American Society of Plastic Surgeons Evidence-Based Clinical Practice Guideline: Eyelid Surgery for Upper Visual Field Improvement.

BACKGROUND: A group of experts from different disciplines was convened to develop guidelines for the management of upper visual field impairments related to eyelid ptosis and dermatochalasis. The goal was to provide evidence-based recommendations to improve patient care. METHODS: A multidisciplinary group of experts representing their specialty organizations was selected. A systematic literature review was performed including topics regarding documentation of the underlying cause for visual field impairment, selection of an appropriate surgical repair, assessment of the type of anesthesia, the use of adjunctive brow procedures, and follow-up assessments. The Grading of Recommendations, Assessment, Development, and Evaluation methodology process was used to evaluate the relevant studies. Clinical practice recommendations were developed using BRIDGE-Wiz (Building Recommendations In a Developers' Guideline Editor) software. RESULTS: Each topic area was assessed. A clinical recommendation was made, and the relevant literature was discussed. CONCLUSIONS: The review of the literature revealed varied complication rates and diverse treatment modalities for the correction of upper visual field deficit. Strong recommendations could not be made in most topic areas because of a paucity of methodologically sound studies in the literature. More rigorously designed studies are needed to measure outcomes of interest, with fewer sources of potential error or bias. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Neomycin, polymyxin B, and dexamethasone allergic reactions following periocular surgery.

BACKGROUND: The aim of this study was to evaluate the rate of periocular allergic skin reactions to topical neomycin, polymyxin B, and dexamethasone (NPD) ophthalmic ointment. METHODS: A consecutive patient prospective study was performed. A total of 522 patients who had a procedure involving incision of the periocular skin with subsequent postoperative application of NPD ophthalmic ointment were included. Patients were evaluated for signs of allergy at 1 week postoperatively or prior if the patient had complaints. A periocular allergic reaction was defined as any periocular skin pruritus, erythema, edematous papules, vesicles, or plaques at the site of ointment application beyond that of the typical postprocedure presentation. The patients continued to be monitored for 30 days postoperatively. RESULTS: Of the 522 patients who completed the study, eight (1.5%) had a definitive periocular allergic contact dermatitis to the NPD ophthalmic ointment. Allergic presentation ranged from postoperative day 3 to 14. CONCLUSIONS: The rate of periocular allergic reactions to NPD ophthalmic ointment is significantly lower than reported in the literature for other topical preparations of neomycin and polymyxin B. The low rate of allergy in this study suggests that NPD ophthalmic ointment can safely be applied to the periocular skin with a very minimal risk of inciting an allergic reaction.

Piezosurgery in External Dacryocystorhinostomy.

BACKGROUND: Dacryocystorhinostomy (DCR) can be performed via an external or endoscopic approach. The use of ultrasonic or piezosurgery has been well described for endoscopic DCRs but is lacking for external DCRs. This study presents a case series of external DCRs performed using piezosurgery evaluating results and complications. METHODS: Prospective, consecutive case series of patients undergoing primary external DCR for lacrimal drainage insufficiency. A standard external DCR technique was used using 1 of 2 piezosurgery systems for all bone incision. All patients received silicone intubation to the lacrimal system. Surgical outcome was measured in terms of patient-reported epiphora as follows: 1) complete resolution, 2) improvement >50%, 3) improvement <50%, and 4) No improvement. Intra and postoperative complications were also recorded. RESULTS: Fifty-two patients, 14 male and 38 female, were included in the study, with 2 patients having bilateral surgery. The average age of the patients was 55.8 years. The average length of follow up was 221 days. Surgical outcomes showed 72% of patients with complete resolution of epiphora and 21% with >50% improvement. There were 4 patients (7%) who had <50% improvement. There was 1 (2%) intraoperative complication and 2 (4%) postoperative complications recorded. CONCLUSIONS: Piezourgery is a viable modality for performing external DCRs. The lack of surgical complications shows a potential for decreased soft tissues damage. The surgical success rate based on patient-reported epiphora is similar to those published for mechanical external DCRs. This modality may benefit the novice surgeon in the reduction of soft and mucosal tissue damage.

Use of Kaolin-impregnated Gauze for Improvement of Intraoperative Hemostasis and Postoperative Wound Healing in Blepharoplasty.

PURPOSE: Kaolin is a mineral shown to be effective in controlling hemorrhage when combined with standard gauze and applied to wounds. This study investigates the application of kaolin to control intraoperative bleeding and promote wound healing in eyelid surgery. METHODS: This prospective, randomized, double-blind study recruited patients who underwent eyelid surgery. Following skin incision, kaolin-impregnated gauzewas placed in one eyelid wound bed and cotton gauze in the other, then removed. Distinct, individual areas of bleeding were recorded. Standardized photographs were obtained postoperatively on Day 1, 4, and 7. Photographs were graded for edema and ecchymosis by four blinded observers. Patients also completed a survey inquiring which side had more bruising, swelling, and pain at each return visit. RESULTS: A total of 46 patients completed the study. The number of intraoperative bleeding sites for kaolin versus plain gauze was not significantly different (p=0.96). Photographic grading by blinded observers did not identify any statistically significant differences in postoperative edema at any time point between lids. There was a statistically significant difference for ecchymosis at postoperative Day 4 (p=0.009) and Day 7 (p=0.016). Patient surveys did not show any difference in perceived edema, ecchymosis, or pain between lids. CONCLUSION: Intraoperative hemostasis was not affected by the use of kaolin-impregnated gauze. The effectiveness of kaolin in wound healing showed improved ecchymosis at Days 4 and 7 when assessed by blinded observers. Patients did not notice any improvement in postoperative edema, ecchymosis, or pain.

Nasolacrimal System Aeration on Computed Tomographic Imaging: Sex and Age Variation.

PURPOSE: To investigate variation in aeration of the nasolacrimal drainage system between age groups and genders, and to report the reliability of repeated aeration grading and nasolacrimal canal measurements on CT. METHODS: Retrospective review of CT images from 92 individuals, 60 female and 32 male, was conducted by 3 independent reviewers for the presence of air within the nasolacrimal drainage system. Diameter and area measurements were also obtained at the smallest identifiable portion of the nasolacrimal canal by 2 independent reviewers. RESULTS: When air is present on CT, it is seen more fully throughout the nasolacrimal system in men as compared to women. Age data demonstrate that patients from the third and fourth decade have significantly more aeration than older patients. Diameter and area of the nasolacrimal duct within the canal at its narrowest point revealed no correlation with sex, age, or nasolacrimal system aeration. Inter-reviewer reliability shows strong repeatability of aeration grading and nasolacrimal duct measurements between multiple reviewers. CONCLUSIONS: The results suggest CT is reliable and repeatable modality to assess nasolacrimal system aeration and nasolacrimal duct diameter. Decreased aeration of the nasolacrimal system in females and the elderly mirrors epidemiologic trends for those at risk to develop primary acquired nasolacrimal duct obstruction. Variables in nasolacrimal drainage system anatomy, specifically nasolacrimal duct diameter and area, did not vary between sexes or age groups, suggesting aeration may be an overlooked variable in nasolacrimal system function.

Nasolacrimal system aeration on computed tomographic imaging: effects of patient positioning and scan orientation.

PURPOSE: To determine the impact of patient positioning and scan orientation on the appearance of air in the nasolacrimal drainage system on computed tomography (CT) imaging, and the repeatability of the observations. METHODS: This was a retrospective analysis of CT images for 92 patients. RESULTS: Air was found to be present more fully in the upright-position group as compared with the supine-position group. Comparing axial and coronal scan orientation, no difference in aeration was found, except for the nasolacrimal duct in the upright-position group. CONCLUSION: Patient position should be accounted for in diagnostic conclusions and treatment decisions based on CT.

Infection Rates after Periocular Surgery Utilizing New versus Re-Processed Monopolar Electrocautery.

BACKGROUND: To determine if there is a difference in periocular post-operative infection rates when utilizing new versus re-processed monopolar electrocautery tips. METHODS: Retrospective cohort study of 4,976 consecutive surgical cases involving 17,149 procedures. Post-operative infections were identified using chart review, facility infection surveillance records, and surgeon reporting. The main outcome measure was the presence or absence of infection within 30 post-operative days. The Fischer exact test was used to compare infection rates between cautery modalities. All statistical analysis was conducted at the 0.05 α level. RESULTS: There was no statistically significant difference between new and re-processed monopolar cautery infection rates (p=0.3879). CONCLUSIONS: Post-operative infection rates are similar for periocular surgery using both new and re-processed monopolar cautery. These findings suggest that re-processed cautery is a viable option for periocular surgery to decrease cost and reduce material waste without affecting the quality of care.

Evolving Minimally Invasive Techniques for Tear Trough Enhancement.

PURPOSE: The aim of this study is to investigate whether volumetric enhancement of the infraorbital rim area or, alternatively, of the deep medial cheek, results in greater improvement of tear trough deformity. METHODS: This prospective, single-blind study recruited 12 patients seeking correction of tear trough deformity. Pretreatment standardized photographs were obtained after which patients were randomized to receive hyaluronic acid gel filler augmentation of the tear trough on one side and hyaluronic acid gel augmentation of the cheek on the contralateral side. The patients were then re-examined at 3 weeks postinjection when standardized photographs were taken again. Following the photographs, filler was added to the side and location where they were not used at the original treatment, resulting in added volume in both the cheek and the tear trough. The patients returned 3 weeks later when final photographs were taken. The pre- and post-treatment images were randomized and evaluated by 3 masked observers asked to evaluate the depth of tear trough. RESULTS: There was a significant improvement in the depth of the tear trough rating after initial treatment on the side treated in the tear trough (p = 0.0001). There was not a significant change in depth of tear trough rating, however, on the side receiving cheek only treatment (p = 0.0963). There was a statistically significant change in tear trough rating after both tear trough and cheek had been treated on each side (p = 0.001). There was no statistically significant difference between sides after lid and cheek treatment had been completed on each side (p = 0.5986). Intraclass correlation between reviewers for all subjects was excellent at 0.94. Tear trough injections were more technique sensitive than cheek volume augmentation to achieve satisfactory results. There were no complications from cheek volume enhancement. Varying degrees of ecchymosis were encountered with tear trough injections. CONCLUSIONS: When the patient's primary concern is the appearance of the tear trough, and the physician is limited to treating either the tear trough or the cheek alone, it appears that treatment in the tear trough offers greater improvement in the appearance of the tear trough deformity when compared with treatment in the cheek alone.

Risk of ocular blood splatter during oculofacial plastic surgery.

PURPOSE: To assess intraoperative blood splatter to the ocular surface and adnexa during oculofacial surgery. METHODS: Four surgeons and multiple assistants at three separate locations wore a total of 331 protective eye shields during 131 surgeries. Postoperatively, a luminol blood detection system was used to identify blood splatter on the shields. In the event of positive blood splatter, the total number of blood spots was counted. Controls were used to verify the blood detection protocol. A postoperative questionnaire was given to all surgeons and assistants after each case, and they were asked whether intraoperative blood splatter was noticed. RESULTS: Blood was detected on 61% of eye shields and in a total of 80% of surgical cases. However, only 2% of blood splatters were recognized intraoperatively by the surgical participants. There was no significant difference in the splatter rate between surgeons (64%), assistants (60%), and surgical technicians (58%) (p = 0.69). Shields worn during full-thickness eyelid procedures, direct brow lifting, orbitotomy with bony window, and orbital fracture repairs were more likely to be splattered (p = 0.03), and there was a significant difference between splatter rates among different surgeons (range, 29-90%; p = 0.0004), suggesting that blood splatter rate may be both procedure dependent and surgeon dependent. CONCLUSIONS: Mucocutaneous and transconjunctival transmission of human immunodeficiency virus and viral hepatitis has been documented. These results suggest that oculofacial plastic surgeons should consider eye protection for patients with known blood-borne diseases and in cases where blood splatter is expected. This precautionary practice is supported by the high incidence (98%) of undetected, intraoperative blood splatter.

Age-matched, case-controlled comparison of clinical indicators for development of entropion and ectropion.

Purpose. To analyze the clinical findings associated with involutional entropion and ectropion and compare them to each other and to age-matched controls. Methods. Prospective, age-matched cohort study involving 30 lids with involutional entropion, 30 lids with involutional ectropion, and 52 age-matched control lids. Results. The statistically significant differences associated with both the entropion and ectropion groups compared to the control group were presence of a retractor dehiscence, presence of a "white line," occurrence of orbital fat prolapse in the cul-de-sac, decreased lower lid excursion, increased lid laxity by the snapback test, and an increased lower lid distraction. Entropion also differed from the control group with an increased lid crease height and decreased lateral canthal excursion. Statistically significant differences associated with entropion compared to ectropion were presence of a retractor dehiscence, decreased lateral canthal excursion, and less laxity in the snapback test. Conclusion. Entropic and ectropic lids demonstrate clinically and statistically significant anatomical and functional differences from normal, age-matched lids. Many clinical findings associated with entropion are also present in ectropion. Entropion is more likely to develop with a pronounced retractor deficiency. Ectropion is more likely to develop with diminished elasticity as measured by the snapback test.

Long-term botulinum toxin treatment of benign essential blepharospasm, hemifacial spasm, and Meige syndrome.

PURPOSE: To report the clinical success and incidence of adverse events of repetitive botulinum toxin treatment of 15 years or greater. DESIGN: Retrospective cohort study. METHODS: The study sample consisted of 37 patients from a clinical practice, 11 male and 26 female. Inclusion criteria consisted of patients treated a minimum of 15 consecutive years for facial dystonia. Seven patients had hemifacial spasm, 4 Meige syndrome, and 26 benign essential blepharospasm. Main outcome measures consisted of treatment efficacy and adverse events. RESULTS: Mean treatment duration was 19.4 years (SD 2.2) with an average of 62 (SD 22) treatments of 70.2 (SD 20.8) neurotoxin units. Mean duration of treatment efficacy was 127 days (SD 37) with a 5% physician-reported minor adverse event rate and no major adverse events over each patient's clinical course. Patients reported no major and 20% incidence of minor adverse events over the treatment course. CONCLUSION: Results suggest that long-term botulinum toxin treatment produces clinical success in the alleviation of facial dystonia symptoms. Treatment produced a low incidence of major adverse events and minor adverse events. Previous studies may under-report clinical success and over-report adverse events because of study design.

Isolated, complete paralytic mydriasis secondary to herpes zoster ophthalmicus.

Herpes zoster ophthalmicus is a manifestation of herpes zoster when the ophthalmic division of the trigeminal nerve becomes involved. Ocular symptoms are varied and mainly due to inflammatory mechanisms. Total, external and/or internal ophthalmoplegias, as well as isolated third, fourth and sixth cranial nerve palsies have all been reported as complications. In a minority of cases, concurrent pupillary paralysis has been documented. The presentation of complete paralytic mydriasis as the sole cranial nerve complication following herpes zoster ophthalmicus infection is a rare finding. The postulated pathophysiologic aetiology is a partial third nerve palsy with the pupillary fibres for light and accommodation-convergence affected and motor fibres spared. The mechanism responsible for the postulated lesion is speculative.

Hydrogel explant extrusion masquerading as a malignant eyelid lesion.

Hydrogel was a commonly used material for scleral buckling in the early 1980s to the mid-1990s. Use of hydrogel ceased due to a high complication rate, including frequent migration. Various symptoms and clinical findings have been reported with hydrogel migration. There have been no published reports of hydrogel migration to the eyelid anterior to the orbital septum with erosion of the orbicularis and bleeding as a presenting symptom. The authors describe a patient with hydrogel migration to the upper eyelid, with symptomology and clinical findings consistent with a malignant eyelid lesion. Excisional biopsy of extraorbital hydrogel is recommended in these cases.

Canalicular obstruction: a histopathologic case series.

OBJECTIVE: To investigate the histopathologic causes of canalicular obstruction in a case series of patients treated by canalicular trephination for symptomatic epiphora. DESIGN: A university and private practice retrospective chart review. PARTICIPANTS: The study involved 12 consecutive patients who underwent unilateral canalicular trephination with tissue retrieval for the treatment of canalicular obstruction. METHODS: Canalicular obstruction was confirmed at the time of preoperative and intraoperative probing and irrigation. Treatment consisted of canalicular trephination combined with silicone intubation and a concomitant dacryocystorhinostomy in 6 cases. Tissue was recovered from the trephine lumen and submitted for pathologic analysis. Predisposing factors that could have caused canalicular obstruction and the clinical course following treatment were reported. RESULTS: The most common histopathologic finding was nonspecific inflammation with associated fibrosis. Cases demonstrating sebaceous gland adenoma, skeletal muscle, adipose tissue, and bone were identified. CONCLUSIONS: Use of the lacrimal trephine to open canalicular obstructions provided tissue samples that revealed nonspecific inflammation and fibrosis as a common underlying histopathology. The presence of skeletal muscle and adipose tissue suggests a decrease in canalicular diameter or such dense scarring that the normal canalicular architecture could not be followed. Other causes of canalicular obstruction such as lacrimal sac tumors should be considered in the differential diagnosis.

Atypical presentations of orbital cellulitis caused by methicillin-resistant Staphylococcus aureus.

PURPOSE: To evaluate the epidemiologic and clinical features of orbital cellulitis caused by methicillin-resistant Staphylococcus aureus (MRSA). DESIGN: Multicenter, retrospective case series. PARTICIPANTS: Fifteen patients with culture-positive MRSA orbital cellulitis. METHODS: All recent cases of orbital cellulitis at several hospitals and surgical centers were reviewed, and cases with culture-positive MRSA from aspirates were identified. The data collected and analyzed retrospectively included patient demographics, medical history, presenting sign, imaging results, surgical procedure performed, surgical culture results, visual acuity at presentation and last follow-up, and duration of antibiotics. MAIN OUTCOME MEASURES: Presenting sign, radiographic evidence of paranasal sinus disease, radiographic evidence of multiple orbital abscesses, presence or absence of antecedent upper respiratory infection, and final visual acuity. RESULTS: Fifteen cases were identified. The mean patient age was 31.9 years (standard deviation, 24.2 years). Lid swelling was the presenting sign in 14 of 15 patients. No patients had a preceding upper respiratory infection, and only 1 patient had antecedent eyelid trauma. Only 3 of 15 patients had documented adjacent paranasal sinus disease on imaging. Lacrimal gland abscess or dacryoadenitis was the presenting finding in 5 of 15 patients. Multiple orbital abscesses were identified in 4 of 15 patients by computed tomography or magnetic resonance imaging. Fourteen of 15 cases required surgical intervention. Four of 15 cases had loss of visual acuity to light perception or worse. All 4 of these cases had a delay in referral for surgical intervention. CONCLUSIONS: In these 15 patients with MRSA orbital cellulitis, the typical clinical setting of orbital cellulitis was absent; chiefly, there was no identified antecedent upper respiratory illness, nor was there a preceding traumatic injury. Lid swelling in the absence of recent upper respiratory illness, lacrimal gland focus, multiple orbital abscesses, and lack of adjacent paranasal sinus disease may be predictive factors that suggest MRSA as the causative organism of orbital cellulitis. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Intraorbital foreign body projectile as a consideration for unilateral pupillary defect.

Intraorbital foreign bodies are frequently the result of high-velocity injuries with varying clinical presentations. The resultant diagnosis, management, and outcome depend on the type of foreign body present, anatomical location, tissue disruption, and symptomatology. A patient who presented to the Emergency Department with a large intraorbital foreign body projectile that was not evident clinically, but found incidentally on computed tomography and subsequent plain films is reported. The emergency room physician needs to be aware of the differential diagnosis of a unilateral irregular pupil with or without visual acuity changes. The differential diagnosis for any trauma patient with an irregular pupil with significant visual loss must include intraorbital foreign body and associated injury to the optic nerve directly or via orbital compartment syndrome secondary to hemorrhage and/or edema. Patients with significantly decreased visual acuity may benefit from emergent surgical intervention. In patients with intact visual acuity, the patient must be monitored closely for any visual changes as this may require emergent surgical intervention.