The Effectiveness and Long-Term Outcome of Conjunctivodacryocystorhinostomy With Frosted Jones Tubes.

PURPOSE: To describe success rates and long-term outcomes of conjunctivodacryocystorhinostomy (CDCR) with frosted Jones tubes (FJT) for epiphora with proximal outflow obstruction. METHODS: A retrospective chart review of all patients undergoing external and endoscopic CDCR with FJTs by one author (RAD) was performed between January 1, 2006 and November 1, 2014 at the Casey Eye Institute. Patient demographics, etiology of tearing, concurrent endonasal and eyelid procedures, and FJT size were recorded. After CDCR, follow-up time, tube size changes, tube position, and tearing status were noted. Exclusion criteria included follow up less than 6 months and/or prior CDCR. The study was IRB approved, HIPAA compliant, and adherent to the declaration of Helsinki. RESULTS: Forty-two eyes of 31 patients met the inclusion criteria, with the majority having epiphora from canalicular obstruction (31%) or flaccid canaliculi (31%). Average follow up was 1,088 days. Forty of 42 eyes, or 30 of 31 patients, had complete resolution of tearing after surgery. Twenty of 42 eyes required tube size changes, usually an increase in collar size (45%) and/or decrease in tube length (55%). Six of 42 FJTs were lost, one migrating outward, with an average time to loss between 61 and 1,122 days (mean 817 days). After collars larger than 4 mm became available, only one tube was lost. All epiphora resolved after repeat CDCR. The most common complication was intermittent irritation (17%) near the FJT that resolved after antibiotic-steroid drops and/or tube replacement/cleaning. CONCLUSION: CDCR with FJTs is highly effective in correcting epiphora, and well tolerated by the majority.

Bacterial Biofilms in Jones Tubes.

PURPOSE: To investigate the presence and microbiology of bacterial biofilms on Jones tubes (JTs) by direct visualization with scanning electron microscopy and polymerase chain reaction (PCR) of representative JTs, and to correlate these findings with inflammation and/or infection related to the JT. METHODS: In this study, prospective case series were performed. JTs were recovered from consecutive patients presenting to clinic for routine cleaning or recurrent irritation/infection. Four tubes were processed for scanning electron microscopy alone to visualize evidence of biofilms. Two tubes underwent PCR alone for bacterial quantification. One tube was divided in half and sent for scanning electron microscopy and PCR. Symptoms related to the JTs were recorded at the time of recovery. RESULTS: Seven tubes were obtained. Five underwent SEM, and 3 out of 5 showed evidence of biofilms (60%). Two of the 3 biofilms demonstrated cocci and the third revealed rods. Three tubes underwent PCR. The predominant bacteria identified were Pseudomonadales (39%), Pseudomonas (16%), and Staphylococcus (14%). Three of the 7 patients (43%) reported irritation and discharge at presentation. Two symptomatic patients, whose tubes were imaged only, revealed biofilms. The third symptomatic patient's tube underwent PCR only, showing predominantly Staphylococcus (56%) and Haemophilus (36%) species. Two of the 4 asymptomatic patients also showed biofilms. All symptomatic patients improved rapidly after tube exchange and steroid antibiotic drops. CONCLUSIONS: Bacterial biofilms were variably present on JTs, and did not always correlate with patients' symptoms. Nevertheless, routine JT cleaning is recommended to treat and possibly prevent inflammation caused by biofilms.

Predictability of Optic Foramen Location From a Ray Through the Ethmoidal Foramina.

PURPOSE: To determine how accurately a ray through the anterior and posterior ethmoidal foramina predicts the location of the optic foramen. METHODS: Dried, well-preserved, complete human skulls without bony defects belonging to the Hamann-Todd osteological collection of the Cleveland Museum of Natural History were examined. Photography was performed and a ray was drawn on orbit photographs extending through the center of the anterior and posterior ethmoidal foramina toward the optic canal. The location of the ray at the anterior aspect of the optic canal was recorded. RESULTS: Sixty-six total orbits were examined from 36 skulls with 6 skulls with only unilateral data. Thirty-eight orbits were of African descent and 28 were of European descent with an average age 45.25 years (range = 19-89 years). The anterior-posterior ethmoidal foramen ray extended superior (12/66), through (53/66), and inferior (1/66) to the optic canal. Of those rays passing through the optic canal, 32/53 (60%) passed through the upper one-third, 19/53 (36%) passed through the middle one-third, and 2/53 (4%) passed through the lower one-third of the optic canal. CONCLUSIONS: The anterior-posterior ethmoidal foramen ray highly predicts the superior aspect of the optic canal. This information can guide medial orbital wall surgery.

Porcine dermal collagen in lower eyelid retraction repair.

PURPOSE: To describe clinical outcomes of patients receiving porcine dermal matrix implants for lower eyelid retraction repair. METHODS: A retrospective review of all patients who underwent lower eyelid retraction repair with porcine dermal matrix implantation between June 2007 and July 2013 at a tertiary care center was conducted. Patient demographics, procedure(s) performed, preoperative and postoperative marginal reflex distance, inferior scleral show, and complications were reviewed. Patients with a prior history of lower eyelid surgery were excluded. The study is Health Insurance Portability and Accountability Act compliant, institutional review board approved, and adherent to the Declaration of Helsinki. RESULTS: One hundred patients (160 eyelids) received porcine dermal collagen implants. Fifty-six patients had thyroid eye disease, 23 had midface descent, 10 had seventh nerve palsies, and 11 had other etiologies of retraction. The average preoperative marginal reflex distance was 7.64 mm in the OD and 7.17 mm in the OS, compared with 6.40 mm in the OD and 6.22 mm in the OS postoperatively. The average preoperative inferior scleral show was 2.04 in the OD and 1.70 in the OS compared with 0.81 mm in the OD and 0.65 mm in the OS postoperatively. Follow up ranged from 1.46 to 66.04 months, with an average of 14.06 months and median of 8.84 months. Nineteen eyelids had implant-related complications: 7 with cyst formation, 7 with exposure/rejection, 2 with long-term pain, 2 with transient inflammation, and 3 with irregular implant contour. CONCLUSIONS: Porcine dermal matrix implants provide reliable support, integration, and function in lower eyelid retraction repair without significant resorption or complications in the majority of patients.

Treatment modalities of thyroid related orbitopathy.

AIMS: The aim was to highlight recent advances in the treatment of thyroid eye disease. SETTINGS AND DESIGN: Review article. MATERIALS AND METHODS: Existing literature and the authors' experience was reviewed. RESULTS: Thyroid ophthalmopathy is a disfiguring and vision-threatening complication of autoimmune thyroid disease that may develop or persist even in the setting of well-controlled systemic thyroid status. Treatment response can be difficult to predict, and optimized algorithms for disease management do not exist. Thyroid ophthalmopathy should be graded for both severity and disease activity before choosing a treatment modality for each patient. The severity of the disease may not correlate directly with the activity; medical treatment is most effective in active disease, and surgery is usually reserved for quiescent disease with persistent proptosis and/or eyelid changes. CONCLUSIONS: Intravenous pulsed corticosteroids, orbital radiotherapy, and orbital surgical techniques form the mainstay of current management of thyroid ophthalmopathy. Immunosuppressive and biologic agents may have a role in treating active disease although additional safety and efficacy studies are needed.

Very late-onset corneal scar triggered by trauma after photorefractive keratectomy.

A 54-year-old woman who had photorefractive keratectomy (PRK) more than 10 years earlier presented with a history of being hit in the eye by a tree branch and developing blurred vision a short time later. The corrected visual acuity was 20/100 with localized grade 3 stromal haze. The haze intensified despite initial response to corticosteroids and cyclosporine, and treatment with phototherapeutic keratectomy and 0.02% mitomycin-C (MMC) was effective in restoring corneal clarity and normal vision. Late-onset stromal scar can be triggered by trauma years after PRK. Phototherapeutic keratectomy with MMC can be an effective treatment for late-onset scar. Persistent haze or scar after trauma if PRK had not been performed previously is exceedingly rare.

Sneezing reflex associated with intravenous sedation and periocular anesthetic injection.

PURPOSE: To assess and compare the frequency of reflex sneezing occurring during periocular anesthetic injections with and without intravenous sedation. DESIGN: Retrospective, comparative case series. METHODS: Seven hundred and twenty-two patients undergoing oculoplastic surgical procedures were included in this study. Those who received a periocular anesthetic injection under intravenous sedation served as the test group of 381 subjects. Those who received a periocular anesthetic injection without intravenous sedation served as the control group of 341 subjects. The absence or presence of reflex sneezing in both groups was recorded and compared using Chi-square analysis. RESULTS: Of the 381 patients who received periocular anesthetic injections under intravenous sedation, 19 (5%) exhibited a vigorous sneeze. Conversely, none of the 341 patients who received periocular anesthetic injections without intravenous sedation sneezed (P < or = .001). CONCLUSIONS: Surgeons, anesthesia staff, and other operating room personnel should be aware of this unusual and potentially dangerous sneeze phenomenon when periocular anesthetic injections are delivered under intravenous sedation to reduce potential ocular complications.