John A. Long

Transconjunctival Lower Eyelid Blepharoplasty

Although transconjunctival lower eyelid blepharoplasty was described as far back as 1924 and it offers certain advantages over the skin-muscle flap, many surgeons continue to use the transcutaneous approach. This is likely due to unfamiliarity with the transconjunctival approach and general overestimation of the ability of skin excision to improve lower eyelid wrinkles. Transconjunctival lower eyelid blepharoplasty, however, continues to gain favor over the transcutaneous approach as more surgeons appreciate the absence of a visible scar and significantly lower incidence of postoperative lower eyelid retraction or change in lower eyelid margin contour, allowing a nonsurgical look.

Evisceration: a new technique of trans-scleral implant placement.

Purpose To describe a modification of the evisceration technique. Method Trans-scleral implant placement of a hydroxyapatite spherical implant. Results Forty-nine patients received implants ranging in diameter from 16 mm to 20 mm. Minor complications occurred in three patients. The functional and aesthetic result in all patients was excellent. Conclusions The described modified evisceration technique has advantages over standard evisceration techniques.

Enucleation: is wrapping the implant necessary for optimal motility?

Purpose To compare the mobility of wrapped and unwrapped hydroxyapatite orbital implants after enucleation. Methods Fifteen consecutive adult patients underwent enucleation with hydroxyapatite implant placement. These patients randomly received either a wrapped or unwrapped implant. A masked observer measured the motility of implants at 6 weeks after implantation. The conjunctiva was marked and measured with a ruler. These measurements were used to compare the motility of the wrapped versus unwrapped implant. Results The mean elevation for the wrapped group (n = 7) was 4 mm and for the unwrapped group (n = 8) was 3.9 mm. Depression was 4.1 mm for the wrapped group and 3.6 mm for the unwrapped group. Medial excursions were 5.3 for the wrapped group and 5.0 mm for the unwrapped group. Lateral excursions were 3.7 mm for the wrapped group and 3.5 mm for the unwrapped group. A repeated-measures analysis of variance was performed, and no statistically significant difference was found between the two groups. Conclusions We conclude that placement of unwrapped hydroxyapatite implants after enucleation provides essentially the same motility as wrapped implants. This technique also saves time and money and eliminates the possibility of infectious disease transmission from donor wrapping materials.

Autogenous dermis skin grafts in lower eyelid reconstruction

Purpose To describe a new procedure using autogenous dermis to correct lower eyelid retraction secondary to posterior lamella shortening. Methods A retrospective case series of 10 eyelids in 7 patients. Autogenous dermis grafts were created from postauricular skin by using dermabrasion. The grafts were placed as posterior lamellar spacers to provide elevation and support for the retracted lower eyelids. The postoperative eyelid height, contour, and complications were documented. Results All patients demonstrated an elevation of the lower eyelid and a decrease in inferior scleral show. Minimal and transient complications were encountered. Conclusions The technique described offers a simple alternative to other methods of posterior lamellar lower eyelid reconstruction.

High Versus Low Concentration Botulinum Toxin A for Benign Essential Blepharospasm: Does Dilution Make a Difference?

Purpose: To evaluate the efficacy and side effects of concentrated versus dilute botulinum toxin A in treating benign essential blepharospasm. Methods: The authors performed a prospective randomized clinical trial of 16 patients with an established diagnosis of benign essential blepharospasm. Patients were randomized to receive low concentration (control, 10 U/ml) injections on one side and high concentration (experimental, 100 U/ml) injections on the other. They were surveyed on a scale of 1 to 10 regarding pain, bruising, and redness immediately after the injection. During their return visit, at an established interval of 1 to 3 months, patients were questioned regarding complications (ptosis, diplopia, tearing, and dry eye), duration of relief, and side preferred. Patients were followed over 8 months for 1 to 6 repeat injections, with the side given the higher concentration alternated at each visit. Results: With 16 patients, there were a total of 42 visits and 84 observations (eyes) documented. Using the Wilcoxon rank sum test, there was a statistically significant reduction in pain scores (1.94 vs. 4.59, p < 0.001) on the experimental side versus the control side. Patient assessment revealed no significant difference in bruising, redness, complications of injection, side preference, or length of relief of symptoms. Conclusions: Compared with the control, the high concentration botulinum toxin A demonstrated a 58% reduction in perceived pain. Patients did not report a significant difference in efficacy or complications with either dilution.

A novel surgical technique for the treatment of giant fornix syndrome.

Purpose: To describe a novel surgical treatment for patients with chronic relapsing conjunctivitis, corneal epitheliopathy, and ptosis secondary to giant fornix syndrome. Methods: A retrospective case series was performed looking at the presence or absence of preoperative symptoms of eye irritation, tearing, blurry vision, and discharge in 6 patients diagnosed with giant fornix syndrome. Their examination findings were noted, and all patients underwent an extensive conjunctivoplasty with resection of redundant forniceal conjunctiva with subconjunctival antibiotics. Final visual acuity, symptoms, and examination findings were noted with a minimum follow up of 9 months. Results: Six patients were treated from November 2009 to November 2011. Duration of symptoms ranged from 3 to 40 months. Four patients were women while 2 were men, with age ranging from 61 to 85 years. Common symptoms were severe mucopurulent discharge, eye redness, tearing, and irritation with examination findings of severe conjunctival discharge and injection, corneal epitheliopathy, upper eyelid ptosis, and a deep upper and lower eyelid fornix. Most patients had undergone previous treatments with topical and/or oral antibiotics or steroids. All patients underwent surgical intervention using the surgical technique to be described with resolution of their symptoms, and even an improvement of 2 or more lines of best corrected visual acuity (3 of 5 patients). Conclusions: The authors’ novel surgical technique helps restore the abnormal anatomy found in patients with giant fornix syndrome and thus, helps resolve chronic relapsing conjunctivitis and surface disease associated with this often underdiagnosed condition. Further studies are needed to evaluate the risk of entropion and dry eye syndrome due to the modification of the posterior lamella.

Osteogenic sarcoma and phthisis bulbi: a case report.

PURPOSE To describe a case of osteogenic sarcoma (osteosarcoma) that developed within a phthisical eye. METHOD Case report. RESULTS An 86-year-old woman with a 20-year history of phthisis bulbi developed pain and proptosis. Tumor was identified by computed tomography. An exenteration was performed, and osteogenic sarcoma was identified. CONCLUSION Osteogenic sarcoma is the most common primary malignant tumor of bone. In the orbit it frequently is associated with prior irradiation for retinoblastoma. We describe the first case of osteogenic sarcoma that developed de novo from bone within a phthisical eye.

The Prevalence of Air Regurgitation and Its Consequences After Conjunctivodacryocystorhinostomy and Dacryocystorhinostomy in Continuous Positive Airway Pressure Patients.

Purpose:To describe the prevalence of air regurgitation into the periocular region in continuous positive airway pressure (CPAP) patients with a history of conjunctivodacryocystorhinostomy with a Lester Jones tube and a dacryocystorhinostomy with silicone intubation, as well as problems caused by this regurgitation and methods to cope. Methods:A retrospective chart review of patients who either underwent a conjunctivodacryocystorhinostomy or dacryocystorhinostomy was performed. Patients were contacted via phone interview. Demographic information, history of sleep apnea, use of CPAP, and presence of air regurgitation and associated complications were recorded. Institutional review board/ethics committee approval was obtained. Results:Two patients who underwent a conjunctivodacryocystorhinostomy with Lester Jones tube and were on CPAP were identified. Both complained of air regurgitation, sensation of Lester Jones tube moving due to regurgitation, and periodic eye pain. Twenty-two patients who underwent a dacryocystorhinostomy with silicone stent and used CPAP were identified. Of these, 16 (72.7%) complained of air regurgitation. Difficulty sleeping (56.2%), dry eye symptoms upon waking (68.8%), eye pain upon waking (31.3%), and blurry vision upon waking (12.5%) were the commonest complaints due to air regurgitation. A total of 7 (43.7%) patients had to discontinue their CPAP at some point due to symptoms. Conclusions:This study brings to light the prevalence of air regurgitation in dacryocystorhinostomy procedures, and its associated symptoms. Given that this procedure is much more common than conjunctivodacryocystorhinostomy, surgeons should consider asking patients before performing surgery whether they use CPAP. Patients should be consented regarding the risk of air regurgitation and associated dry eye, foreign body sensation, and eye pain.