Raman Malhotra

A consideration of the time taken to do dacryo-cystorhinostomy (DCR) surgery.

AbstractPurpose Comparison of surgical times for dacryocystorhinostomy (DCR) by three different approaches: (1) external, (2) endoscopic endonasal surgical (EES), and (3) endoscopic endonasal laser (EEL) using the holmium:YAG laser. The merits and limitations of each approach are considered and surgical throughput predicted.Methods Prospective study of adult patients undergoing primary DCR surgery for nasolacrimal duct obstruction. Surgical times were recorded. Subjective and objective outcomes were assessed at a minimum of 6 months.Results A total of 48 patients undergoing 51 DCR procedures were studied. The mean surgical time for primary external (n=20), EES-DCR (n=16), and EEL-DCR (n=15) was 41.1±10.3, 39.6±13.8, and 20.9±7.8 min, with symptomatic success achieved in 95, 88, and 60%, respectively. Follow-up was 6–36 months, mean 8 months. It was calculated that if six EEL-DCR, four EES-DCR, or three external DCRs are performed per list for 45 lists per annum, this equals a total of 270 EEL-DCR, 180 EES-DCR, and 135 external DCRs. Of these, 108 EEL-DCR, 22 EES-DCR, and seven external DCRs will fail. If 75% of these have redo surgery using the same technique, an extra 13.5 (EEL-DCR), four (EES-DCR), and two (external DCR) lists are needed.Conclusions There was no significant difference between the time taken to do EES-DCR compared to external DCR, and their clinical outcomes. Only EEL-DCR was significantly faster (P<0.001). However, its lower success rate negates the apparent benefit from the greater surgical throughput.

Lower eyelid anatomy: an update.

Eyelid surgery necessitates a thorough knowledge of eyelid anatomy. Recent contributions to the literature have significantly advanced our understanding of eyelid anatomy. In this review, we present an update of the anatomy and the implications for upper eyelid surgery. Aspects to be covered include the levator aponeurosis, Müllers muscle, lamina propria mucosae of conjunctiva, orbital septum, myoneural junction of the levator palpebrae superioris muscle, adipose tissue, and the ligament system.

Use of hyaluronic acid filler for tear-trough rejuvenation as an alternative to lower eyelid surgery.

Purpose: To describe one surgeons experience with the use of hyaluronic acid gel (Perlane) as a tear-trough filler over an 18-month period and to assess patient satisfaction with the procedure. Methods: Consecutive, interventional case series involving case note review, masked grading of clinical photographs, and patient satisfaction survey. Results: A total of 198 eyes of 100 patients were treated, with a mean follow-up of 5.1 months. Patients were principally female (87%), white (89%), and middle-aged (mean age = 47.8 years). Eight percent had previous lower eyelid blepharoplasty, and one had thyroid orbitopathy. The gel was placed preperiosteally, deep to orbicularis, anterior to the inferior orbital rim, with a mean volume of 0.59 ml per eye. The injection procedure was tolerable in 95% of patients without local anesthetic. Side effects described by patients included bruising (75%), swelling (26%), blue discoloration (4%), and lumpiness (33%). However, only 7% required dissolution with hyaluronidase. Eight percent requested additional hyaluronic acid gel within 3 months. Mean downtime was 1 day. Most patients (85%) described marked or moderate satisfaction with the treatment, 5% were ambivalent, and 10% were dissatisfied. Conclusions: This series confirms the effective use of hyaluronic acid gel (Perlane) in tear-trough rejuvenation. It has high patient tolerability, minimal complications, and high patient satisfaction. However, bruising, persistent lumpiness, or lack of perceived effect can lead to dissatisfaction in approximately 10% of cases.

Use of Hyaluronic Acid Gel for Upper Eyelid Filling and Contouring

Purpose: To describe the use of hyaluronic acid gel for upper eyelid filling, contouring, and rejuvenation. Methods: In this consecutive, retrospective, interventional case series, standard serial puncture injections with preperiosteal placement of filler were administered at the superior orbital rim. Outcome measures included classification of upper eyelid volume deficiency as I) medial A-shaped hollow, II) generalized hollow, III) postblepharoplasty volume loss, and IV) upper eyelid hooding with subbrow volume deflation; volume of filler used; masked, independent assessment of pretreatment and posttreatment photographs; patient satisfaction; and complications. Results: Twenty-seven patients were included with a mean follow-up of 13 months. More than 85% were white women with a mean age of 51 years (range, 24–65 years). Five patients were classified as type I, 8 as type II, 11 as type III, and 3 as type IV. The mean volume of filler used was 0.4 ml/eyelid (range, 0.1–1 ml). Photographic assessment showed improved static upper eyelid contour in 23 patients (85%), little change in 3 patients (11%), and deterioration in 1 patient (4%). Twenty-six patients (96%) were satisfied with the treatment, although 5 (19%) requested additional filler and 1 patient underwent dissolution within 3 months. Two of the 3 type IV patients still required blepharoplasty/ptosis surgery. All patients developed mild bruising and swelling but no discoloration or lumpiness. Conclusions: Hyaluronic acid filler is an effective means of rejuvenating the upper eyelid and is particularly successful in patients with medial/generalized upper eyelid hollowing, or significant postblepharoplasty upper eyelid show. A blepharoplasty/brow lift/ptosis procedure is still frequently required for hooding due to subbrow deflation (type IV).

The Management of Eyelid Burns

Eyelid involvement is common in facial burns. Ocular sequelae, including corneal ulceration, are usually preventable and secondary to the development of eyelid deformities, exposure keratopathy, and rarely, orbital compartment syndrome. Early ophthalmic review and prophylactic ocular lubrication is mandatory in burns involving the eyelids. Early surgical intervention, often requiring repeat procedures, is indicated if eyelid retraction causing corneal exposure occurs. Permanent visual impairment is rare with such prompt management. No binding aphorisms exist regarding the tissue used for eyelid reconstruction, with each case requiring an individual approach based on available skin. This review article covers the principles of ophthalmic management in addition to intermediate and long-term management of eyelid burns.

Cerebrospinal Fluid Leaks in Orbital and Lacrimal Surgery

Cerebrospinal fluid leakage is an uncommon but significant complication of orbital and rarely lacrimal surgery which may have serious consequences including death. In a retrospective review of four orbital units, we report an incidence of cerebrospinal fluid leak (diagnosed intraoperatively) during exenteration, orbital decompression, and dacryocystorhinostomy of 1/154 (0.6%), 4/397 (1%), and 0/3,504 (0%), respectively. We found two additional cases of cerebrospinal fluid leaks associated with excision of orbital masses involving the orbital roof. In the literature, the incidence of cerebrospinal fluid leaks associated with orbital exenterations and decompressions was 1.6-16.7% and 0-10%, respectively. Cerebrospinal fluid leaks occur very rarely in dacryocystorhinostomies with only a few case reports found in the literature. Preventative measures, diagnosis, and management of this complication are discussed. Knowledge of anatomy and thorough preoperative assessment may predict areas at high risk for encountering cerebrospinal fluid leaks. Proper surgical technique further minimizes the risk for this complication. If a cerebrospinal fluid leak occurs, however, prompt diagnosis and management usually results in uncomplicated recovery.

Pleomorphic adenoma of the lacrimal gland: is there a role for biopsy?

AimTo review the literature on biopsy of lacrimal gland pleomorphic adenoma (LGPA) and to examine the validity of the prohibition against biopsy in LGPA.MethodLiterature review.ResultsLGPA is usually diagnosed preoperatively based on clinical and radiological characteristics, as current teaching advises complete excision without prior incisional biopsy. The caveat against biopsy is based on older studies that reported increased recurrence rates with increased risk of malignant transformation after incomplete excision or biopsy. On the basis of a detailed examination of the literature on biopsy of both LGPA and pleomorphic adenoma of the salivary glands, it appears that there is no clear evidence to support the claim that biopsy increases the risk of recurrence or of malignant transformation of LGPA.ConclusionLacrimal gland tumours are uncommon lesions and optimal management depends to a great extent on a definite preoperative diagnosis. Preoperative biopsy should therefore be considered in all lacrimal gland mass lesions and management should be tailored to the biopsy findings. If surgical resection is then required, it may be prudent to excise the biopsy tract to ensure complete removal of the tumour.

Techniques of Upper Eyelid Reconstruction

Reconstruction of the upper eyelid is one of the greatest challenges facing the orbitofacial surgeon. This comprehensive review outlines the principles of reconstruction and the range of techniques available. Methods of assessing upper eyelid defects are discussed, and an algorithm for reconstruction based on defect size and lamellar involvement is given. The review contains numerous detailed examples of reconstructive techniques, including secondary intention healing, local flaps, distal flaps, simple and composite grafts, occlusive and non-occlusive methods, and canthal fixation. Eyebrow and eyelash reconstruction is also covered.

The transcaruncular approach to orbital fracture repair: Ophthalmic sequelae

The transcaruncular approach to the medial orbit is growing in popularity and although reported complications are minimal, ophthalmic and orthoptic sequelae can occur after any conjunctival surgery and nonophthalmic surgeons should be aware of these. This study aims to document these sequelae in a cohort of patients having transcaruncular surgery. A retrospective case series of all consecutive patients undergoing orbital fracture repair through a transcaruncular approach for medial wall and floor fractures in two centers over a 2-year period was examined. Computed tomography findings, pre- and postoperative ophthalmic and orthoptic findings, including ocular motility (with Hess chart evaluation), Hertel exophthalmometry, slit lamp biomicroscopy examination, follow-up time, and occurrence of complications were recorded. Thirteen patients, mean age 34 years (range, 18-82 years), underwent repair for medial wall (n = 5) or combined medial wall and orbital floor (n = 8) fractures with median a follow up of 7 months (range, 2-18 months). Preoperative ocular injuries included conjunctival chemosis, eyelid swelling, subconjunctival hemorrhage, retinal haemorrhage, traumatic uveitis and traumatic mydriasis, eye movement restriction, and enophthalmos (range, 3-4 mm). Postoperatively, corneal epitheliopathy with reduced vision (6/60), orbital inflammation, inferior oblique underaction, and superomedial fornix symblepharon at the caruncular incision sight each occurred in one patient along with extensive subconjunctival hemorrhage and a suture-related conjunctival granuloma in others. All patients experienced an improvement in diplopia and globe restriction. Ophthalmic complications can occur with this approach, and so it may be advisable to seek an ophthalmic opinion with the aim of comanagement in planning this approach.

Review and Update of Involuntary Facial Movement Disorders Presenting in the Ophthalmological Setting

We review the existing literature on the involuntary facial movement disorders-benign essential blepharospasm, apraxia of eyelid opening, hemifacial spasm, and aberrant facial nerve regeneration. The etiology of idiopathic blepharospasm, a disorder of the central nervous system, and hemifacial spasm, a condition involving the facial nerve of the peripheral nervous system, is markedly different. We discuss established methods of managing patients and highlight new approaches.