Don O. Kikkawa

Relations of the superficial musculoaponeurotic system to the orbit and characterization of the orbitomalar ligament.

Summary The orbital and eyelid relationships of the superficial musculoaponeurotic system (SMAS) were studied in human cadavers. Using gross and microscopic techniques, the SMAS was found to be intimately related to the eyelids and orbicularis oculi muscle, and to have distinct orbital bony attachments. Sub-SMAS fat in the malar region was found to be continuous with the submuscular fat in the eyebrow region. The malar sub-SMAS fat continued superiorly into the lower eyelid above the inferior orbital rim, as a postorbicularis layer. A bony attachment emanating from the inferior orbital rim, the orbitomalar ligament, traveled through the orbicularis oculi muscle in a lamellar fashion prior to inserting into the dermis. The cutaneous insertion of this attachment corresponds to the malar and nasojugal skin folds. With aging, relaxation of the orbitomalar ligament allows inferior migration of orbital fat, in addition to the anterior migration that occurs through an attenuated orbital septum. These findings have implications not only in cosmetic surgery but also in the understanding of facial soft tissue changes that occur with aging.

Graded orbital decompression based on severity of proptosis

OBJECTIVE To study the results of orbital decompression based on the severity of preoperative proptosis. DESIGN A retrospective noncomparative interventional case series. PARTICIPANTS Thirty-nine orbits in 23 patients with thyroid-related orbitopathy at a university-based referral center. INTERVENTION Graded orbital decompression was performed in all patients based on the severity of preoperative exophthalmometry. MAIN OUTCOME MEASURES Exophthalmometry, visual acuity, margin-to-reflex distance, prism cover testing, and intraocular pressure. RESULTS Mean proptosis reduction in all orbits was 6.4 +/- 2.7 mm (P < 0.01). In group 1 (preoperative exophthalmometry <22 mm), proptosis decreased with a mean of 4.8 +/- 1.3 mm (P < 0.01); mean proptosis reduction was 6.0 +/- 2.3 mm (P < 0.01) and 8.9 +/- 3.4 mm (P < 0.01) in group 2 (exophthalmometry between 22-25 mm) and group 3 (exophthalmometry >25 mm), respectively. In four of five eyes with compressive optic neuropathy there was an improvement of best-corrected visual acuity of 2 lines or more. Margin-to-reflex distance of the upper and lower lids and intraocular pressure were reduced in all groups. New-onset diplopia developed in two patients (8.7%); 13 of 15 patients (86.7%) who had diplopia preoperatively had persistent diplopia postoperatively. Two patients (13.3%) had relief of diplopia postoperatively. CONCLUSIONS Graded orbital decompression based on the severity of preoperative exophthalmometry is useful to determine the type and amount of orbital surgery to be performed.

Prosthetic motility in pegged versus unpegged integrated porous orbital implants.

Purpose To objectively measure and compare prosthetic motility in pegged versus unpegged orbital implants and to determine subjective patient assessment of motility after the pegging procedure. Methods A prospective case series of 10 patients with integrated porous orbital implants, who had secondary motility peg placement procedure, were studied. Infrared oculography was used to quantitatively assess pegged and unpegged prosthetic eye motility in horizontal and vertical excursions. Results For horizontal excursions, prosthetic motility in unpegged implants retained an average of 49.6% of measured motility of the contralateral normal eye, which increased to 86.5% with peg placement (P <0.05). For vertical excursions, prosthetic motility in unpegged implants retained an average of 51.3% of measured motility of the contralateral normal eye, which increased to 54.3% with peg placement (P >0.3). Nine of 10 patients judged their motility as “significantly improved,” and 1 patient gave a rating of “some improvement” after peg placement. Four of 10 patients had granulomas around the peg sites. Conclusions Objective assessment of prosthetic motility shows a significant increase in horizontal gaze after motility peg placement.

Identification and characterization of adult stem cells from human orbital adipose tissue.

Purpose: To identify pluripotential stem cells from human orbital adipose depots. Methods: Pluripotential adipose-derived stem cells were isolated from human orbital adipose during routine blepharoplasty surgery. Fresh adipose tissue was separated in nasal fat and central (preaponeurotic) fat. Individual adipose depots were minced, enzymatically digested, and plated on plastic culture dishes. Adherent populations of cells were expanded in culture, characterized by flow cytometry, and assayed for the potential to differentiate in different cell lineages. Results: Orbital adipose-derived cells from the nasal and central adipose depots showed the potential to differentiate into the adipocyte, smooth muscle, and neuronal/glial lineages and expressed a CD marker protein profile consistent with that observed for adipose-derived stem cells from other adipose depots. Conclusions: A population of adherent cells capable of pluripotential differentiation in vitro exists within adult human orbital adipose tissue. These cells are similar to those described in other adipose depots and will help facilitate understanding of orbital diseases and may provide a novel tissue source for the development of ocular regenerative medicine therapies.

Severe Vision Loss and Neovascular Glaucoma Complicating Superior Ophthalmic Vein Approach to Carotid-Cavernous Sinus Fistula

PURPOSE To report a patient with unilateral vision loss and neovascular glaucoma after attempted superior ophthalmic vein embolization in the treatment of a carotid-cavernous sinus fistula. METHODS A 69-year-old man with a history of a left dural carotid-cavernous sinus fistula underwent attempted treatment with superior ophthalmic vein embolization. The procedure was unsuccessful, and the left superior ophthalmic vein was ligated. RESULTS Uncontrolled left proptosis and intraocular pressure necessitated urgent orbital decompression with severe vision loss and neovascular glaucoma. CONCLUSION Superior ophthalmic vein embolization in the management of carotid-cavernous fistula may be associated with vision-threatening complications.

Trephination and silicone stent intubation for the treatment of canalicular obstruction: effect of the level of obstruction.

Purpose: To investigate the efficacy of canalicular trephination and silicone stent intubation procedure for relief of epiphora according to the level of obstruction within the canaliculus. Methods: The medical records of 32 patients (41 eyes) who underwent canalicular trephination followed by silicone stent intubation of the nasolacrimal system for the treatment of canalicular obstruction were retrospectively reviewed. Canalicular obstruction was diagnosed on preoperative irrigation and probing. Level of obstruction was confirmed by intraoperative probing. Proximal obstruction was classified as those within 4 mm of the punctum, distal obstruction as those 5 mm or greater from the punctum, and common canalicular obstruction as those 10 mm or greater from the punctum. Silicone stents were kept in for a minimum of 5 months, and outcome was based on symptomatic relief of epiphora at the end of follow-up (minimum of 6 months). Partial relief of epiphora was defined as improved symptoms and at least a fair clearance on fluorescein dye disappearance testing. Results: On average, 49% of eyes had complete relief of epiphora, 38% had partial relief, and 13% had no relief. Eighty percent of eyes with distal lower canalicular obstructions had complete relief of epiphora and 20% had partial relief of epiphora. Eyes with distal bicanalicular obstructions had 66% complete and 33% partial relief. Patients with common canalicular obstructions had 59% complete, 29% partial, and 12% no relief. Proximal bicanalicular obstructions were the least successful, with 55% partial relief and 45% no relief. Conclusions: Success of canalicular trephination and silicone stent intubation for treatment of canalicular obstruction is based on the site of obstruction. Distal monocanalicular obstructions have the highest degree of symptomatic epiphora relief, followed by distal bicanalicular, common, and proximal obstructions.

Donor site complications of hard palate mucosal grafting.

Summary The use of hard palate mucosal grafts (HPG) in eyelid surgery is becoming increasingly popular. We present two palatal donor site complications that have not been previously reported. The first is an oro-nasal fistula discovered 1 week following surgery. The second is oral candidiasis, which compromised healing of the palatal donor site. With appropriate treatment, both complications resolved shortly after surgery. Careful preoperative evaluation and postoperative follow-up is recommended to recognize and manage these complications.

Botulinum A toxin injection for restrictive myopathy of thyroid-related orbitopathy: effects on intraocular pressure

PURPOSE To study the effect of extraocular muscle injections of botulinum A toxin on intraocular pressure in patients with thyroid-related orbitopathy. DESIGN Retrospective observational case series. METHODS The medical records of eight consecutive patients with restrictive myopathy secondary to thyroid related orbitopathy (TRO) who underwent botulinum A toxin injection from December 1997 to December 1998 were reviewed and analyzed retrospectively. All patients were seen at the University of California, San Diego (UCSD) Thyroid Eye Center, a university-based tertiary referral center. The main outcome measure was intraocular pressure (IOP) readings taken before and after injection in both primary gaze and upgaze (involving one eye in seven of the patients and both eyes in one patient). Intraocular pressure readings were measured by an unmasked physician using a Goldmann applanation tonometer. RESULTS A statistically significant decrease in IOP in upgaze was noted 2 to 6 weeks following botulinum A toxin injection and in both fields of gaze (primary and upgaze) after 2 to 4 months. The mean IOP before injection was 21.4 +/- 3.0 mm Hg in primary gaze and 29.9 +/- 9.7 mm Hg in upgaze. The mean IOP, following injection at 2 to 6 weeks, was 19.2 +/- 4.2 mm Hg (P <.095) in primary gaze and 25.1 +/- 5.9 mm Hg (P <.023) in upgaze. At 2 to 4 months following injection, the mean IOP was 19.3 +/- 3.9 mm Hg (P <.044) in primary gaze and 27.7 +/- 8.5 mm Hg (P <.024) in upgaze. Six patients indicated improved ocular deviation, which was associated with a lowering of IOP. Two patients indicated no change in IOP or strabismic deviation following botulinum A toxin injection. CONCLUSIONS Botulinum A toxin injections cause a secondary effect to lower IOP in patients with restrictive strabismus associated with thyroid-related orbitopathy.

Small incision nonendoscopic browlift.

PURPOSE To determine the efficacy of a nonendoscopic brow/forehead lift. METHODS Case series of 12 patients. Small scalp and upper eyelid blepharoplasty incisions were used to elevate the brows/forehead and perform protractor myectomy. RESULTS All patients achieved an aesthetically pleasing eyebrow and forehead lift with reduction of vertical and horizontal glabellar creases. Complications included one patient who experienced prolonged ecchymosis after corrugator muscle resection and one patient who had asymmetric lid folds after surgery. The length of follow-up ranged from 9 to 35 months. CONCLUSIONS The small incision nonendoscopic browlift technique provides a useful alternative to the endoscopic approach.

Transcutaneous lower eyelid blepharoplasty with orbitomalar suspension: retrospective review of 212 consecutive cases.

Background: Midfacial aging is associated with increased demarcation of the nasolabial, malar, and nasojugal folds; deflation of facial soft tissues and bones; and descent of the midface. The latter is primarily attributable to attenuation of the orbitomalar ligament. Traditional surgery of the lower eyelid and midface often requires removal of excess skin, orbicularis oculi muscle, and orbital fat, which can be complicated by postoperative lower eyelid malposition. The authors describe a novel adjunct to transcutaneous lower eyelid blepharoplasty that rejuvenates the lower eyelid and midface by reconstituting the orbitomalar ligament and minimizes the development of postoperative eyelid malposition. Methods: This study was a retrospective, consecutive, nonrandomized, interventional case series. The authors reviewed the medical records of 212 consecutive patients who underwent transcutaneous lower eyelid blepharoplasty with orbitomalar suspension. The aesthetic outcome, patient satisfaction, and development of eyelid malposition were evaluated. Results: Transcutaneous lower eyelid blepharoplasty with orbitomalar suspension resulted in improved lower eyelid dermatochalasis, contour, midfacial ptosis, and appearance of the nasojugal and malar folds. All patients reported satisfaction with the aesthetic outcome. One patient (0.5 percent) developed lower eyelid retraction requiring subsequent lower eyelid tightening. Three patients (1.4 percent) developed transient lagophthalmos from lower eyelid orbicularis paresis that resolved spontaneously. Conclusions: Transcutaneous lower eyelid blepharoplasty combined with orbitomalar suspension is a powerful technique that can be performed concomitantly with facial rejuvenative procedures. Orbitomalar suspension addresses midfacial ptosis by restoring the natural function of the orbitomalar ligament and minimizes the development of postoperative lower eyelid malposition.