The Effect of Supine Versus Upright Positioning on Eyelid Height in the Nonsurgical Patient.

PURPOSE: To directly compare margin-reflex distance 1, margin-reflex distance 2, and palpebral fissure in the upright versus supine positions in nonsurgical patients. METHODS: A total of 43 patients (31 female, 12 male, and age range 26-96) were enrolled. Photos were taken in the clinic in the upright and supine position with a ruler placed vertically in the same plane as the eyelid, and the above computer-analyzed measurements were obtained. RESULTS: Among the 86 eyes observed, the average upright margin-reflex distance 1 was 2.97 mm (95% confidence interval [CI], 2.70-3.24), while the average supine margin-reflex distance 1 was 2.38 mm (95% CI, 2.13-2.63). These differences were statistically significant (p < 0.001). Similarly, statistically significant differences were seen with margin-reflex distance 2 (p < 0.001), where upright measurements averaged 5.57 mm (95% CI, 5.33-5.81), and supine measurements averaged 5.01 mm (95% CI, 4.73-5.28). Finally, palpebral fissure showed similar significance (p < 0.001). Upright measurements averaged 8.54 mm (95% CI, 8.19-8.90), while supine measurements averaged 7.38 mm (95% CI, 7.00-7.76). CONCLUSIONS: Supine positioning provides a decrease in margin-reflex distance 1, margin-reflex distance 2, and palpebral fissure when compared with upright positioning in nonsurgical patients. This contradicts a previous study on intraoperative patients when lidocaine with epinephrine was used. This study helps us better understand the normal physiologic response to position changes with regard to eyelid height in the nonsurgical patient. As such, this study may function as a control for future studies comparing anesthetic/surgical parameter effects on intra- and post-operative eyelid heights.

External levator resection for involutional ptosis: is intraoperative suture adjustment necessary for good outcomes?

Purpose: To directly compare an algorithmic external levator resection technique with the choice of intraoperative adjustment to the same technique without intraoperative adjustments. Methods: A sequential controlled prospective comparative cohort study. Two cohorts were compared: a historical control adjustment, and an experimental non-adjustment group. Fourteen patients, 25 eyelids, were in the historical cohort; and 15 patients, 23 eyelids, were in the non-adjustment cohort. Primary acquired ptosis patients who met inclusion criteria were considered. All patients underwent a standardized external levator resection technique. Intraoperative adjustments were performed only in the historical cohort. Age, follow-up time, surgical time, and marginal reflex distance 1 (MRD1) were collected. Statistical analysis was performed using the Mann-Whitney U test. Statistical significance was p < 0.05. Primary and secondary outcome measures were postoperative MRD1 minus goal MRD1, and surgical time, respectively. Results: Twenty-five historical eyelids were compared with 23 non-adjusted eyelids. The average patient age was 68.4 years (range 19-84) and 59.3 years (range 24-83) for the adjusted and non-adjusted groups. Six-month postoperative (postoperative minus goal) MRD1 was -0.1 mm (95% CI -0.3-0.1) and -0.2 mm (95% -0.5-0.0) (p = 0.33), and surgical time was 13.8 min (95% CI 12.6-15.1) and 9.5 min (95% CI 9.0-10.1) (p < 0.001) for the adjusted and non-adjusted cohort, respectively. Conclusions: The external levator resection, utilizing a standardized algorithm approach, is an efficacious technique for involutional eyelid ptosis. With sound technique, this method can be performed without the need for intraoperative adjustment, thereby saving operative time and achieving similar results.

Blepharoplasty Effect on a Described Algorithmic Approach to External Ptosis Repair: Is It Time for Unbundling?

PURPOSE: To investigate the effects of performing a previously described algorithmic levator resection for involutional ptosis with a blepharoplasty instead of through a small incision. METHODS: Eyelids with involutional ptosis and normal levator function were included in the study. An upper blepharoplasty was performed first. An external levator resection was then performed based on a described technique involving 2 mm resection of aponeurosis for 1 mm of desired lift, consistent tension on the aponeurosis between surgical cases, and standardized suture placement. RESULTS: Forty-one eyelids of 25 patients were included. Mean postoperative margin to reflex distance 1 (MRD1) was 2.98 mm, which was significantly higher than preoperative MRD1 (0.67 mm), but lower than the predetermined goal MRD1 (3.35 mm). Eight eyelids did not meet primary outcome of MRD1 within 1 mm of goal MRD1, with 5 undercorrections. There was no difference between the postoperative MRD1 compared with the same ptosis technique performed through a small incision only, but there were more intraoperative suture adjustments and fewer eyelids meeting the primary outcome when a concurrent blepharoplasty was performed. CONCLUSIONS: The addition of blepharoplasty with a previously described algorithmic approach external levator resection has an 80% success rate in achieving the primary outcome. When compared with a small-incision ptosis repair, concurrent blepharoplasty results in a less predictable outcome and an increased need for intraoperative adjustment. Performing an algorithmic technique for external levator resection with a blepharoplasty has less predictable outcomes, which raises the question of separating the procedures to improve patient care.

Primary Extracranial Meningioma of the Lacrimal Sac Fossa.

Primary extracranial meningioma is a rare tumor, unlike its common intracranial counterpart. Infrequently found in the head and neck region, it can cause local or neurologic symptoms depending on its location and interaction with cranial nerves. While uncommon, it is an important diagnosis to have on the differential of periorbital lesions as surgical removal and prognosis are generally good. The authors present the first report of a patient with primary extracranial meningioma originating in the lacrimal sac fossa.

Biomechanics of the Levator Aponeurosis.

PURPOSE: To investigate biomechanical properties of the levator aponeurosis. METHODS: Patients undergoing external levator resection for primary or revision correction of acquired ptosis were analyzed as primary and revision groups. Immediately postoperatively, the resected segments of the levator aponeurosis were stressed by adding sequential masses to the tissue. Specimen length was recorded at each stress level. Stress-strain diagrams were used to summarize how the tissue elongated in response to the external forces, because these diagrams correct for differences in specimen size. Representative specimens were analyzed histologically. RESULTS: Twenty-two specimens from 14 patients in the primary group and 10 specimens from 7 patients in the revision group met inclusion criteria. In the primary group, the mean age was 66 years; 8 patients were women. In the revision group, the mean age was 69 years; 6 patients were women. Levator aponeurosis specimens in both the primary and revision group demonstrated proportional increases in length with increasing stress, demonstrating that the levator aponeurosis is extensile. Given the same amount of stress, the levator aponeurosis from primary specimens elongated more than revision specimens. Histologically, revision specimens exhibited increased collagen and haphazard, tangled elastin fibers. CONCLUSIONS: The levator aponeurosis obtained during surgical correction of acquired ptosis elongates in response to nominal external forces. This biomechanical property is important because the length of the aponeurosis may vary intraoperatively if variable forces are applied to the eyelid. This property might be related to connective tissue architecture and, specifically, fibrosis. Surgeons performing levator aponeurosis resection should be mindful to maintain a consistent amount of force on the levator aponeurosis when performing the resection to maximize intercase consistency.

Retrospective review of eyelash number in patients who have undergone full-thickness eyelid resection.

PURPOSE: The purpose of this study was to determine whether a localized full-thickness eyelid excision results in a proportional decrease in the total number of eyelashes or whether a full complement of visible lashes persists, thus suggesting a compensatory increase in the anagen/telogen ratio among the remaining follicles. METHODS: A retrospective chart review was performed on 38 patients who underwent full-thickness eyelid resections repaired with primary eyelid closure for either benign or malignant eyelid lesions. Demographic and surgical data were collected, postoperative eyelid photographs were reviewed, and eyelashes were counted. RESULTS: There were 10 upper eyelids and 28 lower eyelids in 10 men and 28 women, with an average age of 57.9 years (range, 14-86 years). The lesion pathology was benign in 21 cases (55%) and malignant in 17 cases (45%). The full-thickness defect involved <25% of the eyelid in 16 cases (42%) and >25% of the eyelid in 22 cases (58%). The follow-up period ranged from 50 to 319 days, with an average of 94 days. In contralateral controls, upper eyelids had an average of 72.1 lashes and lower eyelids had an average of 38.2 lashes, and there was no statistical significance between men and women. In lower lids that underwent <25% resection, control lids had an average of 37.3 lashes and operative lids had 37.1 lashes. In lower lids that underwent >25% resection, control lids had an average of 38.7 lashes and operative lids had 34.2 lashes. This represents an 11.6% decrease and was statistically significant. In upper eyelids that underwent <25% resection and >25% resection, control eyelids had an average of 74.9 lashes and 69.3 lashes and operative eyelids had 77.6 lashes and 69.1 lashes, respectively. Finally, lash count was compared by benign versus malignant pathologic diagnosis. In upper eyelids with benign lesions and malignant lesions, control eyelids had an average of 73.8 lashes and 65.3 lashes and operative eyelids had 74.6 lashes and 68.3 lashes, respectively. In lower eyelids with benign pathology and malignant lesions, control eyelids had an average of 34.5 lashes and 41.4 lashes and operative eyelids had 33.8 lashes and 36.8 lashes. This represents an 11.1% decrease and was statistically significant. CONCLUSIONS: Full-thickness excision of eyelid margin tissue including lashes does not usually affect postoperative lash numbers. Because the total number of follicles is reduced, the percentage of lashes in the anagen versus the resting or telogen phase apparently increases compared with the preoperative state. This eyelash study contributes to the growing body of literature on the poorly understood topic of hair follicle cycle regulation.

Bloody epiphora secondary to a lacrimal sac varix.

This is a report of a 57-year-old female patient who sought treatment for multiple episodes of bloody epiphora. A CT of her orbits revealed enhancement and enlargement of her left lacrimal sac and duct. A biopsy was then performed, which showed a varix involving the wall of the lacrimal sac. To the authors' knowledge, this is the first reported case of a lacrimal sac varix causing bloody epiphora.

Subperiosteal orbital hematoma after balloon sinus dilation.

A retrospective case report of an orbital hematoma resulting from balloon sinus dilation during functional endoscopic sinus surgery is presented. The authors propose that this event may be because of shearing of venules that drain in the superior periorbital channels related to microfractures caused by the balloon dilation. To the authors' knowledge, this is the first report of orbital hematoma in the setting of balloon sinus dilation.

Isolated squamous cell carcinoma of the orbital apex.

A 43-year-old woman (Case 1), 63-year-old man (Case 2), and a 67-year-old man (Case 3) presented with diplopia (Cases 1, 2, and 3) and upper-eyelid ptosis (Cases 1 and 3). The cases had preceding cranial nerve V1 disturbances ranging from 3 months to 8 years. Each demonstrated complete internal ophthalmoplegia and external ophthalmoplegia. No case had a cutaneous squamous cell carcinoma (SCC) on presentation or by history. Imaging revealed isolated orbital apex masses. Tumor biopsies revealed SCCs of various differentiations. Systemic workup revealed no extraorbital malignancy. All received radiation therapy, and 2 patients underwent adjuvant chemotherapy. One patient is alive since diagnosis (49 months). In Case 2, SCC developed in the contralateral orbit, and the patient died 19 months after diagnosis; and Case 3 died 12 months after diagnosis. These isolated cases of orbital SCC may have arisen from orbital choristomatous squamous epithelium, may represent de novo or metastatic tumors, or may be manifestations of occult perineural spread.

Atypical presentation of a periocular neurofibroma.

Neurofibromas of the eyelid are a well-recognized manifestation of neurofibromatosis. Several different presentations have been described. The authors present a case of a 52-year-old man with an unusual eyelid neurofibroma that presented as sudden vision loss from obstruction secondary to prolapse of the palpebral conjunctiva.

Facial nerve injury during external dacryocystorhinostomy.

OBJECTIVE: To describe weakness of the orbicularis oculi muscle after external dacryocystorhinostomy (DCR) and propose an anatomic explanation for the complication. DESIGN: Retrospective, observational study. PARTICIPANTS: Sixteen patients (13 female, 3 male) with a mean age of 60 years (median, 61 years; range, 34-85 years). METHODS: A retrospective chart review was performed of consecutive patients who had nasolacrimal duct obstruction repair by external DCR. Patients were identified who developed postoperative orbicularis oculi muscle weakness that manifested as hypometric blink or lagophthalmos with or without punctate keratopathy on the operated side. Patient parameters collected included demographic data, type of incision, incision length, use of lacrimal stent, length of follow-up, intraoperative and postoperative complications, and time to resolution of clinical findings. Statistical analysis was performed using a 2-tailed Fisher exact test with clinical significance designated at alpha = 0.05. MAIN OUTCOME MEASURES: Identification of patients with orbicularis oculi muscle weakness after external DCR, documentation of incision type, clinical findings, and recovery of function. RESULTS: Among 215 patients and 247 surgeries, 16 individuals (7.4%) were identified who demonstrated abnormalities of eyelid closure in the postoperative period after external DCR. Of these, 13 patients had lagophthalmos with or without hypometric blink and 3 patients had hypometric blink alone. Eleven patients underwent surgery through a nasojugal incision, 4 patients underwent surgery through a vertical incision, and 1 patient underwent surgery through an eyelid margin incision. The degree of postoperative lagophthalmos was on average 1.5 mm. Four patients developed punctate keratopathy. Follow-up ranged from 3 to 50 weeks (mean, 20 weeks). Resolution of lagophthalmos was seen on average by 14 weeks with the longest time to resolution of 32 weeks. Three individuals continued to have residual hypometric blink at the time of last follow-up. CONCLUSIONS: Damage to peripheral fibers of the zygomatic and buccal branches of the facial nerve as they course through the medial canthal area to innervate the upper eyelid orbicularis oculi muscle may occur during external DCR surgery. Such injury may be responsible for orbicularis oculi muscle weakness manifesting as postoperative abnormal eyelid closure and lagophthalmos. In our cohort of patients, these findings were temporary and typically resolved in several months.

Intravenous pyogenic granuloma of the angular vein.

A 47-year-old woman presented with a painful mass below her left medial canthus. Examination revealed a 1-cm tender, smooth, pulseless, mobile mass inferior to the level of the anterior lacrimal crest. CT imaging was performed. Excision of the involved angular vein revealed a smooth, intralumenal lesion. Histopathologic examination demonstrated intravenous pyogenic granuloma (IVPG). There are approximately 30 reported cases of IVPG in the English literature, 2 of which arise in the periocular angular vein. The ultrasound and MRI characteristics of IVPG have been previously described. We describe the CT profile of this rare, benign tumor as a mildly heterogeneic, contrast-enhancing cylindrical lesion within, and conforming to the shape of, the angular vein. There is dilatation of the vein proximal to the lesion with marked narrowing distal to it secondary to obstruction of flow. On noncontrast imaging, the lesion is isodense with nasal mucosa and without calcifications.