Dan Georgescu

Upper Eyelid Myectomy in Blepharospasm with Associated Apraxia of Lid Opening

PURPOSE To assess the impact of upper eyelid myectomy surgery on blepharospasm with associated apraxia of lid opening (ALO), dry eye, photophobia, and daily functioning in patients who are refractory to botulinum toxin treatment. DESIGN Noncomparative, consecutive, interventional case series. METHODS A retrospective chart review was performed to identify 100 consecutive patients beginning on January 1, 2000, who underwent upper eyelid myectomy surgery for blepharospasm and fulfilled the inclusion criteria. A survey was sent to all patients. Data were entered in an anonymous manner into a spreadsheet and analysis was performed using the Student t test with significance set at P<.05. RESULTS Forty-five (88%) patients experienced ALO before surgery, among which 15 (33%) patients stated they were completely cured and 20 (44%) others had more than 50% improvement in ALO with surgery. In 20 of 30 patients who continued botulinum toxin treatment after surgery, the effect lasted longer. Twelve (29%) of 42 patients who experienced dry eyes before surgery improved. Eighteen (41%) of the 44 patients who experienced light sensitivity before surgery improved. Thirty-seven (82%) patients noted their cosmetic appearance to be better after surgery. The cumulative preoperative disability score was 14.11+/-5.78 (59%), whereas the cumulative postoperative disability score was 5.20+/-8.25 (22%; P<.01). CONCLUSIONS Upper eyelid myectomy surgery appears to be effective in treating blepharospasm with associated ALO in most patients who are refractory to botulinum toxin injections and can provide improvement in the quality of life.

Brow ptosis correction: a comparison of five techniques.

This study evaluates the effectiveness of five surgical techniques for brow ptosis repair including internal brow release (IBR), internal brow release with brow pexy (IBR + BP), internal brow release with corrugator and depressor supercilii removal (IBR + CDR), direct brow-lift (DB), and endoscopic brow-lift (EB). This is a retrospective study of 120 patients in which the preoperative and postoperative position of the medial, central, and lateral brow on both sides was measured. The brow was elevated 1.16 +/- 0.05 mm by IBR, 1.74 +/- 0.05 mm by IBR + BP, and 2.52 +/- 0.06 mm by IBR + CDR. IBR + BP was more effective than IBR in elevating the lateral brow ( P < 0.05). Removal of the medial brow depressors resulted in greater elevation of the medial and central brow than could be achieved with IBR or IBR + BP alone ( P < 0.01). EB resulted in the greatest amplitude of brow elevation (3.44 +/- 0.06 mm). Eyebrow-lifting surgery performed via the upper eyelid blepharoplasty incision prevents the lowering of brow position caused by blepharoplasty surgery alone. Brow pexy sutures are useful in enhancing elevation of the lateral brow, and removal of the medial brow depressors is useful in raising the medial and central brow.

Skin necrosis after calcium hydroxylapatite injection into the glabellar and nasolabial folds.

Calcium hydroxylapatite-induced skin necrosis occurred in 2 patients after injection in the glabella and the nasolabial fold, respectively. Supportive treatment with oral steroids, nitroglycerin paste, and warm compresses was initiated more than 48 hours after injection, and its role in recovery is uncertain. Both patients underwent microdermabrasion and used hydrocortisone ointment to flatten the scar, which resulted in gradual improvement with a reasonable cosmetic outcome 4 months after injection. This is the first report of calcium hydroxylapatite-induced skin necrosis. Injectors should be aware of this potential adverse event and counsel their patients appropriately.

Phacoemulsification tip vacuum pressure: Comparison of 4 devices

PURPOSE: To determine the vacuum pressure generated by 4 phacoemulsification devices measured at the phacoemulsification tip. SETTING: University ophthalmology department. METHODS: The effective vacuum pressures generated by the Sovereign (AMO), Millennium (Bausch & Lomb), Legacy AdvanTec (Alcon Laboratories), and Infiniti (Alcon Laboratories) phacoemulsification machines were measured with a device that isolated the phacoemulsification tip in a chamber connected to a pressure gauge. The 4 machines were tested at multiple vacuum limit settings, and the values were recorded after the foot pedal was fully depressed and the pressure had stabilized. The AdvanTec and Infiniti machines were tested with and without occlusion of the Aspiration Bypass System (ABS) side port (Alcon Laboratories). The Millennium machine was tested using venturi and peristaltic pumps. RESULTS: The machines generated pressures close to the expected at maximum vacuum settings between 100 mm Hg and 500 mm Hg with few intermachine variations. There was no significant difference between pressures generated using 19‐ or 20‐gauge tips (Millennium and Sovereign). The addition of an ABS side port decreased vacuum by a mean of 12.1% (P<.0001). CONCLUSION: Although there were some variations in vacuum pressures among phacoemulsification machines, particularly when an aspiration bypass tip was used, these discrepancies are probably not clinically significant.

Orbital augmentation with injectable calcium hydroxylapatite for correction of postenucleation/evisceration socket syndrome.

Purpose: To demonstrate the utility of injectable calcium hydroxylapatite (Radiesse) for orbital volume augmentation to correct postenucleation/evisceration socket syndrome (PESS). Methods: A retrospective chart review of all consecutive patients in our practice who received injectable calcium hydroxylapatite placed in the extraconal space to augment orbital volume was conducted. Patients with at least 6 months follow-up were included in the study. Results: Among 26 patients with PESS who received injectable calcium hydroxylapatite for orbital volume augmentation, 15 individuals were identified with adequate follow-up. The mean amount of preoperative relative enophthalmos measured by Hertel exophthalmometry was 4 mm (range 0.5–7 mm). An average reduction of 2.4 mm of enophthalmos per syringe of filler was achieved. The mean follow-up obtained was 46 weeks (range 24–78 weeks). Most patients demonstrated clinical and aesthetic improvement that was observed to continue up to 1.5 years. Complications observed included anterior migration of filler, a peribulbar hemorrhage, and orbital discomfort. Two patients demonstrated little response to filler. Conclusions: Injectable calcium hydroxylapatite provides a novel, safe, simple, cost-effective technique to treat volume deficiency in the anophthalmic orbit. Augmentation achieved with this semipermanent filler has demonstrated a lasting effect in the orbit with little volume loss. Volume replacement can be titrated to the socket requirements. Correction of PESS using this technique may be limited in orbits that demonstrate significant fibrosis as a result of multiple surgeries, severe trauma, or radiation treatment.

Lateral canthal resuspension sine canthotomy.

Purpose: The purpose of this study is to describe a novel canthopexy technique—the lateral canthal resuspension sine canthotomy (LCR-SC)—performed via an upper-eyelid incision and to compare it with the lateral tarsal strip procedure (LTS). Methods: This is a retrospective study in which the pre- and postoperative photographs of 20 patients per group who had LCR-SC, LCR-SC + midface lift (LCR-SC+ML), or LTS were analyzed by using the Image-J 1.40 software. Parameters measured were as follows: the horizontal palpebral aperture margin-reflex distance 2 (MRD-2) and the height of lateral canthus. LCR-SC was performed through an upper-eyelid incision, by using a 4.0 Prolene suture. For the LCR-SC+ML, a large myocutaneous flap was created first and anchored to the orbital-rim periosteum. The surgical technique is described. Two-way ANOVA was used for analysis. Results: The horizontal palpebral aperture was significantly increased by LCR-SC and LCR-SC+ML when compared with LTS (1.61 ± 0.22 mm and 1.56 ± 0.14 vs. 0.04 ± 0.12 mm; p < 0.01). LCR-SC and LCR-SC+ML decreased the MRD-2 more than the LTS (1.06 ± 0.26 and 1.50 ± 0.23 mm vs. 0.86 ± 0.1 mm; p < 0.01). All 3 procedures increased the lateral canthal height by less than 0.5 mm. Conclusions: LCR-SC is a safe and effective procedure for tightening the lower eyelids. It tightens both the upper and the lower cruri of the lateral canthal tendon, avoiding imbrication of the eyelids. LCR-SC obviates the need for a lateral canthal incision and widens the horizontal palpebral aperture. LCR-SC is more effective than LTS at decreasing the MRD-2. Concomitant midface elevation (LCR-SC+ML) further decreases MRD-2.

Effect of bottle height and aspiration rate on postocclusion surge in Infiniti and Millennium peristaltic phacoemulsification machines

PURPOSE: To assess how flow and bottle height affect postocclusion surge in the Infiniti (Alcon, Inc.) and Millennium (Bausch & Lomb) peristaltic machines. SETTING: John A. Moran Eye Center Clinical Laboratories, University of Utah, Salt Lake City, Utah. METHODS: Postocclusion anterior chamber depth changes were measured in human eye‐bank eyes using A‐scan. Surge was simulated by clamping the aspiration tubing and releasing it at maximum vacuum. In both machines, surge was measured (1) with aspiration held constant at 12 mL/min and bottle heights at 60, 120, and 180 cm and (2) with bottle height held constant at 60 cm and aspiration rates at 12, 24, and 36 mL/min. RESULTS: Surge decreased approximately 40% with each 60 cm increase in bottle height in the Infiniti. It was constant at all bottle heights in the Millennium. At 12 and 24 mL/min aspiration rates, surge in the Millennium was less than half that in the Infiniti (P<.001). CONCLUSIONS: Postocclusion surge decreased linearly with increasing bottle height in the Infiniti system and was relatively constant with increasing bottle height in the Millennium system. The Millennium may offer a more stable phacoemulsification platform with respect to surge at a higher aspiration rate.

Efficacy of Cruise Control in controlling postocclusion surge with Legacy and Millennium venturi phacoemulsification machines

PURPOSE: To determine the efficacy of the Cruise Control surge‐limiting device (Staar Surgical) with phacoemulsification machines known to have high levels of surge. SETTING: John A. Moran Eye Center Clinical Laboratories. METHODS: In an in vitro study, postocclusion anterior chamber depth changes were measured in fresh phakic human eye‐bank eyes using the Alcon Legacy and Bausch & Lomb Millennium venturi machines in conjunction with the Staar Cruise Control device. Both machines were tested with 19‐gauge non–Aspiration Bypass System tips at high‐surge settings (500 mm Hg vacuum pressure, 75 cm bottle height, 40 mL/min flow rate for the Legacy) and low‐surge settings (400 mm Hg vacuum pressure, 125 cm bottle height, 40 mL/min flow rate for the Legacy). Adjusted parameters of flow, vacuum, and irrigation were used based on previous studies to create identical conditions for each device tested. The effect of the Cruise Control device on aspiration rates was also tested with both machines at the low‐surge settings. RESULTS: At the high setting with the addition of Cruise Control, surge decreased significantly with the Legacy but was too large to measure with the Millennium venturi. At the low setting with the addition of Cruise Control, surge decreased significantly with both machines. Surge with the Millennium decreased from more than 1.0 mm to a mean of 0.21 mm ± 0.02 (SD) (P<.0001). Surge with the Legacy decreased from a mean of 0.09 ± 0.02 mm to 0.05 ± 0 mm, a 42.9% decrease (P<.0001). The Millennium had the highest surge and aspiration rate before Cruise Control and the greatest percentage decrease in the surge and aspiration rates as a result of the addition of Cruise Control. CONCLUSIONS: In the Legacy machine, the Cruise Control device had a statistically and clinically significant effect. Cruise Control had a large effect on fluidics as well as surge amplitude with the Millennium machine. The greater the flow or greater the initial surge, the greater the impact of the Cruise Control device.

Müller muscle-conjunctiva resection for blepharoptosis in patients with glaucoma filtering blebs.

Purpose: To study the safety and efficacy of Müller muscle-conjunctiva resection (MMCR) for blepharoptosis in patients with functional glaucoma-filtering blebs. Methods: Retrospective chart review of patients who underwent MMCR in the presence of a functioning filtering bleb. Patients offered MMCR all responded satisfactorily to preoperative topical phenylephrine hydrochloride testing. Using a similar technique, MMCR was performed by 6 surgeons at 6 different centers. Two patients had simultaneous upper blepharoplasty. Postoperative slit lamp examination was performed to assess for bleb injury or infection. In addition, all patients had routine glaucoma follow-up visits to assess for bleb functioning. Results: Nine patients with functional filtering blebs tolerated MMCR well and had no bleb complications. All blebs remained functional after surgery. One patient had anterior chamber reaction for 10 days and another patient had foreign body sensation for 6 weeks. At 9.2-months mean follow-up time, the mean change in margin reflex distance-1 was 2.9 mm. Conclusion: MMCR may be safe and effective in the setting of a glaucoma-filtering bleb.

Snip Conjunctivoplasty for Postoperative Conjunctival Chemosis

OBJECTIVE To describe a surgical technique to treat postoperative conjunctival chemosis. DESIGN Case report. RESULTS Two cases of postoperative chemosis in which the conventional methods failed were successfully treated by snip conjunctivoplasty, without recurrence. CONCLUSION Snip conjunctivoplasty is a simple and effective surgical approach to treat refractory postoperative chemosis.