Outcome of lacrimal surgery in older patients.

BACKGROUND: Performance of lacrimal surgery under neuroleptic (local) anesthesia has greatly facilitated the procedure and decreased the associated morbidity. We reviewed the outcome of lacrimal surgery in older patients to determine whether such surgery can be performed safely in the outpatient setting in this group. METHODS: Review of the office and hospital charts and the surgical and anesthetic records of 120 patients (84 women and 36 men) aged 70 to 90 years who underwent lacrimal drainage procedures (dacryocystorhinostomy [DCR], canaliculodacryocystorhinostomy, DCR with insertion of a Jones tube, or a revision endonasal procedure with probing and tube insertion) at a university-affiliated hospital in Toronto in 1996. The interval between surgery and data collection ranged from 10 to 22 months. RESULTS: Of the 120 patients 65 were aged 70 to 75 years, 38 were 76 to 80 years, 11 were 81 to 85 years, and 6 were 86 to 90 years. Ninety-six patients had a unilateral procedure, and 24 (22 of whom were aged 70 to 80) had a bilateral procedure. Concomitant conditions, such as hypertension and cardiac disorders, were found in 104 patients (87%). Of the 120 patients 98 (82%) (including all those aged 81 to 90) had local anesthesia, and 22 (18%) had general anesthesia. In one case anesthesia had to be changed from local to general during the procedure because of noncompliance. A total of 112 patients (93%) whose surgery was planned as a day procedure were able to leave the hospital the same day. Three additional patients were admitted to hospital for an overnight stay because of increased bleeding at the time of surgery (one patient) or a history of cardiac problems (two patients). Five patients who had planned overnight stays because of cardiac problems did well during surgery and were discharged the same day, without consequence. None of the patients had to be readmitted at a later date for bleeding or health problems. In 109 patients (91%) the presenting symptom(s) was completely relieved. Overall, 116 patients (97%) had a totally open system with no reflux on syringing. INTERPRETATION: The surgical goals and techniques of lacrimal surgery in older patients were not compromised by performing the surgery in the outpatient setting and under neuroleptic anesthesia in most cases.

An anatomic and histologic study of the caruncle.

PURPOSE: To describe the histologic features of the caruncle and to determine its anatomic relationship to the common canaliculus. METHODS: Specimens from preserved and fresh-frozen cadavers were studied histopathologically. RESULTS: The average distance between the external surface of the caruncle and the common canaliculus was 0.85 mm, whereas the shortest distance measured was 0.50 mm. Several histologic abnormalities (oncocytic change, apocrine metaplasia, and microscopic stones) were identified in specimens that appeared clinically normal. CONCLUSION: Caution should be exercised when operations are performed on or near the caruncle to avoid inadvertent damage to the canalicular system.

Epiphora in patients receiving systemic 5-fluorouracil therapy.

OBJECTIVE: To determine the prevalence of tearing and canalicular fibrosis in patients receiving systemic 5-fluorouracil (5-FU) therapy and the reversibility of the symptoms when treatment is stopped. DESIGN: Prospective study. SETTING: University-affiliated tertiary care hospital in Toronto. PATIENTS: Thirty patients (17 men and 13 women aged 38 to 81 years) with advanced gastrointestinal carcinoma receiving intravenous 5-FU therapy as palliative (weekly) treatment (20 patients) or adjunctive (cycle) treatment (10 patients). OUTCOME MEASURES: Tearing, eyelid changes and canalicular fibrosis during and after treatment. Patients who experienced tearing were advised to massage and wipe the lower eyelids in an upward direction. RESULTS: Tearing and canalicular fibrosis developed in 10 patients (50%) and 3 patients (15%) respectively in the palliative treatment group; no patient in the adjunctive treatment group experienced these side effects. In the palliative treatment group, the patients who experienced tearing received double the dose of 5-FU (p = 0.03) and received treatment for twice as long (p = 0.042) as those who did not experience tearing. Of the patients with tearing, those in whom canalicular fibrosis developed received treatment for three times as long as those without fibrosis and received 2.6 times the total dose (p < 0.000). Of the seven patients with tearing in whom canalicular fibrosis did not develop, four stopped 5-FU treatment, and 2 to 4 weeks later the epiphora disappeared. CONCLUSIONS: Our findings suggest that the prevalence of tearing and canalicular fibrosis in patients receiving systemic 5-FU therapy as palliative treatment is related to the total dose and duration of treatment. Such side effects are less likely in those receiving adjunctive therapy. The epiphora is often reversible on stopping therapy if canalicular fibrosis has not yet developed.

Sensitivity and specificity of the diagnosis of periocular lesions by oculoplastic surgeons.

BACKGROUND: A few studies have assessed the sensitivity of ophthalmologists in diagnosing periocular lesions. However, no study has assessed their diagnostic specificity or the degree to which they overdiagnose various lesions. We performed a study to determine the sensitivity and specificity of oculoplastic surgeons' preoperative diagnoses of common and uncommon periocular lesions. METHODS: Using the patient records of four oculoplastic ophthalmologists, we reviewed all charts documenting periocular surgery in which lesions were excised and sent for biopsy. For each of 358 cases we recorded the preoperative diagnosis as listed by the surgeon and the postoperative diagnosis as reported by the pathologist. Each preoperative diagnosis was then scored as correct or incorrect. The relative number of each type of lesion was determined, and the ophthalmologists' sensitivity and specificity were calculated. RESULTS: The sensitivity and specificity for the eight most frequently lesions were (in order of frequency) basal cell carcinoma 92.1% and 81.6% respectively, papilloma 81.6% and 66.0%, cyst 66.7% and 69.7%, nevus 53.6% and 75.0%, seborrheic keratosis 27.8% and 71.4%, chalazion 93.3% and 100.0%, squamous cell carcinoma 33.3% and 55.6%, and xanthelasma 100.0% and 76.9%. The values for melanoma were 50.0% and 28.6%, for sebaceous gland carcinoma 0.0% and 100.0%, and for uncommon lesions (nonspecific inflammation, actinic keratosis, granuloma, cavernous hemangioma, folliculitis, benign sweat gland tumour, eccrine hidrocystoma and collagenous tissue) 27.8% and 57.1%. The overall accuracy in lesion identification was 70.0%. INTERPRETATION: Although ophthalmologists have excellent diagnostic sensitivity and specificity for some types of lesion, such as basal cell carcinoma and chalazion, the identification of other lesion types, such as cyst, squamous cell carcinoma and possibly melanoma and sebaceous gland carcinoma, is less optimal.

Orbital cyst of lacrimal sac derivation.

Orbital cyst from lacrimal sac epithelium is rare and thought to originate from diverticulum of the lacrimal sac. The cyst may have direct communication with the sac, or the two structures may be anatomically separate. Since these lesions most commonly present as a medial canthal mass, the differential diagnosis should include other disorders that may cause a mass in this region. A 42 year old woman presented with a two-year history of a mass in the right medial canthal region. Nasolacrimal system was patent on irrigation. Sophisticated radiological investigation utilizing dacryocystography and computed tomography combined with dacryocystography accurately localized the lesion and demonstrated its relationship to the nasolacrimal system. This tremendously facilitated surgical removal. The lesion was excised completely via anterior orbitotomy and submitted for histopathologic examination. Haematoxylin-eosin stains revealed a cystic cavity lined by pseudostratified columnar and cuboidal epithelium with interspersed goblet cells consistent with a cyst derived from lacrimal sac epithelium, located separately, but in close proximity to the lacrimal sac. The Authors present a patient with a mass in the righ medial canthal area histologically diagnosed as an orbital cyst of lacrimal sac epithelium derivation. Sophisticated radiological lacrimal investigation helps in detection, localization and in planning surgery.

Cyanoacrylate tissue adhesive in blepharoplasty.

This article reports the results of an animal study designed to evaluate the usefulness of butyl 2-cyanoacrylate (Histoacryl) in blepharoplasty skin closure. Bilateral upper and lower lid blepharoplasty skin incisions were made on seven pigs. We compared the wounds closed with 6.0 nylon to those closed with Histoacryl at 1, 2, 4, and 9 weeks postoperatively. The tensile strength of the "glued" incisions was significantly greater than that of the sutured incisions only at the 9-week postoperative interval (p < 0.05). There was no significant difference in bond strength, however, between the two methods at 1, 2 and 4 weeks postoperatively. Histopathologic analyses of sutured and glued wounds were compared at the same designated postoperative periods. No deleterious effects were found in the overall healing of the cutaneous wounds closed with Histoacryl.

A rationale for the selection of nasal decongestants in lacrimal drainage surgery.

Adequate hemostasis during lacrimal drainage surgery affects the success of the operation. Nasal decongestants, which are sympathomimetric agents including sympathomimetic amines and imidazoline derivatives, help to decrease bleeding. Certain of the imidazoline derivatives--oxymetazoline and xylometazoline--are potent and long-acting agents that have many of the same adrenergic effects as cocaine. Their use as an alternative to cocaine provide adequate hemostasis with less adverse reactions than cocaine. The authors recommend premedication of the nasal mucosa with oxymetazoline or xylometazoline before lacrimal drainage surgery for obtaining maximal nasal mucosal decongestion.

Comparative study of wound healing in porcine skin with CO2 laser and other surgical modalities: preliminary findings.

BACKGROUND: The CO2 laser is a common surgical modality in dermatology. To clarify conflicting reports on the histological healing properties of CO2 laser on incisional or ablative wounds, we have applied it in a miniature hairless porcine skin model at power settings similar to those used in clinical practice. METHODS: Histological parameters of wound healing in skin incisions using the CO2 laser were compared with those using scalpel, hot scalpel, and electrosection, and in dermal ablation using CO2 laser, fraize, wire brush, and electrofulguration alone or with curettage. RESULTS: In incisional wounds, tissue damage was most extensive in CO2 laser wounds, with delayed dermal healing and reepithelialization. In ablative wounds, CO2 laser caused a similar degree of tissue damage as did the electrosurgical modalities, and more damage than did fraize or wire brush. Reepithelialization was complete in CO2 laser, fraize, and wire brush wounds before electrosurgical wounds. Final histology of both incisional and ablative wounds at 6 weeks was similar with all surgical modalities. CONCLUSION: The CO2 laser and electrosurgery both produce greater focal tissue damage in incisional and ablative applications than the other modalities. Delayed epithelialization of the wound occurs with both modalities in incisional wounds but only with electrosurgery in ablative wounds. At 6 weeks, the appearance of the scar in all incisional and ablative modalities is similar grossly and histologically. Confirmation of these findings requires standardization of power density of the CO2 laser in incision and ablation.

Epithelioid sarcoma of the orbit.

BACKGROUND: Epithelioid sarcoma is a rare and aggressive malignancy commonly occurring in the tendon sheaths of the distal extremities of young adults. This article presents the clinical and pathologic details of two patients with epithelioid sarcoma in the orbit, the first to be reported as occurring in this location. METHODS: The clinical history, results of physical and radiologic examination, surgical procedures, pathologic specimens, and clinical course of each patient were reviewed and recorded. RESULTS: Biopsies were performed of the masses that were found in the superotemporal orbit of both patients. Results of pathologic examination in each patient caused considerable difficulty, and the correct diagnosis was reached only after extensive consultation. The first patient underwent wide soft tissue and bone exenteration and is alive without recurrence at 3 years. The second patient had multiple recurrences and died of recurrent and metastatic disease at 29 months. CONCLUSIONS: Epithelioid sarcoma must be added to the differential diagnosis of orbital sarcomas. The histology is nodular with a pseudogranulomatous appearance. Based on our limited experience, epithelioid sarcoma of the orbit may have a course similar to that which occurs elsewhere in the body, requiring aggressive surgical treatment at the outset.

Involvement of the eyebrow fat pad in Graves' orbitopathy.

Involvement of the eyebrow fat pad in Graves' disease has never been reported. We noted that Graves' orbitopathy patients had bulkier eyebrows due to a larger eyebrow fat pad not associated with the preaponeurotic fat. A cadaver model was used to show that the eyebrow fat could be identified with magnetic resonance imaging (MRI) scans. Then, a series of Graves' orbitopathy patients were sent for orbital MRI scans, and the eyebrow fat was measured with maximum lengths and widths. The averages were compared to two groups of patients, one without orbital pathology, and one with orbital pathology causing proptosis but not due to Graves' disease. Graves' patients with early orbitopathy and incipient optic neuropathy or congestive orbits where optic neuropathy had to be ruled out had statistically significant larger eyebrow fat pads than either comparison group. This has clinical significance: The eyebrow fat may need to be debulked during operations such as blepharoplasty. Furthermore, periorbital fat may play a larger role in the disease process than previously thought.

Hertel exophthalmometry without orbital rim contact.

BACKGROUND: The Hertel exophthalmometer is the most widely used instrument for the measurement of globe malposition, but an absent or damaged lateral orbital rim will preclude its application. To circumvent this shortcoming, the authors have developed a fixation adapter that attaches to a standard Hertel instrument and transfers fixation to the forehead and nasion from the lateral orbit. METHODS: The adapter design is presented and discussed, along with illustrative clinical cases. A study of 30 healthy patients was performed to assess the validity of the adapter with respect to the Hertel standard. The agreement was then evaluated by comparing the Hertel adapter measurements from each patient with that of the adapter. A Wilcoxon statistic was performed to assess differences in the paired values from each patient for both techniques. RESULTS: Analysis on a sample (n = 30) of a healthy adult population does not show a statistical difference between the Hertel adapter and the adapter data (P > 0.05). In addition, more than 90% of the differences fall within +/- 1 mm (standard deviation = 1.02 mm) of the means for both eyes, which is within the accepted variance for the Hertel instrument. CONCLUSION: The new fixation adapter promises to become useful in assessing trauma and surgical cases where the lateral orbital rim has been violated and will expand the application of Hertel exophthalmometry to these situations.

Dacryocystorhinostomy in elderly patients: regional anesthesia without cocaine.

Elderly patients with nasolacrimal obstruction who are in poor health often pose a special anesthetic and surgical risk. General anesthesia and the use of cocaine packs may be contraindicated because of potentially dangerous side effects. Regional block dacryocystorhinostomy has gained popularity in all adult patient groups, but specifically it appears to be the procedure of choice in elderly patients. It is well suited for either hospital-based or ambulatory care. We describe our experience with the procedure in 25 consecutive patients (28 procedures), with emphasis on modification of our standard technique to suit regional blockade. Mechanisms of cocaine toxicity in the surgical setting are reviewed, and a method of local anesthesia without cocaine nasal packing is presented.

Correlation between computed tomography and magnetic resonance imaging in Graves' orbitopathy.

Radiologic examination of patients with severe Graves' disease with possible optic neuropathy has routinely been done with computed tomography (CT). With the more widespread use of magnetic resonance imaging (MRI), its potential use in Graves' disease must be considered. We compared these two imaging techniques for use in severe Graves' orbitopathy. Thirty-nine orbits of 20 consecutive patients with severe Graves' disease (19 with optic neuropathy and 20 without optic neuropathy) were examined clinically. CT and MRI were performed, and the radiologic images were assessed for five measures chosen to illustrate overall muscular changes, tissue plane changes of the orbital apex, optic nerve changes and proptosis. The MR images were significantly more reliable than the CT scans for two measures in particular: degree of fat effacement (a measure of optic nerve compression) and minimal optic nerve index (a measure of optic nerve thickness), both of which involve the orbital apex. We conclude that MRI is a better technique than CT for imaging the apex in Graves' optic neuropathy.

Buccal mucous membrane-fat graft in the management of the contracted socket.

A new surgical technique for reconstructing severely contracted sockets using an autogenous buccal mucous membrane-fat graft is presented. The buccal mucosa provides replacement of deficient conjunctival surface area; the fat in the underlying substantia propria of the buccal mucosa replenishes moderate volume deficiency in a single procedure. A custom-designed conformer is used in the immediate postoperative period to maintain reconstructed vertical fornices. We present four consecutive patients with contracted sockets having both a volume deficit and severe conjunctival contracture who were successfully rehabilitated using this technique.

Ultrasound biomicroscopy in the assessment of anterior scleral disease.

High-frequency ultrasound biomicroscopy is a new method of examining subsurface anterior segment structures of the eye at microscopic resolution. The sclera has a high internal reflectivity and can be differentiated from the cornea, and overlying and underlying tissue. Using this modality, we examined 18 patients with various manifestations of scleral disease. Localized anterior staphyloma could be differentiated from other causes of a black spot on the scleral surface. Episcleral thickening could be differentiated from involvement of the sclera itself. Different patterns of scleral involvement could be imaged including diffuse low-reflective mottling, low-reflective nodules extending into the scleral substance, and scleral thinning. Scleral thinning could be assessed and quantified. Underlying changes in the vitreous could be detected. Ultrasound biomicroscopy was a useful adjunct to clinical examination in the assessment of anterior scleral disease.