Prospective analysis of changes in corneal topography after upper eyelid surgery.

PURPOSE: Some patients note a decrease in visual acuity in the operated eye after eyelid surgery. Although, the most common cause for this change is dry eye syndrome, it has been hypothesized that the symptom of blurred vision may result from a change in the corneal curvature. The study was conducted to determine if there is a change in corneal curvature after upper eyelid surgery. METHODS: Standard keratometry and corneal videokeratography (CVK) were performed 1 and 3 months after blepharoplasty (18 lids) and ptosis repair (24 lids). Pre- and postoperative images from CVK data were digitally subtracted for quantitative evaluation. RESULTS: After ptosis repair, the average dioptric change as measured by keratometry and by CVK was approximately 0.60 diopters (D); of note, nearly 30% of these patients showed transient astigmatic changes greater than 1.00 D; After blepharoplasty, the average dioptric change as measured by keratometry and by CVK was approximately 0.55 D; of note, only 11% of patients showed astigmatic changes greater than 1.00 D. CONCLUSION: Repositioning of the upper eyelid after ptosis repair or blepharoplasty may result in visually significant astigmatic changes in the central and peripheral cornea and may alter the patient's spectacle or contact lens correction.

Concomitant ocular injuries with orbital fractures.

BACKGROUND AND OBJECTIVES: The orbital floor may fracture alone, and the fracture is then defined as "pure"; when there is a rim involvement, the fracture may be defined as "impure". Controversy exists as to the pathophysiology of orbital floor fractures and the incidence of orbital rim involvement. The purpose of this retrospective review was to determine the incidence of purity in orbital floor blowout fractures and the rate of ocular injuries in pure and impure floor fractures. METHODS AND MATERIALS: The charts of 250 patients with orbital fractures, treated at a primary trauma center between 1992 and 1996, were reviewed. All fractures had been examined by the Ophthalmology Service and confirmed by high-resolution computerized tomography scans. The average age of the patients was 45 years; more than 90% were male. Motor vehicle accidents were the most commonly documented mechanism of injury, followed by interpersonal violence and falls. Almost 50% could not be categorized for mechanism of injury. RESULTS AND/OR CONCLUSIONS: The incidence of ocular injuries in pure fractures (n = 54; 5.6%) was higher than in impure fractures (n = 26; 2.0%) (p = 0.05). Serious visual injuries following orbital fractures occurred in 17.1% of the patients; they were more common in patients with pure fractures.

Diplopia following transconjunctival blepharoplasty.

The resurgence of popularity of the transconjunctival approach to lower eyelid fat removal as a component of cosmetic blepharoplasty has been highlighted by a number of publications in recent years. There has been, however, minimal discussion in the literature of the complications of this procedure. Although the mechanism of muscle injury is similar in transcutaneous and transconjunctival surgery, there is a much more direct route to the inferior extraocular musculature via the latter approach. Herein, we present a series of six patients with diplopia status post-transconjunctival lower eyelid blepharoplasty referred to the Manhattan Eye, Ear, and Throat Hospital for evaluation. Transconjunctival lower lid blepharoplasty was performed as a primary procedure in four patients and as a secondary procedure following transcutaneous blepharoplasty in two patients. Patients were evaluated with ocular examination and orthoptic measurements. Magnetic resonance imaging was obtained in two cases. The inferior rectus and inferior oblique muscles were found to be equally injured in these cases (4 of 6), and the lateral rectus was encountered in one case. Two patients required strabismus surgery to correct their diplopia, whereas four patients improved with observation alone. The possible etiologies of postoperative diplopia following transconjunctival lower lid blepharoplasty are manifold. Mechanisms of extraocular muscle injury may include intramuscular hemorrhage and edema, cicatricial changes within the muscle, and accidental incorporation of extraocular muscle in closure of orbital septum. Avoidance of these complications is probably best achieved through intimate understanding on the part of the surgeon of eyelid anatomy from the transconjunctival perspective.

Prediction of late enophthalmos by volumetric analysis of orbital fractures.

The purpose of this study was to determine whether orbital volume assessment by computerized tomography (CT) could provide additional information for the initial evaluation of orbital blowout fractures and guide optimal treatment. The medical records of 30 patients with orbital blowout fractures, either surgically or conservatively managed, were retrospectively reviewed. Orbital volumetric analysis was then determined from digitized CT scans. Fracture-related volume expansion relative to the unaffected fellow orbit was correlated with motility deficits and location and degree of enophthalmos. Early Hertel's measurements (< 4 weeks) were available in 21 patients and did not correlate with the computer volumetric values or with subsequent late enophthalmos. Late Hertel's measurements (> 4 weeks) were obtained in 13 of 15 nonrepaired fractures and in 5 of 15 surgically repaired patients (late presentation; 18 patients). When seen at more than 4 weeks, 11 (92%) of 12 patients with > or = 13% orbital volume expansion manifested significant enophthalmos (> 2 mm) compared with 1 (17%) of 6 patients with < 13% orbital expansion (p = 0.004). Fractures presenting with enophthalmos on initial examination had extensive medial wall involvement in addition to the floor fracture (p = 0.003). CT measurements of orbital volume can predict the final degree of late enophthalmos and may facilitate the planning of surgical intervention.

Conjunctival orbital cyst.

A 61-year-old woman had gradual onset of ptosis and painless proptosis of her left eye of 1-year duration. Orbital computed tomography (CT) showed a well-circumscribed superior nasal orbital tumor with uniform density. The mass was removed by anterior orbitotomy and histopathologically diagnosed as a conjunctival cyst. Recent reports have increased awareness of this entity. This case typifies findings of conjunctival orbital cysts. These cysts should be considered when a differential diagnosis is formulated for orbital tumors with a similar presentation.

Pyogenic granuloma after transconjunctival blepharoplasty: a case report.

This is the first known report of a relatively large postoperative pyogenic granuloma developing after a nonsutured transconjunctival blepharoplasty. Inflammation and separation or malapposition of the conjunctival wound edges probably permitted the lesion to proliferate in the inferior fornix. No foreign material could be implicated because no suture was used to close this incision. Additionally, Polydek suture material (braided polyester fiber) was associated with the complication of a suture tract and granuloma when used for a tarsal suspension procedure for ectropion repair in this patient.

Blepharoplasty.

Cosmetic blepharoplasty is performed in various subspecialties, therefore articles appear in the ophthalmic, plastic surgical, otolaryngologic, and dermatologic literature. We review the past year's articles regarding evaluation, technique, adjunctive procedures, and complications. As the various techniques of upper-eyelid and lower-eyelid blepharoplasty have taken their place in the armamentarium of the aesthetic surgeon, attention has turned toward adjunctive procedures to enhance the surgical result.

Sebaceous carcinoma of the eyelids. The role of adjunctive cryotherapy in the management of conjunctival pagetoid spread.

The extension of sebaceous carcinoma of the eyelid within the epithelium of the palpebral, forniceal, and bulbar conjunctiva (pagetoid spread) is a frequent indication for exenteration, but this recommendation is controversial. Six patients with upper eyelid tumors and variable degrees of epibulbar pagetoid extension were treated without exenteration. All underwent wide local resections of their upper eyelids (repaired by Cutler-Beard procedures), with adjunctive cryotherapy to the involved epibulbar surfaces after preoperative map biopsies of the conjunctiva had been done. Cryotherapy was applied during the second-stage Cutler-Beard procedure after initial resection of the tumor bulk. Follow-ups ranging from 12 to 50 months, with conjunctival biopsies at 6-month intervals, showed no recurrence of pagetoid tumor. Although exenteration was avoided, dry-eye symptoms, symblepharon, corneal erosion, and vascularization were side effects, which the patients were willing to tolerate to avoid radical surgery. The complications were most severe in the two patients who were either elderly or had more than two quadrants of epibulbar pagetoid disease.

Success of the Fasanella-Servat operation independent of Müller's smooth muscle excision.

In an attempt to elucidate the mechanism whereby the Fasanella-Servat operation corrects ptosis, the authors examined the histopathologic features of 40 consecutive surgical specimens from 37 patients. Because all specimens contained tarsus, this tissue was graded into two groups according to vertical height: (1) minimal (30%) and (2) moderate (70%). Müller's smooth muscle was graded into four groups: (1) absent to negligible (42.5%); (2) minimal (45%); (3) moderate (10%); and (4) large (2.5%). Levator aponeurosis was absent, and conjunctive was present, in all resections. Accessory lacrimal gland tissue was present in 42.5% of cases and did not cause decreased tear production. Although 87.5% of cases had absent to minimal smooth muscle resections, these patients had equally successful results in comparison to patients with moderate to large amounts of smooth muscle resections. Based on these data, the authors have concluded that the effectiveness of the Fasanella-Servat operation does not depend on a Müllerectomy, but instead is probably due to a combination of other factors: (1) a vertical posterior lamellar shortening; (2) secondary contractile cicatrization of the wound; and (3) plication or advancement of the Müller's smooth muscle-levator aponeurosis complex on the tarsus.

Complications of blepharoplasty.

Various involutional eyelid changes, such as fine rhytids, dynamic laugh lines in the lateral canthal area, secondary malar bags, and dermal pigmentation are not effectively treated by a blepharoplasty. Preoperative discussions are important to ensure that adequate expectations are held. Too often, a patient is informed that fine rhytids and dermal pigmentation can be successfully treated with lid surgery alone. The importance of the preoperative interview in determining patient expectations cannot be minimized. Preoperative ophthalmic and periocular examination is essential to identify any pre-existing pathology. Even though the surgical approach is adapted to the individual needs of each patient, the most meticulous of surgeons is predetermined to encounter his or her share of complications. There is a fine line between a "complication" and a common, but unwanted, sequela of surgery. Patients, overwhelmingly, do have some widening of their palpebral fissures, even following conservative surgery. Unfortunately, this occasionally creates ocular irritation or gross discomfort in allergic or borderline dry eyed patients. Lower eyelid bowing is so common even in the face of minimal skin resection that we do not consider it a "complication" if it does not produce a functional problem. It is humbling for all surgeons to review their blepharoplasty problems and helpful to recognize that, statistically, we are all due to face these events eventually.

Experience with tarsal suspension as a factor in lower lid blepharoplasty.

The bowed lower eyelid, with scleral show, is a common but untoward result following blepharoplasty with even minimal skin excision. A number of conditions, unrecognized preoperatively, can predispose a patient to scleral show. These include eyelid laxity with or without atrophic orbicularis muscle tone, lax canthal tendons, hypoplastic malar eminences, unrecognized Graves' ophthalmopathy, unilateral high myopia, or the secondary blepharoplasty. Suspension of the tarsus of the lower eyelid, concomitant with or following blepharoplasty, can straighten bowed lids and provide 2 to 3 mm of elevation, if desired. A classification of patients likely to develop scleral show is presented along with a revised technique of tarsal suspension.

Efficacy of surgical treatment for paralytic ectropion.

Paralytic ectropion can be corrected with numerous procedures. Advocates of particular procedures have previously been unable to quote statistical rates of success for each procedure over significant lengths of time. This study reviews over 200 cases of paralytic ectropion, representing the spectrum of seventh nerve disease seen at an eye and ear specialty hospital and a general medical facility. Of all eyelid implantation devices 93 to 95% failed to work or needed reoperation by 3 years postoperatively. Soft tissue surgery without prosthetic implants or exoplants provided 60% success after a 3-year follow-up. Eyelid elevation or tightening coupled with surgery for facial reanimation produced a higher rate of success at 3 years (83%). An overwhelming number of patients (62%) complained of some degree of epiphora after any or all procedures. Based on these findings, soft tissue surgery without prosthetic implants or exoplants has a higher rate of success.

Volkmann's ischemic contractures and blowout fractures.

Volkmann's ischemic contractures have long been recognized by orthopedic surgeons as a sequela of increased pressure within osseofascial muscle compartments. We present evidence that the same mechanism is a cause of fibrosis and contracture of extraocular muscles following orbital blowout fractures. Surgical treatment of a specific, recognizable type of blowout fracture is proposed.

Human bites of the eyelid.

Five patients with traumatic colobomas of the eyelid secondary to human bites were surgically repaired with retrieved autogenous tissue. All patients were treated with prophylactic intravenous antibiotics. Surgical repair consisted of debridement of the autograft, meticulous layered closure of the autograft to the wound, and placement of a lid margin suture. In two of the patients, mild upper eyelid retraction was noted, and two patients had loss of cilia.

Volkmann's contracture of the extraocular muscles following blowout fracture.

In the past decade there has been considerable controversy over the surgical indications for treatment of blowout fractures of the orbit. It has been well recognized that some fracture patients develop an ischemic contracture of the inferior rectus muscle. We have found that a Volkmann's type of contracture of the inferior rectus muscle does exist and is similar to that found in the distal extremities. A specific group of fracture patients is at greater risk for development of a contracture. Elderly patients, hypotensive patients, patients with small fractures, and those with high inferior rectus compartment pressures are more prone to developing a contracted extraocular muscle. We have measured compartment pressures in 18 patients who were surgical candidates following orbital fracture. Our conclusions indicate that surgical intervention following blowout fractures in these high-risk patients may be more prudent than medical management. Patients with persistent diplopia due to a contracted inferior rectus are extremely difficult to treat many months after fracture. We still believe it prudent to surgically repair orbital fractures in patients with diplopia, enophthalmos, and a risk for muscle contracture. The documentation of this additional sequela of unrepaired fractures lends more strength to this belief. There is no evidence to indicate that a Volkmann's contracture would be possible after early repair of a blowout fracture.

Diplopia following blepharoplasty.

The complication of extraocular muscle palsy following blepharoplasty is rare. In a review of 920 blepharoplasties at Manhattan Eye, Ear and Throat Hospital, three well-documented cases of diplopia following blepharoplasty could be found. Only one of these cases resolved within two months postoperatively. The explanation offered for this phenomenon is a Volkmann type contracture of the extraocular muscles following edema and hemorrhage into the muscle sheath.

Eyelid and orbital treatment following radical maxillectomy.

Malignant lesions of the nasopharynx and paranasal sinuses often encroach upon the orbit. A series of nineteen patients who underwent partial or radical maxillectomy is presented to summarize the eyelid and orbital findings that required further treatment. Fifteen of these patients were left with an intact globe and a visually useful eye, but the defects of epiphora, eyelid malposition, dacryocystitis, and diplopia were visually threatening and required treatment. The cosmetic deformities and diplopia following maxillectomy and radiation are partially amenable to treatment with late bone grafting. Lacrimal outflow deficiencies were successfully treated with dacryocystorhinostomy. Only patients with ocular complications following maxillectomy are included in this series; therefore, the range of problems and their treatment confronting the ophthalmologist is summarized.

Dacryoadenopexy as a recognized factor in upper lid blepharoplasty.

The recognition of a herniated lacrimal gland is done by simple examination; it is not usually taught to plastic surgeons. Fullness in the superotemporal aspect of an upper eyelid in younger patients often represents a ptotic gland. Suspension of the glands improves the surgical result of upper-lid blepharoplasty without compromising lacrimal outflow.