Subciliary Rotating Sutures Combined With Modified Hotz Procedure for Correction of Congenital Lower Eyelid Entropion.

PURPOSE: Standard techniques for the treatment of congenital lower eyelid entropion may not yield suitable outcomes or may result in overcorrection if disinsertion of the lower eyelid retractors is not the primary cause. Herein, we propose and evaluate a technique using subciliary rotating sutures combined with a modified Hotz procedure for repair of lower eyelid congenital entropion that addresses these concerns. METHODS: A retrospective chart review was conducted of all patients who underwent lower eyelid congenital entropion repair by a single surgeon using subciliary rotating sutures combined with a modified Hotz procedure between 2016 and 2020. Study variables included patient demographics, follow-up period, postoperative complications, operative success, and recurrence. RESULTS: Twelve patients (19 eyelids) met the study inclusion criteria. The mean patient age was 7.1 ± 6.1 years (range, 0.2-22 years). Nine of the patients were female (75%) and 3 were male (25%). The distribution of eyelids was 8 right (42%) and 11 left (58%). The mean follow-up time was 19.5 ± 15 (range 2.5-45) months. There were two eyelids (11%) that had entropion recurrence after initial repair in patients with concomitant compound disease processes. Repeated repair resulted in success with no recurrence at last follow-up. Overall, the described entropion repair technique was successful and without recurrence in 17 eyelids (89%). There were no cases of ectropion, lid retraction, or other complications. CONCLUSIONS: Subciliary rotating sutures combined with a modified Hotz procedure are effective for correction of congenital lower eyelid entropion. As the technique does not manipulate the posterior layer of the lower eyelid retractors, it may be useful for when retractor reinsertion does not yield adequate improvement and may also reduce the risk of eyelid retraction and overcorrection in particular cases.

Inflammation and Fibrosis in Orbital Inflammatory Disease: A Histopathologic Analysis.

PURPOSE: The purpose of this study was to compare the histopathologic inflammation and fibrosis of orbital adipose tissue in orbital inflammatory disease (OID) specimens. METHODS: In this retrospective cohort study, inflammation, and fibrosis in orbital adipose tissue from patients with thyroid-associated orbitopathy (TAO), granulomatosis with polyangiitis (GPA), sarcoidosis, nonspecific orbital inflammation (NSOI), and healthy controls were scored by 2 masked ocular pathologists. Both categories were scored on a scale of 0 to 3 with scoring criteria based on the percentage of specimens containing inflammation or fibrosis, respectively. Tissue specimens were collected from oculoplastic surgeons at 8 international centers representing 4 countries. Seventy-four specimens were included: 25 with TAO, 6 with orbital GPA, 7 with orbital sarcoidosis, 24 with NSOI, and 12 healthy controls. RESULTS: The mean inflammation and fibrosis scores for healthy controls were 0.0 and 1.1, respectively. Orbital inflammatory disease groups' inflammation (I) and fibrosis (F) scores, formatted [I, F] with respective p -values when compared to controls, were: TAO [0.2, 1.4] ( p = 1, 1), GPA [1.9, 2.6] ( p = 0.003, 0.009), sarcoidosis [2.4, 1.9] ( p = 0.001, 0.023), and NSOI [1.3, 1.8] ( p ≤ 0.001, 0.018). Sarcoidosis had the highest mean inflammation score. The pairwise analysis demonstrated that sarcoidosis had a significantly higher mean inflammation score than NSOI ( p = 0.036) and TAO ( p < 0.0001), but no difference when compared to GPA. GPA had the highest mean fibrosis score, with pairwise analysis demonstrating a significantly higher mean fibrosis score than TAO ( p = 0.048). CONCLUSIONS: Mean inflammation and fibrosis scores in TAO orbital adipose tissue samples did not differ from healthy controls. In contrast, the more "intense" inflammatory diseases such as GPA, sarcoidosis, and NSOI did demonstrate higher histopathologic inflammation and fibrosis. This has implications in prognosis, therapeutic selection, and response monitoring in orbital inflammatory disease.

Orbital cellulitis and cavernous sinus thrombosis with contralateral sinus disease in a COVID-19 positive adolescent patient.

Patients with COVID-19 have been reported to have elevated coagulation factors, which is a well-documented cause of venous thromboembolism events such as deep vein thrombosis and pulmonary embolism. Other venous thrombotic events, however, such as cavernous sinus thrombosis (CST) have been less commonly observed, specifically in combination with primary orbital cellulitis. Due to its unique anatomic location, the cavernous sinus is susceptible to thrombophlebitis processes including septic thrombosis and thrombosis most commonly from sinusitis. Many studies have shown that in the antibiotic era thromboembolic events of the cavernous sinus are less common due to infection spread from the orbit or facial region. This case report describes a 17-year-old COVID-19 positive male who presented with a left-sided primary orbital cellulitis with CST without radiographic evidence of ipsilateral sinus disease.

Antibody Development in Patients Treated Long-Term With OnabotulinumtoxinA for Benign Essential Blepharospasm and Hemifacial Spasm.

BACKGROUND: Report the development of onabotulinumtoxinA neutralizing antibodies in patients treated consecutively for 20 years or longer for benign essential blepharospasm (BEB), hemifacial spasm (HFS), and Meige Syndrome. METHODS: Prospective, randomized, cross-sectional study of 12 randomly selected patients from a single clinical practice that have been treated consecutively for 20 or more years with onabotulinumtoxinA for BEB, HFS, or Meige Syndrome. Serum samples were collected from each subject and analyzed for neutralizing antibody formation using the Mouse Protection Assay. RESULTS: None of the tested patients (0%) displayed neutralizing antibodies to onabotulinumtoxinA. The mean duration of treatment was 27.5 years (range 22.1-34.1, SD 3.1, 95% confidence interval 25.45-29.50). Nine of the patients had a diagnosis of BEB, 2 HFS, and one Meige. Eleven of the 12 patients were women. There was no statistically significant difference in treatment dosage or interval over the course of treatment. CONCLUSIONS: The data support previous studies showing low incidence of antibody formation for botulinum A toxins with this subset of long-term treated patients. The results also provide further evidence for studies that have suggested increased onabotulinumtoxinA treatment volumes and/or decreased intervals between treatments are not due to neutralizing antibody formation and secondary non-response, but rather study designs that do not consider the titration phase of initial treatments. This study is specific to long-term treated patients, and the results cannot be generalized to patients naive to treatment.

Transitioning from a gold weight to an "enhanced" palpebral spring in the management of paralytic lagophthalmos secondary to facial nerve palsy.

PURPOSE: To analyze the outcomes of patients who transitioned from a weight to a spring. METHODS: Case series original investigation. Five consecutive patients undergoing "enhanced" palpebral spring insertion status post gold weight insertion were identified. Outcome measures included visual acuity, lagophthalmos, margin reflex distance 1, and corneal epithelial defects. Subjective outcomes included need for eye lubrication, closure and rapid blink, and symptoms of discomfort and dryness. This study was reviewed by an accredited Institutional Review Board (IRB) and granted exempt status according to federal regulations. RESULTS: Mean visual acuity post weight versus spring was 20/200 (logMAR 1.0, Std Dev. -0.6) and 20/25 (logMAR 0.1, Std Dev. -0.1), respectively (p = 0.0214, CI 0.231 to 1.670). Mean lagophthalmos post weight (3.5 mm, Std Dev. -2.8) versus post spring (0.2 mm, Std Dev. -0.5). Margin reflex distance 1 improved by a mean of 1.4 mm (gold wt -0.6, Std Dev. -0.5/spring -2.0, Std Dev. -0.4) (p = 0.0016, CI -1.773 to -0.977). Superficial punctate keratopathy was present in all patients with weights and present in no patients post transition (p = 0.0079). Post transition, three of five patients rarely required lubrication and experienced a more satisfactory blink rate. CONCLUSION: Patients with lagophthalmos due to cranial nerve seven palsy who have undergone gold weight placement but continue to exhibit objective and subjective corneal symptoms may have symptomatic improvement with the transition to a palpebral spring.

Quantification of the Aesthetically Desirable Female Midface Position.

BACKGROUND: The purpose of this study was to attempt to determine a reliable method of evaluating midface position. We assessed a novel parameter called WIZDOM (Width of the Interzygomatic Distance of the Midface) and its relationship to other facial metrics. OBJECTIVES: The goal was to evaluate midfacial position quantitatively in women by examining 2-dimensional photographs of a subset of women with idealized facial proportions. METHODS: Three examiners analyzed stock photographs of nonsmiling female model faces. Numerous parameters were analyzed for each photograph, including: interpupillary distance, medial canthus (MC) to lip, brow length, WIZDOM, WIZDOM to MC, WIZDOM to hairline, WIZDOM to chin vertical, and lateral brow to WIZDOM. Meaningful relationships between various parameters were statistically analyzed. Examiner measurements were assessed for interobserver reliability. RESULTS: Fifty-five female model photographs were included in the analysis. The average interpupillary distance was 59.2 mm ± 3.54 (range, 50.5-67.3 mm). The WIZDOM average was 108 mm ± 5.81 (range, 93-127 mm) and brow length was 107 mm ± 5.87 (range, 96.7-124 mm). The difference between brow length and WIZDOM was not statistically different (P = 0.834). The interobserver reliability between the 3 examiners was excellent for all parameters (P < 0.01), ranging from 0.718 (WIZDOM-MC) to 0.993 (interpupillary distance). The WIZDOM measurement was reproducible with an interobserver coefficient of 0.939. CONCLUSIONS: WIZDOM can be used to quantify aesthetically desirable midfacial position in patients and can be used as a measurement to aid in assessment and as an ideal to achieve balanced aesthetic results in midface restorative procedures-lifting or volumization-in females.

Piezosurgery in External Dacryocystorhinostomy.

BACKGROUND: Dacryocystorhinostomy (DCR) can be performed via an external or endoscopic approach. The use of ultrasonic or piezosurgery has been well described for endoscopic DCRs but is lacking for external DCRs. This study presents a case series of external DCRs performed using piezosurgery evaluating results and complications. METHODS: Prospective, consecutive case series of patients undergoing primary external DCR for lacrimal drainage insufficiency. A standard external DCR technique was used using 1 of 2 piezosurgery systems for all bone incision. All patients received silicone intubation to the lacrimal system. Surgical outcome was measured in terms of patient-reported epiphora as follows: 1) complete resolution, 2) improvement >50%, 3) improvement <50%, and 4) No improvement. Intra and postoperative complications were also recorded. RESULTS: Fifty-two patients, 14 male and 38 female, were included in the study, with 2 patients having bilateral surgery. The average age of the patients was 55.8 years. The average length of follow up was 221 days. Surgical outcomes showed 72% of patients with complete resolution of epiphora and 21% with >50% improvement. There were 4 patients (7%) who had <50% improvement. There was 1 (2%) intraoperative complication and 2 (4%) postoperative complications recorded. CONCLUSIONS: Piezourgery is a viable modality for performing external DCRs. The lack of surgical complications shows a potential for decreased soft tissues damage. The surgical success rate based on patient-reported epiphora is similar to those published for mechanical external DCRs. This modality may benefit the novice surgeon in the reduction of soft and mucosal tissue damage.

Canthal cutdown for emergent treatment of orbital compartment syndrome.

This article evaluates the use of a "canthal cutdown" technique in orbital compartment syndrome in a cadaveric model. Twelve cadaver orbits were used to simulate orbital compartment syndrome using a blood analog solution. Two pressure probes, in different orbital locations, were used to monitor orbital pressure. Pressure was monitored during successive procedures: canthotomy, cantholysis, and canthal cutdown. Orbits were then re-injected with solution, simulating an active orbital hemorrhage, and pressure measurements were recorded over a 10-minute duration. No statistically significant difference was found between the two orbital pressure monitoring devices at each measurement point (p = 0.99). Significant pressure reductions, for both probes, were observed after canthal cutdown compared to initial measurement after injection of 20 mL blood analog (p < 0.001 and p = 0.005). When comparing the orbital pressure following canthotomy and inferior cantholysis versus canthal cutdown, the cutdown procedure provided an additional 74% in orbital pressure reduction (p =0.01). After re-injection of 10 mL of solution and 10 minutes of egress, pressure returned to baseline (probe 1: baseline 7 mm Hg vs. post-cutdown at 10 minutes 7 mm Hg; p = 0.83; and probe 2: 5 mm Hg vs. 5 mm Hg; p = 0.83). The canthal cutdown technique provides further reduction in orbital pressure versus canthotomy and cantholysis alone. The technique may be effective for treatment of static orbital compartment syndrome and temporizing treatment of compartment syndrome from active orbital hemorrhages.

Nasolacrimal System Aeration on Computed Tomographic Imaging: Sex and Age Variation.

PURPOSE: To investigate variation in aeration of the nasolacrimal drainage system between age groups and genders, and to report the reliability of repeated aeration grading and nasolacrimal canal measurements on CT. METHODS: Retrospective review of CT images from 92 individuals, 60 female and 32 male, was conducted by 3 independent reviewers for the presence of air within the nasolacrimal drainage system. Diameter and area measurements were also obtained at the smallest identifiable portion of the nasolacrimal canal by 2 independent reviewers. RESULTS: When air is present on CT, it is seen more fully throughout the nasolacrimal system in men as compared to women. Age data demonstrate that patients from the third and fourth decade have significantly more aeration than older patients. Diameter and area of the nasolacrimal duct within the canal at its narrowest point revealed no correlation with sex, age, or nasolacrimal system aeration. Inter-reviewer reliability shows strong repeatability of aeration grading and nasolacrimal duct measurements between multiple reviewers. CONCLUSIONS: The results suggest CT is reliable and repeatable modality to assess nasolacrimal system aeration and nasolacrimal duct diameter. Decreased aeration of the nasolacrimal system in females and the elderly mirrors epidemiologic trends for those at risk to develop primary acquired nasolacrimal duct obstruction. Variables in nasolacrimal drainage system anatomy, specifically nasolacrimal duct diameter and area, did not vary between sexes or age groups, suggesting aeration may be an overlooked variable in nasolacrimal system function.

Orbital pseudotumor can be a localized form of granulomatosis with polyangiitis as revealed by gene expression profiling.

Biopsies and ANCA testing for limited forms of granulomatosis with polyangiitis (GPA) are frequently non-diagnostic. We characterized gene expression in GPA and other causes of orbital inflammation. We tested the hypothesis that a sub-set of patients with non-specific orbital inflammation (NSOI, also known as pseudotumor) mimics a limited form of GPA. Formalin-fixed, paraffin-embedded orbital biopsies were obtained from controls (n=20) and patients with GPA (n=6), NSOI (n=25), sarcoidosis (n=7), or thyroid eye disease (TED) (n=20) and were divided into discovery and validation sets. Transcripts in the tissues were quantified using Affymetrix U133 Plus 2.0 microarrays. Distinct gene expression profiles for controls and subjects with GPA, TED, or sarcoidosis were evident by principal coordinate analyses. Compared with healthy controls, 285 probe sets had elevated signals in subjects with GPA and 1472 were decreased (>1.5-fold difference, false discovery rate adjusted p<0.05). The immunoglobulin family of genes had the most dramatic increase in expression. Although gene expression in GPA could be readily distinguished from gene expression in TED, sarcoidosis, or controls, a comparison of gene expression in GPA versus NSOI found no statistically significant differences. Thus, forms of orbital inflammation can be distinguished based on gene expression. NSOI/pseudotumor is heterogeneous but often may be an unrecognized, localized form of GPA.

Caruncular fixation in medial canthal tendon repair: the minimally invasive purse string suture for tendinous laxity and medial ectropion.

PURPOSE: To describe a surgical technique for repair of medial ectropion that simply and reliably addresses tendinous laxity and punctal eversion. METHODS: Prospective, single-blind, consecutive case study of 54 patients (79 eyes) by 3 surgeons. The subject population consisted of 33 males and 21 females, with a mean age of 81 years (SD = 9, range = 64-97). The presenting mechanisms of ectropion were as follows: cicatricial (n = 10), paralytic (n = 1), involutional (n = 62), mechanical (n = 3), and congenital (n = 3). Ectropion and punctal eversion was surgically addressed by use of a purse string suture that incorporated closure of a medial spindle incision and deep fixation to the base of the caruncle. RESULTS: The average postoperative follow-up period was 147 days (SD = 291, range 8-2,352). Sixty-four eyes had a presenting complaint of tearing (81%), with 50 eyes (78%) achieving complete resolution (p = 0.0001). Eyelid malposition was determined to be anatomically corrected in 34 of 35 eyes (97%, p = 0.0001). Four of the 79 operated eyelids had recurrence of ectropion (5%). All other reported complications were minor, resolved without sequalae. CONCLUSION: The technique demonstrated safety, efficacy, and reproducibility, regardless of ectropion mechanism. Incorporation of a purse string suture between the lower eyelid portion of the medial canthal tendon and the caruncle produces a reliable posterior-superior fixation parallel to the vectors of the posterior limb of the medial canthal tendon. This technique is equally effective as a primary correction method or when used in combination with other procedures.

Risk of ocular blood splatter during oculofacial plastic surgery.

PURPOSE: To assess intraoperative blood splatter to the ocular surface and adnexa during oculofacial surgery. METHODS: Four surgeons and multiple assistants at three separate locations wore a total of 331 protective eye shields during 131 surgeries. Postoperatively, a luminol blood detection system was used to identify blood splatter on the shields. In the event of positive blood splatter, the total number of blood spots was counted. Controls were used to verify the blood detection protocol. A postoperative questionnaire was given to all surgeons and assistants after each case, and they were asked whether intraoperative blood splatter was noticed. RESULTS: Blood was detected on 61% of eye shields and in a total of 80% of surgical cases. However, only 2% of blood splatters were recognized intraoperatively by the surgical participants. There was no significant difference in the splatter rate between surgeons (64%), assistants (60%), and surgical technicians (58%) (p = 0.69). Shields worn during full-thickness eyelid procedures, direct brow lifting, orbitotomy with bony window, and orbital fracture repairs were more likely to be splattered (p = 0.03), and there was a significant difference between splatter rates among different surgeons (range, 29-90%; p = 0.0004), suggesting that blood splatter rate may be both procedure dependent and surgeon dependent. CONCLUSIONS: Mucocutaneous and transconjunctival transmission of human immunodeficiency virus and viral hepatitis has been documented. These results suggest that oculofacial plastic surgeons should consider eye protection for patients with known blood-borne diseases and in cases where blood splatter is expected. This precautionary practice is supported by the high incidence (98%) of undetected, intraoperative blood splatter.

Evolving Minimally Invasive Techniques for Tear Trough Enhancement.

PURPOSE: The aim of this study is to investigate whether volumetric enhancement of the infraorbital rim area or, alternatively, of the deep medial cheek, results in greater improvement of tear trough deformity. METHODS: This prospective, single-blind study recruited 12 patients seeking correction of tear trough deformity. Pretreatment standardized photographs were obtained after which patients were randomized to receive hyaluronic acid gel filler augmentation of the tear trough on one side and hyaluronic acid gel augmentation of the cheek on the contralateral side. The patients were then re-examined at 3 weeks postinjection when standardized photographs were taken again. Following the photographs, filler was added to the side and location where they were not used at the original treatment, resulting in added volume in both the cheek and the tear trough. The patients returned 3 weeks later when final photographs were taken. The pre- and post-treatment images were randomized and evaluated by 3 masked observers asked to evaluate the depth of tear trough. RESULTS: There was a significant improvement in the depth of the tear trough rating after initial treatment on the side treated in the tear trough (p = 0.0001). There was not a significant change in depth of tear trough rating, however, on the side receiving cheek only treatment (p = 0.0963). There was a statistically significant change in tear trough rating after both tear trough and cheek had been treated on each side (p = 0.001). There was no statistically significant difference between sides after lid and cheek treatment had been completed on each side (p = 0.5986). Intraclass correlation between reviewers for all subjects was excellent at 0.94. Tear trough injections were more technique sensitive than cheek volume augmentation to achieve satisfactory results. There were no complications from cheek volume enhancement. Varying degrees of ecchymosis were encountered with tear trough injections. CONCLUSIONS: When the patient's primary concern is the appearance of the tear trough, and the physician is limited to treating either the tear trough or the cheek alone, it appears that treatment in the tear trough offers greater improvement in the appearance of the tear trough deformity when compared with treatment in the cheek alone.

Vibration anesthesia for the reduction of pain with facial dermal filler injections.

BACKGROUND: Vibration anesthesia is an effective pain-reduction technique for facial cosmetic injections. The analgesic effect of this method was tested in this study during facial dermal filler injections. The study aimed to evaluate the safety and efficacy of vibration anesthesia for these facial injections. METHODS: This prospective study analyzed 41 patients who received dermal filler injections to the nasolabial folds, tear troughs, cheeks, and other facial sites. The injections were administered in a randomly assigned split-face design. One side of the patient's face received vibration together with dermal filler injections, whereas the other side received dermal filler injections alone. The patients completed a posttreatment questionnaire pertaining to injection pain, adverse effects, and preference for vibration with future dermal filler injections. RESULTS: The patients experienced both clinically and statistically significant pain reduction when a vibration stimulus was co-administered with the dermal filler injections. No adverse events were reported. The majority of the patients (95 %) reported a preference for vibration anesthesia with subsequent dermal filler injections. CONCLUSIONS: Vibration is a safe and effective method of achieving anesthesia during facial dermal filler injections. LEVEL OF EVIDENCE IV: This journal requires that 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 .

The Role of Gravity in Periorbital and Midfacial Aging.

BACKGROUND: With respect to the pathogenesis of periorbital and midfacial aging, gravity may play a greater role than volume loss. OBJECTIVES: The authors determined the effect of shifting from the upright to the supine position on specific attributes of facial appearance and ascertained whether facial appearance in the supine position bore any resemblance to its appearance in youth. METHODS: Participants who showed signs of midface aging were positioned in the upright and supine positions, and photographs were obtained during smiling and repose. For each photograph, examiners graded the following anatomic parameters, using a standardized scale: brow position, tear trough length and depth, steatoblepharon, cheek volume, malar bags/festoons, and nasolabial folds. Some participants provided photographs of themselves taken 10 to 15 years earlier; these were compared with the study images. RESULTS: Interobserver correlation was strong. When participants were transferred from upright to supine, all anatomic parameters examined became more youthful in appearance; findings were statistically significant. The grading of anatomic parameters of the earlier photographs most closely matched that of current supine photographs of the subjects smiling. CONCLUSIONS: In the supine position, as opposed to the upright position, participants with signs of midface aging appear to have much more volume in the periorbita and midface. For the subset of participants who provided photographs obtained 10 to 15 years earlier, the appearance of facial volume was similar between those images and the current supine photographs. This suggests that volume displacement due to gravitational forces plays an integral role in the morphogenesis of midface aging.

Hydrogel explant extrusion masquerading as a malignant eyelid lesion.

Hydrogel was a commonly used material for scleral buckling in the early 1980s to the mid-1990s. Use of hydrogel ceased due to a high complication rate, including frequent migration. Various symptoms and clinical findings have been reported with hydrogel migration. There have been no published reports of hydrogel migration to the eyelid anterior to the orbital septum with erosion of the orbicularis and bleeding as a presenting symptom. The authors describe a patient with hydrogel migration to the upper eyelid, with symptomology and clinical findings consistent with a malignant eyelid lesion. Excisional biopsy of extraorbital hydrogel is recommended in these cases.

Rate of vascularization and exposure of silicone-capped porous polyethylene spherical implants: an animal model.

PURPOSE: This pilot study examines the rates of exposure and fibrovascular ingrowth of silicone-capped, porous, polyethylene orbital implants in the New Zealand white rabbit animal model. METHODS: Unwrapped, silicone-capped, porous, polyethylene orbital spheres were implanted in 16 enucleated rabbit orbits. Four implants were removed at 3, 6, 9, and 12-month intervals and submitted for histopathologic analysis. A board-certified pathologist reviewed and graded vascular ingrowth, inflammation type, and severity for all specimens. RESULTS: Fibrovascular ingrowth in the center of all implants occurred as early as 3 months. No fibrovascular ingrowth occurred at the interface between the silicone cap and the porous polyethylene implant. The overlying Tenon's and conjunctival tissues remained intact without significant host inflammatory response. No implant exposure occurred at any time point. CONCLUSIONS: Silicone-capped porous polyethylene orbital implants appear to offer an inexpensive, easy-to-manufacture implant that resists exposure without the need for a wrapping material and achieves successful biointegration soon after implantation.

Isolated, complete paralytic mydriasis secondary to herpes zoster ophthalmicus.

Herpes zoster ophthalmicus is a manifestation of herpes zoster when the ophthalmic division of the trigeminal nerve becomes involved. Ocular symptoms are varied and mainly due to inflammatory mechanisms. Total, external and/or internal ophthalmoplegias, as well as isolated third, fourth and sixth cranial nerve palsies have all been reported as complications. In a minority of cases, concurrent pupillary paralysis has been documented. The presentation of complete paralytic mydriasis as the sole cranial nerve complication following herpes zoster ophthalmicus infection is a rare finding. The postulated pathophysiologic aetiology is a partial third nerve palsy with the pupillary fibres for light and accommodation-convergence affected and motor fibres spared. The mechanism responsible for the postulated lesion is speculative.

Double-blind, bilateral pain comparison with simultaneous injection of 2% lidocaine versus buffered 2% lidocaine for periocular anesthesia.

PURPOSE: Determine if raising the pH of 2% lidocaine with epinephrine 1:100 000 to a physiologic level decreases pain perception during periocular, subcutaneous anesthesia. DESIGN: Double-blind, prospective, randomized study. Simultaneous unilateral injections of buffered and unbuffered lidocaine solutions were given before surgery to patients having bilateral, periocular surgery. PARTICIPANTS: Fifty-four consecutive patients (27 male and 27 female; mean age, 68 years; standard deviation, 11 years). INTERVENTION: Patients were given simultaneous injections of buffered and unbuffered 2% lidocaine with epinephrine 1:100 000. The needles were inserted simultaneously and the anesthesia was injected for a 20-second count for a total volume of 1.0 ml per injected side. MAIN OUTCOME MEASURES: After the simultaneous injections, the patients were asked to rate the pain on each side on a Likert-type visual analog scale of 0 to 10. RESULTS: Sixty-five percent of patients preferred the buffered lidocaine with a scaled pain reduction of 0.9 (P = 0.0005). Additionally, for the patients who believed that the buffered solution was less painful, the mean decrease in scaled pain rating was 2, for a 51% reduction in pain level (P = 0.001). No gender differences were noted. CONCLUSIONS: Buffering 2% lidocaine with epinephrine 1:100 000 with sodium bicarbonate 8.4% offers a clinically and statistically significant reduction in pain experienced by two-thirds of patients receiving periocular subcutaneous anesthesia.