- Email: [email protected]
Symptomatic cicatrizial occlusion of canaliculi after insertion of herrick lacrimal plugs
in a control lesion, which was made adjacent to the retinoschisis at the same latitude as the break to obtain a similar choroidal pattern. It varied from 100 to 400 mW for 0.1 second. If the laser application through the break caused an equivalent gray response in the outer layers of retina, it was regarded as diagnostic of retinoschisis. A third application at the same energy level was made adjacent to the break through the intact inner layers of retinoschisis to demonstrate the attenuating effect of the inner layers (Figure 1). The patients were examined at 4-month intervals during the first year and yearly thereafter for progression. The laser application through the break was positive for retinoschisis in 40 of 41 eyes. The additional low-energy application through the adjacent inner layers of retina caused an equivocal response or no detectable response at all in the outer layers. The one eye that tested negative for retinoschisis, proved to be an asymptomatic inferior rhegmatogenous detachment. It was treated with a sponge buckle beneath the break, and the retina promptly attached without drainage of subretinal fluid. The remaining 40 eyes were followed for 1 to 10 years during which time they continued to behave as retinoschisis, that is, asymptomatic and without progression. Laser applications through the inner layers of presumed retinoschisis as a diagnostic test to differentiate retinoschisis from retinal detachment has been considered to be of doubtful value because the response in the outer layer is often equivocal. This is because the inner layers of retinoschisis are only relatively transparent and can attenuate the laser beam. Increasing the laser power to overcome this attenuation makes the test less specific. With sufficient energy, a response can be obtained in the absence of outer layers. Aiming a low-energy application (equal to the control) through a break eliminates the attenuation; the outer layers, if present, respond with a gray lesion equivalent to the control lesion and provide an unequivocal diagnosis of retinoschisis.
PURPOSE: To report severe symptomatic complications following bilateral insertion of Herrick lacrimal plugs. DESIGN: Interventional case report. METHODS: Bilateral clinical, surgical, and histologic findings in a patient with surgical revision of canaliculi after plug insertion. RESULTS: A 55-year-old patient presented with recurrent inflammation, discharge, and epiphora 24 months after insertion of lacrimal plugs; surgical intervention and partial resection of the cicatrized canaliculi was necessary. Light microscopic histology revealed canaliculi destruction, reactive tissue embedding of the plugs, and dissociated plug material. CONCLUSIONS: The application of Herrick lacrimal plugs may not be reversible and may require invasive surgical intervention. (Am J Ophthalmol 2003;136:926 –928. © 2003 by Elsevier Inc. All rights reserved.)
D
The first therapeutic option is the substitution or stabilization of the ocular surface tear film. Occlusion of the lacrimal puncta or canaliculi with implants is becoming an increasingly common method of treatment. It is especially helpful for patients with severe symptoms and those who cannot tolerate tear film substitution. Two types of permanent implants have been available for several years: implants used for punctum occlusion and Herrick plugs for intracanalicular insertion. The few reports1– 6 available on the safety and possible complications of Herrick plugs are inconsistent thus far. A 55-year-old female patient presented with a 10-year history of bilateral dry eye symptoms. After 8 years, tear substitution was no longer comfortable. Intracanalicular insertion of Herrick plugs into both inferior canaliculi was performed by an ophthalmologist in another country. Twenty-four months later, the patient was referred to our department with a 12-month history of bilateral epiphora, recurrent conjunctival discharge, and several episodes of canaliculitis. Various antibiotic and antiinflammatory eye drops had been applied without permanent relief of symptoms. Best-corrected visual acuity was 20/20 in both eyes. Examination confirmed normal anatomy and function of the eyelids, extended lacrimal lake, and epiphora bilaterally. The conjunctiva and cornea were normal bilaterally. Probing and irrigation of the superior and inferior canaliculi revealed a deep, soft stop and reflux through the contralateral canaliculus in the right eye and ipsilateral reflux from both canaliculi in the left eye. Bacteriological
REFERENCES
1. Lincoff H, Kreissig I. Patterns of non-rhegmatogenous elevations of the retina. Brit J Ophthalmol 1974;58:899 –906. 2. Kylstra JA, Holdren DN. Indirect ophthalmoscopic perimetry in patients with retinal detachment or retinoschisis. Am J Ophthalmol 1995;119:521–522. 3. Lincoff H, Serag Y, Chang S, Silverman R, Bondok B, El-Aswad M. Tractional elevations of the retina in patients with diabetes. Am J Ophthalmol 1992;113:235–242.
Symptomatic Cicatrizial Occlusion of Canaliculi After Insertion of Herrick Lacrimal Plugs
Accepted for publication May 2, 2003. From the Department of Ophthalmology, University of Mu¨ nster, Mu¨ nster, Germany. Inquiries to Heinrich Gerding, MD, FEBO, Klinik und Poliklinik fu¨ r Augenheilkunde, Universita¨ t Mu¨ nster, Domagkstrasse 15, 48129 Mu¨ nster, Germany; fax: (⫹49) 251-835-6003; e-mail: [email protected]
Heinrich Gerding, MD, FEBO, Judith Ku¨ ppers, MD, and Holger Busse, MD 926
AMERICAN JOURNAL
RY EYE IS A COMMON SYMPTOM IN OLDER ADULTS.
OF
OPHTHALMOLOGY
NOVEMBER 2003
FIGURE 1. Intraoperative situation in the left eye showing the lacrimal plug after isolation from the common canaliculus. Surgical separation of pericanalicular tissue is indicated by a marginal white line. Canalicular ostia are marked by letters: i ⴝ inferior; s ⴝ superior; c ⴝ common canaliculus).
FIGURE 2. Histopathologic specimen of the left eye. (A) Section crossing the canalicular wall on one side lateral to the embedded plug (hematoxylin and eosin stain, ⴛ100). Upper end showing partially preserved (ep) and destructed canalicular epithelium (close to c and below A). FT ⴝ fibrous transformation of pericanalicular tissue; m ⴝ intra- and extraepithelial basal mucous glands; a ⴝ alveolar glands (right of a); d and c ⴝ magnified sections (shown in D and C). (B) Dark field microscopy of the same specimen showing the blue appearance of the dissociated plug material. Areas of main foreign material deposition are indicated by white ellipses. (C) Enlarged area of Panel A. Plug material (indicated by red asterisk) appears as transparent, artificially blue, or yellow. Fibrous transformation, lymphocytes, and epitheloid cells are present subepithelially. Macrophages and giant cell formation can be seen at several locations (f). (D) Enlarged area of A. Subepithelial granulomatous reaction presenting epitheloid cells, macrophages, giant cell formation, and fibrosis. (E) Detail presenting the region of --- in A from another section showing destructed canalicular epithelium, lymphocytes, macrophages, and giant cell formation close to foreign material (red *). (F and G) Detail presenting the area of primary foreign body deposition in C in another section with giant cell formation.
cultures were negative. Because the patient felt handicapped by persistent epiphora and recurrent canaliculitis, she chose to undergo bilateral canaliculus surgery. The transcutaneous approach revealed a cicatrized segmental destruction of the lateral common canaliculus of the right eye that was excised, splinted (bicanalicular silicone tube), and microsurgically readapted. In the left eye, the plug was found in the occluded common canaliculus embedded by proliferative tissue. After scar tissue resection (Figure 1), bicanalicular silicone tube intubation was performed followed by careful microsurgical readaptation of the canaliculi to the nasolacrimal sac. The silicone tubes were left in place for 12 months. Symptomatic epiphora did not reappear before and after tube removal. Light microscopy (Figure 2) of the specimens presented partial destruction of the canalicular mucosa, pericanalicular fibrosis, granulomatous tissue, giant cells, and lymphocytic infiltration. Dark field microscopy revealed deposits of separated plug material in multiple locations. This is the first histologic report on the status of canaliculi after long-term implantation of Herrick plugs in humans. Light microscopic examination revealed destruction of the normal canalicular architecture. Because of severe destruction and tissue reaction, the plugs could not be removed, resulting in a total canalicular occlusion. In addition, separation and embedding of plug material was present. This case and others recently reported in the literature1– 6 suggest that the use of Herrick lacrimal plugs may be an irreversible intervention, possibly leading to chronic adverse reactions such as persistent inflammation or epiphora when basic production of tears is present. Plugs should be reserved for selected patients with severe deficiencies in tear film secretion. The use of more accessible punctum plugs, which allow for easier removal and less invasive surgical intervention if complications may occur, should be considered.
Occlusive Vasculitis in a Patient With Concomitant West Nile Virus Infection Peter K. Kaiser, MD, Michael S. Lee, MD, and Denise A. Martin PURPOSE: To describe a patient with occlusive, retinal vasculitis and concomitant, confirmed, acute West Nile virus (WNV) infection. DESIGN: Observational case report. METHODS: Main outcome measures included comprehensive ophthalmic examination with fluorescein angiography, color photography, and serologic testing for WNV and St. Louis encephalitis (SLE) virus including plaque reduction neutralization testing (PRNT). RESULTS: A 46-year-old woman developed a sudden decrease in vision in her left eye 2 weeks after confirmed WNV infection and demonstrated multiple, small, patchy areas of retinal edema with scattered microaneurysms. Fluorescein angiography showed multiple branch artery occlusions with extensive nonperfusion. Serologic titers for WNV were positive for acute infection. Plaque reduction neutralization testing confirmed WNV infection and excluded St. Louis encephalitis virus infection. Other etiologies of occlusive vasculitis were not present. CONCLUSION: Occlusive, retinal vasculitis may occur in the setting of acute WNV infection. (Am J Ophthalmol 2003;136:928 –930. © 2003 by Elsevier Inc. All rights reserved.)
R
Nile virus may cause uveitis, vitritis, chorioretinitis, and papilledema.1–3 We describe the case of a patient with occlusive retinal vasculitis with confirmed West Nile virus infection. A 46-year-old woman with well-controlled insulindependent diabetes presented to an outside hospital with fever and flulike symptoms. The patient tested positive for West Nile virus by immunoglobulin M (IgM) antibodycapture enzyme linked immunosorbent assay (MACELISA). Two weeks later the patient noted a sudden decrease in vision in her left eye with a visual acuity of 20/30. Her past ocular history revealed mild, nonproliferative diabetic retinopathy with no previous laser treatment. Anterior segment examination showed mild nuclear sclerosis in the left eye with no anterior chamber cell or flare and no vitreous cell. Dilated fundus examination showed two small, patchy areas of retinal edema with scattered
REFERENCES
1. White WL, Bartley GB, Hawes MJ, Linberg JV, Leventer DB. Iatrogenic complications related to the use of Herrick lacrimal plugs. Ophthalmology 2001;108:1835–1837. 2. Jones CE, Anklesaria M, Gordon AD, et al. Retrospective safety study of the Herrick lacrimal plug: a device used to occlude the lacrimal canaliculus. CLAO J 2002;28:206 –210. 3. Nava-Castaneda A, Tovilla-Canales JL, Rodriguez L, Tovilla y Pomar JL, Jones CE. Effects of lacrimal occlusion with collagen and silicone plugs on patients with conjunctivitis associated with dry eyes. Cornea 2003;22:10 –14. 4. Slusser TG, Lowther GE. Effects of lacrimal drainage occlusion with nondissolvable intracanalicular plugs on hydrogel contact lens wear. Optom Vis Sci 1998;75:330 –338. 5. Soparkar CNS, Patrinely JR, Hunts J, Linberg JV, Kersten RC, Andersen R. The perils of permanent punctal plugs. Am J Ophthalmol 1997;123:120 –121. 6. Lee J, Flanagan JC. Complications associated with silicone intracanalicular plugs. Ophthal Plast Reconstr Surg 2001;17: 465–469.
928
AMERICAN JOURNAL
ECENT REPORTS HAVE SUGGESTED THAT ACUTE WEST
Accepted for publication July 21, 2003. From the Cole Eye Institute, Cleveland Clinic Foundation, Cleveland, Ohio (P.K.K., M.S.L.); and the Division of Vector Borne Infectious Diseases, Centers for Disease Control, Fort Collins, Colorado (D.A.M.). Inquiries to Michael Lee, MD, Cole Eye Institute, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Desk i-32, Cleveland, OH 44195; fax: (216) 445-2226; e-mail: [email protected] OF
OPHTHALMOLOGY
NOVEMBER 2003
PURPOSE: To report severe symptomatic complications following bilateral insertion of Herrick lacrimal plugs. DESIGN: Interventional case report. METHODS: Bilateral clinical, surgical, and histologic findings in a patient with surgical revision of canaliculi after plug insertion. RESULTS: A 55-year-old patient presented with recurrent inflammation, discharge, and epiphora 24 months after insertion of lacrimal plugs; surgical intervention and partial resection of the cicatrized canaliculi was necessary. Light microscopic histology revealed canaliculi destruction, reactive tissue embedding of the plugs, and dissociated plug material. CONCLUSIONS: The application of Herrick lacrimal plugs may not be reversible and may require invasive surgical intervention. (Am J Ophthalmol 2003;136:926 –928. © 2003 by Elsevier Inc. All rights reserved.)
D
The first therapeutic option is the substitution or stabilization of the ocular surface tear film. Occlusion of the lacrimal puncta or canaliculi with implants is becoming an increasingly common method of treatment. It is especially helpful for patients with severe symptoms and those who cannot tolerate tear film substitution. Two types of permanent implants have been available for several years: implants used for punctum occlusion and Herrick plugs for intracanalicular insertion. The few reports1– 6 available on the safety and possible complications of Herrick plugs are inconsistent thus far. A 55-year-old female patient presented with a 10-year history of bilateral dry eye symptoms. After 8 years, tear substitution was no longer comfortable. Intracanalicular insertion of Herrick plugs into both inferior canaliculi was performed by an ophthalmologist in another country. Twenty-four months later, the patient was referred to our department with a 12-month history of bilateral epiphora, recurrent conjunctival discharge, and several episodes of canaliculitis. Various antibiotic and antiinflammatory eye drops had been applied without permanent relief of symptoms. Best-corrected visual acuity was 20/20 in both eyes. Examination confirmed normal anatomy and function of the eyelids, extended lacrimal lake, and epiphora bilaterally. The conjunctiva and cornea were normal bilaterally. Probing and irrigation of the superior and inferior canaliculi revealed a deep, soft stop and reflux through the contralateral canaliculus in the right eye and ipsilateral reflux from both canaliculi in the left eye. Bacteriological
REFERENCES
1. Lincoff H, Kreissig I. Patterns of non-rhegmatogenous elevations of the retina. Brit J Ophthalmol 1974;58:899 –906. 2. Kylstra JA, Holdren DN. Indirect ophthalmoscopic perimetry in patients with retinal detachment or retinoschisis. Am J Ophthalmol 1995;119:521–522. 3. Lincoff H, Serag Y, Chang S, Silverman R, Bondok B, El-Aswad M. Tractional elevations of the retina in patients with diabetes. Am J Ophthalmol 1992;113:235–242.
Symptomatic Cicatrizial Occlusion of Canaliculi After Insertion of Herrick Lacrimal Plugs
Accepted for publication May 2, 2003. From the Department of Ophthalmology, University of Mu¨ nster, Mu¨ nster, Germany. Inquiries to Heinrich Gerding, MD, FEBO, Klinik und Poliklinik fu¨ r Augenheilkunde, Universita¨ t Mu¨ nster, Domagkstrasse 15, 48129 Mu¨ nster, Germany; fax: (⫹49) 251-835-6003; e-mail: [email protected]
Heinrich Gerding, MD, FEBO, Judith Ku¨ ppers, MD, and Holger Busse, MD 926
AMERICAN JOURNAL
RY EYE IS A COMMON SYMPTOM IN OLDER ADULTS.
OF
OPHTHALMOLOGY
NOVEMBER 2003
FIGURE 1. Intraoperative situation in the left eye showing the lacrimal plug after isolation from the common canaliculus. Surgical separation of pericanalicular tissue is indicated by a marginal white line. Canalicular ostia are marked by letters: i ⴝ inferior; s ⴝ superior; c ⴝ common canaliculus).
FIGURE 2. Histopathologic specimen of the left eye. (A) Section crossing the canalicular wall on one side lateral to the embedded plug (hematoxylin and eosin stain, ⴛ100). Upper end showing partially preserved (ep) and destructed canalicular epithelium (close to c and below A). FT ⴝ fibrous transformation of pericanalicular tissue; m ⴝ intra- and extraepithelial basal mucous glands; a ⴝ alveolar glands (right of a); d and c ⴝ magnified sections (shown in D and C). (B) Dark field microscopy of the same specimen showing the blue appearance of the dissociated plug material. Areas of main foreign material deposition are indicated by white ellipses. (C) Enlarged area of Panel A. Plug material (indicated by red asterisk) appears as transparent, artificially blue, or yellow. Fibrous transformation, lymphocytes, and epitheloid cells are present subepithelially. Macrophages and giant cell formation can be seen at several locations (f). (D) Enlarged area of A. Subepithelial granulomatous reaction presenting epitheloid cells, macrophages, giant cell formation, and fibrosis. (E) Detail presenting the region of --- in A from another section showing destructed canalicular epithelium, lymphocytes, macrophages, and giant cell formation close to foreign material (red *). (F and G) Detail presenting the area of primary foreign body deposition in C in another section with giant cell formation.
cultures were negative. Because the patient felt handicapped by persistent epiphora and recurrent canaliculitis, she chose to undergo bilateral canaliculus surgery. The transcutaneous approach revealed a cicatrized segmental destruction of the lateral common canaliculus of the right eye that was excised, splinted (bicanalicular silicone tube), and microsurgically readapted. In the left eye, the plug was found in the occluded common canaliculus embedded by proliferative tissue. After scar tissue resection (Figure 1), bicanalicular silicone tube intubation was performed followed by careful microsurgical readaptation of the canaliculi to the nasolacrimal sac. The silicone tubes were left in place for 12 months. Symptomatic epiphora did not reappear before and after tube removal. Light microscopy (Figure 2) of the specimens presented partial destruction of the canalicular mucosa, pericanalicular fibrosis, granulomatous tissue, giant cells, and lymphocytic infiltration. Dark field microscopy revealed deposits of separated plug material in multiple locations. This is the first histologic report on the status of canaliculi after long-term implantation of Herrick plugs in humans. Light microscopic examination revealed destruction of the normal canalicular architecture. Because of severe destruction and tissue reaction, the plugs could not be removed, resulting in a total canalicular occlusion. In addition, separation and embedding of plug material was present. This case and others recently reported in the literature1– 6 suggest that the use of Herrick lacrimal plugs may be an irreversible intervention, possibly leading to chronic adverse reactions such as persistent inflammation or epiphora when basic production of tears is present. Plugs should be reserved for selected patients with severe deficiencies in tear film secretion. The use of more accessible punctum plugs, which allow for easier removal and less invasive surgical intervention if complications may occur, should be considered.
Occlusive Vasculitis in a Patient With Concomitant West Nile Virus Infection Peter K. Kaiser, MD, Michael S. Lee, MD, and Denise A. Martin PURPOSE: To describe a patient with occlusive, retinal vasculitis and concomitant, confirmed, acute West Nile virus (WNV) infection. DESIGN: Observational case report. METHODS: Main outcome measures included comprehensive ophthalmic examination with fluorescein angiography, color photography, and serologic testing for WNV and St. Louis encephalitis (SLE) virus including plaque reduction neutralization testing (PRNT). RESULTS: A 46-year-old woman developed a sudden decrease in vision in her left eye 2 weeks after confirmed WNV infection and demonstrated multiple, small, patchy areas of retinal edema with scattered microaneurysms. Fluorescein angiography showed multiple branch artery occlusions with extensive nonperfusion. Serologic titers for WNV were positive for acute infection. Plaque reduction neutralization testing confirmed WNV infection and excluded St. Louis encephalitis virus infection. Other etiologies of occlusive vasculitis were not present. CONCLUSION: Occlusive, retinal vasculitis may occur in the setting of acute WNV infection. (Am J Ophthalmol 2003;136:928 –930. © 2003 by Elsevier Inc. All rights reserved.)
R
Nile virus may cause uveitis, vitritis, chorioretinitis, and papilledema.1–3 We describe the case of a patient with occlusive retinal vasculitis with confirmed West Nile virus infection. A 46-year-old woman with well-controlled insulindependent diabetes presented to an outside hospital with fever and flulike symptoms. The patient tested positive for West Nile virus by immunoglobulin M (IgM) antibodycapture enzyme linked immunosorbent assay (MACELISA). Two weeks later the patient noted a sudden decrease in vision in her left eye with a visual acuity of 20/30. Her past ocular history revealed mild, nonproliferative diabetic retinopathy with no previous laser treatment. Anterior segment examination showed mild nuclear sclerosis in the left eye with no anterior chamber cell or flare and no vitreous cell. Dilated fundus examination showed two small, patchy areas of retinal edema with scattered
REFERENCES
1. White WL, Bartley GB, Hawes MJ, Linberg JV, Leventer DB. Iatrogenic complications related to the use of Herrick lacrimal plugs. Ophthalmology 2001;108:1835–1837. 2. Jones CE, Anklesaria M, Gordon AD, et al. Retrospective safety study of the Herrick lacrimal plug: a device used to occlude the lacrimal canaliculus. CLAO J 2002;28:206 –210. 3. Nava-Castaneda A, Tovilla-Canales JL, Rodriguez L, Tovilla y Pomar JL, Jones CE. Effects of lacrimal occlusion with collagen and silicone plugs on patients with conjunctivitis associated with dry eyes. Cornea 2003;22:10 –14. 4. Slusser TG, Lowther GE. Effects of lacrimal drainage occlusion with nondissolvable intracanalicular plugs on hydrogel contact lens wear. Optom Vis Sci 1998;75:330 –338. 5. Soparkar CNS, Patrinely JR, Hunts J, Linberg JV, Kersten RC, Andersen R. The perils of permanent punctal plugs. Am J Ophthalmol 1997;123:120 –121. 6. Lee J, Flanagan JC. Complications associated with silicone intracanalicular plugs. Ophthal Plast Reconstr Surg 2001;17: 465–469.
928
AMERICAN JOURNAL
ECENT REPORTS HAVE SUGGESTED THAT ACUTE WEST
Accepted for publication July 21, 2003. From the Cole Eye Institute, Cleveland Clinic Foundation, Cleveland, Ohio (P.K.K., M.S.L.); and the Division of Vector Borne Infectious Diseases, Centers for Disease Control, Fort Collins, Colorado (D.A.M.). Inquiries to Michael Lee, MD, Cole Eye Institute, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Desk i-32, Cleveland, OH 44195; fax: (216) 445-2226; e-mail: [email protected] OF
OPHTHALMOLOGY
NOVEMBER 2003