Ana M. S. Morley

Use of hyaluronic acid filler for tear-trough rejuvenation as an alternative to lower eyelid surgery.

Purpose: To describe one surgeons experience with the use of hyaluronic acid gel (Perlane) as a tear-trough filler over an 18-month period and to assess patient satisfaction with the procedure. Methods: Consecutive, interventional case series involving case note review, masked grading of clinical photographs, and patient satisfaction survey. Results: A total of 198 eyes of 100 patients were treated, with a mean follow-up of 5.1 months. Patients were principally female (87%), white (89%), and middle-aged (mean age = 47.8 years). Eight percent had previous lower eyelid blepharoplasty, and one had thyroid orbitopathy. The gel was placed preperiosteally, deep to orbicularis, anterior to the inferior orbital rim, with a mean volume of 0.59 ml per eye. The injection procedure was tolerable in 95% of patients without local anesthetic. Side effects described by patients included bruising (75%), swelling (26%), blue discoloration (4%), and lumpiness (33%). However, only 7% required dissolution with hyaluronidase. Eight percent requested additional hyaluronic acid gel within 3 months. Mean downtime was 1 day. Most patients (85%) described marked or moderate satisfaction with the treatment, 5% were ambivalent, and 10% were dissatisfied. Conclusions: This series confirms the effective use of hyaluronic acid gel (Perlane) in tear-trough rejuvenation. It has high patient tolerability, minimal complications, and high patient satisfaction. However, bruising, persistent lumpiness, or lack of perceived effect can lead to dissatisfaction in approximately 10% of cases.

Use of Hyaluronic Acid Gel for Upper Eyelid Filling and Contouring

Purpose: To describe the use of hyaluronic acid gel for upper eyelid filling, contouring, and rejuvenation. Methods: In this consecutive, retrospective, interventional case series, standard serial puncture injections with preperiosteal placement of filler were administered at the superior orbital rim. Outcome measures included classification of upper eyelid volume deficiency as I) medial A-shaped hollow, II) generalized hollow, III) postblepharoplasty volume loss, and IV) upper eyelid hooding with subbrow volume deflation; volume of filler used; masked, independent assessment of pretreatment and posttreatment photographs; patient satisfaction; and complications. Results: Twenty-seven patients were included with a mean follow-up of 13 months. More than 85% were white women with a mean age of 51 years (range, 24–65 years). Five patients were classified as type I, 8 as type II, 11 as type III, and 3 as type IV. The mean volume of filler used was 0.4 ml/eyelid (range, 0.1–1 ml). Photographic assessment showed improved static upper eyelid contour in 23 patients (85%), little change in 3 patients (11%), and deterioration in 1 patient (4%). Twenty-six patients (96%) were satisfied with the treatment, although 5 (19%) requested additional filler and 1 patient underwent dissolution within 3 months. Two of the 3 type IV patients still required blepharoplasty/ptosis surgery. All patients developed mild bruising and swelling but no discoloration or lumpiness. Conclusions: Hyaluronic acid filler is an effective means of rejuvenating the upper eyelid and is particularly successful in patients with medial/generalized upper eyelid hollowing, or significant postblepharoplasty upper eyelid show. A blepharoplasty/brow lift/ptosis procedure is still frequently required for hooding due to subbrow deflation (type IV).

Techniques of Upper Eyelid Reconstruction

Reconstruction of the upper eyelid is one of the greatest challenges facing the orbitofacial surgeon. This comprehensive review outlines the principles of reconstruction and the range of techniques available. Methods of assessing upper eyelid defects are discussed, and an algorithm for reconstruction based on defect size and lamellar involvement is given. The review contains numerous detailed examples of reconstructive techniques, including secondary intention healing, local flaps, distal flaps, simple and composite grafts, occlusive and non-occlusive methods, and canthal fixation. Eyebrow and eyelash reconstruction is also covered.

Scleral hydraulic conductivity and macromolecular diffusion in patients with uveal effusion syndrome

PURPOSE To determine whether uveal effusion syndrome (UES) is caused by altered scleral permeability to water and large molecules. METHODS Transscleral water movement was measured using surgically removed sclera clamped in a modified Ussing chamber and connected to a water column set at intraocular pressure. Sclera was also clamped between two hemichambers, and transscleral diffusion of FITC-dextrans (4.4-77 kDa) was measured with a spectrophotometer. Clinical data were prospectively collected using postal questionnaires. RESULTS Ten patients (mean age, 63 years; mean spherical equivalent, +4.7 D) had a median preoperative visual acuity of 0.20 that improved to 0.33 after surgery. Nine eyes showed visual improvement, three worsened, and two were unchanged. Histology showed disorganization of collagen fibrils, with amorphous deposits expanding the interfibrillary spaces. The mean thickness (+/-1 SD) of the excised scleral specimens was 585 +/- 309 microm, and the mean specific hydraulic conductivity was 23.9 +/- 27.5 x 10(-14) cm(2), compared with 5.8 +/- 3.9 x 10(-14) cm(2) in age-matched control specimens (P = 0.068). Three specimens had hydraulic conductivity above the 95% CI of the controls. Control eyes showed a significant reduction in diffusion coefficient (D) with age. Eyes had a mean D of 5.69 +/- 5.35 x 10(-8) cm(2) x s(-1), similar to control eyes (6.14 +/- 2.40 x 10(-8) cm(2) x s(-1), 20 kDa dextran). In one eye, the result was higher than the 95% CI of the control; in three, it was lower. CONCLUSIONS UES is not caused by reduced scleral hydraulic conductivity, which tends to be higher than expected. Reduced macromolecular diffusion may impede the normal transscleral egress of albumin with subsequent osmotic fluid retention in some, but not all eyes.

The Use of Pericranial Flaps for Reconstruction and Elevation of the Lower Eyelid

Purpose: We present the novel approach of using pericranial flaps to reconstruct posterior lamellar eyelid defects or to achieve lower eyelid elevation. This technique has been employed in patients where standard tarso-conjunctival flaps are not an option and free posterior lamellar grafts cannot be supported due to the lack of viable anterior lamellar flaps. Methods: Pericranial flap, comprising inferiorly based forehead periosteum and the overlying loose areolar tissue, is constructed using a vertical paramedian forehead incision. Flaps are tunnelled subcutaneously to emerge at the proximal aspect of the eyelid defect and extend to the lateral orbital rim. They are secured with absorbable sutures. An overlying full-thickness free skin-graft or flap is used for the anterior lamella. Results: Eight patients underwent reconstruction or lower lid elevation. All patients achieved the predicted lower eyelid height with good cosmesis. Median follow-up 7.5 months (6–24 months). Indications were lower lid scarring/retraction (4), facial palsy (1), post BCC reconstruction (2), and exposed keratoprosthesis (1). In 2 (of 5) patients who had free skin-grafting, the overlying free skin-graft did not survive but acted as a biological dressing. All such patients still had good outcomes after epithelialisation of the flap. The posterior aspect of the pericranial flaps seems to act as an ideal substrate for conjunctivalisation, with little detrimental effect on the cornea. The robustness of the flap prevents the development of lid laxity over time. Conclusion: The pericranial flap is a versatile and robust flap that yields good cosmetic and functional outcomes when used in the reconstruction of posterior lamellar eyelid deficits. It is likely that, even when not viable, overlying free skin-grafts act as an excellent biological dressing until epithelialisation occurs.

Orbital plasmablastic lymphoma--comparison of a newly reported entity with diffuse large B-cell lymphoma of the orbit.

Objectives: To describe two cases of orbital plasmablastic lymphoma (PBL), a recently defined aggressive large-cell lymphoma with a plasmacytic immunophenotype, typically occurring in the oral cavity of HIV+ patients. To compare their presentation, management, immunohistochemistry and prognosis with orbital diffuse large B-cell lymphoma (DLBCL). Design: Consecutive, comparative case series of patients presenting to a specialist orbital service with histologically proven PBL or DLBCL. Results: Two cases of PBL and 14 cases of DLBCL were identified. The former were 40–49-year-old men, one HIV+, presenting with marked orbital/sinonasal tumour without oral involvement. Both tumours were negative for B-cell markers (CD20, CD79a), showed a plasmacytic immunophenotype (positive for CD 138, Vs38c), and displayed a Ki67 index of 100%. Despite chemotherapy, both patients died within 1 year. Of the 14 patients with DLBCL, 57% were female, mean age 65 yrs, and none were immunocompromised. Only 7 (50%) had sinus involvement and 3 (21%) had prior systemic lymphoma. All were positive for B-cell markers, with a Ki67 index of 55%–80%. None died within 1 year of diagnosis. Conclusions: PBL can present in the orbit and is more aggressive than DLBCL. It must be considered in the differential of orbital large-cell lymphoid tumours showing plasmablastic morphology or immunophenotype.

Rothia dentocariosa isolated from a corneal ulcer.

Purpose: Rothia dentocariosa is a common commensal in the oropharyngeal cavity but a rare human pathogen. Ocular culture has been documented only twice previously, both from vitreous samples taken in the context of endophthalmitis. These cases, and other reports of human Rothia infection, have proposed hematogenous spread from the oropharynx as the mode of transmission. Methods: A case report of an 11-year-old boy with a progressive right corneal abscess that required penetrating keratoplasty because of corneal perforation is detailed. The keratitis recurred in the graft, leading to an almost total epithelial defect, hypopyon, and descemetocele within 3 months. Results: R. dentocariosa was eventually isolated from the cornea, and the patient made a rapid recovery once topical medication was altered accordingly. Microbial identification was confirmed at a reference laboratory by using partial sequencing of 16s rDNA. The father later described his sons habit of wetting the fingertip with saliva before eyelid rubbing as a means of reducing ocular discomfort. Conclusion: This is the first reported case of corneal isolation of R. dentocariosa. It also suggests a direct mode of transmission of the organism to the eye by contaminated saliva.

Features and Management of an Acute Allergic Response to Acrylic Ocular Prostheses

Purpose: To report the occurrence, causes and treatment of an acute allergic response to the acrylic resin used in ocular prostheses. Methods: Retrospective review of presenting history, clinical findings and treatment of two cases. Results: Both patients developed an acute onset hypersensitivity reaction thought to be due to the acrylic resin found in the ocular prosthesis. The first patient was successfully switched to a glass eye. The prosthesis of the second patient was treated with an extra long curing cycle, after which, the patient was able to tolerate their prosthesis with no complications. Conclusion: The residual unpolymerised monomer that is present within poly-methylmethacrylate (PMMA) can rarely cause an allergic reaction. As an alternative to a glass eye the prosthesis may be subjected to an extended curing cycle converting more of the monomer to polymer.

Sarcoid-Related Dacryoadenitis Following Treatment with Interferon Alpha and Ribavarin for Hepatitis C

Sarcoidosis is an increasingly well-recognised complication of interferon therapy for hepatitis C infection, primarily manifesting with cutaneous or pulmonary involvement. However, we present an unusual case of sarcoid-related dacryoadenitis in a 67-year-old Caucasian lady following such treatment. The literature relating to ophthalmic presentations of interferon-related sarcoidosis is reviewed, and the potential for confusion with interferon-induced thyroid- associated orbitopathy is discussed.

Factors Prompting Sneezing in Intravenously Sedated Patients Receiving Local Anesthetic Injections to the Eyelids

PURPOSE To investigate the frequency of sneezing among patients receiving intravenous sedation and periocular local anesthetic for oculoplastic procedures in a single center. To identify potential risk factors involved. DESIGN Prospective, consecutive, interventional case series in a single tertiary-referral oculoplastic unit. PARTICIPANTS A total of 294 patients undergoing 314 isolated oculoplastic procedures, performed under intravenous sedation with periocular local anesthetic from November 2007 to November 2008. METHODS Prospective data collection on patient demographics, history of photic sneezing, intravenous sedative, depth of sedation, nasal oxygen, and periocular infiltration site. Standard local anesthetic was used in all cases, but the intravenous sedation was at the discretion of the attending anesthesiologist (7 in total). MAIN OUTCOME MEASURES Sneezing or attempted sneezing within 5 minutes of injection of the local anesthetic, as determined by agreed observation between attending staff. RESULTS Sneezing was observed in 16% of cases. No association was found between sneezing and patient age or presence of nasal oxygen. A weakly positive association was observed with male gender (55% sneezers vs. 37% non-sneezers, P = 0.03, relative risk [RR] = 1.5, confidence interval [CI], 1.1-2.0), bilateral infiltration (65% vs. 40%, P = 0.005, RR = 1.6, CI, 1.2-2.1), and upper eyelid infiltration (73% vs. 54%, P = 0.01, RR = 1.4, CI, 1.1-1.7). Photic sneezing was described in 47% of sneezers and 19% of non-sneezers (P = 0.0004, RR = 2.6, CI, 1.6-4.0). Because propofol was given to 95% of patients, no association with sneezing could be ascertained. However, opioid derivatives were found to be protective (12% vs. 43%, P<0.0001, RR = 0.3, CI, 0.1-0.6), whereas midazolam doubled the risk of sneezing (45% vs. 22%, P = 0.0008, RR = 2.1, CI, 1.4-3.0). Deep sedation (Ramsay score 5-6) also strongly increased the sneeze risk (65% vs. 23%, P<0.0001, RR = 2.8, CI, 2.1-3.8). CONCLUSIONS Propofol-based intravenous sedation, in combination with periocular local anesthetic injections, induces sneezing in approximately one sixth of general oculoplastic cases. Male gender, a history of photic sneezing, bilateral or upper eyelid infiltration, deep sedation, and the concurrent administration of midazolam all increased the risk, whereas adjunctive opioid use reduced the risk.