Endolacrimal laser assisted lacrimal surgery.

AIMS: To utilise the improved optical qualities of newly developed lacrimal endoscopes and newly miniaturised laser fibres for diagnostic visualisation and laser surgery of the lacrimal system. METHODS: A KTP laser (wavelength 532 nm, 10 W energy) was used for laser assisted dacryocystorhinostomy (DCR) with endolacrimal visualisation in 26 patients. Bicanalicular silicone intubation was placed in all patients for at least 3 months. RESULTS: After 3-9 months of follow up, the silicone tube in all 21 patients who underwent KTP laser DCR are still patent, three patients have eye watering in extremely cold weather and two required a conventional DCR. CONCLUSIONS: The KTP laser generates enough power to open the bony window in DCR surgery. Precise endolacrimal visualisation via a specially designed miniendoscope is essential for surgical success.

Eyelid healing after carbon dioxide laser skin resurfacing: histological analysis.

OBJECTIVE: To clarify in vivo healing of eyelid skin after carbon dioxide (CO2) laser resurfacing. DESIGN: Patients requesting upper eyelid blepharoplasty consented to undergo previous CO2 laser skin resurfacing of the upper eyelid skin segments to be excised at various time intervals. After blepharoplasty, the skin specimens were analyzed histopathologically by 2 masked pathologists. PATIENTS: Eight patients with Fitzpatrick skin types I and II. INTERVENTION: Upper eyelid CO2 laser resurfacing 1,2, 4, or 12 weeks before planned upper eyelid blepharoplasty. MAIN OUTCOME MEASURES: Epidermis: thickness, polarity, contour, and constituents. Dermis: repair zone thickness, vascular and inflammatory pattern, collagen deposition, and elastic fiber changes. RESULTS: The epidermis regenerated within 7 to 10 days. By 3 months, the epidermis revealed flattening of the rete peg pattern with restoration of polarity, keratinocytes, and melanocytes. The 3-month dermis demonstrated a fibrotic repair zone (500-700 microm), new elastic fibers, and telangiectatic capillaries. CONCLUSIONS: Eyelids heal similarly to other skin regions treated by CO2 laser resurfacing. This cutaneous healing is analogous to that previously reported with use of chemical peels. Histological changes may explain the skin smoothing and wrinkle reduction seen clinically.

Endoscopy of the lacrimal system.

BACKGROUND/AIM: Until recently, diagnosis of disorders of the lacrimal system has depended on digital dacryocystography and on clinical examinations such as the fluorescein dye test, lacrimal probing, and irrigation. The lacrimal system and its mucous membranes can now be viewed directly with a lacrimal endoscope. While the first endoscopes were rigid and limited by poor picture quality in axial illuminations, the new generation of endoscopes are a great leap forward for new diagnostic and therapeutic approaches. METHODS: 132 patients ranging in age from 8 months to 73 years with nasolacrimal obstruction were referred to the lacrimal department. Diagnostic lacrimal imaging utilising various small calibre endoscopes less than 0.5 mm in external diameter was performed. The endoscopes are coupled to specially designed lacrimal probes as well as a CCD camera and a video recorder. The imaging was performed during standard lacrimal probing and irrigation in an outpatient clinic setting in 120 of 132 patients RESULTS: All patients reported the pain of endoscopy as being similar to that of standard lacrimal probing and irrigation. No adverse effects such as bleeding or lacrimal perforation were noted. Endoscopic manipulation was not too difficult and the picture quality, depth of focus, and illumination were satisfactory in all cases. The most common site of stenosis was the nasolacrimal duct (59 patients), followed by the lacrimal sac (39 patients) and the canaliculi (34 patients). In 25 patients, partial obstruction, rather than complete stenosis, was visualised as a narrow lumen, which widened during irrigation. In 14 of 28 patients, obstruction was due to canalicular submucosal folds and was removed with laser. In addition, the colour and consistency of the lining mucosa correlated with type of obstruction. Normal mucosa is smooth and light pink in colour. Inflammatory changes manifest as thickened and reddish grey mucosa. More complete stenosis is shown as fibrotic plaques with grey white inelastic membranes. CONCLUSION: Lacrimal endoscopy is a new, non-invasive method used to view directly and localise obstructions precisely. It allows differentiation between inflammatory, partial, and complete stenosis. Endoscopy enables one to choose the appropriate surgical therapy for patients. Patients tolerated the procedure well without any adverse reactions or effects. While it may not replace standard probing and irrigation, this technique is an extremely useful adjunct in determining the proper surgical modality, ease, and tolerance of the endoscopic manipulation by patients, and obtaining sharp and clear images of the nasolacrimal outflow system anatomy and pathology. Differentiation of various types of obstruction by precise location and severity can be achieved.

Histologic and clinical evaluation of combined eyelid erbium: YAG and CO2 laser resurfacing.

PURPOSE: To report the histopathologic and clinical effects of eyelid resurfacing that combines two different lasers. METHODS: A case series of 23 patients who underwent eyelid resurfacing with two passes of the Erbium:YAG laser followed by one pass of the CO2 laser. With the Student t test, we compared skin re-epithelialization time and duration of erythema with those of a previous group of 25 patients who had undergone eyelid resurfacing with only the CO2 laser (two passes). A pathologist evaluated all skin biopsy specimens. RESULTS: Combining both lasers shortened re-epithelialization time (7 vs 12 days, P = .04) and the duration of erythema (2.5 vs 7.0 weeks, P = .02). Histopathologic examination disclosed less coagulative dermal damage with the combined laser protocol. CONCLUSION: The different biophysical properties of these two lasers can be combined in a periorbital resurfacing protocol to minimize both clinical and histopathologic morbidity.

Factors affecting the success of nasolacrimal duct probing for congenital nasolacrimal duct obstruction.

PURPOSE: To ascertain the effect of certain parameters on nasolacrimal duct probing. METHODS: In a retrospective study of 142 infants and children who underwent nasolacrimal duct probing for congenital nasolacrimal duct obstruction, age at time of probing, gender, symptom severity, presence of mucous discharge, and history of probing were correlated with success of nasolacrimal probing. Success of probing was defined as complete resolution of signs and symptoms of nasolacrimal duct obstruction. Chi-square test was used to analyze covariance. RESULTS: Success of nasolacrimal duct probing was negatively correlated with increasing age: 92%, 89%, 80%, 71%, and 42% at age 12, 24, 36, 48, and 60 months, respectively (P = .001 at each interval). Increasing severity of epiphora was correlated with increased failure of nasolacrimal duct probing (P = .05). CONCLUSIONS: Although the success of nasolacrimal duct probing declines with age, probing in older children can remain the first line of treatment. Because increasing frequency of epiphora correlates with failure of nasolacrimal duct probing, children with daily epiphora should undergo early nasolacrimal duct probing.

Ocular adnexal granulocytic sarcoma as the first sign of acute myelogenous leukemia relapse.

PURPOSE: To report a case of granulocytic sarcoma involving the eyelids and caruncles after bone marrow transplantation. METHODS: Case report. A 30-year-old man with acute myeloid leukemia in remission developed multiple friable eyelid and caruncular lesions in addition to two cutaneous lesions on the chest wall and right axilla approximately 3 months after a successful autologous bone marrow transplant. RESULT: Pathologic examination was consistent with granulocytic sarcoma. CONCLUSION: This condition should be considered in the differential diagnosis of cutaneous or eyelid masses in patients with a history of leukemia.

Combined erbium:YAG and carbon dioxide laser skin resurfacing.

OBJECTIVE: To compare clinical and histological results of 2 different protocols for cosmetic laser skin resurfacing. DESIGN: Masked comparison of 2 cohort groups. PATIENTS: Forty-eight carefully selected patients who met specific inclusion and exclusion criteria for cosmetic laser skin resurfacing. Age, sex, and skin type were matched in both groups. INTERVENTIONS: Twenty-five patients had undergone cosmetic skin resurfacing with 2 impacts of a carbon dioxide laser. Another 23 patients underwent a different protocol involving 2 initial impacts of an erbium:YAG laser to ablate the epidermis followed by a single impact with a carbon dioxide laser. Skin punch biopsy specimens were obtained 1 to 2 weeks after the procedure in both groups of patients. MAIN OUTCOME MEASURES: Time to reepithelialization, duration of erythema, and patient acceptance were compared among 2 patients groups via Student t test. Patients were examined daily until reepithelialization, then weekly for 6 weeks, and then monthly for 6 months. RESULTS: Mean skin reepithelialization time was 7 days (range, 4-9 days) in the combined laser group vs 12 days (range, 9-15 days) in the carbon dioxide laser-only group (P = .04). Mean duration of erythema was 2.5 weeks (range, 1.5-3 weeks) in the combined laser group vs 7 weeks (range, 5-13 weeks) in the carbon dioxide laser-only group (P = .02). All 23 patients (100%) in the combined group but only 15 (60%) of 25 in the carbon dioxide laser-only group were willing to repeat their cosmetic laser surgery (P = .04). There were greater and deeper coagulative changes in the dermis of patients in the carbon dioxide laser-only group compared with those of patients in the combined laser group. CONCLUSIONS: The combined laser protocol showed less significant clinical and histological morbidity than the carbon dioxide laser-only protocol. Patients preferred the combined protocol. Combining these 2 lasers is a safe and patient-friendly alternative to using only the carbon dioxide laser.

Ultrasonic assessment of rhinostomy size following external dacryocystorhinostomy.

AIM: To assess the dimensions and patency of the surgical epithelial fistula after external dacryocystorhinostomy, using B mode ultrasonography to define the postoperative soft tissue anastomosis. METHODS: 12 patients undergoing 16 external dacryocystorhinostomies, with the creation of large osteotomies, were included in a prospective study. The horizontal and vertical dimensions of the bone ostium was recorded during surgery and compared with the ultrasonographic dimensions of the soft tissue anastomosis at 1 day, 2 weeks, and 6 months after surgery. Functional patency was confirmed with dye testing and irrigation. RESULTS: Compared with an osteotomy of between 100 and 380 mm2 (mean 235 mm2), the soft tissue anastomosis on the day after surgery was, in all cases, markedly smaller (72-252 mm2; mean 144 mm2, or 61% of the bone window). The soft tissue anastomosis decreased to between 8 and 208 mm2 (mean 98 mm2; 68% of immediate postoperative value) at 2 weeks and 3-208 mm2 (mean 71 mm2; 49% of immediate postoperative value) at 6 months. 14 of the 16 (88%) dacryocystorhinostomies were functional at the end of the study, the two failures being associated with marked contracture of the soft tissue anastomosis; the outcome of surgery correlated significantly with the area of the anastomosis at 2 weeks (chi 2 = 16.3; p < 0.01) and at 6 months (chi 2 = 16.0, p = 0.01). CONCLUSIONS: B mode ultrasonography provides a simple and effective method for assessing the size of the soft tissue anastomosis after external dacryocystorhinostomy and there is a significant reduction in size after surgery, to which the functional outcome of surgery appears related. As the initial soft tissue anastomosis cannot be larger than (and is, on average, about 60% of) the area of the osteotomy, this emphasises the paramount importance of a large rhinostomy to the success of lacrimal surgery.

Multidisciplinary management of refractory orbital rhabdomyosarcoma.

PURPOSE: Combined chemotherapy and radiation therapy have improved the survival of children with primary orbital rhabdomyosarcoma, but recurrence or persistence of the local orbital tumor still occurs. There are no established guidelines for dealing with these uncommon patients, and the authors present a review of the combined method treatment and outcome of children with refractory primary orbital rhabdomyosarcoma. METHODS: From clinical databases, 67 children with orbital rhabdomyosarcoma were identified. Seven (10%) of the 67 children had tumors refractory to combined chemotherapy and radiation therapy and underwent exenteration or eye-sparing tumor excision. Their clinical course and outcome were reviewed retrospectively. RESULTS: No patient was lost to follow-up, which ranged from 3.2 to 11 years. Five (71%) of the seven children with refractory tumor are still alive at more than 3 years after surgery (3.2-11 years; mean, 6.9). In one of the two children who died, tumor extended beyond the operative margins at exenteration, and the other child died with regional metastasis within a month of exenteration. CONCLUSIONS: Although more than 90% of children with orbital rhabdomyosarcoma respond to combined therapy by pediatric oncologists and radiotherapists, local orbital (salvage) surgery by ophthalmologists may be of value in the minority of children with refractory tumors. All of the five surviving children appear to be disease free.

Outcome of orbital myositis. Clinical features associated with recurrence.

PURPOSE: Although orbital myositis usually responds to prompt systemic therapy, recurrent or persistent episodes often require prolonged therapy. This study presents the clinical and radiologic features of 26 patients with orbital myositis and suggests a treatment regimen with special emphasis on recurrent or persistent orbital myositis. METHODS: Retrospective analysis and comparison of clinical and radiologic parameters with clinical outcome in 26 patients with strictly defined orbital myositis was performed. A consultant radiologist reviewed computed tomography studies without knowledge of the clinical data or outcome. The frequency of certain clinical and radiologic parameters among two outcome groups was analyzed using Fisher's exact test. RESULTS: Comparison of clinical and radiologic features of 20 patients with a single acute episode and 6 patients with recurrent episodes disclosed several characteristics associated with recurrence. Male gender, lack of proptosis, eyelid retraction, horizontal extraocular muscle (EOM) involvement, multiple or bilateral EOM involvement (P = 0.05), muscle tendon sparing, and lack of response to systemic corticosteroids (P = 0.01), or nonsteroidal anti-inflammatory agents (P = 0.01) were associated with recurrent orbital myositis. CONCLUSIONS: A treatment algorithm is suggested for patients with orbital myositis. Those patients whose clinical or radiologic features are associated with recurrence may benefit from early systemic steroid therapy.

Laser Doppler perfusion imaging of eyelid skin.

We report an initial laser Doppler perfusion study of the eyelids and compare the results with those of other cutaneous regions. Eleven healthy subjects with no prior medical or surgical history, or eyelid malposition underwent laser Doppler perfusion scanning of six skin locations: right forearm, right middle fingertip, right upper eyelid, right lower eyelid, left upper eyelid, and left lower eyelid. Cutaneous perfusion in the four eyelid locations and right middle fingertip were statistically similar to each other but significantly higher than that in the right forearm (p = 0.002). Also, mean perfusion in pretarsal skin was > 50% than that in preseptal skin (p = 0.002). In addition, in an eyelid with histopathologically documented basal cell carcinoma, cutaneous perfusion was significantly higher than the mean of the normal eyelids (p = 0.002). Eyelids are perfused at the same high rate as are other regions of the head, and significantly higher than low flow regions, such as the extremities. Future application of this laser Doppler perfusion scanning include assessing burn depth, postoperative monitoring of periorbital tissue transfer, distinguishing benign and malignant adnexal skin lesions, and establishing the pathologic margins of lid tumors.

Lacrimal gland hemangiopericytoma.

PURPOSE/METHODS: A 49-year-old woman with a left orbital mass was referred to an orbital clinic. Clinical investigation suggested a lacrimal gland lesion and the patient underwent lateral orbitotomy and excisional biopsy for a suspected pleomorphic adenoma in the lacrimal gland. RESULTS/CONCLUSION: Histopathologic evaluation disclosed a hemangiopericytoma originating within the lacrimal gland. Although hemangiopericytoma does not usually occur in this location, it may be added to the differential diagnosis of lacrimal gland enlargement.

Hard-palate mucosa graft in Stevens-Johnson syndrome.

PURPOSE: We evaluated the use of hard-palate mucosa grafts in the treatment of cicatricial entropion and trichiasis associated with Stevens-Johnson syndrome. METHODS: Six patients, two men and four women, were treated with hard-palate mucosa grafts of one or more eyelids with cicatricial entropion, trichiasis, and corneal disease. The follow-up ranged from 19 to 33 months. RESULTS: Visual acuity improved in one of nine eyes and remained stable in the rest. Corneal epithelial disease improved in eight of nine eyes, while in one eye the epithelial defect stabilized. The corneal epithelium of all three corneal transplants remained intact, although one of these patients underwent another corneal transplantation and the other two transplants opacified from rejection. Cicatricial entropion resolved and symblephara improved in all 16 eyelids. Trichiasis resolved or improved in 12 of 16 eyelids and remained stable in the other eyelids. CONCLUSIONS: The chronic relapsing nature of Stevens-Johnson syndrome requires caution in interpreting surgical intervention in the treatment of dysfunctional eyelids. However, hard-palate grafts may be considered for patients with the Stevens-Johnson syndrome and severe ocular surface disease.

Lid crease and capsulopalpebral fascia repair in congenital entropion and epiblepharon.

Forty-one eyelids of 21 patients with congenital entropion or epiblepharon underwent transcutaneous reconstruction of the eyelid crease and retractor (capsulopalpebral fascia). All of the patients demonstrated lack of cutaneous-capsulopalpebral fascia attachment. In contrast with the patients with epiblepharon, those with congenital entropion also had partial or complete absence of tarsal-capsulopalpebral fascia attachment. Surgical treatment included anastomosis of the capsulopalpebral fascia, tarsal border, and eyelid skin crease; no skin or muscle was removed. With a minimum follow up of 1 year, malposition recurred in 3 of the 33 (9%) eyelids with epiblepharon, and in none of the 8 eyelids with entropion.

The prognostic value of preoperative dacryocystography in endoscopic intranasal dacryocystorhinostomy.

Endoscopic intranasal dacryocystorhinostomy has been used as a primary treatment of lacrimal obstruction and for revision of conventional dacryocystorhinostomy. This study correlates dacryocystographic anatomy with the success of the endoscopic surgical technique. Eighteen patients with epiphora and nasolacrimal obstruction underwent operations. Preoperative dacryocystography identified 11 patients with either normal or enlarged lacrimal sacs, and seven patients with cicatrized lacrimal sacs. Patients with lacrimal sac stones and tumors were excluded. Endoscopic intranasal dacryocystorhinostomy was successful in nine of 11 (82%) patients with normal or enlarged lacrimal sacs, and in two of seven (29%) patients with cicatrized lacrimal sacs. The endoscopic technique was much more successful with normal or enlarged lacrimal sacs than with cicatrized lacrimal sacs (P = .049). Lacrimal sac anatomy as determined by preoperative dacryocystography is an important prognostic factor in technically achieving surgical success.

Degradation of the 34 amino acid gastrin by rat tissue homogenates.

Extracts of rat kidney contain an enzyme (gastrinase) that is highly specific for degradation of the 34 amino acid gastrin (G34). The Michaelis constant (Km) for kidney is 0.36 +/- 0.04 microM and the Vmax is 9.5 +/- 2.4 nmol X g-1 X min-1. Extracts of liver and brain also have gastrin degrading activity but the enzymes responsible appear to be different from the kidney gastrinase. Km for the liver enzyme is 0.08 +/- 0.02 microM but its Vmax (0.10 +/- 0.02 nmol X g-1 X min-1) is only 1% of the kidney gastrinase; Km for the brain enzyme is 0.10 +/- 0.03 microM but its Vmax (0.023 +/- 0.007 nmol X g-1 X min-1) is even lower than for the liver enzyme. The liver and brain enzymes appear to be less specific than the kidney enzyme with respect to competitive inhibition by insulin and glucagon. Cholecystokinin octapeptide is less inhibitory than the other peptides even though it shares a common C-terminal pentapeptide with G34. These findings are consistent with in vivo studies which have demonstrated that the dog kidney is an important site for extraction and degradation of endogenous dog gastrin but there is little or no hepatic removal of G34.