Michael E. Migliori

Determination of the Normal Range of Exophthalmometric Values for Black and White Adults

We used the Hertel exophthalmometer to measure the degree of protrusion in 681 adults, ranging in age from 18 to 91 years. The 327 white and 354 black subjects had no history of orbital or endocrine disease, severe myopia (more than -7 diopters), or buphthalmos. The mean normal protrusion values were 16.5 mm in white men, 18.5 mm in black men, 15.4 mm in white women, and 17.8 mm in black women. Although protrusion values above 21 mm are usually considered abnormal, we found that the upper limits of normal were 21.7 mm for white men, 24.7 mm for black men, 20.1 mm for white women, and 23.0 mm for black women. These differences were statistically significant (P less than .025). No individual had more than 2 mm of asymmetry between eyes.

Silicone intubation for the treatment of congenital lacrimal duct obstruction: successful results removing the tubes after six weeks.

There is little agreement in the ophthalmic literature on the optimum length of time that silicone tubes should be left in place after lacrimal intubation for the treatment of congenital nasolacrimal duct obstruction. Various authors have recommended leaving the tubes in for 3 to 6 months. The authors of this article believe this to be an excessive amount of time. Lacrimal probing, inferior turbinate fracture, and silicone intubation were performed in children ranging in age from 3 months to 5 years. The tubes were removed after 6 weeks in all cases. Resolution of epiphora and dacryocystitis was achieved in all cases. Follow-up ranged from 4 to 81 months. The authors recommend that the silicone tubes be removed after 6 weeks. They also believe that fracture of the inferior turbinate should be performed along with silicone intubation.

Enucleation versus evisceration.

Removal of the eye may be necessary after severe ocular trauma, to control pain in a blind eye, to treat some intraocular malignancies, in endophthalmitis unresponsive to medical therapy, and for cosmetic improvement of a disfigured eye. The choice of procedure to accomplish this is best made by an informed patient. Enucleation and evisceration can each achieve the desired goals, but several factors must be considered in choosing the most appropriate procedure.

Hyaluronic acid gel (Restylane) filler for facial rhytids: Lessons learned from American Society of Ophthalmic Plastic and Reconstructive Surgery member treatment of 286 patients

Purpose: To review injection techniques and patient satisfaction with injection of Restylane in various facial areas by American Society of Ophthalmic Plastic and Reconstructive Surgery members. Methods: Data from 286 patients treated with Restylane in nine American Society of Ophthalmic Plastic and Reconstructive Surgery practices were abstracted to a spreadsheet for analysis. Results: Nine practices performed Restylane injections for 8.8 months on average (range, 2 to 28 months). Average practice volume per patient was 1.2 ml (range, 0.7 to 2.1 ml). Nine of nine practices injected the nasolabial and melolabial folds, 9 of 9 practices injected the lips, and 6 of 9 injected the glabella. Only 2 of 9 practices injected other fillers concurrently. Botox was injected concurrently by 8 of 9 practices. On a scale of 1 to 10, physicians rated average patient discomfort during Restylane injection 4.6 with topical anesthesia and 2.1 with injectable lidocaine, with or without topical anesthesia. The end point for injection was determined by visual cues, volume of injection, extrusion of the product, and palpation. “Problematic” complications, including bruising, swelling, bumpiness, and redness each had an incidence of 5% or less. Patient satisfaction on a scale of 1 to 10 had an average rating of 8.1, compared with that of Botox injection (8.9), upper blepharoplasty (8.9), and collagen injection (6.6). The source of Restylane patients was estimated to be existing Botox patients (45%); existing non-Botox patients (18%); word of mouth (14%); and new patients for other services (13%). Conclusions: Injection techniques, volume, end points, and anesthesia vary for different facial areas and between practices. Patients experience mild to moderate injection discomfort that is lessened with injectable lidocaine. Self-limited problems occur in about 5% of patients. Physician-determined patient satisfaction is perceived to be higher than that of collagen injection but slightly lower than that of botulinum toxin injection. The major source of Restylane patients was from existing practice patients, especially botulinum toxin patients.

Endoscopic evaluation and management of the lacrimal sump syndrome.

Summary Failed dacryocystorhinostomy caused by the presence of residual lacrimal sac has been termed the “lacrimal sump syndrome.” Epiphora occurs when tears collect in this residual pouch and lacrimal drainage is delayed. Irrigation into the nose may seem normal. This condition can be easily diagnosed with nasal endoscopy and has a characteristic radiologic appearance. Six patients with failed dacryocystorhinostomy caused by lacrimal sump syndrome were successfully treated with an endoscopic contact Nd: YAG laser technique. Endoscopic dacryocystorhinostomy using the contact Nd:YAG laser is an effective method for treating patients who have persistent epiphora or dacryocystitis after failed dacryocystorhinostomy.

The domed dermis-fat graft orbital implant

Dermis-fat grafts have been widely used in the reconstruction of the anophthalmic socket, both primarily after enucleation and secondarily after extrusion or migration of an existing implant. The dermis-fat graft is an effective means of replacing orbital volume and affording motility of the ocular prosthesis with both low morbidity and a satisfactory cosmetic result. We present a modification to the dermis-fat graft technique. Our modification creates a domed shape to the anterior surface of the graft that simulates the curvature of the eye. The dome-shaped graft creates deeper fornices than a standard flat-surfaced dermis-fat graft. It also allows better contact between the prosthesis and the dermis as the graft moves. The prosthesis can be thinner centrally and lighter than a prosthesis fabricated for a socket with a standard dermis-fat graft or spherical implant. This results in better motility of the prosthesis while also replacing orbital volume. There is no additional morbidity associated with this technique. We have used this procedure successfully in 18 patients; 10 were primary grafts and eight secondary grafts. Motility of the prosthesis was satisfactory in all cases. There was no abnormal graft shrinkage. All grafts maintained their domed shape. Follow-up ranged from 6 to 21 months.

Recurrent Jones tube extrusions successfully treated with a modified glass tube.

Displacement or extrusion of the standard glass Jones tube causes conjunctivodacryocystorhinostomy to fail in many cases. Patients who have had trauma, a tumor excised, or have received radiation therapy in the medial canthal area are particularly susceptible to this complication. Gladstone and Putterman developed a modified glass tube that has a second flange 3 to 6 mm from the top flange. The second flange anchors the tube and reduces its mobility. Eleven patients who could not retain a standard Jones tube were fitted with a modified glass tube. Seven of these patients were able to wear the originally placed modified tube comfortably. Two additional patients extruded the originally placed modified tube but were able to retain a shorter modified tube. Follow-up ranged from 3 weeks to 49 months (average, 22.4 months).

The smooth surface tunnel porous polyethylene enucleation implant.

BACKGROUND AND OBJECTIVE To describe early clinical results with the porous polyethylene smooth surface tunnel (SST) enucleation implant. PATIENTS AND METHODS Uncontrolled, prospective interventional case series of patients undergoing enucleation with placement of the SST implant. This implant consists of a porous polyethylene sphere with a smooth anterior surface containing pre-drilled tunnels to facilitate direct suturing of the rectus muscles to the implant without use of an implant wrap. Postoperatively, socket healing was assessed, and prosthesis and socket motility were evaluated by the surgeon using an ordinal scale (0 = no motility to 4 = excellent motility). RESULTS Thirty patients received the SST implant, with a mean follow-up of more than 23 months. Two cases of exposure occurred and were managed surgically without the need for explantation. Mean socket motility was 3.1 on a 0 to 4 ordinal scale, with mean prosthesis motility of 2.8. CONCLUSION The SST implant provides satisfactory socket motility and is generally well tolerated in the anophthalmic socket without the need for wrapping material.

Müller muscle-conjunctiva resection for blepharoptosis in patients with glaucoma filtering blebs.

Purpose: To study the safety and efficacy of Müller muscle-conjunctiva resection (MMCR) for blepharoptosis in patients with functional glaucoma-filtering blebs. Methods: Retrospective chart review of patients who underwent MMCR in the presence of a functioning filtering bleb. Patients offered MMCR all responded satisfactorily to preoperative topical phenylephrine hydrochloride testing. Using a similar technique, MMCR was performed by 6 surgeons at 6 different centers. Two patients had simultaneous upper blepharoplasty. Postoperative slit lamp examination was performed to assess for bleb injury or infection. In addition, all patients had routine glaucoma follow-up visits to assess for bleb functioning. Results: Nine patients with functional filtering blebs tolerated MMCR well and had no bleb complications. All blebs remained functional after surgery. One patient had anterior chamber reaction for 10 days and another patient had foreign body sensation for 6 weeks. At 9.2-months mean follow-up time, the mean change in margin reflex distance-1 was 2.9 mm. Conclusion: MMCR may be safe and effective in the setting of a glaucoma-filtering bleb.

Lower eyelid involutional ectropion repair with lateral tarsal strip and internal retractor reattachment with full-thickness eyelid sutures.

Purpose: To report a novel surgical technique for lower eyelid involutional ectropion repair using a lateral tarsal strip and internal retractor reattachment procedure involving full-thickness eyelid sutures. Methods: A retrospective review was performed of patients who underwent repair of involutional ectropion via lateral tarsal strip and internal retractor reattachment with full-thickness eyelid sutures by 1 surgeon. Patients having concomitant or previous eyelid surgical procedures were excluded. Collected data included patient demographics, surgical outcomes, and length of follow up. Results: Forty-one lower eyelids of 31 patients with involutional ectropion underwent surgical repair. There were 17 men and 14 women in the age range of 69 to 92 years (mean age 82.2 ± 5.9 years). Surgical sites included 22 right and 19 left lower eyelids. Follow up ranged from 1 to 48 months with an average of 5.9 months. Surgical success with anatomical correction of involutional ectropion was achieved in 39 of 41 eyelids (95.1%). There were no perioperative or postoperative complications. Two of 41 (4.9%) eyelids had recurrence of ectropion 7 and 18 months after the procedure. Conclusions: This procedure combining lateral tarsal strip with internal retractor reattachment involving full-thickness eyelid sutures effectively addresses horizontal eyelid laxity and tarsal instability, providing an effective technique to correct involutional ectropion of the lower eyelid.