Rotating suture technique combined with lid margin split and lower eyelid retractor disinsertion for epiblepharon.

Epiblepharon is an eyelid disease affecting 46-52.5% of Asian children. The Hotz procedure was commonly used for the treatment. However, the currently preferred technique is the rotating suture technique. This study aimed to report the recurrence rate and the complications of using the rotating suture technique combined with lid margin split and lower eyelid retractor (LER) disinsertion of epiblepharon. This was a retrospective study of the procedures performed between January 2017 and December 2020. This study included 64 eyelids of 37 patients who underwent the consecutive rotating suture technique, lid margin split, and LER disinsertion simultaneously for lower eyelid epiblepharon and were followed up for at least 6 months. The mean age of the patients who underwent surgery was 9.5 (5-28) years. The mean observation period was 8.3 (6-27) months. Recurrence was observed in one eyelid (1.6%). The complications included an ectopic eyelash on one eyelid (1.6%). LER disinsertion performed in this study had two advantages. First, the imbalance between the anterior and posterior lamellae was corrected. Disinserting the LER, the tarsal plate could be repositioned cranially, effectively addressing this imbalance. Second, LER disinsertion ensured direct exposure of the lower margin of the tarsal plate, facilitating the implementation of a reliable rotating suture. In conclusion, promising results were achieved by combining the rotating suture technique with LER disinsertion and lid margin splitting.

Comparison of postoperative recurrence rates between percutaneous and transconjunctival approaches for involutional entropion.

Lower eyelid entropion is the second most common disease seen after ptosis in oculoplastic outpatients. In this study, we performed percutaneous and transconjunctival shortening of the anterior and posterior layers of the lower eyelid retractor (LER) to treat lower eyelid involutional entropion. This study aimed to examine the recurrence rate and complications of the percutaneous and transconjunctival approaches. This was a retrospective study of procedures conducted from January 2015 to June 2020. The LER shortening was performed for lower eyelid involutional entropion on 103 patients (116 eyelids). From January 2015 to December 2018, LER shortening using the percutaneous approach was implemented; from January 2019 to June 2020, the transconjunctival approach was used to shorten the LER. All patient charts and photographs were retrospectively reviewed. Recurrence occurred in 4 patients (4.3%) in the percutaneous approach. No recurrence was observed in any patient in the transconjunctival approach. Temporary ectropion occurred in 6 patients (7.6%) when the percutaneous approach was used; all cases healed within 3 months after surgery. The study did not reveal any statistically significant difference in recurrence rates between the percutaneous and transconjunctival approaches. We achieved results equal to or better than percutaneous LER shortening by combining transconjunctival LER shortening with horizontal laxity shortening, such as lateral tarsal strip, pentagonal resection, and orbicularis oculi muscle resection. However, it is necessary to be careful about temporary ectropion after surgery when percutaneous LER shortening alone is performed for lower eyelid entropion.

Effects of Fat Repositioning for Tear Trough Deformity on Eye Movement.

ABSTRACT: Fat repositioning is a common surgical technique for treating tear trough deformity. As this technique is mainly performed for cosmetic purposes, its functional outcomes have rarely been evaluated. The purpose of this study was to evaluate the changes in eye movements that occur after fat repositioning for tear trough deformity. The authors performed fat repositioning on 18 eyelids of 9 patients and evaluated their eye movements and binocular vision before surgery and at 1, 3, and 6 months after surgery. Hess screen and Binocular single vision tests were performed during each follow-up examination and the scores were recorded. The authors observed that fat repositioning did not affect binocular vision; however, vertical and horizontal eye movements worsened at 3 months after surgery. Nevertheless, there was no significant difference between the eye movements recorded before surgery and those recorded 6 months after surgery. Regardless of this finding, it should be noted that vertical or horizontal strabismus might occur after fat repositioning for tear trough deformity.

Comparison of postoperative recurrence rates between levator aponeurosis advancement and external Müller's muscle tucking for acquired blepharoptosis.

Treatment options for acquired blepharoptosis include levator resection, levator aponeurosis advancement (LAA), Müller's muscle-conjunctival resection (MMCR), and frontalis suspension. Previously, we reported a technique called external Müller's muscle tucking (EMMT) using the Müller's muscle as a power source. In this study, we compare LAA with EMMT and evaluate the recurrence and reoperation rates. LAA was performed on 96 eyelids in 51 patients. The average follow-up period was 12.2 months, recurrence occurred in four eyelids (4.2%) of three patients, and reoperation was required in one eyelid of one patient (2.0%). EMMT was performed on 94 eyelids in 51 patients, the mean follow-up period was 10.5 months, recurrence occurred in 14 eyelids (15%) of 10 patients, and reoperation was required in three eyelids of two patients (3.9%). A comparison of LAA and EMMT recurrence showed that EMMT was associated with a significantly higher recurrence rate (P = 0.0021). The causes of EMMT recurrence included thinning and fatty degeneration of Müller's muscles, necrosis of ligated Müller's muscles, and less postoperative scar formation. There was no correlation between EMMT recurrence and the severity of the blepharoptosis.

Combination of Dermal fat Grafting and Frontalis Suspension Using Polytetrafluoroethylene Sheet for Blepharoptosis With a Deep Sulcus.

ABSTRACT: The frontalis suspension procedure is a common surgical method for patients with severe blepharoptosis. While frontalis suspension is a very effective method, the transplant material may be visualized after surgery in patients with a deep sulcus and severe blepharoptosis. To prevent this complication, we performed a combination of dermal fat grafting and frontalis suspension using a polytetrafluoroethylene sheet in 5 patients (6 eyelids). We followed-up the patients for at least 6 months postoperatively (mean: 6.8 months) and observed no transplant material visualization or occurrence of infection. The mean pre- and postoperative margin reflex distance-1 was -3.75 (-5 to -2) and 2.10 (1-3), respectively. Bulky upper eyelids were observed 6 months postoperatively in 1 patient (2 eyelids). None of the patients underwent reoperation. In conclusion, the combination of frontalis suspension using a polytetrafluoroethylene sheet and dermal fat grafting for severe blepharoptosis and a deep upper eyelid sulcus was effective in preventing visualization of the transplant material.

A New Surgical Method for Medial Ectropion Repair: Fixing the Lower Eyelid Retractor to the Back of the Tarsal Plate.

ABSTRACT: Involutional ectropion is a disease in which the eyelids are everted outwards, and because the eyelids move away from the eyeballs, the ocular surface and conjunctiva are exposed causing inflammation, pain, photophobia, foreign body sensation, epiphora, and blurred vision. It is thought to be caused by horizontal and vertical laxity. Various surgical methods have reportedly been used to correct involutional ectropion. Shortening the lower eyelid retractor (LER) is an indispensable surgical operation for medial ectropion. When the LER is shortened, it is usually fixed to the lower edge of the tarsal plate. Herein we describe a new type of surgery that has now been performed on 6 eyes in 4 patients. The procedure involves separating the conjunctiva from the tarsal plate, inserting the LER between the conjunctiva and the tarsal plate, and then fixing it to the back of the tarsal plate. In all 6 eyes, the lower eyelid now contacts the eyeball, and morphological improvements were achieved. This new surgical method is a useful way to raise the tarsal plate.

Gingival Sulcus Incision for Zygomaticomaxillary Complex Fracture.

The usual surgical approaches for zygomaticomaxillary complex fracture are subciliary incision, transconjunctival incision, eyebrow incision, lateral canthal incision, coronal incision, preauricular incision, and superior gingivobuccal incision. In the intraoral approach, a horizontal mucoperiosteal incision is performed at the superior gingivobuccal region, and sometimes, includes the upper labial frenum. This may cause discomfort in the oral cavity because of postoperative scarring and shortening of the upper labial frenum. To avoid these complications, the authors performed a novel approach using gingival sulcus incision instead of oral mucosal incision to treat 5 zygomatic fractures. The authors evaluated the regression of the gingival interdental papillae, gingival swelling, and gingival perception at 2 weeks, 1 month, 3 months, and 6 months after the operation. The regression of the gingival papillae and gingival swelling disappeared 3 months and 1 month after the operation, respectively. No paresthesia was observed in any of the cases. The gingival sulcus approach can lead to scarless results and contribute considerably to the aesthetic appearance of the oral cavity.

Evaluation of the eyebrow position after external Müller's muscle tucking: A new technique for ptosis repair.

Eyebrow descent commonly occurs after ptosis repair or blepharoplasty surgery. The procedures used to correct acquired blepharoptosis are primarily classified into four groups. These procedures target the levator aponeurosis, Müller's muscle, both the aponeurosis and Müller's muscle, or the frontalis muscle. In this study, we used a new technique called external Müller's muscle tucking (EMMT) on 51 patients (94 eyelids), which targets the Müller's muscle for involutional blepharoptosis. The patients were assessed by comparative analysis using pre- and post-operative digital photographs. The distances between the medial canthi, in addition to the eyebrow heights at the medial canthus, pupil and lateral canthus, were measured on a computer screen. Eyebrows descended after surgery at the medial canthus in 53 eyelids (56.4%), at the center of the pupil in 55 eyelids (58.5%) and at the lateral canthus in 48 eyelids (51.1%). The mean distances of eyebrow descent in the 94 eyelids were 0.24, 0.51 and 0.32 mm at the medial, center and lateral positions, respectively. The mean preoperative margin reflex distance (MRD) was -0.05 mm, the mean postoperative MRD was 3.79 mm and the mean change in MRD was 3.83 mm. Preoperative MRD and change in MRD were weakly associated with changes in eyebrow position in 94 eyelids. In conclusion, these findings suggest that eyebrow drooping distance is related to the preoperative severity of ptosis.

Evaluation of the eyebrow position after aponeurosis advancement.

Patients often develop eyebrow drooping after blepharoplasty or ptosis repair. After aponeurosis advancement was performed in 53 patients (100 eyelids) with blepharoptosis, the eyebrow heights at the medial canthus, center of the pupil, and lateral canthus were measured using scanned photographs obtained preoperatively and 3 months postoperatively. In the 100 eyelids subjected to aponeurosis advancement, the eyebrow position was lowered at the medial canthus in 81 eyelids (81%), at the center of the pupil in 84 eyelids (84%), and at the lateral canthus in 80 eyelids (80%). The mean distance of eyebrow drooping in the 100 eyelids was 2.80 mm at the medial canthus, 2.87 mm at the center of the pupil, and 2.50 mm at the lateral canthus. The preoperative margin reflex distance (MRD) was significantly associated with the distance of eyebrow drooping at the medial canthus, the center of the pupil, and the lateral canthus in the 100 eyelids, but the postoperative MRD was not significantly associated with these parameters in the 100 eyelids. In conclusion, eyebrow drooping developed after aponeurosis advancement in most cases, and the distance of eyebrow drooping was associated with the severity of blepharoptosis.

Evaluation of the eyebrow position after levator resection.

Although we commonly observe eyebrow drooping during and after blepharoptosis surgery, it may not occur in some cases. After levator resection was performed in 47 patients (84 eyelids) with blepharoptosis, the eyebrow heights at the medial canthus, the center of the pupil, and the lateral canthus were measured using scanned photographs obtained preoperatively and 3 months postoperatively. In the 84 eyelids, after levator resection, the eyebrow position was lowered at the medial canthus in 76 patients (90%), at the center of the pupil in 75 (89%), and at the lateral canthus in 76 (90%). The mean distance of eyebrow drooping in the 84 pupils was 2.74 mm at the medial canthus, 2.91 mm at the center of the pupil, and 2.58 mm at the lateral canthus. In addition, there was a significant difference between the extra skin excision group and the no skin excision group at the medial canthus (p = 0.027), the center of the pupil (p = 0.001), and the lateral canthus (p < 0.001) (Mann-Whitney test). Unfortunately, there was a significant difference in ages between the extra skin excision group and the no skin excision group. In conclusion, eyebrow drooping was caused after levator resection in most cases. However, it is difficult to anticipate eyebrow drooping distance before surgery.

Haemangiopericytoma of the lacrimal sac.

Haemangiopericytomas (HPCs) are rare tumours which infrequently occur in the lacrimal sac. Only 8 cases of lacrimal sac HPC have previously been reported. The authors report 2 additional cases presenting clinically with epiphora and a mass. One case recurred 3 times during an 18-year period. The other case did not recur during 51 months of follow-up. The tumours showed immunohistochemical features consistent with a diagnosis of HPC. The authors recommend wide excision for these tumours and careful long-term follow-up to detect recurrence which is not uncommon.

Clinico-radiological features of primary lacrimal gland pleomorphic adenoma: an analysis of 37 cases.

PURPOSE: To present the radiological and clinical features of primary lacrimal gland pleomorphic adenoma (PLGPA). METHODS: Thirty-seven consecutive PLGPAs presenting to two hospitals in Japan were reviewed. RESULTS: PLGPA cases had 15 men and 22 women with a mean age of 51.9 years. Common presenting features were ptosis (83 %), diplopia (78 %) and globe displacement (78 %). Twenty-two percent of cases reported symptom duration of less than 6 months, but only 5.6 % of cases had pain. Sixteen percent of PLGPAs were centered in the palpebral lobe; none of which were associated with globe indentation or lacrimal fossa expansion. Bony excavation was observed in 84 % of orbital lobe PLGPA; the bone margin was well demarcated and the character of excavation was more frequently smooth than scalloped (2:1). The presence of globe indentation or bony excavation was associated with increased tumor size (p = 0.003). An enhancing rim was visible on T1-weighted fat-suppressed gadolinium-enhanced magnetic resonance imaging (T1FS-Gad MRI) in 27 %. Five (19 %) enclosed cystic spaces were bright on T2-weighted MRI and non-enhancing. Calcification of tumor parenchyma was common in cystic cases but rare in non-cystic cases (p = 0.01). CONCLUSIONS: PLGPAs have varied clinical and radiological features. Common radiological features are a heterogeneous internal architecture on T2-weighted MRI, an enhancing rim on T1FS-Gad MRI, smooth or scalloped bony excavation with intact cortical bone, and globe indentation. Cystic spaces, calcification, and symptom duration less than 6 months are common, but pain is rare. Awareness of the clinico-radiological variants of PLGPA is important when considering incisional biopsy of a lacrimal gland mass.

Frontalis suspension with an expanded polytetrafluoroethylene sheet for congenital ptosis repair.

Congenital ptosis with poor levator function is most often repaired with a frontalis suspension procedure. Autogenous fascia lata grafting is generally effective, with low rates of infection and granuloma formation. However, contraction of the grafted fascia lata may cause eyelash inversion, tarsal deformity, and/or lagophthalmos. Conversely, several synthetic suspensory materials have been used for frontalis suspension, among which polytetrafluoroethylene has been reported to be comparable to the fascia lata. However, in some studies using polytetrafluoroethylene strips or sutures, complications such as infection and granuloma formation were a significant problem. This study evaluated the outcomes of frontalis suspension with an expanded polytetrafluoroethylene sheet for congenital ptosis repair in 97 patients (130 eyelids). No ptosis recurrence was reported in an average follow-up of 31.6 months (range: 6-102 months). Six of the 130 eyelids (4.6%) had complications. Based on these results, frontalis suspension with an expanded polytetrafluoroethylene sheet for congenital ptosis repair can be considered safe and effective and be recommended for clinical use.

Modified auricular cartilage sling for paralytic ectropion.

OBJECTIVE: To evaluate the outcomes of a modified auricular cartilage sling for paralytic ectropion. METHODS: We treated 17 eyelids of 17 patients (average 67 years old) with an auricular cartilage sling between 2004 and 2012. All patients had paralytic ectropion with lower eyelid ptosis. Cartilage was harvested via an incision just inside the anterior rim of the helix. Skin incisions were made at the subciliary, medial and lateral canthal regions. The auricular cartilage graft was sutured to the medial canthal tendon medially, lateral orbital rim laterally, inferior tarsus superiorly, and lower eyelid retractors inferiorly. Average follow-up period was 40 months (range 16-60 months). RESULTS: The median L-MRD (mm) was improved from 8.4 preoperatively (interquartile range 7.5-8.9) to 5.2 postoperatively (4.8-5.3). The median lagophthalmos (mm) was improved from 5.8 preoperatively (4.7-7.0) to 2.2 postoperatively (1.6-2.6). 16 patients had corneal exposure preoperatively and this resolved completely in 12 patients. All patients experienced good anatomical and functional results with relief of their preoperative pain/discomfort symptoms without complications. No patients required reoperation and none experienced infection, exposure of the cartilage graft, or recurrence of lower eyelid malpositions. Postoperatively, all lower eyelids moved downward with down-gaze. The auricular scar left no significant cosmetic deformity. CONCLUSIONS: The modified auricular cartilage sling with 4 point fixation for paralytic ectropion appears to maintain normal eyelid mobility with down-gaze and avoids the problem of lower eyelid fixation.

Orbital blowout fracture location in Japanese and Chinese patients.

PURPOSE: To characterize the location of orbital blowout fractures in Asian individuals. METHODS: This was a retrospective review of 470 consecutive Asian patients with orbital blowout fractures who presented to four tertiary care hospitals in Japan and China. Computed tomography (CT) characterized the location and severity of fractures involving the medial wall, the orbital floor, and/or the maxilloethmoidal strut. RESULTS: A total of 475 orbital blowout fractures were identified. More than one fracture location was involved in 19% of all cases. The medial orbital wall was the most commonly involved location, presenting in 29 cases (61%), of which 204 (43%) were isolated medial blowout fractures. The orbital floor was the second most common location involved, present in 226 cases (48%) with 150 isolated orbital floor fractures (32%), while the maxilloethmoidal strut was involved in 45 cases (9%) with 30 of those being isolated strut fractures (6%). The majority of fractures (62%) were classified as moderately severe, whilst 14% were mild, and 24% were severe. Associated nasal fractures were present in 16% of the cases. CONCLUSIONS: Orbital blowout fractures in Japanese and Chinese individuals occur most commonly in the medial wall. This is in contrast to previous reports on white individuals, who tend to sustain fractures involving the orbital floor rather than the medial wall.

Adhesiotomy with grafting of fat and perifascial areolar tissue for adhesions of extraocular muscles after trauma or surgery.

PURPOSE: To investigate the effect of adhesiotomy with grafting of fat and perifascial areolar tissue (A-GFPAT) on eyes with restricted eye movements after trauma or surgery. DESIGN: Single-center retrospective interventional, consecutive case series. METHODS: Twenty-four eyes of 24 patients that underwent A-GFPAT were studied. The changes in the eye movements was evaluated by the Hess area ratio (HAR %) and in the binocular single vision (BSV) field scores. RESULTS: The HAR % was significantly improved by the A-GFPAT, from 50.9 ± 32.0% (±SD) to 66.4 ± 28.2% at the final visit (Student's t test; P < 0.01). Nine of the 24 cases (37.5%) had an improvement of the final HAR % by >10%. The preoperative mean BSV field score was 15.4 ± 13.3, which improved significantly to 25.9 ± 10.5 after the A-GFPAT (P < 0.001). Thirteen cases (56.5%) had an improvement of the final BSV score by more than 5 points. There were improvements of both HAR % (50%) and BSV score (54.5%) by more than 50% after A-GFPAT in patients with old orbital fractures. All patients who had been treated with Lactosorb earlier had an improvement of the BSV score, while those treated with endoscopic transmaxillary reduction and balloon technique had a lower chance of improvement (20%). CONCLUSIONS: Our new technique of A-GFPAT leads to improvements of eye movements that had been limited by the adhesion of orbital soft tissue and periorbita with less adverse effects. We recommend our surgical procedure for eyes with restrictive eye movements or pain caused by adhesions following trauma or ocular surgery.

[Spontaneous resolving rate of congenital nasolacrimal duct obstruction and success rate of late probing after age 18 months: historical cohort study].

PURPOSE: To determine the spontaneous resolving rate of congenital nasolacrimal duct obstruction (CNDO) and the success rate of late probing after age 18 months. PATIENTS AND METHODS: A single-center, historical cohort study. We retrospectively reviewed the medical records of infants less than 18 months of age who were diagnosed with CNDO and referred to the Department of Ocular Plastic & Orbital Surgery of the Seirei Hamamatsu General Hospital in Japan. We conservatively observed them up to the age of 18 months. We performed late probing for CNDO in the patients 18 months of age or older using lacrimal endoscopy. RESULTS: Eighty-two obstructed nasolacrimal ducts of 72 patients with a mean age of 8.6 +/- 5.4 months were included. Twenty-five lacrimal ducts (31%) had a history of early probing in other hospitals. The spontaneous resolving rate was 42 (51%) at 12 months, and 64 (78%) at 18 months of age. There was no significant difference in spontaneous resolving rate between the existence and absence of early probing. Nine lacrimal ducts (11%) were treated with late probing with silicone tube intubation after age 18 months, and all were cured. CONCLUSIONS: The spontaneous resolving rate of CNDO either with or without early probing history was about 80% at 18 months of age with conservative medical management. Late probing with tube intubation after age 18 months had a high success rate.

Trochlea surgery for acquired Brown syndrome.

PURPOSE: To describe surgical treatment of acquired Brown syndrome by trochlea reconstruction and trochlea adhesiotomy. METHODS: The medical records of patients with acquired Brown syndrome who underwent intraoperative forced duction testing under direct view of the trochlea from 2010 to 2012 were retrospectively reviewed. In all cases, the site of restricted movement was identified, after which either the trochlea was reconstructed or the trochlear adhesion was removed. Surgical results were assessed by means of the pre- and postoperative Hess chart scores and binocular single vision test scores. RESULTS: Six eyes of 6 patients were included. In 4 patients the trochlea was reconstructed; in 2, the adhesion was removed. A significant improvement in the Hess chart scores was observed postoperatively in 5 of the 6 patients (P = 0.047). Binocular single vision test scores also significantly improved in 4 of 5 patients (P = 0.019). No iatrogenic superior oblique muscle paresis was observed in any of the patients. CONCLUSIONS: Our technique of isolating the source of limitation of elevation and treating with trochlea reconstruction or adhesion removal successfully treated acquired Brown syndrome in these patients.

Clinicopathological study of three cases of infantile fibromatosis of the orbit.

We report the clinical and pathological findings in three infants with infantile fibromatosis that involved several extraocular muscles which led to disorders of ocular motility. We also describe their clinical features before and after surgery. This was a retrospective interventional case study with clinicopathological correlations. We present three cases of infantile fibromatosis that were diagnosed by clinical features and histopathlogical examination of biopsy specimens. The three patients were all female children aged 1, 3, and 3 years at their initial visit. The orbital tumor was unilateral in all patients. All three patients had disorders of ocular motility because the tumors involved ≥2 extraocular muscles. The margins between the tumor and the involved extraocular muscles were not distinct. We performed partial resection of the tumors to preserve the extraocular muscles. In all cases, the tumors partially remained, but periodic postoperative magnetic resonance imaging showed no enlargement of the tumors during the follow-up period. All three patients had residual limitations of eye movements. We should consider the postoperative binocular function when we treat infantile benign fibrous tumors involving the extraocular muscles.