Ophthal Plast Reconstr Surg, Vol. 30, No. 1, 2014

Letters to the Editor

Correspondence: Ved Prakash Gupta, M.B.B.S., M.D., D.N.B., Department of Ophthalmology, University College of Medical Sciences and G.T.B. Hospital, Delhi-110095, India (vpg275gv@ yahoo.co.in) The authors have no financial or conflicts of interest to disclose.

REFERENCES 1. Yoon MK, McCulley TJ. Secondary tarsoconjunctival graft: a modification to the Cutler-Beard procedure. Ophthal Plast Reconstr Surg 2013;29:227–30. 2. Cutler NL, Beard C. A method for partial and total upper lid reconstruction. Am J Ophthalmol 1955;39:1–7. 3. Wesley RE, McCord CD Jr. Transplantation of eyebank sclera in the Cutler–Beard method of upper eyelid reconstruction. Ophthalmology 1980;87:1022–8. 4. Carrol RP. Entropion following the Cutler-Beard procedure. Ophthalmology 1983;90:1052–5. 5. Hsuan J, Selva D. Early division of a modified Cutler-Beard flap with a free tarsal graft. Eye (Lond) 2004;18:714–7.

Dr. Gupta and colleagues also note that, in our initial report,1 the second patient had paralytic blepharotosis postoperatively, and therefore, “eyelid retraction would not be expected.” We stand behind our initial assertion that the lack of retraction, even in the setting of preoperative blepharoptosis, is noteworthy. Retraction seen following Cutler-Beard procedures is mechanical in nature, resulting from posterior lamellar contraction. Thus, even though ptotic, a reconstructed eyelid could be retracted evidenced by entropion and lack of complete closure, neither of which were seen in this patient. Again we thank Drs. Gupta for their interest in our recent article “Secondary tarsoconjunctival graft: a modification to the Cutler-Beard procedure.”1 Their thoughts are insightful and interesting and bring to light the opportunity for us to add clarity to our initial work. Perhaps in time, an appropriately designed prospective study comparing various nuances in technique will help determine the truly optimal approach to these challenging reconstructions.

Michael K. Yoon, M.D. Timothy J. McCulley, M.D.

Reply Re: “Secondary Tarsoconjunctival Graft: A Modification to the Cutler-Beard Procedure” To the Editor: We would like to thank Drs. Gupta, Gupta, and Gupta for their interest in our recent article “Secondary tarsoconjunctival graft: a modification to the Cutler-Beard procedure.”1 In this manuscript, we describe our experience with the placement of a tarsoconjunctival graft at the second stage of the ­Cutler-Beard procedure, when the initial flap is divided. This provides structural stability, reducing the occurrence of postoperative eyelid retraction and entropion. This technique also provides additional conjunctiva for the posterior lamella (and in turn the fornix) and, possibly more importantly, allows for the eyelid margin to be covered with mucosa. We place the graft with the formerly superior edge positioned inferiorly to allow for draping of the conjunctiva over the eyelid margin. Dr. Gupta et al. make an insightful observation. They point out that the contour of the reconstructed eyelid of the first patient in our report was uneven, and they are somewhat correct; an irregularity can be seen medially in the photo, looking straight ahead. In our experience, the contours of the reconstructed eyelids have been adequate but less than perfect; however, this has compared well to our experiences with other techniques. In our published figure (Figure 3B),1 the second panel shows with gentle eyelid closure; the upper eyelid margin contour is visible (due to the lack of upper eyelashes) and reasonably smooth. The assertion made by Dr. Gupta and colleagues remains valid; with our technique, perfect contour is not guaranteed, particularly when reconstructing very large defects. The contour of the graft does not match the natural curvature of an upper eyelid. Perhaps as suggested, reshaping the tarsoconjunctival graft could aid the creation of a more natural eyelid contour. A shortcoming of tarsoconjunctival grafts is their limited vertical height. Thus, we make efforts to avoid wasting tissue, especially in upper eyelid reconstruction, that would occur with “trimming” of the graft as suggested by Gupta et al. Perhaps, 1 or more small vertical incisions in the graft would allow for reshaping without loss of tissue.

74

Correspondence: Michael K. Yoon, M.D., Massachusetts Eye and Ear Infirmary, Department of Ophthalmology, Harvard Medical School, Boston, MA, U.S.A. ([email protected]) The authors have no financial or conflicts of interest to disclose.

REFERENCES 1. Yoon MK, McCulley TJ. Secondary tarsoconjunctival graft: a modification to the Cutler-Beard procedure. Ophthal Plast Reconstr Surg 2013;29:227–30.

Re: “A Modified Lacrimal Sac Implant for High-Risk Dacryocystorhinostomy” To the Editor: I read with interest the article by De Castro et al.1 on modified lacrimal sac implant using Rains frontal sinus stent as an alternative to the conventional dacyrocystorhinostomy (DCR) in high-risk cases. I congratulate the authors on this good work. However, I would like to articulate few of my observations. Although I agree with the use of Rains stents in the exceptional pediatric case, the heterogeneity of the remaining etiologies do not stand on the same platform. A good number of studies on Sacroidosis and Wegener’s granulomatosis have shown excellent results with the traditional DCR.2,3 Most patients are usually on long-term systemic immunosuppression to manage the disease systemically, and Lee et al.3 in their series have shown excellent results in Wegener’s granulomatosis with external DCR without additional immunosuppression. Although the authors did not find much anatomical disruption while revising failed DCR’s, it may not be the same experience for many surgeons worldwide. In the more likely event of scarred lacrimal sac with intrasac synechiae and fibrosis, I wonder how easy it would be to place the Rains stents? Another concern is the closure of the bony osteotomy. It is a well-known fact in literature that there is a significant decrease in the size of the ostium, specially in the first 4 weeks.4 With a small osteotomy of just 4 mm and a pliable stent with luminal flow, did the authors observe any focal strangulation

© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.

Ophthal Plast Reconstr Surg, Vol. 30, No. 1, 2014

of the stent and did they observe the flow to be contributed by capillary action along the stent surface? The authors quoted studies from the otolaryngology literature about the long-term efficacy and safety of Rains stents for chronic frontal sinus disease. It is of concern that the criteria to define ‘long term’ is variable with it being as low as 3 months.5 There are also concerns about its long-term use and periodic stent replacements due to dislodgement or obstructions. Lin et al.5 showed retention rates of only 47.6% in a 6-year span. Although supportive, both the positives and negatives of the stent use in frontal sinus disease cannot be extrapolated to authors’ lacrimal surgery series in view of different anatomical boundaries, different high-risk etiology, difference in tissue behaviors, and the use of a modified stent. Canalicular intubation for 2 cases was performed to prevent internal punctal occlusion by the flange of the Rains stent. It would have been interesting to know why were they removed so late at 10 and 19 months, and how has this removal benefited in preventing the reocclusion of the internal punctal opening? It is very important to reiterate the very appropriate conclusions drawn by the authors that the results of this study must be tempered by the small cohort, shorter follow up, heterogenic etiopathogenesis and unknown long-term efficacy. I once again congratulate the authors for starting a newer approach in managing patients with a high-risk DCR and enriching the literature.

Mohammad Javed Ali, F.R.C.S. Correspondence: Mohammad Javed Ali, F.R.C.S., Dacryology Services, L. V. Prasad Eye Institute, Banjara Hills, Hyderabad 500034, India ([email protected]) The authors have no financial or conflicts of interest to disclose.

REFERENCES 1. De Castro DK, Santiago YM, Cunningham M, et al. A modified lacrimal sac implant for high-risk dacryocystorhinostomy. Ophthal Plast Reconstr Surg 2013;29:367–72. 2. Avisar I, McNab AA, Dolman PJ, et al. Endonasal dacryocystorhinostomy for nasolacrimal duct obstruction in patients with sarcoidosis. Orbit 2013;32:225–30. 3. Lee BJ, Nelson CC, Lewis CD, et al. External dacryocystorhinostomy surgery in patients with Wegener granulomatosis. Ophthal Plast Reconstr Surg 2012;28:389–92. 4. Mann BS, Wormald PJ. Endoscopic assessment of the dacryocystorhinostomy ostium after endoscopic surgery. Laryngoscope 2006;116:1172–4. 5. Lin D, Witterick IJ. Frontal sinus stents: how long can they be kept in? J Otolaryngol Head Neck Surg 2008;37:119–23.

Reply Re: “A Modified Lacrimal Sac Implant for High-Risk Dacryocystorhinostomy” To the Editor: We appreciate Dr. Ali’s interest in a surgical technique we recently described, and the opportunity to redress some apparent shortcomings in our original description. The adult patients to whom we offered this approach were phenotypically homogeneous, uniformly demonstrating severe, unrelenting nasal mucositis. We believed we could offer them 1 final attempt to salvage the lacrimal system before relegating them to complete lacrimal bypass with Jones tube. These patients were virtually indistinguishable on preoperative

Letters to the Editor

endonasal examination. Furthermore, they all suffered recurrent dacryocystitis, with 5 of the 6 patients having already undergone failed lacrimal and/or sinonasal surgery. They were severe, recalcitrant cases and, in our judgment, unlikely to respond to traditional dacryocystorhinostomy. We believed, therefore, a new approach was needed. There are, indeed, circumstances in which traditional dacryocystorhinostomy might succeed despite autoimmune rhinitis as reported by both Lee et al1 and Avisar et al.2 All the patients in Lee’s series were maintained on systemic immunosuppression, though none required increased perioperative dosing. Avisar’s patient population was more heterogeneous with a minority of subjects, requiring perioperative systemic corticosteroids. In contrast, only one of our patients was immunosuppressed at the time of surgery, and she did not require augmentation. An important advantage of the sinus stent approach is its independence from the immediate mucosal condition; systemic immunosuppression can be managed solely by the immunologist or rheumatologist based on systemic activity and without regard to the state of the nasal cavity. One of the many limitations of the sinus stent-lacrimal sac implant technique is the need for a patent lacrimal sac. That is why we obtained preoperative CT dacryocystography in all our patients. By revising the silicone head, we were able to implant the Rains stent in a partially stenosed sac. An implant designed expressly to fit the lacrimal sac would be smaller and could be accommodated by an even more severely scarred sac. Certainly, as with any lacrimal duct bypass technique, this method requires patent canaliculi and internal punctum. In the case of extensive lacrimal sac or canalicular scarring, other procedures such as conjunctivocystorhinostomy would be necessary. Regarding potential strangulation of the stent by encroaching bone, we could not identify a report documenting closure of the osteotomy after dacryocystorhinostomy. It is well known that the mucosal ostium contracts to 1.8 mm on average,3 but it seems unlikely that the Rains stent would succumb to a cicatrix of such friable mucosa; if anything, the tightening mucosa might stabilize the implant. To reiterate, the stent is made of medical grade silicone rubber. With an outer diameter of 0.4 cm and an inner diameter of 0.3 cm, the walls are approximately 0.5 mm thick. In any event, we have not observed this potential complication. With an inner diameter of 3 mm, the lumen is far too large to induce capillary flow of the tear fluid. As in a Jones tube, the tears drain by gravity and through volitional negative pressure generated by the patient. Perhaps, some fluid does flow around the stent into the nose—all the better! Frontal sinus stenting is currently considered an alternative to more standard approaches to frontal sinusitis. Typically, it is used by otolaryngologists for cases in which there is a high risk of recurrence—cases in which the frontal neo-ostium is small, or there is excessive denuded bone, osteitic bone in the frontal recess, or severe mucosal disease.4 Like ours, these are more severe cases. Studies on long-term endoscopic frontal sinus stent retention must be interpreted in this light. Furthermore, frontal sinus stents are frequently inserted temporarily, and thus, 6 months is considered relatively “long term.” The conclusion from the literature, however, is reasonably positive on both the safety and efficacy of these stents. While we obviously would not extrapolate those results to lacrimal sac placement, we can conclude that the material and form are reasonably well tolerated in the sinonasal environment, and the risks are acceptable. Table is meant to clarify any misunderstanding related to the frontal sinus stent literature. As for our own study, 8 of the 9 cases have continued to do well and remain symptom-free with no complications at an average of 32 months (range 12–59 months) of follow up. For the 2 with concurrent canalicular intubation, the silicone stents

© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.

75

Re: "A modified lacrimal sac implant for high-risk dacryocystorhinostomy".

Re: "A modified lacrimal sac implant for high-risk dacryocystorhinostomy". - PDF Download Free
206KB Sizes 0 Downloads 0 Views