Ophthalmic Plastic & Reconstructive Surgery

Congenital Dacryocystocele: A Major Review Purpose: To provide a systematic review of the literature on congenital dacryocystoceles (CDCs) and summarize their presentations, investigations, management, and outcomes. Methods: The authors performed a PubMed search of all articles published in English on CDCs. Data captured include demographics, clinical presentations, investigations, management modalities, complications, and outcomes. Fourteen major series (10 or more than 10 cases) and 89 isolated case reports/series on CDCs with a collective patient pool of 1,063 were studied in detail. Specific emphasis was laid on addressing the controversial issues including initial conservative versus surgical management and the role of endoscopic evaluation. Results: Numerous terminologies have been used to describe CDC. Congenital dacryocystoceles are rare variants of congenital nasolacrimal duct obstructions and comprise of 0.1% to 0.3% of all such cases. There is a female predilection (64.2%, 683/1,063) and the mean age at presentation is at 7 days of birth. Initial conservative treatment can be a viable option in the absence of an acute dacryocystitis or a respiratory distress. Endoscopy-assisted probing appears to have better outcomes as compared with the in-office probing. Congenital dacryocystoceles with acute dacryocystitis are preferably managed with intravenous antibiotics and an early probing under endoscopy guidance to avoid missing intranasal cysts. Marsupialization is the preferred technique in the management of intranasal cysts. Silicone intubation was rarely used and has no definitive indications. Dacryocystorhinostomy is very rarely needed in the management of CDC. Conclusions: Congenital dacryocystocele is a commonly accepted term and its use should be advocated to enhance uniformity in reporting. Endoscopic evaluation of CDC is useful in the diagnosis and treatment of associated intranasal cysts and enhances the rates of successful outcomes.

A Prospective Comparative Study Between Subcuticular and Sutureless Technique of Skin Closure Following External Dacryocystorhinostomy Purpose: To compare the cosmetic outcome of the surgical scar of external dacryocystorhinostomy by the subcuticular versus sutureless technique. Methods: This was a prospective interventional randomized control study conducted at tertiary level hospital. Fifty patients of primary-acquired nasolacrimal duct obstruction were included in this study. The control group patients underwent the technique of wound closure in 2 layers, subcutaneous interrupted suture with 6-0 vicryl and superficial skin with 6-0 prolene continuous subcuticular sutures. In the case group, interrupted subcutaneous sutures with 6-0 vicryl with Steristrip for skin apposition was used. The surgical scars were assessed and graded by still photographs on a computer screen by 2 independent observers unaware of the surgical technique used at 2, 6 and 12 weeks postoperatively. Results: The mean scar assessment score by the 2 observers were 2.60 (0.57), 2.04 (0.64), and 1.16 (0.89) in control group and 2.02 (0.65), 1.44 (0.70), and 0.44 (0.61) in case group at 2, 6, and 12 weeks, respectively. Scar grades were analyzed using chi-square test between the 2 group and Wilcoxon signed rank test within the group. The difference between the 2 groups were found to be statistically significant at 2, 6, and 12 weeks (P < 0.05). Thus, the technique of wound closure with steristrip lead to comparatively less scarring as compared with subcuticular technique. Conclusion: The authors recommend the sutureless technique of wound closure using steristrip in Ext DCR as it has superior cosmetic results as compared with subcuticular technique of external dacryocystorhinostomy.

Fractionated Stereotactic Radiotherapy for Cavernous Venous Malformations of the Orbital Apex Purpose: The objective of this study was to investigate the efficacy and safety of fractionated stereotactic radiotherapy in the treatment of cavernous venous malformation of the orbital apex. Methods: The authors reviewed a prospective database from a single center of patients with cavernous venous malformation of the orbital apex who had treatment with fractionated stereotactic radiotherapy. The authors compared the symptoms, visual function and the size of the tumor pre- and posttreatment as well as reviewed the treatment details and the incidence of complications. Results: Six patients received treatment with fractionated stereotactic radiotherapy for cavernous venous malformation involving the orbital apex. The median age was 48 (range, 32–63), and 50% were female. Patients received a dose of 45 to 50.4 Gy in 1.8 to 2 Gy fractions. Median follow up was 33 months (range, 18–66 months). The average tumor volume reduction at posttreatment imaging after 12 months was 63%. All lesions reduced in size postradiotherapy and remained controlled for the duration of follow up. All patients who had proptosis or a visual field defect had an improvement in the symptoms posttreatment. There were no complications of the treatment. Conclusion: Fractionated stereotactic radiotherapy appears to be a safe and effective management option for cavernous venous malformation of the orbital apex and leads to a sustained reduction of the volume of the lesion with associated improvement in symptoms and visual function.

Anthropometric Analysis on the Ocular Region Morphology of Children and Young Adults in Chinese Han Population Purpose: The periocular features vary in different age groups and ethnic populations. In this study, the authors sought to determine whether age-related differences exist for certain periocular parameters between children and young adults of Chinese Han population. Methods: OU of 310 children (aged 7–10 years) and 301 young adults (aged 20–30 years) were evaluated by 2-dimensional photogrammetry. All the subjects were of Chinese Han population. The eyelid crease profiles were classified according to their morphology. Periocular measurements, including 11 linear and 3 angular parameters were acquired from standardized photographs, 3 indices were further derived. The presence of epicanthal fold was also recorded. Each of the parameters was compared between the age groups. Results: A statistical difference was found between the 2 age groups for the distribution of eyelid crease types. Statistical significances existed between the age groups for various parameters, these include palpebral fissure height and width, margin reflex distance, intercanthal and outercanthal width, distance from the medial end of the eyebrow to the medial canthus, distance from the lateral end of the brow to the lateral canthus, crease height and eyebrow height, angle of endocanthion and exocanthion, palpebral fissure inclination, palpebrae fissure index, canthal index, and angular index (p < 0.05). The incidence of epicanthal fold tended to decrease with increase of age. Conclusions: Age differences exist in periocular features between children and young adults of Chinese Han population. Standards of periocular measurements based on age and race could provide reliable guidelines for clinical examination and planning periocular surgery.

Study on the Aging Dynamics of the Periorbital Region: From Observation to Knowledge of Physiopathology Purpose: Several anatomical and physio-pathologic studies of eyelid region have allowed the creation of theories on facial tissues aging dynamics, which have not been clarified yet. We assessed the signs of aging in the region over the time by observing the characteristics in the same person at different times of his/her life. Methods: We compared the position of the main anatomical landmarks of the eyelid region of 80 patients by overlaying their photographs when they were 20, 40, and 60 years old. Then we made comparisons in the group of men (40 people) and in the group of women (40 people) and between men and women. Results: The medial portion of the eyebrow was higher in the photograph taken at 60 years of age than in the one taken at 20 years old in 56.2% of cases; it was higher in 47.5% of cases when comparing the images at 20 and 40. The lateral portion of the eyebrow was seen higher in women in the 20 to 40 group, and it was seen lower in men at 60 years in statistical significance. In more than half of the patients observed, there was not a real descent of the eyebrow and the presence of a more or less accentuated form of upper eyelid's ptosis in the photograph at 60 (globally 47.5%, 55.0% of women and 40.0% of men). This condition was observed in 27.5% of the photographs at 40. There were changes in the horizontal dimension of the palpebral fissure (shortening in 53.7%, preserved in 33.7%, and increased in 12.5% of cases at 60 years old). The position of lateral canthus appeared lower in 40.0% of patients photographed at 60, but it was stable in those photographed at 40. The herniation of the upper eyelid bags was observed in 31.2% of the patients photographed at 60 years old but only in 13.7% at 40. Dermatochalasis of the upper eyelid was present in 67.5% of the people at 60 years old and in 55.0% of those seen when they were 40. Comparing men and women groups 20 to 40, dermatochalasis is more present in men than women at 40 years old with statistical significance. The eyelid-cheek junction was seen to be lower in 75.0% of cases at 60 and in 48.7% of cases at 40, and it is more represented in men than in women. Conclusion: We have highlighted some interesting elements, partly agreeing with the data already recorded by other authors', and our data suggest an important role of the eyelid structures senescence and its impact on the surrounding structures.

Acquired Obliteration of the Proximal Lacrimal Drainage System Purpose: We present a series of patients with acquired obliteration of one or more components of the proximal lacrimal drainage system, including puncta and canaliculi. This finding was noted with and without other obstructions or stenoses of the lacrimal drainage system. Review of these patients in search of possible risk factors for this condition and histopathology of two patients are presented. Methods: Medical records of patients treated at the Massachusetts Eye and Ear Infirmary between 2010 and 2016 with diagnosis codes of lacrimal punctum stenosis, stenosis of unspecified lacrimal punctum, epiphora due to insufficient drainage, and epiphora not otherwise specified were retrospectively reviewed. Patients were excluded if there was a history of congenital punctal agenesis, trauma, or any other identifiable etiology of lacrimal system obstruction. Results: Twelve patients were identified with obliterated puncta. Most patients were female (n = 11, 91.7%) and Caucasian (n = 9, 75%). The mean age was 61 years (median 62, range 22–90 years). Clinical findings ranged from one involved punctum to all four puncta, and associated ipsilateral canalicular obstruction was noted in 4 patients (33.3%). The inferior puncta were the more frequently affected structures (61.5%) compared to the superior puncta (38.5%). Nine patients (75%) reported use of topical ophthalmic medications prior to onset of symptoms. The most frequent class of medication implicated was topical antibiotics; however, patients often used a combination of medications. In 2 cases, pathological specimens of the canaliculi revealed absence of a canalicular lumen. Conclusions: Although various combinations of lacrimal system stenoses and obstructions have been described, acquired punctal obliteration is an under-recognized entity. These cases differ from typical punctal stenosis in that the puncta are completely obliterated, and no indication of a punctal opening is clinically detectable. In this study, 3 patients had previously documented normal lacrimal irrigation. The ipsilateral canaliculi were also found to be obstructed in a third of patients. Two patients had complete absence of a canalicular lumen on histopathology. The predominance of inferior punctum involvement, patient history of symptom onset after ipsilateral medication use, and known prior patent irrigation in several cases support the hypothesis that these cases represent a severe yet insidious idiosyncratic reaction to topical medication.

Perfusion Monitoring Shows Minimal Blood Flow From the Flap Pedicle to the Tarsoconjunctival Flap Background: A previous study in pigs has shown that the pedicle of the tarsoconjunctival flap does not appear to have adequate blood perfusion. The aim of this study was to monitor perfusion in tarsoconjunctival flaps in patients with large lower eyelid defects resulting from tumor surgery. Methods: The modified Hughes procedure was performed in 13 patients. Blood perfusion was monitored using laser Doppler velocimetry and laser speckle-contrast imaging. Results: Blood flow decreased gradually from the pedicle base to the end of the flap and was 19% at the flap base, 11% in the middle of the flap, and 4% in the distal end of the flap. The flaps survived, and there was no tissue necrosis. Conclusions: Tarsoconjunctival tissue survival does not seem to be dependent on a conjunctival flap. Free tarsoconjunctival grafts or composite grafts might be considered as viable alternatives in reconstruction of major eyelid defects.

Impact of Food and Drug Administration Approval of Vismodegib on Prevalence of Orbital Exenteration as a Necessary Surgical Treatment for Locally Advanced Periocular Basal Cell Carcinoma Purpose: To test the hypothesis that the US Food and Drug Administration approval of vismodegib in early 2012 has reduced the prevalence of orbital exenteration for locally advanced periocular basal cell carcinoma (BCC). Methods: Following institutional review board approval, the authors reviewed clinical and pathological data of patients with locally advanced periocular BCC (T4 per the eyelid carcinoma classification in the 8th edition of the AJCC Cancer Staging Manual) treated by the senior author during 2006–2018. Patients were grouped into those who were treated before February 2012 ("before vismodegib approval") and those who presented later ("after vismodegib approval"). Results: Forty-two patients with locally advanced periocular BCC were treated during the study period, of whom 31 were men. The median age at presentation was 66 years (range, 43–90). Twenty-two patients had T4a and 20 had T4b tumors. Thirteen patients were treated before and 29 were treated after vismodegib approval. The 2 groups did not differ in age distribution (p = 0.164), sex distribution (p = 0.270), prevalence of recurrent tumor at presentation (p = 0.317), or duration of treatment with vismodegib (p = 0.605). Orbital exenteration was significantly more prevalent in patients treated before vismodegib approval than after (46% vs. 10%, p = 0.016), and vismodegib treatment was significantly more prevalent in patients treated after vismodegib approval than before (when vismodegib was given in clinical trials; 69% vs. 23%, p = 0.008). There was a trend toward more patients retaining their eyes at last follow-up in patients treated after vismodegib approval (83% vs. 54%, p = 0.066). Conclusions: The prevalence of orbital exenteration as a necessary surgical procedure in patients with a locally advanced periocular BCC has fallen since the Food and Drug Administration approval of vismodegib. Although vismodegib is not specifically approved for organ-sparing, it has changed the authors' practice and enabled eye preservation in patients with locally advanced periocular BCC, who would otherwise require an orbital exenteration.

The Incidence of Lacrimal Drainage Disorders Across a Tertiary Eye Care Network: Customization of an Indigenously Developed Electronic Medical Record System—eyeSmart Purpose: To assess the incidence of lacrimal drainage disorders across a tertiary eye care network in India. Methods: A 5-year retrospective review of all the patients who were diagnosed with lacrimal drainage disorders across the tertiary care network of L.V. Prasad Eye Institute was performed from January 2013 to December 2017. All the patient data were retrieved using all the diagnostic terms assigned to the lacrimal drainage disorders in the in-house electronic medical record system eyeSmart. The incidence of each disorder, demographic details, and clinical presentations were captured. Results: A total of 20,102 patients were diagnosed with lacrimal drainage disorders in the 5-year period. The 2 most prevalent disorders were primary acquired nasolacrimal duct obstruction (n = 10,364, 51.56%) followed by congenital nasolacrimal duct obstruction (CNLDO; n = 5394, 26.83%). The most frequently encountered proximal lacrimal disorder was punctal stenosis (n = 603, 3%). More than 2/3rd of the patients presented with epiphora as their presenting complaint (n = 13,907, 69.18%) followed by a discharge (n = 4023, 20.01%). Although two-thirds of the patient with primary acquired nasolacrimal duct obstruction were females (n = 7081, 68.32%), the same was not true for the CNLDO group, where there was a near equal gender distribution (M:F = 1.06:1). Predisposition to laterality was neither noted in primary acquired nasolacrimal duct obstruction nor in CNLDO. The prevalence of complex CNLDO was 16.80% (n = 907), the rest being simple CNLDO. It was easy to capture the incidence of lacrimal disorders with the electronic medical record system; however, the same was not true for the surgical details. The reasons for this were lack of clarity with surgical codes, no separate drop downs for success/failure or complications, and variations in the documentation. Conclusions: This study depicts the incidence of various lacrimal drainage disorders in a very large cohort of patients. There is a need to modify the International Classification of Diseases (ICD) classification to incorporate all the diagnostic terminologies commonly used so as to capture the real global scenario. The present study helped to further customize the electronic medical record system that caters to the intricacies of lacrimal disorders.

Preoperative Intravenous Ketorolac Safely Reduces Postoperative Pain in Levator Advancement Surgery Purpose: To assess the impact of intravenous ketorolac (IVK) on self-reported pain scores, requirements for opioid analgesic and anti-emetic medications, and bleeding complications in the setting of levator advancement surgery Methods: A prospective randomized controlled trial was performed among adult patients undergoing levator advancement surgery. Pain scores were measured immediately after surgery, prior to discharge from the surgical facility, and on the first postoperative day. The requirements for postoperative analgesic and anti-emetic medications were recorded. Statistical comparisons were performed via a dedicated computerized software package. Results: Fifty patients (20 males, 30 females, mean age = 65.7 years, standard deviation = 11.9 years) underwent levator advancement without IVK and acted as controls. An additional 50 patients received IVK (19 males, 31 females, mean age = 64.6 years, standard deviation = 12.0 years). As compared with control patients, IVK resulted in statistically significant reductions in pain score immediately after surgery (4.62 vs. 1.44, p = 0.0001) and on postoperative day 1 (3.22 vs. 1.24, p = 0.0001). Fourteen patients (28%) in the control and 4 patients (8%) in the group that received IVK required opioid analgesics (p = 0.017). Seven patients (14%) in the control group and 1 patient in the group that received IVK required anti-emetic medications (p = 0.059). No patient experienced a hemorrhagic complication. Conclusions: In the setting of levator advancement surgery, IVK results in a dramatic reduction in self-reported pain score immediately after surgery and on postoperative day 1 and the requirement for opioid analgesics. This medication may be safely utilized for ptosis repair.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
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2841026182

6948891480

alsfakia@gmail.com