Susan R. Carter

Silicone Frontalis Slings for the Correction of Blepharoptosis: Indications and Efficacy

PURPOSE To determine the efficacy of silicone rod frontalis sling ptosis repair in selected patients. METHODS The authors retrospectively studied 35 consecutive patients who underwent silicone sling ptosis repairs in 6 lids at the University of California, San Francisco. RESULTS Preoperative diagnoses included congenital ptosis causing developmental delay or possible amblyopia in children younger than 3 years of age, chronic progressive external ophthalmoplegia, third-nerve palsy, myasthenia gravis, and ocular restriction secondary to glaucoma filtering valves. With a mean follow-up of 22 months, good-to excellent final lid height was achieved in all 61 lids. Recurrence of the ptosis occurred in four lids (7%), requiring replacement of the silicone rod in two lids and revision of the original sling in two lids to reach the final lid height. Chronic exposure keratopathy without corneal infection occurred postoperatively in 9 (15%) of 61 eyes, all in patients with an inadequate or absent Bell phenomenon. Chronic corneal problems did not develop in any of the children. Extrusion of the sling with or without infection occurred in three foreheads (5%) in two patients younger than 15 years of age. CONCLUSION Silicone rod is an effective material for use in frontalis suspension in treating severe ptosis with poor levator function. Children younger than 3 years of age with congenital ptosis and developmental delay or possible amblyopia can undergo silicone frontalis suspension to achieve good visual results. The elasticity and ease of adjustment of the silicone rod are ideal characteristics for a suspensory material used to correct severe ptosis associated with a minimal or absent Bell phenomenon, such as in chronic progressive external ophthalmoplegia, myasthenia gravis, or third-nerve palsy.

Ocular manifestations of leukemia: leukemic infiltration versus infectious process

OBJECTIVE To determine whether specific guidelines can be developed to distinguish whether retinal infiltration in leukemia patients represents infection or neoplasia. DESIGN Retrospective noncomparative interventional case series. PARTICIPANTS Six patients recently seen at University of California San Francisco with retinal infiltrates in a setting of leukemia, for which adequate written and photographic information of disease course was available. INTERVENTION Observation consisted of retrospective review of clinic charts, hospital medical records, and fundus photographs. MAIN OUTCOME MEASURES Determination of whether retinal infiltrates represented neoplasia or infection was made by review of medical records. RESULTS In this series, neoplastic retinal infiltrates were found in patients who had newly diagnosed leukemia and those who were in blast crisis. In contrast, the two patients who were in complete remission, but had undergone bone marrow transplantation, had retinal infiltrates attributable to infection. CONCLUSIONS Every patient with retinal infiltrates in the setting of newly or previously diagnosed leukemia requires a systemic and central nervous system workup before the initiation of ophthalmologic treatment. The systemic status of the patient is highly informative in determining whether infection or neoplasia is responsible for the infiltration.

Orbital solitary fibrous tumor: radiographic and histopathologic correlations.

OBJECTIVE To correlate the clinicopathologic and radiographic features characteristic of orbital solitary fibrous tumor (SFT). METHODS The diagnostic features and clinical outcome of seven adults with orbital SFT are retrospectively outlined. Orbital imaging was performed by ultrasonography, computed tomography, or magnetic resonance imaging. Some cases were imaged by multiple modalities. Histopathologic examination of each tumor specimen included standard light and immunohistochemical stains. RESULTS Heterogeneous internal composition was better appreciated on magnetic resonance imaging than on computed tomography. All cases undergoing magnetic resonance imaging showed T1 isointensity and T2 hypointensity relative to gray matter. Strong, generalized immunohistochemical reactivity to vimentin and CD34 validated the diagnosis of SFT and differentiated the specimens from other spindle cell neoplasms. After complete tumor resection, our patients remain tumor free with postoperative intervals of 15 to 45 months. CONCLUSIONS Solitary fibrous tumor has now been reported in 26 orbits. No physical finding is pathognomonic, but several imaging traits are highly characteristic. Intralesional image heterogeneity and a predominantly low T2 signal intensity are distinctive of SFT. Complete tumor resection and immunohistologic specimen evaluation are emphasized. Clinicians should consider the diagnosis of SFT when confronted with an adult patient having an orbital soft tissue mass demonstrating the distinctive magnetic resonance imaging findings.

Role of local amphotericin B therapy for sino-orbital fungal infections.

PURPOSE Sino-orbital fungal infections are serious complications of diabetes and immunosuppression. Standard treatments include surgical debridement of the involved tissues with possible orbital exenteration, intravenous antifungal therapy, and improvement of the hosts immunocompetence and metabolic state, when possible. The role of conservative orbital debridement combined with local amphotericin B irrigations in the treatment of these patients was evaluated. METHODS The records of seven consecutive patients with sino-orbital fungal infections, who were treated with limited surgical debridement and local and systemic amphotericin B therapy, were reviewed. The underlying disorders of these patients included acute lymphoblastic leukemia, immunosuppression after renal transplantation, diabetes mellitus, and acquired immunodeficiency syndrome. The fungal species identified included Rhizopus, Mucor, and Aspergillus. RESULTS Follow-up ranged from 4 months to 4 years. All patients retained their preoperative visual acuities. Only one patient ultimately underwent an orbital exenteration for progressive orbital fungal infection. The remaining patients had either complete or incomplete (without further progression) resolution of their fungal infection. Two of the seven patients died of unrelated causes, and no patient died of uncontrolled fungal spread. CONCLUSIONS Conservative orbital debridement with local amphotericin B irrigations is an effective adjunct in the control of sino-orbital fungal infections, especially in patients with reversible immunosuppression and good preoperative visual acuities.

Treatment of Facial Palsies With External Eyelid Weights

PURPOSE Because ocular exposure is a major complication of facial paralysis, an external gold eyelid load weight was evaluated for effectiveness in the treatment of this problem. METHODS We prospectively studied 12 patients with unilateral facial paralysis who were treated with the external eyelid weights. Follow-up examinations included corneal exposure, amount of artificial tear usage, patient comfort, and complications associated with the weights. Treatment end points were the patients decision to undergo a canthoplasty or placement of an implanted weight or resolution of the facial paresis to better than Houses grade IV/VI. RESULTS Of the 12 patients studied, ten had decreased corneal exposure on the affected side, with a coincident decrease in artificial tear drop use and increased comfort. One patient had no improvement in a corneal defect, and one was unable to apply the weight. Five patients had some difficulty in positioning the weight, which was related to upper eyelid dermatochalasis in four of the five. Only two weights were lost in over two years of total wearing time. CONCLUSIONS External eyelid weights are useful in the treatment of ocular exposure associated with facial paralysis. The weights decreased corneal exposure, decreased reliance on artificial tear drops, and increased patient comfort. The weights were helpful as a trial before implantation of eyelid weights and as a longer-term treatment for ocular exposure in patients with temporary facial paralysis. Loose upper eyelid skin may limit their usefulness in some patients.

Infection after blepharoplasty with and without carbon dioxide laser resurfacing

PURPOSE To determine the rate of infection in patients who underwent blepharoplasty with and without carbon dioxide laser resurfacing. DESIGN A retrospective, nonrandomized, consecutive case series. PARTICIPANTS Eighteen hundred sixty-one patients who underwent upper or lower blepharoplasty, with or without carbon dioxide laser resurfacing. METHODS Charts of patients who underwent blepharoplasty, with or without laser resurfacing, were analyzed for the presence of postoperative infection, method of treatment, and possible sequelae. MAIN OUTCOME MEASURES The rate of infection (%) was determined for each group of patients. RESULTS Infection occurred in 0.2% of patients who underwent blepharoplasty without laser resurfacing and 0.4% of patients who had adjunctive laser resurfacing. No permanent functional or cosmetic sequelae resulted from the episodes of infection. CONCLUSIONS Infection after blepharoplasty without laser resurfacing is uncommon, indicating that topical antibiotic ointment prophylaxis is a sufficient postoperative regimen. The use of adjunctive laser resurfacing may increase the infection rate slightly.

Tarsal margin rotation with posterior lamella superadvancement for the management of cicatricial entropion of the upper eyelid

PURPOSE To report the efficacy of tarsal margin rotation with posterior lamella superadvancement in the management of cicatricial entropion of the upper eyelid. METHODS In 15 consecutive patients, 22 eyelids with cicatricial entropion were managed with tarsal margin rotation and posterior lamella superadvancement. In a retrospective study, the technique and results were evaluated. RESULTS In all 22 upper eyelids, the normal eyelashes rotated away from the surface of the eye. Mean follow-up was 12.9 +/- 12.4 months (range, 1 to 48 months). One eyelid developed buckling of the tarsus. Three eyelids needed electrolysis to treat isolated metaplastic cilia posterior to the normal lash line. CONCLUSIONS Tarsal margin rotation with posterior lamella superadvancement appears to be effective in managing cicatricial entropion of the upper lid.

Upper eyelid gold weight implantation in the Asian patient with facial paralysis

Patients with facial paralysis may develop ophthalmic complications. Poor eyelid closure and lagophthalmos place the patient at increased risk for the development of corneal problems such as epithelial defects, stromal thinning, bacterial infection, and even perforation. Initial treatment should be conservative and include the use of ocular lubricants, moisture chambers, and taping of the lower eyelid into proper position. Surgical intervention may be required in patients who have failed medical therapy or in whom the facial paralysis is not expected to improve. Gold weight implantation in the upper eyelid has become a popular procedure to correct upper eyelid retraction and to improve corneal coverage. Previous descriptions of gold weight placement in the upper eyelid have focused on Caucasian eyelid anatomy. However, there are distinct anatomic differences between the Caucasian and Asian eyelids, which dictate the overlying aesthetic differences. We describe our technique for placement of a gold weight in the Asian upper lid, with attention to the maintenance of symmetric eyelid creases. We reviewed the charts of six Asian patients with facial paralysis who underwent gold weight placement in the upper eyelid for the correction of lid retraction. All patients did well functionally and aesthetically, and none developed an extrusion of the implant with this approach.

Lower eyelid CO2 laser rejuvenation: A randomized, prospective clinical study1

PURPOSE The effect of transconjunctival blepharoplasty alone compared with transconjunctival blepharoplasty and CO(2) laser skin resurfacing on lower lid bulging and wrinkles was examined. DESIGN Randomized clinical trial. PARTICIPANTS Forty-four subjects, including 13 men and 31 women. METHODS Subjects were prospectively randomly assigned into two groups: (1) transconjunctival blepharoplasty with immediate CO(2) laser resurfacing or (2) transconjunctival blepharoplasty with CO(2) laser resurfacing 2 months later. Standardized photographs were taken before and 2 months after each procedure. A trained, masked observer graded the photographs. MAIN OUTCOME MEASURES Bulging and wrinkles of the medial, central, and lateral portions of the lower lid were scored and compared at specified end points. RESULTS Transconjunctival blepharoplasty alone resulted in an improvement in lower lid bulging in 92% of subjects, whereas lower lid wrinkling worsened in 46%. When transconjunctival blepharoplasty was performed with simultaneous CO(2) laser resurfacing, or with CO(2) laser resurfacing 2 months later, a statistically significant improvement in wrinkles occurred (chi square = 20.625; P < 0.0005). The timing of the procedures had no statistically significant effect on final outcome. No subject had lower lid retraction develop. CONCLUSIONS Transconjunctival blepharoplasty and adjunctive CO(2) laser resurfacing represents an excellent alternative to transcutaneous lower blepharoplasty. The procedure addresses lower lid wrinkles, skin redundancy, and fat herniation without a scar and with little risk of lower lid retraction.

The retrograde tracer Fluoro-Gold interferes with the infectivity of herpes simplex virus

Fluoro-Gold has been used previously to identify those trigeminal ganglion cells that innervate the central cornea. To examine the effects of Fluoro-Gold treatment on infection and spread of HSV in vivo, we measured the number of plaque forming units recovered from trigeminal ganglia 3 or 5 days after corneal scratch and inoculation with Fluoro-Gold and HSV. Treatment with Fluoro-Gold reduced the amount of virus recovered after retrograde transport 63% at 3 days and 28% at 5 days after inoculation. When we examined trigeminal ganglion sections from animals treated with HSV and Fluoro-Gold, we found the number of neurons double labeled with antibodies that recognize HSV and Fluoro-Gold was only 13% of all Fluoro-Gold labeled neurons. This was significantly fewer cells that we had anticipated, on the basis of double labeling experiments with wheat germ agglutinin combined with Fluoro-Gold. The effects of varying doses of the retrograde tracer, Fluoro-Gold on Herpes simplex virus (type 1) (HSV) infectivity were also assayed in vitro using a standard viral plaque assay. At 1 x 10(-3) mg/ml Fluoro-Gold there was no effect on the number of plaque forming units. At 5 x 10(-1) mg/ml the number of plaques was reduced about 67%. We conclude that Fluoro-Gold interferes with productive HSV infection in vivo and in vitro after retrograde transport of HSV by neurons.