The Treatment of Post-blepharoplasty Lower Eyelid Retraction.

Numerous solutions for post-blepharoplasty lower eyelid retraction are reviewed. Patients require permanent recruitment of skin and soft tissue to lengthen the lower eyelid and control of the lower eyelid shape. The authors use a hand-carved expanded polytetrafluoroethylene (ePTFE) implant held with microscrews to provide volume and felting material at the orbital rim and to permanently fix vertically lifted cheek soft tissue into the lower eyelid. The eyelid margin is also controlled with a hard palate graft inset into the conjunctival surface below the tarsus. This eyelid reconstruction avoids tension on the lateral canthoplasty, a point of failure in other solutions.

Revisiting the Safety of Prostaglandin Analog Eyelash Growth Products.

BACKGROUND: The FDA approved bimatoprost ophthalmic solution 0.03% for treatment of eyelash hypotrichosis in 2008. Consumer concern persists regarding potential side effects of this product. OBJECTIVE: To identify gaps in the safety information associated with the use of prostaglandin eyelash growth products. MATERIALS AND METHODS: Literature searches were performed using PubMed, Embase, and Nexis Uni databases without restriction to publication date, language, or study setting. RESULTS: The literature pertaining to bimatoprost for treatment of eyelash hypotrichosis is dominated by industry-sponsored clinical trials. Study design choices create gaps in our understanding of the clinical safety of these products. CONCLUSION: Because of study design choice, clinical trials of bimatoprost for eyelash growth may have systematically underreported the incidence of drug application discomfort and prostaglandin-associated periorbitopathy. The risk of increased iris pigmentation remains inadequately investigated. Consequently, there is an ongoing need to educate and monitor patients who choose to use these products.

Pathology Of "Post-Upper Blepharoplasty Syndrome": Implications For Upper Eyelid Reconstruction.

BACKGROUND: The anatomical basis for eyelid changes after upper blepharoplasty is largely uninvestigated. The post upper blepharoplasty syndrome (PUBS) is here defined as upper eyelid ptosis, hollow sulcus, high or absent upper eyelid crease, eyelash ptosis, loose eyelid platform skin, and compensatory brow elevation. OBJECTIVE: The anatomical basis for the post-upper blepharoplasty syndrome was investigated. METHODS: A retrospective, case-controlled, consecutive series of patients was explored for blepharoptosis after cosmetic blepharoplasty (cases) or ptosis surgery (controls). The upper eyelid crease was lowered, blepharoptosis was corrected by anterior levator aponeurosis resection ptosis surgery, eyelash ptosis was corrected with anchor blepharoplasty, and upper eyelid fold volume was restored using anterior orbital fat. Morphologic and anatomical findings were compared between case and control eyelids. RESULTS: Data were available for 42 patients (81 eyelids). Case and control eyelids presented with a clinically similar appearance but internally had a marked difference in their anatomical findings. Eyelids with post-upper blepharoplasty syndrome (n= 24 patients, 48 eyelids) were internally found to have a white-line disinsertion of the levator aponeurosis. The disinserted, central levator aponeurosis was bound into the septal scar created by removal of anterior orbital fat at blepharoplasty. Among the 18 controls (33 eyelids), levator disinsertion was not identified. CONCLUSION: Hollowness and ptosis in post-upper blepharoplasty syndrome eyelids are related to a white-line disinsertion of the levator aponeurosis and matting of anterior orbital fat in the internal septal scar created during fat removal with blepharoplasty. Knowing where to look for the disinserted central levator is critical to surgically repairing these post-blepharoplasty eyelids.

Surgical Predictors of Reduced Marginal Reflex Distance After Upper Blepharoplasty.

PURPOSE: Ptosis may occur in certain cases after upper blepharoplasty. The authors aim to characterize the incidence of postoperative marginal reflex distance (MRD1) reduction after upper blepharoplasty and surgical variables that may predict this occurrence. METHODS: In this cross-sectional study, patients > 18 years old undergoing upper blepharoplasty were screened. Patients were excluded if they had any history of ptosis and brow surgery. Data regarding the excision of skin, muscle, fat, and brow fat as well as crease formation were documented. The distance in millimeter from the center of the pupil to the upper eyelid margin in the midpupillary line (MRD1) was measured digitally. The primary outcome measure was a postoperative reduction in MRD1 of >1 mm. Secondary outcome was overall mean change in MRD1 and the incidence of ptosis as defined by a final MRD1 ≤ 2.5 mm. RESULTS: The final sample consisted of 100 patients (200 eyelids) and the mean age was 55.8 years. There were 65 patients with orbicularis muscle removal, 52 patients with postseptal fat removed, and 9 patients with crease formation. Overall 15 patients developed MRD1 decrease of greater than 1 mm (5 bilaterally and 10 unilaterally) with 7 eyes demonstrating a final MRD1 of ≤ 2.5 mm. In multivariate modeling, muscle removal was found to be the only variable with significant impact on the development of MRD1 reduction > 1 mm after upper blepharoplasty (p < 0.05, odds ratio = 8.2). The other variables did not significantly contribute. The overall mean (SD) MRD1 was 3.43 mm (1.1) preoperatively and 3.62 mm (1.1) postoperatively (p < 0.01). CONCLUSIONS: Fifteen percent of patients demonstrated a reduction in MRD1 > 1 mm after upper eyelid blepharoplasty, and those with orbicularis resection were more likely to experience this change.The authors' study demonstrates a 15% incidence of postoperative MRD1 reduction after upper eyelid blepharoplasty. Orbicularis oculi muscle removal was significantly associated with this occurrence.

Chlorhexidine Keratitis: Safety of Chlorhexidine as a Facial Antiseptic.

BACKGROUND: Effective antiseptic to reduce surgical site infections is a cornerstone of modern surgery. Chlorhexidine gluconate-based antiseptics are among the most effective of these products. Unfortunately, chlorhexidine solutions are toxic to the cornea and middle ear, and they pose a splash risk to both the patient and health care personnel. OBJECTIVE: To examine the clinical evidence that led to the disavowal of chlorhexidine antiseptic solution for use on the face and head. METHODS AND MATERIALS: Reference searches were performed using PubMed, Embase, and LexisNexis databases without restriction to the date of publication, language, or study setting. RESULTS: The literature revealed 11 sentinel cases of severe chlorhexidine-related keratitis in the late 1980s. These cases are reviewed together with data on ototoxicity and alternative products to understand why chlorhexidine solution should not be used on the face and scalp. CONCLUSION: Chlorhexidine antiseptic solutions are highly effective. However, they pose a risk to the middle ear and have the potential to irreversibly damage the cornea with a minimal splash exposure. Povidone-iodine is a safe and effective alternative.

Persistence of Upper Blepharoptosis After Cosmetic Botulinum Toxin Type A.

BACKGROUND: Upper eyelid ptosis after cosmetic botulinum toxin is generally considered short-lived and responsive to apraclonidine ophthalmic drops. The authors present a series with persistent ptosis. OBJECTIVE: To report a series of patients with persistent upper eyelid ptosis after cosmetic botulinum toxin. MATERIALS AND METHODS: A retrospective case review series of 7 patients referred for management after developing visually significant upper eyelid ptosis after cosmetic botulinum toxin type A treatment. RESULTS: Patients in this series experienced persistent visually significant ptosis after cosmetic botulinum toxin lasting from 6 weeks to 13 months. Six of the 7 patients were treated with apraclonidine ophthalmic solution. Apraclonidine drops appeared to be clinically effective within 4 to 6 weeks of the resolution of ptosis. CONCLUSION: Upper eyelid ptosis after cosmetic botulinum toxin can persist for many months after treatment. Based on this series, the authors propose that apraclonidine drops can be used at the time of initial assessment to predict the relative longevity of ptosis after cosmetic botulinum toxin treatment (Level 4 evidence recommendation). After a 1-week trial, responders can be advised that ptosis is likely to resolve in 4 to 6 weeks. Nonresponders should be counseled that resolution may take longer than 6 weeks.

Cosmetic Microdroplet Botulinum Toxin A Forehead Lift: A New Treatment Paradigm.

PURPOSE: To investigate the safety and efficacy of a microdroplet, cosmetic, periocular botulinum toxin A method that extensively treats the eyebrow depressors but leaves the brow elevators untreated. METHODS: This is a 5-year retrospective, consecutive, nonrandomized series of botulinum toxin treatments. The study was reviewed by an institutional review board and complied with the Health Insurance Portability and Accountability Act (HIPAA). Patients were treated with 33 U onabotulinum toxin (BOTOX, Allergan, Inc., Irvine, CA, U.S.A.) injected in microdroplets of 10 to 20 µl. Sixty to 100 injections of microdroplets were needed to complete a treatment pattern concentrated at the brow, glabella, and crows feet area. The forehead was not treated. Patients who returned between 10 and 45 days were studied with image analysis. RESULTS: There were 563 consecutive microdroplet treatments on 227 unique patients (female, n = 175, mean age 46 ± 4 years; male, n = 52, mean age 44 ± 8 years). The incidence of ptosis was 0.2% and transient. Forty-nine patients returned for a follow-up visit between 10 and 45 days and were included for image analysis to compare the before and after results of treatment. The average brow height was 24.6 mm before and 25 mm after treatment (p = 0.02). Photonumeric scales for forehead lines, brow ptosis, and brow furrow all showed statistically significant improvements (p < 0.0001). CONCLUSIONS: The microdroplet brow lift method safely concentrates cosmetic botulinum toxin treatment along the eyebrow, crows feet, and glabellar area, resulting in a brow lift effect that reduces forehead lines, elevates the eyebrow, and reduces the furrow along the brow. This new treatment paradigm results in an aesthetic improvement to the face and periocular area without the forehead paralysis associated with conventional treatment.

Traumatic optic neuropathy: an evolving understanding.

PURPOSE: To critically review the treatment of traumatic optic neuropathy. DESIGN: A perspective of clinical and basic science studies related to traumatic optic neuropathy and its treatment. METHODS: Published clinical and basic science studies on traumatic optic neuropathy were critically reviewed and interpreted. RESULTS: Clinical progress in the treatment of traumatic optic neuropathy is limited by small clinical studies lacking appropriate control groups. The Corticosteroid Randomization for Acute Head Trauma (CRASH) trial found an increased rate of death among patients with acute head trauma treated with high-dose corticosteroids compared to placebo-treated patients (21% vs 18%, P = .0001). Recent animal studies also suggest that high-dose corticosteroids are toxic to the injured optic nerve. CONCLUSIONS: The Corticosteroid Randomization for Acute Head Trauma study is immediately relevant to the treatment of traumatic optic neuropathy as individuals with traumatic optic neuropathy often have concomitant head trauma. High-dose corticosteroids for traumatic optic neuropathy will result in a measurable loss of life in patients who also have a brain injury. Death has never been an endpoint for traumatic optic neuropathy studies. Given human and animal data suggesting that treatment is harmful and the lack of demonstrated clinical efficacy, corticosteroids should not be used to treat traumatic optic neuropathy. The benefit of optic canal decompression is also unclear. There is a need to identify traumatic optic neuropathy soon after injury to further define the natural history of this injury. This information will provide a basis for assessing potential future treatments for traumatic optic neuropathy.

Deep-fill hyaluronic acid for the temporary treatment of the naso-jugal groove: a report of 303 consecutive treatments.

PURPOSE: To report a 2-year experience of treating the naso-jugal groove with injectable hyaluronic acid gel, using a deep-fill method. METHODS: This was a consecutive, retrospective, nonrandomized case series of patients presenting with concerns involving dark circles, lower eyelid hollows, or other contour irregularities that make up the naso-jugal groove. One author performed all treatments, consisting of transcutaneous injection of hyaluronic acid gel filler, to address the naso-jugal groove. The filler was placed deep on the anterior lip of the orbital rim and molded to the desired shape. RESULTS: Between December 2003 and December 2005, 164 patients (34 male and 130 female) received hyaluronic acid gel filler in the face. Ninety-eight patients were treated just once and 66 had multiple treatment sessions. The mean dose of filler per session was 1.53 +/- 0.8 ml, with 0.84 +/- 0.38 ml divided between the two lower eyelids. The most common complication was localized swelling, followed by bruising, asymmetry, cellulitis (2 cases), and migraine (1 case). There were no cases of visual loss. CONCLUSIONS: Hyaluronic acid gel fillers have had an enormous impact on the practice of cosmetic surgery, and this series demonstrates the usefulness of these fillers for treatment of the lower eyelid and midface. The authors recommend the deep-fill method described as a reliable means of addressing the hollow created by the naso-jugal groove.

Treatment of traumatic optic neuropathy with high-dose corticosteroid.

Based on the favorable clinical results in acute spinal cord injury, high-dose methylprednisolone at an intravenous loading dose of 30 mg/kg followed by a continuous infusion of 5.4 mg/kg/h for 24 or 48 hours has been adopted for the treatment of acute traumatic optic neuropathy (TON). Although there is anecdotal evidence of the efficacy of high-dose corticosteroid in this condition, there are no prospective, randomized trials to attest to its benefit. On the other hand, the largest retrospective study showed no benefit of high-dose corticosteroid treatment of TON. Moreover, subsequent study of such treatment of acute spinal cord injury has disclosed that the clinical benefit is modest and that treatment is actually harmful if administered more than eight hours after injury. A recently reported placebo-controlled randomized clinical trial of high-dose corticosteroids in head injury was stopped prematurely because of a significantly greater mortality in the corticosteroid-treated patients. Recent experimental studies suggest that methylprednisolone may be harmful to the optic nerve. Considering this clinical and experimental evidence, there is no basis for treating TON with high-dose corticosteroid.