Tanuj Nakra

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.

Nonsurgical Management of Congenital Eyelid Malpositions Using Hyaluronic Acid Gel

Purpose: To report our preliminary experience using hyaluronic acid gel fillers as a nonsurgical alternative in the management of congenital eyelid malpositions. Methods: In this retrospective interventional case series, 5 patients (10 eyes) with congenital eyelid malpositions, including eyelid retraction, ectropion, euryblepharon, epiblepharon, and abnormalities associated with a shallow orbit, with resultant lagophthalmos and/or keratopathy and tearing were evaluated before and after injection with hyaluronic acid gel (Restylane) in the pretarsal and/or septal regions of the affected eyelid(s). Pretreatment, posttreatment, and follow-up photographs were analyzed for eyelid position and degree of eyelid closure and lagophthalmos, and slit-lamp evaluation of the degree of keratopathy. Results: All 5 patients demonstrated significant improvement of eyelid position and degree of keratopathy. The mean improvement in lagophthalmos was 4.5 mm (range, 2–7 mm). The average volume of hyaluronic acid gel used was 0.5 ml per eyelid. Complications were minor, including transient edema and ecchymosis at the sites of injection. Of the 10 eyelids injected, only one had increased astigmatism after injection. Conclusions: Hyaluronic acid gel shows promise as a safe and effective nonsurgical treatment for the management of certain eyelid malpositions, disorders traditionally requiring surgical intervention if aggressive ocular lubrication fails. This treatment is particularly useful in such patients who are commonly premature with poor general health and serves as a temporizing measure by allowing the much needed tissue expansion to take effect over time.

Aesthetic lateral canthoplasty.

Introduction: To report our technique and experience in using a minimally invasive approach for aesthetic lateral canthoplasty. Methods: Retrospective analysis of patients undergoing lateral canthoplasty through a minimally invasive, upper eyelid crease incision approach at Jules Stein Eye Institute by one surgeon (R.A.G.) between 2005 and 2008. Concomitant surgical procedures were recorded. Preoperative and postoperative photographs at the longest follow-up visit were analyzed and graded for functional and cosmetic outcomes. Results: A total of 600 patients (1,050 eyelids) underwent successful lateral canthoplasty through a small incision in the upper eyelid crease to correct lower eyelid malposition (laxity, ectropion, entropion, retraction) and/or lateral canthal dystopia, encompassing 806 reconstructive and 244 cosmetic lateral canthoplasties. There were 260 males and 340 females, with mean age of 55 years old (range, 4–92 years old). Minimum follow-up time was 3 months (mean, 6 months; maximum, 6 years). Complications were rare and minor, including transient postoperative chemosis. Eighteen patients underwent reoperation in the following 2 years for recurrent lower eyelid malposition and/or lateral canthal deformity. Conclusions: Lateral canthoplasty through a minimally invasive upper eyelid crease incision and resuspension technique can effectively address lower eyelid laxity and/or dystopia, resulting in an aesthetic lateral canthus.

Spectacle use and reduced unaided vision in third grade students: a comparative study in different educational settings.

Background: The development of myopia is influenced by hereditary factors, environmental factors and geneenvironment interaction. Reading and near‐work activity are associated with myopia and myopic progression. This study sought to determine and compare the prevalence of reduced unaided vision and spectacle use among third grade Israeli students from three different educational settings.

Orbital wall fracture repair using seprafilm

Purpose: Seprafilm is a hybrid product of carboxymethylcellulose and sodium hyaluronate that can act as an absorbable barrier to decrease the formation and severity of postoperative adhesions in abdominal, thoracic, and pelvic surgeries. The authors report their experience with use of Seprafilm in “trap door” orbital wall fracture repair. Methods: Retrospective case series of 4 consecutive patients with trap door orbital wall fractures secondary to blunt trauma with entrapped orbital soft tissue who underwent surgical repair with placement of Seprafilm implant in 2008. Orbitotomy was performed via standard transconjunctival and/or transcaruncular approaches with release of entrapped tissues, and placement of Seprafilm implant over the fracture site without fixation. Patients were followed for at least 6 months. Ophthalmic and orbital examinations, including ocular motility and Hertel exophthalmometry measurements, were recorded. Results: All 6 orbital wall fractures (4 floor, 2 medial wall) were successfully corrected with resolution of restrictive motility in the follow-up period (average 10 months; range 6 months to 1.5 years). Mean patient age was 13.5 years (range, 9–20 years). Two of the 4 patients had 2 separate fractures. There were no complications and no need for reoperation. Conclusions: Seprafilm may have a role in reconstruction of the “trap door” type of orbital wall fractures. The ease of use, lack of fixation, and absorbable properties without inflammation are encouraging for further study.

Clinical manifestations of orbital mass lesions at the Jules Stein Eye Institute, 1999-2003.

BACKGROUND AND OBJECTIVE To describe the clinical manifestations, diagnoses, treatments, and outcomes of orbital mass lesions at a tertiary care referral center. PATIENTS AND METHODS All cases of newly diagnosed or referred orbital tumors at the Jules Stein Eye Institute from 1999 to 2003 were reviewed retrospectively. Demographic and clinical data were extracted from the electronic oculoplastics registry of the Division of Orbital and Ophthalmic Plastic Surgery. RESULTS Three hundred sixty-nine cases of orbital mass lesions were evaluated (167 males and 202 females; mean age = 48 years). The most common presenting symptoms were mass/proptosis, pain, swelling, inflammation, and diplopia. The most common categories of diagnosis were cystic or structural lesions, benign tumors, inflammatory processes, neuronal processes, and fibrous processes. Increasing age was associated with an increased incidence of primary and metastatic malignant tumors. Half of all cases required surgical intervention consisting of excision, debulking, or exenteration; 20% to 30% of cases were managed conservatively. CONCLUSIONS The differential diagnosis of orbital mass lesions differs across age groups. No clinical sign or symptom is specific for the underlying diagnosis and the biological behavior of the abnormal process may be misleading. Therefore, a careful diagnostic approach that considers the benefit of imaging studies must be undertaken. Almost 50% of these mass lesions can be managed with nonsurgical intervention.

Periocular abscesses following brow epilation.

Purpose: The aim of this article was to report the clinical presentation, radiography, culture results, treatment modalities, and outcomes of periocular abscesses associated with brow epilation. Methods: This was a retrospective case series including 26 patients referred for periocular abscess following brow epilation. Results: Twenty-six female patients with a median age of 20.5 (range, 12–73) years were referred for oculoplastic evaluation of periocular abscesses related to recent brow epilation. All patients were treated with incision and drainage along with systemic antibiotics. Culture results revealed 16 cases of methicillin-resistant Staphylococcus aureus, 3 of methicillin-sensitive Staphylococcus aureus, and 7 cultures that showed no growth. All patients had resolution of their abscesses at 1-month follow-up visits without progression to orbital cellulitis. Conclusions: Periocular abscess formation after brow epilation has been previously described in only a single case report in the literature. The authors believe this entity is underreported given their current report describing 26 such cases. Given the high prevalence of cosmetic brow epilation in females, the authors believe a careful history regarding brow epilation in any patient presenting with a periocular abscess or preseptal cellulitis is essential to explore the possible cause of their infection. The majority of patients in the current study’s cohort had methicillin-resistant Staphylococcus aureus-related abscesses, and treatment with antibiotics with methicillin-resistant Staphylococcus aureus coverage may be a prudent first line choice in such patients.

Rare dural arteriovenous fistula of the lesser sphenoid wing sinus.

A fistula of the lesser sphenoid wing sinus is a rare dural arteriovenous fistula resulting from a connection between the middle meningeal artery and recipient vein in the sinus of the lesser sphenoid wing. In this report, MRI/magnetic resonance angiography of a 54-year-old man who presented with sudden-onset glaucoma and proptosis revealed a fistula in this anatomic location. Drainage patterns here may account for the absence of serious complications and optimistic prognosis following embolization. Care in diagnosis is required to avoid superfluous procedures, because classic signs of the more common carotid-cavernous fistula are absent.

The effect of upper eyelid blepharoplasty on eyelid and brow position

ABSTRACT This article evaluates the effect of upper eyelid blepharoplasty on eyelid margin position and brow height. This study is a retrospective analysis of patients who underwent upper eyelid blepharoplasty without concurrent blepharoptosis repair or brow surgery. The medical records of the participants were retrospectively reviewed and an established image analysis software was used to quantify the upper margin reflex distance (MRD1) as well as brow height using high quality standardized clinical photographs. A total of 19 patients (38 eyelids and brows) met the inclusion criteria. The mean preoperative MRD1 was 2.8 mm, and the mean post-operative MRD1 was 3.5 mm, revealing an increase of MRD1 from upper blepharoplasty alone of 0.7 mm (p = 0.0001). The mean preoperative brow position was 17.5 mm above the pupil, and the mean post-operative position was 17.4 mm, for an average change of position of -0.2 mm (p = 0.39) following upper eyelid blepharoplasty. Upper eyelid blepharoplasty without ptosis surgery results in a statistically significant increase in MRD1. Brow position does not demonstrate a statistically significant change in patients who undergo upper eyelid blepharoplasty for simple dermatochalasis.

The Transeyelid Midface Lift

The transeyelid approach to midface lift is an elegant approach for mild descent of malar soft tissue. The subciliary approach is the most commonly used and technically less challenging for surgeons experienced in facelift techniques. This technique in midface rejuvenation also has the advantage of ease of combining with other periocular and mid and upper face rejuvenation, such as blepharoplasty and forehead lift. Complication is rare with lid malposition, scaring, and temporary nerve function impairment being the most common.