Alternating ptosis after bilateral frontalis muscle suspension for congenital ptosis.

PURPOSE: To report an unusual response to bilateral frontalis suspension surgery for congenital ptosis. METHODS: Case report. RESULTS: A 6-year-old child with infantile esotropia and bilateral congenital ptosis received a homologous fascia lata frontalis suspension. After surgery, the patient exhibited an alternating ptosis, caused by alternating unilateral frontalis muscle contraction, which has persisted throughout 3 years of postoperative observation. CONCLUSION: Symmetric frontalis muscle activation may not always occur after bilateral frontalis muscle suspension surgery for congenital ptosis. Amblyopia, strabismus, or fixation preference may predispose patients to use unilateral brow elevation, despite bilateral frontalis muscle suspension surgery.

Primary and secondary transconjunctival involutional entropion repair.

PURPOSE: Lower eyelid involutional entropion is a significant disorder of the aging population resulting from horizontal eyelid laxity, overriding orbicularis oculi muscle, and attenuation of the lower eyelid retractors. The purpose of this study is to describe the long-term results of transconjunctival entropion repair. DESIGN: Interventional noncomparative case series. PARTICIPANTS: Thirty-six eyelids in 31 patients. METHODS: Charts were reviewed of all transconjunctival entropion repairs, which included myectomy, retractor fixation, and horizontal shortening performed by three oculoplastic surgeons between January 1993 and January 1999. Cases with less than 12 months follow-up were excluded. MAIN OUTCOME MEASURES: Entropion recurrence. RESULTS: Thirty-six lids in 31 patients were followed for mean of 31.5 months (12.5-79). Six of 36 lids (16.7%) had postoperative complications. Recurrent entropion occurred in 3 of 36 lids (8.3%) an average 16.3 months (7-35) after surgery. An average of 6 trichiasis lashes (1-10) occurred in 4 of 36 lids (11.1%) at a mean of 2.25 months (1-4) after surgery. There were no overcorrections. Three of 36 lids (8.3%) required additional surgery. CONCLUSIONS: Entropion recurrence after three-step transconjunctival repair is within the 0% to 30% reported recurrence for other repair techniques but more frequent than reported for a similar transcutaneous procedure. The 8.3% recurrence rate might have resulted from inadequate myectomy, inadequate retractor fixation, cicatricial changes directly related to the transconjunctival incision, or progressive involutional changes. Trichiasis was the most frequent complication. Transconjunctival entropion repair may be slightly less effective than transcutaneous repair.

The anatomy of midfacial ptosis.

PURPOSE: To investigate the anatomic and histologic changes present in midfacial ptosis. METHODS: Experimental study applying gross anatomic and histologic techniques to formalin-preserved and fresh-frozen cadaver heads with and without midfacial ptosis. High-resolution surface coil magnetic resonance imaging (MRI) was performed to obtain radiologic correlations. RESULTS: The orbitomalar ligament was further characterized by identification of a well-developed lateral component in the sub-superficial musculoaponeurotic plane; abnormalities of this important supporting structure were present in the subcutaneous plane in 8 of 10 specimens with midfacial ptosis. The zygomatic and masseteric cutaneous ligaments also were further characterized on a gross anatomic level, and histologic evidence of these two structures was produced. The subcutaneous components of the zygomatic and masseteric cutaneous ligaments were attenuated or not identifiable in 40% and 30% of specimens with midfacial ptosis, respectively. High-resolution surface coil MRI provided exquisite correlations of midfacial anatomy. CONCLUSIONS: The lateral component of the orbitomalar ligament provides major osteocutaneous midfacial support. Subcutaneous attenuation of the orbitomalar, masseteric cutaneous, and zygomatic ligaments was associated with midfacial ptosis.

Identification of human orbital lymphatics.

PURPOSE: To identify lymphatic vessels in the human orbit. METHODS: Lymphatic and blood capillaries were distinguished histochemically by light microscopy using a 5'-nucleotidase (5'-Nase) and alkaline phosphatase (ALPase) double staining method. Identification of lymphatic vessels was based on strict morphologic criteria combined with specific 5'-Nase staining. RESULTS: The presence of conjunctival lymphatics was confirmed and used as a control tissue. Lymphatic vessels were identified in the lacrimal gland and in the dura mater of the optic nerve. Structures demonstrating positive 5'-Nase staining at the orbital apex were highly suggestive of lymphatics but did not meet the morphologic criteria established. Lymphatic vessels were not identified in the extraocular muscles or orbital fat. CONCLUSION: To the authors' knowledge, this study presents the first evidence for lymphatic capillaries in the dura mater of the human optic nerve and lacrimal gland.

The Asian upper eyelid: an anatomical study with comparison to the Caucasian eyelid.

OBJECTIVE: To evaluate the differences between Asian and Caucasian upper eyelid anatomy through cadaver dissection, histopathological study, and magnetic resonance imaging. MATERIALS AND METHODS: Upper eyelids of 9 Korean and 5 Caucasian cadavers were dissected, and then were studied microscopically with hematoxylin-eosin, Masson trichrome, and elastin stains. Four healthy young Korean men were studied by dynamic high-resolution magnetic resonance imaging with regard to demonstration of upper eyelid structure. RESULTS: More subcutaneous and suborbicularis fat, with a pretarsal fat component, is present in Asian eyelids. The Asian double eyelids showed an amount of fat intermediate between Asian single eyelids and Caucasian eyelids. Asian single eyelids showed fusion of the orbital septum to the levator aponeurosis below the superior tarsal border, while fusion is above the superior tarsal border in Caucasians. The preaponeurotic fat pad descends anteriorly to the tarsal plate in the Asian single eyelid, but not in the Caucasian eyelid. A pretarsal fat pad is identified in the Asian single eyelids. CONCLUSIONS: The causes of absent or lower crease in the Asian upper eyelid are as follows: (1) the orbital septum fuses to the levator aponeurosis at variable distances below the superior tarsal border; (2) preaponeurotic fat pad protrusion and a thick subcutaneous fat layer prevent levator fibers from extending toward the skin near the superior tarsal border; and (3) the primary insertion of the levator aponeurosis into the orbicularis muscle and into the upper eyelid skin occurs closer to the eyelid margin in Asians. Structural differences relating to increased fat in the Asian upper eyelid include the presence of a pretarsal fat pad and a moderate fat increase in the double Asian eyelid.

Management of moderate-to-severe Marcus-Gunn jaw-winking ptosis.

OBJECTIVE: To report the results of levator excision and frontalis suspension for moderate-to-severe Marcus-Gunn jaw-winking ptosis. DESIGN: A retrospective noncomparative case series. PARTICIPANTS: Twenty-four patients with moderate-to-severe Marcus-Gunn jaw-winking ptosis (21 unilateral and 3 bilateral) were treated surgically between 1978 and 1997 by one surgeon. INTERVENTION: Levator excision either in the involved eyelid or in both eyelids, followed by bilateral frontalis suspension, was performed. MAIN OUTCOME MEASURES: Postoperative improvement of jaw-winking was determined. The surgical results of ptosis surgery were assessed as good, fair, or poor based on habitual upper eyelid heights and symmetry. RESULTS: Postoperative follow-up periods ranged from 6 months to 153 months, with an average of 36.9 months. After levator excision in a total of 27 eyelids exhibiting jaw-winking, 10 eyelids (37.0%) showed complete resolution of jaw-winking, and 13 eyelids (48.2%) showed mild winking (1 mm or less) on the lateral jaw movement only (functionally and cosmetically not a problem). In four eyelids (14.8%), these results were not recorded. In the group of five patients undergoing bilateral frontalis suspension and levator excision only on the involved side, final results were good in two patients (40%) and poor in three (60%). Of the 19 patients who underwent bilateral levator excision, final results were good in 13 (68.4%) and fair in 6 (31.6%). CONCLUSIONS: For moderate-to-severe jaw-winking ptosis, bilateral frontalis suspension after bilateral levator excision generally provided satisfactory correction of both jaw-winking and ptosis.

A tarsal strip-periosteal flap technique for lateral canthal fixation.

Lateral canthal fixation is widely used. This article sought to determine if a periosteal flap used routinely in conjunction with a tarsal strip provides lasting lateral canthal fixation. This consecutive clinical series from two ambulatory surgery centers followed 79 patients who underwent 141 lateral canthal fixation procedures. Outcome was measured by the position of the lateral canthus. Correct positioning of the lateral canthus was achieved in 78 of 79 patients representing 139 of 141 procedures (98%). The failed case was a patient with floppy eyelid syndrome in whom the sutures tore through the tarsal strips. The tarsal strip-periosteal flap technique is a successful, technically direct method of lateral canthal fixation. It is promoted as an enhancement of the tarsal strip technique, and is especially helpful in patients with prominent eyes.

Primary orbital Ewing sarcoma in a middle-aged woman.

A 43-year-old woman had unilateral exophthalmos caused by primary orbital Ewing sarcoma. Specialized immunohistochemical stains, primarily MIC-2 (CD99), aided in the diagnosis of Ewing sarcoma. Twenty-two months after radiotherapy and multiagent chemotherapy, the patient remained tumor free. To our knowledge, this is the first reported case of orbital Ewing sarcoma to present in an adult beyond the fourth decade of life.

Reoperation in acquired involutional ptosis.

Postoperative upper lid asymmetry is a common problem following ptosis surgery. Recently we performed multiple ptosis operative procedures to correct lid asymmetry in the management of a patient with bilateral acquired upper eyelid ptosis. The patient's eyelids were corrected successfully after five procedures. We retrospectively reviewed the treatment of this patient with unsatisfactory results. The medical literature was reviewed for further insight into the common problem of reoperation after ptosis surgery.

Characterization of human orbital fat and connective tissue.

This study was designed to evaluate the characteristics of human orbital fat and connective tissue. Two exenteration specimens were studied by light microscopy with special stains. Four distinct regions were identified on the basis of their connective tissue septa, which contained blood vessels and were composed of elastin and collagen types I, III, and IV. Transmission electron microscopy was performed on the opposite orbits. The fibroblasts and adipocytes appeared metabolically inactive and showed no regional differences. The fat was phase extracted from the connective tissue and subjected to biochemical analysis. No regional differences were found in the content of fatty acids and protein. The fatty acids included palmitic acid (22-24.6%), oleic acid (45-51.5%), and linoleic acid (15-18.6%). Despite demarcation of the orbital fat into distinct regions by the connective tissue septa, ultrastructural and biochemical analysis revealed no regional variations in the fat. The diagnostic and therapeutic implications of these findings are discussed.

Rounding of the inferior rectus muscle: a helpful radiologic findings in the management of orbital floor fractures.

The authors describe a patient with an orbital floor fracture that did not demonstrate a distinct fracture on computed tomography (CT) imaging. The key radiologic finding was rounding of the inferior rectus muscle.

Leiomyosarcoma metastatic to the orbit: diagnosis of fine-needle aspiration.

A 47-yr-old man with history of metastatic low-grade rectal leiomyosarcoma presented with progressive protrusion of his left eye due to an enlarging orbital mass. The differential diagnosis included tumor metastasis or orbital infection due to an unknown infectious agent. Diagnostic fine-needle aspiration (FNA) of the orbit was performed on an urgent basis to institute proper therapy and to save the patient's eyesight. Cytomorphologic examination of the material demonstrated a spindle-cell neoplasm consistent with metastatic leiomyosarcoma. It is a rare event for leiomyosarcoma to occur in the orbit. On our review of the literature, the cytology of primary orbital leiomyosarcoma on FNA has only been reported once. To our knowledge, this is the first report of the FNA cytomorphology of metastatic leiomyosarcoma to the orbit.

Eyelid splitting with excision or microhyfrecation for distichiasis.

Distichiasis is a rare congenital or acquired condition in which an accessory row of eyelashes arises from the posterior lamella of the eyelid margin. Previously described surgical techniques to treat distichiasis can result in complications including trichiasis, loss of normal eyelashes, cicatricial entropion, and eyelid margin deformities. We describe a new technique in which the eyelid margin is split to expose the distichiasis eyelash follicles. Each aberrant eyelash follicle is individually excised or microhyfrecated and then removed. Seventeen eyelids in 5 patients with congenital or acquired distichiasis have been treated. We have achieved excellent functional and cosmetic results using this new technique.

Relations of the superficial musculoaponeurotic system to the orbit and characterization of the orbitomalar ligament.

The orbital and eyelid relationships of the superficial musculoaponeurotic system (SMAS) were studied in human cadavers. Using gross and microscopic techniques, the SMAS was found to be intimately related to the eyelids and orbicularis oculi muscle, and to have distinct orbital bony attachments. Sub-SMAS fat in the malar region was found to be continuous with the submuscular fat in the eyebrow region. The malar sub-SMAS fat continued superiorly into the lower eyelid above the inferior orbital rim, as a postorbicularis layer. A bony attachment emanating from the inferior orbital rim, the orbitomalar ligament, traveled through the orbicularis oculi muscle in a lamellar fashion prior to inserting into the dermis. The cutaneous insertion of this attachment corresponds to the malar and nasojugal skin folds. With aging, relaxation of the orbitomalar ligament allows inferior migration of orbital fat, in addition to the anterior migration that occurs through an attenuated orbital septum. These findings have implications not only in cosmetic surgery but also in the understanding of facial soft tissue changes that occur with aging.

Inverted papillomas that invade the orbit.

We describe 10 patients with inverted papillomas (IPs), uncommon endophytic epithelial tumors that arose in the nose, paranasal sinuses, and lacrimal sac, that invaded the orbit; review the world literature on IP; and discuss treatment options. Patients ranged in age from 49 to 72 years (mean age, 62 years; median age, 66 years). Six patients were men and four were women. Presenting symptoms and signs included a medial canthal mass (n = 5), epiphora/lacrimal drainage obstruction (n = 3), inability to wear eyeglasses (n = 2), diplopia (n = 1), and painful dentures (n = 1). Histopathologic examination was performed in each patient and revealed all patients to have areas with malignant transformation: six patients with IPs that contained areas of squamous cell carcinoma and four with areas of transitional cell carcinoma in the tumor within the orbit. Eight of the patients with IPs had a recurrence after initial resection. In two patients, the IPs were completely excised and did not recur; yet, follow-up was short. Eight patients required orbital exenteration for local control of disease. Nevertheless, local spread of tumor through bone to brain occurred in three patients with orbital involvement. Indeed, IPs that invade the orbit have a high incidence of malignancy and are locally aggressive tumors. Treatment is difficult, and the recurrence rate is high. Early, wide excision of this aggressive tumor provides the best chance of cure.

Oculinum injection-resistant blepharospasm in young patients.

Botulinum toxin has recently been used as a nonsurgical treatment for blepharospasm and other facial dyskinesias. This report describes four patients between the ages of 32 and 37 years who failed to respond to botulinum injections for severe blepharospasm. Other than age, no other features could be identified in these patients that would differentiate this group. Particularly early age of onset for essential blepharospasm might be an indicator of failure to respond to the injections.