Andre S. Litwin

Blepharoptosis surgery in patients with myasthenia gravis

Background/aims To review our approach of cautious surgical correction of blepharoptosis in patients with myasthenia gravis (MG) to minimise risk of exposure complications. Methods Retrospective case note review of 30 patients with symptomatic eyelid concerns despite appropriate medical treatment, who underwent eyelid surgery. The mean age at diagnosis was 47 years. 13/30 patients had systemic MG, 14/30 ocular MG and 3/30 congenital MG. The main outcome measures were improvement in eyelid height and/or position, duration of a successful postoperative result, need for further surgical intervention, and intraoperative or postoperative complications. Results 38 blepharoptosis procedures were performed on 23 patients. Mean age at time of surgery was 62 years, with an average follow-up of 29 months. 10 patients (16 eyelids) underwent anterior approach levator advancement, 4 patients (5 eyelids) posterior approach surgery and 8 patients (15 eyelids) brow suspension. One patient (2 eyelids) had tarsal switch surgery. An average improvement in eyelid height of 1.9 mm was achieved. Postoperative symptoms or signs of exposure keratopathy occurred in 17% of patients. This necessitated lid lowering in one eyelid of one patient. During follow-up, 37% of eyelids required further surgical intervention to improve the upper eyelid height, after an average of 19 months (range 0.5–49 months). Conclusions Over a third of patients in our series required repeat surgery, which would be expected when the initial aim was to under-correct this group. In contrast to previous commentaries, the amount of eyelid excursion was not the main factor used to guide the surgical approach.

Nonsurgical treatment of congenital ichthyosis cicatricial ectropion and eyelid retraction using Restylane hyaluronic acid.

DEAR EDITOR, The ichthyosiform dermatoses are hereditary conditions in which genetic mutations alter the normal development and function of keratinocytes, causing a defect in skin desquamation. Secondary ectropion and cicatricial eyelid retraction are commonly seen, often causing significant functional and cosmetic sequelae. Due to the generalized nature of the skin involved, management options are limited. Here we report three patients with sight-threatening bilateral upperand lower-eyelid cicatricial ectropion, managed with off-label use of hyaluronic acid (HA). Case 1 is a 3-year-old boy with lamellar ichthyosis. At presentation to Queen Victoria Hospital his vision was 4/60 and hand movements, with dense punctate epithelial erosions and 5 mm of lagophthalmos on forced closure. He underwent nonsurgical eyelid expansion using HA. Similarly to previous descriptions, eyelid skin was prepared with chlorhexidine. Injections were performed under general anaesthesia. Restylane lidocaine (Galderma, Lausanne, Switzerland) HA was injected using the 30-gauge needle provided via multiple puncture sites. The upper eyelid was initially injected just above the superior border of the tarsal plate, with injections progressing lateral to medial (Fig. 1). The needle was advanced suborbicularis, injecting deep to this muscle with some passing deep to the orbital septum (although anterior to the levator aponeurosis). Approximately 0 2 mL was injected during each aliquot. When 0 5 mL had been administered, a bulge became visible. The brow was distracted superiorly and this was massaged against the orbital rim in order to mould the contour. Care was taken to avoid any pressure against the globe. A similar technique was used on the lower eyelids, with 1 mL injected into each. Closure of eyes was achieved immediately, and at 4 months his vision (Kay picture cards) had improved to 6/15

Platinum segments: a new platinum chain for adjustable upper eyelid loading

Purpose Prospective study evaluating outcomes of individually sutured platinum segment chains in upper eyelid loading. Methods Single-centre, single-surgeon, prospective study. Upper eyelid loading with 0.4 and 0.2 g platinum segment chains for lagophthalmos. Segments were sutured to create a desired weight and attached to superior tarsus and distal levator aponeurosis following levator recession. Primary outcome measures: improvement in lagophthalmos and complications. Secondary outcome measures: cosmesis of eyelid margin contour and implant prominence. Minimum 3-month follow-up. Results Eighteen eyelids of 17 patients received segment chains (mean weight 1.2 g, range 0.8–1.6 g) and 3 for exchange of pre-existing gold weights. Median follow-up was 10 (range 6–17) months. Mean blink lagophthalmos improved from 7 (3–10) mm to 3 (0–6) mm (p<0.0001), and gentle closure from 3.2 (0–8) mm to 1.1 (0–4.9) mm (p=0.0004). Twelve patients (71%) reported no prominence, and the remainder, mild prominence only. The chain was graded as having no prominence in 78% (14/18) eyelids. Two required segment adjustments with removal of a single 0.2 g segment at 11 months and transfer of 0.4 g segment to the contralateral eyelid at 16 months, respectively. One complication (posterior, trans-conjunctival exposure above the superior border of the tarsal plate) was seen 12 months post surgery, requiring repositioning. Conclusions Platinum segment chains provide benefits of platinum chains with additional advantages of postoperative adjustibility. They can be used as an addition to pre-existing in situ weights or chains. Trial registration number REC reference: 13/SW/0146. IRAS project ID: 119022.

CADS grading scale: towards better grading of ophthalmic involvement in facial nerve paralysis

Introduction Ophthalmologists lack a facial nerve grading instrument (FNGI) that comprehensively encompasses the ophthalmic sequelae of facial nerve paralysis (FNP). Assessment and management of ophthalmic sequelae remains inconsistent, and outcomes of clinical studies are incomparable. We have developed and successfully adopted an FNGI based on four aspects of periorbital involvement: cornea, asymmetry, dynamic function and synkinesis. This CADS classification is specific for periorbital involvement, with objective and subjective parameters, to standardise grading. We present this classification and the results of a validation study in clinical practice. Methods A cross-sectional, validation study. Two clinicians independently assessed and graded each patient on the same day, blinded to each others grading. Each grader assigned a score to each of four parameters: C (0–3, ±a), A (0–2), D (0–3), S (0–2). Results Thirty patients (19 females, mean age 60, range 30–84 years) with unilateral facial paralysis were graded. A total of 60 assessments were conducted. CADS scores ranged from C0A0D1S1 to C3aA2D3S0. In the first 30 assessments (of the first 15 patients), the two assessors disagreed over the corneal grading in four patients. The last 30 assessments of 15 patients showed complete agreement in all four parameters of the grading scale. The overall inter-observer agreement was 86.7% for cornea, 93.3% for resting asymmetry, 93.3% for dynamic function and 86.7% for synkinesis. After the first six patients, Cohens κ reached 1 for all but synkinesis that ranged between 0.9 and 1. Conclusions We present a validation study of an FNGI specifically designed for ophthalmic involvement of FNP. Objective and subjective parameters helped standardise grading and management planning.

Acquired lacrimal sac fistula mimicking basal cell carcinoma

Background Lacrimal sac fistulae can arise after an episode of dacryocystitis, usually forming below the medial canthus. Preceding symptoms of a watery eye with mucous discharge and a history or signs of inflammation are typical.

Periorbital Autologous Fat Grafting in Facial Nerve Palsy.

PURPOSE To report outcomes and complications of periorbital autologous fat grafting (AFG) in improving volume loss-related symmetry and function in facial nerve palsy patients and to assess patient satisfaction. METHODS A retrospective, noncomparative review of all facial nerve palsy patients who underwent periorbital AFG at single center over a 4-year period. Two independent graders objectively assessed standard photographs for any change in volume loss and symmetry: pre- and postoperative periods (early, 0-2 months; intermediate, 3-9 months; and late, >10 months). Any adverse outcomes were recorded. Patient satisfaction was assessed by questionnaire survey. RESULTS A total of 18 facial nerve palsy patients (13 females) underwent periorbital AFG between February 2011 and 2015. Mean age was 51.9 ± 15.3 years (range, 26-76). Mean follow up was 6.8 ± 4.6 (range, 0.5-15) months. Photographs of 14 patients were eligible for evaluation. Tear trough visibility (p < 0.01), infraorbital rim visibility (p = 0.03), and lower eyelid-cheek junction symmetry (p < 0.01) improved in the early postoperative period with persistence of improvement in the latter parameter at intermediate postoperative period (p < 0.01). Lagophthalmos significantly improved (p = 0.03) in the early postoperative period. Two patients developed cheek cellulitis and 4 had persistent malar edema (3 had existing edema). Questionnaire survey showed a reduction in daytime ocular lubricants and an improvement in nocturnal-lagophthalmos symptoms. CONCLUSION Periorbital AFG is a useful adjunct in improving symmetry and lagophthalmos in facial nerve palsy patients where volume loss is a contributory factor but effects were not long lasting. Patient satisfaction is high. Those with preexisting malar bags are at higher risk of developing persistent malar edema following periorbital AFG.

How can we maximize the use of our operating lists? An analysis of factors influencing theatre efficiency in oculoplastic day surgery

ABSTRACT Operating theatre utilization has become the principal measure of NHS operating theatre service performance. We analysed data from oculoplastic theatres in a tertiary centre to identify factors influencing theatre efficiency. We conducted three audits on operating theatre utilization in 2011, 2014 and 2015. Data was collected from real time information entered into the hospital database, including time of arrival, induction, first cut and close of operation. The primary outcome measure was the operating list utilization rate, a combined value of anaesthetic and surgical time as a proportion of the total planned session time. The initial 2011 audit recorded an operating list utilization rate of 81.2%. However, this dropped to 64.5% in 2014 following new management and a move to a new theatre suite. Analysis of the factors contributing to poor theatre efficiency led to changes that streamlined the patient pathway, including standardized case scheduling and reducing staggered patient arrival. A 2015 reaudit analyzing the effects of these changes demonstrated an increase in the operating list utilization rate to 78%. It was significantly higher (p < 0.01) for whole-day lists (85%) compared to half-day lists (75%), suggesting that whole-day lists were more efficient. Operating theatres are a valuable resource and the factors affecting theatre efficiency within our unit are common and will be relevant to units elsewhere. Correcting them can lead to significant improvements in patient care. Data from this study may provide a benchmark for other units in the United Kingdom.

Two New Cases of Metastatic Basal Cell Carcinoma from the Eyelids

Abstract Background: Basal cell carcinoma (BCC) is an extremely common malignancy. Unlike other skin cancers, it very rarely metastasises. Methods: We present two cases of advanced BCC on the eyelids that metastasized to the parotid region after local excision. Discussion: We include a review of patients with metastatic BCC originating from the eyelids. Conclusion: Metastatic BCC from the eyelids is rare, but appears to occur in an older age group with a shorter time before metastasis when compared to metastatic BCC as a whole.

Don't forget ophthalmic differential diagnoses of cluster headache.

Several treatable ophthalmic conditions were missing from the differential diagnoses of cluster headache in the article by Nesbitt and Goadsby.1 For example, scleritis, uveitis, orbital inflammatory disease (including dacryoadenitis and sino-orbital disease), and intermittent angle closure glaucoma may present with recurrent pain, lacrimation, conjunctival injection, periorbital oedema, ptosis, …

Complications and outcomes of grafting of posterior orbital fat into the lower lid-cheek junction during orbital decompression

ABSTRACT Purpose: To report the complications of grafting of excised posterior orbital fat into the lower lid-cheek junction at the time of orbital decompression surgery. Methods: Retrospective review of consecutive patients undergoing orbital decompression combined with grafting of posterior orbital fat to the pre-malar and lateral canthal area (FG). A second group of consecutive patients undergoing orbital decompression but no orbital fat grafting (NoFG) were also studied as a form of comparative control. Standard patient data, including age, sex, visual acuity, degree of proptosis, operative details, diplopia or any other complications was collected. Independent assessment of pre- and post-operative photographs graded the lower lid-cheek junction. Results: Thirty-four orbits of 29 patients, of which 21 orbits underwent orbital decompression with orbital fat grafting (FG). There were no intraoperative complications, postoperative infections, or visual loss. Complications relating to fat grafting included prolonged swelling in 3 (17%) patients at 3 months, in 1 case lasting 6 months, lower lid lumps in 3 (17%), and fat seepage in 1 (6%). The FG group achieved a greater improvement in the appearance of the lower-lid-cheek junction at 12 months in comparison to NoFG. Mean grade improvement 1.24 ± 1.09 vs 0 ± 0.82 (p = 0.025). Median follow-up was 20 months (range 6–30 months). Conclusion: Grafting of excised orbital fat during orbital decompression can improve the appearance of the lower lid-cheek junction in patients being treated for thyroid orbitopathy. However, 24% of patients will experience swelling and/or lumpiness requiring several months to settle or further fat excision.