Hughes flap in the management of lower lid retraction.

PURPOSE: We present a retrospective case series on the use of Hughes flap in managing acquired cicatricial lower lid retraction. METHODS: This was a multicentre, retrospective case series. Data was collected from medical records across different sites within Australia (Adelaide, Melbourne, and Sydney) and New Zealand (Hamilton). RESULTS: Fourteen patients were identified. The aetiology of cicatricial lower lid retraction included previous lid lesion excision and reconstruction, eyelid trauma, orbital fracture repair, orbital radiotherapy, and lateral canthal dystopia from previous lid surgeries. 4/14 (29%) cases had undergone other surgery to correct the retraction prior to the Hughes flap. Pre-operative lagophthalmos due to lower lid retraction was noted in 11/14 (79%) cases with a median 2 mm (range: 1-5 mm). Exposure keratopathy was present in 7/14 (50%) cases. There were no peri-operative complications during Hughes flap reconstruction. One patient had post-operative upper eyelid retraction that did not require any further intervention. One patient had persistent lagophthalmos and exposure keratopathy that is being managed conservatively. One patient had wound dehiscence and further lid retraction following flap division, which required further surgery. Median length of follow-up was 15 months (range: 0.5-84 months). At final review, improvement or resolution of symptoms was seen in 13/14 (93%) cases. CONCLUSIONS: A Hughes flap is an effective surgical technique for the management of cicatricial lower lid retraction.

Lower eyelid excursion: A functional and cosmetically relevant parameter in the treatment of lower eyelid retraction.

The purpose of this study was to assess and quantify lower lid excursion following repair of lower lid retraction. In this retrospective cohort study, a case review of patients who had undergone ear cartilage grafting for lower lid retraction was undertaken. Surgical correction involved the placement of autologous cartilage between the tarsal plate and lower lid retractors. Measurements taken preoperatively and postoperatively were the marginal reflex 2 (MRD2) and the lower scleral show (LSS). The lower lid excursion on downgaze (LLE) was measured only postoperatively with a comparison made between operated eyes and control eyes. Thirteen eyelids of 10 patients were included in the study. Preoperatively, MRD-2 ranged from 4 to 8 mm (6.5 ±â€¯1.5 mm) - mean ±â€¯SD. Postoperatively, MRD-2 ranged from 4 to 6 mm (5.1 ±â€¯0.7 mm). The difference in mean MRD2 was statistically significant (p < 0.05). Preoperatively, LSS ranged from 0 to 5 mm (2.5 ±â€¯1.6 mm). Postoperatively, LSS ranged from 0-1 mm (0.1 ±â€¯0.3 mm). The difference in mean LSS was statistically significant (p < 0.01). Postoperatively, all lower eyelids achieved movement on downgaze. On the operated eyes, the eyelid excursion ranged from 2 to 5 mm (3.1 ±â€¯1.0 mm) on downgaze. On the nonoperated (control) eyes (where the operations were not performed bilaterally), the eyelid excursion ranged from 1 to 4 mm (2.8 ±â€¯1.2 mm). There was no statistically significant difference in the lid excursion of operated and nonoperated eyes (p > 0.05). It is possible to correct lower lid retraction in both primary and secondary positions of gaze if an appropriate surgical technique is employed.

Ultrasonographic motion analysis of lower eyelid compartments in patients with chronic thyroid associated ophthalmopathy.

PURPOSE: To present the qualitative and quantitative ultrasonographic findings of lower eyelid compartments in patients with chronic thyroid associated ophthalmopathy (TAO) compared to normal subjects. METHODS: In a prospective study, dynamic and static ultrasonographic investigation, applying high resolution (15 MHz) ultrasound was performed to assess the lower eyelid, in 15 TAO patients that were in chronic phase and 10 normal subjects. The thickness and echogenisity of dermis, orbicular oculi muscle, lower eyelid retractor muscle, lower eyelid fat pads, and their qualitative relationships during vertical excursion of the globe were evaluated in static and dynamic investigation. Correlation of ultrasonic and clinical findings was evaluated. RESULTS: The mean age of the patients was 41.82 ± 7.4 years, and the controls were age-matched (mean age, 42.8 ± 5.6 years). Mean proptosis of the involved eyes was 3.3 mm, and mean lower lid retraction was 2.4 mm in chronic TAO group. Pattern of fat motion was blocky in chronic TAO patients compared to normal jelly motion of the fat in normal cases. In analyzing the range of motion, the difference was significant in the motion of both superficial and deep fat pockets between the two groups (P < 0.001). Limitation of fat motion correlated both with proptosis and lower eyelid retraction (Pearson correlation coefficient = -0.77 vs -0.43, P < 0.001). Fibrotic changes of lower lid fat pads appear in the tissue around the septum on observation. Considering the ultrasound findings, a new staging method is proposed in this study that starts with the appearance of echodense points, getting worse in fine bands, progresses to thick bands and ends in cord formation in the lower lid fat pocket that determines total fibrosis. CONCLUSION: Development of a series of static and dynamic changes in ultrasound is related to the clinical findings in chronic phase of TAO. The limitation of motion and fibrotic changes of lower eyelid fat pads were more detectable in cases with a more severe proptosis and lower lid retraction. It is considered that ultrasound findings can be a representative of the severity of involvement in the chronic phase of the TAO.

Lower Lid Malposition: Causes and Correction.

Lower lid malposition is a common yet demanding problem that both functional and cosmetic eyelid surgeons will face. It encompasses a spectrum of lower eyelid conditions ranging from lower lid retraction to frank ectropion and entropion. The causes of lower lid malposition are numerous, and the problem can be challenging to correct even for experienced surgeons. Proper treatment of lower lid malpositioning requires a clear understanding of the lower eyelid anatomy, careful preoperative assessment, and appropriate selection of surgical and nonsurgical interventions to have a successful outcome.

A novel technique for inferior rectus recession.

PURPOSE: To introduce a novel technique of inferior rectus recession operation to allow larger amounts of recession without causing lower lid retraction and to compare this method with the results obtained in standard inferior rectus recession. MATERIAL AND METHODS: This study included 20 patients operated on in the authors' clinic. The median age of the patients was 24.5±18.6 (4-73) years and the median follow-up was 9.3±11.8 (3-43) months. Ten patients operated on with the standard method were labeled Group 1 and ten patients operated on with the new method were labeled Group 2. Without exceeding 4 mm, inferior rectus recession to the whole muscle was performed in Group 1 patients. Inferior rectus recession was also performed on patients in Group 2 following the new method. Using a spatula, approximately 10% of the muscle surface fibers were detached intact as a thin layer, and the remaining 90% of deeper fibers were recessed 4-8 mm as planned. Patients' preoperative deviations and lower lid positions were recorded. The same parameters were checked in the first and third month postoperatively. Both groups were evaluated retrospectively by screening their files, and the Mann-Whitney U test was used for statistical evaluation. RESULTS: Lower lid retraction was seen in four patients of Group 1. There was no retraction in Group 2. While there was a need to perform additional vertical muscle procedures for vertical deviations and lower lid retractions in Group 1, it was observed that there was no need for additional procedures in Group 2 patients. There was a statistically meaningful difference between the two procedures (P<0.05). CONCLUSION: This novel technique was found to be an effective surgical method for permitting more recession without the risk of lower lid retraction.

The effect and applications of acellular dermal allograft (AlloDerm) in ophthalmic plastic surgery.

PURPOSE: To describe the use and efficacy of AlloDerm in ophthalmic plastic and reconstructive surgery. METHODS: A retrospective review was conducted of 31 eyes of 25 patients who underwent an AlloDerm graft procedure for correction of lower lid retraction, anophthalmic socket contraction, superior sulcus deformity, implant exposure, or skin defect. Clinical outcomes were measured by the degree of improvement and incidence of complications. Operation success and reoperation rates were also evaluated. RESULTS: There were 15 cases of lower lid retraction, 10 anophthalmic socket contractions, 2 superior sulcus deformities, 2 orbital implant exposures, and 2 periorbital skin defects. The mean age of the patients was 44.7 (±2.8) years. The mean follow-up period was 16.7 (±2.5) months. Twenty-seven eyes (87.1%) had successful outcomes and 4 eyes of 4 patients required further surgery. Three of those were due to undercorrection, and the other was due to severe adhesion. Applications of AlloDerm skin substitute were satisfactory at the 6-month follow-up examination. There were no statistically significant factors, such as underlying causes or degrees and locations of defects that impacted on outcome. CONCLUSIONS: AlloDerm is an excellent material for correction of lid retraction, contracted socket, superior sulcus deformity, and implant exposure. In patients for whom periorbital skin grafts or flaps are inappropriate or difficult to perform, the use of AlloDerm to cover skin defects may be a good option.