Conservative therapy for chalazia: is it really effective?

PURPOSE: To assess the within-treatment efficacy of hot compresses (HC), HC plus tobramycin (Tobrex) and HC plus tobramycin/dexamethasone (Tobradex) for chalazia treatment. METHODS: Design: Multicentre, randomized clinical trial (ClinicalTrials.gov identifier, NCT01230593). SETTING: Two clinical sites in New York and two clinical sites in Ontario. STUDY POPULATION: A total of 149 patients with one or more chalazia on separate eyelids randomly assigned to receive HC (n = 50), HC plus tobramycin (n = 50) or HC plus tobramycin/dexamethasone (n = 49). INTERVENTION: 4-6 weeks of assigned treatment. Patients were measured for chalazion horizontal width and surveyed for pain and treatment satisfaction levels. MAIN OUTCOME MEASURES: Primary outcome was complete resolution (100% size reduction). Secondary outcomes were size change in millimetres and patient reported pre- and post-treatment pain and satisfaction levels. RESULTS: In the intention-to-treat (ITT) population, complete resolution occurred in 36 (18%) lesions total, 13 (21%) treated with HC, 12 (16%) with HC plus tobramycin and 11 (18%) with HC plus tobramycin/dexamethasone, with no significant difference between them (p = .78). Individually by paired t-test, there were statistically significant post-treatment mean size differences: HC 1.20 mm (p < 0.001), HC plus tobramycin 1.69 mm (p < .001) and HC plus tobramycin/dexamethasone 1.54 mm (p < 0.001), but no significant difference between them (p = .61). Lesions that completely resolved had a statistically significant lower pretreatment duration (1.5 months) compared to lesions that did not completely resolve (2.2 months) (p = .04). CONCLUSION: Hot compresses (HC) alone or in combination with tobramycin or tobramycin/dexamethasone drops and ointment are all effective first-line treatment options for chalazia. However, physicians may consider moving directly to the use of more invasive therapies, such as incision and curettage or steroid injections, for chalazia that have been present for more than 2 months, as older lesions are less likely to resolve with conservative therapies alone.

Ptosis Repair in Ocular Myasthenia Gravis.

Ptosis repair was performed in patients with ocular myasthenia gravis by a posterior approach (Fasanella-Servat, 12 eyelids of nine patients) or levator advancement (eight eyelids of five patients) techniques. There were eight males and five females. Median age was 73 years and range 30-86 years. The median duration of myasthenia was 10 years and range 2 to 28 years. Pyridostigmine and prednisone were widely used prior to surgical referral, but ineffective or intolerable in all. The mean preoperative upper margin-reflex distance (MRD) was 0.55 mm (range -1 to 2 mm). The levator excursion range was 10 to 16 mm and mean 12.4 mm. Mean follow-up was 9.1 months. Postoperatively, the MRD ranged from 0.5 to 4 mm, with a mean of 2.3 mm. Two patients had lagophthalmos postoperatively (one posterior approach, one levator advancement) that did not require correction. Three of five patients who underwent levator advancement required repeat ptosis repair.

Oculoplastic surgery.

Esthetic and functional surgery in the periocular region falls into the domain of oculoplastic surgeons, as well as plastic surgeons and otorhinolaryngologists with training in facial plastic surgery. This article provides a description of 8 common eyelid procedures that are routinely performed under local anesthesia, with or without mild intravenous sedation. Serious complications are rare. The rate of postoperative infection in the highly vascularized eyelid tissues is less than 1% in our experience.

Indications for orbital imaging by the oculoplastic surgeon.

OBJECTIVE: To determine the indications for ordering orbital imaging and the indications for ordering CT versus MRI by oculoplastic surgeons and to assess the correlation between surgeon's clinical indications for imaging and the radiologist's diagnosis. DESIGN: Retrospective review of imaging requisitions and radiology reports. PARTICIPANTS: Patients of 4 oculoplastic surgeons who required CT or MRI scans. METHODS: Imaging requisitions and radiology reports of patients from 4 oculoplastic surgeons were reviewed to determine the indication for ordering a CT or MRI scan between March 2006 and March 2009. The indications were then compared with the radiologist's diagnosis. RESULTS: A total of 735 patients were included: 449 (61.1%) female and 286 (38.9%) male, with an average age of 50.1 years and an age range of 7 months to 93 years. Of these patients, a total of 632 CT and 223 MRI scans were ordered, 135 of which were follow-up scans. CONCLUSIONS: The most common indication for CT scan was thyroid disease, followed by orbital tumors and then inflammatory disease, while the most common indication for MRI scan was orbital tumors, followed by inflammatory disease and then thyroid disease. CT scans were more commonly ordered than MRI, largely for trauma and to rule out orbital foreign body.

The "mini tarsal strip" lateral canthopexy for lower eyelid laser-assisted blepharoplasty-indications, technique and complications in 614 cases.

The aim of this article is to describe the "mini tarsal strip procedure", a form of lateral canthal tendon plication to tighten the lower lid and give a better apposition of the lower eyelid to the globe. We describe this procedure in the context of transconjunctival lower lid blepharoplasty.

Adult-onset exposure keratitis after childhood ptosis repair with frontalis sling procedure.

OBJECTIVE: To report the development of adult-onset exposure keratitis in patients having undergone childhood ptosis repair with frontalis sling surgery (FSS). STUDY DESIGN: Retrospective, noncomparative case series. PARTICIPANTS: Seven patients having received childhood FSS who were referred to us as adults with a complaint of ocular dryness that did not develop until years after surgery. METHODS: Single-centre, clinic-based, chart review. RESULTS: Four patients had bilateral, congenital ptosis and 3 had unilateral ptosis, secondary to childhood trauma (2) and third nerve palsy (1). Mean age at first FSS was 6 years (range, 9 months-14 years). Five patients had received additional ophthalmic surgery, including strabismus surgery (2), repeat FSS (4), and prior failed levator resection (1). Mean age at referral to our centre with complaint of ocular dryness was 37 years (range, 23-46 years). Mean time from most recent FSS to presentation was 23 years (range, 17-36 years). On examination, 6 patients had related eyelid abnormalities, including bilateral entropion (1), ptosis recurrence (4), and peaked upper eyelid (1). All patients had measurable lagophthalmos (range, 0.5 mm-3 mm), and 5 had detectable punctate keratopathy (range, "trace" to "2+" on a scale of 0 to 4+). All patients were offered artificial lubricating drops, and 3 were deemed candidates for corrective eyelid surgery, resulting in improvement of exposure keratitis. CONCLUSIONS: Adult-onset exposure keratitis should be included as a potential late complication of FSS ptosis repair in children, particularly when multiple surgeries are required or complications occur.

Solitary fibrous tumor of the orbit: a case series.

PURPOSE: Solitary fibrous tumor (SFT) occurs rarely in the orbit. We present four such cases, representing one of the largest case series reported to date of this rare orbital tumor. METHOD: The four patients ranged from ages 20 to 50, all of whom presented with lid swelling or bulging in the involved eye. All four patients underwent CT scan to confirm the diagnosis of an orbital mass, which was then excised. RESULTS: The tumors of all four specimens contained spindle-shaped cells with bland nuclei and rare mitotic figures. They all stained positively with CD34 and vimentin. Resection margins were positive in two of the four cases. One of these cases demonstrated residual tumor on follow-up CT scan, which remained unchanged at one-year follow-up. No evidence of residual tumor was found in the other three cases, despite one having malignant pathology. CONCLUSION: SFT is a rare and generally benign tumor of the orbit. Immunohistochemical testing with CD34 is necessary to confirm the diagnosis. Although en bloc tumor resection is the definitive treatment, residual tumor may remain stable for some time. However, this must be followed closely if complete resection is not carried out.

Digital photography as a novel technique of measuring ocular surface dimensions.

PURPOSE: To introduce a novel technique for measuring ocular surface dimensions using digital photography and computerized image analysis in the context of ptosis repair surgery. METHODS: Digital photographs and patient questionnaires on dry eye symptoms were obtained from 31 patients before and after ptosis repair. Patients were examined preoperatively and at 1 and 6 weeks postoperatively. Adobe Photoshop 7.0 (Adobe Systems Incorporated, 345 Parkl Avenue, San Jose, CA 95110-2704, USA) was used to digitally measure palpebral fissure height, fissure width, and ocular surface area (OSA). Similar digital measurements were obtained on 30 control subjects as well. Digital calculations of OSA for control, preoperative, and postoperative groups were compared with other published techniques. RESULTS: Graphical comparison between our method of measuring OSA and the mathematical estimations proposed by previous studies suggests that our method is more precise in measuring OSA, and that it is also better able to identify individual variations of OSA from general population trends. CONCLUSION: Digital ocular photography combined with computerized image analysis is a fast, easy to use, and reliable method of measuring ocular surface dimensions. In addition to ptosis surgery, this method can be used in other ocular surface studies.

Treatment of lower eyelid retraction by retractor release and posterior lamellar grafting: an analysis of 659 eyelids in 400 patients.

PURPOSE: To review one surgeon's experience with posterior lamellar grafting for lower eyelid elevation over a 15-year period, comparing the success of different posterior lamellar grafts used in 4 etiology groups. METHODS: A retrospective chart review of 400 patients (659 eyelids) was conducted. Patients were grouped into thyroid ophthalmopathy, previous surgery, trauma, and idiopathic causes. Three graft types were used: hard palate mucosa, free tarsoconjunctival, and free scleral. Objective measurements of lagophthalmos, scleral show, and superficial punctate keratopathy, and subjective patient symptoms, preoperatively and postoperatively were compared between graft types and etiologic groups. Complications were tabulated and compared between groups, as was any need for further surgery. The mean follow-up interval was 16.5 months. The main outcome measures were objective measurements of lagophthalmos, scleral show, and superficial punctate keratopathy. RESULTS: A mean reduction in lagophthalmos ( approximately 0.5 mm), superficial punctate keratopathy (mean score reduction = 0.2, on a scale of 1-3), and scleral show ( approximately 1.3 mm) was demonstrated for all etiology groups and graft types. Furthermore, 90% of patients subjectively reported a reduction of 1 to 3 symptoms. Hard palate mucosa grafts were more likely to be used than tarsoconjunctival grafts in cases with one or more previous surgeries (p < 0.001). Complications were more common with tarsoconjunctival grafts (except for bleeding), but the difference was statistically significant only for wound dehiscence (p = 0.004). CONCLUSIONS: Lower eyelid retraction repair with posterior lamellar grafting and lateral eyelid tightening can be recommended with confidence for eyelid retraction patients because most improved subjectively and by objective examination.

Fasanella-Servat procedure: indications, efficacy, and complications.

BACKGROUND: The Fasanella-Servat procedure is used for the repair of mild to moderate ptosis. The purpose of this study was to determine the efficacy of the Fasanella-Servat procedure for the repair of several forms of ptosis. METHODS: The authors retrospectively reviewed 169 charts of 2 surgeons from 1988 to 1996. All patients had undergone a Fasanella-Servat procedure for ptosis. Patients with less than a 1-month follow-up were excluded, leaving 153 eyelids of 144 patients. Surgical success was defined as lid symmetry within 0.5 mm or correction of eyelid contour abnormality from previous surgery or trauma. RESULTS: Ptosis was classified as involutional, occurring after intraocular surgery, congenital, due to Horner's syndrome present after levator surgery, and myogenic/other. With a mean follow-up of 7 months, success was achieved in 89.5% of cases (137/153). Among subgroups, success was highest at 100% in Horner's syndrome (8/8) and post-levator surgery (11/11), and lowest in congenital ptosis at 76.4% (13/18). Postoperative problems included dry eye symptoms (6/144 patients), contour abnormalities in 12 lids, and dermatochalasis in 10 lids. INTERPRETATION: The Fasanella-Servat operation is effective for mild to moderate ptosis from a variety of causes and for contour abnormality correction in patients with little or no ptosis. Despite the long-held belief that excision of the accessory lacrimal glands of Wolfring leads to dry eye symptoms, our study found this to be the exception. This procedure has the advantage of high reliability when reasonable preoperative criteria are applied and is minimally invasive.

Surgical waiting times for ocular and periocular cancer patients in Toronto.

BACKGROUND: The purpose of this study was to evaluate surgical waiting times experienced by intraocular and periocular cancer patients in Toronto and to assess the period of greatest delay between certain stages of ocular cancer care. METHODS: A retrospective chart review was performed on cases of adult patients who underwent surgery between January 2002 and December 2004 for malignant or premalignant tumours of the eye and ocular adnexa. Waiting time intervals were calculated between 5 time points: initial presentation to referring physician or optometrist, date of referral to oculoplastics or ocular oncology, initial assessment, consent date, and surgery date. Total surgical waiting time was the period between the initial presentation and surgery date. RESULTS: The mean total surgical waiting time was 85.93 (standard error [SE] 212.70) days. The 5% trimmed mean total waiting time was 51.07 days. The longest mean total waiting time averaged 94.16 (SE 18.69) days for patients with orbital or lacrimal tumours. For all patients, the interval of greatest delay was between initial assessment and consent (according to means) or between referral and initial assessment (according to 5% trimmed means). For patients with lid, brow, or conjunctival tumours the interval of greatest delay was between referral and initial assessment, and for those with orbital, lacrimal, or intraocular tumours it was between initial assessment and consent. INTERPRETATION: By measuring the period between consent and surgery, the Ontario government is not measuring the interval of greatest delay in ocular cancer care. The wait-time registry may benefit from including data from patients with periocular tumours.

Adrenergic receptors in the ptotic human eyelid: correlation with phenylephrine testing and surgical success in ptosis repair.

PURPOSE: To investigate the relationship between adrenergic receptors in Müller muscle and response to phenylephrine testing in patients undergoing ptosis surgery. This study also compares outcomes of Fasanella and Putterman approaches to posterior ptosis repair. METHODS: Prospective analysis of 71 patients undergoing posterior ptosis surgery. Eyelid height was measured before and after phenylephrine. Müller muscle was examined for alpha-1D, alpha-2C, beta-1, and beta-2 receptors. Specimens were graded on receptor staining intensity. Patients were seen 1 week and 6 weeks following surgery. Surgical outcomes were scored on a scale of 1 (most favorable) to 3 (least favorable). RESULTS: Adrenergic receptors were found in decreasing order: alpha-1D, beta-1, alpha-2C, and beta-2. Receptor grade significantly predicted eyelid height for alpha-2C receptors (p = .03). Mean outcome scores for 36 Putterman (1.10) and 35 Fasanella (1.27) procedures were not significantly different. CONCLUSIONS: Alpha 1D, alpha-2C, and beta-2 receptors are documented within human Müller muscle. Human eyelid elevation response to phenylephrine is inversely related to the amount of alpha-2C receptor staining in Müller muscle. Fasanella and Putterman procedures have equal outcomes, independent of adrenergic receptors.

Complications of orbital implants: a review of 542 patients who have undergone orbital implantation and 275 subsequent PEG placements.

PURPOSE: To inform patients and physicians of the complications associated with three commonly used orbital implants, as well as associated anophthalmic socket issues. METHODS: A retrospective chart review of 542 patients who underwent eviscerations, enucleations and secondary procedures by one surgeon (Dr. James Oestreicher) was completed, paying special attention to complications in the follow-up period prior to pegging, as well as those that occurred post-pegging. RESULTS: Approximately 60% of patients experienced complications prior to implant drilling, with discharge being the most prevalent (15.9%). Secondary procedures were associated with significantly greater complication rates prior to implant drilling. Silicone implants had significantly less pre-pegging pyogenic granuloma (P = 0.011) and hypo-ophthalmos (P = 0.042) than the other implant types. Seven implants had to be removed due to exposure. Implant drilling and peg placement were performed in 275 patients. Implant drilling complications were experienced by 67.4% of pegged patients, with a change in discharge from prior to pegging (27.2%) being the most prevalent. Plastic peg systems had a significantly higher incidence of complications than titanium systems. CONCLUSIONS: The majority of orbital implantations involve complications, these being largely minor ones which resolve spontaneously or are easily treated. Secondary implant procedures involve a higher likelihood of complications. Silicone implants have the smallest amount of complications. Should patients decide to undergo pegging, evidence sides strongly for the use of a titanium peg and sleeve system over the other peg types. Implant removal is a rare event; occurring in 1.3% (n = 7) of the study population.

Treatment of post-blepharoplasty lower lid retraction by free tarsoconjunctival grafting.

BACKGROUND: Blepharoplasty is probably the most commonly performed facial cosmetic procedure. Despite attempts to prevent its occurrence, post-blepharoplasty lower eyelid malposition with inferior scleral show and corneal exposure can occur, particularly with non-ophthalmologist surgeons. Since a repair must oppose the force of gravity and recurrent scarring, it is often difficult to achieve functional and esthetically pleasing surgical correction. A variety of authors have documented methods to correct post-blepharoplasty lower eyelid malposition. A review of such methods is presented. This is the first paper to analyze results from free tarsoconjunctival grafting specifically in cases of post-blepharoplasty lower lid retraction. METHODS: The present case-series report attempts to examine the efficacy of free tarsoconjuctival grafting in patients with post-blepharoplasty lower lid malposition. Ten patients, ranging in age from 48-75 years (mean = 58.7 years), presented with varied amounts of inferior scleral show and ocular symptoms, including epiphora, dry eye and ocular irritation. Varied amounts of lagophthalmos and superficial punctate keratitis were detected in five eyes and ten eyes, respectively. As described, each patient (20 eyes) underwent bilateral free conjunctival grafting from upper to lower eyelids. RESULTS: After a follow-up interval of 3-32 months (mean = 15 months), all patients experienced a decrease in inferior scleral show and symptomatology. The decrease in inferior scleral show ranged from 0.75 to 3 mm, with an average decrease of 1.61 mm; symptoms of epiphora, dry eye or discomfort persisted in only four eyes. The amount of lagophthalmos and superficial punctate keratitis also decreased postoperatively. Side effects were minimal. INTERPRETATION: We conclude that in the specific case of post-blepharoplasty lower lid retraction, free tarsoconjunctival grafting is both safe and effective.

The correlation of clinical lacrimal bone density and thickness, established at the time of DCR surgery, with systemic bone mineral densitometry testing.

BACKGROUND. Due to a growing concern with regard to the relationship between osteoporosis and fractures, we wished to examine the correlation of systemic bone density with lacrimal bone characteristics (thickness and density), as measured at the time of dacryocystorhinostomy (DCR). Significant correlation would suggest that oculoplastic surgeons may screen for osteoporosis during DCR. METHODS. A prospective study of the bone mineral density in patients (n=32) undergoing DCR was conducted. During DCR, the lacrimal bone thickness and density were estimated clinically. Postoperatively, the systemic bone density was measured by dual-energy x-ray absorptiometry (DEXA) scanning. The data were analyzed using Student's t-test, Pearson correlation and Pearson chi-square methods. RESULTS. Analyzed in a bivariate arrangement, significant correlation (p<0.05) was detected between the systemic bone density (as measured at two sites, the femoral head and lumbar spine) and the lacrimal bone characteristics (thickness and density). Therefore, the lower the lacrimal bone thickness or density, the lower the systemic bone density. INTERPRETATION. With the finding of significant correlation between lacrimal bone thickness and density and systemic bone density, oculoplastic surgeons can screen for osteoporosis during DCR. If low-density thin bone is encountered during DCR, the patient's general practitioner should be alerted.