Primary lacrimal sac melanoma: a case report describing the novel use of fine needle aspiration cytology (FNAC) for diagnosis, together with literature review and immunotherapy treatment update.

Primary lacrimal sac melanoma (PLSM) is exceedingly rare and associated with high morbidity and mortality. Unfortunately, PLSM often presents insidiously resulting in delayed detection and poor prognosis. A 69-year-old Black man was suspected of having a lacrimal sac tumour following presentation with a left sided watery eye, bloody tears, and a lacrimal mass. Due to the patient's implantable pacemaker, defibrillator, and high anticoagulation, an ultrasound-guided FNAC was performed instead of incisional biopsy, revealing a PLSM. Diagnosis was confirmed following complete tumour resection with free flap reconstruction and neck dissection. Unfortunately, disease progression ensued despite further neck dissection and three cycles of both pembrolizumab and iplimumab. This is the first description of FNAC to accurately diagnose PLSM and highlights its use as an accurate, rapid, and minimally invasive technique that may allow an earlier screening diagnosis of lacrimal sac tumours. We also discuss the outcome of immunotherapy in recent similar cases.

Diplopia Following the Insertion of a Canalicular Bypass Tube: Etiology, Risk Factors, Management, and Outcomes.

PURPOSE: To report the etiology, management, and possible risk factors for diplopia after canalicular bypass surgery. METHODS: A multicenter retrospective, noncomparative case series of patients who developed diplopia following canalicular bypass surgery were assessed. RESULTS: Twenty-four cases of diplopia were identified across 12 institutions. Tubes were inserted as a primary procedure with external dacryocystorhinostomy (DCR) (1; 4%) or without DCR (10; 42%) or as a secondary procedure after external (8; 33%) or endonasal (5; 21%) DCR. Factors predisposing to local damage were noted in 17 (71%): these factors included preexisting autoimmune/inflammatory condition (7 cases), medial canthal tumor resection (5 cases), preoperative radiotherapy (2 cases), 2 drug treatments (topical and systemic), and 1 local surgery. Horizontal diplopia was due to restriction of abduction and first noted at a median of 3.5 months (mean: 17.8 months, range: 1 day to 112 months) and persisted in 23 (96%) cases with a mean restriction of -2, affecting primary gaze in 4 patients and activities of daily living in 13 (42%). Seventeen patients received various treatments: 10 were operated on resulting in cure in 1 and improvement in 9. A stable degree of diplopia persisted in all but one patient. CONCLUSIONS: Restriction of abduction causing horizontal diplopia is a rare complication with canalicular bypass surgery and a notably high proportion occurred after tube placement without DCR; carunculectomy was not ubiquitous. Although in some the diplopia may be improved with intervention, the chance of cure is low. This complication should probably be included during informed consent for canalicular bypass tubes.

Macular and Retinal Nerve Fibre Layer Thinning in Xeroderma Pigmentosum: A Cross-sectional Study.

The purpose of this study was to evaluate retinal thickness in different Xeroderma Pigmentosum (XP) complementation groups using spectral-domain optical coherence tomography (SD-OCT). This was a cross-sectional pilot study of 40 patients with XP. All patients had healthy-looking retinae and optic nerves on slit lamp biomicroscopy, and subtle or no neurological deficits. Patients were divided into two groups based on the known tendency for neurodegeneration associated with certain XP complementation groups. A third control group was obtained from a normative database. Using SD-OCT, we compared peripapillary retinal nerve fibre layer (pRNFL) and macular thickness between the groups. XP patients with a known tendency for neurodegeneration were found to have a statistically significant reduction in both pRNFL (p < 0.01) and macular thickness (p < 0.001) compared with healthy controls. In contrast, there was no statistically significant difference between pRNFL and macular thickness in XP patients not expected to develop neurodegeneration compared to the same control group. When both XP groups were compared, a statistically significant reduction in total pRNFL (p = 0.02) and macular thickness (p = 0.002) was found in XP patients predisposed to neurodegeneration. Our results suggest that pRNFL and macular thickness are reduced in XP patients with a known tendency for neurodegeneration, even before any marked neurological deficits become manifest. These findings demonstrate the potential role of retinal thickness as an anatomic biomarker and prognostic indicator for XP neurodegeneration.

Ophthalmic Manifestations of Xeroderma Pigmentosum: A Perspective from the United Kingdom.

PURPOSE: To document the ocular manifestations of xeroderma pigmentosum (XP), presenting via the United Kingdom (UK) XP service, and to analyze the correlations between XP genotype and ophthalmic phenotype. DESIGN: Prospective observational case series. SUBJECTS: Eighty-nine patients seen by the UK Nationally Commissioned XP Service, from April 2010 to December 2014, with a genetically confirmed diagnosis of XP. METHODS: Patients underwent a full ophthalmic examination at each visit. Clinical features from both eyes were recorded on a standard proforma. The most recent assessments were analyzed. A 2-tailed Fisher exact test was used to assess for differences in ocular features between patients in XP subgroups with impaired transcription coupled nucleotide excision repair (TC-NER) (category 1: XP-A, B, D, F, and G) and preserved TC-NER (category 2: XP-C, E, and V). MAIN OUTCOME MEASURES: Lid and periocular abnormalities, ocular surface pathologies, neuro-ophthalmologic abnormalities, lens and retinal abnormalities, and visual acuity (VA). RESULTS: Ninety-three percent of XP patients in our cohort had ocular involvement, with 65% describing photophobia. The most common abnormalities were in the periocular skin and ocular surface, including interpalpebral conjunctival melanosis (44%) and conjunctival injection (43%). Eleven percent of patients had required treatment for periocular cancers and 2% for ocular surface cancers. The most common neuro-ophthalmologic finding was minimal pupillary reaction to light (25%). Patients in category 2 had significantly more ocular surface abnormalities than patients in category 1, including a greater proportion of conjunctival injection (P = 0.003), conjunctival corkscrew vessels (P < 0.001), corneal scarring (P = 0.01) and pingueculae under the age of 50 (P = 0.02). Meanwhile, patients in category 1 had a higher proportion of poorly reactive pupils (P < 0.001) and abnormal ocular movements (P = 0.03) compared with those in category 2. Five patients (6%) presented to ophthalmologists with ocular surface signs related to XP, before any formal diagnosis of XP was made. CONCLUSIONS: A large proportion of XP patients have ocular involvement. Regular examination by an ophthalmologist is essential, especially in screening for eyelid and ocular surface tumors. The ocular phenotype-genotype segregation within XP patients suggests that XP is a heterogeneous and complex disease. With further study, we hope to offer these patients more individualized patient care.

Deep phenotyping of 89 xeroderma pigmentosum patients reveals unexpected heterogeneity dependent on the precise molecular defect.

Xeroderma pigmentosum (XP) is a rare DNA repair disorder characterized by increased susceptibility to UV radiation (UVR)-induced skin pigmentation, skin cancers, ocular surface disease, and, in some patients, sunburn and neurological degeneration. Genetically, it is assigned to eight complementation groups (XP-A to -G and variant). For the last 5 y, the UK national multidisciplinary XP service has provided follow-up for 89 XP patients, representing most of the XP patients in the United Kingdom. Causative mutations, DNA repair levels, and more than 60 clinical variables relating to dermatology, ophthalmology, and neurology have been measured, using scoring systems to categorize disease severity. This deep phenotyping has revealed unanticipated heterogeneity of clinical features, between and within complementation groups. Skin cancer is most common in XP-C, XP-E, and XP-V patients, previously considered to be the milder groups based on cellular analyses. These patients have normal sunburn reactions and are therefore diagnosed later and are less likely to adhere to UVR protection. XP-C patients are specifically hypersensitive to ocular damage, and XP-F and XP-G patients appear to be much less susceptible to skin cancer than other XP groups. Within XP groups, different mutations confer susceptibility or resistance to neurological damage. Our findings on this large cohort of XP patients under long-term follow-up reveal that XP is more heterogeneous than has previously been appreciated. Our data now enable provision of personalized prognostic information and management advice for each XP patient, as well as providing new insights into the functions of the XP proteins.

Use of dermal filler to improve exposure keratopathy in a patient with restrictive dermopathy.

A 26-year-old female with "Progeria-like" phenotype presented with bilateral lagophthalmos and exposure keratopathy. Given the paucity of available skin to harvest, in conjunction with co-morbidities, standard surgery in the form of conventional skin grafting was contraindicated. We highlight the role of dermal fillers in such situations to reduce upper lid sulcus hollowing and increase weight of the upper lid in order to reduce lagophthalmos.

Orbital radiotherapy for adult thyroid eye disease.

BACKGROUND: Thyroid eye disease is an autoimmune inflammatory condition of the orbital and periorbital tissues. Orbital radiotherapy is an anti-inflammatory treatment used in the treatment of active thyroid eye disease. It is administered as an outpatient procedure in 10 to 12 fractionated doses. OBJECTIVES: To assess the effectiveness and adverse events of orbital radiotherapy in thyroid eye disease. The effectiveness was dependent on the level of 'success' of the intervention predefined in each randomised controlled trial (RCT). SEARCH METHODS: We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2012, Issue 2), MEDLINE (January 1950 to March 2012), EMBASE (January 1980 to March 2012), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to March 2012), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not restrict the electronic searches for trials by date or language. We last searched the electronic databases on 12 March 2012. We screened reference lists of reports of included studies, other reviews and book chapters to find additional trials. We contacted trial investigators and experts in the field to identify additionally published studies. SELECTION CRITERIA: We included RCTs of orbital radiotherapy versus sham radiotherapy or other interventions enrolling adults, with a minimum of three months' follow-up and an endpoint of two years or less post treatment. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial quality and extracted data. Trial authors were contacted for missing data. The risk ratio was used for our primary outcome. For our secondary outcomes, the odds ratio and mean difference were reported where possible. MAIN RESULTS: We obtained full-text copies of nine potential studies and included five trials with a total of 244 participants in this review. Orbital radiotherapy was compared to sham radiotherapy in two studies and to glucocorticoids in three studies, as a monotherapy or combination therapy. There was heterogeneity (as defined in our protocol) of trial outcome measures. Our primary outcome of a composite score was used in the two trials comparing radiotherapy versus sham radiotherapy and showed a risk ratio of success of 1.92 (95% confidence interval (CI) 1.27 to 2.91) in favour of orbital radiotherapy. The primary outcome was not used in the other three trials. AUTHORS' CONCLUSIONS: This review found that orbital radiotherapy is more effective than sham radiotherapy for the treatment of mild-to-moderate thyroid eye disease. In a single trial no difference between radiotherapy and steroid monotherapy was found. A meta-analysis of our secondary outcome of disease severity was not possible but results from individual trials suggest a better outcome with combination treatment with steroids versus steroids alone. No significant changes in quality-of-life scores following treatment with radiotherapy versus alternative treatments were found. Short-term adverse events related to radiotherapy that were reported were local and mild but long-term data were lacking and development of retinal changes following radiotherapy was not reported on.

Lacrimal colic--an important ophthalmic symptom.

This concise case report introduces the novel concept of "lacrimal colic"-acute severe medial canthal pain resulting from sudden expansion of the lacrimal sac, commonly due to stone formation. The condition is compared with renal colic, in which a stone causes distension of the renal pelvis and similar severe pain. The case is presented with a concise literature review, and discussion on the relevance of the symptom in clinical practice.

Primary Wegener's granulomatosis of the orbital apex with initial optic nerve infiltration.

Wegener's granulomatosis can involve the orbit and sometimes the optic nerve. This usually occurs as a result of contiguous spread from affected sinuses or extraocular muscles, or from a vasculitic posterior optic neuropathy. However, we present an unusual case of isolated orbital apex infiltrative disease in a patient with known Wegener's granulomatosis. This initially caused painless optic neuropathy and progressed to painful ophthalmoplegia and blindness. Optic nerve biopsy, performed to exclude methotrexate-induced lymphoma, confirmed optic nerve infiltration. The condition was refractory to high-dose pulsed methylprednisolone but the patient gained symptomatic relief from rituximab. Wegener's granulomatosis should be considered in cases of isolated posterior optic neuropathy, and close attention should be placed on imaging the orbital apex.

Sarcoid-related dacryoadenitis following treatment with interferon alpha and ribavarin for hepatitis C.

Sarcoidosis is an increasingly well-recognised complication of interferon therapy for hepatitis C infection, primarily manifesting with cutaneous or pulmonary involvement. However, we present an unusual case of sarcoid-related dacryoadenitis in a 67-year-old Caucasian lady following such treatment. The literature relating to ophthalmic presentations of interferon-related sarcoidosis is reviewed, and the potential for confusion with interferon-induced thyroid- associated orbitopathy is discussed.

Use of hyaluronic acid filler for tear-trough rejuvenation as an alternative to lower eyelid surgery.

PURPOSE: To describe one surgeon's experience with the use of hyaluronic acid gel (Perlane) as a tear-trough filler over an 18-month period and to assess patient satisfaction with the procedure. METHODS: Consecutive, interventional case series involving case note review, masked grading of clinical photographs, and patient satisfaction survey. RESULTS: A total of 198 eyes of 100 patients were treated, with a mean follow-up of 5.1 months. Patients were principally female (87%), white (89%), and middle-aged (mean age = 47.8 years). Eight percent had previous lower eyelid blepharoplasty, and one had thyroid orbitopathy. The gel was placed preperiosteally, deep to orbicularis, anterior to the inferior orbital rim, with a mean volume of 0.59 ml per eye. The injection procedure was tolerable in 95% of patients without local anesthetic. Side effects described by patients included bruising (75%), swelling (26%), blue discoloration (4%), and lumpiness (33%). However, only 7% required dissolution with hyaluronidase. Eight percent requested additional hyaluronic acid gel within 3 months. Mean downtime was 1 day. Most patients (85%) described marked or moderate satisfaction with the treatment, 5% were ambivalent, and 10% were dissatisfied. CONCLUSIONS: This series confirms the effective use of hyaluronic acid gel (Perlane) in tear-trough rejuvenation. It has high patient tolerability, minimal complications, and high patient satisfaction. However, bruising, persistent lumpiness, or lack of perceived effect can lead to dissatisfaction in approximately 10% of cases.

The use of pericranial flaps for reconstruction and elevation of the lower eyelid.

PURPOSE: We present the novel approach of using pericranial flaps to reconstruct posterior lamellar eyelid defects or to achieve lower eyelid elevation. This technique has been employed in patients where standard tarso-conjunctival flaps are not an option and free posterior lamellar grafts cannot be supported due to the lack of viable anterior lamellar flaps. METHODS: Pericranial flap, comprising inferiorly based forehead periosteum and the overlying loose areolar tissue, is constructed using a vertical paramedian forehead incision. Flaps are tunnelled subcutaneously to emerge at the proximal aspect of the eyelid defect and extend to the lateral orbital rim. They are secured with absorbable sutures. An overlying full-thickness free skin-graft or flap is used for the anterior lamella. RESULTS: Eight patients underwent reconstruction or lower lid elevation. All patients achieved the predicted lower eyelid height with good cosmesis. Median follow-up 7.5 months (6-24 months). Indications were lower lid scarring/retraction (4), facial palsy (1), post BCC reconstruction (2), and exposed keratoprosthesis (1). In 2 (of 5) patients who had free skin-grafting, the overlying free skin-graft did not survive but acted as a biological dressing. All such patients still had good outcomes after epithelialisation of the flap. The posterior aspect of the pericranial flaps seems to act as an ideal substrate for conjunctivalisation, with little detrimental effect on the cornea. The robustness of the flap prevents the development of lid laxity over time. CONCLUSION: The pericranial flap is a versatile and robust flap that yields good cosmetic and functional outcomes when used in the reconstruction of posterior lamellar eyelid deficits. It is likely that, even when not viable, overlying free skin-grafts act as an excellent biological dressing until epithelialisation occurs.

Factors prompting sneezing in intravenously sedated patients receiving local anesthetic injections to the eyelids.

PURPOSE: To investigate the frequency of sneezing among patients receiving intravenous sedation and periocular local anesthetic for oculoplastic procedures in a single center. To identify potential risk factors involved. DESIGN: Prospective, consecutive, interventional case series in a single tertiary-referral oculoplastic unit. PARTICIPANTS: A total of 294 patients undergoing 314 isolated oculoplastic procedures, performed under intravenous sedation with periocular local anesthetic from November 2007 to November 2008. METHODS: Prospective data collection on patient demographics, history of photic sneezing, intravenous sedative, depth of sedation, nasal oxygen, and periocular infiltration site. Standard local anesthetic was used in all cases, but the intravenous sedation was at the discretion of the attending anesthesiologist (7 in total). MAIN OUTCOME MEASURES: Sneezing or attempted sneezing within 5 minutes of injection of the local anesthetic, as determined by agreed observation between attending staff. RESULTS: Sneezing was observed in 16% of cases. No association was found between sneezing and patient age or presence of nasal oxygen. A weakly positive association was observed with male gender (55% sneezers vs. 37% non-sneezers, P = 0.03, relative risk [RR] = 1.5, confidence interval [CI], 1.1-2.0), bilateral infiltration (65% vs. 40%, P = 0.005, RR = 1.6, CI, 1.2-2.1), and upper eyelid infiltration (73% vs. 54%, P = 0.01, RR = 1.4, CI, 1.1-1.7). Photic sneezing was described in 47% of sneezers and 19% of non-sneezers (P = 0.0004, RR = 2.6, CI, 1.6-4.0). Because propofol was given to 95% of patients, no association with sneezing could be ascertained. However, opioid derivatives were found to be protective (12% vs. 43%, P<0.0001, RR = 0.3, CI, 0.1-0.6), whereas midazolam doubled the risk of sneezing (45% vs. 22%, P = 0.0008, RR = 2.1, CI, 1.4-3.0). Deep sedation (Ramsay score 5-6) also strongly increased the sneeze risk (65% vs. 23%, P<0.0001, RR = 2.8, CI, 2.1-3.8). CONCLUSIONS: Propofol-based intravenous sedation, in combination with periocular local anesthetic injections, induces sneezing in approximately one sixth of general oculoplastic cases. Male gender, a history of photic sneezing, bilateral or upper eyelid infiltration, deep sedation, and the concurrent administration of midazolam all increased the risk, whereas adjunctive opioid use reduced the risk.

Techniques of upper eyelid reconstruction.

Reconstruction of the upper eyelid is one of the greatest challenges facing the orbitofacial surgeon. This comprehensive review outlines the principles of reconstruction and the range of techniques available. Methods of assessing upper eyelid defects are discussed, and an algorithm for reconstruction based on defect size and lamellar involvement is given. The review contains numerous detailed examples of reconstructive techniques, including secondary intention healing, local flaps, distal flaps, simple and composite grafts, occlusive and non-occlusive methods, and canthal fixation. Eyebrow and eyelash reconstruction is also covered.

Features and management of an acute allergic response to acrylic ocular prostheses.

PURPOSE: To report the occurrence, causes and treatment of an acute allergic response to the acrylic resin used in ocular prostheses. METHODS: Retrospective review of presenting history, clinical findings and treatment of two cases. RESULTS: Both patients developed an acute onset hypersensitivity reaction thought to be due to the acrylic resin found in the ocular prosthesis. The first patient was successfully switched to a glass eye. The prosthesis of the second patient was treated with an extra long curing cycle, after which, the patient was able to tolerate their prosthesis with no complications. CONCLUSION: The residual unpolymerized monomer that is present within poly-methylmethacrylate (PMMA) can rarely cause an allergic reaction. As an alternative to a glass eye the prosthesis may be subjected to an extended curing cycle converting more of the monomer to polymer.

Orbital plasmablastic lymphoma--comparison of a newly reported entity with diffuse large B-cell lymphoma of the orbit.

OBJECTIVES: To describe two cases of orbital plasmablastic lymphoma (PBL), a recently defined aggressive large-cell lymphoma with a plasmacytic immunophenotype, typically occurring in the oral cavity of HIV+ patients. To compare their presentation, management, immunohistochemistry and prognosis with orbital diffuse large B-cell lymphoma (DLBCL). DESIGN: Consecutive, comparative case series of patients presenting to a specialist orbital service with histologically proven PBL or DLBCL. RESULTS: Two cases of PBL and 14 cases of DLBCL were identified. The former were 40-49-year-old men, one HIV+, presenting with marked orbital/sinonasal tumour without oral involvement. Both tumours were negative for B-cell markers (CD20, CD79a), showed a plasmacytic immunophenotype (positive for CD 138, Vs38c), and displayed a Ki67 index of 100%. Despite chemotherapy, both patients died within 1 year. Of the 14 patients with DLBCL, 57% were female, mean age 65 yrs, and none were immunocompromised. Only 7 (50%) had sinus involvement and 3 (21%) had prior systemic lymphoma. All were positive for B-cell markers, with a Ki67 index of 55%-80%. None died within 1 year of diagnosis. CONCLUSIONS: PBL can present in the orbit and is more aggressive than DLBCL. It must be considered in the differential of orbital large-cell lymphoid tumours showing plasmablastic morphology or immunophenotype.

Subconjunctival prolapse of the palpebral lobe of the lacrimal gland occurring in association with occult orbital fat herniation.

INTRODUCTION: Sub-conjunctival prolapse of the palpebral lobe of the lacrimal gland can be a disfiguring and sometimes uncomfortable problem, usually caused by lacrimal gland enlargement or associated orbital lobe displacement. However, we present two novel cases associated with occult orbital fat herniation. METHOD: Retrospective interventional case series of two middle-aged/elderly male patients presenting with unilateral prolapse of the palpebral lobe of the lacrimal gland and no clinically apparent orbital fat prolapse. Neither patient had proptosis, globe displacement or diplopia, but both were aware of a subconjunctival mass in the lateral fornix causing a cosmetic concern. RESULTS: Imaging in both cases revealed a normal sized lacrimal gland with a prominent orbital fat pocket behind this. This fat was excised through an upper-eyelid skin crease approach with temporary detachment of the levator muscle in one case, and through a trans-conjunctival incision in the other. In both cases fat excision resulted in retro-placement of the palpebral lobe of the lacrimal gland such that it was no longer visible. Neither patient experienced any additional dry eye post-operatively. CONCLUSION: Sub-conjunctival prolapse of the palpebral lobe of the lacrimal gland can be associated with occult orbital fat herniation, revealed on imaging. Localised orbital fat excision is an effective means of treating this condition.

Use of an image-guided navigation system for insertion of a Lester-Jones tube in a patient with disturbed orbito-nasal anatomy.

Image-guided navigation systems are increasingly used in orbito-facial surgery where advanced pre-operative image manipulation and intra-operative localisation have proved invaluable. We describe the novel use of one such system for Lester-Jones tube placement to the contralateral nasal space in a 54-year-old man with left nasolacrimal duct obstruction following left rhinectomy, hemi-maxillextomy, radiotherapy and reconstruction for a left sinonasal squamous cell carcinoma. Reconstruction included a vascularised iliac crest graft, titanium mesh implant and polyaryletheretherketone (PEEK) maxillo-orbital implant. Pre-operative image analysis was used to determine the required tube length to extend to the right nasal space. Passive optical tracking facilitated intra-operative localisation of suitable entry and exit sites for the tube to avoid the orbital implants and achieve drainage into the contralateral nasal cavity. Free drainage and good positioning of the tube was confirmed by nasal endoscopy. This case supports a role for image-guided navigation in complex lacrimal surgery, particularly in cases with distorted anatomy.

Use of hyaluronic Acid gel for upper eyelid filling and contouring.

PURPOSE: To describe the use of hyaluronic acid gel for upper eyelid filling, contouring, and rejuvenation. METHODS: In this consecutive, retrospective, interventional case series, standard serial puncture injections with preperiosteal placement of filler were administered at the superior orbital rim. Outcome measures included classification of upper eyelid volume deficiency as I) medial A-shaped hollow, II) generalized hollow, III) postblepharoplasty volume loss, and IV) upper eyelid hooding with subbrow volume deflation; volume of filler used; masked, independent assessment of pretreatment and posttreatment photographs; patient satisfaction; and complications. RESULTS: Twenty-seven patients were included with a mean follow-up of 13 months. More than 85% were white women with a mean age of 51 years (range, 24-65 years). Five patients were classified as type I, 8 as type II, 11 as type III, and 3 as type IV. The mean volume of filler used was 0.4 ml/eyelid (range, 0.1-1 ml). Photographic assessment showed improved static upper eyelid contour in 23 patients (85%), little change in 3 patients (11%), and deterioration in 1 patient (4%). Twenty-six patients (96%) were satisfied with the treatment, although 5 (19%) requested additional filler and 1 patient underwent dissolution within 3 months. Two of the 3 type IV patients still required blepharoplasty/ptosis surgery. All patients developed mild bruising and swelling but no discoloration or lumpiness. CONCLUSIONS: Hyaluronic acid filler is an effective means of rejuvenating the upper eyelid and is particularly successful in patients with medial/generalized upper eyelid hollowing, or significant postblepharoplasty upper eyelid show. A blepharoplasty/brow lift/ptosis procedure is still frequently required for hooding due to subbrow deflation (type IV).