Oral Sedation Anesthesia Protocol for In-Office Oculoplastic Surgery.

PURPOSE: To present an oral anesthesia protocol for in-office oculoplastic surgery and to compare safety outcomes and patient and physician experiences to ambulatory surgery center (ASC)-based surgery with intravenous sedation or general anesthesia. METHODS: A prospective study was performed on consecutive patients undergoing surgery at an oculofacial plastic surgery practice. Surgery was performed in an in-office setting using our standardized oral sedation protocol or at an ASC with intravenous sedation or general anesthesia. Preoperative and postoperative surveys were conducted by patients and physicians to compare surgical experience, safety, and efficacy of our oral sedation protocol for in-office surgery in the ASC setting. RESULTS: Two hundred and fifty-three patients (167 in-office and 86 at ASC) underwent surgery between March and November 2022. There was no significant difference in how patients or physicians rated their experience between the 2 locations. A significantly higher proportion of ASC patients would have rather had surgery in-office (34.9% vs. 19.2%; p = 0.006). A significantly higher number of physicians in the office setting would have rather performed surgery at the ASC than the reverse (12.7% vs. 2.3%, respectfully; p = 0.007). There were no safety complications reported in either setting. CONCLUSIONS: Within our patient cohort, the presented oral sedation protocol provided safe and effective anesthesia for in-office oculoplastic surgery that is comparable to an ASC.

What is in a Name? It is Time to Retire the Term "Asian Blepharoplasty".

PURPOSE: This perspective explores the term "Asian blepharoplasty" and its socioemotional meaning to some patients. METHODS: N/A. RESULTS: Words have power. The term "Asian blepharoplasty" makes some patients uncomfortable. To our knowledge, it is the only medical descriptor that uses race. CONCLUSIONS: The use of the term "Asian Blepharoplasty" may unwittingly make patients uncomfortable and pathologize Asian features. Therefore, we suggest replacing the term "Asian Blepharoplasty" with "Double Eyelid Surgery." For the subset of procedures which do not include the creation of an eyelid crease, "Blepharoplasty" is appropriate.

On-Q pump for pain control after orbital implant surgery.

PURPOSE: To introduce an elastomeric continuous infusion pump for pain control after outpatient orbital implant surgery. METHODS: Retrospective, noncomparative consecutive case series of all patients undergoing enucleation, evisceration, or secondary orbital implantation using the On-Q pain system between August 2004 and January 2006. Postoperative pain score, need for narcotics, and adverse events were recorded. The On-Q catheter is inserted intraoperatively through the lateral lower eyelid into the muscle cone under direct visualization, prior to the orbital implant placement. The On-Q system continually infuses anesthesia (bupivacaine) to the retrobulbar site for 5 days. RESULTS: Among 20 patients, mean postoperative period pain score, with On-Q in place, was 1.3 (scale of 0 to 10). Nine patients (45%) did not need any adjunctive oral narcotics. Two patients experienced postoperative nausea. One catheter connector leaked, thereby decreasing delivery of retrobulbar anesthetic resulting a pain level of 6, the highest level in the study. There were no postoperative infections. No systemic toxic effects from bupivacaine were observed clinically. CONCLUSION: The On-Q pain pump is widely available, low cost, and requires minimal patient manipulation for the use in orbital implant surgery. The device was safe and appeared to minimize postoperative pain in the authors' case series.

The modified fasanella-servat procedure: description and quantified analysis.

PURPOSE: To describe a modified Fasanella-Servat procedure and nomogram for the correction of minimal amounts of ptosis. METHODS: Retrospective review of this modified Fasanella-Servat procedure was performed on 118 eyelids in 86 consecutive patients over 2, 4-year periods by 1 surgeon (S.C.D.). The amount of tarsectomy was based on the amount of ptosis. RESULTS: Mean pre- and postoperative margin-to-reflex distance 1 were +0.7 mm and +2.4mm, respectively. One hundred and twelve eyelids (95%) had satisfactory results with postoperative margin-to-reflex distance 1 ≥ 1.5 mm. Eyelid symmetry was achieved in 92% of eyelids to within 0.5 mm. There was no incidence of overcorrection, tarsal buckling, or corneal abrasion. One eyelid had a contour deficit. Tarsectomy amount ranged from 2 mm to 5 mm. Average amount of tarsectomy to eyelid elevation was 2.4:1. CONCLUSIONS: The modified Fasanella-Servat procedure is technically easy, time-efficient, and has a low complication rate for the treatment of minimal blepharoptosis (< 2.5 mm) with good levator function and negative phenylephrine test. In the authors' hands, the ratio of tarsectomy to eyelid elevation is approximately 2:1. In addition to other techniques such as levator advancement and Müller's muscle conjunctival resection, the modified Fasanella-Servat technique is a useful adjunct to the modern ptosis surgeon's armamentarium.

Using the inferior oblique muscle to augment implant coverage in enucleation surgery.

PURPOSE: We present a technique modification for enucleation surgery that may decrease implant exposure or extrusion by using native tissue to reinforce the implant at the most susceptible area, specifically the anterior-most aspect. METHODS: An enucleation procedure is performed, and an implant is placed into the orbit. The horizontal rectus muscles are attached to the implant, and the vertical rectus muscles are attached directly to the horizontal muscles. The inferior oblique muscle is then spread over the anterior implant surface and sutured to the superior rectus and lateral rectus muscles. RESULTS: 15 patients underwent this procedure, with implantation of an SST porous polyethylene implant. The mean follow-up interval was 18 months with a range of 4-33 months. One patient suffered an implant exposure, and one experienced a post-operative orbital hemorrhage. Two patients required blepharoptosis surgery to achieve eyelid symmetry. CONCLUSIONS: This retrospective series demonstrates the potential usefulness of the inferior oblique muscle to augment coverage of the orbital implant. Reinforcement of the anterior surface of the implant with vascularized tissue may improve the integrity and strength of the tissues anterior to the implant, and thereby reduce the likelihood of implant exposure.

Small incision preperiosteal midface lift for correction of lower eyelid retraction.

PURPOSE: Postblepharoplasty lower eyelid retraction is often due to scarring of the middle lamellae and/or vertical shortening of the anterior lamellae. Traditional reconstructive techniques involve a transconjunctival incision combined with a spacer graft. Other techniques involve a subperiosteal midface dissection or limited preperiosteal dissection. Elevation of the midface reduces the gravitational effect of the cheek on the eyelid and recruits skin for the anterior lamella. This study evaluates a technique for correction of lower eyelid retraction using a preperiosteal midface lift via a lateral canthal incision in a series of patients. METHODS: Twenty-eight patients (56 eyes) with postblepharoplasty lower eyelid retraction were evaluated. Preoperative evaluations for inferior scleral show, corneal staining, and epiphora were documented. The patients underwent bilateral preperiosteal midface lift and canthoplasty via a lateral canthal incision. Follow-up ranged from 12 to 18 months. RESULTS: Average preoperative inferior scleral show was 1.96 mm (range, 1-3 mm). Seventy-eight percent of patients had epiphora, and 54% had corneal staining. Average postoperative lower eyelid position was +0.07 mm (range, 0 to +1 mm) above the inferior limbus. Average change in lower eyelid position relative to the inferior limbus was 2.04 mm. In all eyes, the final lower eyelid position was either at the inferior limbus or above it. All eyes had resolution of epiphora and corneal staining. Two patients required revision of lateral canthus on one side to improve symmetry. CONCLUSION: Mobilizing the midface in the preperiosteal plane through a lateral canthal incision provides excellent elevation and support of the eyelid. The small incision allows easy access to adhesions along the inferior orbital rim and to the preperiosteal plane beneath the entire midface. Preperiosteal midface lift combined with canthoplasty provides significant improvement of postblepharoplasty lower eyelid retraction.

Efficacy and complications of the transconjunctival entropion repair for lower eyelid involutional entropion.

PURPOSE: To evaluate the efficacy of the transconjunctival entropion repair (TCER) for lower eyelid involutional entropion. DESIGN: Retrospective, noncomparative, interventional case series. PARTICIPANTS: One hundred fifty-one eyelids in 120 patients who underwent TCER for involutional entropion over a 12-year period from February 1991 through January 2003. METHODS: Surgical technique addressed all 3 anatomic factors underlying the entropion and was performed through a transconjunctival incision. Lateral tarsal strip procedure addressed horizontal eyelid laxity, lower eyelid retractor reinsertion addressed retractor disinsertion, and excision of a strip of the preseptal orbicularis oculi addressed preseptal orbicularis override. MAIN OUTCOME MEASURES: Entropion resolution, entropion recurrence, postoperative eyelid retraction, and complication rate. RESULTS: Transconjunctival entropion repair resulted in resolution of entropion, with a success rate of 96.7% (146 of 151 eyelids); entropion recurrence rate was 3.3% (5 of 151 eyelids). No patient had postoperative eyelid retraction or scleral show, and there were no overcorrections or secondary ectropions in any of the 151 eyelids. Postoperative complications occurred in 6 of 151 eyelids (4.0%) of 6 of 120 patients (5.0%) and included stitch abscess (1 eyelid, 0.7%), lateral tarsal strip dehiscence (2 eyelids, 1.3%), lateral canthal dystopia (2 eyelids, 1.3%), and conjunctivochalasis (1 eyelid, 0.7%). CONCLUSIONS: The transconjunctival lower eyelid entropion repair is effective and safe with low recurrence and complication rates. The TCER circumvents the risk of lower eyelid retraction and overcorrections that may occur with the transcutaneous approach.

Multipurpose conical orbital implant in evisceration.

PURPOSE: To evaluate the safety and efficacy of the porous polyethylene multipurpose conical orbital implant for use in evisceration. METHODS: A retrospective review of 31 eyes that underwent evisceration and received the multipurpose conical orbital implant. The orbits were evaluated at 1 week, 1 month, and 6 months after final prosthetic fitting for implant exposure, superior sulcus deformity, and prosthetic motility. RESULTS: There were no cases of extrusion, migration, or infection. All patients had a good cosmetic result after final prosthetic fitting. Prosthetic motility was good in all patients. Exposure developed in one eye (3%) and a superior sulcus deformity developed in one eye (3%). CONCLUSIONS: Placement of an multipurpose conical orbital implant in conjunction with evisceration is a safe and effective treatment for blind painful eye that achieves good motility and a good cosmetic result.

The smooth surface tunnel porous polyethylene enucleation implant.

BACKGROUND AND OBJECTIVE: To describe early clinical results with the porous polyethylene smooth surface tunnel (SST) enucleation implant. PATIENTS AND METHODS: Uncontrolled, prospective interventional case series of patients undergoing enucleation with placement of the SST implant. This implant consists of a porous polyethylene sphere with a smooth anterior surface containing pre-drilled tunnels to facilitate direct suturing of the rectus muscles to the implant without use of an implant wrap. Postoperatively, socket healing was assessed, and prosthesis and socket motility were evaluated by the surgeon using an ordinal scale (0 = no motility to 4 = excellent motility). RESULTS: Thirty patients received the SST implant, with a mean follow-up of more than 23 months. Two cases of exposure occurred and were managed surgically without the need for explantation. Mean socket motility was 3.1 on a 0 to 4 ordinal scale, with mean prosthesis motility of 2.8. CONCLUSION: The SST implant provides satisfactory socket motility and is generally well tolerated in the anophthalmic socket without the need for wrapping material.

Safety of blepharoplasty in patients with preoperative dry eyes.

OBJECTIVES: To assess the safety of blepharoplasty in patients with preoperative dry eyes and to report our surgical technique. SETTING: Private practice with academic affiliation. DESIGN: Retrospective medical chart review of 67 patients with preoperative dry eyes who underwent blepharoplasty. The technique was modified by preserving the orbicularis oculi muscle and its innervation during upper blepharoplasty. MAIN OUTCOME MEASURES: The severity of preoperative and postoperative eye dryness by patient survey. RESULTS: Of the 67 patients, 5 had worsening, 5 had improvement, and 50 had no change in the severity of their dry eyes. Seven patients could not be located for the follow-up survey. Preserving the orbicularis did not affect the cosmetic results. CONCLUSIONS: By preserving the orbicularis muscle and its innervation, the dynamics of eyelid closure, tear pumping, and tear distribution are not affected. Blepharoplasty can be a safe operation in patients with dry eyes.

Conjunctival melting syndrome associated with the use of bovine pericardium wrapping material.

PURPOSE: To report 18 cases of unusually large, early conjunctival breakdown occurring with the use of bovine pericardium wrapping material for orbital implants. METHODS: Retrospective case series. The clinical course and histopathologic features of 18 cases of early conjunctival breakdown in patients who had undergone orbital implantation of bovine pericardium-wrapped hydroxyapatite or porous polyethylene are reviewed. RESULTS: Eighteen patients presented with unusually large (average 13.44 mm) conjunctival defects over bovine pericardium-wrapped implants. The average time from enucleation to exposure was approximately 4 months. Implants had to be removed in 8 of 18 cases. There was clinical and histologic evidence of tissue inflammation and conjunctival melting. CONCLUSIONS: The conjunctival melting phenomenon we report herein is alarming. We have abandoned the use of bovine pericardium as a wrapping material for implants after enucleation because of the unfavorable results.