Differences in Common Orbital Blowout Fracture Sites by Age.

BACKGROUND: The purpose of this study was to compare orbital blowout fracture sites among different age groups. METHODS: This retrospective, observational, comparative study included 671 sides of 663 patients with an orbital blowout fracture. The authors classified patients into five groups based on age (childhood, 0 to 9 years; adolescence, 10 to 18 years; early adulthood, 19 to 44 years; middle adulthood, 45 to 64 years; and late adulthood, 65 years or older); causes of injury into five categories (i.e., sports, traffic accident, assault, fall, and others); and orbital blowout fracture sites into four regions [i.e., the orbital floor lateral (lateral floor) or medial to the infraorbital groove/canal (medial floor); the inferomedial orbital strut (strut); and the medial orbital wall (medial wall)]. RESULTS: A single medial floor fracture was observed in 70.3 percent of patients in the childhood age group. However, the proportion of patients with a single medial wall fracture or multiple fracture sites increased with age. A medial wall fracture was more common than a medial floor fracture in late adulthood. The distribution of orbital blowout fracture sites, the ratio of single or multiple fracture sites, and the causes of injury were statistically different among the age groups (p = 0.005, p = 0.003, and p < 0.001, respectively, Pearson chi-square test). CONCLUSIONS: Common orbital blowout fracture sites varied among age groups. These differences may be attributed to multiple factors, including differences in the morphology of the orbit and paranasal sinuses, composition of the facial bone, and causes of injury among age groups.

Orbital trapdoor fractures: different clinical profiles between adult and paediatric patients.

BACKGROUND: To compare clinical findings of orbital trapdoor fractures between adult and paediatric patients. METHODS: Paediatric patients were categorised into two groups by age: children (0-9 years) and adolescents (10-19 years). Adult patients were categorised into two groups by age: early (20-44 years) and middle-late adulthood (≥45 years). Demographic data, ocular and periocular complications, CT findings and binocular single vision field (BSVF) were compared among age groups. RESULTS: This study included 105 patients (105 sides, 22 children, 59 adolescents, 14 patients in early adulthood and 10 patients in middle-late adulthood). In patients with fractures of the orbital floor and medial wall, both walls presented as trapdoor fractures in paediatric patients, while one wall presented as a non-trapdoor fracture in adult patients (p=0.061). None of the adult patients showed extraocular muscle incarceration, whereas this was present in 8 of 22 children (36.4%) and 7 of 59 adolescents (11.9%) (p=0.005). Hypoesthesia of the infraorbital nerve more frequently occurred in adults (p=0.004). As the preoperative BSVF was larger in adult than in paediatric patients (p=0.007), the percentage of adult patients who underwent surgical reduction of orbital fractures tended to be lower (p=0.058). Postoperative change in BSVF was smaller in adult patients (p=0.005). CONCLUSIONS: Fracture pattern, type of incarcerated tissue and incidence of hypoesthesia of the infraorbital nerve were different between adult and paediatric patients. Adult patients had a larger preoperative BSVF and less need for surgical reduction; however, there was less improvement in postoperative BSVF.

Bell's phenomenon in thyroid-associated inferior rectus myopathy.

PURPOSE: To examine Bell's phenomenon in patients with unilateral thyroid-associated inferior rectus myopathy and changes in this phenomenon after inferior rectus muscle recession. METHODS: This prospective interventional study included 12 patients who underwent inferior rectus muscle recession with or without nasal transposition. Bell's phenomenon was examined before and 3 months after surgery. The upper eyelid was held open by a finger to prevent complete eyelid closure. Then, the distance of upward excursion of the inferior corneal limbus or the corneal light reflex was measured during voluntary maximum forced eyelid closure. The pre- and postoperative distances of upward excursion on the affected side were statistically compared with the preoperative distance on the unaffected side using the Mann-Whitney U test, and the pre- and postoperative distances on the affected side were statistically compared using paired t-test. The relationships among postoperative changes of Bell's phenomenon, patient age, the amount of recession and nasal transposition of the inferior rectus muscle, postoperative angle of ocular deviation, and reduction in the angle after surgery were analyzed using stepwise multiple regression analyses. RESULTS: The preoperative measurement of Bell's phenomenon was significantly shorter on the affected side (1.6 ± 1.6 mm) than the unaffected side (4.3 ± 1.6 mm; P = 0.001). However, the distance on the affected side significantly increased after surgery (4.1 ± 1.9 mm; P < 0.001), compared to the preoperative distance on the unaffected side (P = 0.843). Using a stepwise method, all variables were deleted from the regression equation. CONCLUSIONS: Bell's phenomenon decreased on the affected side, which improved after inferior rectus muscle recession.

Incarceration of the inferior oblique muscle branch of the oculomotor nerve in patients with orbital floor trapdoor fracture.

PURPOSE: To examine the clinical characteristics of patients with concomitant incarceration of the inferior oblique muscle branch of the oculomotor nerve who had suffered from an orbital floor trapdoor fracture with orbital fat incarceration. METHODS: Fifty-nine patients were retrospectively reviewed. Concomitant inferior oblique muscle branch incarceration was diagnosed by inferior oblique muscle underaction on the Hess chart and a missing inferior oblique muscle branch on computed tomographic images on baseline examination. RESULTS: Eleven patients (18.6%) were diagnosed with concomitant branch incarceration. The patients with branch incarceration were all under 19 years of age, and were younger than those without branch incarceration (P = 0.026). There were no significant differences between the groups in terms of cause of injury, presence of concomitant medial wall fracture, hypoesthesia of the cheek region, or ocular and periocular complications (P > 0.050). All patients with branch incarceration underwent surgical reduction, whereas 16 of 48 patients without branch incarceration were observed without surgery (P = 0.021). Although preoperative binocular single vision field was smaller in patients with branch incarceration (P = 0.026), it improved after surgery, comparable to that of patients without branch incarceration (P = 0.079). CONCLUSIONS: Concomitant incarceration of inferior oblique muscle branch of the oculomotor nerve occurred in 18.6% of patients who had suffered from an orbital floor trapdoor fracture with orbital fat incarceration. Patients with branch incarceration were all under 19 years of age. Branch incarceration resulted in a smaller binocular single vision field, which considerably improved after surgical reduction.

Prevention of re-obstruction in watery eye treatment: three-flap technique in external dacryocystorhinostomy.

PURPOSE: To examine the surgical outcome of three-flap external dacryocystorhinostomy (3-flap ex-DCR) based on the most common site of granulation occurrence in no-flap endonasal DCR (no-flap en-DCR). METHODS: This was a retrospective observational study. We first examined the location of granulation occurrence in the osteotomy site using nasal endoscopy after no-flap en-DCR on 53 sides of 37 patients (5 male, 32 female) with nasolacrimal duct obstruction. Based on the results of this surgery, we performed 3-flap ex-DCR on 70 sides of 61 patients (18 male, 43 female) with nasolacrimal duct obstruction. Anatomical success was defined as no reflux under lacrimal irrigation and a patent osteotomy site under nasal endoscopic examination at postoperative 12 months. Functional success was defined as no symptoms of watery eyes over the same period. RESULTS: In the no-flap en-DCR patients, the granulation was formed in 42 sides (79.2 %): 18 sides (34.0 %) on the superior portion, 9 sides (17.0 %) on the inferior portion, 35 sides (66.0 %) on the anterior portion, and only 1 side (1.9 %) on the posterior portion, which was very small. Based on these results, we performed the 3-flap ex-DCR with the anterior, superior, and inferior flaps. Anatomical success with this technique was achieved in all sides (100 %), and functional success was obtained in 66 of 70 sides (94.3 %). CONCLUSIONS: The 3-flap ex-DCR did not cause recurrent nasolacrimal duct obstruction, rendering it a very useful technique in terms of quality of life and medical economics.

Correction of Excyclotropia by Surgery on the Inferior Rectus Muscle in Patients with Thyroid Eye Disease: A Retrospective, Observational Study.

PURPOSE: To examine the characteristics of excyclotropia correction through surgery on the inferior rectus muscle in patients with thyroid eye disease. METHODS: This was a retrospective, observational study at a single institution. We reviewed 36 patients who had undergone unilateral inferior rectus muscle recession, with or without nasal inferior rectus muscle transposition. The following factors were investigated as possibly influencing excyclotropia correction: inferior rectus muscle thickness, degree of adipose change in the inferior rectus muscle, smoking status, history of orbital radiotherapy, and the amount of inferior rectus muscle recession. Using T1-weighted coronal magnetic resonance imaging, we measured the cross-sectional area of the inferior rectus muscle at its largest point, as well as the bright-signal area of the inferior rectus muscle, which reflects intermuscular adipose change. We then calculated the percentage internal bright-signal area at the point of the largest inferior rectus muscle cross-sectional area. The history of orbital radiotherapy was graded using a binary system. We evaluated correlations among excyclotropia correction, the amount of nasal inferior rectus muscle transposition, and the possible influencing factors listed, using stepwise multiple regression analyses. RESULTS: The multiple regression model demonstrated a significant relationship among excyclotropia correction, amount of nasal inferior rectus muscle transposition, and the amount of inferior rectus muscle recession (YCORRECTION = 8.546XTENDON WIDTH + 0.405XRECESSION- 0.908; r = 0.844; adjusted r2 = 0.695; P < 0.001). CONCLUSIONS: Excyclotropia correction was correlated with the amount of nasal inferior rectus muscle transposition and the amount of inferior rectus muscle recession, but not with the other factors. The regression model presented in this study will enable us to determine more precisely the amount of nasal inferior rectus muscle transposition in patients with excyclotropia of various angles.

External Dacryocystorhinostomy With or Without Double Mucosal Flap Anastomosis: Comparison of Surgical Outcomes.

The aim of this study was to compare surgical outcomes of external dacryocystorhinostomy with or without double mucosal flap anastomosis. A retrospective chart review was performed for 205 sides of 178 patients diagnosed with nasolacrimal duct obstruction. Double-flap anastomosis was performed on 57 sides (double-flap group) and complete flap excision on 148 sides (no-flap group). Criteria for surgical success were defined as no or minimal intermittent epiphora and no reflux on lacrimal irrigation 12 months postoperatively. Consequently, surgery was successful for 53 sides (93.0%) in the double-flap group and 138 sides (93.2%) in the no-flap group. There was no statistically significant difference in success rate between the groups (P = 0.947, the Fisher exact probability test). This study demonstrated that external dacryocystorhinostomy without flap anastomosis had a surgical outcome similar to that of double-flap anastomosis.

Recurrent ptosis in a patient with blepharochalasis: clinical and histopathologic findings.

A 37-year-old woman presented with right upper eyelid blepharochalasis with ptosis. Right upper eyelid edema had occurred 2 to 3 times per year by 30 years old, although the frequency decreased with age. The edema occurred spontaneously and resolved within 1 to 2 days. She underwent a right levator tucking surgery at 22 years old, and the ptosis recurred 2 years postoperatively. She again underwent ptosis surgery with skin excision at 37 years old. The intraoperative findings showed a thin levator aponeurosis. The white line was therefore advanced to the upper tarsal edge, resulting in an appropriate height and curvature. Three months later, the patient's eyelid height was 1.5 mm higher with a little temporal peaking. The levator aponeurosis was histopathologically shown to contain many capillaries. The increased vascularity of the levator aponeurosis may contribute to recurrent bouts of edema resulting in stretching and disinsertion of the aponeurosis.

Movement of the lacrimal canalicular wall under intracanalicular pressure changes observed with dacryoendoscopy.

BACKGROUND: Movement of the lacrimal canalicular wall has been speculated to occur during blinking. Movement of the common internal ostium has been observed under nasal endoscopy, and pressure changes in the lacrimal canalicular cavity have been observed with a pressure sensor; however, lacrimal canalicular wall movement under pressure changes has not been observed. PURPOSE: To examine movement of the lacrimal canalicular wall under intracanalicular pressure changes using dacryoendoscopy. METHODS: The authors examined 20 obstruction-free lacrimal canaliculi in 10 patients. A dacryoendoscope was inserted, and water was poured into the intracanalicular cavity via the dacryoendoscope's water channel. The water was then poured or suctioned to cause positive or negative pressure changes in the intracanalicular cavity, and movement of the lacrimal canalicular wall was examined. RESULTS: The lacrimal canalicular wall moved flexibly with pressure changes. Under positive pressure, the intracanalicular cavity was dilated; however, it narrowed under negative pressure. The extent of movement was more dramatic in the common canalicular portion than the proximal canalicular portion. CONCLUSIONS: Intracanalicular pressure changes cause movement of the lacrimal canalicular wall. There was a consistent relationship between intracanalicular cavity changes and pressure changes, possibly contributing to lacrimal drainage of the canaliculus.

Consecutive microscopic anatomical characteristics of the lacrimal sac and nasolacrimal duct: cases with or without inflammation.

PURPOSE: We examined the consecutive microscopic anatomy of the lacrimal sac and nasolacrimal duct with or without conspicuous inflammation. METHODS: We used 18 postmortem lacrimal sacs and nasolacrimal ducts of 12 Japanese subjects (5 males, 7 females, aged 75-98 years at death). The removed mucosal wall was transversely sectioned. The first slice was cut around the internal canalicular punctum, the second slice was at the superior opening of the bony nasolacrimal canal, and the other four were harvested from the nasolacrimal duct. All specimens were dehydrated and embedded in paraffin, cut into 7-µm thick sections, and stained with Masson's trichrome. RESULTS: The lumen was larger in the lacrimal sac than in the nasolacrimal duct. The lacrimal sac wall was less developed than the nasolacrimal duct wall. All specimens but two showed a narrowed area in the nasolacrimal duct. Specimens without conspicuous inflammation showed some subepithelial inflammatory cell infiltration. Goblet cells were smaller in number in the lacrimal sac with an increasing tendency in the inferior direction. Specimens with conspicuous inflammation showed narrowed portions in the nasolacrimal duct, in which severe inflammation and exudate in the lumen was observed. The epithelium was denuded and goblet cells were lost. A specimen with focal inflammation illustrated similar findings in the inflammatory part, but the other parts were similar to the specimens without inflammation. CONCLUSIONS: Consecutive microscopic anatomical characteristics of the lacrimal sac and nasolacrimal duct were different from each other. A narrowed part of the nasolacrimal duct lumen is speculated to be a risk for obstruction.

Upper eyelid reconstruction by making a skin defect similar to skin removal in blepharoplasty.

A 49-year-old man had a sebaceous gland carcinoma in the right upper eyelid. The tumor was excised with an additional 5-mm safety margin. The posterior lamellar reconstruction was performed with a reverse modified Hughes flap and residual conjunctiva. The anterior lamellar reconstruction was performed by making a skin defect similar to a skin removal in blepharoplasty. The skin excision part was designed next to the upper portion of the defect, and the excised skin was grafted to the lower portion of the defect. The skin was closed after making 3 buried double eyelid anchors. The conjunctival pedicle was severed 2 weeks postoperatively. Three months later, the appearance was acceptable without a harmful functional outcome. The basic concepts of our procedure were to make an accustomed scenery, such as a defect similar to a skin removal in blepharoplasty, from an unfamiliar one, such as a defect after a tumor excision, and to make good use of the excised tissue.

Frontal suspension for congenital ptosis using an expanded polytetrafluoroethylene (Gore-Tex(®)) sheet: one-year follow-up.

BACKGROUND: The frontalis suspension technique is the surgical method of choice in patients with ptosis and a levator function of 4 mm or less. Several types of materials have been used, including Gore-Tex(®), which has been used successfully as a frontalis sling material since 1986. Recently, a Gore-Tex sheet (wider than a sling or strip) suspension was reported. This paper reports the results of 27 eyes from 20 patients with congenital ptosis treated using the frontalis suspension technique with the newly developed Gore-Tex Most Versatile Patch (MVP) sheet. METHODS: All patients underwent surgery between April 2007 and September 2011 and were followed up for at least one year. The average follow-up duration was 18 months, with a range of 12-36 months. The average patient age was 45 (5-85) years, and the group included 11 males and nine females. Thirteen cases demonstrated ptosis in one eye, and seven cases involved both eyes. The patients were divided by age into a younger group and an older group. All ptosis procedures were performed using the Gore-Tex MVP sheet. The implant was normally 7 mm wide for adults and 5 mm wide for children. The implantation method was the same as that used for the sheet shape fascia. RESULTS: In all patients, satisfactory functional results were observed at the 6-month follow-up examination. Eyelid opening heights were also obtained. The average marginal reflex distance (MRD) was -0.5 mm preoperatively, which improved to +1.9 mm after surgery. After one year, average MRD was +1.6 mm. MRD attenuation was more frequent in the younger group. There were no cases requiring redo surgery and only one case of exposure.

Medial orbitotomy without opening the ethmoid sinus enables wide exposure and safe removal of an orbital tumour located posterosuperomedially.

Tumours in the posterosuperomedial orbital space are hard to remove because of their site. However, medial orbitotomy without opening the ethmoid sinus produces a wide enough view and a direct route without complications. Posterosuperomedial orbital tumours can therefore be safely, accurately, and easily removed.

Assessment of the predictive value of intraoperative eyelid height measurements in sitting and supine positions during blepharoptosis repair.

PURPOSE: To examine relationships between intraoperative and postoperative eyelid heights in relation to patient postures in blepharoptosis surgery. METHODS: Thirty eyelids in 15 patients with bilateral aponeurotic ptosis were selected. The margin reflex distance-1 (MRD-1) was measured with the patients in the sitting position preoperatively, intraoperatively, and in the postoperative 6 weeks. MRD-1 also was measured intraoperatively with patients in the supine position. The intraoperative sitting and supine values and the postoperative values were statistically compared using a paired t test, and lateralities in those groups were statistically analyzed using Student's t test. RESULTS: From the intraoperative measurements, mean MRD-1 values in the sitting position (right: 3.80 mm, left: 3.73 mm) were significantly lower than those in the supine position (right: 4.37 mm, p < 0.001; left: 4.33 mm, p < 0.001). In the postoperative 6 weeks, mean MRD-1 values (right: 3.80 mm, left: 3.63 mm) were not significantly different from intraoperative values in the sitting position (right: p = 1.000, left: p = 0.189), but were significantly lower than intraoperative values in the supine position (right: p < 0.001, left: p < 0.001). There was no significant laterality among the three groups (supine intraoperative: p = 0.890, sitting intraoperative: p = 0.785, postoperative: p = 0.546). CONCLUSION: Intraoperative measurements in the sitting position more accurately predicted postoperative eyelid height than did measurements with the patient in a supine position.

Intraoperative quantification using finger force for involutional blepharoptosis without postoperative lagophthalmos.

PURPOSE: To report intraoperative quantification using finger force for involutional blepharoptosis, which helps in the prevention of postoperative lagophthalmos. METHODS: We carried out levator resection on 20 involutional blepharoptic eyelids. Fissure height was examined intraoperatively to evaluate the extent of resection. If a patient presented more than 3 mm of lagophthalmos in voluntary eyelid closure but could fully open the eye, we forcibly closed the eyelid, using a finger, after voluntary eyelid closure. If more than 3 mm of lagophthalmos was still observed after forced eyelid closure, we corrected eyelid tension until lagophthalmos became less than 2 mm. RESULTS: Six of the ten patients (20 eyelids) presented with full eyelid opening but more than 3 mm of lagophthalmos in voluntary eyelid closure. After the upper eyelids were forcibly lowered, all six eyelids showed less than 2 mm of lagophthalmos. There were no cases of lagophthalmos 1 month postoperatively. CONCLUSIONS: Additional finger force makes precise quantification of blepharoptosis surgery possible and prevents postoperative lagophthalmos.

Primary squamous cell carcinoma of the lacrimal gland.

A 55-year-old Japanese woman presented with proptosis of the left eye that showed rapid progression with profound lid oedema and chemosis with pain. Magnetic resonance imaging and helical computed tomography demonstrated a large mass of the upper temporal orbit and extended bony destruction of the frontal and zygomatic bones. She was successfully treated with orbital exenteration. A diagnosis of primary squamous cell carcinoma of the lacrimal gland was made, which was confirmed by characteristic findings seen on histopathological examination.