Clinical Features and Treatment Outcomes of Orbital Inflammatory Disease in Singapore: A 10-Year Clinicopathologic Review.

PURPOSE: 1) To assess the clinical profile and treatment outcomes of orbital inflammatory disease in the local population, and 2) classify patients using current histopathological criteria. METHODS: Ten-year retrospective clinicopathologic review of patients diagnosed with orbital inflammatory disease who underwent tissue biopsy from January 2001 to December 2011 at a tertiary referral centre in Singapore. Data collection included patient demographics, clinical presentation, investigations, systemic disease, histopathology review, clinical classification, medical and surgical management, response to treatment and recurrence rates. RESULTS: The study comprised 70 patients. Thirty-seven (52.9%) had nonspecific inflammation distributed as follows: lacrimal (n = 23), diffuse (n = 5), anterior (n = 5), myositic (n = 4). Thirty-three (47.1%) had specific inflammation of the following subtypes: idiopathic sclerosing inflammation (n = 9), granulomatous disorders (n = 8), transitional lesions (n = 5), vasculitis (n = 4), and others (n = 7). A total of 76.8% of patients received oral prednisolone, with a median duration of three months. Response to treatment was good in 71.9% of patients. Recurrence occurred in 22 (32.8%) patients at a mean interval of 20 months after completion of treatment, and was higher in myositic and vasculitic subtypes. There was no significant correlation between duration of treatment and recurrence. CONCLUSIONS: This study has re-emphasized the importance and utility of orbital biopsy and histopathologic typing for optimal management of orbital inflammatory disease. It has also improved the knowledge of the rate and response to treatment of its various subtypes.

"Walk the Rim, Feel the Bone" Technique in Superior Sulcus Filling.

Superior sulcus filler injection is a nonsurgical method to rejuvenate the upper face. Blindness and stroke are devastating complications of facial filler injection. This study describes an injection technique that minimizes the risk of blindness and includes a case study demonstrating the cosmetic benefits of this procedure. To avoid retrograde injection of filler embolus into the ophthalmic artery, we advocate a "'walk the rim, feel the bone" approach. Small boluses of hyaluronic acid filler are given in preperiosteal plane, avoiding the superior orbital foramen.

The Looi suture technique for anchoring the lateral tarsal strip to the lateral orbital wall.

INTRODUCTION: The lateral tarsal strip procedure (LTS) was first reported by Anderson and Gordy in 1979 for the management of paralytic or senile eyelid laxity. Since its description, the LTS procedure has been subject to several modifications by various authors. In this study, we described the Looi suture technique, a small modification in the technique of suturing the LTS to the lateral orbital wall periosteum. Using this technique, the surgeon achieves a larger area of contact between the anterior surface of the tarsal strip and the lateral orbital wall periosteum, promoting a stronger adhesion. With a double-armed suture, the technique also allows for adjustment of the lower lid tension to avoid over- or under-correction of horizontal lid laxity. This study aimed to evaluate the technique. MATERIALS AND METHODS: This was a retrospective non-comparative case series of 39 eyelids of 31 patients who underwent LTS with Looi suturing technique for the correction of involutional lower lid laxity which had resulted in either entropion or ectropion. In this procedure, a novel technique utilising a double armed 5/0 Ethibond suture is used to secure the LTS to the lateral orbital rim, with the aim of increasing appositional contact between the LTS and periosteum. RESULTS: In 36 eyelids with entropion, the procedure was combined with lower lid retractor repair, and in 3 eyelids with ectropion, with medial tarsoconjunctivoplasty. Surgery was successful in 37 of 39 eyelids (94.87%) after one procedure. The remaining 2 eyelids required repeat procedures to achieve anatomical success. Both cases had been performed by trainee surgeons under supervision. Postoperative follow-up period ranged from 1 day (in a visiting overseas patient) to 2 years. CONCLUSION: This study described the Looi suturing technique in performing the LTS procedure and we found it a simple and effective modification when dealing with lower lid laxity.

Prospective audit of ptosis surgery at the Singapore National Eye Centre: two-year results.

PURPOSE: To evaluate the demographics, presentation, and surgical outcomes of patients undergoing ptosis surgery in an Asian population in a prospective manner. METHODS: A prospective ptosis audit was conducted over a 2-year period from January 2010 to December 2011 in a tertiary eye hospital in Singapore. All patients undergoing ptosis surgery by, or under the supervision of, an oculoplastic-trained consultant in the institution were included. Institutional Review Board approval was obtained for the study. RESULTS: This study comprises 302 patients, of which 236 were acquired and 66 were congenital ptosis cases. Levator repair (77.2%) was the most commonly performed procedure, followed by levator resection (13.9%) and brow suspension (8.9%). Forty-seven (10.1%) eyes had readjustment within 2 weeks, the reasons for readjustment being eyelid height undercorrection (n = 35), eyelid height overcorrection (n = 9), and unsatisfactory eyelid contour (n = 4). Postoperatively, 93.8% of patients showed an increase in marginal reflex distance-1 (MRD1), 91.3% achieved symmetry or <1 mm of asymmetry in MRD1, 98.5% had good eyelid contour, and 74.3% had symmetric eyelid crease. On a scale of 1 to 10, 83.1% of patients gave a subjective grade of 7 or better. CONCLUSIONS: This study is the first prospective ptosis surgery audit in an Asian population and takes a leading step in assessing both subjective and objective surgical outcomes in a prospective manner. With the continuation of this audit in years to come, it will allow us to generate clinical outcomes in a robust manner and allow for more reliable benchmarking with major centers elsewhere.

Nasolabial fold angle measurement using anterior segment optical coherence tomography in normal subjects.

PURPOSE: The human nasolabial fold angle (NFA) has been measured using MRI and photogrammetry and has been shown to decrease with age. The authors aimed to evaluate a novel method using optical coherence tomography to measure the NFA. METHODS: In this cross-sectional observational series, the authors used anterior segment optical coherence tomography (ASOCT) to image the NFA of both cheeks of 126 subjects aged 21 to 79 years. A dental vinylpolysiloxane custom-designed mould was used as a chin rest. The mean of 3 scans on each side was calculated and analysis of variance, multiple comparisons, and multiple linear regression were carried out using SPSS 11.0. RESULTS: Sixty-one subject (48.4%) were men and 65 (51.6%) were women. Mean age was 50.6 +/- 16.8 years (range, 21-79 years). The ASOCT successfully imaged the NFA in all subjects. Mean right and left NFA were 144.4 degrees +/- 17.1 degrees and 145.4 degrees +/- 17.7 degrees. The NFA were dissimilar between the 6 age categories by decade (p < 0.001). Age was the significant predictor of NFA, accounting for 55% of NFA variation. Every year accounted for a decrease of 0.78 degrees (p < 0.001) and 0.80 degrees (p < 0.001) for the right and left cheeks, respectively. Male sex resulted in an increase in NFA of 5.4 degrees (p = 0.007) and 4.0 degrees (p = 0.06) in the right and left cheeks, respectively. CONCLUSIONS: The NFA decreases with age and increases with male sex and can be measured with ASOCT accurately and easily.

A modified posterior approach for upper eyelid retraction.

PURPOSE: To describe and review a graded technique for lowering the upper eyelid from a posterior approach, recessing or resecting Müller muscle and levator aponeurosis but leaving a central pillar of Müller muscle intact, occasionally including a temporal tarsorrhaphy or superior tarsal strip where needed, and performing tissue dissection with a hot-wire cautery instrument. METHODS: A 10-year retrospective chart review was performed. Where follow-up was less than 6 months, telephone interviews were conducted to assess patient satisfaction with the procedure. Statistical analysis was performed using an unpaired t test. RESULTS: Ninety-nine patients (161 eyelids, 62 bilateral and 37 unilateral) with a mean age of 47 years (range, 21-82 years) were studied. The mean follow-up period was 61 months. The mean preoperative and postoperative margin reflex distances (MRD1) were 7.3 mm (range, 4.5-10 mm) and 4.3 mm (range, 2-7 mm), respectively. Eighty-nine percent (144/161 eyelids) achieved the target result of an MRD1 of 4 +/- 1 mm after one procedure. Fifteen eyelids (9% of operated eyelids) required a second procedure, and in this group, 2 (13% of the reoperated eyelids) underwent a third procedure. Although bilateral cases were more likely to achieve symmetry (p = 0.0071), 90% of either unilateral or bilateral cases achieved a postoperative MRD1 of 4 +/- 1 mm. Both mild (MRD1 of 5-7 mm) and severe (MRD1 > 7 mm) cases of eyelid retraction achieved similar operative outcomes. In the first 6 months after surgery, complications included undercorrection (8 eyelids), overcorrection (2 eyelids), and pyogenic granuloma (2 eyelids). None had a flattened upper eyelid contour. Late recurrence of retraction was seen in 9 eyelids. Mean operative time was 16 minutes per eyelid. CONCLUSIONS: This technique of lowering the retracted upper eyelid is effective even in severe cases of eyelid retraction. Minimal complications were encountered, and upper eyelid contours were well preserved. The use of hot-wire cautery dissection proved useful in shortening operative time.