Martin H. Devoto

Frontalis suspension sling using a silicone rod in patients affected by myogenic blepharoptosis

The charts of 10 patients affected by myogenic ptosis who underwent surgical correction by means of a frontalis suspension sling using a silicone rod were reviewed. The patients included in the study were affected by ptosis secondary to myasthenia gravis (MG), chronic progressive external ophthalmoplegia (CPEO) or mitochondrial myopathy (MM). In every patient the ptosis was severe (MRD 1 <2mm), with the eyelid partially or totally occluding the visual axis; levator function was poor (<5mm), Bells phenomenon was poor or absent and the orbicularis function was reduced. Final eyelid height, patient satisfaction and the presence of complications were our main outcome measures. Analysis of the results showed that the ptosis was corrected in every patient with a clear visual axis. One patient with absent Bells and poor levator function had exposure keratopathy resistant to medical treatment and required surgical revision. We believe that the frontalis suspension sling is safe, effective and is the procedure of choice for patients affected by poor-function acquired ptosis. A silicone rod, because of its elasticity, is the material of choice in this selected category of patients.

Re: "minimally invasive conjunctivodacryocystorhinostomy with Jones tube".

Purpose: To describe a minimally invasive technique for conjunctivodacryocystorhinostomy with the Jones tube. This technique creates a direct communication between the conjunctiva and the middle meatus with the use of a 14-gauge angiocatheter. The glass tube is inserted under endoscopic or direct visualization. Methods: A retrospective review of consecutive patients who underwent the minimally invasive technique for conjunctivodacryocystorhinostomy for complete bicanalicular lacrimal obstruction was performed. The surgical time, intraoperative and postoperative complications, length of the tubes, long-term patency, tube displacement, and need for secondary revision were evaluated. Results: Fifty-five consecutive patients were included in the study. All surgical procedures were successfully performed without significant complications, in an operating time that averaged 16 minutes. In one early case, a patient had persistent postoperative bleeding that required cauterization of the middle turbinate. In 3 patients, late migration of the Jones tube into the nasal cavity required secondary intervention with successful Jones tube repositioning. Minor office tube cleaning was performed without removal of the tube. The patency of the Jones tube was regularly tested with demonstration of aspiration of 2% fluorescein solution from the tear meniscus in the tear lake opening of the tube at the slit lamp, the passage of the same solution in the nose with endoscopic view, and finally, with irrigation of saline solution in the tube. Conclusions: The minimally invasive technique for conjunctivodacryocystorhinostomy with the Jones tube can be successfully performed with a simple “poke-through” technique from the conjunctiva to the nose with direct or endoscopic control. This technique has proved to be time-effective and well tolerated by patients.

Primary cystadenocarcinoma of the lacrimal gland

PURPOSE To report a patient with a cystadenocarcinoma of the lacrimal gland, a tumor not previously described in the ophthalmic literature. Salivary gland cystadenocarcinomas constitute a distinct group of epithelial malignancies characterized by an invasive, predominantly cystic pattern of growth that have an indolent behavior and a low incidence of metastases and recurrences. DESIGN Single interventional case report. METHODS The clinical findings, results of imaging studies, and pathologic findings are presented. RESULTS A 67-year-old man presented with a 5-year history of ptosis in the right upper eyelid. A lacrimal fossa tumor was found. The tumor was excised with an intact capsule, and the histopathologic diagnosis was primary cystadenocarcinoma of the lacrimal gland. The patient received no other form of treatment and has been observed for 1 year without evidence of recurrence or metastatic disease. CONCLUSIONS Until recently, primary adenocarcinomas of the lacrimal gland were not further subclassified. Current knowledge gained from salivary gland tumors indicates that primary adenocarcinoma encompasses a group of tumors with separate morphologic features and varied biologic behavior.

Calcium hydroxyl-apatite (Radiesse) for the correction of periorbital hollows, dark circles, and lower eyelid bags.

Purpose: To describe the authors experience with calcium hydroxyl-apatite (CaHa) injections for the aesthetic correction of tear trough, infraorbital hollows, deep upper sulcus, dark circles and lower eyelid bags. Methods: The records of 63 patients (127 eyelids) injected with CaHa for aesthetic rejuvenation of the periocular region between March 2012 and March 2013 were retrospectively evaluated. All injections were carried out using a 25-gauge cannula after adding 0.5 ml of 2% lidocaine to 1.5 ml vials of the original product. Postoperative visits were scheduled at 1 week and 1 month. Any previous treatment was recorded, and necessity of retreatments and side effects was evaluated. Patient satisfaction was recorded at 1 month with self-evaluation of the treatment result as “worsened,” “unchanged,” or “improved.” Standard pre- and postinjection photographs were taken and compared to analyze the success of the procedure. Pictures were retrospectively graded by the authors on a similar improvement scale of 1 (worse), 2 (no change), and 3 (improvement). Results: Fifty-eight/sixty-three patients were women (92%), with an average age of 42 years (range; 18–57 years). Chief complaints were “hollows” in 94% of patients, “dark circles” in 33%, lower eyelid “bags” in 17%, and deep upper sulcus in 4.7%. Twenty-three patients (36.5%) required an additional correction 1 month after the primary treatment. Satisfaction was as high as 98% among patients treated primarily for hollowness, and the overall satisfaction rate was 92%. Associated dark circles were satisfactorily treated in 68% of the patients. Temporary side effects involved mild erythema and swelling for 2 to 3 days and pseudoxanthalesma effect in 22 eyelids (17.4%) lasting <6 weeks. In 2 patients, erythema lasted longer than 4 weeks. The 2 worse complications in this series were migration of the product above the medial canthal tendon in 1 patient and overcorrection in another patient. These complications were all managed conservatively and resolved spontaneously within 6 to 8 weeks. No case of irregular contour, palpable lumpiness, or unevenness were encountered. In the end, only 1 patient thought she was worsened after the treatment. Conclusions: Treatment of the periocular region with CaHa injections is a safe and effective treatment with high patient satisfaction and low complication rate. Advanced technical skills may have to be acquired for the specific treatment of this area using this particulate material.

The Ophthalmology Surgical Competency Assessment Rubric for Lateral Tarsal Strip Surgery

Purpose: To produce an internationally valid tool to assess skill in performing lateral tarsal strip surgery. Methods: A panel of 7 content experts adapted a previously published tool for assessing lateral tarsal strip surgery by using a modified Dreyfus scale of skill acquisition and providing behavioral descriptors for each level of skill in each category. The tools were then reviewed by 11 international content experts for their constructive comments. Results: Experts’ comments were incorporated, establishing face and content validity. Conclusions: The tool International Council of Ophthalmology-Ophthalmology Surgical Competency Assessment Rubric for Lateral Tarsal Strip Surgery has face and content validity. It can be used globally to assess lateral tarsal strip surgical skill. Reliability and predictive validity still need to be determined.

The modified rhomboid transposition flap in periocular reconstruction

Summary: The traditional rhomboid transposition flap has been widely used in reconstructive surgery. The authors have modified the original technique by eliminating the creation of the rhomboid defect and by directly transposing the flap into the original postexcisional defect. These changes allow maximum flexibility in flap design and minimize normal tissue loss. The authors retrospectively reviewed the charts of patients who underwent periocular reconstruction with flaps from 1990 through 1995. The authors selected those patients in whom the modified rhomboid flap was used. Functional and cosmetic results and complications were reviewed. Two hundred thirty-two patients were identified in whom 242 flaps were performed. The modified rhomboid flap was used in 101 patients (41.7%). Complications occurred in 23 patients (23%), 19 of whom (19%) were treated medically and four of whom (4%) required an additional surgical procedure. Cosmetic and functional results were classified as very good or excellent in 96 patients (96%). The use of a modified rhomboid flap in the reconstruction of the periocular area offers ample versatility in flap design and minimal normal tissue loss. Functional and cosmetic results are satisfactory in the vast majority of cases.

Hering's law and eyebrow position.

A patient with bilateral but asymmetrical brow ptosis is presented in whom the frontalis action on the relative position of the eyebrows could be demonstrated to obey Herings law of equal innervation. The neurological basis for this finding is discussed, along with the implications for the surgical management of brow ptosis.

Supramaximal Levator Resection for Unilateral Congenital Ptosis: Cosmetic and Functional Results

Purpose: To analyze the cosmetic and functional results of a large series of patients with unilateral congenital ptosis without spontaneous compensatory ipsilateral frontalis hyperaction who underwent supramaximal levator resection (SMLPSr). Methods: A multicenter retrospective review of 35 children (14 girls and 21 boys) of mean age 5.5 ± 3.6 SD years with unilateral congenital ptosis who underwent surgery in 3 different countries: Italy, n = 8; Argentina, n = 11; and Brazil, n = 16. Preoperative evaluation included measurements of upper eyelid margin reflex distance (MRD1) and levator palpebrae superioris muscle excursion, assessment of frontalis hyperaction, and ocular motility examination. At least 6 months postoperatively, photographs were used to measure the upper eyelid contour of OU. The spontaneous blinking amplitude and downward eyelid saccades of OU were quantified in a subset of 14 patients. Quantitative comparison among the 3 centers was performed with nonparametric 1-way analysis of variance (Kruskal–Wallis). Paired t tests were used to compare the pre- and postoperative measurements, and p value < 0.05 was statistically significant. Results: The mean preoperative MRD1 of the operated eyes increased from 0.5 ± 1.1 SD mm to 3.4 ± 0.84 SD mm (t = 15.9; p < 0.000001), consequently the eyelid positional asymmetry decreased from 3.1 ± 1.21 mm to 0.1 ± 0.86 SD mm (t = 16.5; p ⩽ 0.000001). Twenty-nine percent of eyelids had mild contour abnormalities and 31.4% showed some degree of lash ptosis. Spontaneous blinks were abnormal in 93% of the cases (eyelids). The amplitude of the abnormal blinks ranged from 12.9% to 65.4% (mean = 37.1%) of the contralateral eyelids. Downward eyelid saccades were reduced in 79% of the eyelids. The amplitudes the saccades ranged from 2.2% to 84.6% (mean = 54.8%). Conclusions: In unilateral congenital ptosis, SMLPSr effectively reduces the positional asymmetry between eyelids. Mild contour abnormalities and lash ptosis are the main complications of the surgery. Postoperatively, spontaneous blinks and downward saccades were reduced in most eyelids. The reduced postoperative eyelid kinetics indicates that only patients with normal upward Bell signs are good candidates for this procedure.

Minimal incisions vertical endoscopic lifting and fat grafting as a systematic approach to the rejuvenation of the periocular esthetic unit.

Purpose:The forehead/brow complex, the temporal region, the upper eyelid, the zygomatic area, the lower eyelid, and the cheek comprise the periocular esthetic unit. The combination of variable degrees of tissue descent and fat deflation of the component parts of the unit determine its appearance with age. The authors report the results of tissue repositioning through a minimal incisions vertical endoscopic lift and volume restoration used in combination to restore the natural youthful appearance of the periocular esthetic unit. Methods:The authors retrospectively reviewed the charts of patients who underwent minimal incisions vertical endoscopic lift and fat grafting over a 12-year period in 3 different centers. Patients results were evaluated with standardized pre- and postoperative pictures graded by masked observers in a scale from poor, fair, satisfactory, to very satisfactory results. Patient satisfaction was self-graded in the same manner. Results:The study consists of 400 patients, of whom 337 (85%) were women and 63 (14.8%) were men, with a mean age of 46 years (range 38–67) for women and mean age of 53 years (range 48–65) for men. Mean follow up was 16 months (range 6 months–8 years); in 180 patients follow up was 2 years or longer. Additional procedures included lower blepharoplasty in 205 patients (51%), neck lift in 102 patients (26%), upper blepharoplasty in 63 patients (15.7%), lateral canthoplasty in 9 patients (2.3%), and upper eyelid ptosis in 6 patients (1.5%). The results were graded as satisfactory or very satisfactory by 95% of patients and by 91% of observers. Conclusions:On the basis of the anatomical changes that occur in the periocular esthetic unit, tissue repositioning is indicated to address the descent of the superior complex and in minor part of the inferior complex, while volume restoration is indicated to address the volume depletion of the inferior and the lateral complexes and for refinements of the superior complex. The authors propose a systematic combination of lifting and filling to naturally restore the youthful appearance of the periocular esthetic unit. Conservative blepharoplasty can be associated in selected cases for result optimization.

Mini-Invasive Ptosis Surgery

Background and objective: Levator aponeurosis advancement is an effective technique that is routinely used to correct aponeurogenic ptosis. The standard technique involve a skin incision of the upper eyelid crease for the entire length of the eyelid, with or without associated blepharoplasty. We believe that, in a selected group of patients, a less invasive approach with an upper lid skin incision of only 0.8 cm is equally effective for the final result and offers several advantages compared to the traditional technique. Materials and methods: We retrospectively reviewed the data of 48 patients affected by involutional ptosis with good levator function that underwent unilateral or bilateral levator advancement ptosis repair through a mini-invasive approach. Final outcome measures included postoperative eyelid height, contour, symmetry, periocular edema, surgical time and visibility of the incision site. Results: The mini-invasive approach for the correction of involutional ptosis resulted in our hands as effective and reliable as the traditional technique, required a shorter surgical time, offered an improved early post-operative course with minimal bruising and swelling and produced no visible scar. Conclusions: This mini-invasive ptosis correction technique replaced in our practice the traditional approach for the treatment of a selected subset of patients affected by aponeurogenic ptosis.