Comparison of automated and manual perimetry in patients with blepharoptosis.

PURPOSE: To compare Goldmann manual perimetry and Humphrey automated perimetry for sensitivity in detecting visual field loss, efficiency, and patient preference. METHODS: This prospective study compared Goldmann manual perimetry and Humphrey automated perimetry testing techniques in 20 consecutive preoperative blepharoptosis patients with unilateral or bilateral blepharoptosis with a marginal reflex distance of ≤+2.5 mm, no dermatochalasis overhanging the eyelid margin, and no superior visual field defects due to glaucoma, neurologic disease, or other causes. Main outcome measures included efficiency, patient preference, and sensitivity in detecting visual field loss. Institutional review board approval was obtained prior to the start of the study. RESULTS: Goldmann perimetry had significantly shorter examination times (-Δ6.4 minutes, 95% confidence interval: 4.5-8.3, p < 0.001) and was preferred by most patients (70%). There was no statistically significant difference between the 2 techniques in detecting superior visual field loss at 90° meridian. CONCLUSIONS: Goldmann manual perimetry for assessing visual field loss in blepharoptosis patients is more efficient than Humphrey automated perimetry and is preferred by patients. Both techniques are sensitive in detecting ptosis-related visual field loss.

Treatment of lower eyelid retraction by retractor release and posterior lamellar grafting: an analysis of 659 eyelids in 400 patients.

PURPOSE: To review one surgeon's experience with posterior lamellar grafting for lower eyelid elevation over a 15-year period, comparing the success of different posterior lamellar grafts used in 4 etiology groups. METHODS: A retrospective chart review of 400 patients (659 eyelids) was conducted. Patients were grouped into thyroid ophthalmopathy, previous surgery, trauma, and idiopathic causes. Three graft types were used: hard palate mucosa, free tarsoconjunctival, and free scleral. Objective measurements of lagophthalmos, scleral show, and superficial punctate keratopathy, and subjective patient symptoms, preoperatively and postoperatively were compared between graft types and etiologic groups. Complications were tabulated and compared between groups, as was any need for further surgery. The mean follow-up interval was 16.5 months. The main outcome measures were objective measurements of lagophthalmos, scleral show, and superficial punctate keratopathy. RESULTS: A mean reduction in lagophthalmos ( approximately 0.5 mm), superficial punctate keratopathy (mean score reduction = 0.2, on a scale of 1-3), and scleral show ( approximately 1.3 mm) was demonstrated for all etiology groups and graft types. Furthermore, 90% of patients subjectively reported a reduction of 1 to 3 symptoms. Hard palate mucosa grafts were more likely to be used than tarsoconjunctival grafts in cases with one or more previous surgeries (p < 0.001). Complications were more common with tarsoconjunctival grafts (except for bleeding), but the difference was statistically significant only for wound dehiscence (p = 0.004). CONCLUSIONS: Lower eyelid retraction repair with posterior lamellar grafting and lateral eyelid tightening can be recommended with confidence for eyelid retraction patients because most improved subjectively and by objective examination.

Fasanella-Servat procedure: indications, efficacy, and complications.

BACKGROUND: The Fasanella-Servat procedure is used for the repair of mild to moderate ptosis. The purpose of this study was to determine the efficacy of the Fasanella-Servat procedure for the repair of several forms of ptosis. METHODS: The authors retrospectively reviewed 169 charts of 2 surgeons from 1988 to 1996. All patients had undergone a Fasanella-Servat procedure for ptosis. Patients with less than a 1-month follow-up were excluded, leaving 153 eyelids of 144 patients. Surgical success was defined as lid symmetry within 0.5 mm or correction of eyelid contour abnormality from previous surgery or trauma. RESULTS: Ptosis was classified as involutional, occurring after intraocular surgery, congenital, due to Horner's syndrome present after levator surgery, and myogenic/other. With a mean follow-up of 7 months, success was achieved in 89.5% of cases (137/153). Among subgroups, success was highest at 100% in Horner's syndrome (8/8) and post-levator surgery (11/11), and lowest in congenital ptosis at 76.4% (13/18). Postoperative problems included dry eye symptoms (6/144 patients), contour abnormalities in 12 lids, and dermatochalasis in 10 lids. INTERPRETATION: The Fasanella-Servat operation is effective for mild to moderate ptosis from a variety of causes and for contour abnormality correction in patients with little or no ptosis. Despite the long-held belief that excision of the accessory lacrimal glands of Wolfring leads to dry eye symptoms, our study found this to be the exception. This procedure has the advantage of high reliability when reasonable preoperative criteria are applied and is minimally invasive.

Complications of orbital implants: a review of 542 patients who have undergone orbital implantation and 275 subsequent PEG placements.

PURPOSE: To inform patients and physicians of the complications associated with three commonly used orbital implants, as well as associated anophthalmic socket issues. METHODS: A retrospective chart review of 542 patients who underwent eviscerations, enucleations and secondary procedures by one surgeon (Dr. James Oestreicher) was completed, paying special attention to complications in the follow-up period prior to pegging, as well as those that occurred post-pegging. RESULTS: Approximately 60% of patients experienced complications prior to implant drilling, with discharge being the most prevalent (15.9%). Secondary procedures were associated with significantly greater complication rates prior to implant drilling. Silicone implants had significantly less pre-pegging pyogenic granuloma (P = 0.011) and hypo-ophthalmos (P = 0.042) than the other implant types. Seven implants had to be removed due to exposure. Implant drilling and peg placement were performed in 275 patients. Implant drilling complications were experienced by 67.4% of pegged patients, with a change in discharge from prior to pegging (27.2%) being the most prevalent. Plastic peg systems had a significantly higher incidence of complications than titanium systems. CONCLUSIONS: The majority of orbital implantations involve complications, these being largely minor ones which resolve spontaneously or are easily treated. Secondary implant procedures involve a higher likelihood of complications. Silicone implants have the smallest amount of complications. Should patients decide to undergo pegging, evidence sides strongly for the use of a titanium peg and sleeve system over the other peg types. Implant removal is a rare event; occurring in 1.3% (n = 7) of the study population.

Primary Ewing sarcoma of the orbit in an adult.

A 42-year-old man presented with visual field loss in the right eye and unintentional weight loss associated with a right orbital mass. Surgical resection and biopsy revealed a diagnosis of Ewing sarcoma, and systemic evaluation showed no metastasis. Subsequent chemotherapy and radiation resulted in tumor resolution without recurrence for 3.5 years. Although systemic symptoms are associated with a poorer prognosis, longer survival may be possible in the absence of metastasis.

Periorbital edema as the initial presentation of T-cell prolymphocytic leukemia.

A 57-year-old woman presented with a history of progressive bilateral upper and lower eyelid edema. Laboratory tests revealed T-cell prolymphocytic leukemia. Despite systemic treatment, she died 2 weeks after presentation. This life-threatening disorder should be added to the differential diagnosis of eyelid edema.

Hard palate mucosal grafts in oculoplastic surgery: donor site lessons.

PURPOSE: Hard palate mucosal grafts have been used successfully in posterior lamellar reconstruction. Atypical surgical findings, techniques, and complications related to the hard palate donor site are reported herein. DESIGN: Interventional case series. METHODS: The medical records of five patients who were cared for in an institutional practice between 1987 and 2002 were retrospectively reviewed. All patients had unusual donor site findings discovered during or after hard palate mucosal grafting for eyelid or socket reconstruction. RESULTS: Seven eyelid reconstructions with hard palate grafts were performed on the five patients (three male, two female), with an age range of 14 to 73 years at surgery. Patients were followed for an average of 6 years (range: 9 months to 11 years). Unusual hard palate findings during surgery or the postoperative period included hard palate and maxillary sinus malignancy, torus palatinus, and persistent donor site bleeding that provoked gastric variceal bleeding in a patient with preexisting liver disease. Atypical surgical techniques included both inadvertent and intentional harvesting of hard palate tissue over the midline palatine raphe. CONCLUSION: Hard palate grafting is a successful and commonly practiced approach to eyelid and socket reconstruction. An awareness of unusual anatomic findings or techniques associated with the hard palate donor site may improve surgical outcomes and decrease patient morbidity.