Rao V. Chundury

Subjective and objective outcome measures in the treatment of facial nerve synkinesis with onabotulinumtoxinA (Botox).

Purpose: To evaluate the Sunnybrook Facial Grading System (SFGS) and Facial Clinimetric Evaluation Scale (FaCE Scale) instrument outcome measures pre- and 30-day posttreatment of facial nerve synkinesis with botulinum toxin with attempts to correlate the 2 scales. Methods: An IRB approved retrospective review of 22 patients with facial nerve synkinesis where the surgeon completed the SFGS and the patient completed the FaCE prior to receiving onabotulinumtoxinA therapy, the SFGS, and FaCE scales were completed again 1 month later. Results: Of the 22 patients, 9 complete datasets were analyzed. Mean patient age was 59.8; 8 (89%) women and 1 (11%) men. Overall SFGS composite score decreased from 57.6 ± 20.9 to 45.2 ± 13.5, (p = 0.001). SFGS subdomain synkinesis significantly improved (p < 0.001), while voluntary movement significantly decreased (p = 0.002). A difference in the resting symmetry was not statistically significant (p = 0.08). The FaCE scale composite score significantly improved from 40.9 ± 9.5 to 47.6 ± 11.9, (p = 0.03). FaCE subdomains facial comfort (p = 0.005) and social function (p = 0.009) significantly improved, while oral function, eye comfort, facial movement, and lacrimal control did not. The &Dgr; pre/post-SFGS composite score did not correlate with the &Dgr; pre/post-FaCE composite score (rs= −0.318). Subdomain analysis demonstrated significant negative correlation between &Dgr; pre/post-SFGS synkinesis score and &Dgr; pre/post-FaCE eye comfort score (rs = −0.826, p < 0.01). Conclusions: Significant improvement was seen in objectively reported synkinesis following botulinum toxin therapy. An improvement was noted in the overall subjective facial nerve functioning following therapy along with improvement in social functioning and facial comfort. A meaningful negative correlation was noted when comparing the SFGS “synkinesis” subdomain with the FaCE scale subdomain “eye comfort”, implying improvement in eye comfort with control of synkinesis.

Reply Re: "Comparison of preferences between onabotulinumtoxinA (Botox) and incobotulinumtoxinA (Xeomin) in the treatment of benign essential blepharospasm".

To the Editor: We thank Drs. Giacometti and Yen for their response demonstrating the proper method for fully reconstituting incobotulinumtoxinA. Merz, manufacturer of commercially available incobotulinumtoxinA, recommends reconstitution via gently mixing with saline, rotating and inverting the vial 2 to 4 times to ensure all the lyophilized powder is off the rubber stopper. We agree that failure to properly reconstitute incobotulinumtoxinA may result in a more weakly concentrated solution than desired. Although not explicitly listed in our methodology, the inversion method has always been used to reconstitute incobotulinumtoxinA at Ophthalmic Plastic and Cosmetic Surgery, Inc. Therefore, it is unlikely that improper reconstitution would account for our findings. We would like to highlight again that the standardization of the biologic activity and true “equivalent” dosing paradigms of new biologics is difficult and therefore could account for our study findings. We look forward to further studies comparing effectiveness of incobotulinumtoxinA toxin and onabotulinumtoxinA.

Regional Variations in Orbicularis Oculi Histology.

Purpose:To investigate and compare the histologic compositions of the pretarsal, preseptal, and orbital orbicularis oculi muscle (OOM) using nonpreserved, fresh-frozen, human cadavers. Methods:The OOM was exposed using sharp and blunt dissection. A metric ruler was used to measure and mark 0.5u2009cm × 1u2009cm samples from each portion of the right, superior OOM. Samples were excised, fixed in formalin, and completely embedded in paraffin. Five-micrometer-thick, hematoxylin- and eosin-stained sections were generated for each sample and analyzed by an anatomical pathologist. The relative percentages of the 4 main tissue types (skeletal muscle, fibrous tissue, adipose tissue, and neurovascular tissue) were quantified. Results:Forty-two samples were obtained from 14 Caucasian cadavers. On average, the pretarsal samples were composed of 83.5% skeletal muscle, 0.0% adipose, 5.0% neurovascular, and 11.5% fibrous tissue. Average preseptal OOM was 46.5% skeletal muscle, 12.7% adipose, 9.2% neurovascular, and 31.5% fibrous tissue. The orbital OOM was, on average, 42.7% skeletal muscle, 32.7% adipose tissue, 6.9% neurovascular, and 17.7% fibrous tissue. Conclusions:The OOM represents a histologically heterogeneous structure.

Microanatomical Location of Hyaluronic Acid Gel Following Injection of the Temporal Hollows.

Purpose: To examine the microanatomical location of hyaluronic acid gel injected within the temporal hollows of cadaver specimens. Methods: The temporal hollows were injected subcutaneously with hyaluronic acid gel in 6 fresh frozen human cadaver hemifaces. Temporal soft tissues were dissected to a preperiosteal plane and fixated in 95% alcohol. A soft tissue section extending from skin to temporal bone was obtained for each specimen. Histologic examination was performed using hematoxylin and eosin stain. Results: In 5 of 6 specimens, at least 95% of the hyaluronic acid was located within the subcutaneous fat. In 1 of 6 specimens, approximately 35% of the material was located within the subcutaneous fat and 60% was located within the superficial temporal fascia. Two specimens had 5% located within the temporalis muscle. In 1 specimen, hyaluronic acid was found to encompass a superficial muscular artery within the superficial temporal fascia. Conclusions: This study elucidates the location of hyaluronic acid gel after subcutaneous injection within the temporal hollow. Histology confirmed consistent placement of the gel within the subcutaneous tissues, but it also showed that injection in this region may produce unintended deeper location of filler, and a significant perivascular collection of the material. The proximity of dense temporal fascial and muscle arterial networks in this region may pose risk for perivascular injection and associated complications.

Periocular Skin Cancer in Solid Organ Transplant Recipients.

PURPOSEnTo determine the proportion of solid organ transplant recipients developing periocular nonmelanoma skin cancer and to describe the morbidity of these cancers in transplant recipients.nnnDESIGNnCohort study.nnnPARTICIPANTSnConsecutive patients undergoing solid organ transplantation at the Cleveland Clinic between 1990 andxa02008.nnnMETHODSnThe charts of all patients receiving a solid organ transplant from 1990-2008 evaluated in the dermatology department for a subsequent biopsy-proven head and neck malignancy through April 2015 were reviewed. Patients with a periocular region nonmelanoma skin cancer (NMSC) or a nonperiocular NMSC causing a complication requiring eyelid surgery were included. Charts were reviewed for demographic data; transplant date, type, and source; immunosuppressive agents received at diagnosis; and type of NMSC, number of nonperiocular NMSCs, ophthalmologic findings, and periocular sequelae after the repair.nnnMAIN OUTCOME MEASURESnPrimary outcome measures included the type, location, final defect size, tumor-node-metastasis classification, presence of perineural invasion, and reconstruction technique(s) used for each periocular NMSC. Secondary outcome measures included the type and treatment of ocular sequelae due to nonperiocular facial NMSC.nnnRESULTSnA total of 3489 patients underwent solid organ transplantation between 1990 and 2008. Of these, 420 patients were evaluated in the dermatology clinic for biopsy-proven NMSC of the head and neck during the study period, and 11 patients (15 malignancies) met inclusion criteria. Nine patients developed 12 periocular malignancies and 3 patients required eyelid surgery for facial malignancies outside the periocular zone. All 11 patients developed a squamous cell carcinoma (14 malignancies), and 1 patient (1 malignancy) also developed a periocular basal cell carcinoma. There was orbital invasion in 4 cases and paranasal and/or cavernous sinus invasion in 3 cases. Two patients underwent exenteration. Seven cases required reconstruction with a free flap or graft. Periocular sequelae included lower eyelid ectropion (6 malignancies), dry eye and/or exposure symptoms (8 malignancies), unilateral vision loss (3 malignancies), and facial nerve paresis (5 malignancies).nnnCONCLUSIONSnSquamous cell carcinoma affecting the periocular region represents a risk of solid organ transplantation and may produce significant ocular morbidity, including the need for major eyelid reconstruction, globe loss, and disfiguring surgery.

Relationship between ocular dominance and brow position in patients with blepharoptosis

ABSTRACT Purpose: This study aims to determine if ocular dominance plays a role in predicting compensatory eyebrow elevation in cases of ptosis. Methods: This retrospective observational cohort study screened all individuals presenting to two tertiary oculoplastics practices with complaints of ptosis for entry. Primary position photographs were obtained. Ocular dominance was assessed via a modified Porta test. Ptosis was defined in bilateral cases as marginal reflex distance of <2.5 mm in both eyes and in unilateral cases as either an MRD1 < 2.5 mm or MRD1 of >1 mm lower on one side. Asymmetry in brow height was defined as a difference of >1 mm. Chi square and t-tests were performed. Results: Sixty-eight patients from the both tertiary practices met inclusion criteria (37 male, 31 female). Concordance between the higher brow and the dominant side was 50.0% (n = 22, p > 0.05). Mean brow height on the dominant side (15.5 mm) was not statistically different than brow height on the non-dominant side (15.3 mm, p > 0.05). The concordance between the higher brow and the lower MRD1 eyelid was not significant (45.5%, n = 20, p > 0.05). The difference in mean brow height between the lower and higher MRD1 eyes was not significantly different (−0.11 mm; p > 0.05). This also held true when restricted to unilateral cases (0.28; p > 0.05). Conclusions: Although asymmetric brow elevation can be noted in patients with ptosis, ocular dominance does not appear to be concordant with this asymmetry. Additionally, brow height does not appear to be concordant with MRD1 in cases of ptosis.

Orbital rhabdomyosarcoma in a child with Leigh syndrome

We present the case of a 6-year old girl with Leigh syndrome and an orbital rhabdomyosarcoma and describe her clinical course and our multidisciplinary approach to treatment. To our knowledge, this isxa0the first report of rhabdomyosarcoma in a patient with Leigh syndrome.

Noninfectious Causes of Proptosis in Children

Proptosis in the pediatric population is alarming to the patients, their families, and treating physicians alike. Limited history, difficult examination, and the broad differential contribute to a challenging scenario. A thorough understanding of orbital diseases in the pediatric population is essential as proptosis can be associated with significant morbidity and even mortality in some cases. Appropriate medical history, full examination, diagnostic imaging/testing, and sometimes tissue biopsy are essential for determining the correct diagnosis and establishing appropriate management plan. This chapter provides an overview of noninfectious causes of proptosis in children.