A histological analysis of the Müllerectomy: redefining its mechanism in ptosis repair.

BACKGROUND: The goals of this study were to determine whether the surgical target amount of Müller's muscle removed is consistent with the histological amount obtained, to assess the clinical outcome of ptosis repair based on these amounts, and to evaluate the role of the levator aponeurosis in the procedure. METHODS: The Müllerectomy procedure was performed on eight eyelids of four cadavers and eight eyelids of seven patients (six unilateral, one bilateral). Histologically, the dimensions of the Müller and levator muscles were measured in the specimens removed. If present, the elastic fiber network of the levator aponeurosis was noted. Ptosis measurements were analyzed according to the target amount of resection and histologic amount obtained. RESULTS: The median percentage of Müller's muscle histologically measured compared with the target tissue resection obtained was 23.25 percent (0 to 37.5 percent, n = 8) in cadavers, compared with 31.13 percent (2.8 to 58.8 percent) in patient specimens. Levator aponeurosis was identified in all cadaver specimens (n = 8) and all patient specimens (n = 8). Elastin stain identified the elastic fiber network of the levator aponeurosis. There was no statistically significant difference between amount of resection and presence of the Müller or levator muscle in cadaver (p > 0.05) or patient specimens (p > 0.05). CONCLUSIONS: There is a consistent presence of levator aponeurosis that may play a role in ptosis repair via aponeurosis advancement and resection using a modified internal Müllerectomy approach. Using the authors' surgical technique, there is no correlation of the histologically measured amount of Müller's muscle to the postoperative marginal reflex distance-1 change in the operative eyelid. The levator aponeurosis may play a greater role in ptosis repair using an internal Müllerectomy approach than previously thought.

The role of bimatoprost eyelash gel in chemotherapy-induced madarosis: an analysis of efficacy and safety.

OBJECTIVES: Breast cancer patients suffer from madarosis (loss of eyelashes) due to chemotherapy side effects. An effective treatment or prevention for alopecia or madarosis induced by chemotherapy is not available. Potential drug side effects of bimatoprost solution include increased eyelash length, darkness, and number. A formulation of bimatoprost which maximizes eyelash enhancement and minimizes intraocular and systemic side effects has not been reported. MATERIALS AND METHODS: An Institutional Review Board (IRB) and Investigational New Drug (IND) approved, randomized, single-blinded, prospective, internally controlled trial compared bimatoprost eyelash gel in relation to eyelash enhancement of madarosis patients. Forty eyelids of 20 chemotherapy-treated breast cancer patients were randomized to treatment or control (fellow eyelid). Both patient and surgeon (blindly) evaluated bimatoprost gel's effectiveness in improving eyelash appearance at baseline and at monthly intervals. RESULTS: The median follow-up time was 3 months (range 1-4). There was a significant difference between treated and fellow eyelash length during month 2 [1.00 mm (P=0.004)] and month 3 [1.00 mm, P=0.02)], in eyelash pigment [month 1 (2.5, P=0.04); month 2 (2, P=0.0009); month 3 (3, P=0.06)] and thickness [month 2 (2, P=0.002); month 3 (3, P=0.01)]. There was an improvement in the patient satisfaction scale from baseline 16 (median, range 7-21) to 26 (median, range 17-33, P=0.002) at last follow-up. CONCLUSIONS: Bimatoprost eyelash gel appears promising for chemotherapy-induced madarosis. Patients may find the effects restorative and cosmetically enhancing.

Development of a community mobility skills course for people who use mobility devices.

OBJECTIVE: We assessed mobility device skills in a lived-in environment on a community mobility skills course (CMSC) and related those skills to previously demonstrated skills in a controlled environment on an inside mobility skills course (IMSC). METHOD: Six mobility device users were selected from 91 adults who had previously completed the IMSC. Each of the following device groups was represented: power wheelchair, manual wheelchair, scooter, cane, crutch, and walker. CMSC tasks were modified from IMSC tasks and designed using materials in the community. RESULTS: All participants completed at least half of the CMSC tasks faster than they completed the corresponding IMSC tasks. The number of tasks on which participants improved and the amount of improvement varied by difficulty of task and mobility device used. CONCLUSION: Some mobility device skills used in controlled environments appear to transfer to community settings; others do not. Skills required for community participation may partially depend on mobility device used.

The allocation of time in decision-making.

We study the allocation of time across decision problems. If a decision-maker (1) has noisy estimates of value, (2) improves those estimates the longer he or she analyzes a choice problem, and (3) allocates time optimally, then the decision-maker should spend less time choosing when the difference in value between two options is relatively large. To test this prediction we ask subjects to make 27 binary incentive-compatible intertemporal choices, and measure response time for each decision. Our time allocation model explains 54% of the variance in average decision time. These results support the view that decision-making is a cognitively costly activity that uses time as an input allocated according to cost-benefit principles.

Intraocular pressure change in orbital disease.

Intraocular pressure change has been found concurrent with many orbital pathologies, particularly those involving proptosis. The objective of this review is to offer an inclusive classification of orbital disease-related intraocular pressure change, not only for oculoplastics and glaucoma specialists, but also for general ophthalmologists. Various orbital conditions associated with increased intraocular pressure and glaucoma are comprehensively summarized, and pathophysiology, clinical manifestations, and treatment options of these diseases are discussed. Graves disease, arterio-venous shunts, trauma, and orbital neoplasia, and other common conditions are discussed in detail; less frequent syndromes such as orbitocraniofacial deformities, phakomatoses, and mucopolysaccharidoses are included for the sake of comprehensiveness, but discussed less extensively.

The influence of verbal training and visual feedback on manual wheelchair propulsion.

PURPOSE: To determine if verbal training with visual feedback improved manual wheelchair propulsion; to examine propulsion differences between an individual with paraplegia and an individual with tetraplegia. METHOD: Quasi-experimental study: Nine manual wheelchair-using adults participated in propulsion assessments and training. Baseline propulsion performance was measured on several tasks on different surfaces. Participants were trained on a wheelchair treadmill with verbal and visual feedback to increase push length, reduce push frequency and to modify propulsion pattern. Handrim biomechanics were measured with an instrumented wheel. Changes in propulsion were assessed. Differences in propulsion characteristics between a participant with paraplegia and a participant with tetraplegia were examined. RESULTS: Push length increased (p < 0.05), push frequency decreased (p < 0.01) and peak (p < 0.05) and average (p < 0.01) forces increased immediately after training. These changes were not sustained over time. Graphic representations showed differences in propulsion characteristics between a participant with paraplegia and a participant with tetraplegia. CONCLUSIONS: Verbal training may produce changes in push biomechanics of manual wheelchair users. Longer training periods may be needed to sustain propulsion changes. Findings from this study support other studies that have shown propulsion differences between people with tetraplegia and paraplegia. Propulsion training for populations with upper-extremity impairments warrants further study.

Influence of a Consumer-Directed Personal Assistance Services Program on the lives of persons with mobility impairments.

OBJECTIVE: To examine the effects of a consumer-directed personal assistance services (CDPAS) program on the lives of persons with disabilities. METHODS: Thirteen individuals receiving paid agency-directed PAS services before enrollment in a CDPAS program (Agency Group) and 40 individuals receiving only unpaid PAS before enrollment (Informal Group) participated in this prospective study. In-home interviews were conducted just prior to CDPAS enrollment and again 6 months after CDPAS enrollment. RESULTS: Overall choice and satisfaction with PAS improved significantly for both groups after CDPAS initiation (p < .05). Total PAS hours increased significantly for the Informal Group (p < .01) but not the Agency Group. The Informal Group used relatives to provide the majority of its CDPAS hours, while the Agency Group chose to use nonrelatives and nonfriends to provide the majority of its CDPAS hours. Few significant changes in health status were observed for either group after the CDPAS intervention, although most changes were in the positive direction. The CDPAS program did not appear to have a large effect on individuals' personal and community participation, but participants reported a relatively high quality of participation at both time points. CONCLUSION: This study supports other findings that consumers prefer CDPAS to agency-directed care and provides new evidence that this preference cannot be explained by an increase in PAS hours that often accompanies enrollment in a CPDAS program. Although CDPAS appear to have subtle positive effects on consumer health and participation, ways in which CDPAS can maximize health status and participation quality among consumers should be explored.

Safety and efficacy of silicone rod frontalis suspension surgery for childhood ptosis repair.

PURPOSE: To evaluate the safety and efficacy of silicone rod frontalis suspension surgery for childhood ptosis. METHODS: The authors retrospectively studied 89 consecutive children (110 eyelids) who had silicone rod frontalis suspension surgery for ptosis at Duke University Eye Center from 1983 to 2004. Marginal reflex distance1 (MRD1) elevation of 2 mm or more (vs preoperative MRD1) was considered satisfactory. MRD1 was measured as the vertical distance from the corneal light reflex in primary gaze to the upper eyelid margin. The postoperative eyelid symmetry (< or = 1 mm = satisfactory) was the difference between the MRD1 of the surgical and fellow eyelid. RESULTS: Median age at surgery was 45 months (range: 3 to 223 months) and median follow-up was 17 months (range: 1 to 88 months). Ptosis types (number of eyelids) were unilateral congenital (53), bilateral congenital (30), third nerve palsy (16), Marcus Gunn jaw wink (7), trauma (2), and myasthenia gravis (2). Median MRD1 elevation was 2 mm or greater for all ptosis types, whereas satisfactory postoperative symmetry occurred in 60% of unilateral and 100% of bilateral congenital ptosis cases (last follow-up). Complications occurred in 10 eyelids (9%) and reoperation occurred in 10 eyelids (9%). CONCLUSION: The use of silicone rod frontalis suspension surgery for ptosis repair in pediatric patients is modestly effective, with few complications and easy removal and adjustment.

Patient-preferred sites of restylane injection in periocular and facial soft-tissue augmentation.

PURPOSE: To determine patient-preferred injection sites and frequency for facial volume augmentation with nonanimal stabilized hyaluronic acid (Restylane). METHODS: : The authors retrospectively reviewed the records of 145 consecutive patients who received 0.4 ml or 1.0 ml subcutaneous facial injections of Restylane. Location, amount, supplemental anesthetic, injection frequency, follow-up time, and use of botulinum toxin type A or other facial aesthetic interventions were reviewed. If recorded, patient satisfaction, revision rate, and any adverse reactions were also noted and analyzed. RESULTS: Median age at time of initial injection was 54 years; median follow-up was 8 months (mean 10.4 months, range 1-37 months). A total of 309 patient injections were performed (mean, 2.14 injections/patient), with 26% of patients receiving adjunctive anesthesia. Injection site frequencies among the 145 patients were nasolabial folds (72%), melolabial folds (70%), lips (51%), infraorbital rims (24%), perioral rhytids (24%), glabella (23%), malar hollows (10%), chin (8%), and other (8%). Among the 75 patients who received repeat injections, injection intervals were > or =4 months in 56 (76%) and > or =6 months in 28 (38%). Forty-four percent of patients received Botox and Restylane injections during the same office visits. Six complications included edema (2); vasovagal reaction during injection (1); ecchymosis (2); and herpes simplex virus dermatitis (1). Three revisions were performed. One patient was dissatisfied with the procedure. CONCLUSIONS: Patients elect to undergo Restylane injections to improve the appearance of rhytids and augment volume along infraorbital rims, malar hollows, lips, and depressed scars. Complications are minimal and easily treated.

Stage IV primitive-appearing sinus and orbital rhabdomyosarcoma presenting in a 68-year-old female previously treated for breast cancer.

A 68-year-old female who had undergone treatment several years previously for breast cancer presented with diplopia and unilateral proptosis and exposure keratopathy related to biopsy-proven rhabdomyosarcoma of the sinus and orbit. Further evaluation revealed multiple metastatic lesions felt to have originated from the primary sinus and orbital tumor. Histopathologic examination showed primitive-appearing rhabdomyosarcoma with some features suggestive of the alveolar subtype. Orbital or sinus rhabdomyosarcoma is seen almost exclusively in the pediatric population, but may very rarely occur in adults. There are several genetic mutations that appear to play a role in both rhabdomyosarcoma and certain breast tumors. There is also increasing evidence that even low doses of radiation may contribute to the future development of cancer, particularly in susceptible individuals. In our patient with atypical demographics for rhabdomyosarcoma, the previous neoplasm and treatment thereof may have predisposed to the development of this rare tumor.

Individual laboratory-measured discount rates predict field behavior.

We estimate discount rates of 555 subjects using a laboratory task and find that these individual discount rates predict inter-individual variation in field behaviors (e.g., exercise, BMI, smoking). The correlation between the discount rate and each field behavior is small: none exceeds 0.28 and many are near 0. However, the discount rate has at least as much predictive power as any variable in our dataset (e.g., sex, age, education). The correlation between the discount rate and field behavior rises when field behaviors are aggregated: these correlations range from 0.09-0.38. We present a model that explains why specific intertemporal choice behaviors are only weakly correlated with discount rates, even though discount rates robustly predict aggregates of intertemporal decisions.