Public perception of laser-assisted blepharoplasty versus blade-assisted blepharoplasty.

OBJECTIVE: To evaluate perceptions of blade- versus laser-based blepharoplasty before and after being provided educational information. METHODS: This interventional pre-post study included 145 randomly selected participants (Maisonneuve-Rosemont Hospital, Montreal, Canada, August 2020) who were asked about their perceptions surrounding blepharoplasty. Participants then received information about the techniques before answering final questions. RESULTS: Participants perceived no difference in outcomes for blade (37%) versus laser (40%) blepharoplasty precounselling. This increased to laser blepharoplasty postintervention (56%, p < 0.001) despite being told that there was no difference in outcomes. The higher the level of education among participants, the more likely they were to correctly believe that both techniques had similar outcomes (p = 0.049). Most participants would choose laser blepharoplasty initially (64%), and this percentage increased postintervention (81%, p < 0.001). The preintervention perception of blade blepharoplasty recovery time (20.1 ± 32.6 days) was longer than that for laser blepharoplasty (13.5 ± 32.0 days, p = 0.01) and increased for both techniques postintervention (p < 0.001). Perceived pain was lower for laser blepharoplasty. Postintervention, participants responded that additional costs of ($975 ± $1,091) would justify laser over blade blepharoplasty. CONCLUSION: Elucidating patient perceptions and preferences for blade- versus laser-based blepharoplasty provides surgeons with perspective on how to tailor preoperative counselling. Before and after the intervention, participants had a bias toward choosing laser blepharoplasty. The intervention seems to falsely convince people that laser blepharoplasty leads to better outcomes. Because the doctor's advice can greatly impact patients' decisions, physicians have to be careful not to give false expectations when counselling patients. Inaccurate recall of key educational takeaways suggests that information should be vulgarized and delivered actively to patients.

Helicobacter pylori Infection of the Gastric Mucosa and Ocular Adnexa-Lack of Association With Ocular Adnexal Lymphoma.

PURPOSE: Helicobacter pylori could theoretically induce ocular adnexal lymphoma (OAL) via 2 mechanisms: the first is that of infection within the ocular adnexa and the second is that of infection within the gastric mucosa, leading to the malignant transformation of lymphocytes that migrate to the ocular adnexa, forming a primary "ectopic" cancer. This study investigated if an association exists between gastric H. pylori or ocular adnexal H. pylori and OAL. METHODS: Prospective case-control study including cases with OAL and controls with nonlymphomatous pathologies. Gastric H. pylori infection was assessed via serologic antibody testing. Ocular adnexal infection was assessed via polymerase chain reaction testing for H. pylori and Chlamydia psittaci within ocular adnexal samples. RESULTS: Seventy-two patients were enrolled, of whom 18 had lymphoma and 54 nonlymphomatous pathologies. H. pylori antibodies were present in 5 cases (28%) and 18 controls (33%) (95% CI, 0.24%-2.50%, p = 0.78). All ocular adnexal specimens were negative for H. pylori and C. psittaci infection. The only relevant statistically significant difference between cases and controls was a history of gastric ulcer (95% CI, 1.23%-44.80%, p = 0.03). CONCLUSIONS: In the study's population, infection of gastric mucosa with H. pylori does not appear to influence the development of OAL. Also, H. pylori or C. psittaci infection within the ocular adnexa does not appear to influence the development of OAL. In the study's practice, authors do not recommend antibiotic administration or routine gastroscopy for patients with OAL. The authors do recommend referral of OAL patients with gastric symptoms to a gastroenterologist.

Prospective case-control trial evaluating silicone gel for the treatment of direct brow lift scars.

OBJECTIVE: To evaluate the effectiveness of a topical silicone gel on scars in patients who had undergone bilateral direct brow lift surgery. DESIGN: A randomized double-blind clinical trial with a placebo applied to one scar and topical silicone gel (Dermatix Ultra; Valeant Pharmaceuticals, Laval, Que.) used on the other scar for 2 months. PARTICIPANTS: Twelve patients (for a total of 24 surgical scars evaluated) were included in the study. METHODS: This study was performed in 2 academic hospitals of the University of Montreal in Montreal, Que. (Maisonneuve-Rosemont Hospital and Notre-Dame Hospital). Inclusion criteria were all bilateral direct brow lift surgeries performed in our hospitals. Exclusion criteria included revision surgery, silicone or latex allergy, and wound infection. Each patient received 2 tubes (1 with silicone gel and 1 with placebo) and applied 1 tube to their right brow scar and the other tube to their left brow scar, following the preassigned instructions. The patient and surgeon were blinded to the nature of the substance that was applied to each scar. At each visit, pictures of both scars were taken, and a questionnaire titled "The Patient and Observer Scar Assessment Scale" was filled out by the patient and the surgeon. A grade ranging from 0 to 10 was given on the multiple criteria in the questionnaire, and the sum of these grades was subsequently used for the data analysis. A lower sum was interpreted as improved scarring. At the end of the study, an independent evaluator graded both scars based on pictures. Follow-up visits were held on day 7, week 6, month 3, and month 6 after surgery. A comparison of the experimental and placebo group was performed with nonparametric tests of Wilcoxon signed rank. RESULTS: A total of 24 scars of 12 patients were analyzed (based on 4 follow-up visits). General improvement of scars was reported by the patient, the surgeon, and based on pictures. No statistically significant difference was found between the group treated with silicone gel and the group treated with placebo. All tests had a p value ≥0.08. CONCLUSIONS: We did not find a statistically significant difference between scars treated with silicone gel and scars treated with the placebo after direct brow lift surgery.

Ocular Penetration Secondary to Cocaine-Induced Midline Destructive Lesion.

Herein, the authors present a retrospective case report of a patient with ocular penetration due to cocaine-induced midline destructive lesion. To their knowledge, this is the first documented case of ocular penetration secondary to cocaine insufflation.

Controversies of the lacrimal system.

Numerous long-standing controversies influence the management of lacrimal sac abscesses, canalicular lacerations, and obstruction of the nasolacrimal duct. We examined the debatable beliefs that underline these controversies and concluded the following: drainage of a pointing lacrimal sac abscess can be well tolerated under local anesthesia, is associated with few adverse events, and should be performed regardless of whether systemic antibiotics have been administered. Reconstruction of monocanalicular lacerations should be considered in all cases, without distinction to whether the injury involves the upper or lower canaliculus. Finally, no firm evidence currently exists supporting intubation with routine dacryocystorhinostomy.

Endocanalicular laser dacryocystorhinostomy with mucosal flaps.

PURPOSE: To describe the technique of endocanalicular laser dacryocystorhinostomy with mucosal flap creation and to report the outcomes of this technique. METHODS: Prospective noncomparative case series of 7 patients with primary acquired nasolacrimal duct obstruction undergoing endocanalicular laser dacryocystorhinostomy with mucosal flap. The mucosal flap was created using an endoscopic endonasal approach. An endocanalicular approach was used to fashion the lacrimal sac opening and the osteotomy of the lacrimal sac fossa. RESULTS: Nine procedures were performed in 7 female patients. Average patient age was 68±15 years. Intraoperative complications included bleeding during the creation of the mucosal flap in 1 patient. The procedure was associated with no pain to moderate pain in all cases. Anatomical success was achieved in 89% of procedures and symptomatic relief was achieved in 89% of surgeries for an average follow up of 10 ± 5 months. Only 1 patient required an external dacryocystorhinostomy revision because of postoperative restenosis. CONCLUSIONS: Endocanalicular laser dacryocystorhinostomy provides a minimally invasive approach to epiphora with a good success rate. The addition of a nasal mucosal flap to this technique may aid in proper fistulization and should be studied in larger prospective trials.

Transplantation of mesenchymal stem cells promotes tissue regeneration in a glaucoma model through laser-induced paracrine factor secretion and progenitor cell recruitment.

Among bone marrow cells, hematopoietic and mesenchymal components can contribute to repair damaged organs. Such cells are usually used in acute diseases but few options are available for the treatment of chronic disorders. In this study, we have used a laser-induced model of open angle glaucoma (OAG) to evaluate the potential of bone marrow cell populations and the mechanisms involved in tissue repair. In addition, we investigated laser-induced tissue remodeling as a method of targeting effector cells into damaged tissues. We demonstrate that among bone marrow cells, mesenchymal stem cells (MSC) induce trabecular meshwork regeneration. MSC injection into the ocular anterior chamber leads to far more efficient decrease in intraocular pressure (IOP) (p < .001) and healing than hematopoietic cells. This robust effect was attributable to paracrine factors from stressed MSC, as injection of conditioned medium from MSC exposed to low but not to normal oxygen levels resulted in an immediate decrease in IOP. Moreover, MSC and their secreted factors induced reactivation of a progenitor cell pool found in the ciliary body and increased cellular proliferation. Proliferating cells were observed within the chamber angle for at least 1 month. Laser-induced remodeling was able to target MSC to damaged areas with ensuing specific increases in ocular progenitor cells. Thus, our results identify MSC and their secretum as crucial mediators of tissue repair in OAG through reactivation of local neural progenitors. In addition, laser treatment could represent an appealing strategy to promote MSC-mediated progenitor cell recruitment and tissue repair in chronic diseases.

Mirror, mirror on the wall: placebo effects that exist only in the eye of the beholder.

Rationale The extent to which placebo effects can be driven exclusively by subjective impressions of improvement in the absence of any independent corroboration is unclear. Methods Thirty-six self-referred patients were treated with a light therapy device intended to rejuvenate facial skin. At each of eight weekly treatments, participants' facial skin was exposed for 40 seconds to pulses of multispectral LED-generated light in the range of 588 nm wavelength at 0.1 J cm(-2). Outcomes were assessed by participants as well as by the treating doctor and by blinded, expert raters. Results Patients reported robust and statistically significant improvements in seven facial features at the conclusion of the 8-week treatment regimen as well as at 1-month follow-up (for all comparisons, P 0.05). Moreover, effect sizes were close to zero and in the opposite direction from improvement (median d = -0.06 for doctor ratings; and for observer ratings, there was only a 46% success rate at identifying post-treatment as compared with pre-treatment photographs). Conclusion The robust placebo responses documented in this trial were confined to the subjective impressions of the patients. Neither the treating doctor nor blinded, expert raters could detect any improvement. Thus, patients can perceive improvement in medical interventions in the absence of any independent corroboration that improvement has occurred. This result is used a heuristic to more clearly define the components of the placebo response.

In the eye of the beholder--skin rejuvenation using a light-emitting diode photomodulation device.

BACKGROUND: A light-emitting diode (LED) photomodulation system can produce pulses of amber light expected to induce structural skin changes and reverse the effects of photoaging. OBJECTIVE: To reproduce the encouraging results already published. METHODS AND MATERIALS: Facial skin was exposed to pulses of 588+/-10-nm-wavelength light from a photomodulation device for 40 seconds once a week for 8 weeks. Photographs, clinical assessment, and a subjective questionnaire were taken at baseline, at the last follow-up, and 1 month after that. Thirty-six patients' pre- and post-treatment photos were arbitrarily scrambled, and 30 independent blinded observers were asked to pick the post-treatment photo. Two time-point comparisons were evaluated. RESULTS: For every facial characteristic studied and for both time-point comparisons, patients reported highly statistically significant improvements. In extremely sharp contrast, neither the physician's assessment nor the independent observers' evaluation indicated any improvement. CONCLUSION: Although subjective findings are comparable between studies, we were unable to reproduce the objective results of efficacy previously reported. Patients genuinely believed that several of their facial features had improved, even though there was no detectable objective change. Our data therefore suggest that the LED photomodulation treatment from the device tested is a placebo.

A lacrimal sac abscess incision and drainage technique.

A comfortable, anatomically based lacrimal sac abscess incision and drainage technique is described. The records of 52 patients were reviewed. The procedure was relieving and well tolerated because of adequate infraorbital and anterior ethmoidal nerve blocks. To promote rapid resolution, both components of the abscess were drained: the distended lacrimal sac and its associated submuscular pocket. The contiguous cavities were packed and allowed to heal by secondary intention. Of 49 cases, 39 (79.6%) were done as outpatient procedures and 41 (83.7%) were performed under locoregional anesthesia. Edema completely resolved by a median of 7 days. A repeat drainage procedure within 1 month was required in only 4 of 48 cases (8.3%). Fistulas and ectropion were not found. Four of 16 patients (25.0%) who did not eventually receive a definitive procedure (dacryocystorhinostomy or dacryocystectomy) developed a recurrent lacrimal sac abscess after complete resolution of the primary episode.

Rhabdomyosarcoma metastases to all extraocular muscles.

A 24-year-old woman developed acute bilateral proptosis. She had a history of rhabdomyosarcoma of the left orbit treated 2 years previously with chemotherapy and radiation. Computed tomography demonstrated enlargement of each of the extraocular muscles in both orbits. Extraocular muscle biopsy confirmed rhabdomyosarcoma. She was treated with radiation but died 2 months after presentation.

Comparison of anesthetic and surgical outcomes of dacryocystorhinostomy using loco-regional versus general anesthesia.

OBJECTIVE: The aim of this study was to compare anesthetic and surgical outcomes of external dacryocystorhinostomy (DCR) under loco-regional anesthesia (LA) versus general anesthesia (GA). METHODS: Retrospective chart review of all patients that underwent DCR by one surgeon (IH) over the course of a ten-year period (April 1994 to March 2003). RESULTS: A total of 221 DCR were performed on 209 patients during the study period: 71 were done under LA (72.0 ± 13.3 years) and 150 under GA (64.2 ± 13.0 years; P<0.001). LA patients had a shorter length of surgery (56.2 ± 15.3 vs. 64.0 ± 18.1 minutes; P=0.001) and required less antiemetic drugs during the first four hours after surgery (P=0.03). Pain was well controlled and patients were comfortable per- and post-operatively. Excluding ecchymosis (38.0% LA vs. 21.6% GA; P=0.01), the rate of minor complications did not differ between the two groups: infection, inflammation or edema (14.1 vs. 18.2%; P=0.13), hematoma (1.4 vs. 2.7%; P=0.52) and epistaxis (22.5 vs. 14.2%; P=0.44). Rates of recurrent symptoms and/or re-intervention (11.3 vs. 13.1%; P=0.91) were comparable for LA and GA. CONCLUSION: This study suggests that external DCR performed under LA and monitored anesthesia care may be advantageous. The length of surgery is reduced, post-operative side effects are diminished, and excluding ecchymosis, the rate of minor complications is not increased. These benefits are desirable in a predominantly elderly population where avoidance of GA risks is at times necessary.

Green bone.

OBJECTIVE: To describe the unusual finding of yellow-green-colored bone during routine orbital surgery, to detail its investigation, and to demonstrate its benign nature. METHODS: When green bone was found, specimens were sent for light and fluorescent microscopy, ultraviolet photography, and spectrophotometry. RESULTS: Yellow-green bone was encountered in 3 patients during orbital tumor excision or orbital fracture repair procedures. The only common cause was prior use of tetracycline during adolescence. All patients had healthy white dentition. In all cases, absence of neoplasia was demonstrated histologically. The bone fluoresced with a bright yellow-green color when exposed to 365-nm ultraviolet light. Histologic analysis demonstrated fluorescence located near the haversian canals. Spectrophotometry revealed absorption at 4 wavelengths specific to tetracycline: 230, 275, 380, and 440 nm. CONCLUSIONS: Fixation of tetracycline and ensuing fluorescence occurs mostly in areas of new bone growth and mineralization. This happens during childhood but also with bone remodeling associated with tumors or fractures. Once mineralized, teeth should therefore not be affected if tetracycline exposure occurs after ages 8 to 10 years. This paucity of external clues can lead to the surprising but innocuous surgical finding of green bone. Careful history and proper investigation can confirm its origin.

Orbital decompression: cadaver study.

BACKGROUND: Patients with Graves' ophthalmopathy may need surgical treatment to alleviate ophthalmologic complications. The degree of reduction in proptosis following surgical intervention remains difficult to predict. OBJECTIVES: To elaborate a human model using cadaver orbits to study surgical management of Graves' ophthalmopathy. To evaluate quantitatively the contribution of each orbital wall decompression and their combinations in reduction in proptosis. To improve the ability to predict the degree of proptosis reduction according to the wall(s) chosen for decompression. METHODS: Artificial exophthalmos was created in 12 cadavers' orbits by injecting a polysaccharide gel in the peribulbar and retrobulbar tissues. Proptosis reduction was measured following successive orbital decompression. RESULTS: Decompression of one wall produced a nonstatistical significant reduction in proptosis. The combination of the medial and lateral walls significantly reduced the proptosis by a mean of 4.2 mm. Three-wall decompression gave a mean significant reduction of 6.6 mm, and when combined with the advancement of the lateral wall, it reduced proptosis by 12.5 mm. CONCLUSIONS: We created an experimental model for research and didactic purposes for surgical mangement of Graves' ophthalmopathy. With this model, to obtain 5 mm or more of proptosis reduction, three-wall decompression is required. Advancement of the lateral wall achieved a further reduction in proptosis. For a proptosis reduction of less than 5 mm, decompression of the medial and lateral walls is appropriate.

Cutaneous melanomas of the eyelid.

Cutaneous eyelid melanomas are very rare lesions. The lentiginous subtypes are the most frequent melanocytic lesions of the eyelid and can be likened to conjunctival melanocytic lesions like PAM, PAM with atypia and conjunctival melanoma. Compared to melanomas elsewhere on the body, eyelid melanomas have special considerations. Eyelid skin is very thin, the mucocutaneous junction at the lid margin can affect prognosis, the lymphatic drainage pattern is very variable and there is an inherent difficulty to excise wide margins without sacrificing important structures. A customized excision approach, using tissue-sparing "Slow-Mohs" technique, is suggested. Sentinel lymph node dissection has an evolving therapeutic role but remains controversial.

Intralesional injection of Tisseel fibrin glue for resection of lymphangiomas and other thin-walled orbital cysts.

PURPOSE: Surgical removal of orbital lymphangiomas is often difficult because the capsule of these lesions is fragile, and, once violated, it tends to collapse, making identification of residual tumor difficult and dissection often incomplete. A surgical technique combining partial controlled decompression of the lesion with intralesional injection of Tisseel fibrin glue is evaluated to determine its effectiveness in resecting the lesion and preventing recurrences. METHODS: This is a retrospective interventional case series. Three young patients, two with lymphangiomas and one with congenital hydrocystoma, underwent surgical resection of their thin-walled cystic lesions of the orbit with the use of intralesional injection of Tisseel fibrin glue. Resolution of the signs and symptoms, complications of the surgery, and recurrence of bleeding are the parameters studied. RESULTS: All 3 patients had improvement of their signs and symptoms. None had complications related to the surgery, and no recurrence of bleeding occurred during the follow-up period. CONCLUSIONS: Our study suggests that this surgical technique with intralesional injection of Tisseel fibrin glue is an effective treatment modality for the resection of lymphangiomas and other orbital thin-walled cystic lesions.

Pneumocele--a rare cause of air in the orbit.

PURPOSE: To report a case of unilateral proptosis and chronic pansinusitis in which the diagnosis of pneumocele was made. DESIGN: Observational case report. METHODS: A retrospective chart review was made. RESULTS: A 52-year-old man with chronic pansinusitis presented with a 5-mm proptosis and a larger palpebral fissure in the left eye. Computed tomography imaging demonstrated an air-filled mass originating from the frontal sinus and protruding into the orbit. After endoscopic sinusotomy and excision of the mucosal sac through anterior orbitotomy, proptosis improved to 3 mm and palpebral fissures became symmetric. CONCLUSIONS: A pneumocele is a rare lesion of the paranasal sinuses that may expand into the orbit and may present with proptosis or motility deficit to the ophthalmologist. Through proper diagnosis and surgical management, the orbital symptoms will resolve.