Outcomes of endonasal dacryocystorhinostomy without mucosal flap preservation.

PURPOSE: Dacryocystorhinostomy (DCR) is the standard procedure for the treatment of acquired nasolacrimal duct obstruction (NLDO) that can be performed through an external or endonasal approach. Both techniques create a fistula from the lacrimal sac into the nasal cavity via a bony osteotomy. Historically, external DCR has been considered the gold standard; however, recent reports suggest endonasal DCR is an effective alternative. There are numerous variations of endonasal DCR described in the literature that report variable success rates. The purpose of this study is to describe the approach and success rate with endonasal DCR in which nasal mucosa, bone, and lacrimal sac mucosa are sequentially removed. METHODS: The authors retrospectively reviewed cases of endonasal DCR from 2004 to 2011 from 2 institutions (the University of California, San Diego, California, and the Fante Eye and Face Center in Denver, Colorado, U.S.A.). Patients with a history of epiphora and NLDO confirmed with punctal irrigation were included. Exclusion criteria were the presence of canalicular obstruction, history of orbital trauma, and prior DCR surgery. Success was defined as subjective relief of epiphora and confirmation of ostium patency with irrigation. RESULTS: A total of 324 patients (74 men, 250 women; mean age 59.3) encompassing 407 endonasal DCR cases were included in the study. The total case success rate was 92.2% with an average follow-up time of 91.5 days. Revision surgery was performed in 7 of the failed cases and resulted in success in 6 of these cases. CONCLUSIONS: Endonasal DCR is a simple and effective approach to surgically treat NLDO and offers success rates comparable with external DCR.

Orbitomalar suspension with combined single drill hole canthoplasty.

PURPOSE: Whether resulting from a surgical complication or involutional change, lower eyelid retraction and canthal dystopia can lead to lagophthalmos and frank ectropion. The authors present their experience with a single drill hole fixation for both the lateral canthus and suborbicularis oculi fat for severe canthal dystopia and lower eyelid retraction. METHODS: In this retrospective, consecutive study, the medical records of 13 patients who underwent single drill hole canthoplasty and suborbicularis oculi fat suspension were reviewed. A 4-0 nonabsorbable polypropylene suture was used to secure the canthal tendon, passed through a single lateral orbital rim drill hole from inside out. The suborbicularis oculi fat was then suspended in the same manner. Outcome measurements included linear marginal reflex distance 2, lagophthalmos, and subjective assessment of the results by the patient. RESULTS: Preoperatively, the average linear marginal reflex distance 2 was 7.3 ± 1.0 mm, the average lagophthalmos was 3.5 ± 0.8 mm, and the average horizontal palpebral fissure width was 25.7 ± 1.3 mm. Postoperatively, average linear marginal reflex distance 2 was 5.3 ± 0.7 mm (p < 0.05), average lagophthalmos was 0.3 ± 0.4 mm (p < 0.05), and average horizontal palpebral fissure width was 30.2 ± 0.7 mm (p < 0.05). All patients noted symptomatic relief and were satisfied with the appearance of their eyelids at 6 months of follow up. CONCLUSIONS: Single drill hole canthoplasty with suborbicularis oculi fat suspension is a viable alternative to previously described procedures. By using a single bony drill hole, rigid fixation is achieved with avoidance of multiple fixation points.

Reduction of orbital inflammation following decompression for thyroid-related orbitopathy.

PURPOSE: Thyroid-related orbitopathy (TRO) is associated with inflammation, expansion of orbital fat, enlargement of extraocular muscles, and optic neuropathy (ON). We examined the effects of orbital decompression on the inflammatory and congestive signs of TRO in patients who underwent emergent orbital decompression. METHODS: This retrospective, consecutive study included patients with ON from TRO who underwent orbital decompression. Pre- and postoperative orbital inflammatory signs in the operated and nonoperated, contralateral eyes were graded with the 10-item clinical activity score (CAS). RESULTS: Thirty-one orbits were included. Postoperatively, 22 patients and 29 orbits had resolution of ON while the remaining 2 patients had improvement in visual acuity. Mean preoperative CAS was 9.5 ± 0.4. At 12 months, postoperative CAS was 2.1 ± 0.6 (P < 0.01) in the operated eye and 3.2 ± 0.5 (P < 0.05) in the nonoperated, contralateral eye. CONCLUSION: In our series, 94% of orbits had resolution of ON. There was also a statistically significant postoperative reduction in the CAS in both the operated and nonoperated, contralateral eyes. This phenomenon may be due to lowered venous congestion, decreased intraorbital pressure, and diminution in inflammatory factors.

Use of antimetabolites in the reconstruction of severe anophthalmic socket contraction.

PURPOSE: The use of antimetabolites is well established in ophthalmology with expanded uses still being defined. We describe our experience of antimetabolite use in the reconstruction of severe anophthalmic socket contraction. METHODS: Nonrandomized, retrospective case series. The medical records and clinical photographs of 5 patients with severe socket contraction were reviewed. Either 5-Fluorouracil (5-FU) (50 mg/ml) or Mitomycin C (MMC) (0.4 mg/ml) was used during the course of the surgery via direct injection into the operative bed in the area of scarring. In addition, in 3 cases, 5-FU was also applied after surgery, in the clinic setting. Variables examined included: number of previous socket operations; preoperative ability to retain a prosthesis; type of socket reconstruction; type, amount, and location of antimetabolite injected; number of postoperative injections; average follow-up; and the postoperative ability to retain a prosthesis. RESULTS: All 5 patients had multiple operations previously. After surgery, all 5 were able to retain an ocular prosthesis. We did not observe any delay in wound healing, implant exposure, or extrusion, and no significant side effects were noted. CONCLUSION: The use of adjunct antimetabolite in severe anophthalmic socket reconstruction is an effective option that is well tolerated with minimal side effects.

Medial canthal degloving injuries: the triad of telecanthus, ptosis, and lacrimal trauma.

BACKGROUND: Medial canthal degloving injury causes a spectrum of damage to the soft tissues of the nasoorbitoethmoid complex. The authors present a case series of medial canthal degloving injuries and discuss clinical findings and treatment options. METHODS: The medical records of nine patients who presented to the University of California, San Diego Ophthalmic Plastic Service with medial canthal degloving injuries between 1999 and 2010 were reviewed retrospectively. Data collected included type and duration of injury, clinical findings, surgical procedures, and duration of follow-up. RESULTS: Nine patients (seven males and two females) were examined and treated from 1999 to 2010. Average age at the time of presentation was 33.3 years (range, 12 to 68 years). Causes of injury included motor vehicle accident (six patients), bicycle accident (one patient), dog bite (one patient), and bear attack (one patient). Average duration of injury before presentation to the authors' clinic was 4.4 years (range, 2 months to 20 years). Average follow-up was 32 months (range, 6 to 110 months). Common findings in these patients included a laceration extending from the forehead or eyebrow region across the medial canthus, telecanthus, eyelid ptosis, and canalicular injury. CONCLUSIONS: Medial canthal degloving injuries typically result in characteristic findings of vertically oriented laceration traversing the medial canthus, telecanthus, ptosis, and injury to the lacrimal outflow system. Reconstruction should be performed in a staged fashion, first addressing telecanthus and lacrimal system repair. Ptosis repair is performed as a second-stage procedure. Adherence to specific surgical principles leads to satisfactory functional and cosmetic results. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Analysis of eyelid fat pad changes with aging.

PURPOSE: Few studies have focused on the aging changes in the upper eyelid. This study evaluated the differential changes in the nasal and central fat pads of the upper eyelid associated with aging. METHODS: In this retrospective, consecutive series, the medical records and photographs of 77 patients were reviewed. The patients were grouped in 7 categories according to decade of life. Using a standardized scale, the volume grade of the nasal and central fat pads was graded from 0 to 3. Statistical evaluation correlating age with central and nasal fat pad change was performed. RESULTS: With aging, the central fat pad volume appeared to diminish, with relative sparing of the nasal fat pad. There was a positive correlation of the volume grade of the nasal fat pad with age and a negative correlation of the central fat pad with age. In addition, there was a statistically significant difference between the volume grades of the nasal and central fat pads in the groups 70 years and older. CONCLUSIONS: With aging, there appears to be a pattern of differential fat pad alteration. This study shows that in the upper eyelids of patients >70 years of age, the medial fat pad becomes prominent whereas the central fat pad atrophies. Teleologically, the relative preservation of nasal fat may be due to its higher abundance of neural-crest progenitor cells. Clinically, this finding has implications in esthetic and functional upper eyelid blepharoplasty.

The man who could not see what he could not eat.

A 55-year-old Hispanic man born in New Mexico presented with progressively worsening bilateral upper eyelid ptosis and dysphagia. External levator advancement 5 years before did not improve his ptosis. A thorough systemic workup for myasthenia gravis was negative, but electromyography suggested a myopathic process. Molecular genetic testing was positive for oculopharyngeal muscular dystrophy.

Modifying the upper eyelid crease in Asian patients with hyaluronic acid fillers.

BACKGROUND: Preliminary experience with the use of hyaluronic acid fillers as a nonsurgical alternative in the management of upper eyelid crease asymmetry and superior sulcus hollowing in Asian patients has proven promising. METHODS: This retrospective, interventional case series included seven patients (11 eyes) of various Asian ancestries. All patients had eyelid crease asymmetry or undesirably elevated eyelid creases along with hollowing of the upper eyelids. Upper eyelid crease asymmetry and hollowing of the superior sulcus were assessed before and after treatment. For all patients, hyaluronic acid fillers (Restylane, Medicis, Scottsdale, Ariz., or Juvéderm, Allergan, Irvine, Calif.) were injected into the retro-septal superior sulcus for eyelid hollowing and into the preseptal eyelid fold for crease asymmetry. Pretreatment and posttreatment photographs were taken. Outcomes were assessed by the total volume injected; masked, independent assessment using preoperative and postoperative photographs; and the subjective assessment of results by the patient. RESULTS: The average age was 43.1 years. The average volume of hyaluronic acid filler injected was 0.61 cc per eye. All seven patients were satisfied with the cosmetic improvement after hyaluronic acid filler injections. No adverse effects were noted. To date, the treatment has remained effective for as long as 18 months. CONCLUSIONS: Hyaluronic acid filler injections into the upper eyelid and superior sulcus are effective in providing volume to recreate the fullness natively present in the Asian upper eyelid. Furthermore, this fullness lowers the surgically created eyelid crease in those patients with eyelid asymmetry following cosmetic blepharoplasty. It should be considered in Asian patients presenting with upper eyelid hollowing or asymmetric eyelid creases.

Three carcinomas in one eyelid.

A 90-year-old woman presented with 2 masses on the right lower eyelid. Excisional biopsy revealed 1 lesion to be Merkel cell carcinoma and the other to be invasive squamous cell carcinoma. The patient also had a prior history of basal cell carcinoma in the same eyelid. This case emphasizes the importance of careful pathologic examination of all eyelid lesions regardless of previous history.

Applied anatomy for the aesthetic surgeon.

PURPOSE OF REVIEW: With the expanding view of the oculofacial surgeon as experts in the realm of aesthetic surgery, familiarity with facial anatomy is essential. The purpose of this review is to present an update on the relevant facial anatomy and its application on rejuvenation. RECENT FINDINGS: Numerous studies have redefined facial morphology and variations in facial features, which are important when treating all aesthetic patients. This particularly becomes valuable when patients of differing ethnic origins present for evaluation. Enhanced surgical options are now available that have expounded on previous work on skeletal and fascial attachments of the face that occur with aging. Additionally, an improved understanding of facial anatomy has led to safer and more effective surgical procedures to anatomically restore youth to the aging face. CONCLUSION: Anatomic and anthropomorphic knowledge is constantly improving in the realm of oculofacial plastic surgery. Newer insights into the treatment of facial aging have resulted from the application of an ever-expanding understanding of facial anatomy.

The trans-septal approach to the orbital apex via the contralateral exenterated orbit.

PURPOSE: To report a unique approach to the orbital apex through the contralateral orbit. METHODS: A 65-year-old male presented with right compressive optic neuropathy due to nasopharyngeal carcinoma spread. Clinical evaluation and imaging showed a right orbital apex mass. Surgery included apical orbital tumor debulking, and orbital decompression performed via the contralateral exenterated side. Postoperatively, symptoms were relieved. CONCLUSIONS: Orbitotomy via the contralateral exenterated orbit should be considered as a surgical option in these unique patients requiring direct access to the orbital apex.