Transnasal or transglabellar semicircular flap for medial canthal reconstruction.

PURPOSE: To review the results of medial canthal reconstruction with the medial (transnasal or transglabellar) semicircular flap. METHODS: Medical charts of 38 patients who underwent the described procedure were reviewed. After tumor excision, a semicircular flap created along the nasal bridge or glabella was advanced to the canthal defect; if necessary, this flap was combined with other reconstructive methods. RESULTS: The patients (19 male, 19 female; mean age, 66 years) had basal cell (n = 36) or squamous cell (n = 2) carcinomas. The mean tumor diameter was 9.2 mm (range, 3-21 mm). Tumor epicenters were in the midcanthal area in 21 patients (55%) and in the infra- or supracanthal areas in 17 patients (45%). After excision, 22 patients had only canthal defects, and 16 had an associated upper and/or lower eyelid defect. To cover the defect, the medial semicircular flap alone was used in 19 patients (50%) and in association with other flaps in 19 patients (50%). The excisional defect was primarily closed in 37 patients (97%). Flap necrosis or infection did not occur. During follow-up (range, 1-91 months; median, 19 months), 10 patients (26%) developed a total of 17 complications. Three patients (8%) required secondary surgery for eyelid reconstruction-related complications. CONCLUSIONS: Transnasal or transglabellar semicircular flap may be a good alternative for medial canthal reconstruction. For large or complex defects, the medial semicircular flap can be combined with other periocular flaps. In the latter case, postoperative complications requiring secondary surgery may develop.

Association of Involutional Lower Eyelid Entropion with Reduced Upper Eyelid Position Relative to the Corneal Light Reflex: Quantification of Facial Asymmetry.

PURPOSE: To investigate the association between upper eyelid position relative to the corneal light reflex (MRD1) and to delineate an association between eyelid height and involutional lower eyelid entropion. METHODS: Retrospective study of patients presenting for entropion repair to an academic ophthalmic plastic surgery service. A total of 111 patients were included in the study; 95 had unilateral involutional lower eyelid entropion, and 16 had bilateral lower eyelid entropion. Patients with a history of previous eyelid surgery, trauma, upper eyelid entropion, or cicatricial changes were excluded from the study. RESULTS: Of the 95 patients with unilateral involutional lower eyelid entropion, 45 (47.4%) had a lesser MRD1 on the side ipsilateral to the involutional lower eyelid entropion. In this unilateral group, the mean MRD1 (± standard deviation) on the ipsilateral to the involutional lower eyelid entropion was 2.9 (±1.2) mm, while the mean MRD1 on the contralateral side was 3.3 (±1.0) mm. This difference was 0.4 mm and was statistically significant (p < 0.0001). Most patients with unilateral involutional entropion demonstrated a right-sided involutional lower eyelid entropion (56 of 95; 58.9%), although this finding was not statistically significant (p = 0.083). The frequency of true blepharoptosis (MRD1 ≤ 2.0 mm) was 24 of 95 (25.3%) in the unilateral involutional entropion group and was even higher in the bilateral involutional lower eyelid entropion group, with 7 of 16 (43.8%) patients exhibiting bilateral blepharoptosis. CONCLUSIONS: Patients presenting with involutional lower eyelid entropion tend to have a relatively reduced MRD1 on the ipsilateral (affected) side. When both lower eyelids are affected by involutional entropion, the reduced MRD1 tends to be more pronounced.

Facial Asymmetry: Brow and Ear Position.

The purpose of the current study was to analyze brow and ear position, and examine the relationship between these structures in patients presenting for blepharoplasty evaluation. A retrospective chart review was performed, which included all patients presenting to one oculoplastic physician for a blepharoplasty evaluation from November, 2012 to March, 2014. The prevalence of brow ptosis and brow and ear asymmetry was calculated; the proportional distribution was determined, and chi-square analysis and the z-test of proportions were used to calculate the significance. Institutional Review Board approval was obtained for this study. A total of 133 patients met the inclusion criteria. Some degree of brow ptosis was noted in 83% of patients. Brow asymmetry was found in 88% of patients, and ear asymmetry in 77%. Of those patients who had asymmetry, 61% had the right brow lower and 75% had the right ear lower; 73% of all patients had the brow and ear lower on the same side (p < 0.001). In this study, brow ptosis and asymmetry were quite common. In addition, the side of the lower brow correlated strongly with the side of the lower ear, and the right side structures were lower more often than the left. Patients presenting for blepharoplasty evaluation may have an element of generalized facial asymmetry which includes the brows and ears. These observations can be important for preoperative planning and patient counseling.

Proliferative Fasciitis of the Orbit.

Proliferative fasciitis is a rare entity in the orbit. A 16-year-old boy presented with a growing right orbital mass, which was palpable just inferior to the medial right eyebrow. MRI demonstrated a 12 × 8 × 9 mm mass located medial to and slightly above the right globe within the subcutaneous soft tissues. An anterior orbitotomy with debulking of the lesion was performed. Histopathological examination confirmed a diagnosis of proliferative fasciitis. To the authors' knowledge, there is only one prior case in the literature demonstrating proliferative fasciitis of the orbit.

Extreme Eyelid Lymphedema Associated With Rosacea (Morbihan Disease): Case Series, Literature Review, and Therapeutic Considerations.

PURPOSE: To describe severe lymphedema of the eyelids, known as Morbihan disease, a previously characterized but infrequently reported and poorly understood entity related to rosacea that features solid mid-facial and eyelid lymphedema. METHODS: Retrospective chart review, histopathologic and immunohistochemical analysis, and pertinent literature consideration. RESULTS: Five cases of Morbihan disease were identified. Histopathologic examination revealed pleomorphic perivascular and perilymphatic inflammation with profound lymphangiectasis and lymph stasis, thus suggesting elements of both rosacea and localized, chronic lymphedema. Multiple therapeutic interventions were performed including systemic anti-inflammatory therapy, surgical debulking, and corticosteroid injection. CONCLUSIONS: Extreme eyelid edema associated with characteristic skin changes and histopathologic findings represents an entity known as Morbihan disease which is rare and difficult to treat. While multiple modalities have been employed with variable results, future therapeutic considerations may include the use of targeted biologic agents.

Safety and Efficacy of Lacrimal Drainage System Plugs for Dry Eye Syndrome: A Report by the American Academy of Ophthalmology.

OBJECTIVE: To review the published literature assessing the efficacy and safety of lacrimal drainage system plug insertion for dry eye in adults. METHODS: Literature searches of the PubMed and Cochrane Library databases were last conducted on March 9, 2015, without date restrictions and were limited to English language abstracts. The searches retrieved 309 unique citations. The primary authors reviewed the titles and abstracts. Inclusion criteria specified reports that provided original data on plugs for the treatment of dry eyes in at least 25 patients. Fifty-three studies of potential relevance were assigned to full-text review. The 27 studies that met the inclusion criteria underwent data abstraction by the panels. Abstracted data included study characteristics, patient characteristics, plug type, insertion technique, treatment response, and safety information. All studies were observational and rated by a methodologist as level II or III evidence. RESULTS: The plugs included punctal, intracanalicular, and dissolving types. Fifteen studies reported metrics of improvement in dry eye symptoms, ocular-surface status, artificial tear use, contact lens comfort, and tear break-up time. Twenty-five studies included safety data. Plug placement resulted in ≥50% improvement of symptoms, improvement in ocular-surface health, reduction in artificial tear use, and improved contact lens comfort in patients with dry eye. Serious complications from plugs were infrequent. Plug loss was the most commonly reported problem with punctal plugs, occurring on average in 40% of patients. Overall, among all plug types, approximately 9% of patients experienced epiphora and 10% required removal because of irritation from the plugs. Canaliculitis was the most commonly reported problem for intracanalicular plugs and occurred in approximately 8% of patients. Other complications were reported in less than 4% of patients on average and included tearing, discomfort, pyogenic granuloma, and dacryocystitis. CONCLUSIONS: On the basis of level II and III evidence in these studies, plugs improve the signs and symptoms of moderate dry eye that are not improved with topical lubrication, and they are well tolerated. There are no level I studies that describe the efficacy or safety of lacrimal drainage system plugs.

Vertical canaliculotomy with retrograde expression of concretions for the treatment of canaliculitis.

PURPOSE: To evaluate the efficacy and safety of the technique of vertical canaliculotomy with retrograde expression of concretions for the treatment of canaliculitis. METHODS: This is a retrospective, interventional case series. Patients who underwent vertical canaliculotomy by 1 surgeon (D.R.M.) from August 2011 to December 2013 were identified. On initial diagnosis of canaliculitis, all patients were treated with a combination antibiotic/steroid eyedrop and an oral antibiotic. The procedure was performed 1 month later and consisted of a 2-mm vertical canaliculotomy with sharp-tipped scissors followed by retrograde expression of the canalicular contents by compressing the canaliculus medial to lateral with 2 cotton-tipped applicators. All concretion specimens were sent for pathologic examination. Pre- and postoperative subjective complaints and objective findings on examination, including eyelid thickening and probing/irrigation results, were recorded. RESULTS: Canalicular contents were readily expressed from all 8 patients who underwent the procedure. Pathologic analysis revealed Actinomyces species in 5 of 8 specimens and other Gram-negative and Gram-positive bacteria in the remaining specimens. All patients reported significant improvement in their symptoms and were patent to irrigation. CONCLUSIONS: Many reported surgical procedures for the treatment of canaliculitis involve the use of a curette, an instrument with sharp edges, that could potentially damage the lining of the canaliculus. Previous studies examining these procedures have reported canalicular stricture and dysfunction postoperatively. The current technique of vertical canaliculotomy with retrograde expression of canalicular contents described herein has been effective, limits iatrogenic trauma, and had a low incidence of postoperative complications in this series.

Treatment of severe thyroid eye disease: a survey of the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS).

PURPOSE: To evaluate the current practice patterns for the treatment of severe thyroid eye disease (TED) in the United States by conducting a survey of the American Society of Ophthalmic Plastic and Reconstructive Surgery. METHODS: This is a questionnaire study. The survey encompassed the use of different modalities, including intravenous steroids, oral steroids, orbital decompression, orbital radiation, intraorbital steroid injections, and steroid-sparing biologic agents, in the treatment of severe TED. Specifics on the dosing regimens of steroids and types of decompression used were queried. RESULTS: With regard to treatments used "at all" in the management of severe TED, 87% use oral steroids and 74% use intravenous steroids. Eighty-three percent use orbital decompression, 70% use radiation, 33% use biologic agents, and 28% use intraorbital steroid injections. Oral steroids were slightly preferred to intravenous steroids at 43% versus 40% for first-line treatment. Most responders (61%) chose 2-wall decompression as their preferred technique. CONCLUSIONS: Severe TED can be a devastating disease leading to diplopia and vision loss. Treatment recommendations have varied and continue to evolve. The survey reported herein found that oral steroids were slightly preferred over intravenous steroids by the members of the American Society of Ophthalmic Plastic and Reconstructive Surgery, most of who practice in the United States. This is in contrast to survey results from European and Latin American physicians, which more strongly favored intravenous steroids. In addition, orbital decompression and orbital radiation still play significant roles in the management of severe TED.

Angiolipoma of the Orbit: A Rare Tumor in an Unusual Location.

Despite their relatively frequent occurrence on the trunk and extremities, lipomas rarely present in the orbit. Rarer still are variants of lipoma such as fibrolipoma, myxoid lipoma, and angiolipoma. The authors report a 66-year-old woman who presented with a large, slowly growing tumor of the forehead and orbit. The case presentation conforms to the tenets of the Declaration of Helsinki and is HIPAA compliant. Clinical and radiographic evidence suggested a lipomatous type of tumor, and excisional biopsy revealed adipose proliferation with numerous small vessels and fibrin thrombi consistent with angiolipoma. The tumor was completely excised without ophthalmic sequelae or recurrence in 6 months of follow up. To the authors' knowledge, this tumor represents only the second reported case of this type of highly vascularized lipomatous lesion within the orbit. This case is a novel entity in the differential diagnosis of orbital tumors and demonstrates the value of total excision in such cases.

Favre-Racouchot Disease of the Periocular Region.

This study details the case of periocular Favre-Racouchot disease an often underdiagnosed entity with a complex differential diagnosis. This is an unusual condition that can potentially affect the periocular region; however, there is little information regarding Favre-Racouchot disease reported in the peer-reviewed ophthalmology literature. Increased awareness of Favre-Racouchot disease among ophthalmologists, oculofacial surgeons, and other specialists can lead to proper diagnosis impacting treatment options and patient outcome.

Proximal tarsal attachments of the levator aponeurosis: implications for blepharoptosis repair.

PURPOSE: To examine the tarsal attachments of the levator aponeurosis. DESIGN: Experimental anatomic study. PARTICIPANTS: Sixteen orbits from 12 fresh frozen white cadavers. METHODS: Eight specimens served as controls. In the remaining 8 specimens from 4 cadavers, the upper eyelid was everted. All specimens then were fixed in formalin. The age, sex, and laterality were recorded in both groups. The eyelid lamellae and tarsal attachments of the levator aponeurosis in particular were examined microscopically. Lamellar and nonlamellar ocular anatomic features and the relationships of the preaponeurotic and postaponeurotic spaces were measured. MAIN OUTCOME MEASURES: Histologic findings of the extent and pattern of the tarsal attachments of the levator aponeurosis in relation to the tarsus and Müller's muscle and of the changes in the lamellae in eyelid eversion. RESULTS: The demographic and baseline anatomic characteristics of both the noneverted control and everted eyelid groups were similar. In comparing everted with noneverted controls, the preaponeurotic space was significantly shorter (6.22 and 10.61 mm, respectively; P = 0.003) and the preaponeurotic-to-postaponeurotic space ratio was halved (0.57 and 1.16, respectively; P = 0.005). Although the distance from the superior tarsal border to Whitnall's ligament increased significantly in everted versus noneverted eyes (14.65 and 11. 03 mm, respectively; P = 0.016), there was no significant difference in the length of postaponeurotic space in the 2 groups (11.07 and 9.69 mm, respectively; P = 0.370). The levator aponeurosis attached to the anterior tarsus in both groups. The proximal point of attachment was the superior border of the tarsal plate, adjacent to the insertion of Müller's muscle tendon. CONCLUSIONS: The deeper aponeurotic fibers and Müller's muscle attach proximally at the superior tarsal border. Upon eyelid eversion, the 2 lamellae move as a unit and the postaponeurotic space remains stable. A proximal tarsal attachment suggests that blepharoptosis procedures that advance an involutional or disinserted levator aponeurosis onto to the superior tarsus approximate that aspect of native anatomic features. In addition, posterior surgical approaches that address Müller's muscle may involve resections in closer proximity to the aponeurosis than previously thought. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Simplified Müller's muscle-conjunctival resection internal ptosis repair.

PURPOSE: To describe and evaluate a modified technique for blepharoptosis repair via Müller's muscle-conjunctival resection. METHODS: An observational case series is reported. Records of 29 consecutive patients (42 eyelids) with blepharoptosis undergoing internal ptosis repair between January 2008 and December 2010 were reviewed including detailed preoperative and postoperative evaluations, eyelid measurements, surgical outcome, and complications. The procedure performed was a modified Müller's muscle-conjunctival resection with simple measurements, no traction sutures, a double-opposing mattress suture, and single external knot. Main outcome measures included success of ptosis repair surgery defined by improvement in margin reflex distance, symmetry of upper eyelid position, and incidence of complications. RESULTS: The described modified Müller's muscle-conjunctival resection procedure achieved improvement in eyelid position in all patients with mean margin reflex distance change of 2.3 mm (p < 0.001). No patient experienced significant complications, and all procedures resulted in objective eyelid symmetry (within 1 mm) and satisfactory cosmetic appearance. CONCLUSIONS: The procedure described is an efficient, safe, and successful technique for internal blepharoptosis repair.

Linear IgA bullous dermatosis: an unusual cause of upper eyelid cicatricial entropion.

Chronic cicatrizing conjunctivitis is a relatively uncommon condition resulting in significant ophthalmic morbidity, including keratoconjunctivitis sicca, cicatricial entropion, trichiasis, corneal scarring, significant discomfort, and visual loss. The potential causes of cicatrizing conjunctivitis are varied and include commonly encountered entities such as ocular cicatricial pemphigoid, Stevens-Johnson syndrome, and trachoma and many more rare causes which are particularly difficult to diagnose and treat and may not be familiar to the ophthalmologist. The authors herein present a case of chronic cicatrizing conjunctivitis, cicatricial entropion, and trichiasis caused by a rare entity called linear IgA bullous dermatosis. The case presentation conforms to the tenets of the Declaration of Helsinki and is Health Insurance Portability and Accountability Act compliant. This chronic dermatosis has a varied presentation, and the ophthalmic manifestations in particular have been infrequently described. This case demonstrates the benefits of immunohistochemistry in diagnosis and the difficulties in medical and surgical management of linear IgA bullous dermatosis while underscoring the lifelong difficulties in managing chronic inflammatory conditions causing ocular cicatrization.

Fibrolipoma of the orbit.

Herein we present a retrospective case report of a very rare fibrolipoma originating in the orbit. Lipomas and related variants presenting in the orbit are very rare. Only 2 documented orbital fibrolipomas were noted in our review of literature. A 26-year-old woman presented with a growing mass below the left eyebrow 4 years after suffering facial trauma after being kicked in the face by a horse. CT demonstrated a hypodense nodule adherent to the orbital portion of the left frontal bone that was not encapsulated. An elective left anterior orbitotomy with excisional biopsy was performed, and fibrolipoma was confirmed on histopathologic examination. There was no evidence of tumor after 2-year follow up. The presence of a fibrolipoma in the periosteum of the orbital rim is very rare and might be a result of inflammatory transformation following facial trauma.

The modified Bick quick strip procedure for surgical treatment of eyelid malposition.

PURPOSE: To describe the quick strip technique, a hybrid procedure that combines features of the classic Bick procedure and lateral tarsal strip, and to evaluate its effectiveness for correction of lower eyelid malpositions due to horizontal laxity (including both ectropion and entropion). METHODS: Retrospective chart review of 225 eyelids of 160 patients receiving the quick strip. Patient demographics, results, complications, and symptomatic improvement were evaluated. Subgroups included 54 eyelids of 42 patients with entropion and 171 eyelids of 118 patients with various degrees of ectropion. RESULTS: Complete resolution of eyelid malposition was achieved in 208/225 (92.4%) eyelids of 146/160 (91.3%) patients. Late recurrences occurred in 1/225 (0.4%) eyelids of 1/160 (0.6%) patients. Symptomatic improvement was achieved in 152/160 (95.0%) patients. Complications were infrequent with no cases of infection, hematoma, or lateral canthal rounding. The procedure can be combined in a straightforward manner with adjunctive procedures such as suborbicularis oculi fat lift and medial spindle for more advanced cases of ectropion. CONCLUSION: Quick Strip is an effective and efficient surgical treatment for the correction of eyelid malpositions that require horizontal tightening as a component of their management.

Late complications of hydrogel scleral buckle implants and a technique for effective removal.

PURPOSE: The aim of this article is to describe complications of hydrogel (MIRAgel) scleral buckle implants that may appear many years after implantation, and to describe an effective technique to facilitate safe removal of these implants, which become extremely friable with time. METHODS: Four case reports of patients with complications of hydrogel orbital implants and a technique for removal of the implants are described with review of the literature. The technique involves a conjunctival incision into each involved quadrant, followed by use of blunt instrumentation for "push" and a Frasier suction handpiece for "pull" to allow segmental removal. This technique limits the tendency of the implant to fragment, which has been a problem described with previous techniques. RESULTS: Cases typically present simulating an orbital tumor or infection, with the diagnosis not immediately apparent, as was the case in 3 of 4 cases in our series. The technique we used allowed for expeditious removal and prompt recovery in all 4 patients. CONCLUSIONS: Hydrogel scleral buckle implants can produce late complications that may be difficult to diagnose and manage. The "push-pull" technique described in this article facilitates effective removal, and may have implications for other types of orbital hydrogel implants as well.

Isolated squamous cell carcinoma of the orbital apex.

A 43-year-old woman (Case 1), 63-year-old man (Case 2), and a 67-year-old man (Case 3) presented with diplopia (Cases 1, 2, and 3) and upper-eyelid ptosis (Cases 1 and 3). The cases had preceding cranial nerve V1 disturbances ranging from 3 months to 8 years. Each demonstrated complete internal ophthalmoplegia and external ophthalmoplegia. No case had a cutaneous squamous cell carcinoma (SCC) on presentation or by history. Imaging revealed isolated orbital apex masses. Tumor biopsies revealed SCCs of various differentiations. Systemic workup revealed no extraorbital malignancy. All received radiation therapy, and 2 patients underwent adjuvant chemotherapy. One patient is alive since diagnosis (49 months). In Case 2, SCC developed in the contralateral orbit, and the patient died 19 months after diagnosis; and Case 3 died 12 months after diagnosis. These isolated cases of orbital SCC may have arisen from orbital choristomatous squamous epithelium, may represent de novo or metastatic tumors, or may be manifestations of occult perineural spread.

Adult orbital myeloid sarcoma (granulocytic sarcoma): two cases and review of the literature.

BACKGROUND/AIMS: [corrected] To report two rare cases of orbital myeloid sarcoma in adults and discuss special features relevant to this entity. METHODS: Complete ophthalmologic and systemic examinations followed by incisional biopsy and pathological examination. RESULTS: Two cases of myeloid sarcoma with orbital involvement were identified. Both cases presented with a clinical picture and imaging which demonstrated infiltrative orbital masses. When combined with 8 previous reported cases, 8/10 demonstrated systemic AML involvement. CONCLUSIONS: Orbital myeloid sarcoma is a rare entity in adults and highly associated with myelodysplastic syndromes, especially acute myelogenous leukemia (AML). It may present at any stage of AML and requires appropriate workup and treatment, though generally carries a poor prognosis.

Functional indications for upper eyelid ptosis and blepharoplasty surgery: a report by the American Academy of Ophthalmology.

OBJECTIVE: To evaluate the functional indications and outcomes for blepharoplasty and blepharoptosis repair by assessing functional preoperative impairment and surgical results. METHODS: Literature searches of the PubMed and Cochrane Library databases were conducted on July 24, 2008, with no age or date restrictions, and they were limited to articles published in English. These searches retrieved 1147 citations; 87 studies were reviewed in full text, and 13 studies met inclusion criteria and were included in the evidence analysis. RESULTS: The 13 studies reported the functional effects or treatment results of simulated ptosis; several types of blepharoptosis repair, including conjunctiva-Müller's muscle resection, frontalis suspension, and external levator resection; and upper eyelid blepharoplasty. CONCLUSIONS: Repair of blepharoptosis and upper eyelid dermatochalasis provides significant improvement in vision, peripheral vision, and quality of life activities. Preoperative indicators of improvement include margin reflex distance 1 (MRD(1)) of 2 mm or less, superior visual field loss of at least 12 degrees or 24%, down-gaze ptosis impairing reading and other close-work activities, a chin-up backward head tilt due to visual axis obscuration, symptoms of discomfort or eye strain due to droopy lids, central visual interference due to upper eyelid position, and patient self-reported functional impairment. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.