Botulinum toxin type a for dysthyroid upper eyelid retraction.

PURPOSE: To evaluate the safety and efficacy of botulinum toxin type A for treatment of eyelid retraction resulting from thyroid eye disease (TED) during the inflammatory phase of the condition. METHODS: In this prospective, nonrandomized case series, 18 patients with inflammatory eyelid retraction caused by active TED received botulinum toxin type A injection (10, 5, or 2.5 U) for treatment of upper eyelid retraction. Botulinum toxin type A (Allergan, Irvine, CA, U.S.A.) was injected transconjunctivally just above the superior tarsal border in the elevator complex of the upper eyelid. RESULTS: Seventeen of 18 patients (94%) demonstrated a reduced marginal reflex distance (MRD1) after botulinum toxin injection. The average change in MRD1 of the treated eyelid after injection was -2.35 mm (range, 0 to -8.0 mm). Of the 27 eyelids injected, 33% had a 0- to 1-mm drop in eyelid height, 30% had a 1.5- to 2-mm decrease, 22% had a 2.5- to 3-mm decrease, and 15% had a greater than 3-mm decrease in eyelid height. None of the treated eyelids were noted to increase in height. One patient showed no alteration inafter treatment. One patient had clinically MRD1 significant ptosis and one patient reported worsening of preexisting diplopia after injection. Three patients undergoing unilateral injection had relative contralateral eyelid elevation. All untoward effects resolved spontaneously without sequelae. CONCLUSIONS: : Botulinum toxin type A may be used in the inflammatory stage of thyroid eye disease to improve upper eyelid retraction. Individual response to treatment is variable, but this modality should be considered as a temporizing measure until stability for surgery is reached.

Bovine pericardium as a wrapping for orbital implants.

PURPOSE: We report the use of bovine pericardium as an alternative wrapping for porous orbital implants after enucleation. METHODS: We retrospectively reviewed the records of all patients who received a bovine pericardium-wrapped orbital implant after enucleation by the authors between August 1, 1996, and December 1, 1999. RESULTS: Eighty patients underwent placement of bovine pericardium-wrapped orbital implants. The average age at the time of implantation was 49.3 years (range, 5 years to 83 years). The mean follow-up interval was 11.8 months (range, 2 to 41 months). There were no intraoperative complications. No patient had secondary systemic infection or showed evidence of rejection. There was no clinical evidence to suggest that vascularization of the porous implant was unusually delayed, and there were no complications after secondary drilling and placement of a coupling post. Four (5%) of 80 patients had complications requiring removal of the spherical implant. All 4 patients had hydroxyapatite implants. Two patients had significant exposure requiring removal of the implant at 2 months after surgery; 1 patient had a chronic fistulous tract with secondary infection 3 years after surgery: and 1 patient had chronic orbital pain requiring removal of the implant at 1 year after surgery. CONCLUSIONS: The incidence of implant exposure was less than 4%. This compares favorably to the incidence of exposure of 9% to 21% reported in recent literature. Other complications were few and of minimal clinical significance. The authors conclude that bovine pericardium is a viable option to sclera as a wrapping for porous orbital implants.

Orbital solitary fibrous tumor: radiographic and histopathologic correlations.

OBJECTIVE: To correlate the clinicopathologic and radiographic features characteristic of orbital solitary fibrous tumor (SFT). METHODS: The diagnostic features and clinical outcome of seven adults with orbital SFT are retrospectively outlined. Orbital imaging was performed by ultrasonography, computed tomography, or magnetic resonance imaging. Some cases were imaged by multiple modalities. Histopathologic examination of each tumor specimen included standard light and immunohistochemical stains. RESULTS: Heterogeneous internal composition was better appreciated on magnetic resonance imaging than on computed tomography. All cases undergoing magnetic resonance imaging showed T1 isointensity and T2 hypointensity relative to gray matter. Strong, generalized immunohistochemical reactivity to vimentin and CD34 validated the diagnosis of SFT and differentiated the specimens from other spindle cell neoplasms. After complete tumor resection, our patients remain tumor free with postoperative intervals of 15 to 45 months. CONCLUSIONS: Solitary fibrous tumor has now been reported in 26 orbits. No physical finding is pathognomonic, but several imaging traits are highly characteristic. Intralesional image heterogeneity and a predominantly low T2 signal intensity are distinctive of SFT. Complete tumor resection and immunohistologic specimen evaluation are emphasized. Clinicians should consider the diagnosis of SFT when confronted with an adult patient having an orbital soft tissue mass demonstrating the distinctive magnetic resonance imaging findings.

The fate of fresh, layered, nonsutured and sutured, autogenous cartilage in the rabbit model.

OBJECTIVE: To compare the thickness, area, and volume of sutured and nonsutured multilayered cartilage grafts in a rabbit population. DESIGN: Autogenous rabbit cartilage grafts were harvested, layered, and placed in the contralateral auricle. Half the grafts were sutured; the other half were nonsutured. Graft thickness, area, and volume were measured before implantation, after 90 days in vivo, and after explantation. RESULTS: The area and volume of the cartilage grafts increased during the 90-day period. Histologically, this was caused by increased fibrous tissue around the cartilage grafts. Minimal cartilage resorption was observed. No differences were noted between sutured and nonsutured grafts. CONCLUSIONS: Autogenous, fresh, uncrushed, layered nonsutured or sutured cartilage grafts are well tolerated. Statistically significant increases in the area and volume of autogenous, fresh, uncrushed, layered cartilage grafts occurred primarily because of fibrous tissue formation at the margins of the layered grafts. Suturing had no effect on the postoperative volume retention of these layered grafts. This information will be helpful to the facial plastic surgeon when using fresh-layered autogenous cartilage grafts during cosmetic or reconstructive procedures. Arch Facial Plast Surg. 2000;2:256-259

Localized conjunctival argyrosis: a late sequela of strabismus surgery.

We describe a case of focal argyrosis of the conjunctiva clinically simulating a melanoma. An 82-year-old woman was referred for an asymptomatic pigmented conjunctival lesion. Her only significant past ocular history was strabismus surgery 76 years earlier. Biopsy of the conjunctiva and lateral rectus muscle revealed the discoloration was pigment granules. Energy-dispersive x-ray microanalysis revealed the pigmentation to be silver deposits. The patient had strabismus surgery probably using a silver clip. Argyrosis should be considered in the differential diagnosis of focal pigmented conjunctival lesions.

A comparative study of bovine pericardium (periguard) and homologous sclera as lower eyelid spacer graft analogs in New Zealand white rabbits.

PURPOSE: To compare bovine pericardium (Periguard; Bio-Vascular, Inc., St. Paul, MN, U.S.A.) and homologous sclera as spacer graft analogs in a rabbit model. METHODS: A nonrandomized experimental animal study was conducted. Elliptical subconjunctival implants were placed in one lower eyelid each of 10 rabbits. Five rabbits received homologous sclera implants, and five received bovine pericardium implants. The rabbits were killed 7 weeks later, and the lower eyelids were examined clinically and histopathologically. RESULTS: Rabbit eyelids implanted with Periguard had a more marked inflammatory reaction and more significant collagen lamellar disruption than eyelids implanted with homologous sclera, although clinically they appeared quite similar. CONCLUSIONS: Although bovine pericardium elicited a more intense inflammatory response at the histopathologic level, both implants were similarly tolerated at the clinical level. These findings are consistent with animal and human investigations of bovine pericardium in other parts of the body, and warrant further studies into its potential use in the human eyelid.

The influence of hyperbaric oxygen therapy and irradiation on hydroxyapatite ocular implant exposure and fibrovascular ingrowth in New Zealand white rabbits.

PURPOSE: Lack of adequate fibrovascular ingrowth has been implicated as a cause of exposure of hydroxyapatite (HA) implants in anophthalmic sockets. We investigated the vasculopathic effects of external beam irradiation, and the fibrovascular-enhancement effects of hyperbaric oxygen (HBO), on HA implant exposure and fibrovascular ingrowth in a rabbit model. METHODS: Eighteen rabbits underwent enucleation with implantation of a 12-mm HA sphere. Six rabbits received 20 Gy of external beam orbital irradiation prior to enucleation. Three irradiated and 6 nonirradiated rabbits received postoperative HBO. Three weeks postoperatively, all rabbits were evaluated clinically for evidence of implant exposure. Implants were then removed, and histopathologic analysis of fibrovascular ingrowth was performed. RESULTS: The amount of vascularization as measured by the depth of ingrowth was greater for nonirradiated (89% ingrowth) than for irradiated (71% ingrowth) animals. HA implant exposure occurred in 1 of 12 (8%) of the nonirradiated, and 4 of 6 (67%) of the irradiated rabbit orbits. HBO did not protect irradiated rabbits from exposure, but did enhance fibrovascular ingrowth in nonirradiated rabbits (100% ingrowth vs. 77% ingrowth). CONCLUSION: Impaired orbital vascularization from prior irradiation appears to retard fibrovascular ingrowth into HA implants, and is associated with an increased incidence of exposure. While HBO did not diminish the likelihood of exposure in irradiated sockets, HA fibrovascular ingrowth in normal orbits appeared to increase with HBO. This may have beneficial clinical application in cases of exposure in nonirradiated orbits.

Bovine pericardium versus homologous sclera as wrapping materials for hydroxyapatite ocular implants: an animal study.

PURPOSE: We compared bovine pericardium and homologous sclera as wrapping materials for hydroxyapatite (HA) ocular implants in enucleated New Zealand white rabbits. METHODS: Eighteen rabbits were unilaterally enucleated and the sockets implanted with 10-mm HA spherical implants. Six implants were wrapped with homologous sclera, 6 with bovine pericardium, and 6 were not wrapped. The rabbits were killed 7 weeks later and the sockets were examined clinically for inflammation and implant exposure. Exenterated specimens were assessed histopathologically for inflammation and vascularization. RESULTS: No clinical evidence of implant exposure or extrusion was detected in rabbits receiving sclera or bovine pericardium wrapped implants. Histopathologically, the bovine pericardium displayed more inflammation in its outer portion, as well as more disruption of its lamellar arrangement than did the sclera. Fibrovascular in-growth was complete in all wrapped implants. CONCLUSION: Bovine pericardium behaves similar clinically to homologous sclera as a wrapping material for spherical HA ocular implants in a rabbit model, and may represent a reasonable alternative to sclera in such procedures in humans.

Benefits of stereolithography in orbital reconstruction.

OBJECTIVE: To describe the benefits of the stereolithography (SLA) modeling system in the evaluation and surgical planning of selected bony orbital pathology. DESIGN: Two case reports. PARTICIPANTS: One patient presented with a displaced left orbital roof fracture into his orbit causing globe compression and binocular vertical diplopia. A second patient underwent removal of his right orbital floor, medial wall, and inferior portion of his lateral wall during excision of a cylindrical cell papilloma of the paranasal sinuses. Postoperatively, he suffered from globe ptosis and binocular oblique diplopia. INTERVENTION: Stereolithographic models of the patients' orbits were obtained from computed tomography data to better assess the bony orbital pathology. In the second patient, the model was used as a template to create a temporary custom fit prosthesis to repair the defect of his orbital walls. RESULTS: The SLA models were useful in evaluating the dimensions of the bony defects and in preoperative surgical planning. Intraoperatively, the SLA models facilitated orbital surgical rehabilitation. Postoperatively, both patients noted resolution of their diplopia after reconstruction of more normal bony anatomy. CONCLUSIONS: In selected cases, SLA offers highly accurate models of the bony orbit for preoperative evaluation, surgical planning, and teaching and can act as a template for custom prosthesis manufacturing. This technology increases the orbital surgeon's options in managing complex orbital pathology.

Hard palate mucosal grafts in the treatment of the contracted socket.

PURPOSE: The treatment of the traumatic contracted anophthalmic socket is challenging. The ability to wear an ocular prosthesis may require multiple operations to replace orbital volume, mucosa, or both. Hard palate mucosal grafts are a logical choice to augment mucosa and volume in the reconstruction of a contracted socket. METHODS: Ten patients with severely contracted sockets underwent socket reconstruction using hard palate mucosal grafts. The mucosal surface lining the contracted sockets was undermined and recessed toward the lid margins. Hard palate mucosal grafts that were harvested freehand and by using a radiofrequency instrument were placed in the socket fundus and sutured to the recessed mucosal edges. Forniceal sutures were placed full thickness through the lids, and custom conformers were placed in the sockets. In six patients, fixation sutures were passed through the conformer, fornices, and full thickness through the lid. In four patients, temporary tarsorrhaphies were placed for a minimum of 4 weeks postoperatively. RESULTS: Postoperatively, 8 of the 10 patients were able to wear an ocular prosthesis comfortably. Cosmesis was acceptable. Two patients had recurrent socket contracture and were unable to wear a prosthesis. CONCLUSIONS: Hard palate mucosal grafts are a useful option in the surgical rehabilitation of contracted sockets. A mucosal surface, resistance to contracture, ease of harvesting, and ability for additional harvesting are advantages over other graft materials.

Cosmetic indications for botulinum A toxin.

This article describes the use of botulinum toxin type A in the cosmetic treatment of facial wrinkles. Injection techniques, volumes, and concentration of the botulinum A toxin are described for various types of facial wrinkles.

The endoscopic browlift for forehead rejuvenation.

Since its initial description by Vasconez et al in 1992, the endoscopic browlift has evolved into a popular method for addressing brow ptosis and forehead rejuvenation. The advantages of fewer incisions, less postoperative swelling, alopecia and prolonged scalp anesthesia, and more rapid rehabilitation have provided greater patient acceptance than the traditional coronal approach. Unlike the coronal browlift where the amount of elevation is determined by the amount of skin excised, the elevation in the endoscopic browlift is determined by periosteal release at the arcus marginalis and forehead flap fixation. Though equipment costs are greater and a learning curve exists, the endoscopic browlift offers the oculoplastic surgeon additional beneficial options in the management of brow ptosis.

Changes in astigmatism after ptosis surgery measured by corneal topography.

A computerized topographic analysis system (EyeSys [EyeSys Technologies, Houston, TX, U.S.A.]) was used to evaluate corneal astigmatic changes (central corneal power and astigmatic axis) after blepharoptosis surgery on 29 eyelids (22 patients). Fifteen nonoperated eyelids of study patients undergoing unilateral ptosis repair were used as controls. All patients were evaluated preoperatively and again 6 weeks after surgery. Fifteen operated eyelids and five controls were also examined 12 months after surgery to evaluate the stability of these measurements. In 72.4% of operated eyes, corneal topography demonstrated increased with-the-rule astigmatism 6 weeks after surgery, 13.8% of surgical eyes showed increasing against-the-rule astigmatism, and in 13.8%, no change was noted from preoperative measurements. None of the 15 control eyes demonstrated any change in corneal astigmatic axis or significant change in central corneal power. By 12 months after surgery, all of the operated eyes showed a regression toward the amount and pattern of preoperative astigmatism. Only two of 15 eyes maintained a difference of > 0.3 D of central corneal power greater than their preoperative measurement at 1 year. These data suggest that corneal topography may be altered by changes in eyelid position, although the changes appear to be temporary in most patients.

Rate of vascularization of coralline hydroxyapatite spherical implants pretreated with saline/gentamicin, rTGF-beta 2, and autogenous plasma.

Several authors have reported significant exposure rates using the hydroxyapatite orbital implant in the treatment of the anophthalmic socket. Histologic studies by ourselves and others have suggested that lack of fibrovascular ingrowth into the implants may contribute to conjunctival breakdown and exposure. Recently, much attention has been given to angiogenic factors, such as rTGF-beta 2 and those found in plasma, in accelerating wound healing and fibrovascular ingrowth. This pilot study compares the rate of vascularization of hydroxyapatite orbital implants pretreated with plasma, rTGF-beta 2, and a saline/gentamicin solution with that in untreated controls ina population of New Zealand albino rabbits. Hydroxyapatite orbital spheres were implanted subcutaneously and in enucleated orbits. Untreated implants were used as a control. Implants pretreated with plasma, rTGF-beta 2, and a saline/gentamicin solution were removed and examined histologically at weekly intervals for the first 3 weeks after implantation. Histologic studies demonstrated that the rate of vascularization significantly increased between 2 and 3 weeks postoperatively in all study groups. Pretreating the implants with rTGF-beta 2 in phosphate buffered solution (PBS) or autogenous plasma did not significantly increase the rate of vascularization in comparison with controls at weeks 1 and 2. However, pretreating the implants with a saline/gentamicin solution or PBS alone was associated with an increased rate of vascularization at weeks 2 and 3. No statistically significant difference in vascularization was noted between the subcutaneous and orbital implants at any week. Hydroxyapatite implants pretreated with saline/gentamicin or phosphate buffered solutions underwent more rapid vascularization at weeks 2 and 3 in comparison with controls. Additionally, all groups were noted to have a more rapid rate of ingrowth between weeks 2 and 3 than between weeks 1 and 2. Plasma and rTGF-beta 2 (at the dose used) did not significantly alter the rate of vascularization of hydroxyapatite implants during the first 2 to 3 weeks. The significance of these findings is discussed.

Double choroidal malignant melanoma in an eye with apparent clinical regression.

Multicentric melanomas in the same eye are rare, with few cases substantiated by histology and serial sectioning. We report a patient with two documented choroidal malignant melanomas in one eye. The initial tumor spontaneously decreased in size for over 2 years before a second tumor appeared in a noncontiguous location in the same eye. After enucleation, serial sections showed that the two lesions were independent choroidal melanomas. We review the literature regarding multiple, independent intraocular choroidal malignant melanomas.

Age-related changes in type-I collagen synthesis in human eyelid skin.

PURPOSE: This study was to determine whether age-related decrements in type I collagen synthesis occur in human eyelid skin. METHODS: Using an antibody to procollagen I, we investigated collagen synthetic activity in skin removed for cosmetic purposes from 10 white patients between the ages of 4 and 77 years. Eleven masked referees graded the immunostaining on a scale of 1 (most intense) to 10 (least intense). RESULTS: The multiple range test for rank by group demonstrated more intense staining in younger patients compared with older patients. An average correlation coefficient of 0.8432 (p < 0.05) existed between each of the referee's rankings. CONCLUSION: Type I collagen synthesis diminishes with age in eyelid skin.

Deviated hydroxyapatite orbital implant syndrome.

PURPOSE: To describe a patient with a deviated orbital implant after enucleation. METHOD: Case report. RESULT: We examined a postenucleation patient with a medially deviated ("esotropic") implant after peg drilling. Modification of the posterior surface of the prosthesis improved cosmesis in the primary position. CONCLUSIONS: During enucleation surgery, surgeons may use a spherical implant rather than modify the anterior face in patients with preexisting strabismus, with severe trauma to the extraocular muscles, or with risk of implant deviation. Additionally, secondary procedures may alter implant position. Occasionally, patients without obvious preoperative risk factors may have deviation of the modified face of the implant. Flattening the implant creates an asymmetric surface that may lead to a deviated orbital implant.

Lower eyelid recession combined with ptosis surgery in patients with poor ocular motility.

BACKGROUND: The authors treated ten patients (13 eyelids) with visually significant blepharoptosis and compromised corneal protective mechanisms resulting from paresis of ocular motility and absent Bell phenomenon. METHODS: Traditional upper eyelid surgery consisting of frontalis suspension (6 eyelids) or levator aponeurosis advancement (7 eyelids) was used. In all patients, the ptosis repair was combined with maximum recession of the lower eyelid, using a posterior lamellar scleral spacer graft. The goal was to maintain a narrow, vertical, interpalpebral fissure to allow for eyelid closure, but to reposition this opening centrally over the pupil. RESULTS: Postoperatively, all patients achieved significant improvement in superior visual field, with no associated keratopathy. Complications were few, minor, and transient. The postoperative cosmetic appearance was acceptable in all patients. CONCLUSIONS: This combined procedure allows repair of fair- to poor-function ptosis in patients in whom ptosis surgery previously has been considered risky. For the authors, this technique has been proven safe and effective and should be considered in any patient population with compromised corneal protective mechanisms.

Holmium laser canaliculoplasty.

Thirty canaliculi of 18 patients with complete or nearly complete canalicular obstruction were subjected to laser canaliculoplasty as a substitute for the standard Jones-type bypass conduct. Etiologies for the obstruction included congenital lacrimal system atresia, eyelid trauma, scarring following previous lacrimal surgery, and chronic inflammatory fibrosis. The procedure utilized a holmium laser delivered via a 1,000 mu optical fiber to cut a 1-mm channel from the punctum into the lacrimal sac. In nine eyes, this procedure was combined with a surgical dacryocystorhinostomy (DCR) for concurrent lower nasolacrimal duct obstruction. Silicone stents were left in place for 6 months postoperatively. Follow-up data were available for 28 canaliculi of 17 patients. Moderate or better improvement in symptomatic epiphora and evidence of canalicular patency to drainage was seen in 16 of 28 (57%) treated canaliculi, and significant improvement was recorded in 12 of 28 (43%). Although these figures are lower than those obtainable after repair of small areas of focal canalicular stenosis or obstruction, the procedure is superior to any previous attempts at reconstruction of extensive obstructions, short of placement of a Jones tube. When successful, this procedure offers re-establishment of a near normal physiologic system, and avoids the complications of and patient dissatisfaction associated with a Jones tube.

Choroidal hemorrhage associated with systemic tissue plasminogen activator.

PURPOSE: To determine the cause of spontaneous choroidal hemorrhage in a 67-year-old man after a myocardial infarction and administration of tissue plasminogen activator. METHODS: The patient underwent ocular examination. RESULTS: The patient retained excellent visual acuity and the choroidal hemorrhage resolved completely within two months. CONCLUSION: The administration of tissue plasminogen activator was responsible for the large extent of hemorrhage and should be considered in the differential diagnosis of hemorrhagic choroidal detachment.