The Effect of Supine Versus Upright Positioning on Eyelid Height in the Nonsurgical Patient.

PURPOSE: To directly compare margin-reflex distance 1, margin-reflex distance 2, and palpebral fissure in the upright versus supine positions in nonsurgical patients. METHODS: A total of 43 patients (31 female, 12 male, and age range 26-96) were enrolled. Photos were taken in the clinic in the upright and supine position with a ruler placed vertically in the same plane as the eyelid, and the above computer-analyzed measurements were obtained. RESULTS: Among the 86 eyes observed, the average upright margin-reflex distance 1 was 2.97 mm (95% confidence interval [CI], 2.70-3.24), while the average supine margin-reflex distance 1 was 2.38 mm (95% CI, 2.13-2.63). These differences were statistically significant (p < 0.001). Similarly, statistically significant differences were seen with margin-reflex distance 2 (p < 0.001), where upright measurements averaged 5.57 mm (95% CI, 5.33-5.81), and supine measurements averaged 5.01 mm (95% CI, 4.73-5.28). Finally, palpebral fissure showed similar significance (p < 0.001). Upright measurements averaged 8.54 mm (95% CI, 8.19-8.90), while supine measurements averaged 7.38 mm (95% CI, 7.00-7.76). CONCLUSIONS: Supine positioning provides a decrease in margin-reflex distance 1, margin-reflex distance 2, and palpebral fissure when compared with upright positioning in nonsurgical patients. This contradicts a previous study on intraoperative patients when lidocaine with epinephrine was used. This study helps us better understand the normal physiologic response to position changes with regard to eyelid height in the nonsurgical patient. As such, this study may function as a control for future studies comparing anesthetic/surgical parameter effects on intra- and post-operative eyelid heights.

External levator resection for involutional ptosis: is intraoperative suture adjustment necessary for good outcomes?

Purpose: To directly compare an algorithmic external levator resection technique with the choice of intraoperative adjustment to the same technique without intraoperative adjustments. Methods: A sequential controlled prospective comparative cohort study. Two cohorts were compared: a historical control adjustment, and an experimental non-adjustment group. Fourteen patients, 25 eyelids, were in the historical cohort; and 15 patients, 23 eyelids, were in the non-adjustment cohort. Primary acquired ptosis patients who met inclusion criteria were considered. All patients underwent a standardized external levator resection technique. Intraoperative adjustments were performed only in the historical cohort. Age, follow-up time, surgical time, and marginal reflex distance 1 (MRD1) were collected. Statistical analysis was performed using the Mann-Whitney U test. Statistical significance was p < 0.05. Primary and secondary outcome measures were postoperative MRD1 minus goal MRD1, and surgical time, respectively. Results: Twenty-five historical eyelids were compared with 23 non-adjusted eyelids. The average patient age was 68.4 years (range 19-84) and 59.3 years (range 24-83) for the adjusted and non-adjusted groups. Six-month postoperative (postoperative minus goal) MRD1 was -0.1 mm (95% CI -0.3-0.1) and -0.2 mm (95% -0.5-0.0) (p = 0.33), and surgical time was 13.8 min (95% CI 12.6-15.1) and 9.5 min (95% CI 9.0-10.1) (p < 0.001) for the adjusted and non-adjusted cohort, respectively. Conclusions: The external levator resection, utilizing a standardized algorithm approach, is an efficacious technique for involutional eyelid ptosis. With sound technique, this method can be performed without the need for intraoperative adjustment, thereby saving operative time and achieving similar results.

The Translaminar Pressure Gradient: Papilledema After Trabeculectomy Treated With Optic Nerve Sheath Fenestration.

INTRODUCTION: Trans-lamina cribrosa pressure has been postulated to be a contributor in the development of a glaucomatous optic nerve versus optic nerve edema, depending on the pressure gradient. Uncertainty remains in the therapeutic outcome of adjusting this gradient. CASE REPORT: We discuss a unique case of idiopathic intracranial hypertension presenting as asymmetric optic disc edema following trabeculectomy. It was treated via optic nerve fenestration due to the patient remaining symptomatic on maximum tolerated acetazolamide. Intraocular pressure stabilized into target range and the optic nerve edema resolved. CONCLUSIONS: Rarely, intraocular pressure reduction can unmask elevated intracranial pressure, leading to optic nerve edema. Optic nerve sheath fenestration is a practical therapeutic modality to consider when treating this occurrence.

Primary Extracranial Meningioma of the Lacrimal Sac Fossa.

Primary extracranial meningioma is a rare tumor, unlike its common intracranial counterpart. Infrequently found in the head and neck region, it can cause local or neurologic symptoms depending on its location and interaction with cranial nerves. While uncommon, it is an important diagnosis to have on the differential of periorbital lesions as surgical removal and prognosis are generally good. The authors present the first report of a patient with primary extracranial meningioma originating in the lacrimal sac fossa.

Ocular/adnexal lymphoma: dissimilar to systemic lymphoma.

Ocular adnexal lymphoma and intraocular lymphoma, whether occurring simultaneously or sequentially, are often similar to associated systemic lymphoma. We describe 4 cases of ocular adnexal lymphoma or intraocular lymphoma with a dissimilar systemic lymphoma. Two of the cases represent Richter transformation of chronic lymphocytic leukemia/small-cell lymphoma into diffuse large B-cell lymphoma. In the third patient, conjunctival extranodal marginal zone lymphoma developed following treatment for Hodgkin lymphoma. The fourth patient had a remote history of systemic diffuse large B-cell lymphoma with a subsequent diagnosis of orbital extranodal marginal zone lymphoma. Clinical-pathological correlation is reported for all cases in addition to pertinent review of the literature.

Blepharoplasty Effect on a Described Algorithmic Approach to External Ptosis Repair: Is It Time for Unbundling?

PURPOSE: To investigate the effects of performing a previously described algorithmic levator resection for involutional ptosis with a blepharoplasty instead of through a small incision. METHODS: Eyelids with involutional ptosis and normal levator function were included in the study. An upper blepharoplasty was performed first. An external levator resection was then performed based on a described technique involving 2 mm resection of aponeurosis for 1 mm of desired lift, consistent tension on the aponeurosis between surgical cases, and standardized suture placement. RESULTS: Forty-one eyelids of 25 patients were included. Mean postoperative margin to reflex distance 1 (MRD1) was 2.98 mm, which was significantly higher than preoperative MRD1 (0.67 mm), but lower than the predetermined goal MRD1 (3.35 mm). Eight eyelids did not meet primary outcome of MRD1 within 1 mm of goal MRD1, with 5 undercorrections. There was no difference between the postoperative MRD1 compared with the same ptosis technique performed through a small incision only, but there were more intraoperative suture adjustments and fewer eyelids meeting the primary outcome when a concurrent blepharoplasty was performed. CONCLUSIONS: The addition of blepharoplasty with a previously described algorithmic approach external levator resection has an 80% success rate in achieving the primary outcome. When compared with a small-incision ptosis repair, concurrent blepharoplasty results in a less predictable outcome and an increased need for intraoperative adjustment. Performing an algorithmic technique for external levator resection with a blepharoplasty has less predictable outcomes, which raises the question of separating the procedures to improve patient care.

Role of Algorithm-Based Levator Aponeurectomy in Small-Incision External Ptosis Surgery for Involutional Ptosis.

IMPORTANCE: External surgical treatment of involutional ptosis with normal levator function is challenging owing to lack of an established algorithm. Developing an algorithm-based technique could improve postoperative results while limiting intraoperative inefficiencies. OBJECTIVE: To investigate the postoperative success of an algorithmic external levator aponeurosis resection technique for aponeurotic ptosis with good levator function. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study included patients with involutional ptosis and normal levator function who were treated from July 1, 2015, through November 30, 2016, at a private ophthalmic plastic surgery clinic. INTERVENTIONS: The technique involved a small incision in the eyelid crease, with dissection through the orbital septum to expose the levator aponeurosis. The leading edge of the aponeurosis was then clamped to a medical-grade spring scale to standardize the stress on the eyelid between patients. Two millimeters of aponeurosis were resected for every 1 mm of desired ptosis correction. Two sutures were then placed to connect the aponeurosis to the tarsus at predetermined locations. MAIN OUTCOMES AND MEASURES: Preoperative predicted (goal) vs actual margin reflex distance-1 (MRD1). RESULTS: Twenty-six eyelids of 15 patients (6 men and 9 women; mean [SD] age, 65 years [range, 17-84 years]) met inclusion criteria. The mean follow-up was 189 days (range, 63-343 days). The mean preoperative MRD1 was 0.44 mm (range, -0.5 to 2 mm; 95% CI, 0.18-0.70 mm) compared with the final mean MRD1 of 3.2 mm (range, 2.5-4.0 mm; 95% CI, 3.1-3.4 mm; P < .001). The mean predicted goal MRD1 was 3.4 mm (range, 2.5-4.0 mm; 95% CI, 3.2-3.5 mm). The final MRD1 of all eyelids was within 1 mm of the goal MRD1. The mean surgical time per eyelid was 14.6 minutes (range, 10.5-34.0 minutes). Twelve eyelids (46%) did not have intraoperative suture adjustments. CONCLUSIONS AND RELEVANCE: In correcting aponeurotic ptosis, a small-incision levator aponeurectomy incorporating an algorithm and consistent stress on the aponeurosis during resection achieves the goal MRD1 efficiently. The algorithm closely estimates the desired height intraoperatively such that only small intraoperative suture height revisions, if any, are needed. No intraoperative adjustments were made in 12 eyelids, necessitating future studies to determine whether any adjustments are needed. LEVEL OF EVIDENCE: 3.

Biomechanics of the Levator Aponeurosis.

PURPOSE: To investigate biomechanical properties of the levator aponeurosis. METHODS: Patients undergoing external levator resection for primary or revision correction of acquired ptosis were analyzed as primary and revision groups. Immediately postoperatively, the resected segments of the levator aponeurosis were stressed by adding sequential masses to the tissue. Specimen length was recorded at each stress level. Stress-strain diagrams were used to summarize how the tissue elongated in response to the external forces, because these diagrams correct for differences in specimen size. Representative specimens were analyzed histologically. RESULTS: Twenty-two specimens from 14 patients in the primary group and 10 specimens from 7 patients in the revision group met inclusion criteria. In the primary group, the mean age was 66 years; 8 patients were women. In the revision group, the mean age was 69 years; 6 patients were women. Levator aponeurosis specimens in both the primary and revision group demonstrated proportional increases in length with increasing stress, demonstrating that the levator aponeurosis is extensile. Given the same amount of stress, the levator aponeurosis from primary specimens elongated more than revision specimens. Histologically, revision specimens exhibited increased collagen and haphazard, tangled elastin fibers. CONCLUSIONS: The levator aponeurosis obtained during surgical correction of acquired ptosis elongates in response to nominal external forces. This biomechanical property is important because the length of the aponeurosis may vary intraoperatively if variable forces are applied to the eyelid. This property might be related to connective tissue architecture and, specifically, fibrosis. Surgeons performing levator aponeurosis resection should be mindful to maintain a consistent amount of force on the levator aponeurosis when performing the resection to maximize intercase consistency.

Clinical-Radiological Correlation of Retained Silicone Sponge Presenting as Orbital Inflammation.

A 32-year-old female who underwent scleral buckle removal presented 5 weeks postoperatively with a red, fluctuant subconjunctival mass. CT scan identified an irregularly bordered, hypoattenuated lesion next to the globe with the density of air. Ophthalmic plastic and reconstructive surgeons were consulted to evaluate orbital cellulitis with intraorbital gas, at which point it was deemed that the hypoattenuated mass was likely a retained sponge element based on its radiological features. Additional surgical exploration identified the retained silicone sponge. This clinical photographic-radiological correlation of retained silicone sponges presenting as orbital inflammation reminds surgeons to meticulously explant buckle material.

Retrospective review of eyelash number in patients who have undergone full-thickness eyelid resection.

PURPOSE: The purpose of this study was to determine whether a localized full-thickness eyelid excision results in a proportional decrease in the total number of eyelashes or whether a full complement of visible lashes persists, thus suggesting a compensatory increase in the anagen/telogen ratio among the remaining follicles. METHODS: A retrospective chart review was performed on 38 patients who underwent full-thickness eyelid resections repaired with primary eyelid closure for either benign or malignant eyelid lesions. Demographic and surgical data were collected, postoperative eyelid photographs were reviewed, and eyelashes were counted. RESULTS: There were 10 upper eyelids and 28 lower eyelids in 10 men and 28 women, with an average age of 57.9 years (range, 14-86 years). The lesion pathology was benign in 21 cases (55%) and malignant in 17 cases (45%). The full-thickness defect involved <25% of the eyelid in 16 cases (42%) and >25% of the eyelid in 22 cases (58%). The follow-up period ranged from 50 to 319 days, with an average of 94 days. In contralateral controls, upper eyelids had an average of 72.1 lashes and lower eyelids had an average of 38.2 lashes, and there was no statistical significance between men and women. In lower lids that underwent <25% resection, control lids had an average of 37.3 lashes and operative lids had 37.1 lashes. In lower lids that underwent >25% resection, control lids had an average of 38.7 lashes and operative lids had 34.2 lashes. This represents an 11.6% decrease and was statistically significant. In upper eyelids that underwent <25% resection and >25% resection, control eyelids had an average of 74.9 lashes and 69.3 lashes and operative eyelids had 77.6 lashes and 69.1 lashes, respectively. Finally, lash count was compared by benign versus malignant pathologic diagnosis. In upper eyelids with benign lesions and malignant lesions, control eyelids had an average of 73.8 lashes and 65.3 lashes and operative eyelids had 74.6 lashes and 68.3 lashes, respectively. In lower eyelids with benign pathology and malignant lesions, control eyelids had an average of 34.5 lashes and 41.4 lashes and operative eyelids had 33.8 lashes and 36.8 lashes. This represents an 11.1% decrease and was statistically significant. CONCLUSIONS: Full-thickness excision of eyelid margin tissue including lashes does not usually affect postoperative lash numbers. Because the total number of follicles is reduced, the percentage of lashes in the anagen versus the resting or telogen phase apparently increases compared with the preoperative state. This eyelash study contributes to the growing body of literature on the poorly understood topic of hair follicle cycle regulation.

Subperiosteal orbital hematoma after balloon sinus dilation.

A retrospective case report of an orbital hematoma resulting from balloon sinus dilation during functional endoscopic sinus surgery is presented. The authors propose that this event may be because of shearing of venules that drain in the superior periorbital channels related to microfractures caused by the balloon dilation. To the authors' knowledge, this is the first report of orbital hematoma in the setting of balloon sinus dilation.