Bartley R. Frueh

The Mechanistic Classification of Ptosis

The commonly used classifications for ptosis do not have a unifying concept, and this may contribute to confusion rather than clarification. Based on the mechanisms that cause ptosis, all cases can be classified into one or more of the following categories: (1) neurogenic; (2) myogenic; (3) aponeurotic; and (4) mechanical. While none of these mechanisms is original, this paper presents them together for the first time as an inclusive and helpful classification of ptosis. Before placing a patient in one or more of the four categories, a thorough history must be taken, an examination must be done, and appropriate laboratory tests must be performed. The thought processes then necessary to classify the ptosis should clarify not only the site of the defect but also the prognosis and range of procedures that may be used to correct the ptosis.

Treatment of Facial Spasm with Botulinum Toxin: An Interim Report

Forty-eight patients were given serial injections of botulinum toxin in their eyelids for treatment of eyelid spasm during a two-year interval. Ninety-four percent obtained relief of spasm from botulinum toxin injection. The duration of the spasm-free interval as well as the incidence of ptosis and of diplopia was dose dependent. The marked increase in the incidence of these side effects with only a small increase in the duration of the spasm-free interval, when a dose of 25 units per lid was used, leads the authors to conclude that this dose is too high and should not be used. Since diplopia was most commonly caused by paresis of the inferior oblique muscle, and since blepharospasm usually can be controlled by excising the upper lid protractors, further studies are required to determine whether lower lid injection is necessary and, if it is found to be so, whether injecting only the lateral portion of the lid would be adequate.

Evaluation and Treatment of the Patient with Ectropion

Abstract The evaluation of the factors that cause ectropion or may be present with it have not been described systematically. This paper discusses the significance of and examinations for horizontal tarsal laxity, medial canthal tendon laxity, punctal malposition, vertical inadequacy of the skin, orbicularis oculi paresis, and inferior lid retractor defects, and recommends surgical techniques for correcting each defect.

Long-term efficacy of orbital decompression for compressive optic neuropathy of Graves' eye disease.

In a retrospective evaluation of the long-term effect of transantral-ethmoidal decompression for compressive optic neuropathy, the authors evaluated visual acuity, visual fields, color vision, and motility in 30 patients (52 orbits) for a median follow-up period of 2.5 years (range, 0.6 to 6.5 years). Patients with preoperative visual acuity of 20/40 or better uniformly remained in this category and demonstrated an earlier stabilization of vision than those with poorer preoperative visual acuity. Of the ten patients whose preoperative visual acuity was 20/50 to 20/100, 80% attained acuity of 20/40 or better. In patients whose visual acuity was 20/200 or less (n = 7), 57% attained an acuity of 20/40 or better. The most common visual field defect was generalized constriction, which was noted in 43 of the 52 eyes (83%). After decompression, the preoperative visual field defect had improved or completely resolved in all but one case. Dyschromatopsia, noted in 20 eyes preoperatively, cleared in 17 (85%) postoperatively. Although the study showed that surgical decompression is beneficial, some patients may require additional modalities of treatment.

The Effect of Omitting Botulinum Toxin From the Lower Eyelid in Blepharospasm Treatment

We randomly selected 26 patients with essential blepharospasm to receive either botulinum toxin or saline injection in their lower eyelids to evaluate the necessity of lower eyelid injection to relieve blepharospasm. As diplopia may occur from botulinum toxin injections for blepharospasm, most commonly from injection of the lower eyelid, and surgical relief of blepharospasm is often achieved by excision of only the upper eyelid protractors, omission of toxin from the lower eyelid seemed both desirable and possible. All patients received botulinum toxin in the upper eyelids, above the eyebrows, across the glabella, and near the lateral canthus. Thirteen of 15 patients who received saline in their lower eyelids had relief of spasm, with the same spasm-free interval as those who received toxin. We recommend avoiding injection of toxin in the medial two thirds of the lower eyelid in order to diminish the likelihood of diplopia from inferior oblique muscle paresis.

A Comparison of Two Methods of Punctal Occlusion

We performed punctal occlusion by thermal cautery on 23 patients (45 sides, 90 puncta). One punctum on the right side was randomly assigned to deep cauterization of the punctum and vertical canaliculus, and the other punctum assigned to cauterization of the punctum only. The two treatments were assigned to the opposite puncta on the left side. One month after cauterization, the puncta that received deep cauterization were significantly more likely to have remained closed than those that received superficial cauterization (P less than .01). Survival analysis over a period of follow-up that exceeded one year after surgery, using time to examination because of a reopened punctum as the endpoint, indicated a long-term advantageous effect of deep over superficial cauterization.

Palpebral spring in the management of lagophthalmos and exposure keratopathy secondary to facial nerve palsy

Purpose: To evaluate the use of a palpebral spring, a dynamic facial reanimation technique, in the management of lagophthalmos and exposure keratopathy secondary to facial nerve palsy. Methods: A palpebral spring was placed in 29 eyelids of 28 patients with symptomatic facial nerve palsy. Preoperative and postoperative symptoms, upper eyelid margin to midpupil distance, lagophthalmos, and exposure keratopathy were evaluated. Results: At an average of 83 months follow-up, preoperative symptoms improved or resolved in 26 (90%) eyes. The upper eyelid margin to midpupil distance decreased and lagophthalmos and exposure keratopathy significantly improved after palpebral spring placement (p < 0.001). After modification of the technique by suturing the spring to the anterior tarsal surface, rather than encasing the tip in a silicone tube and letting it ride freely, tension of the spring required adjustment in 4 eyes (27%). Dislocation of the spring from the tarsus without exposure through the skin was observed in 1 eyelid (7%). The spring was replaced because of loss of function secondary to metal fatigue in 5 eyelids (33%) after an average of 43 months. Exposure of the spring through the skin was observed in 2 eyelids (14%) and required spring removal from 1 eyelid and replacement of the spring in the other. Conclusion: A palpebral spring is an effective treatment for lagophthalmos and exposure keratopathy in patients with facial nerve palsy who do not receive adequate relief from the static procedures of lower eyelid tightening and upper eyelid lowering. This technique significantly improved symptoms and signs in these patients while allowing some of the blink reflex.

CORNEAL THICKNESS MEASURED BY INTERFEROMETRY.

An optical method for measuring the thickness of transparent structures has been developed, and has been used to measure, in vivo, the thickness of the human cornea. The thickness is measured by placing the anterior surface of the cornea at the focus of a beam of coherent laser light and then measuring the spacing between the interference fringes generated by the reflected light. The thickness is then calculated from the fringe spacing. The method has been used to measure corneal thickness in frog and human corneas. These measurements have been correlated with histologic and pachometer measurements of corneal thickness. A significant capability of this technique is to measure the thickness of optically opaque corneas.

Marcus Gunn jaw-winking synkinesis: clinical features and management.

OBJECTIVE To evaluate the clinical features including eyelid excursion and management of Marcus Gunn jaw-winking synkinesis (MGJWS). DESIGN Observational case series. PARTICIPANTS Forty-eight consecutive patients with MGJWS. METHODS Clinical features and management of 48 patients with MGJWS were reviewed retrospectively. Upper eyelid excursion was measured and graded. Complications of surgical intervention were evaluated. MAIN OUTCOME MEASURES Resolution of MGJWS and symmetry of upper eyelids in primary position. RESULTS Excursion of the ptotic eyelid with jaw movement in MGJWS was graded as mild (<2 mm) in 16% of patients, moderate (2-4 mm) in 76% of patients, and severe (> or = 5 mm) in 8% of patients. Thirty patients with moderate or severe MGJWS underwent disabling of the involved levator muscle and bilateral or unilateral frontalis suspension and had more than 6 months of follow-up. After a mean follow-up of 62 months, MGJWS resolved in 29 (97%) patients and improved from 6 mm to 2 mm in 1 (3%) patient. Relative upper eyelid height was within 1 mm in 87% of patients in primary position and within 1 mm in 80% of patients in downgaze. Twenty-six patients had bilateral frontalis suspension with disabling of unilateral levator muscle on the involved side. Relative upper eyelid height was within 1 mm in 88% of patients in the primary position and within 1 mm in 88% of patients in downgaze. Four non-amblyopic patients had unilateral frontalis suspension with levator muscle disabling. Relative upper eyelid height was symmetrical in 75% of the patients in primary position and in 25% of patients in downgaze. Complications included eyelash ptosis in 10% of the patients, loss of eyelid crease in 10%, and entropion in 3%. CONCLUSIONS Most of the patients with MGJWS exhibited moderate eyelid excursion. Disabling of the involved levator muscle and bilateral frontalis suspension and, in selected cases, disabling of the involved levator muscle and unilateral frontalis suspension were effective in the treatment of MGJWS. Eyelash ptosis and loss of eyelid crease were the most common complications, each occurring in 10% of the patients. FINANCIAL DISCLOSURE(S) The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Intraorbital wood foreign body

Summary It is frequently difficult to identify and localize organic intraorbital foreign bodies despite modern day high-resolution imaging studies. Although there can be grave complications associated with retention of organic intraorbital foreign bodies, many believe that removal of such bodies in most cases is unwarranted. A high clinical suspicion, proper choice of imaging studies, and removal by a skilled orbital surgeon probably make the risk of surgical exploration and foreign body removal less than the risk of foreign body retention. We present a case of an intraorbital wood foreign body that required two separate explorations for retrieval. An initial intraconal exploration failed to locate the foreign body. Although the clinical suspicion was high, the imaging studies were equivocal, complicating the management. A second exploration yielded a large intraorbital wooden foreign body in the inferior extraconal space. The patient fully recovered and regained visual acuity of 20/20. The evaluation of such patients and details of management strategy are discussed.