The effect of cigarette smoke constituents on the expression of HLA-DR in orbital fibroblasts derived from patients with Graves ophthalmopathy.

PURPOSE: Numerous studies have established a strong association between smoking and Graves disease, but the underlying mechanism of Graves ophthalmopathy has not been elucidated. Recent studies of Graves ophthalmopathy have focused on the orbital fibroblast as an integral component in the pathogenesis of this disorder. This investigation focuses on the effect of cigarette smoke constituents, nicotine and tar, to alter the expression of human leukocyte antigen (HLA-DR) in cultured orbital fibroblasts from patients with Graves disease. METHODS: HLA-DR expression was quantified by scanning densitometry of whole cell lysates subjected to sodium dodecyl sulfate--polyacrylamide gel electrophoresis with immunoblotting and also by direct immunofluorescence. RESULTS: Cultured orbital fibroblasts, obtained from patients undergoing orbital decompression for severe Graves ophthalmopathy, failed to express HLA-DR as analyzed by both immunoblotting and direct immunofluorescence when treated with nicotine alone (25-300 ng/ml). The expression of HLA-DR increased three-fold when nicotine (25 ng/ml) in combination with interferon-gamma (500 U/ml) was added to the cultured orbital fibroblasts (p < 0.0001). Cultured orbital fibroblasts treated with tar alone (60-600 ng/ml) failed to exhibit HLA-DR expression as assessed by direct immunofluorescence and immunoblotting. A greater than two-fold increase in HLA-DR expression occurred when tar (600 ng/ml) combined with interferon-gamma (500 U/ml) was added to the cultured orbital fibroblasts (p < 0.0001). CONCLUSION: The results suggest a possible molecular mechanism for the more severe ophthalmopathy observed in Graves patients who smoke cigarettes. These findings could prove useful for possible medical interventions to decrease or even inhibit the interaction between cigarette constituents, cytokines, and orbital fibroblasts.

Fused eyelids in premature infants.

The charts of 161 extremely premature newborns were reviewed to characterize and report the incidence of infants born with fused eyelids, to determine when postbirth eyelid dysjunction occurs, and to address the survivability of these infants. Logistic regression analysis was used to examine the relationship between various ophthalmic outcomes and possible predictors of these outcomes. For babies born with eyelids fused, Cox regression analysis was used to assess time to eyelid opening. From the analysis of our data, we found that the critical time for eyelid opening is between 25.5 and 26.5 weeks gestational age. If fused at birth, the average time to eyelid opening after birth was 5.5 days. Fifty-two percent of babies born with their eyelids fused survived to be discharged from the hospital, compared to 83% of those born with eyelids open. Gestational age was found to be the most important predictor of the status of the eyelids at birth, of survival, and of the presence of retinopathy of prematurity (ROP). Other variables were found to be significant, but the significance was lost once the variable was adjusted for gestational age.

Ptosis repair in aesthetic blepharoplasty.

It is important to recognize ptosis of the upper eyelids in patients who are contemplating aesthetic blepharoplasty. When ptosis is present, it should be corrected simultaneously with the blepharoplasty.

The surgical relations of the levator palpebrae superioris muscle.

We conducted a cadaver study of the levator palpebrae superioris muscle to examine several areas of interest that have been reported in the current medical literature. A very strong intermuscular fascia exists between the levator and superior rectus muscles; it is unlikely that a superior rectus bridle suture could pull them apart during cataract surgery. The superior transverse ligament of Whitnall functions to check the posterior movement of the levator; it provides longitudinal support to the resected levator, but does not act as a vertical fulcrum.

Treatment of blepharospasm with high dose brow injection of botulinum toxin.

We treated 12 patients who had essential blepharospasm with brow and eyelid injections of botulinum toxin. The eyelid injections were kept constant while varying doses were used in the brow. The duration of the effect of the toxin was longer and the degree of improvement greater in those patients receiving more than 20 U in the brow than in those receiving less than 20 U. However, the degree of improvement in spasm intensity in those patients receiving greater than 20 U was similar. Ptosis occurred in seven patients. No systemic side effects were noted.

Infracanalicular full-thickness transverse blepharotomy for medical ectropion.

Procedures performed for total lid ectropion often fail to correct medial ectropion of the lower eyelid. Described herein is a technique of infracanalicular full-thickness transverse blepharotomy using rotational sutures for the treatment of medial ectropion. This procedure has been very useful for recurrent medial ectropion and also as a primary procedure. Concomitant canthal laxity should also be corrected.

Thermal orbital injuries from disposable cauteries.

Forty rabbits divided in six groups and three brands of hot wire cautery with temperature ranging from 190 degrees C to 1035 degrees C were used in this experiment. A surgical procedure resembling a cosmetic blepharoplasty was performed on a total of 60 lower eyelids of the rabbits. The remaining eyelids were either shams or normal controls. Cautery application to orbital fat was carefully controlled, i.e., 10 or 20 seconds in single or double applications. Gross observation and microscopic examination of the biopsied specimens taken at 3 hours, 2 days, and 2 weeks after the procedures were performed. Evidence of thermal injury to the lacrimal gland and extraocular muscle damage was found. Although no evidence of thermal injury to the optic nerve was found, it was conceivable that either by a direct transfer of heat or by an indirect inflammatory and compressive effect the health of the optic nerve might be threatened. It is strongly recommended that hot wire cautery be used with extreme caution when working with orbital tissues.

Lower-eyelid distractor.

An instrument is designed to measure the distractibility or horizontal laxity of the lower eyelid. It gives precise measurement of laxity independent of the examiner. It enables the surgeon to determine when and how much tightening of the lower eyelid is necessary to achieve the desired result in repair of entropion or ectropion and in cosmetic blepharoplasty.

A new technique of threading fascia lata strip.

By using disposable needles, we have developed a new technique of threading the fascia lata strip through the stripper or through the eye of a needle. The technique is simple, effective, and needs no special instruments.

Lower eyelid laxity and ocular symptoms.

We measured lower eyelid length in 288 healthy subjects to establish a norm and then in 95 patients with complaints of intractable photophobia, foreign-body sensation, chronic tearing, or chronic recurrent conjunctivitis. The difference in length was statistically significant (34.25 +/- 2.43 mm for healthy men vs 36.51 +/- 2.59 mm in male patients [P - .001] and 32.97 +/- 2.46 mm for healthy women vs 33.95 +/- 2.9 mm for female patients [P = .01]). There appears to be a cause-and-effect relationship between a flaccid lower eyelid and these ocular symptoms.

Traumatic enophthalmos.

Traumatic enophthalmos, either following orbital floor fracture or enucleation, is caused by decreased orbital volume. Volume replacement, both surgical and/or nonsurgical, provides a direct treatment. Surgical treatment can increase orbital volume by reducing the herniated orbital tissue and/or implanting alloplastic or autogenous material. When a seeing eye is present, implant surgery may compromise vision; volume replacement must be judicious. Alternative surgical management creates the illusion that little or no enophthalmos exists by enlarging the palpebral fissure or changing orbital contour.

The anatomy of eyebrow ptosis.

An anatomical study was performed to gain a better understanding of the pathogenesis of eyebrow ptosis. Through cadaver dissection, we sought to establish the anatomy of the normal eyebrow, to determine why the temporal part of the eyebrow becomes ptotic earlier than the medial portion, and to locate precisely the regional nerves and vessels to aid the eyebrow surgeon. a fat-pad exists beneath the eyebrow. Dense attachments on the underside of the eyebrow fat-pad secure the eyebrow to the supraorbital ridge. Because the supraorbital ridge extends only over the medial one half to two thirds of the orbit, the lateral part of the eyebrow lacks deep support and droops with the frontal skin and muscle relaxation seen in age. Vertical lateral orbicularis fibers are consistently seen in the cadaver. Because of their location, they may play a role in producing "laugh lines."

Blindness associated with cosmetic blepharoplasty.

Blindness associated with cosmetic blepharoplasty is a rare but real occurrence. Thorough ophthalmic and medical preoperative screening of patients and minimal gentle orbital surgery are necessary to decrease the incidence of this tragic complication. We must continue to try to return prolapsed orbital fat from the eyelids back into the orbit and maintain it there by reinforcing the orbital septum rather than by excising fat. Until such operative procedures are perfected, it is suggested that deep orbital injections be avoided and that patients be monitored carefully postoperatively. If an orbital hemorrhage should occur, immediate lateral canthotomy should be performed, followed by whatever other decompressing or ocular hypotensive measures may be necessary.