Spontaneous regression of a conjunctival malignant melanoma.

INTRODUCTION: Conjunctival malignant melanoma (MM) is a rare malignancy and accounts for 2% of all ocular malignancies. We describe what we believe to be the first reported case of complete spontaneous regression of a conjunctival malignant melanoma. METHODS: A 75-year-old female presented with a large, pigmented lesion in her left lower fornix. Histopathology revealed a mixed cell type MM. The tumour regressed spontaneously. Now, 6 years after she first presented, she remains well and there is no sign of recurrence or metastasis. CONCLUSION: Spontaneous regression is not always synonymous with complete cure from the underlying disease but may represent a temporary regression due to host protective mechanisms. In our patient regression and cure were complete.

The incidence of ptosis following extracapsular and phacoemulsification surgery: comparison of two prospective studies and review of the literature.

We prospectively compared 120 patients who underwent either phacoemulsification or extracapsular cataract (ECCE) surgery to establish the incidence of postoperative ptosis between the two techniques. Of the 120 patients, 60 underwent ECCE (unpublished data 1989) and 60 had phacoemulsification. Data was collected prospectively on upper and lower margin reflex distance, upper lid skin crease and levator function, preoperatively and 6 weeks postoperatively. Photographs were taken pre and postoperatively and examined by a blinded observer. At 6 weeks, ptosis was present in 18% of ECCE patients compared with 0% in the phacoemulsification group. By changing from ECCE to phacoemulsification the incidence of postoperative ptosis has reduced. The possibility to induce postoperative ptosis remains, potential mechanisms are discussed.

Silicone sling allows adjustable ptosis correction in children and in adults at risk of corneal exposure.

BACKGROUND/AIM: Brow suspension is the procedure of choice for ptosis correction in patients with poor levator function. A subgroup of these patients, namely the ocular myopathies, is at risk of progressive muscle weakness and subsequent corneal exposure. We aim to demonstrate that silicone rods can be easily adjusted and therefore allows greater control of lid height in these patients. METHOD: A retrospective review of 42 consecutive silicone sling brow suspensions in 26 patients performed in Salisbury District Hospital between 1998 and 2007. The recurrence rate and ease of adjustment after silicone slings are compared with published results using monofilament prolene, polyfilament nylon, Mersilene mesh and expanded polytetrafluoroethylene. RESULTS: Children: 12 lids of 10 children had primary brow suspension using silicone slings. Median follow up was 42 months. One lid required adjustment 3.75 years after surgery. Adults: 30 lids of 16 patients had silicone sling brow suspensions. Median follow up was 22 months. Seven lids (19.4%) needed adjustment between 2 and 11 months after surgery (median 8 months). CONCLUSION: Our results were comparable to alternative materials in respect of recurrence and were superior in respect of both granuloma formation and infection. Silicone is superior to all listed materials in respect of ease of adjustment of the sling in cases where the ideal lid position was not achieved after primary surgery.

Results of levator excision followed by fascia lata brow suspension in patients with congenital and jaw-winking ptosis.

AIM: The purpose of the study was to examine the results of frontalis brow suspension after levator excision in patients with ptosis, and to determine whether satisfactory cosmetic results can be achieved with this procedure. METHODS: A retrospective case notes review of 13 patients (21 lids) undergoing levator weakening and frontalis brow suspension using autogenous fascia lata was performed. Seven patients (14 lids) were affected by the Marcus Gunn jaw-winking phenomenon. These had bilateral levator muscle excision. Five patients (5 lids) had unilateral congenital levator dystrophy (isolated congenital ptosis) with poor levator function. These had levator muscle excision on the normal side only. One patient (2 lids) had congenital aberrant regeneration of the third nerve. This patient had bilateral levator muscle excision. A successful result in terms of lid height was defined as a lid height within 1 mm of the desired height. RESULTS: During the first post-operative month, 11 out of 21 lids were undercorrected by more than 1 mm, whilst 10 achieved a satisfactory lid height. At subsequent follow-up visits, 18 lids were within 1 mm of the desired height and only 3 lids of 2 patients remained undercorrected by more than 1 mm and required further surgery. There were no overcorrections. CONCLUSIONS: Excision of the levator muscle followed by brow suspension ptosis correction can reliably produce satisfactory cosmetic results with good symmetry of lid movement and position. It is used selectively in the normal upper lid in congenital ptosis with poor levator function and in both upper lids in synkinetic ptosis.

Blepharophimosis-ptosis-epicanthus inversus syndrome: objective analysis of surgical outcome in patients from a single unit.

BACKGROUND: The aim was to objectively assess surgical outcome in blepharophimosis-ptosis-epicanthus inversus syndrome (BPES). METHOD: Retrospective review of 14 consecutive patients with BPES. Mustardé double z plasty (at about age 4) and autogenous fascia lata Crawford brow suspension (9-12 months later) were used in all. One consultant performed all operations. Patient photographs were scanned and magnified for analysis. Preoperative and postoperative intercanthal distance, vertical palpebral aperture and cosmetic outcome were measured. Values were converted into ratios. RESULTS: Bilateral (mildly asymmetrical) ptosis and symmetrical epicanthic folds were found in all preoperatively. Seventy-one per cent had severe folds. Preoperative intercanthal distance ratio range was 1.26-1.60 (non-BPES=1.0). Median reduction post surgery was 26% (P=0.001, Wilcoxon's signed ranks test). Patients with largest preoperative ratio displayed greatest correction (P=0.029). Mustardé technique completely abolished all epicanthic folds and unmasked prominent caruncles in all. Fifty per cent had mild scarring postoperatively in the medial canthal region. Median change in marginal reflex distance ratio (right)=22.2% (P=0.012), left=18.2% (P=0.008), Wilcoxon's signed ranks tests. Postoperatively all had formed eyelid creases with improved upper lid position symmetry. CONCLUSIONS: This is the first known study objectively assessing surgical outcome in BPES. Mustardé double z plasty and Crawford autogenous fascia lata brow suspension are an effective surgical combination in the treatment of this syndrome, with overall cosmetic benefit.

Towards an understanding of congenital ptosis.

This paper examines the developmental substrate for congenital ptosis with particular emphasis on the transcription factors that are thought to be involved. We summarize my research findings and present a review of the relevant literature.

Everting sutures in involutional entropion.

Involutional entropion is the commonest cause of entropion in the elderly population. Many surgical procedures have been described to correct it. The everting suture technique is simple and quick and can be undertaken in the clinic or even away from a medical setting. However, it has been regarded as a temporary cure, especially in the presence of horizontal lower lid laxity. We reviewed the results of everting sutures in 55 lids of 50 patients. The minimum follow-up was 18 months. 78% of patients had no recurrence of their entropion. Our results suggest that horizontal eyelid laxity may not be the only major factor in recurrent entropion following everting sutures. Dermatochalasis with orbital fat prolapse may also contribute.