Oral cimetidine (Tagamet) for recalcitrant, diffuse conjunctival papillomatosis.

PURPOSE: To report the efficacy of cimetidine for treatment of conjunctival papillomatosis. METHODS: An 11-year-old boy had an 8-year history of diffuse conjunctival papillomas, treated previously with standard measures of excisional biopsy and cryotherapy. He developed spontaneous conjunctival bleeding and diffuse tumor recurrence over the entire conjunctival surface. Oral cimetidine liquid (30 mg/kg/day) was prescribed. RESULTS: Within 2 months, dramatic tumor regression was noted, with nearly complete resolution by 4 months. The patient had no local or systemic side effects from the medication. CONCLUSIONS: Oral cimetidine possesses immune modulation properties and may be useful in some cases of virus-induced conjunctival papillomatosis.

Balloon catheter dilation for treatment of adults with partial nasolacrimal duct obstruction: a preliminary report.

PURPOSE: The purpose of this study is to determine the efficacy and morbidity of balloon catheter dilation for treatment of partial acquired nasolacrimal duct obstruction in adults with epiphora. METHODS: We performed balloon dacryocystoplasty prospectively on a series of 15 partial nasolacrimal duct obstructions in 13 adults with epiphora. Partial obstruction was diagnosed by a negative Jones-1 test and canalicular irrigation revealing simultaneous reflux through the opposing punctum and drainage into the nose. Balloon dacryocystoplasty was performed under local anesthesia using an antegrade insertion technique. Silicone intubation of the nasolacrimal system was performed immediately after balloon catheter dilation, and the tubes were removed 2 months postoperatively. RESULTS: Success was measured objectively and subjectively at follow-up examinations 2 months and 6 months after the procedure. At 2 months, 11 (73%) of 15 obstructions were open on irrigation, with subjective success (Munk, grade 0 or grade 1) reported in 13 (87%) of 15 obstructions. At 6 months, 11 (73%) of 15 obstructions were open on irrigation, with subjective success (Munk, grade 0 or grade 1) reported in 9 (60%) of 15 obstructions. CONCLUSIONS: Balloon dacryocystoplasty may be a satisfactory primary treatment for adults with acquired partial nasolacrimal duct obstruction who exhibit no clinical signs of chronic infection. Additional long-term observations following balloon dacryocystoplasty are required.

Ocular manifestations of sarcoidosis.

Sarcoidosis remains an enigmatic disease with serious ocular morbidity. Recent literature continues to expand our knowledge of the ocular manifestations and their sequelae. Advances in diagnostic clinical testing are reviewed, including updates on angiotensin-converting enzyme levels, gallium scanning, bronchoalveolar lavage, and transbronchial lung biopsy.

Spontaneous orbital hemorrhage in pregnant women treated with subcutaneous heparin.

PURPOSE: To describe two pregnant women who developed spontaneous orbital hemorrhage following treatment with subcutaneous heparin. METHOD: Case histories and subsequent management of spontaneous orbital hemorrhage. RESULTS: Both women developed severe unilateral visual loss. CONCLUSION: In spontaneous orbital hemorrhage, anticoagulation therapy such as heparin may contribute to severe hemorrhage and visual loss.

Ocular motility disorders secondary to sinus surgery.

Sinus surgery has multiple potential ocular complications including visual loss, diplopia, infection, hemorrhage, and epiphora. We report six patients with ocular motility problems secondary to sinus surgery, review the literature on ocular motility disorders secondary to sinus surgery, and propose an approach for management of those ocular motility problems following sinus surgery. Intranasal sinus surgery was found to be the most common procedure resulting in injury to an extraocular muscle and the ethmoid sinus the most common structure being operated on when injury occurred. The medial rectus was the muscle most commonly injured and it had the poorest prognosis for recovery of functional vision free of diplopia. Optimal timing for repair depends on the structure injured, but early recognition and management appear to be a key to the best outcome for these injuries.

Orbicularis oculi muscle extirpation in a combined procedure for involutional entropion.

Many factors are important in the pathophysiology of involutional entropion, including defects of the lower eyelid retractors, canthal tendon laxity, and acquired enophthalmos. The role of the overriding preseptal orbicularis oculi muscle is often ignored in modern techniques of entropion repair. The author describes a technique of extirpation of the preseptal orbicularis oculi muscle combined with repair of the lower eyelid retractors and a lateral tarsal strip procedure for the repair of primary and recurrent involutional entropion. Lateral canthal tendon laxity is recognized in most patients in this age group and must be corrected to avoid postoperative overcorrection and ectropion. Removal of the preseptal muscle had no clinical effect on the lacrimal pump and did not cause any significant cicatricial eyelid abnormalities. This combined procedure has been used in 50 eyelids of 40 patients with excellent functional and cosmetic results. Orbicularis extirpation is not advocated in combination with a marginal rotation procedure.

Tarsoconjunctival flap for upper eyelid reconstruction.

Reconstruction of large, full-thickness upper eyelid defects is a challenge to the ophthalmic plastic surgeon. Ideally, the defect should be reconstructed with tissues similar or identical to those that have been lost. We present a procedure similar to the Hughes tarsoconjunctival flap technique for lower eyelid reconstruction. However, our technique was used for upper eyelid reconstruction. A remnant of tarsus at least 3 mm wide must be available to be advanced inferiorly in the upper eyelid. We have performed this procedure on 13 patients over ten years (1977 to 1987) with good to excellent results.

The five-flap technique for blepharophimosis.

The correction of epicanthus associated with blepharophimosis is a difficult surgical problem. Most commonly used techniques, such as the Mustardé technique, require meticulous measurements, and their theoretical geometric basis and flap designs are often confusing. We present the five-flap technique utilizing logical flap design, which is a combination of a Y-to-V flap with double opposing Z-plasties on the apex, that is well suited to this difficult problem. It is important to remove excess muscle and deep tissues underlying the flaps in the medial canthal region, which are present in blepharophimosis cases and contribute to the deformity in these patients. Medial canthal tendon resection and tucks or transnasal wiring are then performed. The technique has been utilized in 14 patients with a minimum of one year of follow-up over the past six years with good results.

The medial spindle procedure for involutional medial ectropion.

Involutional medial ectropion responds poorly to traditional ectropion procedures. Eversion of the lacrimal punctum must be functionally corrected to reestablish normal corneal wetting physiology as well as tear-lake drainage. We describe our retropunctal approach with emphasis on a new, enhanced closure that utilizes the lower eyelid retractors. This stabilizes the medial eyelid margin in order to obtain and maintain good functional and cosmetic results. This procedure allows a predictable anatomic approach that is easily performed and can be combined with other procedures, such as a lateral tarsal strip, medial canthal tendon plication, or skin graft or flap, when required.

Pediatric dacryocystorhinostomy.

Dacryocystorhinostomy (DCR) often has uncertain results in the pediatric age group. Poorly defined and rapidly changing anatomy, along with a tendency toward vigorous growth of scar tissue, may alter surgical results. We report our experience with 29 primary pediatric dacryocystorhinostomies and five reoperations. Strict attention to surgical anatomy allows attainment of success results (83%) comparable with those in adults in both traumatic and nontraumatic cases. Our results, surgical technique, and evaluation of failures are discussed. Meticulous suturing of anterior and posterior flaps is not necessary for good surgical results. Dacryocystorhinostomy is a successful therapeutic modality in childhood dacryostenosis with chronic dacryocystitis when medical therapy, probing, and silicone intubation have been unsuccessful.

Advances in orbital surgery.

Advances in diagnostic modalities, orbital anatomy, pathophysiology of orbital disorders, and surgical techniques have allowed a more functional and safer approach to orbital surgery. Recent and future research commitments to orbital disease will continue to advance our knowledge in this complex, rapidly evolving field.