Use of hyaluronic acid gel filler to improve contact lens wear in patients with deep sunken superior sulcus.

PURPOSE: Deep sunken superior sulcus of the upper eyelid can result from aging, genetic, prostaglandin use, and prior aggressive upper blepharoplasty. If severe, it can cause exposure keratopathy, lagophthalmos, and giant fornix syndrome. We herein report on another milder manifestation of deep superior sulcus and its treatments. METHODS: Case report. RESULTS: Deep sunken superior sulcus syndrome caused to soft contact lens displacement and wear intolerance and was treated with upper eyelid suclus hyaluronic acid gel injection. CONCLUSIONS: Contact lens wear intolerance is likely more common in patients with deep sunken superior sulcus syndrome and can potentially be treated with superior sulcus hyaluronic acid gel injection.

Combined orbital decompression and lower eyelid retraction surgery.

PURPOSE: Orbital decompression and lower eyelid retraction surgery are traditionally performed separately in staged fashion, which may be unnecessary. Herein, we evaluate the safety and efficacy of combined orbital decompression and lower eyelid retraction surgery. METHODS: Retrospective analysis of patients undergoing combined orbital decompression and lower eyelid retraction surgery in patients with or without Graves orbitopathy, by one surgeon from 2016 to 2017. Patients with previous orbital or lower eyelid surgery were excluded. Surgical technique for orbital decompression included eyelid crease lateral-wall decompression, transconjunctival inferolateral-wall decompression, or transcaruncular medial-wall decompression, or combination. Surgical technique for lower eyelid retraction surgery described previously. Analysis included 34 surgeries (19 patients). Preoperative and postoperative photographs at longest follow-up visit were standardized and analyzed. RESULTS: Etiologies of lower eyelid retraction included thyroid eye disease (13 patients) and inherited (6 patients). Etiologies of proptosis included thyroid eye disease (13 patients) and inherited with shallow orbits and/or poor maxilla (6 patients). All 34 eyelids demonstrated improvement of lower eyelid position. The mean improvement of marginal reflex distance was 2.4 mm (range, 1.7-2.9 mm). There was one case of mild overcorrection and once case of prolonged chemosis. The average follow-up was 9 months (range, 6 months to 1 year). CONCLUSIONS: This study demonstrates improvement of lower lid position in patients undergoing simultaneous orbital decompression and correction of lower eyelid retraction, irrespective of the etiology of lower eyelid retraction and proptosis or orbital decompression technique. Combined procedures may reduce the number of total procedures, patient anxiety, recovery time, and costs, without compromising the results.

Ultrasonographic motion analysis of lower eyelid compartments in patients with chronic thyroid associated ophthalmopathy.

PURPOSE: To present the qualitative and quantitative ultrasonographic findings of lower eyelid compartments in patients with chronic thyroid associated ophthalmopathy (TAO) compared to normal subjects. METHODS: In a prospective study, dynamic and static ultrasonographic investigation, applying high resolution (15 MHz) ultrasound was performed to assess the lower eyelid, in 15 TAO patients that were in chronic phase and 10 normal subjects. The thickness and echogenisity of dermis, orbicular oculi muscle, lower eyelid retractor muscle, lower eyelid fat pads, and their qualitative relationships during vertical excursion of the globe were evaluated in static and dynamic investigation. Correlation of ultrasonic and clinical findings was evaluated. RESULTS: The mean age of the patients was 41.82 ± 7.4 years, and the controls were age-matched (mean age, 42.8 ± 5.6 years). Mean proptosis of the involved eyes was 3.3 mm, and mean lower lid retraction was 2.4 mm in chronic TAO group. Pattern of fat motion was blocky in chronic TAO patients compared to normal jelly motion of the fat in normal cases. In analyzing the range of motion, the difference was significant in the motion of both superficial and deep fat pockets between the two groups (P < 0.001). Limitation of fat motion correlated both with proptosis and lower eyelid retraction (Pearson correlation coefficient = -0.77 vs -0.43, P < 0.001). Fibrotic changes of lower lid fat pads appear in the tissue around the septum on observation. Considering the ultrasound findings, a new staging method is proposed in this study that starts with the appearance of echodense points, getting worse in fine bands, progresses to thick bands and ends in cord formation in the lower lid fat pocket that determines total fibrosis. CONCLUSION: Development of a series of static and dynamic changes in ultrasound is related to the clinical findings in chronic phase of TAO. The limitation of motion and fibrotic changes of lower eyelid fat pads were more detectable in cases with a more severe proptosis and lower lid retraction. It is considered that ultrasound findings can be a representative of the severity of involvement in the chronic phase of the TAO.

Expanding Role of Orbital Decompression in Aesthetic Surgery.

Background: Eye prominence is a source of cosmetic "deformity" for many patients not afflicted by Graves. Objectives: To report our experience in using customized orbital decompression for purely aesthetic reason to reduce eye prominence in non-thyroid patients. Methods: Retrospective analysis of patients undergoing cosmetic orbital decompression by one surgeon. Surgical technique included customized graded orbital bony-wall decompression (lateral-wall, basin, medial-wall, posterior-strut) and intraconal fat removal using eyelid crease and/or caruncle incisions. Inclusion criteria included any patient with relative prominent eye due to non-thyroid etiology. Preoperative and postoperative photographs at longest follow-up were used for analysis. Outcome measures included patient satisfaction (via a written questionnaire) and complication rates. Results: Etiologies of prominent eyes included congenital shallow orbits (14), congenital hypoplasia of malar-eminence (5), enlarged globe from high myopia (5), buphthalmos (1), and relative proptosis from contralateral enophthalmos (1). Concurrent procedures included lower eyelid-retractors lysis (5), periocular fat injection (3), tear-trough implant (3), canthoplasty (3), and periocular filler injection (3). Mean patient age was 33.8 years (range, 19-60 years). The average follow-up was 9 months (range, 6 months-4 years). All 26 patients (11 males, 15 females) had reduction in globe prominence. The mean reduction in axial globe position was 3.1 mm (range, 1.5-6.2 mm). Twenty-four of 26 patients were satisfied with the surgical outcome, with 2 patients complaining of sunken eyes. No case of permanent diplopia occurred. Conclusions: Orbital decompression may be done for cosmetic purpose, effectively and safely, to reduce eye prominence in non-thyroid patients by an experienced orbital surgeon. Level of Evidence: 4.

Lower Eyelid Retraction Surgery Without Internal Spacer Graft.

BACKGROUND: Internal eyelid spacer graft is routinely placed during lower eyelid retraction surgery, which may be unnecessary. OBJECTIVES: To evaluate the efficacy of lower eyelid retraction surgery without internal graft in select cases. METHODS: Retrospective analysis of patients undergoing reconstructive lower eyelid retraction surgery without internal graft, by one surgeon from 2013 to 2015. Surgical technique included transconjunctival lower eyelid retractor lysis, canthoplasty, and temporary tarsorrhaphy, with or without subperiosteal midface-sub oribularis oculi fat (SOOF) lifting and scar lysis. Eyelids with true lower eyelid middle-lamella shortage were excluded. Analysis included 17 surgeries (11 patients). Eight of 11 patients had undergone at least one previous lower eyelid surgery with resultant lower eyelid retraction and sclera show. Preoperative and postoperative photographs at longest follow-up visit were analyzed with standardized measurements. Patient satisfaction was recorded using questionnaire. RESULTS: Etiologies of lower eyelid retraction included prior lower blepharoplasty, thyroid eye disease, and chronic facial palsy. All 11 patients (17 procedures) demonstrated improvement of lower eyelid position. The mean improvement of marginal reflex distance was 2.2 mm (range, 1.6-2.8 mm). There was one case of mild overcorrection. The average follow-up was 7 months (range, 6 months-2 years). Midface lift was performed for 14 of 17 eyelids. CONCLUSIONS: This study demonstrates improvement of lower lid position after lower eyelid retraction surgery without internal eyelid spacer graft in select patients. Most patients in our study had undergone previous lower eyelid blepharoplasty and required midface-SOOF lifting. The author proposes that "routine" placement of lower eyelid internal spacer/graft may not be necessary during lower eyelid retraction surgery.

Ultrasonographic visualization of lower eyelid structures and dynamic motion analysis.

AIM: To define the ultrasonographic structure of normal lower eyelid anatomic compartments and their spacial relationship in dynamic motion. METHODS: High resolution ultrasound (15MHz) was performed on the lower eyelids of 7 normal subjects. Movements of the lower eyelid and its compartments were visualized with ultrasound. In addition, the maximal excursion area of the lower eyelid fat compartments and retractor motions was measured before and after motion. RESULTS: The orbicularis muscle could be seen as an echolucent structure between the dermis and the echodence fat pads. Lower eyelid fat pad seems to be divided into 2 compartments as range of motion and direction of movement of each of them varies. It seems that these compartments have also different behavior. The measured profile area of the visible normal lower eyelid fat pads during movement of globe from up-gaze to down-gaze decreased by 50%. Order of movement of lower eyelid structures seems to be as follows: after globe movement fist we see retractor movement, anterior orbital fat pad, then skin and septum, and finally movement of inferior fat pad. CONCLUSION: Ultrasound represents a noninvasive tool for the visualization of lower eyelid morphology. Expanding its application could help us understand the compartmental changes in physiological eyelid movement, in aging and diseased study populations, as well as assess operative outcomes.

Facial asymmetry and nasal septal deviation in acquired nasolacrimal duct obstruction.

INTRODUCTION: Acquired nasolacrimal duct obstruction is a common disorder affecting adults. Its pathogenesis is not known. We hypothesize that facial and bony asymmetry can contribute to the unilaterality of the nasolacrimal duct obstruction. MATERIALS AND METHODS: Retrospective study was done on all patients with acquired nasolacrimal duct obstruction who presented to our practice from January through June 2010. External photographs were obtained. Lacrimal probing and irrigation was used to confirm blockage of the nasolacrimal duct. Nasal endoscopy was performed to visualize the intranasal anatomy and location of the nasal septum. RESULTS: There were 23 patients who underwent endoscopic dacryocystorhinostomy (11 males, 12 females) for acquired nasolacrimal duct obstruction. Average age was 58 years old (range, 27 to 84 years). Facial photos analysis showed facial asymmetry in 17 patients, with one side being smaller than the other side. This corresponded to the side of the nasolacrimal duct obstruction in 12 out of these 17 patients (p-value 0.03). Nasal endoscopy revealed septal deviation to the side of the nasolacrimal duct obstruction in 21 of the 23 patients, with one having twisted septal deviation. Septoplasty was performed in 10 cases in addition to endoscopic dacryocystorhinostomy. CONCLUSIONS: Unilateral nasolacrimal duct obstruction appears to occur on the side in which the nasal septum is deviated. There is a trend of nasal septal deviation toward the smaller side of the face. Further prospective studies are needed to clarify the above relationships.

Characterization of ocular tissues using microindentation and hertzian viscoelastic models.

PURPOSE: The authors applied a novel microindentation technique to characterize biomechanical properties of small ocular and orbital tissue specimens using the hertzian viscoelastic formulation, which defines material viscoelasticity in terms of the contact pressure required to maintain deformation by a harder body. METHODS: They used a hard spherical indenter having 100 nm displacement and 100 µg force precision to impose small deformations on fresh bovine sclera, iris, crystalline lens, kidney fat, orbital pulley tissue, and orbital fatty tissue; normal human orbital fat, eyelid fat, and dermal fat; and orbital fat associated with thyroid eye disease. For each tissue, stress relaxation testing was performed using a range of ramp displacements. Results for single displacements were used to build quantitative hertzian models that were, in turn, compared with behavior for other displacements. Findings in orbital tissues were correlated with quantitative histology. RESULTS: Viscoelastic properties of small specimens of orbital and ocular tissues were reliably characterized over a wide range of rates and displacements by microindentation using the hertzian formulation. Bovine and human orbital fatty tissues exhibited highly similar elastic and viscous behaviors, but all other orbital tissues exhibited a wide range of biomechanical properties. Stiffness of fatty tissues tissue depended strongly on the connective tissue content. CONCLUSIONS: Relaxation testing by microindentation is a powerful method for characterization of time-dependent behaviors of a wide range of ocular and orbital tissues using small specimens, and provides data suitable to define finite element models of a wide range of tissue interactions.

"En-glove" lysis of lower eyelid retractors with AlloDerm and dermis-fat grafts in lower eyelid retraction surgery.

PURPOSE: To describe a minimally invasive surgical technique using AlloDerm or dermis-fat grafts for lower eyelid retraction. METHODS: A retrospective review of all patients undergoing lower eyelid retraction surgery via a minimal invasive, "en-glove" technique from 2005 through 2009. Charts were reviewed for the type of graft (AlloDerm or dermis-fat) used, the etiology of lower eyelid retraction, and the follow-up time. Outcome measures included lower eyelid height (measured from the corneal light reflex to the lower eyelid margin, or MRD2), reduction of lagophthalmos, cosmetic appearance, complications, and need for further surgery. Presurgery and postreconstruction photographs were reviewed and graded for functional and cosmetic outcome. RESULTS: A total of 8 patients underwent successful lower eyelid retraction surgery using this minimally invasive technique. Etiologies included thyroid eye disease and cicatricial paralytic lower eyelid retraction. Mean improvement in MRD2 was 1.5 mm for the AlloDerm group (4 patients, 7 eyelids) and 1.0 mm for the dermis-fat group (4 patients, 4 eyelids) after a minimum of 3 months' follow-up. The cosmetic result was satisfactory in all cases. CONCLUSIONS: "En-glove" lower eyelid retraction surgical technique offers a minimally invasive approach for the release of the lower eyelid retractors and allows for volume augmentation using either AlloDerm or dermis-fat spacer graft.

The utilitarian upper eyelid operation.

Techniques in oculofacial surgery continue to develop as our understanding of anatomy and pathophysiology continue to evolve. While the centerpiece of the quest to rejuvenate the upper eyelid and brow has for years been the upper blepharoplasty, several modifications to traditional techniques have been developed that allow for enhanced outcomes utilizing less invasive approaches. Techniques discussed include removal of lower lid lateral fat via the upper blepharoplasty, a minimally invasive resuspension lateral canthoplasty performed via the upper eyelid exposure, brassiere lateral brow contouring closure, and correction of lower lid retraction by an "en-glove" technique.

Aesthetic lateral canthoplasty.

INTRODUCTION: To report our technique and experience in using a minimally invasive approach for aesthetic lateral canthoplasty. METHODS: Retrospective analysis of patients undergoing lateral canthoplasty through a minimally invasive, upper eyelid crease incision approach at Jules Stein Eye Institute by one surgeon (R.A.G.) between 2005 and 2008. Concomitant surgical procedures were recorded. Preoperative and postoperative photographs at the longest follow-up visit were analyzed and graded for functional and cosmetic outcomes. RESULTS: A total of 600 patients (1,050 eyelids) underwent successful lateral canthoplasty through a small incision in the upper eyelid crease to correct lower eyelid malposition (laxity, ectropion, entropion, retraction) and/or lateral canthal dystopia, encompassing 806 reconstructive and 244 cosmetic lateral canthoplasties. There were 260 males and 340 females, with mean age of 55 years old (range, 4-92 years old). Minimum follow-up time was 3 months (mean, 6 months; maximum, 6 years). Complications were rare and minor, including transient postoperative chemosis. Eighteen patients underwent reoperation in the following 2 years for recurrent lower eyelid malposition and/or lateral canthal deformity. CONCLUSIONS: Lateral canthoplasty through a minimally invasive upper eyelid crease incision and resuspension technique can effectively address lower eyelid laxity and/or dystopia, resulting in an aesthetic lateral canthus.

Localized Intraorbital Castleman's disease: a case report.

A 69-year-old man was found to have a right orbital soft-tissue mass on imaging as an incidental finding. Excisional biopsy revealed a well-circumscribed mass encasing the infraorbital nerve, consistent with Castleman's disease (CD) on histopathology. In the orbit, CD is extremely rare with few reported cases. We report this patient with localized intraorbital Castleman's disease.

Endoscopic removal of nasoglabellar dermoid cysts.

Dermoid cysts are common tumors resulting from entrapped ectodermal elements at fetal suture lines. Management is conceptually straightforward, with surgical excision of the mass in its entirety without rupture. The conspicuous location and potential scarring from direct excision can be objectionable, particularly in children. The authors describe 2 cases using a hidden hairline incision and an endoscopic approach to remove dermoid cysts in the nasoglabellar region.

Use of hyaluronic Acid gel for upper eyelid filling and contouring.

PURPOSE: To describe the use of hyaluronic acid gel for upper eyelid filling, contouring, and rejuvenation. METHODS: In this consecutive, retrospective, interventional case series, standard serial puncture injections with preperiosteal placement of filler were administered at the superior orbital rim. Outcome measures included classification of upper eyelid volume deficiency as I) medial A-shaped hollow, II) generalized hollow, III) postblepharoplasty volume loss, and IV) upper eyelid hooding with subbrow volume deflation; volume of filler used; masked, independent assessment of pretreatment and posttreatment photographs; patient satisfaction; and complications. RESULTS: Twenty-seven patients were included with a mean follow-up of 13 months. More than 85% were white women with a mean age of 51 years (range, 24-65 years). Five patients were classified as type I, 8 as type II, 11 as type III, and 3 as type IV. The mean volume of filler used was 0.4 ml/eyelid (range, 0.1-1 ml). Photographic assessment showed improved static upper eyelid contour in 23 patients (85%), little change in 3 patients (11%), and deterioration in 1 patient (4%). Twenty-six patients (96%) were satisfied with the treatment, although 5 (19%) requested additional filler and 1 patient underwent dissolution within 3 months. Two of the 3 type IV patients still required blepharoplasty/ptosis surgery. All patients developed mild bruising and swelling but no discoloration or lumpiness. CONCLUSIONS: Hyaluronic acid filler is an effective means of rejuvenating the upper eyelid and is particularly successful in patients with medial/generalized upper eyelid hollowing, or significant postblepharoplasty upper eyelid show. A blepharoplasty/brow lift/ptosis procedure is still frequently required for hooding due to subbrow deflation (type IV).

Nonsurgical management of congenital eyelid malpositions using hyaluronic Acid gel.

PURPOSE: To report our preliminary experience using hyaluronic acid gel fillers as a nonsurgical alternative in the management of congenital eyelid malpositions. METHODS: In this retrospective interventional case series, 5 patients (10 eyes) with congenital eyelid malpositions, including eyelid retraction, ectropion, euryblepharon, epiblepharon, and abnormalities associated with a shallow orbit, with resultant lagophthalmos and/or keratopathy and tearing were evaluated before and after injection with hyaluronic acid gel (Restylane) in the pretarsal and/or septal regions of the affected eyelid(s). Pretreatment, posttreatment, and follow-up photographs were analyzed for eyelid position and degree of eyelid closure and lagophthalmos, and slit-lamp evaluation of the degree of keratopathy. RESULTS: All 5 patients demonstrated significant improvement of eyelid position and degree of keratopathy. The mean improvement in lagophthalmos was 4.5 mm (range, 2-7 mm). The average volume of hyaluronic acid gel used was 0.5 ml per eyelid. Complications were minor, including transient edema and ecchymosis at the sites of injection. Of the 10 eyelids injected, only one had increased astigmatism after injection. CONCLUSIONS: Hyaluronic acid gel shows promise as a safe and effective nonsurgical treatment for the management of certain eyelid malpositions, disorders traditionally requiring surgical intervention if aggressive ocular lubrication fails. This treatment is particularly useful in such patients who are commonly premature with poor general health and serves as a temporizing measure by allowing the much needed tissue expansion to take effect over time.

Superiorly based bilobed flap for inferior medial canthal and nasojugal fold defect reconstruction.

PURPOSE: To evaluate the use of a superiorly based bilobed flap for reconstruction of nasojugal fold region defects. METHODS: Retrospective review of all patients undergoing medial canthal, nasal sidewall, and nasojugal fold region reconstruction using a superiorly based bilobed flap from October 2000 through March 2008. Charts were reviewed for patient age and gender, indication, defect size and location, flap(s) used, and follow-up time. Outcome measures included ability to completely close the defect with minimal tension, cosmetic appearance, complications, and need for further surgery. RESULTS: Eighteen cases of medial canthal and nasojugal fold area reconstruction were performed using a superiorly based bilobed flap in 17 patients. There were 8 male and 9 female patients with an average age of 68.2 years (range, 11-88 years) and mean follow-up time of 17.8 months (range, 1-60 months). Mean defect size measured 2.0 x 1.4 cm (range, 0.7-4 cm). One patient underwent simultaneous glabellar flap repair, 2 patients underwent simultaneous lateral lower eyelid rotational flap repair, and 1 patient underwent simultaneous upper eyelid V-Y advancement flap. All defects closed completely with no wound tension. No cases of hemorrhage, infection, dehiscence, or necrosis developed during the follow-up period. Cosmetic satisfaction occurred in 16 of 17 patients. Complications included mild medial ectropion (2 patients) and canalicular stenosis (1 patient). None of these patients elected reoperation. Trapdoor deformity did not occur in any case. Two patients underwent reoperation for local tumor recurrence. CONCLUSIONS: A superiorly based bilobed flap adequately reconstructs inferior medial canthal, nasal sidewall, and nasojugal fold defects.

Orbital wall fracture repair using Seprafilm.

PURPOSE: Seprafilm is a hybrid product of carboxymethylcellulose and sodium hyaluronate that can act as an absorbable barrier to decrease the formation and severity of postoperative adhesions in abdominal, thoracic, and pelvic surgeries. The authors report their experience with use of Seprafilm in "trap door" orbital wall fracture repair. METHODS: Retrospective case series of 4 consecutive patients with trap door orbital wall fractures secondary to blunt trauma with entrapped orbital soft tissue who underwent surgical repair with placement of Seprafilm implant in 2008. Orbitotomy was performed via standard transconjunctival and/or transcaruncular approaches with release of entrapped tissues, and placement of Seprafilm implant over the fracture site without fixation. Patients were followed for at least 6 months. Ophthalmic and orbital examinations, including ocular motility and Hertel exophthalmometry measurements, were recorded. RESULTS: All 6 orbital wall fractures (4 floor, 2 medial wall) were successfully corrected with resolution of restrictive motility in the follow-up period (average 10 months; range 6 months to 1.5 years). Mean patient age was 13.5 years (range, 9-20 years). Two of the 4 patients had 2 separate fractures. There were no complications and no need for reoperation. CONCLUSIONS: Seprafilm may have a role in reconstruction of the "trap door" type of orbital wall fractures. The ease of use, lack of fixation, and absorbable properties without inflammation are encouraging for further study.