Amy M. Fowler

Floppy eyelid syndrome as a subset of lax eyelid conditions: relationships and clinical relevance (an ASOPRS thesis).

Purpose: To better define the wide spectrum of lax eyelid conditions, especially the subtype referred to as floppy eyelid syndrome, and to clarify its relationship with associated ophthalmic findings. Methods: A case-based retrospective review of all patients seen at UNC Department of Ophthalmology with a diagnosis of floppy eyelid syndrome or lax upper eyelid was performed. The period of review was from March 2002 to March 2007. A literature review was also performed using the term “floppy eyelid syndrome” and “lax eyelid syndrome” as the keywords in a PubMed search. Charts and cases were reviewed for the following information: age, sex, presence or absence of obesity, presence or absence of upper eyelid laxity, presence or absence of lower eyelid laxity, symmetry or asymmetry of eyelid laxity, sleeping position preference, diagnosis of obstructive sleep apnea (OSA), history of eye rubbing, diagnosis of keratoconus (KCN), lash ptosis, history of spontaneous eyelid eversion, papillary conjunctivitis, systemic hyperlaxity, diagnosis of meibomianitis, signs of anterior segment inflammation, and smoking or excessive sun exposure history. Results: From our UNC case review, 14 patients involving 17 eyelids were identified. From the literature review, 72 articles were recovered and evaluated to yield a total of 324 reported cases through February 2007. From the combined data (n = 338), the overall minimum prevalence of sleep apnea in patients with lax eyelid condition was 16% compared with an estimated 9% to 24% in the general population. Of patients with lax eyelid syndrome, those identified with OSA had significantly more individuals with obesity (76% vs. 20%) and male gender (89% vs. 61%) than the group without OSA. The prevalence of KCN in patients with lax eyelid syndrome was a minimum of 6.8%, which is considerably higher than the estimated prevalence in the general population of 0.6%. However, KCN appears to show a significant association with the patients side of sleeping preference. Conclusions: Eyelid laxity can result from a number of involutional, local, and systemic diseases but is frequently of unknown etiology. When it is consistently associated with papillary conjunctivitis and dry eyes it can be referred to as lax eyelid syndrome (LES). A number of specific subsets of LES can be identified. One such subset, occurring primarily though not exclusively in males and associated with obesity, has been defined as the floppy eyelid syndrome (FES). OSA has been associated with FES where it occurs with greater frequency than in the general population, but no greater than seen in obese males without FES, and therefore appears to represent an epiphonomenom only. However, given the demographics of FES, this condition offers some predictive value for OSA and should alert the physician to evaluate the sleep habits of all such patients. Keratoconus also shows some association with FES and with LES. However, data suggest that the causative factors are sleep preference for the involved side and nocturnal eyelid eversion, rather than any underlying physiologic or anatomic relationship.

Mycobacterium chelonae canaliculitis associated with SmartPlug use.

Mycobacterium chelonae is ubiquitous in the environment but is an uncommon cause of ocular and periocular infections. It is a pathogen that has been gaining increased attention in the ophthalmic literature because of the relatively large number of infections associated with laser-assisted in situ keratomileusis and other forms of refractive surgery. The authors present 3 patients who developed canaliculitis culture positive for M. chelonae more than a year after SmartPlug placement. These cases highlight some of the clinical scenarios that may be encountered in those who present with canaliculitis with a history of intracanalicular plug placement. Therapeutic considerations are also suggested.

Double-bridged flap procedure for nonmarginal, full-thickness, upper eyelid reconstruction

Purpose: To describe the technique and results of double-bridged flap reconstruction of full-thickness upper eyelid defects that spares the upper eyelid margin. Methods: The surgical technique is described and illustrated in 2 patients who underwent this procedure. Results: The 2 patients presented in this study achieved excellent functional and cosmetic results following the procedure. One patient subsequently underwent a frontalis sling procedure to correct residual ptosis. Conclusions: Double-bridged flap reconstruction of the upper eyelid that spares the eyelid margin can provide excellent functional and cosmetic results, particularly in cases of nonmarginal eyelid tumor excision, severe upper eyelid scarring, and severe cicatricial retraction.

Lipoblastomatosis: Case report and review of the literature

Purpose: To describe an unusual presentation of lipoblastomatosis and review the existing literature on lipoblastomatosis and lipoblastoma. Methods: Case report and literature review. Results: A 9-year-old girl was originally diagnosed as having preseptal cellulitis. After failure of systemic therapy, a CT scan showed a mass in the orbit. Biopsy of the lesion confirmed the presence of lipoblastomatosis, consisting of immature lipoblasts admixed with more-mature adipocytes. Conclusions: Lipoblastomatosis is a rare benign diffuse lipomatous tumor of embryonal fat that is uncommonly found in the head and face of children.

Piezosurgery in External Dacryocystorhinostomy.

BACKGROUND Dacryocystorhinostomy (DCR) can be performed via an external or endoscopic approach. The use of ultrasonic or piezosurgery has been well described for endoscopic DCRs but is lacking for external DCRs. This study presents a case series of external DCRs performed using piezosurgery evaluating results and complications. METHODS Prospective, consecutive case series of patients undergoing primary external DCR for lacrimal drainage insufficiency. A standard external DCR technique was used using 1 of 2 piezosurgery systems for all bone incision. All patients received silicone intubation to the lacrimal system. Surgical outcome was measured in terms of patient-reported epiphora as follows: 1) complete resolution, 2) improvement >50%, 3) improvement <50%, and 4) No improvement. Intra and postoperative complications were also recorded. RESULTS Fifty-two patients, 14 male and 38 female, were included in the study, with 2 patients having bilateral surgery. The average age of the patients was 55.8 years. The average length of follow up was 221 days. Surgical outcomes showed 72% of patients with complete resolution of epiphora and 21% with >50% improvement. There were 4 patients (7%) who had <50% improvement. There was 1 (2%) intraoperative complication and 2 (4%) postoperative complications recorded. CONCLUSIONS Piezourgery is a viable modality for performing external DCRs. The lack of surgical complications shows a potential for decreased soft tissues damage. The surgical success rate based on patient-reported epiphora is similar to those published for mechanical external DCRs. This modality may benefit the novice surgeon in the reduction of soft and mucosal tissue damage.