Lambda-double-fixation for medial epicanthoplasty in Blepharophimosis - Ptosis - Epicanthus Inversus Syndrome.

PURPOSE: This study aims to describe a novel approach to medial epicanthoplasty in patients with blepharophimosis-ptosis-epicanthus inversus syndrome (BPES) and evaluate the surgical outcome of this technique. METHODS: A retrospective, noncomparative, interventional case series involving 22 BPES patients who underwent medial epicanthoplasty using the Lambda-Double-Fixation technique (LDFT) performed by a single surgeon. Pre- and postoperative measurements of inner intercanthal distance (DIC) and horizontal palpebral fissure (HPFL) were recorded. Concurrent or staged ptosis surgery and lateral cantholysis, along with any complications, were documented. RESULTS: The mean age of the patients was 2.9 ± 2.2 years. Preoperatively, the mean DIC measured 34.0 ± 2.7 mm, significantly reducing to 23.7 ± 2.1 mm postoperatively (p < 0.001). A notable increase in mean HPFL was observed in both eyes postoperatively: right eye form 18.4 ± 2.4 mm to 23.7 ± 1.8 mm (p < 0.001) and left eye from 18.3 ± 2.4 mm to 23.8 ± 1.9 mm (p < 0.001). Postoperative scars were barely visible in all patients. CONCLUSION: LDFT is a simple and reproducible technique for medial epicanthoplasty in BPES. Our results affirm that LDFT induces a physiologically concave reshaping of the medial canthal region, optimizing access to the peritarsal zone and ensuring a secure fixation of the new canthus. These benefits lead to a reduction in ICD and an increase in HPFL, leading to a cosmetically appealing postoperative outcome.

Long-term stability of transconjunctival midface lift surgery for postblepharoplasty lower eyelid retraction.

Lower eyelid retraction occurring as a complication of lower eyelid blepharoplasty may give rise to symptoms of exposure keratitis as well as cosmetic considerations. This retrospective longitudinal study describes our clinical experience with 74 patients with bilateral lower eyelid retraction postblepharoplasty (148 eyes) undergoing a transconjunctival subperiosteal midface lift with the implantation of a hard palate spacer graft over the period 2002 to 2019. All patients had a forced-up traction test result of less than or equal to 2 mm, indicating a significant fibrosis of the middle lamellae. Margin reflex distances (MRD2) were examined at follow-up visits scheduled for 2 weeks, 1 month, and 1, 3, 6, 9, and 12 years. Mean follow-up duration was ± 102 months (range 6 to 144 months). In all patients, MRD2 varied up until 1-year postsurgery and stabilized thereafter. Last follow-up MRD2 values indicated retraction improvements of 1.4, 2.4, and 3.2 mm, respectively, for those with mild: MRD2 6.3 mm [5.5 - 6.6], moderate: 7.0 mm [6.7 - 7.8], and severe retraction: 8.5 mm [7.9 - 9]. This improvement was statistically significant in patients with severe baseline retraction (p = 0.04). This approach proved to be safe and functional, and cosmetic results were excellent and remained stable over time.

Periorbital Surgical Anatomy.

This article discusses the periocular anatomy region thoroughly because its knowledge in detail is of paramount importance for any surgeon dedicated to periocular surgery or any practitioner who dedicate their practice to aesthetic medicine. Mastering the anatomical details permits obtaining consistently good results with the minimal amount of complications possible.

Retroauricular myoperiosteal autograft for orbital implant exposure: 11 years of experience.

PURPOSE: To describe our experience with retroauricular myoperiosteal autograft for surgical coverage of exposed orbital implants. METHODS: This was a single-center, retrospective, observational cohort study, in which demographic and clinical data were compiled by reviewing the clinical records of anophthalmic patients with implant exposure treated with an autogenous retroauricular myoperiosteal graft at the Instituto de Microcirugía Ocular (IMO, Barcelona, Spain) over the period January 2007 to December 2017. Main outcome was the long-term coverage of implant after retroauricular myoperiosteal autograft; secondary outcome was the rate of post-surgical complications and management. RESULTS: Over the 11-year period, 27 eyes of 27 patients with implant exposure received a retroauricular myoperiosteal autograft. Mean participant age was 47.3 ± 17.9 years (range 9-78, median 45). Primary surgery was enucleation in 8 eyes (29.6%) and evisceration in 19 (70.4%). Implant materials were porous polyethylene in 17 (63%), hydroxyapatite in 3 (11.1%), and bioceramics in 4 (14.8%). In the remaining three patients (11.1%), the implant material and size were unknown. Implant exposure was diagnosed after a mean of 98 ± 111.7 months. Mean exposure diameter was 5.9 ± 3.1 mm. Mean follow-up duration after graft surgery was 37.5 ± 39 months. In four patients (14.8%), implant re-exposure was recorded and in two of these patients a re-graft using the same technique was performed. In the last follow-up session, all patients showed good implant coverage. CONCLUSIONS: Myoperiosteal graft could be a valid option for the long-term management of implant exposure irrespective of primary surgery, exposed area, and implant material.

Postoperative Care of the Facial Plastic Surgery Patient-Forehead and Blepharoplasty.

In any kind of surgery, postoperative care is essential for a good result, but especially when the matter at stake is facial plastic surgery. Despite having performed a perfect surgery, with the least amount of damage to the soft tissues and osteocartilaginous structures, minimal bleeding, and in terms of the surgical time, without adequate postoperative care our results can be affected considerably in the short and long run. Therefore, we must have very clear guidelines regarding postoperative care and the duties of our patients, which should be emphasized during the informed consent of the intervention. It is also essential to comment on the warning signs of postoperative complications, which need to be detected and treated in time to achieve the expected post-surgery results. Before being discharged from the hospital, the patient again receives the postoperative instructions, as well as receiving a paper copy to avoid any possible misunderstandings. In this article, we will detail the postoperative care and complications of brow lift and upper and lower blepharoplasty.

Frontalis Muscle Flap Versus Maximal Anterior Levator Resection as First Option for Patients With Severe Congenital Ptosis.

PURPOSE: To compare 2 surgical techniques (frontalis flap versus maximal anterior levator resection) as first surgical options for the treatment of congenital ptosis with poor levator function in patients younger than 2 years of age with a follow up of 10 years. METHODS: A retrospective study of 58 patients (71 eyelids) with severe ptosis and poor levator function who underwent frontalis muscle flap (FMF = 47) or maximal anterior levator resection (ALR = 24) for correction of their ptosis. Eyelid measurements were taken at baseline, 1, 5, and 10 years after surgery. The presence of complications, need for reoperations, and palpebral contour were evaluated. RESULTS: Most patients in both groups required only one surgical procedure with a stable average margin-reflex distance 1 over the 10-year follow-up period in both groups, with no statistically significant difference between the 2 techniques in achieving an adequate palpebral height after one single procedure. Eleven eyelids treated with FMF (23%) and 12 treated with ALR (50%) needed a reoperation, with a statistically significant difference between the 2 techniques. Five ALR patients (21%) and 6 FMF patients (13%) had alterations of eyelid contour. Pop-eyelid and eyelash ptosis were observed in 8% of patients operated with FMF. CONCLUSION: Good functional and aesthetic results were obtained with both surgical techniques. FMF required fewer reoperations compared with maximal ALR, offering a better long-term result without residual ptosis.

Inferior tarsal muscle-conjunctivectomy for reverse ptosis repair: A novel technique.

We describe a new technique for treatment of reverse ptosis in a patient with Horner Syndrome by means of excision of conjunctiva and inferior tarsal muscle. Surgery with eversion of inferior ptotic eyelid, placement of the Putterman ptosis clamp on the conjunctiva under inferior tarsus, suturing under incarcerated tissue and resection of 6mm of conjunctiva and inferior tarsal muscle was done under local anaesthesia in a short operating time with good cosmetic results without eyelid malposition or skin scar.

Lagophthalmos after facial palsy: current therapeutic options.

As the facial nerve carries sensory, motor and parasympathetic fibres involved in facial muscle innervation, facial palsy results in functional and cosmetic impairment. It can result from a wide variety of causes like infectious processes, trauma, neoplasms, autoimmune diseases, and most commonly Bell's palsy, but it can also be of iatrogenic origin. The main ophthalmic sequel is lagophthalmos. The increased surface exposure increases the risk of keratitis, corneal ulceration, and potentially loss of vision. Treatment options are wide; some are temporary, some permanent. In addition to gold standard and traditional therapies and procedures, new options are being proposed aiming to improve not only lagophthalmos but also the quality of life of these patients.

Direct frontalis flap with and without levator pulley for correction of severe ptosis with poor levator function in the same patient.

PURPOSE: To compare two techniques of frontalis muscle flap suspension in different eyelids of the same patient for correction of severe ptosis with minimal levator function. MATERIAL AND METHODS: A prospective study of four patients with severe bilateral ptosis and poor levator function, who underwent direct frontalis muscle flap on the right eyelid and frontalis muscle flap with levator pulley on the left eyelid was conducted. Eyelid studies measurements were taken at baseline, 2 months, one year and 5 years after surgery. The presence of complications, flap function and palpebral contour were evaluated. RESULTS: Despite the surgical technique performed, good results in terms of functionality, contour and aesthetics were observed. In the eyes that underwent frontalis muscle flap (FMF)-direct, there were 2 cases with moderate anteriorization of eyelid margin in extreme upgaze and all patients showed eyelash ptosis that persisted one year after surgery, but improved after 5 years. In the eyes that underwent FMF-pulley, no upgaze anteriorization of eyelid margin was observed and three patients had eyelash ptosis of lesser extent than the fellow eye, improving after 1 year follow-up. FMF-pulley showed more long-term stability in eyelid height, compared with FMF-direct. CONCLUSIONS: Frontalis muscle flap with a pulley in the levator aponeurosis prevents some complications caused by the excessive vertical component of the direct frontalis muscle flap, especially in deep-set eye patients, with better stability of the eyelid height and contour over time.

Factors predictive of radiation retinopathy post (125)Iodine brachytherapy for uveal melanoma.

OBJECTIVE: To report the host, tumour, and radiation-related predictive factors for developing radiation retinopathy post (125)Iodine brachytherapy for uveal melanoma. DESIGN: A retrospective clinical case series. PARTICIPANTS: Three hundred consecutive patients with uveal melanoma treated with (125)Iodine brachytherapy. METHODS: Electronic chart review of demographic, clinical, treatment, and follow-up data. Proliferative and (or) nonproliferative radiation retinopathy patients were included. Cumulative incidence rates were calculated using Kaplan-Meier estimates. Univariate and multivariate statistical regression analyses were performed to identify factors predictive of radiation retinopathy. RESULTS: The mean follow-up period was 48 months. Radiation retinopathy occurred in 107 patients (36%). Actuarial incidence of radiation retinopathy was 30% (CI 24%-36%) at 24 months post-treatment. In the multivariate model, the predictive factors were a younger age (hazard ratio [HR] 0.98, p < 0.03), diabetes (HR 2.17, p < 0.007), and hypertension (HR 2.17, p < 0.004). Tumour-related factors were proximity to optic disc (HR 0.95, p < 0.02) and proximity to foveola (HR 0.96, p < 0.02). Pretreatment tumour dimensions, other tumour characteristics, and total radiation dose did not demonstrate statistically significant risks for developing radiation retinopathy. CONCLUSIONS: Radiation retinopathy affects 30% of patients 2 years following (125)Iodine brachytherapy for uveal melanoma. The predictive factors for radiation retinopathy are a younger age, comorbidity with diabetes or hypertension, and proximity of the tumour margin to the optic disc or foveola. Identifying the predictive factors for developing radiation retinopathy can modify follow-up for patients at risk, which may permit earlier management of the developing radiation-induced ischemic retinal changes.

Permanent blindness after endoscopic sinus surgery.

Few cases of ophthalmic complications have been reported following sinus endoscopic surgery with current techniques. Irreversible damage to orbital structures was found in a 21-year-old patient referred to our department for evaluation after sinus endoscopic surgery and ipsilateral amaurosis.

Hyaluronic acid treatment for upper eyelid retraction after glaucoma filtering surgery.

A 51-year old female presented with upper lid retraction after glaucoma filtering surgery. After two surgical procedures to correct the retraction with only transient effect, she was finally treated with hyaluronic acid gel filling achieving good aesthetic and functional result.

Management of ciliary body melanoma with iodine-125 plaque brachytherapy.

OBJECTIVE: Because ciliary body melanoma often defies early diagnosis, and its treatment is controversial, we report our experience with the clinical presentation and management of ciliary body melanoma, treated with iodine-125 plaque brachytherapy. STUDY DESIGN: A retrospective noncomparative case series. PARTICIPANTS: Forty-two patients with ciliary body melanoma treated with iodine-125 brachytherapy. METHODS: Electronic chart review of ciliary body melanoma patients treated at Princess Margaret Hospital, University of Toronto, Toronto, Ont. Patients' demographics and clinical, management, and follow-up data, including brachytherapy-related complications, were reviewed. Outcome measures included rates of tumour control, eye preservation, systemic metastases, and brachytherapy-related complications. RESULTS: Median age at diagnosis was 58 years and median follow-up was 43 months. Ciliary body melanoma was asymptomatic in 55% of patients, whereas floaters or flashes were the main symptom in 33%. Median tumour thickness before brachytherapy was 5.2 mm and after brachytherapy was 3.3 mm. Radiation-induced cataract was the main complication in 55% of patients, radiation retinopathy in 24%, and neovascular glaucoma in 15%, which was controlled by topical treatment in half of the cases. Two patients developed metastases and 3 required secondary enucleation. CONCLUSIONS: Medium-sized ciliary body melanoma produced no or minimal symptoms on presentation in 88% of the patients. Iodine-125 plaque brachytherapy offered 98% tumour control at 43 months' follow-up. Radiation-related complications are generally manageable in most patients, which permits retention of the treated eye.

Anterior segment optical coherence tomography and ultrasound biomicroscopy in the imaging of anterior segment tumors.

PURPOSE: To evaluate the utility of anterior segment optical coherence tomography (OCT) in the imaging of anterior segment tumors and compare the images to ultrasound biomicroscopy (UBM). DESIGN: Prospective observational case series. METHODS: Eighteen eyes of 18 patients with anterior segment tumors were evaluated at Princess Margaret Hospital. The evaluation included clinical examination, clinical photography, anterior segment OCT, and UBM. Comparison of images obtained by both methods was done. RESULTS: Anterior segment OCT imaged small hypopigmented tumors with complete penetration. Cysts were incompletely imaged behind the iris pigment epithelium. Highly pigmented tumors, large tumors, and ciliary body tumors were incompletely penetrated. Even without complete penetration it was possible to differentiate cystic lesions from solid lesions. UBM penetrated all tumors completely. CONCLUSIONS: Anterior segment OCT can penetrate small hypopigmented tumors and supply some information on internal characteristics of other tumors. UBM is preferable for clinical anterior tumor assessment and follow-up because of its superior ability to penetrate large tumors, highly pigmented tumors, and ciliary body tumors.