Piezosurgery in External Dacryocystorhinostomy.

BACKGROUND: Dacryocystorhinostomy (DCR) can be performed via an external or endoscopic approach. The use of ultrasonic or piezosurgery has been well described for endoscopic DCRs but is lacking for external DCRs. This study presents a case series of external DCRs performed using piezosurgery evaluating results and complications. METHODS: Prospective, consecutive case series of patients undergoing primary external DCR for lacrimal drainage insufficiency. A standard external DCR technique was used using 1 of 2 piezosurgery systems for all bone incision. All patients received silicone intubation to the lacrimal system. Surgical outcome was measured in terms of patient-reported epiphora as follows: 1) complete resolution, 2) improvement >50%, 3) improvement <50%, and 4) No improvement. Intra and postoperative complications were also recorded. RESULTS: Fifty-two patients, 14 male and 38 female, were included in the study, with 2 patients having bilateral surgery. The average age of the patients was 55.8 years. The average length of follow up was 221 days. Surgical outcomes showed 72% of patients with complete resolution of epiphora and 21% with >50% improvement. There were 4 patients (7%) who had <50% improvement. There was 1 (2%) intraoperative complication and 2 (4%) postoperative complications recorded. CONCLUSIONS: Piezourgery is a viable modality for performing external DCRs. The lack of surgical complications shows a potential for decreased soft tissues damage. The surgical success rate based on patient-reported epiphora is similar to those published for mechanical external DCRs. This modality may benefit the novice surgeon in the reduction of soft and mucosal tissue damage.

The Prevalence of Air Regurgitation and Its Consequences After Conjunctivodacryocystorhinostomy and Dacryocystorhinostomy in Continuous Positive Airway Pressure Patients.

PURPOSE: To describe the prevalence of air regurgitation into the periocular region in continuous positive airway pressure (CPAP) patients with a history of conjunctivodacryocystorhinostomy with a Lester Jones tube and a dacryocystorhinostomy with silicone intubation, as well as problems caused by this regurgitation and methods to cope. METHODS: A retrospective chart review of patients who either underwent a conjunctivodacryocystorhinostomy or dacryocystorhinostomy was performed. Patients were contacted via phone interview. Demographic information, history of sleep apnea, use of CPAP, and presence of air regurgitation and associated complications were recorded. Institutional review board/ethics committee approval was obtained. RESULTS: Two patients who underwent a conjunctivodacryocystorhinostomy with Lester Jones tube and were on CPAP were identified. Both complained of air regurgitation, sensation of Lester Jones tube moving due to regurgitation, and periodic eye pain. Twenty-two patients who underwent a dacryocystorhinostomy with silicone stent and used CPAP were identified. Of these, 16 (72.7%) complained of air regurgitation. Difficulty sleeping (56.2%), dry eye symptoms upon waking (68.8%), eye pain upon waking (31.3%), and blurry vision upon waking (12.5%) were the commonest complaints due to air regurgitation. A total of 7 (43.7%) patients had to discontinue their CPAP at some point due to symptoms. CONCLUSIONS: This study brings to light the prevalence of air regurgitation in dacryocystorhinostomy procedures, and its associated symptoms. Given that this procedure is much more common than conjunctivodacryocystorhinostomy, surgeons should consider asking patients before performing surgery whether they use CPAP. Patients should be consented regarding the risk of air regurgitation and associated dry eye, foreign body sensation, and eye pain.

A novel surgical technique for the treatment of giant fornix syndrome.

PURPOSE: To describe a novel surgical treatment for patients with chronic relapsing conjunctivitis, corneal epitheliopathy, and ptosis secondary to giant fornix syndrome. METHODS: A retrospective case series was performed looking at the presence or absence of preoperative symptoms of eye irritation, tearing, blurry vision, and discharge in 6 patients diagnosed with giant fornix syndrome. Their examination findings were noted, and all patients underwent an extensive conjunctivoplasty with resection of redundant forniceal conjunctiva with subconjunctival antibiotics. Final visual acuity, symptoms, and examination findings were noted with a minimum follow up of 9 months. RESULTS: Six patients were treated from November 2009 to November 2011. Duration of symptoms ranged from 3 to 40 months. Four patients were women while 2 were men, with age ranging from 61 to 85 years. Common symptoms were severe mucopurulent discharge, eye redness, tearing, and irritation with examination findings of severe conjunctival discharge and injection, corneal epitheliopathy, upper eyelid ptosis, and a deep upper and lower eyelid fornix. Most patients had undergone previous treatments with topical and/or oral antibiotics or steroids. All patients underwent surgical intervention using the surgical technique to be described with resolution of their symptoms, and even an improvement of 2 or more lines of best corrected visual acuity (3 of 5 patients). CONCLUSIONS: The authors' novel surgical technique helps restore the abnormal anatomy found in patients with giant fornix syndrome and thus, helps resolve chronic relapsing conjunctivitis and surface disease associated with this often underdiagnosed condition. Further studies are needed to evaluate the risk of entropion and dry eye syndrome due to the modification of the posterior lamella.

The effect of tissue wrapping on the expansion of hydrophilic orbital implants.

PURPOSE: Hydrogel implants have been used in hypoplastic orbital expansion. Advantages include insertion through a small incision and expansion without manipulation. The rapid rate of expansion, however, may lead to undesirable outcomes, including implant migration. The authors evaluate the effect of tissue wrapping on expansion of hydrogel implants. METHODS: Three identical hydrogel implants were subjected to one of 3 in vitro interventions: unwrapped control, porcine scleral-wrapped, and porcine fascia-wrapped. Each implant was submerged in normal saline solution. Diameter and volume were measured hourly for 24 hours and then every 4 hours until a plateau or maximal weight was achieved. Measurements were plotted with time as the independent variable and the above measurements as dependent variables. In addition, the best exponential function was graphed and the area under the curve was calculated. RESULTS: Linear plots of data showed a reduction in the rate of diameter and volume expansion for wrapped implants. The areas under the curve of the best-fit exponential function were less for both scleral- and fascia-wrapped implants. Fascia wrapping slowed the rate of volume expansion more than sclera. Also, fascia wrapping seemed to significantly reduce the final implant diameter and volume. CONCLUSIONS: Tissue wrapping slows the rate of expansion of hydrogel spheres in vitro. Fascia wrapping may also reduce the final implant size.

Histologic features of mesotherapy-induced orbital fat inflammation.

A 67-year-old man developed acute orbital inflammation after receiving cosmetic mesotherapy (Lipo-Dissolve) to the inferior orbital fat compartments. The injection was intended to cause lipolysis and shrinkage of fat lobules with subsequent cosmetic improvement. Injections of a mixture of bile salts, phospholipid, and alcohol preservative bilaterally in inferior orbital fat lobules led to an acute inflammatory reaction characterized histologically 12 days later by mild lymphocytic infiltration, fat necrosis, and fibrosis in the target areas. Benign proliferation of peripheral nerve trunks consistent with a traumatic neuroma was also noted histologically on one side. Inflammation including fat necrosis and traumatic neuroma are all possible consequences of mesotherapy.

Molecular characterization of antibody specificities against myelin/oligodendrocyte glycoprotein in autoimmune demyelination.

Myelin/oligodendrocyte glycoprotein (MOG) is a target antigen for myelin-destructive Abs in autoimmune central nervous system demyelinating disorders. Little is known about the molecular and structural basis of these pathogenic Ab responses. Here, we have characterized anti-MOG Ab specificities in the marmoset model of experimental allergic encephalomyelitis, by means of a combinatorial IgG-Fab library. We found that a diverse population of Ig genes encodes for auto-Abs that exclusively recognize conformation-dependent antigenic targets on MOG. These antigenic domains correspond to exposed epitopes in vivo, as the Fab fragments recognize native MOG in situ in marmoset brain tissue. The Ab fragments described here represent Ab specificities that are common constituents of the humoral immune repertoire against MOG in outbred populations, as demonstrated by their ability to displace native anti-MOG Abs present in sera from MOG-immune marmosets and patients with multiple sclerosis. Furthermore, neuropathological analysis and characterization of Ab epitope specificities in animals immunized with MOG or MOG-derived peptides revealed that only conformation-dependent Abs are associated with demyelinating activity, suggesting that epitope recognition is an important factor for Ab pathogenicity. Our findings provide novel and unexpected knowledge on the diversity of anti-MOG Ab responses in nonhuman primates and humans, and will permit the dissection of pathogenic auto-Ab properties in multiple sclerosis.