Use of oxymetazoline hydrochloride ophthalmic solution, 0.1% for improved lid symmetry in Graves' disease.

PURPOSE: The purpose of this study is to evaluate the usage of oxymetazoline hydrochloride ophthalmic solution, 0.1% in the treatment of Graves' disease to improve lid symmetry. METHODS: Fourteen patients were identified with unilateral upper eyelid retraction, secondary to Graves' disease. A phenylephrine test was performed to evaluate whether treating the unaffected (non-retracted) side would result in improved symmetry using Hering's law. Patients were prescribed oxymetazoline hydrochloride ophthalmic solution, 0.1% to instill into the unaffected eye. Marginal reflex distance 1 (MRD1) measurements were taken pre- and post-treatment and patient satisfaction surveys were completed. RESULTS: The average pre-treatment MRD1 difference between the right eye (OD) and the left eye (OS) was 2.46 [range 1.50-4.00]. The average post-treatment MRD1 difference between OD and OS was 0.39 [range 0.00-1.00]. One hundred percent of patients were satisfied or very satisfied with the improvement in symmetry. CONCLUSIONS: Oxymetazoline hydrochloride ophthalmic solution, 0.1% is a potential method to improve symmetry in patients with Graves' disease and unilateral upper eyelid retraction via Hering's law, especially for non-surgical candidates or those who prefer non-surgical treatment. Our results indicate improved MRD1 differences between fellow eyes and patient satisfaction regarding the symmetry of the upper eyelids.

Correction of severe medial ectropion using a novel osseous fixation technique.

PURPOSE: To study the feasibility of osseous medial canthal fixation for severe medial ectropion. METHODS: Retrospective analysis over a period of 3 years identified 10 patients who had undergone the modified medial canthoplasty. Outcome measures were based on the presence of complications and cosmetic/functional results. RESULTS: Post-operative evaluations of all patients were significant for excellent functionality and cosmetic results in the medial canthal area following the novel osseous fixation technique. No complications were reported intra-operatively or post-operatively. CONCLUSIONS: For repair of severe medial ectropion, especially cicatricial and paralytic ectropion, the modified medial "puncture hole" canthoplasty is an effective alternative to traditional repair techniques and does not necessitate the use of anchoring systems such as wiring or microplates.

Histologic Evaluation of Nonvisual Afferent Sensory Upper Eyelid Proprioception.

PURPOSE: Recent research has suggested a possible role for proprioception in ipsilateral frontalis activation in the setting of ptosis; however, there has not been any robust histologic or anatomic evidence to support this theory. To further elucidate proprioceptive structures in the eyelid, this investigation uses validated histologic techniques to explore the presence of proprioceptive structures or afferent neural networks in the Levator Palpebrae Superioris (LPS) and Müller muscle. METHODS: Müller muscle and LPS samples were evaluated by a laboratory with extensive experience with the histology of extraocular muscle proprioception. Immunofluorescence and confocal laser scanning microscopy were used to analyze the tissue samples. RESULTS: Thirty-four Müller muscle samples and 10 LPS samples were analyzed. Golgi tendon bodies and muscle spindles were not identified in the Müller muscle and LPS samples. This result is expected in the Müller muscle given that these structures are not typically present in smooth muscle, but noteworthy in the skeletal muscle of the LPS. Previously undescribed synaptophysin-positive free nerve terminals within the intermuscular connective tissue of the Müller muscle were identified. CONCLUSIONS: The nerve terminals identified are anatomically consistent with free nerve endings present in the extraocular muscles that have been implicated in proprioception. These findings advance our current knowledge of the ultrastructure of Müller muscle and the LPS and suggest a possible mechanism for proprioception in the upper eyelid that may have a role in ipsilateral brow elevation in the setting of ptosis.The authors describe proprioception in the upper eyelid: A histologic analysis.

Volumization of the Brow at the Time of Blepharoplasty: Treating the Eyebrow Fat Pad as an Independent Unit.

PURPOSE: Loss of volume in the sub-brow fat pad with associated descent of the eyebrow is a common anatomical finding resulting in both functional and aesthetic consequences. A variety of techniques have been described to address brow position at the time of blepharoplasty. To our knowledge, none of these techniques treat the sub-brow fat pad as an isolated unit. Doing so enables the surgeon to stabilize and volumize the brow without resultant tension on the blepharoplasty wound. The authors describe a technique for addressing volume loss in the eyebrow with associated brow descent that treats the sub-brow fat pad as an isolated unit. METHODS: A retrospective review of all patients undergoing brow ptosis repair by a single surgeon (J.W.S.) over an 11-month period was performed. RESULTS: Eighteen patients and 33 brows underwent the technique described. Patients were followed for an average of 11 weeks (range: 4 weeks to 20 weeks). All patients preoperatively displayed both visually significant dermatochalasis and brow descent below the orbital rim. Evaluation of pre- and postoperative photos demonstrates successful volumization of the brow with skin redraping without focal dimpling or undue tension on the eyelid wound. CONCLUSIONS: Performing a dissection that allows the sub-brow fat pad to be elevated in isolation from the overlying orbicularis and underlying periosteum allows for volumization and of the brow without compromising closure. This technique is a safe and effective means of volumizing the brow and treating secondary brow descent.

Multicentric Mucinous Adenocarcinoma in the Periorbital Region.

Primary mucinous adenocarcinoma of the skin is an uncommon malignancy in clinical practice, but multicentric presentation of the malignancy is considered even more rare. In this case report, the authors present a 70-year-old woman with multicentric primary mucinous adenocarcinoma of the skin manifesting with 2 separate lesions located on the right eyelid and cheek. Lesion removal and immunohistochemical staining ruled out mucinous adenocarcinoma of the skin secondary to lung or thyroid carcinoma, however, was inconclusive for breast carcinoma. A negative breast examination and mammography determined the lesions were primary mucinous adenocarcinoma of the skin. Lesion removal resulted in a large defect, which was repaired using a tarsoconjunctival flap and right cheek rotational/advancement flap. Six months postoperatively, the patient's vision returned to baseline with excellent eyelid position and no evidence of local recurrence. Oral consent for the report and photographs was obtained from the patient and filed.

Dilated Superior Ophthalmic Vein: Clinical and Radiographic Features of 113 Cases.

PURPOSE: Dilated superior ophthalmic vein (SOV) is an uncommon radiographic finding. The authors review the presentation, etiology, radiography, and visual implications of 113 patients with dilated SOV. METHODS: An observational case series and multicenter retrospective chart review were conducted. There were 113 patients with a dilated SOV. Outcome measures included patient demographics, clinical features, radiographic findings, diagnosis, and treatment, and treatment outcomes were assessed. RESULTS: Cases included 75 women (66%) and 38 men (34%) with a mean age of 49 ± 24 years (range, 0.4-90 years). Diagnoses fell under 6 categories: vascular malformation (n = 92, 81%), venous thrombosis (n = 11, 10%), inflammatory (n = 6, 5%), traumatic hemorrhage (n = 2, 2%), lymphoproliferative (n = 1, 1%), and infectious (n = 1, 1%). Imaging modalities utilized included MRI (n = 98, 87%), digital subtraction angiography (n = 77, 68%), CT (n = 29, 26%), and ultrasonography (n = 4, 4%). Disease status at last follow up included no evidence of disease (n = 57, 50%), alive with persistent disease (n = 53, 47%), and expired from disease (n = 3, 3%). Treatment and management was tailored to the underlying disease process with a mean follow up of 18 months (range, 1 day to 180 months). Visual impairment observed at presentation and last follow up across all cases was 26% and 22%, respectively. CONCLUSION: Dilated SOV is a rare radiographic finding resulting from a wide spectrum of etiologies with clinical implications ranging from benign to sight- and life-threatening. Dilated SOV is most often found with dural-cavernous fistula or carotid-cavernous fistula, orbital or facial arteriovenous malformation, and venous thrombosis. Recognition of this finding and management of the underlying condition is critical.

Operating room fires in periocular surgery.

AIM: A survey of ophthalmic plastic and reconstructive surgeons as well as seven-year data regarding claims made to the Ophthalmic Mutual Insurance Company (OMIC) is used to discuss operating room fires in periocular surgery. METHODS: A retrospective review of all closed claim operating room fires submitted to OMIC was performed. A survey soliciting personal experiences with operating room fires was distributed to all American Society of Oculoplastic and Reconstructive Surgeons. RESULTS: Over the last 2 decades, OMIC managed 7 lawsuits resulting from an operating room fire during periocular surgery. The mean settlement per lawsuit was $145,285 (range $10,000-474,994). All six patients suffered burns to the face, and three required admission to a burn unit. One hundred and sixty-eight surgeons participated in the online survey. Approximately 44% of survey respondents have experienced at least one operating room fire. Supplemental oxygen was administered in 88% of these cases. Most surgical fires reported occurred in a hospital-based operating room (59%) under monitored anesthesia care (79%). Monopolar cautery (41%) and thermal, high-temperature cautery (41%) were most commonly reported as the inciting agents. Almost half of the patients involved in a surgical fire experienced a complication from the fire (48%). Sixty-nine percent of hospital operating rooms and 66% of ambulatory surgery centers maintain an operating room fire prevention policy. CONCLUSIONS: An intraoperative fire can be costly for both the patient and the surgeon. Ophthalmic surgeons operate in an oxygen rich and therefore flammable environment. Proactive measures can be undertaken to reduce the incidence of surgical fires periocular surgery; however, a fire can occur at any time and the entire operating room team must be constantly vigilant to prevent and manage operating room fires.

Neuropathic Pain Following Poly-L-Lactic Acid (Sculptra) Injection.

Injectable fillers have become a prevalent means of facial rejuvenation and volume expansion. While typically well tolerated, serious complications have been reported. The authors present a case in which an otherwise healthy female with a history of multiple filler injections including poly-L-lactic acid, developed 3 weeks of neuropathic pain in the left temporal fossa following injection. To the best of the authors knowledge, neuropathic pain has not been reported as a complication following poly-L-lactic acid injection. The patient was treated with an injection of steroid and long-acting anesthetic with resolution of symptoms.

Wingtip Flap for Reconstruction of Full-Thickness Upper and Lower Eyelid Defects.

PURPOSE: Pentagonal wedge resection is a technique used to address a wide variety of eyelid pathology. This procedure frequently results in excess skin at the apex of the wound, commonly known as a "dog ear." A variety of methods have been described to address the cutaneous redundancy, the most classic of which is the Burow's triangle repair. The authors present a technique to address the anterior lamellar excess that avoids placement of a vertical scar traversing the pretarsal and preseptal portion of the affected eyelid. The repair moves the preseptal closure of the wound temporally, away from the moving portion of the eyelid. The horizontal incision that transposes the vertical closure temporally is concealed in the eyelid crease. METHODS: A retrospective review of all patients undergoing this technique for eyelid reconstruction was undertaken. The surgical technique is described in detail. RESULTS: The procedure has been performed on 7 patients (8 eyelids). Patients were followed for an average of 12 weeks. Indications for surgery were floppy eyelid syndrome requiring horizontal shortening of the upper eyelid and neoplastic lesions involving the upper or lower eyelid. There were no complications. All patients had a satisfactory outcome with regard to function and cosmesis. CONCLUSIONS: Full-thickness excision of the central two-thirds of the lower and upper eyelid is used extensively to manage a wide variety of conditions. The authors present a technique for addressing the anterior lamellar closure with notable advantages over previously described methods. The major advantages of this technique are that it results in a vertical closure that is horizontally displaced from the primary action of the levator aponeurosis and avoids anterior and midlamellar scarring of the upper and lower eyelid that may inhibit vertical movement. In addition, the cutaneous scar is more easily concealed.

Self-inflicted enucleations: Clinical features of seven cases.

We report the clinical presentation, radiography, and management outcomes of autoenucleations (AE). Charts of 7 patients evaluated at 4 institutions with AE were reviewed. Four males and three females had a mean age of 50 years (range 26-72 years). The etiologies were psychosis secondary to underlying mental illness (6, 88%) and substance use (1, 12%), and the mechanism was largely blunt digital injury (6, 88%). Three (43%) AE patients suffered bilateral enucleations. Common concomitant injuries included eyelid lacerations (5, 71%) and optic nerve avulsion (3, 43%). Radiography was utilized for all of the study patients with computed tomography as the most common (5, 71%), followed by ultrasound (1, 14%), and magnetic resonance imaging with CT angiography (1, 14). Orbital exploration was performed in the management of all patients. Orbital implants were placed in 4 (57%) patients. Patients were followed for a mean of 1.9 months (range 1-4 months). Autoenucleation affects both genders and is commonly associated with eyelid lacerations, optic nerve avulsion, and intracranial hemorrhage. The association with intracranial hemorrhage is consistent with prior reports of internal carotid artery injury following shearing of the optic nerve. Autoenucleation cases were seen secondary to mental or substance induced psychosis, and these patients may be at risk for future injuries such as AE of the contralateral globe. The common causes for psychosis reported our patient group include schizophrenia, depression, schizoaffective disorder, and methamphetamine-induced psychosis, which corroborates with similar cases in the literature. Two of three cases of bilateral AE suffered sequential AE where the contralateral globe was enucleated days apart. All patients suffering AE should have full medical, psychiatric, neurologic, and radiologic evaluation and monitoring while under care. When evaluating patients with obvious ocular injury, accompanying intracranial injuries should be ruled out in a timely fashion before pursuing surgical intervention.

Evaluating the growth of eyelid lesions: comparison of clinical evaluation and a software-based model.

PURPOSE: To evaluate the accuracy of clinicians in evaluating the growth of eyelid lesions and to compare the measurements of experienced ophthalmologists to a novel computerized measurement method. DESIGN: Prospective, single center, observational study. METHODS: Six experienced ophthalmologists were asked to measure 3 simulated eyelid lesions using a slit lamp. These lesions were then enlarged, and the same examiners were asked to measure the enlarged lesions without prompting that the lesions had changed. Slit lamp photography of the original lesions and enlarged lesions were analyzed using freely available software from the National Institutes of Health. The results of clinician measurements were compared to the software-generated data. RESULTS: Clinician data regarding the growth of the lesions were as follows: -40.9 to +76.8% for lesion 1, +29.3 to +134.4% for lesion 2, and +148.5 to +1169.2% for lesion 3. Software-based measurements were as follows: +53.6, +100.7, and +182.2% for lesions 1, 2, and 3, respectively. CONCLUSIONS: Monitoring growth of eyelid lesions in clinical practice can be challenging. We propose that using computerized software to analyze surface area of concerning eyelid lesions may provide a significant advantage over current clinical practices.

Conjunctiva-Sparing Posterior Ptosis Surgery: A Novel Approach.

PURPOSE: Müller's muscle conjunctiva resection is a well-established means of correcting blepharoptosis. The primary objective of this prospective study was to determine if modifying Müller's muscle conjunctiva resection by sparing the conjunctiva would accomplish successful repair while allowing patients to retain their conjunctiva. The potential advantages of preserving conjunctiva are significant and include: conservation of an anatomically normal tissue, retention of goblet cells, reduction of suture-related complications such as corneal irritation or abrasion as the conjunctiva covers the suture during postoperative healing, and preservation of conjunctiva for potential future surgical procedures critical to ocular health. METHODS: This is a prospective study enrolling patients with mild to moderate ptosis. RESULTS: The procedure has been performed in 18 patients and 30 eyelids. Follow up at 1 week revealed normal healing with expected postoperative edema and ecchymosis. Notably, all patients were free of any corneal abrasion or irritation. Follow up at 1 month and a minimum of 3 months (average 5.7 months) revealed that all patients had satisfactory correction of their blepharoptosis with Margin Reflex Distance 1 (MRD1) improvement to within 1 mm of the anticipated goal, preserved eyelid margin contour, and good symmetry (average 0.26 mm difference in MRD1 between the sides). CONCLUSION: These results show an effective correction of blepharoptosis with a favorable cosmetic outcome and low postoperative complication rate; all while preserving the conjunctiva.

Effect of optic nerve sheath fenestration for idiopathic intracranial hypertension on retinal nerve fiber layer thickness.

The objective of the study was to evaluate whether optic nerve sheath fenestration in patients with idiopathic intracranial hypertension was associated with improvement in visual field pattern deviation and optical coherence tomography retinal nerve fiber layer thickness.The records of 13 eyes of 11 patients who underwent optic nerve sheath fenestration were reviewed. The subjects were patients of a clinical practice in Dallas, Texas. Charts were reviewed for pre- and postoperative visual field pattern deviation (PD) and retinal nerve fiber layer thickness (RNFL).PD and RNFL significantly improved after surgery. Average PD preoperatively was 8.51 DB and postoperatively was 4.80 DB (p = 0.0002). Average RNFL preoperatively was 113.63 and postoperatively was 102.70 (p = 0.01). The preoperative PD and RNFL did not correlate strongly.Our results demonstrate that PD and RNFL are improved after optic nerve sheath fenestration. The pre- and postoperative RNFL values were compared to the average RNFL value of healthy optic nerves obtained from the literature. Post-ONSF RNFL values were significantly closer to the normal value than preoperative. RNFL is an objective parameter for monitoring the optic nerve after optic nerve sheath fenestration. This study adds to the evidence that OCT RNFL may be an effective monitoring tool for patients with IIH and that it continues to be a useful parameter after ONSF.

The effect of upper eyelid blepharoplasty on eyelid and brow position.

This article evaluates the effect of upper eyelid blepharoplasty on eyelid margin position and brow height. This study is a retrospective analysis of patients who underwent upper eyelid blepharoplasty without concurrent blepharoptosis repair or brow surgery. The medical records of the participants were retrospectively reviewed and an established image analysis software was used to quantify the upper margin reflex distance (MRD1) as well as brow height using high quality standardized clinical photographs. A total of 19 patients (38 eyelids and brows) met the inclusion criteria. The mean preoperative MRD1 was 2.8 mm, and the mean post-operative MRD1 was 3.5 mm, revealing an increase of MRD1 from upper blepharoplasty alone of 0.7 mm (p = 0.0001). The mean preoperative brow position was 17.5 mm above the pupil, and the mean post-operative position was 17.4 mm, for an average change of position of -0.2 mm (p = 0.39) following upper eyelid blepharoplasty. Upper eyelid blepharoplasty without ptosis surgery results in a statistically significant increase in MRD1. Brow position does not demonstrate a statistically significant change in patients who undergo upper eyelid blepharoplasty for simple dermatochalasis.

Cutaneous squamous cell carcinoma of the eyelid masquerading as a chalazion.

Chalazia are among the most common eyelid lesions presenting to eye care providers. Often successfully managed conservatively, some require more invasive intervention such as incision and drainage or steroid injection. Lesions that recur, do not respond to treatment, or are atypical in appearance or natural history should prompt more thorough analysis, often with biopsy and subsequent microscopic analysis. Not uncommonly, such atypical chalazia may be masking a more serious diagnosis. Eyelid cutaneous squamous cell carcinoma masquerading as a chalazion is exceedingly rare. We present a case report of an atypical chalazion that was refractory to incision and drainage as well as intralesional steroid injection. Incisional biopsy revealed the lesion to be a cutaneous squamous cell carcinoma requiring full-thickness excision and subsequent reconstruction. The patient provided written informed consent, and the contents herein are acceptable under the provisions of the institutional review board. Following Mohs excision and oculoplastic reconstruction with a Hughes flap, the patient has had a good outcome and is currently free of recurrence. Recurrent chalazia that are defiant to surgical and medical interventions should prompt biopsy and evaluation by pathology. Cutaneous squamous cell carcinoma should be considered in the differential diagnosis as early intervention can save a patient's eye and, not infrequently, their life.

Periorbital cellulitis due to cutaneous anthrax.

Virgil's plague of the ancient world, Bacillus anthracis, is rare in developed nations. Unfortunately rural communities across the globe continue to be exposed to this potentially lethal bacterium. Herein we report a case of periorbital cutaneous anthrax infection in a 3-year-old girl from the rural area surrounding Harare, Zimbabwe with a brief review of the literature.

Relapsing acute lymphoblastic leukemia presenting with a rapidly enlarging and vision-threatening orbital mass.

This case report describes a patient with known acute lymphoblastic leukemia (ALL) presenting with a rapidly enlarging and vision-threatening orbital mass. Orbital disease is rare in patients with ALL, and to our knowledge only six cases have been previously described, five of which are in children. We describe a 36-year-old Caucasian female with known acute lymphoblastic leukemia who developed markedly decreased visual acuity, proptosis, and elevated intraocular pressure over the course of 12 h. She was treated with emergent surgical intervention followed by intrathecal chemotherapy and intravenous steroids. Following medical and surgical intervention, the patient demonstrated rapid resolution of symptoms and a return to baseline visual acuity. The initial presentation of acute onset proptosis with optic nerve compromise can be suggestive of infectious etiologies, however, this case suggests caution in evaluation of patients with known systemic malignancy, particularly ALL, as early intervention with systemic steroids and surgery may result in return of visual function.

Surgical treatment of a spontaneous intraorbital arteriovenous fistula with direct embolization via transconjunctival orbitotomy.

Spontaneous arteriovenous fistula is a rare orbital lesion that may cause proptosis, ptosis, chemosis, and visual disturbances. The widely practiced treatment is a transvenous embolization approach accessed from the femoral or petrosal sinus. In this case report, we present a surgical approach via transconjunctival orbitotomy for direct access to achieve complete fistula embolization. The postoperative course revealed progressive, near-complete symptomatic improvement.

The Effect of Intravenous Tranexamic Acid on Postoperative Ecchymoses after Upper Blepharoplasty.

Background: Tranexamic acid has been increasingly used in facial plastic surgery to improve perioperative hemostasis. While subcutaneous tranexamic acid has been found to not significantly decrease postoperative ecchymoses following upper blepharoplasty, systemic administration has not previously been studied. Methods: A total of 325 patients undergoing upper blepharoplasty were randomly assigned to either receive intravenous tranexamic acid or serve as a control. Patients in the experimental group were administered 1 g of tranexamic acid intravenously 10 minutes before surgical incision. A similar upper blepharoplasty technique was performed by two American Society of Ophthalmic Plastic and Reconstructive Surgery-trained surgeons. Follow-up was conducted at a median of 8 days postsurgery. Patient photographs were evaluated by two independent graders to rate ecchymoses on a scale of 0 (least) to 10 (most). Results: Of the 325 included patients, 138 patients received intravenous tranexamic acid and 187 patients did not. The average ecchymosis rating for the control group at day 8 was 5.8 ± 1.7, while the average rating for the tranexamic acid group at the same time point was 4.1 ± 1.6 (P < 0.0001). There was a trend toward decreased ecchymoses in the tranexamic acid group at earlier and later postoperative timepoints that did not reach statistical significance. No hemorrhagic or systemic embolic complications occurred. Conclusions: Systemic tranexamic acid may reduce postoperative ecchymoses after upper blepharoplasty surgery, reaching significance at the eighth postoperative day, which may lead to improved patient satisfaction and decreased occupational downtime.