Sombat Tanaboonyawat, Oluwatobi O. Idowu, Thomas S. Copperman, M. Reza Vagefi & Robert C. Kersten
Purpose: To review and summarize the epidemiology, clinical presentations, histopathologic characteristics and management of dacryops.
Methods: A comprehensive PubMed, Embase and Google Scholar search of all articles written in English and non-English language articles with abstract translated to English on dacryops were reviewed. Data reviewed included epidemiology, etiology, pathogenesis, clinical presentations, histopathologic characteristics and management of dacryops.
Results: Lacrimal ductal cysts or dacryops are classified based on locations: palpebral lobe cysts (simple dacryops); orbital lobe cysts; cysts of the accessory lacrimal glands of Krause and Wolfring; and cysts of ectopic (choristomatous) lacrimal glands. The exact etiology of dacryops remains unknown. Dacryops is usually asymptomatic but can present with varied symptoms depending on the type and associated complications. While complete excision of dacryops is generally recommended, marsupialization is also a safe and effective method for the treatment of dacryops in the palpebral lobe of lacrimal gland. Complete surgical excision via orbitotomy is required for deep orbital lesions.
Conclusion: Dacryops is an uncommon benign cystic lacrimal gland tissue neoplasm. Dacryops can be classified into four types based on locations. Lesions could be either superficial that can be seen through the fornix or deep into the orbit. Observation is also an option for small or asymptomatic lesions. Surgery remains the mainstay of treatment for symptomatic cases, but approaches are different depending on the location of the lesions.
Giorgio Albanese, Shivani Kasbekar & Lorraine C. Abercrombie
Aim: To describe and evaluate surgical outcomes of the Modified Cheek Advancement Flap (MCAF) to reconstruct defects involving medial lower eyelid, nasal sidewall and infraorbital cheek following Mohs micrographic surgery for basal cell carcinoma (BCC).
Materials and Methods: All patients who underwent MCAF between 2012 and 2018 under the care of a single surgeon (LCA) were identified. The technique described in this report is a significant modification of the traditional cheek advancement flap. The MCAF was undertaken without subciliary or infraorbital incisions, less extensive dissection and use of flap advancement rather than rotation. A retrospective chart review was completed using a pro-forma which included risk factors for flap failure, early and late complications and additional reconstructive procedures. Patient satisfaction was rated using a five-point Likert-type scale.
Results: 42 patients underwent the MCAF. Mean follow up was 28.4 months (±19.9 months). Early complications were found in 11.9% of the patients and resolved completely within the first four post-operative weeks. There were no long term complications secondary to the reconstruction. No lower eyelid ectropion was noted. 78.6% of the patients cited they were ‘extremely satisfied’ with the final cosmetic outcome.
Conclusion: The MCAF proves a valuable and safe option in periocular reconstructive surgery with excellent cosmetic results and no post-operative ectropion. The necessity for eyelid tightening as part of the reconstructive process should encourage oculoplastic surgeons to use the MCAF when reconstructing defects involving medial lower eyelid, infraorbital cheek and nasal sidewall.
Austin Pharo, James Chelnis, Tara Goecks, Kendra C. DeAngelis, Brian Fowler, J. Chris Fleming & Thomas C. Naugle
Purpose: Traditional (tCDCR) and endoscopic conjunctivodacryocystorhinostomy (eCDCR) are challenging surgical techniques requiring general anesthesia, a facial incision, and a large osteotomy and mucosal flap. Minimally invasive CDCR (miCDCR) techniques eliminate the need for some of the steps in t/eCDCR. Introduced here is a variation of the miCDCR technique using a Naugle-Fleming knurled dilator (NKD) to create the osteotomy and instruments within a central line catheter kit to help easily place or replace a Jones’ tube into position within a bony conduit.
Methods: This IRB-approved retrospective chart review examined all patients who underwent this miCDCR technique performed by two oculoplastic surgeons at Hamilton Eye Institute at the University of Tennessee Health Sciences Center from 2014 to 2016. Inclusion criteria: need for CDCR (either primary or repeat). Exclusion criteria: loss to follow up prior to six months. Primary endpoints: operative time, incidence of tube migration and complications, and cessation of epiphora.
Results: Sixteen patients (nine men, seven women) were reviewed, with three undergoing bilateral procedure, totaling 19 cases. Age range: 47.0 to 84.0 years, average of 66.6 years (SD = 11.1). Ten patients had surgery under local/MAC augmented with IV sedation, and six had general anesthesia (38%). Average operative time was 17.4 min (SD = 10.9). One patient (5%) required revision in the six-month immediate post-operative period because of tube migration. All patients had cessation of epiphora.
Conclusions: This procedure can be done safely and quickly without general anesthesia, resulting in a satisfactorily lower rate of tube migration and cessation of epiphora rates.
David S. Curragh, Craig James & Dinesh Selva
Purpose: To report a case of a lacrimal sac tumour identified at the time of endoscopic dacryocystorhinostomy and describe a swinging inferior turbinate approach to the nasolacrimal duct (NLD) to facilitate an en-bloc excision of the lacrimal drainage apparatus.
Methods: An 88-year-old male presented with a 6-month history of epiphora and mucocele. Endonasal DCR was performed for nasolacrimal duct obstruction (NLDO). Intraoperatively, a biopsy was performed of abnormal appearing lacrimal sac mucosa, following opening of the lacrimal sac. Subsequent definitive management was performed via a combined external and endoscopic approach using a swinging inferior turbinate approach to the NLD to facilitate an en-bloc excision of the lacrimal drainage apparatus, without removal of the bony medial wall of the maxillary sinus.
Results: The excised lacrimal drainage showed insitu and invasive squamous cell carcinoma of the canaliculi and lacrimal sac with focal divergent neuroendocrine and sebaceous differentiation. There was no local tumour recurrence or metastatic spread at 3 months of follow-up.
Conclusions: We describe a swinging inferior turbinate approach to the NLD to facilitate an en-bloc excision of the lacrimal drainage apparatus, without entering the maxillary sinus. We believe this modified technique is a useful option to consider in the management of tumours of the lacrimal drainage apparatus.
Abbas Bagheri, Koroush Shahraki & Shahin Yazdani
Purpose: To evaluate the effect of intra-lesional injection of Trichloroacetic acid (TCA) 10% in patients with conjunctival inclusion cysts.
Methods: This prospective case series study included all patients with conjunctival inclusion cyst who were referred to our referral center from August 2016 to August 2018. All patients received TCA 10% injection into the conjunctival cyst, and outcomes of the intervention were evaluated at least 6 months later.
Results: Ten patients with mean age of 24 ± 17.6 (range 6–65) years including three children received TCA 10% injection into the conjunctival cyst. We included 6 anophthalmic and 4 ophthalmic cases. All patients were treated successfully and no recurrence of the lesion was observed in any case. Mean follow up duration was 18.1 ± 8.3 (range 6–28) months.
Conclusion: Intra-lesional injection of TCA 10% is a safe, simple, and effective treatment in patients with conjunctival inclusion cysts including ophthalmic cases and anophthalmic cases, both in adults and in children. This concentration may avoid ocular surface complications.
Eri Ishikawa, Maria Suzanne Sabundayo, Shinjiro Kono, Hirohiko Kakizaki & Yasuhiro Takahashi
Purpose: To examine the patency or secondary obstruction of the lacrimal drainage system in patients with a peripunctal tumour.
Methods: This retrospective, observational, and comparative study included 10 patients with a peripunctal tumour. Lacrimal probing and syringing in all patients and dacryoendoscopic examinations in 5 patients were performed to check for patency of the lacrimal drainage system. Tear meniscus height (TMH) was measured bilaterally in the upper and lower eyelids using anterior segment optical coherence tomography and compared in relation to the affected side using one-way ANOVA.
Results: All patients did not complain of epiphora. Probing gave a hard stop and irrigation fluid passed into the nose. A patent punctum/canaliculus was also confirmed by dacryoendoscopy in all of the 5 patients. TMH was not significantly different among the sides (P = .900).
Conclusions: This study shows patency of the lacrimal drainage system in patients with a peripunctal tumour and no significant difference in TMH among the sides, resulting in absence of epiphora in all patients.
Preamjit Saonanon & Panida Potita
Purpose: To evaluate pre- and post-operative marginal reflex distance 1 (MRD1) when conducting Mueller’s muscle-conjunctiva resection (MMCR) on the normal eyelid of thyroid eye disease (TED) patients with unilateral eyelid retraction.
Methods: This was a retrospective non-comparative case series. Medical records of TED patients with unilateral eyelid retraction, who underwent a contralateral MMCR from November 2015 to September 2017, were reviewed. Standard photographs of pre-operative, post-phenylephrine test and post-operative were measured for eyelid positions including MRD1, MRD2 and inter-palpebral fissure width. MMCR was indicated on the contralateral eyelid only in patients who had a cosmetically acceptable result from phenylephrine test and were willing to receive the operation on the normal eye.
Results: Twelve TED patients who underwent MMCR on the normal eyelid were included in the study. Mean pre-operative MRD1 of retracted and normal eyelid were 5.7 mm (SD = 0.86) and 3.5 mm (SD = 0.65), respectively. Mean post-operative MRD1 of retracted and normal eyelid were 4.4 mm (SD = 0.76) and 4.1 mm (SD = 0.46), respectively. The asymmetry of MRD1 between eyes was significantly decreased from 2.1 mm (inter-quartile range (IQR) = 1.5–2.9 mm) pre-operatively to 0.3 mm (IQR = 0.1–0.7 mm) post-operatively (p = .002). None of these patients needed further eyelid correction surgery and there was no complication.
Conclusions: In TED patients with unilateral eyelid retraction, using phenylephrine test on their normal eyes should be initiated. If eyelid position was satisfactorily equalized, performing MMCR on the normal eyelid is considered an effective alternative treatment with a predictable outcome.
Frederick A. Jakobiec, Paula Cortes Barrantes, Daniel R. Lefebvre, Tatyana Milman
Over several months, a painless, multinodular, non-erythematous swelling of the deep tissues of his left upper eyelid developed in a 63-year-old man. An excisional biopsy with histopathologic evaluation disclosed a unique sebaceous papilloma within a cyst lined by non-keratinizing squamous epithelium that focally displayed a variably thick, superficial, eosinophilic cuticular layer. Immunohistochemical staining demonstrated that the tumor and its epithelial cystic lining had a profile consistent with Meibomian gland duct epithelium. Adipophilin highlighted cytoplasmic vacuolar lipid positivity. The encapsulation of the lesion, absence of nuclear atypia, and Ki-67 nuclear positivity restricted to the basilar cells established its intrinsically benign nature. The patient’s clinical history was remarkable for pulmonary and colonic carcinomas resected, respectively, 20 years and 8 years earlier. DNA mismatch repair protein expression studies disclosed loss of nuclear immunostaining of MSH6 protein, pointing to the possibility of an underlying rare MSH6 variant of the Muir-Torre syndrome, not yet described in the ophthalmic literature. p16 nuclear positivity was also found in the tumor cells, indicating the possible role of high-risk human papillomavirus as an additional factor in the genesis of the tumor. Genetic evaluation of normal and tumoral tissues in future similar cases will detect if there is an underlying germline mutation versus a somatic mutation limited to the tumor. This will be required to fully establish a predictable linkage with this new subtype of the Muir-Torre syndrome.
Ching-Hsuan Hu, Yi-Wen Tseng, Chien-Wei Lee, Chih-Yung Chiou, Shiow-Shuh Chuang, Jui-Yung Yang, Oscar K. Lee
Both mesenchymal stem cell-conditioned medium (MSC CM) and Botox have demonstrated therapeutic effects for hypertrophic scar (HS). It is unclear whether a synergistic effect occurs when these treatments are used in combination. We aimed to investigate the therapeutic effects of MSC CM and Botox alone when compared with those of a combined regimen on HS.
Fibroblasts from human HS were isolated and treated with Dulbecco’s modified Eagle’s medium (DMEM), MSC CM, or Botox alone or a combination of MSC CM and Botox. We also used an in vivo HS-buried null mice model to investigate the efficacy of combination treatment.
The results demonstrated that the combination of MSC CM and Botox downregulated both mRNA and protein levels of type I collagen, type III collagen, and alpha-smooth muscle actin (α-SMA) in HS fibroblasts. The combined regimen also suppressed fibroblast proliferative activity, increased apoptosis, and displayed significant inhibitory effects on the contractile ability of HS fibroblasts compared to MSC CM, Botox, or DMEM alone. Using an in vivo HS-buried null mice model, significant scar weight reduction, cell apoptosis, and less α-SMA expression were observed from the combined regimen of MSC CM and Botox compared to those from the other groups. The combined regimen also significantly improved arrangement and deposition of collagen fibers.
This study demonstrates that a combination of MSC CM and Botox exhibited a significant therapeutic effect compared to monotherapy. Clinical translation of this therapy should be further considered.
Min Ji Kim, Min Jin Lee, Woo Shik Jeong, Helen Hong, Jong Woo Choi
Although some data for western norms in orbit shape were reported, the standard norms for Asian orbits were not established yet. The data would be very valuable for the various surgical procedures as well as the production of the appropriate instruments and implants. Therefore, we suggest a Korean orbit mean shape model based on the three-dimensional computer modeling, which includes the analysis of the various parameters with the calculated average value, thereby providing a standard mean shape orbital model that could be used for the Asian patients’ orbital surgeries. This paper would be the first literature that provides the standard orbit model for Asians.
We developed orbit-specific computer software (AMC-SWUⓇ) for the production of an orbit mean shape model. The production steps included semi-automatic segmentation, shape reconstruction, statistical shape model generation, and mean shape and variance model production. The study included records of 48 male and 48 female patients who met the inclusion criteria. Three-dimensional facial bone computed tomography (CT) images of 96 patients were obtained, and these images were used to produce a representative mean shape model.
The mean models had vertical dimensions of 36.93 and 35.11 mm, horizontal dimensions of 38.49 and 36.79 mm, and rim dimensions of 45.76 and 42.90 mm for males and females, respectively. We developed a realistic, visualized three-dimensional Korean orbit mean shape model and compared its parameters with calculated values. There is a variance in orbital dimensions between the sexes and the orbital changes with age. We also demonstrated orbital anatomic differences between ethnic groups.