Effects of Orbicularis Oculi Flap Suspension on Transcutaneous Lower Blepharoplasty.

OBJECTIVE: The purpose of this study was to analyze the clinical effects of orbicularis oculi muscle suspension in conjunction with transcutaneous blepharoplasty in patients 60 years of age or older. METHODS: A retrospective study was conducted on patients aged 60 or older who underwent orbicularis oculi flap suspension in conjunction with transcutaneous blepharoplasty to treat lower lid festoons, lower lid fat prolapse, and lid laxity at Korea University Guro Hospital. The outcomes were surgical success rate, recurrence rate, postoperative complications, and patient satisfaction. RESULTS: In total, 39 patients (18 males and 21 females) were included, with an average age of 67.5 years (60-86 y) and a follow-up period of 145.7 days (95-195 d). In all patients, eyelid laxity was effectively corrected, and there was no recurrence of eyelid laxity after surgery. Three patients suffered postoperative complications, transient skin edema in 2 patients, and transient ectropion in 1 patient. Subjective satisfaction score following surgery was high, with an average score of 2.56 out of 3 points. CONCLUSIONS: Orbicularis oculi flap suspension with transcutaneous blepharoplasty can shorten operation time due to surgical ease. It also has the advantage of not involving conjunctival-related complications such as conjunctival edema since it does not pass through the conjunctiva. Finally, it can successfully treat lid laxity and could be used in lower blepharoplasty procedures.

An Experimental Design to Compare the Compatibility of Absorbable and Nonabsorbable Suture Materials in the Lateral Canthus Area.

Polyglactin 910 (Vicryl) and polypropylene (Prolene) are common suture materials used in ophthalmic surgical procedures. However, there are limited studies assessing tissue reactions to different sutures in eyelid areas. In this study, these suture materials were used subcutaneously in 10 lateral canthi of 5 pigs. Clinical reactive score (CRS) was assessed 14 days and 60 days after surgery. On histology, subcutaneous tissue reactions were assessed by the presence of different inflammatory cells, and the aggregate tissue irritation score was calculated. CRS and the histology score did not differ between these sutures. None of the suture materials used were superior for use in the lateral canthi of pig eyes. Therefore, we recommend both of these sutures for use in the subcutaneous tissue of the eyelid area in animal experiments or clinical practice.

Clinical Efficacy of Orbital Computed Tomographic Assessment in Determination of the Optimal Length of the Jones Tube in Endo CDCR.

PURPOSE: To investigate whether preoperative orbital computed tomography (CT) may be useful for predicting the optimal length of the Jones tube and determining the predictive parameters of orbital CT that are associated with the optimal length of Jones tubes in endoscopic conjunctivodacryocystorhinostomy (CDCR). METHODS: The medical records of 36 patients (42 eyes) who underwent endoscopic CDCR with Jones tube insertion and preoperative orbital CT from March 2018 to April 2022 were retrospectively evaluated. Analyzing the orbital CT films using the Picture Archiving and Communication System, the distance from the lacrimal fossa to the nasal septum was measured in coronal and axial views. RESULTS: In the successful group, the length of the inserted Jones tube was significantly correlated with the length difference between the inserted tube and the diagonal length measured in the axial view ( r=-0.485, P= 0.030). Equivalency of the length verified in the operating room and length measured on orbital CT were demonstrated as follows: diagonal length measured in axial view (Da), horizontal length between the medial eyeball to the nasal septum in coronal view (Hc) and the estimated length (Ej) in axial view with α = tan30° and α = tan25°. CONCLUSION: The optimal length of the Jones tube is best predicted using the length of the lacrimal fossa to nasal septum in coronal and axial views. Preoperative orbital CT assessments can be noninvasive and useful in predicting adequate lengths of the Jones tube.

Clinical Importance of the Lateral Tarsal Strip Procedure by a Single Experienced Oculoplastic Surgeon: 8 Years of Experience in a Tertiary Medical Center (Cross-Sectional Study).

Lateral tarsal strip (LTS) is a simple surgical technique that can correct eyelid malposition. Clinical indications vary from involutional entropion and ectropion, lower eyelid laxity, and lower eyelid retraction to punctal and paralytic ectropion. Lateral tarsal strip mainly treats eyelid malposition by correcting horizontal laxity. Herein, the authors report the clinical indications for and effects of LTS. The authors retrospectively reviewed medical records of patients who underwent LTS by a single oculoplastic surgeon with 8 years of experience performing the procedure at Korea University Guro Hospital. The authors included 247 patients with 325 treated eyelids. Involutional entropion was the most common indication, accounting for 69 patients (27.94%) and 88 eyelids (27.08%). The second most common indication was lower eyelid laxity [n=44 patients (17.81%) and 68 eyelids (20.92%)]. Simultaneous surgery in addition to LTS was performed in 167 patients (67.6%) and 219 eyelids (67.4%); the most common was endoscopic dacryocystorhinostomy (DCR), which was performed in 50 patients (29.94%) and 80 eyelids (36.53%). Lateral tarsal strip can be performed alone or simultaneously with oculoplastic procedures for various indications. Overcorrection with fixation above the canthal angle is useful to reduce recurrence. This study aims to explain the clinical importance of the LTS procedure.

Meibomian Gland Dysfunction in Primary Acquired Nasolacrimal Duct Obstruction.

This study was designed to investigate the influence of primary nasolacrimal duct obstruction (PANDO) on the structure and function of the Meibomian gland and to examine whether it is related to functional failure after dacryocystorhinostomy surgery. Medical records of patients diagnosed as PANDO from August 2021 to February 2022 were retrospectively studied. Results of slit lamp examination, lacrimal drainage test, tear break-up time, anterior segment optical coherence tomography, and meibography were collected. Tear meniscus height, tear break-up time, meiboscore, and lipid layer thickness of tear membrane were parameters compared between the eyes with complete PANDO and the control group. Medical records of 44 patients, therefore 88 eyes were collected, and there were 28 eyes with complete PANDO (total obstruction group), while normal eyes (control group) were 30. Mean tear meniscus height was significantly higher than that of the control group ( P value<0.001), but tear break-up time ( P value=0.322), lipid layer thickness ( P value=0.755), and meiboscore ( P value=0.268) were not significantly different. However, in the cases with moderate and severe meibomian gland destruction, the lipid layer thickness of the total obstruction group was significantly thinner than the control group. Lipid secretion of meibomian glands was less in eyes with PANDO than in eyes without PANDO, under moderate to severe meibomian gland destruction. It can lead to persistent epiphora after dacryocystorhinostomy due to a compensatory response against evaporative dry eye disease. Patients should be educated before the decision to undergo surgeries about the possibilities of persistent epiphora. Further studies are needed to prove the mechanism of meibomian gland function disturbance in PANDO.

Causes of Tearing in Patients With Chemotherapy: Meibomian Gland Dysfunction Versus Lacrimal Drainage Obstruction.

Numerous ocular toxicities that have been associated with the use of chemotherapeutic agents present as problems with the ocular surface, ocular adnexa, and lacrimal system, and many chemotherapeutic agents have tearing as a side effect. In this study, 34 eyes from 17 patients with a mean age of 62.4±14.8 years were analyzed. Chemotherapy was administered for a mean of 13.8±7.6 months. Chemotherapeutic agents of the following types were included: titanium silicate-1 (58.8%), Docetaxel (23.5%), Paclitaxel (11.8%), and 5-fluorouracil (5.9%). Tearing began 9.1 to 10.9 months after chemotherapy treatment. Within 3 months of beginning chemotherapy, tearing occurred in 9 patients (52.9%), and within 6 months, it occurred in 11 patients (64.7%). Mean tear break-up time was 5.4±2.6 sec. Ten eyes (29.4%) had normal fluorescein dye disappearance test findings (within grade 1), and the mean fluorescein dye disappearance test was 1.91±0.87. Among the 34 eyes, 24 (70.6%) had normal puncta and 9 (26.5%) and 1 (2.9%) had stenosis and blockage, respectively. Ten eyes (29.4%) showed total regurgitation, 19 eyes (55.9%) showed partial regurgitation, and 5 eyes (14.7%) showed no regurgitation upon syringing. Four eyes (11.8%) and 30 eyes (88.2%), respectively, showed soft and hard stops upon probing. Dacryoscintigraphy confirmed that 6 eyes (17.6%) were normal, 8 eyes (23.5%) showed post-sac delay or obstruction, and 20 eyes (58.8%) showed pre-sac delay or obstruction. The mean meiboscores for the upper and lower eyelids on LipiView were 2.15±0.86 and 2.53±0.79, respectively. The difference in meiboscores between the upper and lower eyelids was significant ( P=0.004 ). Obstruction of the lacrimal drainage system is a significant contributing factor to tearing in chemotherapy patients. However, reflex tearing because of meibomian gland dysfunction should also be fully considered to effectively manage the tearing because of the high incidence of accompanying meibomian glands loss when the lacrimal drainage system is obstructed.

Anterior Segment Optical Coherence Tomography for Canaliculitis.

Canaliculitis is an uncommon inflammation of the lacrimal canaliculi, and it is often misdiagnosed as conjunctivitis or dacryocystitis. There are no gold-standard methods to diagnose canaliculitis, therefore newer methods such as ulrasound biomicroscopy are being introduced. Anterior segment optical coherence tomography (OCT) is being utilized to evaluate punctum and canaliculus, but no previous study has applied anterior OCT for canaliculitis. One case of canaliculitis with canaliculith was diagnosed by anterior segment OCT noninvasively, by successful detection of canaliculith. Pouting of the punctum and detection of canaliculith as hyper-reflective signals by OCT were checked, which was impossible with other conventional methods. Surgical incision and drainage confirmed the presence of stones. This article is meaningful as a first study about the diagnosis of canaliculitis with canaliculith using anterior segment OCT. Presence of canaliculith in vertical canaliculus, and the status of punctal epithelium and canalicular mucosa was possible in this study.

Clinical Findings and Management of Punctal Apposition Syndrome: Rare Cause of Epiphora.

ABSTRACT: The purpose of this study is to evaluate the diagnosis and treatment of punctal apposition syndrome. We retrospectively reviewed the medical records of 2 patients diagnosed with punctal apposition syndrome who underwent lateral tarsal strip procedure. The patients included 1 male and 1 female, with an average age of 76.5 years. Before surgery, both patients had epiphora symptoms with a Munk score of 4 in both eyes. in the primary gaze, it was noted that the upper and lower puncta were appose with each other in both eyes throughout the blinking cycle. On slit lamp examination, there were no keratoconjunctival diseases, and the shape of the puncta were normal. On fluorescein dye disappearance test, grade 3 findings were observed in both eyes of both patients. in dacryos-cintigraphy of the 2 patients, both eyes showed complete obstruction, However, no obstruction of the lacrimal duct system was found in probing and syringing tests. The patient's subjective symptoms improved after patching test. A lateral tarsal strip procedure was performed as a treatment and we obtain satisfactory results. Therefore, punctal apposition syndrome could be 1 of the causes of epiphora.

Comparison of Blowout Fracture Sites Observed in Young and Elderly East Asians.

ABSTRACT: The purpose of this study was to investigate the distribution of blowout fracture sites among age groups and compare clinical factors that can affect the fracture site. The authors reviewed 330 cases of blowout fracture surgeries and included 226 eyes of 226 patients aged between 20 and 29 years and between 50 and 59 years who underwent blowout fracture reconstruction between January 2017 and December 2020, in the Department of Ophthalmology at Korea University Hospital.Medical records including patient demography, trauma etiology, and preoperative computed tomography image were evaluated. Ethmoidal cell septa and fracture site position were compared between the 2 age groups. The causes of injury were categorized into 3 groups: focal trauma, gross trauma, and other causes. Orbital floor fracture was the most common type (40.00%) in the young group, followed by medial wall fracture (25.33%). in contrast, medial wall fracture accounted for the largest proportion (42.11%) in the older group, and orbital floor fracture accounted for only 26.67%. The major cause of blowout fracture in young patients was focal trauma, whereas gross trauma was the most common cause in the older group. The number of ethmoidal cells was 4.19 ±â€Š0.831 (2-6) in the young group and 3.91 ±â€Š1.022 (2-6) in the old group (P  < 0.05). Distribution of blowout fracture site differed between age groups, and these differences can be explained by cause of injury and number of ethmoidal cells.

Analysis of Patients With Blowout Fracture Caused by Baseball Trauma.

ABSTRACT: The purpose of this study was to investigate the characteristics of blowout fractures caused by baseball trauma. The authors reviewed 337 cases of blowout fracture surgeries and included 330 eyes of 330 patients who underwent blowout fracture reconstruction between January 2017 and December 2020, in the Department of Ophthalmology at Korea university Hospital.Medical records including patient demography, trauma etiology, accompanied ocular disease, and preoperative computed tomography images were evaluated. Patients were categorized into 2 groups: a group with blowout fracture caused by baseball trauma and another group with trauma due to other causes. Two-wall blowout fracture (orbital floor fracture and medial wall fracture) was most common (63.16%) in the baseball group, followed by medial wall fracture (21.05%). In contrast, orbital floor fracture accounted for the largest proportion (42.11%) among other causes, and 2-wall blowout fracture accounted for the second largest proportion (31.83%). The most common accompanied ocular disease was traumatic hyphema and traumatic iridocyclitis (36.84%) in the baseball blowout fracture group. in contrast, subconjunctival hemorrhage was the most common ocular disease in the other-causes group (16.08%). The frequency of traumatic hyphema and irido-cyclitis was significantly different among the 2 groups (P  < 0.05). Distribution of blowout fracture sites and frequent ocular disease differed between baseball blowout fracture patients and other-cause blowout fracture patients.

Changes in Lower Eyelid Positions After Blepharoplasty and Levator Advancement Surgery.

PURPOSE: To investigate changes in the upper and lower eyelid positions using information from before and immediately after surgery in patients who underwent upper blepharoplasty and ptosis surgery. MATERIALS AND METHODS: We retrospectively reviewed the clinical records of patients who underwent upper blepharoplasty with a diagnosis of dermatochalasis and patients who underwent levator advancement or levator resection with a diagnosis of congenital or aponeurotic ptosis. The marginal reflex distance 1 (MRD1), marginal reflex distance 2 (MRD2), palpebral fissure height (PFH), and operation time were also investigated. RESULT: In the dermatochalasis group, the preoperative mean MRD1, MRD2, and PFH were 1.94±1.27, 4.71±0.95, and 6.65±1.65 mm, respectively. Mean MRD1, MRD2, and PFH values immediately after surgery were 1.80±0.79, 4.22±0.90, and 6.02±1.34 mm, respectively. In the ptosis group, the preoperative mean MRD1, MRD2, and PFH values were 0.27±1.34, 5.73±1.13, and 5.99±1.94 mm, respectively. Postoperative mean MRD1, MRD2, and PFH were 1.76±1.13, 4.22±1.01, and 5.98±1.60 mm, respectively. CONCLUSIONS: It is important to remember that MRD2 could decrease during surgery. Therefore, to prevent overcorrection after upper eyelid surgery, MRD1 (not the overall PFH) should be considered to determine the appropriate extent of surgery during the procedure.

Outcomes of Lateral Tarsal Strip in Conjunction with a Minimal Skin Muscle Excision Underlying Cauterization in Korean Patients with Involutional Entropion.

We reviewed the medical records of 53 involutional entropion patients, who underwent lateral tarsal strip (LTS) with a minimal skin muscle excision by cauterization from March 2014 to December 2017, to evaluate the effectiveness and efficiency of LTS in conjunction with a minimal skin muscle excision using cautery in patients with involutional entropion. We evaluated the success rate, complications, recurrence rate, and degree of satisfaction of our technique. Of 53 patients, there were 5 bilateral cases for a total of 58 eyelids. The average of age was 71.2 years old (57-90 years). The average follow-up period was 18 months (12-39 months). The success rate for involutional entropion correction was 98.1% with our technique. There was one mild recurrence case at 7 months. In our study, the average operation time was 20.8 min (15-29 min) for 48 unilateral cases and 27.2 min (20-32 min) for 5 bilateral cases without intraoperative complications. Of 42 responders of patients' satisfaction questionnaire, 38 patients showed good satisfaction and were willing to recommend the surgery to their acquaintances. The technique of LTS with minimal skin excision with cauterization was effective and provided satisfying outcomes to patients with involutional entropion.

Effects of Hyaluronic Acid/Collagen Resorbable Gel Use in Endoscopic Dacryocystorhinostomy.

The purpose of this study was to investigate whether the use of hyaluronic acid/collagen resorbable gel (Regenwel®) has an inhibitory effect on rhinostomy obstruction during endoscopic dacryocystorhinostomy (Endo DCR). A total of 298 patients diagnosed with unilateral primary acquired nasolacrimal duct obstruction from May 2017 to June 2021 who underwent Endo DCR were enrolled. The patients were divided into the Regenwel group (152 patients) and the Control group (146 patients) that did not use Regenwel during surgery, and the medical records were compared and analyzed retrospectively. The mean age of the Regenwel group was 65.8 years, and that of the Control group was 63.2 years. Regarding anatomical success as the primary outcome, the Regenwel group had a higher success rate than the Control group (96.7% vs 86.3%, P = .012), and the functional success result confirmed that the Regenwel group had a higher success rate than the Control group (94.1% vs 84.3%, P = .024). Among secondary outcomes, granulation formation occurred less frequently in the Regenwel group than in the Control group (9.2% vs 32.2%, P < .001), and there was no statistically significant difference in postoperative bleeding between the 2 groups (0% vs 1.4%, P = .478). The Regenwel group had fewer infections after surgery than the Control group (5.3% vs 8.9%, P = .012) and required less frequent revision surgery (2.0% vs 15.8%, P < .001). In conclusion, Regenwel is a resorbable gel containing hyaluronic acid and collagen that is used during Endo DCR and is thought to contribute to the improvement of surgical success rate by preventing complications such as rhinostomy obstruction and bleeding after surgery.

Orbital Metastasis From Gastric Cancer Presenting as Orbital Cellulitis With Ptosis.

ABSTRACT: We report a rare case of orbital metastasis that originated from gastric carcinoma, which presented as orbital cellulitis with ptosis. Orbital metastasis accounts for about only 1% to 13% of orbital tumors. Orbital metastasis in orbital soft tissue or bony structures is very uncommon.A female patient with advanced gastric cancer with multiple metastases was referred to our clinic. She showed mild swelling and ptosis in her left eye. Contrast enhanced computed tomography imaging suggested orbital metastasis from gastric cancer in the superolateral aspect of the orbit. Based on her general condition and after consulting with an oncologist, we determined that fine needle biopsy and excisional biopsy for pathological diagnosis should not be performed as a therapeutic treatment.It is important to distinguish orbital metastasis from orbital cellulitis with ptosis especially for patients with family or personal history of cancer. Clinicians should collect a through medical history from patients and suggest contrast enhanced computed tomography for appropriate diagnosis. Assessing quality of life and aggressive treatment options is crucial for determining the best treatment for orbital metastasis.

Orbital subperiosteal hematoma associated with frontal and ethmoidal sinusitis.

BACKGROUND: We report a rare case of orbital subperiosteal hematoma associated with frontal and ethmoidal sinusitis. Common concerns involving the orbital subperiosteal space include abscess, hematoma and tumor. CASE PRESENTATION: A patient presented to our clinic with periorbital swelling and limited extraocular muscle movement in her left eye. Computed tomography revealed a superior subperiosteal mass with frontal and ethmoidal sinusitis. We diagnosed the patient with subperiosteal hematoma and surgical evacuation was performed via superior orbitotomy. Brown serous discharge was drained and biopsy demonstrated fibrin clots. The final diagnosis was orbital subperiosteal hematoma and the patient was discharged with symptoms resolved. CONCLUSION: Orbital subperiosteal hematoma is difficult to distinguish from abscess owing to its rarity and similar presentation. Computed tomography is helpful in diagnosis, and surgical evacuation during the early stages is essential to achieving a good outcome.

Changes in Direction of Eyelashes After Epiblepharon Surgery Using the Hotz Procedure.

PURPOSE: To analyze the change of direction of eyelashes after epiblepharon surgery using the Hotz procedure and to propose the appropriate correction amount to reduce the risk of undercorrection or overcorrection. METHODS: Surgical correction using the Hotz procedure was performed in 60 patients who then were followed for 3 months in Korea University Anam Hospital. Clinical photographs were collected before and after the correction to measure the angle of the lower eyelashes. RESULT: The average angle before and after correction was 38.5° and -24.1°, respectively. The lower eyelashes gradually became introverted, and the amount of angle change was 9.3° at postoperative 1 month ( P < 0.001). These lashes become slightly extroverted to -15.0° at 3 months after the correction. CONCLUSIONS: Lower eyelashes become introverted to about 9 degrees after surgical correction. They become more introverted after operation when the epiblepharon is more severe and when they are more reconditioned to extroversion immediately after the operation.

Diagnostic clues of IOP pulsation on applanation tonometry in carotid-cavernous fistula patients.

BACKGROUND: Carotid-cavernous fistula (CCF) is an abnormal communication between the cavernous sinus and the carotid arterial system and exhibits typical symptoms of red eye, diplopia, blurred vision, headache, and murmur. However, the symptoms for CCF may vary and can lead to misdiagnosis. IOP pulsations provide a hint leading to suspicion of CCF. We report three cases related to CCF differential diagnosis: two cases of CCF patients and one case of conjunctivitis with corkscrew conjunctival vessels. CASE PRESENTATION: The case 1 patient, with a typical unilateral CCF, exhibited significant IOP pulsation in Goldmann tonometry measurements in the affected eye. The case 2 patient did not show typical symptoms of CCF except asymmetric upper eyelid swelling (right > left). In clinical evaluation, IOP elevation in the right eye and IOP pulsation in both eyes were noted. Based on radiology, the patient was diagnosed with bilateral CCF. The case 3 patient was referred to our institution for differential diagnosis of CCF. The patient had corkscrew conjunctival vessels in both eyes, which had appeared after he had been revived through CPR (cardiopulmonary resuscitation) 25 years prior. IOP pulsation was not observed in Goldmann tonometry. Radiology test result for arterio-venous fistula was negative in the case 3 patient. CONCLUSION: For diagnosis of CCF, IOP pulsation by Goldmann applanation tonometry exhibits a good correlation with the disease in our cases and provides useful diagnostic clues.

Blowout Fracture Assessment Based on Computed Tomography and Endoscopy: The Effectiveness of Endoscopy for Fracture Repair.

ABSTRACT: The purpose of this study was to compare the configuration of blowout fracture observed through orbital computed tomography (CT) and endoscopy, then present the effectiveness of using an endoscope in reconstruction surgery of blowout fracture. We retrospectively reviewed the clinical records of 337 patients who underwent reconstruction surgery of blowout fracture between January 2017 and December 2020 in the Department of Ophthalmology at Korea University Guro Hospital. The patients were categorized into 3 groups based on preoperative CT findings as follows: combined orbital medial and floor wall fractures, trapdoor fractures, and large blowout fractures. The images obtained through CT and endoscopy were compared among the 3 groups. Endoscopy helped identify herniated soft tissue and posterior fracture margins, and it also provides better magnification and a brighter view of the posterior aspects of the fracture site. Furthermore, endoscopy can also provide educational opportunities to visualize the fracture site and help trainees understand the surgical procedure approach or orbital anatomy. Based on our results, we suggest using an endoscope during blowout fracture surgery as an effective approach to reduce postoperative complications due to endoscopy's advantages in clear visualization of the fracture site during operation.

Intraoperative Significance of Lower Eyelid Positions in Levator Advancement to Prevent Overcorrection.

PURPOSE: The purpose of this study was to investigate changes in the position of the upper and lower eyelids before and immediately after surgery in patients that underwent ptosis surgery. METHODS: The authors retrospectively reviewed the clinical records of patients diagnosed with congenital or aponeurotic ptosis and that were treated with levator advancement with local anesthesia. The marginal reflex distance 1 (MRD1), marginal reflex distance 2 (MRD2), and palpebral fissure height (PFH) were measured using clinical photographs. RESULT: The preoperative mean MRD1, MRD2, and PFH were 0.27 ± 1.34 mm, 5.73 ± 1.13 mm, and 5.99 ± 1.94 mm, respectively. The postoperative mean MRD1, MRD2, and PFH were 1.76 ± 1.03 mm, 4.22 ± 1.01 mm, and 5.98 ± 1.60 mm, respectively. The postoperative MRD1 was significantly increased and postoperative MRD2 was decreased significantly compared to preoperative values (both, P < 0.001). The preoperative and postoperative PFH values were not significantly different ( P = 0.941). CONCLUSIONS: It is important to assess the degree of reverse ptosis before surgery in patients that undergo ptosis surgery, and to remember that MRD2 and PFH may be reduced during surgery. Therefore, the position of the upper eyelid should be intraoperatively adjusted based on MRD1, not the PFH, to prevent overcorrection after surgery.