PURPOSE To determine the relation between the fluorescein transit test time and postoperative relief of epiphora in patent dacryocystorhinostomies. METHODS A retrospective study of 40 patients who underwent 42 external dacryocystorhinostomies between January 1994 and January 2000 was performed. Postoperative symptomatic success was assessed by a questionnaire. Intranasal rigid endoscopy was performed to measure the fluorescein transit test time, defined as the time from instillation of fluorescein to its free flow from the osteotomy site. The main outcome measures were symptomatic success, fluorescein transit test time, and anatomic patency to irrigation. Statistical analysis was performed with the use of the Fisher exact test. RESULTS Of the 42 dacryocystorhinostomies studied, 92.8% were patent to irrigation. There was a statistically significant association between a fluorescein transit test time of < or = 45 seconds and subjective success (P<0.001), with 96% of patients reporting a successful postoperative outcome. A slow fluorescein transit test, with an average time of 138.9 seconds, was associated with symptomatic failure (P<0.001), with 56.2% of this group reporting significant postoperative epiphora. CONCLUSIONS The fluorescein transit test provides a quantitative measure of lacrimal drainage function after dacryocystorhinostomy, with a fluorescein transit test time of < or = 45 seconds being the relevant parameter to characterize symptomatic success. Postoperative failure in external dacryocystorhinostomy, as evidenced by slow transit times, may result from surgical interference with the lacrimal pump.

PURPOSE: This prospective study explores the efficacy of a combined approach by intranasal microsurgical dacryocystorhinostomy and fiberglass endoillumination of the tear passage for difficult cases of lacrimal sac or nasolacrimal duct obstruction. METHODS: Microscopic dacryocystorhinostomy was performed in 67 patients with lacrimal obstruction and for revision of external dacryocystorhinostomy. Improved endonasal visualization by microscope and combination with endoillumination of the tear passage allows instant identification and opening of the lacrimal nasal sac without skin incision. Silicon tubes were used for bicanalicular intubation. The patients were prospectively observed for at least 1 year. RESULTS: The operation was well tolerated by all patients. In 95%, a persistently open tear passage was successfully established. No serious complications were observed. CONCLUSION: Endoillumination of the lacrimal sac is useful for locating the sac precisely and refining the endonasal operation technique.

Histopathological examinations were performed in 193 embryos of mice; Peters's anomaly was found in 2 cases. The authors discuss various theories of formation of this developmental defect and oppose them their own formulation.

The conjunctiva as a mucous membrane provides a protective barrier to the eye. It represents a small segment of the skin - the largest organ of the body, which has a size of about 1.7 square metres. For this reason conjunctival ageing is affected by equivalent processes as skin ageing. Common causes for these ageing processes are biological and genetic effects as well as environmental conditions and exposure to light. The resulting dysfunction in conjunctival homoeostasis and protective function represent common factors which contribute to increased incidences of tumours and malignant transformations in elderly patients. At the time of tumour manifestation the patient's age is an important parameter for differential diagnosis and regimen strategy. All therapeutic options (surgical incision or excision, cryotherapy, chemo- or radiotherapy, exenteratio orbitae etc.) have to be determined individually depending on clinically relevant findings and previous anamnesis. Due to the patient's age geriatric aspects have to be considered in therapeutic management (tissue fragility, wound healing, multimorbidity, decreased adherence).

For medical professionals, home monitoring represents an innovative health service for remote patient care: The patient may remain in his or her domestic environment and continue normal activities. The physician can also, through technical and organizational integration, provide medical attendance from his or her usual working environment. All in all, in the near future home monitoring can help provide sufficient health services while also enabling medical resources to be used more effectively. The patient may benefit from individually optimized treatment and active integration into medical care. The better we manage the technical, organizational, medical, legal, and economic challenges of telemedicine, the better we can minimize the limitations of telemedical home monitoring. Other existing subjective concerns will be eliminated only if telemedical concepts are adapted to the specific needs of affected patients and physicians.

Home monitoring will soon be established as an innovative way to provide telemedical care in ophthalmology. At present there are no fundamental technical restrictions for telemedical enhancements in ophthalmology, however a wider application range and depth could lead to harmonized and simplified device and interface development. This may help to initiate new concepts in ophthalmological home monitoring.

Data security must be considered seriously in the context of telemedical home monitoring because of the transmission and communication of patients' personal data. The contract governing medical treatment allows the ophthalmologist to process all data relevant to treatment. In Germany the legal framework for this purpose is provided by the Data Protection Act, various German hospital acts, and codes of medical professional conduct. In principle, these rules apply to telemedical home monitoring as well as to common physician-patient relationships. The patient must be informed extensively in an understandable manner and must give his or her written consent. However, the advanced options of new IT technologies demand the development of technical and organizational concepts that guarantee compliance with legal and regulatory affairs, assure data security, and prevent data abuse.

In the subject of this case report, a self-inflating hydrogel expander was implanted as a treatment for posttraumatic enophthalmos in a fully sighted eye. The intervention caused hypertropia with diplopia, restriction of eye movements, visual field defects, and colour desaturation as a result of excessive swelling of the expander. Once the expander volume was adjusted, clinical signs regressed, and the aesthetic results were excellent. Following the implantation of self-inflating orbit expanders, it is advisable to carry out immediate follow-up during the expander's swelling period, and long-term follow-up is also advised to rule out late sequelae, as a position-dependent secondary glaucoma could occur.

Home-monitoring represents an innovative and growing health service area in which suitable conditions have to be created for the attending doctor and also for the patient. For this it is necessary to offer the technical supply and also to establish simultaneously organisational structures in the cooperation between the doctor and the patient based on prevalent experiences of general ambulant care. The medical care as a whole can be optimised to be more patient-orientated by integrating assistant medical staff and by establishing modern IT communication channels. The evolving home-monitoring in consideration of the doctor-patient experiences can contribute to an improvement in the patient's quality of life.

In lacrimal system lacerations the canaliculi are involved in 70% of cases and the lacrimal sac and/or nasolacrimal duct in 30%. Lacrimal system lacerations can be the result of sharp or blunt trauma. Nasolacrimal ducts may become obstructed by indirect trauma as an aftereffect of naso-orbital fractures. The epidemiology, main principles of surgical repair of canaliculi and of lacrimal sacs and/or nasolacrimal ducts, special techniques of surgical reconstruction and approximate success rates are reviewed with respect to the outcome of our patient collective compared to the literature. Canalicular and lacrimal sac lacerations need urgent primary microsurgical repair with silicone intubation and paying special attention to the medial nasal canthus. In cases of traumatic nasolacrimal duct obstruction as an aftereffect of mid-facial fractures, a secondary reconstruction should be planned.

BACKGROUND: The daily ward round is the main opportunity for communicative interaction between physician and patient during a patient's hospital stay. We analysed to what extent the round was capable of fulfilling the patients' needs for information and emotional support, using the ophthalmologic ward of a university hospital as an example. MATERIAL AND METHODS: For a period of 4 months in 2006, doctor-patient-interactions in an ophthalmologic ward round were recorded with a dictating machine. Fifty physician-patient interactions between 50 patients and five different physicians were selected according to uniform criteria. After the recordings were transcribed, the interactions were evaluated using formal quantitative speech analysis. We examined the patients' subjective perceptions by means of a standardised questionnaire. RESULTS: The average doctor-patient interaction lasted just under 4 min. The formal quantitative analysis of the effective verbal communication between physician and patient indicated an asymmetry to the advantage of the physician, who spoke 73% of the words (Chi 245.48 words). The patient remained rather incommunicative during the course of the conversation. Medical terms were used in only 0.53% of the direct doctor-patient dialogue. The ward round conversation was characterised by numerous personnel internal dialogues. During much of the rounds (46% of the time), the patients were unable to participate actively in the conversations. As a result, information could not reach the patients. Requests to speak were initiated 83% of the time by the physicians and only 33% of the time by the patients. Nevertheless, the patients indicated high (22%) and very high (66%) satisfaction with the ward rounds. CONCLUSIONS: In the future, the ophthalmologic ward round should satisfy the criteria of patient-centric conversation. Therefore, the informational value of the daily ward round must be increased, and organisational and structural changes must be made to promote direct conversation between the patient and the eye specialist. A team conference before and after the physician-patient interaction would allow a focus on team-referred and patient-referred interests within the ward round.

Objective: To determine the indications, relative frequencies, surgical times, and complications for enucleation and evisceration performed at a single academic center. Methods: Medical records of all patients who underwent an enucleation or evisceration between January 1st, 1990 and December 31st, 2009 at a single academic center were reviewed. Patient demographics and surgical indications, times, and complications were recorded. Results: A total of 85 eyes in 85 patients underwent enucleation (n = 31; 36%) or evisceration (n = 54; 64%) during the study period. Almost all patients were of African descent (96%). The most common underlying cause leading to eye removal was trauma. On average, eviscerations (47.3 ± 10.3 minutes) took significantly less time to perform than enucleations (89.6 ± 10.1 minutes; p < 0.01). Complications included implant exposure, infection, lower lid laxity, fornix insufficiency, and need for subsequent surgery; the occurrence of these complications was found to be similar between the two groups (p = 0.77). No case of sympathetic ophthalmia or inadvertent evisceration of an eye with an occult intraocular malignancy was noted. From the first decade for which data were available (1990- 1999) to the second decade (2000- 2009), the average number of enucleations decreased (p = 0.02) and the average number of eviscerations (p = 0.04) increased. Conclusion: Evisceration was found to be a safe and quicker alternative to enucleation in our study. A change in surgical preference from enucleation to evisceration was seen during the 20-year study period.

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OBJECTIVES: The objectives of this study are to report the outcomes of pediatric patients with lacrimal system obstruction who underwent primary endoscopic dacryocystorhinostomy (EDCR). STUDY DESIGN: The authors conducted a retrospective noncomparative case series. METHODS: The operative and postoperative data have been collected in 58 children aged between 3 months and 13 years (mean 4.1 years). The total of 58 primary EDCRs has been performed by two surgeons using a standardized surgical technique. The EDCRs were performed 52 times on one eye, 6 times on both eyes (3 times simultaneously, 3 times at the separate sitting with an interval of 4-6 months). The follow-up evaluations include taking history, clinical examinations including a fluorescein disappearance test. RESULTS: The follow-up interval ranged from 12 to 36 months (mean 17 months, median 15 months). The success rate was 51/58 (87.9%) in all 58 EDCRs. The success rate was 47/51 (92.2%) in the group of postsaccal obstructions, 3/5 (60.0%) in the group of postsaccal and suprasaccal obstrutions and 1/2 (50.0%) in presaccal obstructions. The procedures were successful in all eight children aged under 1 year old (100%) and in 14 of 15 children between 1 and 2 years old (93.3%). The silicone intubation was used in 54 EDCRs. CONCLUSIONS: The endoscopic DCR is a safe and effective procedure for most children with the success rate comparable to that achieved in the external DCR and in adults. The success rate of the postsaccal obstructions is significantly higher than in presaccal or combined pre- and postsaccal obstructions.

PURPOSE Dacryocystorhinostomy (DCR) success may depend on mucous membrane alignment across the osteotomy and entire surgical lacrimal outflow conduit. Scar tissue, obliteration of the lacrimal sac, and obstruction at the level of the common canaliculus may result from prior surgery or may occur as an isolated problem. We describe and evaluate the efficacy of a technique of grafting autologous buccal mucous membrane during external DCR in cases complicated by scarring and/or common canalicular obstruction. METHODS We retrospectively reviewed 11 nasolacrimal outflow system obstructions (in 9 patients) treated with a buccal mucous membrane graft-assisted DCR. The surgical technique is described in detail. RESULTS All cases presented with insufficient nasolacrimal outflow. Ten tear ducts failed prior DCR procedures, while one case had isolated common canalicular obstruction, resistant to multiple probing and intubation and was previously recommended a Jones tube procedure. Three tear outflow systems (in 2 patients) exhibited common canalicular obstruction; the rest were obstructed at the level of the lacrimal sac. Two patients had bilateral obstruction. Ten eyes had symptomatic epiphora. One eye had dacryocystitis alone, and 2 eyes had dacryocystitis and epiphora. Six tear ducts had more than one previous DCR procedure. Four tear ducts had prior endonasal DCR procedures, while 6 had a previous external DCR. All eyes with epiphora preoperatively had complete relief of tearing. All cases of dacryocystitis resolved with no recurrences. Nine tear ducts were patent to irrigation testing postoperatively (2 were not tested). CONCLUSIONS Buccal mucous membrane grafting may improve the success of DCR in cases complicated by scarring, mucosal shortage, and/or common canalicular obstruction.

AIMS AND OBJECTIVES To compare the success rates of non endoscopic endonasal dacryocystorhinostomy and conventional external dacryocystorhinostomy for the surgical management of primary acquired nasolacrimal duct obstruction. MATERIAL AND METHODS A retrospective, nonrandomized, comparative interventional case series of 302 patients who underwent either endonasal or external dacryocystorhinostomy over a period of 2 years. All surgeries were performed by a single surgeon and patients with primary nasolacrimal duct obstruction with a minimum of 6 months post operative follow up were included in the study. While external dacryocystorhinostomy was performed using traditional technique, endonasal dacryocystorhinostomy was performed using direct method of nonendoscopic visualization. RESULTS Of the 302 cases included in the study 165 patients had endonasal dacryocystorhinostomy whereas 137 underwent external dacryocystorhinostomy. Success was defined by resolution of symptoms of tearing, a negative fluorescein dye disappearance test and patency of the canalicular system on lacrimal irrigation. In the external dacryocystorhinostomy group 124 (90.5%) patients had surgical success whereas 146 (88.5%) of the endonasal dacryocystorhinostomy patients had successful outcome. The overall success rate was 89.4%, and the difference of surgical success between the two groups was not statistically significant ( P=0.57). CONCLUSION Non endoscopic endonasal dacryocystorhinostomy gives surgical results comparable to those of external dacryocystorhinostomy and is a viable alternative where dacryocystorhinostomy is indicated for primary acquired nasolacrimal duct obstruction.

PURPOSE We aimed to evaluate the effectiveness of bicanalicular double silicone intubation in dacryocystorhinostomy (DCR) and canaliculoplasty for distal or common canalicular obstruction. METHODS We reviewed the medical records of patients with distal or common canalicular obstruction who had undergone bicanalicular double silicone intubation (insertion of two tubes into each canaliculus) during external DCR and canaliculoplasty. We reviewed the records of subjects who had undergone the same surgery with a bicanalicular single intubation as control material. The tubes were removed at around 6 months after surgery. Anatomical and functional success rates of patients who were followed up for > 2 months after the removal of tube(s) were evaluated. In addition, complications related to the silicone tube were evaluated. RESULTS Data for 60 eyes of 45 patients in the double-intubation group and 69 eyes of 65 patients in the single-intubation group were retrieved. The double-intubation group showed higher anatomical success rates (96.5%) than the single-intubation group (85.5%). Functional success was achieved by 53 (88.3%) of 60 eyes in the double-intubation group and 56 (81.2%) of 69 eyes in the single-intubation group. There was no significant difference in complication rates between the two groups. CONCLUSIONS Bicanalicular double silicone intubation for DCR and canaliculoplasty may be an effective mode of treatment for patients with distal or common canalicular obstruction.

PURPOSE To report the results of transcanalicular-endonasal revision dacryocystorhinostomy (DCR) with a semiconductor diode laser in cases of failed external DCR. DESIGN Prospective, nonrandomized, interventional case series. METHODS Fifteen cases in 13 patients with failed external DCR underwent transcanalicular-endonasal DCR with a semiconductor diode laser. A functional successful outcome was defined as a patent nasolacrimal drainage system in nasolacrimal irrigation and a resolution of the symptomatic epiphora and/or mucoid discharge. RESULTS The patients were followed for a mean postoperative period of 27.3 months (range, nine to 54 months). The mean duration of the surgery was 19.6 minutes. After the initial revision transcanalicular-endonasal DCR surgery, patency to irrigation was obtained in 12 cases (80%), and 15 cases (100%) after a second revision treatment. Three cases required repeated revision surgery, and three other cases were considered to be functional failures in spite of a patent lacrimal system after the final revision surgery. The overall functional success rate was 80%(12 cases) at the final examination (mean, 27.3 months after surgery), and there were no intraoperative and postoperative complications. The presence of a canalicular obstruction or granulation tissue was not significantly related to the success rates of the revision surgery. The length of time between the primary and revision surgery, gender, age, the duration of the first revision surgery, and the timing of stent removal were also not significantly related to the failed cases. CONCLUSION Transcanalicular-endonasal DCR is a minimally invasive procedure and is recommended for patients as an alternative procedure for failed external DCR.

CONCLUSIONS Endoscopic intranasal dacryocystorhinostomy (DCR) has the following advantages over external surgery: pain and hemorrhage are minimal; postoperative facial swelling and scarring are absent; and symptoms resolve rapidly after surgery. Furthermore, as no significant differences in postoperative results were apparent between external and endoscopic intranasal DCR, and because no facial skin incision is required, the clinical usefulness of endoscopic intranasal DCR is high. OBJECTIVES In the treatment of nasolacrimal duct obstruction or chronic dacryocystitis in which epiphora or ocular discharge are chief complaints, endoscopic intranasal DCR is a safe, easy, minimally invasive, and reliable approach. In the present study, we describe the surgical procedures, techniques, and results of endoscopic intranasal DCR, and investigate its clinical usefulness. SUBJECTS AND METHODS The subjects were 21 patients with nasolacrimal duct obstruction who underwent a total of 24 endoscopic intranasal DCR procedures. Etiologies of the obstruction were, respectively, cryptogenic (62.5%), secondary to partial maxillectomy (16.7%), complication of sinus surgery (12.5%), and due to underlying disease--Wegener's granulomatosis (4.2%) or nasal T-cell lymphoma (4.2%). To assess the clinical usefulness of this procedure, postoperative courses were assessed by reviewing medical records and conducting telephone interviews. In addition, to assess the therapeutic effects, postoperative results were statistically compared to those of external DCR. RESULTS Closure of the surgical opening was seen in two cases (8.3%). In both cases, after the closed region was opened using an endoscopic procedure, symptoms resolved. Finally, lacrimal passage obstruction was not observed by lacrimal irrigation in any patient. None of the patients in the present study experienced major complications during or after surgery, and since their symptoms improved, the degree of satisfaction was high. When compared to external DCR, endoscopic intranasal DCR showed no statistically significant difference in postoperative results, thus confirming that similar therapeutic effects could be obtained for the two procedures.

PURPOSE To present our experience with external dacryocystorhinostomy (DCR) outcome and to compare cases of early and late DCR. METHODS Retrospective data review of all patients who had external DCR with silicone intubation in a 7-year period. Data were collected and analyzed concerning patients' preoperative and postoperative symptoms, and the lacrimal drainage system examination before, during, and after surgery. RESULTS In all, 162 patients underwent 195 DCR surgeries for nasolacrimal duct obstruction. Success was achieved in 81% of surgeries. Success rates were higher in patients who had early DCR (tearing only or early inflammatory signs of the lacrimal sac, 84% success) than in cases that had late DCR (more than 6 months after inflammation started, 77% success). These differences were statistically insignificant. Failure of DCR was much higher in posttraumatic DCR than in DCR for other etiologies. Complications (in 9% of surgeries) were generally mild and infrequent, except 1 case of meningitis. CONCLUSIONS In experienced hands, external DCR has good postoperative success with a low complication rate. Early DCR does not have a substantial advantage over late surgery with regard to surgical outcome.

PURPOSE To evaluate the complications and success of treatment of migrated or lodged intracanalicular and punctal plugs. METHODS A retrospective chart review of all cases having either a dacryocystorhinostomy or surgical removal of an intracanalicular or punctal plug from 1992 to 2006, in a single physician referral oculoplastics practice, was performed to identify cases in which a retained lacrimal plug required surgical intervention. Patients presented with symptoms of tearing, infection, or granuloma formation. The charts of 998 surgical cases were reviewed, from which 66 eyes (6.6%) were determined to have had lodged lacrimal plugs that required surgical removal, thus qualifying them for inclusion in this study. Patients were followed after surgery until reconstructive silicone tubing was removed (range, 6 weeks to 6 months), and each patient was questioned regarding symptoms. A comparison group of 336 eyes that had collared punctal plugs placed served as the control group. RESULTS All cases were noted to have complications from intracanalicular plugs. No complications were noted from other forms of lacrimal plugs. All eyes in this series required a canaliculotomy or a dacryocystorhinostomy after office irrigation failed to dislodge the plug. Five eyes presented with canaliculitis, 28 eyes presented with epiphora, and 29 eyes presented with dacryocystitis. Four of 66 eyes (6%) in this cohort presented with a pyogenic granuloma. Five eyes (8%) presented with canaliculitis. Forty-nine of 66 eyes (74%) were asymptomatic following treatment, with no observable infection or epiphora. Seven of 66 eyes (11%) had some improvement in symptoms and another 10 of 66 eyes (15%) had no change in symptoms after treatment. No complications requiring surgical intervention were encountered in the control group of collared punctal plugs. CONCLUSIONS Intracanalicular-type plugs may lodge in the lacrimal outflow system. This may result in epiphora, canaliculitis, or dacryocystitis that may require major reconstructive surgery. Despite surgical intervention, these symptoms do not always resolve (26% of eyes in this study had persistent epiphora). Intracanalicular plugs were observed to be associated with a higher rate of granulation tissue formation in the lacrimal outflow tract when compared with other forms of punctal plugs. As a result of the increased number of complications seen with intracanalicular plugs, caution is advised with respect to use of these devices. The relative infrequency of complications seen with collared punctal plugs suggests a safer alternative. Data from this study lead the authors to advocate the consideration of other forms of lacrimal occlusion due to the high number of complications noted with intracanalicular plugs, and the availability of other reversible forms of punctal occlusion.