Silicone Scaffold Support Using a Bilayer Dermal Regeneration Matrix Template for Correction of Primary or Recurrent Eyelid Retraction.

PURPOSE: To evaluate the efficacy and safety of a bilayer dermal regenerative matrix for primary or complex/recurrent eyelid retraction. METHODS: Retrospective review of patients undergoing eyelid retraction repair using the bilayer dermal regenerative matrix from 2005 to 2019. Nineteen eyelid surgeries from 15 patients were identified. Collected data included patient demographics, symptoms, preoperative/postoperative lower eyelid position, inferior scleral show, lagophthalmos, etiology of retraction, history of prior retraction surgeries, major/minor complications, and follow-up duration (minimum 6 months). Postoperative measurements were taken at a minimum of 1 week, 3-6 weeks, 2-4 months, and 6 months. RESULTS: Postoperatively, 90% of cases had good improvement of lower eyelid retraction (defined as 1 mm or less below the inferior limbus). Postoperative elevation of the lower eyelid ranged 1-3.5 mm compared with preoperative measurements. When used in the upper eyelid for conjunctival scarring, the implant improved the superior fornix depth. Complications were minimal and included transient conjunctival injection, eyelid edema, and foreign body sensation. No patients requested early removal of the silicone layer due to ocular pain. CONCLUSIONS: The bilayer dermal regeneration matrix template may be considered a reasonable alternative to other spacers to reduce the vertical palpebral fissure and eyelid malposition in primary, complex, or recurrent cases. It also worked well for first-line correction of thyroid retraction, which tend to be more challenging due to globe proptosis. Suboptimal results may have occurred due to active cicatrizing conjunctival disease, or residual negative vector of the cheek and orbit. High cost may be a consideration, and the bilayer dermal regeneration matrix template was not studied directly against hard palate and other spacer materials.

Tear Trough Incision for External Dacryocystorhinostomy.

PURPOSE: Scar formation is a frequently cited complication of external dacryocystorhinostomy (exDCR). The purpose of this study is to evaluate scar appearance after exDCR with the skin incision placed in the tear trough. METHODS: Multicenter, prospective, noncomparative interventional study was approved by the University of Colorado Institutional Review Board. Patients undergoing exDCR from February 2013 to January 2014 were included in the study, and surgeries were performed by all authors. The incision site for all patients started just under the medial canthal tendon and extended inferolaterally into the tear trough for 10 mm to 15 mm. External dacryocystorhinostomy was performed in the usual manner, and the incision was closed according to the surgeon's preference. At 3 months postop, all patients were asked to rate their scar on the basis of the following grading scale: 0, invisible incision; 1, minimally visible incision; 2, moderately visible incision; and 3, very visible incision. Functional success of the surgery was also determined by asking the patients if their symptoms resolved, improved, or did not change. External photographs taken at 3 months after surgery were graded by 3 independent oculofacial and facial plastic surgeons using the same grading scale. RESULTS: Seventy-two surgeries were performed in 68 consecutive exDCR patients with nasolacrimal duct obstruction during the study period. Sixty-nine out of 72 patients reported improved or resolved symptoms (95.8%). The average patient scar grade was 0.21, while the average surgeon scar grade was 0.99 (p < 0.001). Sixty out of the 72 patients graded the scar as invisible (83.3%), and only 3 patients graded the scar as moderately visible (4.2%). No patients graded the scar as very visible. Of the 216 surgeon grades, 55 scars were graded as invisible (25.5%), while 8 were graded as very visible (3.7%). CONCLUSIONS: Scar appearance after exDCR with the incision placed in the tear trough is minimally visible to surgeons, and more importantly, nearly invisible to patients.

Comparison of free tarsoconjunctival grafts and Hughes tarsoconjunctival grafts for lower eyelid reconstruction.

PURPOSE: To review the use of free autogenous tarsoconjunctival (TC) grafts and Hughes TC flaps in the practice of one of the authors (MJH) and compare complications and outcomes and develop a rationale for the selection of surgical technique. METHODS: Retrospective comparative case series of 70 patients who underwent reconstructive surgery for a major full-thickness lower eyelid defect using a free autogenous TC graft or Hughes TC pedicle flap by one of the authors (MJH). Rates of complications, including erythema of the eyelid margin, eyelid position abnormalities, and need for additional surgeries, were reviewed. RESULTS: During a 15-year period, 70 patients with full-thickness lower eyelid defects were treated with autogenous TC grafts and flaps. The average age of the patients receiving a free TC graft was younger than the average age of patients receiving a Hughes TC graft (63 versus 73 years, p < 0.001). Patients with a free TC graft were more likely to have a smaller eyelid defect than the patients receiving a Hughes TC graft (52% versus 72%, p < 0.001). Patients receiving a free TC graft were less likely to require surgery to repair eyelid margin erythema than those in receiving a Hughes TC flap (one patient [2%] versus 5 patients [19%], respectively [odds ratio = 0.10, confidence interval = 0.01 to 0.95]). The average follow up was 22 months. CONCLUSIONS: Free TC flaps associated with mycocutaneous advancement flaps are less likely to lead to complications of eyelid margin erythema and subsequent revision surgery than Hughes TC flaps with full-thickness skin grafts.

Pediatric golf-related ophthalmic injuries.

OBJECTIVES: To document ophthalmic morbidity of golf-related injuries in children and to report specific injury patterns. DESIGN: A noncomparative, interventional, retrospective case series of 11 pediatric patients treated at 2 institutions for ophthalmic trauma resulting from golf-related injuries during 15 years. RESULTS: Eleven eyes of 11 patients were injured. There were 6 boys and 5 girls, with a mean age of 10.2 years (age range, 7-14 years). Ten patients were injured by golf clubs and 1 patient by a golf ball. One injury occurred on a golf course. At the initial ophthalmic examination, visual acuity was 20/20 in 4 eyes (36%), 20/25 to 20/80 in 3 eyes (27%), no light perception in 3 eyes (27%), and undeterminable in 1 eye (9%). Nine of 11 patients required surgery. Follow-up ranged from 0 to 66 months (mean follow-up, 12 months). Three of 11 subjects had permanent deficits, including blindness, decreased vision, and anophthalmia. Final visual acuity was no light perception in 2 eyes (18%), 20/70 in 1 eye (9%), and 20/20 or better in 8 eyes (73%). CONCLUSIONS: The findings from this series reveal that pediatric ophthalmic golf injuries, although rare, may be devastating to the eye, periocular adnexa, and visual system. Among our cases, most injuries occurred off the golf course, many required surgery, and some resulted in permanent loss of vision.

Mucinous eccrine adenocarcinoma of the periocular region.

PURPOSE: To report 4 patients with mucinous eccrine adenocarcinoma of the periocular region. METHODS: Interventional case series of 4 patients with mucinous eccrine adenocarcinoma of the periocular region treated at 2 centers. RESULTS: Two patients with mucinous eccrine adenocarcinoma of the upper eyelid, 1 with mucinous eccrine adenocarcinoma of the lower eyelid, and 1 with mucinous eccrine adenocarcinoma of the eyebrow were included in this report. The lower eyelid lesion and the eyebrow lesion recurred after Mohs micrographic surgery. Both recurrent lesions were treated with Mohs micrographic surgery and postoperative adjuvant external-beam radiation therapy. The other 2 primary tumors were treated with wide local excision with frozen section control of margins and did not recur. The follow-up time after the most recent surgical procedure ranged from 8 to 17 months (median, 12 months). CONCLUSIONS: Mucinous eccrine adenocarcinoma is a rare ocular adnexal neoplasm that can involve the eyelid and periocular skin, can be locally invasive, and has a high risk of local recurrence despite Mohs surgery.

Growth factor receptor expression in orbital lymphangioma: possible therapeutic implications.

OBJECTIVE: To examine the expression of molecules targeted by imatinib mesylate (STI571;Gleevec) and epidermal growth factor receptor (EGFR) inhibitors in orbital lymphangiomas. DESIGN: Retrospective observational case series. PARTICIPANTS: Six patients with orbital lymphangioma treated at four institutions between March 2000 and December 2002. METHODS: Tissue specimens and medical records from six patients were collected. Immunohistochemical analysis was performed using antibodies against c-kit and platelet-derived growth factor receptor (PDGFR) alpha and beta and EGFR tyrosine kinase.

Conjunctival melting syndrome associated with the use of bovine pericardium wrapping material.

PURPOSE: To report 18 cases of unusually large, early conjunctival breakdown occurring with the use of bovine pericardium wrapping material for orbital implants. METHODS: Retrospective case series. The clinical course and histopathologic features of 18 cases of early conjunctival breakdown in patients who had undergone orbital implantation of bovine pericardium-wrapped hydroxyapatite or porous polyethylene are reviewed. RESULTS: Eighteen patients presented with unusually large (average 13.44 mm) conjunctival defects over bovine pericardium-wrapped implants. The average time from enucleation to exposure was approximately 4 months. Implants had to be removed in 8 of 18 cases. There was clinical and histologic evidence of tissue inflammation and conjunctival melting. CONCLUSIONS: The conjunctival melting phenomenon we report herein is alarming. We have abandoned the use of bovine pericardium as a wrapping material for implants after enucleation because of the unfavorable results.

Lower eyelid reverse ptosis repair.

PURPOSE: To report the results of the surgical repair of lower eyelid reverse ptosis. METHODS: Retrospective case series. Eight patients ranging in age from 31 to 77 years underwent surgical repair of lower eyelid reverse ptosis. The pupillary axis of the affected eye(s) in each patient was obscured in downgaze, interfering with reading. The lower eyelid reverse ptosis resulted from involutional changes in 3 patients, previous orbital decompression in 3 patients, multiple prior retinal and extraocular muscle operations in 1 patient, and previous orbital floor fracture and repair in 1 patient. Transcutaneous advancement of the lower eyelid retractors was performed in 12 eyelids of the 8 patients. RESULTS: The mean preoperative vertical eyelid fissure was 6.2 mm (median, 6 mm; range, 3-9 mm), increasing after surgery to a mean of 7.7 mm (median, 8 mm; range, 5-11 mm). The mean preoperative distance between the central light reflex and the lower eyelid margin was 1.7 mm (median, 1.25 mm; range, 1-4 mm); this distance increased to a mean of 3.3 mm (median, 3.25 mm; range, 2.5-4.5 mm) after surgery. Symptoms improved in all patients, and there were no perioperative complications. Follow-up intervals ranged from 2 months to 24 months (mean, 9 months; median, 13 months). CONCLUSIONS: Analogous to upper eyelid ptosis repair by advancement of the levator aponeurosis, lower eyelid reverse ptosis may be corrected effectively and safely by advancing the lower eyelid retractors.