Evan H. Black

Eyelid sensation after supratarsal lid crease incision.

Purpose To determine the severity and duration of the loss of eyelid sensation after upper eyelid crease incision. Methods This clinic-based case study was performed by analyzing observational measurements of patients undergoing upper blepharoplasty or ptosis surgery. Eighty-three eyelids of 50 patients were studied. A Cochet-Bonnet filament-type aesthesiometer was used to obtain all measurements. Preoperative and postoperative measurements were recorded at 1 week, 1 month, and final (2–6 months) time periods. Statistical analysis evaluated the degree and duration of the sensory loss and the extent of recovery during the evaluation period. Recovery of sensation was defined as a numerical reading within one point of baseline. Results The mean aesthesiometry reading was calculated at the preoperative (3.45), 1-week (1.20), 1-month (1.56), and final postoperative (2.56) periods. Paired t testing showed a decreased but significant difference in sensation measurement at each comparison. Recovery of sensation to within one point occurs at the preoperative to late time period comparison. All but 4 of the 68 eyelids tested at the 1-week postoperative time period had a measured loss of sensation. Of the 44 eyelids tested at the final time period, all but 1 had regained some or all of this sensory loss. Conclusions Loss of skin sensation in the eyelid after upper eyelid crease incision blepharoplasty or blepharoptosis repair occurs in most patients and should be considered an expected outcome of the procedure. Partial to complete recovery of eyelid sensation over 2 to 6 months should also be expected, though in rare instances this does not occur.

Electromagnetic image-guided orbital decompression: technique, principles, and preliminary experience with 6 consecutive cases.

Abstract Purpose: To assess the feasibility of routine use of electromagnetic image guidance systems in orbital decompression. Methods: Six consecutive patients underwent stereotactic-guided three wall orbital decompression using the novel Fusion ENT Navigation System (Medtronic), a portable and expandable electromagnetic guidance system with multi-instrument tracking capabilities. The system consists of the Medtronic LandmarX System software-enabled computer station, signal generator, field-generating magnet, head-mounted marker coil, and surgical tracking instruments. In preparation for use of the LandmarX/Fusion protocol, all patients underwent preoperative non-contrast CT scan from the superior aspect of the frontal sinuses to the inferior aspect of the maxillary sinuses that includes the nasal tip. Results: The Fusion ENT Navigation System (Medtronic™) was used in 6 patients undergoing maximal 3-wall orbital decompression for Graves’ orbitopthy after a minimum of six months of disease inactivity. Preoperative Hertel exophthalmometry measured more than 27 mm in all patients. The navigation system proved to be no more difficult technically than the traditional orbital decompression approach. Conclusion: Electromagnetic image guidance is a stereotactic surgical navigation system that provides additional intraoperative flexibility in orbital surgery. Electromagnetic image-guidance offers the ability to perform more aggressive orbital decompressions with reduced risk.

Botox: Shaken, not stirred

Purpose: To determine whether the effect of botulinum toxin type A is maintained and has the same duration when it is reconstituted vigorously. Methods: A prospective, double-blinded, randomized study was performed on 7 consecutive patients who underwent botulinum toxin type A injections to the forehead by one oculoplastic surgeon. Half of each patient’s forehead was injected with botulinum toxin type A that had been gently reconstituted according to the package insert and the other half of the forehead was injected with botulinum toxin type A that had been reconstituted vigorously. Eyebrow excursion was measured in millimeters before injection, 1 week after injection, and every month after injection up to a total of 6 months. Results: Seven consecutive patients with an average age of 39.9 ± 2.8 years were evaluated. There was no statistically significant difference in eyebrow excursion between the side of the forehead that had been injected with gently reconstituted botulinum toxin type A and the side that had been injected with vigorously reconstituted botulinum toxin type A at every visit. Conclusion: The effect of botulinum toxin type A is maintained and has the same duration when it is reconstituted vigorously compared with when it is reconstituted gently.

A prospective study assessing the utility of Cogan's lid twitch sign in patients with isolated unilateral or bilateral ptosis.

OBJECTIVE Cogans lid twitch is thought to suggest myasthenia gravis in patients with unexplained ptosis. The validity of this clinical test has not been established. We conducted a prospective study to ascertain the sensitivity and specificity of this finding. METHODS 35 patients with isolated, symptomatic ptosis, referred to a neuro-ophthalmologist or oculoplastics specialist were enrolled. The presence or absence of Cogans lid twitch was noted, according to standard technique. Further testing was performed, and the final diagnosis for each patient was recorded. RESULTS Four patients were found to have a Cogans lid twitch. Two patients had ocular myasthenia gravis as the final diagnosis, and of those, only one had a twitch. CONCLUSIONS The sensitivity and specificity of Cogans lid twitch is relatively low. Other conditions may cause a lid twitch as well. The presence of a Cogans lid twitch may increase suspicion of myasthenia, but is not diagnostic, and does not exclude alternate etiologies of ptosis.

Phakomatous choristoma: A rare orbital tumor presenting as an eyelid mass with obstruction of the nasolacrimal duct

We describe a case of phakomatous choristoma presenting as a lower eyelid mass with nasolacrimal duct obstruction. The literature is reviewed and the unique aspects of the case are discussed.

Choroidal melanoma with massive extrascleral extension in a young black man.

The reported incidence of choroidal melanoma is low among the general population and is especially low among blacks. Choroidal melanoma is seen most commonly in whites in the sixth to seventh decades. The tumor is complicated by orbital invasion in only a small percentage of cases. This report describes the case of a 38-year-old black man diagnosed with a choroidal melanoma of the right eye. The tumor exhibited extensive orbital invasion. Primary or metastatic disease elsewhere in the body was ruled out, and the patient underwent an eyelid-sparing orbital exenteration. Histopathologic examination of the orbital specimen confirmed the diagnosis of spindle cell-type choroidal melanoma. Orbital invasion by a primary choroidal melanoma in a black person under the age of 40 is highly unusual. To our knowledge, this represents the youngest reported case of choroidal melanoma with extrascleral extension in a black patient. Ophthalmologists should consider the possibility of this potentially deadly tumor, even in young, black patients.

Diode laser-assisted endocanalicular dacryocystorhinostomy: A prospective study

Purpose: To evaluate the efficacy of the diode laser in endocanalicular dacryocystorhinostomy. Methods: A prospective, noncomparative, interventional case series using the diode laser for endocanalicular dacryocystorhinostomy in patients with tearing and nasolacrimal duct obstruction. Outcome measures included subjective tearing complaints and objective patency of the nasolacrimal system. Success was defined as improvement of symptoms with patency of nasolacrimal drainage. Patients were followed for 12 months. Institutional review board approval was obtained. Results: Forty eyes (28 unilateral, 6 bilateral) underwent surgery. Five cases were excluded because of inadequate follow-up. Patients ranged in age from 27 to 88 years (66.7 ± 15.7). Seventy-seven percent were female and 23% were male. At 1 week, 88% had improvement in tearing, 12% had no change or worsening of symptoms, and all patients were patent on irrigation. At 1 month, 86% had improvement, 14% had no change, and all patients were patent on irrigation. At 3 months, 83% had improvement and were patent on irrigation. Seventeen percent had no change or worsening with reflux and were considered failures. At 6 months, 77% had improvement and were patent on irrigation. Five additional patients had no change, reflux on exam and were failed surgeries. At 12 months, 74% had complete resolution and were patent. One additional patient failed. Nine surgeries in 35 cases were considered failures by 12 months. Conclusions: Subjective complaints of tearing correlated with patency of the nasolacrimal system after 3 months. A success rate of 74.3% (26 out of 35 cases) was observed by 12 months.

A solution to the Jones tube continuous positive airway pressure (CPAP) dilemma

A 49-year-old woman, who had previously undergone bilateral Jones tube placement, began nasal continuous positive airway pressure for obstructive sleep apnea. The patients use of continuous positive airway pressure was limited by intolerance of the transfer of air through the Jones tube to her ocular surface resulting in irritation and discomfort. A change from nasal continuous positive airway pressure to a full face mask, including both Jones tubes in the pressure circuit, resolved the problem.

Aggressive Glabellar Angiomyxoma with Orbital Extension

A 62-year-old male presented with a large non-tender mass in the glabella, extending into the right orbit that had been steadily growing for 6 months. Imaging revealed a 2.5 x 1.8 cm cystic mass with extension into the right anterior orbit. Biopsy with microscopic examination revealed a predominantly myxoid stroma containing spindle-shaped cells with bipolar cigar-shaped nuclei and small caliber capillary-type vascular proliferations. These findings are consistent with an angiomyxoma. Although angiomyxomas typically present in the pelvic region or peritoneum in female patients, there have been rare examples of angiomyxomas with orbital involvement.

A comparison of surgical outcomes with the use of 2 different biodegradable multipoint fixation devices for endoscopic forehead elevation.

Purpose: To assess the efficacy and rates of inflammatory cyst formation with the use of 2 different biodegradable multipoint fixation devices, Endotine versus Ultratine, for endoscopic forehead elevation. Methods: The charts of 138 patients who underwent endoscopic forehead elevation by the same surgeon (E.H.B.) were reviewed retrospectively. Data regarding patient demographics, type of biodegradable fixation device, loss of fixation in the immediate and late postoperative period, inflammatory cyst formation of the fixation device, additional complications, and reoperation status were collected from the charts. Patients implanted with Endotine and Ultratine were compared postoperatively for early and late loss of elevation (efficacy), inflammatory cyst formation, additional complications, and reoperation rates. Results: Of the 276 fixation devices implanted (117 Endotine and 159 Ultratine), 11 inflammatory cysts were found, all of them in the Ultratine group (p = 0.0037). Four patients required reoperation due to early loss of fixation. Three of these cases were in the Endotine group, and 1 case was observed in the Ultratine group (p = 0.18). A total of 4 patients had late loss of fixation, all of them in the Ultratine group (p = 0.08). Scalp hypoesthesia and/or dysesthesia beyond the sixth postoperative month were observed in 3.62% of the cases. Postsurgical neuralgia was observed in 2.17%, and focal alopecia was seen in 1.44%. Conclusions: The presence of inflammatory cysts with the implantation of the Ultratine device is statistically higher than with Endotine. No statistical significant difference was found in either early or late fixation loss between the 2 groups.