Direct eyelid defect closure: a prospective study of functional and aesthetic outcomes.

BACKGROUND/OBJECTIVES: Direct closure (DC) of eyelid defects has been retrospectively shown to give excellent outcomes. We present prospective outcome data as further evidence to promote its wider use. SUBJECTS AND METHODS: A consecutive, unselected, series of patients undergoing eyelid tumour resection was studied prospectively. DC was attempted at the time of biopsy in all of them. If DC proved impossible, delayed reconstruction using other techniques was later performed. Defect size, pre- and post-operative palpebral aperture (PA) measurements and the final visit patients' and surgeons' satisfaction scores for function and appearance were recorded. RESULTS: Seventy-three eyelids of 70 patients were studied. Mean resected specimen width was 16.4 mm (4-26 mm) in the DC group, versus 23.9 mm (11-42 mm) for other, non-DC reconstructions. Primary DC was achieved in 74% of this cohort. Mean final post-operative PA measurements in the DC group were 0.7 mm vertically (p = 0.003) and 0.8 mm horizontally (p = 0.009) less than preoperatively, but there was no statistical difference (p = 0.1) in the final horizontal measurements between the operated and un-operated sides in the DC group. DC satisfaction scores were excellent for both eyelid function and appearance. CONCLUSIONS: DC of eyelid defects, irrespective of per-operative PA distortion, gives excellent late post-operative outcomes. We recommend that DC, aligning the closure tension parallel to the lid margin, is attempted whenever wound margin approximation is possible in preference to alternative reconstruction techniques, regardless of any temporary PA distortion and globe displacement that this may cause. Eyelid function and appearance recover to near normal within 2 months.

Periocular Amyloidosis Manifesting as Pseudopemphigoid Treated With Mitomycin C.

PURPOSE: To describe an unusual cicatrizing manifestation of periocular amyloid and the utility of adjuvant antimetabolite therapy. METHODS: This is a case report of a 49-year old woman with progressive bilateral upper lid ptosis, who was found to have bilateral inferior forniceal masses with thickening of the conjunctiva. Conjunctival and eyelid biopsies showed evidence of amyloid deposition. Systemic evaluation did not reveal any evidence of systemic amyloidosis. Her blepharoptosis continued to deteriorate, and she underwent bilateral sequential upper lid ptosis correction surgery and debulking procedures. Subsequently, she developed severe and progressive cicatricial conjunctivitis with extensive symblepharon formation in all 4 fornices and restriction of ocular motility, simulating a clinical picture of ocular mucous membrane pemphigoid. RESULTS: She was treated surgically by division of symblepharon augmented with application of topical mitomycin C intraoperatively. This has been partially successful in freeing up differential movement between her lid and her eye and consequently improving eye protection and lubrication. CONCLUSIONS: Pseudopemphigoid represents a rare manifestation of periocular amyloid. Risks and benefits of surgical procedures in this context need to be carefully weighed to minimize the risk of secondary complications. Topical mitomycin C may be considered as a relatively safe adjunct in managing the cicatricial component of the disease.

Globe-sparing surgery for medial canthal Basal cell carcinoma with anterior orbital invasion.

PURPOSE: To describe a case series of patients with anterior orbital invasion by medial canthal basal cell carcinoma (BCC) managed with non-exenterating surgery. DESIGN: International, multicenter, retrospective, noncomparative, consecutive case series. PARTICIPANTS: Twenty patients identified from the individual institutions' databases with histologically confirmed orbital invasion by periocular BCC. METHODS: Examination of charts, relevant imaging, and histopathologic data. MAIN OUTCOME MEASURES: Demographics; clinical characteristics and radiologic features; histopathologic features; surgical techniques for excision, reconstruction, and subsequent procedures; complications; visual acuity; and recurrence. RESULTS: Twenty patients were identified. Twelve of 20 patients (60%) had recurrent BCCs, with 1 patient having had prior radiotherapy for previously incomplete excision. Eighteen of 20 patients (90%) had a palpable mass, 16 of 20 patients (80%) had clinical involvement of the nasolacrimal system, and 1 of 20 patients (5%) had limited extraocular movements. Preoperative radiologic evidence of orbital invasion was found in 10 of 20 patients (50%). Histologic evidence of orbital invasion was present in every patient, the subtypes being infiltrative (9/20, 45%), nodular (4/20, 20%), micronodular (2/20, 10%), multifocal (1/20, 5%), and mixed (4/20, 20%); extratumoral perineural invasion was present in 1 patient (5%). Final margins were clear in 18 of 20 patients (90%), positive in 1 of 20 patients (5%), and unclear in 1 of 20 patients (5%). Reconstruction was by direct closure in 1 patient and by a variety of standard oculoplastic flaps and grafts in 19 of 20 patients (95%). Twelve of 20 patients (60%) had postoperative extraocular muscle movement restriction, and 15 of 20 patients (75%) had epiphora. Subsequent revision procedures were needed in 12 of 20 patients (60%), including insertion of a lacrimal bypass tube and revision of medial canthal position. At a mean follow-up of 38 months, 18 of 20 patients (90%) were still alive (2 deaths due to other causes) with 1 recurrence (exenterated). Postoperative visual acuity was within 2 Snellen lines of preoperative visual acuity in 17 of 20 patients (85%). CONCLUSIONS: With careful planning and margin control, conservative surgery in this highly selected group proved possible with a low rate of disease recurrence, albeit with a relatively short follow-up. Postoperative complications, such as epiphora and ophthalmoplegia, were largely expected; most patients underwent subsequent revision procedures to address these and other complications. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Unilateral optic disc pit and orbital cyst in an eye with normal axial length.

Orbital cyst and optic disc pits are both congenital embryological anomalies. Orbital cysts occurring in association with optic disc colobomata and microphthalmic eyes have been widely reported in literature. The authors describe the case of a 69-year-old man with an asymptomatic orbital mass, who was investigated and found to have a coexistent optic disc pit and orbital cyst. The axial length was normal. Visual acuity was reduced due to epiretinal membrane at the macula as a consequence of serous maculopathy secondary to the optic disc pit. No active intervention was offered due to poor visual potential, and no changes in the cyst occurred over time. This is an unusual case of coexistent orbital cyst and optic disc pit in an eye with normal axial length, although the dual pathology has previously been described in a microphthalmic eye.