Virtual Reality and Mixed Reality-Assisted Endoscopic DCR in Extremely Complex Lacrimal Obstructions.

OBJECTIVE: To report the techniques and outcomes of virtual reality (VR) and mixed reality (MR)-assisted powered endoscopic dacryocystorhinostomy (DCR) in extremely complex lacrimal drainage obstructions. METHODS: A prospective, non-randomized clinical study was performed in complex syndromic congenital nasolacrimal duct obstruction (CNLDO) and post-traumatic secondary acquired lacrimal duct obstruction (SALDO) in the setting of Le Fort fractures. All patients underwent preoperative planning in VR and intraoperative planning with a step ahead with MR assistance during the surgery. Surgery was supported by mixed reality intraoperative guidance with the use of the prearranged 3D models and real-time-rendered digital models. Parameters assessed include demographics, clinical presentation, complexities of the nasolacrimal duct obstruction, preoperative and intraoperative utility of VR and MR models, surgical techniques, complications, and outcomes. RESULTS: The technique is described as a proof of concept in challenging situations with Apert syndrome and traumatic SALDOs with gross malposition of the sac, and gross nasal and lacrimal anatomical deformities. The VR models helped the surgeon to assess the details of the altered anatomy preoperatively to plan an appropriate approach. Intraoperatively, MR models were present in the surgeon's view without disturbing the endoscopic procedure. Intermittently, the surgeon could pull any of the models virtually present in the operating room, slice them, rotate them, and intricately study the alterations in a stepwise manner, as the surgery proceeds. CONCLUSION: Virtual reality and mixed reality-assisted powered endoscopic DCR can be an alternate approach reserved for extremely challenging cases of complex syndromic CNLDOs and post-traumatic SALDOs. LEVEL OF EVIDENCE: Level 4 Laryngoscope, 2024.

A new algorithm for the transconjunctival correction of moderate to severe upper eyelid ptosis in adults.

A posterior approach is recommended for the correction of mild to moderate upper eyelid ptosis in adults. The aim of this study is to propose a new algorithm that helps to predict outcomes in the transconjunctival correction of moderate to severe blepharoptosis. This study included adult patients with moderate to severe upper eyelid ptosis treated between 2019 and 2021. Patients meeting inclusion criteria underwent ptosis correction through a posterior approach using an algorithm: 4 mm Mueller's muscle transconjunctival resection to correct 1 mm ptosis (depending on a test with 10% phenylephrine: 3-12 mm) ± tarsal plate resection: 1 mm for every 1 mm of residual ptosis after phenylephrine test, but leaving a minimum of 4 mm upper tarsus intact. Outcomes were ovserved within at least 6-months. Outcomes were assessed based on pre- and postoperative MRD1 changes, inter-eyelid height symmetry, cosmetic effect, and complications. Outcomes of 118 procedures in 81 patients (average age 69, range: 47-87) were analyzed. MRD1 changes were statistically significant, from 0.2 ± 1.6 mm before to 4.1 ± 1 mm after surgery. The function of the levator palpebrae superioris muscle was 10.2 ± 3.4 (range 5-17) mm. Upper eyelid lifted by an average of 1.8 ± 0.7 (range 0-3) mm after the instillation of 10% phenylephrine eyedrops. An average of 8.5 ± 0.8 (range 8-10) mm of conjunctiva and Mueller's muscle and 2.2 ± 0.9 (range 1-5) mm of the tarsal plate were resected during the procedure. Inter-eyelid height symmetry within 1 mm was achieved in 95% of outcomes. The algorithm introduced in this study appears to be useful to achieve repeatable satisfactory outcomes in the transconjunctival correction of moderate to severe upper eyelid ptosis in adults with at least "fair" levator function.

The impact of implantation site on procedure success in patients with unresolved facial palsy treated with upper-eyelid gold weight loading.

Loading of the upper eyelid is a well-established procedure for the correction of incomplete eyelid closure due to unresolved facial palsy. Some incurable complications are attributed to type IV hypersensivity reaction, but there is no confirmation of this hypothesis. The aim of the study was to show the impact of gold weights on eyelid tissues depending on the implantation site. Out of 94 total patients (aged 53 ± 17 years) treated from July 2009-2021, since 2014 thirty consecutive patients were randomised into one of 3 groups: the GLE group (gold weight fixed 2 mm above the eyelash line), the GUE group (gold weight fixed at the border of the tarsus and the levator aponeurosis), and the PUE group (platinum chain fixed in the same way as in the GUE group). In the cases of complications, the explanted weights were evaluated histopathologically. The outcomes were compared between groups. Incomplete eyelid closure was corrected in all patients. Serious complications were noted in 100% of patients in the GLE group and 20% in the GUE group (p < 0.0001). A slight lymphocytic reaction was observed in the GUE group. A moderate to significant lymphocytic reaction was observed in the GLE group (p < 0.001). Adverse reactions of the upper eyelid microenvironment resulting from gold weights seem to be dependent on mechanical damage to the eyelid structures, rather than on implants themselves. The site of placement of the weight in the upper eyelid may be critical for procedure success.

Lacrimal Sac Reconstruction Using a Nasal Mucosal Graft.

Iatrogenic lacrimal drainage trauma during surgery is not common. It has been reported during orbital surgeries, medial maxillectomies, post-trauma repairs, excision of adherent lesions in the vicinity, and facial reconstructive procedures. The present case reports a focal loss of the lacrimal sac wall during the excision of an intricate dermoid cyst. The defect was sealed by a nasal mucosal graft harvested from the floor of the ipsilateral nasal cavity. Postoperatively, the epiphora was resolved, and a CT-dacryocystography confirmed the anatomical integrity of the reconstructed lacrimal sac.

Predicting Factors Influencing Visual Function of the Eye in Patients with Unresolved Facial Nerve Palsy after Upper Eyelid Gold Weight Loading.

Implantation of gold weights into the upper eyelid is a proven method of treating lagophthalmos and exposure keratopathy in patients with unresolved facial nerve palsy. The aim of this study was to evaluate the factors affecting visual acuity and corneal complications in patients after upper eyelid gold weight lid loading. MATERIAL AND METHODS: This prospective consecutive clinical study was conducted in years 2012-2018. In total, 59 people (40 women, 19 men aged 55.5 ± 17.4 years) meeting the inclusion criteria were treated with gold weights. The ordered multinomial logit model was used to analyze the factors affecting best-corrected visual acuity (BCVA) and degree of exposure keratopathy after surgery. The influence of the following variables was analyzed: patient age, etiology and duration of the facial nerve palsy, history of the previous eyelid surgery, degree of lagophthalmos in mm, presence of Bell's phenomenon, and corneal sensation, Schirmer test results. RESULTS: Implantation of gold weights into the upper eyelid effectively reduced lagophthalmos and exposure keratopathy in the study group (p < 0.001). BCVA was maintained or better in 95% of patients after surgery. Patient age, presence of the Bell's phenomenon, and corneal sensation significantly affected the final BCVA (p < 0.1). The presence of Bell's phenomenon and corneal sensation had a positive effect on the degree of keratopathy after surgery (p < 0.1). In turn, patient age and history of tarsorrhaphy were significant negative prognostic factors of exposure keratopathy and BCVA after surgery (p < 0.05). Etiology and duration of facial nerve palsy, degree of corneal exposure in mm, and results of the Schirmer test did not have a significant impact on the outcome after surgery (p > 0.1). CONCLUSIONS: The results of our study may help to answer the question of how to direct ophthalmologists and other specialists who refer to ophthalmologists for management advice in patients with facial nerve palsy. Elderly patients with a history of tarsorrhaphy who present with poor Bell's phenomenon and/or a lack of corneal sensation should be the first candidates for immediate correction of lagophthalmos.

Quality of Life in Patients with Unresolved Facial Nerve Palsy and Exposure Keratopathy Treated by Upper Eyelid Gold Weight Loading.

BACKGROUND: Loading of the upper eyelid with gold weights is a well-established procedure for the correction of paralytic lagophthalmos. There is no reliable research evaluating the results of this treatment from the patients' viewpoint. AIM: The aim of this research was to evaluate quality of life (QOL) domains through two standardized questionnaires (SF-36 and NEI-VFQ39) in patients treated by upper eyelid gold weight loading compared to healthy individuals (the "healthy" group) as well as patients with other ophthalmologic conditions (the "sick" group). PATIENTS AND METHODS: This prospective comparative clinical study of 416 surveys was conducted in 2012-2018. The study group includes 59 people: 40 women, 19 men aged 55.5 ± 17.4 treated with gold weights for corneal complications due to unresolved facial nerve palsy. General QOL was assessed using the SF-36 questionnaire. Eye-related QOL was assessed through the NEI-VFQ39 questionnaire. The results were compared with those obtained in 2 control groups: the "healthy" and the "sick," 53 individuals each. RESULTS: A statistically significant increase in QOL domains was noted in patients with facial nerve palsy after treatment (p<0.001). No statistically significant differences were found in categories defining the Physical Component Score in these patients as compared to those from the "sick" control group (p = 0.95). After surgery, the results of the Mental Component Score were comparable to those in the "healthy" control group (p = 0.51). The eye-related health scores changed significantly after surgery and differed significantly compared to the "sick" control group (p <0.05); however, they did not reach the level of the "healthy" control group (p <0.001). CONCLUSION: Patients with untreated facial nerve palsy had the lowest QOL levels among all individuals involved in this study. Treatment of lagophthalmos by gold weights significantly improved their QOL, with the greatest impact on mental aspects of health.

Sclerokeratoplasty as the Therapy for Corneal Perforation due to Exposure and Neurotrophic Keratopathy.

A case report of exposure and neurotrophic keratopathy after acoustic neuroma surgery resulting in perforation if not managed appropriately and timely is presented. Sclerokeratoplasty on 360 degrees may be an effective treatment method of corneal perforation in complete anaesthetic cornea when the standard penetrating keratoplasty failed. At a 12-month follow-up, the patient is doing well. UCVA is 0.5, the IOP is normal, and the graft remains clear. Systemic immunosuppression is the main disadvantage of this method. Further investigation is needed to assess the effectiveness and safety of this method.