David A. Weinberg

Eyelid mucous membrane grafts: a histologic study of hard palate, nasal turbinate, and buccal mucosal grafts.

Purpose: To histologically evaluate the outcome of mucous membrane grafts to the eyelid. Methods: Case series of 31 eyes from 24 patients who underwent transplantation of hard palate (25 eyes), buccal (1 eye), or nasal turbinate (5 eyes) mucosa to the posterior eyelid surface. These grafts were biopsied at 0.5 months to 84 months (mean, 20 months) postoperatively. They were examined with light microscopy and compared with either the donor mucosa from the same patient (2 patients) or the typical donor site histology (22 patients). Results: Graft biopsies revealed general epithelial morphology that was quite similar to the respective donor sites in virtually all cases. Six (25%) of 24 hard palate graft biopsies, which were obtained at 8 months to 49 months (mean, 22 months) postoperatively, displayed orthokeratosis alternating with parakeratosis, while 12 (50%) demonstrated parakeratosis alone, and another 6 (25%) showed adjacent regions of parakeratotic and nonkeratinized epithelium. No hard palate grafts showed complete absence of keratinization after transplantation. Other significant findings included loss of goblet cells in nasal turbinate grafts and few submucosal glands remaining in any specimen. Conclusions: Full-thickness mucosal grafts typically maintain their native epithelial morphology following transplantation to the ocular surface. Submucosal glands usually do not survive transplantation, which could be the result of intentional thinning of the graft at the time of transplantation. Contrary to the opinion that hard palate graft epithelium usually undergoes metaplasia from keratinized to nonkeratinized within 6 months following transplantation to the eye, all hard palate grafts in this study remained orthokeratotic and/or parakeratotic.

Transconjunctival Lower Eyelid Blepharoplasty

Although transconjunctival lower eyelid blepharoplasty was described as far back as 1924 and it offers certain advantages over the skin-muscle flap, many surgeons continue to use the transcutaneous approach. This is likely due to unfamiliarity with the transconjunctival approach and general overestimation of the ability of skin excision to improve lower eyelid wrinkles. Transconjunctival lower eyelid blepharoplasty, however, continues to gain favor over the transcutaneous approach as more surgeons appreciate the absence of a visible scar and significantly lower incidence of postoperative lower eyelid retraction or change in lower eyelid margin contour, allowing a nonsurgical look.

Draining cutaneous fistula associated with infection of hydroxyapatite orbital implant.

Summary The implantation of an orbital hydroxyapatite implant was complicated by conjunctival dehiscence, cutaneous fistula formation, and infection with Staphylococcus aureus. Pathologic examination of the sphere 2 years after its implantation revealed reduction in the size of the implant, peripheral lamellar bone formation and central necrosis. This is the first report of this constellation of complications with hydroxyapatite spheres positioned in the orbit. The 2-year interval between implantation and removal of the sphere is the longest reported in a case with histopathologic analysis.

Management of relative proptosis with a porous polyethylene orbital rim onlay implant

PURPOSE The position of the globe relative to the orbital rim plays a significant role in the relationship between the eyelids and the cornea. A prominent globe (relative proptosis) may cause eyelid retraction and exposure keratopathy. Simple horizontal lower eyelid tightening exacerbates eyelid retraction. Optimal correction with an orbital decompression or advancement of the orbital rim entails considerable risk. A technically simpler alternative, placement of an orbital rim onlay implant, was evaluated. METHODS Fourteen patients with symptomatic relative proptosis underwent placement of a porous polyethylene orbital rim onlay implant. RESULTS Lower eyelid position, exposure keratopathy, and ocular discomfort were improved in all patients. Two patients required minor surgical revisions. CONCLUSIONS Porous polyethylene orbital rim onlay implants are a satisfactory option to treat the sequelae of relative proptosis.

Eyelash resection procedure for severe, recurrent, or segmental cicatricial entropion.

Purpose: To study the safety, efficacy, and cosmetic outcome of the eyelash resection procedure for treatment of severe, recurrent, or segmental cicatricial entropion. Methods: Retrospective consecutive case series of patients with severe, recurrent, or segmental cicatricial entropion treated with eyelash resection at the Moran Eye Center and the University of Vermont. Investigators performed chart reviews of these patients and evaluated effectiveness of the treatment and outcome data, including age, gender, diagnoses, method of repair, recurrence of trichiasis, and cosmetic satisfaction. There were no exclusionary characteristics specified in the study. Results: A total of 26 eyelids were operated on in 5 male and 11 female patients. The mean age was 74 years, with the following diagnoses: idiopathic (6), ocular cicatricial pemphigoid (2), postoperative (2), ocular pseudopemphigoid (drug related) (1), graft-versus-host disease (1), Stevens-Johnson syndrome (1), trachoma (1), linear IgA bullous dermatosis (1), and trauma (1). Mean postoperative follow-up was 13 months. The functional success rate was 90.5%, and the cosmetic success rate was 100%. Conclusion: The eyelash resection procedure is a safe, effective, and cosmetically acceptable procedure for treatment of severe, recurrent, or segmental cicatricial entropion.

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.

Müller's muscle-conjunctival resection for blepharoptosis with poor levator function.

We describe a patient with blepharoptosis, poor levator function, and a positive phenylephrine test who responded favorably to Müllers muscle-conjunctival resection, alleviating the need for a frontalis suspension ptosis repair in the presence of very deep superior sulci.