Multi-channel orbicularis oculi stimulation to restore eye-blink function in facial paralysis.

Facial paralysis due to facial nerve injury results in the loss of function of the muscles of the hemiface. The most serious complication in extreme cases is the loss of vision. In this study, we compared the effectiveness of single- and multiple-channel electrical stimulation to restore a complete and cosmetically acceptable eye blink. We established bilateral orbicularis oculi muscle (OOM) paralysis in eight dogs; the OOM of one side was directly stimulated using single-channel electrical stimulation and the opposite side was stimulated using multi-channel electrical stimulation. The changes in the palpebral fissure and complete palpebral closure were measured. The difference in current intensities between the multi-channel and single-channel simulation groups was significant, while only multi-channel stimulation produced complete eyelid closure. The latest electronic stimulation circuitry with high-quality implantable electrodes will make it possible to regulate precisely OOM contractions and thus generate complete and cosmetically acceptable eye-blink motion in patients with facial paralysis.

Orbital ganglioglioma arising from ectopic neural tissue.

PURPOSE: To report a case of neonatal orbital ganglioglioma originating from ectopic neural tissue. METHOD: Case report. RESULTS: An African-American male presented at birth with proptosis and expansion of the left orbit. A discrete soft-tissue mass was located inferolateral to the globe, which proved to be a ganglioglioma. CONCLUSION: The tumor is presumed to have originated from ectopic neural tissue in the orbit. Although infrequent, this tumor should be included in the differential diagnosis of neonatal orbital neoplasms.

Expansion of the human microphthalmic orbit.

OBJECTIVE: To determine the effects of long-term, incremental enlargement of an orbital tissue expander on bone and eyelid growth in microphthalmia. DESIGN: A prospective, noncomparative case series. PARTICIPANTS: Five consecutive patients with microphthalmos treated with orbital expansion were evaluated. INTERVENTION: A tissue expander was placed into the orbits of five children (age, 10 months-6 years) with unilateral microphthalmos and gradually enlarged by saline injections. MAIN OUTCOME MEASURE: The midorbital width of each patient was determined from axial computed tomographic scans before insertion of the device. The length of the normal and abnormal eyelid fissures was measured at surgery. The postexpansion dimensions of both the normal and microphthalmic orbits and the eyelids were remeasured when the expanders were removed. The residual deficits between the normal and the microphthalmic sides were expressed in percentages. RESULTS: Gradual inflation of the expander to a diameter of 22 mm reduced the average preoperative orbital dimension deficit of the group from 14.6% (range, 8%-25%) to 3.8% after surgery (range, 0.5%-6.3%). The average pre-expansion eyelid length deficit for the group was 17.5% (range, 12%-26%) compared to 2.3% (range, 0.0%-5.3%) after expansion. The average expansion period was 56.8 weeks (range, 20-100 weeks). Two outpatient surgical procedures were required in each patient. CONCLUSION: Incremental inflation of a tissue expander placed within the microphthalmic orbit induced sufficient osseous and eyelid growth to ameliorate the major stigmata of this syndrome in all patients treated.

Involutional entropion repair by posterior lamella tightening and myectomy.

Involutional entropion is a common eyelid malposition of diverse etiology that may recur after surgical repair. Laxity of the tarsoligamentous complex combined with posteriorly directed rotational force exerted by the orbicularis, in our view, seems to be the most important in the production of entropion. A surgical technique has been developed that is carried out through a standard transcutaneous lower eyelid blepharoplasty incision. It includes tarsoligamentous tightening at the lateral canthus, bolstering of the lateral canthal tendon, and partial orbicularis myectomy. Forty-two procedures in 35 consecutive patients (29% for recurrent entropion) have been performed and evaluated (mean follow-up, 33 months). There have been no recurrences, and the esthetic outcome has been very good.

Spontaneous direct carotid-cavernous fistula in childhood.

We report the occurrence, surgical treatment and long-term follow-up of a spontaneous, direct carotid-cavernous fistula in a child. It is the third angiographically documented, spontaneously occurring fistula to be reported in this age group and the first to arise directly from the internal carotid artery based on our review of the literature. Although our patient required fistula closure, other reported fistulae were nonprogressive and did not require treatment. The communication between the internal carotid artery and the cavernous sinus was left sided while the contralateral eye was proptotic. The clinical features, selected hemodynamic characteristics, and treatment of carotid-cavernous fistulas are reviewed.

Restoration of orbicularis oculi function by contralateral orbicularis oculi innervated muscle flap vs neuromuscular pedicle technique.

In preliminary experiments with dogs and cats, unilateral paralysis of the orbicularis oculi muscle group was produced by a section of the seventh nerve that included the posterior auricular branch. Either one of two procedures was then employed in attempts to reinnervate the paralyzed eyelid. In one group of animals, a neuromuscular pedicle was employed and in another, a contralateral orbicularis innervated muscle flap was used. Both methods restored synchronous, reflex blinking to the denervated eyelid. Of the two procedures, neurotization appears to offer the greater promise because the use of a neuromuscular pedicle requires an expendable nerve that is functional, and no such suitable substitute is available in humans.

The tarsal pillar technique for narrowing and maintenance of the interpalpebral fissure.

We describe a tarsorrhaphy technique whereby an ipsilateral upper-eyelid tarsal pillar is sutured to a corresponding lower-eyelid recipient site. This technique allows maintenance of a narrowed interpalpebral fissure indefinitely, yet is easy to reverse without incurring lid-margin damage. Additionally, the procedure can be adjusted postoperatively to either narrow or widen the initial surgical result. We report our combined surgical experience in 35 consecutive procedures using this technique to treat eyes with exposure-related keratopathy of varied etiology, including facial nerve palsies, combined facial nerve palsy and trigeminal neuropathy with an anesthetic cornea, Graves' disease, congenital craniofacial anomalies, and severe keratitis sicca syndrome. The procedure was successful in improving exposure keratopathy symptoms in all 35 cases. Complications, reflecting the authors' learning curve with this new procedure, included intermarginal pyogenic granulomas, stretching of the tarsal pillar, minor lower-eyelid-margin eversion, and tarsal pillar dehiscence.

Prospective evaluation of the argon laser in the treatment of trichiasis.

We report the results of argon-laser treatment in 60 consecutive eyelids with focal, symptomatic trichiasis. Permanence of eyelash destruction compared favorably with that reported for cryosurgery; complications were limited to minimal contour abnormalities and hypopigmentation.

Ophthalmic aspects of orbital injury. A comprehensive diagnostic and management approach.

Improved prognosis for eye injuries sustained during facial trauma depends on early assessment and accurate diagnosis. The surgeon responsible for management of the orbital fracture(s) must perform an ocular assessment at the time of initial examination. Abnormalities found on the five-point assessment outlined herein should lead to urgent ophthalmic consultation. Fracture repair should not be undertaken until the results of consultation have been discussed with the ophthalmologist. Vision should be carefully monitored in the preoperative period because delayed optic neuropathy may occur. Similarly, vision should be followed regularly in the postoperative period after reduction of fractures of the orbital bones. Decreased postoperative vision should lead to immediate ocular assessment and early ophthalmologic consultation.

Three primitive reflexes in normal adults.

One or more of three primitive reflexes (palmomental, snout, and corneomandible) was elicited in 50.5% of 105 normal subjects in the third through the ninth decades of life. The reflexes appeared in a patterned fashion with advancing age. The palmomental reflex appeared earliest and was the most frequent reflex elicited at all ages. The snout and corneomandibular reflexes appeared at later ages and were elicited less frequently. The palmomental and snout reflexes often occurred alone, but the corneomandibular was elicited only when one or both of the other reflexes was also present. These reflexes appear to be normal phenomena in a significant proportion of the healthy population.

Three primitive reflexes in parkinsonism patients.

One or more of three rimitive reflexes (palmomental snout, and corneomandibular) was elicited in 63.8% of 58 parkinsonism patients in the sixth through ninth decades of life. The incidences of the palmomental and snout reflexes in parkinsonism patients did not differ significantly from the incidences in 60 normal subjects of similar ages. The incidence of the corneomandibular reflex in parkinsonism patients was approximately 2 1/2 times greater than the incidence observed in the normal subjects. The high incidence of the corneomandibular reflex in parkinsonism appears to be related to the disease, but the incidences observed for the palmomental and snout reflexes can be attributed to aging.