Ivana Cardoso Pereira

Comparative study of Botox ® injection treatment for upper eyelid retraction with 6-month follow-up in patients with thyroid eye disease in the congestive or fibrotic stage

AimTo compare morphometric data of the eyelid fissure and the levator muscle function (LF) before and up to 6 months after transcutaneous injection with five units of Botox® in patients with upper lid retraction (ULR) from congestive or fibrotic thyroid eye disease (TED).MethodsTwenty-four patients with ULR from TED were submitted to transcutaneous injection of 5 units (0.1 ml) of Botox in one eye only. Patients were divided into two groups: 12 with congestive-stage TED (CG), and 12 with fibrotic-stage TED (FG). Bilateral lid fissure measurements using digital imaging and computer-aided analysis were taken at baseline and at regular intervals 2 weeks, 1 month, 3 months and 6 months after unilateral Botox injection. Mean values taken at different follow-up points were compared for the two groups.ResultsMost patients experienced marked improvement in ULR, with a mean reduction of 3.81 mm in FG and 3.05 mm in CG. The upper eyelid margin reflex distance, fissure height and total area of exposed interpalpebral fissure were significantly smaller during 1 month in CG and during 3 months in FG. Reduction in LF and in the difference between lateral and medial lid fissure measurements was observed in both groups. The treatment lasted significantly longer in FG than in CG.ConclusionsA single 5-unit Botox injection improved ULR, reduced LF and produced an adequate lid contour in patients with congestive or fibrotic TED. The effect lasts longer in patients with fibrotic orbitopathy than in patients with congestive orbitopathy.

Functional and cosmetic results of a lower eyelid crease approach for external dacryocystorhinostomy

PURPOSE External dacryocystorhinostomy is routinely performed through a cutaneous vertical incision placed on the lateral aspect of the nose. The lower eyelid crease approach has been seldom reported. The purpose of this study is to report the cosmetic and functional results of the lid crease approach for external dacryocystorhinostomy in a series of patients. METHODS Prospective, interventional case series. Twenty-five consecutive patients (17 women) ranging in age from 3 to 85 years (mean ± SD= 44.84 ± 23.67) were included in the study. All patients but one underwent unilateral external dacryocystorhinostomy with a 10 to 15 mm horizontal incision placed on a subciliary relaxed eyelid tension line. The inner canthus was photographed with a Nikon D70S digital camera with a macrolens and resolution of 3008 x 2000 pixels at 1, 3 and 6 months after surgery. The resulting scar was judged from the photographs by 3 observers (ophthalmologist, plastic and head and neck surgeons) according to a four level scale (1= unapparent, 2= minimally visible, 3= moderately visible, 4= very visible). RESULTS The surgery was easily performed in all patients with a 90.48% success. Three of the elderly patients (ages 61, 79 and 85 yr) developed mild lacrimal punctum ectropion, which resolved with conservative treatment. One patient had a hypometric blink which spontaneously recovered within one month. The mean score for scar visibility was 2.19 (1(st) mo), 1.65 (3(th) mo) and 1.44 (6(th) mo). CONCLUSIONS The eyelid crease approach is an excellent option for external dacryocystorhinostomy. It leaves an unapparent scar since the first month after surgery, even in younger patients. The functional results are excellent and comparable to other techniques. Care should be taken in elderly patients with lower eyelid laxity in order to prevent lacrimal punctum ectropion.

Implante de peso de ouro: complicações precoces e tardias

PURPOSE To evaluate the indications, the results and the complications seen in the patients submitted to gold weight implantation to correct paralytic lagophthalmos. METHODS Charts of 20 patients with lagophthalmos secondary to facial nerve palsy of diverse etiologies, which were submitted to gold weight implantation in the upper eyelid of the affected side, were retrospectively examined. RESULTS The most frequent cause of paralytic lagophthalmos was acoustic neurinoma after surgery (40%). Early and late complications occurred in 40% of the implants. Four patients (20%) presented a local inflammatory reaction in the first 3 months after surgery. Two patients (10%) presented skin and orbicular muscle thinness over the gold weight 4 and 7 years after the implant, respectively. One patient (5%) presented gold weight displacement after 3 years and another patient (5%) had late gold weight extrusion after 10 years. CONCLUSIONS In this series, the complication rate of gold weight implantation was high (40%). The complications were divided into early, possibly related to the material impurity and the late, due to the evolution of the facial nerve palsy that presented a decrease in muscle tonus.

Browlifting as an alternative procedure for apraxia of eyelid opening.

Essential blepharospasm is an idiopathic disorder that consists of spontaneous, spasmodic, and involuntary eyelid closure in the absence of ocular disease. Some patients develop an inability to open their eyelids in the absence of orbicularis spasms. These patients have essential blepharospasm combined with apraxia of eyelid opening. Botulinum toxin injections are the treatment of choice for blepharospasm but results may be insufficient, especially in cases associated with apraxia. Apraxia can be treated surgically by levator aponeurosis advancement, frontalis suspension, and upper myectomy. The authors report the first browlift using polypropylene suture to manage eyelid apraxia associated with blepharospasm as an alternative and minimally invasive procedure.

Paquimeningite hipertrófica idiopática craniana associada a pseudotumor orbitário: relato de caso

Hypertrophic pachymeningitis is a rare disorder characterized by meningeal thickness, that can be caused by infection, tumoral infiltration, inflammatory disorders or idiopathic. We report the case of a 40 year-old man that presented with longstanding headache and progressive bilateral visual loss and proptosis. Cranial and orbital magnetic resonance imaging revealed diffuse dural thickness and bilateral extraconal orbital lesion. Extensive investigation did not reveal any systemic condition. Histopathological study after meningeal and orbital biopsy disclosed a chronic inflammatory process compatible respectively with idiopathic hypertrophic pachymeningitis (IHP) and orbital pseudotumor. This case emphasizes that orbital involvement can occur in IHP and that its early identification is of great importance in order to improve the visual prognosis of this condition.

Palpebral position interdependence in blepharoptosis: comparison of the effect of instillation of 10% phenylephrine drop and digital lifting

PURPOSE To quantify and compare the effects of instillation with 10% phenylephrine and digital lifting on the contralateral upper eyelid of patients with involutional bilateral blepharoptosis. METHODS The present prospective clinical study involved patients with involutional bilateral blepharoptosis who underwent two tests: 1) digital lifting of the more ptotic eyelid and observation of the effect on the contralateral eyelid and 2) instillation of two drops of 10% phenylephrine in the more ptotic eye and observation of the effect on the contralateral eyelid. Patients were filmed before and 5, 10, and 15 min after instillation, and the resulting images were analyzed to obtain eyelid measurements. The results were tested using a linear mixed-effects model. RESULTS A total of 27 patients, ranging from 52 to 82 years of age (mean age 68.51 ± 8.21 years), 24 (88.88%) of whom were women, were included in the present study. In eyes that received instillation, the marginal distance reflex-1 (MDR1) values increased from baseline (1.21 ± 0.60 mm) until 10 min after instillation, then remained statistically unchanged until 15 min after instillation (2.42 ± 0.90 mm). Significant differences were observed in the contralateral eye of the group that underwent digital lifting (1.51 ± 0.53 mm - 1.63 ± 0.56 mm) and in the contralateral eye of the group that underwent 10% phenylephrine instillation (1.38 ± 0.54 mm - 1.63 ± 0.56 mm); p=0.02 and p<0.01, respectively. CONCLUSION In all eyes, 10% phenylephrine elevated the upper eyelid, with improved eyelid height at 10 min after instillation. Significant differences were observed in the height of the contralateral eyelid when compared before and after each intervention in each group; however, this difference was very small and nearly undetectable by conventional clinical evaluation in the digital lifting group. However, the 10% phenylephrine eye-drop test resulted in substantial changes in MDR1 values in the treated and contralateral eyes, indicating clinical and statistical efficiency.

Análise morfométrica da fenda palpebral de pacientes com retração palpebral na fase aguda da orbitopatia distireoidiana submetidos à injeção palpebral de toxina botulínica tipo A

PURPOSE: To compare morphometric data of eyelid fissure using computerized image analysis before and after application of botulinum toxin type A in patients with eyelid retraction caused by dysthyroid orbitopathy in acute stage. METHODS: This was a prospective study with 12 individuals that received transcutaneous 5 UI/0.1 ml injection of botulinum toxin in the upper eyelid. They were examined periodically for 6 months. Clinical eyelid examination was performed and re corded using a video camera connected to a microcomputer. RESULTS: Vertical eyelid fissure, upper eyelid margin to reflex distance and the eyelid area showed reduction in the treated eye. A decrease in the levator function of the upper eyelid was observed, and also, a reduction in the difference between the lateral and medial areas. The lower eyelid margin reflex distance did not show any significant differences after the application. Measurements of the contralateral eye increased up to 2 weeks after the application. CONCLUSIONS: These results showed a reduction in eyelid retraction and improving the upper eyelid contour, without changes in the lower eyelid position.

Quantitative Comparison of the Effect of 10% Phenylephrine Instillation and Manual Elevation in Patients with Involutional Blepharoptosis

Abstract Objective: To compare the effect of 10% phenylephrine (PE) instillation and manual elevation (ME) on the upper eyelid position of the tested eye and the contralateral eye in patients with involutional blepharoptosis (IB). Methods: IB patients were submitted to two tests followed by observation of the effect on the contralateral eyelid: (1) ME of the more ptotic eyelid; and (2) instillation of two drops of 10% PE (phenylephrine test) in the more ptotic eye. The patients were filmed before and 5, 10, and 15 minutes after instillation. The upper eyelid margin reflex distance (MRD1) was measured using the software Image J, and the results were analyzed with the linear mixed-effects model. Results: The study included 70 patients aged 44–86 years, 64 of whom were female (91.43%), divided into three groups: subjects with unilateral IB, subjects with bilateral IB, and controls. The eye submitted to instillation with 10% PE displayed significant elevation during the first 10 min: from 1.33 ± 0.66 mm to 2.06 ± 0.89 mm (unilateral group), from 1.26 ± 0.63 mm to 2.29 ± 0.86 mm (bilateral group), and from 3.12 ± 0.68 mm to 4.06 ± 0.92 mm (control group). MRD1 decreased in the contralateral eye in IB patients, significantly more so after the phenylephrine test: PE vs. ME = 18.9% versus 17.2% reduction in the unilateral group, and 13.6% versus 10.7% reduction in the bilateral group. The outcome was not influenced by IB severity and the concurrence of IB and eye dominance. Conclusion: Both ME and 10% PE affected the contralateral upper eyelid, but the response was significantly better with the latter.

Tratamento cirúrgico da blefaroptose congênita

A blefaroptose e o posicionamento inadequado da palpebra superior, estando abaixo de sua posicao normal na posicao primaria do olhar, a qual seria 0,5 – 2mm abaixo do limbo superior. Pode causar bloqueio parcial ou completo do campo visual superior, alem do comprometimento estetico. As causas sao categorizadas em congenitas ou adquiridas. E considerada congenita se presente ao nascimento ou diagnosticada no primeiro ano de vida. As principais tecnicas utilizadas para o tratamento da ptose congenita sao a resseccao da aponeurose do musculo levantador da palpebra superior (MLPS) e a suspensao frontal. A medida da funcao do MLPS e o parâmetro mais importante na escolha da tecnica cirurgica. Quando a funcao e fraca, a suspensao frontal e mais indicada; a resseccao supramaxima do MLPS tambem pode ser empregada. Acima de 4 ou 5mm de funcao do MLPS, prefere-se a resseccao da aponeurose. Para a cirurgia de suspensao frontal, varios sao os materiais utilizados, portanto apresentamos uma comparacao entre os estudos mais relevantes. Discutiremos tambem particularidades em casos mais complicados, como as Sindromes da Blefarofimose e de Marcus-Gunn, alem de tecnicas cirurgicas menos utilizadas e as complicacoes relatadas.