Bhupendra C. K. Patel

Blepharospasm: past, present, and future.

Summary: To investigate causes, associations, and results of treatment with blepharospasm, 1,653 patients were evaluated by extensive questionnaires to study blepharospasm and long-term results of treatment with the full myectomy operation, botulinum-A toxin, drug therapy, and help from the Benign Essential Blepharospasm Research Foundation (BEBRF). The percent of patients improved by the BEBRF was 90%, full myectomy 88%, botulinum-A toxin 86%, and drug therapy 43%. The patient acceptance rate for the BEBRF was 96%, full myectomy 82%, botulinum-A toxin 95%, and drug therapy 57%. Blepharospasm is multifactorial in origin and manifestation. A vicious cycle and defective circuit theory to explain origin and direct treatment rather than a defective specific locus is presented. All four forms of therapy evaluated are useful and must be tailored to the patients needs. Mattie Lou Koster and the BEBRF have helped blepharospasm sufferers more than any other modality, and all patients should be informed of this support group. The full myectomy is reserved for botulinum-A toxin failures, and the limited myectomy is an excellent adjunct to botulinum-A toxin.

Management of postblepharoplasty lower eyelid retraction with hard palate grafts and lateral tarsal strip.

Lower eyelid malposition is the most common long-term complication following transcutaneous lower eyelid blepharoplasty. The malposition may include rounding of the lateral canthal angle, lower eyelid retraction with inferior scleral show, or frank ectropion. The result is cosmetically unacceptable and may be associated with tearing, irritation, and other exposure keratitis symptoms. Multiple factors, including lower eyelid laxity, shortage of skin, and scarring of the middle lamella, may be responsible for this malposition. A systematic examination of the lower eyelid, as presented, helps to assess the degree to which each of these factors is responsible for the malposition. Patients with the most severe degree of lower eyelid malposition generally have middle lamella scarring. If this abnormality is not addressed, lower eyelid procedures aimed at correcting the malposition are doomed to failure. In the presence of significant middle lamella scarring, a spacer is required to provide vertical height and stiffness to support the lower eyelid following release of the cicatrix. A systematic approach aimed at addressing the underlying abnormalities was developed. In patients with significant middle lamella scarring, hard palate mucosa grafts were used as spacers in 29 eyelids (17 patients). A lateral canthotomy and transconjunctival incision allow access to the scarring in the lower eyelid retractors and septum. After careful release of all cicatrix, a hard palate mucosa graft is inserted between the lower border of the tarsal plate and the recessed conjunctiva, lower eyelid retractors, and septum. Horizontal lower eyelid laxity, when present, is corrected by performing a lateral tarsal strip. Most patients do not have a true deficiency of the anterior lamella (skin and orbicularis oculi muscle). When a moderate amount of anterior lamella deficiency is present with significant scarring of the middle lamella, the technique we describe allows correction of the lower eyelid malposition without a skin graft. After a follow-up interval of 6 to 30 months (mean 14 months), excellent results were obtained in all eyelids. Complications included corneal abrasions in two eyes before routine use of bandage cornea contact lenses at the end of surgery and a secondary bleed from the roof of the mouth in one patient. Palate mucosa closely resembles tarsus and provides excellent vertical support to the eyelid. It is stiff enough to maintain eyelid contour without causing a cosmetically unacceptable bump. Tissue can be obtained with ease. The technique, as described, addresses the underlying causes of lower eyelid malposition and gives excellent functional and cosmetic results.

Successful treatment of rhino-orbital mucormycosis without exenteration: the use of multiple treatment modalities.

Purpose To describe the successful management of rhino-orbital mucormycosis without the use of orbital exenteration. Method Case report. Results The patient had successful eradication of the fungal infection with retention of normal vision and ocular function. Conclusions The use of multiple treatment modalities including aggressive surgical debridement guided by intraoperative frozen section monitoring, intravenous liposomal amphotericin B, intraorbital regular amphotericin B and hyperbaric oxygen may allow complete resolution of orbital phycomycosis and spare the patient from the blindness and disfigurement associated with exenteration.

Superomedial Lid Crease Approach to the Medial Intraconal Space: A New Technique for Access to the Optic Nerve and Central Space

Purpose To present clinical and cadaver studies of a new approach to the medial intraconal space. Methods We retrospectively review our clinical results by using a new technique to gain access to the medial intraconal space through a superomedial lid crease incision. We also use cadaver dissection studies to compare this new approach with the medial transconjunctival approach, the lateral orbitotomy without bone-flap, and the lateral orbitotomy with bone-flap. Results Access to the medial intraconal orbital space through the superomedial lid crease incision allowed optic nerve sheath fenestration or biopsy in 18 eyes with few postoperative complications. One case of tonic pupil, one case of transient vertical diplopia, and two cases of transient medial ptosis were seen. Five cavernous hemangiomas were removed from the intraconal space with this approach, with one case of transient vertical diplopia and one case of transient medial ptosis. The cadaver studies showed that when the superomedial lid crease approach is used, the tangent angle with the optic nerve and the incision-to-nerve distance measurements compare favorably with the medial transconjunctival and the lateral orbital approaches. Conclusions The superomedial lid crease approach to the medial intraconal space has a number of advantages over the medial transconjunctival and lateral orbital approaches, including ease of dissection, incision-to-nerve distance, and angle of approach to the optic nerve. This technique allows for optic nerve sheath fenestration or tumor removal from the central space with few complications.

Extracapsular Cataract Surgery with and without Intraocular Lens Implantation in Fuchs Heterochromic Cyclitis

PURPOSEnTo compare the surgical and postoperative complications and visual outcome of extracapsular cataract extraction (ECCE) with and without intraocular lens (IOL) implant in Fuchs heterochromic cyclitis.nnnMETHODSnThe records of 77 patients with Fuchs heterochromic cyclitis who had undergone ECCE were reviewed. Of a total of 77 eyes, a posterior chamber IOL (PC IOL) was implanted in 43 eyes, whereas 34 eyes did not receive an implant.nnnRESULTSnIn the pseudophakic group, 40 (93%) eyes achieved 20/40 or better. This level also was achieved in 29 (85%) eyes not receiving an implant. Intraoperative anterior chamber hemorrhage was documented in 18 eyes but there was no correlation with preoperative gonioscopic findings. A temporary or permanent elevation of intraocular pressure was noted in five of eight eyes that had marked anterior chamber hemorrhage. Severe postoperative uveitis occurred in ten eyes and was more common in patients with glaucoma who had PC IOL implantation, but this did not adversely affect the visual outcome. Of 40 eyes with PC IOL implant, severe postoperative uveitis developed in 7. In six of these seven eyes, the implant was a three-piece lens with polypropylene haptics. Severe postoperative uveitis developed in 6 of 16 eyes with preoperative glaucoma. Five of these six eyes had a PC IOL implant. Of the 34 aphakic patients, 10 (29%) were intolerant of contact lens correction. There was no difference in the incidence of postoperative uveitis, cystoid macular edema, and development of glaucoma between the two groups.nnnCONCLUSIONnImplantation of PC IOLs in ECCE in patients with Fuchs heterochromic cyclitis appears to a safe procedure, but careful postoperative follow-up of intraocular pressure, particularly in patients with intraoperative hemorrhage or postoperative uveitis, is indicated.

Blepharospasm and related facial movement disorders.

&NA; The variable clinical features and the relatively good response of blepharospasm to botulinum‐toxin type A are now well established. The etiology and pathophysiology of blepharospasm and related facial movement disorders are still poorly understood. Genetic and histopathologic studies over the last year have contributed to our understanding of this disease. The most significant progress has been made in the electromyographic studies of the the levator palpebrae and orbicularis oculi muscles. Subclassification based on the electromyographic abnormalities of these two muscles have begun to improve our understanding of the variable responses to botulinum‐toxin type A. Further electromyographic studies may help identify the best sites of injection for optimal response and differentiate patients requiring limited or complete myectomy. The development of the limited myectomy has provided excellent functional and cosmetic results with quick recovery times in selected patients.

Standardized range of conformers and symblepharon rings.

Conformers and symblepharon rings are routinely used to keep fornices formed after socket surgery or in the presence of conjunctival cicatricial disease. However, there is no accepted standard size or shape of conformers or symblepharon rings. We measured the ideal conformer and symblepharon sizes in patients undergoing socket surgery and designed six conformer and symblepharon sizes. The full set of six conformers and symblepharon rings is available to the surgeon at the end of surgery. We have successfully used these conformers and symblepharon rings in over 600 cases during the last 7 years. These standardized sizes allow more accurate fitting of conformers and symblepharon rings.

An Orbital Abscess Secondary to Acute Dacryocystitis

An orbital abscess is an ophthalmic surgical emergency that is typically caused by the spread of bacteria from adjacent structures, such as the sinuses, eyelids, or teeth. Although acute dacryocystitis is commonly associated with preseptal cellulitis, it rarely causes orbital infection. Infection of the lacrimal sac will typically localize in the preseptal space because the lacrimal sac lies anterior to the orbital septum. To the authors knowledge, this is the first report of an intraconal abscess secondary to acute dacryocystitis. The key points in the surgical management of this entity are discussed.

Lower eyelid reverse ptosis repair.

Purpose To report the results of the surgical repair of lower eyelid reverse ptosis. Methods Retrospective case series. Eight patients ranging in age from 31 to 77 years underwent surgical repair of lower eyelid reverse ptosis. The pupillary axis of the affected eye(s) in each patient was obscured in downgaze, interfering with reading. The lower eyelid reverse ptosis resulted from involutional changes in 3 patients, previous orbital decompression in 3 patients, multiple prior retinal and extraocular muscle operations in 1 patient, and previous orbital floor fracture and repair in 1 patient. Transcutaneous advancement of the lower eyelid retractors was performed in 12 eyelids of the 8 patients. Results The mean preoperative vertical eyelid fissure was 6.2 mm (median, 6 mm; range, 3–9 mm), increasing after surgery to a mean of 7.7 mm (median, 8 mm; range, 5–11 mm). The mean preoperative distance between the central light reflex and the lower eyelid margin was 1.7 mm (median, 1.25 mm; range, 1–4 mm); this distance increased to a mean of 3.3 mm (median, 3.25 mm; range, 2.5–4.5 mm) after surgery. Symptoms improved in all patients, and there were no perioperative complications. Follow-up intervals ranged from 2 months to 24 months (mean, 9 months; median, 13 months). Conclusions Analogous to upper eyelid ptosis repair by advancement of the levator aponeurosis, lower eyelid reverse ptosis may be corrected effectively and safely by advancing the lower eyelid retractors.

Silent Sinus Syndrome

Silent sinus syndrom (SSS) je vzacne onemocněni, ktere bylo poprve popsano roku 1964. V literatuře se casto vyskytuje jako synonymum pro chronickou maxilarni atelektazu (CMA) - jedna se vsak o podtyp CMA vzhledem k absenci typických přiznaků pro chronickou sinusitidu. Pro SSS je typicka postupně se rozvijejici bezbolestna asymetrie obliceje s diplopii (až u 96% pacientů), enoftalmem a hypoglobem (dislokace ocniho bulbu kaudalnim směrem) vznikajici na podkladě unilateralni chronicke maxilarni atelektazy nebo hypoplazie celistni dutiny. Pro onemocněni je typicka absence rinologických zanětlivých potiži. Endoskopický nalez je chudý (vpaceni medialni stěny maxilarni dutiny). SSS se vyskytuje u pacientů ve věku 30-60 let bez rozdilu pohlavi, etiologie onemocněni je neznama. Dřive se předpokladalo, že je výsledkem infekce kongenitalně hypoplasticke maxilarni dutiny, byla vsak popsana i u pacientů s dřive normalně utvořenou celistni dutinou. Cilem kazuistickeho sděleni je představit toto vzacne onemocněni s neznamou prevalenci, pro kterou je typicka delsi dobu nevýrazna symptomatologie a potřeba interdisciplinarni spoluprace.