The failed probing.

The management of failed probing for congenital nasolacrimal duct obstruction is given by a panel of authors. Treatment options examined are repeat probing, inferiorturbinate infracture, closed lacrimal intubation and dacryocystorhinostomy. There is considerable variation as to the timing of these interventional techniques.

Surgical debulking of eyelid and anterior orbital plexiform neurofibromas by means of the carbon dioxide laser.

PURPOSE: To present the carbon dioxide laser as an effective tool for surgical debulking of eyelid and orbital neurofibromas. METHOD: Two patients with neurofibromatosis underwent surgical debulking of their eyelid and orbital plexiform neurofibromas by means of the carbon dioxide laser. RESULTS: Acceptable cosmetic results were obtained with the removal of eyelid and orbital neurofibromas with improved hemostasis and minimal destruction of surrounding tissue when compared with conventional methods of removal. CONCLUSIONS: The carbon dioxide laser may allow significant improvement in the removal of plexiform neurofibromas.

Secondary fractures of Le Fort I osteotomy.

PURPOSE: To report the ophthalmic complications of Le Fort I osteotomy for the correction of dentofacial deformities and to determine the maximal compressive loads applied during pterygomaxillary separation in a cadaver model. METHODS: Two cases of ophthalmic complications arising after Le Fort I osteotomy are reported. Le Fort I osteotomy was performed on five cadavers. The maximal compressive load applied during pterygomaxillary separation was recorded with a 10 kN (3,000 lbf) load cell of a MTS Mini-Bionix servo-hydraulic machine (MTS, Eden Prairie, MN, U.S.A.). A paired t test was used to compare forces applied to the right and left sides. Computed tomography scans of each specimen were obtained after Le Fort I osteotomy to document secondary fractures. The skulls were subsequently stained with 1% fuschin red to highlight secondary fractures. RESULTS: Maximum compressive loads during pterygomaxillary separation ranged from 22 N (5.0 lbf) to 162 N (36.5 lbf), with an average of 106 N (23.8 lbf) (SD 47.6 N [10.7 lbf]). Forces applied on the first operative side were significantly greater than forces applied on the second operative side (p = 0.0034). Secondary fractures were found in three specimens by computed tomography and in two specimens by 1% fuschin red. All secondary fractures occurred on the second operative side. CONCLUSION: Secondary fractures in the Le Fort I osteotomy procedures occurred on the side opposite the greater maximal compressive load and on the second operative side.

Transconjunctival frontalis suspension: a clinical evaluation.

PURPOSE: To determine the effectiveness of transconjunctival frontalis suspension in patients with blepharoptosis and poor levator function (eyelid excursion less then 5 mm). METHODS: The medical records of 29 patients (50 ptotic eyelids) were reviewed. RESULTS: Four patients (eight eyelids) had blepharophimosis syndrome, ten patients (27 eyelids) had congenital ptosis, seven patients (14 eyelids) had myogenic ptosis, and one patient (one eyelid) had neurogenic ptosis. Surgical results were good and complications were minimal during follow-up intervals ranging from six months to seven years. CONCLUSIONS: Transconjunctival frontalis suspension is technically simpler than traditional external frontalis suspension and yields satisfactory functional and cosmetic results in patients with poor levator function.

Levator aponeurosis disinsertion in congenital entropion of the upper eyelid.

PURPOSE: To present a patient with congenital entropion of the upper eyelid caused by levator aponeurosis disinsertion. METHODS: Case report. RESULTS: Surgical correction of the levator aponeurosis disinsertion corrected the upper eyelid entropion. CONCLUSIONS: Congenital upper eyelid entropion may be caused by levator aponeurosis disinsertion and treated effectively by repairing the anatomic defect.

Severe ocular and orbital toxicity after intracarotid etoposide phosphate and carboplatin therapy.

PURPOSE: To report severe ocular and orbital toxicity after administration of intracarotid etoposide phosphate and carboplatin. METHOD: Case report. RESULTS: A 52-year-old man with glioblastoma multiforme underwent left intracarotid administration of eto poside phosphate and carboplatin inferior to the ophthalmic artery. Within 7 hours, a nonpupillary block angle-closure glaucoma developed secondary to uveal effusion in the ipsilateral eye, which was relieved by cycloplegia. Four days later, severe orbital inflammation resulted in a visual acuity of counting fingers, proptosis, optic neuropathy, and total external ophthalmoplegia in the eye. The patient's condition improved after a lateral cantholysis and administration of high-dose intravenous corticosteroids. Two weeks later, an anterior uveitis occurred in the left eye, which responded to topical corticosteroids. During a 2-month period, the patient recovered to a visual acuity of 20/70, near normal motility, and normal intraocular pressure, and the ocular and orbital inflammation resolved. Preexisting ipsilateral chemotherapy-induced maculopathy became more pronounced. CONCLUSION: Ocular and orbital toxicity after intracarotid etoposide phosphate and carboplatin therapy is infrequently reported.

Infection of a porous polyethylene orbital implant with Capnocytophaga.

A 68-year-old woman experienced an infection of a porous polyethylene orbital implant caused by Capnocytophaga after a dental procedure. The infection was unresponsive to both topical and oral antibiotics and required removal of the porous polyethylene orbital implant. Capnocytophaga is a capnophilic, gram-negative bacillus. Capnocytophaga is a normal commensal of the mouth and is responsible for both gingivitis and periodontal disease. Capnocytophaga is a rare cause of ocular infections. This is the first reported patient with an infection of a porous polyethylene orbital implant caused by Capnocytophaga. The authors believe infected integrated orbital implants must be removed because neither topical or systemic therapy provide effective treatment.

A modified surgical technique in the treatment of facial nerve palsies.

The ophthalmic complications associated with facial nerve palsy present a challenging problem to the treating ophthalmologist. Over the last hundred years, a wide variety of techniques have been used to rehabilitate patients with facial nerve palsy. Each of these techniques is associated with unique complications. We describe a significantly modified surgical technique for the rehabilitation of patients with facial nerve palsy that has not, to our knowledge, previously appeared in the literature.

Histopathologic changes of the eyelid skin following trichloroacetic acid chemical peel.

The use of trichloroacetic acid (TCA) as a periorbital and eyelid peel for skin rejuvenation is gaining significant acceptance among oculoplastic surgeons, dermatologists, and other surgery groups. In spite of the current enthusiasm, there remain potentially serious complications resulting from any periorbital peel. Cases of cicatricial ectropion have been reported in phenol-peeled patients, and lower eyelid ectropion has reportedly occurred in patients undergoing deep eyelid peel in conjunction with a blepharoplasty (1,2). To avoid this complication, it is necessary to better understand the depth of the wound produced by different strengths and combinations of peeling agents applied to living eyelid tissue and, more important, to determine the concentrations of TCA that are likely to lead to cicatricial ectropion when applied in a consistent fashion. We chose upper-eyelid skin because it is easier to obtain for histopathologic study than lower-eyelid skin and, in our experience, is more sensitive to hypertrophic changes after chemical peeling or carbon dioxide laser resurfacing. We applied TCA to the preseptal skin of 10 patients 48 h before standard upper-eyelid blepharoplasty. The acid was applied to produce a "frost," using varying concentrations of acid, ranging from 20 to 50%. The treated skin removed at the time of blepharoplasty was reviewed in a masked fashion by a dermatopathologist to determine the depth of necrosis. We found that superficial peels with necrosis involving 30% of the epidermis were produced by the lowest-concentration combination of TCA applied (20% followed by 0%). As the strength increased, so did the depth of peel. The combination of 50% followed by a second application of 50% produced the deepest peel, with necrosis into the papillary dermis. This finding would indicate that the chance of developing cicatricial ectropion with any of the tested combinations of TCA should be very remote.

LeFort I orbitotomy: a new approach to the inferonasal orbital apex.

Numerous approaches to the orbit have been elegantly described in the literature. One area of the orbit that remains difficult to approach with standard techniques is the inferonasal apex. We describe a new surgical procedure we have termed the LeFort I orbitotomy. The technique involves creation of a LeFort I osteotomy to separate the maxilla from the zygoma and nose bilaterally. The posterior inferomedial orbital bone is then removed and the periorbita opened. This approach allows a more direct, less tangential view to this area of the orbit than does a Caldwell-Luc approach. Wider access for tumor manipulation is gained than would be possible with a transnasal endoscopic approach. An illustrative case report is presented.

Cementifying fibroma presenting as proptosis.

Cementifying fibromas are rare fibro-osseous tumors that arise from the periodontal ligament. These tumors are usually small, asymptomatic lesions noted on routine dental radiography, but they can develop into aggressive, expansile masses. The authors report the case of a 12-year-old boy with a tumor involving the maxillary, ethmoid, and frontal sinuses that extended to the right orbit, causing proptosis and disfigurement of the right side of his face. Removal of the tumor with facial reconstruction resulted in significant improvement of vision, despite long-standing disc edema and tension on the optic nerve. On histopathologic examination the lesion was found to be a cementifying fibroma.

Improvement in subjective visual function and quality of life outcome measures after blepharoptosis surgery.

PURPOSE: To examine patients' subjective perception of visual function and health-related quality of life as affected by blepharoptosis and the change in these perceptions after blepharoptosis surgery. METHODS: A 27-item questionnaire pertaining to vision-related activities and symptoms was used preoperatively to assess 50 consecutive patients (18 years old or older) with unilateral or bilateral acquired involutional blepharoptosis, and postoperatively six to eight weeks after blepharoptosis repair. RESULTS: Of the 24 items statistically analyzed, 16 items (67%) demonstrated significant improvement postoperatively (P < .05) among the unilateral cases and 18 items (75%) showed significant improvement postoperatively (P < .05) among the bilateral cases. The four activities that improved the most after surgery for both the unilateral and bilateral groups were the ability to perform fine manual work, hanging or reaching objects above eye level, watching television, and reading. CONCLUSIONS: Surgical repair of acquired involutional blepharoptosis resulted in significant improvement in several aspects of patients' subjective visual function and health-related quality of life. These issues are important in determining both the indications for and outcome of blepharoptosis surgery.

The bubble test: an atraumatic method for canalicular laceration repair.

Canalicular lacerations need to be correctly identified before surgical repair. Methods to find the medial cut end are numerous. With the use of direct sight or the bubble test or both, the identification and repair of the medial cut end of the lacerated canaliculus should be achievable in the majority of cases.

Eyelid anatomy.

BACKGROUND: The following anatomic information concerning the complex structure of the eyelids is distilled from gross and histologic study as well as surgical experience. OBJECTIVE: Our aim is to familiarize the reader with eyelid anatomy. CONCLUSION: Appropriate shape, contour, height and mobility of the lids are essential to adequate protection and function of the eyes as well as overall appearance. A thorough understanding of eyelid anatomy is therefore necessary to achieve optimal surgical results. For the purpose of this discussion the eyelids can be divided into the following structural planes: 1) skin and subcutaneous tissue; 2) orbicularis muscle and submuscular fibroadipose layer; 3) orbital septum; 4) preaponeurotic fat; 5) eyelid retractors; and 6) the tarsi and conjunctiva.

Bilateral localized orbital neurofibromas.

BACKGROUND: The authors report on a 30-year-old man who presented with progressive bilateral exophthalmos over a 2-year period. FINDINGS: Computed tomography showed large heterogeneous masses in the superior aspect of both orbits. Excisional biopsy via bilateral lateral orbitotomies showed the tumors to be well-circumscribed, relatively avascular, localized neurofibromas. The patient had several features suggestive of multiple endocrine neoplasia type IIB, including Marfanoid habitus, enlarged corneal nerves, thickened lips, and mucosal neuromas. CONCLUSION: Localized neurofibromas are rare in the orbit and, unlike plexiform neurofibromas, are not typically associated with von Recklinghausen's neurofibromatosis. Bilaterality of such localized neurofibromas has not been previously reported. Recognition of ophthalmic lesions suggestive of multiple endocrine neoplasia IIB should prompt evaluation for systemic manifestations of this disorder.

Detection of contralateral eyelid retraction associated with blepharoptosis.

The association between induced contralateral upper eyelid retraction and blepharoptosis, although well known, has not been well analyzed. The authors prospectively studied 50 consecutive patients with blepharoptosis. Interpalpebral fissure measurements of the contralateral "normal" or relatively less blepharoptotic eyelids were made in the resting position, with the blepharoptotic eye occluded, manually elevated, and after instillation of phenylephrine 2.5%. Ocular dominance also was tested. Contralateral interpalpebral fissure height decreased greater than or equal to 1 mm in 10 of 50 patients (20%) after manual elevation. Blepharoptosis was present or greater in the dominant eye in 7 of 10 (70%) patients in this group, but in only 7 of 40 (18%) patients in the group not showing such a response (P less than 0.001). Of 12 patients with congenital blepharoptosis, none demonstrated this response. In patients with acquired blepharoptosis, contralateral decrease in eyelid position also was directly associated with severity of blepharoptosis in the opposite eye. These findings suggest that contralateral induced eyelid elevation or retraction is frequently associated with blepharoptosis and is more apparent as visual impairment secondary to blepharoptosis increases. Detection of contralateral eyelid retraction is important in the preoperative evaluation of blepharoptosis.

Anatomy of the orbital septum and associated eyelid connective tissues. Implications for ptosis surgery.

The anatomy of the orbital septum and associated eyelid connective tissues was examined using cadaver dissection, histologic sections, surgical observations, and special radiologic imaging. The embryologic development of the eyelid connective tissues was also reviewed. Examination revealed a distinct layer of fibroadipose tissue in the eyelid and eyebrow posterior to the orbicularis and frontalis muscles, and anterior to the orbital septum. Fibrous septa within the submuscular fibroadipose tissue become contiguous with more compact lamellae of the orbital septum posteriorly imparting a multilayered quality to the orbital septum. Fat within the fibroadipose layer anterior to the orbital septum may be mistaken for the preaponeurotic fat pad by the unwary surgeon and may lead to surgical error. The orbital septum and the levator aponeurosis were found to join 2 to 5 mm above the superior tarsal border (average, 3.4 mm). Recommendations for ptosis surgery based on these anatomic principles are given.