Refractory Dry Eye Syndrome after Transconjunctival Excision of the Palpebral Lobe of the Lacrimal Gland

The aim of the present study was to report two cases of refractory dry eye syndrome (DES) after transconjunctival excision of the palpebral lobe of the lacrimal gland. A 25-year-old female patient with a chief complaint of a palpable mass in both upper eyelids visited our medical center. Preoperative orbital computer tomography showed high-attenuation lesions in both lacrimal glands. Incisional biopsy of the lacrimal gland palpebral lobe via transconjunctival incision was performed in January 2019. At 1 month after the biopsy, a lack of tears and persistent corneal erosions were found in both eyes. Artificial tears, punctal occlusion, autologous serum eye drops, and therapeutic contact lenses were applied in an attempt to control the dry eye symptoms. The patient continues to suffer from intractable DES at 2.5 years after the procedure. The second case involved a 52-year-old female patient who visited our medical center with a chief complaint of a palpable mass in both upper eyelids. Bilateral orbital tumors were diagnosed with preoperative magnetic resonance imaging. An incisional biopsy of the lacrimal gland was performed. Immunoglobulin G4-related dacryoadenitis was confirmed through lacrimal palpebral lobe incisional biopsy. Intractable DES and corneal erosion of her left eye persisted thereafter. A transconjunctival incision is an effective approach for minimizing postoperative scars and is suitable for the biopsy of tumors that are visible through the conjunctiva. After a biopsy of the palpebral lobe of the main lacrimal glands, the secretion of reflex tears decreases due to damage to the secreting ducts of the main lacrimal glands. However, total tear secretion can be maintained by basal tear secretion from the accessory lacrimal glands. In this report, we describe two cases of refractory DES due to decreased total tear secretion, although only the palpebral lobes of the main lacrimal glands were biopsied.

Palpebral lobe of the human lacrimal gland: morphometric analysis in normal versus dry eyes

AimTo study the morphological features of the palpebral lobe of the main lacrimal gland in normal and dry eyes.MethodsThis cross-sectional study included 25 healthy subjects and 83 patients with dry eye disease (DED). The aetiological groups of DED were cicatrising conjunctivitis (CC, n=35), evaporative dry eyes (EDE, n=25) and Sjogren’s syndrome (SS, n=23). The palpebral lobes in both eyes were evaluated using slit-lamp biomicroscopy and photography for size (exposed area in mm2), shape (convex or flat), presence of cicatrisation (scarring and/or symblepharon) and appearance of the overlying conjunctival vessels.ResultsThe palpebral lobes in the normal and EDE group were similar in terms of size (41.5±15.6 mm2 vs 39±12.2 mm2, p=0.203), convex shape (100%) and absence of cicatrisation or vascular engorgement (0%). However, as compared to normal controls, the size of the palpebral lobe was markedly reduced in the SS (27.9±12.3, p<0.0001) and CC (18.1±13.7, p<0.0001) groups. The size of the lobes was asymmetric in the CC group (p<0.0001) and differed significantly from the SS group (p=0.0003). Flat contour (79% vs 50%, p=0.0028), subepithelial scarring with or without symblepharon (52% vs 13%, p<0.0001) and engorged conjunctival vessels (96% vs 63%, p=0.00011) were seen in a significantly higher proportion of lobes in the CC as compared to the SS group.ConclusionThe morphological features of the palpebral lobe of the main lacrimal gland are significantly distorted in aqueous deficient dry eyes due to CC and SS; however, the lobes in patients with EDE are similar to normal eyes.

Role of Botulinum toxin-A for epiphora in lacrimal drainage disorders:interventional case series (Preprint)

BACKGROUND • Obstruction of the tear drainage system is one of the most common causes of epiphora, and surgical procedures have been the standard treatments. • Several reports described the effects of injection of BTA in the lacrimal gland in patients with epiphora. • However, there have been few previous studies that quantitatively assessed the effect of BTA injection. • Transconjunctival injection of BTA in the lacrimal gland shows favourable outcomes for epiphora without permanent complications. • Injections has consistent efficacy and duration of effect, and BTA injections can be repeated for symptomatic epiphora as an alternative to complex surgery OBJECTIVE • To report the outcome of botulinum toxin-A (BTA) injections in the lacrimal glands in patients with epiphora. • To study effectivness of lacrimal gland injections of botulinum toxin A for epiphora secondary to lacrimal drainage disorders METHODS • This will be a prospective, interventional case series to be conducted in Acharya vinoba rural hospital, Sawangi, Wardha. • Demographic information, previous medical history, aetiology of epiphora, clinical information needed for epiphora assessment, treatment information, outcomes, and complications will be noted. • Each patient will undergo lacrimal system examination at presentation that included lacrimal irrigation and diagnostic probing, and dacryocystography if needed. • INCLUSION CRITERIA- proximal canalicular obstruction, functional nasolacrimal duct obstruction (NLDO), and inoperable general condition. • EXCLUSION CRITERIA- Hyperscretion, crocodile tears, lacrimal pump failure due to 7th nerve palsy, patient not coming for followup. • Follow-up on 1st week, 1 month, 2 months. • All patients included in the study will undergo one or more BTA injections in the lacrimal gland and will be followed up for 2 months. Repeated BTA injections will be given when the patient recquire another injection for recurrent epiphora. • The severity of epiphora will be assessed with the Munk epiphora rating system and the Schirmer-1 test before injection and at 1 month and 2 months after injection. • Under topical anaesthesia with proparacaine, after elevating the lateral portion of the upper eyelid to expose the palpebral lobe of the lacrimal gland while the patient looked down and to the nasal side, a transconjunctival injection of 2.5 units/0.05 ml of BTA using a 30-gauge needle tuberculin syringe will be administered into the bulging part of the exposed palpebral lobe. RESULTS EXPECTED OUTCOME Reduction in epiphora after lacrimal gland injection of botulinum toxin will be seen in cases with functional epiphora as well as those with a physical obstruction in the lacrimal drainage pathway. CONCLUSIONS Reduction in epiphora after lacrimal gland injection of botulinum toxin will be seen in cases with functional epiphora as well as those with a physical obstruction in the lacrimal drainage pathway.

The Upper Ordovician trilobite Raymondites Sinclair, 1944 in North America

The Upper Ordovician (Sandbian–Katian) bathyurid trilobite Raymondites Sinclair is revised using new collections from Missouri and Ontario, and archival material from Illinois, Wisconsin, New York, and Ontario. Phylogenetic analysis supports monophyly of Raymondites, but recognition of this genus renders Bathyurus Billings paraphyletic. We treat Raymondites as a subgenus of Bathyurus and label the paraphylum of species traditionally assigned to the latter as Bathyurus sensu lato. Bathyurus (Raymondites) is composed of five previously named species, B. (R.) spiniger (Hall), B. (R.) longispinus (Walcott), B. (R.) ingalli (Raymond), B. (R.) bandifer Sinclair, and B. (R.) trispinosus (Wilson), and two new species, B. (R.) clochensis, and B. (R.) missouriensis; an eighth species is placed in open nomenclature. All species share tuberculate sculpture on the glabella, a relatively short palpebral lobe whose length is less than half of preoccipital glabellar length, and a pygidial outline that is well rounded posteriorly. Aside from the most basal species, B. (R.) longispinus, they also possess occipital spines and, where the pygidium is known, axial pygidial spines.