Ptosis repair and blepharoplasty in the adult.

When contemplating upper lid ptosis and blepharoplasty surgery, preoperative evaluation is essential so that the patient and the surgeon have similar expectations as to the final result of the surgery. Blepharoplasty and ptosis repair can be performed as a combined procedure in the adult. The procedure involves excising excess skin and underlying orbicularis muscle, and in some cases, orbital fat. The levator aponeurosis is advanced onto the tarsus and the excess levator excised. An eyelid crease is formed during closure by passing a suture through the advanced aponeurosis.

Upper lid blepharoplasty and ptosis repair using a transcutaneous approach.

Ptosis repair can be combined with a transcutaneous upper eyelid approach. The procedure includes removal of the excess skin, underlying orbicularis, and, possibly, orbital fat combined with levator aponeurosis advancement. Excellent results have been achieved for patients with dermatochalasis and ptosis causing significant visual field abnormalities, as well as for patients with no visual field abnormalities who desire improved cosmesis.

Canaliculorhinostomy following dacryocystectomy for removal of a benign fibrous histiocytoma of the lacrimal sac.

A 41-year-old woman had epiphora and a right lacrimal sac mass. A solid mass filling the entire lacrimal sac was found at surgery. After a month of testing and evaluation at the Armed Forces Institute of Pathology, the final diagnosis was benign fibrous histiocytoma. A dacryocystectomy was performed, and the entire tumor was removed. The area of the common canaliculus was then attached to a nasal mucosal flap, and the system was intubated with silicone tubing for 1 year. Two years after the tubing was removed, the epiphora had resolved and there was no recurrence of the tumor.

Surgical treatment of eyelid retraction associated with thyroid eye disease.

Fifteen patients (22 eyelids) were treated for upper eyelid retraction related to thyroid eye disease by recessing the levator aponeurosis and Müller's muscle through a lid crease incision. Neither spacers nor traction sutures were used, and the recessed muscles were not sutured to any of the surrounding tissues. The patients were not sedated and thus were able to sit up during the procedure; final lid heights also were determined with the patients in the sitting position. There were no overcorrections or undercorrections during follow up of at least 3 months.

Advances in oculoplastic surgery.

Ophthalmic plastic surgery, a sub-specialty within ophthalmology, encompasses diagnosis and treatment of diseases and abnormalities of the eyelids, orbit, and lacrimal systems. Eyelid carcinoma is a more common entity as well as blepharoptosis seen in children and adults. It can usually be corrected by surgery involving the levator palpebrae superioris or a tarsofrontalis suspension using synthetic material or human tissue. Retraction of the upper eyelid, the opposite of blepharoptosis, may be seen in patients with thyroid eye (Graves') disease. Treatment by recession of the levator aponeurosis and Muller's sympathetic muscle yields excellent results. Blepharoplasty and other procedures frequently performed by the ophthalmic plastic surgeon can be done for cosmetic or functional (correction of vision) reasons and often in conjunction with other eyelid surgery such as ptosis repair.

Bilateral lymphocytic infiltrates causing dacryostenosis after bilateral successful dacryocystorhinostomies.

A 73-year-old woman with a history of chronic lymphocytic leukemia had bilateral dacryocystorhinostomies for bilateral chronic dacryocystitis. The procedures were performed 7 months apart. Twenty-four months after the first dacryocystorhinostomy on the left side, the patient developed a mass in the area of the left lacrimal sac causing epiphora. A repeat dacryocystorhinostomy revealed a lymphocytic infiltrate causing the left dacryostenosis. Thirty-three months after the right dacryocystorhinostomy, the patient developed a right dacryostenosis with epiphora and no mass. Pathology specimens obtained during a repeat dacryocystorhinostomy on the right side revealed a similar lymphocytic infiltrate. This case is an unusual presentation of solid lymphoma in a traumatized area in a patient with chronic lymphocytic leukemia.

Orbital hemorrhage with proptosis following a dacryocystorhinostomy.

A 65-year-old patient with chronic leukemia underwent an uncomplicated dacryocystorhinostomy. On the first postoperative day, the eye was proptotic and chemotic with restricted movements. A CT scan revealed a medial juxtabulbar hemorrhage that blocked the surgical osteotomy. A clot was locally suctioned through the nose, and the symptoms resolved over the following weeks.

Silicone slings for the correction of ptosis associated with progressive external ophthalmoplegia.

Tarsofrontalis suspensions using silicone rods were performed in eleven patients for the ptosis associated with progressive external ophthalmoplegia. All patients had the eyelids elevated above the level of the pupils with resultant full field of vision and improved cosmesis. Patients have been followed for three to 24 months.

Levator aponeurosis surgery for the correction of acquired ptosis. Analysis of 113 procedures.

Levator aponeurosis surgery was used to treat 113 upper eyelids with acquired ptosis. Ninety-five percent of the eyelids were corrected to within 1 mm of the desired result. The range of eyelift lift was 1 to 5.5 mm. Follow-up period for these patients was 6 months to 7 years. Local anesthesia is required for this technique since the lid height is determined by asking the patient to look in various fields of gaze. Levator function of at least 8 mm should be present if more than 1 mm of ptosis needs to be corrected.

Graves' orbitopathy and the thyrotropin-releasing hormone (TRH) test.

The value of the thyrotropin-releasing hormone (TRH) test may be insufficiently emphasized in the diagnosis of patients with euthyroid Graves' disease who have unexplained proptosis or vertical diplopia. We saw three patients who had these orbital symptoms and normal routine serum thyroid studies. The orbital computed tomograms (CT) found an orbital myopathy in all, and the diagnosis of Graves' orbitopathy was made by an abnormal TRH test. Not all euthyroid Graves' patients will show a positive result, but in those who do, the test is diagnostic. The clinical summaries of our three patients and the applications of the thyrotropin-releasing hormone test in ophthalmic practice are reviewed.

Testicular seminoma metastatic to the orbit.

Painful exophthalmos, ophthalmoplegia, and visual loss in the right eye developed in a 28-year-old man four months after he underwent a radical orchiectomy and irradiation for a seminoma of the right testicle. Prednisone therapy failed to relieve the symptoms, and an orbital biopsy found a metastatic testicular seminoma. Orbital irradiation with radioactive cobalt reduced the exophthalmos, reversed the ophthalmoplegia, and improved his visual acuity. Previous cases of nonmetastatic exophthalmos in patients who had testicular seminoma have been reported, but, to the best of our knowledge, this is the first report of a patient who had orbital seminoma metastatic from the testis. Successful irradiation of the orbital focus can minimize ocular morbidity and may improve the prognosis.

Encysted corneal contact lens presenting as an eyelid mass.

A 57-year-old woman presented with a 10 by 10 mm movable eyelid mass which had been present for 8 months before examination by me. Diagnostic exploration of the eyelid was performed, and a cyst containing a hard corneal contact lens was discovered. Further history obtained after surgery revealed that the patient had lost her contact lens approximately 4 years prior to the surgical exploration.

Treatment of the lacrimal excretory system after resection of medial canthal and eyelid tumors.

A simplified method of lacrimal excretory system repair is presented. If part of a canaliculus is resected during removal of an eyelid tumor, the remaining section of the canaliculus can be exteriorized to the lacrimal lake. A silicone tube is threaded into the canaliculus and allowed to remain in place for one to two weeks. If both canaliculi and the common canaliculus are removed during resection for a medial canthal tumor, a silicone tube can be threaded into the nasolacrimal duct and brought out the area of the medial canthal angle. Conjunctiva which is wrapped around the tube can then form a new drainage canal into the remainder of the lacrimal excretory system.

Levator aponeurosis disinsertion in the young adult. A cause of ptosis.

Three patients, under the age of 35 years, had acquired ptosis. All patients gave a history of notable eyelid edema during extended periods. The patients underwent surgery under local anesthesia. Four eyelids were explored through the skin route, and a levator disinsertion was found in all cases. Repair was accomplished by reattaching the lower edge of the levator aponeurosis to the tarsus. Since the surgery was done under local anesthesia, the patient could elevate the eyelids during the entire procedure. The amount of eyelid elevation could, therefore, be determined at surgery. Levator aponeurosis disinsertion may be a cause for acquired ptosis following substantial eyelid edema in the young adult.

Levator aponeurosis tuck: a treatment for ptosis.

Seven patients with acquired ptosis were treated with a tuck in the aponeurosis of the levator palpebrae superioris muscle. Although the etiology for the ptosis was not always clear, associated conditions included progressive external ophthalmoplegia, prior ocular irradiation, prior ocular surgery and enucleation. One patient with progressive external ophthalmoplegia had good functional results. All of the other patients had good cosmetic, as well as good functional results. Since local infiltrative anesthesia was used, patients were able to cooperate during surgery by elevating and lowering their eyelids. The amount of tuck necessary to sufficiently elevate the eyelid could therefore be determined at surgery. The amount of lid elevation attained at surgery closely resembled the final postoperative result.