Effect of upper eyelid blepharoplasty on the ocular surface, tear film, and corneal microstructure.

PURPOSE: This study aimed to investigate the effect of upper eyelid blepharoplasty with the removal of the skin and a strip of orbicularis oculi muscle on the ocular surface, tear film, and dry eye-related symptoms. METHODS: Twenty-two eyes of 22 consecutive patients operated by a single surgeon (21 females; mean age, 61 years; age range, 41-75 years) were included. All subjects completed the Ocular Surface Disease Index questionnaire, underwent in vivo confocal microscopy, tear film breakup time measurements, the Schirmer test with anesthesia, and fluorescein and lissamine green staining measurements before, 1 month, and 6 months after upper blepharoplasty alone with preseptal orbicularis excision. RESULTS: A significant increase in Ocular Surface Disease Index, and corneal fluorescein and lissamine green staining and a significant decrease in tear film breakup time were observed after 1 month (p=0.003, p=0.004, p=0.029, and p=0.024 respectively) and 6 months (p=0.001 for all findings). No significant difference in the Schirmer test score was observed during the follow-up. None of the in vivo confocal microscopy parameters showed significant changes during the study. CONCLUSIONS: An increase in dry eye symptoms and a decrease in tear film stability along with ocular surface staining were observed in patients undergoing upper eyelid blepharoplasty.

Effect of upper eyelid blepharoplasty on the ocular surface, tear film, and corneal microstructure

ABSTRACT Purpose: This study aimed to investigate the effect of upper eyelid blepharoplasty with the removal of the skin and a strip of orbicularis oculi muscle on the ocular surface, tear film, and dry eye-related symptoms. Methods: Twenty-two eyes of 22 consecutive patients operated by a single surgeon (21 females; mean age, 61 years; age range, 41-75 years) were included. All subjects completed the Ocular Surface Disease Index questionnaire, underwent in vivo confocal microscopy, tear film breakup time measurements, the Schirmer test with anesthesia, and fluorescein and lissamine green staining measurements before, 1 month, and 6 months after upper blepharoplasty alone with preseptal orbicularis excision. Results: A significant increase in Ocular Surface Disease Index, and corneal fluorescein and lissamine green staining and a significant decrease in tear film breakup time were observed after 1 month (p=0.003, p=0.004, p=0.029, and p=0.024 respectively) and 6 months (p=0.001 for all findings). No significant difference in the Schirmer test score was observed during the follow-up. None of the in vivo confocal microscopy parameters showed significant changes during the study. Conclusions: An increase in dry eye symptoms and a decrease in tear film stability along with ocular surface staining were observed in patients undergoing upper eyelid blepharoplasty.

The role of choroidal optical coherence tomography for follow-up of carotid cavernous fistula with anterior drainage.

BACKGROUND: To evaluate the role of the choroidal vascularity index (CVI) and the tortuosity index (TI), along with choroidal thickness measurements, in follow-up for anteriorly draining carotid cavernous fistulas (CCF) that would otherwise necessitate an invasive carotid angiogram. METHODS: In this longitudinal observational study, analysis of enhanced depth imaging spectral domain optical coherence tomography (SD-EDI-OCT) images of 22 patients with angiographically proven unilateral CCF with anterior drainage was performed for subfoveal choroidal thickness (SFCT), central foveal thickness (CFT), CVI and TI. Baseline measurements were compared with those taken at the last visit after occlusion of the fistula. RESULTS: Both in the clinically affected and unaffected eyes, there was a significant decrease in CFT (p = 0.015 and p = 0.005, respectively), SFCT (p = 0.000 for both eyes), CVI (p = 0.002 and 0.001, respectively) and all three TI parameters, including inferior (p < 0.001 and p = 0.01, respectively) and superior temporal vein tortuosity index (p = 0.005 and p = 0.02, respectively) as well as total venular tortuosity index (p < 0.001 and p = 0.002, respectively) after successful closure of the fistula compared to first presentation. Changes in all parameters were similar between the D-CCF and I-CCF groups except for CVI. CONCLUSIONS: In this first study concerning follow-up of anteriorly draining unilateral CCFs by SD-EDI-OCT, we not only demonstrated involvement of the clinically unaffected eye but also showed that, this modality, utilizing CVI and TI together with choroidal thickness measurements, can be used as a readily available, noninvasive first-line followup method for evaluating occlusion of fistulas by endovascular treatment or spontaneous resolution.

Retinal and Choroidal Optical Coherence Tomography Findings of Carotid Cavernous Fistula.

PURPOSE: To define the retinal and choroidal imaging findings of carotid cavernous fistula (CCF) including central foveal thickness, subfoveal choroidal thickness, choroidal vascularity index (CVI) parameters, and tortuosity indexes (TIs) as compared to a control group (CG). DESIGN: Cross-sectional study. MATERIALS AND METHODS: The spectral domain enhanced-depth imaging optical coherence tomography images of 19 eyes of 19 consecutive patients with angiographically proven CCF and 19 eyes of 19 age- and sex-matched healthy control subjects were included. The patient group was divided according to CCF venous drainage pattern as anterior (A-CCF: draining into ophthalmic veins) and posterior (P-CCF: not draining into ophthalmic veins). The clinically affected eyes of the patient group, ipsilateral to the fistula, were included in the analysis. RESULTS: There were 15 A-CCFs (78.9%) and 4 P-CCFs (21.1%). The mean SFCT of the A-CCF group (395.21 ± 111.69 µm) was significantly higher than those of the P-CCF (246.84 ± 94.12 µm) and CG groups (280.79 ± 111.36 µm) (P = .039 and P = .006, respectively). The mean CVI of the A-CCF group was significantly higher than that of the CG (68.97 ± 4.81 and 65.66 ± 3.37, respectively, P = .033). The A-CCF group had significantly higher inferior, superior, and total venous TI than the CG group (P = .001, P = .001, and P < .001, respectively). CONCLUSION: In this first study investigating the CVI and TI in CCF patients, we demonstrated that SFCT, CVI, and TI could potentially be used to aid in the diagnosis of A-CCF.

Association of Disease Activity with Serum and Tear IL-2 Levels in Behçet Disease.

PURPOSE: To investigate the association of Behçet disease activity with serum and tear interleukin-2 levels. METHODS: The study was designed as a prospective case control study. The study population consisted of 45 patients with Behçet disease and 24 age and sex-matched healthy participants. Behçet disease patients were classified as active (24 patients) or inactive (21 patients) according to disease activity. Serum and tear interleukin-2 levels were determined using the enzyme-linked immunosorbent assay method. RESULTS: The mean serum and tear interleukin-2 levels of the active disease, inactive disease, and control groups were 17.04 ± 5.02 and 32.61 ± 16.53 pg/mL; 15.20 ± 4.68 and 29.61 ± 8.30 pg/mL; and 14.22 ± 4.18 and 28.89 ± 8.73 pg/mL, respectively. There was no statistically significant difference between the groups with respect to all measured data. CONCLUSIONS: There was no significant difference in serum or tear IL-2 levels between Behçet patients and controls; there was no association of disease activity with serum and tear IL-2 levels.

An unusual eyelid mass: Tarsal dermoid cyst.

We report the case of a 15-month-old boy who presented with a mass lesion of the right upper eyelid that had been present since birth and had slowly enlarged over the last 3 months. The lesion had minimal surrounding erythema simulating the appearance of a chalazion. Intraoperatively the lesion was noted to be firmly adherent to the underlying tarsus. The lesion was excised completely through an eyelid crease approach leaving the tarsus intact. The histopathology was consistent with dermoid cyst. To our knowledge, this is the third case of a tarsal dermoid cyst reported in the literature. Dermoid cyst should be included in the differential diagnosis of eyelid mass lesions, and particulary differentiated from a chalazion to avoid mismanagement that may lead to scarring, recurrence and inflammation. The excision of these lesions sparing the underlying tarsus can be possible.

Angiographic Morphometry of Internal Carotid Artery Circulation in Turkish Children.

AIM: Knowledge of cerebrovascular morphology is integral in planning neuroendovascular interventions, especially for procedures involving placement of stents, flow diverters or stentrievers. There is insufficient data on angiographic normative values of cerebral circulation in the pediatric age group since angiograms are uncommonly performed in children except for arteriovenous malformations in which arterial dimensions are larger than normal. We aimed to measure the diameters of internal carotid circulation (ICC) arteries on digital subtraction angiograms of pediatric patients and determine the growth trends. MATERIAL AND METHODS: This is a retrospective cross-sectional study measurements of ICC arteries of 64 pediatric patients (4-122 months) with retinoblastoma undergoing intra-arterial chemotherapy. RESULTS: Petrous, cavernous, supraclinoid and choroidal segments of internal carotid artery (ICA) and anterior cerebral artery (ACA) diameters had significant correlation with age. Most of the growth was noted in the first 36-48 months of life. Middle cerebral artery (MCA) diameter did not show significant correlation with age. 87% of the adult diameter of the MCA was attained in the first 6 months of life. ICC arteries reached 81% to 99% of adult sizes in the first 48 months of life. On the contrary, the main iliac artery was only 59% of the adult diameter at this age group. CONCLUSION: Use of current intracranial stents in children appears tolerable due to the growth pattern of ICC arteries. Based on this data, the current armamentarium of intracranial stents or stent-like devices is sufficient to cover the need in the pediatric population.

Acute, unilateral transient blepharoptosis of unknown etiology: a review.

PURPOSE: To describe 5 patients with transient, acute, unilateral blepharoptosis of unknown etiology. METHODS: Medical records of 5 patients, which were seen in 5 different clinics between 1998 and 2011, were reviewed. RESULTS: The ages of the patients were 7, 7, 32, 44, and 75 years (2 women and 3 men). Four patients had partial (1.5-3.5 mm) and 1 patient had total ptosis. Levator function was normal in 2 patients, and 3 patients had only 2 to 3 mm decreased levator function on the affected side. None of the patients had limited motility or any pupil abnormalities. All patients had a history of flu-like illness preceding the development of blepharoptosis. The ptosis completely resolved in 3 to 14 days in all patients and did not recur during the follow-up period (range: 2 months-7 years). CONCLUSIONS: Transient, acute, unilateral blepharoptosis is a very rare condition. Patients presenting with acute ptosis should be questioned about a recent history of flu-like syndrome, and if workup is negative with this history, the clinicians should suspect this rare condition.

Red lesions of the iris, choroid, and skin secondary to metastatic carcinoma of the thyroid: a review.

An 83-year-old man was seen with a history of bilateral progressive loss of vision of 1 month's duration. On examination, there was a reddish, nodular lesion adjacent to the right side of the nose. Slit-lamp examination revealed a reddish iris mass in the left eye. Ophthalmoscopic examination revealed two orange choroidal lesions in the right eye and a large subretinal hemorrhage in the posterior pole with a central reddish vascular lesion in the left eye. An excisional biopsy of the skin lesion was performed. A diagnosis of metastatic follicular thyroid carcinoma was made according to the histopathologic findings and immunohistochemistry. The patient had no known history of thyroid malignancy and a metastatic survey revealed widespread metastasis. The patient had a total thyroidectomy followed by two series of radioactive iodine ablation. The iris lesion completely resolved and the choroidal lesions in the right eye showed partial regression during the follow-up period. Ocular and skin metastasis secondary to thyroid carcinoma is uncommon. In a review of English literature we found reports of 12 clinically well-documented cases of choroidal metastasis and two cases of iris metastasis. Our case and review of the previous cases reveal that reddish/orange color is a commonly observed feature of the uveal metastasis of thyroid carcinoma. Although ocular and skin metastases from thyroid carcinoma are rare, this possibility should be considered in the differential diagnosis of reddish-colored iris and choroidal masses as well as reddish nodular lesions of the scalp, face, and neck.

Effect of botulinum toxin type a on tear production after treatment of lateral canthal rhytids.

PURPOSE: To evaluate the incidence of temporary dry eye and the effects on lacrimal gland tear production after treatment of lateral canthal rhytids with botulinum toxin type A injections. METHODS: Twenty-six crow's feet areas were injected with botulinum toxin type A in 13 women with an age range of 31 to 58 years. A total of 10 units of botulinum toxin was injected per side, with two separate injections. Schirmer 1 testing was performed before and at 1 week, 1 month, and 4 months after the injections in all patients. The test was repeated at 6 months and 9 months for the patients whose Schirmer test results were not back to baseline at the 4-month follow-up. Statistical significance was evaluated with paired t test analysis. RESULTS: Overall, no statistical difference was found in Schirmer test results from baseline at 1 week (p = 0.23), 1 month (p = 0.32), or 4 months (p = 0.30) after injection. Five eyes of three patients had a significant decrease in Schirmer test results from baseline at 1 week and 1 month after injection. Three eyes of 2 patients had a significant decrease in Schirmer test results at 4 months after injection. Only one patient reported dry-eye symptoms at the 4-month follow-up. Schirmer test results of two eyes of one patient remained significantly lower than baseline at 6 months follow-up, which returned to the normal range at 9 months. CONCLUSIONS: Botulinum toxin for lateral canthal rhytids usually does not suppress tear production. However, decreased tear production after botulinum toxin injection for crow's feet is a possible complication and patients should be advised of the small but definite risk of a temporary dry eye.

Compressive optic neuropathy after use of oxidized regenerated cellulose in orbital surgery: review of complications, prophylaxis, and treatment.

PURPOSE: We report 2 cases of compressive optic neuropathy after use of oxidized regenerated cellulose (ORC) in orbital surgery. To our knowledge, no complications have been reported previously after use of this material in orbital surgery. We also review the complications related to its retention at operative sites outside the orbit and recommend precautions to avoid them. DESIGN: Retrospective interventional case reports. PARTICIPANTS: Two patients with compressive optic neuropathy after use of ORC in orbital surgery. METHODS: Case reports from 2 different clinics and review of the English scientific literature. MAIN OUTCOME MEASURES: Best-corrected visual acuity, extraocular motility, proptosis, and chemosis. RESULTS: One patient underwent orbital exploration and biopsy of an orbital tumor, and the second had repair of an orbital floor fracture. Postoperatively, both presented with chemosis, ophthalmoplegia, and progressive loss of vision. Orbital imaging revealed a retrobulbar soft-tissue density compatible with hematoma. Repeat orbital exploration revealed the soft-tissue mass to be swollen ORC. CONCLUSIONS: Retained intraorbital ORC may cause a compartment syndrome and should be suspected in postoperative patients with orbital symptoms. When ORC is used around the optic nerve, it should be removed after hemostasis is achieved.

Leiomyoma of the orbit and periocular region: a clinicopathologic study of four cases.

PURPOSE: Leiomyomas are exceedingly rare tumors of the orbit and periorbital region. Our objective is to describe the clinical, histopathologic, and radiologic features and the management of 4 cases of orbital leiomyomas and to summarize the cases from the literature. METHODS: This retrospective review describes 4 patients with orbital leiomyoma diagnosed by clinical and histopathologic studies. Electron microscopy was performed in 2 cases. Immunohistochemical techniques were performed with 5 monoclonal antibodies. Selected papers describing well-documented cases of orbital leiomyoma in the English literature published since 1960 were reviewed. RESULTS: CT and MRI showed well-circumscribed contrast-enhancing mass lesions. Three tumors were completely excised and 1 had subtotal excision. All 4 tumors showed immunoreactivity for actin, desmin, and vimentin. Follow-up examination showed no evidence of recurrence in 3 patients. One patient was lost to follow-up. CONCLUSIONS: Leiomyoma should be considered in the differential diagnosis of a well-circumscribed mass lesion involving the orbit and periorbital region. Immunohistochemistry provides conclusive evidence to confirm the diagnosis.

Orbital venous malformations: current multidisciplinary treatment approach.

OBJECTIVE: To evaluate the clinical, radiological, and histopathological features, treatment, and outcome of a series of orbital venous flow malformations (OVMs) with the aim of delineating a more systematic approach for treatment. METHODS: A 38-year retrospective review of 22 patients with OVMs followed up at 1 institute. RESULTS: Eighteen of 22 patients (13 women and 9 men) showed clinical or radiological evidence of distensibility. The mean age at the initial manifestation was 28.3 and 50.7 years in patients with distensible and nondistensible OVMs, respectively. Eight patients (36.3%) had deep orbital lesions, 6 (27.3%) had superficial orbital lesions, and 8 (36.3%) had combined orbital lesions. All 3 patients with deep nondistensible OVMs had a sudden onset of proptosis and pain or diplopia secondary to thrombosis or hemorrhage. Seventeen patients required treatment. All 4 nondistensible lesions were treated by surgical excision. A variety of techniques were used to treat distensible OVMs including carbon dioxide laser ablation, percutaneous alcohol sclerotherapy, or embolization with Guglielmi detachable coils after surgical exposure and surgical excision. Of the 14 patients with follow-up, 8 had complete resolution of the signs and symptoms and 6 patients showed marked improvement following surgery. Mean follow-up was 57.8 months. CONCLUSION: If intervention is indicated, less invasive methods such as carbon dioxide laser ablation and percutaneous alcohol sclerotherapy for superficial and combined orbital lesions and endovascular treatment by Guglielmi detachable coil embolization for deep orbital lesions should be considered before proceeding with more invasive procedures.

Orbitofrontal cholesterol granuloma: distinct diagnostic features and management.

PURPOSE: To describe the distinct clinical, radiologic, and histopathologic findings of orbitofrontal cholesterol granuloma and treatment approaches. We also present 2 atypical cases of cholesterol granuloma, one of which we believe represents the smallest and one of which the most extensive lesion among the previously reported cases in the literature. METHODS: The records of 8 patients with orbital cholesterol granuloma were reviewed retrospectively. RESULTS: Mean age at presentation was 45 years. Six of 8 patients were male. The most common symptom at presentation was proptosis (50%). Computerized tomography of orbits showed a lytic lesion in the superolateral bony orbit with an extraconal soft tissue mass in 2 patients and a cystic lesion eroding the superolateral orbital roof in 4 patients. One patient had a small lytic lesion in the frontal bone without associated soft tissue mass and one patient had a very large destructive mass with extensive intracranial and orbital extension. Magnetic resonance imaging was obtained in 2 patients and showed a non-contrast-enhancing lesion with high signal intensity on both T1- and T2-weighted images. Seven patients were treated by aspiration of the contents and curettage of the lining by an extraperiosteal approach through a subbrow incision. One patient who was clinically thought to have a frontal mucocele was treated by frontal sinus exploration, removal of the lesion, and obliteration of the sinus. Two of 7 patients required lateral orbitotomy for better exposure of the tumor. Only one patient had recurrent symptoms and required a second surgery. CONCLUSIONS: Orbitofrontal cholesterol granulomas have typical clinical and radiologic features. Surgical excision has a high success rate with a low incidence of recurrence.

Bovine pericardium versus homologous sclera as a wrapping for hydroxyapatite orbital implants.

PURPOSE: To report our experience with bovine pericardium as a wrapping material for hydroxyapatite orbital implants after enucleation and to compare the exposure rates of the implants wrapped with bovine pericardium versus donor sclera. METHODS: We retrospectively reviewed the records of all patients who received bovine pericardium-wrapped or donor sclera-wrapped hydroxyapatite implant after primary enucleation between March 1995 and December 2001. RESULTS: Of the 26 patients who received donor sclera-wrapped implants after enucleation, 1 (3.8%) had implant exposure. Of the 26 patients who received bovine pericardium-wrapped implants after enucleation, 6 (23%) had implant exposure. The incidence of implant exposure with the use bovine pericardium wrapping material was found to be significantly higher than with sclera (P = 0.05). Six of the 7 implant exposures were noted in the first 6 months after placement of the orbital implant. Five of the 6 exposed bovine pericardium-wrapped hydroxyapatite implants were associated with socket infection. The case of exposure of the sclera-wrapped implant was treated conservatively by observation. Six patients who had exposure of bovine pericardium-wrapped implants required multiple repairs because of recurrent exposures. Four of these patients eventually required removal of the implant. CONCLUSIONS: Despite the advantages of using bovine pericardium as a wrapping material for hydroxyapatite orbital implants, we observed a significantly higher incidence of exposure with bovine pericardium compared with donor sclera in the early postoperative period. Use of bovine pericardium as a wrapping material for orbital implants should be avoided unless some future modifications of the technique can be developed to prevent such complications.

Incidental diagnosis of orbital lymphoma during blepharoplasty.

PURPOSE: To describe the incidental diagnosis of orbital lymphoma in 3 patients, in whom unusual findings at the time of blepharoplasty led to the diagnosis of orbital lymphoma. METHODS: A retrospective review of the medical records of 3 patients. RESULTS: Two patients presented with bilateral dermatochalasis that obscured the upper visual field and was more prominent on one side. One patient presented with bilateral ptosis and dermatochalasis. All three patients underwent bilateral upper blepharoplasty. In one patient, bilateral ptosis repair was performed in addition to upper blepharoplasty. Blepharoplasty specimens were sent for histopathologic analysis because of the unusual appearance of the preaponeurotic fat at the time of surgery. Histopathology showed low-grade B-cell lymphocytic lymphoma in all three cases. Postoperative CT scan showed a mass in the lacrimal fossa in one patient. None of the patients had evidence of systemic involvement. Two patients were treated with external beam radiotherapy with good results. One patient recently diagnosed with orbital lymphoma was referred to the oncology clinic for further treatment. CONCLUSIONS: Histopathologic evaluation of blepharoplasty specimens is highly recommended in cases in which the orbital fat has an unusual appearance, color, or consistency at the time of surgery.