Journal of Ophthalmic Plastic and Reconstructive Surgery

Update on Idiopathic Canalicular Inflammatory Disease (ICID): Outcomes With Addition of Topical Cyclosporine and the Modified Treatment Protocol

Ali, Mohammad Javed M.D., Ph.D., F.R.C.S.; Bothra, Nandini M.D.

Abstract

Purpose: 

The objective of this study is to present clinical outcomes with addition of topical cyclosporine while managing cases of “idiopathic canalicular inflammatory disease” and to propose a modified treatment protocol.

Methods: 

Prospective case series of 88 canaliculi of 44 eyes of 22 patients diagnosed as “idiopathic canalicular inflammatory disease” at a tertiary care Dacryology service over a period of 2 years. All the patients were diagnosed based on the published major and minor criteria and each of the canaliculus was clinically staged. All patients were treated initially with a combination of topical cyclosporine (0.05%) and rapidly tapering topical steroids followed by punctal dilatation and placement of mini-monoka stents after control of inflammation. Monoka stents were extubated at 6 weeks and the cyclosporine was continued for at least up to 3 months beyond the extubation of stents. Patient demographics, investigations, response to cyclosporine, management modalities, recurrence of inflammation, anatomical and functional outcomes were analyzed.

Results: 

Eighty-eight canaliculi were diagnosed to have idiopathic canalicular inflammatory disease during the study period. There was a female preponderance (77%, 17/22) and the mean age at presentation was 51 years. All patients presented with bilateral epiphora (mean duration 4.5 months) without any discharge. Staging revealed 18, 27, 24, and 19 canaliculi were involved with stages 1–۴, respectively. The mean duration of cyclosporine use was 5.7 months. All patients except 3 (19/22) underwent monoka dilatation. Complete anatomical and functional resolution were noted in 62% (55/88), of which 12 puncta and canaliculi, all stage 1 (13.6%, 12/88) showed complete resolution with cyclosporine alone. Relentless disease progression to stage 5 was noted in 30% (26/88) of the puncta and canaliculi. All the younger patients (<30 years, 13.6%, 3/22) demonstrated poor outcomes.

Conclusions: 

The addition of topical cyclosporine is beneficial in controlling inflammation and disease downstaging in patients with idiopathic canalicular inflammatory disease. The current modified treatment protocol salvages majority of the canaliculi.

Topical Corticosteroid Use Associated with Increased Degree of Ptosis and Rate of Ptosis Repair Failure

Dermarkarian, Christopher R. M.D.; Williams, Katherine J. M.D.; Sweeney, Adam R. M.D.; Allen, Richard C. M.D., Ph.D.; Yen, Michael T. M.D.

Abstract

Purpose: 

To compare the degree of ptosis and the risk of ptosis repair failure among patients with and without a history of topical corticosteroid use.

Methods: 

Retrospective, case-controlled study examining topical corticosteroid use among adults with ptosis who underwent external levator advancement/resection (ELR) or Müller muscle conjunctival resection with at least 3 months postoperative follow-up. Comparative statistical analyses of surgical outcomes were performed amongst patients with and without history of topical corticosteroid use.

Results: 

A total of 240 patients (406 eyelids) met study criteria, of which 36 patients (44 eyelids) had history of topical corticosteroid use. Mean preoperative margin reflex distance was 0.20 mm and 0.58 mm for topical corticosteroid and non-corticosteroids users (p = ۰.۰۱). Mean preoperative levator function was 9.78 mm and 10.38 mm for topical corticosteroid and non-corticosteroid users (p = ۰.۰۲). The rate of ptosis repair failure was 30% and 16% in patients with and without a history of topical corticosteroid use (odds ratio 2.25, 95% confidence interval 1.10–۴.۵۵; p = ۰.۰۳). The rate of recurrence per surgical type in eyelids with and without history of topical corticosteroid use was: external levator advancement/resection 11/27 (41%) and 48/266 (18%) (odds ratio = 3.12, confidence interval 1.36–۷.۱۵ ۰; p = ۰.۰۱); Müller muscle conjunctival resection 2/17 (12%) and 9/96 (9%) (odds ratio 1.29, confidence interval 0.25–۶.۵۶; p = ۰.۷۶).

Conclusions: 

Topical corticosteroid use is associated with more severe presenting ptosis and increased rates of ptosis repair failure. Compared to Müller muscle conjunctival resection, there is a significantly higher rate of ptosis repair failure in patients undergoing external levator advancement/resection.

The Role of Postoperative Bandage Contact Lens in Patients Undergoing Fasanella-Servat Ptosis Repair

Adam, Robert S. M.D; Harvey, John T. M.D; Gould, Jonah N. B.MSc., M.MASc. Suntheralingam, Sivisan B.MSc; Farrokhyar, Forough Ph.D.

Abstract

Purpose: 

To determine whether a bandage contact lens (BCL) improves patient comfort in the postoperative period in patients undergoing ptosis repair using the Fasanella-Servat technique, compared with no BCL.

Methods: 

In this prospective, randomized, double-masked, comparison study, all patients had bilateral Fasanella-Servat surgery. A total of 30 patients were randomized to receive a BCL in one eye and no BCL in the other eye. Patient discomfort was measured as the primary outcome using the Eye Sensation Scale. Blurred vision was measured as a secondary outcome using selected questions from the Ocular Surface Disease Index. The surgeries were performed by 2 surgeons (J.T.H and R.S.A). Outcomes were measured one week following the procedure.

Results: 

Patients reported significantly less discomfort in the eye receiving a BCL, with only 13.3% ranking discomfort as “moderate” or “severe,” compared with the eye not receiving BCL, where 63.3% of patients rated discomfort as “moderate” or “severe” (p < 0.001). There was no significant difference in patient-reported blurred vision between the 2 groups (p = ۰.۵۲۰).

Conclusions: 

The use of a bandage contact lens after Fasanella-Servat procedure for ptosis repair is recommended as it improves patient comfort. In addition, it has no detrimental effect on patient-reported blurring of vision.

Treatment of Congenital Ptosis in Infants With Associated Amblyopia Using a Frontalis Muscle Flap Eyelid Reanimation Technique

Eton, Emily A. M.D; Carniciu, Anaïs L. M.D; Prabhu, Shreya S. M.D., M.P.H; Wang, Grace M. M.D., Ph.D; Kahana, Alon M.D., Ph.D.

Abstract

Purpose: 

To determine the efficacy of a frontalis muscle flap eyelid reanimation technique for correction of severe congenital ptosis and associated amblyopia in infants.

Methods: 

The authors performed a retrospective chart review of patients 12 months of age or younger with unilateral or bilateral congenital ptosis and associated amblyopia or deemed at high risk for amblyopia due to visual deprivation. Following ptosis repair via a frontalis muscle flap technique, primary outcomes of postoperative eyelid position and amblyopia reversal were assessed.

Results: 

Seventeen eyes of 12 participants were included for study. Seven of these patients had simple congenital ptosis, and the remainder had ptosis as part of a syndrome. Nine were diagnosed with amblyopia preoperatively, and the remaining 3 were too young for acuity testing but had occlusion of the visual axis by the ptotic eyelid in primary gaze. Postoperatively, the mean margin-to-reflex distance 1 was 2.4 mm (range: 0.0–۴.۰), and 9 patients (75%) demonstrated no evidence of amblyopia. Only 2 patients had eyelid asymmetry greater than 2 mm, which in both cases was due to lack of frontalis activation by the patient secondary to ongoing visual impairment. The most common complication was lagophthalmos in 6 eyes (35.3%), with no significant associated surface keratopathy.

Conclusions: 

The frontalis muscle flap technique may offer a new and effective approach to treating infants with severe congenital ptosis causing poor eyelid excursion and associated amblyopia while avoiding use of an implant.

Adjustable Ptosis Correction via Posterior Levator Advancement With Minimal Superior Tarsectomy

Tran, Ann Q. M.D; DeMaria, Lauren N. M.D; Nair, Archana A. M; Tooley, Andrea A. M.D; Godfrey, Kyle J. M.D; Lisman, Richard D. M.D., F.A.C.S.

Abstract

Purpose: 

To report the surgical technique and outcomes for adjustable ptosis correction using a posterior levator advancement with minimal superior tarsectomy.

Methods: 

A retrospective single-center study was conducted on patients who underwent adjustable ptosis repair via posterior levator advancement with minimal superior tarsectomy by a single surgeon from 2002 to 2018. Patients with greater than 1 mm asymmetry between eyes or contour abnormalities underwent nonsurgical adjustment in the office within 6 days of surgery.

Results: 

A total of 79 patients (146 eyelids) were included in this study. The patients were female (67%), underwent bilateral surgery (87%) with mean age of 63 years (range, 20–۹۲). The mean improvement in marginal reflex distance 1 at postoperative month 1 was 2.56 ± ۱.۰۴ mm (p ≤ ۰.۰۰۰۱). Postoperative symmetry of 1 mm or less between eyes was achieved in 96.6% of patients. Only 8 eyes (5.4%) underwent in-office adjustment postoperatively. No demographic or clinical differences were noted in eyes that required adjustments. Postoperative complications included dry eyes that resolved by 3 months (13.6%), suture cyst (1.4%), corneal abrasion (1.4%), and persistent eyelid edema (1.4%). Surgical revision was required in 2.8% of eyes.

Conclusions: 

The adjustable posterior levator advancement with minimal superior tarsectomy is an effective surgical technique for ptosis repair with the added benefit of in-office adjustability to correct minor asymmetries.