Transorbital Endoscopic Approach to the Pterygopalatine Fossa: A Less Invasive Alternative to Traditional Access.

PURPOSE: The purpose of this article and accompanying video is to demonstrate a transorbital endoscopic approach for accessing the pterygopalatine fossa (PPF). This technique does not require a skin incision, avoids dissection of critical neurovascular structures, and utilizes a comparatively small osteotomy. The 2 cases presented in this article highlight the utility of a transorbital endoscopic approach for accessing an anatomic region that has traditionally required more invasive techniques to reach. METHODS: Description of surgical technique with 2 illustrative clinical cases and accompanying surgical video. RESULTS: Surgical technique: A trans-conjunctival approach is taken to the inferior orbital rim, and a subperiosteal dissection is propagated posteriorly. The bone of the posterior orbital floor is then deroofed, and the superior portion of the posterior wall of the maxillary sinus is removed, allowing access to the PPF for an incisional biopsy. CASE: A 76-year-old male with a history of left cheek squamous cell carcinoma presented with progressive V2 paresthesia and an abnormally enhancing lesion in the left PPF on MRI. CASE: A 58-year-old male with no significant medical history presented with left facial numbness (V1-V3), ptosis, an abduction deficit, and decreased hearing. Contrast-enhanced MRI demonstrated an abnormally enhanced lesion in the left PPF extending to Meckel's cave.The transorbital approach described was used to successfully obtain a diagnostic biopsy in both cases. CONCLUSIONS: These cases highlight the utility of a transorbital endoscopic approach to the PPF as a less morbid alternative to traditional access. Patient selection is key to identifying appropriate cases.

Visual Outcomes Following Surgical Debulking in Exophytic Optic Nerve Sheath Meningiomas.

PURPOSE: To report a case of a globular primary optic nerve sheath meningioma managed surgically with improvement in vision and review the literature for outcomes of purely intraorbital exophytic-globular primary optic nerve sheath meningiomas managed surgically. METHODS: A literature review was conducted using Google Scholar and PubMed with the search terms "primary optic nerve sheath meningioma," "surgery," "exophytic," and "globular." Articles were included if they were available in English. Individual cases from the reviewed articles were included if the tumor was purely intraorbital with a globular or exophytic morphology, was managed with total or subtotal surgical excision, and visual outcomes were reported. Cases were excluded if the tumor extended intracanalicularly or intracranially, tumor morphology was unknown, or surgical management consisted of biopsy, optic nerve sheath decompression, or optic canal decompression rather than tumor debulking. RESULTS: A total of 28 patients with intraorbital globular-exophytic primary optic nerve sheath meningiomas managed surgically have been reported in the literature. Vision improved in 29% (n = 8/28) and remained stable in 43% (n = 12/28) of patients. Furthermore, patients with good (Snellen notation ≥ 0.5) vision (n = 10) typically retained good vision postoperatively and at follow-up, with 1 patient experiencing a decline to poor (Snellen ≤0.1) vision at the last follow-up (92 months postoperatively). Similarly, patients with fair (Snellen notation >0.1 and <0.5) vision (n = 5) often improved to good vision (n = 3) or stayed at fair vision (n = 1), with 1 declining to poor vision at postoperative hospital discharge. CONCLUSIONS: Surgical management of exophytic or globular optic nerve meningiomas does not universally lead to vision loss and may be appropriate in select patients.

Radiologic Features of Well-circumscribed Orbital Tumors With Histopathologic Correlation: A Multi-center Study.

PURPOSE: To delineate specific imaging characteristics of solitary fibrous tumors, schwannomas, cavernous venous malformations, and well-circumscribed orbital lymphoma. METHODS: Patients undergoing excisional biopsy of solitary fibrous tumor, schwannomas, cavernous venous malformations, or well-circumscribed orbital lymphoma with preoperative MRIs available for review were identified at 3 academic centers in the United States and Australia. An exploratory statistical analysis was performed to identify important radiologic features, which were subsequently included in a random forest model. Histopathologic correlates were evaluated in representative cases. RESULTS: A total of 91 cases were included with a mean age of 52.9 ± 17.2 years. Nearly all solitary fibrous tumors were located in the anterior or mid orbit (87.5%) and they more commonly demonstrated intralesional heterogeneity on T2-weighted imaging (45.5%) ( p < 0.01). Compared with the other tumors, schwannomas tended to be intraconal (66.7%) and were often in the mid or posterior orbit (83.4%) ( p < 0.01). Cavernous venous malformations characteristically demonstrated progressive contrast enhancement (93.9%; p < 0.01). Most lesions in all 4 groups were hypointense on T1-weighted imaging (80%-100%; p = 0.14) and only well-circumscribed orbital lymphoma tended to also be hypointense on T2 (81.8%) ( p < 0.01). Finally, cases of lymphoma had significantly lower apparent diffusion coefficient ratios (0.9 ± 0.2) ( p < 0.001), while the other 3 groups were not significantly different from one another (cavernous venous malformations: 1.8 ± 0.4; schwannomas: 1.8 ± 0.5; and solitary fibrous tumor: 1.6 ± 0.6) ( p = 0.739). CONCLUSIONS: Key features that aid in the differentiation of these 4 tumors from one another include T2 intensity and homogeneity, early contrast-enhancement pattern, and ADC ratio.

Orbital Decompression: Conceptual Approach for Orbital Volume Expansion.

PURPOSE: To review the advances in the surgical techniques of orbital decompression. METHODS: A literature review of orbital decompression surgery and experience-based consideration of bony areas for decompression. RESULTS: In the 100-year-plus span of orbital decompression literature, multiple incisions and multiple bone and fat removal strategies have been described. In general, bone removal has been conceptualized as consisting of 4 walls of the orbit. However, the orbital bony anatomy is more subtle than a simple box, and considering 6 areas of potential bony removal allows a more nuanced paradigm for clinical decision-making and for understanding various technique descriptions. Historical and current techniques, and surgical planning and decision-making, are described from the perspective of a 6 area paradigm. Potential complications are reviewed. CONCLUSION: A conceptual framework for orbital decompression focusing on 6 potential areas of bone removal provides a nuanced and flexible paradigm for understanding and describing surgical techniques, and for designing individualized surgery. Orbital decompression surgery should be customized to the patient's anatomy and symptoms.

Banking Autologous Tarsus: A Simple Technique for Maximizing Preservation of Healthy Tissue.

A 28-year-old female with congenital left-sided ptosis presented after 3 prior surgeries elsewhere. Although centrally her margin to reflex distance1 was 3 mm, persistent ptosis was noted laterally. In an effort to improve the symmetry of her eyelid contour, a lateral tarsectomy was performed. As the authors worried this might worsen her dryness, the decision was made to bank the excised tarso-conjunctival tissue in case additional revision surgery is required at a later date. To accomplish this, a conjunctival incision was created at the inferior tarsal margin in the ipsilateral lower lateral eyelid and the excised upper eyelid tarso-conjunctival tissue was secured in this pocket. Four months postoperatively, the banked tissue appeared healthy and the upper eyelid contour was improved. This technique may be most helpful in multi-operated situations, where the chance of future revision is not insignificant.

Optimizing Management of Asymmetric Ptosis: A Comparison of Three Posterior Approach Resection Algorithms.

PURPOSE: The purpose of this study was to compare the efficacy of 3 resection algorithms in the management of patients with asymmetric ptosis. METHODS: Patients undergoing bilateral Muller's muscle-conjunctival resection (MMCR) were identified. Standardized preoperative clinical photographs were examined and margin reflex distance 1 (MRD1) was measured using ImageJ. Patients presenting with ≥1 mm of asymmetry in MRD1 were included. Three groups were identified: variable (4:1 ratio, with the lower side receiving a greater resection), fixed (7 mm resection bilaterally), and tarsectomy (7 mm bilaterally + 1 mm of tarsus resected on the lower preoperative side). Postoperative MRD1 was measured from photographs obtained 3 months after surgery. The primary outcome was postoperative asymmetry. RESULTS: A total of 95 patients with a mean age of 71.0 ± 11.0 years were included. There was no significant difference in age ( p = 0.277) or length of follow-up ( p = 0.782) between the groups. Although the fixed tarsectomy group had significantly greater preoperative asymmetry ( p = 0.001), there was no significant difference in postoperative asymmetry ( p = 0.166). On multivariate analysis, preoperative asymmetry was the only significant predictor of postoperative asymmetry ( p < 0.001). Specifically, the surgical group was not a predictor of the primary outcome ( p = 0.723). CONCLUSIONS: Resection amount and technique did not predict postoperative outcomes in cases of asymmetric ptosis. This may support the hypothesis that changes in eyelid position and symmetry following MMCR is due to a dynamic system, rather than as a result of purely mechanical forces.

Orbital Involvement in Acute Adult Leukemias: Case Series and Review of Literature.

Orbital involvement in acute myeloid leukemia (AML) and acute lymphoblastic leukemia (ALL) is well-described in children but is uncommon in adults. This series reports 2 adult patients with orbital leukemic involvement and summarizes the existing literature. A 37-year-old male with recently diagnosed AML underwent induction therapy and subsequently developed a tan-pink colored sub-conjunctival lesion in the left eye. Incisional biopsy confirmed AML. A 35-year-old male with history of ALL presented with left-sided orbital mass. Fine needle aspiration biopsy confirmed ALL. Literature review of adult-onset orbital leukemia yielded 29 cases of AML and 3 cases of ALL. Orbital involvement of acute adult-onset leukemia tends to be unilateral, presents in the extraconal space and can occur at any point during systemic leukemic disease. Chemotherapy is the mainstay of treatment, often in combination with radiation and/or hematopoietic stem cell transplant.

Teprotumumab and Orbital Decompression for the Management of Proptosis in Patients With Thyroid Eye Disease.

PURPOSE: To compare outcomes of patients with thyroid eye disease treated with teprotumumab or orbital decompression, or both in sequence. METHODS: Patients with thyroid eye disease and treated with decompression, teprotumumab, or both were included. Four groups were defined: decompression only, teprotumumab only, teprotumumab first with decompression later, and decompression first with teprotumumab later. The primary outcome was change in exophthalmometry. Secondary outcomes included change in extraocular muscle motility, strabismus, diplopia, and side effects. RESULTS: One hundred and thirty-nine patients were included. The mean duration for early follow-up was 1.2 months for both decompression and teprotumumab groups. The mean late follow-up was 14.4 and 8.2 months for the decompression and teprotumumab groups respectively. Mean change in exophthalmometry was significantly greater for the decompression group (3.5 mm) compared with teprotumumab (2.0 mm) at late follow-up. Improvement in total extraocular muscle restriction was significantly greater in the teprotumumab group (14.7 degrees) than in the decompression group (2.6 degrees). The teprotumumab group had a significantly higher percentage of patients with diplopia score >1 at baseline and late follow-up (p < 0.01) compared with the decompression group. Additional treatment with teprotumumab or decompression when previously treated with the opposite had similar proptosis reduction effect as that therapy alone. CONCLUSIONS: Surgical decompression has a greater proptosis reduction effect than teprotumumab, whereas teprotumumab better improves extraocular muscle motility. The addition of teprotumumab or decompression to a previous course of the opposite adds a similar effect to the supplemental treatment alone.

External carotid artery to ophthalmic artery flow associated with internal carotid artery stenosis.

PURPOSE: One of the most devastating complications of facial filler injection is sudden ischemic blindness. However, its mechanisms and predisposing factors are poorly understood. The purpose of this study was to investigate the prevalence of external carotid artery (ECA) to ophthalmic artery (OA) anterograde flow in patients with internal carotid artery (ICA) stenosis and in a control population without carotid disease. METHODS: In this cross-sectional cohort study, two groups of patients who underwent catheter cerebral angiography over a 5-year period were identified: patients with symptomatic ICA stenosis and a control group of patients with refractory epistaxis undergoing embolization. Angiograms were reviewed by an interventional neuroradiologist. The primary outcome measure was the presence of ECA to OA flow, defined as choroidal blush before filling of the circle of Willis. Secondary outcome measures included the percentage and location of ICA stenosis and ECA anastomotic branches involved. RESULTS: The study included 149 patients with ICA stenosis and 69 control patients. ECA to OA flow was more prevalent in patients with ICA stenosis (34.9%) compared to controls (2.9%) (p < .001). Logistic regression demonstrated that for each 10% increase in ICA stenosis over 70%, there was 2.8 times increased risk of ECA to OA flow (p < .001). CONCLUSIONS: ECA to ICA anterograde flow can be demonstrated in approximately 3% of control patients and in over 1/3 of patients with symptomatic carotid stenosis. This provides a plausible pathway for small filler particles to pass with blood flow from the facial to the ophthalmic circulation.

Endoscopic endonasal approach for resection of a recurrent spheno-orbital meningioma resulting in complete resolution of visual symptoms: A case report and review of literature.

PURPOSE: Spheno-orbital meningiomas are rare tumors, accounting for up to 9% of all intracranial meningiomas. Patients commonly present with proptosis, and visual deficits. These slow growing tumors are hard to resect due to extension into several anatomical compartments, resulting in recurrence rates as high as 35-50%. Although open surgical approaches have been historically used for resection, a handful of endoscopic approaches have been reported in recent years. We aimed to review the literature and describe a case of spheno-orbital meningioma with severe vision loss which was resected with an endoscopic endonasal approach achieving complete resolution of visual symptoms. METHODS: A systematic review of literature was conducted in accordance with the PRISMA guidelines. PubMed, Cochrane, and Web of Science databases were queried for spheno-orbital meningiomas resected via an endoscopic endonasal approach. Furthermore, the presentation, surgical management, and post-operative outcomes of a 53-year-old female with a recurrent spheno-orbital meningioma are described. RESULTS: The search yielded 26 articles, of which 8 were included, yielding 19 cases. Average age at presentation was 60.5 years (range: 44-82), and 68.4% of patients were female. More than half of the cases achieved subtotal resection. Common complications associated with endoscopic endonasal surgery included CN V2 or CN V2/V3 hypoesthesia. Following surgical intervention, visual acuity and visual field remained stable or improved in the majority of the patients. CONCLUSION: Endoscopic approaches are slowly gaining momentum for treatment of spheno-orbital meningiomas. Further studies on the clinical benefits of this approach on patient outcomes and post-operative complications is warranted.

Recurrence of Distensible Orbital Venous-dominant Venolymphatic Malformations After Sclerotherapy Versus Embolization With Excision.

PURPOSE: Treatment for orbital venolymphatic malformations (VLMs) commonly includes 3 major options: sclerotherapy, surgery, and embolization followed by surgical excision. Each has certain advantages, although it is not clear whether all are effective. The authors characterize the clinical course for a series of patients with distensible orbital venous-dominant VLM treated with sclerotherapy and/or embolization with excision. METHODS: In this cross-sectional cohort study, patients affected by distensible orbital venous-dominant VLM presenting to the orbital and ophthalmic plastic surgery service from 2014 to 2020 were identified. Patients were included if they presented with a moderate-flow, distensible venous-dominant malformation associated with Valsalva-related symptoms (e.g., pain, proptosis, and diplopia). RESULTS: Six cases were treated with sclerotherapy. Four underwent multiple treatments, with a mean ± SD of 3.5 ± 2.3 (range 1-7). All patients in this group failed to improve or experienced recurrence of symptoms after sclerotherapy. Twelve cases were treated with embolization and excision. Resolution of symptoms in all 12 cases was noted and maintained for a mean of 3.4 ± 2.1 years. There have been no cases of recurrence. Patients treated with sclerotherapy were more likely to experience recurrence of symptoms compared to those treated with embolization and excision (p < 0.001). CONCLUSIONS: Treatment of distensible venous-dominant moderate-flow orbital VLM with sclerotherapy may provide temporary improvement in some cases. However, in the medium to long term, recurrence was universal in this series. Embolization with excision appears to provide more definitive management, avoiding recurrence in all cases for a mean follow-up of 3 years.

The Effect of Lighting and Photograph Exposure on Perceived Attractiveness.

PURPOSE: To assess the effect of various lighting conditions and photograph exposures on perceived attractiveness. METHODS: In the first experiment, 5 variably exposed photographs were taken of 10 subjects using a consistent lighting condition (45° superior box light). In the second experiment, 10 subjects were photographed under variable lighting conditions with consistent exposure: 1) 90° overhead box light, 2) ring light, 3) 45° superior box light, 4) built-in camera flash, 5) 2 straight on box lights, each 45° from midline, and 6) natural light. Participants were instructed to maintain a neutral expression, were placed in front of a standardized blue-gray background, and were photographed during a single session. Photographs were imported into an online survey platform (Qualtrics 2020) and displayed in random order. Volunteer survey respondents were instructed to rate the subject's attractiveness on a scale of 0 to 10. Between the two experiments, a total of 22,000 scored photographs were included in the analysis. Mixed ANOVA and pairwise comparisons with Bonferroni correction were used to compare between- and within-subject ratings. RESULTS: Lighting condition had a significant impact on perceived attractiveness ( p < 0.001), with the 90° overhead box light achieving lower scores and the 45° superior box light yielding greater scores of attractiveness relative to the other conditions. Photograph exposure did not have a significant impact on subjective attractiveness ( p = 1.000). CONCLUSIONS: Our findings suggest that perceived attractiveness is enhanced when a 45° superior box light is used for illumination, and attractiveness is reduced when 90° overhead exposure is utilized. Exposure did not play a prominent role in perceived attractiveness.

Upper Eyelid Contour Changes After Orbital Decompression in Graves Orbitopathy.

PURPOSE: To evaluate the effect of orbital decompression on the upper eyelid contour. METHODS: A paired cross-sectional analysis of the upper eyelid contour was performed for 103 eyes of 66 patients who underwent orbital decompression. A control group of 26 normal subjects was also included. The eyelid contour of all participants were measured with Bézier lines adjusted to the eyelid contour and 9 midpupil eyelid margin (MPD) distances from a horizontal line bisecting the pupil. One central, corresponding to the margin reflex distance (MRD 1), and 8 equally distributed medially and laterally at 20% of the interval between the lines. Patients were classified as with flare if the height of the most lateral MPD relative to the MRD 1 was above the upper limit of the controls. RESULTS: Preoperatively 63 of the 103 contours were classified as flare + (F+). After decompression MRD1 showed a mean decrease of 0.4 mm and the location of the contour shifted 0.8 mm medially. These changes were not correlated with proptosis reduction. Orbital decompression decreased the lateral curvature of the contours especially for the F+ lids. In 40% of the F+ eyelids the flare sign disappeared after decompression. CONCLUSIONS: Orbital decompression affects the lateral eyelid contour and diminishes the amount of lateral eyelid retraction surgery necessary to correct the flare sign. In 40% of the patients, the eyelid contour is normalized with proptosis reduction only.

Hyperostosis associated with orbital vascular malformation.

A previously healthy adult male presented with a slowly enlarging orbital mass associated with 5 mm of non-pulsatile proptosis. On imaging, a soft tissue lesion with avid contrast enhancement and associated bony hyperostosis was noted. The lesion and hyperostotic bone were surgically debulked, and significant arterial bleeding was noted intraoperatively consistent with an arteriovenous malformation. Histopathologic analysis revealed a vascular malformation with enhanced microvasculature infiltrating the periosteum. While vascular lesions elsewhere in the body can be associated with skeletal changes, bony hyperostosis is a rare feature of orbital vascular malformations.

Generation of Filler Emboli as a Mechanism for Filler-Related Blindness.

BACKGROUND: Intra-arterial injection of fillers can lead to occlusion of the ophthalmic artery or its branches supplying the retina or the optic nerve. The mechanism through which this occurs is incompletely understood. We investigated the possibility of generating microparticles after injecting commercially available fillers into a flowing system in vitro. METHODS: Three hyaluronic acid fillers and one calcium hydroxylapatite filler were injected into an artificial saline flow system mimicking arterial systolic blood pressure and corresponding to the diameter of the facial artery. All the saline at the end of the tube was collected, centrifuged, and inspected for filler particles. RESULTS: After injection into the system, all fillers immediately disintegrated into small particles that were carried downstream with the flow of the saline. The saline at the end of the tube contained collections of filler. CONCLUSION: Hyaluronic acid and hydroxylapatite fillers break up into small particles immediately after injection into a flowing system, generating emboli rather than a column of filler. The results of this study lead us to hypothesize another potential mechanism leading to filler-related blindness.

Ophthalmic Surgeries and Systemic Medical Conditions Associated With the Development of Involutional Ptosis.

PURPOSE: To investigate the associations between systemic medical conditions and types of ocular surgery and the development of aponeurotic ptosis. METHODS: In this case-control observational cohort study, the relative prevalence of involutional ptosis in a large population of adult patients was assessed. Deidentified patient data from a 10-year time period was obtained from the electronic medical records of 5 large academic medical centers. Patients were selected based on ICD9 and ICD10 codes for involutional ptosis. Control patients were age and gender matched and randomly selected from a general adult population. Systemic comorbidities were determined based on ICD9 and ICD10 codes, and prior ocular surgeries based on CPT codes. The influence of systemic comorbidities and ocular surgery was examined utilizing logistic regression analysis. RESULTS: The study cohort consisted of 8297 adult patients with involutional blepharoptosis and 13,128 matched controls. The average age was 65 years. The 3 significant risk factors for developing ptosis were ocular surgery, hyperthyroidism, and type II diabetes with odds ratios of 4.2, 2.5, and 1.45, respectively (p < 0.05). Strabismus, cornea, and glaucoma surgeries were more highly associated with developing ptosis (p < 0.05). Strabismus surgery had the greatest odds ratio of 3.37, followed by cornea surgery at 2.31, and glaucoma surgery at 1.56. CONCLUSIONS: Involutional ptosis is likely a multifactorial process. This study demonstrates that risk factors for the development of ptosis include ocular surgery, specifically strabismus, cornea, and glaucoma surgery, as well as hyperthyroidism and type II diabetes.

Teprotumumab for Thyroid-Associated Ophthalmopathy.

BACKGROUND: Thyroid-associated ophthalmopathy, a condition commonly associated with Graves' disease, remains inadequately treated. Current medical therapies, which primarily consist of glucocorticoids, have limited efficacy and present safety concerns. Inhibition of the insulin-like growth factor I receptor (IGF-IR) is a new therapeutic strategy to attenuate the underlying autoimmune pathogenesis of ophthalmopathy. METHODS: We conducted a multicenter, double-masked, randomized, placebo-controlled trial to determine the efficacy and safety of teprotumumab, a human monoclonal antibody inhibitor of IGF-IR, in patients with active, moderate-to-severe ophthalmopathy. A total of 88 patients were randomly assigned to receive placebo or active drug administered intravenously once every 3 weeks for a total of eight infusions. The primary end point was the response in the study eye. This response was defined as a reduction of 2 points or more in the Clinical Activity Score (scores range from 0 to 7, with a score of ≥3 indicating active thyroid-associated ophthalmopathy) and a reduction of 2 mm or more in proptosis at week 24. Secondary end points, measured as continuous variables, included proptosis, the Clinical Activity Score, and results on the Graves' ophthalmopathy-specific quality-of-life questionnaire. Adverse events were assessed. RESULTS: In the intention-to-treat population, 29 of 42 patients who received teprotumumab (69%), as compared with 9 of 45 patients who received placebo (20%), had a response at week 24 (P<0.001). Therapeutic effects were rapid; at week 6, a total of 18 of 42 patients in the teprotumumab group (43%) and 2 of 45 patients in the placebo group (4%) had a response (P<0.001). Differences between the groups increased at subsequent time points. The only drug-related adverse event was hyperglycemia in patients with diabetes; this event was controlled by adjusting medication for diabetes. CONCLUSIONS: In patients with active ophthalmopathy, teprotumumab was more effective than placebo in reducing proptosis and the Clinical Activity Score. (Funded by River Vision Development and others; ClinicalTrials.gov number, NCT01868997 .).

The Adnexal Phenotype of Sagging Eye Syndrome.

PURPOSE: The sagging eye syndrome (SES) describes a condition that presents with age-related distance esotropia, alone or in combination with cyclovertical strabismus. It has a high prevalence in those aged over age 40 years presenting with binocular diplopia. The authors aim to characterize the adnexal phenotype of those who have been diagnosed with SES. METHODS: In this case-control study, patients were recruited from a prospectively maintained clinical and imaging database. The inclusion criteria required that subjects be above the age of 18 years and have a diagnosis of age-related distance esotropia or cyclovertical strabismus due to SES. Age-matched controls were selected from a validated database of normal faces that were not affected by any medical or surgical conditions. The margin to reflex distance from the upper eyelid, margin to reflex distance to the lower eyelid, the tarsal platform show, intracanthal distance, and inferior scleral bow were measured. Differences in the measurements between patients and controls were analyzed using a 2-tailed Student t tests. RESULTS: Twenty-two patients and 22 age-matched controls (11 males and 11 females per group) were included for study. Females with SES had a significantly greater margin to reflex distance to the lower eyelid and inferior scleral bow, with a lower tarsal platform show and margin to reflex distance from the upper eyelid than controls. Male patients with SES had a significantly greater margin to reflex distance to the lower eyelid and inferior scleral bow with a significantly lower margin to reflex distance from the upper eyelid and tarsal platform show than controls. DISCUSSION: This study supports the growing body of evidence which suggests that the SES represents age-related mechanical changes in the orbit that manifest as a specific adnexal phenotype.

Photochemical Collagen Cross-Linking Reverses Elastase-Induced Mechanical Degradation of Upper Eyelid Tarsus.

INTRODUCTION: The floppy eyelid syndrome describes an eyelid disorder characterized by floppy tarsal plates that may be caused by a loss of elastin. The authors attempted to create floppy eyelids by digesting elastin from cadaveric tarsus and then treated them with cross-linking using ultraviolet A and riboflavin. METHODS: Nine right and 9 left upper eyelids were excised from cadavers. Four vertical strips of central tarsus were removed from each eyelid. One strip of tarsus from each eyelid was treated with 10 units/ml of elastase for 2 hours. Another tarsal strip from each eyelid was immersed in normal saline for 2 hours (control). A third strip from the same eyelid was cross-linked using ultraviolet A at 6 mW/cm for 18 minutes. Finally, a fourth strip of tarsus was cross-linked in the same manner following treatment with elastase for 2 hours. A microtensile load cell was used to measure the Young modulus (stiffness) of each tissue. RESULTS: Mean (standard deviation) Young modulus for controls (18.9 ± 3.6 MPa) was significantly higher than samples treated with elastase alone (6.6 ± 3.8 MPa, p <0.01). Samples that were treated with cross-linking after elastase had a mean (standard deviation) Young modulus of 26 ± 2.3 MPa, while those treated with cross-linking alone had a mean (standard deviation) Young modulus of 34 ± 0.15 MPa. The differences in stiffness between all groups were significant (p <0.01). DISCUSSION: Treatment with elastase significantly reduces the stiffness of tarsal plates. This effect is reversed by cross-linking, raising the possibility of using this modality for the treatment of FES.

Periocular hyaluronic acid fillers: applications, implications, complications.

PURPOSE OF REVIEW: The use of dermal filler in the periocular area is increasing - both for functional and aesthetic indications. Hyaluronic acid fillers dominate the market; these treatments offer an alternative to some surgical procedures with the advantage of instant results, minimal healing time and low complication rates. However, success depends on judicious selection of patients, products and procedures to achieve favourable outcomes. This article reviews current understanding of the principal complications in the periocular area and their management. RECENT FINDINGS: Hyaluronic acid is a ubiquitous, biodegradable, nonspecies-specific molecular substrate with limited potential for immunogenic reactions. However, in the periocular area, such products can migrate and last significantly longer than the expected filler lifespan. Contamination or subsequent immune stimulation can trigger delayed-onset inflammatory reactions. Though minor vascular occlusions are not uncommon, cases of blindness secondary to facial filler injections are thought to be rare. Timely enzymatic degradation with injectable hyaluronidase can be effective in the treatment of some such complications. But recent studies demonstrate lack of penetration through arterial walls and optic nerve sheath, casting doubt on the role of retrobulbar hyaluronidase in the management of vision loss because of embolism with hyaluronic acid filler. SUMMARY: Hyaluronic acid fillers represent an emerging and important addition to the armamentarium of the oculofacial plastic surgeon with their use in the aesthetic field also expected continue to rise. The oculoplastic facial surgeon, armed with a thorough knowledge of facial anatomy, safe injection planes and the means of minimizing and treating complications is in the best position to lead clinically in the use of this well tolerated and effective treatment modality.