Superior Conjunctival Fornix Research Articles

Conjunctival tumour as an acute myeloblastic lymphoma presentation in a paediatric patient

AbstractPurpose: The most frequent ocular tumours are those that affect the conjunctiva which have a wide spectrum of presentation and can arise from any cell lineage that forms the conjunctiva, being the most representatives those that origins from epithelial and melanocytic cells. A case of a 10‐month‐old female patient who was diagnosed with acute myeloblastic leukaemia after studying a conjunctival tumour is presented.Methods: The case of a 10‐month‐old female with a conjunctival lesion located in the right eye who was also being studied for two masses, one on the right preauricular zone and the other on the left zygomatic area is described. About her medical history, she had an aplastic crisis due to parvovirus infection when she was 8 months old. No ophthalmological background was reported. On the clinical exam of the right eye, a pink conjunctival lesion located in the outer corner of the superior conjunctival fornix was found. The ocular motility was normal and the eyeball position was normal.Results: A biopsy of the conjunctival mass was performed immediately. The histopathology report showed infiltration with leukaemic cells. After this finding, a bone marrow biopsy, lumbar puncture, full‐body CT scan and an orbit MRI were performed, concluding the patient was suffering from an acute myeloblastic leukaemia with extramedullary involvement (face, orbit, ovaries) and central nervous system affection. After two cycles of chemotherapy, complete remission is achieved, including the conjunctival and orbital lesions.Conclusions: Haematology‐Oncology systemic diseases can imply the eye and the orbit. The manifestations most commonly found in children with leukaemia are proptosis, retinal and choroidal affection, optic nerve damage, and sixth nerve palsy. In the conjunctiva, it usually manifests as a subconjunctival salmon‐pink flesh coloured mass. Excision‐biopsy study is essential in the differential diagnosis of conjunctival neoplasms.

PRIMARY CONJUNCTIVAL TUBERCULOSIS: A CASE REPORT

A 11 year old female was referred from ophthalmology clinic to pulmonary medicine department for further evaluation of a case of unilateral conjunctivitis not responding to treatment as suspected case of conjuctival tuberculosis. In the right eye, bulbar conjunctiva in supranasal quadrant polypoidal appearance was seen and there was subconjunctival cystic nodular mass in the superior conjunctival fornix. Systemic examination was unremarkable. Microbiological and histopathological examination of excision biopsy of the subconjunctival cyst revealed a granulomatous inflammation but acid fast bacilli was negative. Tissue sample was subjected to CBNAAT (Cartridge based nucleic acid amplification technique) examination in which mycobacterium tuberculosis was detected and sensitive to rifampicin. Patient was started on anti tuberculosis treatment under NTEP (national tuberculosis elimination programme) and full remission was achieved with 6 months of anti tuberculosis treatment. Although primary tuberculous conjunctivitis is a very rare condition, it should be considered in the differential diagnosis of treatment-resistant unilateral conjunctivitis. For definitive diagnosis, microbiological, histopathological and molecular examinations should be performed in conjunctival samples.

The Effect of Vault on Conjunctiva Combined with Fascia Sheath Suspension on the Mobility and Aesthetics of Eyelid in Patients with Ptosis

Objective: To investigate the effect of vault on conjunctiva combined with fascia sheath suspension on the mobility and aesthetics of eyelid in patients with ptosis. Methods: A total of 80 patients with ptosis who were admitted to our hospital from January 2017 to January 2019 were selected as the subjects. They were divided into 2 groups with random number table method, 40 cases each. The control group was treated with modified single-incision frontalis fascia flap suspension, and the observation group was treated with vault on conjunctiva combined with fascia sheath suspension. The eyelid margin activity, aesthetics and complications were compared between the two groups. Results: The eyelid margin activity of the observation group after treatment was higher than that of the control group, the difference was statistically significant (P<0.05); the aesthetic satisfaction of the observation group after treatment was 95.00% (38/40) higher than that of the control group 70.00% (28/40) The difference was statistically significant (P<0.05); the incidence of complications in the observation group was 2.50% (1/40) lower than that in the control group 20.00% (8/40), and the difference was statistically significant (P<0.05). Conclusion: Patients with ptosis are treated with superior conjunctival fornix combined with fascia sheath suspension, which can improve the mobility of eyelid margin, and it is more beautiful and has less complications.

Measurement of Tear Production and Intraocular Pressure in Healthy Captive Helmeted Guinea Fowl (Numida meleagris)

We establish reference values of tear production by the phenol red thread test (PRTT) and intraocular pressure (IOP) by rebound tonometry in helmeted guinea fowl ( Numida meleagris ). Aqueous tear production and IOP were measured in 44 (22 males, 22 females) clinically normal captive helmeted guinea fowl. Birds were gently physically restrained in the sitting position without any pressure to the head or neck. In each bird, aqueous tear production was measured by placing phenol red threads in the superior conjunctival fornix, and IOP was measured by using a Tonovet rebound tonometer. Overall mean ± standard deviation (SD) values of PRTT and IOP of all eyes were 16.5 ± 1.3 mm/15 s (ranging from 14-18 mm/15 s) and 9.1 ± 0.9 mm Hg (ranging from 7-10 mm Hg), respectively. No significant differences were found in IOP or PRTT between males and females (P = .76; P = .83, respectively) or between the left and right eyes (P = .34 and .66, respectively) in the guinea fowl. Results of this study may be beneficial for the diagnosis and therapy of keratoconjunctivitis sicca, glaucoma, and uveitis in helmeted guinea fowl.

Three dimensional meibography for diagnosis of dry eye syndrome

PurposeThe dysfunction of meibomian glands which secrete components of lipid layer in tears is currently pointed out as one of the main causes occurring dry eye. The distribution of that is more than 70% in Asian, especially. This brought out the importance for the dysfunction of meibomian glands. Our study was aimed to confirm the efficacy of 3D meibography to evaluate the structures of meibomian glands.MethodsThis study is a cross sectional study for patients who had diagnosed as dry eye disease associated with the dysfunction of meibomian glands at Seoul Saint Mary's Hospital from July to October, 2014. To confirm the structure of dry eye patients, 3D images using 3D OCT (optical coherence tomography) and 2D images using infrared camera were obtained. Patients who had the drop‐out lesion in 3D and 2D images were divided as two groups, and differences between them were analyzed. At the same time, to find the clinical signification for structural changes of meibomian glands, all patients had an ocular surface and a tear function examination to define the degree of dry eye.ResultsAs compared between 3D and 2D images for dry eye patients who had the drop‐out lesion on meibomian glands, 3D images was more useful for diagnosis of dry eye than 2D, especially in dry eye related with mild meibomian gland disease.ConclusionsOur study confirmed that the structural change of meibomian glands was reflected in optical coherence tomography 3D images. Especially, 3D meibography was more powerful than 2D infrared camera to find out the real state of drop‐out lesion on meibomian glands. But, there was no statistical significance between the location of drop‐out lesions; such as near lid margin, middle area, near superior conjunctival fornix, and clinical features in these study.

Three dimensional meibography for diagnosis of dry eye syndrome

PurposeThe dysfunction of meibomian glands which secrete components of lipid layer in tears is currently pointed out as one of the main causes occurring dry eye. The distribution of that is more than 70% in Asian, especially. This brought out the importance for the dysfunction of meibomian glands. Our study was aimed to confirm the efficacy of 3D meibography to evaluate the structures of meibomian glands.MethodsThis study is a cross sectional study for patients who had diagnosed as dry eye disease associated with the dysfunction of meibomian glands at Seoul Saint Mary's Hospital from July to October, 2014. To confirm the structure of dry eye patients, 3D images using 3D OCT (optical coherence tomography) and 2D images using infrared camera were obtained. Patients who had the drop‐out lesion in 3D and 2D images were divided as two groups, and differences between them were analyzed. At the same time, to find the clinical signification for structural changes of meibomian glands, all patients had an ocular surface and a tear function examination to define the degree of dry eye.ResultsAs compared between 3D and 2D images for dry eye patients who had the drop‐out lesion on meibomian glands, 3D images was more useful for diagnosis of dry eye than 2D, especially in dry eye related with mild meibomian gland disease.ConclusionsOur study confirmed that the structural change of meibomian glands was reflected in optical coherence tomography 3D images. Especially, 3D meibography was more powerful than 2D infrared camera to find out the real state of drop‐out lesion on meibomian glands. But, there was no statistical significance between the location of drop‐out lesions; such as near lid margin, middle area, near superior conjunctival fornix, and clinical features in these study.

Superior Conjunctivoplasty-Mullerectomy for Correction of Chronic Discharge and Concurrent Ptosis in the Anophthalmic Socket With Enlarged Superior Fornix

Many anophthlamic patients with ocular prostheses experience chronic discharge. A subset of these patients is found to have concurrent ptosis and an enlarged superior conjunctival fornix. Examination reveals an enlarged superior fornix with copious mucopurulent discharge. The subset of patients meeting these criteria is very small, and estimated incidence cannot be determined. The authors propose that using a modification of the conjunctivomullerectomy to decrease the potential space in the enlarged fornix while at the same time correcting the ptosis will help alleviate this chronic discharge. A retrospective review of 5 anophthalmic patients who underwent a modified superior conjunctivoplasty- mullerectomy was performed. All patients had chronic discharge and an enlarged superior conjunctival fornix, with mucous collection noted in the cul-de-sac. All patients had a concomitant ptosis and superior sulcus deformity on the affected side. Postoperative outcomes regarding correction of discharge, ptosis, and enlarged superior fornix were obtained. All patients had improvement in their chronic discharge. Palpebral fissure measurements improved from a median of 6.5 mm (range 6-8 mm) at baseline to 9.25 mm (range 8-10 mm) at last follow-up. The enlarged superior fornix was corrected in all patients. A modified superior conjunctivoplasty- mullerectomy is an effective method for correcting chronic discharge and ptosis in anophthalmic patients who have an enlarged superior conjunctival fornix.

Conjoint Fascial Sheath of the Levator and Superior Rectus Attached to the Conjunctival Fornix

The aim of this study is to elucidate the microscopic structures above the superior fornix relation to blepharoptosis operation. Eight fixed cadavers of Korean adults were used. In six cadavers, 12 orbits were explored after removal of brain. In two cadavers, histologic sections were made. Below the levator, thick fibrous sheath was covering superior rectus. According to Whitnall's description, we called the thickened portion the "conjoint fascial sheath" (CFS) of the levator and superior rectus attached to the conjunctival fornix. CFS was located 2.5 +/- 0.2 mm (range, 2-8 mm) posterior to the fornix. It was 12.2 +/- 2.0 mm (range, 8-14 mm) anteroposterior length and 1.1 +/- 0.1 mm (range, 0.5-1.5 mm) thick. The shape was equilateral trapezoid with a longer base anteriorly. Posteriorly, it was extended from the fascia of the levator and superior rectus. Anteriorly superficial and deep extensions of CFS were continued approximately 2 mm to the superior conjunctival fornix and then 2 to 3 mm distally along and beneath the palpebral and bulbar conjunctiva. Surgeons should be aware of the presence of CFS between levator and superior rectus in performing ptosis surgery.

Malignant Fibrous Histiocytoma of the Lateral Conjunctiva and Anterior Orbit

A 25-year-old woman presented for evaluation of a rapidly enlarging mass of the left bulbar conjunctiva. Debulking biopsy was performed, which led to the diagnosis of myxoid malignant fibrous histiocytoma. The patient underwent left orbital exenteration with clear margins. Histopathology showed involvement of the conjunctiva substantia propria, superior conjunctival fornix, and episclera, as well as extension from the lateral rectus muscle sheath. Immunohistochemical staining was strongly positive for CD68, alpha1-antitrypsin, CD34, and vimentin.

Morphogenesis of the human lacrimal gland.

The aim of this study was to determine the main stages of the lacrimal gland's developmental process in humans and to establish its precise morphogenetic timetable. Its onset is generally assumed to take place at O'Rahilly's stage 21, arising from an epithelial thickening of the superior extreme of the temporary conjunctival fornix. However, the present study points to a prior stage in the process: the presence of epithelial-mesenchymal changes in embryos at O'Rahilly's stage 19. The study was performed using light microscopy on serial sections of 37 human specimens: 23 embryos and 14 fetuses ranging from 15 to 137 mm crown-rump length (7-116 weeks of development). Three stages in lacrimal gland morphogenesis were identified: (1) the presumptive glandular stage, O'Rahilly's stages 19-20, characterized by a thickening of the superior fornix epithelium together with surrounding mesenchymal condensation; (2) the bud stage, generally assumed to be the first manifestation of glandular origin, characterized initially by the appearance of nodular formations in the region of the superior conjunctival fornix and concluding with the appearance of lumina within the epithelial buds; and (3) the glandular maturity stage, weeks 9-16, the period in which the gland begins to take on the morphology of adulthood.

Suspension of the eyelid to the check ligament of the superior fornix for congenital blepharoptosis.

A new surgical procedure for the treatment of all types of congenital blepharoptosis is described: suspension of the eyelid to the check ligament of the superior fornix. This is a dynamic suspension technique by which the check ligament, which is an extension of Tenon's capsule and normally inserts into the superior conjunctival fornix, is brought forward and sutured to the tarsus, which raises the eyelid. This technique does not sacrifice or add any tissue and is simple to repeat if necessary. Sixty-two patients were operated on using the technique and followed up for a mean of 23 months (range 3 months to 9.6 years). In a group of patients not operated on before for ptosis, 50 eyelids were raised with 74% normalisation, 22% improvement, and one eyelid each that showed only slight change or overcorrection. In a group of patients with 27 eyelids operated on before using other techniques, 67% of the eyelids were normalised, 30% were improved, and only one eyelid showed no change. In conclusion, this new technique has proved to be quite successful in raising the level of the upper eyelid in congenital blepharoptosis, with results at least comparable to those of most other techniques. The advantages with the check ligament over other techniques are the minimal trauma of the surgery, its simplicity, and its repeatability.

Botulinum Toxin Injections in the Treatment of Seventh Nerve Misdirection

Inquiries to Allen M. Putterman, M.D., 111 N. Wabash Ave., Ste. 1714, Chicago, LL 60602. Misdirection of the seventh nerve occasionally occurs after regeneration of the nerve after paresis, which may be caused by such conditions as Bell's palsy. Many patients find that when they smile their eyelids narrow on the side of the seventh nerve misdirection and create a cosmetic deformity. Some of these patients can be adequately treated through a blepharoptosis procedure, such as the Fasanella-Servat procedure.' The Muller's muscle-conjunctival resection blepharoptosis procedure is effective in patients who preoperatively demonstrate a good response of their eyelid level and palpebral fissure both in the primary position of gaze and on smiling after instillation of 10% phenylephrine to the superior conjunctival fornix. There are patients, however, whose upper eyelids elevate to a cosmetically unacceptable high level in the primary position of gaze on instillation of phenylephrine even though they may have an acceptable appearance when they smile. In this group of patients, there has not been a procedure to correct the eyelid deformity fully on smiling without causing a retracted eyelid without smiling. I treated a patient who had seventh nerve misdirection whose upper eyelid elevated too high with 10% phenylephrine by injection of botulinum toxin. A 28-year-old woman had Bell's palsy, which had affected her right side ten years previously. The patient continued to be bothered by the narrowing of her right eye when she smiled. In the primary position of gaze, her palpebral fissure width measured 9.0 mm on each side. When she smiled, the right palpebral fissure narrowed to 5.5 mm (Fig. 1). On instillation of 10% phenylephrine to the right upper fornix, the right upper eyelid retracted to a level 2.0 mm higher than the left upper eyelid. When the patient smiled after phenylephrine instillation, her upper eyelid levels were symmetric. A blepharoptosis procedure in the right upper eyelid was contraindicated because of the probability that the upper eyelid would have cosmetically unacceptable retraction when the patient was not smiling. Botulinum A toxin (0.1 ml of 2.5 units per 0.1 mm of solution) was injected into the right cheek and five sites of the right upper and lower eyelids. The sites injected were the temporal and nasal ends of the right upper eyelid, the temporal and central positions of the right lower eyelid, and the temporal right inferior orbital rim. Postoperatively, the palpebral fissure width measured 9.0 mm on the right side and 9.5 mm on the left. There was no change on smiling (Fig. 2). For three months postoperatively the

Flexible anterior chamber intraocular lens expulsion

We report a case of presumed traumatic expulsion of an anterior chamber intraocular lens two weeks postoperatively. The 59-year-old patient presented complaining of foreign-body sensation; we found the intraocular lens in his superior conjunctival fornix.

Congenital Fistula of Lacrimal Duct

CONGENITAL fistula of the lacrimal duct is very rare, and is usually associated with other congenital anomalies (Duke-Elder, 1932, 1952; Gray, 1949; Spaeth, 1948). The epithelium of the ducts and alveoli of the lacrimal gland is derived from a series of ectodermal invaginations in the region of the superior conjunctival fornix. Early buds form the orbital portion, while secondary buds from above appear later and form the palpebral lobe at the 40-60 mm. stage of the foetus. The stalk of the ectodermal invaginations, at first solid, are later canalized (50-55 mm.). The full development of the gland occurs at about 3 to 4 yrs. The gland ducts are about twelve in number, two to five being derived from the orbital lobe, and six to eight from the palpebral lobe; they all pass through the palpebral lobe as would be expected from their development. The majority of ducts open into the lateral part of the superior fornix, but a large duct (which may be called the inferolateral duct) traverses the extreme outer end of the gland, passes just deep to the conjunctival epithelium, and opens a few millimetres lateral to and some distance below the external commissure. The case described below is that of a little girl who had a congenital fistula of the right inferolateral lacrimal duct and right dacryocystitis with no associated deformity of the external canthus or elsewhere.

LACHRYMAL GLAND TUMORS

A knowledge of the anatomy of the lachrymal gland is of prime importance to one who undertakes an operation for its removal, and therefore I offer a brief description of it. ANATOMY OF THE LACHRYMAL GLAND In character it belongs to the acinous gland and occupies a place in the upper outer and anterior portion of the orbital cavity, being lodged in what is termed the lachrymal fossa on the under surface of the orbital plate of the frontal bone. While in close apposition with the overlying periosteal covering at this point, it is, nevertheless, but loosely connected therewith. Through the expanded insertion of the elevator muscle of the upper lid the gland is divided into a superior, more compact portion of grayish-red color, and an inferior or accessory portion of looser texture and in close relation with the superior conjunctival fornix. Investing the gland is a fibrous