Ophthal Plast Reconstr Surg, Vol. 30, No. 5, 2014
Letters to the Editor
more homogeneous distribution of the material. The 1.5 ml content of the syringe is diluted with 0.5 ml lidocaine. This has the double purpose of making the procedure virtually painless, and facilitating the injection of a more fluid filler than the original one. It may be possible that this has helped us to avoid granuloma formation. Calcium hydroxylapatite (Radiesse) is indeed a powerful filler for the correction of periorbital hollows, dark circles, and lower eyelid bags. We have stated in our report that the advantage of this material is not limited to the absence of Tyndall effect, but more importantly that it avoids the risks of eyelid and malar edema inherent to the hydrophilic nature of any HA filler. Finally, its white color has a distinct advantage in improving dark circles. Concerning the advantages of cannulas, we agree with the concept that it is safer and reduces the risk of hematomas. We also believe that the tear trough region, being an area void of big vessels, is inherently a safe area to inject. We thank again Dr. Burroughs for his insight into this topic and for allowing us to further discuss the use of calcium hydroxylapatite in the rejuvenation of the periocular region.
Marco Carifi, M.D. Monica Morandi Gianluca Carifi, M.D. Correspondence: Marco Carifi, M.D., Department of Otolaryngology, Azienda Ospedaliera di Rilievo Nazionale “A. Cardarelli” (A.O.R.N. “A. Cardarelli”), Via Antonio Cardarelli 9, 80131 Naples, Italy ([email protected]) The authors have no financial or conflicts of interest to disclose
REFERENCES
The authors have no financial or conflicts of interest to disclose.
1. Kamal S, Ali MJ, Naik MN. Circumostial injection of mitomycin C (COS-MMC) in external and endoscopic dacryocystorhinostomy: efficacy, safety profile, and outcomes. Ophthal Plast Reconstr Surg 2014;30:187–90. 2. Chan W, Malhotra R, Kakizaki H, et al. Perspective: what does the term functional mean in the context of epiphora? Clin Experiment Ophthalmol 2012;40:749–54. 3. Cho WK, Paik JS, Yang SW. Surgical success rate comparison in functional nasolacrimal duct obstruction: simple lacrimal stent versus endoscopic versus external dacryocystorhinostomy. Eur Arch Otorhinolaryngol 2013;270:535–40. 4. Feng YF, Cai JQ, Zhang JY, et al. A meta-analysis of primary dacryocystorhinostomy with and without silicone intubation. Can J Ophthalmol 2011;46:521–7. 5. Mohamad SH, Khan I, Shakeel M, et al. Long-term results of endonasal dacryocystorhinostomy with and without stenting. Ann R Coll Surg Engl 2013;95:196–9. 6. Yigit O, Samancioglu M, Taskin U, et al. External and endoscopic dacryocystorhinostomy in chronic dacryocystitis: comparison of results. Eur Arch Otorhinolaryngol 2007;264:879–85. 7. Elmorsy SM, Fayk HM. Nasal endoscopic assessment of failure after external dacryocystorhinostomy. Orbit 2010;29:197–201.
Re: Use of Mitomycin C in Dacryocystorhinostomies
Reply re: “Use of Mitomycin C in Dacryocystorhinostomies”
To the Editor: We were interested in the recent article from Kamal et al.1 regarding the use of mitomycin C during dacryocystorhinostomy. We read that patients diagnosed with epiphora secondary to different etiopathogenesis were enrolled, including patients undergoing surgery following previous surgical failure (redo dacryocystorhinostomy). Moreover, both external and endonasal approaches were performed, and the authors wanted to clarify the criteria they adopted to choose the type of surgical procedure. Although the study reports on the authors’ experience in the time period they investigated, we fear that the information provided may be of limited clinical interest. In fact, the case-mix might be different in other settings or even at the authors’ institution in a different time period. The specific etiopathogenesis of the nasolacrimal duct obstruction, the surgical approach (external versus endonasal), the application of a stent, and whether the case is naïve or a redo are important prognostic factors.2–6 The reliability of the reported outcomes might have also been affected by the follow-up length, which was very short for a considerable proportion of the studied patients. Lastly, mitomycin C injections were performed all around the ostium and its morphology assessed as a outcome measure of functional success; however, it would be important to read details regarding the ostium area, which has been reported to directly relate to the likelihood of success of dacryocystorhinostomy procedures.7
To the Editor: We appreciate Drs Carifi and Morandi for their interest in a surgical technique we had recently described1 regarding the use of mitomycin C in dacryocystorhinostomy. Many of the queries raised have already been discussed within the article; however, we thank the authors for this opportunity to redress certain important issues in greater detail. While we agree with the fact that the patient group was heterogeneous with different approaches, the significance of such consecutive patient inclusion with regard to clinical practice implications cannot be entirely discredited. The letter later mentions, “In fact the case-mix might be different in other settings.” This we believe is a contradictory statement to the query raised itself and precisely answers why we chose a case-mix that spanned the spectrum of varied etiopathologies and approaches. In addition, a subset analysis of each end of this spectrum has been provided, facilitating surgeons to draw their own conclusions based on the subset(s) most frequently encountered in their clinical practice. The patients had a minimum follow up of 6 months following stent removal, which was performed at 3 months following surgery. In essence, the follow up was 9 months postsurgery, which is very much acceptable as an adequate follow up in lacrimal literature.2,3 We believe it would be inappropriate for the authors to directly correlate the ostium area to the success of dacryocystorhinostomy since it is not evidence based and there are numerous
Martin H. Devoto, Francesco P. Bernardini, Altug Cetinkaya, Alessandra Zambelli,
M.D. M.D. M.D. M.D.
Correspondence: Martin H. Devoto, M.D., Consultores Oftalmológicos, Arenales 1611, Piso 4, 1061 Buenos Aires, Argentina ([email protected])
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
441
Ophthal Plast Reconstr Surg, Vol. 30, No. 5, 2014
Letters to the Editor
opinions to the contrary.4,5 The reference provided (Elmorsy and Fayk6) by them to support this correlation has neither studied ostium areas nor do their results discuss such measurements. On the contrary, Elmorsy and Fayk,6 based on their study, discussed a proposal to define 6 months postsurgery as an adequate follow up for a dacryocystorhinostomy surgery.
Mohammad Javed Ali M.D., F.R.C.S. Saurabh Kamal, M.D. Milind N. Naik, M.D. Correspondence: Mohammad Javed Ali, M.D., F.R.C.S., Dacryology Service, Ophthalmic Plastics Surgery, L.V. Prasad Eye Institute, Road No. 2, Banjara Hills, Hyderabad 500034, India ([email protected]) The authors have no financial or conflicts of interest to disclose. This study has been reviewed by the ethics committee and has been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki.
REFERENCES 1. Kamal S, Ali MJ, Naik MN. Circumostial injection of mitomycin C (COS-MMC) in external and endoscopic dacryocystorhinostomy: efficacy, safety profile, and outcomes. Ophthal Plast Reconstr Surg 2014;30:187–90. 2. Leong SC, Karkos PD, Burgess P, et al. A comparison of outcomes between nonlaser endoscopic endonasal and external dacryocystorhinostomy: single-center experience and a review of British trends. Am J Otolaryngol 2010;31:32–7. 3. Malhotra R, Wright M, Olver JM. A consideration of the time taken to do dacryo-cystorhinostomy (DCR) surgery. Eye (Lond) 2003;17:691–6. 4. Yazici B, Yazici Z. Final nasolacrimal ostium after external dacryocystorhinostomy. Arch Ophthalmol 2003;121:76–80. 5. Ben Simon GJ, Brown C, McNab AA. Larger osteotomies result in larger ostia in external dacryocystorhinostomies. Arch Facial Plast Surg 2012;14:127–31. 6. Elmorsy SM, Fayk HM. Nasal endoscopic assessment of failure after external dacryocystorhinostomy. Orbit 2010;29:197–201.
Re: “Novel Technique to Appose Flaps Using the BioGlue in the External Dacryocystorhinostomy” To the Editor: I read with interest the article by Jung et al.1 about the use of BioGlue in external dacryocystorhinostomy. I congratulate the authors on this novel work. However, I would like to document a few of my observations. Although rare but the use of bovine serum can give rise to allergic reactions.2,3 The authors did not find any such reactions in their cohort, but the readers would benefit if they know what were the precautions taken in anticipation of such an eventuality. The use of glutaraldehyde is a safety concern. The in vivo toxic effects are well known, and the release of this chemical from polymerized glue can have potential risk4 to the nasal mucosa itself other than that of the ostium in the vicinity. While I can agree with the possibility of its use with fragile flaps, the conclusion with regard to intraoperative hemostasis appears farfetched. This advantage should be compared only for the flap apposition step and not overall. There is hardly any hemostasis issues arising out of suturing the flaps during a
442
regular surgery.5 Additionally, if there was no significant time difference between suturing and glue, we wonder where its overall advantage stands. If there is not much advantage, why should we levy an additional 500$ burden on the health care system and contribute to the already rising health-care cost?
Mohammad Javed Ali, M.D., F.R.C.S. Correspondence: Mohammad Javed Ali, M.D., F.R.C.S., Dacryology Services, L.V. Prasad Eye Institute, Banjara Hills, Hyderabad 500034, India ([email protected]) The authors have no financial or conflicts of interest to disclose.
REFERENCES 1. Jung H, Kim J, Kim SC, et al. Novel technique to appose flaps using the BioGlue in the external dacryocystorhinostomy. Ophthal Plast Reconstr Surg 2013;29:500–2. 2. Voltolini S, Spigno F, Cioè Et Al A. Bovine Serum Albumin: a double allergy risk. Eur Ann Allergy Clin Immunol 2013;45:144–7. 3. Chruszcz M, Mikolajczak K, Mank N, et al. Serum albumins-unusual allergens. Biochim Biophys Acta 2013;1830:5375–81. 4. Fürst W, Banerjee A. Release of glutaraldehyde from an albuminglutaraldehyde tissue adhesive causes significant in vitro and in vivo toxicity. Ann Thorac Surg 2005;79:1522–8. 5. Ali MJ, Naik MN, Honavar SG. External dacryocystorhinostomy: tips and tricks. Oman J Ophthalmol 2012;5:191–5.
Re: “Isolated Squamous Cell Carcinoma of the Orbital Apex” To the Editor: We read with great interest the recent case series from Peckinpaugh et al.1 describing 3 cases of isolated orbital apex squamous cell carcinoma. We write to relate a similar case of our own. Our patient was a 46-year-old Caucasian man with a history of smoking and type 2 diabetes. He was referred to our Oculoplastics service by an outside Ophthalmologist, who had obtained an MRI demonstrating a left orbital mass after the patient had initially presented with signs and symptoms suggestive of an optic neuropathy. On our initial exam, visual acuities were 20/20 and 20/300 on the right and left side, respectively, with a 4+ afferent pupillary defect on the left and 3 mm proptosis on the left as compared with the right. Motility on the left showed a slight restriction in all fields of gaze. Posterior segment exam was normal, with sharp disk margins bilaterally. The MRI accompanying the patient showed a left posterior orbital lesion situated between the inferior rectus and optic nerve which was noted to be hyperintense on the T2-weighted MRI. The decision was made to proceed with left lateral orbitotomy with bone flap for excisional biopsy of the lesion, and pathologic study demonstrated moderately differentiated invasive squamous cell carcinoma. A systemic workup, including positron emission tomography scan and a full dermatologic exam, failed to identify a separate tumor source. Options discussed with the patient included chemotherapy, radiation, and orbital exenteration. The patient sought and was referred for a second opinion, after which an extensive discussion took place; the patient subsequently elected to proceed with orbital exenteration followed by local radiation. He was recently seen in a 2-year follow up, with no evidence of tumor recurrence or any sign of a separate primary tumor. As Dr. Peckinpaugh et al.1 pointed out, isolated orbital squamous cell carcinoma is rare, and a detailed systemic
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
Letters to the Editor
more homogeneous distribution of the material. The 1.5 ml content of the syringe is diluted with 0.5 ml lidocaine. This has the double purpose of making the procedure virtually painless, and facilitating the injection of a more fluid filler than the original one. It may be possible that this has helped us to avoid granuloma formation. Calcium hydroxylapatite (Radiesse) is indeed a powerful filler for the correction of periorbital hollows, dark circles, and lower eyelid bags. We have stated in our report that the advantage of this material is not limited to the absence of Tyndall effect, but more importantly that it avoids the risks of eyelid and malar edema inherent to the hydrophilic nature of any HA filler. Finally, its white color has a distinct advantage in improving dark circles. Concerning the advantages of cannulas, we agree with the concept that it is safer and reduces the risk of hematomas. We also believe that the tear trough region, being an area void of big vessels, is inherently a safe area to inject. We thank again Dr. Burroughs for his insight into this topic and for allowing us to further discuss the use of calcium hydroxylapatite in the rejuvenation of the periocular region.
Marco Carifi, M.D. Monica Morandi Gianluca Carifi, M.D. Correspondence: Marco Carifi, M.D., Department of Otolaryngology, Azienda Ospedaliera di Rilievo Nazionale “A. Cardarelli” (A.O.R.N. “A. Cardarelli”), Via Antonio Cardarelli 9, 80131 Naples, Italy ([email protected]) The authors have no financial or conflicts of interest to disclose
REFERENCES
The authors have no financial or conflicts of interest to disclose.
1. Kamal S, Ali MJ, Naik MN. Circumostial injection of mitomycin C (COS-MMC) in external and endoscopic dacryocystorhinostomy: efficacy, safety profile, and outcomes. Ophthal Plast Reconstr Surg 2014;30:187–90. 2. Chan W, Malhotra R, Kakizaki H, et al. Perspective: what does the term functional mean in the context of epiphora? Clin Experiment Ophthalmol 2012;40:749–54. 3. Cho WK, Paik JS, Yang SW. Surgical success rate comparison in functional nasolacrimal duct obstruction: simple lacrimal stent versus endoscopic versus external dacryocystorhinostomy. Eur Arch Otorhinolaryngol 2013;270:535–40. 4. Feng YF, Cai JQ, Zhang JY, et al. A meta-analysis of primary dacryocystorhinostomy with and without silicone intubation. Can J Ophthalmol 2011;46:521–7. 5. Mohamad SH, Khan I, Shakeel M, et al. Long-term results of endonasal dacryocystorhinostomy with and without stenting. Ann R Coll Surg Engl 2013;95:196–9. 6. Yigit O, Samancioglu M, Taskin U, et al. External and endoscopic dacryocystorhinostomy in chronic dacryocystitis: comparison of results. Eur Arch Otorhinolaryngol 2007;264:879–85. 7. Elmorsy SM, Fayk HM. Nasal endoscopic assessment of failure after external dacryocystorhinostomy. Orbit 2010;29:197–201.
Re: Use of Mitomycin C in Dacryocystorhinostomies
Reply re: “Use of Mitomycin C in Dacryocystorhinostomies”
To the Editor: We were interested in the recent article from Kamal et al.1 regarding the use of mitomycin C during dacryocystorhinostomy. We read that patients diagnosed with epiphora secondary to different etiopathogenesis were enrolled, including patients undergoing surgery following previous surgical failure (redo dacryocystorhinostomy). Moreover, both external and endonasal approaches were performed, and the authors wanted to clarify the criteria they adopted to choose the type of surgical procedure. Although the study reports on the authors’ experience in the time period they investigated, we fear that the information provided may be of limited clinical interest. In fact, the case-mix might be different in other settings or even at the authors’ institution in a different time period. The specific etiopathogenesis of the nasolacrimal duct obstruction, the surgical approach (external versus endonasal), the application of a stent, and whether the case is naïve or a redo are important prognostic factors.2–6 The reliability of the reported outcomes might have also been affected by the follow-up length, which was very short for a considerable proportion of the studied patients. Lastly, mitomycin C injections were performed all around the ostium and its morphology assessed as a outcome measure of functional success; however, it would be important to read details regarding the ostium area, which has been reported to directly relate to the likelihood of success of dacryocystorhinostomy procedures.7
To the Editor: We appreciate Drs Carifi and Morandi for their interest in a surgical technique we had recently described1 regarding the use of mitomycin C in dacryocystorhinostomy. Many of the queries raised have already been discussed within the article; however, we thank the authors for this opportunity to redress certain important issues in greater detail. While we agree with the fact that the patient group was heterogeneous with different approaches, the significance of such consecutive patient inclusion with regard to clinical practice implications cannot be entirely discredited. The letter later mentions, “In fact the case-mix might be different in other settings.” This we believe is a contradictory statement to the query raised itself and precisely answers why we chose a case-mix that spanned the spectrum of varied etiopathologies and approaches. In addition, a subset analysis of each end of this spectrum has been provided, facilitating surgeons to draw their own conclusions based on the subset(s) most frequently encountered in their clinical practice. The patients had a minimum follow up of 6 months following stent removal, which was performed at 3 months following surgery. In essence, the follow up was 9 months postsurgery, which is very much acceptable as an adequate follow up in lacrimal literature.2,3 We believe it would be inappropriate for the authors to directly correlate the ostium area to the success of dacryocystorhinostomy since it is not evidence based and there are numerous
Martin H. Devoto, Francesco P. Bernardini, Altug Cetinkaya, Alessandra Zambelli,
M.D. M.D. M.D. M.D.
Correspondence: Martin H. Devoto, M.D., Consultores Oftalmológicos, Arenales 1611, Piso 4, 1061 Buenos Aires, Argentina ([email protected])
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
441
Ophthal Plast Reconstr Surg, Vol. 30, No. 5, 2014
Letters to the Editor
opinions to the contrary.4,5 The reference provided (Elmorsy and Fayk6) by them to support this correlation has neither studied ostium areas nor do their results discuss such measurements. On the contrary, Elmorsy and Fayk,6 based on their study, discussed a proposal to define 6 months postsurgery as an adequate follow up for a dacryocystorhinostomy surgery.
Mohammad Javed Ali M.D., F.R.C.S. Saurabh Kamal, M.D. Milind N. Naik, M.D. Correspondence: Mohammad Javed Ali, M.D., F.R.C.S., Dacryology Service, Ophthalmic Plastics Surgery, L.V. Prasad Eye Institute, Road No. 2, Banjara Hills, Hyderabad 500034, India ([email protected]) The authors have no financial or conflicts of interest to disclose. This study has been reviewed by the ethics committee and has been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki.
REFERENCES 1. Kamal S, Ali MJ, Naik MN. Circumostial injection of mitomycin C (COS-MMC) in external and endoscopic dacryocystorhinostomy: efficacy, safety profile, and outcomes. Ophthal Plast Reconstr Surg 2014;30:187–90. 2. Leong SC, Karkos PD, Burgess P, et al. A comparison of outcomes between nonlaser endoscopic endonasal and external dacryocystorhinostomy: single-center experience and a review of British trends. Am J Otolaryngol 2010;31:32–7. 3. Malhotra R, Wright M, Olver JM. A consideration of the time taken to do dacryo-cystorhinostomy (DCR) surgery. Eye (Lond) 2003;17:691–6. 4. Yazici B, Yazici Z. Final nasolacrimal ostium after external dacryocystorhinostomy. Arch Ophthalmol 2003;121:76–80. 5. Ben Simon GJ, Brown C, McNab AA. Larger osteotomies result in larger ostia in external dacryocystorhinostomies. Arch Facial Plast Surg 2012;14:127–31. 6. Elmorsy SM, Fayk HM. Nasal endoscopic assessment of failure after external dacryocystorhinostomy. Orbit 2010;29:197–201.
Re: “Novel Technique to Appose Flaps Using the BioGlue in the External Dacryocystorhinostomy” To the Editor: I read with interest the article by Jung et al.1 about the use of BioGlue in external dacryocystorhinostomy. I congratulate the authors on this novel work. However, I would like to document a few of my observations. Although rare but the use of bovine serum can give rise to allergic reactions.2,3 The authors did not find any such reactions in their cohort, but the readers would benefit if they know what were the precautions taken in anticipation of such an eventuality. The use of glutaraldehyde is a safety concern. The in vivo toxic effects are well known, and the release of this chemical from polymerized glue can have potential risk4 to the nasal mucosa itself other than that of the ostium in the vicinity. While I can agree with the possibility of its use with fragile flaps, the conclusion with regard to intraoperative hemostasis appears farfetched. This advantage should be compared only for the flap apposition step and not overall. There is hardly any hemostasis issues arising out of suturing the flaps during a
442
regular surgery.5 Additionally, if there was no significant time difference between suturing and glue, we wonder where its overall advantage stands. If there is not much advantage, why should we levy an additional 500$ burden on the health care system and contribute to the already rising health-care cost?
Mohammad Javed Ali, M.D., F.R.C.S. Correspondence: Mohammad Javed Ali, M.D., F.R.C.S., Dacryology Services, L.V. Prasad Eye Institute, Banjara Hills, Hyderabad 500034, India ([email protected]) The authors have no financial or conflicts of interest to disclose.
REFERENCES 1. Jung H, Kim J, Kim SC, et al. Novel technique to appose flaps using the BioGlue in the external dacryocystorhinostomy. Ophthal Plast Reconstr Surg 2013;29:500–2. 2. Voltolini S, Spigno F, Cioè Et Al A. Bovine Serum Albumin: a double allergy risk. Eur Ann Allergy Clin Immunol 2013;45:144–7. 3. Chruszcz M, Mikolajczak K, Mank N, et al. Serum albumins-unusual allergens. Biochim Biophys Acta 2013;1830:5375–81. 4. Fürst W, Banerjee A. Release of glutaraldehyde from an albuminglutaraldehyde tissue adhesive causes significant in vitro and in vivo toxicity. Ann Thorac Surg 2005;79:1522–8. 5. Ali MJ, Naik MN, Honavar SG. External dacryocystorhinostomy: tips and tricks. Oman J Ophthalmol 2012;5:191–5.
Re: “Isolated Squamous Cell Carcinoma of the Orbital Apex” To the Editor: We read with great interest the recent case series from Peckinpaugh et al.1 describing 3 cases of isolated orbital apex squamous cell carcinoma. We write to relate a similar case of our own. Our patient was a 46-year-old Caucasian man with a history of smoking and type 2 diabetes. He was referred to our Oculoplastics service by an outside Ophthalmologist, who had obtained an MRI demonstrating a left orbital mass after the patient had initially presented with signs and symptoms suggestive of an optic neuropathy. On our initial exam, visual acuities were 20/20 and 20/300 on the right and left side, respectively, with a 4+ afferent pupillary defect on the left and 3 mm proptosis on the left as compared with the right. Motility on the left showed a slight restriction in all fields of gaze. Posterior segment exam was normal, with sharp disk margins bilaterally. The MRI accompanying the patient showed a left posterior orbital lesion situated between the inferior rectus and optic nerve which was noted to be hyperintense on the T2-weighted MRI. The decision was made to proceed with left lateral orbitotomy with bone flap for excisional biopsy of the lesion, and pathologic study demonstrated moderately differentiated invasive squamous cell carcinoma. A systemic workup, including positron emission tomography scan and a full dermatologic exam, failed to identify a separate tumor source. Options discussed with the patient included chemotherapy, radiation, and orbital exenteration. The patient sought and was referred for a second opinion, after which an extensive discussion took place; the patient subsequently elected to proceed with orbital exenteration followed by local radiation. He was recently seen in a 2-year follow up, with no evidence of tumor recurrence or any sign of a separate primary tumor. As Dr. Peckinpaugh et al.1 pointed out, isolated orbital squamous cell carcinoma is rare, and a detailed systemic
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
