Lower eyelid retractor (white-line) advancement to correct tarsal ectropion.

OBJECTIVE: To describe a modification of trans-conjunctival, lower eyelid retractor advancement to correct tarsal ectropion. DESIGN: A retrospective case review. PARTICIPANTS: Consecutive patients with lower eyelid tarsal ectropion. METHODS: Cases of lower eyelid tarsal ectropion, surgically corrected by advancement of inferior retractor to the lower border of tarsus via a transconjunctival approach, were identified. Lateral tarsal strip was also performed simultaneously in all cases. RESULTS: Twenty patients (25 eyelids) were included in this study. There were 19 primary lower eyelid tarsal ectropion and 6 recurrent tarsal ectropion. Complete resolution of tarsal ectropion was achieved in all patients postoperatively. Mean follow-up was 8.4 months (range 1-36 months). There were no cases of overcorrection, recurrent ectropion, suture abscess, wound dehiscence, or inferior fornix shortening after surgery. CONCLUSIONS: Visualization of the lower eyelid retractor (white-line) and advancement to the inferior border of tarsus through a transconjunctival approach is effective in correcting both primary and recurrent cases of tarsal ectropion. This can be performed through a small conjunctival incision in the middle third of the lower eyelid, without the need for any excision of tissue or suture loop tie on the skin surface.

Self-inflicted bilateral ocular and eyelid injuries in an unsuspected individual.

BACKGROUND AND AIMS: This report aims to illustrate a case of self-inflicted ocular and orbital injury, resulting in severe tissue loss and ophthalmoplegia in a patient with no known history of mental illness. METHODS AND RESULTS: A 71-year-old male initially presented to the emergency department with significant tissue loss from his left upper and lower lids, orbital tissue loss and complete ophthalmoplegia, after reportedly tripping and falling onto his desk. He subsequently attended the emergency department on two further occasions with similar injuries, affecting the same and contralateral eye, whilst maintaining a traumatic cause for his injuries. He was eventually admitted to a psychiatric ward for mental health assessment. This report covers his progress as well as illustrating his injuries with images. CONCLUSION: Self-harm is an important differential diagnosis in cases where the mechanism of injury does not correspond to the extent of injury or tissue loss. It can, however, be difficult to differentiate from accidental injury and even with repeated assessments, a formal psychiatric diagnosis may not be possible.

Chronic lymphocytic leukemia presenting as unilateral extraocular muscle enlargement and proptosis.

Orbital involvement in chronic lymphocytic leukemia (CLL) is rare with very few published cases. We describe a case of unilateral isolated extraocular muscle enlargement in a patient with CLL. An incisional biopsy was performed from the left medial rectus muscle and histology revealed a lymphocytic infiltrate suggestive of CLL. Complete resolution of signs and symptoms was subsequently achieved with chemotherapy. We would suggest that in patients presenting with atypical clinical features, it is important to consider nonthyroid-related causes of extraocular muscle enlargement and a muscle biopsy should be considered to exclude neoplastic causes.

Suture-assisted punctoplasty.

PURPOSE: To describe a surgical technique in which a suture, instead of forceps, is used to improve access for the introduction of scissors and more easily achieve an appropriately-sized punctoplasty. MATERIALS AND METHODS: In this technique, a new modification of the 2-snip punctoplasty, a 6-0 polyglactin 910 suture is passed through the posterior wall of the punctum to apply traction. A video of the technique is provided. RESULTS: This technique improves the surgical field of view and eases access for introduction of Vannas scissors into the punctum to perform the punctoplasty. CONCLUSIONS: This simple and practical modification of the 2-snip punctoplasty improves instrument access so that an appropriately-sized punctoplasty can be performed with ease.

Effect of Manuka Honey on Eyelid Wound Healing: A Randomized Controlled Trial.

PURPOSE: To report outcomes of a randomized trial on the role of "active" Manuka honey on eyelid surgical wound healing. METHOD: Prospective, randomized, single-blinded study was performed for patients undergoing bilateral upper blepharoplasty. Vaseline was applied 4 times a day to both sides for 6 weeks and in addition, one eyelid was randomized to receive Manuka honey twice daily. Postoperative wounds were graded by a masked observer at 1 week, 1 month, and 4 months using Manchester scar scale and a modified eyelid scar grading scale. Patients scored symptoms, expressed preferred side, and of any problems they experienced using honey. Standard photographs were graded by 2 independent assessors. RESULTS: Fifty-five patients were randomized. One week after surgery, 46 (29 women, 17 men, mean age 68 years, median 69, range 49-85) were available for analysis. There was a trend toward distortion of the surrounding skin being less (1.6 vs. 1.8, p = 0.07) and the scar being less palpable (1.8 vs. 2.0, p = 0.08) on the Manuka-treated side. Patients reported the scar on the Manuka side to have less stiffness (1.3 vs. 1.6, p = 0.058). At 1 month, all 3 grading scales showed no difference between the 2 sides. At 4 months, scar grading scales showed no differences; however, patients reported scar pain to be significantly less on the Manuka-treated side than control (0.48 vs. 1.9, p = 0.005). Thirty-one of 46 patients believed the scars were similar on both sides, 11 preferred the honey-treated side, and 4 preferred the control. CONCLUSION: Upper eyelid scars treated with or without Manuka honey heal well, without significant difference when assessed by validated scar grading scales; however, honey may provide subjective benefits early, postoperatively.

The Learning Curve in Endoscopic Dacryocystorhinostomy: Outcomes in Surgery Performed by Trainee Oculoplastic Surgeons.

PURPOSE: To report outcomes of endoscopic DCR (En-DCR) performed by oculoplastic trainees and describe factors to improve success rates for trainees. METHODS: Retrospective, single-centre audit of En-DCR procedures performed by three consecutive trainee oculoplastic surgeons, over a 3-year period. Trainees also completed a reflective-learning questionnaire highlighting challenging and technically difficult aspects of En-DCR surgery, with relevant tips. RESULTS: Thirty-eight consecutive independently-performed en-DCR procedures on 38 patients (mean age 58.6 ± 21.4 years) were studied. Mean time spent in the operating-theatre was 95.7 ± 27.3 minutes. Success rate for each year was 15/17(88%), 8/8(100%) and 7/13(54%), respectively, at mean follow-up 12.5 ± 12 months. The lowest success rate year coincided with use of silicone stents in 31% cases compared to 94% and 100% in the previous 2 years. In cases that failed, video-analysis highlighted inadequate superior bony rhinostomy (2 cases), incomplete retroplacement of posterior-nasal mucosal-flaps (3 cases), significant bleeding (1 case). Those who underwent revision surgery (n = 6), were found to have soft-tissue ostium and sac closure requiring flap revision. Two-cases required further bone removal supero-posterior to the lacrimal sac. Trainees-tips that helped improve their surgery related to patient positioning, instrument handling, bone removal and posture. CONCLUSION: Good surgical outcomes are achievable training in en-DCR surgery. Adequate operating time needs to be planned. Failure was primarily due to closure of the soft-tissue ostium, either secondary to inadequate osteotomy and sac-marsupialisation or postoperative scarring. Intra-operative mucosal trauma is higher amongst trainees and adjuvant silicone stenting during the training period may be of value where mucosal adhesions are anticipated.

Anterior Approach White-Line Advancement: A Hybrid Technique for Ptosis Correction.

PURPOSE: To describe the technique of anterior approach white-line advancement for correction of ptosis. METHODS: Retrospective review of consecutive cases that underwent anterior approach white-line advancement for correction of aponeurotic ptosis. In this technique, the posterior surface of the levator aponeurosis (white line) is accessed through a skin crease incision (anterior approach) and advanced toward the tarsal plate. Surgery was considered successful if the following 3 criteria were simultaneously met: postoperative upper margin reflex distance of ≥2 and ≤4.5 mm, inter-eyelid height asymmetry of ≤1 mm, and satisfactory eyelid contour. Written informed consent was obtained from all the patients and the study was HIPPA compliant. RESULTS: Twenty patients (29 eyelids) were included in this study. Mean postoperative follow up was 1.25 months (1 to 6 months). Mean preoperative margin reflex distance was 0.38 mm (-1 to 2 mm) and the mean postoperative margin reflex distance was 3.16 mm (2 to 4 mm). Eighteen patients (90%) fulfilled the criteria set for success. The patients rated the outcome of surgery as follows: 80% completely satisfied and 20% significantly improved. CONCLUSION: Anterior approach white-line advancement is a hybrid technique that incorporates the principles of both anterior and posterior approach ptosis correction techniques. The posterior surface of levator aponeurosis (white line) is exposed and advanced toward the superior border of tarsal plate with minimal disruption of eyelid anatomy including the orbital septum and preaponeurotic fat pad. Hence, this technique can achieve superior cosmetic results similar to a posterior approach procedure, without the need for a conjunctival incision.

Platinum segments: a new platinum chain for adjustable upper eyelid loading.

PURPOSE: Prospective study evaluating outcomes of individually sutured platinum segment chains in upper eyelid loading. METHODS: Single-centre, single-surgeon, prospective study. Upper eyelid loading with 0.4 and 0.2 g platinum segment chains for lagophthalmos. Segments were sutured to create a desired weight and attached to superior tarsus and distal levator aponeurosis following levator recession. PRIMARY OUTCOME MEASURES: improvement in lagophthalmos and complications. SECONDARY OUTCOME MEASURES: cosmesis of eyelid margin contour and implant prominence. Minimum 3-month follow-up. RESULTS: Eighteen eyelids of 17 patients received segment chains (mean weight 1.2 g, range 0.8-1.6 g) and 3 for exchange of pre-existing gold weights. Median follow-up was 10 (range 6-17) months. Mean blink lagophthalmos improved from 7 (3-10) mm to 3 (0-6) mm (p<0.0001), and gentle closure from 3.2 (0-8) mm to 1.1 (0-4.9) mm (p=0.0004). Twelve patients (71%) reported no prominence, and the remainder, mild prominence only. The chain was graded as having no prominence in 78% (14/18) eyelids. Two required segment adjustments with removal of a single 0.2 g segment at 11 months and transfer of 0.4 g segment to the contralateral eyelid at 16 months, respectively. One complication (posterior, trans-conjunctival exposure above the superior border of the tarsal plate) was seen 12 months post surgery, requiring repositioning. CONCLUSIONS: Platinum segment chains provide benefits of platinum chains with additional advantages of postoperative adjustibility. They can be used as an addition to pre-existing in situ weights or chains. TRIAL REGISTRATION NUMBER: REC reference: 13/SW/0146. IRAS project ID: 119022.

Squamous Cell Carcinoma of the Caruncle.

Squamous cell carcinoma (SCC) of the lacrimal caruncle is a rare entity. The authors report the management and outcomes of 3 cases of caruncle SCC. Case 1 underwent wide margin surgical excision with adjuvant topical chemotherapy for a poorly differentiated SCC. He later developed regional lymph node metastasis and required modified radical neck dissection. Case 2 underwent wide margin surgical excision with cryotherapy and adjuvant topical chemotherapy for an invasive moderately differentiated SCC. She later developed a recurrence and underwent orbital exenteration. Case 3 was a moderately differentiated SCC treated with wide margin excision alone and had no recurrence during 5-year follow up. Careful surveillance of caruncle SCC is required, given the observed propensity for local recurrence and/or regional metastasis.

Outcomes of posterior-approach 'levatorpexy' in congenital ptosis repair.

PURPOSE: We describe a minimally invasive technique and report our experience of posterior approach levator plication ('levatorpexy') for congenital ptosis. STUDY DESIGN: Retrospective review. PARTICIPANTS: Consecutive series of 16 patients. MATERIALS AND METHODS: Posterior approach levatorpexy was performed for congenital ptosis under general anaesthesia. This surgical procedure involves exposing the posterior surface of the levator muscle through a transconjunctival approach. The levator muscle is advanced and plicated using a suture passed through its posterior surface, partial-thickness, to tarsal plate and tied on the skin. No tissue (conjunctiva, Muller's muscle, levator) are excised during this procedure. MAIN OUTCOME MEASURES: Data collected included margin reflex distance (MRD1), symmetry of eyelid height, contour and complications. Surgery was considered successful if the following three criteria were simultaneously met: A postoperative MRD1 of ≥2 mm and ≤4.5 mm, inter-eyelid height asymmetry of ≤1 mm, and satisfactory eyelid contour. RESULTS: Mean age was 9.1 years (range 3-26 years). Mean postoperative follow-up was 8.1 months (4-24 months). Preoperative phenylephrine test was positive in 81% of patients. Mean levator function was 11 mm (5-15 mm). Mean preoperative MRD1 was 1.5 mm and the mean postoperative MRD1 was 2.6 mm. Fourteen patients (87%) achieved the desired eyelid height and fulfilled our criteria set for success. CONCLUSIONS: Posterior approach levatorpexy appears to be a safe and effective procedure for correction of congenital ptosis particularly with moderate or better levator function.

Skin contracture following upper eyelid orbiculectomy: is primary skin excision advisable?

AIM: To report the incidence and consequences of skin contracture following upper eyelid orbiculectomy. METHODS: A retrospective case note review identified 8 consecutive patients undergoing skin sparing upper eyelid limited orbiculectomy for essential blepharospasm associated with apraxia of eyelid opening. Clinical data collected from this review included age, gender, type of surgery performed, surgical complications, the need for additional surgeries, botulinum toxin treatment after surgery, dry eyes and blepharospasm functional disability assessment score. Pre and post operative photographs (at 1 year follow up) were used to assess the change in upper eyelid skin. RESULTS: The mean preoperative functional disability score was 72 ± 18 and improved to 25 ± 18 postoperatively at last follow-up. One patient needed botulinum toxin injections postoperatively. Intraoperative complications included bleeding in one case and haematoma in another case. Although we did not excise excess skin in any of our cases, we noted a reduction in upper eyelid skin excess in all cases, postoperatively. Restrictive lagophthalmos was noted in 3 cases (who had orbiculectomy alone) which required skin grafting and/or levator recession. CONCLUSION: Upper eyelid limited orbiculectomy with meticulous attention to pre-tarsal and pre-septal orbicularis only is effective in improving apraxia of eyelid opening and blepharospasm. Although we did not excise excess skin in any of our cases, we noted skin contracture postoperatively in three cases severe enough to require skin grafting or scar release. In our experience, skin contracture and orbital septal scarring appears to be relatively common following upper eyelid orbiculectomy, particularly if pre-tarsal and septal orbicularis is meticulously excised. In such a scenario we suggest avoiding concurrent excision of any dermatochalasis.

Eyelid lymphedema following neck dissection and radiotherapy.

Chronic eyelid lymphedema following neck dissection and radiotherapy is rare with 1 report in the literature. The authors report 3 cases and review the literature. Two cases had bilateral neck dissection and developed bilateral eyelid lymphedema and 1 case had unilateral neck dissection (left side) and developed ipsilateral lymphedema. Two patients underwent surgical debulking of lymphedema with significant improvement in symptoms. One patient declined surgical intervention, and the lymphedema remained unchanged. Chronic eyelid lymphedema following neck dissection and radiotherapy occurs where predominant lymphatic drainage to the submandibular and deep cervical lymph node basin is removed. Lymphedema tends to persist when it occurs and in selected cases appearance can be effectively improved by debulking and excision of festoons.

Excision of periocular basal cell carcinoma guided by en face frozen section.

We describe a technique for monitoring excision margins in periocular basal cell carcinoma (BCC) using en face frozen sections and report outcomes. We excised periocular BCC with 3mm margins. An outer 1mm sliver of the perimeter of the specimen was mapped and sent for evaluation by en face frozen section. The central tumour mass was processed using routine paraffin sections. A further 3mm level was excised at the site of any affected margin and the outer 1mm sliver was again evaluated by frozen section. We identified 78 patients from November 2003 to July 2009; 67 had primary tumours and 11 (14%) had recurrent BCC of which 52 (66%) were located on the lower eyelid. Growth patterns were nodular (n=34, 43%), infiltrative (n=25, 32%), micronodular (n=12, 16%), and superficial (n=7, 9%). A third of BCC with a clinically nodular appearance showed additional histological patterns including infiltrative and micronodular growth patterns. Of 30 clinically nodular carcinomas, 29 were excised completely with one level, and one required 2 levels of excision for clearance after evaluation by frozen section. Mean follow-up was 23 months (range 2-60). There was one recurrence (1%). Excision of margins guided by en face frozen section is justified by the low rates of recurrence, and it can easily be taught or imported into hospital practice. Clinically nodular BCC have subclinical extensions that can be missed on bread loaf sectioning, which makes the sampling of margins a standard for periocular BCC.

Lacrimal scintigraphy: "interpretation more art than science".

Lacrimal scintigraphy (LS) or dacryoscintigraphy can demonstrate abnormalities in 80%-95% of patients with symptoms of epiphora and a patent lacrimal system on syringing and up to 40% asymptomatic individuals. Precise localization of the site of delay may not always be possible due to lack of anatomic detail on LS. LS is considered useful in patients with epiphora with delayed tear clearance and patency to syringing and suspected to have either nasolacrimal duct (NLD) stenosis or lacrimal pump failure. It remains unclear, however, as to whether LS can reliably distinguish between the two. The literature reports considerable variation in the technique, normative data, analysis, and interpretation of LS. Qualitative or visual analysis is simpler to perform and to our knowledge used more frequently in comparison to quantitative analysis. There is little extra information to be gained from LS in cases with complete NLD obstruction or severe NLD stenosis on syringing.

Discrepancy between fluorescence in situ hybridization and multiplex ligation-dependent probe amplification in orbital recurrence of uveal melanoma 26 years after enucleation.

Cytogenetic analysis has transformed the management of uveal melanoma in recent years and allows categorization of such tumors into low-grade tumors with a favorable prognosis and high-grade tumors that metastasize with a fatal outcome. The authors report the case of a 73-year-old man who presented with recurrent melanoma in his left socket, 26 years after enucleation for uveal melanoma. Chromosomal analysis by multiplex ligation-dependent probe amplification revealed partial loss of chromosome 3 and gains in chromosomes 6 and 8, which were missed with fluorescence in situ hybridization. The patient developed multiple liver metastases 14 months after orbital exenteration and died 8 months later. To the best of authors' knowledge, this is the first report of late recurrence of uveal melanoma after enucleation, in which multiplex ligation-dependent probe amplification chromosomal analysis has been used. The case also highlights the limitations of fluorescence in situ hybridization and the benefits of multiplex ligation-dependent probe amplification, which is more reliable at predicting survival.

Dacryocystorhinostomy precipitating keratoconjunctivitis sicca in aplasia of lacrimal and major salivary glands (ALSG).

We report a 16-month-old girl referred for bilateral epiphora and sticky eyes since birth. Examination revealed a refluxible left lacrimal sac mucocele, agenesis of the left lower punctum, and agenesis of both puncta on the right side. Complete bony obstruction was noted on probing of the left nasolacrimal duct. At 4 years of age, she underwent left external dacryocystorhinostomy (DCR) with silicone intubation because of chronic dacryocystitis. Her epiphora and stickiness improved significantly in the first postoperative year, but she subsequently developed dryness of the left eye, dry mouth, and dental caries. CT and MRI scans revealed the absence of the lacrimal and salivary glands. The clinical signs and symptoms improved with plugging the left upper punctum and topical lubricants. Aplasia of the lacrimal and salivary glands may present with symptoms of congenital lacrimal obstruction, and failure to make an early diagnosis will result in inappropriate lacrimal surgery and dry eye.