Transitioning from a gold weight to an "enhanced" palpebral spring in the management of paralytic lagophthalmos secondary to facial nerve palsy.

PURPOSE: To analyze the outcomes of patients who transitioned from a weight to a spring. METHODS: Case series original investigation. Five consecutive patients undergoing "enhanced" palpebral spring insertion status post gold weight insertion were identified. Outcome measures included visual acuity, lagophthalmos, margin reflex distance 1, and corneal epithelial defects. Subjective outcomes included need for eye lubrication, closure and rapid blink, and symptoms of discomfort and dryness. This study was reviewed by an accredited Institutional Review Board (IRB) and granted exempt status according to federal regulations. RESULTS: Mean visual acuity post weight versus spring was 20/200 (logMAR 1.0, Std Dev. -0.6) and 20/25 (logMAR 0.1, Std Dev. -0.1), respectively (p = 0.0214, CI 0.231 to 1.670). Mean lagophthalmos post weight (3.5 mm, Std Dev. -2.8) versus post spring (0.2 mm, Std Dev. -0.5). Margin reflex distance 1 improved by a mean of 1.4 mm (gold wt -0.6, Std Dev. -0.5/spring -2.0, Std Dev. -0.4) (p = 0.0016, CI -1.773 to -0.977). Superficial punctate keratopathy was present in all patients with weights and present in no patients post transition (p = 0.0079). Post transition, three of five patients rarely required lubrication and experienced a more satisfactory blink rate. CONCLUSION: Patients with lagophthalmos due to cranial nerve seven palsy who have undergone gold weight placement but continue to exhibit objective and subjective corneal symptoms may have symptomatic improvement with the transition to a palpebral spring.

Orbital Myxofibrosarcoma: Case Report and Review of Literature.

Myxofibrosarcoma is rarely found in the orbit, let alone as a primary orbital tumor. With this having only been previously reported 5 times in the literature, there is a very limited understanding of its presentation and course. Typical management involves surgical excision with or without postoperative radiotherapy. Low-grade malignancy, although rare to metastasize, still has a high rate of local recurrence and with each recurrence increases the risk of metastatic potential. With this in mind, analysis of each case is critical in better understanding the disease, and this case adds to the current literature.

Diagnosis, Treatment, and Surgical Repair in a Case of Isolated Conjunctival Lichen Planus Causing Cicatricial Entropion.

A 50-year-old male presented with bilateral cicatricial entropion with subepithelial fibrosis and fornix foreshortening. Conjunctival biopsy showed lymphocytic infiltrate along the interface of the epithelium and lamina propria with linear, shaggy fibrinogen deposition along the epithelial basement membrane zone, supporting a diagnosis of lichen planus. The patient was treated with commercially available topical cyclosporine for 5 months after which bilateral lower eyelid splitting procedure with recession of the anterior lamella and complete excision of the lower eyelid lashes was performed.

Piezosurgery in External Dacryocystorhinostomy.

BACKGROUND: Dacryocystorhinostomy (DCR) can be performed via an external or endoscopic approach. The use of ultrasonic or piezosurgery has been well described for endoscopic DCRs but is lacking for external DCRs. This study presents a case series of external DCRs performed using piezosurgery evaluating results and complications. METHODS: Prospective, consecutive case series of patients undergoing primary external DCR for lacrimal drainage insufficiency. A standard external DCR technique was used using 1 of 2 piezosurgery systems for all bone incision. All patients received silicone intubation to the lacrimal system. Surgical outcome was measured in terms of patient-reported epiphora as follows: 1) complete resolution, 2) improvement >50%, 3) improvement <50%, and 4) No improvement. Intra and postoperative complications were also recorded. RESULTS: Fifty-two patients, 14 male and 38 female, were included in the study, with 2 patients having bilateral surgery. The average age of the patients was 55.8 years. The average length of follow up was 221 days. Surgical outcomes showed 72% of patients with complete resolution of epiphora and 21% with >50% improvement. There were 4 patients (7%) who had <50% improvement. There was 1 (2%) intraoperative complication and 2 (4%) postoperative complications recorded. CONCLUSIONS: Piezourgery is a viable modality for performing external DCRs. The lack of surgical complications shows a potential for decreased soft tissues damage. The surgical success rate based on patient-reported epiphora is similar to those published for mechanical external DCRs. This modality may benefit the novice surgeon in the reduction of soft and mucosal tissue damage.

Evolving Minimally Invasive Techniques for Tear Trough Enhancement.

PURPOSE: The aim of this study is to investigate whether volumetric enhancement of the infraorbital rim area or, alternatively, of the deep medial cheek, results in greater improvement of tear trough deformity. METHODS: This prospective, single-blind study recruited 12 patients seeking correction of tear trough deformity. Pretreatment standardized photographs were obtained after which patients were randomized to receive hyaluronic acid gel filler augmentation of the tear trough on one side and hyaluronic acid gel augmentation of the cheek on the contralateral side. The patients were then re-examined at 3 weeks postinjection when standardized photographs were taken again. Following the photographs, filler was added to the side and location where they were not used at the original treatment, resulting in added volume in both the cheek and the tear trough. The patients returned 3 weeks later when final photographs were taken. The pre- and post-treatment images were randomized and evaluated by 3 masked observers asked to evaluate the depth of tear trough. RESULTS: There was a significant improvement in the depth of the tear trough rating after initial treatment on the side treated in the tear trough (p = 0.0001). There was not a significant change in depth of tear trough rating, however, on the side receiving cheek only treatment (p = 0.0963). There was a statistically significant change in tear trough rating after both tear trough and cheek had been treated on each side (p = 0.001). There was no statistically significant difference between sides after lid and cheek treatment had been completed on each side (p = 0.5986). Intraclass correlation between reviewers for all subjects was excellent at 0.94. Tear trough injections were more technique sensitive than cheek volume augmentation to achieve satisfactory results. There were no complications from cheek volume enhancement. Varying degrees of ecchymosis were encountered with tear trough injections. CONCLUSIONS: When the patient's primary concern is the appearance of the tear trough, and the physician is limited to treating either the tear trough or the cheek alone, it appears that treatment in the tear trough offers greater improvement in the appearance of the tear trough deformity when compared with treatment in the cheek alone.

Regression of a paraganglioma tumor of the orbit.

PURPOSE: To describe a clinical case of an orbital paraganglioma that displayed regression after biopsy alone. METHODS: Case report. RESULTS: A 75-year-old female was examined for a right orbital tumor suspected to be metastatic breast carcinoma. An orbital biopsy was performed with significant hemorrhage encountered requiring extensive cautery. There was apparent clinical regression of the tumor with no signs of proptosis or eye movement restriction two years after this patient's biopsy. Histology was consistent with paraganglioma (glomus tumor). CONCLUSION: Although we cannot rule out spontaneous regression of this unique tumor, we postulate that tissue necrosis caused by the use of cautery induced regression. Unless encapsulated and easily accessible, we suggest that the best management of this rare tumor is that of observation after being found negative for malignancy by biopsy given their propensity for slow progression and in rare cases, regression.

Risk of ocular blood splatter during oculofacial plastic surgery.

PURPOSE: To assess intraoperative blood splatter to the ocular surface and adnexa during oculofacial surgery. METHODS: Four surgeons and multiple assistants at three separate locations wore a total of 331 protective eye shields during 131 surgeries. Postoperatively, a luminol blood detection system was used to identify blood splatter on the shields. In the event of positive blood splatter, the total number of blood spots was counted. Controls were used to verify the blood detection protocol. A postoperative questionnaire was given to all surgeons and assistants after each case, and they were asked whether intraoperative blood splatter was noticed. RESULTS: Blood was detected on 61% of eye shields and in a total of 80% of surgical cases. However, only 2% of blood splatters were recognized intraoperatively by the surgical participants. There was no significant difference in the splatter rate between surgeons (64%), assistants (60%), and surgical technicians (58%) (p = 0.69). Shields worn during full-thickness eyelid procedures, direct brow lifting, orbitotomy with bony window, and orbital fracture repairs were more likely to be splattered (p = 0.03), and there was a significant difference between splatter rates among different surgeons (range, 29-90%; p = 0.0004), suggesting that blood splatter rate may be both procedure dependent and surgeon dependent. CONCLUSIONS: Mucocutaneous and transconjunctival transmission of human immunodeficiency virus and viral hepatitis has been documented. These results suggest that oculofacial plastic surgeons should consider eye protection for patients with known blood-borne diseases and in cases where blood splatter is expected. This precautionary practice is supported by the high incidence (98%) of undetected, intraoperative blood splatter.

Preoperative evaluation of the brow-lid continuum.

This article presents a thorough review for evaluation of the upper eyelid and brow preceding rejuvenation surgery. It is emphasized that surgical and nonsurgical rejuvenation is directed toward modifying the anatomic causes of facial aging. Relevant anatomy of the lid and brow area is delineated. The discussion includes surgical notes that highlight cautions or tips related to the anatomic area concerned.

Canalicular obstruction: a histopathologic case series.

OBJECTIVE: To investigate the histopathologic causes of canalicular obstruction in a case series of patients treated by canalicular trephination for symptomatic epiphora. DESIGN: A university and private practice retrospective chart review. PARTICIPANTS: The study involved 12 consecutive patients who underwent unilateral canalicular trephination with tissue retrieval for the treatment of canalicular obstruction. METHODS: Canalicular obstruction was confirmed at the time of preoperative and intraoperative probing and irrigation. Treatment consisted of canalicular trephination combined with silicone intubation and a concomitant dacryocystorhinostomy in 6 cases. Tissue was recovered from the trephine lumen and submitted for pathologic analysis. Predisposing factors that could have caused canalicular obstruction and the clinical course following treatment were reported. RESULTS: The most common histopathologic finding was nonspecific inflammation with associated fibrosis. Cases demonstrating sebaceous gland adenoma, skeletal muscle, adipose tissue, and bone were identified. CONCLUSIONS: Use of the lacrimal trephine to open canalicular obstructions provided tissue samples that revealed nonspecific inflammation and fibrosis as a common underlying histopathology. The presence of skeletal muscle and adipose tissue suggests a decrease in canalicular diameter or such dense scarring that the normal canalicular architecture could not be followed. Other causes of canalicular obstruction such as lacrimal sac tumors should be considered in the differential diagnosis.

Transcaruncular medial wall orbital decompression: an effective approach for patients with unilateral graves ophthalmopathy.

PURPOSE: To evaluate the reduction in proptosis, incidence of postoperative diplopia, and postoperative globe symmetry after transcaruncular medial wall decompression in patients with unilateral Graves ophthalmopathy. METHODS: Retrospective review of 16 consecutive patients who underwent unilateral transcaruncular medial wall orbital decompression from 1995 to 2007. The diagnosis of Graves ophthalmopathy was based on history and clinical findings including proptosis, lagophthalmos, lid retraction, motility restriction, and systemic thyroid dysfunction. RESULTS: The mean reduction in proptosis was 2.3 mm. The mean difference in exophthalmometry preoperatively between the two eyes in each patient was 3.1 mm whereas postoperatively the mean difference was 1.1 mm (P = 0.0002). Eleven of 16 patients (69%) had 1 mm or less of asymmetry postoperatively. There was no statistically significant difference in the incidence of diplopia pre and postoperatively (P = 1.0). CONCLUSIONS: Medial wall orbital decompression is a safe and practical surgical approach for patients with unilateral Graves orbitopathy. The procedure carries a low risk of morbidity and yields anatomic retrusion of the globe that is comparable to other more invasive methods and may yield more symmetric postoperative results.

Percutaneous drainage and ablation as first line therapy for macrocystic and microcystic orbital lymphatic malformations.

PURPOSE: To review the management of orbital lymphangiomas and to propose a new treatment for both macrocystic and microcystic lymphatic malformations of the orbit. METHODS: A retrospective case series of all patients from the authors' practice from 2001 to the present who met the histopathologic and/or diagnostic imaging criteria for orbital lymphatic malformation was reviewed. Lymphatic malformation was diagnosed if there was a multilobulated pattern on CT or a cystic internal structure on ultrasonography. In patients that were treated, macrocysts (>1 cm) were treated with dual-drug chemoablation (sequential intracystic sodium tetradecyl sulfate and ethanol); doxycycline injections were used for microcysts. The goal of treatment was complete cyst ablation documented by ultrasonography or MRI. RESULTS: Twenty patients met the inclusion criteria. They were separated in 3 groups based on the anatomical location of the lymphatic malformation: deep, superficial, or combined. Deep orbital lymphatic malformation presented in 14 patients (70%), superficial presented in 4 patients (20%), and both deep and superficial presented in 2 patients (10%). Thirteen of the 20 patients underwent percutaneous sclerotherapy. Of those treated, 7 patients (53.8%) had lymphatic malformations (LM), while 6 patients (46.2%) had venous-lymphatic malformations (VLMs). The average number of treatments required to achieve complete cyst ablation in patients with LM was 1.7. The average number of treatments required for patients with VLM was 3.0; however, some of these patients continue to have the venous component of their lesions treated. Clinically, all treated patients maintained or improved an average of one Snellen line (-0.16 decimal Snellen equivalent) from their preoperative visual acuity to their last recorded follow-up visit. There was a mean reduction in proptosis of 2.4 mm (p - 0.003, confidence interval [CI] 0.838 to 3.962), which was statistically significant. There were no recurrences (0%) in patients who completed treatment with cyst ablation (n - 8) at an average follow-up period of 43 months (range 6-96, standard deviation 30). There were no data available as to the recurrence status of one patient. Four patients were still undergoing treatment for a venous component at the time of this review. CONCLUSIONS: Percutaneous sclerotherapy provides a safe and effective treatment for both macrocystic and microcystic orbital lymphatic malformations as a primary treatment or for recurrence after surgical intervention.

Prevalence of canaliculitis requiring removal of SmartPlugs.

PURPOSE: To report the first accurate prevalence of canaliculitis associated with the use of the SmartPlug. METHODS: All patients from a single private ophthalmology practice who received SmartPlugs from 2002 to 2007 were identified. All patients from the private ophthalmology practice that developed canaliculitis secondary to SmartPlug insertion were referred to a single private ophthalmic plastic and reconstructive surgery office. A retrospective review of those 17 patients was performed. RESULTS: From 2002 to 2007, a total of 235 patients were identified from a single private ophthalmology practice with a total of 402 SmartPlugs inserted. Of those 235 patients, 17 developed canaliculitis and were referred to a single private ophthalmic plastic and reconstructive surgery office. The prevalence of canaliculitis per patient was 7.23%. The prevalence of canaliculitis per SmartPlug inserted was 4.73%. The average time from SmartPlugs insertion to onset of symptoms was 3 years. All affected patients required canaliculotomy and plug removal. CONCLUSIONS: This is the first study reporting the prevalence of canaliculitis associated with the use of the SmartPlug. All affected patients required surgical intervention, after which many continued to have dry eye and one required bilateral Jones tubes. Ophthalmologists using the SmartPlug for the treatment of dry eye syndrome should carefully weigh the risks and benefits of their use.

Bulbar conjunctival autograft with rectus muscle transeyelid traction suture for diplopia due to bulbar conjunctival scarring.

Cases of bulbar conjunctival fibrosis from pterygium surgery, strabismus surgery, trauma, chemical exposure, and inflammatory conditions can be difficult to manage. Despite surgical approaches entailing autografts, amniotic membranes, and antimetabolites, preventing postoperative scarring and contracture can be difficult, particularly in patients with susceptibility to scarring. The authors present a case of a 39-year-old man with diplopia secondary to subconjunctival scarring and fibrosis after multiple pterygium surgeries. The authors describe a unique surgical approach using a medial rectus transeyelid traction suture as a means of preventing postoperative conjunctival graft contracture and functional disability.

Introduction--the methyl parathion story: a chronicle of misuse and preventable human exposure.

In the fall of 1994, Lorain County, Ohio, became the site of the first investigation of several large-scale incidences in which the organophosphate pesticide methyl parathion was illegally applied to private residences. The extent of potential human exposure to this pesticide led the Ohio Department of Health to formally request technical assistance from the Centers for Disease Control and Prevention (CDC). This article describes the initial investigation of 64 homes in Ohio and introduces the method of using both biological markers of exposure (p-nitrophenol levels in human urine samples) and environmental markers of contamination in dust and air samples when making public health decisions about the cleanup of homes sprayed with methyl parathion. The results of the CDC rapid investigation led the U.S. Environmental Protection Agency to declare the contaminated homes in Lorain County a Superfund cleanup site. Seven years after the Lorain incident, and after subsequent Superfund actions had been implemented in Illinois and Mississippi, researchers participated in an expanded session devoted to methyl parathion at the 11th Annual Meeting of the International Society of Exposure Analysis held in Charleston, South Carolina, in the fall of 2001. The articles included in this monograph are based on presentations at that meeting. They report previously unpublished data that tell the methyl parathion story from different perspectives, each providing in-depth information about separate aspects of this multistate, multiagency, and multimillion dollar chemical exposure. This monograph is the methyl parathion story.

Assessment of human exposure and human health effects after indoor application of methyl parathion in Lorain County, Ohio, 1995-1996.

In January 1995 the U.S. Environmental Protection Agency declared methyl parathion-contaminated homes in Lorain County, Ohio, as a Superfund cleanup site. During the 2-year cleanup, the Centers for Disease Control and Prevention in collaboration with county and city health officials conducted a study of exposure and health effects among residents. We administered 254 household and 747 individual questionnaires; urine analysis for p-nitrophenol (PNP, a metabolite of methyl parathion) was available for 626 participants. We also reviewed medical records of 49 people who were hospitalized or died after their homes were sprayed. People living in homes sprayed <180 days previously were most likely to have the highest PNP levels (22.9% > 100 ppb PNP), but even people living in homes sprayed more than a year previously appeared to be highly exposed (8.5% > 100 ppb PNP). The National Health and Nutrition Examination Survey reference range is 0-63 ppb. Median detectable PNP levels among children younger than 3 years of age were 93.9 ppb compared with 41.6 ppb among people older than 3 years. Younger children appeared to be at greatest risk of exposure. In none of the medical records that we reviewed did a health care provider consider pesticide poisoning as a potential etiology.

Public health decisions: the laboratory's role in the Lorain County, Ohio, investigation.

In 1994 officials from the Ohio Department of Health reported that some residents of Lorain County, Ohio, possibly had been exposed to methyl parathion (MP), a highly toxic restricted-use pesticide. The U.S. Centers for Disease Control and Prevention (CDC) assisted in the investigation by providing epidemiologic and laboratory support to the state and local health departments. Although the initial investigation found MP inside the homes, it was unclear if the residents were exposed. CDC used a new biological monitoring method to measure urinary p-nitrophenol (PNP), the metabolite of MP. This biological monitoring measures the internal dose from exposure to toxic chemicals from all routes. Laboratory analyses demonstrated that the urine of residents contained moderate to high levels of PNP, with median, mean, and highest reported concentrations of 28, 240, and 4,800 g/L, respectively, thus confirming exposure of the residents. Almost 80% of the residents had urinary PNP concentrations above the 95th percentile of the reference range concentrations. This information, combined with other analytical results of air and wipe tests, guided public health officials' decisions about the potential risk in each household. In this article we illustrate the laboratory's role in providing information to assist in making these public health decisions. Furthermore, it illustrates how a multidisciplinary team from various governmental agencies worked together to protect the public's health.

Measurement of p-nitrophenol in the urine of residents whose homes were contaminated with methyl parathion.

During the last several years, illegal commercial application of methyl parathion (MP) in domestic settings in several U.S. Southeastern and Midwestern States has affected largely inner-city residents. As part of a multiagency response involving the U.S. Environmental Protection Agency (U.S. EPA), the Agency for Toxic Substances and Disease Registry (ATSDR), and state and local health departments, our laboratory developed a rapid, high-throughput, selective method for quantifying p-nitrophenol (PNP), a biomarker of MP exposure, using isotope dilution high-performance liquid chromatography-tandem mass spectrometry. We measured PNP in approximately 16,000 samples collected from residents of seven different states. Using this method, we were able to receive sample batches from each state; prepare, analyze, and quantify the samples for PNP; verify the results; and report the data to the health departments and ATSDR in about 48 hr. These data indicate that many residents had urinary PNP concentrations well in excess of those of the general U.S. population. In fact, their urinary PNP concentrations were more consistent with those seen in occupational settings or in poisoning cases. Although these data, when coupled with other MP metabolite data, suggest that many residents with the highest concentrations of urinary PNP had significant exposure to MP, they do not unequivocally rule out exposure to PNP resulting from environmental degradation of MP. Even with their limitations, these data were used with the assumption that all PNP was derived from MP exposure, which enabled the U.S. EPA and ATSDR to develop a comprehensive, biologically driven response that was protective of human health, especially susceptible populations, and included clinical evaluations, outreach activities, community education, integrated pest management, and decontamination of homes.