Ophthal Plast Reconstr Surg, Vol. 31, No. 3, 2015
Letters to the Editor
periorbita as in our case or posteriorly into the intraconal orbit in the case presented by Baker and Allen, with detrimental effect in both instances. Our response to this increased risk, while similar in some respects, does differ somewhat in our respective institutions. For example, at the Gaslini Children Hospital in Genova, after having recognized this complication, we have lowered the threshold for imaging, mostly MRI, to all the patients affected by congenital dacryocystocele that display signs of expansion, or whose dacryocystocele fails to resolve spontaneously within 48–72 hours. We feel that early imaging may prevent silent orbital expansion and prompt early intervention. At the Children’s Hospital of Philadelphia, however, we have a slightly different approach, in that we reserve imaging predominantly for bilateral cases and avoid massage before ruling out any intraorbital extension in these instances. We are particularly concerned regarding the high incidence of associated intranasal cyst extension in these cases and recommend early nasal endoscopic evaluation and probing under general anesthesia to avoid any respiratory compromise. This then permits irrigation, excision of any intranasal cyst and stenting as appropriate. For unilateral cases, however, without any evidence of acute dacryocystitis, we do apply gentle pressure on the dilated sac while everting the lower eyelid. If there is no visible expression of material from the punctum, we will then proceed with an office probing alone without sedation, using a #000 or #0000 Bowman probe. We do recommend postprobing massage in these instances, using the Crigler method of forefinger pressure on the sac and massaging inferiorly down the side of the nose over the nasolacrimal duct several times daily until dye disappearance testing confirms the clinical impression of symptom resolution. Anecdotally, this has proven effective in the majority of cases. In any event, we have not seen any instances of cellulitis with this approach and further intervention under general anesthesia can then be done at an appropriate time if there is any persistent tearing. We commend Baker and Allen for adding a very interesting case report and to direct the attention of the potential complications that could originate by inappropriate maneuvers performed by nonophthalmologists.
Francesco P. Bernardini, M.D. James A. Katowitz, M.D. Paolo Capris, M.D. The authors have no financial or conflicts interests to disclose. Correspondence: Francesco P. Bernardini, M.D., Department of Ophthalmology, Ospedale Gaslini, Genova, Italy. E-mail: [email protected]
REFERENCES 1. Baker MS, Allen RC. Re: “orbital and periorbital extension of congenital dacryocystoceles: suggested mechanism and management”. Ophthal Plast Reconstr Surg 2015;31:248–9.
Re: “Orbital Necrotizing Fasciitis and Osteomyelitis Caused by Arcanobacterium haemolyticum: A Case Report” To the Editor: We thank Drs. Stone and Harshbarger1 for contributing their interesting case of severe Arcanobacterium haemolyticum orbital infection to the oculofacial literature. Their
250
case represents the third report of A. haemolyticum pathogenicity in the orbit in the past 2 years,2 and the sixth case documented since its description 30 years ago,3–6 suggesting that recognition and/or reporting of this pathogen may be improving. The comments of Stone and Harschbarger1 echo our experience and prior review of this important pathogen. A. haemolyticum orbital infections can be aggressive and lifethreatening, requiring a multidisciplinary medical and surgical approach. Repeated assertive surgical debridement may be necessary, but visual prognosis has typically been favorable, despite advanced orbital involvement. Microbiological characterization of this pathogen may be difficult and should be specifically pursued by the laboratory to establish sensitivity profiles early. A high level of suspicion is necessary to correctly diagnose and promptly treat orbital infections from A. haemolyticum. We hope to learn more about this rare entity as clinicians and laboratories continue to identify and report experiences with A. haemolyticum in severe orbital disease.
Nicholas A. Ramey, M.D. Cat N. Burkat, M.D. Correspondence: Nicholas A. Ramey, M.D., Vistar Eye Center, Oculofacial Plastic and Reconstructive Service, 707 S. Jefferson St, Roanoke, VA 24016 ([email protected]) The authors have no financial or conflicts of interest to disclose.
REFERENCES 1. Stone LA, Harshbarger RJ. Orbital necrotizing fasciitis and osteomyelitis caused by Arcanobacterium haemolyticum: a case report. Ophthal Plast Reconstr Surg 2014. 2. Ramey NA, Burkat CN. Arcanobacterium hemolyticum orbital cellulitis: a rare but aggressive disease. Ophthal Plast Reconstr Surg 2013;29:e69–72. 3. Burroughs JR, Hsueh JB, Pelton RW. Re: “Arcanobacterium hemolyticum orbital cellulitis: a rare but aggressive disease.” Ophthal Plast Reconstr Surg 2013;29:332–3. 4. Limjoco-Antonio AD, Janda WM, Schreckenberger PC. Arcanobacterium haemolyticum sinusitis and orbital cellulitis. Pediatr Infect Dis J 2003;22:465–7. 5. Ford JG, Yeatts RP, Givner LB. Orbital cellulitis, subperiosteal abscess, sinusitis, and septicemia caused b Arcanobacterium haemolyticum. Am J Ophthalmol 1995;120:261–2. 6. Givner LB, McGehee D, Taber LH, et al. Sinusitis, orbital cellulitis and polymicrobial bacteremia in a patient with primary EpsteinBarr virus infection. Pediatr Infect Dis 1984;3:254–6.
Re: “Lower Eyelid Involutional Ectropion Repair With Lateral Tarsal Strip and Internal Retractor Reattachment With Full-Thickness Eyelid Sutures” To the Editor: We read with interest the report by Ghafouri et al.1 on “Lower eyelid involutional ectropion repair with lateral tarsal strip and internal retractor reattachment with full-thickness eyelid sutures.” The authors present a useful technique to repair ectropion associated with lower eyelid retractor disinsertion. We believe that numerous patients would benefit from readvancement of the lower eyelid retractors, in addition to horizontal tightening. We also
© 2015 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
Copyright © 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
Letters to the Editor
periorbita as in our case or posteriorly into the intraconal orbit in the case presented by Baker and Allen, with detrimental effect in both instances. Our response to this increased risk, while similar in some respects, does differ somewhat in our respective institutions. For example, at the Gaslini Children Hospital in Genova, after having recognized this complication, we have lowered the threshold for imaging, mostly MRI, to all the patients affected by congenital dacryocystocele that display signs of expansion, or whose dacryocystocele fails to resolve spontaneously within 48–72 hours. We feel that early imaging may prevent silent orbital expansion and prompt early intervention. At the Children’s Hospital of Philadelphia, however, we have a slightly different approach, in that we reserve imaging predominantly for bilateral cases and avoid massage before ruling out any intraorbital extension in these instances. We are particularly concerned regarding the high incidence of associated intranasal cyst extension in these cases and recommend early nasal endoscopic evaluation and probing under general anesthesia to avoid any respiratory compromise. This then permits irrigation, excision of any intranasal cyst and stenting as appropriate. For unilateral cases, however, without any evidence of acute dacryocystitis, we do apply gentle pressure on the dilated sac while everting the lower eyelid. If there is no visible expression of material from the punctum, we will then proceed with an office probing alone without sedation, using a #000 or #0000 Bowman probe. We do recommend postprobing massage in these instances, using the Crigler method of forefinger pressure on the sac and massaging inferiorly down the side of the nose over the nasolacrimal duct several times daily until dye disappearance testing confirms the clinical impression of symptom resolution. Anecdotally, this has proven effective in the majority of cases. In any event, we have not seen any instances of cellulitis with this approach and further intervention under general anesthesia can then be done at an appropriate time if there is any persistent tearing. We commend Baker and Allen for adding a very interesting case report and to direct the attention of the potential complications that could originate by inappropriate maneuvers performed by nonophthalmologists.
Francesco P. Bernardini, M.D. James A. Katowitz, M.D. Paolo Capris, M.D. The authors have no financial or conflicts interests to disclose. Correspondence: Francesco P. Bernardini, M.D., Department of Ophthalmology, Ospedale Gaslini, Genova, Italy. E-mail: [email protected]
REFERENCES 1. Baker MS, Allen RC. Re: “orbital and periorbital extension of congenital dacryocystoceles: suggested mechanism and management”. Ophthal Plast Reconstr Surg 2015;31:248–9.
Re: “Orbital Necrotizing Fasciitis and Osteomyelitis Caused by Arcanobacterium haemolyticum: A Case Report” To the Editor: We thank Drs. Stone and Harshbarger1 for contributing their interesting case of severe Arcanobacterium haemolyticum orbital infection to the oculofacial literature. Their
250
case represents the third report of A. haemolyticum pathogenicity in the orbit in the past 2 years,2 and the sixth case documented since its description 30 years ago,3–6 suggesting that recognition and/or reporting of this pathogen may be improving. The comments of Stone and Harschbarger1 echo our experience and prior review of this important pathogen. A. haemolyticum orbital infections can be aggressive and lifethreatening, requiring a multidisciplinary medical and surgical approach. Repeated assertive surgical debridement may be necessary, but visual prognosis has typically been favorable, despite advanced orbital involvement. Microbiological characterization of this pathogen may be difficult and should be specifically pursued by the laboratory to establish sensitivity profiles early. A high level of suspicion is necessary to correctly diagnose and promptly treat orbital infections from A. haemolyticum. We hope to learn more about this rare entity as clinicians and laboratories continue to identify and report experiences with A. haemolyticum in severe orbital disease.
Nicholas A. Ramey, M.D. Cat N. Burkat, M.D. Correspondence: Nicholas A. Ramey, M.D., Vistar Eye Center, Oculofacial Plastic and Reconstructive Service, 707 S. Jefferson St, Roanoke, VA 24016 ([email protected]) The authors have no financial or conflicts of interest to disclose.
REFERENCES 1. Stone LA, Harshbarger RJ. Orbital necrotizing fasciitis and osteomyelitis caused by Arcanobacterium haemolyticum: a case report. Ophthal Plast Reconstr Surg 2014. 2. Ramey NA, Burkat CN. Arcanobacterium hemolyticum orbital cellulitis: a rare but aggressive disease. Ophthal Plast Reconstr Surg 2013;29:e69–72. 3. Burroughs JR, Hsueh JB, Pelton RW. Re: “Arcanobacterium hemolyticum orbital cellulitis: a rare but aggressive disease.” Ophthal Plast Reconstr Surg 2013;29:332–3. 4. Limjoco-Antonio AD, Janda WM, Schreckenberger PC. Arcanobacterium haemolyticum sinusitis and orbital cellulitis. Pediatr Infect Dis J 2003;22:465–7. 5. Ford JG, Yeatts RP, Givner LB. Orbital cellulitis, subperiosteal abscess, sinusitis, and septicemia caused b Arcanobacterium haemolyticum. Am J Ophthalmol 1995;120:261–2. 6. Givner LB, McGehee D, Taber LH, et al. Sinusitis, orbital cellulitis and polymicrobial bacteremia in a patient with primary EpsteinBarr virus infection. Pediatr Infect Dis 1984;3:254–6.
Re: “Lower Eyelid Involutional Ectropion Repair With Lateral Tarsal Strip and Internal Retractor Reattachment With Full-Thickness Eyelid Sutures” To the Editor: We read with interest the report by Ghafouri et al.1 on “Lower eyelid involutional ectropion repair with lateral tarsal strip and internal retractor reattachment with full-thickness eyelid sutures.” The authors present a useful technique to repair ectropion associated with lower eyelid retractor disinsertion. We believe that numerous patients would benefit from readvancement of the lower eyelid retractors, in addition to horizontal tightening. We also
© 2015 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
Copyright © 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
