Lateral Canthal Position Following Lateral Orbitotomy and the Influence of Ocular Proptosis.

PURPOSE: Anecdotal evidence suggests that detachment of the lateral canthal tendon during lateral orbitotomy results in shortening of the horizontal palpebral aperture (HPA) and rounding of the lateral canthal angle (LCA). This study investigated the change in HPA and LCA following lateral orbitotomy and the effect of proptosis on the HPA. METHODS: Retrospective, single surgeon, review of all cases undergoing lateral orbitotomy, comprising of a canthotomy and cantholysis and reconstruction of the lateral canthus using a single suture. The HPA and lateral canthal height (LCH) were measured on pre- and postoperative photographs using ImageJ software. Changes in the LCA and degree of proptosis were also investigated. Exclusion criteria included previous eyelid surgery, acute trauma, and less than 6 months' follow up. RESULTS: There were 41 cases of lateral orbitotomy in 27 patients, 67% female, average age 51 years. Twenty patients had thyroid eye disease of which 14 underwent bilateral surgery; the other 7 patients had a variety of orbital pathologies. Thirteen patients underwent unilateral orbitotomy with the contralateral eye serving as a control. Average follow up was 23 months. Overall, the HPA and proptosis were reduced by 0.6 mm (p = 0.143) and 3.4 mm (p < 0.001), respectively. A 0.2-mm reduction in HPA was observed for every 1-mm reduction in proptosis. A difference in post-orbitotomy HPA was observed between cases and their matched controls (p = 0.016). No rounding of the LCA or significant change in LCH was observed following lateral orbitotomy. CONCLUSIONS: The described technique of lateral orbitotomy and simple reconstruction do not appear to cause lateral canthal drift or rounding. There was no significant change in HPA or LCH. The degree of change of proptosis does appear to influence the change of HPA.

The Quantitated Internal Suture Browpexy: Comparison of Two Brow-Lifting Techniques in Patients Undergoing Upper Blepharoplasty.

PURPOSE: To describe and evaluate 1) the quantitated internal suture browpexy (ISB), which combines the advantages of a browpexy and "brassiere suture," 2) the endoscopic Endotine browplasty, and 3) to compare these two techniques in patients undergoing simultaneous upper blepharoplasty. METHODS: Retrospective review of patients undergoing bilateral upper blepharoplasty alone, bilateral ISB with upper blepharoplasty, and bilateral Endotine (MicroAire, Charlottesville, VA, U.S.A.) browplasty with upper blepharoplasty by one surgeon was performed. ImageJ 1.47v software (Wayne Rasband, National Institutes of Health, Bethesda, MD, U.S.A.) and standardized photographs were used to measure pre- and postoperative brow position at three positions (central, medial, lateral). Statistical analysis was performed using Sigmaplot version 12.5 for Windows (Systat Software, Inc., San Jose, CA, U.S.A.). RESULTS: Thirty-three patients undergoing ISB with blepharoplasty, 33 undergoing Endotine browplasty with blepharoplasty, and 30 patients undergoing blepharoplasty alone were included. The 3 groups were matched for age and gender. Patients undergoing upper blepharoplasty alone showed statistically significant brow descent at all three brow positions (mean: -1.7 mm [p ≤ 0.04]). The quantitated ISB prevented brow descent but provided minimal brow elevation (mean lateral elevation: right eye (OD) +1.3 mm [p = 0.03]; OS +0.9 mm [p = 0.08]). Endotine browplasty with upper blepharoplasty provided significant brow elevation at all brow positions, particularly laterally (OD +4.0 mm [p < 0.001]; OS +3.5 mm [p < 0.001]). There were no complications. CONCLUSIONS: Upper blepharoplasty alone is associated with brow descent; performing ISB simultaneously effectively prevents this descent. Endotine browplasty with upper blepharoplasty achieves significant brow elevation. Quantitation of the browpexy allows reproducible placement of the suture thereby producing consistent and symmetrical results.

Anatomical landmarks of the lateral nasal wall: implications for endonasal lacrimal surgery.

PURPOSE OF REVIEW: An accurate understanding of the anatomy of the lateral nasal wall is key to achieving complete exposure of the lacrimal sac during endonasal dacryocystorhinostomy (EnDCR) and the avoidance of complications such as basal skull fracture and orbital fat prolapse. This review provides a comprehensive summary of the clinical and cadaveric anatomical studies of the lateral nasal wall to date and their application to endonasal lacrimal surgery. RECENT FINDINGS: The maxillary line and the axilla of the middle turbinate are the major landmarks commonly utilized by lacrimal surgeons to localize the lacrimal sac. Numerous clinical, cadaveric and radiologic studies have attempted to define the relationship of these and other important anatomical landmarks, closely related to the lacrimal sac and routinely encountered during endonasal surgery, such as the frontal process of the maxilla, the agger nasi air cell and the uncinate process. A greater understanding of the relevant endonasal anatomy over time has led to safer and more effective surgical techniques. SUMMARY: Greater insights into the precise anatomical relationship of the lacrimal sac to other structures on the lateral nasal wall has enabled lacrimal surgeons to perform EnDCR surgery in a more accurate, efficient and well tolerated manner, matching its success to that of the external approach.

Chronic anophthalmic socket pain treated by implant removal and dermis fat graft.

AIMS: To report the outcome of orbital implant removal and dermis fat graft (DFG) implantation in patients with chronic anophthalmic socket pain (ASP), in whom all detectable causes of pain had been ruled out and medical management had failed. METHODS: Retrospective, multicentre case series. A review of all cases undergoing orbital implant replacement with DFG between 2007 and 2013 was conducted at the University of Iowa Hospitals and Clinics (UIHC), USA, and St. Erik Eye Hospital, Sweden. Inclusion criteria included (1) chronic ASP >2 years and unresponsive to treatment, (2) absence of pathological or structural cause for pain established by socket examination and orbital imaging, and (3) minimum 12-month post-surgical follow-up. RESULTS: Six cases with chronic ASP were identified, four were post-enucleation and two were eviscerated at an average age of 45 years. The incidence of chronic ASP among enucleations at UIHC over a 6-year period was 0.7%. Indications for enucleation and evisceration included tumours and glaucoma. Intractable ASP had been present for an average of 11 years and persisted despite medical management. All patients were free of pain within 3 months of implant removal and DFG placement and remained pain free at an average 24 months following surgery. CONCLUSIONS: Orbital implant replacement with DFG was effective at relieving chronic ASP, and pain resolution was sustained in all cases. This surgical intervention may be a useful management option for patients in whom all detectable causes of chronic pain have been excluded and have failed medical pain management.

Adult-Onset Asthma Associated With Simultaneous Conjunctival, Eyelid, and Orbital Xanthogranulomatosis Responsive to Systemic Immunosuppression.

Adult xanthogranulomatous disease involving the ocular or orbital tissues is rare. The authors present a 63-year-old asthmatic woman with progressive left eyelid ptosis and fatigue in whom this diagnosis was clinically suspected on the basis of the characteristic waxy indurated yellow periocular and conjunctival lesions. These findings prompted an incisional biopsy which found evidence of Touton giant cells, necessitating a systemic evaluation which excluded the presence of hematological abnormalities or malignancy. The simultaneous occurrence of conjunctival, eyelid, and orbital xanthogranulomas has not been previously described in adult-onset asthma and periocular xanthogranuloma. The lesions were responsive to long-term systemic immunosuppression.

Orbital Varix Thrombosis and Review of Orbital Vascular Anomalies in Blue Rubber Bleb Nevus Syndrome.

A 57-year-old woman with cutaneous manifestations of (BRBNS) presented with acute left proptosis and venous congestion secondary to thrombosis within a superior ophthalmic vein varix. Multiple phleboliths were noted in the contralateral right orbit, and an incidental right middle cerebral artery aneurysm. Her symptoms spontaneously resolved within a few days. An English literature review found 7 reported cases of orbital vascular lesions in association with BRBNS from 1950 to 2012. All lesions showed contrast enhancement on CT or MRI: 4 had small orbital calcifications and 3 were distensible with raised venous pressure. The occurrence of a thrombosed orbital varix or cerebral artery aneurysm in BRBNS, to the best of the authors' knowledge, has not been previously reported. Although orbital vascular lesions in BRBNS have been described as hemangiomas, the biologic behavior and histology of most of the reported orbital lesions are most compatible with venous malformations.

Management of functional epiphora in patients with an anatomically patent dacryocystorhinostomy.

IMPORTANCE: Approximately 5% to 10% of patients continue to experience persistent epiphora following an anatomically successful dacryocystorhinostomy (DCR) for nasolacrimal duct obstruction or stenosis. OBJECTIVE: To investigate the management and success rate of so-called "functional failure" of DCR for nasolacrimal duct obstruction by experienced lacrimal surgeons. DESIGN, SETTING, AND PARTICIPANTS: Multicenter retrospective case series including 5 Australian and New Zealand centers. Participants included 61 patients (71% women [n = 46]; mean age, 66 years) with functional epiphora after 65 DCRs (69% transnasal) who were recruited over a mean of 7.6 years. Inclusion criteria included confirmed preoperative diagnosis of nasolacrimal duct obstruction or stenosis, age greater than 18 years, recurrent or persistent epiphora after DCR, an anatomically successful DCR, and follow-up longer than 6 months. Exclusion criteria included evidence of lacrimal hypersecretion, eyelid malposition, and punctal or canalicular abnormalities. MAIN OUTCOMES AND MEASURES: The number, type, timing, and success of all clinical interventions performed for the management of functional epiphora after DCR. RESULTS: Epiphora recurred a mean of 8.9 months after primary DCR; 89% of the cases (n = 58) had evidence of a patent ostium and 100% were patent on lacrimal irrigation. Intubation with a lacrimal stent was performed in 82% of the cases at the time of surgery, and all stents were removed a mean of 8 weeks postoperatively. Epiphora was reported immediately following DCR in 32% (n = 21) of the cases and within 6 weeks after removal of the stent in 31% (n = 20); late recurrence (>12 months after DCR) developed in 37% (n = 24) of the cases. In a total of 15% of the cases, participants declined any treatment following DCR. The remainder underwent a mean of 1.3 interventions (range, 1-3) during a mean of 23 to 41 months after primary DCR, following which 72% (n = 47) of the cases had a successful outcome; 12% (n = 8) failed to achieve improvement, and the patients declined further intervention. Thirty-nine interventions (60%) were intubation with a silicone stent with a 54% success rate. Almost half of those undergoing intubation elected to keep the stent permanently; 34% (n = 22) had an eyelid-tightening procedure with 50% success, and 15% (n = 10) required a Lester-Jones tube despite patent canaliculi, with a success rate of 90%. CONCLUSIONS AND RELEVANCE: Functional epiphora after DCR among patients with preoperative nasolacrimal duct obstruction or stenosis appears to be uncommon. Benefits can be achieved in most patients with intubation (transient or permanent) or eyelid tightening. More than one procedure is often required.

Upper eyelid retraction in the anophthalmic socket: review and survey of the Australian and New Zealand Society of Ophthalmic Plastic Surgeons (ANZSOPS).

PURPOSE: Unlike ptosis, upper eyelid retraction (ULR) is not a widely reported complication of the anophthalmic socket or post-enucleation socket syndrome (PESS). The clinical entity of post-enucleation ULR is investigated. METHODS: 1) Two cases of post-enucleation ULR presenting to a specialist oculoplastic center (South Australian Institute of Ophthalmology, Adelaide, Australia) are described, 2) Single forced choice survey of 22 members of the Australian and New Zealand Society of Ophthalmic Plastic Surgeons regarding their clinical experience of ULR in anophthalmia, and 3) English literature review. RESULTS: One case of ULR occurred less than 1 year and the other several decades following enucleation, both cases underwent eyelid surgery. Eighty-two percent of oculoplastic surgeons surveyed believe ULR is a rare and late (50%) complication of anophthalmia and 13.5% had never seen a case. Ninety-five percent indicated that ptosis is more common than retraction. A literature review supports the rarity of ULR in anophthalmia and a number of etiological factors are discussed. CONCLUSIONS: Upper eyelid retraction is a rare and often late complication of the anophthalmic socket. It occurs less commonly than ptosis as part of PESS, but increased recognition and reporting may improve the understanding of its true incidence and cause.

Reduced risk of compressive optic neuropathy using orbital radiotherapy in patients with active thyroid eye disease.

PURPOSE: To compare the risk of developing compressive optic neuropathy in patients with active thyroid eye disease (TED) treated with corticosteroids with or without orbital radiotherapy. DESIGN: Retrospective single-center case-control study. METHODS: The clinical charts of 351 patients with active TED who received corticosteroids with or without orbital radiotherapy between 1999 and 2010 were reviewed. Patients with compressive optic neuropathy at the time of presentation were excluded. Group 1 received corticosteroids only and Group 2 received corticosteroids as well as orbital radiotherapy. The primary outcome measure was the development of compressive optic neuropathy. Secondary outcome measures were changes in other parameters indicating the activity of TED, including soft tissue inflammation, diplopia, ocular motility restriction, and appearance. RESULTS: There were 144 cases in Group 1 and 105 in Group 2. Both groups were matched for age, sex, and stability of thyroid function. The 2 groups differed only in the modality of treatment for active TED. The main indication for treatment in both groups was soft tissue inflammation. Corticosteroids were initiated an average of 2.6 months following symptom onset in Group 1 and 2.5 months in Group 2. Group 2 received orbital radiotherapy on average 4.2 months following the initiation of corticosteroid therapy and 8% (9/105) were intolerant to corticosteroids. At an average of 3.2 years follow-up, compressive optic neuropathy had developed in 17% (25/144) of Group 1 and 0% of Group 2 (P < .0001), on average 5.5 months following the initiation of corticosteroid therapy. Although both groups experienced a significant reduction in periocular inflammation, the radiotherapy-treated group demonstrated a significantly greater improvement in ocular motility. CONCLUSION: The rate of compressive optic neuropathy was significantly lower and improvement in ocular motility greater in patients receiving orbital radiotherapy in addition to corticosteroids. Patients with active TED appear to have an effective and sustained response to orbital radiotherapy combined with corticosteroids that is protective against disease progression and the development of compressive optic neuropathy.

Clinical anatomy of the periocular region.

The aims of this article are twofold: (1) to provide the facial plastic surgeon with a comprehensive and up-to-date overview of periocular anatomy including the brow, midface, and temporal region and (2) to highlight important anatomical relationships that must be appreciated in order to achieve the best possible functional and aesthetic surgical outcomes.

An endoscopic endonasal approach to dacryocystectomy.

ABSTRACT A 78-year-old woman with dementia presented with functional visual loss secondary to bilateral chronic purulent dacryocystitis. A right external dacryocystorhinostomy (DCR) under local anaesthesia and sedation (LAS) was performed which failed after one month. Wound care was problematic as the patient removed all dressings and picked at the incision resulting in dehiscence and wound infection. She then underwent bilateral dacryocystectomy (DCT) under LAS and cauterisation of the common canaliculus via an endoscopic endonasal approach. Post-operatively her symptoms fully resolved. An endoscopic approach to lacrimal sac excision may be feasible in selected cases where a skin incision may not be desirable.

Traumatic sinolacrimocutaneous fistula managed with endonasal dacryocystorhinostomy and anterior ethmoidectomy.

A 31-year-old man with epiphora and mucous discharge from a traumatic lacrimal fistula underwent a computed tomographic dacryocystogram, revealing a fistula extending from the anterior ethmoid air cells through the lacrimal sac to the overlying skin with coexisting nasolacrimal duct obstruction. Endoscopic dacryocystorhinostomy enabled complete marsupialization of the lacrimal sac and agger nasi air cell, removing the tract between these structures. Simultaneous probing of the common canaliculus and fistula tract under direct visualization allowed the identification of the internal fistula origin in relation to the internal ostium on the lateral sac wall. The fistula was excised with a trephine over a guide wire via an external approach. Use of the endoscopic technique for excision of acquired lacrimal fistulas may be especially helpful in cases with coexisting nasolacrimal duct obstruction where the fistula extends to the sinus cavity or suspected foreign bodies.

A cadaveric study of the morphometric relationships and bony composition of the caucasian nasolacrimal fossa.

AIMS: To describe the morphometric relationships and bony composition of the nasolacrimal fossa in a Caucasian population with particular reference to the lacrimo-maxillary suture (LMS). METHODS: Forty-seven orbits from 24 formalin fixed cadavers were exenterated. Morphometric measurements were taken between anatomical landmarks forming the lacrimal fossa on the medial orbital wall. RESULTS: The mean recorded distance from the anterior lacrimal crest (ALC) to the posterior lacrimal crest (PLC) and the LMS were 8.8 mm (± 1.6) and 4.3 mm (± 1.1), respectively. In 25.5% of the orbits the LMS was at the mid-vertical line (MVL), defined as a line equidistant from the ALC and PLC. In 42.5% the LMS was located anterior to the MVL toward the ALC. In 66% of the orbits the LMS was at or within one standard deviation (SD) of the MVL. The LMS was >1 SD away from the MVL toward the ALC and PLC in 19% and 15% of orbits, respectively. CONCLUSIONS: In a quarter of the orbits in our Caucasian population the nasolacrimal fossa was formed equally by the maxillary and lacrimal bones. However, in nearly a third of the cases the LMS was located closer to the PLC, indicating predominance of the thicker maxillary bone. This may result in greater difficulty in initiating the surgical osteotomy when performing a dacryocystorhinostomy. These data contribute to our understanding of the variation in lacrimal fossa anatomy and encourage further studies in different racial groups.

Clinical outcomes after lens extraction for visually significant cataract in eyes with primary angle closure.

PURPOSE: To examine the clinical outcomes of cataract extraction in eyes with primary angle closure (PAC) and coexisting cataract. PATIENTS AND METHODS: Retrospective study of surgical outcomes after phacoemulsification and intraocular lens implantation in 55 eyes of 39 patients with PAC or occludable angles and visually symptomatic cataract. Approximately, 61.8% of eyes had received a peripheral iridotomy and 65% had evidence of glaucomatous optic neuropathy (GON). RESULTS: At 7.2 months after cataract extraction, a statistically significant reduction in intraocular pressure (IOP) was observed in all eyes with PAC (median 3 mm Hg, P=<0.0001). The reduction in IOP was significantly greater in eyes with a higher preoperative IOP (P=<0.0001). On average, one less glaucoma medication was in use postoperatively (P=0.01). Eyes with >180 degrees of peripheral anterior synechiae (PAS) preoperatively achieved a significantly greater reduction in IOP postoperatively compared with those with less PAS (7.5 vs. 4.4 mm Hg, P=0.03). The observed reduction in IOP in eyes with PAC and GON was significantly greater compared with those without GON (5.6 vs. 2.5 mm Hg, P=0.01). Visual acuity was significantly improved after cataract extraction by a mean of -0.23 LogMAR units (P=0.0001). CONCLUSIONS: Contrary to earlier expectations, the observed reduction in postoperative IOP in eyes with PAC was significantly greater in the presence of a higher preoperative IOP, a larger number of glaucoma medication, narrower iridotrabecular angle width, and greater extent of PAS formation and in eyes with evidence of GON. Lens extraction seems to have a beneficial effect on IOP control in PAC, and is especially efficacious in more advanced cases.

Morphometric and geometric anatomy of the caucasian orbital floor.

INTRODUCTION: To describe the morphometric and geometric relationships of the orbital floor in a Caucasian population. MATERIALS AND METHODS: Exenterations of 47 orbits from 24 formalin fixed cadavers were performed. Morphometric measurements were taken between anatomical landmarks located along the orbital floor and the orbital apex. The mean measurements were used to calculate geometric data. These results were analysed according to sex and side and compared to results from other ethnic populations. RESULTS: The average distances from the infraorbital foramen to the nasolacrimal fossa, inferior orbital fissure, optic canal and inferior orbital rim were 20.67 mm (± 2.42), 25.40 mm (±2.70), 43.23 mm (±3.35) and 8.95 mm (± 1.53), respectively. The average distances from the tip of the infraorbital groove to the tip of the inferior orbital fissure, lateral aspect of the inferomedial strut, optic canal and the intersection with the inferior orbital fissure were 14.08 mm (±2.41), 12.12 mm (±2.42), 35.02 mm (±3.17) and 20.05 mm (± 2.87), respectively. The distances from the tip of the inferior orbital fissure to the optic canal and the intersection with the inferior orbital groove were 29.56 mm (±2.73) and 13.37 mm (±2.76), respectively. DISCUSSION: Orbital surgeons should be aware of the morphometric relationships of the orbital floor due to the degree of variation that exists between different ethnic groups. Geometric data may be used to provide orbital surgeons with a navigational template that can be used to plan surgery and as a guide intraoperatively.