Qualitative use of ICG angiography and lymphography in periorbital surgery.

PURPOSE: Open imaging fluorescence devices have been utilized in surgical oncology, vascular and plastic surgery; however, the role of indocyanine green (ICG) in periorbital surgery and lymphatics has not been explored. METHODS: A prospective, single-center diagnostic study was conducted from 2021 to 2022 utilizing ICG to assess both the periorbital vasculature and lymphatics. Fluorescence was captured with open-imaging fluorescent devices. For ICG angiography, a total of 5-10 mg of ICG was given intravenously at various time points to visualize intraoperative blood flow to eyelid flaps, vascular tumors, or extraocular muscles. For ICG lymphography, 0.03-0.06 mg of ICG was injected subcutaneously to visualize the periorbital and facial lymphatic drainage. RESULTS: Twenty-two patients underwent ICG angiography. Periorbital vascular supply was seen in eyelid reconstructions (n = 8), anophthalmic reconstructions (n = 2), lacrimal gland tumors (n = 2), orbital venous malformations (n = 2), tumor metastasis (n = 1) and benign tumors (n = 1). The anterior ciliary arteries were visualized to the extraocular muscles in fracture repairs (n = 3) and muscle biopsies (n = 2). Ten patients underwent ICG lymphangiography highlighting the global periorbital lymphatic system. CONCLUSION: ICG allows for visualization of the vasculature of extraocular muscles and tumors, assessing perfusion of flaps during reconstruction and the global periorbital lymphatic drainage pathways.

Double Frost Suture Technique for Simultaneous Skin Grafting of the Upper and Lower Eyelids.

The double Frost suture is a useful supplement to the reconstruction of ipsilateral upper and lower eyelid defects with full-thickness skin grafts. This technique involves silk traction sutures that overlap the upper and lower eyelids to place them on maximal stretch after placement of 2 full-thickness skin grafts. It has the added benefit of protecting the cornea and compressing both grafts under 1 bolster. The authors illustrate this technique in 2 pediatric cases-a congenital melanocytic kissing eyelid nevus and a periocular burn. Each case resulted in large upper and lower anterior lamellar defects, which were reconstructed with supraclavicular and retroauricular free skin grafts. The double Frost sutures counter vertical cicatricial forces during graft healing, obviating the need for staged procedures. Both described cases resulted in excellent graft survival with minimal contracture.

Adjustable Ptosis Correction via Posterior Levator Advancement With Minimal Superior Tarsectomy.

PURPOSE: To report the surgical technique and outcomes for adjustable ptosis correction using a posterior levator advancement with minimal superior tarsectomy. METHODS: A retrospective single-center study was conducted on patients who underwent adjustable ptosis repair via posterior levator advancement with minimal superior tarsectomy by a single surgeon from 2002 to 2018. Patients with greater than 1 mm asymmetry between eyes or contour abnormalities underwent nonsurgical adjustment in the office within 6 days of surgery. RESULTS: A total of 79 patients (146 eyelids) were included in this study. The patients were female (67%), underwent bilateral surgery (87%) with mean age of 63 years (range, 20-92). The mean improvement in marginal reflex distance 1 at postoperative month 1 was 2.56 ± 1.04 mm (p ≤ 0.0001). Postoperative symmetry of 1 mm or less between eyes was achieved in 96.6% of patients. Only 8 eyes (5.4%) underwent in-office adjustment postoperatively. No demographic or clinical differences were noted in eyes that required adjustments. Postoperative complications included dry eyes that resolved by 3 months (13.6%), suture cyst (1.4%), corneal abrasion (1.4%), and persistent eyelid edema (1.4%). Surgical revision was required in 2.8% of eyes. CONCLUSIONS: The adjustable posterior levator advancement with minimal superior tarsectomy is an effective surgical technique for ptosis repair with the added benefit of in-office adjustability to correct minor asymmetries.

Doxycycline Injection for Sclerotherapy of Lower Eyelid Festoons and Malar Edema: Preliminary Results.

PURPOSE: To investigate the safety and efficacy of direct, intralesional doxycycline hyclate injection for improving the appearance of cosmetically significant lower eyelid festoons and malar edema. METHODS: An Institutional Review Board approved, retrospective review was performed of 15 consecutive patients with malar edema and/or festoons injected with doxycycline hyclate at a concentration of 10 mg/ml. Pre- and postinjection photographs were reviewed and graded on a scale of 0 to 3 (0: no festoon; 1: small festoon; 2: medium festoon; 3: large festoon) by 2 masked physician observers. Patients were excluded from the final analysis if they received an alternate dose concentration, had incomplete photographic records, or did not follow up. Student t test was used for statistical analysis. RESULTS: Twenty consecutive treatment areas of 11 patients were included in the analysis. Final follow up ranged from 3 to 104 weeks, with a mean follow up of 22.5 weeks. The average (standard deviation) initial festoon grade of 2.5 (0.58) decreased to 0.9 (0.82) with a p value of <0.001. The average number of injections performed per side was 1.4 (range: 1-2). The mean volume per injection was 0.72 ml (range: 0.15-2.0 ml). Commonly documented subjective complaints were burning sensation with injection, pain, bruising, and erythema. There were no other dermatologic or visual complications following treatment. CONCLUSIONS: These preliminary results suggest that intralesional injections of doxycycline hyclate at a concentration of 10 mg/ml may be an effective treatment option for cosmetically significant lower eyelid festoons and malar edema. Future prospective studies with increased patient numbers, increasing concentrations, combination therapies with local anesthetic or regional nerve blocks, and longer follow up are needed to validate these results and determine optimal injection technique.

Nasal Glioma: A Rare Cause of Congenital Inner Canthal Swelling.

Nasal glioma, encephalocele, and ectopic brain are rare congenital anomalies. The terminology applied to these entities has been historically confusing. In many cases, the terms overlap and may be employed synonymously although some authors emphasize their differences. The authors describe herein a child with an inner canthal mass of brain-like tissue that they interpret as nasal glioma, a variety of encephalocele that has lost its connection to the intracranial contents. This research was conducted in conformity with the Helsinki Declaration and Health Insurance Portability and Accountability Act regulations.

Microvascular Free Flap for Total Eyelid Reconstruction With a Visually Useful Eye.

Total eyelid loss, full thickness loss of the upper and lower eyelids, is uncommon and surgically challenging. Eyelid reconstruction after such injuries can be further complicated by loss of adjacent tissue. When tissue for local flaps is unavailable, free flaps must be considered. Few cases of total eyelid reconstruction via microvascular free flap have been reported, especially with an intact globe and good visual acuity. In this report, we describe the use of a microvascular free flap based on the radial artery for total eyelid reconstruction in a patient with an intact globe and useful visual acuity.

Proprioceptive Phenomenon With Involutional Ptosis: Evidential Findings in Anophthalmic Ptosis.

PURPOSE: To determine the effect of ptosis on compensatory frontalis contraction in patients without visual input and to identify if a sensory stimulus contributes to brow elevation. METHODS: A prospective study. Clinical photographs were measured by 2 masked oculoplastic surgeons to determine brow height in 8 patients with unilateral ocular prosthesis in 3 conditions: at baseline, after a gold weight was applied to the upper eyelid inducing acute ptosis, and with the gold weight plus topical anesthetic. The measured brow height was then compared between the 3 scenarios. RESULTS: Mean brow height increased after application of the gold weight when compared with baseline, and this difference reached significance (p = 0.012). After topical anesthetic was applied, the mean brow height decreased but not back to baseline. When mean brow height during the gold weight with topical anesthesia was compared with baseline and with the gold weight only scenarios, the difference was not significant (p > 0.05). CONCLUSIONS: Frontalis contraction is observed when acute ptosis is simulated in anophthalmic patients, confirming that a contracted visual field cannot be the only stimulus for compensatory brow elevation. A sensory or proprioceptive mechanism is suggested but not confirmed by the trend of reduction in brow elevation with topical anesthesia.

The Effect of Transconjunctival Blepharoplasty on Margin Reflex Distance 2.

BACKGROUND: The objective of this study was to determine the effects of lower eyelid transconjunctival blepharoplasty (TCB) on lower eyelid position. METHODS: Transconjunctival blepharoplasty was performed alone in 15 lower eyelids without simultaneous canthoplasty or upper eyelid procedure. In this study, blepharoplasty was performed by the transconjunctival approach without removal of skin. Four eyes received TCB plus Erbium laser, two patients received TCB plus trichloroacetic acid peel (TCA), and three patients received TCB plus fat transposition. Pre-operative and post-operative margin reflex distance 1 (MRD 1) and margin reflex distance 2 (MRD 2) were compared, with MRD 1 acting as the control. RESULTS: Average time to post-operative photo was 4.6 months (1-10 months). The changes in MRD 2 and MRD 1 were compared pre- and post-operatively, and the difference reached significance by one-tailed comparison (P < 0.05). In 11/15 eyes (73 %), MRD 2 decreased post-operatively. In 6/7 eyes (86 %), lower lid scleral show was eliminated post-operatively. There were no cases of lid retraction noted. CONCLUSIONS: Transconjunctival blepharoplasty (± skin resurfacing) did not induce lid retraction but elevated the lower lid in majority of patients. Elevation of the lower lid can reduce or eliminate scleral show inferiorly, providing further cosmetic advantage. The presumed mechanism of lower lid height elevation is partial recession of the lower lid retractors during the surgical approach to the fat pockets. LEVEL OF EVIDENCE IV: This journal requires that the authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Ointment Granulomas Following Sutureless Transconjunctival Blepharoplasty: Diagnosis and Management.

PURPOSE: To describe a case series of ointment granuloma as a complication of sutureless transconjunctival blepharoplasty. METHODS: A retrospective review of the medical records of 8 patients with this complication was conducted, including the histopathology of excised tissues. Institutional review board oversight was waived as this was not an institutional study but a Health Insurance Portability and Accountability Act-compliant retrospective chart review from the private medical practice of one of authors' coauthors. It adhered to the principles set forth in the Declaration of Helsinki. RESULTS: Eight patients developed painless lower eyelid and anterior orbital masses following presumed successful blepharoplasty. Each had received intra- or immediate postoperative lubricating ointment. The mean time from surgery to appearance of the lesions was 50 days (range: 9 days-10 months). Three patients responded to intralesional injection of steroid with complete resolution. Five patients required surgical excision of the lesions without recurrence to date. Histopathological examination of the excised tissues revealed large, pleomorphic lipid-dropout pools bordered by attenuated histiocytes and giant cells. CONCLUSIONS: The appearance of eyelid lumps or fullness in the early and mid-postoperative recovery should suggest ointment granuloma. If recognized early, management should commence with intralesional injection of steroids, although the definitive treatment is surgical excision. The authors recommend minimizing the access of topical ointments to the open inferior fornix, placing the medication sparingly onto the cornea at the close of surgery and instructing patients in avoiding overuse.

Complete Vision Recovery After Filler-Induced Blindness Using Hyperbaric Oxygen Therapy: Case Report and Literature Review.

Injecting soft-tissue fillers, such as hyaluronic acid, has become an extremely popular method of facial augmentation. Although rare, adverse effects, ranging from cosmetically dissatisfactory to dangerous, may occur. The most severe adverse effect of these is vascular occlusion of the central retinal artery, resulting in vision loss. Protocols for the treatment of filler-induced blindness have not been well established, but there is evidence to suggest that hyperbaric oxygen therapy (HBOT) may aid in the therapeutic algorithm for filler-induced blindness. We present a clinical case of filler-induced blindness successfully treated with prompt administration of HBOT. A 38-year-old healthy female presented to the emergency room after immediate pain and complete vision loss following an at-home injection of mail-order filler into the left glabella and medial eyebrow. After treatment with hyaluronidase and ocular massage, neither of which relieved her symptoms, she received HBOT within 10 h of the injury, after which her vision improved significantly. After 2 additional sessions, the patient had complete vision recovery. This case report contributes to the very sparse literature documenting successful treatment of filler-induced blindness using HBOT, advocating for further study, and possible incorporation into the treatment algorithm for filler-induced blindness. Improper soft-tissue filler administration possesses a potential risk of severe adverse effects. It is crucial that the medical community is aware of treatments that offer the highest chance of visual recovery and sustained benefit for patients.

Evaluation of the canalicular entrance into the lacrimal sac: an anatomical study.

PURPOSE: The purpose of this study was to investigate the prevalence of a common canalicular entrance in the lacrimal sac and to investigate the anatomy of the canalicular/lacrimal sac junction with direct visualization using a novel cadaveric dissection technique. METHODS: Preserved cadavers were dissected to allow direct visualization of the canalicular entrance(s) to the lumen of the lacrimal sac. The prevalence of a common canaliculus and the anatomical variations of the canalicular/lacrimal sac mucosal fold of tissue were recorded. RESULTS: One hundred twenty-four lacrimal systems (95 cadavers; 43 female, 52 male) were included in the study analysis. Overall, 123 lacrimal systems demonstrated a common canaliculus entering the lacrimal sac. Only one demonstrated 2 separate orifices (right orbit; male) in the sac (0.08%; 95% confidence interval, 0.1%-4.4%). Seventy-four lacrimal systems had some variation of a canalicular/lacrimal sac mucosal fold (59.7%). The remaining 50 (40.3%) had no visible canalicular/lacrimal sac mucosal fold. CONCLUSIONS: This study provides direct anatomical evidence that the prevalence of separate canalicular orifices in the lacrimal sac is lower than previously reported (<1%). Additionally, the presence of a valve-like structure at the canalicular/lacrimal sac junction is common. These observations can potentially play a role in evaluating and treating lacrimal system pathology.

Balloon canaliculoplasty for acquired canalicular stenosis.

PURPOSE: Canalicular stenosis is a frequent cause of epiphora. Patients with canalicular stenosis often require timely insertion of bicanalicular silicone stents to prevent permanent and complete closure of the canaliculi. This study reports the use of balloon canaliculoplasty in conjunction with silicone tube intubation in selected cases of canalicular stenosis. METHODS: Patients with canalicular stenosis noted upon probing of the upper and lower lacrimal systems were included in the study. Patients with punctal stenosis underwent concurrent punctoplasty. Patients with complete canalicular obstruction were excluded from the study. The procedure was as follows. Canalicular dilation was achieved with 2 successive dilations of 90 seconds with a 2-mm-diameter balloon dilator, followed by probing and intubation of the lacrimal system with bicanalicular Crawford tubes. RESULTS: Twenty-one eyes (41 canaliculi) of 12 patients (10 females, 2 males) with canalicular stenosis were included in this study. The average age was 64.5 ± 7.5 years. Silicone tubes were left in place for an average 5.5 ± 2.6 (range: 2 to 12) months. Mean follow up after tube removal was 6.2 ± 1.1 months. Improvement within 1 week of the procedure was recorded in 20 out of 21 canaliculi (95.2%). Final clinical outcomes were successful or acceptable in 16 out of 21 eyes (76.2%). CONCLUSIONS: Balloon canaliculoplasty with silicone tube intubation is simple and safe and appears to be an effective alternative treatment in patients with canalicular stenosis.

Evaluation and management of unilateral ptosis and avoiding contralateral ptosis.

Treating unilateral ptosis can be challenging and a proper preoperative evaluation may help prevent unexpected outcomes on the contralateral lid. Preoperative evaluation should include testing for Hering's law, which remains useful in understanding the phenomenon of induced contralateral eyelid retraction in the context of ptosis. Approximately 10% to 20% of patients with unilateral ptosis have some degree of induced retraction on clinical evaluation in the contralateral lid. When there is a positive Hering's test on preoperative examination, the surgeon should consider a bilateral ptosis procedure. The surgical approach to unilateral ptosis depends on the severity of the ptosis and its etiology, and the surgeon should be aware of which procedure is most likely to provide the best outcome in selected instances.

Inferior Oblique Entrapment After Orbital Fracture With Transection and Repair.

Extraocular muscle (EOM) entrapment with resulting reduction in motility and diplopia is a known complication of orbital fractures. Less commonly, transection of the EOMs due to trauma, iatrogenic injury, or intentional myotomy may lead to persistent diplopia. The inferior oblique (IO) is often encountered during orbital surgery along the medial wall and floor, and may be disinserted to aid in visualization. The authors present a case of IO entrapment which occurred during zygomaticomaxillary fracture reduction. Intraoperatively, an IO transection was performed and the muscle was reattached within the orbit. Postoperatively, the patient did not develop diplopia or motility disruption. This technique may provide a useful solution to an unusual problem during orbital fracture repair.