Showing papers in "Ophthalmic Plastic and Reconstructive Surgery in 2006"
TL;DR: Most patients considered themselves improved cosmetically, despite occasional side effects including contour irregularity or lumps, bruising, color change, and fluid accumulation, and it is possible to achieve acceptable improvement after hyaluronic acid gel injections.
Abstract: PURPOSE: To review our initial experience using hyaluronic acid gel (Restylane) as a filler to treat the periorbital hollows.
METHODS: This is a retrospective, anecdotal case review of 244 cosmetic hyaluronic acid gel injections in 155 patients. An average volume of 0.9 ml per injection session was used in an individualized pattern that variably included the orbital rim hollow, zygomatic hollow, septal confluence hollow, and eyebrow and cheek fat pad. To achieve smooth contours, a layered, feathered threading technique was used, placing the filler deep to the orbicularis. Hyaluronidase injections were used in 11% of patients at follow-up visits to "dissolve" some of the filler to reduce contour irregularities.
RESULTS: One hundred eight of 121 (89%) patients with follow-up visits were satisfied with the cosmetic improvement after hyaluronic acid gel injections. For maintenance, the interval to second injection averaged 6.5 months. Side effects included lumps or contour irregularities (11%), bruising (10%), color change (7%), and fluid (15%). Twelve patients were unsatisfied and were not interested in additional injections: 5 with malar fluid, 3 with lumpy irregularity, and 3 with color change.
CONCLUSIONS: Complex 3-dimensional contours and thin skin over bone render periorbital filling difficult. However, with individualized planning and with care taken to create smooth, feathered contours, it is possible to achieve acceptable improvement. We found that most patients considered themselves improved cosmetically, despite occasional side effects including contour irregularity or lumps, bruising, color change, and fluid accumulation. Patients with very thin skin, preexisting color problems, or preexisting eyelid fluid may not be good candidates for periorbital filling with hyaluronic acid gel. The effect of the filler is temporary, of course, and we counsel patients to anticipate maintenance injections at 6- to 12-month intervals.
391 citations
TL;DR: The four patients shown in Figure 1 have severe complications of GO, but their cosmetic and functional deficits and associated treatment needs are quite different.
Abstract: One of the challenges in Graves orbitopathy (GO) is how to classify and grade its various clinical manifestations. For example, the four patients shown in Figure 1 have severe complications of GO, but their cosmetic and functional deficits and associated treatment needs are quite different. One pati
156 citations
TL;DR: No standard of care currently exists to guide physicians on when exenteration may benefit a mucormycosis patient, and further study is needed to determine which variables indicate the extent of disease and which variables or analytic scheme might predict the progression of orbital mucormYcosis with or without exEnteration.
Abstract: Purpose To determine whether evidence-based standards exist regarding the indications for orbital exenteration in patients with orbital mucormycosis. Methods A literature review was performed of 113 articles (1943 to 2004). Factors possibly related to patient survival were analyzed. Additionally, a survey was sent to all ASOPRS Fellowship Preceptors to ascertain the frequency, outcome, treatment modalities, and indications for exenteration by these practicing physicians. Results For published cases, parameter estimates (PE 46 years, frontal sinus involvement, and fever were less likely to survive compared with patients without these conditions. Patients treated with amphotericin B (OR, 4.476) and those with diabetes (OR, 4.987) were more likely to survive compared with patients without these conditions. Exenterated patients with fever were more likely to survive compared with nonexenterated patients with fever (P=0.0468). Thirty-four ASOPRS Fellowship Preceptors received surveys; 26 (76%) completed the survey. Responses to specific survey questions showed a varied experience and indication for exenteration throughout the country. Conclusions : Our study underscores the lack of adequate data regarding the evaluation of treatment of orbital mucormycosis. No standard of care currently exists to guide physicians on when exenteration may benefit a mucormycosis patient. Further study is needed to determine which variables indicate the extent of disease and which variables or analytic scheme might predict the progression of orbital mucormycosis with or without exenteration.
119 citations
TL;DR: There remains a constellation of signs, symptoms, imaging features, and histopathologic findings that is known by several names, including IOI, nonspecific orbital inflammation, and orbital pseudotumor, despite changes in its meaning.
Abstract: Although it is generally recognized when seen, idiopathic orbital inflammation (IOI) can be difficult to define with precision. It can be distinguished from inflammation with an identifiable cause, including bacterial and fungal infection, foreign body reaction, and the response to dermoid cyst leakage. It can be separated from conditions—although equally idiopathic—that have characteristic histopathologic patterns or systemic associations. Examples include Wegener granulomatosis, lupus erythematosus, histiocytoses, xanthogranulomas, sarcoidosis, and Graves disease. There remains a constellation of signs, symptoms, imaging features, and histopathologic findings that is known by several names, including IOI, nonspecific orbital inflammation, and orbital pseudotumor. Despite changes in its meaning, the last term appears to be tenaciously entrenched in the lexicon. When it was coined 75 years ago, pseudotumor subsumed all of the foregoing entities; as they were better characterized, many were moved out of the category, and the term’s scope has gradually contracted. Although that trend will continue, we must manage what is left, preferably in a systematic manner. As clinicians, we get the clear impression that “what is left” is not a uniform or monolithic condition.
87 citations
TL;DR: Of the various processing techniques currently used during autologous fat transfer, sedimentation appears to yield a higher proportion of viable adipocytes than does washing or centrifuging.
Abstract: Purpose To perform a quantitative analysis of adipocyte viability after fat processing during autologous fat transfer, comparing the processing methods of washing, centrifuging, and sedimentation. Methods An experimental study was conducted in which 24 fat samples were obtained after processing from 22 patients undergoing autologous fat transfer. Histologic analysis of periodic acid-Schiff-stained specimens was then performed. Results Cell counts per high-powered field of intact adipocytes and nucleated adipocytes and adipocyte cross-sectional area were significantly greater in samples processed by sedimentation, compared with those by centrifuging or washing. Conclusions Of the various processing techniques currently used during autologous fat transfer, sedimentation appears to yield a higher proportion of viable adipocytes than does washing or centrifuging.
76 citations
TL;DR: Orbitectomy with bone removal may be indicated for achieving local and regional control in advanced cases of adenoid cystic carcinoma of the lacrimal gland, but this surgery does not decrease the risk of distant metastasis.
Abstract: Purpose To review our experience with multidisciplinary surgical management of locally advanced adenoid cystic carcinoma of the lacrimal gland. Methods We present a case series of 7 patients with lacrimal gland adenoid cystic carcinoma treated at our institution between June 2001 and October 2003. Clinical records, histologic sections, and radiographic images were reviewed. Results The study included 3 men and 4 women (mean age at diagnosis, 44 years). All 7 patients underwent an orbital exenteration with bone removal. Five patients had an orbitectomy through a craniotomy approach and 2 patients had an exenteration through a fronto-orbito-zygomatic approach, all with removal of the bone of the superior and lateral wall. Six patients underwent reconstruction of the socket through the use of a vascularized flap. The surgical approach involved a neurosurgeon, an oculoplastic or head and neck surgeon, and a plastic surgeon. Six patients received postoperative radiation therapy. One patient with a recurrent tumor had already received radiation therapy, which precluded additional radiation therapy after surgical resection. The radiation field included the orbit and the skull base because all patients had evidence of perineural invasion. As of this writing, there have been no local recurrences. Five patients had development of distant metastases and died of disease, at follow-up times from 12 to 32 months after surgery. Two patients are alive without evidence of disease, both at 24 months' follow-up. Conclusions Orbitectomy with bone removal may be indicated for achieving local and regional control in advanced cases of adenoid cystic carcinoma of the lacrimal gland. This surgery does not decrease the risk of distant metastasis. The cases in our series highlight the locally invasive and metastatic behavior of this cancer.
74 citations
TL;DR: A stepwise approach to the treatment of congenital nasolacrimal duct obstruction is a clinically and financially effective model for treatment.
Abstract: Purpose To compare the outcomes achieved by a series of patients treated in a stepwise fashion who presented with congenital nasolacrimal duct obstruction. Methods In this retrospective interventional case series, 127 patients, ranging in age from 1 month to 81 months, with 173 lacrimal systems diagnosed with congenital nasolacrimal duct obstruction, were treated in a stepwise fashion. A treatment paradigm was evaluated that prescribed probing as an initial procedure regardless of age. Those who failed probing received balloon catheter dilation. Those who failed probing and balloon catheterization received silicone intubation. Dacryocystorhinostomy was reserved for patients failing the above treatments. Clinical success was defined as complete resolution of symptoms. Success rates at each step were evaluated, and a cost analysis was performed. Results Lacrimal probing was successful in 134 of 173 (76.9%) cases. Of the 39 probing failures, 32 (82.1%) were cured with balloon catheterization. All 7 cases (100%) that failed probing and balloon catheterization were cured with silicone intubation. No patient in this series required dacryocystorhinostomy. Conclusions A stepwise approach to the treatment of congenital nasolacrimal duct obstruction is a clinically and financially effective model for treatment.
68 citations
TL;DR: Haluronic acid gel fillers have had an enormous impact on the practice of cosmetic surgery, and this series demonstrates the usefulness of these fillers for treatment of the lower eyelid and midface, and recommends the deep-fill method described as a reliable means of addressing the hollow created by the naso-jugal groove.
Abstract: Purpose To report a 2-year experience of treating the naso-jugal groove with injectable hyaluronic acid gel, using a deep-fill method. Methods This was a consecutive, retrospective, nonrandomized case series of patients presenting with concerns involving dark circles, lower eyelid hollows, or other contour irregularities that make up the naso-jugal groove. One author performed all treatments, consisting of transcutaneous injection of hyaluronic acid gel filler, to address the naso-jugal groove. The filler was placed deep on the anterior lip of the orbital rim and molded to the desired shape. Results Between December 2003 and December 2005, 164 patients (34 male and 130 female) received hyaluronic acid gel filler in the face. Ninety-eight patients were treated just once and 66 had multiple treatment sessions. The mean dose of filler per session was 1.53 +/- 0.8 ml, with 0.84 +/- 0.38 ml divided between the two lower eyelids. The most common complication was localized swelling, followed by bruising, asymmetry, cellulitis (2 cases), and migraine (1 case). There were no cases of visual loss. Conclusions Hyaluronic acid gel fillers have had an enormous impact on the practice of cosmetic surgery, and this series demonstrates the usefulness of these fillers for treatment of the lower eyelid and midface. The authors recommend the deep-fill method described as a reliable means of addressing the hollow created by the naso-jugal groove.
67 citations
TL;DR: Investigation of the efficacy of canalicular trephination and silicone stent intubation procedure for relief of epiphora according to the level of obstruction within the canaliculus found distal monocanalicular obstructions have the highest degree of symptomaticEpiphora relief, followed by distal bicanalicular, common, and proximal obstructions.
Abstract: PURPOSE To investigate the efficacy of canalicular trephination and silicone stent intubation procedure for relief of epiphora according to the level of obstruction within the canaliculus. METHODS The medical records of 32 patients (41 eyes) who underwent canalicular trephination followed by silicone stent intubation of the nasolacrimal system for the treatment of canalicular obstruction were retrospectively reviewed. Canalicular obstruction was diagnosed on preoperative irrigation and probing. Level of obstruction was confirmed by intraoperative probing. Proximal obstruction was classified as those within 4 mm of the punctum, distal obstruction as those 5 mm or greater from the punctum, and common canalicular obstruction as those 10 mm or greater from the punctum. Silicone stents were kept in for a minimum of 5 months, and outcome was based on symptomatic relief of epiphora at the end of follow-up (minimum of 6 months). Partial relief of epiphora was defined as improved symptoms and at least a fair clearance on fluorescein dye disappearance testing. RESULTS On average, 49% of eyes had complete relief of epiphora, 38% had partial relief, and 13% had no relief. Eighty percent of eyes with distal lower canalicular obstructions had complete relief of epiphora and 20% had partial relief of epiphora. Eyes with distal bicanalicular obstructions had 66% complete and 33% partial relief. Patients with common canalicular obstructions had 59% complete, 29% partial, and 12% no relief. Proximal bicanalicular obstructions were the least successful, with 55% partial relief and 45% no relief. CONCLUSIONS Success of canalicular trephination and silicone stent intubation for treatment of canalicular obstruction is based on the site of obstruction. Distal monocanalicular obstructions have the highest degree of symptomatic epiphora relief, followed by distal bicanalicular, common, and proximal obstructions.
58 citations
57 citations
TL;DR: Upper eyelid gold weight implantation causes an increase in corneal astigmatism, predominantly in the vertical axis, which appears to be reversible on removal of the gold weight.
Abstract: Purpose:To determine the effect of upper eyelid gold weight implantation on corneal astigmatism.Methods:This is a prospective, cohort study. Eighteen eyes of 18 patients underwent upper eyelid gold weight implantation for facial nerve palsy. Nine of these patients recovered facial nerve function and
TL;DR: Patients with 2 mm and less of measurable enophthalmos had a normal appearance as frequently as those without enophilethalmos, and nearly all patients with measurements of 5 mm and greater had abnormal appearances.
Abstract: PURPOSE It is currently unknown how many measurable millimeters of enophthalmos may be noticeable to an observer. Identifying the amount of enophthalmos present may help to guide patients and clinicians in regard to surgical management of enophthalmos. METHODS The Massachusetts Eye and Ear Infirmary Oculoplastics imaging database was used to select 12 photographs of patients with unilateral enophthalmos whose measurements ranged between 1 mm and 8 mm for the study group and 12 photographs of patients who did not have enophthalmos as the control group. Observers were asked to review each of the photographs from both groups and to comment on whether the appearance was normal or abnormal. RESULTS There was no statistical difference found when observers reviewed photographs from the control group and patients whose measurements ranged between 1 mm and 2 mm (87%, 83% respondents identifying patients as normal, respectively). Twenty-eight percent of observers found patients with 3 mm and 4 mm of enophthalmos as having a normal appearance (P < 0.001). Ninety-seven percent of observers commented that patients with measurements of 5 mm and 8 mm had an abnormal appearance (P < 0.001). CONCLUSIONS Patients with 2 mm and less of measurable enophthalmos had a normal appearance as frequently as those without enophthalmos. Nearly all patients with measurements of 5 mm and greater had abnormal appearances. The point at which enophthalmos becomes detectable lies between 3 mm and 4 mm.
TL;DR: The clinical manifestations of Graves ophthalmopathy are relatively less severe in pediatric patients, and surgical therapy is infrequently necessary.
Abstract: Purpose To determine the clinical characteristics and review the frequencies of medical and surgical treatment of children with Graves ophthalmopathy. Methods Retrospective case series identifying patients 18 years or younger in whom Graves ophthalmopathy was diagnosed from 1985 through 1999. Data also were obtained from a follow-up survey. Results The 35 children with Graves ophthalmopathy included 27 girls (77.1%) and 8 boys (22.9%). At the time of initial ophthalmic examination, 31 patients (88.6%) were hyperthyroid, 1 (2.9%) was hypothyroid, and 3 (8.6%) were euthyroid. The mean age at diagnosis of thyroid dysfunction was 13.1 years (range, 3 to 18). The mean age at diagnosis of ophthalmopathy was 15.0 years (range, 5 to 18). No patient had compressive optic neuropathy. Thirty-one patients (88.6%) required no therapy or only supportive therapy. One patient (2.9%) required eyelid surgery and 3 (8.6%) underwent transantral orbital decompression for proptosis that caused discomfort and exposure keratitis. No patient received systemic corticosteroids or orbital radiotherapy. A follow-up survey was returned by 20 respondents at a mean follow-up of 11.0 years after the initial examination (range, 3.4 to 19.4). One patient (5.0%) had undergone eye muscle surgery. All patients stated that their vision was good, and 19 (95.0%) had no diplopia. Two patients (10.0%) reported that family members had Graves ophthalmopathy, and 12 (60.0%) had family members with thyroid dysfunction. Conclusions The clinical manifestations of Graves ophthalmopathy are relatively less severe in pediatric patients. Surgical therapy is infrequently necessary.
TL;DR: Lower eyelid fat repositioning blepharoplasty in an intra-SOOF plane is an alternative technique to address the tear trough deformity and provides excellent surgical results and high patient satisfaction.
Abstract: PURPOSE To describe a novel surgical technique for lower eyelid blepharoplasty with fat repositioning in an intrasuborbicularis oculi fat (intra-SOOF) plane. METHODS Description of surgical technique and outcome of a retrospective, interventional case series of 66 consecutive patients who underwent surgery. RESULTS Sixty-six patients with an average age of 56 years underwent bilateral transconjunctival lower eyelid blepharoplasty with fat repositioning in an intra-SOOF plane. Surgery was most commonly done in an office-based operating or procedure room under local anesthetic only. Patients were observed for an average of 6 months. Complications and revisions were few. Surgical outcomes and subjective patient satisfaction rate were excellent. CONCLUSIONS Lower eyelid fat repositioning blepharoplasty in an intra-SOOF plane is an alternative technique to address the tear trough deformity. This technique provides excellent surgical results and high patient satisfaction. Convenient for both patient and surgeon, this technique is readily performed in an office-based procedure room under local anesthetic. Further follow-up will determine long-term outcomes.
TL;DR: Lymphomas should be treated according to protocols, whereas noninvasive carcinoma and extensive papillomas require complete excision of the system, and Invasive disease requires en bloc excision.
Abstract: Purpose: To report the clinical features of a series of patients with lacrimal drainage apparatus tumors and present guidelines for management based on histopathology. Methods: A noncomparative retrospective chart review of the clinical, imaging, and pathologic findings of 37 patients presenting to four regional orbital Surgery departments with tumors affecting the lacrimal drainage apparatus between 1990 and 2004. Results: There were 37 patients, of whom 62% were male. The mean age at referral was 54 years. Epiphora, a palpable mass, and dacryocystitis were the most common presentations. Two thirds of the tumors were epithelial. with carcinomas being the most frequent (38%). followed by papillomas (27%). Lymphomas were the most common nonepithelial malignancy (30%). Epithelial tumors were more common in men (87%), whereas lymphomas were more common in women (57%). Treatment modalities included surgery, in addition to radiotherapy and/or chemotherapy and immunotherapy. Mean follow-up was 38 months. Thirty-three patients (89%) remain alive without evidence of disease and 4 patients died of recurrence and/or metastases. Conclusions: Lacrimal drainage apparatus tumors require careful initial management to ensure adequate local and systemic disease control. Atypical mucosa encountered during dacryocystorhinostomy should be biopsied and small papillomas or pedunculated tumors excised and analyzed with frozen sections. If a diffuse or infiltrative mass is encountered, it should be biopsied and managed on the basis of histopathology and extent of disease. Lymphomas should be treated according to protocols. whereas noninvasive carcinoma and extensive papillomas require complete excision of the system. Invasive disease requires en bloc excision. Long-term follow-up is essential for early detection of recurrence.
TL;DR: In this article, the authors performed a retrospective chart review of 6 patients receiving local triamcinolone acetonide (40 mg/ml) injections for the treatment of eyelid and orbital xanthogranuloma at the University of Michigan.
Abstract: Purpose To demonstrate the efficacy of local corticosteroid therapy for the treatment of eyelid and orbital xanthogranuloma in adults. Methods The authors performed a retrospective chart review of 6 patients receiving local triamcinolone acetonide (40 mg/ml) injections for the treatment of eyelid and orbital xanthogranuloma at the University of Michigan. All patients underwent diagnostic biopsy before treatment. The effects of this therapy on symptoms and signs of the disease were assessed. Results All 6 patients had eyelid swelling or nodularity and 5 had yellow discoloration of their eyelids. All lesions involved the eyelids and anterior orbit and 5 were present bilaterally. Biopsy revealed necrobiotic xanthogranuloma in 4 patients and adult-onset xanthogranuloma in 2 patients. Triamcinolone acetonide was administered intralesionally as series of 2 to 25 injections. Local control was obtained in all 6 cases, with the reduction of symptoms and signs of the disease in 5 cases. Two patients with necrobiotic xanthogranuloma had development of non-Hodgkin lymphoma. Average follow-up of patients whose treatment was not truncated by systemic chemotherapy was 52 months (range, 30 to 86 months). No complications occurred as a result of this treatment. Conclusions Intralesional injection of triamcinolone acetonide is an effective, safe treatment for orbital xanthogranuloma in adults. This modality avoids the side effects associated with systemic corticosteroid or cytotoxic agent therapy.
TL;DR: Rosai-Dorfman disease, although historically described as benign and self-limiting, may cause significant morbidity and mortality involving multiple organ systems and available treatment options may not control the disease.
Abstract: PURPOSE To describe the spectrum and treatment of orbital Rosai-Dorfman disease and to review previously documented cases. METHODS Retrospective, interventional case series of seven patients and literature review. RESULTS Each patient with Rosai-Dorfman disease had unique disease expression requiring aggressive therapy, such as chemotherapy, radiation, and/or surgical excision. One systemically aggressive case presented with intraocular and choroidal invasion, a previously unreported finding. Response to therapy was variable and unpredictable. CONCLUSIONS Rosai-Dorfman disease, although historically described as benign and self-limiting, may cause significant morbidity and mortality involving multiple organ systems. Available treatment options may not control the disease. Further research and long-term clinical correlation is necessary.
TL;DR: Mucinous eccrine adenocarcinoma is a rare ocular adnexal neoplasm that can involve the eyelid and periocular skin, can be locally invasive, and has a high risk of local recurrence despite Mohs surgery.
Abstract: Purpose To report 4 patients with mucinous eccrine adenocarcinoma of the periocular region. Methods Interventional case series of 4 patients with mucinous eccrine adenocarcinoma of the periocular region treated at 2 centers. Results Two patients with mucinous eccrine adenocarcinoma of the upper eyelid, 1 with mucinous eccrine adenocarcinoma of the lower eyelid, and 1 with mucinous eccrine adenocarcinoma of the eyebrow were included in this report. The lower eyelid lesion and the eyebrow lesion recurred after Mohs micrographic surgery. Both recurrent lesions were treated with Mohs micrographic surgery and postoperative adjuvant external-beam radiation therapy. The other 2 primary tumors were treated with wide local excision with frozen section control of margins and did not recur. The follow-up time after the most recent surgical procedure ranged from 8 to 17 months (median, 12 months). Conclusions Mucinous eccrine adenocarcinoma is a rare ocular adnexal neoplasm that can involve the eyelid and periocular skin, can be locally invasive, and has a high risk of local recurrence despite Mohs surgery.
TL;DR: Injection techniques, volume, end points, and anesthesia vary for different facial areas and between practices, and Physician-determined patient satisfaction is perceived to be higher than that of collagen injection but slightly lower than those of botulinum toxin injection.
Abstract: Purpose: To review injection techniques and patient satisfaction with injection of Restylane in various facial areas by American Society of Ophthalmic Plastic and Reconstructive Surgery members. Methods: Data from 286 patients treated with Restylane in nine American Society of Ophthalmic Plastic and Reconstructive Surgery practices were abstracted to a spreadsheet for analysis. Results: Nine practices performed Restylane injections for 8.8 months on average (range, 2 to 28 months). Average practice volume per patient was 1.2 ml (range, 0.7 to 2.1 ml). Nine of nine practices injected the nasolabial and melolabial folds, 9 of 9 practices injected the lips, and 6 of 9 injected the glabella. Only 2 of 9 practices injected other fillers concurrently. Botox was injected concurrently by 8 of 9 practices. On a scale of 1 to 10, physicians rated average patient discomfort during Restylane injection 4.6 with topical anesthesia and 2.1 with injectable lidocaine, with or without topical anesthesia. The end point for injection was determined by visual cues, volume of injection, extrusion of the product, and palpation. “Problematic” complications, including bruising, swelling, bumpiness, and redness each had an incidence of 5% or less. Patient satisfaction on a scale of 1 to 10 had an average rating of 8.1, compared with that of Botox injection (8.9), upper blepharoplasty (8.9), and collagen injection (6.6). The source of Restylane patients was estimated to be existing Botox patients (45%); existing non-Botox patients (18%); word of mouth (14%); and new patients for other services (13%). Conclusions: Injection techniques, volume, end points, and anesthesia vary for different facial areas and between practices. Patients experience mild to moderate injection discomfort that is lessened with injectable lidocaine. Self-limited problems occur in about 5% of patients. Physician-determined patient satisfaction is perceived to be higher than that of collagen injection but slightly lower than that of botulinum toxin injection. The major source of Restylane patients was from existing practice patients, especially botulinum toxin patients.
TL;DR: The microscopic findings of Asian lower eyelid, especially fascial components, were mostly similar to those of non-Asian eyelids, but differences existed in higher or indistinct septum fusion, anterior and superior orbital fat projection, and the overriding of the preseptal orbicularis oculi muscle.
Abstract: Purpose To elucidate the microscopic anatomy of the Asian lower eyelid. Methods Specimens (full-thickness sections of lower eyelids from 19 postmortem lower eyelids) from 11 Asians aged 73 to 96 years at death were fixed in 10% buffered formalin and microscopically examined. After pretreatment, sagittal sliced sections of the central part were stained with Masson trichrome. Results The distinct junction of the orbital septum to the capsulopalpebral fascia (CPF) was confirmed in 7 eyelids in which orbital septum was clearly stained, with an average distance from the tarsus to the junction of 2.38 mm. The other 12 eyelids did not show a distinct junction, and the orbital septum was poorly defined anteriorly and indistinct posteriorly. There was a distinct layer between the orbicularis oculi muscle and the orbital septum. The inferior and the posterior attachments of the CPF to the tarsus were seen in all eyelids. Seventeen of the 19 eyelids had attachment of the CPF on the anterior aspect of the tarsus, from which an extension of the CPF through the pretarsal orbicularis oculi muscle was observed. All eyelids had anterior extension of the CPF through the preseptal orbicularis oculi muscle, which was overridden on the pretarsal orbicularis oculi muscle. Conclusions The microscopic findings of Asian lower eyelids, especially fascial components, were mostly similar to those of non-Asian eyelids, but differences existed in higher or indistinct septum fusion, anterior and superior orbital fat projection, and the overriding of the preseptal orbicularis oculi muscle.
TL;DR: A multidisciplinary approach to orbital fibrous dysplasia is fundamental for treatment planning and execution, and morphologic and aesthetic results were good in all cases.
Abstract: Purpose To describe the multidisciplinary diagnosis and treatment of patients with orbital fibrous dysplasia, a slowly progressive disease that may lead to asymmetry, disfigurement, and functional ocular problems. Methods Ten patients with orbital fibrous dysplasia underwent bifrontal craniotomy through a coronal flap, with the removal of the supraorbital arch and dysplastic process involving the anterior and middle base of the skull. Four patients underwent superior orbital fissure and optic nerve canal decompression. Reconstruction was performed by using an autologous bone graft for both the adults and children, in whom a rib graft was preferred. The mean follow-up was 53.2 +/- 18.3 months (range, 14 to 94 months). The patients' preoperative status and postoperative status were compared. Results The immediate and long-term morphologic and aesthetic results were good in all cases. All of the patients complained of some degree of diplopia during the immediate postoperative period, but the problem spontaneously resolved within 1 to 6 months in all but one case. No postoperative reduction in visual function was observed in the patients who underwent optic nerve decompression. The only reported complication was the irregular reabsorption of regrafted dysplastic bone in one patient. Conclusions A multidisciplinary approach to orbital fibrous dysplasia is fundamental for treatment planning and execution.
TL;DR: Clinicians should be alerted to the anticipated presentation of medial wall fractures with incarceration of the medial rectus muscle, including the possibility of a “white eye” and normal abduction of the traumatized eye.
Abstract: PURPOSE To retrospectively review and analyze cases of isolated medial orbital wall fractures with medial rectus muscle incarceration presenting to a tertiary ophthalmic plastic surgery practice from 1997 to 2005. METHODS Retrospective chart review and literature review. RESULTS Nine cases of isolated medial wall fracture with medial rectus muscle incarceration are presented. The most frequently encountered clinical feature was adduction deficit on the affected side. Extraocular motility improved in all patients who underwent surgery, and mean postoperative enophthalmos was minimal. CONCLUSIONS Isolated medial orbital wall fractures with medial rectus muscle incarceration are rare. Ocular motility abnormalities were the only indication of underlying fracture in the majority of our cases. Clinicians should be alerted to the anticipated presentation of medial wall fractures with incarceration of the medial rectus muscle, including the possibility of a "white eye" and normal abduction of the traumatized eye.
TL;DR: Findings suggest that serial TSI measurements may be an adjunct in assessing clinical inflammatory activity of TAO and may help direct clinical decision making regarding treatment decisions in TAO.
Abstract: Purpose To investigate the possible correlation between the changes in inflammatory active phase of thyroid-associated orbitopathy (TAO) with measured changes in thyroid-stimulating immunoglobulin (TSI) levels over time. This study was undertaken to evaluate the potential usefulness of measured TSI values in following and treating patients with TAO. Methods A retrospective chart analysis was performed on 23 patients who had been referred to a tertiary care oculoplastics service between July of 2002 and April of 2004 with suspected TAO. The activity status of patients with TAO was graded by using the TAO activity scale (TAOS), created to distinguish between the active and cicatricial phases of TAO. Laboratory values of TSI reported during the course of the study period were compiled for each study patient. Results Linear regression analysis revealed a statistical correlation between the changes in activity of TAO, as measured by the TAOS score, and changes in measured values of TSI over time. A statistically significant correlation was also found between the activity of TAO (measured by the TAOS score) and TSI value. Conclusions It was found that changes in inflammatory phase of TAO, as measured by the TAOS score, statistically correlate with changes in measured TSI. An additional correlation was also found between the absolute score of TAO activity and measured level of TSI. These findings suggest that serial TSI measurements may be an adjunct in assessing clinical inflammatory activity of TAO and may help direct clinical decision making regarding treatment decisions in TAO.
TL;DR: The repair of combined orbital floor and medial wall fractures using thin overlapping implants inserted through transcaruncular and inferior transconjunctival incisions is a safe, effective, and cosmetically sensitive surgical technique.
Abstract: PURPOSE To evaluate the clinical outcome of combined orbital floor and medial wall fracture repair using overlapping thin implants METHODS A retrospective chart review was conducted on 19 fracture repairs performed by one surgeon using thin overlapping implants inserted through transcaruncular and inferior fornix incisions RESULTS Nineteen combined medial wall and floor fractures were repaired in 18 patients (14 male, 4 female) The median age was 37 years (range, 13-60 years) The median trauma-to-surgery interval was 9 days (range, 1 day to 6 years) Two overlapped implants (02-04 mm) were used in 12 fracture repairs, and 3 overlapped implants (02-03 mm) were used in 7 fracture repairs Materials included prepunched nylon foil in 18 fractures and, in one fracture, high-density polyethylene Follow-up time ranged from 1 month to 53 months (median, 7 months) No complications occurred during the postoperative follow-up period Clinically significant enophthalmos was not observed after treatment CONCLUSION The repair of combined orbital floor and medial wall fractures using thin overlapping implants inserted through transcaruncular and inferior transconjunctival incisions is a safe, effective, and cosmetically sensitive surgical technique
TL;DR: The effect of 2.5 units of BTX-A injected into the lacrimal gland lasted 6 months, a duration similar to that reported for other application sites.
Abstract: PURPOSE To provide clinical evidence of the duration of botulinum toxin type A (BTX-A) effect when applied in the palpebral lobe of the lacrimal gland in patients with gustatory epiphora. METHODS Prospective, nonrandomized, nonblinded study. Patients with history of gustatory epiphora were included. A Schirmer test was performed to quantify tearing induced by chewing. Clinical examination included visual acuity, tear-duct syringing, slit lamp examination, corneal staining, and eyelid malpositions. A questionnaire was completed by each patient to asses the severity of hyperlacrimation. A single dose of 2.5 units of BTX-A was injected directly into the lacrimal gland palpebral lobe. Patients were evaluated before and at 1, 4, 12, and 24 weeks after injection. The same person performed the examination and the BTX-A injection. Descriptive statistics, using repeated measures and a paired t test, were used for statistical analysis. RESULTS Fifteen patients were included. Mean age was 63 years. Before BTX-A injection, mean Schirmer test values were 5.47 mm in the unaffected eyes (NAE) and 12.07 mm in the affected eyes (AE). When comparing Schirmer test values in the AE before and after BTX-A injection, there were statistically significant differences (p < 0.05). Only 2 patients developed mild transitory ptosis. No other complications were noted. CONCLUSIONS The effect of 2.5 units of BTX-A injected into the lacrimal gland lasted 6 months, a duration similar to that reported for other application sites.
TL;DR: Amniotic membrane grafting gave cosmetically and functionally acceptable results in cases of mild to moderate grades of anophthalmic socket contraction and was comparable to those of mucous membranes grafting.
Abstract: Purpose: To study the use of amniotic membrane for the reconstruction of mild to moderate grades of contracted socket and compare it to mucous membrane grafting. Methods: A total of 20 patients with acquired, anophthalmic contracted socket of mild to moderate grades were studied and divided into two groups: the amniotic membrane graft (AMG) group (10 patients) and the mucous membrane graft (MMG) group (10 patients). The preoperative and postoperative measurements of forniceal depth and volume of socket were compared. After surgery, motility of the prosthesis was also compared. Results: The mean preoperative depth of the lower fornix in the AMG group and the MMG group was 1.5 mm and 1.4 mm, and after surgery, at final follow-up was 5.4 mm and 5.5 mm, respectively. The preoperative mean height of the upper fornix in the AMG group and the MMG group was 10.3 mm and 10.7 mm, and after surgery, at final follow-up was 12.6 mm and 13.2 mm, respectively. The mean preoperative volume of the socket was 0.84 ml in the AMG group and 0.80 ml in the MMG group, and after surgery, at final follow-up was 1.43 ml and 1.48 ml, respectively. The various quantitative parameters including motility of the prosthesis were comparable in the two groups. Conclusions: Amniotic membrane grafting gave cosmetically and functionally acceptable results in cases of mild to moderate grades of anophthalmic socket contraction. The results were comparable to those of mucous membrane grafting.
TL;DR: An allergic granulomatous reaction is one of the adverse reactions seen after permanent eyeliner tattoo and can be challenging and may ultimately require excision of tattoo pigment to remove the inciting factor.
Abstract: To report the potential for serious adverse reactions associated with permanent eyeliner tattoos.An observational case series was conducted on 4 patients who presented with inflammatory eyelid reactions after receiving permanent eyeliner tattoo.Clinically, the tattoo-associated lesions were typically firm, raised masses underlying the areas of pigmentation. Histopathologic analysis of tissue from all 4 patients demonstrated a granulomatous inflammatory response with negative cultures for any organisms. Treatment approaches varied between a combination of topical steroid creams, local steroid injections, local resection, intramuscular steroid injection, and systemic oral steroids. These treatments were successful in all 4 cases.An allergic granulomatous reaction is one of the adverse reactions seen after permanent eyeliner tattoo. Treatment can be challenging and may ultimately require excision of tattoo pigment to remove the inciting factor. Systemic steroids may aid in controlling the inflammation associated with reaction to the tattoo pigment.
TL;DR: Müller muscle–conjunctiva resection ptosis repair with fibrin sealant used for wound closure may allow for predictable results with few complications and appears to be an acceptable alternative to traditional suture techniques.
Abstract: To determine the safety and efficacy of fibrin sealant for use in Muller muscle-conjunctiva resection ptosis repair.This was a retrospective review of a consecutive case series. All patients underwent Muller muscle-conjunctiva resection ptosis repair with fibrin sealant used for wound closure. Surgery was performed in a manner similar to a previously described technique, using fibrin tissue sealant rather that suture for wound closure. Postoperative symmetry was defined as MRD1 of each eyelid within 0.5 mm.Muller muscle-conjunctiva resection ptosis repair with fibrin sealant used for wound closure was performed on 53 eyelids of 33 patients. There were 27 female patients and 6 male patients. Twenty patients underwent bilateral ptosis repair and 13 patients underwent unilateral ptosis repair. Average follow-up was 17 weeks (range, 3 to 45 weeks). Mean preoperative MRD1 was 1.22 mm (range, -1.5 to 2.5 mm) in the right upper eyelid and 1.50 mm (range, 0 to 2 mm) in the left upper eyelid. Mean postoperative MRD1 was 3.11 mm (range, 2 to 4.5 mm) in the right upper eyelid and 3.12 mm (range, 1 to 4.5 mm) in the left upper eyelid. Postoperative symmetry was found in 32 of 33 patients (97%). We found no evidence of keratopathy or other complications attributable to the fibrin sealant.Muller muscle-conjunctiva resection ptosis repair with fibrin sealant used for wound closure may allow for predictable results with few complications and appears to be an acceptable alternative to traditional suture techniques.
TL;DR: Botulinum toxins B is a useful treatment for cases that have become refractory to botulinum toxin A, and the duration of beneficial effect is shorter than for type A.
Abstract: PURPOSE A small percentage of cases with essential blepharospasm or hemifacial spasm will become resistant to botulinum toxin A (Botox). We present our experience treating these patients with botulinum toxin B (Myobloc). METHODS We reviewed all charts of patients in one physician's practice who received botulinum toxin B after becoming refractory to botulinum toxin A. For each treatment session, patients were evaluated for side effects, relief of spasms, and duration of treatment effect. RESULTS Data were collected on 16 patients and a total of 93 treatment visits. Average total dosage was 3,633 U per treatment session. Mean duration of beneficial effect was 7.3 weeks and was most commonly rated as fair to excellent. Side effects for botulinum toxin B occurred at a higher rate than is typical for botulinum toxin A. Most common side effects were pain on injection (100%), ptosis (32.3%), facial or mouth droop (22.6%), dry mouth (17.2%), dry eye (9.7%), exposure keratitis (7.5%), and blurred vision (5.4%). The rate of occurrence of side effects appears to be dose-dependent. CONCLUSIONS Botulinum toxin B is a useful treatment for cases that have become refractory to botulinum toxin A. The duration of beneficial effect is shorter than for type A. The side effect profile is similar to that for toxin type A except for pain on injection and the occurrence of dry mouth. Side effects occurred at a higher frequency than with botulinum toxin A, and the pattern suggests that botulinum toxin B spreads more diffusely. Side effects appear to be dosage-related.
TL;DR: A healthy 45-year-old man had a retrobulbar hemorrhage 9 days after cosmetic upper eyelid blepharoplasty that resulted in permanent visual loss; however, the patient did have permanent visual field loss.
Abstract: A healthy 45-year-old man had a retrobulbar hemorrhage 9 days after cosmetic upper eyelid blepharoplasty that resulted in permanent visual loss. After performing a left lateral canthotomy and cantholysis, intraocular pressure returned to normal and vision improved from no light perception to 20/40; however, the patient did have permanent visual field loss. To our knowledge, this is the longest period of time after blepharoplasty that a retrobulbar hemorrhage occurred. Ophthalmologists should have a heightened level of suspicion 1 to 2 weeks after surgery.