Katherine M. Whipple

Spontaneous superior ophthalmic vein thrombosis: a rare entity with potentially devastating consequences.

PurposeSpontaneous superior ophthalmic vein thrombosis (SOVT) is a rare entity. We describe three patients with spontaneous ophthalmic vein thrombosis, each with various risk factors.Patients and MethodsA retrospective review of three patients with a diagnosis of superior ophthalmic vein thrombosis. Clinical characteristics, radiographic features, management techniques and outcomes are described.ResultsAll patients presented with unilateral painful proptosis. Two patients had intact light perception, whereas one patient presented with absent light perception. All patients had identifiable risk factors for thrombosis, which included sickle cell trait, hereditary hemorrhagic telangectasia and colon cancer with recurrent deep vein thrombosis. Anticoagulation was initiated in two patients. Resolution of proptosis was seen in all patients, with no recovery of vision in one patient.ConclusionsRisk factors for spontaneous superior ophthalmic vein thrombosis are multifactorial. MRI and MRV confirm the diagnosis of SOVT. Despite urgent intervention devastating visual loss may occur.

Modifying the upper eyelid crease in Asian patients with hyaluronic acid fillers.

Background: Preliminary experience with the use of hyaluronic acid fillers as a nonsurgical alternative in the management of upper eyelid crease asymmetry and superior sulcus hollowing in Asian patients has proven promising. Methods: This retrospective, interventional case series included seven patients (11 eyes) of various Asian ancestries. All patients had eyelid crease asymmetry or undesirably elevated eyelid creases along with hollowing of the upper eyelids. Upper eyelid crease asymmetry and hollowing of the superior sulcus were assessed before and after treatment. For all patients, hyaluronic acid fillers (Restylane, Medicis, Scottsdale, Ariz., or Juvéderm, Allergan, Irvine, Calif.) were injected into the retro-septal superior sulcus for eyelid hollowing and into the preseptal eyelid fold for crease asymmetry. Pretreatment and posttreatment photographs were taken. Outcomes were assessed by the total volume injected; masked, independent assessment using preoperative and postoperative photographs; and the subjective assessment of results by the patient. Results: The average age was 43.1 years. The average volume of hyaluronic acid filler injected was 0.61 cc per eye. All seven patients were satisfied with the cosmetic improvement after hyaluronic acid filler injections. No adverse effects were noted. To date, the treatment has remained effective for as long as 18 months. Conclusions: Hyaluronic acid filler injections into the upper eyelid and superior sulcus are effective in providing volume to recreate the fullness natively present in the Asian upper eyelid. Furthermore, this fullness lowers the surgically created eyelid crease in those patients with eyelid asymmetry following cosmetic blepharoplasty. It should be considered in Asian patients presenting with upper eyelid hollowing or asymmetric eyelid creases.

Blepharoplasty Complications: Prevention and Management

This article presents common and rare complications following blepharoplasty, with discussion of avoidance of these complications through presurgical planning and review. Management of the complications is provided, with surgical details supported by images and advice for the best approaches. The complications discussed include hemorrhage, infection, corneal abrasion, ptosis, lacrimal gland injury, and residual excess skin.

Reply re: "Use of antimetabolites in the reconstruction of severe anophthalmic socket contraction".

Purpose: The use of antimetabolites is well established in ophthalmology with expanded uses still being defined. We describe our experience of antimetabolite use in the reconstruction of severe anophthalmic socket contraction. Methods: Nonrandomized, retrospective case series. The medical records and clinical photographs of 5 patients with severe socket contraction were reviewed. Either 5-Fluorouracil (5-FU) (50 mg/ml) or Mitomycin C (MMC) (0.4 mg/ml) was used during the course of the surgery via direct injection into the operative bed in the area of scarring. In addition, in 3 cases, 5-FU was also applied after surgery, in the clinic setting. Variables examined included: number of previous socket operations; preoperative ability to retain a prosthesis; type of socket reconstruction; type, amount, and location of antimetabolite injected; number of postoperative injections; average follow-up; and the postoperative ability to retain a prosthesis. Results: All 5 patients had multiple operations previously. After surgery, all 5 were able to retain an ocular prosthesis. We did not observe any delay in wound healing, implant exposure, or extrusion, and no significant side effects were noted. Conclusion: The use of adjunct antimetabolite in severe anophthalmic socket reconstruction is an effective option that is well tolerated with minimal side effects.

Recognizing and Managing Complications in Blepharoplasty

The goal of this article is to enhance the surgical precision and accuracy of surgeons performing upper and lower eyelid blepharoplasty. The most common blepharoplasty complications are described and how to avoid them is discussed in detail. Complications range from mild to severe and for each, preoperative measures to prevent, perioperative measures to avoid, and postoperative measures to minimize complications are detailed. After reading this article the surgeon should have a greater understanding of blepharoplasty complications and how to best manage and avoid them.

Outcomes of Orbital Blow-Out Fracture Repair Performed Beyond 6 Weeks After Injury.

Purpose: Blow-out fractures cause expansion of the bony orbital walls and prolapse of orbital contents in the sinuses. This can result in diplopia, enophthalmos, and hypoglobus. Early surgical repair has been previously recommended, however, recent reports show that delayed surgery can also be effective. In this study, the clinical and functional outcome of patients with delayed presentation and blow-out fracture repair beyond 6 weeks after injury are described. Methods: This is a noncomparative retrospective study. Medical records of adult patients with late orbital floor fracture repair performed by 4 surgeons from April 2008 to January 2014 at 3 tertiary referral centers were reviewed. All repairs were performed more than 6 weeks from the time of injury. Patients with prior orbital fracture repair surgery were excluded. Results: Twenty patients were included in the study. The duration from time of injury to surgery ranged from 7 weeks to 21 years with a mean of 19 months. Follow up ranged from 6 weeks to 56 months (mean 8 months). Mean age was 48 years (range, 25–80). Male to female ratio was 11:9. Surgery was performed on 10 right eyes and 10 left eyes. CT imaging demonstrated 10 patients had isolated floor fractures, while the remaining 10 patients had combined floor and medial wall fractures. Four patients also had associated facial fractures that did not require surgery. Indications for surgery included enophthalmos of 2 mm or more (18 of 20) and/or significant diplopia within 30° of primary gaze (6 of 20). Mean pre- and postoperative enophthalmos was 2.4 ± 0.9 mm and 0.3 ± 0.2 mm, respectively, corresponding to a mean reduction in enophthalmos of 2.1 ± 1.2 mm (range, 1–5 mm). Four of 7 patients with hypoglobus ranging from 1.5 mm to 8 mm preoperatively had complete resolution postoperatively, the remaining 3 patients showed reduced hypoglobus. Of the 12 patients that had diplopia preoperatively in any position of gaze, 6 patients had complete resolution of diplopia postoperatively, 4 patients had reduced but residual diplopia in extreme gaze, and 2 patients had persistent diplopia, in primary position and down gaze, respectively. Two patients had poor vision that precluded the manifestation of diplopia. None of the 6 patients without preoperative diplopia developed symptoms post operatively. Conclusion: Surgical repair of blow-out fractures of the orbit occurring more than 6 weeks or more from injury can achieve marked improvement in both the functional and cosmetic aspects. The likelihood of induced diplopia is low. Orbital floor fracture repair should be considered to successfully treat enophthalmos or diplopia in patients with delayed clinical presentation, even decades postinjury.

Outcomes of endonasal dacryocystorhinostomy without mucosal flap preservation.

Purpose: Dacryocystorhinostomy (DCR) is the standard procedure for the treatment of acquired nasolacrimal duct obstruction (NLDO) that can be performed through an external or endonasal approach. Both techniques create a fistula from the lacrimal sac into the nasal cavity via a bony osteotomy. Historically, external DCR has been considered the gold standard; however, recent reports suggest endonasal DCR is an effective alternative. There are numerous variations of endonasal DCR described in the literature that report variable success rates. The purpose of this study is to describe the approach and success rate with endonasal DCR in which nasal mucosa, bone, and lacrimal sac mucosa are sequentially removed. Methods: The authors retrospectively reviewed cases of endonasal DCR from 2004 to 2011 from 2 institutions (the University of California, San Diego, California, and the Fante Eye and Face Center in Denver, Colorado, U.S.A.). Patients with a history of epiphora and NLDO confirmed with punctal irrigation were included. Exclusion criteria were the presence of canalicular obstruction, history of orbital trauma, and prior DCR surgery. Success was defined as subjective relief of epiphora and confirmation of ostium patency with irrigation. Results: A total of 324 patients (74 men, 250 women; mean age 59.3) encompassing 407 endonasal DCR cases were included in the study. The total case success rate was 92.2% with an average follow-up time of 91.5 days. Revision surgery was performed in 7 of the failed cases and resulted in success in 6 of these cases. Conclusions: Endonasal DCR is a simple and effective approach to surgically treat NLDO and offers success rates comparable with external DCR.

Principles of Periocular Reconstruction following Excision of Cutaneous Malignancy.

Reconstruction of periocular defects following excision of cutaneous malignancy can present difficulties for oculofacial and reconstructive surgeons. The intricate anatomy of the eyelids and face requires precise restoration in order to avoid postoperative functional anesthetic concerns. Various reconstructive procedures based on common principles, location and size of the defect, can be applied to achieve restoration with the best possible functional and aesthetic outcomes.

Three carcinomas in one eyelid.

A 90-year-old woman presented with 2 masses on the right lower eyelid. Excisional biopsy revealed 1 lesion to be Merkel cell carcinoma and the other to be invasive squamous cell carcinoma. The patient also had a prior history of basal cell carcinoma in the same eyelid. This case emphasizes the importance of careful pathologic examination of all eyelid lesions regardless of previous history.

Glomuvenous Malformation: A Rare Periorbital Lesion of the Thermoregulatory Apparatus.

Glomuvenous malformations (GVMs), previously referred to as glomus tumors or glomangiomas, are benign, mesenchymal venous malformations arising from glomus bodies. Glomus bodies are modified smooth muscle neuromyoarterial structures involved in temperature regulation via blood shunting. These classically occur in the digits but can occur in other locations. The authors present a case of a periorbital GVM presented following blunt trauma to the area.