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Prospective Evaluation of the Argon Laser Treatment of Trachomatous Trichiasis
BRIEF COMMUNICATION
Prospective Evaluation of the Argon Laser Treatment of Trachomatous Trichiasis Kaan Ünlü, Ahmet Aksünger, Sevin Söker, Candan Karaca and Kubilay Bilek Department of Ophthalmology, University of Dicle School of Medicine, Diyarbakır, Turkey
The treatment of trichiasis with the argon laser was first reported by Berry in 1979.1 Although many studies of the treatment of trichiasis with laser have been reported since then, opinions differ about the success rate of this treatment method in the few studies involving trachomatous trichiasis.2,3 In this prospective study, we present our results with the use of argon laser photocoagulation in the treatment of trachomatous trichiasis.
Materials and Methods Purpose: To evaluate the effectiveness of argon laser photocoagulation for the treatment of trachomatous trichiasis. Methods: This report presents a prospective, non-masked study of 22 patients (36 eyelids) with trachomatous trichiasis treated with the argon laser. Each abnormal lash was treated with a beam of 50- to 200-micron spot size, for 0.2 seconds, and 1 to 1.2 watts power. In 30 lids (83.3%) infiltration anesthesia was used and in 6 lids (16.7%) no anesthesia was used. Results: Successful treatment with no evidence of recurrence was achieved in 55.5% of lids after one laser session. The remaining 44.5% of the lids required two or three sessions. The final success rate of the method was 88.9%. No complications were observed. The mean follow-up time was 10.6 months. Conclusion: Argon laser photocoagulation is an effective and safe method for the treatment of trachomatous trichiasis. Jpn J Ophthalmol 2000;44:677–679 © 2000 Japanese Ophthalmological Society Key Words: Argon laser photocoagulation, trachoma, trichiasis.
Introduction Trachoma is the greatest single cause of preventable blindness worldwide. Four hundred million people may be afflicted with this disease, 6 million of whom are blind. Characteristically, trachoma causes deep scarring of the conjunctiva that results in trichiasis, entropion, and tear deficiency. Corneal damage from trachoma is related to trichiasis, which may affect over 10% of the adults in endemic communities. The management of trichiasis includes epilation, radiotherapy, electrolysis, cryotherapy, surgery, and laser ablation. Although cryotherapy is probably the most widely used, it has some well-known side effects. Radiotherapy can result in excessive structural and functional complications. On the other hand, the rate of success of epilation and electrolysis is low. Jpn J Ophthalmol 44, 677–689 (2000) © 2000 Japanese Ophthalmological Society Published by Elsevier Science Inc.
Twenty-two patients (36 eyelids; 8 men and 14 women) with trachomatous trichiasis involving the upper lid, lower lid, or both, were recruited for the study. Trachoma was inactive in all patients (Stage IV according to MacCallan staging). The mean age of the patients was 64.9 years (range, 49–71 years). Patients with more than 10 rubbing lashes per eyelid and those who had associated entropion were not included in this study. Fifteen eyelids had previously been treated for trichiasis with repeated epilation and/or electrolysis. The remaining 21 eyelids had not undergone previous treatment. Prior to the treatment, each patient had a general ophthalmic examination. The laser treatment procedure was explained to the patient and informed consent was obtained. Initially no anesthesia was used during the procedure. If the patient could not tolerate this, the eyelid in the region of trichiasis was anesthetized by an injection of 0.3 mL or less of 2% lidocaine with 1:100,000 adrenaline. Abnormal eyelashes were ablated as follows: (1) The patient was placed at the slit-lamp of the blue-green argon laser unit and the eyelid was rotated slightly outwards to align the laser beam with the axis of the root of the rubbing lash. (2) The patient was asked to look in the direction opposite to that of the planned area of treatment. (3) The laser controls were set to a spot size of 50 m, an exposure time of 0.2 seconds and a power of 1–1.2 watts. (4) The laser aiming beam was focused at the root of each cilium to be treated. (5) The initial laser burn vaporized the eyelash and produced a small black spot at the lid margin (Figure 1). After the first 2–3 applications, a crater was created at the base of the treated lash. (6) This crater was deepened (approximately 2–2.5 mm) to destroy the whole cilia follicle with an increased spot size of 200 m. All the abnormal lashes were treated by the same technique. Antibiotic-corticosteroid ointment was applied to the eyelid margin at the conclusion of the procedure and twice a day during the next 5 days. 0021-5155/00/$–see front matter
678
Jpn J Ophthalmol Vol 44: 677–689, 2000
16) required two or three sessions. The final success rate of the method was 88.9%. Four eyelids, which had an unsatisfactory result, were treated with cryotherapy for persistent trichiasis. A satisfactory result with one treatment was achieved in 14 of the eyelids (66.7%) that had 5 or less misdirected cilia. Of the 7 lids that had an unsatisfactory results, 6 responded well to one or two additional laser treatments; the final success rate was 95.3% in this group. After one laser session the success rate was 40.0% (6 eyelids) in eyelids with more than 5 misdirected cilia. In this group, the recurrence rate was 20.0% after 3 sessions of laser treatment (Table 1). The procedure was well-tolerated by the patients. None of the patients had any general or visual complication. All the treated areas healed completely within 8 weeks after treatment without any scarring or vascularization.
Figure 1. Initial laser burns (50 m) produced small black spots and created craters.
The patients were examined 8 weeks after therapy and then every 3 months during the follow-up time. Patients were advised to come back earlier if they experienced any symptoms suggestive of recurrence. Recurrences were treated by the same method. The results of the treatment were considered satisfactory if no recurrence of trichiasis had occurred for at least 6 months after the last laser session. Recurrence after three laser sessions was considered as treatment failure.
Discussion Trichiasis is a common complication of several disorders of the eyelids that can lead to corneal damage. The epilation of the misdirected eyelashes has no morbidity but does not usually effect a permanent cure. Electrolysis may be uncomfortable for the patient and has a high recurrence rate. Radiotherapy can result in excessive structural and functional complications and currently is not favored by ophthalmologists. Surgery usually is reserved for patients refractory to conservative treatment or cases with coexisting entropion. Cryotherapy is successful in treating trichiasis in 70–90% of cases, but it is a painful method and may produce many complications, such as lid edema, loss of all lashes, loss of meibomian gland secretion, skin depigmentation and lid notching. There are many reports regarding the use of the argon laser for the treatment of trichiasis. The results of these studies were satisfactory with a final success rate of 70–100%. The underlying causes for trichiasis were multiple in these studies and there are only two reports in the literature2,3 concerning the
Results The upper lid was involved in 20 eyes and the lower lid in 12 eyes. In 2 eyes both eyelids were involved. The average number of rubbing lashes per lid was 4.52. In treating 30 lids (83.3%) infiltration anesthesia was required, and in 6 lids (16.7%) no anesthesia was used. The mean number of laser burns per lash was 17.3 in the first laser session. The follow-up period after the last session of laser treatment varied from a minimum of 6 months to a maximum of 22 months (mean ⫽ 10.6 months). Successful treatment with no evidence of recurrence was achieved in 55.5% of lids (n ⫽ 20) after one laser session. The remaining 44.5% of the lids (n ⫽
Table 1. Number of Misdirected Cilia per Lid and Success Rates Success Rates After Laser Treatment
No. of Misdirected Cilia
No. of Eyelids*
1 Session (%)
2–3 Sessions (%)
Failures (%)
ⱕ5 ⬎5
21 (58.3) 15 (41.7)
66.7 (n ⫽ 14) 40.0 (n ⫽ 6)
95.3 (n ⫽ 20) 80.0 (n ⫽ 12)
4.7 (n ⫽ 1) 20.0 (n ⫽ 3)
*Values in parentheses are percentages. n: Number of eyelids.
679
BRIEF COMMUNICATIONS
success rate of this method in patients with trachomatous trichiasis. A significantly low success rate (27.7%) was reported by Yeung3 in trachoma after one session of laser treatment. The author suggested that aiming the laser during treatment is more difficult in trachomatous trichiasis because of scarring. In a study of Oshry et al2, they used argon green laser in the treatment of trachomatous trichiasis. They treated 70 eyelashes in 17 patients with 80% success and found this treatment modality convenient both for the patient and the practitioner. In our study, successful treatment with no evidence of recurrence was achieved in 55.5% of lids after one blue-green argon laser session. The final success rate of the method was 88.9%. The results of our study showed that the success rate for this method of treating trachomatous trichiasis is comparable to success rates in the other reports, which included the patients who had different underlying causes for trichiasis. Sharıf et al4 reported that the number of aberrant lashes per lid is correlated with the number of required treatment sessions. They explained this by observing that, in the case of numerous lashes, it is very difficult to apply enough laser burns per lash to achieve complete destruction of the lash follicle. Ladas et al5 reported that not only the number of recurrences but also the final success rate is closely correlated to the number of treated lashes per lid. Our results confirm the suggestion in both of the above studies; success rates after one laser session and after the last laser session were lower in eyelids with more than 5 aberrant lashes. Yeung3 suggested another possible explanation for recurrence. According to this theory, in lids with a high number of aberrant lashes, the disease leading to trichiasis is still active and the lashes regrow after treatment. We do not think this explanation applies to our cases with recurrence, because trachoma was inactive in all our patients. It was thought that in the argon laser treatment of trichiasis, no anesthesia, topical anesthesia, or infiltration should be used. After using different types of anesthesia according to individual need, Yeung3 suggested that if a patient could not tolerate the treatment without anesthesia, a topical anesthetic would not be beneficial in most of the cases. For that reason we used infiltration anesthesia in patients who experienced discomfort without anesthesia. In our study, none of the patients had any general or visual complication. All the treated areas healed completely without any scarring or vascularization. To the best of our knowledge, there is no report in the literature of complications related to the use of the laser for this treatment method.
In conclusion, argon laser therapy was found to be an effective and safe method for the treatment of trachomatous trichiasis. Received: August 20, 1999 Correspondence and reprint requests to: Kaan ÜNLÜ, MD, Department of Ophthalmology, University of Dicle School of Medicine, 21280 Diyarbakır, Turkey
References 22.Berry J. Recurrent trichiasis: treatment with laser photocoagulation. Ophthalmic Surg 1979;10:36–8. 23.Oshry T, Rosenthal G, Lifshitz T, Shani L, Yassur Y. Argon green laser photoepilation in the treatment of trachomatous trichiasis. Ophthalmol Plast Reconstr Surg 1994;4:253–5. 24.Yeung YM. Argon laser treatment of trichiasis in Hong Kong (letter). Br J Ophthalmol 1995;5:506–7. 25.Sharıf KW, Arafat AFA, Wykes WC. The treatment of recurrent trichiasis with argon laser photocoagulation. Eye 1991;5:591–5. 26.Ladas ID, Karamaounas N, Vergados J, Damanakis A, Theodossiadis GP. Use of argon laser photocoagulation in the treatment of recurrent trichiasis: long-term results. Ophthalmologica 1993;207:90–3. PII S0021-5155(00)00284-7
Poland-Moebius Syndrome: A Case Report Hayyam Kıratlı and Ug˘ur Erdener Department of Ophthalmology, Hacettepe School of Medicine, Ankara, Turkey Background: The primary site of pathology in Moebius syndrome is still unknown, although several studies have variably localized the lesion in the extraocular muscles, cranial nerves, or central nervous system. Case: A 24-year-old man with Poland-Moebius syndrome and acquired progressive bilateral paralytic lower eyelid ectropion is described. Observations: In this patient, magnetic resonance imaging studies revealed a barely detectable pontine hypoplasia and normal recti muscles. Nerve conduction studies of the facial nerves showed a severe demyelinating or dysmyelinating type of neuropathy. Bilateral lower eyelid ectropium of the patient was successfully corrected by canthal tightening procedures. Conclusion: Contrary to many reported cases, this patient serves as a rare example of a progressive type of PolandMoebius syndrome presumably resulting from a combination of a brainstem abnormality and a peripheral neural degenerative process. Jpn J Ophthalmol 2000;44:679– 682 © 2000 Japanese Ophthalmological Society Key Words: Extraocular muscles, eyelid ectropion, eye motility, Poland-Moebius Syndrome, pons.
Prospective Evaluation of the Argon Laser Treatment of Trachomatous Trichiasis Kaan Ünlü, Ahmet Aksünger, Sevin Söker, Candan Karaca and Kubilay Bilek Department of Ophthalmology, University of Dicle School of Medicine, Diyarbakır, Turkey
The treatment of trichiasis with the argon laser was first reported by Berry in 1979.1 Although many studies of the treatment of trichiasis with laser have been reported since then, opinions differ about the success rate of this treatment method in the few studies involving trachomatous trichiasis.2,3 In this prospective study, we present our results with the use of argon laser photocoagulation in the treatment of trachomatous trichiasis.
Materials and Methods Purpose: To evaluate the effectiveness of argon laser photocoagulation for the treatment of trachomatous trichiasis. Methods: This report presents a prospective, non-masked study of 22 patients (36 eyelids) with trachomatous trichiasis treated with the argon laser. Each abnormal lash was treated with a beam of 50- to 200-micron spot size, for 0.2 seconds, and 1 to 1.2 watts power. In 30 lids (83.3%) infiltration anesthesia was used and in 6 lids (16.7%) no anesthesia was used. Results: Successful treatment with no evidence of recurrence was achieved in 55.5% of lids after one laser session. The remaining 44.5% of the lids required two or three sessions. The final success rate of the method was 88.9%. No complications were observed. The mean follow-up time was 10.6 months. Conclusion: Argon laser photocoagulation is an effective and safe method for the treatment of trachomatous trichiasis. Jpn J Ophthalmol 2000;44:677–679 © 2000 Japanese Ophthalmological Society Key Words: Argon laser photocoagulation, trachoma, trichiasis.
Introduction Trachoma is the greatest single cause of preventable blindness worldwide. Four hundred million people may be afflicted with this disease, 6 million of whom are blind. Characteristically, trachoma causes deep scarring of the conjunctiva that results in trichiasis, entropion, and tear deficiency. Corneal damage from trachoma is related to trichiasis, which may affect over 10% of the adults in endemic communities. The management of trichiasis includes epilation, radiotherapy, electrolysis, cryotherapy, surgery, and laser ablation. Although cryotherapy is probably the most widely used, it has some well-known side effects. Radiotherapy can result in excessive structural and functional complications. On the other hand, the rate of success of epilation and electrolysis is low. Jpn J Ophthalmol 44, 677–689 (2000) © 2000 Japanese Ophthalmological Society Published by Elsevier Science Inc.
Twenty-two patients (36 eyelids; 8 men and 14 women) with trachomatous trichiasis involving the upper lid, lower lid, or both, were recruited for the study. Trachoma was inactive in all patients (Stage IV according to MacCallan staging). The mean age of the patients was 64.9 years (range, 49–71 years). Patients with more than 10 rubbing lashes per eyelid and those who had associated entropion were not included in this study. Fifteen eyelids had previously been treated for trichiasis with repeated epilation and/or electrolysis. The remaining 21 eyelids had not undergone previous treatment. Prior to the treatment, each patient had a general ophthalmic examination. The laser treatment procedure was explained to the patient and informed consent was obtained. Initially no anesthesia was used during the procedure. If the patient could not tolerate this, the eyelid in the region of trichiasis was anesthetized by an injection of 0.3 mL or less of 2% lidocaine with 1:100,000 adrenaline. Abnormal eyelashes were ablated as follows: (1) The patient was placed at the slit-lamp of the blue-green argon laser unit and the eyelid was rotated slightly outwards to align the laser beam with the axis of the root of the rubbing lash. (2) The patient was asked to look in the direction opposite to that of the planned area of treatment. (3) The laser controls were set to a spot size of 50 m, an exposure time of 0.2 seconds and a power of 1–1.2 watts. (4) The laser aiming beam was focused at the root of each cilium to be treated. (5) The initial laser burn vaporized the eyelash and produced a small black spot at the lid margin (Figure 1). After the first 2–3 applications, a crater was created at the base of the treated lash. (6) This crater was deepened (approximately 2–2.5 mm) to destroy the whole cilia follicle with an increased spot size of 200 m. All the abnormal lashes were treated by the same technique. Antibiotic-corticosteroid ointment was applied to the eyelid margin at the conclusion of the procedure and twice a day during the next 5 days. 0021-5155/00/$–see front matter
678
Jpn J Ophthalmol Vol 44: 677–689, 2000
16) required two or three sessions. The final success rate of the method was 88.9%. Four eyelids, which had an unsatisfactory result, were treated with cryotherapy for persistent trichiasis. A satisfactory result with one treatment was achieved in 14 of the eyelids (66.7%) that had 5 or less misdirected cilia. Of the 7 lids that had an unsatisfactory results, 6 responded well to one or two additional laser treatments; the final success rate was 95.3% in this group. After one laser session the success rate was 40.0% (6 eyelids) in eyelids with more than 5 misdirected cilia. In this group, the recurrence rate was 20.0% after 3 sessions of laser treatment (Table 1). The procedure was well-tolerated by the patients. None of the patients had any general or visual complication. All the treated areas healed completely within 8 weeks after treatment without any scarring or vascularization.
Figure 1. Initial laser burns (50 m) produced small black spots and created craters.
The patients were examined 8 weeks after therapy and then every 3 months during the follow-up time. Patients were advised to come back earlier if they experienced any symptoms suggestive of recurrence. Recurrences were treated by the same method. The results of the treatment were considered satisfactory if no recurrence of trichiasis had occurred for at least 6 months after the last laser session. Recurrence after three laser sessions was considered as treatment failure.
Discussion Trichiasis is a common complication of several disorders of the eyelids that can lead to corneal damage. The epilation of the misdirected eyelashes has no morbidity but does not usually effect a permanent cure. Electrolysis may be uncomfortable for the patient and has a high recurrence rate. Radiotherapy can result in excessive structural and functional complications and currently is not favored by ophthalmologists. Surgery usually is reserved for patients refractory to conservative treatment or cases with coexisting entropion. Cryotherapy is successful in treating trichiasis in 70–90% of cases, but it is a painful method and may produce many complications, such as lid edema, loss of all lashes, loss of meibomian gland secretion, skin depigmentation and lid notching. There are many reports regarding the use of the argon laser for the treatment of trichiasis. The results of these studies were satisfactory with a final success rate of 70–100%. The underlying causes for trichiasis were multiple in these studies and there are only two reports in the literature2,3 concerning the
Results The upper lid was involved in 20 eyes and the lower lid in 12 eyes. In 2 eyes both eyelids were involved. The average number of rubbing lashes per lid was 4.52. In treating 30 lids (83.3%) infiltration anesthesia was required, and in 6 lids (16.7%) no anesthesia was used. The mean number of laser burns per lash was 17.3 in the first laser session. The follow-up period after the last session of laser treatment varied from a minimum of 6 months to a maximum of 22 months (mean ⫽ 10.6 months). Successful treatment with no evidence of recurrence was achieved in 55.5% of lids (n ⫽ 20) after one laser session. The remaining 44.5% of the lids (n ⫽
Table 1. Number of Misdirected Cilia per Lid and Success Rates Success Rates After Laser Treatment
No. of Misdirected Cilia
No. of Eyelids*
1 Session (%)
2–3 Sessions (%)
Failures (%)
ⱕ5 ⬎5
21 (58.3) 15 (41.7)
66.7 (n ⫽ 14) 40.0 (n ⫽ 6)
95.3 (n ⫽ 20) 80.0 (n ⫽ 12)
4.7 (n ⫽ 1) 20.0 (n ⫽ 3)
*Values in parentheses are percentages. n: Number of eyelids.
679
BRIEF COMMUNICATIONS
success rate of this method in patients with trachomatous trichiasis. A significantly low success rate (27.7%) was reported by Yeung3 in trachoma after one session of laser treatment. The author suggested that aiming the laser during treatment is more difficult in trachomatous trichiasis because of scarring. In a study of Oshry et al2, they used argon green laser in the treatment of trachomatous trichiasis. They treated 70 eyelashes in 17 patients with 80% success and found this treatment modality convenient both for the patient and the practitioner. In our study, successful treatment with no evidence of recurrence was achieved in 55.5% of lids after one blue-green argon laser session. The final success rate of the method was 88.9%. The results of our study showed that the success rate for this method of treating trachomatous trichiasis is comparable to success rates in the other reports, which included the patients who had different underlying causes for trichiasis. Sharıf et al4 reported that the number of aberrant lashes per lid is correlated with the number of required treatment sessions. They explained this by observing that, in the case of numerous lashes, it is very difficult to apply enough laser burns per lash to achieve complete destruction of the lash follicle. Ladas et al5 reported that not only the number of recurrences but also the final success rate is closely correlated to the number of treated lashes per lid. Our results confirm the suggestion in both of the above studies; success rates after one laser session and after the last laser session were lower in eyelids with more than 5 aberrant lashes. Yeung3 suggested another possible explanation for recurrence. According to this theory, in lids with a high number of aberrant lashes, the disease leading to trichiasis is still active and the lashes regrow after treatment. We do not think this explanation applies to our cases with recurrence, because trachoma was inactive in all our patients. It was thought that in the argon laser treatment of trichiasis, no anesthesia, topical anesthesia, or infiltration should be used. After using different types of anesthesia according to individual need, Yeung3 suggested that if a patient could not tolerate the treatment without anesthesia, a topical anesthetic would not be beneficial in most of the cases. For that reason we used infiltration anesthesia in patients who experienced discomfort without anesthesia. In our study, none of the patients had any general or visual complication. All the treated areas healed completely without any scarring or vascularization. To the best of our knowledge, there is no report in the literature of complications related to the use of the laser for this treatment method.
In conclusion, argon laser therapy was found to be an effective and safe method for the treatment of trachomatous trichiasis. Received: August 20, 1999 Correspondence and reprint requests to: Kaan ÜNLÜ, MD, Department of Ophthalmology, University of Dicle School of Medicine, 21280 Diyarbakır, Turkey
References 22.Berry J. Recurrent trichiasis: treatment with laser photocoagulation. Ophthalmic Surg 1979;10:36–8. 23.Oshry T, Rosenthal G, Lifshitz T, Shani L, Yassur Y. Argon green laser photoepilation in the treatment of trachomatous trichiasis. Ophthalmol Plast Reconstr Surg 1994;4:253–5. 24.Yeung YM. Argon laser treatment of trichiasis in Hong Kong (letter). Br J Ophthalmol 1995;5:506–7. 25.Sharıf KW, Arafat AFA, Wykes WC. The treatment of recurrent trichiasis with argon laser photocoagulation. Eye 1991;5:591–5. 26.Ladas ID, Karamaounas N, Vergados J, Damanakis A, Theodossiadis GP. Use of argon laser photocoagulation in the treatment of recurrent trichiasis: long-term results. Ophthalmologica 1993;207:90–3. PII S0021-5155(00)00284-7
Poland-Moebius Syndrome: A Case Report Hayyam Kıratlı and Ug˘ur Erdener Department of Ophthalmology, Hacettepe School of Medicine, Ankara, Turkey Background: The primary site of pathology in Moebius syndrome is still unknown, although several studies have variably localized the lesion in the extraocular muscles, cranial nerves, or central nervous system. Case: A 24-year-old man with Poland-Moebius syndrome and acquired progressive bilateral paralytic lower eyelid ectropion is described. Observations: In this patient, magnetic resonance imaging studies revealed a barely detectable pontine hypoplasia and normal recti muscles. Nerve conduction studies of the facial nerves showed a severe demyelinating or dysmyelinating type of neuropathy. Bilateral lower eyelid ectropium of the patient was successfully corrected by canthal tightening procedures. Conclusion: Contrary to many reported cases, this patient serves as a rare example of a progressive type of PolandMoebius syndrome presumably resulting from a combination of a brainstem abnormality and a peripheral neural degenerative process. Jpn J Ophthalmol 2000;44:679– 682 © 2000 Japanese Ophthalmological Society Key Words: Extraocular muscles, eyelid ectropion, eye motility, Poland-Moebius Syndrome, pons.