Upper Eyelid Contour Changes After Müller's Muscle Conjunctiva Resection.

PURPOSE: To analyze the upper eyelid contour after Müller's muscle conjunctiva resection (MMCR) performed by four different surgeons. METHODS: Comparative cross-sectional analysis of the pre- and postoperative contours of a control group and four groups of upper lids (n = 88) of 65 patients who underwent MMCR at four international centers. The procedure employed was essentially the same as described by Putterman but performed with different instruments to entrap the posterior lamella. Multiple medial and lateral margin lid distances were measured on Bézier lines expressing the pre- and postoperative lid contours. RESULTS: Preoperatively, two groups had significant lateral and medial ptosis. After MMCR, the lateral segment of the lid's contour was corrected in all groups. In the two groups with more pronounced ptosis, the nasal lid contour was undercorrected. CONCLUSIONS: In MMCR, regardless of the instrument used to entrap the posterior lamella, the amount of medial tissue resection is essential to avoid postoperative nasal undercorrection. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Dysmorphic Concern Questionnaire: Is It Possible to Predict a Satisfactory Result After Cosmetic Eyelid Surgery?

PURPOSE: As oculofacial surgeons performing esthetic surgery, the most valuable result is a satisfied patient. It can be extremely frustrating to have an unhappy patient with, what we believe is, a satisfactory result. Therefore, the ability to predict satisfaction is of extreme importance. We studied our cosmetic eyelid surgery patients to try to find factors that can predict satisfaction. METHODS: We retrospectively studied 454 consecutive patients, who underwent any combination of 7 cosmetic surgical procedures. Patients answered the Dysmorphic Concern Questionnaire (DCQ) before surgery. We studied age, gender, type and number of procedures performed, DCQ score, presence of complications, and history of previous fillers. At the 3-month follow-up visit, patients were given an outcome report survey to graduate their surgical results on a scale from 1 to 5. Results were evaluated using a model of binary logistic regression in which the outcome variable was divided into 2 groups. RESULTS: Three hundred eighty-six patients (85%) were female and the median age was 54.8 years old. The median for the number of procedures was 2 (range, 1-5). Two hundred two of the 454 patients (44.5%) had a history of fillers. Twenty-five patients had complications. DCQ score was significantly lower in the satisfied group (median score, 3) versus the unsatisfied group (median, 6), p = 0.007. In the multiple binary logistical model, the variables age, male gender, DCQ, presence of complications, and upper eyelid blepharoplasty resulted as significant. CONCLUSIONS: We found a significant positive association with upper lid blepharoplasty and a negative association with increasing age, male gender, occurrence of complications, and DCQ score, as predictors of patient satisfaction. We routinely administer the DCQ to all cosmetic patients: It is a brief, sensitive, and specific screening instrument for body dysmorphic disorder.

Long-term outcomes of symptomatic and asymptomatic patients undergoing carotid endarterectomy in an average-volume community hospital.

BACKGROUND: Long-term benefit of carotid endarectomy has not yet been fully investigated in average volume centers. Thus our purpose is to evaluate long-term results of carotid endarterectomies at a medium-volume hospital. METHODS: A retrospective analysis of carotid artery stenosis operated between 2008 and 2017 in a community hospital was done. Demographic and postoperative outcomes were evaluated in short and long-term by Kaplan-Meier survival analysis. RESULTS: 167 procedures in 159 patients were included. Average age was 72 years, and 65% were men. Twenty-nine percent of the patients were symptomatic and the rest asymptomatic. Median hospitalization was 3 (IQR 3-4) days and the mean follow-up was 56 months. No hospital mortality was recorded. At 120-month follow-up, freedom of stroke was 97.4%, death 97.3%, restenosis, 98.7% and all combined events 92.9% (log rank p = .042) Combined event-free survival was 84.4% in symptomatic patients, and 96.1% in asymptomatic patients (log rank p = .025). CONCLUSIONS: In a medium-volume hospital combined event-free survival was 84.4% in symptomatic patients and 96.1% in asymptomatic at a 10-year follow-up.

Orbital Bone Decompression for Non-Thyroid Eye Disease Proptosis.

PURPOSE: To report a multicenter large case series of orbital decompression for non-thyroid eye disease proptosis. METHODS: Retrospective chart review of cases of orbital decompression performed by 9 experienced orbital surgeons from different countries from 2014 to 2017 for non-thyroid eye disease proptosis. Patients were divided into 3 groups: 1) negative vector (high axial length or shallow orbit), 2) inflammatory, and 3) tumor. Types of orbital decompression and Hertel exophthalmometry (preoperative and minimum 6 months postoperative) were recorded. Charts were also assessed for serious complications. The amount of exophthalmometry improvement was recorded according to the above groups. RESULTS: The analysis included 41 orbits of 29 patients (14 women and 15 men) with a mean age of 38.9 years (ranging from 9 to 74; standard deviation (SD) 15.66). There were 17 orbits of 11 patients in the negative vector group, 16 orbits of 10 patients in the inflammatory group, and 8 orbits of 8 patients in the tumor group. The mean reduction of proptosis was 2.95 mm in the negative vector group, 2.54 mm in the inflammatory group, and 5.75 mm in the tumor group. There were no serious complications. CONCLUSIONS: Orbital decompression was safe and effective in reducing proptosis for non-thyroid eye disease indications in this series. The amount of exophthalmometry improvement was less in the inflammatory orbitopathy group compared with other proptosis etiology groups.Orbital decompression may have a role in improving proptosis in non-thyroid eye disease entities.

[Recalcitrant cicatrizing conjunctivitis. Treatment of nine patients with rituximab]. / Conjuntivitis cicatrizal recalcitrante. Tratamiento de nueve pacientes con rituximab.

Cicatrizing conjunctivitis is the final consequence of several diseases. The most severe among them are cicatricial pemphigoid and chronic Stevens-Johnson syndrome. Systemic immunosuppressive drugs and steroids are usually an effective approach to these diseases. However, a few patients follow a recalcitrant course unremitting to usual therapy. We describe the treatment with rituximab of seven patients with cicatricial pemphigoid and two with chronic Stevens-Johnson syndrome. Eight of them also received gammaglobulin and all achieved clinical remission. Three relapsed and required two or three new courses of rituximab with good control of disease activity. Rituximab proved to be an efficacious drug for chronic recalcitrant cicatrizing conjunctivitis.

La conjuntivitis cicatrizal es la consecuencia de distintas enfermedades oculares. Entre ellas, las más graves son el penfigoide cicatrizal y el síndrome de Stevens-Johnson crónico. El tratamiento de estas enfermedades con corticoides e inmunosupresores es habitualmente exitoso, pero unos pocos pacientes siguen un curso recalcitrante. En los últimos años se introdujo el uso de rituximab, asociado o no a gammaglobulina endovenosa, en forma abierta, para el control de la inflamación conjuntival. Describimos aquí el tratamiento de siete pacientes con penfigoide y dos con Stevens-Johnson recalcitrante, con rituximab. Ocho recibieron también gammaglobulina y todos alcanzaron la remisión de la actividad. Tres recayeron y recibieron dos o tres nuevos cursos de la medicación con mejoría sintomática. El rituximab probó ser una droga efectiva para el tratamiento de la conjuntivitis cicatrizal crónica recalcitrante.

Conjuntivitis cicatrizal recalcitrante: Tratamiento de nueve pacientes con rituximab / Recalcitrant cicatrizing conjunctivitis. Treatment of nine patients with rituximab

La conjuntivitis cicatrizal es la consecuencia de distintas enfermedades oculares. Entre ellas, las más graves son el penfigoide cicatrizal y el síndrome de Stevens-Johnson crónico. El tratamiento de estas enfermedades con corticoides e inmunosupresores es habitualmente exitoso, pero unos pocos pacientes siguen un curso recalcitrante. En los últimos años se introdujo el uso de rituximab, asociado o no a gammaglobulina endovenosa, en forma abierta, para el control de la inflamación conjuntival. Describimos aquí el tratamiento de siete pacientes con penfigoide y dos con Stevens-Johnson recalcitrante, con rituximab. Ocho recibieron también gammaglobulina y todos alcanzaron la remisión de la actividad. Tres recayeron y recibieron dos o tres nuevos cursos de la medicación con mejoría sintomática. El rituximab probó ser una droga efectiva para el tratamiento de la conjuntivitis cicatrizal crónica recalcitrante.

Cicatrizing conjunctivitis is the final consequence of several diseases. The most severe among them are cicatricial pemphigoid and chronic Stevens-Johnson syndrome. Systemic immunosuppressive drugs and steroids are usually an effective approach to these diseases. However, a few patients follow a recalcitrant course unremitting to usual therapy. We describe the treatment with rituximab of seven patients with cicatricial pemphigoid and two with chronic Stevens-Johnson syndrome. Eight of them also received gammaglobulin and all achieved clinical remission. Three relapsed and required two or three new courses of rituximab with good control of disease activity. Rituximab proved to be an efficacious drug for chronic recalcitrant cicatrizing conjunctivitis.

Autologous fat transfer with SEFFI (superficial enhanced fluid fat injection) technique in periocular reconstruction.

PURPOSE: To evaluate the aesthetic and functional outcomes of autologous fat transfer using the SEFFI (superficial enhanced fluid fat injection) technique for reconstruction of the periocular area. METHODS: Autologous fat injections prepared with the 0.5 mL and 0.8 mL SEFFI technique were used in four patients for periocular rehabilitation. RESULTS: Case 1 (C1): A patient with left-sided progressive facial hemiatrophy underwent ipsilateral volumizing with 0.8 SEFFI in the superior, temporal, and inferior periorbital areas, and 0.5 SEFFI in both eyelids. C2: A 21-year-old female with a post trauma frontal scar, left ptosis, and lower eyelid retraction was treated with 0.5 SEFFI applied in the scar area associated with an upper eyelid conjunctivomullerectomy and resection of the lower eyelid retractors. C3: A patient with previous left-eye evisceration and orbital floor and medial wall fractures underwent socket reconstruction with buccal mucosal graft in the lower fornix and 0.5 SEFFI injections in both superior and inferior eyelids. SEFFI was also applied in the intraorbital space for correction of the enophthalmos. C4: A patient with lower lid retraction post blepharoplasty was treated with 0.8 SEFFI injections in lower eyelids and malar areas, complemented with a bilateral lateral cantopexy. CONCLUSIONS: Autologous fat transfer with SEFFI technique is an effective and safe procedure in cases of periocular rehabilitation.

Multinational Comparison of Prophylactic Antibiotic Use for Eyelid Surgery.

IMPORTANCE: Antibiotic stewardship is important in controlling resistance, adverse reactions, and cost. The literature regarding antibiotic use for eyelid surgery is lacking. OBJECTIVES: To determine standard care and assess factors influencing antibiotic prescribing practices for eyelid surgery. DESIGN, SETTING, AND PARTICIPANTS: A survey study was conducted from February 2, 2014, to March 24, 2014. The survey was distributed to 2397 oculoplastic surgeons in private and academic oculoplastic surgery practices in 43 countries. All surgeons were members of ophthalmic plastic and reconstructive surgery societies. Data were analyzed by geographic location. Linear regression was performed to quantify contributions to rates of prescribing postoperative antibiotics for routine eyelid surgical procedures. MAIN OUTCOMES AND MEASURES: Rates of prescribing prophylactic intravenous, oral, and topical antibiotics as well as factors that influence surgeons' prescribing practices. RESULTS: A total of 782 responses were received from 2397 surgeons (average response rate, 36.7%; 2.5% margin of error) from 43 countries. Topical antibiotic use was common in all regions (85.2%). Perioperative intravenous antibiotic use was uncommon in all regions (13.5%). Geographic location was the greatest predictor of antibiotic prescribing practices (range, 2.9% in the United Kingdom to 86.7% in India; mean, 24%). Within Europe, Italy had the highest rate of antibiotic prescriptions for eyelid surgery (41.7%) and the United Kingdom had the lowest rate (2.9%.) In South America, Venezuela had the highest rate of antibiotic prescriptions for eyelid surgery (83.3%) and Chile had the lowest rate (0%). The practice locations that were associated with routinely prescribing postoperative oral antibiotics were India (odds ratio [OR], 15.83; 95% CI, 4.85-51.68; P < .001), Venezuela (OR, 13.47; 95% CI, 1.43-127.19; P = .02), and Southeast Asia (OR, 2.80; 95% CI, 1.15-6.84; P = .02). Conversely, practice location in the United Kingdom (OR, 0.048; 95% CI, 0.0063-0.37; P = .004), Australia and New Zealand (OR, 0.15; 95% CI, 0.033-0.67; P = .01), and the United States and Canada (OR, 0.41; 95% CI, 0.23-0.72; P = .002) were associated with decreased rates of postoperative oral antibiotic use. Surgeons' concern for allergic reactions was associated with decreased rates of prescribing antibiotics (OR, 0.34; 95% CI, 0.23-0.49; P < .001), while surgeons' concern for infection was associated with increased rates of prescribing antibiotics (OR 1.80; 95% CI, 1.45-2.23; P < .001). CONCLUSIONS AND RELEVANCE: These results from members of ophthalmic plastic and reconstructive surgery societies confirm that antibiotic prescribing practices for routine eyelid surgical procedures vary widely throughout the world. No standard of care has been established that would require the routine use of postoperative prophylactic antibiotics following eyelid surgery.

Supramaximal levator resection for unilateral congenital ptosis: cosmetic and functional results.

PURPOSE: To analyze the cosmetic and functional results of a large series of patients with unilateral congenital ptosis without spontaneous compensatory ipsilateral frontalis hyperaction who underwent supramaximal levator resection (SMLPSr). METHODS: A multicenter retrospective review of 35 children (14 girls and 21 boys) of mean age 5.5±3.6 SD years with unilateral congenital ptosis who underwent surgery in 3 different countries: Italy, n=8; Argentina, n=11; and Brazil, n=16. Preoperative evaluation included measurements of upper eyelid margin reflex distance (MRD1) and levator palpebrae superioris muscle excursion, assessment of frontalis hyperaction, and ocular motility examination. At least 6 months postoperatively, photographs were used to measure the upper eyelid contour of OU. The spontaneous blinking amplitude and downward eyelid saccades of OU were quantified in a subset of 14 patients. Quantitative comparison among the 3 centers was performed with nonparametric 1-way analysis of variance (Kruskal-Wallis). Paired t tests were used to compare the pre- and postoperative measurements, and p value<0.05 was statistically significant. RESULTS: The mean preoperative MRD1 of the operated eyes increased from 0.5±1.1 SD mm to 3.4±0.84 SD mm (t=15.9; p<0.000001), consequently the eyelid positional asymmetry decreased from 3.1±1.21 mm to 0.1±0.86 SD mm (t=16.5; p≤0.000001). Twenty-nine percent of eyelids had mild contour abnormalities and 31.4% showed some degree of lash ptosis. Spontaneous blinks were abnormal in 93% of the cases (eyelids). The amplitude of the abnormal blinks ranged from 12.9% to 65.4% (mean=37.1%) of the contralateral eyelids. Downward eyelid saccades were reduced in 79% of the eyelids. The amplitudes the saccades ranged from 2.2% to 84.6% (mean=54.8%). CONCLUSIONS: In unilateral congenital ptosis, SMLPSr effectively reduces the positional asymmetry between eyelids. Mild contour abnormalities and lash ptosis are the main complications of the surgery. Postoperatively, spontaneous blinks and downward saccades were reduced in most eyelids. The reduced postoperative eyelid kinetics indicates that only patients with normal upward Bell signs are good candidates for this procedure.

Calcium hydroxyl-apatite (Radiesse) for the correction of periorbital hollows, dark circles, and lower eyelid bags.

PURPOSE: To describe the authors experience with calcium hydroxyl-apatite (CaHa) injections for the aesthetic correction of tear trough, infraorbital hollows, deep upper sulcus, dark circles and lower eyelid bags. METHODS: The records of 63 patients (127 eyelids) injected with CaHa for aesthetic rejuvenation of the periocular region between March 2012 and March 2013 were retrospectively evaluated. All injections were carried out using a 25-gauge cannula after adding 0.5 ml of 2% lidocaine to 1.5 ml vials of the original product. Postoperative visits were scheduled at 1 week and 1 month. Any previous treatment was recorded, and necessity of retreatments and side effects was evaluated. Patient satisfaction was recorded at 1 month with self-evaluation of the treatment result as "worsened," "unchanged," or "improved." Standard pre- and postinjection photographs were taken and compared to analyze the success of the procedure. Pictures were retrospectively graded by the authors on a similar improvement scale of 1 (worse), 2 (no change), and 3 (improvement). RESULTS: Fifty-eight/sixty-three patients were women (92%), with an average age of 42 years (range; 18-57 years). Chief complaints were "hollows" in 94% of patients, "dark circles" in 33%, lower eyelid "bags" in 17%, and deep upper sulcus in 4.7%. Twenty-three patients (36.5%) required an additional correction 1 month after the primary treatment. Satisfaction was as high as 98% among patients treated primarily for hollowness, and the overall satisfaction rate was 92%. Associated dark circles were satisfactorily treated in 68% of the patients. Temporary side effects involved mild erythema and swelling for 2 to 3 days and pseudoxanthalesma effect in 22 eyelids (17.4%) lasting <6 weeks. In 2 patients, erythema lasted longer than 4 weeks. The 2 worse complications in this series were migration of the product above the medial canthal tendon in 1 patient and overcorrection in another patient. These complications were all managed conservatively and resolved spontaneously within 6 to 8 weeks. No case of irregular contour, palpable lumpiness, or unevenness were encountered. In the end, only 1 patient thought she was worsened after the treatment. CONCLUSIONS: Treatment of the periocular region with CaHa injections is a safe and effective treatment with high patient satisfaction and low complication rate. Advanced technical skills may have to be acquired for the specific treatment of this area using this particulate material.

[Systemic treatment of ocular cicatricial pemphigoid]. / Tratamiento sistémico del penfigoide cicatrizal ocular.

Ocular cicatricial pemphigoid (OCP) is a blistering autoimmune disease that can produce severe conjunctival damage. Its response to immunosuppressive treatment is poorly known. We describe a group of 76 patients, 62 women and 14 men. Mean age at diagnosis was 67±14 years old, with a delay to diagnosis of 7.5±10 years. Sixty patients continued their follow up in our services for 19±21 months. Nineteen out of 51 had mild disease, 19 moderate, 5 severe and 8 very severe at onset of treatment. The more frequently prescribed drugs were dapsone, in 35 (23 discontinued it because of adverse effects), and methotrexate in 42 patients, nine of them stopped it. Other patients received azathioprine, cyclophosphamide and ciclosporine. Seventeen received oral steroids in addition to immunosuppressive drugs. Four patients combined two immunosuppressive drugs to control their disease. In three refractory cases IV immunoglobulin (Ig) was administered with good response. From 48 evaluated patients, 39 improved with treatment, eight remained stable and one progressed. In our experience, methotrexate and azathioprine were effective drugs, with low toxicity. Dapsone was useful in mild cases, with frequent adverse effects. IVIg was effective for refractory cases.

Tratamiento sistémico del penfigoide cicatrizal ocular / Systemic treatment of ocular cicatricial pemphigoid

El penfigoide cicatrizal ocular (PCO) es una enfermedad ampollar autoinmune que produce daño conjuntival grave. Se conoce poco acerca de la respuesta del PCO al tratamiento inmunosupresor. Describimos un grupo de 76 pacientes con PCO, 62 mujeres y 14 hombres. La edad media al diagnóstico fue de 67 ± 14 años, con un retraso de 7.5 ± 10 años. Sesenta se siguieron en nuestro servicio por 19 ± 21 meses. De 51 en quienes se describe la gravedad de la enfermedad al inicio del tratamiento, fue leve en 19 pacientes, moderada en 19, grave en cinco y muy grave en ocho. Las drogas mayormente prescriptas fueron dapsona en 35 pacientes, de los que 23 la discontinuaron por efectos adversos, y metotrexate en 42, de los que nueve lo suspendieron. Otros recibieron azatioprina, ciclofosfamida y ciclosporina. A 17 se les indicaron corticoides orales, además del inmunosupresor. Cuatro combinaron dos drogas para controlar la enfermedad. Tres pacientes refractarios recibieron gammaglobulina EV con buena respuesta. De 48 evaluados, 39 mostraron mejoría, ocho no tuvieron cambios y uno progresó. En nuestra experiencia, metotrexate y azatioprina son efectivos, con baja toxicidad. Dapsona es útil en casos leves, con efectos adversos frecuentes. La gammaglobulina EV fue efectiva en casos refractarios.(AU)

Ocular cicatricial pemphigoid (OCP) is a blistering autoimmune disease that can produce severe conjunctival damage. Its response to immunosuppressive treatment is poorly known. We describe a group of 76 patients, 62 women and 14 men. Mean age at diagnosis was 67±14 years old, with a delay to diagnosis of 7.5±10 years. Sixty patients continued their follow up in our services for 19±21 months. Nineteen out of 51 had mild disease, 19 moderate, 5 severe and 8 very severe at onset of treatment. The more frequently prescribed drugs were dapsone, in 35 (23 discontinued it because of adverse effects), and methotrexate in 42 patients, nine of them stopped it. Other patients received azathioprine, cyclophosphamide and ciclosporine. Seventeen received oral steroids in addition to immunosuppresive drugs. Four patients combined two immunosupressive drugs to control their disease. In three refractory cases IV immunoglobulin (Ig) was administered with good response. From 48 evaluated patients, 39 improved with treatment, eight remained stable and one progressed. In our experience, methotrexate and azathioprine were effective drugs, with low toxicity. Dapsone was useful in mild cases, with frequent adverse effects. IVIg was effective for refractory cases.(AU)

Tratamiento sistémico del penfigoide cicatrizal ocular / Systemic treatment of ocular cicatricial pemphigoid

El penfigoide cicatrizal ocular (PCO) es una enfermedad ampollar autoinmune que produce daño conjuntival grave. Se conoce poco acerca de la respuesta del PCO al tratamiento inmunosupresor. Describimos un grupo de 76 pacientes con PCO, 62 mujeres y 14 hombres. La edad media al diagnóstico fue de 67 ñ 14 años, con un retraso de 7.5 ñ 10 años. Sesenta se siguieron en nuestro servicio por 19 ñ 21 meses. De 51 en quienes se describe la gravedad de la enfermedad al inicio del tratamiento, fue leve en 19 pacientes, moderada en 19, grave en cinco y muy grave en ocho. Las drogas mayormente prescriptas fueron dapsona en 35 pacientes, de los que 23 la discontinuaron por efectos adversos, y metotrexate en 42, de los que nueve lo suspendieron. Otros recibieron azatioprina, ciclofosfamida y ciclosporina. A 17 se les indicaron corticoides orales, además del inmunosupresor. Cuatro combinaron dos drogas para controlar la enfermedad. Tres pacientes refractarios recibieron gammaglobulina EV con buena respuesta. De 48 evaluados, 39 mostraron mejoría, ocho no tuvieron cambios y uno progresó. En nuestra experiencia, metotrexate y azatioprina son efectivos, con baja toxicidad. Dapsona es útil en casos leves, con efectos adversos frecuentes. La gammaglobulina EV fue efectiva en casos refractarios.(AU)

Ocular cicatricial pemphigoid (OCP) is a blistering autoimmune disease that can produce severe conjunctival damage. Its response to immunosuppressive treatment is poorly known. We describe a group of 76 patients, 62 women and 14 men. Mean age at diagnosis was 67ñ14 years old, with a delay to diagnosis of 7.5ñ10 years. Sixty patients continued their follow up in our services for 19ñ21 months. Nineteen out of 51 had mild disease, 19 moderate, 5 severe and 8 very severe at onset of treatment. The more frequently prescribed drugs were dapsone, in 35 (23 discontinued it because of adverse effects), and methotrexate in 42 patients, nine of them stopped it. Other patients received azathioprine, cyclophosphamide and ciclosporine. Seventeen received oral steroids in addition to immunosuppresive drugs. Four patients combined two immunosupressive drugs to control their disease. In three refractory cases IV immunoglobulin (Ig) was administered with good response. From 48 evaluated patients, 39 improved with treatment, eight remained stable and one progressed. In our experience, methotrexate and azathioprine were effective drugs, with low toxicity. Dapsone was useful in mild cases, with frequent adverse effects. IVIg was effective for refractory cases.(AU)

Tratamiento sistémico del penfigoide cicatrizal ocular / Systemic treatment of ocular cicatricial pemphigoid

El penfigoide cicatrizal ocular (PCO) es una enfermedad ampollar autoinmune que produce daño conjuntival grave. Se conoce poco acerca de la respuesta del PCO al tratamiento inmunosupresor. Describimos un grupo de 76 pacientes con PCO, 62 mujeres y 14 hombres. La edad media al diagnóstico fue de 67 ± 14 años, con un retraso de 7.5 ± 10 años. Sesenta se siguieron en nuestro servicio por 19 ± 21 meses. De 51 en quienes se describe la gravedad de la enfermedad al inicio del tratamiento, fue leve en 19 pacientes, moderada en 19, grave en cinco y muy grave en ocho. Las drogas mayormente prescriptas fueron dapsona en 35 pacientes, de los que 23 la discontinuaron por efectos adversos, y metotrexate en 42, de los que nueve lo suspendieron. Otros recibieron azatioprina, ciclofosfamida y ciclosporina. A 17 se les indicaron corticoides orales, además del inmunosupresor. Cuatro combinaron dos drogas para controlar la enfermedad. Tres pacientes refractarios recibieron gammaglobulina EV con buena respuesta. De 48 evaluados, 39 mostraron mejoría, ocho no tuvieron cambios y uno progresó. En nuestra experiencia, metotrexate y azatioprina son efectivos, con baja toxicidad. Dapsona es útil en casos leves, con efectos adversos frecuentes. La gammaglobulina EV fue efectiva en casos refractarios.

Ocular cicatricial pemphigoid (OCP) is a blistering autoimmune disease that can produce severe conjunctival damage. Its response to immunosuppressive treatment is poorly known. We describe a group of 76 patients, 62 women and 14 men. Mean age at diagnosis was 67±14 years old, with a delay to diagnosis of 7.5±10 years. Sixty patients continued their follow up in our services for 19±21 months. Nineteen out of 51 had mild disease, 19 moderate, 5 severe and 8 very severe at onset of treatment. The more frequently prescribed drugs were dapsone, in 35 (23 discontinued it because of adverse effects), and methotrexate in 42 patients, nine of them stopped it. Other patients received azathioprine, cyclophosphamide and ciclosporine. Seventeen received oral steroids in addition to immunosuppresive drugs. Four patients combined two immunosupressive drugs to control their disease. In three refractory cases IV immunoglobulin (Ig) was administered with good response. From 48 evaluated patients, 39 improved with treatment, eight remained stable and one progressed. In our experience, methotrexate and azathioprine were effective drugs, with low toxicity. Dapsone was useful in mild cases, with frequent adverse effects. IVIg was effective for refractory cases.

Minimally invasive conjunctivodacryocystorhinostomy with Jones tube.

PURPOSE: To describe a minimally invasive technique for conjunctivodacryocystorhinostomy with the Jones tube. This technique creates a direct communication between the conjunctiva and the middle meatus with the use of a 14-gauge angiocatheter. The glass tube is inserted under endoscopic or direct visualization. METHODS: A retrospective review of consecutive patients who underwent the minimally invasive technique for conjunctivodacryocystorhinostomy for complete bicanalicular lacrimal obstruction was performed. The surgical time, intraoperative and postoperative complications, length of the tubes, long-term patency, tube displacement, and need for secondary revision were evaluated. RESULTS: Fifty-five consecutive patients were included in the study. All surgical procedures were successfully performed without significant complications, in an operating time that averaged 16 minutes. In one early case, a patient had persistent postoperative bleeding that required cauterization of the middle turbinate. In 3 patients, late migration of the Jones tube into the nasal cavity required secondary intervention with successful Jones tube repositioning. Minor office tube cleaning was performed without removal of the tube. The patency of the Jones tube was regularly tested with demonstration of aspiration of 2% fluorescein solution from the tear meniscus in the tear lake opening of the tube at the slit lamp, the passage of the same solution in the nose with endoscopic view, and finally, with irrigation of saline solution in the tube. CONCLUSIONS: The minimally invasive technique for conjunctivodacryocystorhinostomy with the Jones tube can be successfully performed with a simple "poke-through" technique from the conjunctiva to the nose with direct or endoscopic control. This technique has proved to be time-effective and well tolerated by patients.