Herbert J. Glatt

Follow-up methods and the apparent success of entropion surgery.

PURPOSE To determine if follow-up methods affect the apparent success rate of the surgical repair of involutional entropion. METHODS A review of articles published in English between 1939 and 1997, and a review of a series of 112 patients who underwent entropion repair with a combination of a tarsal strip procedure, a partial pretarsal orbiculectomy, and creation of an eyelid crease. RESULTS Only ten of 104 published reports contained information on the method by which follow-up data were attained. The apparent success rate of surgery in the case series declined in proportion to the effort made to detect unsuccessful cases. Long-term follow-up office examinations revealed cases of residual postoperative entropion that had not been detected by spontaneous patient complaints or by telephone interviews. CONCLUSION Future reports on the results of entropion repair should include long-term follow-up that includes physical examination with testing to provoke latent entropion.

Tarsoconjunctival flap supplementation : An approach to the reconstruction of large lower eyelid defects

In the presence of a full-thickness lower eyelid defect too large for reconstruction with a tarsoconjunctival flap alone, the posterior lamella is often reconstructed with a free graft of nasal septal cartilage and mucosa, ear cartilage, or hard palate mucosa. In this series, an alternative approach was taken: a tarsoconjunctival flap of maximum horizontal dimension was created to reconstruct the majority of the posterior lamella defect. A second reconstruction technique, such as a periosteal flap or a Tenzel semicircular flap, was then used to supplement the tarsoconjunctival flap and reconstruct the remainder of the posterior lamella defect. Tarsoconjunctival flap supplementation yielded favorable results in eight patients and is advocated for the reconstruction of large posterior lamella defects too large for reconstruction with a tarsoconjunctival flap alone.

Dacryocystorhinostomy in Wegener's granulomatosis.

Dacryocystorhinostomy was performed on two patients with Wegeners granulomatosis that had been quiescent for many years. Excellent results were attained, with elimination of dacryocystitis, complete relief from epiphora, and maintenance of a patent outflow tract. No wound necrosis occurred postoperatively, in contrast to a previous report in the literature. Our experience suggests that nasolacrimal duct obstruction in the setting of quiescent Wegeners granulomatosis can be treated safely and effectively with dacryocystorhinostomy.

Muller's Muscle-conjunctival Resection Procedure in the Treatment of Ptosis in Horner's Syndrome

The predictability of the phenylephrine test and the efficacy of the Mullers muscle-conjunctival resection procedure in the management of blepharoptosis in six cases of Horners syndrome were assessed. Before phenylephrine testing or surgery, an average of 2.3 mm of ptosis was present. Topical phenylephrine elevated upper lids an average of 2.2 mm. The amount of elevation produced by the phenylephrine guided the amount of Mullers muscle and conjunctiva resected. Postoperative upper lid levels were exactly symmetrical in five of six patients. In one patient the previously ptotic lid was 0.5 mm higher than the contralateral lid. Even though Mullers muscle is rendered nonfunctional in Horners syndrome by denervation, the Mullers muscle-conjunctival resection procedure proved to be a very effective method of treating ptosis in this setting. Our findings imply that the mechanism by which this procedure alleviates ptosis is independent of active contraction of Mullers muscle.

Evaluation of lacrimal obstruction secondary to facial fractures using computed tomography or computed tomographic dacryocystography.

Facial fractures that result in lacrimal drainage obstruction may add complexities to lacrimal surgery. The role of preoperative assessment of lacrimal obstruction after facial fractures using computed tomography (CT) or CT dacryocystography was assessed in this study. Consecutive patients (n = 13) with symptomatic lacrimal obstruction after facial fractures underwent radiologic evaluation prior to lacrimal surgery. The first three patients underwent CT alone. The subsequent 10 patients underwent CT dacryocystography, in which radio-opaque dye was instilled into the lacrimal sac prior to CT. Radiographic findings pertinent to surgical management were present in 11 of the 13 patients and included alterations in bony anatomy, plates or wires adjacent to the lacrimal sac, nasal septal deviation, sinusitis, anterior ethmoid air cells, and anteriorly located middle turbinates. CT or CT dacryocystography prior to lacrimal surgery in patients with previous facial fractures may facilitate preoperative planning and intraoperative execution. It is recommended that the cost of these studies be minimized by adherence to streamlined protocols widely used in sinus CT.

Failure of Collagen Plugs to Predict Epiphora After Permanent Punctal Occlusion

In two patients with keratoconjunctivitis sicca, epiphora did not occur after temporary canalicular occlusion with collagen implants, but did occur after subsequent permanent punctal occlusion. This suggests that collagen implants may not always produce total occlusion. Patients should be warned of this possibility.

Comparison of 2.5% and 10% Phenylephrine in the Elevation of Upper Eyelids with Ptosis

The Muellers muscle-conjunctival resection procedure has been effective in treating ptosis in eyelids that elevate upon instillation of topical 10% phenylephrine (Neo-Synephrine). The small risk of an adverse systemic reaction to phenylephrine could be even further decreased by using 2.5% phenylephrine instead of 10% phenylephrine. In order to assess the feasibility of using 2.5% phenylephrine instead of 10% phenylephrine in ptosis evaluation, we compared the amount of upper eyelid elevation produced by the two solutions. Thirty ptotic upper eyelids in 20 patients exposed to 10% phenylephrine rose an average of 0.2 mm higher than the same lids exposed to 2.5% phenylephrine. Although this difference was statistically significant, we suspect that the small magnitude of this difference would have little effect on the decision to perform a Muellers muscle-conjunctival resection procedure or on the calculation of the amount of tissue to resect.

Conventional Frozen Sections in Periocular Basal-Cell Carcinoma: A Review of 236 Cases/COMMENTARY*

Two hundred thirty-six periocular basal-cell carcinomas were resected under conventional frozen-section control. Only two tumors recurred, yielding a success rate of 99.2%. The mean follow up was 56 months. Eighty-one of the 236 patients were followed for at least 5 years; the 5-year cure rate was 97.5%. To our knowledge, this is the largest reported series of periocular basal-cell carcinoma resected under conventional frozen-section control; also, we believe the follow-up data are superior to those of previous series. The high success rates with conventional frozen-section techniques in this and other series are comparable to those reported for the Mohs micrographic techniques.