Ophthal Plast Reconstr Surg, Vol. 30, No. 4, 2014

Reply re: “Medial Conjunctival Resection for Tearing Associated With Conjunctivochalasis” To the Editor: We thank the authors for their commentary on the recent article “Medial conjunctival resection for tearing associated with conjunctivochalasis.”1 In this review, all patients were found to have nasally located conjunctivochalasis for which they underwent treatment with medial conjunctival resection. While the cause of epiphora in this population is usually multifactorial, those with clinically significant eyelid disorders, nasolacrimal duct obstruction, or corneal pathology were excluded to focus on the efficacy of treating the most medial redundancy of conjunctiva. In clinical practice, we have found that the more conservative medial conjunctivoplasty provides an 80% success rate. It is possible that clinically insignificant central or temporal conjunctivochalasis is also at play causing tear instability. We agree that a detailed grading system created by Meller and Tseng2 may help carefully and accurately portray the degree of conjunctivochalasis in all 3 locations (medial, central, and temporal) while characterizing the degree of conjunctivochalasis in comparison with tear meniscus height, as well as noting the presence of punctal occlusion, changes in downgaze, and changes with digital pressure. This system may assist in a detailed evaluation conjunctivochalasis before and after surgical correction. For retrospective studies, the degree of detail required by the grading system may not exist in most medical records and may be challenging to achieve prospectively. A more simplified grading system as the authors proposed in 20073 based on the Meller and Tseng grading system may be more amenable for such studies.

Carisa K. Petris, M.D., Ph.D. John B. Holds, M.D., F.A.C.S. Correspondence: Carisa Petris, M.D., Ph.D., 635 W. 165th Street, Suite 207, New York, NY 10032 ([email protected]) J.B.H. is a consultant for Merz and Allergan Pharmaceuticals. C.K.P. has no financial or conflicts of interest to disclose.

Letters to the Editor

2. Was there any implant migration in any direction noted in your study?2 3. Can the x-ray film be fixated to the orbital rim with pre punched holes in the edges of film.3

Dayakar Yadalla, M.D. JayaGayatri Rajagopalan, M.B.B.S., D.O., D.N.B. Correspondence: Dayakar Yadalla, M.D., Aravind Eye Hospital, Tavalakuppam, Pondicherry 605007, India ([email protected] gmail.com)

REFERENCES 1. Insull EA, Hart RH, Sloan BH, Ben-Simon GJ, McNab AA. Use of x-ray film implant for the repair of orbital fractures. Ophthal Plast Reconstr Surg 2013;29:393–5. 2. Ellis E 3rd, Messo E. Use of nonresorbable alloplastic implants for internal orbital reconstruction. J Oral Maxillofac Surg 2004;62:873–81. 3. Shoaib KK, Haq I, Ali K, et al. Management of orbital floor fracture with autoclaved x-ray film. Pak Armed Forces Med J 2008;58:353–4.

Reply re: “Use of Sterilized X-Ray Film Implant for the Repair of Orbital Blow-Out Fractures” To the Editor: We thank the author for their recent letter regarding our article.1,2 We are pleased that they have found the technique to be useful. To answer their questions: 1. The implant can be sterilized using ethylene oxide. This was the method employed at our hospital until our s­ terile supply department switched to the use of h­ ydrogen p­ eroxide gas. 2. No implant migration occurred in our study population. 3. We have not used holes to fixate this type of implant, but they could easily be drilled into the film prior to insertion to allow fixation with either screws or sutures.

REFERENCES 1. Petris CK, Holds JB. Medial conjunctival resection for tearing associated with conjunctivochalasis. Ophthal Plast Reconstr Surg 2013;29:304–7. 2. Meller D, Tseng SC. Conjunctivochalasis: literature review and possible pathophysiology. Surv Ophthalmol 1998;43:225–32. 3. Erdogan-Poyraz C, Mocan MC, Irkec M, et al. Delayed tear clearance in patients with conjunctivochalasis is associated with punctal occlusion. Cornea 2007;26:290–3.

Richard H. Hart, M.B.Ch.B., F.R.A.N.Z.C.O. Elizabeth A. Insull, B.Sc., M.B.Ch.B. Guy J. Ben-Simon, M.D. Brian H. Sloan, M.H.B.(Hons.), M.B.Ch.B., F.R.A.N.Z.C.O. Alan A. McNab, D.Med.Sc., M.B.B.S., F.R.A.N.Z.C.O.

Re: “Use of X-Ray Film for the Repair of Orbital Blow Out Fractures”

Correspondence: Richard H. Hart, M.B.Ch.B., F.R.A.N.Z.C.O., Ophthalmology Department, Greenlane Clinical Centre, Ground Floor, Building 8, Greelane Clinical Centre, Greelane Road, Greenlane, Auckland, New Zealand ([email protected])

To the Editor: We read the article by Insull et al.1 on the “Use of X-Ray film for the repair of Orbital blow out Fractures.” We found it very useful for practical implementation in our practice. We have a few queries and we will be very happy to get an explanation from the authors. 1. Can the x-ray implant be sterilized by ethylene oxide gas sterilization (ETO)?

The authors have no financial or conflicts of interest to disclose.

REFERENCES 1. Yadalla D, Rajagopalan J. Re: "Use of x-ray film for the repair of orbital blow out fractures. Ophthal Plast Reconstr Surg. 2014;30:355. 2. Insull EA, Hart RH, Sloan BH, Ben-Simon GJ, McNab AA. Use of x-ray film implant for the repairt of orbital fractures. Ophthal Plast Reconstr Surg. 2013;29:393–95.

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

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