Ocular Manifestations of Cutaneous Rosacea
Coauthors: Cristina DUCASSE; Dolores SALDUNA; Andrea PICCO

Abstract:
PURPOSE: To study the ocular manifestations of rosacea in the different clinic stages of the dermatologic disease.
METHODS: A total of 153 patients were registered in this prospective study between November 2002 and November 2004, in Hospital Privado of Córdoba. Criteria of dermatologic and ophthalmologic clinic diagnosis were established and the patients were classified according to the four stages of the disease. The patients underwent complete dermatologic and ocular examinations, test of Tear break-up time and Schirmer test.
RESULTS: The age at presentation ranged between 18 and 82 years (mean 54 years). Cutaneous manifestations of rosacea were present in 130 patients (85%) and ocular manifestations were present in 23 patients (15%), but in this case, without cutaneous lesions.
The dermatologic staging for our patients was as follows: stage I: 32 patients (21%); stage II: 50 patients (33%); stage III: 31 patients (20%); stage IV: 8 patients (5%). Five patients (3%) had corticosteroid-induced rosacea and 4 patients (2.6%) had edematous rosacea.
In all evolutionary stages of dermatologic rosacea and its different variants, the most frequent ocular symptoms were: foreign body sensation (61 patients, 39%), dryness (61 patients, 39%) and irritation (64 patients, 42%); and the most common signs were: meibomian gland dysfunction (146 patients, 95%), blepharitis (122 patients, 80%) and telangiectasia and irregularity of lid margins (84 patients, 55%). One patient of stage IV presented corneal thinning and perforation.
Patients with severe ocular and cutaneous signs had a significantly shorter Tear break-up time and lower Schirmer test.
CONCLUSIONS: Rosacea is a common disease involving the skin and the eyes. The results of our study suggest that all patients with cutaneous rosacea had some degree of ocular involvement, and that the major and most easily observable ocular problems are lid disease related manifestations. Correlation between severity of cutaneous disease and ocular disease was evident. Therapeutic recommendations should be based on evaluation of both the eyes and the skin.

Endonasal Endoscopic Dacryocystorhinostomy (DCR) with Mitomicyn C and Endonasal Tube
Coauthors: C. BIANCIOTTO (1,2); J. HINCAPIE (1,2); J. SANTOS (1)
(1) Oculoplastic Unit., Instituto Univ. Oftalmobiología Aplicada (I.O.B.A.), University of Valladolid (Valladolid, Spain); (2) Fundación Carolina Postgraduate Master

Abstract:
PURPOSE: To present a series of endoscopic endonasal DCR with endonasal tube.
METHODS: Patients treated with endonasal DCR from April 2002 to November 2004 were reviewed. Clinical relevant information was registered including age, gender, laterality, preoperative symptoms, associated findings, date of surgery, length of time with Crawford tubes, complications, follow up, postoperative exams and clinical result.
RESULTS: Nineteen patients (21 eyes) were treated (age rage 40 to 82, mean 57.9 years); 15 women and 4 men, 10 right eyes and 11 left eyes and (two patients were treated both eyes). The predominant symptom was epiphora. Five patients had previous lacrimal surgery (1 patient with facial palsy, three previous failed external DCR and one failed endoscopic DCR). Six primary cases presented with acute dacryocystitis. Mitomycin C 0,04% was applied in the osteotomy site intraoperatively for five minutes and a latex endonasal tube was combined with Crawford tubes. Tubes were kept in place for an average time of 3 months. The average postoperative examinations were 5 (3-8); average follow up time was 10.3 months (2-22). One case was converted to external DCR. A complete resolution of the symptoms was obtained in 18 cases (14 primary and 3 secondary). Two lacerations of the lacrimal punctum were registered due to tension tubes; three conjunctival irritations and two prolapses of Crawford tubes.
CONCLUSIONS: Endoscopic endonasal DCR with mitomycin C and endonasal tube is an effective technique for both primary cases with acute and chronic dacryocystitis and secondary cases with previous lacrimal surgery. The favourable clinical outcome with better cosmesis and less postoperative morbidity than the external approach should prompt to consider this technique as the procedure of choice for inferior lacrimal blockage conditions.
KEY WORDS: Endoscopy, dacryocystorhinostomy, mitomycin.

Suspension Made with Amniotic Membrane: Clinical Trial
Coauthors: Paolo BONCI, MD, PhD; Antonino LIA, MD
Dept. of Ophthalm., Eye Bank, S. Maria della Scaletta Hospital (imola (BO), Italy)

Abstract:
PURPOSE: To investigate if a suspension made with amniotic membrane could have a beneficial effect on ocular surface diseases.
METHODS: in the Imola branch of the Eye Bank of Emilia Romagna, we prepared a suspension containing homogenized amniotic membrane previously conserved at –80 degrees Celsius. Subsequently we gave this preparation to 31 patients 18 of which, had been operated on for lamellar keratoplasty, 4 operated on for penetrating keratoplasty, 2 photorefractive keratectomy (PRK), all with a delay of epithelialization; 3 neurotrophic corneal ulcers; 2 corneal burning, 1 torpid corneal ulcer, 1 Sjogren syndrome. Each patient had been treated with conventional therapy for at least, 6 months without any clinic improvement. In this sample of eyes we evaluated the transparency and integrity of epithelium, before and after the therapy also by means of the evaluation of fluorescein staining in corneal lesions , as well as the flogistic situation and the symptoms referred by patients. Nine eyes from this group of patients were studied by impression cytology before and after 3 months of use of suspension. The follow-up was of 7 months with an eye visit once a week.
RESULTS: In all the patients just after 15-30 days the corneas became negative to fluorescein test and the epithelium seemed more complete and regular, there was an evident decrease of flogistic situation also in the conjunctiva, and an improvement of symptoms referred by patient. The situation was stable during the whole follow-up. No side effects. The impression cytology repeated three months after the treatment showed a significant corneal recovery of the cytological situation with an important decrease of CK19+ cells on the corneal surface.
CONCLUSIONS: Patients with corneal superficial defects could be also cured with this new therapy which is less traumatic than an implant of amniotic membrane, it is safe and it can be repeated for a long period.

Bicanalicular Intubation for Congenital Nasolacrimal Duct Obstruction
Coauthors: P. KOMINEK; P. MATOUSEK
Ophthalmologic Clinic (Otrokovice, Czech Republic); Dept. of Otolaryngology (Frydek-Mistek, Czech Republic)

Abstract:
INTRODUCTION: Congenital nasolacrimal duct obstruction (CNDO) symptoms occur in up to 6% of infants. The management of CNDO has always been controversial. Some authors advise a short conservative treatment with early probing in babies up to 1 month old, while others recommend late probing, when the infant is more than 12 months old. If the first and second probings fail and the symptoms are still present, nasolacrimal duct intubation is indicated.
METHODS: After checking with a Bowman probe the metal probes of the intubation set is introduced into the lacrimal pathways through the upper and lower canaliculi. A special titanium loop is used to remove of the probes from the inferior nasal meatus. The intubation is then finished by tying as knot in both silicone tubes and placing the knots into the inferior nasal meatus. All bicanalicular intubations are performed under general anaesthesia and under endoscopic control. The silicone tube is removed under local anaesthesia in accordance with the Fluorescein Dye Disappearance test results and CNDO symptoms.
RESULTS: 526 bicanalicular intubations have been performed in the period between July 2000 and July 2004 on 388 children. The average age was 12,6 months (ranging from 5 months old to 12 years). The silicone tubes were removed after 3,1 months on average (ranging from 1 - 12 months) with a 95,3% success rate.
CONCLUSIONS: Bicanalicular silicone intubation for CNDO under endoscopic control is an effective surgical procedure in cases where conservative treatment and secondary probing have failed. Ophthalmologist and otolaryngologist collaboration is very useful and increases the possibilities of lacrimal drainage system surgery.
References:
1. HURWITZ, J.J.: The Lacrimal System. 1st ed. Philadelphia: Lippincott Raven Publ., 1996
2. McNAB, A.A.: Manual Orbital and Lacrimal Surgery. 1st ed. Edinburg: Churchill Livingstone, 1994
3. OLVER, J.: Colour Atlas of Lacrimal Surgery. 1st ed. Oxford: Butterworth-Heinemann, 2002
4. KOMINEK P., CERVENKA S., MÜLLNER K.: Nemoci Slznych Cest (The Lacrimal Drainage System Diseases). 1st ed. Praha, Czech Republic: Maxdorf, 2003

DOGRU, Murat
Tokyo Dental College. 5-11-13 Sugano. Ichikawa-Shi - 272-8513 CHIBA (JAPAN)
Phone: (+81) 473226781 - E-mail: muratodooru@yahoo.com

Changing Perspectives in the Definition and Diagnosis of Dry Eye. The Tentative Recommendation of the 2004 Dry Eye WorkShop (DEWS) Meeting
Coauthors:M. STERN; J. SMITH; G. FOULKS; A. BRON; P. PFLUGFELDER; M. LEMP; K. TSUBOTA and the 2004 Dry Eye Workshop (DEWS) Committee Members 9

Abstract:
PURPOSE: The Dry Eye Workshop (DEWS) was a follow up meeting to the National Eye Institute/Industry Workshop on Clinical Trials in Dry Eyes. The1995 report from the initial workshop meeting, reported a definition of dry eye and a classification system of dry eyes. This report has been widely adopted and has formed a framework for much of the clinical research performed over the last ten years. There is, however, recognition that our knowledge base has been broadened extensively with improved diagnostic technology related to tear osmolarity, tear stability measurements and new biomarkers such as adhesion molecules, cytokines and aquaporins. Diagnostic definitions, protocols and sequencing of clinical testing still varies throughout the world. The 2004 DEWS aimed to establish a contemporary, internationally accepted definition and classification of dry eye, and outline current thinking on the design of clinical trials in dry eye.
METHODS: A group of internationally recognized experts has been invited to discuss the topics concerning dry eye research. The DEWS group has held a preliminary meeting and three committees have been formed; the tear film, the ocular surface, and symptoms. Several keynote addresses summarized the state of knowledge in key areas. A preliminary agenda for discussion of each committee was created and subgroups have prepared detailed information on dry eye knowledge which accumulated in the literature over 10 years. After each committee has prepared its report, the group as a whole met and prepared a tentative report which will be finalized at the 2005 DEWS follow up meeting.
RESULTS: The final report will include a new definition and classification of dry eye, a critique of current and new diagnostic methodologies with recommendation for their incorporation into clinical trial design and endpoints.
CONCLUSIONS: The current presentation will focus on the tentative recommendations of the 2004 DEWS. The final report of DEWS will pave the way for a better understanding of the pathogenesis of dry eye, evaluation of treatment responses and direction for future clinical trial design.

DOGRU, Murat
Tokyo Dental College. 5-11-13 Sugano. Ichikawa-Shi - 272-8513 CHIBA (JAPAN)
Phone: (+81) 473226781 - E-mail: muratodooru@yahoo.com

Kinetic Analyses of the Ocular Surface and Tear Functions
Coauthors:E. GOTO; T. KOJIMA; R. ISHIDA; M. KAIDO; S. MEGUMI; K. TSUBOTA

Abstract:
PURPOSE: Recent advances in dry eye diagnostic technologies such as the tear stability analyses system (TSAS) and the DR-1 tear film lipid layer interferometry generated extensive interest related to the dynamic evaluation of tear functions. The impact of dynamic tear film changes on visual acuity can also be assessed in a kinetic manner owing to developments of a new dynamic visual acuity assessment system called the "Functional Visual Acuity Meter". We aimed to measure the tear stability dynamically in dry eye subjects by the aferomentioned diagnostics and evaluated the effect of tear stability on kinetic visual acuity in dry eye patients and healthy control subjects.
METHODS: Examinations using the FVAM system were conducted in 35 eyes of 20 healthy controls and 19 eyes of 13 dry eye patients. Tear function examinations including TSAS, DR-1 lipid layer interferometry, Schirmer test, tear film break-up time, fluorescein and Rose Bengal staining were performed in all subjects. Functional visual acuity and tear functions were also examined before and after insertion of punctum plugs (PP) in dry eye patients. Functional visual acuity results at 10, 20 and 30 seconds were compared.
RESULTS: Functional visual acuity in dry eyes were significantly lower than control subjects at all time points (p <0.05). Functional visual acuity after PP insertion improved significantly at all time points (P <0.05). Likewise, tear stability indices measured with TSAS such as SRI and SAI fared significantly worse in dry eye subjects compared to controls and improved significantly with PP insertion (P <0.05). DR-1 interferometry grades revealed similar findings.
CONCLUSIONS: TSAS and DR-1 systems were observed to be useful in the diagnosis of tear stability and functions in dry eye syndromes and evaluation of treatment responses. FVAM system also seemed not only to be an effective tool in the assessment of dynamic visual acuity changes in dry eye and normal subjects but in evaluating the outcome of management of dry eye disease by punctum plugs.

Arterial Vascularisation of the Lacrimal Gland
Coauthors: M. LABROUSSE; J.F. DELATTRE

Abstract:
The authors report the results of one hundred dissections of human cadavers which have been injected by red neoprene latex.
There are two types of lacrimal artery: a classical lacrimal artery from the ophthalmic artery which has usually a diameter between 0.3 to 1.8 millimeters (average 0.99). This classical lacrimal artery has been found in 83 orbits. This artery receives frequently an anastomosis coming from the middle meningeal artery (54%). Usually, it supplies the lateral rectus and superior rectus muscles and the levator.
The second type is a meningo-lacrimal artery which comes from the middle meningeal artery. We found this meningo-lacrimal artery in twenty seven orbits. Its diameter is less small: 0.3 to 1.5 millimeters (average of 0.73). It supplies less frequently the muscles and they are more frequently found when the ophthalmic artery crosses the optic nerve under. In this case, there is frequently a lateral muscular artery which supplies the lateral rectus muscle.
So it is possible to describe three types of vascularisation of the lacrimal gland: type one: lacrimal artery alone coming from the ophthalmic artery: 73%; type two: meningo-lacrimal artery alone: 17% and type three: two lacrimal arteries: one from the ophthalmic artery, the other from the middle meningeal artery: 10%. In this case, there is an anastomosis between the two carotidian system into the lacrimal gland.

Acute Dacryocystitis: Epidemiology, Evolution and, Treatment
Coauthors: J.C. MEROL; F. BEKOIN

Abstract:
The authors report the epidemiological caracteristics of patients with acute dacryocystitis between 2000 and 2004.
There were 71 patients with predominance of women (three fourth for the women, one fourth for the men). The age was between 0 to 95 years. Usually the treatment is generally antibiotics and anticoagulants. In most cases lacrimal abcess involves treatment and a surgical treatment is radically performed between three weeks or two months later: dacryo-cysto-rhinostomy external or endonasal.
The results of this group of patients is reported.

Confocal Microscopy of the Corneal Epithelium in Dry Eye Patients
Coauthors: R. KRAAK (2); R. GUTHOFF (2); J.NEMETH (1)
(1) Ist Department Ophthalmology, Semmelweis University, (Budapest, Hungary); (2) Universitäts Augenklinik, Rostock

Abstract:
AIM: Quantitative investigation of the corneal epithelium in dry eye patients.
SUBJECTS: Nineteen eyes of 18 dry eye patients (12 females, 6 males, mean age: 64.1±8.2 years) and 9 age matched control subjects (5 females, 4 males, mean age: 64.6±12 years) were examined in this study.
METHODS: Standard dry eye tests were performed in each subject (Schirmer I test, BUT, and ocular surface staining with fluorescein). For confocal microscopic investigation the Rostock Cornea Module of the Heidelberg Retina Tomograph (Heidelberg Engineering GmBH) was used. The field of view provided by the objective was 300x300 microns. Images were acquired from the centre, the lower and upper periphery of the corneas. Analysis included cell density of the superficial-, intermediate- and basal epithelial cell-layers, the measurement of epithelial thickness and the morphological examination of the subepithelial nerve plexus
RESULTS: The mean superficial epithelial cell density was lower in the dry eye group than in the normal subjects (873 and 1111cells/mm2). The epithelial thickness at the centre, lower periphery and upper periphery was 49.7, 54.0 and 52.1 microns in dry eyes; and 53.4, 61.2 and 59.4 microns in normal subjects respectively. We also found morphological changes of the subepithelial nerves in some of the dry eye patients.
CONCLUSIONS: It is important to introduce objective measures in the diagnostics of dry eye. Most of these give information only about the tear-film and do not describe the state of the cornea. In the present study changes in the superficial epithelium, the subepithelial nerve plexus and the epithelial thickness were observed in dry eye patients.

Abstract:
PURPOSE: To study which of this well-known dry eye surveys may be a better diagnostic tool as part of the pre-fitting evaluation for contact lenses.
METHODS: In this small study, 15 cases (3 keratoconus, 5 post-LASIK and 7 iatrogenic ectasias) were screened using the McMonnies questionnaire, and the OSDI (ocular surface disease index) test translated into Spanish as part of the pre-fitting protocol for contact lenses. At the moment of the examination, all patients were wearing glasses. After the fitting, with an average of three months, these tests were repeated and compared.
RESULTS: The OSDI showed a higher dry eye index than the McMonnies questionnaire before and after the fitting. With the McMonnies, 10 cases were assessed as normal and 5 as marginal dry eye (average index 8.2 with standard deviation of 5.87). With the OSDI none cases were assessed as normal, 6 cases as mild, 4 as moderate, and as 5 cases were classified as severe (OSDI average 48.72, standard deviation 23.75). After three months of contact lens wearing, the McMonnies scores were slightly lower (average 7.5, standard deviation 4.76), but the OSDI test showed a dramatic decrease in symptoms. Ten patients were recorded as normal, 3 as mild and two as moderate (average 12.96, standard deviation 13.41). Correlation coefficient with the McMonnies test between pre-fitting and post was 0.948 and with the OSDI 0.6577.
CONCLUSIONS: Although both tests are well known as dry eye symptom questionnaires this study showed that the OSDI is also dependant of other factors related to vision that can be solved with a better quality of vision i.e. a contact lens fitting. The OSDI might tend to estimate the degree of dryness while the McMonnies showed dry eyes. Dryness as a symptom might not always mean dry eye.

Keratoconjunctivitis Sicca in Patients after Allogeneic Haematopoietic Stem Cell Transplantation
Coauthors: Johannes NEPP, MD (1); Margit MITTERBAUER, MD (2); Hildegard GREINIX, MD (1); Andreas WEDRICH, MD (1)
(1) Univ. Clinic of Ophthalm. & (2) Dept. of Internal Med., Medical Univ. Of Vienna (Vienna, Austria)

Abstract:
Haematopoietic stem cell transplantation (HSCT) is the treatment of choice for many haematological disorders and can cause severe ocular diseases. The purpose of our study was to evaluate the incidence of dry eye syndrome and other ophthalmologic complications in patients after HSCT, with particular attention to the occurrence of chronic graft-versus-host disease.
We conducted a prospective study with eight patients (mean age 39 years, IQR 35-42), who underwent a full ophthalmologic examination before and after allogeneic HSCT. The median observation time was 109 days (IQR 103-130).
Dry eyes were staged using a sicca score, estimated by following examinations: Schirmer test, break-up-time, lipid layer thickness, fluorescein staining, rose bengal staining, impression cytology, LIPCOF, and subjective condition.
The major ocular complication after HSCT was the development of keratoconjunctivitis sicca with a statistically significant difference of the sicca score before and after HSCT (p= 0.033). Other ocular findings were bilateral optic disc oedema, retinal bleeding, amaurosis fugax, temporarily visual impairment during chemotherapy, facial nerve paresis, and uveitis.
No correlation was found between the sicca score and age, acute GVHD, chronic GVHD, or grade of GVHD.
In conclusion, the abundance of observations of ocular complications after HSCT even in this small sample of patients emphasizes the importance of further investigations and routine ophthalmologic screening and care.

Bilateral Programmable Infusion Pumps Implanted in CREST Syndrome
Coauthors: J. DE ANDRES; P. UDAONDO; M. SERRANO; M. DIAZ-LLOPIS; D. SALOM; M. GARCIA-POUS; L. AMSELEM; A. PEREZ; M. HERNANDEZ

Abstract:
PURPOSE: We present one patient with severe dry eye secondary to a CREST syndrome treated with a bilateral programmable artificial tear pump, to achieve a continuous artificial tear infusion with daily and nightly tear flow fluctuations.
METHODS: Using Murube’s technique we implanted two pumps in the abdominal region, conected to the conjunctival superior sac of both eyes by a silicone tube.
RESULTS: No intraoperative nor postoperative complications were observed. The reservoir and the silicone tube was well tolerated and the patient experimented a dramatical improve of dry eye signs and symptoms after the surgery.
CONCLUSIONS: To our knowledge this is the first time that a bilateral programmable infusion pumps has been implanted to treat a dry eye secondary to a CREST syndrome. It has been a safe and effective procedure for our patient.

Dietary Omega-3 Fatty Acid Intake and Risk of Clinically Diagnosed Dry Eye Syndrome in Women
Coauthors: Biljana MILJANOVIC, MD, MPH, MS; Komal A. TRIVED, MDI; M. Reza DANA, MD, MPH; Julie BURING, ScD; Debra A. SCHAUMBERG, ScD, OD, MPH
Depts. Of Medicine & Ophthalm., Brigham and Women’s Hospital, and Schepens Eye Research Institute, Harvard Medical School (Boston, MA)

Abstract:
PURPOSE: To determine the association between dietary intake of omega-3 fatty acids and the ratio of omega-3 to omega-6 fatty acids and risk of dry eye syndrome (DES).
METHODS: A total of 32,470 female health professionals aged between 45 and 84 years who provided information on diet and DES were chosen from the 39,876 women participating in the Women’s Health Study. Intake of omega-3 fatty acids was assessed by a validated food frequency questionnaire. DES was assessed using self-reports of clinically diagnosed DES. We used logistic regression models to estimate the odds ratios (OR) and 95% confidence intervals (CI) to describe the relationships of omega-3 fatty acid intake and DES. We also analyzed the relationship between consumption of fish and DES in a similar way.
RESULTS: After adjusting for age, other demographic factors, postmenopausal hormone therapy, and total fat intake, the OR (CI) for the highest versus the lowest dietary intake of omega-3 fatty acids was 0.83 (0.70-0.98), P for trend=0.04. In addition, we observed a significant association between tuna fish consumption and DES (OR=0.82, CI=0.67-1.00 for 2 to 4 servings/week, and OR=0.34, CI=0.13-0.81 for 5 to 6 four-ounce servings/week versus <2 servings/week: P for trend=0.004). Results were similar in other models additionally controlling for diabetes, hypertension, and connective tissue diseases.
CONCLUSIONS: These results suggest that women with a higher dietary intake of omega-3 fatty acids are at decreased risk of developing DES. Although this is the first study that has evaluated this relationship, and confirmation from other studies is needed, the findings are consistent with clinical observations and postulated biological mechanisms.

Lacrimal Drainage System Endoscopy: Our Technique and Results
Coauthors: C.M. VALAZZI; S. CECCHINI

Abstract:
PURPOSE: To describe the technique used for the exploration of the lacrimal drainage system under local anesthesia and to present the results after 2 years.
METHODS: The authors describe the device, the probes and the method used, emphasizing its indications and limits. This technique, developed by Prof. J.M. Piffaretti and modified by Dr. C.M. Valazzi, allows the direct visualization of the lacrimal pathology and in a good percentage of cases even the resolution of lacrimal drainage system stenosis and obstructions by endoscopic surgery.
RESULTS: The endoscopic method presents important advantages: 1.- pathologies can be visualized and often solved without general anesthesia and without hospital admission; 2.- it’s the only method that allows us to directly see the cause of the obstruction and understand the reason for previous failures; 3.-the absolute respect of the lacrimal drainage system anatomy.
CONCLUSIONS: The lacrimal pathways endoscopy results to be a valuable method for the diagnosis and the therapy of Lacrimal drainage system obstructions, even if not all the cases can be solved by this technique; the authors discuss the cases more suitables for being treated by endoscopy. Besides if the endoscopic recanalization is not achieved, it is still possible the subsequent use of conventional surgery.
Key words: Lacrimal drainage system endoscopy, recanalization, endoscopic surgery.

GÓMEZ FERNÁNDEZ, Teresa
C/. Ana Teresa, 24 - 28023 MADRID (SPAIN)
Phone: (+34) 913571522 - E-mail: incivi@incivi.com
Topics: 02. Lacrimal system surgery

Endonasal Dacryocystorhinostomy
Coauthors: Pablo ZARAGOZA CASARES; Miguel A. ZATO GOMEZ DE LIAÑO

Abstract:
PURPOSE: Compare post-operative results ot this surgical tecnique versus the external approach.
METHODS: We operated 83 eyes (52 patients) under general anesthesia since 1999. Patientes before surgery were examined at the otolaryngologist clinic to rule out any nasal pathology and the necessity of performed a combined procedure to correct it. Surgery was ambulatory in all the cases and intubation of the lacrimal system was done by using a set of silicone tubes. Patientes were examined at the clinic by a team of an ophthalmologist and a otolaryngologist a week and month later.
RESULTS: The follow-up period was of 5 years. We have to reoperate 3 cases, 2 of them due to the obstruction after the removal of the silicone tubes and the other for probe entraptment at the scar of the nasal mucosa. Tubes are removed after 3 months and patients are seen at the clinic every three months during the first year.
CONCLUSIONS: This technique provides a better post-operative nasal assessment, is less invasive, since does not requires the skin aperture and respects the medial canthal tendon.

Amniotic Membrane for Ocular Surface Reconstruction after Surgical Escision of Conjunctival Tumors
Coauthors: C. BIANCIOTTO (1, 2); M.C. MENDEZ (3); M.A. SAORNIL (3); G. BLANCO (2, 3)
(1) Fundación Carolina Postgraduate Master; (2) Oculoplastic Unit, Instituto Univ. Oftalmobiología Aplicada (I.O.B.A.), University of Valladolid (Valladolid, Spain); (3) Ophthalmic Pathology Laboratory, Miguel N. Burnier Registry of Pathology, Instituto Univ. Oftalmobiología Aplicada (I.O.B.A.), University of Valladolid (Valladolid, Spain)

Abstract:
PURPOSE: To study the efficacy of amniotic membrane transplantation in reconstruction of ocular surface after surgical escision of conjuntival tumors.
METHODS: Amniotic membrane transplantation was used in six patients after surgical removal of different conjunctival tumors including extensive malignant melanoma (1), malignant melanoma from primary acquired melanosis (1), conjunctival nevus (1), primary acquired melanosis with atypia (1), actinic keratosis (1) and epithelial dysplasia (1).The grafts were sutured to the margins of the surface defect.
RESULTS: Six patients were treated (age range 17-65 years). All patient were female. Adjunctive cryotherapy was used in two patients. An adequate result was obtained in all cases with a rapid postoperative recovery. One patient with extensive conjunctival escision develop a minimal symblepharon formation.
CONCLUSIONS: The amniotic membrane should be considered an adequate alternative for conjunctival surface reconstruction after removal of conjunctival tumors.
KEY WORDS: Amniotic membrane, conjunctival tumors, ocular surface, reconstruction.

Surgical Management of Canaliculitis
Coauthors: C. BIANCIOTTO (1, 2); M.C. MENDEZ (3); M.A. SAORNIL (3); G. BLANCO (2, 3)
(1) Fundación Carolina Postgraduate Master; (2) Oculoplastic Unit, Instituto Univ. Oftalmobiología Aplicada (I.O.B.A.), University of Valladolid (Valladolid, Spain); (3) Ophthalmic Pathology Laboratory, Miguel N. Burnier Registry of Pathology, Instituto Univ. Oftalmobiología Aplicada (I.O.B.A.), University of Valladolid (Valladolid, Spain)

Abstract:
BACKGROUND: Primary canaliculitis is an uncommon disease usually caused by Actinomyces israelii. The most relevant clinical features include unilateral conjunctivitis, mucopurulent discharge, swollen eyelid in the area of the affected canaliculus and dacryolites in some cases. Treatment options are topical antibiotics, antibiotic or antiseptic irrigation and surgical debriment.
METHODS: Patients with clinical diagnosis of canaliculitis were studied retrospectively. Gender, age, duration of symptoms, treatment, histopathologic findings and clinical outcome were registered.
RESULTS: Four females and one male (age range 42 - 76 years) were included in the study. All cases presented with more than six months of symptoms, two cases presented mucopurulent discharge and pain in the area of the affected canaliculus, two cases complained of red eye and swelling of the canaliculus, one case presented with epiphora. Cultures of the canaliculus discharge were negative in four patients and only one patient demonstrated staphylococcus spp growth. Four patients were surgically treated after failure of medical treatment with canaliculostomy and surgical removal of canalicular concretions. Histopathologic study of canalicular concretions revealed bacterial accumulation suggestive of actinomyces. All four patients had resolution of symptoms after surgical treatment.
CONCLUSIONS: Surgical treatment of canaliculitis is a safe and efficacious treatment of this rare infectious problem after failure of medical treatment allowing for histopathologic confirmation of the disease.
KEY WORDS: Canaliculitis, actinomyces.

HÖH, Helmut
Pfaffenstrasse 24 - D17033 NEUBRANDENBURG (GERMANY)
Topics: Dacryology

Lid-Parallel Conjunctival Folds (LIPCOF) Are a Definite Sign of Dry Eye
Coauthors: F. SCHIRRA; F. KIENECKER; K.W. RUPRECHT

Abstract:
Dry eye is a disease that is becoming increasingly important for the ophthalmologist. Very different symptoms lead to significant disturbance in the three layers of precorneal film. This disturbance of their equilibrium causes various pathological changes in the ocular surface. As well as case histories and clinical findings, various clinical tests and laboratory procedures can be used to confirm the diagnosis. Nevertheless diagnosis is problematic, as there is no specific test for sicca syndrome. We looked at the value of the lid-parallel conjunctival fold (LIPCOF) with regard to diagnosis of "dry eye". In this presentation we describe and classify LIPCOF stage 0 to stage 3, and investigate its relationship to the severity of dry eye. Dryness is determined by the "sicca score", a scale ranging between 0 and 12 based on a broad spectrum of tests, including the Schirmer I test and tear film break-up time, Rose bengal and fluorescein staining, the lysozyme test and impression cytology. In this prospective study we examined one eye in each of 267 patients, assigning them to one of two groups based on the absence or presence of LIPCOF. These two groups are comparable in gender and age (group matching). Statistical analysis of data showed a negative predictive value of 75.95% and a positive predictive value of 93.09% for the diagnosis of dry eye, using LIPCOF. There was a close correlation between LIPCOF and the patient´s medical history and slit lamp findings. LIPCOFs can be classified easily and quickly by the slit lamp. They are a dependable diagnostic sign of dry eye. Observation and classification of LIPCOF increase and facilitate diagnosis of dry eye syndromes by the ophthalmologist.

The Long-Lasting Dilemma of the Dry Eye
Dry Eye Institute (Yantis, TX)

Abstract:
The ocular surface disease, and its most common form the "dry eye", is a serious health problem world-wide. Despite intensive research efforts in the past few decades employing the most modern methods available we have not made a significant progress in the understanding of the disease. What we have now is myriad pieces of disjointed information on the complicated life processes that may or may not control the homeostasis of the ocular surface and its vitally important refractive and protective layer, the preocular tear film. Since a clear-cut directive and basic understanding are now lacking at the research level it is no wonder that ignorance and confusion exists at the "trenches" as shown by the quality of care the dry eye patients at the clinics and offices receive. Not only this care has not improved, the rapidly growing refractive surgery in the past decade years is steadily contributing to the number of moderate to severe dry eye patients. Careful analyses of the present dogmas indicate that there are certain plausible beliefs strongly held by their proponents and followers that are not justified by rational thinking, although some may have a plausible appeal. By replacing such fashionable beliefs with a scientifically sound rationale rapid progress could be experienced in the field. Such an understanding would immediately provide criteria by which the critical components and their properties could be predicted and techniques devised to identify those which have such properties. One then could focus more on the functional components and speculate more fruitfully on the mechanism of their role. Such an approach would also eliminate most of the guesswork that presently exist in the formulation of collyria. Basically sound scientific rules and guidelines will be suggested to improve the present, logically weak, system. Proof in the form of cllinical and laboratory examples will be offered to demonstrate that this approach not only works but actually simplifies the understanding of the complex lacrimal system and enable the researcher to direct present research efforts into more productive channels.
350 words 20 minute panel talk.
Microsoft Powerpoint slide show.

Abstract:
PURPOSE: To describe Endoscopic Radiofrequency-Assisted Dacryoplasty in restoring the passage of tears in an obstructed lacrimal drainage system in patients with complete Primary Acquired Nasolacrimal Duct Obstruction (PANDO) and to compare the efficacy of this procedure with that of the Standard External Dacryocystorhinostomy.
METHODS: Patients with complete Primary Acquired Nasolacrimal Duct Obstruction were randomly allocated to two treatment groups using completely randomized design. Group 1 were treated using Endoscopic Radiofrequency-Assisted Dacryoplasty; while group 2 were treated using Standard External Dacryocystorhinostomy. Patients were then followed up for at least 3 months and evaluated for anatomic and functional patency. Complications were also noted for both procedures.
RESULTS: Twenty out of 20 cases who underwent Endoscopic Radiofrequency-assisted Dacryoplasty were patent on irrigation (100% anatomic patency). At 3 months post operatively, 19 out of 20 cases were relieved of pre operative signs and symptoms of tearing (95% functional patency). In contrast, 19 out of 20 cases who underwent Standard External Dacryocystorhinostomy achieved 95% anatomic and functional patency. Only minor and no major complications occured during and after the Endoscopic Radiofrequency-Assisted Dacryoplasty consisting of a hematoma or edema of the surrounding soft tissues. While, peri-orbital bruishing and post operative hemorrhage were observed in 2 cases who underwent Standard External Dacryocystorhinostomy.
CONCLUSIONS: Endoscopic Radiofrequency-Assisted Dacryoplasty is as efficacious as Standard External Dacryocystorhinostomy with less major complications.

Ho: YAG LASER Lacrimal By-pass Surgery with PVP Coated Silicone Tubes
Coauthors: Ömer FARUK YILMAZ
Beyoglu Eye Research Hospital (Istanbul, Turkey)

Abstract:
PURPOSE: To evaluate the efficacy of lacrimal by-pass surgery where PVP coated silicone tubes were used to keep the patency of the conjunctivorhinostomy instead of Pyrex tubes.
METHODS: 10 patients who had severe trauma to the lacrimal canaliculi and sac of the affected eye were included in this study. All patients underwent Ho:YAG LASER assisted lacrimal by-pass surgery. Laser energy between 6 to 10 Watts was delivered via a 500 micron fiberoptic probe, to ablate the soft tissue and bone and thus create a tunnel shaped anasthomosis between the semilunar caruncle and the nasal cavity. PVP coated silicone tubes (Metaireau tubes,FCI ophtalmics,Cedex France) were inserted into the tunnel to keep the anasthomosis open. All the tubes were trimmed in the nose to the appropriate length and anchored to the caruncle with 7/0 nylon suture. Patients were followed up for relief of epiphora postoperatively between 24 to 58 months (mean follow-up time: 35 months).Patient satisfaction and complaints were also evaluated.
RESULTS: Epiphora had resolved in all patients after surgery and the tubes and carunculonasal anasthomoses were patent during the entire follow-up time. 1 patient developed a pyogenic granuloma which obstructed the proximal end of the tube in the postoperative 5th month. Epiphora recurred and konjunctivitis accompanied buth both resolved after granuloma excision. No complications related to the tubes ,such as extrusion,trauma to the medial carunculoconjunctival region or nasal mucosa, loss or migration into the nasal cavity were observed in the remaining patients.To all patients the outcome of the surgery was satisfactory, without discomfort due to either the presence or the maintenance of the tubes.
CONCLUSIONS: PVP coated silicone tubes used in Ho:YAG LASER lacrimal by-passsurgery are tolerated well by patients without serious complications, therefore can be used instead of Pyrex Jones tubes.

Conjunctivocystorhinostomy - Analysis of 100 cases
Coauthors: S. CERVENKA; P. MATOUSEK
Frydek-Mistec, Czech Republic

Abstract:
INTRODUCTION: Conjunctivodacryocystorhinostomy (CDCR) with the insertion of a Lester Jones glass tube is an effective surgical procedure used in the cases with extensive proximal canalicular obstructions.
METHODS: The CDCR consists of two steps. One step, the dacryocystorhinostomy with endonasal approach, is performed. The anterior part of the middle turbinate is resected in all cases. The other step is the closed placement of the Jones tube. The tube is inserted into the tunel between the medial canthus and nasal cavity with the help of Tiemann urologic catheter.
RESULTS: Since 1996 one hundred CDCRs have been performed for the relief of lacrimal canalicular obstructions so far. The age of cases ranged from 9 to 75 years. The complications have been found in 2/5 of the cases and the lateral migration or tube missing were the most common complications. To stabilize the tube, a suture placed around its collar through the lower eyelid can be carried out. Better functional results have been found in cases with glass tubes. The glass tubes have also been preferred to the silicone tubes, which had been used before, since 1999. Good motivation of the patients is necessary before the procedure.
CONCLUSIONS: Conjunctivodacryocystorhinostomy is an effective surgical procedure used in the cases with extensive proximal canalicular obstructions. A lot of complications (migration, misissing, tube plugging) can be found in the CDCR. Better functional results can be expected with using of glass tubes. It is recommended to have enough experience with the dacryocystorhinostomy before starting this kind of surgery.
References:
1. HURWITZ, J.J.: The Lacrimal System. 1st ed. Philadelphia: Lippincott Raven Publ., 1996, pp. 331
2. McNAB, A.A.: Manual Orbital and Lacrimal Surgery. 1st ed. Edinburg: Churchill Livingstone, 1994, pp. 99
3. OLVER, J.: Colour Atlas of Lacrimal Surgery. 1st ed. Oxford: Butterworth-Heinemann, 2002, pp. 207
4. DOTRZBACH, R.K.: Ophthalmic Plastic Surgery: Prevention and Management of Complications. 1st ed. New York: Lippincott Raven Press, 1994, pp. 448

LEMP, Michael A.
4000 Cathedral Avenue NW, apartment 828B - 20016 WASHINGTON D. C. (U.S.A.)
Phone: (+1 202) 3386424 - E-mail: malemp@lempdc.com

Abstract:
Damage to the ocular surface is the single most characteristic feature of dry eye. Recent advances in our understanding of the pathogenesis of dry eye disease and the breakdown in homeostatic mechanisms operative at the ocular surface in dry eye have enabled us to understand the roles of a number of pathological alterations in causing ocular surface damage. These alterations include: repetitive interblink dessicative assault, chronic hyperosmotic stress, inflammatory changes leading to tissue destruction, an unstable tear film and decreased lubricity between the lids and the cornea and conjunctiva. The interrelated roles of these factors will be presented and the potential for therapeutic strategies to intervene in this "zone of interaction" at the ocular surface will be developed.

LEMP, Michael A.
4000 Cathedral Avenue NW, apartment 828B - 20016 WASHINGTON D. C. (U.S.A.)
Phone: (+1 202) 3386424 - E-mail: malemp@lempdc.com

Abstract:
Dry eye is a common condition affecting hundreds of millions of people world-wide. Despite advances in our knowledge of the pathogenetic factors in dry eye, diagnostic rates are limited by the lack of a single highly sensitive and specific objective test that is practical in the clinical setting. Hyperosmolarity of the tear film is a global feature of dry eye and recent studies have implicated increased osmolarity in the pathogenesis of ocular surface damage in dry eye. Measurement of tear osmolarity has been hampered by the need for large tear samples, a lack of reproducibility and the time required to perform each measurement.
Recently a new "lab-on-a-chip" tear osmometry technology (OcuSense Tear Osmometry: OTO) has been developed. This involves a disposable microchip and requires only small tear samples which can be easily obtained with a capillary tube without inducing reflex tearing. This technology has been employed in a clinical trial. The results of this trial have demonstrated the rapidity ,ease of use,reproducibility, inter-eye variability and diagnostic utility of this test. The means of the tear osmolarity values for normals (306 milliOsm/L) and dry eye patients (334 milliOsm/L) were statistically significantly different(p=0.014). The sensitivity and specificity for the OcuSense osmometer in the diagnosis of dry eye were 94% and 84% respectively.
The OTO test appears to open the way to a new paradigm for the diagnosis of dry eye.

MAESO RIERA, José
C/. Cisterna, 2 - 08221 TERRASSA BARCELONA (SPAIN)
Phone: (+34) 937889112 - E-mail: 24024jmr@comb.es
Topics: 02. Lacrimal system surgery

Endolaser Transcanalicular Dacryocystorhinostomy: Why Can it Fail and How to Avoid it
Coauthors: M.ª T. SELLARES FABRES

Abstract:
PURPOSE: Try to determine possible failure causes in transcanalicular laser dacryocystorhinostomy and the way to avoid it.
METHODS: Among 71 eyes treated by transcanalicular laser, we have studied the cause of failure of the procedure in 11 cases, proceeding to their re-treatment and the practical solutions practiced, with simultaneous procedures in the nasal fosa.
RESULTS: 9 of the 11 eyes that have undergone a second laser treatment, with simultaneous nasal procedures, have presented a complete clinical and anatomical improvement. In all the 11 cases we have observed a closure of the nasal ostium by sinechiae between the head of the middle turbinate and the lateral nasal wall. We have solved them by a planned reduction of the turbinal head with the same laser guide.
CONCLUSIONS: The local nasal study previous to the laser treatment, and the planned simultaneous procedures on the lachrymal system and in the nose, could greatly improve anatomical and clincal results of a technique that is demonstrating its usefulness and simplicity in the management of the obstructive pathology of the lachrymal system.

MERAYO-LLOVES, Jesús
Gaztambide, 85 - 28033 MADRID (SPAIN)
Phone: (+34) 917684300 - E-mail: info@oculab.com
Topics: Dacryology

Laboratory Test in Ocular Surface Diseases (Course)
Coauthors: Sued J, Escribano N

Abstract:
OBJECTIVE: The aim of this course is to introduce to the practical ophthalmologist in the laboratory aids for the differential diagnosis of ocular surface diseases, with special stress in the diagnosis of dry eye. Understanding impression cytology, osmolarity, levels of IgA, and IgE among others, could be hepful for diagnosis and treatment decision-making.
LEVEL: Basic-Intermediate.

MURUBE, Juan
University of Alcalá. Hospital Ramón y Cajal - E28034 MADRID (SPAIN)
Phone: (+34) 917350760 – E-mail: murubejuan@terra.es
Topics: Surgery. Dacryology. Dry eye

Treatment of Dry Eye by Patching the Lacrimal Punctum with Dragged Autologous Lid Skin
Coauthors: Marcos SALES, Francisco ARNALICH, Carlos VEIGA

MURUBE, Juan
University of Alcalá. Hospital Ramón y Cajal - E28034 MADRID (SPAIN)
Phone: (+34) 917350760 – E-mail: murubejuan@terra.es
Topics: Vertical carunculo-rhinostomy. Conjunctivo-rhinostomy

MURUBE, Juan
University of Alcalá. Hospital Ramón y Cajal - E28034 MADRID (SPAIN)
Phone: (+34) 917350760 – E-mail: murubejuan@terra.es
Topics: Surgery. Conjunctivo-chalasis, conjunctival Z-plasty and YV-pasty

Effects of Tear Film Build-up and Break-up on the Total Refraction of the Eye
Coauthors: Krisztina HAGYO; Bela ERDELYI; Bela CSAKANY

Abstract:
PURPOSE: As both tear film build-up and break-up processes influence corneal topography it seems to be interesting to examine the fluctuation of the overall refraction of the eyeball in the interblink period.
METHODS: High-speed wavefront analysis (7 measurements/second) was used to follow the total refractive alterations during the first 21 seconds after complete blinks. Ten eyes of 10 young subjects with no eye disease were examined. To prevent instrument-induced myopia and spontaneous accommodation, a distant fixation target was employed.
RESULTS: In seven of the 10 subjects, the refraction was shifted towards hyperopia by 0.5 diopters in the first 3 seconds after blinking. At later times only apparently random fluctuations were found on average 0.12 diopters for spherical and spherical equivalent values, and 0.09 diopters for cylindrical values. The variability of the measurements was significantly reduced at a time approximately 6 seconds after a blink, compared to that found immediately after blinking. At later times the measurement error exhibited an increase again.
CONCLUSIONS: High-speed wavefront follow-up of the the total refraction of the eye during the inter-blink period proved a significant fluctuation both in the refraction and also in the reliability of the measurements. Based on these data, the most suitable time to perform wavefront measurements is the period after the tear film build-up has already finished, starting around at 6 seconds after the last blink but before the tear film break-up starts, around at 9-11 seconds post blink. The measurement error is the lowest in this time period.

Psychic Influence in Dry Eye Symptoms
Coauthors: Leopold LINZMAYER (2); Gebtraud SCHILD (1); Joerg SCHAUERSBERGER (1); Sibylla RICHTER-MÜKSCH (1); Andreas WEDRICH (1)
(1) Dept. of Ophthalm., Med. Univ. Of Vienna; (2) Dept. of Psychiatry, Psychodiagnostics, Med. Univ. Of Vienna (Vienna, Austria)

Abstract:
PURPOSE: To evaluate aspects of psychic problems in the dry eyes syndrome as one etiological cause.
METHODS: Patients were observed with the Freiburger Personality Inventory (FPI). This is a standardized record consisting of 12 items, like nervousness (FPI-1), aggressivity (FPI-2), depression (FPI-3), agitation (FPI-4), sociability (FPI-5), composure (FPI-6), striving dominance (FPI-7), inhibition (FPI-8), frankness (FPI-9), extroversion (FPI-E), emotional lability (FPI-M), gender feeling (FPI-N). We observed the expected changes and changes after a relaxing method (acupuncture). A double blind study was performed with 50 patients. We measured the outcome of the FPI before and after treatment and the subjective severity by an visual analogue scale (100 parted). For clinical evaluation there was a measurement of the Schirmer (I), break up time, lipid-interference and the usage of artificial tears, all calculated in a sicca score.
RESULTS: All patients had elevated FPI-scores. The Score of FPI4, N and M improved with significant difference, p<0,05. FPI 3-6-8-9 improved slightly (trend: p<0,1). The VAS -Score improved in both groups, too. The Sicca Score ameliorated with significance in the verum group, while the falsum group had only little improvements.
CONCLUSIONS: Psychic problems are present in patients with DES and relaxing methods showed improved effects on subjective condition. Therefore we propose to add the psychic troubles to the Madrid Triple Classification of Dry Eye (Neurologic §9.4).

TFF-Peptides Accelerate Healing of Wounded Cornea
Coauthors: Anne JANSEN (1); Chee-Wai WOO (3); Stefan MERGLER (4); Daniel PODOLSKI (5); Niklas BARKER (3); Kristin RECKER (2); Christian KINDLER (2); Uwe PLEYER (6); Deike VAROGA (1)
(1) Dept. of Anatomy, Christian Albrecht Univ. Kiel; (2) Dept. of Antomy&Cell Biology, Martin-Luther Univ. Halle; (3) GI Company (Framingham, MA); (4) Depts. Of Hepatology&Gastroenterology and (6) Dept. of Ophthalmology, Charité-Univ. Med. Berlin (Germany); (5) Gastrointestinal Unit., Massachusetts General Hosp. (Boston, MA)

Abstract:
The ocular surface shares many characteristics in common with other mucosal surfaces. In both, healing is tightly regulated by peptide growth factors, cytokines and extracellular matrix proteins. However, these factors are not often sufficient to ensure rapid healing. TFF-peptides (formerly P domain peptides, trefoil factors) have been established as secretory products typical of the gastrointestinal tract. Their synthesis has recently been recognized in a number of mucin-producing epithelial cells, for example, of the respiratory tract, the salivary glands, the uterus and also of the conjunctiva. They are abundantly expressed as epithelial cell products, which exert protective effects and function as key regulators of gastrointestinal epithelial restitution, a critical early phase of cell migration after mucosal injury. Recent findings showed an enhancement in corneal epithelial wound healing in vitro in the presence of the TFF-peptide, TFF3. Moreover, in vivo TFF3 is induced under certain corneal disease states like keratokonus, Fuch’s dystrophy or herpetic keratitis. To assess further the role of TFF3 in corneal epithelial wound healing in vivo, the effect of recombinant human TFF3 was evaluated in the acute corneal alkali burn and corneal epithelial laser ablation models in mice. Moreover, we tried to determine possible effects of recombinant TFF3 on intracellular calcium concentration ([Ca2+]i) in corneal epithelial cells. The in vivo results revealed a strong, dose-dependent restitution-enhancing effect of TFF3 in both models used. In vitro results showed that TFF3 induced an increase in [Ca2+]i. In conclusion, the results suggest a potential role of topical TFF3 for the management of slow healing ulcerative corneal lesions and other corneal wounds.
Supported by GI Company and Sicca Forschungsförderung

Mucins and TFF-Peptides Are a Major Components of Dacryoliths
Coauthors: Alexander FABIAN (2); Dirk EHRICH (3); Sadettin SEL (3); Kristin RECKER (1); Christian KINDLER (1); Ulrich SCHAUDIG (4)
(1) Depts. of Anatomy&Cell Biology and (3) Dept. of Ophthalmology, Martin-Luther-Univ. of Halle-Wittenberg (Halle, Germany); (2) Otorhinolaryngology, Circular Hosp. Of Pirna (Pirna, Germ.); (4) Ophthalm., Univ. Hosp. Hamburg-Eppendorf (Hamburg, Germany)

Abstract:
Lacrimal sac dacryoliths are often diagnosed during dacryocystorhinostomy (DCR), although their cause is unclear. Recent findings have shown the production of several mucins and TFF-peptides by the epithelium of the nasolacrimal ducts. The objective of this study was to determine whether dacryoliths contain mucins and TFF-peptides and therefore play a role in dacryolith formation. The presence and distribution of mucins MUC1, -2, -3, -4, 5AC, -5B, -6, -7 and -8 as well as TFF-peptides 1-3 in dacryoliths were assessed with antisera to mucin peptide cores and TFF-peptides. 26 dacryoliths from patients were analyzed. Furthermore, the expression of TFF2 in human dacryoliths was monitored by reverse transcription-polymerase chain reaction analysis.
Immunohistochemistry showed the presence of mucins MUC1, -2, -3, -4, 5AC, -5B, -6, -7 and -8 as well as all three TFF-peptides 1-3 in dacryoliths. Mucins and TFF-peptides were distributed as spotted islands throughout the dacryoliths suggesting that a mixing up of the different and TFF-peptides was lacking during stone formation. The results confirm that mucins and TFF-peptides form the major component of dacryoliths. The changed and increased production of TFF-peptides seems to have an impact on dacryolith formation as TFF-peptides, especially TFF2 which is not build in the healthy nasolacrimal system, are known to change the reological properties of mucous gels.
Supported by DFG grant PA 738/1-4

The Efficacy of Mini Monoka Silicone Tube for Treatment of Punctal Phimosis and Associated Canalicular Stenosis
Coauthors: E. LINARDOS; B.BEIGI

Abstract:
AIM: To assess the success rate of mono-canalicular insertion of a silicone tube for treatment of epiphora presenting with punctal phimosis.
METHODS and MATERIALS: Thirty six eyes of 28 consecutive patients presenting with epiphora due to punctal phimosis were examined. They all had standard probing of the canaliculi and irrigation of the nasolacrimal ducts (NLD). Regardless of the finding, under local anaesthesia, a Mini Monoka silicone tube (FCI, France) was inserted following a small single snip. It was left in the lower and common canaliculi for six weeks. At the conclusion of the study time, all patients were examined to assess and grade the size of their punctum and the improvement of the symptoms.
RESULTS: Thirty six eyes of 22 women and 6 men with the mean age of 71 (21-96) had puncto-canaliculoplasty. All had punctal phimosis. Twenty-three (64%) had canalicular stenosis, 7 (19%)had NLD stenosis and 8 (22%) had ectropion. After a mean follow up of 10 months (2-28), 34 eyes (94%) had well patent punti. Seven eyes (19%) had persistent epiphora, 81% were much improved or completely recovered (64%).
CONCLUSIONS: There is a high degree of association between canalicular stenosis and punctal phimosis. Mini Monoka tube is effective in the treatment of these two conditions simultaneously.

Bloody Discharge Due to Iatrogenic Metallic Foreign Body in the Lacrimal Sac
Coauthors: Z. TABATABAIE, MD; M.T. RAJABI, MD; A. SADEGHI, MD; A. KASAI, MD
Eye Research Center, Farabi Eye Hospital, Tehran Univ. of Medical Sciences (Iran)

Abstract:
A 19-year-old girl was seen with symptoms of intermittent tearingand bloody discharge from punctae of the left eye. She had a history of probing 15-years ego due to nasolacrimal duct obstraction. In medial canthus palpation she had induration and tenderness. Orbital radiography revealed a matalic foreign body seems to be tip of lacrimal probe. After dacryocystorhinostomy with foreign body removal she showed relief of symptoms and no recurrence of epiphora.

Repair of Canalicular Laceration with Silicone Intubation
Coauthors: Z. TABATABAIE, MD; A. SADEGHI, MD; A. SARVARIAN, MD; A. KASAI, MD
Eye Research Center, Farabi Eye Hospital, Tehran Univ. of Medical Sciences (Iran)

Abstract:
PURPOSE: To evaluate the success rate of canalicular laceration repair with silicone intubation.
METHODS and MATERIALS: In this prospective interventional case series, 65 consecutive patients underwent repair of the lacerated canaliculi with re-approximation of the overlying orbicularis, and anastomosis of the cut ends of the canaliculi, in conjunction with monocanalicular or bicanalicular silicone intubation. All patients were operated on under general anaesthesia. Stents were left in place for at least 3 months if tolerated and not complicated. Probing across the lacerated portion of the canaliculus was carried out at the time of stent removal to check the patency and was repeated 1.5 and 3 months later.
RESULTS: 65 patients completed the study. Probing showed canalicular patency in 52 patients (success rate: 80%). Four patients out of 13 failed repair cases were asymptomatic. We were not able to prove a significant correlation between outcome and sex, site of involvement, severity of the primary injury, intervention type & the time intervals between trauma and referral; referral and surgery, or surgery and tube removal.
CONCLUSIONS: Repair of canalicular laceration with silicone intubation seems to be a successful procedure and would prevent post operative canalicular stenosis with a low complication rate. It also appears to be the best method of soft tissue reconstruction of the medial canthal region.

Mechanical Endonasal Dacryocystorhinostomy in Nasolacrimal Duct Obstruction. Results
Coauthors: A. KASAI, MD; A. SADEGHI, MD; M. GHAHREMAN, MD; Z. TABATABAIE, MD
Eye Research Center, Farabi Eye Hospital, Tehran Univ. of Medical Sciences (Iran)

Abstract:
PURPOSE: To ascertain the success rate of mechanical Endonasal DCR (EDCR) and its complications during a 1 year follow up period.
METHODS and MATERIALS: In a prospective, non-comparative clinical trial, 65 cases with NLD obstruction, with a mean age of 33.3 (8-73 years), and mean duration of disease of 3.9 months (1-8 months), were enrolled according to inclusion & exclusion criteria. The patients underwent endonasal dacryocystorhinostomy under general anaesthesia. Data based on the patient, the duration of disease, success and complications were collected in the year following.
RESULTS: The success rate of EDCR in our experience was 73.8%, 70.7% & 70.7% at 6,9 & 12 months after the operation. Post operative bleeding at 0-2 day versus 2-7 day intervals were 23.1 % Vs 3.1% and pain was 64.1% Vs 20%, respectively. 29.7% of eyes experienced periorbital swelling & echymosis. Mean (SD) duration of operation was 25.0±2.54 minutes.

Results of Silicone Intubations in Acquired Nasolacrimal Duct Obstruction
Coauthors: Z. TABATABAIE, MD; M. KHATAMI, MD; A. KASAI, MD; A. SADEGHI, MD
Eye Research Center, Farabi Eye Hospital, Tehran Univ. of Medical Sciences (Iran)

Abstract:
BACKGROUND: Acquired NLD obstruction is a common condition faced by every Ophthalmologist. Currently, the gold standard of treatment is Dacryocystorhinostomy (DCR). This study aims to determine the efficacy of NLD intubation as a safer and less invasive alternative to DCR.
METHODS and MATERIALS: Seventy one procedures were performed in 58 patients (13 cases of bilateral intubation), under local anesthesia. (All patients were surgical candidates for DCR). Post operative medications were betamethasone and chloramphenicol eye drops qid for 4 weeks. The silicone tube was left in situ for 3 months and then removed. The patients were followed up for another 3 months. Success criteria were defined as cessation of tearing and discharge, plus patency of the duct , confirmed by irrigation.
RESULTS: 66.2% of cases responded to simple intubation, while the failure rate was 33.8%. Failure was positively correlated with the following:
- Duration of symptoms prior to intubation (p<0.04).
- Existence of mucopurulent discharge at the time of intubation (p<0.04).
- History of previous probing (p<0.05).
CONCLUSIONS: Provided long term follow up of this procedure proves its relative efficacy, this low-risk, minimally invasive outpatient procedure can be recommended prior to scheduling patients for DCR. Treatment of the discharge before intubation is expected to increase the success rate.

Transplantation of Labial Salivary Glands to Conjunctiva in Cases of Severe Dry Eyes
Coauthors:

Abstract:
INTRODUCTION: Transplantation of labial salivary glands to conjunctiva, an operation described by Prof. Juan Murube, has proven to be an excellent therapy in cases of severe dry eyes. I slightly modified the technique (that will be shown step by step):
- Radiosurgery is used to excise the graft and to prepare the recipient bed.
- a continuous Prolene 5/0 submucosal suture is used to fixate the graft instead of separate Vicryl 8/0 sutures.
RESULTS:
- Thanks to the Radiosurgery bleeding and postoperative edema is significantly reduced.
- the postop recovery period is further shortened because the Prolene suture can already be taken out on day 14 and so can be the contact lens that has to protect the cornea.
- histological examination of the transplanted tissue after 18 months shows functional glandular structures.
- all patients improved to some extent after the surgery.
CONCLUSIONS: Transplantation of labial salivary glands to conjunctiva is a big help where artificial tears fail. My modifications can reduce the risk and discomfort for the patient and so increase the indication for this intervention.

Transplantation of Amniotic Membrane Combined with Limbal Allograft in Patients with Aniridia
Coauthors: S. LOPEZ-GARCIA; E. CORREDERA

Abstract:
PURPOSE: To evaluate the curative effect of amniotic membrane (AM) transplantation combined with limbal allograft (LA) on the corneal surface in patients with aniridia.
METHODS: Twelve patients with aniridia were divided into two groups: group A (9 eyes from 9 patients with MA transplantation) and group B (3 eyes from 3 patients with LA combined with AM transplantation). General immunosuppressive therapy was switched-on in all patients. Four clock hours of stem cell tissue grafts from an HLA compatible donor were harvested and transplanted to the recipient eye. We have studied the clinic, morphology and immunocytology of the corneal epithelium: prior to transplantation, after 3, 6, 9, 12, 24 and 36 months. Morphological changes were verified by impression cytology and biopsy and the epithelial phenotype was determined by immunostaining, depending on the expression of CK-19.
RESULTS: Limbal allograft survival was 80% at 36 months of follow-up. No complications in donor eyes were found. Corneal clarity and loss of neovascularization only in group B were showed after 6 months. The morphology of corneal cells in group A showed a decrease of squamous metaplasia after 3 months, but after 9 months corneal cells returned to prior characteristics. In group B, the improvement was continuous; after 3 months the corneal cells showed a decrease, at least, of 2 grades in squamous metaplasia. The phenotype of corneal epithelium in group A (expression of CK19-negative) after 3 months was normal in 66,7% of cases, but after 9 months only the 11,1% of patients with aniridia had normal staining; and in group B, all corneal cells had normal corneal phenotype after 3 months.
CONCLUSIONS: MA transplantation is an effective procedure for restoring the corneal surface integrity in eyes from patients with aniridia until 9 months after transplantation. AM transplantation combined with LA contributes to a higher rate of success and to a lower rate of complications.

Abstract:
PURPOSE: Study to evaluate goblet cell populations in pre and post laser assisted in situ keratomileusis (LASIK) patients.
METHODS: Prospective study included analysis of 20 eyes with LASIK procedures by one surgeon for correction of myopia. Patients with a normal ocular surface before the surgery were evaluated before applying the suction ring and after the surgery (1 week and 1 month) doing conjunctival impression cytology in two places (upper at 12 and down-temporal) of the perilimbal conjunctiva to determine goblet cells density.
RESULTS: Analysis of impression cytology before and after LASIK showed a reduction in the goblet cells populations. All the examined samples showed 100 % decrease in the goblet cell number with a difference in the percentage between each eye ranging from 32 % to 90 % decrease in the number of goblet cells per mm2 with a mean of 63.5 %. All epithelial cells had some disorders related with an increase in cytoplasm, decrease in nuclear size and decrease in nucleus-cytoplasm ratio according different degrees of squamous metaplasia.
CONCLUSIONS: Surgery caused a significant decrease in goblet cells density and alteration of epithelial cells. These histopathological changes in the ocular surface cells occurring in the course of LASIK surgery may be evidenced clinically by dryness and discomfort. We need to study if there is a relation with the epithelial cells apoptosis phenomenon and we should
improve our ability to diagnose and treat patients, who have these challenging conditions, treating them with other than the usual artificial tears, which is only a symptomatic treatment to prevent symptoms and disease.

Abstract:
PURPOSE: A study was carried out on pacients who have been operated of lasik surgery, between the years of 1999 and the first semester of 2004, in order to determine the efect of dry eye symptoms on them.
METHODS: A pacient, to be considered as a potentially member for the study, must have answered a survay consistng of six questions. Each answerer was evaluated and given a minimun of 15 points to a maximun of 35 points. The total number of pacients evalluated were 1.472, from which 1.011 were considered negatives and 461 were positives, for a study sample of 31,31 % pacients.
RESULTS: During the first six months of post surgery, it was a reported a total of 61,71% pacients with symptoms of dry eye and after the first year this porcentage drops to 35,15%. Also, when you compare with pacients who have been operated for a period of  2, 3, 4 or 5 years, the keep average values of 26,37 %, which are very close to standard values of the general population.
CONCLUSIONS: It can be said that during the first yerar of post lasik surgery, pacients have a high incidence of dry eye, however as time goes on , this values tend to drop to those consider standard to the general population.

Abstract:
In this essay we have studied three components of the lachrymal film: Mucine, Lysozime and, Fibronectin.
OBJECTIVES:
1.Acknowledgment of Mucin´s role in the multiplication of Gram + coccus: S. Aureus ATCC 25923, S. Aureus Meticilin resistant and S. Pneumoniae serotype 3 and, the interaction with the fagocitosis.
2.Study the antimicrobial action of the Amoxiciline/Clavulanic acid, Ciprofloxazine and Levofloxacine against the three bacteria.
3.Acknowledgment Lysozime in the bacteria growing.
4.Study of the developing and adherence of the Fibronectin with this micro organism.
RESULTS: We present bacterial development slopes versus the three components. We demonstrate that it is possible to evaluate the three components role separately. Lysozime has synergic action with the antimicrobial used in the study. Fibronectin is a decisive factor in the interactions with Gram + bacterias.

Endolaser Transcanalicular Dacryocystorhinostomy after Previous Techniques Failure: Initial Results
Coauthors: J. MAESO RIERA

Abstract:
PURPOSE: We have tried to determine if transcanalicular diode laser dacryocystorhinostomy can be useful for failure cases of patients previously treated for lachrymal obstruction by any technique.
METHODS: We have studied the results of 18 eyes with previous lachrymal surgery failures (11 previous endolachrymal laser, 5 previous endonasal surgery and 2 external surgery). All the cases have been treated with diode endolachrymal laser under endonasal endoscopic control. All eyes have been trated under local anaesthesia. In 14 cases we have left lachrymal silicone probing at the end of the procedure. In the other 4 cases probing has been impossible due to anatomical impairment. All patients have a minimum follow-up period of 3 months (from 3 to 9 months).
RESULTS: 15 of the 18 eyes - 83,33% - (13/14 probed; 2/4 without probing) have presented clinical improvement and anatomical drainage.
CONCLUSIONS: Transcanalicular laser dacryocystorhinostomy seem to be an effective technique for the treatment of recurrent lachrymal obstructions. Postoperative lachrymal probing has to be considered in recurrent cases, in order to improve results.

Endolaser Transcanalicular Dacryocystorhinostomy: Indications and Results
Coauthors: J. MAESO RIERA

Abstract:
PURPOSE: Evaluate indications and effectiveness of endolaser transcanalicular dacryocystorhinostomy with diode laser in the treatment of lachrymal occlusions.
METHODS: 71 eyes have been treated with transcanalicular diode laser under endonasal endoscopic control. All eyes have been treated under local anaesthesia, without lachrymal probing at the end of the procedure.
RESULTS: After a minimum follow-up period of 6 months, 60 eyes (84,51%) have maintained lachrymal permeability, with a good functional and symptomatic result, after the first procedure. This technique can be indicated in patients with general contraindications for major procedures under general anaesthesia, or local conditions impairing external dacryocystorhinostomy.
CONCLUSIONS: Transcanalicular laser dacryocystorhinostomy is an effective technique for the treatment of lachrymal obstructions, and safer for patients with general or local pathologies impairing major surgical procedures.

Evaluation of the Recanalization Techniques in Different Types of Canalicular Obstructions
Tanta University (Tanta, Egypt)

Abstract:
PURPOSE: Is to evaluate the results obtained in the recanalization of the obstructed canaliculi.
METHODS and MATERIALS: 10 cases of bilateral congenital canalicular obstruction with absent puncti, 13 cases of acquired occluded punctum impossible to dilate or perforate, 16 eyes of 10 patients of acquired totally occluded one punctum and the other one could be dilated. Carunculo canalicular vent of Murube was used to explore the calnalicular system, opening a window at the level of the caruncle. For the cases with patent one punctum, we used the pigtail probe to pass through and to open over it through the other occluded punctum. A bicanalicular annular intubation was then inserted.
RESULTS: We could be able to recanalize 8 bilateral congenital cases where we found the obstructing scar at the level of the punctum in 6 cases, and extending to the vertical part of the canaliculus in 2 cases. In acquired cases, 8 of them were found to have the obstructing scar in the verticl part of the canaliculs. We failed in one bilateral case due to absence of canalicular tissue. All acquired cases could be canalized. All cases were intubated with bicanalicular silicone tube.
CONCLUSIONS: Every type of canalicular obstruction should be evaluated and managed individually according to the etiology and the site and extent of the obstructing scar and presence or absence of the punctum. Carunculo canaliclar veent of murube offers a good dagnostic and therapeutic tool in canalicular obstructions.

Management of Different Types of Corneal Perforations
Tanta University (Tanta, Egypt)

Abstract:
PURPOSE: To study the outcome of the management of different types of corneal perforations and defects resulting from different etiologies.
METHODS and MATERIALS: The study included 24 cases of different types of corneal perforation admitted to Tanta University Ophthalmic Hospital during a period of 2 years. The perforations were of different sizes associated or not with loss of anterior chamber +/- iris prolapse. The management was planed according to the size of the perforation. All cases were treated under general anaesthesia by multilayer (4-6) amniotic membrane fixation to the corneal defect as a primary procedure, larger perforations needed tectonic patch corneal graft.
Reformation of the anterior chamber by sodium hyalurinate 0.3% in cases of loss of anterior chamber. A large layer of amniotic membrane covering the whole cornea fixed by continuous running sutures at the limbus is used as a patch contact lens.
RESULTS: Restoration of the globe integrity and sealing of the perforation was achieved in 22 out of 24 cases (91.66%), and failure in 2 cases (8.33%). Improvement in the visual acuity was obtained in 8 cases (33.33%), preservation of the same visual acuity was found in 5 (20.83%) cases, worsening of vision due to increased opacity was recorded in 11cases (45.83%).
CONCLUSIONS: Multilayer amniotic membrane transplantation offered a good option for restoring the globe integrity in most types of corneal perforations. Tectonic patch corneal graft if available offers a the last option in very large perforations and failed cases after amniotic membrane trial.

Microsurgical Submandibular Gland Transfer in the Treatment of Severe Keratoconjunctivitis Sicca. A 10 Year Experience
Coauthors: S.G. HAKIM; H.C. JACOBSEN

Abstract:
PURPOSE: Micorvascular submandibular gland transfer to the temple with implantation of Wharton’s duct into the upper conjunctival fold offers a surgical approach to permanent autologous substitution of tears using the secretion of the transplanted revascularized denervated gland. After the first report on submandibular gland transfer in the management of keratokonjunctivitis sicca (KCS) by Murube del Castillo in 1989, only a few reports were published about the clinical results of this method. Using this method for 10 years in our institution we are able to present functional long term results.
METHODS: 38 submandibular gland transfers were performed in selected cases of severe KCS. Vital incorporation of the gland was proven by clinical detectable secretion and scintigraphic controls. Ophthalmological checkups were performed up to 24 months after transfer. In 10 patients the quality of the saliva-tears was examined up to 8 years post-op. In 9 patients 7-24 months after transfer due to epiphora the size of the gland was reduced and salivary gland tissue histologically examined.
RESULTS: 33 of 38 glands healed without complications. Vascular complications caused 4 total and 1partial loss of gland. At all checkups secretion was irregular, all patients developed at least occasional epiphora provoked by physical activity, chewing motions or hyperthermia of the temporal region. The base-secretion of proteins was increased in comparison with normal submandibular saliva as well as normal tears. After stimulation with carbachol the protein content fell dramatically. This observation suggests, that years after the transfer the transplanted denervated glands are highly sensitive to cholinergic stimulation. Histological examination showed a long term survival of all investigated cell types.
CONCLUSIONS: In about 2/3 of patients, submandibular gland transfer resulted in a longlasting improvement of the clinical symptoms of KCS. This procedure is able to stabilise the clinical findings on the ocular surface and conjunctivae. Questions are still open about regulation of the function of the transferred gland and how to manage the irregular secretion.

Up-Date on Lacrimal Endoscopy
Coauthors: S. GAMBARO

Abstract:
Lachrymal endoscopy is today the most recent technique able to allow a direct examination of all the lachrymal ways: canaliculus, lachrymal sac and nasolachrymal duct. This technique relatively easy, non-traumatic and reproducible; in compliating patients this procedure is done under topical anaesthesia. It can be used not only for diagnostic, but also for surgical approaches. The lachrymal endoscopy allows us to evaluate the internal walls quality of the lachrymal ways, the presence and the entity of lachrymal stenosis at various levels (pre-sac or post-sac) the presence of dacryolithes or inflammatory modifications of the secretion of the sac; this procedure can be useful also to evaluate the outcomes of previous surgery such as DCR, and to demonstrate the possible causes of failure of surgery (inflammatory oedema, intranasal ostium granuloma, canalicular stenosis, fibrotic reactions in ostium area). Surgical endoscopic approaches in canalicular surgery demonstrated to be promising, even if external approach remains the first choice. Fiber optic assisted lachrymal surgery leaves no cutaneous scars and gives excellent short and long term functional results and shorter recovery time. This technique allows us to operate both canalicular and post-lachrymal sac. New perspectives are given in this particular branch of lachrymal surgery with the aid of an adequate laser.

Amniotic Membrane Transplantation in Ocular Surface Reconstruction
Coauthors: S. GAMBARO, A. SPINELLI

Abstract:
Amniotic membrane is a thin, transparent, avascular tissue composed of an epithelium, a basal membrane and of a loose connective tissue. The epithelium is rich in growth factors such as epidermal and nerve growth factors, anti-inflammatory interleukine as IL10 and inhibitors of angiogenesis. There are four different preparations:
1.-Amniotic membrane non-conserved
2.-Demydrated
3.-Cross-linked
4.-Cryo-preserved
The amniotic membrane is a non immunogenic, bacteriostatic and non-adhesive tissue, and has been demonstrated to promote epithelium formation and decrease the angiogenesis. The indications to the amniotic membrane transplantation are: reconstruction of the conjunctival surface, treatment of non-infections pathologies, treatment of corneal epithelial lesions not responding to the pharmacological therapy, treatment of the corneal pain.
Recently amniotic membrane has been used in cases of keratoconjunctivitis sicca, with good clinical outcomes and patient’s satisfaction.
However this technique can be repeated more than one time. In conclusion amniotic membrane transplantation is demonstrated to be a valuable choice in ocular surface reconstruction but not sufficient in case of severe limbar stem cells damage; new perspectives are opened in cases of dry eye pathologies.

Evaporation Rates from Cornea and Sclera
Coauthors: Stefan S. LACHOWICZ
Nuffield Lab. of Ophthalm., University of Oxford (Oxford, UK)

Abstract:
PURPOSE: Little is known about evaporation from the tear film over the sclera. The areas and proportions of exposed cornea and sclera change in upgaze and downgaze. We measured total evaporation from known areas and calculated the corneal and scleral contributions.
METHODS: We used a closed goggle incorporating the ServaMed humidity probe and recorded the time for RH to rise from 30 to 50%. The right eyes of 11 adult volunteers (7M, 4F, mean age 27y) were tested with the eye closed (to assess skin contribution), and in 15 upgaze and 15 downgaze. 3-dimensional areas and scleral/corneal ratios (S/C) in both upgaze and downgaze were calculated using the Ocularea® program. Scleral curvatures were measured near the limbus with the Marcher Scheimpflug camera. A single-subject evaporation reading was also made where the eye looked straight ahead or to the side, so that exposed area was constant despite a twofold change in S/C.
RESULTS: Total evaporative rates were corrected for the contribution from surrounding skin. Mean values for S/C were 1.4 (up) and 0.7 (down) and the range of total areas was 1.6-2.7 cm2 (up) and 0.9-1.9 cm2 (down). The rate in upgaze was significantly greater than that in downgaze (mean ± SD, 4.0 ± 1.9 vs. 2.7 ± 1.4 x 10-7 g.cm-2. s-1 respectively, p ? 0.001) although individuals varied widely. Individual S and C rates were found by solving simultaneous equations, giving calculated mean ± SD of 5.9 ± 2.0 x 10-7 (scleral) and 1.4 ± 2.8 x 10-7 (corneal). In the single-subject case, both exposed areas were 1.7 cm2 but S/C for axial and side view was 1.6 and 0.8 respectively; calculated evaporation rates were 2.3 x 10-7 (scleral) and 0.5 x 10-7 (corneal).
CONCLUSIONS: The evaporation rate is greater from sclera than from cornea. Upgaze may thin the lipid layer, giving less control of evaporation, but this seems unlikely in side-gaze. The nature or integrity of the tear film over the sclera are still undetermined.

TSENG, Scheffer C. G.
7000 SW 97^th Avenue, Suite 203 - FL33179 MIAMI (U.S.A.)
E-mail: stseng@ocularsurface.com

Limbal Stem Cell Transplantation
Ocular Surface Center (Miami, U.S.A.)

Abstract:
Limbal stem cell deficiency (LSCD) is a new disease entity that has been recognized as one of the major causes of ocular surface failure. LSCD manifests the hallmark of conjunctivalization of the cornea, and is frequently associated with superficial vascularization and compromised corneal surface. LSCD can be found in a number of corneal diseases such as chemical burns, Stevens Johnson syndrome, aniridia, peripheral keratitis, severe limbitis, etc. Patients with LSCD suffer from a severe loss of vision and annoying photophobia, and cannot be corrected by conventional PKP. Therefore, it is important to diagnose LSCD accurately because erroneous diagnosis may subject the patient to unnecessary surgeries, and correct diagnosis, which may require the use of impression cytology, will lead to reconstruction with limbal stem cell transplantation. This lecture will review the indication, contraindications and surgical procedures of conjunctival limbal autograft (CLAU) for total unilateral LSCD, and keratolimbal allograft (KLAL) for total bilateral LSCD. For complex diseases manifesting LSCD, it is important to restore ocular surface defense first so that a stable tear film can be maintained before limbal stem cell transplantation. For KLAL, the success is dictated by effective immunosuppression (to be described in more details). Because amniotic membrane is an ideal substrate to help expand limbal epithelial stem cells, amniotic membrane transplantation can also be used to reconstruct both donor and recipient eyes during CLAU, for recipient eyes receiving KLAL, and for ex vivo expansion for subsequent transplantation (a new surgical procedure currently approved by FDA for phase 1 clinical trial to be conducted by Dr. Tseng). Clinical examples and surgical videos will be presented.

Effect of Posterior Approach Ptosis Surgery on Tear Production
Coauthors: Atilla ALPAY; Sebnem KARGI; Emin ÖZCAN; Tuncer GÜNEY

Abstract:
PURPOSE: Either anterior approach with lid crease incision or posterior approach from conjunctiva are the preferred techniques for ptosis repair. Since conjunctival tissue is removed in conjunctiva-Müller muscle resection, a possible effect on tear secretion may be detected.
METHODS: Eleven cases who had a unilateral ptosis repair with conjunctiva-Müller muscle resection were retrospectively included in this study. Patients were operated with a technique similar to that described by Putterman and Urist. Schirmer test was applied to both eyes in postoperative period.
RESULTS: No case suffered from dry eye in post operative follow-up. There was no significant difference in Schirmer test measurements obtained from operated eye and the other non-operated eye.
CONCLUSIONS: Conjunctiva-Müller muscle resection which is a simple method especially used for small amount of ptosis cases has no decreasing effect on tear production.

The Contact Lens in the Medium of Tears: Effects and Interaction with Cytokines in Eyes with Tear Deficiency. A Model
St. Eriks Eye Hospital (Stockholm, Sweden)

Abstract:
CL tolerance is partly judged by the presence and occurrence of a pannus or limbal vessel formation. Some of the changes seen have similarities to surface pathologies observed in the dry eye. The purpose of the study is to find a rationale for this observation and to identify the specific changes concerned. Considering the results of biochemical analysis of tears and immunohistochemical analysis of tissue sections we have tried to outline possible mechanisms of cytokine action for CL wearers. It appears that CL wear could trigger effects of various cytokines such as CTGF and VEGF in a way that is usually not observed in normal eyes. CL morphology and fitting is essential to prevent undesired cytokine effects. In our current understanding dry eye as part of the ocular surface syndrome does occur in different stages of severity and reversibility. Amongst them the possible transition from ALIRS to the CLIRS stage is probably the most severe and most permanent change for the ocular surface. CL wear might influence the transition between ALIRS and CLIRS. CL wear in dry eye patients or under drying conditions should hence be recommended only in association with good ophthalmological surveillance and guidance.

Reintervention of D.C.R.
Coauthors: M.ª Cruz CIPRES; Pedro Luis BLASCO; Agustín FERNANDEZ; Jesús DIAZ; Charlotte WOLLEY DOD; M.ª del Carmen MORENO; Antoni ALEMANY

Abstract:
PURPOSE: We present our surgical technique in the reintervention of D.C.R.
METHODS and MATERIALS: In order to fully examine the osteotomy site and sacular area a CT scan with axial and coronal sections and dacriocystography or dacrio-TAC were employed. In reintervention cases the sacular surgery is of utmost importance, due to the marked fibrosis from the original operation. The ampliation of the osteotomy site and bicanicular intubation to the nasal fossa are also important cosiderations. As a rule we use local anaesthesia with additional topical application to the nasal mucosa.
RESULTS and CONCLUSIONS: We obtained a good functional result with the aid of a generous ampliation of the osteotomy site and by maintainig the bicanicular intubation in situ for approximately six months.

Abstract:
PURPOSE: This surgical technique consists of a gauged trepanation of the stenosis located by endoscopy according to the methodology described by Pr Piffaretti
METHODS and RESULTS: It acts of a retrospective study relating to 33 cases of chronic epiphora. The follow-up is higher than one year for all the cases and certain case higher than two years. The success rate (epiphora which ceased or which is decreased by at least half) is 85% at 6 months and 75% at one year.
CONCLUSIONS: There currently does not exist such surgical technique combinating at the same time diagnosis and therapeutic in the treatment of the chronic epiphora. This technique presents such undeniable advantages that it becomes, according to the author, the technique to propose in first intention in front of a chronic epiphora.