Clinical analysis and classification of dark eye circle.

BACKGROUND: Dark eye circle (DEC) is a common problem that usually lacks detailed classification in the etiology and structural variations. A newly-developed DEC Assessment Score using Wood's lamp and ultrasonogram will provide a more precise evaluation of DEC for improving treatment results. MATERIALS AND METHODS: Sixty-five cases, including eight males and 57 females with a mean age of 38.9 years, were enrolled. DEC were classified into pigmented (brown), vascular (blue to purple), structural, and mixed type by Wood's lamp and ultrasonogram. A scoring system with nine parameters, including brown hue, pigmented lesions, blue/pink/purple hue, periorbital puffiness, shadow hue, infraorbital palpebral bags, infraorbital grooves, blepharoptosis, and skin type, was used for clinical evaluation. RESULTS: Pigmented, vascular, structural, and mixed types of DEC represented 5%, 14%, 3%, and 78%, respectively. Thirty-three cases with periorbital puffiness were found to have higher "pre-septal thickness" than those of 20 controlled cases (P = 0.032). Fourteen patients with infraorbital palpebral bags were proved to have protruded retroseptal fat pads by ultrasonography. CONCLUSION: Pigmentation and vascular and structural components may play important roles in DEC. Detailed classification of DEC types will access physicians in the decision of appropriate therapeutic modalities.

Use of extraocular muscle flaps in the correction of orbital implant exposure.

PURPOSES: The study is to describe a new surgical technique for correcting large orbital implant exposure with extraocular muscle flaps and to propose a treatment algorithm for orbital implant exposure. METHODS: In a retrospective study, seven patients with orbital implant exposure were treated with extraocular muscle flaps. All data were collected from patients in Chang Gung Memorial Hospital, Taiwan during 2007-2012. All surgeries were performed by one surgeon (Y.J.T). Patient demographics, the original etiology, details of surgical procedures, implant types, and follow-up interval were recorded. Small exposure, defined as exposure area smaller than 3 mm in diameter, was treated conservatively first with topical lubricant and prophylactic antibiotics. Larger defects were managed surgically. RESULTS: Seven patients consisting of two males and five females were successfully treated for orbital implant exposure with extraocular muscle flaps. The average age was 36.4 (range, 3-55) years old. Five patients were referred from other hospitals. One eye was enucleated for retinoblastoma. The other six eyes were eviscerated, including one for endophthalmitis and five for trauma. Mean follow-up time of all seven patients was 19.5 (range, 2-60) months. No patient developed recurrence of exposure during follow-up. All patients were fitted with an acceptable prosthesis and had satisfactory cosmetic and functional results. CONCLUSIONS: The most common complication of orbital implant is exposure, caused by breakdown of the covering layers, leading to extrusion. Several methods were reported to manage the exposed implants. We report our experience of treating implant exposure with extraocular muscle flaps to establish a well-vascularized environment that supplies both the wrapping material and the overlying ocular surface tissue. We believe it can work as a good strategy to manage or to prevent orbital implant exposure.

Analysis of visual outcomes and complications following levator resection for unilateral congenital blepharoptosis without strabismus.

BACKGROUND: It is challenging to manage congenital blepharoptosis, especially unilateral, because symmetry is difficult to achieve under general anesthesia and age at which the ptosis should be corrected is still controversial. The aim of our study is to analyze visual and surgical outcomes after levator resection for unilateral congenital blepharoptosis. METHODS: Charts of patients with unilateral congenital blepharoptosis who underwent levator resection at the Chang Gung Memorial Hospital from 1991 through 2000 were reviewed. The resultant database was interrogated for demographic data, severity, surgical timing, visual outcomes, surgical outcomes, and complications. RESULTS: Eighty-four children underwent levator resection for unilateral congenital blepharoptosis: 16.7% of these patients had amblyopia and 84.5% had surgical success following levator resection. Severe ptosis (p = 0.0288, p < 0.05) and surgery at less than 2 years of age (p = 0.0126, p < 0.05) were the important factors contributing to surgical failure. Age at surgery (p = 0.0058, p < 0.01) and amblyogenic ametropia (p = 0.0001, p < 0.001) were found to be significantly associated with the postoperative visual results. CONCLUSION: The levator resection provides satisfactory results both in function and cosmesis in patients with unilateral congenital blepharoptosis. Amblyogenic ametropia is the leading cause of amblyopia in the patients with unilateral isolated congenital blepharoptosis. However, patients with unilateral congenital blepharoptosis should have cycloplegic refraction as early as possible, and their visual status monitored until visual maturity.

Comparing pericanalicular sutures with direct canalicular wall sutures for canalicular laceration.

PURPOSE: To determine whether a statistically significant difference exists between direct canalicular wall sutures (DCs) and pericanalicular sutures (PCs) in the repair of traumatic canalicular lacerations. METHODS: The medical records of 63 patients who underwent primary repairs for traumatic canalicular lacerations were retrospectively reviewed. Patients were divided in 2 groups according to the suturing techniques used: the DC group (n = 41) and the PC group (n = 22). Anatomic results were compared between these 2 groups. A successful result was determined by attempted irrigation and probing of the injured canaliculus at the last follow-up visit. RESULTS: There were 6 failed procedures among the patients who underwent pericanalicular repair and 1 failed procedure among the patients who underwent direct canalicular wall repair (p = 0.024). CONCLUSIONS: These data support the higher success rates in patients treated with direct canalicular repair compared with pericanalicular repair.

Orbital blow-out fractures in children: characterization and surgical outcome.

BACKGROUND: Trapdoor-type orbital fractures usually associated with marked motility restriction are common in the pediatric age group. We reviewed the characterization and surgical outcomes of orbital blow-out fracture in children. METHOD: This is a retrospective review study. From Jan. 1997 to Dec. 2006, 75 patients under 18 years of age with orbital blow-out fractures were seen in the department of ophthalmology, Chang Gung Memorial Hospital. The medical records and computed tomography scans of these patients were reviewed. RESULTS: Forty-one patients were identified whose records were adequate to compare data. The mean age of the patients was 12.7 years and the mean duration of follow-up was 6.5 months. The most common causes of injury were assault (43.9%) and motor vehicle accidents (29.3%). Ninety-five percent of the patients had diplopia and ninety-three percent had extraocular muscle limitation. The incidence of trapdoor fracture in pediatric orbital fracture was 68.3%. Orbital blow-out fractures in these children most frequently involved the isolated orbital floor. The average time to surgical intervention was 23 days after injury; 53.8% patients received immediate (0-2 days) or early (3- 14 days) repair. Improvement from preoperative supraduction limitation was statistically significant in the immediate (0-2 days), early (3-14 days) and delayed (15-30 days) surgical groups. CONCLUSION: Orbital blow-out fractures in our pediatric patients were usually the result of assault or motor vehicle accident. Surgical repair within one month of injury led to better improvement and more complete resolution of ocular motility limitation and diplopia than late repairs.

Analysis of bicanalicular nasal intubation in the repair of canalicular lacerations.

PURPOSE: To analyze the outcomes (success, failure) and complications of surgical repair of canalicular lacerations by bicanalicular nasal intubation in a series of patients treated over a 7-year period. METHODS: The case records of 98 patients undergoing surgical repair of canalicular lacerations were retrospectively reviewed. Patient characteristics and results of the surgical repair were analyzed to identify factors that may influence the outcomes. Two groups (success and failure) were statistically compared with the Mann-Whitney U test for scale variables and with Fisher's exact test for categorical variables. RESULTS: Of the 98 patients, 78 (79.6%) had patency after irrigation (anatomic success) and 83 (84.7%) were asymptomatic (functional success). Patients age, sex, injury location, anesthetic methods, and timing of surgical repair were not significantly associated with the postoperative patency of the lacerated canaliculus. Having a stent left for more than 90 days was significantly associated with restoration of the canalicular anatomy (P < 0.01). Patients with postoperative anatomic patency had a significantly lower rate of symptomatic epiphora than patients with anatomic obstruction (P < 0.001). Symptomatic epiphora was significantly more frequent in patients with combined upper and lower canalicular injuries (P < 0.01). CONCLUSION: Our results suggest that retaining bicanalicular silicone nasal intubation for more than 90 days can provide satisfactory results in restoring both canalicular anatomy and function. With an experienced operating team, repair of canalicular lacerations can be delayed for up to 11 days. However, patients with combined upper and lower canalicular lacerations are at an increased risk of developing postoperative symptomatic epiphora.

Managing epibulbar choristoma with microphthalmos.

A 3-year-old boy had a large epibulbar choristoma with microphthalmos of his left eye. He received simple partial tumor excision due to significant local mechanical erosion and disfiguring appearance. The cosmetic outcome was satisfactory.

Pneumomediastinum after external dacryocystorhinostomy.

A 73-year-old man had right chronic epiphora for many years. After uneventful external dacryocystorhinostomy, he developed dyspnea and neck swelling after forcefully blowing his nose. CT showed diffuse cervicofacial subcutaneous emphysema and pneumomediastinum. He was admitted to prevent further cardiovascular complications. Pneumomediastinum is a rare complication of routine dacryocystorhinostomy. Supportive treatment to prevent additional air trapping is mandatory.

Optic nerve compression in craniofacial fibrous dysplasia: the role and indications for decompression.

BACKGROUND: Fibrous dysplasia is a benign bone disorder in which craniofacial bones are involved in approximately one-fifth of cases. Optic nerve compression is one of its most potentially devastating complications. The approach to visual disturbance caused by disease involvement of the optic canal has been varied and controversial. This is especially the case with regard to surgical decompression, particularly prophylactic decompression. METHODS: The authors performed a retrospective review of fibrous dysplasia patients who showed clinical or radiographic evidence of optic canal involvement over a 27-year period. RESULTS: Twenty-two optic canals in 18 patients were affected by disease. Of these, 14 optic canals had symptoms (i.e., affected visual acuity or visual field). Twelve therapeutic and six prophylactic optic nerve decompressions were performed in total. At long-term follow-up (of at least 1 year), there was deterioration of vision in one-third of the patients who had undergone prophylactic decompression. Therapeutic decompression seemed to prevent visual deterioration in slightly more than half of the patients, with the majority having improvement in vision. There was visual deterioration in the remaining patients within this group, with most ultimately ending up with blindness. CONCLUSIONS: Therapeutic optic nerve decompression is advocated in patients with continuous deterioration of vision. Prophylactic decompression, in contrast, is not advised to be performed as a primary surgical procedure but as a procedure secondary to excision of lesion in the anterior skull base during the same operation.

Medial canthal tophus associated with gout.

PURPOSE: To report a case with a gouty tophus at the medial canthus. DESIGN: Observational case report. METHODS: Review of the clinical, laboratory, photographic, and pathologic records of a patient with a gouty tophus at the medial canthus. RESULTS: A 27-year-old man had a 3-year history of gouty arthritis and poorly controlled hyperuricemia. A medial canthal mass without discomfort developed gradually over 3 months. An excisional biopsy was performed, and the tissue was fixed in formalin for pathology. Analysis of a routine hematoxylin-and-eosin-stained section disclosed a multilobulated pseudocyst filled with amorphous eosinophilic material. Further staining with nonaqueous alcoholic eosin and viewed under a polarizing microscope indicated the presence of birefringent urate crystals. CONCLUSIONS: Gouty tophus can develop progressively at the medial canthus, especially in people with uncontrolled hyperuricemia. A formalin-fixed specimen, stained with nonaqueous alcoholic eosin, demonstrates abundant birefringent urate crystals under a polarizing microscope.

Restoration of enophthalmos in anophthalmic socket by HTR polymer.

A 2-year-old girl had undergone preoperative radiotherapy and enucleation without implantation for retinoblastoma in her right eye. She presented with supratarsal depression after secondary hydroxyapatite implantation. Computed tomography revealed insufficient right orbital volume, relative to left orbital volume. Injections of Bioplant hard tissue replacement synthetic bone filled the subperiosteal space of the orbital floor and lateral and medial wall for supratarsal augmentation. This had the desired effect: The filler lasted without sequela at least through 1.5 years of follow-up. Hard tissue replacement was also used to fill the remaining socket void and enhance the facial ridge width.

The surgical outcome of strabismus in patients with general fibrosis syndrome.

BACKGROUND: This study investigates the clinical features of strabismus in patients with general fibrosis syndrome (GFS) and the results of surgery performed on such patients. METHODS: We conducted a retrospective review of patients with GFS who visited our clinic at Chang Gung Memorial Hospital between 1 August 1992 and 31 January 2002. After evaluating the family histories of 9 patients with GFS, patients were given a complete ophthalmic evaluation. Myectomies of the inferior rectus muscle were performed to correct hypotropia and recessions and/or resections of medial rectus and/or lateral rectus were performed to correct esotropia or exotropia, respectively. The post-operative conditions of the survey patients were reviewed for at least 6 months after the completion of the procedures. RESULTS: Six patients (67%) were identified with inherited autosomal dominance. All patients displayed the characteristic 'chin-up' position, limited extraocular muscle movement and eye abnormalities. High astigmatism (>=-2.0 diopter) was noted in 9 eyes (50%) and amblyopia was noted in all cases. With regard to vertical eye deviation, 11 eyes (61%) were corrected through myectomy of the inferior rectus muscle to within 5 degrees as measured using a Hirschberg test. Furthermore, three cases (33%) were complicated by lower scleral show. CONCLUSION: The presence of GFS complicates the surgical correction of strabismus making procedure results more difficult to predict. Strabismus surgery has been demonstrated to reduce eye deviation in the primary position, thus improving patients' head posture. The resulting improvements to cosmetic appearance and functionality lead us to recommend that strabismus surgery be performed in conjunction with ptosis surgery for GFS patients.

Highly efficient ex vivo gene delivery into human corneal endothelial cells by recombinant adeno-associated virus.

PURPOSE: Gene delivery at high efficiency is crucial for cornea endothelial cell gene therapy. This study investigated the efficiency of gene transfer by recombinant adeno-associated virus (rAAV) in an organ culture system. METHODS: Human cornea tissue was exposed to rAAV delivering green fluorescent protein (ss-rAAV2-CMV-GFP) for one hour and then cultured at 31 degrees C for 2 weeks in a medium supplemented with growth factors. Endothelial cells expressing GFP gene were then identified. RESULTS: High-efficiency gene transfer was found in over 90% of endothelial cells. Gene expression could be detected within 24 hours and remained stable up to 2 weeks in the organ culture system. CONCLUSIONS: The high-delivery efficiency and rapid induction of gene expression indicate that rAAV is a promising vector for cornea endothelial cell gene therapy for ocular diseases. Organ culture at 31 degrees C using culture medium supplemented with growth factors significantly facilitates gene transfer into human corneal endothelium.

Recombinant adeno-associated virus vector expressing angiostatin inhibits preretinal neovascularization in adult rats.

Clinically, preretinal neovascularization (PNV) induced by vessel occlusion is one of the leading causes to induce blindness. The present study was designed to determine if a recombinant adeno-associated viral vector expressing mouse angiostatin (rAAV-angiostatin) can inhibit experimental PNV in an adult Sprague-Dawley rat model. rAAV-angiostatin and rAAV-lacZ were delivered by intravitreal injections to the right and left eyes of rats. Transgenetic expression of angiostatin in the retina was determined by reverse-transcriptase polymerase chain reaction (RT-PCR). PNV was established by rose-bengal-assisted laser-induced retinal vein occlusion 21 days after the viral injections. The total number and sizes of the neovascular tufts were analyzed 14 days after venous occlusion using retinal flat mount by fluorescein-isothiocyanate-dextran angiography. Electroretinograms (ERGs) were recorded to study any possibility of retinal toxicity of rAAV-angiostatin 3 months after the injections. Angiostatin gene expression in the retina was detectable by RT-PCR, and ERG analysis showed no reduction of b-waves in the rAAV-angiostatin-injected eyes. The number and size of neovascular tufts were significantly lower in rAAV-angiostatin-injected eyes (p = 0.001) than controls. These findings indicated that rAAV-angiostatin successfully suppressed experimental PNV, and no retinal toxicity of the rAAV-angiostatin injection was observed according to ERG recordings.

Partial removal of orbital tumor in Rosai-Dorfman disease.

BACKGROUND: Rosai-Dorfman disease is a rare idiopathic histiocytic proliferation disorder that typically presents with painless cervical lymphadenopathy. We report our experience with the management of a case of Rosai-Dorfman disease with compressive optic neuropathy. CASE: Rosai-Dorfman disease involving the bilateral orbital and paranasal sinuses was diagnosed in a 14-year-old boy. Diagnosis was based on the characteristic histopathologic features of sinus histiocytosis, composed of large, round S-100 protein-positive histiocytes with striking emperipolesis. The boy received chemotherapy to resolve the bilateral proptosis and compressive optic neuropathy in the right eye, but this treatment failed. Orbital debulking surgery using the Lynch approach was performed. OBSERVATIONS: Corneal exposure was resolved and visual acuity recovered from 14/20 to 20/20 after partial removal of the tumor mass. There were no complications after surgery. During the 22 months of follow-up, orbital tumor masses redeveloped to cause lagophthalmos again, but did not cause visual impairment. CONCLUSIONS: Rosai-Dorfman disease is a rare disorder, especially in Asia. The disease is usually chronic with spontaneous remission and is refractory to treatment. Partial removal of tumor masses is a workable way to improve visual acuity and correct corneal exposure. Before carrying out this procedure, we discussed with the parents of the patient the potential complications that might follow surgery and secured their permission before proceeding further.

Surgical management of strabismus for dysthyroid ophthalmopathy.

BACKGROUND: The study reports our 8-year experience in the surgical treatment of restrictive myopathy resulting from dysthyroid ophthalmopathy. We tried to determine the factors that contributed to favorable surgical outcomes. METHODS: The charts of patients who had surgical treatment for strabismus related to dysthyroid ophthalmopathy at Chang Gung Memorial Hospital between January 1995 and December 2002 (n=25) were retrospectively reviewed, and factors that possibly influenced the outcome were statistically analyzed for significance. RESULTS: The mean pre-operative vertical deviation of the 25 patients was 23.3 prism diopters and the pre-operative horizontal deviation was 11.3 prism diopters. The mean follow-up time was 29.7 months. Each patient had strabismus surgery an average of 1.5 times. The majority of patients (84%) were satisfied with the result. No significant difference in the success rate was evident between patients who waited less than 3 months before the surgery and those who waited for a longer period. The repeat surgery rate was significantly higher in the latter group. A shorter duration of diplopia and smaller angle of pre-operative horizontal deviation were contributors towards a favorable outcome. CONCLUSIONS: A waiting time of less than 3 months prior to treatment of strabismus associated with dysthyroid ophthalmopathy produced a favorable outcome. The duration of diplopia and the pre-operative angle of horizontal deviation were the most important prognostic factors.

Bilateral idiopathic sclerosing inflammation of the orbit: report of three cases.

We report 3 cases of bilateral orbital sclerosing inflammation and review the literatures concerning bilateral idiopathic orbital inflammation. We found that when idiopathic orbital inflammation presents as a bilaterally diffuse retrobulbar apical mass, the sclerosing subtype must be considered first, and an orbital biopsy should be performed. The present cases were characterized by chronic-onset, cicatricial inflammation with a mass effect. The most common ocular findings in our study were vision decrease, proptosis, and restriction of extraocular muscle movement. We found that current treatment, using systemic corticosteroids and radiotherapy, was nonspecific, incomplete, or frequently resulted in relapse. For cases refractory to corticosteroids and radiotherapy, early and aggressive multiagent immunosuppressive therapy should be used to minimize visual and ocular disabilities.

Idiopathic granulomatous orbital inflammation.

Idiopathic granulomatous inflammation is regarded as a histopathologic variant of an orbital pseudotumor and has a similar clinical presentation and treatment. However, the differential diagnosis including sarcoidosis, Wegener's granulomatosis, trauma, and infection must be ruled out. We present a 77-year-old man with a biopsy-proven lacrimal gland granulomatous inflammation of an unknown origin. Management by surgical debulking via an anterior orbitotomy achieved a good result with minimal complications.

Bilateral orbital Kimura's disease in a young Asian man.

A 16-year-old Asian man adolescent presented with bilateral eyelid swelling with multiple palpable mass lesions, which waned after treatment with corticosteroids but waxed after medications were discontinued, for about 1 year. He was otherwise healthy except that bilateral postauricular lymphadenopathy had developed for about 9 years. Laboratory study revealed peripheral eosinophilia with an elevated IgE level. The tumor masses of the left orbit were completely excised through an incision similar to that used in blepharoplasty, which gave good cosmetic results. Postoperative computed tomography scan showed no residual tumor mass in the left orbit but contralateral homogeneous soft-tissue mass lesions around the lacrimal gland and extending deep into the orbit, between the superior and lateral rectus muscles. Pathology reported numerous lymphoid follicles with active germinal centers and extensive lymphocyte and eosinophil infiltration, which characterize Kimura's disease (KD). The tumor mass in the right orbit was also excised during a second elective surgery 10 days later. No evidence of recurrence was noted after follow-up for 7 months. KD of the orbit is rare and usually occurs in middle-aged to elderly Asian men but can also be present in young adolescent. Complete excision with simultaneous blepharoplasty gives satisfactory cosmetic results.