Lateral Fornix Research Articles

The lateral fornix orbitotomy: a novel surgical corridor to lacrimal gland lesions.

Current practice for diagnostic biopsy of lacrimal gland lesions entails an orbitotomy procedure via an upper eyelid crease or lateral canthotomy skin incision. We describe a novel surgical technique to address these lesions via the lateral conjunctival fornix. Retrospective case series of all patients who underwent a lateral fornix orbitotomy procedure for incisional or excisional diagnostic biopsy of lacrimal gland lesions. The procedure involves a conjunctival incision in the lateral fornix remote from the openings of the lacrimal ductules, and an intraperiosteal surgical corridor to access the lacrimal gland. The study cohort included 16 patients (3 male, 13 female) with a mean age of 48.3 years (range, 24.0-78,9 years). The sampled lesions involved the orbital lobe in 14 patients, the palpebral lobe in 1 patient, and the entire gland in 1 patient. A histopathological diagnosis was obtained in all cases. Postoperatively, new moderate adduction deficit developed in one patient (6.3%) that recovered after adhesiolysis of the conjunctival scar. 3 patients (18.8%) experienced transient mild limitation of adduction or abduction. There was no new or worse ptosis or dry eye disease related to the surgery. The mean length of postoperative follow-up was 1.3 years (median 1.0 years, range, 0.6-4.7 years). The lateral fornix orbitotomy approach was successful in obtaining biopsy specimens of histopathological diagnostic value. It provides transconjunctival access to the lacrimal gland without damage to the excretory lacrimal ductules or displacement of the eyelid support system.

Subpalpebral Antibiotic Lavage for the Treatment of Refractory Infectious Scleritis.

Infectious scleritis is a potentially devastating condition that can result in severe vision loss. When traditional management fails, a subpalpebral antibiotic lavage system (SAL) can be considered to bathe the infected area with a high volume and concentration of antibiotics. Several reports show that this method can be curative for infectious scleritis, otherwise refractory to care. However, surgical approaches for this technique are either not well described, advocate for transecting the levator aponeurosis, or do not expose the entire width of the superior fornix, which can lead to postoperative ptosis. The authors describe a case where a novel approach was utilized, using a fenestrated angiocather in the superior lateral fornix, to maximize outcomes and minimize postoperative complications. In the setting of infectious scleritis refractory to traditional management, a SAL can be safely and effectively placed with the technique detailed in this report.

Cervicovaginal Complement Activation and Microbiota During Pregnancy and in Parturition.

BackgroundVaginal microbiome and the local innate immune defense, including the complement system, contribute to anti- and proinflammatory homeostasis during pregnancy and parturition. The relationship between commensal vaginal bacteria and complement activation during pregnancy and delivery is not known.ObjectiveTo study the association of the cervicovaginal microbiota composition to activation and regulation of the complement system during pregnancy and labor.Study designWe recruited women during late pregnancy (weeks 41 + 5 to 42 + 0, n=48) and women in active labor (weeks 38 + 4 to 42 + 2, n=25). Mucosal swabs were taken from the external cervix and lateral fornix of the vagina. From the same sampling site, microbiota was analyzed with 16S RNA gene amplicon sequencing. A Western blot technique was used to detect complement C3, C4 and factor B activation and presence of complement inhibitors. For semiquantitative analysis, the bands of the electrophoresed proteins in gels were digitized on a flatbed photo scanner and staining intensities were analyzed using ImageJ/Fiji win-64 software. Patient data was collected from medical records and questionnaires.ResultsThe vaginal microbiota was Lactobacillus-dominant in most of the samples (n=60), L. iners and L. crispatus being the dominant species. L. gasseri and L. jensenii were found to be more abundant during pregnancy than active labor. L. jensenii abundance correlated with C4 activation during pregnancy but not in labor. Gardnerella vaginalis was associated with C4 activation both during pregnancy and labor. The amount of L. gasseri correlated with factor B activation during pregnancy but not during labor. Atopobium vaginae was more abundant during pregnancy than labor and correlated with C4 activation during labor and with factor B activation during pregnancy. Activation of the alternative pathway factor B was significantly stronger during pregnancy compared to labor. During labor complement activation may be inhibited by the abundant presence of factor H and FHL1.ConclusionsThese results indicate that bacterial composition of the vaginal microbiota could have a role in the local activation and regulation of complement-mediated inflammation during pregnancy. At the time of parturition complement activation appears to be more strictly regulated than during pregnancy.

Activation of the Complement System in the Lower Genital Tract During Pregnancy and Delivery

BackgroundHuman pregnancy alters profoundly the immune system. The local involvement and mechanisms of activation of the complement system in the cervicovaginal milieu during pregnancy and delivery remain unexplored.ObjectivesTo determine whether normal pregnancy and delivery are associated with local activation of complement or changes in the immunoglobulin profile in the cervix.Study DesignThis study was designed to assess IgA, IgG, and complement activation in the cervicovaginal area in three groups of patients: i) 49 pregnant women (week 41+3–42+0) not in active labor, ii) 24 women in active labor (38+4–42+2), and iii) a control group of nonpregnant women (n=23) at child-bearing age. We collected mucosal samples from the lateral fornix of the vagina and external cervix during routine visits and delivery. The Western blot technique was used to detect complement C3 and its activation products. For semiquantitative analysis, the bands of the electrophoresed proteins in gels were digitized on a flatbed photo scanner and analyzed. IgA and IgG were analyzed by Western blotting and quantified by ELISA. One-way ANOVA and Tukey’s Multiple Comparison tests were used for statistical comparisons.ResultsA higher abundance but lower activation level of C3 in both the external cervix (P<0.001) and lateral fornix of the vagina (P<0.001) was observed during delivery (58 ± 22, n= 24) in comparison to the groups of nonpregnant (72 ± 13%; mean ± SD, n=23) and pregnant women (78 ± 22%, n=49). Complement activating IgG was detected in higher abundance than IgA in the cervicovaginal secretions of pregnant women. In a small proportion samples also C3-IgG complexes were detected.ConclusionsOur results reveal an unexpectedly strong activation of the complement system and the presence IgG immunoglobulins in the cervicovaginal area during pregnancy, active labor, and among nonpregnant women. In contrast to the higher amounts of C3 in the cervicovaginal secretions during labor, its activation level was lower. Complement activating IgG was detected in higher concentrations than IgA in the mucosal secretions during pregnancy and labor. Taken together our results imply the presence a locally operating humoral immune system in the cervicovaginal mucosa.

Lateral canthal choristomas associated with colobomas of lateral canthus

Choristomas are congenital lesions presenting normal tissue in an abnormal location. A conjunctival dermolipoma is a congenital choristomas tumor usually localized in the temporal aspects of the bulbar conjunctiva, near the lateral canthus. It may be associated with developmental anomalies of the second branchial arch, such as Goldenhar syndrome. The association between dermolipoma and lateral canthal cleft without other congenital anomalies is uncommon. The purpose of this paper is to present a series of isolated choristomas in the lateral canthus associated with a lateral cleft. We present 3 cases of dermolipoma at the lateral canthus associated with isolated lateral cleft. The dermolipomas’ appearance ranges from a flat lesion to a large pedunculated tumor, obliterating the lateral conjunctival fornix. A partial removal of the dermolipoma was done with canthoplasty to close the lateral coloboma. Surgical management of dermolipoma with partial excision aimed at reducing visible tumor produced good cosmetic results, without complications. Microscopic examination of the tumor revealed a mass covered by stratified squamous keratinized epithelium. The mass comprised largely of mature adipose tissue interspersed with bundles of collagen. The presence of pilosebaceous units was also noted. Based on these features, a histopathological diagnosis of a dermolipoma was made. The association between dermolipoma and isolated lateral canthal cleft is much less common than the associations with other distinguishing abnormalities. In summary, these cases illustrate that dermolipomas are also a part of a wide spectrum that characterizes benign growths of the eyelids. Level of evidence: Level V, therapeutic study.

Step-by-step colpotomy in total laparoscopic hysterectomy: a technique to avoid apical support damage to the upper vagina

The purpose of this video article is to demonstrate our colpotomy technique that enables maximal protection of the cervical ring, helps to prevent the ureteral injury by distancing, and avoids shortening of the vagina at total laparoscopic hysterectomy. Step-by-step explanation of the colpotomy technique is presented using educational video setting in university-affiliated private hospital. After the uterine artery transection, a VECTEC surgical uterine manipulator (VECTEC, Hauterive, France) was inserted into the vagina in place of the sharp curette. The plastic rotating blade of uterine manipulator was strongly pushed forward into the anterior vaginal fornix. Colpotomy incision was started from the uppermost middle point of an anterior vagina, and extended to both sides with a monopolar L-hook electrocautery at 40 watts cutting mode. Then the manipulator’s blade was maneuvered into the right lateral fornix, and THUNDERBEAT platform (Olympus Medical Systems Corp, Tokyo, Japan) was chosen as the modality of energy for the transection of the rest of the vagina. At the posterior part of colpotomy, the vaginal wall was cut from the uppermost part of uterosacral ligaments, as well. Finally, the left lateral fornix was cut by the same principles, and colpotomy was completed circumferentially. In conclusion, maximal preservation of paracervical ligaments with this technique preserve the apical support of vagina, and avoids shortening of vaginal length. The technique also minimizes the ureteral injury by distancing.

Topographic separation of fornical fibers associated with the anterior and posterior hippocampus in the human brain: An MRI-diffusion study.

Background and ObjectiveEvidence from rat and nonhuman primate studies indicates that axons comprising the fornix have a characteristic topographical organization: projections from the temporal/anterior hippocampus mainly occupy the lateral fornix, whereas the more medial fornix contains fibers from the septal/posterior hippocampus. The aim of this study was to investigate whether the same topographical organization exists in the human brain.MethodsUsing high angular resolution diffusion MRI‐based tractography at 3T, subdivisions of the fornix were reconstructed in 40 healthy adults by selecting fiber pathways from either the anterior or the posterior hippocampus.ResultsThe tract reconstructions revealed that anterior hippocampal fibers predominantly comprise the lateral body of the fornix, whereas posterior fibers make up the medial body of the fornix. Quantitative analyses support this medial:lateral distinction in humans, which matches the topographical organization of the fornix in other primates.ConclusionThis novel tractography protocol enables the separation of fornix fibers from anterior and posterior hippocampal regions in the human brain and, hence, provides a means by which to compare functions associated with different sets of connections along the longitudinal axis of the hippocampus.

Assessment of perioperative, early, and late postoperative complications of the inside-out transobturator tape procedure in the treatment of stress urinary incontinence

Objective: To evaluate the complications of urinary incontinence surgery with transobturator tape (TVT-O) system and to describe itsdiagnosis and management. Materials and Methods: A total of 156 patients who were diagnosed as having stress incontinence and mixedincontinence with stress predominance underwent a TOT operation under spinal anesthesia by one surgeon or two surgeons (MB, AEY) from the team. TVT-obturator inside out material was used in the operation. Urodynamic tests and pad tests were done on all the patients. This is a prospective and retrospective study of the complications of TVT- O. The operation was performed under regional anesthesia, asdescribed by Deval et al. Patients were excluded from the study if they had been operated under general or local anesthesia, had undergoneany vaginal operations except for anterior repair (cystocele), wanted to have a baby, had severe systemic diseases or had been diagnosedas having urge incontinence in urodynamic tests. These situations may affect the rate of complications, the authors also excluded slings thathad materials other than monofilament polypropylene, and patients who were suspected of having neurologic bladder conditions. The bladderand urethra were evaluated using cystoscopy. The durations of the TOT procedure, cystoscopy, and if performed, the cystocele operation,were recorded. Perioperative, early, and late postoperative complications were analyzed by follow-up visits (after two months to fouryears). Results: Of the 156 patients included in the study, 100 (64.1%) had pure stress urinary incontinence and 56 (35.9%) had mixed incontinence,20 (12.8%) had previous incontinence surgery. The mean duration of follow up was 30.3 &#x00B1; 7.4 (range 17-42) months. Themean age of the patients was found to be 48.43 &#x00B1; 6.24 years (range 42-68). The mean parity of the patients was 5.24 &#x00B1; 2.86 (range 2-13), and mean body mass index was found to be 23.7 &#x00B1; 4.8. Mean maximum detrusor pressure was 10.30 &#x00B1; 4.08 and the mean ALP value was80.80 &#x00B1; 25.57. Mean operative time was found to be 13.8 &#x00B1; 5.16 min in patients who underwent only TOT and TOT-anterior repair. Vaginalinjury including to the lateral fornix (4.4%), hemorrhaging of more than 200 ml (3.2%), vascular damage (1.9%), hematoma on the leg(1.9%), hemorrhaging of more than 500 ml (0.064%), and bladder perforation (1.2%) were detected as perioperative complications. Urethralinjury and perioperative nerve and intestinal injury did not occur. The most common complication in early postoperative period wasinguinal pain extending the legs (30.7%), followed by headaches (23.7%), fever (12.8%), urinary tract infection (5.7%), and urinary retention(3.2%), respectively. Late postoperative complications included vaginal erosion (4.4%), de novo urge incontinence (8.9%), de novo dyspareunia(7.1%), perineal pain (4.4%), and worsening urgency (8.9%). Conclusion: Although the TVT-O technique is a minimal invasivesurgery method applied to treat the urinary incontinence surgically, it does not imply that it is a complication-free surgical procedure. Despitethe low incidence of intraoperative complications, there is a mild risk of early and late postoperative complications. Fortunately thesecomplications can be taken under control by either conservative and simple medical treatments or surgical procedures.

The reconstruction of a contracted eye socket using a post-auricular full-thickness skin graft

To report the efficacy of a full-thickness skin graft (FTSG) for the reconstruction of a contracted eye socket. A retrospective, non-comparative, interventional case series. This was a retrospective review of patients with a contracted eye socket who underwent socket reconstruction using a post-auricular FTSG from 2001 to 2011 at the National Taiwan University Hospital. The postoperative results including prosthetic fitting, the cosmetic result, and eyelid function were assessed. There were 11 male and 15 female patients, with a mean age of 52.3 ± 15.6 years (range 21 to 76). The duration of the socket contracture varied from three months to three years (average 7.4 ± 8.1 months). The severity of the socket contracture ranged from grade 2 to grade 4, based on Tawfik's classification. The mean follow-up time was 35.7 ± 9.6 months. After socket reconstruction, using a post-auricular FTSG, 96% of the cases (25 of 26) demonstrated a successful prosthetic fitting and a satisfactory cosmetic outcome. Both good eyelid function and a stable fornix depth were maintained during the follow-up time. One case received a second socket reconstruction three months after the first operation, using a FTSG, because of an inadequate lateral fornix. The final result was satisfactory. There were no serious complications, but a granuloma formed in one case, and there was prolonged discharge in one case. The reconstruction of a contracted eye socket using a post-auricular FTSG is an effective method with a high success rate, which causes less discomfort to donor sites and results in few complications.

Associations between white matter microstructure and amyloid burden in preclinical Alzheimer's disease: A multimodal imaging investigation.

Some cognitively healthy individuals develop brain amyloid accumulation, suggestive of incipient Alzheimer's disease (AD), but the effect of amyloid on other potentially informative imaging modalities, such as Diffusion Tensor Imaging (DTI), in characterizing brain changes in preclinical AD requires further exploration. In this study, a sample (N = 139, mean age 60.6, range 46 to 71) from the Wisconsin Registry for Alzheimer's Prevention (WRAP), a cohort enriched for AD risk factors, was recruited for a multimodal imaging investigation that included DTI and [C-11]Pittsburgh Compound B (PiB) positron emission tomography (PET). Participants were grouped as amyloid positive (Aβ+), amyloid indeterminate (Aβi), or amyloid negative (Aβ−) based on the amount and pattern of amyloid deposition. Regional voxel-wise analyses of four DTI metrics, fractional anisotropy (FA), mean diffusivity (MD), axial diffusivity (Da), and radial diffusivity (Dr), were performed based on amyloid grouping. Three regions of interest (ROIs), the cingulum adjacent to the corpus callosum, hippocampal cingulum, and lateral fornix, were selected based on their involvement in the early stages of AD. Voxel-wise analysis revealed higher FA among Aβ+ compared to Aβ− in all three ROIs and in Aβi compared to Aβ− in the cingulum adjacent to the corpus callosum. Follow-up exploratory whole-brain analyses were consistent with the ROI findings, revealing multiple regions where higher FA was associated with greater amyloid. Lower fronto-lateral gray matter MD was associated with higher amyloid burden. Further investigation showed a negative correlation between MD and PiB signal, suggesting that Aβ accumulation impairs diffusion. Interestingly, these findings in a largely presymptomatic sample are in contradistinction to relationships reported in the literature in symptomatic disease stages of Mild Cognitive Impairment and AD, which usually show higher MD and lower FA. Together with analyses showing that cognitive function in these participants is not associated with any of the four DTI metrics, the present results suggest an early relationship between PiB and DTI, which may be a meaningful indicator of the initiating or compensatory mechanisms of AD prior to cognitive decline.

Bilateral nerve alterations in a unilateral experimental neurotrophic keratopathy model: a lateral conjunctival approach for trigeminal axotomy.

To study bilateral nerve changes in a newly developed novel mouse model for neurotrophic keratopathy by approaching the trigeminal nerve from the lateral fornix. Surgical axotomy of the ciliary nerve of the trigeminal nerve was performed in adult BALB/c mice at the posterior sclera. Axotomized, contralateral, and sham-treated corneas were excised on post-operative days 1, 3, 5, 7 and 14 and immunofluorescence histochemistry was performed with anti-β-tubulin antibody to evaluate corneal nerve density. Blink reflex was evaluated using a nylon thread. The survival rate was 100% with minimal bleeding during axotomy and a surgical time of 8±0.5 minutes. The blink reflex was diminished at day 1 after axotomy, but remained intact in the contralateral eyes in all mice. The central and peripheral subbasal nerves were not detectable in the axotomized cornea at day 1 (p<0.001), compared to normal eyes (101.3±14.8 and 69.7±12.0 mm/mm2 centrally and peripherally). Interestingly, the subbasal nerve density in the contralateral non-surgical eyes also decreased significantly to 62.4±2.8 mm/mm2 in the center from day 1 (p<0.001), but did not change in the periphery (77.3±11.7 mm/mm2, P = 0.819). Our novel trigeminal axotomy mouse model is highly effective, less invasive, rapid, and has a high survival rate, demonstrating immediate loss of subbasal nerves in axotomized eyes and decreased subbasal nerves in contralateral eyes after unilateral axotomy. This model will allow investigating the effects of corneal nerve damage and serves as a new model for neurotrophic keratopathy.

Direct reconstruction and associated uncertainties of 192Ir source dwell positions in ring applicators using gafchromic film in the treatment planning of HDR brachytherapy cervix patients

This paper details a practical method for the direct reconstruction of high dose rate 192Ir source dwell positions in ring applicators using gafchromic film in the treatment planning of brachytherapy cervix patients. It also details the uncertainties associated with such a process. Eight Nucletron interstitial ring applicators—Ø26 mm (×4), Ø30 mm (×3) and Ø34 mm (×1), and one 60 mm intrauterine tube were used in this study. RTQA2 and XRQA2 gafchromic films were irradiated at pre-programmed dwell positions with three successive 192Ir sources and used to derive the coordinates of the source dwell positions. The source was observed to deviate significantly from its expected position by up to 6.1 mm in all ring sizes. Significant inter applicator differences of up to 2.6 mm were observed between a subset of ring applicators. Also, the measured data were observed to differ significantly from commercially available source path models provided by Nucletron with differences of up to 3.7 mm across all ring applicator sizes. The total expanded uncertainty (k = 2) averaged over all measured dwell positions in the rings was observed to be 1.1 ± 0.1 mm (Ø26 mm and Ø30 mm rings) and 1.0 ± 0.3 mm (Ø34 mm ring) respectively, and when transferred to the treatment planning system, equated to maximum %dose changes of 1.9%, 13.2% and 1.5% at regions representative of the parametrium, lateral fornix and organs at risk respectively.

Linfoma De Colo Uterino: Relato De Caso E Revisão De Literatura

Report a case of uterine cervix lymphoma (NHL), its ultrasonographic aspects, correlation with magnetic resonance and review of literature. Female, 35 years old, asymptomatic, in wich routine transvaginal ultrasonography revealed nodule on the cervix. Physical examination detected a bulging on the left lateral fornix and parametrial fixed mass. A previous history of non-Hodgkin lymphoma treated two years ago. Transvaginal US showed hypoechoic nodule near the cervix, well delimited, with rich vascularity at Doppler. Magnetic resonance (MR) imaging of pelvis revealed a cervical mass, isointense to uterine muscle on T1 and T2 weighted images and low signal in Gadolinium-enhanced MR images. A transvaginal ultrasound guided core needle biopsy was performed, and cervical uterine lymphoma infiltration confirmed diagnosis. Although cervical lymphoma is rare, comprising less than 1% of cervical malignancies, it should be considered. Diffuse uterine cervical enlargement is the most common appearance. Less commonly, there may be a polypoidal or multinodular mass or a submucosal mass mimicking leiomyoma. CT or MR is required for staging the extent of disease, and to determinate the precise histological subtype by biopsy for treatment and prognostic purposes. Even if underused, transvaginal US-guided procedures are simple, safe and can be performed quickly and inexpensively.

ISUOG Practice Guidelines: use of Doppler ultrasonography in obstetrics

<scp>ISUOG</scp> Practice Guidelines: use of Doppler ultrasonography in obstetrics

Dacryoliths in the lacrimal gland ductule

Editor, We present the clinical and histologic findings in a series of four cases of dacryolithiasis in the lateral fornix. All four patients (one female, three male patients aged 21, 43, 51 and 66, respectively) were examined by slit lamp microscopy, and ultrasonography was performed in three. One patient underwent magnetic resonance imaging (MRI) (Fig. 1). The excised tissue and concretions were fixed in paraformaldehyde and embedded in paraffin. Ophthalmopathologic examination of paraffin sections included routine staining with hematoxylin and eosin and Periodic acid-Schiff as well as special stains for microorganisms. All provisions followed the Tenets of the Declaration of Helsinki. Patients gave written consent for study inclusion. (A) T1-weighted Magnetic resonance imaging. Arrows mark dacryolith; (B) Yellowish mass at the lateral canthal angle; inset shows removed dacryoliths; (C) cilium (arrow) with chronic inflammatory cells, giant cell (short arrow), dacryoliths (asterisks), magnification bar: 100 μm (hematoxylin-eosin). The clinical presentation of dacryoliths of the temporal canthus varies between a tumorous aspect and a non-specific inflammatory swelling. Thus, pre-operative diagnosis is difficult. All patients presented with a short duration of symptoms with little pain unresponsive to conservative treatment. Lesions were located in the region of the outlet duct of the lacrimal gland at the lateral canthus and appeared slightly hyperemic. Macroscopic characteristics of stones varied between small multiple round whitish–yellow concretions of hard consistency (0.7 mm in diameter, in association with a large dacryops) and bigger more irregular stones (up to 7 mm, in patients without surrounding cystoid structure). In all specimens, the histopathologic examination revealed amorphous acellular organic material without any evidence of microorganisms. In one patient, sections showed a cilium surrounded by an infiltrate of chronic inflammatory cells. The pathogenesis of stone formation in the ductules of the lacrimal gland is uncertain. Twelve cases of dacryoliths in the lacrimal gland have been reported (Naito et al. 1973; Duke-Elder 1952; Baker & Bartley 1990; Baratz et al. 1991; Mawn et al. 1997; Zafar et al. 2004; Halborg et al. 2009). In our series of four patients, there was no evidence of Actinomyces, Haemophilus influenzae or any other microorganisms in the sections examined. In one of our patients, histopathology showed a cilium closely associated with the dacryolith. Regarding the small number of cases a causative relation can hardly be proven. However, the findings suggest that cilia, amongst other potential agents, can possibly cause dacryolith formation in the lacrimal gland. It may be assumed that the relatively shorter ductal system and the few organic components in tears prior to their exposure to lipids, cell debris and bacteria on the ocular surface are responsible for their rare incidence and their mostly ‘sterile’ nature. However, microorganisms as the inciting but eventually no longer detectable agent cannot be excluded. The short duration of symptoms, on the other hand, would argue against such a mechanism. Bacteria associated with dacryolithiasis in the lacrimal gland may be more likely to be a secondary phenomenon since short history cases do not show any evidence of bacteria (this study), while microorganisms could primarily be detected in patients with a longer history of symptoms (Halborg et al. 2009). Both ultrasonography and MRI appear ineffective in reliably identifiying dacryoliths in the lacrimal gland ductule. Surgical intervention leads to rapid relief of symptoms and regression of clinical signs. Despite their infrequent occurrence lacrimal gland ductular dacryoliths should be included in the differential diagnosis of patients with a symptomatic or asymptomatic tumour in the lateral fornix or a chronic unilateral conjunctivitis.

Vaginal Leiomyoma Presenting as Dysfunctional Uterine Bleeding

Leiomyoma (fibroid) is the most common pelvic tumor. It is present in 20% of women of reproductive age, and its incidence increases with age. Fibroids are usually uterine in origin, and only rarely are they ectopic. They may arise from the round ligament, utero-ovarian ligament, uterosacral ligament, the vagina, or the vulva. In 1–4% of cases, the myoma grows primarily in the cervix. Primary vaginal fibroids are even rarer. We report a case of vaginal fibroid, which was diagnosed as cervical fibroid (or broad ligament fibroid) before surgery. A 35-year-old, para 3, woman presented with acute onset of vaginal bleeding for 2 days, with no associated pain or tenderness. On enquiry, she revealed that this bleeding had been on and off for the previous 3 months. In the past, she had three normal, uneventful vaginal deliveries; the last delivery was 7 years before. She had tubal a ligation done previously. She had no relevant family or past history. On abdominal examination, there were no palpable lumps. Speculum examination showed a swelling of about 5 × 5 cm on the right vaginal wall; mucosa over the swelling appeared to be healthy. Vaginal examination showed a backward cervix, uterus anteverted and anteflexed, normal in size, with a firm mass of about 5 × 5c m felt in right lateral fornix of the vagina. The swelling was not mobile and non-tender. Upper margin of the swelling could not be reached. It could be felt separately from uterus and appeared to be arising from broad ligament or subserosally so it was provisionally diagnosed as broad ligament fibroid or subserosal fibroid. Routine hemogram, coagulogram and biochemical profile were normal. Sonography showed a well-defined lesion of 5.2 × 5.7 cm in the right cervical region, likely to be a subserosal or broad ligament fibroid. Endometrial thickness was 6.2 mm. Both ovaries were separately visualized. Liver, gall bladder, spleen, kidneys and urinary bladder were normal. The patient was kept for total abdominal hysterectomy (TAH). Abdomen was opened by Pfannenstiel incision. Uterus was normal in size; both adnexa were healthy. A 5 × 5-cm mass was felt that did not arise from the uterus or cervix; it appeared to be from the vaginal swelling. On palpation, it was a well-defined, rounded, firm, non-mobile mass arising from the right lateral fornix of vagina with smooth surface, nonadherent to the vaginal mucosa. Because the patient had presented with dysfunctional uterine bleeding, and did not plan on having any more children, the planned TAH was performed. After removing the uterus, the vaginal swelling was approached through the vault. Incision was made on the most prominent part of the swelling and the mass was dissected away from all the surrounding tissue. It could be easily separated digitally. The cavity was closed with hemostatic sutures. The removed mass was excised; it showed a typical whorled pattern suggestive of vaginal leiomyoma. It was sent for histopathology. The vault was closed with continuous sutures. Blood loss was minimal. There were no intraoperative complications and her postoperative period was uneventful. Stitches were removed on the eighth postoperative day. She was discharged on the ninth day in good condition. Histopathological examination of the removed mass

Dacryoliths in the lacrimal gland ductule

Abstract Purpose Lacrimal duct obstruction can occasionally be associated with dacryolithiasis. Dacryoliths (DLs) have been found in the nasolacrimal sac, nasolacrimal duct, canaliculi, and rarely in the lacrimal gland ductules. Here, we would like to present the clinical, intra‐operative, and histologic findings in 4 cases of DLs in the lateral fornix Methods All 4 patients were examined by slit lamp microscopy, and ultrasound (US) was performed in 3 patients; 1 patient underwent Magnetic resonance imaging (MRI). Following surgery, the excised tissue and concretions were fixed in formalin and embedded in paraffin. Ophthalmopathologic examination included routine staining with H&amp;E and PAS as well as stains for microorganisms. Results All patients presented with a short duration of symptoms with only little pain. Lesions were located at the lateral canthus and appeared slightly hyperemic and to a varying degree cystic. US showed hypo‐ and hyperreflective signals but did not demonstrate any concretions. The DLs were found intraoperatively during removal of the "tumour". Macroscopic characteristics varied between small multiple round whitish–yellow concretions of hard consistency (0.7mm in diameter) and bigger more irregular stones (up to 7mm). Histology revealed amorphous acellular material without any evidence of microorganisms. In one patient, a cilium was found. All symptoms resolved quickly after removal of the DLs. Conclusion DLs of the lacrimal system can – albeit rarely – form in the excretory duct of the lacrimal gland. Possible agents responsible for stone formation in the lacrimal gland ductule include cilia and – less likely ‐ bacteria. Both US and MRI appear ineffective in reliably identifiying dacryoliths at this site but surgical intervention leads to rapid relief of all symptoms.

Pleomorphic adenoma of a subconjunctival ectopic lacrimal gland

This report describes a case of pleomorphic adenoma of an ectopic lacrimal gland arising subconjunctivally in the lateral fornix in a 13-year-old girl. The tumor was removed surgically in toto with the capsule. This is probably the first reported case.

Subconjunctival Prolapse of the Palpebral Lobe of the Lacrimal Gland Occurring in Association with Occult Orbital Fat Herniation

Introduction: Sub-conjunctival prolapse of the palpebral lobe of the lacrimal gland can be a disfiguring and sometimes uncomfortable problem, usually caused by lacrimal gland enlargement or associated orbital lobe displacement. However, we present two novel cases associated with occult orbital fat herniation.Method: Retrospective interventional case series of two middle-aged/elderly male patients presenting with unilateral prolapse of the palpebral lobe of the lacrimal gland and no clinically apparent orbital fat prolapse. Neither patient had proptosis, globe displacement or diplopia, but both were aware of a subconjunctival mass in the lateral fornix causing a cosmetic concern.Results: Imaging in both cases revealed a normal sized lacrimal gland with a prominent orbital fat pocket behind this. This fat was excised through an upper-eyelid skin crease approach with temporary detachment of the levator muscle in one case, and through a trans-conjunctival incision in the other. In both cases fat excision resulted in retroplacement of the palpebral lobe of the lacrimal gland such that it was no longer visible. Neither patient experienced any additional dry eye post-operatively.Conclusion: Sub-conjunctival prolapse of the palpebral lobe of the lacrimal gland can be associated with occult orbital fat herniation, revealed on imaging. Localised orbital fat excision is an effective means of treating this condition.

Shrinking Upper and Lower Eyelid Skin with a Novel Radiofrequency Tip

Many subjects wish to have tightening of eyelid skin but are reluctant to undergo aesthetic blepharoplasty surgery. We wanted to perform a small pilot study to test the efficacy and safety of a 0.25-cm(2) monopolar radiofrequency tip in a prospective noncomparative study as a novel nonsurgical method to safely tighten upper and lower eyelid skin in subjects of differing ethnicity and sex. Twenty adult subjects were enrolled in this prospective pilot study. All received symmetrical monopolar radiofrequency treatments in multiple passes to the pretarsal, preseptal, and lateral orbital skin. All subjects wore a protective plastic haptic contact lens to protect their vision during the radiofrequency treatment. (Haptic contact lenses fit over the entire anterior surface of the globe from superior to inferior and medial to lateral fornix. The purpose of using such a large contact lens was to protect the globe itself from radiofrequency energy.) Standardized color digital photography with eyes both open and closed was taken on each visit. Treatment efficacy was evaluated by both the expert observer and the subject at each visit. RESULTS At 6-month follow-up, according to the expert observer, 26 upper lids (87%) showed 25% or more tightening. Twenty lower lids (67%) showed 25% or more tightening. Two subjects (3.33%) had 51% to 75% upper lid tightening at 6 months. There were no adverse events beyond one subject with minimal corneal epithelial punctate defects on the treatment day. These resolved over several hours. The use of this new tip was shown to be safe. Effectiveness at shrinking eyelid skin was at best mild to moderate.