H. B. Harold Lee

Recession and Extirpation of the Lower Eyelid Retractors for Paralytic Lagophthalmos.

Purpose:To describe a technique to correct lower eyelid malposition and lagophthalmos due to facial nerve palsy. Methods:Chart review was performed and identified 13 patients with facial nerve palsy, who presented with paralytic eyelid malposition and were treated with recession and extirpation of the lower eyelid retractors between September 2012 and March 2014 by 1 surgeon (HBL). Results:A total of 12 eyelids in 11 patients met inclusion criteria. Mean preoperative MRD2 was 10 mm (range, 9.0–12.0 mm) and the mean postoperative MRD2 was 7 mm (range, 5.0–9.0 mm). The MRD2 improved an average of 3.0 mm in each patient (range, 2.0–4.0 mm). Patients had an average of 6.9 mm (range, 4.0–10.0 mm) of lagophthalmos preoperatively, which improved to 2.1 mm (range, 0.0–4 mm). The amount of lagophthalmos improved an average of 4.8 mm in the patients. There were no complications encountered in the patients. All patients had a subjective improvement in ocular comfort. Conclusions:The authors’ surgical technique is effective in addressing lower eyelid malposition and ocular surface disease in paralytic lagophthalmos.

Transcutaneous medial canthal tendon incision to the medial orbit.

Purpose: The surgical approach to the medial orbit allows superior exposure of the medial orbital wall and nasal bones, extending to the orbital apex, with excellent cosmetic results. Methods: This is a retrospective database study of all patients (N = 98) undergoing a transcutaneous medial canthal tendon incision in practice during 2009. This 1.5- to 2.0-cm incision is made just anterior to, in the same plane as, and shaving the anterior ramus of the medial canthal tendon. After exposing the origin of the anterior ramus of the medial canthal tendon, the periorbita along with the attached medial canthal tendon is elevated, exposing the entire medial orbital wall from the orbital strut to the trochlea. Anterior dissection allows access to the nasal bones to the dorsum of the nasal bridge. The parameters studied in this report were the complication rates (including scarring requiring revision, telecanthus, diplopia related to the technique, and injury to the optic nerve or other orbital structures) and photographic evidence of the final cosmetic result of this approach. Results: During 2009, 173 surgical procedures were performed through the transcutaneous medial canthal tendon incision. The procedures comprised 89 fracture repairs of the nasal or ethmoid complex, 2 naso-orbito-ethmoid fracture repairs, 4 cases of isolated nasal fracture repair, 37 medial wall decompressions for ophthalmic Graves disease, 13 cases of subperiosteal abscess drainage, and 28 dacyrocystorhinostomies using a slightly modified incisional position. The inferior oblique was not cut or released in any of these cases. There were no observed cases of medial canthal webbing, injury to orbital structures, telecanthus, optic neuropathy, or iatrogenically induced diplopia related to the technique. By definition, the authors’ follow-up time is limited to less than 2 years in each case; however, all complications, which the authors have considered for this report, would have been readily observable in this postoperative period. Conclusions: The small incision, transcutaneous medial canthal approach offers excellent and safe exposure of the medial wall, nose, and the orbital apex. The authors differentiate this transcutaneous medial canthal tendon incision from the less cosmetically acceptable, larger and more anterior Lynch incision. This medial canthal tendon incision has, and continues to be, a workhorse in the authors’ approach to the medial orbit and nose while offering unparalleled exposure with an excellent safety and complication profile.

Single-Stage Repair of Paralytic Ectropion Using a Novel Modification of the Tarsoconjunctival Flap

Patients with facial paralysis present with a constellation of ocular manifestations. Ectropion resulting from downward displacement of the lower eyelid appears after loss of orbicularis tone and function.1 In addition, upper eyelid retraction, resulting in lagophthalmos and a decrease in tear production and/or proper tear distribution and channeling,may result in dry eyes and epiphora. Tear flow is impairedbecause of a dysfunctional orbicularis oculimuscle and a decrease in transportation of tears.2 Thegoalsof surgery forparalytic lowereyelidectropionand lagophthalmos are to preserve visual acuity, improve corneal exposure, reduce ocular complaints, and restore facial symmetry. Initial management would include the application of an ocular lubricant, use of a moisture chamber, or possibly temporary tarsorrhaphy.Whenparalysis is expected to persist, a more permanent procedure is needed. The use of a laterally based tarsoconjunctival flap combinedwith a standard lower eyelid ectropion repair allows for correction of the constellations of symptoms observed in patients with paralytic ectropion in a single-stage surgical procedure. The technique can be viewed in the Video.

Improving outcomes by combining septoplasty with primary external dacryocystorhinostomy

PURPOSE External dacryocystorhinostomy (EXT-DCR) is the gold standard in the treatment of acquired nasolacrimal duct obstruction. Intranasal pathology can compromise the success of primary and revision external dacryocystorhinostomy EXT-DCR procedures. Nasal septal deviations resulting in unfavorable anatomy are an identified cause of DCR failures. In this study, we examine the causes of failure in our patient population and propose that concomitant treatment of septal deviations at the time of primary EXT-DCR can decrease the rate of revision surgery. MATERIALS AND METHODS Retrospective review of patients who had undergone an EXT-DCR. RESULTS Over a five year period, 12 EXT-DCR failures were identified and 8 were directly attributable to nasal septal deviations. Revision surgery was successful in all 8 cases after correction of the nasal septal deviation. A second cohort of patients was identified who had undergone primary EXT-DCR and septoplasty concomitantly. Eight consecutive patients underwent the combined procedure for a total of 10 EXT-DCR and 8 septoplasties. The only failure was due to a common canalicular obstruction (90% success rate for the combined approach). CONCLUSIONS As a result of our findings, we believe that treating nasal septal deviation at the time of the initial surgery can help minimize the need for revision surgery.

Nylon foil (supramid) orbital implants in pediatric orbital fracture repair.

Purpose: To present the authors experience with the nylon foil (Supramid) implant as a safe and effective method to repair pediatric orbital wall fractures. Methods: A retrospective chart review of all pediatric patients (⩽18 years) that underwent orbital wall fracture repair with an unsecured 0.4-mm Supramid implant between 2007 and 2010. Outcome variables were diplopia and surgical complications. This study was carried out with IRB approval. Results: A total of 59 orbits in 57 patients underwent orbital fracture repair using solely the 0.4-mm Supramid implant that were included in this retrospective chart review with the average age being 12 years. Trauma related to daily activities (42.1%) was the most frequent cause of orbital fractures. Eight patients (14.0%) had associated ocular/orbital injuries. Thirty-one patients (54.8%) were symptomatic at presentation with the most common presenting symptom being diplopia (n = 19, 33.3%). The most common fracture pattern sustained was combined orbital floor and medial wall fractures, which occurred in 21 patients (36.8%). Of the 3 patients (5.3%) that required immediate intervention due to extraocular muscle entrapment resulting in vasovagal responses, all returned to full and normal extraocular motility. There were 2 postoperative complications without any permanent sequelae; no patient developed postoperative enophthalmos recognizable by both physician and parents, and diplopia improved in all the 6 patients who suffered from immediate postoperative diplopia (10.7%). Conclusions: The nylon foil implant is a safe and effective method to repair pediatric orbital wall fractures given the low complication rate.

General Principles of Management of Orbital Fractures

The bony orbit develops from the mesenchyme that encircles the optic vesicle starting at the 6 week embryonic stage [1]. In the adult, the bony orbit encloses a volume of 30 cm [2]. The anterior entrance dimensions measure approximately 4 cm wide by 3.5 cm vertically. The orbit’s widest dimension is situated approximately 1 cm posterior to the bony rim. The angle between the lateral walls of each orbit is approximately 90°, whereas the angle between the lateral and medial walls is approximately 45°, with the two medial walls being essentially parallel.