Periocular management in recent facial palsy patients treated with triple innervation technique: A retrospective case series.

Facial paralysis decreases eye protection mechanisms leading to ocular problems up to corneal ulceration, and blindness. This study aimed to evaluate the outcomes of periocular procedures for recent facial paralysis. Medical records of patients with unilateral recent complete facial palsy who did periocular procedures at the Maxillofacial Surgery Department of San Paolo Hospital (Milan, Italy) between April 2018 and November 2021 were retrospectively reviewed. 26 patients were included. All patients were evaluated 4 months after surgery. The first group included 9 patients who underwent upper eye lid lipofilling and midface suspension with fascia lata graft; they had no ocular dryness symptoms and no need for eye protection measures in 33.3% of cases, significant reduction of ocular symptoms and need for eye protection measures in 66.6% of patient, 0-2 mm lagophthalmos in 66.6% and 3-4 mm lagophthalmos in 33.3%. The second group of 17 patients who underwent upper eyelid lipofilling, midface suspension with fascia lata graft and lateral tarsorrhaphy, had no ocular dryness symptoms and no need for eye protection measures in 17.6% of patient, significant reduction of ocular symptoms and need for eye protection measures in 76.4% of patient, 0-2 mm lagophthalmos in 70.5%, 3-4 mm lagophthalmos in 23.5% and one patient 5,8%had 8 mm lagophthalmos and persistent symptoms. No ocular complication, cosmetic complain or donner site morbidity were reported. Upper eyelid lipofilling, midface suspension with fascia lata graft and lateral tarsorrhaphy decrease ocular dryness symptoms and need for eye protection measures and improve lagophthalmos: the association of the reinnervation with these complementary techniques is therefore highly recommended in order to immediately protect the eye.

Botulinum Toxin Type A Injection for Correction of Upper Eyelid Retraction in Thyroid-Associated Ophthalmopathy.

Upper lid retraction (ULR) is the most common and earliest symptom in thyroid-associated ophthalmopathy (TAO) patients. Surgical correction is effective for ULR in stable diseases. However, non-invasive treatment is also required for the TAO patient in active phase. Here, we reported a complex case with TAO and unilateral ULR simultaneously. The patient had a history of progressive ptosis in the left eyelid and underwent anterior levator aponeurotic-Muller muscle resection to correct the ptosis. However, the patient gradually developed bilateral proptosis and ULR, mainly in the left eyelid. The patient was finally diagnosed with TAO with left ULR. Then, the patient was treated with botulinum toxin type A (BTX-A) injection in the left eyelid. The effect of BTX-A treatment started 7 days after injection, peaked at one month, and lasted for approximately 3 months. This study highlighted the therapeutic effect of BTX-A injection for the treatment of ULR-related TAO.

Periocular Manifestation of Obstructive Sleep Apnea as a Novel Perioperative Screening Tool.

PURPOSE: Obstructive sleep apnea (OSA) presents perioperative challenges with increased risk for complications. Floppy eyelid syndrome (FES) is associated with OSA yet has not been addressed perioperatively. The current standard for perioperative OSA screening includes assessing patient risk factors or the STOP-BANG tool, which requires an active participant. We aimed to confirm a connection between FES and OSA in presurgical patients and develop a screening method appropriate for patients with perioperative OSA risk. MATERIALS AND METHODS: 162 presurgical pre-anesthesia clinic patients were enrolled. Screening questions determined eligibility. Those who were pregnant or aged < 19 were excluded. Control group included those with a STOP-BANG score < 3. Experimental group included those with BMI > 35 and OSA diagnosis. Examiners photographed participants' eyes with vertical and horizontal retraction while two blinded ophthalmologists used a grading scale to review grade of eyelid laxity. RESULTS: Differences in habitus, ASA score, and hypertension as a comorbidity were significant. Sensitivity of FES screening was 52% (CI 37-66%) and specificity was 56% (CI 46-66%) for reviewer 1. For reviewer 2, sensitivity was 48% (CI 28-69%) and specificity was 72% (CI 60-81%). Negative predictive value was 86% (CI 81-90) for reviewer 1 and 88% (CI 83-92%) for reviewer 2. Inter-rater agreement was moderate. CONCLUSION: While specificity and sensitivity were lower than anticipated, negative predictive value was high. Given this strong negative predictive value, our findings indicate using eyelid retraction to screen for FES has perioperative clinical utility. These findings encourage further research addressing the connection of lid laxity/FES to OSA. KEY POINTS: • Aimed to investigate if a FES screening tool could identify perioperative OSA risk. • Negative predictive value for FES with OSA was 86%. • Observing periocular lid laxity has clinical utility; is feasible in any patient.

Lower eyelid entropion in thyroid eye disease.

PURPOSE: To report the clinical features, ultrasound biomicroscopic features, and management outcome in patients presenting with thyroid eye disease (TED) and lower eyelid entropion. METHODS: Retrospective interventional case review of patients with TED presenting with lower eyelid entropion over a 12-year period. RESULTS: Five patients (eight eyes) of a total of 1211 presented with lower eyelid entropion as one of the presenting signs of TED (0.41%). The average age was 28.8 years (18-39 years), and three patients were males. Three had systemic hyperthyroidism, and two were euthyroid. Four (80%) had bilateral TED, three had inactive disease, and two were active. The average Hertel exophthalmometry reading was 24.6 mm. All patients had upper lid retraction. Four (80%) had concomitant lower eyelid retraction. Entropion was medial in five and complete in three eyes. Symptomatic corneal epitheliopathy was noted in four eyes. UBM was performed in four eyes which showed a thickened middle lamella. In four eyes (three patients), the entropion was managed conservatively as the patient was not contemplating surgery for proptosis. In the remaining four eyes (two patients) orbital decompression was performed and the lower eyelid retractor release corrected the symptomatic entropion. The average follow-up was 11.6 months (range 1-30). CONCLUSION: Lower eyelid entropion is a rare presenting sign in TED. The mechanism is multifactorial and could be caused by the thickened and fibrosed lower lid retractors, as demonstrated by UBM. Young age and globe projection may play a role. Decompression approaches that involve lower lid retractor release correct the entropion.

Unilateral Periocular Intralymphatic Histiocytosis, Associated With Rosacea (Morbihan Disease).

Intralymphatic histiocytosis is a rare reactive skin condition characterized by a nonspecific clinical presentation and, microscopically, by the collections of mononuclear histiocytes within the lumina of dilated lymphatic vessels. We report a rare case of intralymphatic histiocytosis associated with rosacea and prominent periocular edema (Morbihan disease). The patient is a 56-year-old woman with a 12-year history of rosacea who suddenly developed edema of the right upper eyelid that persisted 6 months before she sought medical advice. Because of an unclear clinical diagnosis, surgical excision of the edematous upper eyelid was performed. The histologic slides showed interstitial edema of the dermis with dilated vascular channels and small epithelioid cell granulomas around hair follicles. In addition, there were aggregates of cells inside numerous lymphatic vessels that were immunohistochemically positive for CD45, CD4, CD68, CD163, CD64, CD14, CD11c, and lysozyme and negative for CD3, CD20, CD30, CD56, S100, CD1a, and langerin.

A modified tarsorrhaphy in patients with facial nerve palsy.

PURPOSE: We report our experience with a modified tarsorrhaphy (MT) technique in patients with facial nerve palsy (FNP). METHODS: This study involved a retrospective chart review of patients with FNP undergoing MT over a 10-year period in one Medical Center. Patient demographics, presence of lagophthalmos, occurrence of eyelid malpositions, recurrent retraction, and repeat procedures were noted from medical records. RESULTS: Twenty patients (11 females, mean age 38 years) were included. Mean follow-up was 41 months (range 6-132). All patients had lagophthalmos prior to surgery compared with four on last follow-up. The number of patients with punctate epithelial erosions (PEEs) reduced from nine preoperatively to five postoperatively. While seven patients used lubricating drops prior to surgery, two stopped lubrication completely and five reduced the amount after surgery. No patients developed a new-onset lower eyelid malposition. No recurrence or postoperative complications were noted. CONCLUSION: This MT technique avoids grey line split and excision of orbicularis muscle or skin. It improves lower eyelid retraction and reduces lagophthalmos in FNP.

Retalho zigomático-palpebral: uma técnica opcional para a reconstrução da pálpebra inferior / Zygomatic-palpebral flap: an optional technique for lower eyelid reconstruction

Introdução: A reconstrução de pálpebra inferior representa um desafio peculiar ao cirurgião plástico, uma vez que traduz uma região facial de importância estética e funcional. O objetivo é apresentar uma técnica opcional para a reconstrução de defeitos da pálpebra inferior com o retalho cutâneo zigomáticopalpebral. Esta técnica mostra uma alternativa nos casos de pele escleroatrófica de pessoas idosas, bem como para pessoas jovens, que não apresentam redundância da pele palpebral superior, impossibilitando por exemplo o uso de enxertos de pálpebra superior ou retalhos como o de Fricke ou Tripier. Métodos: Os autores mostram a indicação do retalho em casos de ectrópio cicatricial, reconstrução após ressecção de neoplasias, associação com outros retalhos como de Hughes ou para cobertura de enxertos cartilaginosos. É um retalho de transposição composto por pele e subcutâneo, randomizado. A técnica baseia-se no uso de retalho local, de características muito semelhantes à área do defeito, o que permite mimetização, segurança e exequibilidade. Resultados: Os resultados imediatos e tardios são satisfatórios e bem aceitos pelos pacientes e pela equipe cirúrgica em termos estéticos e funcionais, com oclusão palpebral adequada e lubrificação ocular preservada. Conclusão: O retalho zigomático-palpebral apresenta como vantagens a simplicidade de execução, sangramento mínimo, baixa morbidade de área doadora e feito sob anestesia local. O objetivo de reconstruir defeitos da pálpebra é restaurar a anatomia e função. Esta pode ser uma tarefa desafiadora, especialmente em defeitos maiores que podem estar presentes nos procedimentos oncológicos em jovens e em idosos com pele escleroatrófica e mínima frouxidão.

Introduction: Lower eyelid reconstruction represents a unique challenge to plastic surgeons, since it involves a facial region of aesthetic and functional importance. The objective is to present an optional technique for the reconstruction of lower eyelid defects using zygomatic-palpebral skin flap. This technique represents an alternative in cases of scleroatrophic skin in older patients, and for young people who do not have an upper eyelid skin redundancy, which prevents, for example, the use of upper eyelid grafts or flaps such as those of Fricke or Tripier. Methods: The authors describe the flap used in cases of cicatricial ectropion and reconstruction after resection of neoplasms and association with other flaps, such as those of Hughes, or for coverage of cartilage grafts. The flap consisted of a transposition flap made up of skin and underlying subcutaneous tissues, randomized . The technique was based on the use of a local flap with highly similar characteristics to the defect area, which allowed it to mimic functions, while being safe and feasible. Results: The immediate and late results in terms of aesthetics and function were satisfactory and well accepted by patients and the surgical team, with adequate eyelid occlusion and preserved ocular lubrication. Conclusion: The advantages of the zygomatic-palpebral flap are its ease of execution, minimal bleeding, low morbidity of the donor area, and the use of local anesthesia. The reconstruction of eyelid defects aims to restore anatomy and function. This can be a challenging task, especially in cases with larger defects that may be present after oncologic procedures both in young and old patients presenting with scleroatrophic skin and minimal tissue laxity.

[Meibomian glands dysfunction and ocular surface in black people]. / Dysfonctionnement des glandes de Meibomius et surface oculaire du sujet âgé mélanoderme.

Meibomian gland dysfunction is the leading cause of evaporative-type dry eye syndrome. Our goal was to determine the epidemiological and clinical features of meibomian gland dysfunction as well as its impact on the ocular surface in elderly black patients in Cameroon. PATIENTS AND METHODS: We performed a cross-sectional analysis from January 2 through May 31, 2017 in the ophthalmology department of Laquintinie Hospital in Douala, including blacks aged 50 years and older. The examination focused on the Meibomian glands, Tear film Break Up Time and Schirmer I test for qualitative and quantitative assessment of tears. The relationship between the quantitative and qualitative variables and meibomian gland dysfunction was determined by linear regression tests. RESULTS: We enrolled 340 elderly black patients. The mean age was 62±9 years. The prevalence of meibomian gland dysfunction was 71.8 % and did not increase with age. The hypoproductive clinical form was the most frequent (47.9 %). The prevalence of asymptomatic Meibomian gland dysfunction was 19.7 %. Evaporative dry eye disease was the most frequent (34.7 %). Aside from advanced age, Meibomian gland dysfunction was associated with high blood pressure (P=0.020), cataract surgery (P=0.034), long-term glaucoma medication (P=0.041) and alcohol consumption (P=0.043). CONCLUSION: Meibomian gland dysfunction is very common in elderly black patients in Cameroon.

Successful chemical ablation of an intraorbital cyst caused by an eyelid injury and iatrogenic ankyloblepharon formation in a duck.

CASE DESCRIPTION A client-owned 2-year-old 1.8-kg (4-lb) male pet Rouen duck (Anas platyrhynchos domesticus) was evaluated because of severe swelling around the left eye following traumatic injury to the upper and lower eyelids and 2 associated surgeries that resulted in the removal of the entire upper and lower eyelid margins. CLINICAL FINDINGS At initial evaluation, ankyloblepharon of the left eye was observed, with no upper or lower eyelid margins and a large, round, fluctuant subcutaneous mass over the left orbit. Orbital exploration and histologic examination revealed a benign cyst consisting of fibrous tissue, conjunctiva, and skeletal muscle bundles. Bacterial culture of cystic fluid yielded few Staphylococcus delphini. TREATMENT AND OUTCOME Excision of the cyst and evisceration of the left globe were performed, and once daily treatment with orally administered enrofloxacin suspension (12.6 mg/kg [5.7 mg/lb]) and meloxicam (1 mg/kg [0.45 mg/lb]) was initiated. Over the next 4 days, the cyst redeveloped and progressively enlarged. Accumulated fluid was aspirated from the cyst, and 20 mg of gentamicin was injected intraorbitally with ultrasound guidance. Over the subsequent 27-month period, no recurrence of clinical signs or adverse effects were reported by the owner. CLINICAL RELEVANCE To the authors' knowledge, this is the first report of cyst formation after adnexal injury and evisceration in birds and its successful treatment with intralesional gentamicin injection. Findings emphasized the importance of preserving lacrimal puncta during adnexal or eye removal surgeries in birds. Intralesional injection of gentamicin with the goal of destroying fluid-producing cells may be a safe and effective way to treat intraorbital cysts in birds and other species, although additional research would be required to confirm this.

Changes in Corneal Curvature After Epiblepharon Surgery in Children.

PURPOSE: We aimed to determine the change in corneal topography for 2-different corneal zones and 4-quadrants after epiblepharon correction in children. METHODS: We retrospectively reviewed 39 patients (74 eyes) who underwent epiblepharon surgery. Keratometry measurements of corneal curvature were performed for 2 optical zones defined as circular areas with a radius of 3 and 5 mm from the corneal apex. Each optical zone was divided into quadrants (nasal, superior, temporal, and inferior). Keratometry readings for each quadrant of zone were compared between the preoperative and postoperative examinations (at 1, 3, and 6 months). The correlation between corneal astigmatism and curvature change was analyzed for each quadrant of the 3-mm optical zone. RESULTS: At 1 month postoperatively, the inferior and superior quadrants of the 3-mm optical zone became significantly flatter compared with the preoperative state, and this phenomenon became more pronounced at 3 months postoperatively (P < 0.05). However, no significant postoperative change in corneal curvature was noted for any quadrant of the 5-mm optical zone. There was a statistically significant correlation between the change in astigmatism and corneal curvature for the superior and inferior quadrants of the 3-mm optical zone (R = 0.394, P < 0.05; R = 0.460, P < 0.05; respectively). CONCLUSIONS: Astigmatism reduction was affected by corneal flatness in the inferior rather than the superior quadrant. Epiblepharon surgery results in reduction of corneal steepness at the vertical axis of the 3-mm optical zone, which correlates to astigmatism reduction.

Outcomes of two surgical techniques for major trichiasis treatment.

The purpose of this article is to analyze the outcomes of two surgical techniques to treat major trichiasis. A retrospective chart review of 67 patients (89 eyelids) with major trichiasis was performed who underwent surgical treatment using one of two techniques: intermarginal split lamella with graft (ISLG group) or lid lamella resection (LLR group). There were 30 lids in the ISLG group with mean patient age of 71.8 years and 63.3% were females. There were 59 lids in the LLR group with mean patient age of 72.5 years and 52.5% were female. The minimum postoperative follow up was six months. Statistical analysis included descriptive measures, Goodman association test for contrasts between and within multinomial populations and nonparametric Mann-Whitney test for comparison between groups. P < 0.05 was considered statistically significant. The underlying causes of trichiasis were blepharitis (37.07%), chronic meibomitis (21.3%), multiple causes (20.2%), ectropion (11.2%), actinic keratosis (6.7%), or prior ocular surgery (3.3%). Postoperatively, in the ISLG group, there were 20% lids with complete success, 50% underwent laser or electrolysis, 16.7% required further surgery, and 13.3% were unsuccessful. Postoperatively, in the LLR group, there were 47.5% eyelids with complete success, 46.7% underwent laser or electrolysis, 6.8% required further surgery, and 5.1% were unsuccessful. There was a higher statistical chance of complete success with LLR (P < 0.05). LLR is superior to ISLG surgery for the treatment of major trichiasis. There is a greater chance of success with LLR and it is technically simpler.

Leucemia linfocítica crónica con infiltración ocular / Chronic lymphocytic leukemia with eye infiltration

La incidencia de la leucemia linfocítica crónica (LLC) aumenta progresivamente con la edad; aproximadamente el 75 por ciento de los casos presentan 60 años o más. Este tipo de leucemia es más frecuente en varones y se desconoce su causa, existen casos que son de origen hereditario. Se presenta el caso de un paciente con el diagnóstico de LLC con infiltración ocular. Paciente blanco, masculino de 76 años de edad con antecedentes de salud de haber sido diagnosticado con LLC desde hace 5 años que se trata con Leukeran (Clorambucil) (2mg) 2 tabletas en el almuerzo y 3 tab en la comida, así como de prednisona (5mg) 1 cada 8 horas solo cuando está descompensado. Hace alrededor de 3 días comenzó con astenia, anorexia, mareos, dolor e inflamación del párpado superior derecho. El examen físico, la biopsia del párpado superior y el frotis de sangre revelaron la presencia de una recaída hematológica de la LLC con infiltración ocular(AU)

The incidence of chronic lymphocytic leukemia (CLL) increases progressively with age, approximately 75 percent of cases present 60 years or more. This type of leukemia is more frequent in men and its cause is unknown, there are cases that are of hereditary origin. A clinical case of a patient with the diagnosis of Chronic Lymphocytic Leukemia with ocular infiltration is presented. A 76-year-old white male patient with a health history of having been diagnosed with a Chronic Lymphocytic Leukemia for 5 years who is treated with Leukeran (Chlorambucil) ( 2mg) 2 tab at lunch and 3 at night; and prednisone (5mg) 1 tab every 8 hours. About 3 days ago begins with asthenia, anorexia, dizziness, pain and swelling of the upper right eyelid. Physical examination, upper eyelid biopsy and blood smears reveal the presence of a hematological relapse with ocular infiltration(AU)

Unilateral floppy eyelid syndrome with ipsilateral intolerance to brimonidine / Síndrome da palpebral flácida unilateral com intolerância a brimonidina ipsilateral

Abstract The authors report a case of unilateral floppy eyelid syndrome with ipsilateral intolerance to brimonidine in a 65-year-old man. The singularity of this case is the combination of two rare illnesses of great phlogistic potentiality in the same eye. The purpose of this article is to report a case of unilateral floppy eyelid syndrome with ipsilateral intolerance to brimonidine, emphasizing a possible relation between them. The result was a unilateral keratopathy that emulated an intraepithelial neoplasia. The key to solving the problem was an unexplained anterior uveitis that raised the suspicion of drug toxicity.The upper eyelid eversion of the affected eye during sleep seemed to be the common denominator of both ailments. The bizarre aspect of the epitheliopathy most likely resulted from the combination of trauma, insufficient lubrication, and drug intolerance.

Resumo Os autores relatam um caso de síndrome da pálpebra flácida unilateral com intolerância ipsilateral à brimonidina em um homem de 65 anos de idade. A singularidade deste caso é a combinação de duas doenças raras de grande potencialidade inflamatória no mesmo olho. O objetivo deste artigo é relatar um caso de síndrome da pálpebra flácida com intolerância ipsilateral à brimonidina, enfatizando uma possível relação entre eles. O resultado foi uma ceratopatia unilateral que simulou uma neoplasia intra-epitelial. A chave para resolver o problema foi uma uveíte anterior inexplicável que levantou a suspeita de toxicidade medicamentosa. A eversão da pálpebra superior do olho afetado durante o sono parece ser o denominador comum de ambas as doenças. O aspecto bizarro da epiteliopatia provavelmente resultou da combinação de trauma, lubrificação insuficiente e intolerância ao medicamento.

Effects of chalazia on corneal astigmatism : Large-sized chalazia in middle upper eyelids compress the cornea and induce the corneal astigmatism.

BACKGROUND: A chalazion is a common eyelid disease that causes eye morbidity due to inflammation and cosmetic disfigurement. Corneal topographic changes are important factors in corneal refractive surgery, intraocular lens power calculations for cataract surgery, and visual acuity assessments. However, the effects of chalazia on corneal astigmatism have not been thoroughly investigated. The changes in corneal astigmatism according to chalazion size and location is necessary for better outcome of ocular surgery. The aim of this study is to evaluate changes in corneal astigmatism according to chalazion size and location. METHODS: In this cross-sectional study, a total of 44 eyes from 33 patients were included in the chalazion group and 70 eyes from 46 patients comprised the control group. Chalazia were classified according to location and size. An autokeratorefractometer (KR8100, Topcon; Japan) and a Galilei™ dual-Scheimpflug analyzer (Ziemer Group; Port, Switzerland) were utilized to evaluate corneal changes. RESULT: Oblique astigmatism was greater in the chalazion group compared with the control group (p < 0.05). Astigmatism by simulated keratometry (simK), steep K by simK, total root mean square, second order aberration, oblique astigmatism, and vertical astigmatism were significantly greater in the upper eyelid group (p < 0.05). Astigmatism by simK, second order aberration, oblique astigmatism, and vertical astigmatism were significantly greater in the large-sized chalazion group (p < 0.05). Corneal wavefront aberration was the greatest in the upper eyelid chalazion group, whole area group, and large-sized chalazion group (p < 0.05). CONCLUSIONS: Large-sized chalazia in the whole upper eyelid should be treated in the early phase because they induced the greatest change in corneal topography. Chalazion should be treated before corneal topography is performed preoperatively and before the diagnosis of corneal diseases.

A Concomitant Case of Orbital Granuloma Faciale and Eosinophilic Angiocentric Fibrosis.

Granuloma faciale is an eosinophilic dermatosis that typically presents as red-brown facial plaques of middle-aged white men, while eosinophilic angiocentric fibrosis is a histologically similar fibrotic condition affecting the respiratory mucosa. Both are very uncommon conditions and pose a therapeutic challenge. While a handful of reports have reported concurrent presentation, the authors present the first case of eyelid granuloma faciale with eosinophlilic angiocentric fibrosis.