Digital subtraction dacryocystography and syringing in the management of epiphora.

AIM: To compare the diagnostic information provided by digital subtraction dacryocystography (DCG) and syringing of the nasolacrimal system in patients with epiphora. METHODS: Twenty-five lacrimal systems of 17 patients, who presented with unilateral or bilateral epiphora and no concurrent ocular or lid abnormality, were prospectively entered into the study. The patients initially underwent syringing by a lacrimal specialist followed by DCG. RESULTS: Anatomical obstructions were detected in 88% of systems with syringing and in 84% with DCG. The anatomical sites of obstruction varied between the two tests in 20% of lacrimal drainage systems. Additional useful information was provided by DCG in 28% of the cases, including identification of multiple sites of obstruction, the presence of dacryoliths, fistulae, and congenital malpositions of the nasolacrimal sac-duct junction. CONCLUSION: The two investigations were found to have comparable detection rates for anatomical obstructions. Syringing thus appears to be able to detect the problem in the majority of cases but DCG can help delineate unidentified factors of surgical significance in a selected subgroup of patients.

Sub-Tenon anaesthesia: reduction in subconjunctival haemorrhage with controlled bipolar conjunctival cautery.

PURPOSE: To evaluate the effect of controlled conjunctival cautery on the frequency and extent of subconjunctival haemorrhage (SCH) associated with sub-Tenon anaesthetic (STA) injection in patients with various clotting states. METHODS: One hundred forty-four patients suitable for cataract surgery with STA were prospectively divided into four groups: group A (n=36) were on warfarin (INR 1.8-4.2); group B (n=48) on aspirin (75 mg); group C (n=12) on clopidogrel (75 mg); and group D (n=48) on no anticoagulant or antiplatelet agents. All patients had no other known coagulopathy. Each group was randomly divided into two subgroups, one of which received localised bipolar cautery under microscope control to the STA conjunctival entry site before tissue dissection, whereas the other served as a control. chi(2) and Fisher's exact tests were used to analyse the data with the SPSS package (v11.0). RESULTS: Conjunctival cautery reduced the frequency of SCH from 67 to 6% in group A (P=0.0001); from 37.5 to 4% in group B (P=0.005); from 50 to 0% in group C (P=0.9); and from 17 to 0% in group D (P=0.55). This overall reduction in SCH was highly significant (P<0.0001), especially in groups A and B. No statistically significant reduction in the extent of SCH was found. CONCLUSIONS: Controlled localised bipolar conjunctival cautery before STA injection may significantly reduce the frequency of SCH, especially in patients on warfarin or aspirin.

Eye injury as a result of coat toggle trauma.

PURPOSE: To report the severity of ocular injury in three adults with blunt ocular trauma resulting from elastic corded coat toggles. DESIGN: Observational case series. METHODS: We retrospectively reviewed the case records of all patients (n=3) with blunt ocular trauma secondary to elastic corded coat toggles that presented to our department. RESULTS: Injuries included traumatic hyphaema, cataract, angle recession, vitreous haemorrhage and retinal tears. CONCLUSIONS: Significant ocular injury can result from elasticated coat toggles. The general ophthalmologist should be aware of this new method of potentially sight threatening trauma.

Radiological classification of anterior skull base anatomy prior to performing medial orbital wall decompression.

PURPOSE: To study a radiological classification, originally described by Keros in 1965, which provides an objective assessment of anterior skull base anatomy relevant in patients undergoing external medial orbital decompression. MATERIALS AND METHODS: The classification is based on anatomical landmarks measured via coronal CT-scan. The patients are divided into 3 Keros categories based on their olfactory fossa depth; Keros 1 (1-3 mm), Keros 2 (4-7 mm) and Keros 3 (8-16 mm). A cross-sectional group of 32 consecutive patients on the hospital radiology database with coronal CT scans were classified according to the Keros system. RESULTS: All the patients fell into one of the three Keros categories. Anatomical associations of the Keros classification suggest that Keros 1 patients have the least risk of intracranial entry whilst Keros 3 patients carry the greatest risk. CONCLUSION: Keros classification provides an objective assessment of anterior skull base anatomy and can therefore guide the surgeon on the superior extent of medial wall bone removal during orbital decompression. This may help improve the safety profile of the procedure.

Spontaneous bony orbital auto-decompression in thyroid ophthalmopathy.

Orbital 'auto-decompression' in TED (thyroid eye disease) is a well recognised phenomenon in older patients where lax orbital septa allow proptosis to decompress the orbit. Bony 'auto-decompression' in TED is a different entity which to the best of our knowledge has not been previously reported. We describe such a case which presented spontaneously, in the absence of trauma or bony pathology, and discuss possible causes.