Factors associated with rhinostomy shape after endoscopic dacryocystorhinostomy

OBJECTIVE

To determine the factors associated with rhinostomy shape after endoscopic dacryocystorhinostomy (DCR) in patients with primary acquired nasolacrimal duct obstruction.

DESIGN

Retrospective comparative study.

SETTING

University hospital.

PARTICIPANTS

One hundred and two cases in 70 patients were included in the study.

MAIN OUTCOME MEASURE

All cases were classified into three groups according to the healed appearance of the rhinostomy: flat, ladle and ice scoop type. The flat shape was characterised by an opening with a flat surrounding and no clear border between the lacrimal sac and the nasal mucosa. The ladle shape had a depressed base without markings of a lacrimal sac. The ice scoop shape had a depressed base with a clear border between the lacrimal sac and the nasal mucosa. Anatomic success was defined as patency with syringing and endoscopic evidence of ostial patency. Functional success was defined as visualisation of fluorescein dye at the ostium and relief from epiphora. Clinical information and intra- and postoperative endoscopic video findings were compared between the three groups.

RESULTS

Of the 102 cases, 19 flat, 37 ladle and 46 ice scoop type rhinostomies were observed during the follow-up examinations. Among the variables studied, patient demographics and rhinostomy size and location did not differ between the three groups. However, intraoperative lacrimal sac findings (sac size, wall thickness and mobility), postoperative ostial shrinkage and rhinostomy movement were associated with postoperative rhinostomy shape (all P < 0.05). With regard to surgical outcomes, there were no differences in anatomical patency between the three groups. However, the flat group had a worse functional success rate (73.7%) than the ladle (91.9%) and ice scoop (97.8%) groups (P = 0.008). A higher degree of ostial shrinkage and poor rhinostomy movement was observed with the flat shape appearance, which had a small, thick and poorly mobile lacrimal sac.

CONCLUSIONS

Lacrimal sac characteristics play a prominent role in determining rhinostomy shape after endoscopic DCR. The rhinostomy shape, along with the degree of ostial shrinkage and rhinostomy movement, is predictive of functional success after endoscopic DCR.

Subconjunctival fat prolapse and dermolipoma of the orbit: differentiation on CT and MR imaging

BACKGROUND AND PURPOSE

Subconjunctival fat prolapse and dermolipoma of the orbit are unfamiliar to radiologists and yet should be differentiated because their treatments are different. The purpose of this study was to investigate the CT and MR imaging findings that distinguish these 2 conditions.

MATERIALS AND METHODS

Between 1995 and 2009, we found 33 patients (27 men, 6 women; mean age, 63 years) with surgically proved subconjunctival fat prolapse and 27 patients (3 males, 24 females; mean age, 17 years) with dermolipoma in our hospital. Among them, 8 patients with subconjunctival fat prolapse and 6 patients with dermolipoma underwent CT and/or MR imaging examinations. We retrospectively reviewed CT scans and MR images in these patients.

RESULTS

In all of the 8 patients with subconjunctival fat prolapse, CT and MR images demonstrated the herniated fat at the superotemporal epibulbar area, continuous with the intraconal fat, extending forward between the lateral wall of the globe medially and the lateral rectus muscle and the lacrimal gland laterally, either bilaterally (n = 7) or unilaterally (n = 1). In contrast, all 6 patients with dermolipoma had a unilateral, crescent- (n = 5), or triangle-shaped (n = 1) fatty mass at the temporal or superotemporal epibulbar area, which lay on the lateral wall of the globe, anterior to the insertion of the lateral rectus muscle and medial to the lacrimal gland, without connection to the intraconal fat.

CONCLUSIONS

The characteristic CT and MR imaging findings may help easily differentiate subconjunctival fat prolapse and dermolipoma, both of which usually present as an epibulbar fatty mass in the lateral canthal area.

Surgical correction for lower lid epiblepharon in Asians

BACKGROUND/AIMS

Epiblepharon is a congenital lid anomaly in which a fold of skin and underlying orbicularis muscle push the lashes against the eyeball. It is important to get a good lash eversion effect without forming a prominent lid crease in Asian patients. The surgical effect of this rotating suture technique was evaluated.

METHODS

Surgical correction for epiblepharon was performed on 197 patients and the results analysed in 169 patients who had been followed for 1 month or more. After subciliary incision, several buried 8-0 nylon sutures were placed to allow adhesion between the tarsal plate and the subcutaneous tissue of the upper skin flap with minimal resection of pretarsal orbicularis and redundant skin.

RESULTS

156 patients (92.3%) showed satisfactory results during 7.1 months of average follow up. Reoperation was performed only on two patients out of 13 because of mildness of symptoms and signs. Complications were minimal including suture abscesses in four patients and wound dehiscence in one.

CONCLUSION

The rotating suture technique was very effective in repairing epiblepharon without forming a prominent lower eyelid crease.

Vascular hamartoma of the orbit

The aim of this presentation is to report a combined form of vascular malformation of the orbit. A 2-year-old girl had a four-month history of severe proptosis in the right eye. The patient had intermittent proptosis in association with a common cold. The globe was displaced downward and extraocular motility was markedly limited. Multiple intraconal and some extraconal cysts were removed with transcutaneous transseptal anterior orbitotomy. Histological examination showed several characteristics of vascular anomaly. There were malformatively dilated veins intermingled with dilated lymphatic channels, focal cavernous and capillary hemangiomatous features. This combined form of vascular anomaly can be presented as a venous lymphatic malformation associated with hemangiomatous features.

Solitary fibrous tumor of the lacrimal sac

PURPOSE

Solitary fibrous tumor is a rare spindle cell tumor arising in the pleura. We report two cases of this tumor occurring in the lacrimal sac.

METHODS

A 23-year-old man and a 34-year-old woman presented with a medial canthal mass. They underwent surgical excision of their tumors.

RESULTS

Solitary fibrous tumors were diagnosed by light microscopy, immunohistochemical study, and electron microscopy. Immunohistochemical staining showed that tumor cells were reactive with vimentin and CD34 and demonstrated no smooth muscle or neural differentiation (nonreactive with desmin and S-100 protein).

CONCLUSIONS

The findings indicate that solitary fibrous tumor can occur in the lacrimal sac and may recur locally if it is removed incompletely. To our knowledge, these are the first reported cases of solitary fibrous tumors occurring in the lacrimal sac.

Transcanalicular laser-assisted revision of failed dacryocystorhinostomy

BACKGROUND AND OBJECTIVE

Despite the high success rate of external dacryocystorhinostomy (DCR), recurrent tearing after DCR can be troublesome. The authors performed transcanalicular revision in 6 patients with failed DCR.

PATIENTS AND METHODS

With the use of a continuous wave Nd:YAG laser with a sclerostomy probe, the internal ostium was reopened by a transcanalicular approach. The authors applied 0.4 mg/ml of mitomycin-C around the opening for 5 minutes intranasally and inserted a silicone tube as a stent.

RESULTS

A total of 7 operations were performed in 6 patients. The operation was successful after the first revision in 5 of the 6 patients, but 1 of the patients required a second procedure.

CONCLUSIONS

The transcanalicular laser-assisted revision has several advantages. It is simple and fast, skin incision is avoided, there is good hemostasis, it is less traumatic, and there is less postoperative morbidity.

Subperiosteal hematoma of the orbit associated with sinusitis

Subperiosteal hematoma of the orbit is a rare but well-recognized entity, usually caused by trauma. Two cases of subperiosteal hematoma associated with sinusitis are presented. A 44-year-old woman experienced the sudden onset of proptosis, and decreased visual acuity. Computed tomographic scanning and magnetic resonance imaging revealed a frontoethmoidal mucocele and a biconvex mass in the upper part of the left orbit. The mucocele was drained during nasal endoscopic surgery and the subperiosteal hematoma was evacuated during superior orbitotomy. A 42-year-old man had a headache and proptosis. Computed tomographic scan revealed sinusitis and subperiosteal orbital hematoma of the left orbit. Subperiosteal orbital hematoma associated with sinusitis is extremely rare but should be suspected in a patient with acute onset of proptosis in whom computed tomographic scanning reveals paranasal sinusitis.

Four cases of dacryocystocele

Dacryocystocele is a rare complication of chronic dacryocystitis. We report four such cases in which epiphora and painless cystic mass located inferior to the medical canthus were manifested. Computed tomographic scanning of the orbit showed a well-demarcated low density mass in the lacrimal sac area, and extending to the nasolacrimal duct. We completely or partially excised the mass and depending on the condition of the canaliculi and puncta, performed dacryocystorhinostomy, canaliculorhinostomy, or conjunctivodacryocystorhinostomy using Jones' tube. Operative findings revealed that the lacrimal sac and nasolacrimal duct were dilated with obliterated proximal and distal portions the cyst. When cysts in the lacrimal sac area develop subsequent to chronic epiphora or are accompanied by punctal agenesis, differential diagnosis should consider the possibility of dacryocystocele.

Cyst of accessory lacrimal gland

When a patient is presented with a subconjunctival cyst, it is not only hard to reveal its true nature clinically but also easy to rupture during excision. We experienced cases with cysts of the accessory lacrimal gland in two patients with subconjunctival cysts. They had lid swelling at initial presentation and underwent surgical excision of subconjunctival cysts located in superior portion of the upper tarsal plate. The lining of these cysts composed of ductal epithelia. Biochemical analyses for serum and cystic fluid were performed in one case, in which was found high Ig A titer in the cystic fluid. These cysts seemed to originate from the duct of Wolfring's accessory lacrimal gland, considering their anatomic locations and pathologic findings. Complete removal of the cyst is important, because recurrences have been reported in cases of incomplete removal or simple aspiration.

The effects of ascorbic acid on free radical injury in cultured retinal pigment epithelial cells

This study was conducted to investigate the effect of ascorbic acid on oxidative injury of cultured porcine retinal pigment epithelial (RPE) cells induced by t-butylhydroperoxide. The porcine RPE cells were cultured in Dulbecco's modified Eagle's medium and the culture medium was replaced with one containing 0.01 mM to 5 mM ascorbic acid and/or 0.2 mM t-butylhydroperoxide. After 2 hours incubation, the test medium was replaced with the control medium. The number of cells was counted with a Coulter counter after a 2-day incubation period. The medium was pretreated with 900 U/ml and the previous procedure was repeated to eliminate the toxic effects of hydrogen peroxide induced by ascorbic acid. Not only t-butylhydroperoxide (p < 0.01) but also ascorbic acid (p < 0.01) were found to have dose-dependent cytotoxicity on RPE cells. The cytotoxicity was more significant when both agents were added to the culture media. In the presence of catalase, the cytotoxicity of ascorbic acid became insignificant (p < 0.05). The cytotoxicity of t-butylhydroperoxide decreased when 1 mM and 5 mM of ascorbic acid was added to the culture media with catalase pretreatment (p = 0.0277). These results indicate that ascorbic acid was toxic to RPE cells in our culture model but this cytotoxicity was not detected in the presence of catalase. With catalase pretreatment, ascorbic acid in relatively high concentration provided protection against oxidative injury of t-butylhydroperoxide.

The components of the proliferative membranes in retinopathy of prematurity: an electron microscopic study

Electron microscopic examination of proliferative membranes in retinopathy of prematurity (ROP) was performed in order to evaluate the components of the membranes. The proliferative membranes were obtained from nine patients with ROP stage 5 during pars plicata lensectomy, vitrectomy, and delamination of membrane. Fibrous astrocytes, myofibroblasts, lymphocytes, macrophages, and calcification were found respectively in two cases, and fibroblast-like cells were found in one case. Varying amounts of collagen tissues were found in eight cases and vascular tissues in four cases. Most of membranes were hypocellular and composed mainly of collagen matrix. It is considered that fibrous astrocytes, myofibroblasts, fibroblasts, and vascular structures are involved in the formation of proliferative membranes of ROP, and that later these cells degenerate and disappear, and that finally only collagen matrix remains in the membranes.