Matthew G. Vicinanzo

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.

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.

Autogenous Fascia Lata Graft Fixation to Treat Exotropia Resulting From Iatrogenic Medial Rectus Transection.

PURPOSE To describe autogenous fascia lata graft fixation as a novel method to treat exotropia related to medial rectus (MR) muscle injury following functional endoscopic sinus surgery. METHODS Three consecutive patients with MR transection and exotropia after functional endoscopic sinus surgery were selected. Preoperative examination was performed; no MR function was noted for over 3 months after injury. CT and dynamic functional MRI were performed, where MR transection and medial wall breach were noted. An autogenous fascia lata graft was harvested and fixated from the remaining periosteum of the posterior-most extent of the medial orbital wall and attached to the globe at the MR insertion. In addition, an ipsilateral lateral rectus muscle recession was performed. RESULTS Alignment of the eyes in primary gaze and downgaze was achieved and remained so at the 3-month postoperative examinations, with minimal head turn or prism correction (<5 prism diopters) necessary to control diplopia. Two patients required recession of the fascial graft for a minor overcorrection and have remained stable for over 6 months. CONCLUSIONS Severe exotropia secondary to MR damage following functional endoscopic sinus surgery is a known complication historically difficult to treat. Traditional surgical methods, including vertical muscle transposition, commonly result in complete recurrence of exotropia and increase risk of anterior ocular ischemia. Unlike simple nonabsorbable suture fixation, fascial grafts are completely biointegratable, do not result in significant inflammation, and are unlikely to rupture. Fascia lata graft fixation of the MR to the posterior orbital medial wall is a new and successful method to eliminate exotropia after MR injury.

Internet-Initiated Patient Characteristics

The purpose of the study is to evaluate the differences between patients who access an oculoplastic practice via the Internet from patients who are referred by other physicians or patients. A retrospective chart review of sequential patients who accessed an oculoplastic practice via the Internet from July 1, 2008, to June 30, 2014, was reviewed. A comparison group of the next sequential chart number after each Internet patient was also reviewed. One hundred eighty-nine Internet patients and 165 non-Internet patients were identified. The average age of the Internet patients was 52 years (range, 19-82 years) and non-Internet patients was 51.8 years (range, 1-82 years). The Internet patients were more likely to be female. (P < .0001). The average income per household of the Internet patients was

The consequence of premature silicone stent loss after external dacryocystorhinostomy.

61,415 as compared with the non-Internet patients at

Unusual presentation of gastric adenocarcinoma metastatic to the orbit.

54,389 (P = .003); they were also more likely to have private insurance (87% vs. 61%, respectively) (P < .01). A surgical procedure was more likely to be performed in the Internet group (71%) versus the non-Internet group (58%) (P = .003). Internet patients were more likely to have cosmetic and/or functional procedures (P < .0001). Postoperative visits (P = .001) and phone calls (P = .03) were significantly higher for Internet patients. The patients who accessed the practice via Internet were most likely to be a middle-aged female and reside in zip codes with higher household incomes. They were more likely to undergo cosmetic surgery and averaged more postoperative visits and phone calls.