Challenging issues in ocular adnexal disorders.

Ocular adnexa includes a wide variety of anatomical structures including the eyelids, conjunctiva, carunculae, lacrimal gland, lacrimal drainage system, extraocular muscles, and soft tissues, and it is surrounded by seven bones. These complex and highly specialized tissues result in a large spectrum of inflammatory, benign, and malignant disorders. In this issue, we selected several challenging topics about the diagnosis and management of ocular adnexal disorders.

Unilateral Congenital Ptosis

Patients with unilateral congenital ptosis are more predisposed to developing amblyopia, usually due to strabismus, high astigmatism, or anisometropia.[123]

Unilateral severe congenital ptosis remains a major challenge for the oculoplastic surgeon because there is still much debate about which one is the optimal method. Common surgical procedures include unilateral frontalis suspension with autogenous or exogenous materials, maximal levator resection, or bilateral frontalis suspension with or without levator muscle excision of the normal eyelid. To reduce the morbidity of donor site or the normal eyelid, and postoperative complications such as undercorrection, lid asymmetry, and poor cosmetic results remain a major concern. Lee and Kim reviewed the literature and introduced the rationale, advantages, and disadvantages of various surgical treatments for unilateral severe congenital ptosis.

Immunoglobulin G4-Related Ophthalmic Disease

Immunoglobulin G4-related disease (IgG4-RD) is increasingly considered to be an emerging fibro-inflammatory condition comprised of a collection of disorders that share particular clinical, pathological, and serological features.[4] IgG4-RD often presents to clinicians with a diagnostic challenge not only for limited understanding but also because of its simultaneous or sequential involvement of multiple organs, including ocular adnexa.[5] Recent evidence supports that part of idiopathic orbital inflammatory syndrome is linked to IgG4-RD and a Japanese prevalence study of IgG4-related ophthalmic disease (IgG4-ROD) showed that approximately a quarter of orbital lymphoproliferative disorders are IgG4-ROD.[6] Yu et al. reviewed and updated the evidence regarding its epidemiology, diagnosis, clinical features, treatment, and the association between lymphoma and IgG4-ROD. The study emphasized the importance of careful clinicoradiologic examination, investigation for other organ involvement, and long-term monitoring for disease relapse or potential neoplastic transformation for patients with IgG4-ROD.

Conjunctival Papilloma

Conjunctival papilloma is an acquired benign epithelial tumor of the conjunctiva with a close causal relationship to human papillomavirus. Despite the multiple choices of therapeutic modalities for treating conjunctival papilloma, recurrences are not uncommon, ranging from 3% to 27%.[78] Huang et al. investigated the clinical features, treatment, and factors related to the recurrence of conjunctival papilloma. Their results suggest that surgical excision with adequate adjunctive therapy such as double freeze–thaw cryotherapy, intraoperative mitomycin-C, and/or carbon dioxide laser-assisted resection can reduce the risk of recurrence rate of conjunctival papilloma.

Treatment of Primary Acquired Nasolacrimal Duct Obstruction: Endoscopic or External Dacryocystorhinostomy?

Transcutaneous or external dacryocystorhinostomy has long been the standard procedure for treating primary acquired nasolacrimal duct obstruction. However, endoscopic endonasal dacryocystorhinostomy has become an increasingly popular procedure for this disease with the advent of new endoscopy instruments and technique.[9] In this issue, Su and Chang compared the success rates of endoscopic endonasal dacryocystorhinostomy and external dacryocystorhinostomy for the treatment of acquired nasolacrimal duct obstruction. Their results reveal that there was no statistically significant difference between endoscopic and external approaches. They suggest that endoscopic dacryocystorhinostomy can provide higher satisfaction due to quicker recovery and no external incision and should be considered as the primary treatment choice for acquired nasolacrimal duct obstruction.