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A 45-year-old female patient who had previously undergone endoscopic dacryocystorhinostomy (EN-DCR) at another surgical center was diagnosed with functional failure after DCR and underwent an uneventful transcanalicular laser-assisted DCR (TCL-DCR). After 5 months, the patient underwent endoscopic examination due to persistent epiphora and dacryocystitis attacks. Endonasal visualization revealed a large dacryolith that filled the ostium and sac and was removed en bloc mechanically with forceps. Carbonized material on the dacryolith's superior part indicated that it was perforated through-and-through by the laser beam during TCL-DCR. The patient's complaints were resolved completely following the removal of the dacryolith. The transcanalicular lacrimal procedures do not allow complete visualization of the contents of the lacrimal sac, and the laser beam can ablate even an undetected dacryolith and may result in unsuccessful DCR, although the surgical course may look completely uneventful.

Purpose. To compare the outcomes of transcanalicular diode laser-assisted dacryocystorhinostomy (TCL-DCR), nonendoscopic endonasal dacryocystorhinostomy (NEN-DCR), and external dacryocystorhinostomy (EXT-DCR) as first-line treatments for functional epiphora. Methods. This multicenter, retrospective, case-control study included 135 eyes of 135 patients with functional epiphora (86 females and 49 males). Functional epiphora was diagnosed based on a patent lacrimal system with a delay in the fluorescein dye disappearance test (FDDT) or dacryoscintigraphy (DSG) and no ocular surface or eyelid abnormalities. The patients were treated with TCL-DCR (2008–2011) or Ext-DCR (2005–2008, 2011–2017) at Beyoglu Eye Research Hospital (Istanbul, Turkey) and NEN-DCR at Carrot Eye Surgery Clinic affiliated with the McMaster University (Hamilton, ON, Canada) (2010–2016). Success was defined as the absence of epiphora and the normalization of an earlier delayed FDDT after surgery. Results. The TCL-DCR, NEN-DCR, and EXT-DCR groups consisted of 38, 47, and 50 eyes with 25.9, 44.2, and 45.9 months of follow-up. The success rate for TCL-DCR was 65.8%, 70.2% for NEN-DCR, and 84.0% for EXT-DCR. During the follow-up period, 13.2% of TCL-DCR cases and 6.4% of NEN-DCR cases developed an anatomic obstruction of the lacrimal system. Conclusion. The EXT-DCR group had a higher success rate in the management of functional epiphora than the NEN-DCR and TCL-DCR groups and was significantly safer in terms of an iatrogenic anatomic block of the lacrimal system.

To evaluate the efficacy and complications of transconjunctival Botulinum toxin A injections performed according to an algorithm, for the management of upper eyelid retraction associated with thyroid eye disease.Seventy one eyes of 60 patients at the inactive stage, who had undergone Botulinum toxin A injection were reviewed retrospectively. Botulinum toxin A was injected transconjunctivally, just above the superior tarsal border of the upper eyelid in doses between 2-15 units according to an algorithm, depending on the amount of retraction. Margin-reflex distances were measured according to the photographs taken under standard conditions before and after the injections at the tenth day, then the second month and the fourth month. Additional Botulinum toxin A injections were performed in patients who had an undercorrection on the tenth day. Complications such as diplopia and ptosis were recorded.The study included 38 females, 22 males with a mean age of 43.3 ± 13.1. Normal margin-reflex distances (3-4 mm) were reached in the 58 of 71 eyes (81.7%). Additional injections were needed in eight eyes (11.2%) for residual retraction on the tenth day. Ptosis was the major complication in four eyes for 1-3 weeks after injection. Upper eyelid retraction recurred after 5.1 ± 0.9 months in all patients.In the treatment of upper eyelid retraction due to thyroid eye disease, transconjunctival injection of Botulinum toxin A is an effective, safe, transient, and repeatable method with few complications in patients. The algorithm used in this study resulted in high success rate in long-term follow-up.

PURPOSE To compare the effectiveness and complications of levator reinsertion in aponeurotic ptosis surgery using anterior and posterior approaches. METHODS Seventy-eight (36 females, 42 males) patients with acquired aponeurotic ptosis were evaluated. Pre- and postoperative margin reflex distance, symmetry of height, contour and skin crease, corneal problems, and lagophthalmus were evaluated and compared between the 2 groups. Independent and paired samples t-test, Pearson Chi-square, and Fisher exact test were used to evaluate the results. RESULTS The anterior approach was performed on 43 eyelids and the posterior approach was performed on 35 eyelids. The mean age of the anterior-approach group was 62.1 ± 11 years, and posterior-approach group was 50.1 ± 15.1 years, respectively (P

Floppy eyelid syndrome (FES) is described as easily everted upper eyelids and associated papillary conjunctivitis. It can lead to many serious ocular and systemic complications, and ophthalmologists should be aware of it because of the strong associations and potential systemic hazards. The treatment of the ocular problems is usually surgical.

Tearing, a common complaint in the daily oculoplastic clinic can result from hypersecretion of tears, eyelids or eyelash malpositioning, or more commonly from stenosis or obstruction in the lacrimal drainage system. Disorders of the lacrimal drainage system, which cause tearing, discharge, or medial canthal swelling, are common ophthalmic complaints and account for about 3% of visits to general ophthalmology clinics. Accurate evaluation and localization of the pathology is essential for proper treatment and management.

The therapeutic use of botulinum toxin (BTX) for periocular area pathologies is repeatable, safe and temporarily effective. BTX applications for the treatment of eyelid retraction, entropion, blepharospasm and hemifacial spasm, lagophthalmos due to facial paralysis, apraxia of eyelid opening and synkinetic eyelid movements and functional epiphora are reviewed.

Purpose: The aim of this study was to evaluate whether orbital changes induced by thyroid eye disease affect the ocular pulse amplitude and choroidal perfusion.Materials and Methods: A tota...

Congenital dacryocystocele (or dacryocele, amniotocele) is the diffuse, nonneoplastic, cystic dilation of the lacrimal sac in newborns with congenital nasolacrimal duct obstruction (CNLDO) as a result of consequent functional obstruction of the proximal opening of the enlarging lacrimal sac.

In the search of the ideal dacryocystorhinostomy (DCR) that avoids a surgical scar in the medial canthus, transcanalicular laser-assisted dacryocystorhinostomy (TCL-DCR) is considered a fast and relatively simple alternative procedure for the management of nasolacrimal duct obstruction. The success rates of TCL-DCR are between 34% and 95.2%, and anatomical success rates up to 100% have been published. The functional failure rate of TCL-DCR is higher, often related to a sump syndrome in the majority of patients, when compared to non-laser-assisted DCR methods. Complications, such as tissue necrosis and proximal lacrimal drainage system trauma, have been reported. Surgical modifications to decrease the amount of laser energy delivered have resulted in better anatomical and functional outcomes.

The lacrimal gland is innervated by the cholinergic fibers of the seventh cranial nerve. Injection of botulinum toxin A (BTA) in the lacrimal gland is hypothesized to decrease the tear production by blocking presynaptic release of acetylcholine into neuromuscular end plates of cholinergic nerve fibers. Therefore, injection of BTA into the lacrimal gland can be an alternative treatment for epiphora due to severe gustatory hyperlacrimation, unsalvageable proximal lacrimal drainage system obstructions, and refractory functional epiphora. This chapter will discuss BTA properties, mechanism of action, and injection techniques into the lacrimal gland and complications.

To describe and to evaluate a new and relatively easy technique for porous implant exposure repair. Eleven patients with exposed porous orbital implants after evisceration were included in this study. Five patients with large exposures (diameter>7 mm) and six patients with small exposures of orbital implants (diameter

To evaluate the success rate of 980 nm transcanalicular diode laser-assisted dacryocystorhinostomy (TDL-DCR) in patients with primary acquired nasolacrimal duct obstruction (PANDO) and to consider the time and the reasons of failure.Hundred and thirty eyes of 125 patients who underwent of TDL-DCR for the treatment of PANDO are included in this retrospective, noncomparative, nonrandomized, interventional study. The mean follow-up time was 24.29 months (range 8-34 months). Functional success was described as disappearance of epiphora and presence of a patent ostium on lacrimal irrigation. Anatomical success was described as a patent ostium to irrigation but continuing epiphora. Patients with persistent epiphora and a closed ostium were classified as a surgical failure.At third month follow up, 85.4% of cases had complete resolution of their symptoms. The functional success rate decreased to 67.7% at 6 months, to 63.3% at first year, and to 60.3% at second year, while the patency of the lacrimal drainage system was restored in 93.1%, 74.6%, 69.5%, and 68.2% of the cases, respectively. The average total amount of delivered laser energy was 1322.7 J. No correlation could be found between the age of the patient, delivered laser energy, and the surgical success (p = 0.38, p = 0.62).Transcanalicular diode laser-assisted DCR is a fast and relatively easy alternative surgical method, which avoids a facial skin scar, to treat PANDO. The functional success rate is higher in the first months but decreases to low 60 %'s at the end of first year and remains the same at the second-year follow up.

Purpose: To report the efficacy in preventing lower eyelid retraction and long-term results of a new technique of inferior rectus (IR) recession for vertical strabismus and compare this method with the results obtained by a conventional IR recession operation. Methods: This retrospective study included 35 patients who underwent a new IR recession method (study group) and 22 patients who underwent the conventional IR recession (control group) for vertical strabismus. In the study group, an IR recession was applied to the deeper fibers and included approximately 90% of the IR muscle thickness. This group was divided into two subgroups: small IR recessions (4 to 6 mm) and large IR recessions (7 to 8 mm). In the control group, an IR recession of the entire muscle was applied without exceeding 6 mm. The photographs were analyzed for lower eyelid position. Digital image analysis was used to standardize each patient’s preoperative and postoperative photographs at final follow-up examination. The main outcome measures were the margin-to-reflex distance, lower eyelid retraction, and vertical deviation angles (at near and distance fixation). Results: The mean change in margin-to-reflex distance after surgery was 0.03 mm in the small IR recessions group, 0.1 mm in the large IR recessions group, and 2.04 mm in the control group. Postoperatively, the lower eyelid retraction in the study group, which occurred after both small and large IR recessions, was significantly less than that in the control group ( P < .001). There was no significant difference between the study and control groups in improvements in near and distance vertical deviations and success ratios ( P > .05). Conclusions: At long-term follow-up, recession of the deeper fibers layer, including approximately 90% of the IR muscle thickness, was a procedure that minimized or eliminated the possibility of lower eyelid retraction and did not limit the success of strabismus surgery. [J Pediatr Ophthalmol Strabismus 2014;51(1):17–26.]

A 6-year-old boy diagnosed with congenital microphthalmic OS was referred for prosthetic eye fitting. He was otherwise healthy without known congenital anomalies. His visual acuity was 20/20 in the OD and no light perception in the OS. His disfigured OS with a conjunctivalized opaque cornea appeared smaller than his OD. He had left esotropia with severely restricted ductions in all directions of gaze. The preoperative orbital MRI of the patient revealed a small orbital cyst posteroinferior to the OS. Because the patient could not tolerate the prosthetic eye worn over his disfigured eye, evisceration was planned. During the surgery, blunt dissection of the conjunctiva and Tenon's capsule uncovered a large orbital cyst that was misdiagnosed as phthisis bulbi preoperatively based on the clinical examination and imaging findings. The structure that was thought to be an orbital cyst on orbital MRI was the microphthalmic eye. Enucleation with cyst excision was performed. Patient had uneventful postoperative course and has been wearing an artificial eye for 1 year since surgery.

PurposeTo investigate and compare the efficacy of botulinum toxin-A injection in the lacrimal gland and conjunctivodacryocystorhinostomy surgery for the treatment of epiphora caused by proximal lacrimal system obstruction.MethodsCharts of the patients with proximal canalicular obstruction who had undergone conjunctivodacryocystorhinostomy with permanent tube insertion (18 patients, group 1) or 4 units of botulinum toxin-A injection in the palpebral lobe of the lacrimal gland (20 patients, group 2) were reviewed retrospectively. The upper lacrimal system obstruction was diagnosed by lacrimal system irrigation. Schirmer-1 test and Munk epiphora grading for evaluation of epiphora were performed before the interventions and on tenth day, first, third, and sixth months after the interventions.ResultsImprovement of epiphora was statistically significant at all visits when compared with values before injection (P0.001) in both of groups. When two techniques were compared, difference in degree of epiphora before and after intervention was not statistically significant (P0.05). In group 2, none of the patients had punctate epitheliopathy, although there was a significant decrease in Schirmer test results (P0.001, paired t-test). In group 1, 9 cases (50%) had tube dislocation, 4 cases (22.2%) had obstruction, and granuloma formation. Five cases (25%) had ptosis in group 2.Conclusion Conjunctivodacryocystorhinostomy requires surgical experience, special postoperative care, and multiple revisions. As botulinum toxin-A injection in the lacrimal gland is technically easy, less-invasive, safe, with reversible effects, it can be considered as an alternative treatment in patients with proximal lacrimal system obstruction.

Lacrimal bypass surgery is the preferred surgical procedure in cases with epiphora, where the canalicular and lacrimal sacral injury is not repairable either by canaliculodacryocystorhinostomy or by conjunctivodacryocystorhinostomy. Accidental and/or surgical trauma being the most common etiology distorts the normal anatomy of the lacrimal drainage system and replaces the normal soft tissue with highly vascularized granulation tissue and eventually fibrosis. Surrounding bony structures may be repaired by callus formation as well, if there is a fracture. These healing changes render the conventional lacrimal bypass surgery difficult to perform. Additional extensive surgical trauma results with additional scar tissue and limited successful outcome. This article describes Holmium:YAG (Ho:YAG) LASER-assisted lacrimal bypass surgery. By means of the hemostatic and less traumatic disruptive properties of Ho:YAG LASER, the surgeon performs an easier, fast, and effective procedure with minimum early and late complications.

Primary and secondary nasolacrimal duct obstructions are quite frequently encountered in ophthalmology practice. The traditional surgical approach for managing nasolacrimal duct obstruction (NLDO) is an external dacryocystorhinostomy (Ex-DCR), first described by Toti in 1904 [1]. He gained access to the sac and nasal cavity via a skin incision in the medial canthal region. Dupuy-Dutemps and Bourget later described an Ex-DCR technique where mucosal anastomosis was achieved with suturing of the nasal and saccal flaps [2]. External DCR is still performed in a similar way with minor alterations and high success rates of over 90 % [3–9]. However, external DCR leaves a scar in the medial canthal area.

Orbital and periorbital extension of congenital dacryocystoceles is rarely observed in neonatal infants. The authors describe 4 cases of congenital dacryocystocele that presented with extension to the orbital and periorbital regions. The first 3 newborns underwent marsupialization of the orbital and periorbital dacryocystoceles with aspiration of the purulent material followed by nasolacrimal duct probing after radiographic evidence of diffuse orbital or periorbital expansion. The fourth patient was successfully treated with an external dacryocystorhinostomy with excision of the enlarged cystic walls. Transconjunctival orbitotomy with sac marsupialization followed by nasolacrimal intubation can provide immediate and permanent resolutions of this unusual complication in most instances. External dacryocystorhinostomy may be required, however, when the orbital or periorbital dacryocystocele is complicated by acute or recurrent dacryocystitis.

Purpose: To evaluate the outcomes of transconjunctival dacryocystorhinostomy (TRC-DCR) surgery in patients with epiphora due to primary acquired nasolacrimal duct obstruction (PANDO) at second year follow-up. Methods: In this retrospective, interventional study, 33 eyes of 29 patients, with epiphora due to PANDO, are included. Lower eyelid conjunctiva is incised at vestibulum inferomedially to access the lacrimal sac and nasal mucosa. Bone is perforated with burr and rongeurs and saccal and nasal flaps are anastomosed. Conjunctival wound edges are apposed and left unsutured. Intraoperative difficulties, surgical time and complications are noted. Average follow-up time was 2 years. Anatomical success was defined as patent lacrimal passages upon irrigation and functional success was defined as relief of epiphora. Results: In nineteen (57.6%) eyes the surgeries were completed with the anterior and the posterior flaps sutured. In eight eyes (24.2%) only anterior flaps could be sutured. In 6 eyes (18.2%), the surgical procedure was converted to external dacryocystorhinostomy since the nasal mucosa could not be exposed adequately via transconjunctival route. The mean surgical time was 65.1 min. One patient had a millimeter long lower eyelid margin laceration in one eye (3.7%) intraoperatively due to traction for visualization of the operative site.Epiphora resolved in 25 of 27 eyes (92.5%) in whom TRC-DCR could be completed. Epiphora and failure to irrigation were noted in two eyes (7.4%) at the postoperative 4th and 8th months, respectively and required reoperation. No complications occurred, except granuloma formation at the conjunctival incision site in three eyes (11.1%).Epiphora resolved in all the six eyes of patients who underwent an external DCR (100%). Conclusion: Transconjunctival dacryocystorhinostomy is a scarless dacryocystorhinostomy technique which is performed without endoscope and/or laser assistance, with 92.5% success rate comparable to external DCR at the second year follow-up without major complications. Keywords: Primary nasolacrimal duct obstruction, Conjunctival dacryocystorhinostomy, External dacryocystorhinostomy, Endoscopic dacryocystorhinostomy, Laser assisted dacryocystorhinostomy

Corneal hydrops after intrastromal corneal ring segment implantation Although the imaging quality in the article by G€ uell at el. is limited, the corneal topography shows an increase in elevation values inferiorly and superotemporally, steepening in the inferior segment in the keratometric map, and peripheral thinning in the pachymetric map; these are more prominent in the left eye. The topographic pattern may be compatible with peripheral thinning disorders rather than keratoconus. Multiple pachymetric measurements are needed to determine the minimum thickness of the planned tunnel site prior to intrastromal corneal ring segment (ICRS) implantation. G€ uell at el. planned ICRS implantation at 400 mmdepth; however, they did not mention how they obtained this value. The central corneal thickness (457 mm) was reported, but pachymetric value at the tunnel site, which is crucial for the ophthalmologist to perform this procedure, is not reported. Topographic pachymetry in the left eye was below 300 mm, especially at the 6 o'clock position. Briefly, in the article there is no evidence of how the authors determined the adequate implantation depth; therefore, there is the possibility of corneal perforation. However, the authors checked whether there was perforation into the anterior chamber by injecting saline solution through the stromal tunnel, proving that there was no perforation. Considering the topographic findings, we think this case is more suggestive of a peripheral thinning disease of the cornea that increases corneal fragility than of keratoconus.

Purpose To evaluate the efficacy of a novel external dacryocystorhinostomy technique with transconjunctival approach to avoid facial scarring without the use of endoscope and/or laser. Methods In this prospective interventional case series, 25 eyes of 22 patients with epiphora due to primary nasolacrimal duct obstruction were included. Lower eyelid conjunctival inferomedial vestibular incision was used to access the lacrimal sac and nasal mucosa. Bone apertures were created with burr and rongeurs, and saccal and nasal flaps were anastomosed. Bicanalicular silicone intubation was done. Conjunctival wound edges were apposed and left unsutured. Intraoperative difficulties and complications are noted. Patients were followed up postoperatively for an average period of 11 months. Criteria for success were relief of epiphora and patency to irrigation. Results In 12 (48%) eyes, the surgeries were completed without complications with the formation of both the anterior and posterior flaps. Epiphora resolved in 18 of 19 eyes (94.7%) in which transconjunctival dacryocystorhinostomy could be completed. In 7 eyes (28%), only anterior flaps could be sutured. The authors needed to convert to external dacryocystorhinostomy in 6 patients (34%) during whose surgeries the nasal mucosa could not be exposed adequately via the transconjunctival route. Epiphora and failure to irrigation started in one eye (5.3%) at the postoperative fourth month and required reoperation. No complications occurred, except granuloma formation at the conjunctival incision site in 2 eyes (10.6%) and a 1-mm-long lower eyelid margin laceration in one eye (5.3%). Epiphora resolved in the remaining 6 eyes that underwent external DCR. Conclusion Transconjunctival dacryocystorhinostomy, which is performed without endoscope and/or laser assistance, has a high success rate comparable to external DCR and does not leave a visible facial scar.

Botulinum toxin blocks acetylcholine release at the neuromuscular junction. The drug which was initially found to be useful in the treatment of strabismus has been extremely effective in the treatment of variety of conditions, both cosmetic and noncosmetic. Some of the noncosmetic uses of botulinum toxin applications include treatment of spastic facial dystonias, temporary treatment of idiopathic or thyroid dysfunction-induced upper eyelid retraction, suppression of undesired hyperlacrimation, induction of temporary ptosis by chemodenervation in facial paralysis, and correction of lower eyelid spastic entropion. Additional periocular uses include control of synchronic eyelid and extraocular muscle movements after aberrant regeneration of cranial nerve palsies. Cosmetic effects of botulinum toxin were discovered accidentally during treatments of facial dystonias. Some of the emerging nonperiocular application for the drug includes treatment of hyperhidrosis, migraine, tension-type headaches, and paralytic spasticity. Some of the undesired side effects of periocular applications of botulinum toxin inlcude ecchymosis, rash, hematoma, headache, flu-like symptoms, nausea, dizziness, loss of facial expression, lower eyelid laxity, dermatochalasis, ectropion, epiphora, eyebrow and eyelid ptosis, lagophthalmos, keratitis sicca, and diplopia.

To investigate the efficacy of EMLA cream and local dry cold application for pain relief before periocular botulinum toxin injection, and to compare these two methods.In this prospective study, 40 patients underwent bilateral periocular botulinum injections for blepharospasm treatment or wrinkle reduction. Patients were divided into three treatment groups. In the first group (n = 12), cold was applied to the periocular area on one side before injection; the other side served as the control. In the second group (n = 12), topical anesthetic cream (EMLA) was applied to one side and the other side served as the control. In the third group (n = 16), cold was applied to one side and EMLA was applied to the other side. A visual analog scale was used for pain intensity, and patients in the third group were asked which treatment they preferred.In the first group, the average pain score on the side where cold was applied was 3.00 +/- 1.70, whereas it was 5.83 +/- 1.40 on the control side (p0.001). In the second group, the average pain score on the side receiving EMLA was 3.25 +/- 1.86, and on the control side was 5.83 +/- 1.89 (p0.001). In the third group, the average pain score was 3.18 +/- 1.68 for the EMLA side and 3.12 +/- 1.31 for the cooled side (p0.05); nine of the 16 patients (56.2%) preferred EMLA.Skin cooling and EMLA applications significantly decrease the pain associated with periocular botulinum toxin injections. Clinically or statistically significant difference in pain scores between the two methods was not noted. Patients had a slight preference for EMLA cream over skin cooling.

Birsen Gokyigit, MD, Aslihan Ozturk, MD, Serpil Akar, MD, Pelin Kaynak Hekimhan, MD, Umut Akbas, MD, Omer Faruk Yilmaz, MD; Istanbul Beyoglu Educational and Research Hospital, Istanbul, Turkey Purpose: To introduce a new technique of inferior rectus recession operation to let larger amounts of recession without causing lower lid ptosis and comparing this method with the results obtained in conventional inferior rectus recession. Materials: This study includes 21 patients operated in our clinic. Patients’ ages were median 25.7 18.6 (4 to 73) and median follow-up was 6.6 8.8 (1 to 40) months. Eleven patients operated with conventional method were labeled as Group 1 and 10 patients operated with the new method were labeled as Group 2. Method: Without exceeding 4 mm, inferior rectus recession to whole muscle was applied in Group 1 patients. To patients in Group 2 inferior rectus recession was applied similar to vessel protective surgery but, 90% anterior fibers of muscle were detached in whole and as a thin layer with a spatula and posterior fibers were recessed 4 to 8 mm as planned. This way, lower lid retractors were not affected. Patients’ preoperative deviations and lower lid positions were recorded. Same parameters were checked 1 month postoperatively. Both groups were evaluated retrospectively by screening their files and Mann–WhitneyUtest was used in statistical evaluation. Findings: Lower lid ptosis was seen in four of Group 1. There was no ptosis in Group 2. While there was a need to apply second and third vertical muscle procedures for vertical deviations in Group 1, it was observed that there was no need for additional vertical muscle procedures in Group 2 patients. There is statistically meaningful difference between two procedures (P 0.05). Conclusion: We found that the new technique was an effective surgical method for recession of 90% of inferior rectus’ posterior fibers, permitting to do more recession, without the risk of lower lid ptosis.