Melanie H. Erb

Effect of unilateral blepharoptosis repair on contralateral eyelid position

Purpose: This study evaluates the effect of unilateral blepharoptosis repair on contralateral eyelid position and assesses the relation between preoperative eyelid height interdependence, consistent with Hering law, and surgical outcome. Methods: The medical records of 54 patients (21 men, 33 women; mean age, 65 years) who underwent external levator advancement for unilateral aponeurotic blepharoptosis were reviewed for preoperative and postoperative margin reflex distance (MRD) of the nonoperated eye. To assess the relation between preoperative Hering dependence (mechanical elevation of the ptotic eyelid causing a decrease in contralateral eyelid height) and postoperative eyelid position, the change in MRD of the nonoperated eye was compared between subjects who on preoperative evaluation did (n = 18) and did not (n = 36) demonstrate eyelid height interdependence, using the 2-sample t test. Results: After unilateral blepharoptosis repair, the mean (± SD) change in contralateral MRD was −0.2 ± 0.8 mm. There was no significant difference in contralateral MRD change in subjects with and without preoperative Hering dependence (−0.3 ± 0.8 mm versus −0.2 ± 0.9 mm, respectively, p = 0.78). Seventeen percent (9 of 54) of patients had a contralateral MRD decrease of more than 1 mm. Three patients (5.6%) required contralateral blepharoptosis repair within 1 year of initial surgery. Conclusions: After levator advancement for unilateral blepharoptosis, roughly 17% of patients will have a decrease in contralateral eyelid height of more than 1 mm, with 5% of patients requiring surgical repair during the first postoperative year. The degree of change in contralateral eyelid height cannot be reliably predicted by preoperative assessment of Hering dependence.

Orbitotemporal Neurofibromatosis: Classification and Treatment ∗

Purpose: To review the clinical findings in orbitotemporal neurofibromatosis and discuss treatment options. Clinical features, histopathologic characteristics, and treatment options are reviewed. Methods: A Medline literature search from 1966 to 2004 was performed, using the key words: orbitotemporal neurofibromatosis, orbitopalpebral neurofibromatosis, orbitofacial neurofibromatosis, cranio-orbital neurofibromatosis, and cranio-orbital-temporal neurofibromatosis, and the pertinent literature was reviewed. Additionally, our experience with two patients is reported. The surgical procedures are discussed. Conclusion: The management of orbitotemporal neurofibromatosis is challenging. The planned surgical approach and extent of resection depend on the severity of the orbital soft tissue and bony involvement and on the visual potential. Ultimately, orbital exenteration may be needed for rehabilitation and cosmesis.

The Modified Fasanella-Servat Procedure: Description and Quantified Analysis

Purpose: To describe a modified Fasanella-Servat procedure and nomogram for the correction of minimal amounts of ptosis. Methods: Retrospective review of this modified Fasanella-Servat procedure was performed on 118 eyelids in 86 consecutive patients over 2, 4-year periods by 1 surgeon (S.C.D.). The amount of tarsectomy was based on the amount of ptosis. Results: Mean pre- and postoperative margin-to-reflex distance 1 were +0.7 mm and +2.4mm, respectively. One hundred and twelve eyelids (95%) had satisfactory results with postoperative margin-to-reflex distance 1 ≥ 1.5 mm. Eyelid symmetry was achieved in 92% of eyelids to within 0.5 mm. There was no incidence of overcorrection, tarsal buckling, or corneal abrasion. One eyelid had a contour deficit. Tarsectomy amount ranged from 2 mm to 5 mm. Average amount of tarsectomy to eyelid elevation was 2.4:1. Conclusions: The modified Fasanella-Servat procedure is technically easy, time-efficient, and has a low complication rate for the treatment of minimal blepharoptosis (< 2.5 mm) with good levator function and negative phenylephrine test. In the authors’ hands, the ratio of tarsectomy to eyelid elevation is approximately 2:1. In addition to other techniques such as levator advancement and Müller’s muscle conjunctival resection, the modified Fasanella-Servat technique is a useful adjunct to the modern ptosis surgeon’s armamentarium.

Periorbital xanthogranuloma after blepharoplasty.

Periocular xanthogranuloma is a rare inflammatory condition characterised by histiocytes and Touton giant cells. It is encountered in several settings: juvenile xanthogranuloma, Erdheim–Chester disease (ECD) and necrobiotic xanthogranuloma. Recently, cases with an adult onset not associated with ECD have been described, with frequent involvement of the eyelids and orbit.1–3 In this report, we describe a unique case of adult-onset periocular xanthogranuloma precipitated by blepharoplasty. A 57-year-old woman was referred for persistent postoperative oedema/inflammation 18 months after bilateral upper and lower blepharoplasty. On the basis of a review of her medical record and a conversation with her cosmetic surgeon, there was no suggestion of disease before surgery: her periocular involutional changes were typical and no abnormalities were noted intraoperatively. Her …

Müller’s Muscle-Conjunctival Resection Procedure Tips

Preoperatively, with the patient sitting up, the center of the pupillary axis is marked on the eyelid margin (Figure 163.1). Intraoperatively, this mark is used to align the Muller’s muscle-conjunctival resection (MMCR) clamp. The clamp is centered above this mark, thus ensuring that the highest archpoint of the clamp is aligned above the pupil. This provides proper lid contour postoperatively. Open image in new window Figure 163.1. Preoperatively, with the patient sitting up, the center of the pupillary axis is marked on the eyelid margin.

On-Q pump for pain control after orbital implant surgery.

Purpose: To introduce an elastomeric continuous infusion pump for pain control after outpatient orbital implant surgery. Methods: Retrospective, noncomparative consecutive case series of all patients undergoing enucleation, evisceration, or secondary orbital implantation using the On-Q pain system between August 2004 and January 2006. Postoperative pain score, need for narcotics, and adverse events were recorded. The On-Q catheter is inserted intraoperatively through the lateral lower eyelid into the muscle cone under direct visualization, prior to the orbital implant placement. The On-Q system continually infuses anesthesia (bupivacaine) to the retrobulbar site for 5 days. Results: Among 20 patients, mean postoperative period pain score, with On-Q in place, was 1.3 (scale of 0 to 10). Nine patients (45%) did not need any adjunctive oral narcotics. Two patients experienced postoperative nausea. One catheter connector leaked, thereby decreasing delivery of retrobulbar anesthetic resulting a pain level of 6, the highest level in the study. There were no postoperative infections. No systemic toxic effects from bupivacaine were observed clinically. Conclusion: The On-Q pain pump is widely available, low cost, and requires minimal patient manipulation for the use in orbital implant surgery. The device was safe and appeared to minimize postoperative pain in the authors’ case series.

Müller’s Muscle-Conjunctival Resection Pearls: Phenylephrine and Resection Considerations

The goal of blepharoptosis repair is to elevate the eyelids to an acceptable level while maintaining proper contour, lid crease, and final symmetry of eyelid height to within 0.5 mm. Muller’s muscle-conjunctival resection (MMCR)1 predictably attains these goals because the correction is consistently titratable according to published2 or personal nomograms. MMCR is the preferred approach to raise an eyelid by 2.5 mm or less in patients with a positive phenylephrine test.