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.

Orbital histiocytosis with systemic involvement: A case with complex affiliations.

A 70-year-old male presented with orbital masses affecting the muscular cone. His past medical history was notable for diabetes mellitus, ischemic cardiopathy, sleep-apnea syndrome, and multiple serous effusions. The first biopsy specimen of affected orbital tissue revealed fibrohistiocytic infiltration resembling xanthogranuloma or Erdheim-Chester disease (ECD). An ulterior biopsy of affected orbital tissue showed lymphocyte emperipolesis with immunopositivity for CD68 and S100 but negative staining for CD1a marker, strongly suggesting Rosai-Dorfman disease (RDD). Afterward, pericardium and peritoneal effusions resulted in constrictive pericarditis and retroperitoneal fibrosis, respectively. The absence of distinctive clinical features made the diagnosis especially challenging. Attempts to control the disease using corticosteroids, radiation, orbital surgery, and interferon were unsuccessful. Aggressive treatments such as chemotherapy were not considered appropriate due to the general deterioration of our patient. Although the possibility of two concurrent diseases (e.g., systemic ECD and orbital RDD) cannot be discarded, we interpreted the orbital findings as likely due to RDD, and the entire condition of our patient as an extranodal RDD with atypical clinicopathological findings and outcome.

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.

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.

Periumbilical fat auto-graft associated to a porous orbital implant for socket reconstruction after enucleation.

Having to remove the sclera, fat and the optic nerve in patients undergoing an enucleation, translates in a larger volume that needs to be replaced to achieve good motility and aesthetic results. Using a 20 or 22 mm implant can only partially replace the removed volume. We report the results of our enucleation technique, which includes the use of a porous orbital implant combined with a primary fat graft to replace a higher percentage of the removed volume to achieve a better cosmetic outcome and to avoid implant related complications in high risk patients. Prospective, non-randomized study of enucleated patients for whom porous orbital implantation was performed with anterior placement of a fat auto-graft. The development of implant extrusion or exposure was recorded as well as the presence of conjunctival wound dehiscence and infection. Orbital volume was clinically and radiologically evaluated as well. Twenty-eight patients were included, with a postop follow-up of at least 6 months (6-79 months). No cases of migration or extrusion were found. One case of a large exposure resolved completely. All MRI demonstrated proper implant-graft integration and vascularisation. The aesthetic result and the symmetry were very adequate, with Hertel differences of less than 2 mm in all cases and good motility range. The fat graft is well tolerated, showing low incidence of implant-related complications whilst maintaining good volume and motility.

Intramuscular Lipoma of Superior Rectus Muscle.

The authors describe a case of a 27-year-old man with progressive diplopia and proptosis in whom imaging studies revealed the presence of a mass in the superior rectus muscle. Biopsy showed an infiltrative tumor of mature adipocytes with striated muscle fibres, corresponding to an intramuscular lipoma. Although extraocular muscle lipomas are very rare, with only two cases reported, they must be considered in the differential diagnosis of an orbital mass. They may cause significant morbidity to the patient, thus requiring surgical removal. Complete excision is usually difficult because of their infiltrative nature to the surrounding muscular fibres and their tendency to recur.

Giant Blue Nevus: A New Association to Nevus of Ota.

Nevus of Ota, also known as oculodermal melanocytosis, is a congenital pigmentary condition that can affect structures in the distribution of the ophthalmic and maxillary divisions of the trigeminal cranial nerve. Malignant transformation, although rare, may occur within nevus of Ota and result in uveal, cutaneous, orbital or even dural melanoma. We present a new association of Nevus of Ota complicated with a giant orbital Blue Nevus in a young white male and the management of this tumor.

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.

Fat transposition with a single subdermal stitch for the treatment of deep tear trough.

GOAL: To describe a fixation technique of the medial and central fat pads in the subperiosteal pocket for transconjunctival fat transposition, using a single subdermal, non-removable, non-absorbable stitch. MATERIALS AND METHODS: Retrospective study of 19 patients with bilateral deep tear through treated by means of transconjunctival fat transposition. Charts and photographic records were reviewed. RESULTS: Photographical and clinical improvement of the deep tear through and fat prolapse was observed in all patients in variable degrees. There were no intraoperative complications. Significant periocular hematoma occurred in 1 patient and solved without complications. Two patients presented transitory fat pedicle hardening and one patient presented a conjunctival inferior fornix granuloma, surgically removed. All patients were satisfied. CONCLUSIONS: Transconjunctival subperiosteal fat transposition with single subdermal stitch to fix the medial and central fat pads, for the treatment of deep tear trough and fat prolapse demonstrated high patient satisfaction, good aesthetic results with no significant or permanent complications.

Upper eyelid tarsoconjunctival flap for the treatment of Ahmed valve plate exposure.

PURPOSE: The aim of this study was to describe a new technique for the treatment of Ahmed valve plate exposure used in a patient with recurrent valvular plate exposure. BACKGROUND: An important complication of glaucoma drainage devices is its exposure. The treatment options reported include the use of different grafts covered by mucosa or conjunctiva. Despite these treatments many valves reexpose, especially in patients with previously damaged conjunctiva. METHODS: We report the case of a patient with Acanthamoeba keratitis and secondary angle closure glaucoma, who underwent a penetrating keratoplasty and an Ahmed valve implantation, and presented with repeated valvular plate exposure. After consecutive unsuccessful coverage methods, a novel use of a tarsoconjunctival flap was performed to solve this complication. CONCLUSIONS: Upper eyelid tarsoconjunctival flap is a useful option to cover exposed valvular plates in patients where traditional methods have failed.

Periumbilical fat graft: a new resource to replace large volume in the orbit.

GOAL: To describe the technique we use to obtain a fat graft from the periumbilical area to replace volume in our patients requiring total or partial orbital volume restoration or replacement. MATERIALS AND METHODS: Under local anaesthesia a one-piece fat auto-graft is obtained from one of the quadrants of the periumbilical zone through a 10- to 15-mm incision at the umbilicus edge. RESULTS: Excised adipose tissue contains connective tracts, with medium and small vascular vessels with discrete thickened wall and preserved endothelium, with more blood cells, and less dead cells. CONCLUSIONS: Fat grafts are the ideal fillers for patients requiring orbital volume replacement. The periumbilical fat graft technique we describe is simple, safe and fast, the learning slope shallow and the results gratifying in both the replaced volume, and the donor area with an invisible scar. The amount of fat that can be obtained with this technique through a minimal incision can be large enough.

Early frontalis flap surgery as first option to correct congenital ptosis with poor levator function.

UNLABELLED: In congenital blepharoptosis the upper eyelid cannot be lifted normally because of congenital impairment in the levator function. The descended eyelid margin partially or completely obstructs of the visual axis with the consequent risk of amblyopia. Frontalis suspension is the surgery of choice for ptosis with poor levator function creating a linkage between the frontalis muscle and the tarsus; the frontalis muscle is used to elevate the eyelid. Direct transplantation of frontalis muscle to the upper eyelid has been widely described. We report our experience using frontalis flap in congenital ptosis with poor levator function in children. METHODS: Retrospective study of 30 eyes with severe congenital ptosis and poor levator function treated by means of direct frontalis flap. Mean age 2 years. Eyelid measurements were taken at baseline, 1, 3, 12 months postoperatively and last visit. Mean ptosis degree was 5 mm (3-8 mm) and levator function 2 mm (1-5 mm). The presence of complications, flap function and palpebral contour were evaluated. Mean follow up time was 27 months. At last visit, ptosis degree ranged from 0 to 3 mm. DISCUSSION: Direct advancement of the frontalis muscle to treat severe eyelid ptosis is effective and stable in the long term avoiding the use of a linking structure, therefore the risk of foreign-body reaction, absorption, granuloma and late exposure, as well as the need for a second visible incision in the forehead. Patients learn how to control the lid height by means of the frontalis muscle achieving more symmetry.

Thermal damage influences endonasal dacryocystorhinostomy success.

OBJECTIVE: To compare the success rates of two surgical methods of endonasal dacryocystorhinostomy (DCR) at the stage of ostium creation. In procedure 1, a Colorado needle is used to create the mucosectomy, while in procedure 2 no heated instruments are applied to the mucosa. METHODS: A total of 173 patients (218 eyes) underwent endonasal DCR between 2006 and 2009. Efficacy was assessed by a fluorescein endoscopic test at 6 months of follow-up. RESULTS: The success rate in group 2 was higher than in group 1 (91 vs. 81%, p < 0.05). CONCLUSIONS: We have found a significant difference, which supports that a 'cold' surgical technique may be better than the use of heated instruments.

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.

Thyroid orbitopathy obscuring the diagnosis of a rare neuromuscular hamartoma of the superior rectus muscle in an adult.

A neuromuscular hamartoma is a rare benign tumour that is most frequently associated with peripheral nerves. The authors present a case of a 61 year-old man with bilateral exophthalmos and lid retraction who developed further proptosis and chemosis in the left eye over a five month period. An initial diagnosis of thyroid orbitopathy was made and he had a limited response to two courses of oral steroid administered in another centre. He was subsequently referred to our institution for further management when his condition worsened following withdrawal of treatment. Orbital CT scan showed a thickening of the recti muscles and particularly the left superior rectus and overlying soft tissue. Given this unusual pattern of muscle involvement in thyroid orbitopathy, a muscle biopsy was performed. This showed the presence of a neuromuscular hamartoma without malignant features. The orbital fat biopsy showed no pathological findings. A neuromuscular hamartoma not associated with a peripheral nerve is a rare entity, especially when coupled with an extraocular muscle. We wish to highlight the importance of a muscle biopsy when faced with a clinical picture and radiological pattern of extraocular muscle enlargement not typical of what we know to occur traditionally in thyroid eye disease.

La investigación experimental y la experiencia clínica de las superficies de los implantes dentales (I) / No disponible

La utilización de los implantes oseointegrados para restaurar a los pacientes edéntulos se ha incrementado en la práctica general. Lasuperficie de los implantes es muy importante para conseguir la oseointegración. Existen muchos tipos de superficies en los implantes dentales. La investigación en superficie de implantes comienza con la superficie mecanizada. La superficie rugosa incrementa la adherencia celular y muestra una mayor área de contacto hueso-implante. El recubrimiento con plasma de titanio e hidroxiapatita fueron métodos comunes para modificar la rugosidad de la superficie. Más recientemente, el chorreado con partículas (ej. alúmina, óxido de titanio) de diferentes diámetros y el grabado ácido (ej. chorhídrico, sulfúrico, nítrico) son otros procesos que pueden incrementar la superficie rugosa de los implantes. El tratamiento de la superficie de los implantes constituye un importante campo en futuras investigaciones de la implantología oral (AU)

Use of osseointegrated implants to restore edentulous patients has increased in the general dentistry. Implant surface is very important for enhance osseointegration. They are many types of dental implant surfaces. Implant surface research begins with machined or turned surface. Roughened surface titanium increase cell adhesion and exhibit stronger bone-implant contact area. Plasma-spray and hydroxyapatite coating were common methods for rough surface modification. Most recently, blasting with particles (i.e. aluminium, titanium oxide) of various diameters and chemical acid-etching(i.e. hydrochloric, sulphuric and nitric acids) are another process by which surface roughness can be increased. The surface modifications of titanium constitute an important field for future research of implant dentistry (AU)

Predictability of conjunctival-Müellerectomy for blepharoptosis repair.

PURPOSE: To assess the predictability of the algorithm used to determine the amount of tissue resection for conjunctival-Müellerectomy during blepharoptosis repair. METHODS: A consecutive case series of all patients undergoing conjunctival-Müellerectomy during blepharoptosis repair between July 2001 and February 2005. All of the cases had a positive phenylephrine test, and the mean preoperative upper marginal reflex distance (MRD1) was +1.60 mm (range: -1 +/-3.5 mm). Each patient underwent excision according to the following algorithm: 10 mm of resection for 2 mm of ptosis, 8 mm of resection for 1.5 mm of ptosis, and 6 mm of resection for 1 mm of ptosis. RESULTS: Fifty-five patients underwent conjunctival-Müellerectomy during blepharoptosis repair on 73 eyelids, using the above algorithm. Thirty-seven cases were unilateral and 18 were bilateral. The mean postoperative MRD1 was +3.42 mm (range 0-+4.5 mm). Postoperative symmetry was found in 42 of 55 patients (76.4%) after one surgical procedure. Patient satisfaction based on contour, symmetry and height after one repair was achieved in 52 of 55 patients (94.55%). There were three reoperations for previous undercorrection. CONCLUSION: This algorithm quantifies conjunctival-Müellerectomy during blepharoptosis repair. Excellent and very predictable results are obtained by a technique that is both simple and achievable in a short operating time.