Ivan Vrcek

Conjunctiva-Sparing Posterior Ptosis Surgery: A Novel Approach.

Purpose: Müller’s muscle conjunctiva resection is a well-established means of correcting blepharoptosis. The primary objective of this prospective study was to determine if modifying Müller’s muscle conjunctiva resection by sparing the conjunctiva would accomplish successful repair while allowing patients to retain their conjunctiva. The potential advantages of preserving conjunctiva are significant and include: conservation of an anatomically normal tissue, retention of goblet cells, reduction of suture-related complications such as corneal irritation or abrasion as the conjunctiva covers the suture during postoperative healing, and preservation of conjunctiva for potential future surgical procedures critical to ocular health. Methods: This is a prospective study enrolling patients with mild to moderate ptosis. Results: The procedure has been performed in 18 patients and 30 eyelids. Follow up at 1 week revealed normal healing with expected postoperative edema and ecchymosis. Notably, all patients were free of any corneal abrasion or irritation. Follow up at 1 month and a minimum of 3 months (average 5.7 months) revealed that all patients had satisfactory correction of their blepharoptosis with Margin Reflex Distance 1 (MRD1) improvement to within 1 mm of the anticipated goal, preserved eyelid margin contour, and good symmetry (average 0.26 mm difference in MRD1 between the sides). Conclusion: These results show an effective correction of blepharoptosis with a favorable cosmetic outcome and low postoperative complication rate; all while preserving the conjunctiva.

Dilated Superior Ophthalmic Vein: Clinical and Radiographic Features of 113 Cases.

PURPOSE Dilated superior ophthalmic vein (SOV) is an uncommon radiographic finding. The authors review the presentation, etiology, radiography, and visual implications of 113 patients with dilated SOV. METHODS An observational case series and multicenter retrospective chart review were conducted. There were 113 patients with a dilated SOV. Outcome measures included patient demographics, clinical features, radiographic findings, diagnosis, and treatment, and treatment outcomes were assessed. RESULTS Cases included 75 women (66%) and 38 men (34%) with a mean age of 49 ± 24 years (range, 0.4-90 years). Diagnoses fell under 6 categories: vascular malformation (n = 92, 81%), venous thrombosis (n = 11, 10%), inflammatory (n = 6, 5%), traumatic hemorrhage (n = 2, 2%), lymphoproliferative (n = 1, 1%), and infectious (n = 1, 1%). Imaging modalities utilized included MRI (n = 98, 87%), digital subtraction angiography (n = 77, 68%), CT (n = 29, 26%), and ultrasonography (n = 4, 4%). Disease status at last follow up included no evidence of disease (n = 57, 50%), alive with persistent disease (n = 53, 47%), and expired from disease (n = 3, 3%). Treatment and management was tailored to the underlying disease process with a mean follow up of 18 months (range, 1 day to 180 months). Visual impairment observed at presentation and last follow up across all cases was 26% and 22%, respectively. CONCLUSION Dilated SOV is a rare radiographic finding resulting from a wide spectrum of etiologies with clinical implications ranging from benign to sight- and life-threatening. Dilated SOV is most often found with dural-cavernous fistula or carotid-cavernous fistula, orbital or facial arteriovenous malformation, and venous thrombosis. Recognition of this finding and management of the underlying condition is critical.

Periorbital cellulitis due to cutaneous anthrax

Virgil’s plague of the ancient world, Bacillus anthracis, is rare in developed nations. Unfortunately rural communities across the globe continue to be exposed to this potentially lethal bacterium. Herein we report a case of periorbital cutaneous anthrax infection in a 3-year-old girl from the rural area surrounding Harare, Zimbabwe with a brief review of the literature.

A Novel Solution for Superficially Placed Calcium Hydroxylapatite (Radiesse) in the Inferior Eyelid

Injectable fillers such as calcium hydroxylapatite (Radiesse) have become increasingly prevalent given their availability as an office procedure as well as their satisfying results. Calcium hydroxylapatite is well suited for use along bony structures in the face such as the inferior orbital rim and zygoma. On the other hand, it is not well suited for injection into the soft periorbital tissues and eyelid. In this case series we describe two cases of misplaced calcium hydroxylapatite in the inferior periorbita and eyelid; with a successful and relatively quick resolution of the complication using saline injections and erbium laser treatments.

The effect of upper eyelid blepharoplasty on eyelid and brow position

ABSTRACT This article evaluates the effect of upper eyelid blepharoplasty on eyelid margin position and brow height. This study is a retrospective analysis of patients who underwent upper eyelid blepharoplasty without concurrent blepharoptosis repair or brow surgery. The medical records of the participants were retrospectively reviewed and an established image analysis software was used to quantify the upper margin reflex distance (MRD1) as well as brow height using high quality standardized clinical photographs. A total of 19 patients (38 eyelids and brows) met the inclusion criteria. The mean preoperative MRD1 was 2.8 mm, and the mean post-operative MRD1 was 3.5 mm, revealing an increase of MRD1 from upper blepharoplasty alone of 0.7 mm (p = 0.0001). The mean preoperative brow position was 17.5 mm above the pupil, and the mean post-operative position was 17.4 mm, for an average change of position of -0.2 mm (p = 0.39) following upper eyelid blepharoplasty. Upper eyelid blepharoplasty without ptosis surgery results in a statistically significant increase in MRD1. Brow position does not demonstrate a statistically significant change in patients who undergo upper eyelid blepharoplasty for simple dermatochalasis.

Effect of optic nerve sheath fenestration for idiopathic intracranial hypertension on retinal nerve fiber layer thickness

ABSTRACT The objective of the study was to evaluate whether optic nerve sheath fenestration in patients with idiopathic intracranial hypertension was associated with improvement in visual field pattern deviation and optical coherence tomography retinal nerve fiber layer thickness.The records of 13 eyes of 11 patients who underwent optic nerve sheath fenestration were reviewed. The subjects were patients of a clinical practice in Dallas, Texas. Charts were reviewed for pre- and postoperative visual field pattern deviation (PD) and retinal nerve fiber layer thickness (RNFL).PD and RNFL significantly improved after surgery. Average PD preoperatively was 8.51 DB and postoperatively was 4.80 DB (p = 0.0002). Average RNFL preoperatively was 113.63 and postoperatively was 102.70 (p = 0.01). The preoperative PD and RNFL did not correlate strongly.Our results demonstrate that PD and RNFL are improved after optic nerve sheath fenestration. The pre- and postoperative RNFL values were compared to the average RNFL value of healthy optic nerves obtained from the literature. Post-ONSF RNFL values were significantly closer to the normal value than preoperative. RNFL is an objective parameter for monitoring the optic nerve after optic nerve sheath fenestration. This study adds to the evidence that OCT RNFL may be an effective monitoring tool for patients with IIH and that it continues to be a useful parameter after ONSF.

Neuropathic Pain Following Poly-l-lactic Acid (sculptra) Injection

Injectable fillers have become a prevalent means of facial rejuvenation and volume expansion. While typically well tolerated, serious complications have been reported. The authors present a case in which an otherwise healthy female with a history of multiple filler injections including poly-L-lactic acid, developed 3 weeks of neuropathic pain in the left temporal fossa following injection. To the best of the authors knowledge, neuropathic pain has not been reported as a complication following poly-L-lactic acid injection. The patient was treated with an injection of steroid and long-acting anesthetic with resolution of symptoms.

Self-inflicted enucleations: Clinical features of seven cases

ABSTRACT We report the clinical presentation, radiography, and management outcomes of autoenucleations (AE). Charts of 7 patients evaluated at 4 institutions with AE were reviewed. Four males and three females had a mean age of 50 years (range 26–72 years). The etiologies were psychosis secondary to underlying mental illness (6, 88%) and substance use (1, 12%), and the mechanism was largely blunt digital injury (6, 88%). Three (43%) AE patients suffered bilateral enucleations. Common concomitant injuries included eyelid lacerations (5, 71%) and optic nerve avulsion (3, 43%). Radiography was utilized for all of the study patients with computed tomography as the most common (5, 71%), followed by ultrasound (1, 14%), and magnetic resonance imaging with CT angiography (1, 14). Orbital exploration was performed in the management of all patients. Orbital implants were placed in 4 (57%) patients. Patients were followed for a mean of 1.9 months (range 1–4 months). Autoenucleation affects both genders and is commonly associated with eyelid lacerations, optic nerve avulsion, and intracranial hemorrhage. The association with intracranial hemorrhage is consistent with prior reports of internal carotid artery injury following shearing of the optic nerve. Autoenucleation cases were seen secondary to mental or substance induced psychosis, and these patients may be at risk for future injuries such as AE of the contralateral globe. The common causes for psychosis reported our patient group include schizophrenia, depression, schizoaffective disorder, and methamphetamine-induced psychosis, which corroborates with similar cases in the literature. Two of three cases of bilateral AE suffered sequential AE where the contralateral globe was enucleated days apart. All patients suffering AE should have full medical, psychiatric, neurologic, and radiologic evaluation and monitoring while under care. When evaluating patients with obvious ocular injury, accompanying intracranial injuries should be ruled out in a timely fashion before pursuing surgical intervention.

Re: “Proprioceptive Phenomenon With Involutional Ptosis

To the Editor: We read with great interest the contribution of Segal et al. regarding the role of proprioception in anophthalmic patients with ptosis. They present a series of 8 anophthalmic patients in which gold weight-induced ptosis on the anophthalmic side resulted in ipsilateral frontalis contraction. They suggest that proprioception, and not just contracted visual field, must be stimulating brow elevation. Our group also observed and has previously described the finding of frontalis activation in anophthalmic patients with ptosis and postulated that proprioception may be playing a role. In fact, we presented data at the Annual Meeting of the Association for Research in Vision and Ophthalmology (ARVO) in 2005 describing the relationship between frontalis recruitment and ptosis in this unique subset of patients. Our data revealed that in a subset of 44 patients with anophthalmic sockets, 52% of patients demonstrated some degree of increased ipsilateral frontalis recruitment. Our study was a retrospective analysis of patients who underwent enucleation or evisceration over a 4-year period. We also suggested that proprioception and not afferent light pathways must be contributing to this mechanism. Ipsilateral frontalis muscle activation in anophthalmic patients demonstrates the presence of nonvisual stimuli in frontalis recruitment, challenging the predominant notion that afferent light pathways alone modulate frontalis recruitment in patients with ptosis. Orbital volume loss with redraping of the levator palpebrae superioris muscle over the orbital implant in anophthalmic patients may result in significant stretching of the muscle and resultant ptosis. Histologic studies have confirmed the presence of Golgi tendon organs, muscle spindles, and myotendinous cylinders within the extraocular muscles including the levator palpebrae superioris. Levator stretch, detected by these specialized structures, may provide an alternative or accessory pathway to stimulate ipsilateral frontalis recruitment. We thank Dr. Lisman’s group for their contribution and look forward to explore this phenomenon. We agree that a mechanism independent of afferent light stimulation to explain frontalis recruitment in patients with ptosis could shift our understanding of the pathogenesis of this common entity, as well as neuro-ophthalmic circuitry. Ivan Vrcek, M.D. Guy Ben Simon, M.D. John McCann, M.D., Ph.D. Robert A. Goldberg, M.D. Tanuj Nakra, M.D.

Use of an ultrasonic bone curette (Sonopet) in orbital and oculoplastic surgery.

The use of the Sonopet Omni, an ultrasonic bone curette, has been discussed for ear, nose, and throat, neurosurgical, and maxillofacial procedures. Its use in oculoplastic and orbital surgery has not been extensively described. The Sonopet has a number of advantages that impart particular utility when operating in the orbit. We present three illustrative cases highlighting the unique advantages of the Sonopet: 1) the ability to spare critical soft tissues; 2) the facility to sculpt and restore the complex contour of the orbit; 3) the capability to biopsy infiltrative lesions that may not be as amenable to manipulation with conventional drills; and 4) a small footprint ideal for small operative fields such as the orbit.