Norman Shorr

Transcaruncular approach to the medial orbit and orbital apex.

OBJECTIVE To present a versatile approach to the medial orbit and orbital apex through the caruncle. DESIGN Retrospective, noncomparative, case series with description of surgical technique. PARTICIPANTS Twenty-five consecutive patients underwent orbital surgery by use of a transcaruncular approach. INTERVENTION Inferior and medial wall fracture repair or orbital decompression by means of a transcaruncular or combined transfornix-transcaruncular approach. MAIN OUTCOME MEASURES The surgical indications and complications were recorded for each patient. RESULTS Ten patients (10 orbits) underwent combined inferior and medial orbital wall fracture repair through a combined transfornix-transcaruncular approach. In 8 of 10 (80%) orbits, the inferior oblique muscle was disinserted during surgery. Fifteen patients (24 orbits) underwent orbital decompression surgery for dysthyroid orbitopathy. An isolated transcaruncular approach was used in 5 of 24 orbits, and a combined transfornix-transcaruncular approach was used in 19 of 24 orbits. There were no complications related to either approach. CONCLUSIONS Orbital bone removal and fracture reduction may be safely completed through a combined transfornix-transcaruncular approach. The transcaruncular approach provides excellent and safe exposure of the medial orbital wall, and it avoids scarring associated with the Lynch approach.

Eyelid reconstruction with hard palate mucosa grafts.

Hard palate mucosa grafts are an excellent replacement for tarsus and conjunctiva in eyelid reconstruction. Twenty-five eyelids from 18 patients underwent eyelid reconstruction using hard palate mucosa grafts. Patients were treated for a variety of disorders including postblepharoplasty lower eyelid retraction, cicatricial entropion, eyelid retraction secondary to thyroid eye disease, and lagophthalmos following surgery for paralytic ptosis. Surgical results were evaluated, grafts were measured for postoperative shrinkage, and donor site healing was recorded. Several patients had hard palate biopsy specimens evaluated. One of these patients also had a graft biopsied after it had been in place for 3 months. A review of hard palate anatomy and histology and a discussion of surgical technique are presented.

Central Retinal Artery Occlusion Associated With Periocular Corticosteroid Injection for Juvenile Hemangioma

Intralesional corticosteroid injections are an accepted treatment for periocular juvenile hemangiomas. This treatment is felt to be relatively free of complications. We report, however, a case of central retinal artery occlusion associated with steroid injection for a periocular juvenile hemangioma in a four-year-old child. It is presumed that the force of injection or digital massage caused retrograde arterial flow, moving steroid suspension particles into the central retinal artery where vascular occlusion occurred. As a result of this case, our treatment regimen has been modified. We now use 0.1 cc steroid alloquats injected slowly through a 30-gauge needle and avoid firm digital pressure on the lesion.

The medial orbital strut in the prevention of postdecompression dystopia in dysthyroid ophthalmopathy

Ocular dystopia with inferomedial displacement of the globe is an unusual but well-recognized complication of bony orbital decompression. It is caused by displacement of the muscle cone and orbital connective tissue system into the maxillary and ethmoidal sinuses. We illustrate a surgical variation of bony orbital decompression leaving intact a strut of bone at the maxillary-ethmoid junction. This bony strut reduces inferomedial displacement of the muscle cone and provides a medial supporting “ledge” in cases requiring late orbital reconstruction.

The Use of Botulinum Toxin in Blepharospasm

Twenty-two patients, 17 with benign essential blepharospasm and five with hemifacial spasm, received botulinum toxin by subcutaneous injections in the eyelids and eyebrows. All 22 patients received a standard treatment of 12.5 units of botulinum toxin per side at each injection session. The orbicularis oculi muscle showed pronounced weakness after injection and the spasms decreased. Spasms often recurred despite persistent orbicularis oculi muscle weakness. Side effects were minimal. All patients received some relief, which generally lasted six to 12 weeks.

The safety and applications of acellular human dermal allograft in ophthalmic plastic and reconstructive surgery: a preliminary report.

Purpose To describe the uses and determine the safety of a commercially available acellular dermal allograft in ophthalmic plastic and reconstructive surgery. The existing literature regarding current applications and results using acellular dermal allograft is reviewed. Methods The study design was a retrospective, noncomparative case series. Participants consisted of 63 consecutive patients undergoing ophthalmic plastic and reconstructive surgery using an acellular dermal matrix graft. The main intervention was placement of a dermal allograft. Outcome measures included the degree of clinical improvement and complications for each patient. Results We used AlloDerm (LifeCell Corporation, The Woodlands, TX, U.S.A.) as a posterior lamellar conjunctival spacer graft, a soft tissue interpositional graft, and an orbital implant wrapping material. Clinical improvement was noted in all cases. There were no complications attributable to the acellular dermal matrix material. Conclusions We describe several novel ophthalmic plastic and reconstructive surgical applications using acellular dermal allograft tissue. This material may be used safely as a posterior lamellar conjunctival spacer graft, a soft tissue interpositional graft, and a wrapping material. Clinically, the allograft appears to be biocompatible, nontoxic, and nonallergenic in the orbit, eyelid, and midfacial tissues. Long-term data and studies comparing the efficacy of acellular dermal allograft with conventional materials are necessary.

Floppy Eyelid Syndrome and Blepharochalasis

Floppy eyelid syndrome and blepharochalasis may represent a spectrum of one underlying disease. Two patients with floppy eyelid syndrome and one with blepharochalasis shared important clinical similarities. All three patients displayed eyelid laxity associated with papillary conjunctivitis and ocular surface abnormalities. Histopathologic findings were similar in the three cases, characterized by chronic conjunctival inflammation with normal tarsal collagen. In all three patients surgical horizontal eyelid shortening led to improvement in symptoms and findings.

Madame Butterfly procedure: combined cheek and lateral canthal suspension procedure for post-blepharoplasty, "round eye," and lower eyelid retraction.

&NA; The most common complication of lower eyelid blepharoplasty is eyelid retraction (“scleral show”) of the lateral one‐third of the lower eyelid, with associated rounding and inferior displacement of the lateral canthus. A procedure in which the middle lamellar cicatrix is lysed, the lateral canthus reconstructed, and the cheek elevated to provide additional vertical anterior lamellar skin is described. Skin grafting is often aesthetically poor in the lower eyelid and is unacceptable in the upper eyelid. This new procedure may be used to elevate the lower eyelid rather than lower the upper eyelid in cases of post‐blepharoplasty lagophthalmos with exposure keratopathy. Thus, the procedure offers cosmetic and functional repair, without the use of skin grafts, for the patient who would normally need upper and lower eyelid skin grafting.

Infraorbital pigmented skin. Preliminary observations of laser therapy.

BACKGROUND The presence of infraorbital dark skin, often known as dark circles under the eyes, is a frequent cosmetic concern. There has been little reported on therapy of this condition. One group of patients was determined to have dermal melanin deposition, which we treated with a Q‐switched ruby laser. OBJECTIVE Our study evaluated the clinical and histological appearance of infraorbital skin pigment in 17 patients with dermal melanin deposition treated with a Q‐switched ruby laser. METHODS Seventeen patients with melanin deposition were treated with the Q‐switched ruby laser (694 nm) with a pulse width of 28 nanoseconds and flucnces of 7.5 J/cm2. Response to treatment was assessed by an independent investigator with patient and photograph evaluation. Skin biopsies were obtained in nine of the 17 patients. RESULTS Of those patients treated with one Q‐switched ruby session, 23.5% achieved a greater than 50% response. Of those treated twice, 88.9% achieved greater than 50% response. In postrcatment skin biopsies there was reduction of dermal melanin deposition. CONCLUSIONS. Patients with infraorbital pigmented skin due to dermal melanin deposition may be considered candidates for Q‐switched Ruby laser treatment.

Use of Hyaluronic Acid Gel in the Management of Paralytic Lagophthalmos: The Hyaluronic Acid Gel "Gold Weight"

Purpose: To evaluate the safety and efficacy of injecting hyaluronic acid gel in the upper eyelid as a nonsurgical alternative in the treatment of paralytic lagophthalmos. Methods: This is a retrospective study of 9 patients (10 eyelids) with paralytic lagophthalmos treated with hyaluronic acid gel in the prelevator aponeurosis region and/or pretarsal region of the paralytic upper eyelid. Pretreatment, posttreatment, and follow-up photographs were digitized, and overall outcomes assessed. Measurements of lagophthalmos were standardized and compared. Slit-lamp examination was used to evaluate the degree of exposure keratopathy. ImageJ was used for photographic analysis. Results: Ten eyelids (9 patients, 7 men; mean age 69.2 years; range, 31–90 years) with paralytic lagophthalmos were treated with hyaluronic acid gel. The average amount of injected hyaluronic acid gel was 0.9 ml (range, 0.2–1.2 ml). All patients demonstrated significant improvement in lagophthalmos and exposure keratopathy. The mean improvement in lagophthalmos was 4.8 mm (range, 0.9–11.9 mm; p = 0.001). Of the 5 patients with follow-up, the mean follow-up period was 3.6 months (range, 2–5 months). Of these, 2 had no change in lagophthalmos (both maintained 0 mm at 5 months), one had a slight decrease in lagophthalmos (4.8–4.6 mm at 2 months), one had a slight increase in lagophthalmos (0.3–0.5 mm at 2 months), and one had a more significant increase in lagophthalmos (1.9–4.3 mm at 4 months). The latter patient underwent a second treatment with further reduction of lagophthalmos to 0.4 mm. Overall, there was a decrease in margin reflex distance from the upper eyelid margin to the corneal light reflex (MRD1) but it was not statistically significant. Complications were minor and included transient ecchymosis, edema, and tenderness at the injection sites. Conclusions: On the basis of these preliminary results, hyaluronic acid gel shows promise as a safe and effective nonsurgical treatment for the management of paralytic lagophthalmos. This treatment may be particularly useful in patients who are poor surgical candidates and/or as a temporizing measure in patients in whom return of facial nerve function is anticipated, given the hyaluronic acid gel’s properties of slow resorption and reversibility with hyaluronidase.