- Email: [email protected]
Surgical management of Centurion syndrome
Correspondence Meesmann’s corneal dystrophy is a mildly symptomatic, autosomal dominant, inherited condition characterized by microcysts in the anterior corneal epithelium. It reflects mutation of either the KRT3 or KRT12 genes, which encode for cytokeratins K3 and K12, expressed solely in the cornea.3 An abnormal cytokeratin K3 or K12 protein leads to instability of the cytoskeleton of the corneal epithelial cells.3 Accumulation of degenerated tonofilaments of the cytoskeleton contributes to the electron-dense “peculiar substance” that is characteristic of Meesmann’s corneal dystrophy.4 Eventually, degenerated cells result in epithelial cyst formation and cellular debris, which may correspond to the hyperreflective material within the cysts that were identified on confocal microscopy (Fig. 1B).5 Furthermore, the fragile epithelium may lead to recurrent corneal erosions, and basement membrane dystrophy is often observed with Meesmann’s corneal dystrophy.2,5 In our case, the clinical presentation of Meesmann’s corneal dystrophy correlated with the findings on confocal, light, and electron microscopy. Only 2 papers, which did not include histologic examination, reported on the in vivo confocal microscopic findings of Meesmann’s corneal dystrophy.5 To the best of our knowledge, this is the first reported case using an epithelial delaminator to remove the epithelium. This method is safe for the patient, preserves the structure of the excised tissue, and is a useful addition in the armamentarium for managing Meesmann’s corneal dystrophy. The authors thank Jeffrey McClintock, MSc, for his technical assistance with the electron microscopy. The authors have no proprietary interest in any aspect of this article.
Surgical management of Centurion syndrome
C
enturion syndrome refers to an anterior displacement of the medial canthal tendon, a prominent nasal bridge, and displacement of the lacrimal punctum away from the lacrimal lake.1 The release of the most anterior attachment of the anterior medial canthal tendon is the usual procedure for relief of the associated epiphora.1–4 A 33-year-old male presented with epiphora in his right eye over the previous 10–15 years. Various ephitheliectomies of the puncta and a lateral tarsal strip procedure showed no resolution. A separation of the medial right lower lid of the globe and displacement of the lacrimal puncta forward out of the tear lake were observable (Fig. 1A). A prominent nasal bridge was also noted. This observation was suggestive of Centurion syndrome. An anterior medial canthal tendon release and suture to the periosteum of the anterior lacrimal crest were then performed. The eyelid was correctly appositioned, but the puncta continued to be displaced forward, and the epiphora persisted (Fig. 1B). Finally, the patient underwent a plication of the lower eyelid retractor (Fig. 1C). The punctum rotated to the lacrimal lake, and the epiphora disappeared (Fig. 1D). Improvement persisted through 10 months of postoperative follow-up. Fifteen percent of cases of Centurion syndrome may be unilateral.1 The lateral strip procedure improved the lid–globe apposition, but the puncta continued forward out of the lake. This antecedent made the diagnosis difficult when the patient visited our service. The medial canthal tendon release and plication of the tendon stump posterior to the periosteum of the lacrimal fossa for lid–eye apposition
REFERENCES 1. Fine BS, Yanoff M, Pitts E, Slaughter FD. Meesmann’s epithelial dystrophy of the cornea. Am J Ophthalmol 1977;83:633–42. 2. Waring GO 3rd, Rodrigues MM, Laibson PR. Corneal dystrophies. I. Dystrophies of the epithelium, Bowman’s layer and stroma. Surv Ophthalmol 1978;23:71–122. 3. Chen YT, Tseng SH, Chao SC. Novel mutations in the helix termination motif of keratin 3 and keratin 12 in 2 Taiwanese families with Meesmann corneal dystrophy. Cornea 2005;24:928–32. 4. Tremblay M, Dube I. Meesmann’s corneal dystrophy: ultrastructural features. Can J Ophthalmol 1982;17:24–8. 5. Patel DV, Grupcheva CN, McGhee CN. Imaging the microstructural abnormalities of Meesmann corneal dystrophy by in vivo confocal microscopy. Cornea 2005;24:669–73.
Patrick Gooi,* † Seymour Brownstein,* † W. Bruce Jackson,* George Mintsioulis* * Department of Ophthalmology, University of Ottawa Eye Institute and The Ottawa Hospital, Ottawa, Ontario; and †Department of Pathology, University of Ottawa and The Ottawa Hospital, Ottawa, Ontario Correspondence to: Seymour Brownstein, MD; [email protected] Can J Ophthalmol 2007;42:878–9 doi:10.3129.i07-168
Fig. 1—(A) Periocular eczema by tear irritation. Separation of the medial right lower lid of the globe and persistent displacement of the lacrimal puncta forward out of the tear lake after a lateral tarsal strip procedure. (B) Inferior eyelid correctly appositioned with respect to the globus, but the puncta continued forward out of the tear lake after anterior medial canthal tendon release and excision of a diamond of tarsoconjunctiva. (C) Localization of the lower eyelid retractor through conjunctival approach. (D) Disappearance of the periocular eczemas. Rotated punctum to the lacrimal lake after plication of the lower eyelid retractor. CAN J OPHTHALMOL—VOL. 42, NO. 6, 2007
879
Correspondence was proposed for epiphora relief.1,3 However, total improvement has also been observed without posterior plication of the tendon.2 We observed the restoration of lid–eye apposition with the posterior plication of the medial canthal tendon to the lacrimal crest, but the puncta remained forward with persistent epiphora. Lower eyelid retractor plication has been added concurrently with anterior medial canthal tendon release in the treatment of this anomaly.4 We observed total epiphora relief after this second procedure. In conclusion, the anterior medial canthal tendon release restores the lid–globe apposition but not the retrodisplacement of the puncta, which requires a lower eyelid retractor plication for Centurion syndrome correction. REFERENCES 1. Sullivan TJ, Welham RAN, Collin JRO. Centurion syndrome. Idiopathic anterior displacement of the medial canthus. Ophthalmology 1993;100:328–33. 2. Sujatha Y, Sathish S, Stewart WB. Centurion syndrome and its surgical management. Ophthal Plast Reconstr Surg 1999;15: 243–4. 3. Ma’luf RN, Bashshur ZF, Noureddin BN. Anterior canthal tendon release for correction of the Centurion syndrome. Ophthal Plast Reconstr Surg 2003;19:446–8. 4. Chang JH, O’Donnell BA. Medial canthal tendon release and lower eyelid retractor plication for Centurion syndrome. Clin Experiment Ophthalmol 2006;34:284–5.
Valentín Huerva,* M. Carmen Sánchez,* Luisa M. Canto† *Department of Ophthalmology, University Hospital Arnau de Vilanova, Lleida, Spain; and †Department of Ophthalmology, Santa María Hospital, Lleida, Spain Correspondence to: Valentín Huerva, MD, PhD; [email protected] Can J Ophthalmol 2007;42:879–80 doi:10.3129/i07-166
Alcohol as an alternative therapy in accommodative and convergence insufficiency
A
ccommodative and convergence insufficiency is a heterogeneous disease often associated with functional disorders, but is sometimes also associated with neurological disorders, such as dorsal midbrain infarction or hemorrhage and parkinsonism.1 It can also be related to infectious diseases or autoimmune diseases, or be caused by diabetes, botulism, or chronic alcohol abuse. Although accommodative and convergence insufficiency is quite common, therapy is controversial and often frustrating. In such cases of missing associations, reading glasses and base-in prism glasses, as well as orthoptic exercises and psychotherapy, are therapeutically promising.2 Surgical procedures, especially in cases with accompanying exodeviation, have also been shown to be succesful.3 We report on a 25-year-old woman with a 10-year
880
CAN J OPHTHALMOL—VOL. 42, NO. 6, 2007
history of accommodative and convergence insufficiency, who for several years had suffered from asthenopic symptoms. She recognized distinct improvement after having sex and after drinking a small amount of alcohol (0.15 L beer). We were able to rule out organic causes, and even magnetic resonance imaging revealed no abnormalities. Treatments, such as reading or base-in prism glasses, and orthoptic exercises did not show any long-lasting effect. Even a unilateral medial rectus folding for exotropia of the convergence insufficiency type was unsatisfactory. On admission, we confirmed the “alcohol therapy” with the same amount of a common type of beer: convergence and accommodation were almost normal. The effect lasted about 6 hours. Placebo, administrated as a mild “chemical alcohol”, did not work. A low dose (40 mg) of propanol (a true chemical alcohol) was also effective. The etiology of accommodative and convergence insufficiency is not yet fully understood even though the pathway has been identified, for the most part, in both monkeys and humans, and the cerebral cortical accommodation and convergence center in the midbrain has been shown to project into the bilateral oculomotor nuclei.4,5 However, therapy is often not successful, and patients’ symptoms are troublesome and sometimes increasing. This may justify efforts to develop alternative therapies, even those based on mechanisms that may not yet be completely clear. Surprisingly, a small amount of alcohol has been shown to be an effective therapy in accommodative and convergence insufficiency, as opposed to the impairing effect of large amounts of alcohol. REFERENCES 1. Kim JS. Internuclear ophthalmoplegia as an isolated or predominant symptom of brainstem infarction. Neurology 2004;62:1491–6. 2. Birnbaum MH, Soden R, Cohen AH. Efficacy of vision therapy for convergence insufficiency in an adult male population. J Am Optom Assoc 1999;70:225–32. 3. Choi MY, Hwang JM. The long-term result of slanted medial rectus resection in exotropia of the convergence insufficiency type. Eye 2006;20:1279–83. 4. Judge SJ, Cumming BG. Neurons in the monkey midbrain with activity related to vergence eye movement and accommodation. J Neurophysiol 1986;55:915–30. 5. Ohtsuka K, Maekawa H, Takeda M, Ueda N, Chiba S. Accommodation and convergence insufficiency with left middle cerebral artery occlusion. Am J Ophthalmol 1988;106:60–4.
Veit Sturm,* † Roland W. Berger,† Wolfgang H. Zangemeister‡ *Department of Ophthalmology, University Hospital of Zurich, Switzerland; and †Department of Ophthalmology and ‡Department of Neurology, University Hospital of Hamburg, Germany Correspondence to: Veit Sturm, MD; [email protected] Can J Ophthalmol 2007;42:880 doi:10.3129/i07-164
Surgical management of Centurion syndrome
C
enturion syndrome refers to an anterior displacement of the medial canthal tendon, a prominent nasal bridge, and displacement of the lacrimal punctum away from the lacrimal lake.1 The release of the most anterior attachment of the anterior medial canthal tendon is the usual procedure for relief of the associated epiphora.1–4 A 33-year-old male presented with epiphora in his right eye over the previous 10–15 years. Various ephitheliectomies of the puncta and a lateral tarsal strip procedure showed no resolution. A separation of the medial right lower lid of the globe and displacement of the lacrimal puncta forward out of the tear lake were observable (Fig. 1A). A prominent nasal bridge was also noted. This observation was suggestive of Centurion syndrome. An anterior medial canthal tendon release and suture to the periosteum of the anterior lacrimal crest were then performed. The eyelid was correctly appositioned, but the puncta continued to be displaced forward, and the epiphora persisted (Fig. 1B). Finally, the patient underwent a plication of the lower eyelid retractor (Fig. 1C). The punctum rotated to the lacrimal lake, and the epiphora disappeared (Fig. 1D). Improvement persisted through 10 months of postoperative follow-up. Fifteen percent of cases of Centurion syndrome may be unilateral.1 The lateral strip procedure improved the lid–globe apposition, but the puncta continued forward out of the lake. This antecedent made the diagnosis difficult when the patient visited our service. The medial canthal tendon release and plication of the tendon stump posterior to the periosteum of the lacrimal fossa for lid–eye apposition
REFERENCES 1. Fine BS, Yanoff M, Pitts E, Slaughter FD. Meesmann’s epithelial dystrophy of the cornea. Am J Ophthalmol 1977;83:633–42. 2. Waring GO 3rd, Rodrigues MM, Laibson PR. Corneal dystrophies. I. Dystrophies of the epithelium, Bowman’s layer and stroma. Surv Ophthalmol 1978;23:71–122. 3. Chen YT, Tseng SH, Chao SC. Novel mutations in the helix termination motif of keratin 3 and keratin 12 in 2 Taiwanese families with Meesmann corneal dystrophy. Cornea 2005;24:928–32. 4. Tremblay M, Dube I. Meesmann’s corneal dystrophy: ultrastructural features. Can J Ophthalmol 1982;17:24–8. 5. Patel DV, Grupcheva CN, McGhee CN. Imaging the microstructural abnormalities of Meesmann corneal dystrophy by in vivo confocal microscopy. Cornea 2005;24:669–73.
Patrick Gooi,* † Seymour Brownstein,* † W. Bruce Jackson,* George Mintsioulis* * Department of Ophthalmology, University of Ottawa Eye Institute and The Ottawa Hospital, Ottawa, Ontario; and †Department of Pathology, University of Ottawa and The Ottawa Hospital, Ottawa, Ontario Correspondence to: Seymour Brownstein, MD; [email protected] Can J Ophthalmol 2007;42:878–9 doi:10.3129.i07-168
Fig. 1—(A) Periocular eczema by tear irritation. Separation of the medial right lower lid of the globe and persistent displacement of the lacrimal puncta forward out of the tear lake after a lateral tarsal strip procedure. (B) Inferior eyelid correctly appositioned with respect to the globus, but the puncta continued forward out of the tear lake after anterior medial canthal tendon release and excision of a diamond of tarsoconjunctiva. (C) Localization of the lower eyelid retractor through conjunctival approach. (D) Disappearance of the periocular eczemas. Rotated punctum to the lacrimal lake after plication of the lower eyelid retractor. CAN J OPHTHALMOL—VOL. 42, NO. 6, 2007
879
Correspondence was proposed for epiphora relief.1,3 However, total improvement has also been observed without posterior plication of the tendon.2 We observed the restoration of lid–eye apposition with the posterior plication of the medial canthal tendon to the lacrimal crest, but the puncta remained forward with persistent epiphora. Lower eyelid retractor plication has been added concurrently with anterior medial canthal tendon release in the treatment of this anomaly.4 We observed total epiphora relief after this second procedure. In conclusion, the anterior medial canthal tendon release restores the lid–globe apposition but not the retrodisplacement of the puncta, which requires a lower eyelid retractor plication for Centurion syndrome correction. REFERENCES 1. Sullivan TJ, Welham RAN, Collin JRO. Centurion syndrome. Idiopathic anterior displacement of the medial canthus. Ophthalmology 1993;100:328–33. 2. Sujatha Y, Sathish S, Stewart WB. Centurion syndrome and its surgical management. Ophthal Plast Reconstr Surg 1999;15: 243–4. 3. Ma’luf RN, Bashshur ZF, Noureddin BN. Anterior canthal tendon release for correction of the Centurion syndrome. Ophthal Plast Reconstr Surg 2003;19:446–8. 4. Chang JH, O’Donnell BA. Medial canthal tendon release and lower eyelid retractor plication for Centurion syndrome. Clin Experiment Ophthalmol 2006;34:284–5.
Valentín Huerva,* M. Carmen Sánchez,* Luisa M. Canto† *Department of Ophthalmology, University Hospital Arnau de Vilanova, Lleida, Spain; and †Department of Ophthalmology, Santa María Hospital, Lleida, Spain Correspondence to: Valentín Huerva, MD, PhD; [email protected] Can J Ophthalmol 2007;42:879–80 doi:10.3129/i07-166
Alcohol as an alternative therapy in accommodative and convergence insufficiency
A
ccommodative and convergence insufficiency is a heterogeneous disease often associated with functional disorders, but is sometimes also associated with neurological disorders, such as dorsal midbrain infarction or hemorrhage and parkinsonism.1 It can also be related to infectious diseases or autoimmune diseases, or be caused by diabetes, botulism, or chronic alcohol abuse. Although accommodative and convergence insufficiency is quite common, therapy is controversial and often frustrating. In such cases of missing associations, reading glasses and base-in prism glasses, as well as orthoptic exercises and psychotherapy, are therapeutically promising.2 Surgical procedures, especially in cases with accompanying exodeviation, have also been shown to be succesful.3 We report on a 25-year-old woman with a 10-year
880
CAN J OPHTHALMOL—VOL. 42, NO. 6, 2007
history of accommodative and convergence insufficiency, who for several years had suffered from asthenopic symptoms. She recognized distinct improvement after having sex and after drinking a small amount of alcohol (0.15 L beer). We were able to rule out organic causes, and even magnetic resonance imaging revealed no abnormalities. Treatments, such as reading or base-in prism glasses, and orthoptic exercises did not show any long-lasting effect. Even a unilateral medial rectus folding for exotropia of the convergence insufficiency type was unsatisfactory. On admission, we confirmed the “alcohol therapy” with the same amount of a common type of beer: convergence and accommodation were almost normal. The effect lasted about 6 hours. Placebo, administrated as a mild “chemical alcohol”, did not work. A low dose (40 mg) of propanol (a true chemical alcohol) was also effective. The etiology of accommodative and convergence insufficiency is not yet fully understood even though the pathway has been identified, for the most part, in both monkeys and humans, and the cerebral cortical accommodation and convergence center in the midbrain has been shown to project into the bilateral oculomotor nuclei.4,5 However, therapy is often not successful, and patients’ symptoms are troublesome and sometimes increasing. This may justify efforts to develop alternative therapies, even those based on mechanisms that may not yet be completely clear. Surprisingly, a small amount of alcohol has been shown to be an effective therapy in accommodative and convergence insufficiency, as opposed to the impairing effect of large amounts of alcohol. REFERENCES 1. Kim JS. Internuclear ophthalmoplegia as an isolated or predominant symptom of brainstem infarction. Neurology 2004;62:1491–6. 2. Birnbaum MH, Soden R, Cohen AH. Efficacy of vision therapy for convergence insufficiency in an adult male population. J Am Optom Assoc 1999;70:225–32. 3. Choi MY, Hwang JM. The long-term result of slanted medial rectus resection in exotropia of the convergence insufficiency type. Eye 2006;20:1279–83. 4. Judge SJ, Cumming BG. Neurons in the monkey midbrain with activity related to vergence eye movement and accommodation. J Neurophysiol 1986;55:915–30. 5. Ohtsuka K, Maekawa H, Takeda M, Ueda N, Chiba S. Accommodation and convergence insufficiency with left middle cerebral artery occlusion. Am J Ophthalmol 1988;106:60–4.
Veit Sturm,* † Roland W. Berger,† Wolfgang H. Zangemeister‡ *Department of Ophthalmology, University Hospital of Zurich, Switzerland; and †Department of Ophthalmology and ‡Department of Neurology, University Hospital of Hamburg, Germany Correspondence to: Veit Sturm, MD; [email protected] Can J Ophthalmol 2007;42:880 doi:10.3129/i07-164