause symptoms later in life, occur preferentially in the superonasal aspect of the orbit, and are less likely to be associated with underlying bony changes.

The myofibroblast and the anophthalmic socket.

One of the greatest advances in the understanding of wound healing was the identification and characterization of the myofibroblast by Gabbiani in 1971. Since that time this contractile cell has been found in the early stages of wound healing and in many pathologic states. In a recent study, the myofibroblast was found in healing and contracting anophthalmic sockets.

Destructive cysts of the maxillary sinus affecting the orbit.

Symptomatic maxillary sinus cysts are diagnosed less frequently than similar cysts of the frontal and ethmoidal sinuses and are rarely reported in the ophthalmic literature. Patients with cysts of the maxillary sinus may present to the ophthalmologist with proptosis, enophthalmos, diplopia, ptosis, epiphora, and, rarely, decreased visual acuity. Four patients with maxillary sinus mucoceles are presented; one of these patients had a concurrent retention cyst in the orbit. Clinical history, radiologic findings, and histopathologic mechanisms are discussed. Mucocele is a recognized complication of the Caldwell-Luc procedure and midface trauma. Blockage of the sinus ostia was the cause previously proposed to explain antral mucocele development. Clinical and histopathologic features may support more than one single mechanism for the pathogenesis of maxillary sinus cysts. Maxillary sinus mucocele or retention cysts should be considered in the differential diagnosis of exophthalmos or enophthalmos following blowout fracture of the orbital floor.

Leiomyosarcoma of the orbit. A case report and review of the literature.

Leiomyosarcoma has been rarely encountered in the orbit. Leiomyosarcoma may arise as a primary tumor in the orbit, metastasize from distant sites to the orbit, extend into the orbit from the paranasal sinuses, or appear after radiation therapy to the orbit. The 43-year-old female patient described in this paper underwent excision of a leiomyosarcoma in the subcutaneous tissue of the buttock. Seven years later, a leiomyosarcoma in the medial orbit was removed. The clinical course of this patient's disease was similar to that of other subcutaneous leiomyosarcomas documented in the literature. Gynecological history was remarkable for a leiomyoma of the uterus, an interesting association found in at least one other case in the literature. This was the third documented case of metastatic leiomyosarcoma in the orbit.

The anatomy and histology of the anophthalmic socket--is the myofibroblast present?

For some anophthalmic patients, the contracted socket is a severe problem that precludes the wearing of a prosthesis. A normal and cosmetically acceptable appearance is dependent on the ability of a socket to retain a prosthesis. The disfigurement and distress caused by the contracted socket and its inability to accommodate a prosthesis may have a profound detrimental effect on the patient's career, self-esteem, and psychosocial interactions. The tissue dynamics at work in the anophthalmic socket and in the contracting socket are not yet understood. There are many unanswered questions regarding the histology and anatomy of the normal, as well as the contracting, socket. The tissue responsible for clinical contraction has not been identified. This thesis, using the cynomolgus monkey socket as an experimental model, investigated healing in both the normal and contracting socket. Qualitative observations of the anatomy and histology of eight sockets were made. Two of the sockets were treated with Croton oil to induce contractions. Biopsy specimens from two human sockets, one contracted and the other merely volume deficient, were also examined. Histopathology of the normal and contracting sockets were compared. Myosin subfragment 1 staining of actin for electron microscopy and immunoperoxidase staining of actin for light microscopy were performed on selected specimens. The myofibroblast, probably a modified fibroblast, is known to be present in the early stages of open wound healing and in contracting scar tissue elsewhere in the body. The myofibroblast has been incriminated as an agent generating contractile force. Under the conditions of this experiment, cells with the characteristics of myofibroblasts were identified by both immunoperoxidase staining and electron microscopy. They were found in healing noncontracting and contracting sockets. Cytoplasmic actin was also distinguished in arterioles, venules, capillaries, myoepithelial cells, smooth muscle, and skeletal muscle.

Actinic granuloma of the conjunctiva.

The key histologic feature of pingueculas is the presence of actinic elastosis of the conjunctival connective-tissue fibers. We describe a patient who had a pinguecula that, on pathologic examination, exhibited a prominent foreign-body giant-cell reaction in association with the elastotic fibers. The term actinic granuloma has been coined recently to designate a similar reaction in sun-damaged skin. Because the nature of the inflammatory reaction may be misinterpreted on pathologic examination as indicating the presence of microorganisms or a foreign body, both the clinician and the pathologist should be aware of this peculiar inflammatory response, which has been described on two previous occasions in patients with pingueculas.