Constance L. Fry

Anterior ischemic optic neuropathy is not associated with carotid artery atherosclerosis.

Background and Purpose: The relation between anterior ischemic optic neuropathy and carotid artery atherosclerotic disease is unclear. We studied patients with anterior ischemic optic neuropathy to determine if they had an increased occurrence of carotid artery stenosis. Methods: Fifteen consecutive patients with anterior ischemic optic neuropathy were evaluated prospectively for cervical carotid artery stenosis and compared with 30 age‐ and sex‐matched asymptomatic patients and also with 11 age‐ and sex‐matched patients experiencing transient monocular blindness. Results: There was no difference in the mean stenosis of the internal carotid artery between patients with anterior ischemic optic neuropathy (mean carotid stenosis, 19%) and asymptomatic patients (mean carotid stenosis, 9%; p >0.05), whereas patients with transient monocular blindness had significantly more stenosis (mean, 77%) in the cervical carotid arteries than both control subjects (p < 0.0001) and patients with anterior ischemic optic neuropathy (p < 0.0001). There was also no difference in the percentage of patients with stenosis ≥30% in anterior ischemic optic neuropathy (two of 15) and asymptomatic patients (five of 30), whereas 10 of 11 patients with transient monocular blindness had stenoses ≥30%, significantly more than patients with anterior ischemic optic neuropathy (p < 0.0001) and asymptomatic patients (p < 0.0001). Conclusions: Anterior ischemic optic neuropathy is not a marker for atherosclerotic carotid artery stenosis. The pathogenesis of nonarteritic anterior ischemic optic neuropathy does not involve carotid artery stenosis in most patients. (Stroke 1993;24:539‐542)

High leg incision fascia lata harvesting

OBJECTIVE The traditional method of harvesting fascia lata has been through an incision above the lateral knee. Problems with this method include a conspicuous scar, herniation of the muscle belly, and hematoma formation. The authors describe a new method of harvesting fascia lata in the region of the hip to minimize these complications. DESIGN Cohort study. PARTICIPANTS Twenty-three patients underwent harvesting of fascia lata by the technique described by the authors. Twenty-one patients had ptosis with poor levator function. In two patients, the fascia lata was used to wrap a hydroxyapatite implant. INTERVENTION The technique for harvesting fascia lata through an incision between the greater trochanter and anterior iliac crest is described. Long-term results were collected from chart reviews and patient interviews after surgery. MAIN OUTCOME MEASURES The patients were evaluated to determine whether any complications resulted from the new incision site. RESULTS No permanent complications were noted at the incision site. CONCLUSIONS Fascia lata can be harvested safely in the region of the iliac crest with an inconspicuous scar and with fewer complications than with the more traditional site slightly above the lateral knee.

Treatment of biopsy proved conjunctival intraepithelial neoplasia with topical interferon alfa-2b

Conjunctival intraepithelial neoplasia (CIN) is the most common conjunctival malignancy in the United States. It occurs in exposed areas of the bulbar conjunctiva with frequent involvement of the adjacent corneal epithelium. Recent studies1 have noted a recurrence rate of about 50% when there is pathological evidence of residual tumour in the surgical margin and a 5–33% recurrence rate with clear margins.2 We describe two cases of primary CIN successfully treated with topical INFα-2b. This chart review was conducted with a waiver from the Ochsner Clinic Foundation’s institutional review board, and conforms to HIPPA regulations. A 65 year old retired welder was referred for further treatment of a partially resected CIN 1 month earlier. The patient had a long history of ultraviolet …

Plasminogen deficiency as a rare cause of conjunctivitis and lymphadenopathy

Plasminogen deficiency is a rare disorder complicated by the subsequent formation of firm “woody” plaques in the eye (ligneous conjunctivitis) or other mucosal sites as the result of inflammation or trauma. The plaques are composed of fibrinogen, granulation tissue, and inflammatory cells. The findings may be considered nonspecific by the unsuspecting surgical pathologist and delay the appropriate diagnosis. We report the first case of lymph node involvement with characteristic eosinophilic hyaline deposits that are periodic acid Schiff positive, stain dark red with Masson trichrome, and contain fibrinogen as detected by immunofluorescence and describe the longitudinal evolution of this patients disease over a 15-year period. The differential diagnosis of amorphous hyaline material in lymph node biopsies is discussed.

Socioeconomic Factors and Diagnosis of Uveal Melanoma in the Mid-Southern United States

Purpose: To establish the base incidence of uveal melanoma in the mid-southern United States and to explore the regional frequency of uveal melanoma diagnosis as a function of area-based socioeconomic measures (ABSM) aggregated at the level of small geographic units delimited by Zoning Improvement Plan (ZIP) codes. Methods: Based on a retrospective chart review (1996–2007) of patients seen at our institutions with the diagnosis of uveal melanoma, the number of uveal melanoma cases was calculated for each ZIP-code in Arkansas, Mississippi, western Tennessee and Louisiana. The base incidence of uveal melanoma was calculated using the population size reported in the 2000 census as the population at risk for each geographic area. Data on the average house value and average household income reported in the 2000 census were used in a Poisson regression analysis to examine their effect on the frequency of uveal melanoma diagnosis. Results: There were 327 (of 1,669) regional ZIP-codes that were the source of 457 patients with uveal melanoma. Higher ABSM, defined as greater average house value or household income, were positively associated with the number of observed melanoma cases per ZIP-code. The annualized incidence of uveal melanoma was at least 3.5 cases per million in the areas studied. Conclusion: Higher ABSM were associated with the increased frequency of uveal melanoma diagnosis in the regions studied. Extrapolating from similar trends observed with non-ocular cancers, this may signify a need for increased access to ophthalmologic care to ensure timely diagnosis.

Trichiasis and Distichiasis

Trichiasis is a condition of abnormal eyelash growth with misdirection posteriorly. Distichiasis is an abnormality of a second row of lashes emanating from meibomian glands. In both conditions the lid margin is in a normal position. Involutional entropion is an eyelid malposition with secondary trichiasis. These conditions can cause significant keratopathy. This chapter explores treatment modalities.

Repair of Eyelid Defects with the Orbicularis Oculi Mobilization Technique: Naugle-Levine Procedure

Full-thickness large (>50%) defects of the upper and lower eyelids are challenging to reconstruct. The blood supply from advanced orbicularis oculi muscle flap allows for the utilization of both a skin graft and a posterior lamellar graft when desirable. The repair of eyelid defects incorporating orbicularis mobilization is particularly useful in patients who are monocular and in those patients who wish to avoid occlusion of the visual axis created by an eyelid sharing procedure. Herein, we describe the technique.

The Latino Eyelid: Anthropometric Analysis of a Spectrum of Findings

PURPOSE Published anthropometric measurements of the Latino eyelid are limited. This study describes features spanning the morphologic range from non-Latino whites to East Asians in the spectrum of the Latino eyelid. METHODS A cross-sectional study of 68 people (32 Latinos, 18 non-Latino whites, and 18 East Asians, ages 18-39), approved by the Institutional Review Board and HIPAA-compliant, was performed. Saliva samples determined genetic components. Indirect anthropometric measurements were performed with ImageJ software. Eyelid measurements included margin reflex distance, palpebral fissure height, eyelid crease height, orbital height, horizontal fissure length, inner and outer canthal distances, medial and lateral canthal angles, and lateral canthal angle of inclination. Additionally, exophthalmometry and epicanthal folds were recorded. RESULTS Analysis of 184 markers from HumanExome Chip data revealed distinct clustering patterns. Genetically, the Asian participants were in 1 group, the whites in another group, and the Latinos spanned the spectrum between these 2 groups. In Latinos, the inner canthal distance and lateral canthal angle of inclination were similar to Asians, whereas the eyelid crease spanned the range from Asians to whites. Half of the Latinos had epicanthal folds. CONCLUSIONS Latinos possess a spectrum of eyelid features spanning the morphologic characteristics from those of non-Latino whites to those of East Asians. These normative data on Latinos from Texas and Mexico aid in the diagnoses of Latino eyelid disorders and are a reference for optimizing oculofacial surgery outcomes.

Re: "Re: Muscle prolapse after harvesting autogenous fascia lata for frontalis suspension in children," by Fry and Naugle.

To the Editor: We read with interest the letter to the editor by Malhotra et al. regarding Bleyen’s article “Muscle prolapse after harvesting autogenous fascia lata for frontalis suspension in children.” Bleyen et al. had reported bulging of the muscle belly in 50% of patients who had undergone fascia lata retrieval via a low leg incision and 1 patient with chronic discomfort. Concerns regarding the high leg incision for fascia lata retrieval raised by Malhotra et al. were “occasional” poor quality of the fascia lata from the proximal location and difficulty harvesting the tissue in the setting of an obese abdomen. In contrast to Malhotra’s experience, we have found the fascia lata from the high leg incision to be more robust and thicker than tissue harvested from the lower thigh. This has necessitated routinely making the strips for frontalis suspension 1.5 mm wide instead of the 2 mm that is traditional for the fascia harvested in the lower portion of the thigh (Fig.). In only 1 instance have we found the fascia to be of poor quality. This was a patient with fetal alcohol syndrome. In this patient, the fascia was very thin and the muscle was easily visualized through the fascia to at least 15 cm below the high leg

Re: "Muscle prolapse after harvesting autogenous fascia lata used for frontalis suspension in children".

To the Editor: Bleyen et al. are to be congratulated for broaching the complication of muscle prolapse after harvesting fascia lata via an incision slightly above the lateral aspect of the knee. On evaluating 30 patients in whom this technique was used, they noted 50% had some form of muscle prolapse; 2 patients had invisible but palpable bulging, 5 patients had mildly visible bulging, and 8 patients had obvious, visible bulging. While 90% of patients had no functional discomfort, 2 patients (6.7%) had occasional discomfort, and one patient (3.3%) had frequent discomfort on exercising. The authors noted that no herniation of the muscle has been reported with harvesting fascia lata superiorly on the thigh, halfway between the greater trochanter and the anterior iliac crest, as described by Naugle et al. Since the time of our original report in 1997, there have been no reports of muscle herniation. Malhotra et al. have used the Naugle high leg incision via an endoscope with good results. We postulate that the absence of muscle herniation with our incision is primarily due to the deeper position of the fascia lata in the upper leg. Additionally, high in the leg there appears to be less gravitational force exerted by the quadriceps femoris than that exerted at the traditional lower leg harvesting site. The tensile strength of the homologue of Scarpa fascia aids in preventing herniation of the muscle belly. Also, there is less muscle mass directly beneath the incision with this technique, and if herniation were to occur, which it has not, it ostensibly would be less noticeable. Moreover, our technique includes a 2-layered closure with polygalactin suture of the deep subcutaneous tissue, including the homologue of Scarpa fascia, which is not present lower in the leg, thus improving the tensile strength of the wound. Another benefit of the high incision technique using a fiberoptic retractor is that one may reflect above and below the incision to allow for good visualization of the entire dissection and can usually obviate the use of a fascia lata stripper. This capability enables the surgeon to control bleeders during the harvesting process and postoperatively should bleeding occur. Another advantage of this technique is that there is a less conspicuous scar. The high leg scar may be hidden by short pants, undergarments, or bathing apparel. Unsightly scars have been reported in 11% to 38% of patients undergoing fascia lata harvesting. This issue is particularly important in those patients with a history of forming hypertrophic or keloid scars. We concur with the authors that the risk of muscle herniation should be discussed with patients and their families preoperatively and commend the authors on their review.