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Purpose: Topical chloramphenicol is one of the most ubiquitous antibiotics used in ophthalmology and oculoplastic surgery globally. It shows broad-spectrum activity against a variety of different pathogenic organisms, is well tolerated on the ocular surface and displays excellent topical pharmacokinetics. Chloramphenicol has been available for purchase over the counter in the United Kingdom since 2005. Despite this, the largest health economy in the world, The United States has had a de-facto moratorium on its use for the past 30 years. In this review, we aim to evaluate topical chloramphenicol in ophthalmology and oculoplastic surgery and to determine whether its reputation within the US is warranted and justified., Methods: We conducted a comprehensive literature review to evaluate the different facets of chloramphenicol, providing a detailed understanding of the drug, its historical context, the benefits and perceived risks, including safety concerns, and clinical perspectives of its use in clinical practice., Results: The mechanism of chloramphenicol, the context around which the drug's use in the US declined, and the drug's evidence base and safety data, including published case reports of serious adverse events, were analysed. The perceived benefits of the drug, particularly in light of antimicrobial resistance and its economic impact, were reviewed. Finally, perspectives on its use in clinical practice in ophthalmology and associated allied specialities were presented., Conclusion: Chloramphenicol and its topical application have been misunderstood for many decades, particularly in the United States. Its demise across the Atlantic was due to an overzealous response to a dubious association with a weak evidence base. Numerous authors have since validated the safety profile of the and its safety has been borne out. The benefits of chloramphenicol, an effective broad-spectrum agent with a positive cost differential in the era of anti-microbial resistance and fiscal tightening, cannot be understated. Its likely effectiveness as a therapeutic topical agent in ophthalmic surgery makes it a valuable tool in the ophthalmic anti-microbial armoury. We would encourage the reinstatement of this valuable yet misunderstood drug as a first-line agent for simple ophthalmic infections.

The human microbiome has progressively been recognised for its role in various disease processes. In ophthalmology, complex interactions between the gut and distinct ocular microbiota within each structure and microenvironment of the eye has advanced our knowledge on the multi-directional relationships of these ecosystems. Increasingly, studies have shown that modulation of the microbiome can be achieved through faecal microbiota transplantation and synbiotics producing favourable outcomes for ophthalmic diseases. As ophthalmologists, we are obliged to educate our patients on measures to cultivate a healthy gut microbiome through a range of holistic measures. Further integrative studies combining microbial metagenomics, metatranscriptomics and metabolomics are necessary to fully characterise the human microbiome and enable targeted therapeutic interventions., Competing Interests: Competing interests: The authors declare no competing interests., (© 2024. The Author(s), under exclusive licence to The Royal College of Ophthalmologists.)

Intraorbital foreign bodies (IOrFBs) are a significant cause of ocular morbidity. Although plastic IOrFBs are rare, the increasing use of plastic and polymer composites in motor vehicles will increase their prevalence. Although challenging to identify, plastic IOrFBs have unique radiographic characteristics. The authors describe a case of an 18-year-old man with a history of a motor vehicle accident and a left upper eyelid laceration. In retrospect, imaging suggested a plastic IOrFB, which was initially overlooked. A follow-up examination demonstrated persistent left upper lid ptosis with an underlying mass. Further work-up revealed a retained IOrFB, which was removed via anterior orbitotomy. Scanning electron microscopy of the material was consistent with a plastic polymer. This case demonstrates the importance of maintaining a high suspicion for IOrFBs in the correct clinical context, the need for increased awareness of plastic and polymer composite IOrFBs, and the use of diagnostic imaging for identification.

Mask-Associated Dry Eye (MADE) has emerged as a consequence of widespread face mask usage during the Covid-19 pandemic. This review critically assesses the available evidence. A comprehensive search on PUBMED and EMBASE was conducted to identify studies on MADE, which were then categorized based on their design. A total of 26 studies were critically appraised, with the majority exhibiting poor study design quality. Investigating the impact of mask use on ocular surface irritation faced challenges due to global mask mandates, pandemic-related behavioural changes, and a lack of validated methods to measure the response to mask wear. Among the 15 studies, 12 reported a statistically significant reduction in TBUT associated with mask wear; however, the median decrease of 1.3 s was considered clinically insignificant. Results from Schirmer's test in 8 studies varied, with 5 studies reporting a decrease, contradicting the hypothesis of misdirected airflow. Out of 7 studies on corneal and conjunctival staining, 6 indicated a worsening associated with mask wear. Five studies investigating OSDI scores reported an increase following mask wear, but 3 studies repeated the survey too soon. Limited evidence suggests that masks may cause mild ocular surface irritation, but the quality and certainty of this evidence remain low. Methodological limitations were prevalent across the majority of studies, and the observed changes were minimal. Therefore, it is unlikely that significant ocular surface pathology will develop in the majority of mask wearers. Currently, there is insufficient data to support the establishment of a new syndrome., (© 2024. Crown.)

Background/objectives: To determine whether horizontal lower eyelid margin length shortens following facial nerve palsy (FNP)., Subjects/methods: A single-centre retrospective audit of lower eyelid margin horizontal length, measuring from the lower lacrimal punctum to lateral canthal angle with a straight plastic ruler, with the eyelid on gentle stretch ('punctum-to-canthus (PC) distance'), recorded in all FNP patients reviewed in July-September 2021. Affected and fellow eyes were compared using parametric testing., Results: Forty-one patients were reviewed. Seventeen were excluded due to previous surgery that would lengthen (e.g., periosteal flap) or shorten (e.g., lateral tarsal strip) the lower eyelid margin. Of the remaining 24, mean age was 52.5 years (range, 27-79) and 54% were female. Mean PC distance was significantly shorter in affected eyes (26.0 mm, range: 22-34 mm) compared to fellow eyes (27.5 mm, 24-35 mm) (paired t-test, T(23) = 6.06, p < 0.00001). Mean difference between both eyes' PC distance was 1.5 mm (0-4 mm). Only three patients were still in the 'paralytic phase' (i.e., <1 year since FNP onset), and difference in PC distance was 0 mm in all three. A reduction in lower eyelid PC distance was weakly associated with a reduction in upper eyelid lid-margin-to-brow distance (R = 0.4775, p = 0.0286)., Conclusions: The lower eyelid margin appears to shorten horizontally following FNP. This study provides proof-of-concept for the use of measuring PC distance in patients with FNP as an additional tool for the overall assessment of soft tissue contraction following FNP. It may help identify patients in whom further lower eyelid margin shortening should be avoided and in whom eyelid lengthening may be required., (© 2023. The Author(s), under exclusive licence to The Royal College of Ophthalmologists.)

Background: This study evaluates the effectiveness of a multidisciplinary protocol for management of patients with papilledema and vision loss secondary to increased intracranial pressure., Methods: Retrospective record review of all adult patients who presented with vision-threatening papilledema (VTPE) and were treated under this protocol. Patients are admitted for lumbar drain placement and diuretics and followed daily to determine if they may be managed medically or require surgery (optic nerve sheath fenestration [ONSF] and/or cerebrospinal fluid [CSF] shunting)., Results: Nineteen patients were included. Twelve had body mass index in the obese range and 6 were morbidly obese. Fourteen had idiopathic intracranial hypertension. Five had secondary pseudotumor cerebri syndrome related to medication use, dural venous sinus thrombosis, hypothyroidism, end-stage renal disease, pulmonary disease, and diastolic heart failure. Three patients did not require surgery and were discharged on oral diuretics; 3 patients underwent unilateral ONSF, 9 underwent bilateral ONSF, and 4 underwent bilateral ONSF followed by ventriculoperitoneal shunt placement. The average follow-up was 10.1 months. The visual acuity improved bilaterally in 12 patients and unilaterally in 4 patients. The remaining 3 patients had worsened vision in both eyes. Fifteen patients had bilateral improvement in their visual fields. Five eyes in 3 patients showed further constriction of the visual field at follow-up., Conclusions: We demonstrate how a multidisciplinary complex care protocol for treating VTPE can expedite and streamline treatment and restore vision. We found that most patients had improved symptoms and signs, including visual acuity, visual fields, and papilledema. We encourage institutions that manage VTPE to adopt similar institutional protocols., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 by North American Neuro-Ophthalmology Society.)

Purpose: To report the etiology, management, and possible risk factors for diplopia after canalicular bypass surgery., Methods: A multicenter retrospective, noncomparative case series of patients who developed diplopia following canalicular bypass surgery were assessed., Results: Twenty-four cases of diplopia were identified across 12 institutions. Tubes were inserted as a primary procedure with external dacryocystorhinostomy (DCR) (1; 4%) or without DCR (10; 42%) or as a secondary procedure after external (8; 33%) or endonasal (5; 21%) DCR. Factors predisposing to local damage were noted in 17 (71%): these factors included preexisting autoimmune/inflammatory condition (7 cases), medial canthal tumor resection (5 cases), preoperative radiotherapy (2 cases), 2 drug treatments (topical and systemic), and 1 local surgery. Horizontal diplopia was due to restriction of abduction and first noted at a median of 3.5 months (mean: 17.8 months, range: 1 day to 112 months) and persisted in 23 (96%) cases with a mean restriction of -2, affecting primary gaze in 4 patients and activities of daily living in 13 (42%). Seventeen patients received various treatments: 10 were operated on resulting in cure in 1 and improvement in 9. A stable degree of diplopia persisted in all but one patient., Conclusions: Restriction of abduction causing horizontal diplopia is a rare complication with canalicular bypass surgery and a notably high proportion occurred after tube placement without DCR; carunculectomy was not ubiquitous. Although in some the diplopia may be improved with intervention, the chance of cure is low. This complication should probably be included during informed consent for canalicular bypass tubes., Competing Interests: The authors have no financial or conflicts of interest to disclose., (Copyright © 2021 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Adenoid cystic carcinoma (ACC) of the eyelid is a very rare tumor, and only 11 cases have been previously reported in the literature. Here the authors report the 12th case of eyelid ACC that was initially diagnosed as adenoid basal cell carcinoma. This is the first report of local recurrence after wide local excision using the Mohs technique. Additionally, this is the first report that demonstrates that ACC can present clinically and histologically similar to basal cell carcinoma. The authors summarize the previous reports of eyelid ACC to compile a reference for this growing body of literature. It is important for oculoplastic surgeons and dermatopathologists to keep ACC in the differential diagnosis of eyelid tumors and carefully examine histology specimens with this differential in mind.

Idiopathic subepidermal calcinosis, also known as idiopathic calcinosis cutis, is a rare condition, which typically presents as a small, hard, subepithelial mass in the absence of systemic disease and trauma. We report on an atypical case of idiopathic calcinosis, which appeared in an otherwise healthy 61-year-old female along the tarsus of her right upper eyelid. The purpose of this case report is to demonstrate idiopathic calcinosis in an unusual location that is deep to the dermis and to discuss the vast differential diagnosis of this entity.

Background: 'Kissing puncta' (KP) or punctal apposition is an anatomical phenomenon sparsely reported in the English literature. We describe our experience of managing chronic epiphora in patients with punctal apposition., Methods: A retrospective audit of five patients (nine eyes) with KP associated with epiphora. Data including: presenting symptoms, physical signs and surgical outcomes were collected., Results: Five patients aged between 66 and 77 years were reviewed. Common clinical features were: chronic epiphora, involutional eyelid laxity, kissing puncta (present at all phases of the blink) and reduced upper and lower margin-reflex distances. Medial upper eyelid ptosis with orbital fat prolapse was a prominent feature. Four patients (nine eyes underwent eyelid-tightening surgery to restore normal anatomical position of the puncta. Only one of the four patients achieved improvement in epiphora at 3 months. One patient with continued epiphora underwent subsequent dacrocystorhinostomy with improvement in symptoms. The fifth patient had mild laxity and underwent dacrocystorhinostomy at first instance, with no improvement in symptoms, despite surgical success., Conclusions: The KP sign is commonly found in those with involutional eyelid changes. Epiphora is present in variable degrees in the presence of punctal apposition. Restoration of normal punctal position with eyelid-tightening surgery does not always confer an improvement in epiphora. Surgical management in the setting of KP is therefore challenging with a guarded prognosis. Symptomatic patients with KP should be counselled accordingly.

Purpose: To review the clinical and histopathologic findings associated with subepidermal calcinosis of the eyelids., Methods: A systematic review of the literature on subepidermal calcinosis of the eyelids was performed. Cases included were idiopathic in nature and met the histologic criteria for subepidermal calcinosis with calcium deposits in the dermis of the skin., Results: Twenty-one publications presenting 53 cases of subepidermal calcinosis involving the eyelids were published between 1970 and 2016. Males were affected more than females (67% vs. 33%), and 89% of patients were 21 years of age or younger. A total of 63% were non-Caucasian. Most cases involved a single lesion (82%), and lesions were most frequently located on the upper eyelid (63%). In 81% of cases, the lesion was less than 5 mm in diameter. When reported, the treatment of choice was complete surgical excision., Conclusions: Subepidermal calcinosis should be considered in the differential diagnosis of idiopathic lesions on the eyelid, particularly in young males with no history of systemic disease or laboratory abnormalities. These nodules usually present as painless, small, firm, mobile solitary cutaneous lesions with a predilection for the upper eyelid. Diagnosis is confirmed by histopathology, and treatment is with surgical excision.

Eruptive vellus hair cysts are a developmental abnormality of vellus hair follicles that result in small cystic papules occurring most frequently on the chest and proximal extremities. Lesions of the ocular adnexa are extremely rare, and to the best of the authors knowledge, involvement of the orbit has never been reported. The authors describe a patient with an eruptive vellus hair cyst involving the orbit.

A 6-month-old boy presented with recurrent, poorly differentiated orbital sarcoma diagnosed as nonrhabdomyosarcoma soft tissue sarcoma, as pathologic and immunohistochemical evaluation was inconsistent with rhabdomyosarcoma or other specific sarcoma subtypes. He responded favorably to a treatment regimen for poorly differentiated sarcomas.

The authors report a case of a 72-year-old woman with unilateral, complete, reversible blindness (no light perception) immediately after uncomplicated repair of an orbital floor fracture. In this case, vision loss was reversed with prompt surgical intervention with removal of the orbital floor implant. The authors review the etiology of vision loss after orbital fracture repair and hypothesize as to the cause of blindness in this case. Given the frequency with which orbital fracture repair is performed by a variety of surgical subspecialists, it is imperative for surgeons to be familiar with the ophthalmic complications and be aware of the multiple causes of postoperative vision loss. The authors propose that immediate postoperative assessment of visual function be performed on all patients undergoing orbital fracture repair.

Precise description of clinical findings is a sine qua non of effective communication and documentation in medicine. To that end, there have not, to date, been accurate words to describe lateral or medial displacement of the globe. Such displacements are frequently seen with orbital disease. The author makes a case for the use of esoglobus and exoglobus to describe such displacements.

The aim of this study was to describe a modified technique of intraorbital irrigation of amphotericin B in the treatment of rhino-orbital mucormycosis. A 38-year-old man was diagnosed with rhino-orbital mucormycosis and subsequently underwent orbital and sinus debridement with postoperative intraorbital irrigation of amphotericin B. Daily irrigation of amphotericin B was infused in the orbit with measures taken to avoid iatrogenic toxicity to the ocular surface and gastrointestinal tract. The use of local amphotericin B irrigation directly in the orbit allowed for local control of infection without orbital exenteration, a good cosmetic outcome and excellent postoperative visual acuity. The published reports on the use of intraorbital irrigation with amphotericin B in mucormycosis infections were reviewed and the technique used at the institution was outlined.

We performed bilateral optic nerve sheath fenestrations on a patient with the syndrome of acquired hyperopia and choroidal folds. We are unaware of previous reports of this procedure being performed in this clinical setting. Despite the incomplete resolution of his posterior segment findings postoperatively, the results of the procedure, along with an understanding of the relevant anatomy, may help to shed light on the pathogenesis of this rare entity.

The human tear film is a 3-layered coating of the surface of the eye and a loss, or reduction, in any layer of this film may result in a syndrome of blurry vision and burning pain of the eyes known as dry eye. The lacrimal gland and accessory glands provide multiple components to the tear film, most notably the aqueous. Dysfunction of these glands results in the loss of aqueous and other products required in ocular surface maintenance and health resulting in dry eye and the potential for significant surface pathology. In this paper, we have reviewed products of the lacrimal gland, diseases known to affect the gland, and historical and emerging dry eye therapies targeting lacrimal gland dysfunction.

A 39-year-old man without a significant medical history developed headaches, OS swelling, and limited left-sided ocular motility. An ultrasound of the left orbit and head MRI revealed a retro-orbital mass. A partial left anterior orbitotomy with partial resection was performed, and histopathologic examination of the resected tumor portion was suggestive of a neuroendocrine carcinoma. A large, anterior mediastinal mass was found on chest imaging, and the patient was diagnosed with a primary thymic neuroendocrine tumor. To the authors' knowledge, this is the first report of an otherwise healthy patient presenting with the mass effects of a thymic neuroendocrine carcinoma metastasis to the orbital tissues before detection of the primary thymic malignancy.

Object: Lesions of the cavernous sinus remain a technical challenge. The most common surgical approaches involve some variation of the standard frontotemporal craniotomy. Here, the authors describe a surgical approach to access the cavernous sinus that involves the removal of the lateral orbital wall., Methods: To achieve exposure of the cavernous sinus, a lateral canthal incision is performed, and the lateral orbital rim and anterior lateral wall are removed, for later replacement at closure. The posterior lateral orbital wall is removed to the region of the superior and inferior orbital fissures. With reflection of the dural covering of the lateral cavernous sinus and removal of the anterior clinoid process, the cavernous sinus is exposed., Results: Exposure and details of the procedure were derived from anatomical study in cadavers. After the approach, with removal of the anterior clinoid process, the entire cavernous sinus from the superior orbital fissure anteriorly to the Meckel cave posteriorly is exposed. More exposure to the lateral middle fossa, foramen spinosum, and petrous carotid artery is obtained by further removal of the lateral sphenoid wing. An illustrative case example for approaching a cavernous sinus meningioma is presented., Conclusions: The translateral orbital wall approach provides a simple, rapid approach for lesions with primary or secondary involvement of the cavernous sinus. Advantages of this simple, extradural approach include the lack of brain retraction and no interruption of the temporalis muscle.

Metastatic mucinous adenocarcinoma in the orbit is extremely rare. We review the literature and report a case of metastatic mucinous adenocarcinoma of the orbit in a 37-year-old male with primary pancreatic adenocarcinoma.

As the surgeon learns to address the aging changes of the forehead, brows, eyelids and cheeks, the natural progression is to understand aging of the lower one-third of the face and aging of the neck. An understanding of surface anatomy, a review of the underlying anatomical changes of aging and an overview of the palette of procedures applicable to the aging of the neck are presented to introduce the surgeon to this important part of the aging face.

Innumerable approaches to the ptotic brow and forehead have been described in the past. Over the last twenty-five years, we have used all these techniques in cosmetic and reconstructive patients. We have used the endoscopic brow lift technique since 1995. While no one technique is applicable to all patients, the endoscopic brow lift, with appropriate modifications for individual patients, can be used effectively for most patients with brow ptosis. We present the nuances of this technique and show several different fixation methods we have found useful.

Purpose: To test light sensitivity thresholds rigorously in patients with benign essential blepharospasm (BEB) compared with patients who have known light sensitivity (migraineurs) and to normal control subjects., Design: Prospective, observational, case control study., Methods: We recruited a total of 87 subjects into each of three groups: BEB, migraine, and normal control subjects. A modified slit-lamp chin rest, heat shield, light meter, and halogen light that was modulated by a rheostat were used to measure light sensitivity thresholds. Participants were tested without spectacles, with gray-tinted spectacles, and with FL-41-tinted spectacles., Results: Light discomfort thresholds for subjects with BEB were significantly lower compared with normal control subjects (P < or = .009) and similar to the migraine group. Both gray and FL-41-tinted lenses improved light sensitivity thresholds in all groups (P < or = .0005). There was no observed difference in the improvement in light sensitivity when the gray and FL-41-tinted lenses were compared., Conclusion: Patients with BEB are considerably more sensitive to light than control subjects and as sensitive to light as patients with migraine. Physicians who care for patients with BEB should consider using tinted lenses to help ameliorate symptoms.

Purpose: To review injection techniques and patient satisfaction with injection of Restylane in various facial areas by American Society of Ophthalmic Plastic and Reconstructive Surgery members., Methods: Data from 286 patients treated with Restylane in nine American Society of Ophthalmic Plastic and Reconstructive Surgery practices were abstracted to a spreadsheet for analysis., Results: Nine practices performed Restylane injections for 8.8 months on average (range, 2 to 28 months). Average practice volume per patient was 1.2 ml (range, 0.7 to 2.1 ml). Nine of nine practices injected the nasolabial and melolabial folds, 9 of 9 practices injected the lips, and 6 of 9 injected the glabella. Only 2 of 9 practices injected other fillers concurrently. Botox was injected concurrently by 8 of 9 practices. On a scale of 1 to 10, physicians rated average patient discomfort during Restylane injection 4.6 with topical anesthesia and 2.1 with injectable lidocaine, with or without topical anesthesia. The end point for injection was determined by visual cues, volume of injection, extrusion of the product, and palpation. "Problematic" complications, including bruising, swelling, bumpiness, and redness each had an incidence of 5% or less. Patient satisfaction on a scale of 1 to 10 had an average rating of 8.1, compared with that of Botox injection (8.9), upper blepharoplasty (8.9), and collagen injection (6.6). The source of Restylane patients was estimated to be existing Botox patients (45%); existing non-Botox patients (18%); word of mouth (14%); and new patients for other services (13%)., Conclusions: Injection techniques, volume, end points, and anesthesia vary for different facial areas and between practices. Patients experience mild to moderate injection discomfort that is lessened with injectable lidocaine. Self-limited problems occur in about 5% of patients. Physician-determined patient satisfaction is perceived to be higher than that of collagen injection but slightly lower than that of botulinum toxin injection. The major source of Restylane patients was from existing practice patients, especially botulinum toxin patients.

Objective: To evaluate the outcomes of a new surgical approach in children with acute sinusitis and medial orbital subperiosteal abscess., Design: Case series., Setting: Tertiary pediatric hospital., Patients: Eleven children aged 6 weeks to 13 years with orbital subperiosteal abscess and acute sinusitis who met indication for surgery by visual compromise and/or refractory course to medical therapy., Intervention: The medial orbital abscess was drained via a transcaruncular approach, which provided access to the medial orbital wall. An endoscopic ethmoidectomy was also performed., Main Outcome Measures: Judgment of cosmetic appearance by surgeon and family, resolution of symptoms, length of hospital stay, and complications., Results: All children had prompt resolution of symptoms after surgical drainage. Cosmetic outcome was excellent in all patients with no cutaneous scar or eyelid malposition. After edema and cellulitis had resolved, no family member could tell a difference in appearance between the eyes. No complications of these combined procedures were identified. One patient who had initially undergone transnasal endoscopic orbital drainage alone experienced a recurrence of infection 17 days later. He was then treated by the combined transcaruncular and endoscopic approach with prompt resolution of his symptoms. One of 4 patients treated initially with transcaruncular approach alone without endoscopic ethmoidectomy had recurrence of acute sinusitis and orbital abscess 16 months later and was successfully treated with an endoscopic approach., Conclusions: The combined endoscopic and transcaruncular surgical approach to medial orbital subperiosteal abscess and acute sinusitis provides a cosmetically superior outcome compared with standard orbital approaches requiring a cutaneous incision. The transcaruncular approach can be considered as an alternative or adjunct approach to the medial orbit, with the same cosmetic advantages as transnasal endoscopic drainage.

Purpose: To compare the safety and efficacy of topical versus retrobulbar anesthesia for primary trabeculectomy, Methods: A prospective study of 36 consecutive patients undergoing trabeculectomy who were randomized to receive topical (n = 18) or retrobulbar (n = 18) anesthesia. Operating conditions, patient comfort, and surgical outcome were evaluated., Settings: Tertiary-care university hospital ambulatory surgical center., Results: There were no differences in operating conditions (P = 0.14), pain during (P = 0.54) or after (P = 0.76) surgery, or supplemental anesthesia required (P = 0.34) between the two groups. Very few patients in either group were bothered by touch sensation, tissue manipulation, or the microscope light. Chemosis, subconjunctival hemorrhage and eyelid hemorrhage were seen exclusively in the retrobulbar group (P <0.03), and were all attributable to the injection. Inadvertent eye movement was present more frequently in the topical group (P = 0.01), although this did not pose a problem to the surgeon. No surgical complications were encountered in either group., Conclusion: Topical anesthesia is a safe and effective alternative to retrobulbar anesthesia for primary trabeculectomy.

Purpose: To compare the safety and efficacy of topical and retrobulbar anesthesia for combined phacotrabeculectomy., Setting: Tertiary-care university hospital ambulatory surgical center., Methods: In this prospective study, 40 consecutive patients having combined phacotrabeculectomy were randomized to receive topical (n = 20) or retrobulbar (n = 20) anesthesia. Operating conditions, patient comfort, and surgical outcome were evaluated., Results: There was no significant between-group difference in operating conditions (P =.56), pain during (P =.41) or after (P =.23) surgery, or supplemental anesthesia required (P =.49). Few patients in either group were bothered by tissue manipulation or the microscope light, although more patients in the topical group were slightly bothered by touch sensation (P =.05). Chemosis, subconjunctival hemorrhage, and eyelid hematoma were seen almost exclusively in the retrobulbar group (P <.05). Inadvertent eye movement was present more frequently in the topical group (P =.04), although this did not pose a problem to the surgeon., Conclusion: Topical anesthesia is a safe and effective alternative to retrobulbar anesthesia for combined phacotrabeculectomy.

Purpose: To report the results of the surgical repair of lower eyelid reverse ptosis., Methods: Retrospective case series. Eight patients ranging in age from 31 to 77 years underwent surgical repair of lower eyelid reverse ptosis. The pupillary axis of the affected eye(s) in each patient was obscured in downgaze, interfering with reading. The lower eyelid reverse ptosis resulted from involutional changes in 3 patients, previous orbital decompression in 3 patients, multiple prior retinal and extraocular muscle operations in 1 patient, and previous orbital floor fracture and repair in 1 patient. Transcutaneous advancement of the lower eyelid retractors was performed in 12 eyelids of the 8 patients., Results: The mean preoperative vertical eyelid fissure was 6.2 mm (median, 6 mm; range, 3-9 mm), increasing after surgery to a mean of 7.7 mm (median, 8 mm; range, 5-11 mm). The mean preoperative distance between the central light reflex and the lower eyelid margin was 1.7 mm (median, 1.25 mm; range, 1-4 mm); this distance increased to a mean of 3.3 mm (median, 3.25 mm; range, 2.5-4.5 mm) after surgery. Symptoms improved in all patients, and there were no perioperative complications. Follow-up intervals ranged from 2 months to 24 months (mean, 9 months; median, 13 months)., Conclusions: Analogous to upper eyelid ptosis repair by advancement of the levator aponeurosis, lower eyelid reverse ptosis may be corrected effectively and safely by advancing the lower eyelid retractors.