The anatomy of eyebrow ptosis.

An anatomical study was performed to gain a better understanding of the pathogenesis of eyebrow ptosis. Through cadaver dissection, we sought to establish the anatomy of the normal eyebrow, to determine why the temporal part of the eyebrow becomes ptotic earlier than the medial portion, and to locate precisely the regional nerves and vessels to aid the eyebrow surgeon. a fat-pad exists beneath the eyebrow. Dense attachments on the underside of the eyebrow fat-pad secure the eyebrow to the supraorbital ridge. Because the supraorbital ridge extends only over the medial one half to two thirds of the orbit, the lateral part of the eyebrow lacks deep support and droops with the frontal skin and muscle relaxation seen in age. Vertical lateral orbicularis fibers are consistently seen in the cadaver. Because of their location, they may play a role in producing "laugh lines."

Adjuvant lateral canthal advancement in the surgical management of exophthalmic eyelid retraction.

The eye is convergent from the orbital axis when in the primary gaze position; greater projection of the lateral sclera results from the posterior location of the lateral orbital rim relative to the medial orbital rim. If the horizontal tarsal ligamentous band cannot lengthen to accommodate an increasingly exophthalmic globe in thyroid ophthalmopathy, a horizontally tight eyelid with increased exposure of the lateral sclera will result; thus, temporal flare is accentuated. Lateral canthal advancement was developed as an adjuvant procedure to reduce temporal flare in the surgical repair of thyroid-related eyelid retraction. Lateral canthal advancement is a theoretically rational and effective adjunct to retractor recession when horizontal tightness of the eyelid is present. In the horizontally tight eyelid, lateral canthal advancement is effective in enhancing the effect of retractor recession and in reducing temporal flare.

An anatomical basis for primary acquired nasolacrimal duct obstruction.

OBJECTIVE: To measure any sex size differences in the bony nasolacrimal drainage systems in a normal, age-matched population. METHODS: A retrospective study of axial cut maxillofacial computed tomographic scans was conducted. Three levels of the bony nasolacrimal duct (NLD) system on the right and left sides were measured along the anteroposterior diameter. The data were analyzed using 2-tail t test, analysis of variance, and linear regression methods. RESULTS: Scans from 71 adult patients (36 men and 35 women) were reviewed. Women were found to have a smaller bony diameter at the level of the lower fossa (P = .01) and the middle NLD (P = .06) compared with those of men. The adult inferior bony fossa increased in size with age in both men and women, while the middle NLD increased in size in men only. No significant size difference was found between the right and left side at any level. CONCLUSIONS: Size differences are found in measurements of bony nasolacrimal excretory systems in men vs women. Women have significantly smaller dimensions in the lower nasolacrimal fossa and the middle NLD. The anteroposterior dimension of the bony nasolacrimal canal at the fossa level enlarged in both sexes, with age co-inciding with osteoporotic changes throughout the body. These quantitative anatomical observations provide a contributory factor to explain the increased prevalence of primary acquired NLD obstruction in women.

A search for lymphatic drainage of the monkey orbit.

Colloid solutions of technetium Tc 99m and india ink injected into the retrobulbar space of the cynomolgus monkey outside the extraocular muscle cone were removed from the orbit by the lymphatic vessels of the conjunctiva and eyelids and were then concentrated within the lymph nodes that drained the conjunctival and eyelid areas. Colloid solutions injected into the retrobulbar space inside the extraocular muscle cone did not reach the conjunctiva and did not collect in any lymph nodes over a 24-hour period. Within the orbit, the injected colloids spread along the planes of the connective-tissue septa. No lymphatic vessels were identified within the orbits posterior to the conjunctiva. Small amounts of india ink left the posterior orbit and ultimately entered the contralateral orbit. This posterior pathway did not lead to lymphatic vessels or lymph nodes and therefore does not appear to represent a prelymphatic pathway.

Eyelid splitting with excision or microhyfrecation for distichiasis.

Distichiasis is a rare congenital or acquired condition in which an accessory row of eyelashes arises from the posterior lamella of the eyelid margin. Previously described surgical techniques to treat distichiasis can result in complications including trichiasis, loss of normal eyelashes, cicatricial entropion, and eyelid margin deformities. We describe a new technique in which the eyelid margin is split to expose the distichiasis eyelash follicles. Each aberrant eyelash follicle is individually excised or microhyfrecated and then removed. Seventeen eyelids in 5 patients with congenital or acquired distichiasis have been treated. We have achieved excellent functional and cosmetic results using this new technique.

Lateral extensions of the Müller muscle.

OBJECTIVES: To define the lateral extension of the Müller muscle and to elucidate its involvement in the development and surgical treatment of Graves (thyroid) eye disease. METHODS: Twelve lateral halves of orbits exenterated from patients with medial or posterior orbital neoplasms were fixed, embedded, and step sectioned at 250-microns intervals to produce histological sections. Gross anatomical dissections of human cadaver heads were also used to corroborate the histological findings. RESULTS: Histological analysis revealed that the Müller muscle extended laterally between the orbital and palpebral lobes of the lacrimal gland in all specimens. The smooth muscle fibers were found to interdigitate with lacrimal ducts passing from the orbital to palpebral lobe and to extend close to the ductal orifices at the conjunctival surface. Gross dissections confirmed that the Müller muscle accompanied the levator aponeurosis lateral extension, which is known to pass between the orbital and palpebral lobes of the lacrimal gland. CONCLUSIONS: Our anatomical findings suggest that the Müller muscle may contribute to the temporal flare frequently seen in eyelid retraction associated with thyroid eye disease. They may also explain the difficulty of treating lateral eyelid retraction in thyroid eye disease and indicate the need for new surgical approaches for severe lateral eyelid retraction.

Ancient schwannoma of the orbit.

The ancient schwannoma is a rare variant of a neurilemoma with a course typical of a slow-growing benign neoplasm. Histologically, it can be confused with a malignant mesenchymal tumor because of increased cellularity, nuclear pleomorphism, and hyperchromatism. Despite the degree of nuclear atypia, mitotic figures are absent. We describe the clinical and histopathologic features of an ancient schwannoma of the orbit.

The Asian upper eyelid: an anatomical study with comparison to the Caucasian eyelid.

OBJECTIVE: To evaluate the differences between Asian and Caucasian upper eyelid anatomy through cadaver dissection, histopathological study, and magnetic resonance imaging. MATERIALS AND METHODS: Upper eyelids of 9 Korean and 5 Caucasian cadavers were dissected, and then were studied microscopically with hematoxylin-eosin, Masson trichrome, and elastin stains. Four healthy young Korean men were studied by dynamic high-resolution magnetic resonance imaging with regard to demonstration of upper eyelid structure. RESULTS: More subcutaneous and suborbicularis fat, with a pretarsal fat component, is present in Asian eyelids. The Asian double eyelids showed an amount of fat intermediate between Asian single eyelids and Caucasian eyelids. Asian single eyelids showed fusion of the orbital septum to the levator aponeurosis below the superior tarsal border, while fusion is above the superior tarsal border in Caucasians. The preaponeurotic fat pad descends anteriorly to the tarsal plate in the Asian single eyelid, but not in the Caucasian eyelid. A pretarsal fat pad is identified in the Asian single eyelids. CONCLUSIONS: The causes of absent or lower crease in the Asian upper eyelid are as follows: (1) the orbital septum fuses to the levator aponeurosis at variable distances below the superior tarsal border; (2) preaponeurotic fat pad protrusion and a thick subcutaneous fat layer prevent levator fibers from extending toward the skin near the superior tarsal border; and (3) the primary insertion of the levator aponeurosis into the orbicularis muscle and into the upper eyelid skin occurs closer to the eyelid margin in Asians. Structural differences relating to increased fat in the Asian upper eyelid include the presence of a pretarsal fat pad and a moderate fat increase in the double Asian eyelid.

Small incision external levator repair: technique and early results.

PURPOSE: To describe a new surgical technique and early results of external levator repair performed through a small skin incision. METHODS: A chart review of consecutive patients undergoing small incision external levator repair was conducted. This modified external levator repair was performed through an 8-mm eyelid crease incision. Patients with unilateral or bilateral aponeurogenic blepharoptosis were candidates for the technique. Patients with excessive horizontal upper eyelid laxity and those requiring blepharoplasty in addition to blepharoptosis surgery did not undergo this technique. Patients who underwent previous upper eyelid surgery or concurrent brow surgery were excluded from the review. Preoperative measurements included upper eyelid margin reflex distance, levator function, and degree of dermatochalasis, as well as Goldmann visual field results. Outcome measures included incidence and type of intraoperative complications, postoperative upper eyelid position (including margin reflex distance, eyelid contour, and symmetry), incidence and type of postoperative complications, and revisions or additional necessary surgery. RESULTS: Twenty-eight eyelids of 17 patients met study inclusion criteria. Preoperative margin reflex distance +/- SD averaged 0.8 +/- 0.4 mm. Average length of follow-up was 28 +/- 5 weeks (range, 15 to 52 weeks). No significant intraoperative complications occurred. Postoperative margin reflex distance averaged 3.7 +/- 0.3 mm. Two eyelids were mildly undercorrected, and one demonstrated moderately peaked contour postoperatively. Satisfactory eyelid position and contour were achieved in 25 of 28 treated eyelids. No patient elected reoperation. CONCLUSIONS: Early results demonstrated that small incision levator repair is safe and generally effective. This minimally invasive external levator repair is useful for a carefully selected subset of patients with aponeurogenic blepharoptosis.

Problems associated with conjunctivodacryocystorhinostomy.

Fifty-eight patients (69 eyes) underwent conjunctivodacryocystorhinostomy for lacrimal canalicular obstruction. The cause of lacrimal obstruction and the results and complications of the operation were analyzed. Trauma and idiopathic disease were the most common causes of lacrimal canalicular obstruction in 24 of 69 (34.8%) eyes each. Relief of epiphora was achieved in 68 of the 69 eyes (98.5%). The complications included tube displacement in 40 of the 69 eyes (57.9%), tube obstruction in 19 of the 69 eyes (27.5%), and infection of the lacrimal sac in four of the 69 eyes (5.8%). Despite frequent complications, most Jones tubes can be made to function satisfactorily. Conjunctivodacryocystorhinostomy remains the best surgical treatment at this time for permanent loss of canalicular function.

Epiblepharon. An important and often missed diagnosis.

Epiblepharon is a common, often unrecognized cause of epiphora and ocular irritation in the child. Epiblepharon consists of an extra fold of eyelid skin and orbicularis muscle overlying an eyelid margin. Occasionally an epiblepharon can push the lashes against the sensitive corneas, especially in downgaze. This paper illustrates epiblepharon and stresses the need for eyelid margin examination in downgaze in the child with epiphora or conjunctivitis.

Monopolar electrosurgical flash fire.

A 78-year-old man underwent ectropion repair with a monopolar electrosurgical unit. A flash fire occurred, resulting in a loss of eyelashes of the left upper and lower eyelids. A retrospective analysis of the case was conducted, including a review of the relevant literature. Although rare, the possibility of a flash fire should be considered when performing surgery with an electrosurgical unit. Minimizing supplemental oxygen and electrosurgical power settings may help to avoid such an incident.

A tarsal strip-periosteal flap technique for lateral canthal fixation.

Lateral canthal fixation is widely used. This article sought to determine if a periosteal flap used routinely in conjunction with a tarsal strip provides lasting lateral canthal fixation. This consecutive clinical series from two ambulatory surgery centers followed 79 patients who underwent 141 lateral canthal fixation procedures. Outcome was measured by the position of the lateral canthus. Correct positioning of the lateral canthus was achieved in 78 of 79 patients representing 139 of 141 procedures (98%). The failed case was a patient with floppy eyelid syndrome in whom the sutures tore through the tarsal strips. The tarsal strip-periosteal flap technique is a successful, technically direct method of lateral canthal fixation. It is promoted as an enhancement of the tarsal strip technique, and is especially helpful in patients with prominent eyes.

Reoperation in acquired involutional ptosis.

Postoperative upper lid asymmetry is a common problem following ptosis surgery. Recently we performed multiple ptosis operative procedures to correct lid asymmetry in the management of a patient with bilateral acquired upper eyelid ptosis. The patient's eyelids were corrected successfully after five procedures. We retrospectively reviewed the treatment of this patient with unsatisfactory results. The medical literature was reviewed for further insight into the common problem of reoperation after ptosis surgery.