Ophthal Plast Reconstr Surg, Vol. 31, No. 3, 2015
nasolacrimal duct obstruction and a 1 week history of a dacryocystocele on the left. The dacryocystocele was aggressively decompressed by an outside physician on the day of referral which, per the patient’s parents, resulted in immediate erythema and edema on the left which worsened throughout the day. On examination the patient demonstrated erythema and tense edema on the left with chemosis (Fig. 1); he had a temperature of 38.9°C and a significantly elevated white blood cell count of 24.8 K/ml. A CT scan was obtained which was consistent with a left orbital cellulitis and dacryocystitis (Fig. 1). Blood, cerebrospinal fluid, and urine cultures were negative. The patient was started on intravenous vancomycin and clindamycin. The patient was taken urgently to the operating room where a probing and stenting of the lacrimal system was performed along with an anterior orbitotomy and drainage of an inferior orbital abscess. Cultures grew methicillin-sensitive Staphylococcus aureus. The patient improved postoperatively and entirely resolved without negative sequelae at the final 6 month follow-up (Fig. 2). The literature lacks a consistent, standard treatment of congenital dacryocystoceles. Many reports emphasize the importance of treating those patients with intranasal components that cause respiratory distress. The most recent comprehensive study was published by Becker in 2006 where he evaluated his treatment of congenital dacryocystoceles.2 He recommended “probing at the earliest possible age [to] reduce the incidence of dacryocystitis and cellulitis.” He also thought that “patients with dacryocystocele should have a probing on urgent basis if the lacrimal sac does not decompress into the nose with massage during the first examination.” We believe that the conclusions from Becker and the observations by Bernardini et al. highlight some important points: dacryocystoceles that are mismanaged may result in significant morbidity; dacryocystoceles should be decompressed
FIG. 1. A coronal CT scan showing a heterogeneous, loculated collection consistent with a left, inferomedial orbital abscess in the setting of dacryocystitis (left). Preoperative photograph demonstrating erythema and tense edema on the left with chemosis (right).
FIG. 2. Postoperative clinical photograph showing significant improvement in periorbital edema and erythema 1 month after surgery (left). Clinical photograph showing complete resolution without negative sequelae 6 months after surgery at final follow-up (right).
Letters to the Editor
digitally at first appointment by a physician familiar in the management of these lesions; if the dacryocystocele does not decompress easily under appropriate digital pressure, probing of the lacrimal system should be performed prudently.1,2 The question we have for the authors has to do with massage of the lacrimal sac. The term “massage” is used somewhat liberally in the literature, usually under the rubric of simply recommending “massage” without any frequency, pressure, or motion. The authors state that “forceful massage may be dangerous and may spread the contents of the mucocele unpredictably into the orbit,” and we agree. Our question to the authors is if they could clarify either through their experience or review of the literature how to perform “massage” in these patients.
Meredith S. Baker, M.D. Richard C. Allen, M.D., PH.D. The authors have no financial or conflicts interests to disclose. Correspondence: Richard C. Allen, M.D., Ph.D., Department of Ophthalmology and Visual Sciences, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52246. E-mail: [email protected]
REFERENCES 1. Bernardini FP, Cetinkaya A, Capris P, Rossi A, Kaynak P, Katowitz JA. Orbital and periorbital extension of congenital dacryocystoceles: suggested mechanism and management. Ophthal Plast Reconstr Surg 2014;e1–e4. 2. Becker BB. The treatment of congenital dacryocystocele. Am J Ophthalmol 2006;142:835–8.
Reply re: “Orbital and Periorbital Extension of Congenital Dacryocystoceles: Suggested Mechanism and Management” To the Editor: We thank Baker and Allen1 for their interest in our report and for adding 1 more case of this rare but serious complication of an otherwise benign and common condition. Orbital expansion of a dacryocystocele is in fact rare, but posterior expansion of a lacrimal sac filled with infected material may have serious sequelae if not promptly recognized and appropriately managed. The similarity of presentation between the case reported by Baker and Allen and the ones presented in our previous report is noteworthy. Interestingly, imaging shows in all cases an evagination of the lacrimal sac toward the orbit or periorbital area. Both iatrogenic cases presented with an acute infection of the orbit, indicating that the digital pressure of the sac can cause a significant worsening of the dacryocystocele. The case reported by Baker and Allen is the second iatrogenic orbital expansion of a congenital dacryocystocele, indicating that the risk of a wrongful medical maneuver is not limited to one isolated “bad doctor,” but can occur anywhere when performed by physicians who are not familiar with the anatomical area. In regard to the question that Baker and Allen pose regarding the role of digital massage in these children, we do not have a definitive answer. All of the authors on this article concur that the internal pressure of the lacrimal sac is most likely already very high in most cases of dacryocystocele as evidenced by a rock-hard sac on palpation. For this reason, it is our collective belief that a sudden further increase of internal pressure from massage does increase the risk of breaking the lacrimal sac wall unpredictably, into the anterior
© 2015 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
249
Copyright © 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
Ophthal Plast Reconstr Surg, Vol. 31, No. 3, 2015
Letters to the Editor
periorbita as in our case or posteriorly into the intraconal orbit in the case presented by Baker and Allen, with detrimental effect in both instances. Our response to this increased risk, while similar in some respects, does differ somewhat in our respective institutions. For example, at the Gaslini Children Hospital in Genova, after having recognized this complication, we have lowered the threshold for imaging, mostly MRI, to all the patients affected by congenital dacryocystocele that display signs of expansion, or whose dacryocystocele fails to resolve spontaneously within 48–72 hours. We feel that early imaging may prevent silent orbital expansion and prompt early intervention. At the Children’s Hospital of Philadelphia, however, we have a slightly different approach, in that we reserve imaging predominantly for bilateral cases and avoid massage before ruling out any intraorbital extension in these instances. We are particularly concerned regarding the high incidence of associated intranasal cyst extension in these cases and recommend early nasal endoscopic evaluation and probing under general anesthesia to avoid any respiratory compromise. This then permits irrigation, excision of any intranasal cyst and stenting as appropriate. For unilateral cases, however, without any evidence of acute dacryocystitis, we do apply gentle pressure on the dilated sac while everting the lower eyelid. If there is no visible expression of material from the punctum, we will then proceed with an office probing alone without sedation, using a #000 or #0000 Bowman probe. We do recommend postprobing massage in these instances, using the Crigler method of forefinger pressure on the sac and massaging inferiorly down the side of the nose over the nasolacrimal duct several times daily until dye disappearance testing confirms the clinical impression of symptom resolution. Anecdotally, this has proven effective in the majority of cases. In any event, we have not seen any instances of cellulitis with this approach and further intervention under general anesthesia can then be done at an appropriate time if there is any persistent tearing. We commend Baker and Allen for adding a very interesting case report and to direct the attention of the potential complications that could originate by inappropriate maneuvers performed by nonophthalmologists.
Francesco P. Bernardini, M.D. James A. Katowitz, M.D. Paolo Capris, M.D. The authors have no financial or conflicts interests to disclose. Correspondence: Francesco P. Bernardini, M.D., Department of Ophthalmology, Ospedale Gaslini, Genova, Italy. E-mail: [email protected]
REFERENCES 1. Baker MS, Allen RC. Re: “orbital and periorbital extension of congenital dacryocystoceles: suggested mechanism and management”. Ophthal Plast Reconstr Surg 2015;31:248–9.
Re: “Orbital Necrotizing Fasciitis and Osteomyelitis Caused by Arcanobacterium haemolyticum: A Case Report” To the Editor: We thank Drs. Stone and Harshbarger1 for contributing their interesting case of severe Arcanobacterium haemolyticum orbital infection to the oculofacial literature. Their
250
case represents the third report of A. haemolyticum pathogenicity in the orbit in the past 2 years,2 and the sixth case documented since its description 30 years ago,3–6 suggesting that recognition and/or reporting of this pathogen may be improving. The comments of Stone and Harschbarger1 echo our experience and prior review of this important pathogen. A. haemolyticum orbital infections can be aggressive and lifethreatening, requiring a multidisciplinary medical and surgical approach. Repeated assertive surgical debridement may be necessary, but visual prognosis has typically been favorable, despite advanced orbital involvement. Microbiological characterization of this pathogen may be difficult and should be specifically pursued by the laboratory to establish sensitivity profiles early. A high level of suspicion is necessary to correctly diagnose and promptly treat orbital infections from A. haemolyticum. We hope to learn more about this rare entity as clinicians and laboratories continue to identify and report experiences with A. haemolyticum in severe orbital disease.
Nicholas A. Ramey, M.D. Cat N. Burkat, M.D. Correspondence: Nicholas A. Ramey, M.D., Vistar Eye Center, Oculofacial Plastic and Reconstructive Service, 707 S. Jefferson St, Roanoke, VA 24016 ([email protected]) The authors have no financial or conflicts of interest to disclose.
REFERENCES 1. Stone LA, Harshbarger RJ. Orbital necrotizing fasciitis and osteomyelitis caused by Arcanobacterium haemolyticum: a case report. Ophthal Plast Reconstr Surg 2014. 2. Ramey NA, Burkat CN. Arcanobacterium hemolyticum orbital cellulitis: a rare but aggressive disease. Ophthal Plast Reconstr Surg 2013;29:e69–72. 3. Burroughs JR, Hsueh JB, Pelton RW. Re: “Arcanobacterium hemolyticum orbital cellulitis: a rare but aggressive disease.” Ophthal Plast Reconstr Surg 2013;29:332–3. 4. Limjoco-Antonio AD, Janda WM, Schreckenberger PC. Arcanobacterium haemolyticum sinusitis and orbital cellulitis. Pediatr Infect Dis J 2003;22:465–7. 5. Ford JG, Yeatts RP, Givner LB. Orbital cellulitis, subperiosteal abscess, sinusitis, and septicemia caused b Arcanobacterium haemolyticum. Am J Ophthalmol 1995;120:261–2. 6. Givner LB, McGehee D, Taber LH, et al. Sinusitis, orbital cellulitis and polymicrobial bacteremia in a patient with primary EpsteinBarr virus infection. Pediatr Infect Dis 1984;3:254–6.
Re: “Lower Eyelid Involutional Ectropion Repair With Lateral Tarsal Strip and Internal Retractor Reattachment With Full-Thickness Eyelid Sutures” To the Editor: We read with interest the report by Ghafouri et al.1 on “Lower eyelid involutional ectropion repair with lateral tarsal strip and internal retractor reattachment with full-thickness eyelid sutures.” The authors present a useful technique to repair ectropion associated with lower eyelid retractor disinsertion. We believe that numerous patients would benefit from readvancement of the lower eyelid retractors, in addition to horizontal tightening. We also
© 2015 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
Copyright © 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
nasolacrimal duct obstruction and a 1 week history of a dacryocystocele on the left. The dacryocystocele was aggressively decompressed by an outside physician on the day of referral which, per the patient’s parents, resulted in immediate erythema and edema on the left which worsened throughout the day. On examination the patient demonstrated erythema and tense edema on the left with chemosis (Fig. 1); he had a temperature of 38.9°C and a significantly elevated white blood cell count of 24.8 K/ml. A CT scan was obtained which was consistent with a left orbital cellulitis and dacryocystitis (Fig. 1). Blood, cerebrospinal fluid, and urine cultures were negative. The patient was started on intravenous vancomycin and clindamycin. The patient was taken urgently to the operating room where a probing and stenting of the lacrimal system was performed along with an anterior orbitotomy and drainage of an inferior orbital abscess. Cultures grew methicillin-sensitive Staphylococcus aureus. The patient improved postoperatively and entirely resolved without negative sequelae at the final 6 month follow-up (Fig. 2). The literature lacks a consistent, standard treatment of congenital dacryocystoceles. Many reports emphasize the importance of treating those patients with intranasal components that cause respiratory distress. The most recent comprehensive study was published by Becker in 2006 where he evaluated his treatment of congenital dacryocystoceles.2 He recommended “probing at the earliest possible age [to] reduce the incidence of dacryocystitis and cellulitis.” He also thought that “patients with dacryocystocele should have a probing on urgent basis if the lacrimal sac does not decompress into the nose with massage during the first examination.” We believe that the conclusions from Becker and the observations by Bernardini et al. highlight some important points: dacryocystoceles that are mismanaged may result in significant morbidity; dacryocystoceles should be decompressed
FIG. 1. A coronal CT scan showing a heterogeneous, loculated collection consistent with a left, inferomedial orbital abscess in the setting of dacryocystitis (left). Preoperative photograph demonstrating erythema and tense edema on the left with chemosis (right).
FIG. 2. Postoperative clinical photograph showing significant improvement in periorbital edema and erythema 1 month after surgery (left). Clinical photograph showing complete resolution without negative sequelae 6 months after surgery at final follow-up (right).
Letters to the Editor
digitally at first appointment by a physician familiar in the management of these lesions; if the dacryocystocele does not decompress easily under appropriate digital pressure, probing of the lacrimal system should be performed prudently.1,2 The question we have for the authors has to do with massage of the lacrimal sac. The term “massage” is used somewhat liberally in the literature, usually under the rubric of simply recommending “massage” without any frequency, pressure, or motion. The authors state that “forceful massage may be dangerous and may spread the contents of the mucocele unpredictably into the orbit,” and we agree. Our question to the authors is if they could clarify either through their experience or review of the literature how to perform “massage” in these patients.
Meredith S. Baker, M.D. Richard C. Allen, M.D., PH.D. The authors have no financial or conflicts interests to disclose. Correspondence: Richard C. Allen, M.D., Ph.D., Department of Ophthalmology and Visual Sciences, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52246. E-mail: [email protected]
REFERENCES 1. Bernardini FP, Cetinkaya A, Capris P, Rossi A, Kaynak P, Katowitz JA. Orbital and periorbital extension of congenital dacryocystoceles: suggested mechanism and management. Ophthal Plast Reconstr Surg 2014;e1–e4. 2. Becker BB. The treatment of congenital dacryocystocele. Am J Ophthalmol 2006;142:835–8.
Reply re: “Orbital and Periorbital Extension of Congenital Dacryocystoceles: Suggested Mechanism and Management” To the Editor: We thank Baker and Allen1 for their interest in our report and for adding 1 more case of this rare but serious complication of an otherwise benign and common condition. Orbital expansion of a dacryocystocele is in fact rare, but posterior expansion of a lacrimal sac filled with infected material may have serious sequelae if not promptly recognized and appropriately managed. The similarity of presentation between the case reported by Baker and Allen and the ones presented in our previous report is noteworthy. Interestingly, imaging shows in all cases an evagination of the lacrimal sac toward the orbit or periorbital area. Both iatrogenic cases presented with an acute infection of the orbit, indicating that the digital pressure of the sac can cause a significant worsening of the dacryocystocele. The case reported by Baker and Allen is the second iatrogenic orbital expansion of a congenital dacryocystocele, indicating that the risk of a wrongful medical maneuver is not limited to one isolated “bad doctor,” but can occur anywhere when performed by physicians who are not familiar with the anatomical area. In regard to the question that Baker and Allen pose regarding the role of digital massage in these children, we do not have a definitive answer. All of the authors on this article concur that the internal pressure of the lacrimal sac is most likely already very high in most cases of dacryocystocele as evidenced by a rock-hard sac on palpation. For this reason, it is our collective belief that a sudden further increase of internal pressure from massage does increase the risk of breaking the lacrimal sac wall unpredictably, into the anterior
© 2015 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
249
Copyright © 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
Ophthal Plast Reconstr Surg, Vol. 31, No. 3, 2015
Letters to the Editor
periorbita as in our case or posteriorly into the intraconal orbit in the case presented by Baker and Allen, with detrimental effect in both instances. Our response to this increased risk, while similar in some respects, does differ somewhat in our respective institutions. For example, at the Gaslini Children Hospital in Genova, after having recognized this complication, we have lowered the threshold for imaging, mostly MRI, to all the patients affected by congenital dacryocystocele that display signs of expansion, or whose dacryocystocele fails to resolve spontaneously within 48–72 hours. We feel that early imaging may prevent silent orbital expansion and prompt early intervention. At the Children’s Hospital of Philadelphia, however, we have a slightly different approach, in that we reserve imaging predominantly for bilateral cases and avoid massage before ruling out any intraorbital extension in these instances. We are particularly concerned regarding the high incidence of associated intranasal cyst extension in these cases and recommend early nasal endoscopic evaluation and probing under general anesthesia to avoid any respiratory compromise. This then permits irrigation, excision of any intranasal cyst and stenting as appropriate. For unilateral cases, however, without any evidence of acute dacryocystitis, we do apply gentle pressure on the dilated sac while everting the lower eyelid. If there is no visible expression of material from the punctum, we will then proceed with an office probing alone without sedation, using a #000 or #0000 Bowman probe. We do recommend postprobing massage in these instances, using the Crigler method of forefinger pressure on the sac and massaging inferiorly down the side of the nose over the nasolacrimal duct several times daily until dye disappearance testing confirms the clinical impression of symptom resolution. Anecdotally, this has proven effective in the majority of cases. In any event, we have not seen any instances of cellulitis with this approach and further intervention under general anesthesia can then be done at an appropriate time if there is any persistent tearing. We commend Baker and Allen for adding a very interesting case report and to direct the attention of the potential complications that could originate by inappropriate maneuvers performed by nonophthalmologists.
Francesco P. Bernardini, M.D. James A. Katowitz, M.D. Paolo Capris, M.D. The authors have no financial or conflicts interests to disclose. Correspondence: Francesco P. Bernardini, M.D., Department of Ophthalmology, Ospedale Gaslini, Genova, Italy. E-mail: [email protected]
REFERENCES 1. Baker MS, Allen RC. Re: “orbital and periorbital extension of congenital dacryocystoceles: suggested mechanism and management”. Ophthal Plast Reconstr Surg 2015;31:248–9.
Re: “Orbital Necrotizing Fasciitis and Osteomyelitis Caused by Arcanobacterium haemolyticum: A Case Report” To the Editor: We thank Drs. Stone and Harshbarger1 for contributing their interesting case of severe Arcanobacterium haemolyticum orbital infection to the oculofacial literature. Their
250
case represents the third report of A. haemolyticum pathogenicity in the orbit in the past 2 years,2 and the sixth case documented since its description 30 years ago,3–6 suggesting that recognition and/or reporting of this pathogen may be improving. The comments of Stone and Harschbarger1 echo our experience and prior review of this important pathogen. A. haemolyticum orbital infections can be aggressive and lifethreatening, requiring a multidisciplinary medical and surgical approach. Repeated assertive surgical debridement may be necessary, but visual prognosis has typically been favorable, despite advanced orbital involvement. Microbiological characterization of this pathogen may be difficult and should be specifically pursued by the laboratory to establish sensitivity profiles early. A high level of suspicion is necessary to correctly diagnose and promptly treat orbital infections from A. haemolyticum. We hope to learn more about this rare entity as clinicians and laboratories continue to identify and report experiences with A. haemolyticum in severe orbital disease.
Nicholas A. Ramey, M.D. Cat N. Burkat, M.D. Correspondence: Nicholas A. Ramey, M.D., Vistar Eye Center, Oculofacial Plastic and Reconstructive Service, 707 S. Jefferson St, Roanoke, VA 24016 ([email protected]) The authors have no financial or conflicts of interest to disclose.
REFERENCES 1. Stone LA, Harshbarger RJ. Orbital necrotizing fasciitis and osteomyelitis caused by Arcanobacterium haemolyticum: a case report. Ophthal Plast Reconstr Surg 2014. 2. Ramey NA, Burkat CN. Arcanobacterium hemolyticum orbital cellulitis: a rare but aggressive disease. Ophthal Plast Reconstr Surg 2013;29:e69–72. 3. Burroughs JR, Hsueh JB, Pelton RW. Re: “Arcanobacterium hemolyticum orbital cellulitis: a rare but aggressive disease.” Ophthal Plast Reconstr Surg 2013;29:332–3. 4. Limjoco-Antonio AD, Janda WM, Schreckenberger PC. Arcanobacterium haemolyticum sinusitis and orbital cellulitis. Pediatr Infect Dis J 2003;22:465–7. 5. Ford JG, Yeatts RP, Givner LB. Orbital cellulitis, subperiosteal abscess, sinusitis, and septicemia caused b Arcanobacterium haemolyticum. Am J Ophthalmol 1995;120:261–2. 6. Givner LB, McGehee D, Taber LH, et al. Sinusitis, orbital cellulitis and polymicrobial bacteremia in a patient with primary EpsteinBarr virus infection. Pediatr Infect Dis 1984;3:254–6.
Re: “Lower Eyelid Involutional Ectropion Repair With Lateral Tarsal Strip and Internal Retractor Reattachment With Full-Thickness Eyelid Sutures” To the Editor: We read with interest the report by Ghafouri et al.1 on “Lower eyelid involutional ectropion repair with lateral tarsal strip and internal retractor reattachment with full-thickness eyelid sutures.” The authors present a useful technique to repair ectropion associated with lower eyelid retractor disinsertion. We believe that numerous patients would benefit from readvancement of the lower eyelid retractors, in addition to horizontal tightening. We also
© 2015 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
Copyright © 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
