Lacrimal canalicular bypass surgery with the Lester Jones tube

PURPOSE: To analyze outcomes of lacrimal bypass surgery with the Lester Jones tube and to determine the level of patient satisfaction. DESIGN: Interventional case series. METHODS: We retrospectively analyzed the outcomes of 49 patients (42 patients) who underwent conjunctivodacryocystorhinostomy between 1984 and 2002. Data were obtained from medical records, semistructured phone interviews, and written questionnaires. RESULTS: The causes of lacrimal obstruction were idiopathic and trauma, congenital agenesis, infection, inflammation, herpes, basal cell carcinoma, radiation therapy, penicillin-induced Steven-Johnsons syndrome, systemic chemotherapy, and facial nerve palsy. Patients had undergone previous failed lacrimal surgery in 21% of cases. Complete or significant improvement of epiphora was achieved in 94% of cases. Best results were obtained for trauma and herpetic obstruction. Complications were frequent and included extrusion, recurrent extrusion, malposition, obstruction, discomfort, infection, and diplopia. Of the 32 patients who were interviewed, 70% were satisfied with the result, 35% reported tube maintenance to be troublesome, and all patients were pleased with the esthetics of the Jones tube. CONCLUSIONS: Conjunctivodacryocystorhinostomy with the insertion of a Jones tube can be expected to improve epiphora significantly in most cases and remains the standard treatment for canalicular obstruction. Complications occur in most cases, requiring replacement, repositioning, and cleaning of the tube by the ophthalmologist over an indefinite period of time. Despite frequent complications, patients will usually be satisfied if they obtain a comfortable, dry eye. If, however, a completely dry eye is not achieved, frequent complications may contribute to patient dissatisfaction.     

Lacrimal drainage surgery in patients with rare nasal diseases

AIM: To examine the results of open lacrimal drainage surgery in patients with rare nasal diseases. METHOD: A retrospective review of a group of patients with rare nasal disease who underwent open lacrimal surgery over a 15-year period at Moorfields Eye Hospital. Three main groups of disease were identified: (I) patients with treated mid-face tumours; (II) patients with prior major midfacial injury or surgery; and (III) patients with congenital nasal anomalies, including nasal aplasia. The more common systemic conditions of Wegener's granulomatosis and sarcoidosis were specifically excluded. RESULTS: Eighty-six patients (43 men; 50%) were identified with an age range between 1 and 82 years at the time of surgery. A total of 100 primary procedures were performed in 85 patients and symptomatic relief was achieved in 83/100 (83%) eyes, with 18/100 eyes (18%) requiring two or more lacrimal procedures. Lacrimal reconstructive surgery was considered impractical in two further patients. There were no intraoperative and few postoperative complications. CONCLUSION: With adequate experience, open lacrimal surgery appears to be a safe and effective procedure in the majority of patients with rare nasal diseases or major nasofacial anomalies.     

Lacrimal gland enlargement in familial sarcoidosis

Familial sarcoidosis is rare. It is unusual for lacrimal gland enlargement to be the initial manifestation of sarcoidosis. Two sisters are described with lacrimal gland enlargement as the initial manifestation of sarcoidosis. Gallium-67 scan was a useful adjunct to lacrimal biopsy in sarcoidosis. Sarcoid dacryoadenitis responded dramatically to a short term course of low dose prednisone.     

Lacrimal surgery in children

Of 142 children who underwent major lacrimal surgery (160 dacryocystorhinostomies, one congenital fistula excision, one dacryocystectomy, and one canaliculostomy), 49 had congenital nasolacrimal duct obstruction (34%). Lacrimal obstruction was also associated with canaliculitis, punctal agenesis, trauma, congenital fistula, dacryocystitis, craniofacial defects, and functional eyelid abnormalities. Although the timing and technique of the surgery varied according to the abnormalities, an overall functional success rate of 90% (144 of 160 procedures) was achieved.     

Lacrimal gland hypertrophy: revealing sarcoidosis]

We present a case of systemic sarcoidosis in a 34-year-old woman initially presenting with bilateral and symmetric proptosis caused by lacrimal gland enlargement. Based upon clinical, biological and radiological findings, sarcoidosis was suspected with lacrymal gland, parotid and pulmonary lesions. Biopsy of enlarged lacrimal gland for histological examination revealed a non caseating granuloma compatible with the diagnosis of sarcoidosis. Sarcoid lesions regressed with corticosteroid therapy.     

Lacrimal disease and surgery

The lacrimal drainage system includes the nasolacrimal duct, lacrimal sac, and canaliculi. Stenosis or obstruction at any portion of the lacrimal drainage system or an impaired lacrimal pump may cause bothersome epiphora. Tear stasis may also be associated with ocular or adnexal infections. This article reviews the recent literature pertaining to anatomy and physiology, pathology, and clinical evaluation and treatment, as well as complications of lacrimal drainage-system disorders.     

Lacrimal drainage surgery in Wegener's granulomatosis

AIM: To examine the results of open lacrimal surgery in patients with Wegener's granulomatosis. METHODS: A retrospective review of patients with Wegener's granulomatosis who underwent lacrimal surgery over a 17 year period. RESULTS: 11 patients were identified and a total of 14 primary dacryocystorhinostomies (DCR) and one revisional DCR were performed; symptomatic relief was achieved in 13/14 operations and one patient required revisional surgery for persistent symptoms. There were no intraoperative and few postoperative complications. CONCLUSIONS: In contrast with some previous reports, open DCR appears to be a safe procedure and it is recommended as a treatment for lacrimal obstruction in patients with Wegener's granulomatosis, but an increase of perioperative immunosuppression is recommended in certain cases.     

眼部不适患者309例的泪液学分析

目的 通过对309例眼部不适患者的泪液学分析,以指导治疗。方法 对309例患者均做Schirmer’s试验,眼表上皮 细胞活体染色,泪膜破裂时间(BUT)。结果 244例患者平均泪液分泌量<10mm,242例患者存在表层点状角膜病变,268例 患者泪膜破裂时间缩短。结论 该组患者泪液分泌量明显不足,角结膜破损程度较重,泪膜破裂时间缩短,泪膜稳定性下降。     

Clinical course of ocular sarcoidosis in patients with histologically proven systemic sarcoidosis]

PURPOSE: We reviewed the clinical features, natural history and visual prognosis of 9 patients with histologically confirmed ocular and systemic sarcoidosis. PATIENTS: Nine patients underwent a follow-up study between 1993 and 1998. The diagnosis of sarcoidosis was supported by histological evidence of non caseating epithelioid-cell granuloma in tissue biopsy. RESULTS: The mean age was 40.912 years. The mean follow-up was 22.7 months (range 6 - 54 months). The ophthalmic involvement was bilateral in 8 patients. Before treatment, 3 eyes (17.6%) had a visual acuity less than 1/10. Two eyes (11.7%) had a visual acuity less than 3/10 and 10 eyes (58.8%) more than 6/10. The anterior uveitis was granulomatous in 2 eyes (11.7%) and non granulomatous in 8 eyes (47%). Five eyes (29.4%) had a pars planitis. The posterior segment manifestations of sarcoidosis were retinal vasculitis in 7 eyes (41.1%), papillitis in 10 eyes (58.8%) and choroidal granulomas in 2 eyes (11.7%). Seven patients were treated with systemic corticosteroids. One patient was treated with steroid eye-drops. After treatment, one eye (5.8%) had a visual acuity less than 1/10 and 13 eyes more than 6/10. After treatment, the choroidal granulomas disappeared and the intra-ocular inflammation was controlled in all cases. CONCLUSION: Although the number of patients in our series is small, the prognosis for ocular sarcoidosis appears to be good.     

Lacrimal function and ocular complications in patients treated with systemic isotretinoin

PURPOSE: To evaluate the effect on lacrimal function and ocular complications in patients with severe acne vulgaris during systemic treatment with 13-cis-retinoic acid (isotretinoin). METHODS: Forty patients with acne vulgaris were treated with systemic isotretinoin at dosages of 0.5-1 mg/kg per day for two months. Full ophthalmologic examination, Schirmer I test, fluorescein break-up (BUT) and microbiological investigations of the conjunctival flora were done before, during the second month and at least one month after the end of the treatment. RESULTS: The average Schirmer values before and after the treatment were 21.6 mm/5 minutes (SD +/- 7.01) and 18.48 mm/5 minutes (SD +/- 7.87) respectively. After the treatment BUT was less than 10 seconds in 50% of the patients and 55% had blepharitis. Subjective symptoms like dryness, itching and contact lens intolerance occurred in 42.5% and colonization of the conjunctiva by Staphylococcus aureus increased significantly during treatment (p= 0.031). All abnormal findings disappeared one month after the cessation of treatment. DISCUSSION: Isotretinoin causes signs and symptoms of dry eye, probably by reducing meibomian gland function, but ocular complications are generally not serious when low doses are used for a limited time, and are reversible after discontinuation.     

Induced sputum for identifying sarcoidosis in patients with uveitis

OBJECTIVE: To evaluate the value of the induced sputum technique in diagnosing sarcoidosis as the cause of uveitis. DESIGN: Comparative case series. PARTICIPANTS: Seventeen patients with uveitis. Two control groups were used. The first included 10 patients with sarcoid without uveitis; the second included 5 healthy volunteers. TESTING: Sputum was induced by a 20-minute inhalation of 3.5% saline using an ultrasonic nebulizer. Samples were studied by differential counts of 200 cells on cytopreps stained by Giemsa. T lymphocyte subset analyses were done by fluorescence-activated cell sorter using the monoclonal antibodies CD4 (T helper cells) and CD8 (T suppressor-cytotoxic cells). Angiotensin-converting enzyme (ACE) serum levels were obtained. MAIN OUTCOME MEASURES: A CD4/CD8 ratio >2.5 and an ACE level >145 microl/ml/minute were considered to be abnormal. RESULTS: The difference in the CD4/CD8 ratios in the induced sputum examination between the group of patients with an elevated ACE level and the group of patients with an ACE level within normal limits was statistically significant (P = 0.0001). CONCLUSIONS: The induced sputum examination showed increased CD4/CD8 ratios in patients with uveitis who also had elevated ACE levels, suggesting the presence of sarcoidosis.     

Multiple arterial ectasias in patients with sarcoidosis and uveitis

PURPOSE: To describe and evaluate the cause of a clinical entity characterized by bilateral intraocular inflammation, multiple arterial ectasias including beading, macroaneurysms, comma-like ectasias and kinking, with vasculitis, staining of the optic disk and multiple peripheral round punched-out hypopigmented chorioretinal scars in elderly patients. The formation and the course of the arterial ectasias is analyzed. METHODS: Seven patients with this syndrome were evaluated by clinical examination, fluorescein angiography, and systemic investigations. RESULTS: Three of the seven patients had a biopsy characteristic of sarcoidosis, two others showed positive bronchoalveolar lavage, as well as other analyses and tests suggesting sarcoidosis, and two showed other findings suggestive of sarcoidosis. The patients were all over 60 years of age and had arterial hypertension. In two patients, an arterial ectasia developed at the site of previous focal inflammation. The macroaneurysms either remained unchanged, became comma-like ectasias, arterial kinks, or completely vanished. CONCLUSION: Elderly patients with multiple arterial ectasias, uveitis, disk staining, and peripheral chorioretinitis should be thoroughly investigated for sarcoidosis. We suggest that sarcoidosis may cause some degree of arteritis, which may weaken the arterial wall, with resulting ectasia. Arterial hypertension may play a role in the formation of the ectasias by increasing the pressure on the arterial wall weakened by inflammation.     

Tear-film deficiencies in patients with sarcoidosis; clinical study of 56 patients

BACKGROUND: The eye and its adnexa are frequently involved in sarcoidosis. Keratoconjunctivitis sicca is a typical manifestation that is believed to result from aqueous-layer deficiency in context with lacrimal gland disease. In this study we determined which layer of the tear-film might be involved. PATIENTS AND METHODS: Fifty-six patients with clinically and histologically proven sarcoidosis were prospectively analysed for symptoms of dry eye, visual acuity, signs of blepharitis, Schirmer II test, rose bengal test, fluorescein staining, break-up time (BUT), and impression cytology (IPC). Deficiencies of the lipid, water and mucin layers were differentiated. The observations were compared with those from a control group of patients with symptoms of "dry eye" (n = 56). RESULTS: All patients in the control group, but only 20 sarcoidosis patients had dry eye symptoms. The BUT in the control group (7.2 +/- 5.4; mean +/- SEM) was shorter (p < 0.02) than in sarcoidosis patients (8.9 +/- 4.5; mean +/- SEM). Compared with the sarcoidosis patients, conjunctivitis occurred more frequently in the control group (p < 0.01). Rose bengal staining was positive in 18 sarcoidosis patients, and in 35 patients of the control group (p < 0.01). Signs of blepharitis, the results of Schirmer test, fluorescein staining and IPC, and the frequent incidence of deficiencies of aqueous layer, lipid layer and combined deficiencies of two or more layers did not differ significantly between the two groups. Deficiencies of the mucin layer were detected in 43 sarcoidosis patients, and in 51 patients in the control group (p < 0.05). CONCLUSIONS: Tear-film deficiencies are common in sarcoidosis patients, even when clinical symptoms are absent. Observations herein suggest that patients with sarcoidosis may not only suffer from deficiencies of the aqueous layer, but also of the mucin and lipid layers.     

Lymphocyte subsets of peripheral blood in patients with sarcoidosis]

Cytofluorometric analysis of lymphocyte subsets was performed in the peripheral blood samples from fifteen sarcoidosis patients with uveitis as well as normal controls. The percentage of T cells (CD3+) was significantly decreased, whereas that of B cells (CD19+) was markedly increased in patients with sarcoidosis compared to controls. Natural killer cells (CD8+CD57+) as well as activated T cells (CD3+HLA-DR+) were significantly increased in patients with sarcoidosis. The percentage of the Leu 1-B cells and the ratio of Leu 1-B/B were significantly higher in sarcoidosis patients with respect to controls. Moreover, the ratio of Leu 1-B/B was significantly correlated with the serum level of angiotensin converting enzyme (ACE) in sarcoidosis. Therefore, it is considered that the Leu 1-B/B value could be a useful indicator not only for the activity but also for the diagnosis of sarcoidosis. No significant difference was found in any subset between the patients with active uveitis and patients with inactive uveitis.