[Endogenous Candida endophthalmitis: diagnostics and treatment options based on case studies]

BACKGROUND

Endogenous Candida endophthalmitis is an emergency that can threaten vision and the eye as a whole organ but also the life of the patient due to its systemic cause.

MATERIAL AND METHOD

Retrospective case evaluation of the University Hospital for Ophthalmology Halle (Saale) and the Eye Clinic of the Ernst von Bergmann Hospital Potsdam from 2017-2022. (Age, gender, side involvement, underlying diseases, symptoms, preoperative and postoperative visual acuity, diagnostics, treatment and complications). The standardized procedures for endogenous Candida endophthalmitis are explained, the data are compared with the literature and treatment suggestions are presented.

RESULTS

8 patients with 14 eyes were treated for endogenous Candida endophthalmitis. Of the patients 2 were women and 6 were men. The overall average age was 70.25 years (53-82 years), 6 patients had bilateral eye involvement and 2 patients were affected on one side. All patients had several serious immunocompromising underlying diseases that were the cause of the candidemia. All patients underwent a pars plana vitrectomy (ppV) on the affected eyes except for one male patient who did not obtain permission for anesthesia. In addition to systemic treatment with antimycotics, voriconazole was routinely administered intravitreally during ppV. The patients received further intravitreal doses of voriconazole based on the findings. Vitreous body samples were taken from all patients during the ppV and detection of Candida albicans was possible in all cases. As part of the local perioperative treatment 1 patient received parabulbar administration of a triamcinolone depot in both eyes, 7 patients received a dexamethasone depot in 11 eyes and all 8 patients received findings-oriented local treatment with prednisolone acetate eye drops. visual acuity increased from preoperatively 1.2 logMar to 1.0 logMar. Postoperative retinal detachment did not occur and there were no serious perioperative complications. 2 patients died from one of the underlying diseases after 3 and 25 months, respectively.

CONCLUSION

Despite an increasing number of case series, there are still no uniform guidelines for ophthalmologists in Germany. There is agreement regarding systemic treatment and the intravitreal administration of antifungal agents. The role of ppV has not yet been clearly defined and the question of the adjuvant use of steroids (systemic and/or local) has also not been conclusively clarified.

Augenverätzungen

Chemical burns of the ocular surface (CBOS) are emergencies of highest urgency. Therefore, an adequate emergency care is mandatory. Following a precise analysis of the initial damage, a staged therapeutic approach is used to prevent persistent impairment of the ocular surface. In the acute stage, the prevention of complications is targeted (symblepharon, conjunctival scarring, lacrimal stenosis, corneal ulceration, intraocular inflammation, elevated intraocular pressure, etc.). In later stages, if complications have developed, a secondary restoration of the ocular surface is focussed. Sometimes this requires several surgical interventions. Based on a review of international literature, this review highlights the pathophysiology according to different chemical agents, CBOS stages as well as main therapy strategies in early and advanced stages of CBOS. Acute treatment aims to lower inflammation, oxidative stress and tries to promote reepithelialisation. Besides conjunctival scarring, loss of goblet cells and corneal opacification a limbal stem cell insufficiency is the most harming complication. Several new techniques have been developed to recover the ocular surface with a sufficient and clear epithelial layer in order to avoid neovascularization of the cornea. The knowledge concerning the high risk potential for persistent visual impairment in CBOS patients and the ability for appropriate emergency care should be kept in every physician's mind dealing with CBOS.

[Concrements of the lacrimal apparatus]

Concrements of the lacrimal apparatus, known as dacryoliths, can occur at different localizations and can cause a variety of symptoms. A common clinical sign is chronic inflammation, possibly exhibiting acute exacerbation. Based on a literature review and descriptive clinical cases with histopathological correlations, this contribution summarises the most important information concerning epidemiology, aetiopathogenesis, composition, histology, and therapy of lacrimal concrements. Furthermore, factors known to affect lacrimal lithogenesis are addressed. Concrements of the lacrimal gland cause a swelling at the lateral canthus. With only mild pain, this manifests as circumscribed conjunctival hyperaemia. Histologically, the gland tissue is characterised by acute-erosive to chronic inflammation. The concrements consist of amorphic material. Inflammatory infiltration is dominated by neutrophil granulocytes. Canalicular concrements are highly correlated with chronic canaliculitis. Besides epiphora, patients present with purulent discharge at the affected canaliculus. Actinomyces are frequently found inside these deposits and form drusen-like formations. The surrounding tissue reacts with plasma-cellular and granulocytic inflammation. Dacryoliths (concrements of the lacrimal sac) are associated with dacryocystitis, whereby acute and chronic types are common. Stones can be found in up to 18% of patients undergoing dacryocystorhinostomy or dacryoendoscopy. Preoperative diagnostic testing is challenging, as many lacrimal sac stones cannot be reliably visualised by diagnostic procedures. Recurring episodes of epiphora, mucopurulent discharge, and dacryocystitis are common indicators of dacryoliths. Lacrimal syringing is often possible and shows that total blockage is not present. Histology of the lacrimal mucosa reveals lymphocytic infiltration and submucosal fibrosis. The immediate vicinity of the dacryoliths shows acute inflammation. Therapy consists of stone extraction and improving lacrimal drainage, as the latter is recognised as the main risk factor for dacryolith formation.

Transcutaneous (External) Dacryocystorhinostomy with Reconstruction of the Ductus nasolacrimalis

BACKGROUND

Dacryocystorhinostomy (DCR) is regarded as the gold standard for the treatment of chronic dacryocystitis (CDC). Different modifications of the surgical procedure have been developed over the years.

METHODS

Patients with CDC due to postsaccal lacrimal stenosis and under treatment with DCR have been included in this retrospective study. Two groups of different surgical procedures were analysed: firstly DCR without reconstruction of the ductus nasolacrimalis (DNL, group 1) and secondly patients with reopening the DNL (group 2). Criteria for success were absence of permanent epiphora, absence of inflammation of the lacrimal sac (functional success), and no recurrent surgery with free patency of the lacrimal duct (anatomical success). This was obtained by questionnaire after a follow-up of at least 12 months. The impact of gender, ectasia of the lacrimal sac, dacryoliths, and prior lacrimal surgeries was analysed.

RESULTS

Overall, 248 surgeries were enrolled in this trial. Mean age in group 1 was 68 years (range: 22 to 92 years) and gender ratio was 3.2 to 1 (female : male). In that group, 68 operations could be followed up. In group 2, 62 operations on patients of a mean age of 63 years (range: 24 to 89 years) and a gender ratio of 2.9 to 1 (female : male) were observed. Complete success occurred in 75.0% in group 1 and 75.8% in group 2. Recurrent operations were necessary in one case of group 2 (1.6%) and 4 cases of group 1 (5.9%). Gender (group 1 p = 1; group 2 p = 0.115; between groups p = 0.511), ectasia of the lacrimal sac (group 1 p = 0.877; group 2 p = 0.674; between groups p = 0.878), dacryolith (group 1 p = 1; group 2 p = 0.465; between groups p = 1), and prior lacrimal surgery (group 1 p = 0.092; group 2 p = 0.051; between groups p = 0.520) did not influence the success rates in each group or between groups. Significantly more dacryoliths were found during operations of group 2 (p = 0.010).

CONCLUSION

Reconstruction of the DNL during DCR is a possible and easy modification, with a slightly better success rate in curing CDC. Intraoperatively, dacryoliths might not be apparent remain in the deeper parts of the lacrimal ducts. Therefore, these segments should be inspected during surgery.

Dacryolithogenesis or Dacryolithiasis-The Story So Far

The term dacryoliths refers to the concretions found within the lacrimal system. When the term dacryoliths is unspecified, it usually refers to the noninfectious dacryoliths commonly isolated from the lacrimal sac and the nasolacrimal duct. More often, they are diagnosed incidentally during a dacryocystorhinostomy, and the reported incidence among all dacryocystorhinostomy surgeries is 5.7% to as high as 18%. Dacryolithiasis is a complex process occurring within the lacrimal system, and current evidence suggests a multifactorial etiology. The sequence of events can be summarized broadly into 4 stages: stage of susceptibility, stage of initiation/trigger, stage of development, and stage of maintenance. The triggering event is the breach of the lacrimal sac or nasolacrimal duct epithelium, resulting in microtrauma with blood leakage. The blood clots act as a nidus for subsequent sequential laying of mucopeptides, cellular debris present locally, debris washed from the ocular surface, and extraneous agents in tears. This process is aided by altered rheology and composition of the tear film. After the formation of dacryoliths, extracellular neutrophil traps usually form on the surface, which help to maintain the dacryoliths (which do not dissolve). This review highlights and discusses the possible sequence of events during dacryolithiasis.

Pressure-Lowering Effect of Interventional Fistula Occlusion in Secondary Glaucoma due to Orbital Draining Intracerebral Fistulae

BACKGROUND

Carotid cavernous sinus fistulas (CSCF) are pathological connections of the internal and/or external carotid artery (and/or its branches) to the cavernous sinus. Ophthalmological symptoms and problems occur particularly when drainage is via the superior ophthalmic vein.

MATERIAL AND METHODS

Seven eyes of six patients with a high-grade suspicion of CSCF were included in this retrospective monocentric study. Digital subtraction angiography (DSA) was performed in the included patients, where an interventional fistula closure was performed in the case of CSCF. Four of the six patients received a pre- and post-interventional day-night intraocular pressure profile. Furthermore, medical history, symptoms, visual acuity, slit lamp microscopic findings, and DSA findings were evaluated.

RESULTS

The most common symptoms reported by patients were red eyes, diplopia, and exophthalmos. When the intraocular pressure (IOP) was measured, 83.33% of the patients showed increased values. The mean IOP in the day-night intraocular pressure profile in the affected eye before intervention was 23.5 (± 2.7) mmHg compared to 14.1 (± 2.3) mmHg in the healthy eye. A significant difference could thus be demonstrated in side comparison (p = 0.0047). The post-interventional measurement showed a mean IOP of 15.3 (± 1.0) mmHg in the affected eye and thus a significant difference to the pre-interventional measurement in the affected eye (p = 0.0018). Four of the six patients with CSCF were taking antiglaucomatous eye drops before the intervention, and two patients after the intervention. The number of antiglaucoma drugs used could also be reduced.

CONCLUSION

Interventional fistula closure is an effective method for treating the secondary increase of IOP in CSCF. Successful closure of the fistula showed a significant reduction in IOP, which was not possible with the sole administration of antiglaucoma drugs. Radius-Maumenee syndrome should be considered as a differential diagnosis.

On the Current Care Situation and Treatment of Ocular Mucous Membrane Pemphigoid in Germany

BACKGROUND

Ocular involvement in mucous membrane pemphigoid (MMP) is relatively rare, with a prevalence of 25 cases per million population, equating to approx. 2,100 patients throughout Germany. Diagnosis can be difficult - especially in cases of isolated ocular involvement - and treatment can be complex and lengthy. Immunosuppressants or immunomodulatory drugs are often used. Due to the complexity of diagnosis and treatment, MMP patients are usually referred to specialized centers. The aim of this project was to evaluate the current care situation of patients with ocular MMP in Germany.

METHODS

A paper-based survey was designed and sent to all university eye clinics and other specialized centers in Germany in April 2020. The survey asked about the existence of a specialized outpatient service, the total annual number of patients with MMP, the annual number of newly diagnosed patients, any interdisciplinary collaboration for diagnostic or therapeutic purposes, as well as the local and systemic therapy used.

RESULTS

Of a total of 44 clinics, 28 (64%) responded, reporting a total average of 27 ± 42 (0 - 200) patients and 3.6 ± 2.2 (0 - 10) new cases per year. This corresponds to a total of 741 patients. Only nine (32%) of the responding clinics offer specialized MMP clinics. 93% of the centers collaborate with the local dermatology department. 79% perform serological and histological diagnostics in-house. About half of the centers (n = 16) apply a standardized treatment regime. Systemic glucocorticoids (66.7%) are most commonly used, followed by mycophenolate mofetil and dapsone (57.1%), rituximab (33.3%), azathioprine and cyclophosphamide (28.6%), as well as methotrexate (19.0%). The least frequently used treatment is intravenous immunoglobulin (14.3%).

CONCLUSION

This survey of German ophthalmology departments obtained data from about one third of the estimated total cohort of all patients with MMP in Germany. These are presumed to be exclusively patients with at least one ocular involvement. The complex care of these patients is usually provided in collaboration with a dermatologist and with the use of systemic anti-inflammatory medication. Currently, an ophthalmological MMP register is being established to better record the epidemiology and care situation of this rare disease in Germany and to improve it in the long term.

Neutrophil Extracellular Traps Drive Dacryolithiasis

Mucopeptide concretions, previously called dacryoliths, are macroscopic stones that commonly obstruct the lacrimal sac. The mechanism behind dacryolithiasis remains unclear; however, the involvement of various immune cells, including neutrophils, has been confirmed. These findings remain limited, and no information on neutrophil extracellular traps (NETs), essentially involved in the pathogenesis of other lithiases, is available yet. Here, we employ microcomputed tomography, magnetic resonance tomography, histochemistry, mass spectrometry, and enzyme activity analyses to investigate the role of neutrophils and NETs in dacryolithiasis. We classify mucopeptide concretions into three types, with respect to the quantity of cellular and acellular material, polysaccharides, and mucosubstances. We propose the role of neutrophils and NETs within the existing model of gradual formation and growth of mucopeptide concretions, with neutrophils contributing to the initial stages of dacryolithiasis, as they localized on the inner (older) parts of the tissue. As NETs localized on the outer (newer) parts of the tissue, we link their role to the late stages of dacryolithiasis, presumably maintaining the proinflammatory environment and preventing efficient clearance. An abundance of IgG on the surface indicates the involvement of the adaptive immune system later as well. These findings bring new perspectives on dacryolithiasis, in which the innate and adaptive immune system are essentially involved.

[Congenital anomalies in lacrimal drainage]

Congenital dacryostenosis is the most common reason for ophthalmic consultation in childhood. It is most often caused by persisting of Hasner's membrane. However, congenital malformations of the lacrimal drainage system can also occur in rare cases. In the area of the proximal lacrimal drainage system, supernumerary lacrimal puncta and canaliculi can arise as well as diverticula, fistula, and atresia. The distal lacrimal drainage system can be affected by fistulas, amniotoceles, and cysts. Association of lacrimal malformations with congenital systemic diseases is reported in about 10% of cases. Depending on the severity of the symptoms, surgical rehabilitation can be performed, and endoscopic procedures and modern lacrimal drainage intubation systems may be employed.

Concrements of the Lacrimal Apparatus

Concrements of the lacrimal apparatus, known as dacryoliths, can occur at different localizations and can cause a variety of symptoms. A common clinical sign is chronic inflammation, possibly exhibiting acute exacerbation. Based on a literature review and descriptive clinical cases with histopathological correlations, this contribution summarises the most important information concerning epidemiology, aetiopathogenesis, composition, histology, and therapy of lacrimal concrements. Furthermore, factors known to affect lacrimal lithogenesis are addressed. Concrements of the lacrimal gland cause a swelling at the lateral canthus. With only mild pain, this manifests as circumscribed conjunctival hyperaemia. Histologically, the gland tissue is characterised by acute-erosive to chronic inflammation. The concrements consist of amorphic material. Inflammatory infiltration is dominated by neutrophil granulocytes. Canalicular concrements are highly correlated with chronic canaliculitis. Besides epiphora, patients present with purulent discharge at the affected canaliculus. Actinomyces are frequently found inside these deposits and form drusen-like formations. The surrounding tissue reacts with plasma-cellular and granulocytic inflammation. Dacryoliths (concrements of the lacrimal sac) are associated with dacryocystitis, whereby acute and chronic types are common. Stones can be found in up to 18% of patients undergoing dacryocystorhinostomy or dacryoendoscopy. Preoperative diagnostic testing is challenging, as many lacrimal sac stones cannot be reliably visualised by diagnostic procedures. Recurring episodes of epiphora, mucopurulent discharge, and dacryocystitis are common indicators of dacryoliths. Lacrimal syringing is often possible and shows that total blockage is not present. Histology of the lacrimal mucosa reveals lymphocytic infiltration and submucosal fibrosis. The immediate vicinity of the dacryoliths shows acute inflammation. Therapy consists of stone extraction and improving lacrimal drainage, as the latter is recognised as the main risk factor for dacryolith formation.

Congenital Anomalies in Lacrimal Drainage

Congenital dacryostenosis is the most common reason for ophthalmic consultation in childhood. It is most often caused by persisting of Hasner's membrane. However, congenital malformations of the lacrimal drainage system can also occur in rare cases. In the area of the proximal lacrimal drainage system, supernumerary lacrimal puncta and canaliculi can arise as well as diverticula, fistula, and atresia. The distal lacrimal drainage system can be affected by fistulas, amniotoceles, and cysts. Association of lacrimal malformations with congenital systemic diseases is reported in about 10% of cases. Depending on the severity of the symptoms, surgical rehabilitation can be performed, and endoscopic procedures and modern lacrimal drainage intubation systems may be employed.

Rare Diseases of the Orbit

This article provides an overview of rare orbital diseases. Congenital malformations, inflammatory diseases, benign and malignant neoplasias are described. Although it represents a relatively small area of the body the orbit contains multiple different tissues. Therefore, a great variety of diseases can be found within the orbital space. That is the reason, why both the completeness and the level of detail in the description of particular diseases must be somewhat limited. Nevertheless, clinical manifestations, important aspects of diagnosis, treatment strategies, and, when specific data are available, the prognosis are described. The authors tried to highlight the most characteristic aspects of the different diseases to describe their relevant aspects in spite of the brevity of the subsections.

[Deep periocular trauma with affection of the lacrimal ducts during Caesarean section]

Periokuläre Verletzungen im Rahmen einer Kaiserschnittentbindung sind extrem selten. Anhand einer Kasuistik eines 5 h alten Neugeborenen soll das Trauma-Management in Hinblick auf Diagnostik, Therapie und Nachsorge einer tiefen periokulären Weichteilwunde dargestellt werden. Das Verletzungsmuster umfasste durchgreifende Wunden des medialen und lateralen Lidwinkels mit Eröffnung der Bindehautumschlagsfalte, der Tenonkapsel und Durchtrennung des oberen Tränenröhrchens. Der schichtweise Wundverschluss beinhaltete eine autostabile monokanalikulonasale Intubation der ableitenden Tränenwege.

[Primary Reconstruction of Lacrimal Ducts after Trauma - Bicanaliculonasal Intubation Using Autostable Tubes]

Trauma of the medial canthal region can affect all parts of the lacrimal ducts. Depending on the patient's age, there may be different mechanisms of injury. Surgical reconstruction using two autostable ("self-retaining") monocanaliculonasal lacrimal tubes is demonstrated by two case reports. Here, a 6 years old girl attacked by a dog (Rottweiler) showed severe periocular soft tissue damage with deep involvement of the lacrimal ducts. The child's inferior canaliculus was lacerated. Furthermore, the common canaliculus was dissected from the lacrimal sac. Deep soft tissue damage consisted of blunt and sharp injuries down to the cheek and nose. After lacrimal intubation with two autostable monocanaliculonasal tubes, the soft tissue was reconstructed by direct canalicular suturing and stepwise closure of each layer. One of the lacrimal tubes was fixated at the lid by additional sutures, in order to avoid stent prolapse. Beside slight medial depression of inferior lid, there were no signs of functional disturbance of the lacrimal ducts. The follow-up was 18 months. The second case report presents a 43 years old man. He accidentally cut himself with a butcher's knife. He suffered a deep wound of his medial canthal region. The patient presented with proximal (located near the lacrimal sac) laceration of both canaliculi. The medial canthal ligament as well as the orbicularis muscle had been cut. Using two autostable monocanaliculonasal lacrimal tubes, the lacrimal ducts were stented and reconstructed with sutures. During the follow-up of 6 months, no epiphora or mucopurulent lacrimal discharge occurred. In lacrimal trauma, different parts of the lacrimal ducts may be affected at the same time. Identification of the injured structures with respect to the kind of injury, localisation and the extent of damage is crucial. Stepwise wound closure in respect to the topographic anatomy is mandatory. Here, lid and lacrimal ducts must be respected as one functional unit. Simultaneous use of autostable monocanaliculonasal lacrimal tubes in both canaliculi can be applied for trauma reconstruction of the lacrimal ducts in children and adults.

[Management of posttraumatic ocular hypotony]

The posttraumatic ocular hypotony (3% after ocular contusion, 50-74% after open globe injury) can lead to severe secondary damage of the eyeball. In addition to corneal folds, ciliary body and choroidal detachment, papilledema e vacuo and macular folds, the shrinking of the eye can lead to substantial visual impairment. Subsequently, the contralateral eye may react with ocular hypertension. The cause of the hypotony must be identified and causally treated. A preservation of the globe is possible if more than 210 ° of the ciliary body are intact. One of the major causes of posttraumatic hypotony is cyclodialysis. Smaller cyclodialysis clefts respond to a cycloplegic treatment, larger clefts require a surgical approach. The direct cyclopexy can be combined with primary wound repair or pole to pole surgery. An alternative consists of silicone oil endotamponade or occlusion of Schlemm's canal. The posttraumatic ocular hypotony is complex and requires exact diagnostics to be able to differentially and specifically treat the causes of hypotony.

[Diseases and Surgery of the Orbit]

Most orbital diseases are rarely diagnosed in the clinic. Because the consequences for the eye can be severe, it is important to recognize the signs of orbital disease early in order to initiate the correct diagnostic and therapeutic steps in good time. This article presents the basics of the systematics, diagnostics and therapy of orbital diseases in preparation for the specialist examination for ENT medicine. Some orbital diseases are typical manifestations of systemic diseases (e. g. Graves' disease) or typical complications of diseases in the vicinity of the orbit (e. g. orbital complications from inflammatory or tumorous sinus diseases). The diseases of the lacrimal system and the eyelids as well as their therapy are closely related to the diseases of the orbit. Basically, it can be said that the diagnosis and therapy of orbital diseases should always be carried out on an interdisciplinary basis, whereby the involvement of the ophthalmologist is of particular importance.

Tränenwegsstenosen im Erwachsenenalter

Zur Aufrechterhaltung der okulären Oberflächenhomöostase und damit den Erhalt der optischen Eigenschaften sind Tränenproduktion, -verteilung und -abtransport essenzielle physiologische Funktionen. Störungen dieser funktionellen Einheit gehen mit starken Beschwerden und einem hohen Leidensdruck bei den Patienten einher. Da etwa 3% unserer Patienten eine Tränenabflussstörung aufweisen, ist die Thematik von hohem klinischem Interesse.

[Lacrimal Duct Obstruction in Adults]

The tearing eye (epiphora) is the guiding symptome of nasolacrimal duct obstruction. Depending on the localization of stenosis, mucopurulent lacrimal discharge occurs additionally. These symptoms induce alterations of the optical system and can cause severe complications such as acute phlegmonous dacryocystitis. The grade of suffering in these patients is very high. For the diagnosis, patient's history, ocular surface conditions and inspection (macro-/microscopically) as well as palpation of the lacrimal region are essential examinations. Moreover, functional and anatomical tests enable a classification of nasolacrimal duct obstruction regarding grade of stenosis (incomplete vs. complete), type (functional vs. mechanical), and localization (pre-, intra-, postsaccal). ENT consultation prior to lacrimal surgery is obligate. Through this, a purposeful therapeutic intervention is warranted. Surgical methods consist of minimally invasive transcanalicular procedures or anastomosing surgeries. Dependent on the clinical findings, these treatment options can be applied in a patient centered therapeutic concept.

[Disorders of the Lacrimal Apparatus, Part 2: Basics of Therapy]

The tearing eye (epiphora) is deemed to be the leading symptome of efferent tear duct stenosis. Nevertheless, epiphora might be caused by ocular surface pathologies or even intraocular diseases. A distinguished anamnesis and sufficient clinical examination is most meaningful for the differential diagnostic distinction. Therapy is based on pathologic changes. In case of ocular surface disease, a suitable tear substitution and antiinflammatory approach is mandatory. Multifarious triggers have to be considered as well. Addressing tear film distribution, suitable oculoplastic surgery is required. Efferent tear duct stenosis necessitates surgical treatment as the level of suffering is often very high and acute exacerbations may develop. Besides recanalization, anastomosing techniques represent the available therapeutic principles. Possible surgical approaches offer a great variety and many influencing factors navigate therapy decisions. This part of the review comments on the most important therapeutic approaches for lacrimal apparatus diseases.

[Disorders of the Lacrimal Apparatus, Part 1: Anatomy, Physiology, Diagnostics]

The lacrimal apparatus is a part of the ocular adnexa preserving ocular surface homoeostasis and therefore enabling sufficiant visual functioning. Tear producting tissues, eyelids and efferent tear ducts operate as one functional unit. Pathologic changes consist of inflammatory diseases, congenital disorders, degenerations and neoplasia. Common to all these conditions is a potential impairment of the ocular integrity as well as a substantial degree of suffering for the affected patients. This review reflects basics of the anatomy, physiology, and diagnostics of the lacrimal apparatus.

[Orbital Amyloidosis - Comparison of Two Different Clinical Courses]

BACKGROUND

Primary localised orbital amyloidosis (PLOA) is a very rare disease. In contrast to the isolated manifestation, systemic involvement can be associated with potentially life-threatening consequences. However, the isolated involvement of the orbit can also lead to serious complications.

MATERIAL AND METHODS

Two cases of PLOA are described and the necessary ophthalmic, internistic and immunohistochemical diagnostic testing are explained.

RESULTS

The first case describes a 71-year-old woman with PLOA. In the clinic, a yellow-orange bumpy prominence in the nasal lower quadrant without further ophthalmological abnormalities was found. Extensive diagnostic testing found no systemic manifestation. The patient herself was free of complaints. In the follow-up over 4 years, patient showed slow progression without ocular complications. The second case is a 72-year-old male patient with similar clinical signs but localisation in the temporal superior quadrant. During the clinical course, multiple ophthalmological complications developed (ptosis, protrusio bulbi, diplopia, secondary glaucoma, perforated corneal ulcer in neurotrophic keratopathy). Perforating keratoplasty had to be performed. Fractioned radiotherapy led to stabilisation of the disease. The follow-up period was 4 years.

CONCLUSION

PLOA can lead to visual and organ threatening complications. Accurate diagnosis is required for further diagnostic and therapeutic procedures and to counteract potential local and systemic complications. Interindividual differences in the course have to be considered.

[Acute compression of the optic nerve due to orbital emphysema]

Bony defects of the orbit with connection to the paranasal sinuses can lead to orbital emphysema. A case of compression of the optic nerve due to orbital emphysema in a 39-year-old man is reported. Visual acuity was hand movements only and intraocular pressure was increased to 32 mm Hg with an exophthalmus of 6 mm in comparison to the unaffected side. A sufficient pressure relief could be achieved by canthotomy with cantholysis and radial peritomy.

[Pediatric acute dacryocystitis due to frontoethmoidal mucocele]

BACKGROUND

Pediatric acute dacryocystitis typically develops due to persistence of Hasner's membrane. Pediatric paranasal mucoceles are rare entities. In contrast, chronic dacryocystitis in cases of congenital dacryostenosis is one of the most frequent pediatric ophthalmologic issues.

METHODS

The case report of a 10-year-old girl suffering acute dacryocystitis is presented.

RESULTS

The area around the left lacrimal sac showed a painful swelling with edema and hyperemia. Systemic and local antibiotic therapy resulted in only slight improvement. Dacryoendoscopy detected acute dacryocystitis with significant stenosis of the nasolacrimal duct. The nasolacrimal duct was widened dacryoendoscopically and autostable bicanalicular nasolacrimal intubation was performed. Nevertheless, the lacrimal ducts were blocked subtotally and a widening of the ethmoid on the left side was shown by rhinoscopy. Magnetic resonance imaging confirmed a frontoethmoidal mucocele which was treated by marsupialization. During the 24-month follow-up there was no recurrence of acute dacryocystitis. There were no signs of sinusitis.

CONCLUSION

Paranasal mucoceles, e. g., ethmoidal mucoceles, can compress the lacrimal pathways and cause acute lacrimal inflammation in childhood. Paranasal mucoceles should thus be excluded in cases of unclear masses in the lacrimal region.

[Primary Reconstruction of Lacrimal Ducts after Trauma - Bicanaliculonasal Intubation Using Autostable Tubes]

Trauma of the medial canthal region can affect all parts of the lacrimal ducts. Depending on the patient's age, there may be different mechanisms of injury. Surgical reconstruction using two autostable ("self-retaining") monocanaliculonasal lacrimal tubes is demonstrated by two case reports. Here, a 6 years old girl attacked by a dog (Rottweiler) showed severe periocular soft tissue damage with deep involvement of the lacrimal ducts. The child's inferior canaliculus was lacerated. Furthermore, the common canaliculus was dissected from the lacrimal sac. Deep soft tissue damage consisted of blunt and sharp injuries down to the cheek and nose. After lacrimal intubation with two autostable monocanaliculonasal tubes, the soft tissue was reconstructed by direct canalicular suturing and stepwise closure of each layer. One of the lacrimal tubes was fixated at the lid by additional sutures, in order to avoid stent prolapse. Beside slight medial depression of inferior lid, there were no signs of functional disturbance of the lacrimal ducts. The follow-up was 18 months. The second case report presents a 43 years old man. He accidentally cut himself with a butcher's knife. He suffered a deep wound of his medial canthal region. The patient presented with proximal (located near the lacrimal sac) laceration of both canaliculi. The medial canthal ligament as well as the orbicularis muscle had been cut. Using two autostable monocanaliculonasal lacrimal tubes, the lacrimal ducts were stented and reconstructed with sutures. During the follow-up of 6 months, no epiphora or mucopurulent lacrimal discharge occurred. In lacrimal trauma, different parts of the lacrimal ducts may be affected at the same time. Identification of the injured structures with respect to the kind of injury, localisation and the extent of damage is crucial. Stepwise wound closure in respect to the topographic anatomy is mandatory. Here, lid and lacrimal ducts must be respected as one functional unit. Simultaneous use of autostable monocanaliculonasal lacrimal tubes in both canaliculi can be applied for trauma reconstruction of the lacrimal ducts in children and adults.

Tränenwegstenosen durch Verätzungen und Verbrennungen

Hintergrund Verätzungen und Verbrennungen der Augenoberfläche gehören zu den ophthalmologischen Notfällen mit hohem Gefährdungspotenzial. Eine in der Folge resultierende chronische Epiphora kann zu einem hohen Leidensdruck bei den betroffenen Patienten führen.

Methode Anhand einer Literaturrecherche unter Berücksichtigung aktueller Arbeiten und Darstellung eigener Erkenntnisse, beruhend auf langjährigen Erfahrungen, sollen Handlungsempfehlungen zum Umgang mit sekundär erworbenen Tränenwegstenosen nach Schädigung der okulären Oberfläche durch Verätzungen und Verbrennungen gegeben werden.

Ergebnisse Initial ist eine Einstufung des Schädigungsgrades essenziell. Nach Demarkation der Nekrosen sollte deren Abtragung erfolgen. Hierbei sind die ableitenden Tränenwege (TNW) auf ihre Durchgängigkeit zu prüfen. Liegt primär eine Beteiligung der TNW vor, sind diese zu behandeln. Dabei sind vor allem Stenosen im Bereich der Tränenpünktchen bzw. -röhrchen zu erwarten. Hier kann eine Rekanalisierung mittels konischer Sonden oder Bangerter-Kanülen erfolgen. Die TNW sind nachfolgend durch eine endokanalikuläre Schienung zu sichern. Besteht primär keine Beteiligung der TNW, sollte für eine sekundäre Rekonstruktion bis zum Abschluss der Narbenbildung abgewartet werden.

Schlussfolgerung Nur selten kommt es zu einer behandlungsbedürftigen Epiphora aufgrund einer TNW-Stenose nach Verätzung oder Verbrennung der Augenoberfläche. Eine chirurgische Intervention sollte, wenn möglich, nicht vor 6 Monaten nach Trauma durchgeführt werden.

[Periocular metastasis as differential diagnosis of pyogenic granuloma and therapeutic marker of a systemic disease]

BACKGROUND

A pyogenic granuloma is a frequent palpebral pseudotumor. Showing a typical clinical picture after an inflammation (hordeolum, chalazion) it can be easily diagnosed and sometimes a histopathological analysis is thought to be unnecessary.

METHODS

A case report of a patient suffering from a palpebral metastasis of a clear cell renal cell carcinoma (cRCC) as an atypical differential diagnosis of an inflammatory pseudotumor of the eyelid is presented.

RESULTS

A 72-year-old man presented for surgical treatment of a pyogenic granuloma. The medial portion of the inferior eyelid showed a nodular and pediculate lesion of the tarsal conjunctiva. At the time of presentation the patient was receiving adjuvant systemic treatment with cabozantinib because of lymphonodal and pulmonal metastases of the cRCC. The tumor was resected and the histopathological examination revealed a sarcomatoid dedifferentiated metastasis of the cRCC. After 4 weeks the tumor showed a local recurrence and histologically a local relapse was found. Therefore, a change in the systemic therapy was initiated (nivolumab). In the follow-up of 18 months no recurrence of the palpebral tumor occurred. A stable disease condition of the cRCC was achieved.

CONCLUSION

Even if the clinical aspect of an inflammatory tumor of the lids seems to be clear, a histopathological examination is still necessary. An interdisciplinary approach with reevaluation of the systemic therapy led to an improvement of the patient treatment.

[Laser membranotomy of acute subhyaloidal hemorrhage after indirect ocular trauma]

INTRODUCTION

Subhyaloidal premacular hemorrhage (SPH) causes a painless acute loss of vision with central scotoma. Typically, it can be caused by vascular retinal diseases or in the context of a Valsalva retinopathy. Ocular trauma is a less common cause of SPH.

METHODS

This case report describes a 54-year-old male who presented with a painless decrease of vision in the left eye after blunt frontal trauma to the forehead during a car accident.

RESULTS

A car accident resulted in an abrupt deceleration of the head by hitting the windscreen. There was no direct trauma to the eyes. The initial visual acuity of the affected left eye was 0.1 and the visual acuity of the right eye was 1.0. Funduscopy verified an incomplete detachment of the posterior vitreous body with rupture of a retinal venous vessel of the temporal upper vascular arch and prominent SPH. Furthermore, a cystoid macular edema was detected. For internal drainage a neodymium-doped yttrium aluminium garnet (Nd:YAG) laser membranotomy of the posterior vitreous body was performed 1 day after the trauma. On the first postoperative day visual acuity increased to 0.32 with a complete resolution of the macular edema. During the follow-up, visual acuity was 1.0 after 3 months and 1.25 after 6 months.

CONCLUSION

Acceleration and subsequent deceleration can result in a relevant transfer of force to the vitreoretinal interface as an indirect trauma. The Nd:YAG laser membranotomy is a minimally invasive treatment option for SPH after indirect ocular trauma.

[Diagnostics and treatment of lacrimal duct diseases : A structured patient-centred care concept]

BACKGROUND

The cardinal symptom of lacrimal stenosis is epiphora and a subjective high level of discomfort due to continuous dacryorrhea.

OBJECTIVE

The aim of the current paper is to present a structured review of common diagnostic and therapeutic strategies for lacrimal stenosis.

MATERIALS AND METHODS

The most important diagnostic and therapeutic approaches are analysed using the existing literature and by reporting the authors' own experiences.

RESULTS

A detailed patient history is crucial for diagnosis of lacrimal disorders. Precise inspection and palpation of the lacrimal and lid region may confirm lacrimal stenosis. Examinations of tear production, tear quality and the properties of the ocular surface are helpful. The most important diagnostic tool is lacrimal duct probing and syringing. Therapy is guided by underlying pathologies. Treatment of congenital lacrimal stenosis follows a staged concept. Epiphora in adults without signs of dacryocystitis should be treated with dacryoendoscopy. Dacryoendoscopy is also a therapeutic option for chronic dacryocystitis, but dacryocystorhinostomy may also be required. Lacrimal trauma should be reconstructed rapidly after the incident by lacrimal intubation. Neoplasia of the lacrimal excretory system requires histological classification to enable multidisciplinary management.

CONCLUSION

Basic ophthalmologic diagnostics are complemented by special symptom-based examinations. Due to ongoing improvement of available diagnostic and therapeutic options, patients' care is becoming increasingly individualised.

Dakryoendoskopische Tränenwegschirurgie – Einflussfaktoren auf das postoperative Ergebnis

Hintergrund Die Dakryoendoskopie (DE) gilt als etablierte Methode der minimalinvasiven Tränenwegschirurgie. Langzeituntersuchungen zum Behandlungserfolg dieser Therapiemethode sind von großer Bedeutung. Hierbei sollten Einflussfaktoren auf das postoperative Ergebnis Berücksichtigung finden, um eine angepasste Patientenauswahl im Vorfeld der Behandlung treffen zu können.

Material und Methoden Es fand eine Auswertung des Patientenguts in Form einer retrospektiven Studie statt. Anhand eines festgelegten Fragebogens erfolgte prospektiv eine Follow-up-Analyse. Prä- und intraoperative Einflussfaktoren wurden mit dem Behandlungserfolg korreliert. Dieser definierte sich durch eine deutlich gebesserte oder fehlende Epiphora, das Fehlen einer erneuten tränenwegschirurgischen Operation und die Freiheit von Zeichen einer chronischen Dakryozystitis (Sekretion, Schmerzen in der Tränensackregion). Zusätzlich wurde die subjektive Zufriedenheit der Patienten mit dem Ergebnis der Operation erfragt (kategorisiert in „sehr gut“, „gut“, „unzureichend“ und „schlecht“).

Ergebnisse Insgesamt wurden 215 DE von 182 Patienten (130 Frauen, 52 Männer) in die Follow-up-Analyse eingeschlossen. Das Durchschnittsalter betrug 58 ± 17 Jahre (Altersspanne: 18 bis 91 Jahre). Die Nachbeobachtungszeit lag bei 31 bis 77 Monaten (Median: 55 Monate). Der Behandlungserfolg betrug im Nachbeobachtungszeitraum 59,1%, wobei weder Patientenalter noch Geschlecht Einfluss nahmen. Im Vergleich zu absoluten Stenosen ist der Operationserfolg bei relativen Stenosen doppelt so hoch (p = 0,02). Eine Tränensackektasie führt mit einem 1,9-fach erhöhten Risiko zum Misserfolg (p = 0,01). Es bestand ein Trend zu schlechteren Heilungsraten bei postsakkaler Stenosenlokalisation (p = 0,2) und einem Patientenalter von mehr als 49 Jahren (p = 0,1). Das Ergebnis der Operation wurde in 32,1% mit „sehr gut“ und in 30,2% mit „gut“ bewertet.

Schlussfolgerung Die DE eignet sich mit ihrem minimalinvasiven Vorgehen als „first-step procedure“. Das Ausbleiben einer Narbe und die schnelle Genesung sind für Patienten von starker Bedeutung. Medizinisch bedeutsam ist, dass die topografische Anatomie erhalten bleibt und somit alle Therapieoptionen im Falle erneut notwendiger Operationen bewahrt werden. Patienten mit relativen Stenosen und prä- bis intrasakkaler Lokalisation profitieren in besonderem Maße von dieser Art der Intervention.

[Scanning electron microscopic investigations of cutting edge quality in lamellar keratotomy using the Wavelight femtosecond laser (FS-200) : What influence do spot distance and an additional tunnel have?]

BACKGROUND

Femtosecond lasers (fs-lasers) are established cutting instruments for the creation of LASIK flaps. Previous studies often showed even rougher surfaces after application of fs-laser systems compared to lamellar keratotomy with mechanical microkeratomes. When cutting the cornea with fs-lasers, an intrastromal gas development occurs, which has a potentially negative influence on the cutting quality if the gas cannot be dissipated; therefore, manufacturers have chosen the way of gas assimilation in so-called pockets. The investigated system creates a tunnel which opens under the conjunctiva. The aim of this study was to investigate the effects of a tunnel as well as the influence of different spot distances on the quality of cut surfaces and edges.

MATERIAL AND METHODS

In this experimental study on freshly enucleated porcine eyes (n = 15), the following cuts were carried out with the FS-200 (Wavelight, Erlangen, Germany): 1. standard setting (spot and line separation 8 µm), 2. with tunnel for gas drainage, 3. without gas-conducting tunnel, 4. with increased spot spacing (spot and line separation 9 μm instead of 8 μm) and 5. with reduced spot spacing (spot and line separation 7 μm instead of 8 μm). Subsequently, scanning electron microscopy (FEI Quanta 650, Hillsboro, OR) of the cut edges and surfaces as well as the gas drain tunnel were performed. The evaluation was based on an established score.

RESULTS

The current fs-laser system (200 Hz) is able to create smooth cutting surfaces and sharp edges. The changed density of laser pulses compared to the standard settings with a reduced or increased distance between the pulses, did not achieve any further improvement in the surface quality. The gas-conducting tunnel could be detected by scanning electron microscope. In the case of cutting without a tunnel, roughened surfaces and irregularities on the cutting edges were found.

CONCLUSION

When the FS-200 fs-laser is used, LASIK cuts with very smooth cut surfaces and sharp cutting edges are achieved. This is only valid as long as an additional tunnel with the fs-laser is placed under the conjunctiva. It can be assumed that the resulting gas is effectively drained through this tunnel. The installation of the tunnel represents a new possibility to replace previous techniques of gas assimilation in deeper lying cutting areas.

Anatomic landmarks in lacrimal surgery from an ophthalmologist's point of view: Clinical findings of external dacryocystorhinostomy and dacryoendoscopy

Epiphora is a common clinical symptom of nasolacrimal duct obstruction. However, it is present in several pathologies and can lead to decreased quality of life for patients. A careful clinical examination including a detailed patient's history and diagnostic tests such as the fluorescein dye disappearance test and diagnostic syringing of the lacrimal duct are essential. Depending on the time of presentation (congenital, primary, or secondary acquired), grade (subtotal or total) and location of the stenosis, different surgical approaches can be considered. These are subdivided into minimally invasive (transcanalicular) and anastomosing (dacryocystorhinostomy) procedures. Furthermore, the anatomical landmarks and the site of surgical intervention differentiate the surgical techniques into endoscopic or transcutaneous. Modern intubation techniques offer a large spectrum of therapeutic possibilities enabling patient care to be customized and individualized. Knowledge of the topographical anatomy is crucial for achieving greater success and a lower complication rate. Clin. Anat. 30:1034-1042, 2017. © 2017 Wiley Periodicals, Inc.

[Dacryoliths and Iatrogenic Foreign Bodies as Classical Triggers for Inflammatory Pseudotumors of the Lacrimal Drainage System]

BACKGROUND

Tumors of the lacrimal duct are rare. Inflammatory pseudotumors do not represent neoplasias as such. Chronic inflammation may lead to an angiomatous granulation tissue.

PATIENTS

The first case presents a 53-year-old male patient suffering a mass of the mediocaudal orbit after an acute dacryocystitis has been cured. Using diagnostic dacryoendoscopy, a large dacryolith was detected. Removing the concrement, via external dacryocystorhinostomy, a polypous tissue appeared which was resected as well. The second case concerns a 29-year-old female patient. She had a lacrimal surgery with stenting seven years prior to surgery. The patient's history revealed recurrent mucous secretion of the tear duct and tenderness of the lacrimal sac. An intrasaccal silicon foreign body could be confirmed by dacryoendoscopy. An external dacryocystorhinostomy was performed and the material was extracted. Hereby, an inflammatory tissue mass filling the whole efferent tear duct was removed.

RESULTS

In both patients, external dacryocystorhinostomy was performed complication-free. Surgery enabled the reconstruction of the nasolacrimal duct. Temporary autostable silicon intubation was inserted into the nasolacrimal duct (case 1 and 2), as well into osteotomy (case 2). Histologically, reactive granulation tissue was confirmed. During the follow-up of 9 months (patient 1) and 12 months (patient 2), patients were free of complaints. Lacrimal stentings were removed uneventfully and completely.

CONCLUSIONS

Dacryoliths and intrasaccal foreign bodies may cause a chronic dacryocystitis. Due to inflammation, reactive tissue proliferation can be initiated. In these cases, a hypertrophic granulation arose. Endogenous (dacryoliths) and exogenous (iatrogenic foreign bodies) triggers may be underlying reasons. Histological examination is essential for differentiating other inflammatory pathologies or tumors.

[Graduated Treatment Concept for Connatal Dacryostenosis]

Unresolved epiphora in childhood is one of the most frequent issues in paediatric ophthalmology. In this context, connatal nasolacrimal duct obstruction (CNLDO) is the most important differential diagnosis and the condition is caused by a persistent Hasner's membrane in most cases. As there is a risk of complications, treatment should be considered. Therapeutic options include conservative and invasive approaches. As CNLDO is associated with high spontaneous recovery rates during the first years of life, the indication for invasive interventions must be carefully deliberated in that period. Conservative treatment with digital compression of the lacrimal sac should be performed whenever CNLDO is suspected. Invasive treatment is recommended in case of complications such as acute dacryocystitis or recurrent ascending infections. Furthermore, CNLDO seems to be amblyogenic. In addition to probing and syringing, temporary intubation of the lacrimal duct is possible. Further transcanalicular approaches include dacryoendoscopy or balloon dacryoplasty. Dacryocystorhinostomy should be reserved for special indications, although it has a low rate of complications and treatment is successful in 90 % of cases. The available treatment approaches can be integrated into a graduated treatment concept, which is influenced by many factors and should therefore be individualised.

[The Interdisciplinary Conference on Lacrimal System Disorders of ophthalmic and ENT surgeons at the University Hospital Halle : An analysis of present patient material]

BACKGROUND AND AIM

The lacrimal system (LS) crosses regions of ocular adnexa, the nose, and the paranasal sinuses. Surgery of disorders requires a targeted ophthalmologic and otolaryngologic examination. Since 2013, an Interdisciplinary Conference on Lacrimal System Disorders (ICLSD) has existed at the University Hospital Halle. First results of our experiences with this cooperation between ophthalmic and ENT surgeons are presented.

METHODS

In a retrospective study at the Department of Ophthalmology, University Hospital Halle, all patients aged 22-80 years (n = 43, 10 with bilateral manifestation; mean age 65.1 years) having had a consultation in ICLSD between February 2013 and May 2015 were analyzed. Thereby, 53 LS were included in the descriptive evaluation.

RESULTS

The main relevant pathology in terms of ophthalmologic manifestation was chronic dacryocystitis and its complications (n = 42), whereas nasal septum deviation (n = 11) and chronic rhinosinusitis (n = 10) were the most frequent otorhinolaryngologic pathologies. Prior to consultation, ENT (n = 34) and/or ophthalmic surgery (n = 40) had been performed. During ICLSD, an individualized therapeutic regime for each patient was developed. Surgery was required in 43 out of 53 LS. Of these, 32 were mainly ophthalmic, 11 mainly ENT interventions. At the time of evaluation (median 3 months; range 1 to 24 months), 29 out of 38 patients (76.3 %) were free of complaints.

CONCLUSION

Since 2013, competences of ophthalmic and ENT surgeons have been integrated in ICLSD for advanced diagnosis and therapy of lacrimal disorders at the University Hospital Halle. Encouraging functional results are shown in this study, as most patients have had a long and complicated history of lacrimal system disorders. ICLSD enables interdisciplinary patient care.

Intravitreal Anti-Vascular Endothelial Growth Factor for Macular Edema due to Complex Retinal Arterial Macroaneurysms

Introduction

Complex retinal arterial macroaneurysms (RAM) are often accompanied by hemorrhage and/or affect the macula. We evaluated the effect of intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy using ranibizumab or aflibercept with or without laser photocoagulation in the treatment of macular edema due to RAM.

Methods

A case report of two patients with secondary macular edema caused by RAM is presented. The first case was a 76-year-old female treated with two 0.5-mg injections of ranibizumab and additional focal laser photocoagulation. This patient presented a solely intraretinal exudation. The second patient was a 96-year-old female, who received one 2.0-mg injection of aflibercept. She showed sub- and intraretinal edema. We documented the clinical courses of these patients based on fundus photography, fluorescein angiography, and spectral-domain optical coherence tomography. Patients were followed-up for 12 months.

Results

Patients were treated successfully using anti-VEGF therapy (ranibizumab or aflibercept) with or without laser photocoagulation. In both cases, we observed a complete regression of the macular edema and an increase in visual acuity.

Conclusion

RAM can manifest with heterogeneous findings. Intravitreal anti-VEGF therapy with or without laser photocoagulation may be an effective treatment option in cases of macular edema due to RAM. Aflibercept and ranibizumab seem to be a potent anti-VEGF therapy for RAM. Individualized patient care is needed.

[Prognostic value of lacrimal duct diagnostics after tube removal : Retrospective analysis of risk of relapse during the first postoperative year after transcanalicular lacrimal duct surgery with silicone tubing]

BACKGROUND

Transcanalicular lacrimal duct surgery has become more important over the past two decades.

OBJECTIVES

The aim of the study was to prove the prognostic value of postoperative lacrimal syringing and the testing of spontaneous drainage of lacrimal fluid immediately after tube removal.

METHODS

A total of 110 cases with postoperative lacrimal syringing and 183 cases with verification of the postoperative lacrimal fluid drainage performed between January 2001 and August 2008 were retrospectively evaluated. The indication for postoperative diagnostics was set by the investigator. The prognostic value of these two procedures was determined by using prognostic parameters (positive predictive value, PPV; negative predictive value, NPV) and analyzing recurrence nonexistence via Cox regression and Kaplan-Meier estimator. The observation period was limited to 12 months. Predominantly, recurrence was defined on the patient's satisfaction and absence of symptoms, which was determined with the help of a questionnaire.

RESULTS

Postoperative verification of the lacrimal syringing is a suitable instrument to estimate surgical success within the first year after lacrimal surgery with a PPV of 92.31%. Testing of the spontaneous drainage of lacrimal fluid after tube removal reached a PPV of 63.33%.

CONCLUSION

The proven prognostic value shows that syringing of the lacrimal duct and verification of spontaneous drainage should be integrated into postoperative care in a standardized manner. Hereby, early information for the patient about the expected result of the surgical procedure is enabled.