Hidenori Mito

Assessment of the predictive value of intraoperative eyelid height measurements in sitting and supine positions during blepharoptosis repair.

Purpose: To examine relationships between intraoperative and postoperative eyelid heights in relation to patient postures in blepharoptosis surgery. Methods: Thirty eyelids in 15 patients with bilateral aponeurotic ptosis were selected. The margin reflex distance-1 (MRD-1) was measured with the patients in the sitting position preoperatively, intraoperatively, and in the postoperative 6 weeks. MRD-1 also was measured intraoperatively with patients in the supine position. The intraoperative sitting and supine values and the postoperative values were statistically compared using a paired t test, and lateralities in those groups were statistically analyzed using Students t test. Results: From the intraoperative measurements, mean MRD-1 values in the sitting position (right: 3.80 mm, left: 3.73 mm) were significantly lower than those in the supine position (right: 4.37 mm, p < 0.001; left: 4.33 mm, p < 0.001). In the postoperative 6 weeks, mean MRD-1 values (right: 3.80 mm, left: 3.63 mm) were not significantly different from intraoperative values in the sitting position (right: p = 1.000, left: p = 0.189), but were significantly lower than intraoperative values in the supine position (right: p < 0.001, left: p < 0.001). There was no significant laterality among the three groups (supine intraoperative: p = 0.890, sitting intraoperative: p = 0.785, postoperative: p = 0.546). Conclusion: Intraoperative measurements in the sitting position more accurately predicted postoperative eyelid height than did measurements with the patient in a supine position.

Incarceration of the Inferior Oblique Muscle Branch of the Oculomotor Nerve in Two Cases of Orbital Floor Trapdoor Fracture

BackgroundIncarceration of the inferior oblique muscle (IO) branch of the oculomotor nerve may occur in cases of orbital floor trapdoor fracture.CasesTwo orbital floor trapdoor fracture cases, with lesions located just outside of the inferior rectus muscle but without its incarceration, were examined pre- and postoperatively for visual acuity, intraocular details, the nine diagnostic ocular positions of gaze, binocular single vision field with the Hess chart, and by computed tomography (CT). One case was also examined by magnetic resonance imaging (MRI; T1-weighted images). A forced duction test was conducted intraoperatively.ObservationsEach case presented good visual acuity and neither globe showed any injury. Motility disturbance of the IO was shown in each case by binocular single vision field testing and the Hess chart. The possibility of the incarceration of the IO branch of the oculomotor nerve, which runs from the incarcerated lesion to the superior belly of the IO, in an orbital floor trapdoor fracture was shown on CT and MRI. Intraoperative forced duction testing revealed a restriction due to the incarceration of the connective tissue septa.ConclusionsAs inferred from the CT and MRI analyses conducted in this study, IO palsy may be one of the causes of ocular motility disturbance of the IO in an orbital floor trapdoor fracture, in addition to the ocular motility disturbance due to the connective tissue septa. Jpn J Ophthalmol 2005;49:246–252

The Medial Canthal Tendon Is Composed of Anterior and Posterior Lobes in Japanese Eyes and Fixes the Eyelid Complementarily with Horner’s Muscle

PurposeTo report that the medial canthal tendon (MCT) is not simply the aggregate of the orbicularis oculi muscle (OOM) and its tendon.MethodsTwenty eyelids of 10 cadavers were used. The cadavers, seven male and three female, were all Japanese, with an average age of death of 76.2 years. The relationship between the MCT and the OOM, and between the tarsus and Horner’s muscle were investigated. Histological findings were obtained with hematoxylin and eosin staining.ResultsThe MCT was structured with an anterior lobe, the tendon from the tarsal area of the OOM, and a posterior lobe, the muscle–tendon transition area in the orbital area of the OOM. The nasal aspect of the tarsus was fixed by Horner’s muscle.ConclusionsThe MCT and Horner’s muscle are located in an important area of the eyelid; therefore, it is essential to understand their precise anatomy.

Intraoperative quantification using finger force for involutional blepharoptosis without postoperative lagophthalmos

PurposeTo report intraoperative quantification using finger force for involutional blepharoptosis, which helps in the prevention of postoperative lagophthalmos.MethodsWe carried out levator resection on 20 involutional blepharoptic eyelids. Fissure height was examined intraoperatively to evaluate the extent of resection. If a patient presented more than 3 mm of lagophthalmos in voluntary eyelid closure but could fully open the eye, we forcibly closed the eyelid, using a finger, after voluntary eyelid closure. If more than 3 mm of lagophthalmos was still observed after forced eyelid closure, we corrected eyelid tension until lagophthalmos became less than 2 mm.ResultsSix of the ten patients (20 eyelids) presented with full eyelid opening but more than 3 mm of lagophthalmos in voluntary eyelid closure. After the upper eyelids were forcibly lowered, all six eyelids showed less than 2 mm of lagophthalmos. There were no cases of lagophthalmos 1 month postoperatively.ConclusionsAdditional finger force makes precise quantification of blepharoptosis surgery possible and prevents postoperative lagophthalmos. Jpn J Ophthalmol 2006;50:135–140

Magnetic Resonance Imaging of Pre- and Postoperative Lower Eyelid States in Involutional Entropion

PurposeTo disclose pre- and postoperative lower eyelid gradients in involutional entropion using sagittal magnetic resonance imaging (MRI).MethodsThree female patients, average age 82 (two right eyes and one left), were operated on for involutional entropion by the Jones procedure. Before and after the surgery, the lower eyelid gradient was evaluated by MRI and photography.ResultsPreoperatively, each lower eyelid presented anterior protrusion, and the retractor was apart from the globe. Postoperatively, no anterior protrusion was observed, and the retractor was pulled posteroinferiorly and located parallel to the globe.ConclusionsThe MRI visualization of pre- and postoperative changes of gradient in the lower involutional entropion supports surgical reconstruction.

External Dacryocystorhinostomy With or Without Double Mucosal Flap Anastomosis: Comparison of Surgical Outcomes.

AbstractThe aim of this study was to compare surgical outcomes of external dacryocystorhinostomy with or without double mucosal flap anastomosis. A retrospective chart review was performed for 205 sides of 178 patients diagnosed with nasolacrimal duct obstruction. Double-flap anastomosis was performed on 57 sides (double-flap group) and complete flap excision on 148 sides (no-flap group). Criteria for surgical success were defined as no or minimal intermittent epiphora and no reflux on lacrimal irrigation 12 months postoperatively. Consequently, surgery was successful for 53 sides (93.0%) in the double-flap group and 138 sides (93.2%) in the no-flap group. There was no statistically significant difference in success rate between the groups (P = 0.947, the Fisher exact probability test). This study demonstrated that external dacryocystorhinostomy without flap anastomosis had a surgical outcome similar to that of double-flap anastomosis.

Orbital trapdoor fractures: different clinical profiles between adult and paediatric patients

Background To compare clinical findings of orbital trapdoor fractures between adult and paediatric patients. Methods Paediatric patients were categorised into two groups by age: children (0–9 years) and adolescents (10–19 years). Adult patients were categorised into two groups by age: early (20–44 years) and middle-late adulthood (≥45 years). Demographic data, ocular and periocular complications, CT findings and binocular single vision field (BSVF) were compared among age groups. Results This study included 105 patients (105 sides, 22 children, 59 adolescents, 14 patients in early adulthood and 10 patients in middle-late adulthood). In patients with fractures of the orbital floor and medial wall, both walls presented as trapdoor fractures in paediatric patients, while one wall presented as a non-trapdoor fracture in adult patients (p=0.061). None of the adult patients showed extraocular muscle incarceration, whereas this was present in 8 of 22 children (36.4%) and 7 of 59 adolescents (11.9%) (p=0.005). Hypoesthesia of the infraorbital nerve more frequently occurred in adults (p=0.004). As the preoperative BSVF was larger in adult than in paediatric patients (p=0.007), the percentage of adult patients who underwent surgical reduction of orbital fractures tended to be lower (p=0.058). Postoperative change in BSVF was smaller in adult patients (p=0.005). Conclusions Fracture pattern, type of incarcerated tissue and incidence of hypoesthesia of the infraorbital nerve were different between adult and paediatric patients. Adult patients had a larger preoperative BSVF and less need for surgical reduction; however, there was less improvement in postoperative BSVF.

Peripheral T-cell Lymphoma of the Eyelid

hand-held I/A device for lacrimal surgery is especially useful. Both the lacrimal sac and nasal mucosa are excised with an H-shaped incision. Ninety-three consecutive patients (100 eyes) underwent external DCR using the two new devices, and a transnasal endoscopic examination was performed before and after surgery. All these cases showed patency on irrigation postoperatively. In summary, we developed two new devices for DCR. These instruments may help improve the success rate and shorten the time of DCR.

Movement of the lacrimal canalicular wall under intracanalicular pressure changes observed with dacryoendoscopy.

Background: Movement of the lacrimal canalicular wall has been speculated to occur during blinking. Movement of the common internal ostium has been observed under nasal endoscopy, and pressure changes in the lacrimal canalicular cavity have been observed with a pressure sensor; however, lacrimal canalicular wall movement under pressure changes has not been observed. Purpose: To examine movement of the lacrimal canalicular wall under intracanalicular pressure changes using dacryoendoscopy. Methods: The authors examined 20 obstruction-free lacrimal canaliculi in 10 patients. A dacryoendoscope was inserted, and water was poured into the intracanalicular cavity via the dacryoendoscope’s water channel. The water was then poured or suctioned to cause positive or negative pressure changes in the intracanalicular cavity, and movement of the lacrimal canalicular wall was examined. Results: The lacrimal canalicular wall moved flexibly with pressure changes. Under positive pressure, the intracanalicular cavity was dilated; however, it narrowed under negative pressure. The extent of movement was more dramatic in the common canalicular portion than the proximal canalicular portion. Conclusions: Intracanalicular pressure changes cause movement of the lacrimal canalicular wall. There was a consistent relationship between intracanalicular cavity changes and pressure changes, possibly contributing to lacrimal drainage of the canaliculus.

Recurrent ptosis in a patient with blepharochalasis: clinical and histopathologic findings.

A 37-year-old woman presented with right upper eyelid blepharochalasis with ptosis. Right upper eyelid edema had occurred 2 to 3 times per year by 30 years old, although the frequency decreased with age. The edema occurred spontaneously and resolved within 1 to 2 days. She underwent a right levator tucking surgery at 22 years old, and the ptosis recurred 2 years postoperatively. She again underwent ptosis surgery with skin excision at 37 years old. The intraoperative findings showed a thin levator aponeurosis. The white line was therefore advanced to the upper tarsal edge, resulting in an appropriate height and curvature. Three months later, the patients eyelid height was 1.5 mm higher with a little temporal peaking. The levator aponeurosis was histopathologically shown to contain many capillaries. The increased vascularity of the levator aponeurosis may contribute to recurrent bouts of edema resulting in stretching and disinsertion of the aponeurosis.