Jemshed A. Khan

Sebaceous and meibomian carcinomas of the eyelid: recognition, diagnosis, and management

Sebaceous carcinoma of the eyelid is frequently misdiagnosed clinically and histopathologically. The tumor may present as a lid mass, recurrent chalazion, or diffuse unilateral blepharoconjunctivitis. Fifty percent of cases are misdiagnosed, often by an inexperienced general pathologist interpreting the initial biopsy. Frozen-section monitoring of surgical margins has been reported unreliable in 25% of cases. Mohs surgery is also unreliable in cases where there is pagetoid intraepithelial spread or skip lesions. This tumor may spread regionally into the lacrimal secretory and excretory systems, to regional lymph nodes, and rarely disseminate hematogenously. Guidelines for management are discussed.

Hyaluronic acid gel (Restylane) filler for facial rhytids: Lessons learned from American Society of Ophthalmic Plastic and Reconstructive Surgery member treatment of 286 patients

Purpose: To review injection techniques and patient satisfaction with injection of Restylane in various facial areas by American Society of Ophthalmic Plastic and Reconstructive Surgery members. Methods: Data from 286 patients treated with Restylane in nine American Society of Ophthalmic Plastic and Reconstructive Surgery practices were abstracted to a spreadsheet for analysis. Results: Nine practices performed Restylane injections for 8.8 months on average (range, 2 to 28 months). Average practice volume per patient was 1.2 ml (range, 0.7 to 2.1 ml). Nine of nine practices injected the nasolabial and melolabial folds, 9 of 9 practices injected the lips, and 6 of 9 injected the glabella. Only 2 of 9 practices injected other fillers concurrently. Botox was injected concurrently by 8 of 9 practices. On a scale of 1 to 10, physicians rated average patient discomfort during Restylane injection 4.6 with topical anesthesia and 2.1 with injectable lidocaine, with or without topical anesthesia. The end point for injection was determined by visual cues, volume of injection, extrusion of the product, and palpation. “Problematic” complications, including bruising, swelling, bumpiness, and redness each had an incidence of 5% or less. Patient satisfaction on a scale of 1 to 10 had an average rating of 8.1, compared with that of Botox injection (8.9), upper blepharoplasty (8.9), and collagen injection (6.6). The source of Restylane patients was estimated to be existing Botox patients (45%); existing non-Botox patients (18%); word of mouth (14%); and new patients for other services (13%). Conclusions: Injection techniques, volume, end points, and anesthesia vary for different facial areas and between practices. Patients experience mild to moderate injection discomfort that is lessened with injectable lidocaine. Self-limited problems occur in about 5% of patients. Physician-determined patient satisfaction is perceived to be higher than that of collagen injection but slightly lower than that of botulinum toxin injection. The major source of Restylane patients was from existing practice patients, especially botulinum toxin patients.

Sebaceous carcinoma: diuretic use, lacrimal system spread, and surgical margins

Twenty cases of adnexal sebaceous carcinoma managed by contemporary methods, including monitoring of surgical margins, were reviewed. Eight of 20 patients were taking diuretic medications. The initial clinical diagnosis was incorrect in all cases, and 50% of cases were misdiagnosed by the pathologist interpreting the initial biopsy. The canaliculus was identified in 7 cases, and was involved by tumor in 3 cases. Tumor was identified in the lacrimal sac and inferior turbinate in an additional case. Thus, tumor spread into the lacrimal excretory system was documented by histologic findings in 4 cases.

Infection after blepharoplasty with and without carbon dioxide laser resurfacing

PURPOSE To determine the rate of infection in patients who underwent blepharoplasty with and without carbon dioxide laser resurfacing. DESIGN A retrospective, nonrandomized, consecutive case series. PARTICIPANTS Eighteen hundred sixty-one patients who underwent upper or lower blepharoplasty, with or without carbon dioxide laser resurfacing. METHODS Charts of patients who underwent blepharoplasty, with or without laser resurfacing, were analyzed for the presence of postoperative infection, method of treatment, and possible sequelae. MAIN OUTCOME MEASURES The rate of infection (%) was determined for each group of patients. RESULTS Infection occurred in 0.2% of patients who underwent blepharoplasty without laser resurfacing and 0.4% of patients who had adjunctive laser resurfacing. No permanent functional or cosmetic sequelae resulted from the episodes of infection. CONCLUSIONS Infection after blepharoplasty without laser resurfacing is uncommon, indicating that topical antibiotic ointment prophylaxis is a sufficient postoperative regimen. The use of adjunctive laser resurfacing may increase the infection rate slightly.

Tono-Pen Estimation of Intraocular Pressure Through Bandage Contact Lenses

The Tono-Pen was used to determine the reliability of intraocular pressure readings obtained through bandage contact lenses in 48 eyes of 24 healthy volunteers. The mean difference between readings obtained before lens insertion and readings obtained with the lens in place was 0.27 mm Hg and was not statistically significant (P greater than .2). The mean difference between readings obtained with the lens in place and readings obtained after lens removal was 0.85 mm Hg and was statistically significant (P less than .01). Ninety-five percent confidence intervals suggest that the true difference between mean Tono-Pen readings obtained with and without the lens in place ranges from -0.3 to +1.5 mm Hg. Our results suggest that the Tono-Pen is probably an effective way to estimate intraocular pressure through bandage contact lenses, with a probable true mean difference of less than 1.5 mm Hg and a standard deviation of about 2 mm Hg.

Effect of Esmolol on hemodynamics and intraocular pressure response to succinylcholine and intubation following low-dose alfentanil premedication

STUDY OBJECTIVE To determine the effectiveness of esmolol hydrochloride (Brevibloc) as an additional adjunct to low-dose alfentanil premedication in controlling the hemodynamic response [heart rate (HR), mean arterial pressure (MAP), and intraocular pressure (IOP)] to succinylcholine and endotracheal intubation. DESIGN Randomized, double-blind, placebo-controlled, prospective study. SETTING Ambulatory gynecologic surgery at a university medical center. PATIENTS Twenty ASA physical status I and II female patients scheduled for outpatient laparoscopy under general anesthesia. INTERVENTIONS All patients received alfentanil 10 micrograms/kg as a preoperative medication 4 minutes prior to induction of anesthesia. Study patients (n = 10 in each group) received either esmolol 1.5 mg/kg or a placebo (normal saline) 30 seconds prior to induction (210 seconds after alfentanil and 90 seconds prior to endotracheal intubation). Anesthesia was induced with thiopental sodium 5 mg/kg and succinylcholine 1 mg/kg. Postintubation, 70% nitrous oxide, 30% oxygen, and 1% isoflurane were administered. MEASUREMENTS AND MAIN RESULTS Time of study drug administration was defined as time zero. Measurements of HR, MAP, and IOP were made at baseline (patient awake) and at each minute from minutes 1 through 6 after administration of the study drug (time zero). Analysis of variance was used to analyze the data, with a value of p less than 0.05 considered significant. Esmolol 1.5 mg/kg was found to blunt the maximum increase in HR but not MAP or IOP following low-dose alfentanil premedication. CONCLUSIONS In an eye patient with coronary artery disease, or in any patient in whom tachycardia may be detrimental, esmolol may be a useful adjunct in combination with low-dose alfentanil to attenuate the increase in HR due to laryngoscopy and endotracheal intubation.

Does decompression diminish the discomfort of severe dysthyroid orbitopathy

Summary We assessed whether patients perceived that surgical decompression had reduced the discomfort of dysthyroid orbitopathy. Standard pain instruments were administered to 13 consecutive patients of a university-based oculoplastic practice who had undergone two-wall orbital decompression for dysthyroid optic neuropathy. We used visual analog scale (VAS) ratings of pre- and postoperative orbital discomfort. On a 0 to 10 scale, relief of discomfort after decompression was rated as moderate or better (VAS > 9.0) in 13 of 13 patients (mean VAS = 9.22, SD = 0.91) and complete (VAS = 10.0) in 8 of 13. Patients perceived that surgical decompression was associated with a clinically and statistically significant (p < 0.001) reduction of discomfort.

Nonablative 4-MHz Dual Radiofrequency Wand Rejuvenation Treatment for Periorbital Rhytides and Midface Laxity

Purpose: To evaluate the wrinkle-reducing effects of 4-MHz radiofrequency (RF) energy applied to human periorbital, frontal, and midface facial skin using clinical wrinkle grading, patient self-satisfaction survey, and limited histologic studies. Methods: Thirty-two patients, ranging from 29 to 71 years of age with skin types varying from class I to class III using the Fitzpatrick Wrinkle Classification system, underwent 8 weekly treatment sessions of nonablative RF therapy on the periorbital, frontal, and midface regions and were subjected to follow up for 6 months after treatment. Pretreatment and post-treatment evaluations were compared. Two female subjects gave informed consent for RF treatment for the right upper eyelid and no treatment for left upper eyelid. Specimens from both upper eyelids then underwent histologic examination using light and transmission electron microscopy. Results: Pre- and post-RF treatment evaluation by 3 independent observers using the Fitzpatrick wrinkle classification system showed progressive improvements in wrinkle score at 1-, 3-, and 6-month intervals (p < 0.01). Self-evaluation of 32 patients using a 9-point rating scale after application of RF treatment also showed improving satisfaction (p < 0.01). The most commonly noted adverse reaction was transient erythema (62.5%) lasting from a few hours to a day. Transmission electron microscopy (25,000×) showed scattered diffuse changes in collagen fibril architecture with a shift from smaller-diameter collagen fibers in the untreated samples to larger-diameter fibers in the treated samples and a loss of distinct fibril borders. Conclusions: Four-megahertz dual RF wand delivery rejuvenation treatment produces a reduction in periorbital and midface rhytides.

Re: "Combined flap repair of moderate lower eyelid defects".

Purpose: To report a series of moderate-sized lower eyelid defects repaired by combined flap repair in 6 patients. The combined flap marries a horizontal rotational and a temporal Z-plasty flap for repair of moderate-sized lower eyelid defects. Methods: Six case summaries are reported along with flap configuration and surgical technique. Results: In 6 patients over a 20-month period, the combined flap repair was successfully utilized for repair of moderate-sized lower eyelid defects. Conclusions: The combined flap appears well suited to the overall anatomic configuration of the lower eyelid and lateral periorbital region.

Dermal graft : alternative to Gunderson flap allows fitting scleral shell over sensitive cornea

Corneal discomfort often prevents the successful wearing of a cosmetic scleral shell. Such sensitive corneas are traditionally covered with a Gunderson conjunctival flap. I describe two patients in whom preexisting severe conjunctival scarring precluded the possibility of developing a Gunderson flap. An alternative procedure in which autogenous split-thickness dermal grafts were sutured over the sensitive cornea was utilized in each patient. The dermal grafts reepithelialized with mucosa within 4 weeks, and both patients were then able to retain an ocular prosthesis without discomfort. I conclude that satisfactory corneal coverage may be obtained with a dermal graft when conjunctival scarring precludes the use of a Gunderson flap.