AIM: To investigate the clinical outcomes of different intubation techniques in the cases of failed primary probing.METHODS: This retrospective study was performed on 338 patients with the diagnosis of congenital nasolacrimal duct obstruction with age 1-4y that had failed primary probing. Intubation was performed under light sedation in operating room and the stent was left 3mo in place. Clinical outcome was investigated 3mo after tube removal.RESULTS: Bicanalicular intubation method had higher complete and relative success rates compared to monocanalicular intubation (P=0.00). In addition, Monoka intubation had better outcomes compared to Masterka technique (P=0.046). No difference was found between genders but the higher the age, the better the outcomes with bicanalicular technique rather than monocanalicular.CONCLUSION: Overall success rate of bicanalicular intubation is superior to monocanalicular technique especially in older ages. Also, based upon our clinical outcomes, Masterka intubation is not recommended in cases of failed probing.

PURPOSE:To evaluate the efficacy of tightening of lateral portion of orbicularis oculi muscle in patients with functional nasolacrimal duct obstruction (FNLDO).METHODS:This is an interventional cross-section study for evaluation of effect of orbicularis oculi tightening procedure in patients with FNLDO. Patients with unexplained epiphora, open lacrimal system in syringing and evidences of lacrimal pump weakness in lacrimal scintigraphy underwent surgery. In this procedure, a stripe of preseptal and pretarsal orbicularis muscle was dissected, slightly resected and secured to the periosteum of lateral orbital rim. Each subject completed a questionnaire about the intensity of epiphora before surgery and 1, 3 and 6 months after surgery. Furthermore, fluorescein dye disappearance test (FDDT) was performed before surgery and repeated in the follow-up visits. At last visit, the pre- and post-operative data were analyzed and compared.RESULTS:Fifteen eyes of 12 patients (5 males and 7 females) with the mean age of 56.7 years included in the study. Severity of epiphora and tearing effect on daily life were significantly improved following the operation. FDDT result was improved significantly after 1 month follow-up in all eyes (15 eyes), at 3 months follow-up in 80% of eyes (12 eyes) and at the end of the 6th month in 66.7% of eyes (10 eyes). Subjective and objective success rates were 87% and 80%, respectively. No significant complications or side-effects were observed.CONCLUSION:Tightening of lateral portion of preseptal and pretarsal orbicularis muscle seems an effective, safe, and easy procedure to decrease epiphora in patients with FNLDO.

Conjunctival invasive squamous cell carcinoma (SCC) is the most common malignancy of the conjunctiva in the world.1Farah S. Baum T.D. Conlon M.R. et al.Tumours of the cornea and conjunctiva.in: Albert D.M. Jakobiec F.A. Principles and practice of ophthalmology. WB Saunders, Philadelphia2000: 1002-1101Google Scholar Incidence of this disease varies from 0.02 to 3.5 cases per 100,000 population per year.2Gichuhi S. Irlam J.J. Interventions for squamous cell carcinoma of the conjunctiva in HIV-infected individuals.Cochrane Database Syst Rev. 2007; (CD005643): 18Google Scholar Although relatively uncommon, the disease carries potentially devastating ocular morbidity, and if neglected and not treated promptly can cause mortality. Epidermodysplasia verruciformis (EV) is a rare genetic lifelong disease that was first described by Lewandowsky and Lutz3Lewandowsky F. Lutz W. A case of a previously undescribed skin disease (epidermodysplasia verruciformis).Arch Dermatol Syphilol. 1922; 141: 193-203Crossref Scopus (147) Google Scholar in 1922 and is associated with a profound susceptibility to cutaneous infection with certain types of human papillomavirus (HPV). These strains of HPV were termed EV-HPV types because they were originally believed to occur only in association with the disease. Several HPVs, such as HPV-5, -8, -9,-12, -14, -15, -17, -19, -25, -36, -38, -47, and -50, have been identified, and they are now known to be present both in several types of benign and malignant cutaneous lesions and in normal skin in the unaffected population.4Lane J.E. Bowman P.H. Cohen D.J. Epidermodysplasia verruciformis.South Med J. 2003; 96: 613-615Crossref PubMed Scopus (29) Google Scholar Only a few types of HPV, specifically HPV-5 and HPV-8, as well as HPV-14, have been implicated in malignant transformation of EV lesions.5Oliveira W.R. Rady P.L. Festa C. et al.Skin cancer in epidermodysplasia verruciformis patients from Brazil.J Eur Acad Dermatol Venereol. 2006; 20: 1154-1156Crossref PubMed Scopus (15) Google Scholar It appears that T cells and natural killer cells in patients with EV may have a decreased response to specific HPVs. Interestingly, these patients do not appear to be at increased risk for development of other viral or bacterial infections.6Jablonska S. Orth G. Epidermodysplasia verruciformis.Clin Dermatol. 1985; 3: 83-96Abstract Full Text PDF PubMed Scopus (51) Google Scholar For affected individuals, classic EV first appears during early childhood. Polymorphic cutaneous lesions, including flat, wartlike papules and pityriasis versicolour-like macules, persist. Approximately half of all patient conditions may transform to cutaneous malignancies such as Bowen's type carcinoma in situ and invasive SCC, usually in sun-exposed areas, in the fourth or fifth decade of life.7Oliveira W.R. Festa Neto C. Rady P.L. Tyring S.K. Clinical aspects of epidermodysplasia verruciformis.J Eur Acad Dermatol Venereol. 2003; 17: 394-398Crossref PubMed Scopus (86) Google Scholar These malignancies have been reported to occur on the forehead, lips, and periorbital areas, and tend to be locally invasive but only rarely metastasize, unless treated with radiation therapy.8Majewski S. Jablonska S. Human papillomavirus-associated tumors of the skin and mucosa.J Am Acad Dermatol. 1997; 36: 659-685Abstract Full Text PDF PubMed Scopus (191) Google Scholar, 9Segura S. Carrera C. Ferrando J. et al.Dermoscopy in epidermodysplasia verruciformis.Dermatol Surg. 2006; 32: 103-106Crossref PubMed Google Scholar In this article, we report a patient with EV and SCC of the scalp, forehead, and conjunctiva who after radiotherapy experienced intraocular invasion of the SCC and blindness. A 78-year-old male was referred to Farabi Eye Hospital, Tehran, Iran, because of pain and redness in his right eye lasting 6 months. His right eye visual acuity was finger counting at 1 m, and the left eye was 20/80. Slit-lamp examination revealed a white elevated lesion in the inferonasal area of the bulbar conjunctiva near the limbus with some extension over the cornea (Fig. 1). Furthermore, a ball of whitish yellow material had invaded into the anterior chamber. The iris was irregular and had a superior iridectomy from an old complicated cataract surgery 10 years ago. The left eye was normal. The cutaneous lesions on his forehead, ear, and scalp were crusted, keratotic, ulcerated plaques with varying diameters from 1 to 3 cm (Fig. 2A, 2B). The patient had deformities of the midface, nose, and scalp because of multiple surgeries for excision of cutaneous SCC (Fig. 2C).Fig. 2A and B, Photograph illustrating the cutaneous lesions on forehead, ear, and scalp that were crusted, keratotic, ulcerated plaque with different diameters from 1 to 3 cm. C, The patient has deformity of midface, nose, and scalp because of multiple surgeries for excision of cutaneous squamous cell carcinoma.View Large Image Figure ViewerDownload (PPT) Despite multiple local excisions, he experienced several recurrences. He had been treated with 30 sessions of radiotherapy (6000 cGy) for management of periorbital cutaneous SCC 1 year before referral to our clinic and before the diagnosis of EV. As an incidental finding, scattered, slightly scaly hypopigmented macules were noted on his trunk, back, and upper extremities. He reported that these lesions had been present since childhood. There was no family history of similar lesions. HPV-8 was identified in tissue samples using DNA hybridization. A biopsy of conjunctiva was done and on pathologic examination, SCC of conjunctiva was diagnosed (Fig. 3A, B). Intraocular lesion biopsy also confirmed the diagnosis of SCC. Unfortunately, the patient refused any further treatment, returned to his home at his small village in the west of Iran, and was lost to follow-up. EV is a rare hereditary disease; it is inherited mainly in an autosomal recessive pattern, although X-linked inheritance has been described.10Androphy E.J. Dvoretsky I. Lowy D.R. X-linked inheritance of epidermodysplasia verruciformis: genetic and virologic studies of a kindred.Arch Dermatol. 1985; 69: 864-868Crossref Scopus (95) Google Scholar EV is a model for viral-induced carcinogenesis and was the first skin disease in which cancer was clearly associated with viral infection. The first manifestation of the disease usually is in early childhood. Macules on the trunk, shoulders, neck, arms, and face appear with a scaly surface. They may, however, be more widely distributed. The appearance and distribution of these lesions mimics tinea versicolour.11Lutzner M. Blanchet-Bardon C. Othr G. Clinical observations, virologic studies, and treatment trials in patients with epidermodysplasia verruciformis, a disease induced by specific human papillomaviruses.J Invest Dermatol. 1984; 83: 18-25SCrossref Scopus (134) Google Scholar Papular lesions, which resemble flat warts, often appear on the back of the hands, the wrists, and the forearms. Malignant lesions such as seborrheic keratoses, actinic keratoses, or SCCs usually arise in sun-exposed areas, most commonly on the forehead. Malignant conversion of EV benign lesions has been described for HPV-5, HPV-8, and HPV-14, and occurs in more than half of patients who have had the disease for ≥20 years and particularly on sun-exposed areas.8Majewski S. Jablonska S. Human papillomavirus-associated tumors of the skin and mucosa.J Am Acad Dermatol. 1997; 36: 659-685Abstract Full Text PDF PubMed Scopus (191) Google Scholar The natural course of SCCs arising in lesions of EV is generally minimally aggressive and almost always only locally invasive. Furthermore, the risk for metastasis to local lymph nodes is low.8Majewski S. Jablonska S. Human papillomavirus-associated tumors of the skin and mucosa.J Am Acad Dermatol. 1997; 36: 659-685Abstract Full Text PDF PubMed Scopus (191) Google Scholar Radiation therapy is a well-known risk factor for metastasis in these patients.12Majewski S. Jablonska S. Epidermodysplasia verruciformis as a model of human papillomavirus-induced genetic cancer of the skin.Arch Dermatol. 1995; 131: 1312Crossref PubMed Scopus (204) Google Scholar It is believed that radiation therapy acts synergistically with sunlight to induce mutations in the p53 antioncogene and causes both local and systemic immunosuppression.13Brash D.E. Rudolph J.A. Simon J.A. A role for sunlight in skin cancer: UV induced p53 mutations in squamous cell carcinoma.Proc Natl Acad Sci U S A. 1991; 88: 1024-1028Crossref PubMed Scopus (1751) Google Scholar In our case, because of delay in diagnosis of EV, the patient had received 30 sessions of radiation for treatment of periorbital cutaneous SCC and 1 year after radiation, conjunctival SCC had developed. Conjunctival SCC usually is low grade with rare intraocular invasion and metastasis. Our patient was an exception to this rule. The conjunctival tumour in our patient was unusual because it was highly aggressive with extensive local invasion (probably because of radiation). In HPV-induced lesions, radiation is a major risk factor for carcinogenesis. Transformation of benign EV lesions to malignancy and eventually metastasis has been reported in patients after radiation therapy. Therefore, radiation therapy is thought to be contraindicated in patients with EV.12Majewski S. Jablonska S. Epidermodysplasia verruciformis as a model of human papillomavirus-induced genetic cancer of the skin.Arch Dermatol. 1995; 131: 1312Crossref PubMed Scopus (204) Google Scholar Treatment of EV is limited, and preventing the progression of benign lesions to malignant ones is the goal. Protection from ultraviolet light in early childhood and avoidance of radiation is encouraged. In summary, our patient with typical clinical and virological evidence of EV showed the unusual features of aggressive ocular malignancy resulting in loss of sight.

BACKGROUND:The angle kappa is important in proper centration of corneal ablation in keratorefractive surgery. Orbscan II device is widely used preoperatively in photoablation surgeries and can be used to measure the angle kappa.OBJECTIVES:This study aimed to determine the mean angle kappa and its intercepts in healthy young Iranian adults.PATIENTS AND METHODS:In this cross-sectional study, orthotropic patients (age range, 18-35 years) who were referred to the Khatam Eye Hospital (Mashhad, Iran) were included. Exclusion criteria were as follows: history of any eye deviation or strabismus with or without orthoptic or surgical treatment; any intraocular, corneal, or keratorefractive surgery; contact lens use; any corneal anomaly; any ophthalmic or systemic drug consumption; and hyperopic spherical refraction > + 3.00 diopters (D), spherical refraction > -5.00 D, or cylindrical refraction > 2.00 D. All of the parameters were measured by the same operator through an Orbscan II device.RESULTS:A total of 977 healthy participants who aged 18 to 45 years were included consecutively. The study population consisted of 614 females and 363 males. The average angle kappa was 5.00º ± 1.36º at 240.21º ± 97.17º in males and 4.97º ± 1.30º at 244.22º ± 94.39º in females (P = 0.63). The average horizontal (x-axis) angle kappa was -0.02º ± 0.49º, with a mean of -0.02º ± 0.50º in males and -0.02º ± 0.49º in females (P = 0.93). The average vertical (y-axis) angle kappa was -0.09º ± 0.32º, with a mean of -0.09º ± 0.33º in males and -0.09º ± 0.32º in females (P = 0.74).CONCLUSIONS:By using the normal angle kappa determined in this study, pseudodeviations can be identified more precisely in those who might undergo keratorefractive surgery.

A 69-year-old female came to Oculoplastic Clinic, Farabi Eye Hospital, Tehran, Iran, with the complaint of new-onset proptosis and loss of vision in her left eye from 4 months ago. She had no history of any trauma. On examination, there was no visible skin scar of any previous surgery around the orbit. The right eye had best corrected visual acuity (BCVA) of 9/10, and slit-lamp examination of its anterior segment and funduscopy showed no pathology except mild cataract. In her left eye, she had BCVA of 2/10, mild conjunctival injection and chemosis, severe proptosis (10-mm difference in exophthalmometry; Fig. 1A), lateral gaze limitation, and a reactive pupil with 2+ relative afferent pupillary defect. The left eye had also mild cataract, and its funduscopy showed no significant abnormal finding. Radiologic evaluation for the eye was started with CT scan (Fig. 1B). CT scan revealed a well-defined, dumbbell-shaped cystic lesion—internal density similar to water, delineated by a perceptible hyperdense rim—in lateral wall of orbit, with destruction of the bone and extension into the orbit, compressing orbital contents and pushing the globe forward. For further evaluation of the lesion, magnetic resonance imaging (MRI) was performed (Fig. 1C, 1F). MRI showed a multiloculated cystic lesion with better depicting peripheral fibrous capsule and internal septations. The lesion had low signal intensity in T1-wighted imaging without enhancement and high signal intensity in T2-weighted images. The signal intensity of the lesion was consistent with an isolated multiloculated cystic lesion with content density similar to water or cerebrospinal fluid (CSF), with no internal enhancement, which could be a hydatid cyst, a dermoid cyst, an abscess, a mucocele, a hematocele, or an encephalocele. However, in T1-weighted images, hypersignal intensity is expected in dermoid cysts (because of their fat content) and hematocele (because of methemoglobin inside them). Moreover, abscess usually has a notable wall enhancement in contrast studies, whereas thin peripheral enhancement is sometimes evident in mucocele and hydatid cyst, mostly as a result of superinfection. In the case of encephalocele, a cranial defect, and hence a connection with intracranial extra-axial CSF space, could be depicted. With these findings, the most probable diagnosis was an intraosseous hydatid cyst. Considering its compressive effect, the lesion had to be excised as soon as possible. Surgical en bloc excision of the cyst is the mainstay of treatment. To avoid intraorbital dissemination of the cyst's content, considering its location, we approached through an incision 1.5 cm posterior to lateral orbital rim (Fig. 2A). Although the cyst ruptured during last step, there was no spillage into orbital space and it could be totally removed (Fig. 2B). Pathology confirmed hydatid cyst (Fig. 3A, 3B). After surgery, albendazole was prescribed for the patient for 3 months. After 2 years of follow-up, no sign of recurrence has been detected in this patient.Fig. 3Histopathologic view of the patient's lesion showing laminated hyalinized cystic wall of hydatid cyst (A) attached to some scolexes (B). Hematoxylin and eosin stains. Original magnification ×100 (A); ×400 (B).View Large Image Figure ViewerDownload (PPT) Brain imaging was performed for evaluation of any intracranial extension or dissemination, which was negative. To assess whether the patient had pulmonary hydatidosis, we performed a chest x-ray, which showed no finding. Also, abdominal ultrasonography was performed to evaluate the liver, which showed no abnormal finding. Echinococcosis is one of the most common parasitoses that affect humans in its endemic areas. When contaminated, it mostly affects liver, lung, and kidneys.1Siddiqui M.A. Rizvi S.W. Rizvi S.A. et al.Atypical multifocal hydatid disease of cranial vault: simultaneous orbital and extradural meningeal involvement.Emerg Radiol. 2010; 17: 427-430Crossref PubMed Scopus (12) Google Scholar, 2Aouchiche M. Benrabah R. Abanou A. et al.[Computed x-ray tomographic aspects of intra-orbital hydatid cyst. Apropos of 10 cases]. [Article in French].J Fr Ophtalmol. 1983; 6: 901-916PubMed Google Scholar Orbital involvement is rare, and only about 1% of hydatidoses occur in orbit.3Limaiem F. Bellil S. Bellil K. et al.Primary orbital hydatid cyst in an elderly patient.Surg Infect (Larchmt). 2010; 11: 393-395Crossref PubMed Scopus (10) Google Scholar, 4Danziger A. Price H. Computed tomographic findings in orbital echinococciasis.J Comp Assist Tomogr. 1980; 4: 128-129Crossref PubMed Scopus (9) Google Scholar It has been reported that hydatidosis accounts for only 1% of orbital tumours2Aouchiche M. Benrabah R. Abanou A. et al.[Computed x-ray tomographic aspects of intra-orbital hydatid cyst. Apropos of 10 cases]. [Article in French].J Fr Ophtalmol. 1983; 6: 901-916PubMed Google Scholar; but among orbital cystic lesions, it has been the second most frequent lesion (25.8%) after dermoid cysts (29.7%).5Günalp I. Gündüz K. Cystic lesions of the orbit.Int Ophthalmol. 1996-1997; 20: 273-277PubMed Google Scholar Although in endemic areas such as Spain, Lebanon, Iraq, and Turkey, the incidence rate of hydatid cyst has been reported to be 13.6%, 6%, 20%, and 6.6% among orbital tumours, respectively.6Kars Z. Kanzu T. Ozcan O. et al.Orbital echinococcosis, report of two cases studied by computerized tomography.J Clin Neuro-ophthalmol. 1982; 2: 197-199PubMed Google Scholar In North America, Echinococcus granulosus is rarely reported in Canada and Alaska, and a few human cases have also been reported in Arizona and New Mexico in sheep-raising areas. In the United States, most infections are diagnosed in immigrants from countries where cystic echinococcosis is endemic.7Centers for Disease Control and Prevention. Cystic echinococcosis. http://www.cdc.gov/parasites/echinococcosis/gen_info/ce-faqs.htmlGoogle Scholar Orbital hydatidosis mostly affects children and young adults. This occurs most frequently when individuals handle or contact infected dogs or other infected carnivores, or inadvertently ingest food or drink contaminated with fecal material that contains tapeworm eggs. In our case, we think that she has ingested vegetables possibly contaminated with fecal material of an infected dog. It is usually unilateral with a trend for left eye involvement,3Limaiem F. Bellil S. Bellil K. et al.Primary orbital hydatid cyst in an elderly patient.Surg Infect (Larchmt). 2010; 11: 393-395Crossref PubMed Scopus (10) Google Scholar and occurs with an insidious onset, causing slowly progressive proptosis, which mostly leads to visual loss and limited eye movements.1Siddiqui M.A. Rizvi S.W. Rizvi S.A. et al.Atypical multifocal hydatid disease of cranial vault: simultaneous orbital and extradural meningeal involvement.Emerg Radiol. 2010; 17: 427-430Crossref PubMed Scopus (12) Google Scholar, 3Limaiem F. Bellil S. Bellil K. et al.Primary orbital hydatid cyst in an elderly patient.Surg Infect (Larchmt). 2010; 11: 393-395Crossref PubMed Scopus (10) Google Scholar, 4Danziger A. Price H. Computed tomographic findings in orbital echinococciasis.J Comp Assist Tomogr. 1980; 4: 128-129Crossref PubMed Scopus (9) Google Scholar, 8Benazzou S. Arkha Y. Derraz S. et al.Orbital hydatid cyst: review of 10 cases.J Craniomaxillofac Surg. 2010; 38: 274-278Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar There can be sudden symptoms, for example, complete loss of vision, proptosis, pain, among others, caused by spontaneous cyst rupture. These lesions are usually not associated with hydatid cysts of other organs3Limaiem F. Bellil S. Bellil K. et al.Primary orbital hydatid cyst in an elderly patient.Surg Infect (Larchmt). 2010; 11: 393-395Crossref PubMed Scopus (10) Google Scholar; however, accompanied involvement of liver, lung, brain, spleen, and thyroid has been reported.9Turgut A. Turgut M. Kosar U. Hydatidosis of the orbit in Turkey: results from review of the literature 1963–2001.Int Ophthalmol. 2004; 25: 193-200Crossref PubMed Scopus (34) Google Scholar Thus, chest x-ray and abdominal ultrasonography should be performed as a routine work-up for all patients.1Siddiqui M.A. Rizvi S.W. Rizvi S.A. et al.Atypical multifocal hydatid disease of cranial vault: simultaneous orbital and extradural meningeal involvement.Emerg Radiol. 2010; 17: 427-430Crossref PubMed Scopus (12) Google Scholar About 2% of hydatid cysts have been reported to be located in skeleton,9Turgut A. Turgut M. Kosar U. Hydatidosis of the orbit in Turkey: results from review of the literature 1963–2001.Int Ophthalmol. 2004; 25: 193-200Crossref PubMed Scopus (34) Google Scholar and there is small number of case reports on intraosseous hydatid cysts,10Erman T. Tuna M. Göçer I. et al.Intracranial intraosseous hydatid cyst. Case report and review of literature.Neurosurg Focus. 2001; 11 (ECP1)Google Scholar, 11Yazdani N. Basam A. Heidarali M. et al.Infratemporal hydatid cyst: a case presenting with blindness.J Laryngol Otol. 2010; 124: 456-459Crossref PubMed Scopus (10) Google Scholar, 12Pelegri C. Gaertner E. Bernard E. et al.Recurrence of femoral echinococcosis 5 years after a primary surgical procedure.Orthop Traumatol Surg Res. 2010; 96: 94-96Crossref PubMed Scopus (3) Google Scholar, 13Fyfe B. Amazon K. Poppiti Jr, R.J. et al.Intraosseous echinococcosis: a rare manifestation of echinococcal disease.South Med J. 1990; 83: 66-68Crossref PubMed Scopus (10) Google Scholar although periorbital bone involvement has not been reported. Eosinophilia can be seen in a few patients. Although serologic tests are generally positive in systemic hydatidosis, they are almost always negative in orbital hydatidosis, and thus are not reliable.1Siddiqui M.A. Rizvi S.W. Rizvi S.A. et al.Atypical multifocal hydatid disease of cranial vault: simultaneous orbital and extradural meningeal involvement.Emerg Radiol. 2010; 17: 427-430Crossref PubMed Scopus (12) Google Scholar, 9Turgut A. Turgut M. Kosar U. Hydatidosis of the orbit in Turkey: results from review of the literature 1963–2001.Int Ophthalmol. 2004; 25: 193-200Crossref PubMed Scopus (34) Google Scholar Imaging studies including CT scan and MRI are now standard diagnostic evaluation for these lesions.1Siddiqui M.A. Rizvi S.W. Rizvi S.A. et al.Atypical multifocal hydatid disease of cranial vault: simultaneous orbital and extradural meningeal involvement.Emerg Radiol. 2010; 17: 427-430Crossref PubMed Scopus (12) Google Scholar, 3Limaiem F. Bellil S. Bellil K. et al.Primary orbital hydatid cyst in an elderly patient.Surg Infect (Larchmt). 2010; 11: 393-395Crossref PubMed Scopus (10) Google Scholar On CT scan, they are shown as well-defined encapsulated cystic lesions with internal density of water or CSF, which can show increased peripheral density at its capsule area (a hyperdense rim); this can show rim enhancement with contrast.6Kars Z. Kanzu T. Ozcan O. et al.Orbital echinococcosis, report of two cases studied by computerized tomography.J Clin Neuro-ophthalmol. 1982; 2: 197-199PubMed Google Scholar, 9Turgut A. Turgut M. Kosar U. Hydatidosis of the orbit in Turkey: results from review of the literature 1963–2001.Int Ophthalmol. 2004; 25: 193-200Crossref PubMed Scopus (34) Google Scholar These lesions can result in bone destruction (mostly medial wall into nasal cavity).6Kars Z. Kanzu T. Ozcan O. et al.Orbital echinococcosis, report of two cases studied by computerized tomography.J Clin Neuro-ophthalmol. 1982; 2: 197-199PubMed Google Scholar, 14Murthy R. Honavar S.G. Vemuganti G.K. et al.Polycystic echinococcosis of the orbit.Am J Ophthalmol. 2005; 140: 561-563Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar On MRI, we can see the lesion as a well-defined cystic mass with low-intensity signal in T1-weighted imaging, which can show peripheral rim enhancement with contrast and high internal signal intensity, and a hyposignal peripheral rim (caused by fibrous component of the capsule) in T2-weighted images.9Turgut A. Turgut M. Kosar U. Hydatidosis of the orbit in Turkey: results from review of the literature 1963–2001.Int Ophthalmol. 2004; 25: 193-200Crossref PubMed Scopus (34) Google Scholar Surgical en bloc resection of the cyst is the mainstay of treatment and it can be curative if we are sure there has been no spillage of the contents intraoperatively3Limaiem F. Bellil S. Bellil K. et al.Primary orbital hydatid cyst in an elderly patient.Surg Infect (Larchmt). 2010; 11: 393-395Crossref PubMed Scopus (10) Google Scholar; however, it frequently has leakage through small punctures in the cyst wall, made during the procedure, which necessitates antihelmintic therapy, albendazole or mebendazole, postoperatively to reduce recurrence.1Siddiqui M.A. Rizvi S.W. Rizvi S.A. et al.Atypical multifocal hydatid disease of cranial vault: simultaneous orbital and extradural meningeal involvement.Emerg Radiol. 2010; 17: 427-430Crossref PubMed Scopus (12) Google Scholar, 3Limaiem F. Bellil S. Bellil K. et al.Primary orbital hydatid cyst in an elderly patient.Surg Infect (Larchmt). 2010; 11: 393-395Crossref PubMed Scopus (10) Google Scholar, 8Benazzou S. Arkha Y. Derraz S. et al.Orbital hydatid cyst: review of 10 cases.J Craniomaxillofac Surg. 2010; 38: 274-278Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar, 9Turgut A. Turgut M. Kosar U. Hydatidosis of the orbit in Turkey: results from review of the literature 1963–2001.Int Ophthalmol. 2004; 25: 193-200Crossref PubMed Scopus (34) Google Scholar Also, preoperative medical therapy has been advised to sterilize the lesion before the procedure, causing reduced risk for complications such as anaphylaxis and recurrence.1Siddiqui M.A. Rizvi S.W. Rizvi S.A. et al.Atypical multifocal hydatid disease of cranial vault: simultaneous orbital and extradural meningeal involvement.Emerg Radiol. 2010; 17: 427-430Crossref PubMed Scopus (12) Google Scholar For intraosseous lesions, extensive bony curettage is suggested.12Pelegri C. Gaertner E. Bernard E. et al.Recurrence of femoral echinococcosis 5 years after a primary surgical procedure.Orthop Traumatol Surg Res. 2010; 96: 94-96Crossref PubMed Scopus (3) Google Scholar Irrigation of the affected area with hypertonic saline has also been advised, especially in the case of spillage.8Benazzou S. Arkha Y. Derraz S. et al.Orbital hydatid cyst: review of 10 cases.J Craniomaxillofac Surg. 2010; 38: 274-278Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar, 9Turgut A. Turgut M. Kosar U. Hydatidosis of the orbit in Turkey: results from review of the literature 1963–2001.Int Ophthalmol. 2004; 25: 193-200Crossref PubMed Scopus (34) Google Scholar, 11Yazdani N. Basam A. Heidarali M. et al.Infratemporal hydatid cyst: a case presenting with blindness.J Laryngol Otol. 2010; 124: 456-459Crossref PubMed Scopus (10) Google Scholar One important key in managing these patients is to have regular follow-up visits to detect any recurrence, especially in adjacent organs.1Siddiqui M.A. Rizvi S.W. Rizvi S.A. et al.Atypical multifocal hydatid disease of cranial vault: simultaneous orbital and extradural meningeal involvement.Emerg Radiol. 2010; 17: 427-430Crossref PubMed Scopus (12) Google Scholar, 11Yazdani N. Basam A. Heidarali M. et al.Infratemporal hydatid cyst: a case presenting with blindness.J Laryngol Otol. 2010; 124: 456-459Crossref PubMed Scopus (10) Google Scholar, 12Pelegri C. Gaertner E. Bernard E. et al.Recurrence of femoral echinococcosis 5 years after a primary surgical procedure.Orthop Traumatol Surg Res. 2010; 96: 94-96Crossref PubMed Scopus (3) Google Scholar In conclusion, we should consider the hydatidosis as a cause of progressive unilateral proptosis and visual loss in its endemic areas, which can be diagnosed with the help of imaging studies. Immediate intervention should be performed because of its compressive effects, and its recurrence must always be kept in mind, which can result in poor visual outcomes.

AIM:To report the clinical outcomes of utilizing a three-layer flap and graft in reconstruction of the lower lid in one session.METHODS:Seventeen patients with total or near total lower eyelid defect were included. The defects were reconstructed in three layers. Posterior lamella was reconstructed by using tarsoconjunctival free graft from the ipsilateral upper lid and periosteal flap from lateral orbital rim. Mobilization of residual orbicularis muscle provided a rich blood supply; and the anterior lamella was reconstructed by skin flap prepared from upper lid blepharoplasty as a one-pedicular or bipedicular bucket handle flap.RESULTS:The cause of lower eyelid defect was basal cell carcinoma in 15 patients and trauma in two of them. No intraoperative and postoperative complication occurred. Patients were followed from 10 to 15mo postoperatively. Cosmetic results were favorable in all patients and we had acceptable functional results. Thickness of the reconstructed tissue was a concern in early postoperative period.CONCLUSION:Three-layer lower lid reconstruction in one session is an effective technique for total lower lid reconstruction with minimal complications and acceptable functional and aesthetic outcomes and can be considered as a safe alternative for the preexisting techniques.

Purpose: To investigate the clinical outcomes of late primary probing in congenital nasolacrimal duct (NLD) obstruction.Methods: A prospective interventional study was designed to recruit children older than 24 months who presented with clinical manifestations of NLD obstruction since February 2008 to Farabi Eye Hospital, Tehran, Iran. No prior surgical intervention for NLD obstruction was performed on these patients; they underwent probing of the nasolacrimal system and irrigation under general anesthesia by oculoplastic surgeons. The outcome of the procedure was assessed 2 to 3 months postoperatively. Data of the patients until February 2013 were considered for analysis.Results: The total number of patients during the 5-year study was 343. The total success rate considering all of the age groups was 75.8%. The success rate was 85% in those who were 2 to 3 years old, 63% in those who were 3 to 4 years old, and 50% in those who were 4 to 5 years old. In patients with chronic dacryocystitis with mucopurulent discharge, 83% had successful probing and irrigation. In patients with epiphora with no mucopurulent discharge, 59% had successful results with probing.Conclusions: In the cases of congenital NLD obstruction, primary probing before 2 years of age has a high success rate; there is a high overall success rate (75.8%) in the 2- to 5-years age group, but when older than 5 years, further procedures such as intubation and dacryocystorhinostomy would be needed because of the high failure rate of probing.

Patients with mitochondrial myopathies, of which chronic progressive external ophthalmoplegia (CPEO) is the most common, can present with ptosis and proximal limb weakness.1 Ptosis associated with CPEO can provide challenging management problems. This form of ptosis may have poor levator function. Additional features must be considered in determining the surgical treatment. For example, these patients may have limited upgaze and a poor Bell’s phenomenon, poor orbicularis function, dry eye, and resultant poor corneal protective mechanisms.2 This would put them at greater risk for exposure keratopathy after ptosis repair. In this article, we describe our experience with a patient with CPEO who had pre-operative moderate levator function and good orbicularis function that after performing levator resection developed severe exposure keratopathy. A 20-year-old man was referred to Farabi Eye Hospital, Tehran, Iran with bilateral lagophthalmos. He had a Hutchinson myopatic face similar to the CPEO facial pattern. He had lid swelling. Visual acuity was 2/10 in both eyes. Slit lamp examination revealed corneal edema, epithelial defects bilaterally, and signs of corneal exposure keratopathy (Figure 1A). Figure 1 (A) Photograph showing eyelid edema and corneal injection 2 months after the first surgery in right tarsorrhaphied eye. (B) Photograph 5 years after the first surgery showing narrow palpebral fissure in both eye with corneal opacity at the right eye. ... The patient had been undergone bilateral levator resection 2 weeks before in a city at North of Iran. His pre-operative visual acuity was 10/10 and bilateral ptosis was present with levator function measuring 8-mm in both eyes. The histological report showed ragged red fibers compatible with CPEO. To avoid more severe complications from corneal exposure, tarsorrhaphy was performed on both eyes. After 3 weeks and when corneal signs subsided, one of the tarsorrhaphied eyes was opened, but after 10 days, he represented with signs of exposure keratopathy and again underwent tarsorrhaphy. Tarsorrhaphy and opening of the sutured lids was repeated 4 times in a period of 5 months, and then due to corneal haziness and vascularization the surgery was revised. Both upper eyelids were so tight and without any movement so that after opening of tarsorrhaphy, upper lid retracted and there was not any option unless repeating tarsorrhaphy. In both eyes after opening of the previous incision, the levator was recessed. Lower lid recession with posterior lamellar scleral spacer graft was performed on both eyes for narrowing the vertical palpebral fissure. After this operation, he had mild ptosis with marginal reflex distance measuring 2 mm, and lower lid elevation, so that the vertical palpebral fissure measured 5 mm. Slit lamp examination showed corneal haziness and vascularization in both eyes. Acuity decreased in the right eye to 1/10 and left eye to 4/10. No worsening of signs and symptoms were noticed during the 60 months follow-up (Figure 1B and ​andC).C). However, due to extension of corneal vascularization and thinning the right eye, vision was 3 m finger count in both eyes. In patients with CPEO and ptosis, even with cautious approaches, lagophthalmos with corneal exposure will usually ensue, partially due to increased vertical palpebral fissure and partially due to poor orbicularis function, in addition to poor corneal protective mechanisms.2 To overcome such complication Shorr et al.3 have advocated upper eyelid surgery in conjunction with lower eyelid elevation to improve visually significant ptosis and to maintain corneal protection in these patients. In this procedure, the ptosis repair was combined with maximum recession of the lower eyelid, using a posterior lamellar scleral spacer graft. This combined procedure allows a more aggressive upper lid elevation while minimizing the overall change in vertical palpebral fissure. The overall pre-operative vertical palpebral fissure height is maintained or even decreased. Thus, a more significant improvement in superior visual field is obtained with maintenance of eyelid closure and without the accompanying exposure risk.3 In patients with moderate to poor levator function, between 4 and 8 mm levator resection has been recommended. However, attention just to levator function in determining the surgical treatment is misleading. Since preoperative good function of orbicularis in these patients is not exactly equivalent to its’ function postoperatively, and because of underlying problems such as poor Bell’s phenomenon and poor corneal protection, it is recommended not to increase palpebral fissure height. If one performs levator resection it is better to recess the lower lid with a spacer graft to maintain a narrow, vertical interpalpebral fissure to maximize eyelid closure ability, and reposition this opening centrally over the pupil. One can argue that because the disease is progressive, and sling surgery is adjustable and potentially reversible (by removal), this technique is preferable to levator resection surgery.4 This article suggests that ptosis surgery in CPEO be performed only when vision is compromised by lid height and affects the visual axis. Surgery should be done with full follow-up care. We recommend lower lid recession, using a spacer graft to be combined with sling (with silicone) or levator resection procedures, in poor or good levator function, respectively. This procedure is done to avoid accompanying exposure keratopathy due to increased palpebral fissure and to allow eyelid closure.