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Purpose: To determine the narrowest diameter of the bony nasolacrimal canal., Methods: Fifty-eight bony nasolacrimal canals from 29 Japanese cadavers (12 men and 17 women; average age at death, 83.4 years; range, 70-99 years) had been fixed in 10% buffered formalin before use. After exposing the medial (44 canals) or posterior half (14 canals) of the bony nasolacrimal canal, the part with the shortest anteroposterior or transverse diameter was determined on inspection. These positions from the canal entrance were measured, and the distance ratio, indicating where the shortest diameter was located in relation to the total length of the canal, was calculated., Results: The shortest anteroposterior and transverse diameters were at the entrance to the canal in 32 of 44 canals (72.7%) and in 9 of 14 canals (64.3%), respectively. In the other canals, the shortest anteroposterior and transverse diameters were located at an average of 3.6 and 5.6 mm from the entrance, and the distance ratios were 29.0% and 46.7%, respectively. The mean shortest anteroposterior and transverse diameters were 5.6 and 5.6 mm, respectively., Conclusions: The shortest anteroposterior and transverse diameters were at the entrance of the canal in most of the bony nasolacrimal canals. These results are comparable with the rate of obstruction at the canal entrance in primary acquired nasolacrimal duct obstruction. more...

Purpose: To examine the relative positions of the lacrimal fossa (LF) and the bony nasolacrimal canal (BNLC) in relation to each other and a reference plane., Methods: Forty-two orbits and BNLCs from 21 Asian cadavers (9 men and 12 women; average age at death, 84.4 years; range, 70-99 years) had been fixed in 10% buffered formalin before use. After exposing the LF and the medial half of the BNLC, the authors measured the angles of the longitudinal axis of the LF and the BNLC relative to the aesthetic horizontal plane respectively. Based on these values, the relative orientation of the LF and the BNLC was determined and defined in terms of Δ BNLC-LF. A positive Δ BNLC-LF represents a nasolacrimal canal that descends posteriorly relative to the LF., Results: The mean LF, BNLC, and Δ BNLC-LF were 9.5°, 19.8°, and 10.3°, respectively. In 39 passages (92.9%), the Δ BNLC-LF was positive, representing a nasolacrimal canal that is more posteriorly oriented than the LF. In 3 passages (7.1%), the Δ BNLC-LF was equal to or less than 0°; 2 of them (4.8%) had a straight course and 1 passage (2.4%) had a negative value., Conclusions: In most patients, the BNLC is directed more posteriorly than the LF. This finding may help in preventing an inadvertent false passage during probing and intubation in patients with epiphora. more...

Purpose: To clarify the causative factor of Asian double eyelid., Design: Experimental anatomic study., Participants: Twenty-six upper eyelids (13 right and 13 left) from 17 Japanese cadavers (9 males and 8 females, mean age at death: 73.1 years)., Methods: The specimens, obtained from the central part of the upper eyelids, were dehydrated, embedded in paraffin, cut into 7-μm thick slices and stained with Masson trichrome. Statistical analysis was based on the Mann-Whitney U test. Statistical significance was defined as p < 0.05., Main Outcome Measures: Orbicularis oculi muscle thickness and shape, with or without the levator extension, orbicularis oculi muscle bundle spacing, thickness of upper eyelid skin and subcutaneous tissue, fusional site between the levator aponeurosis and the orbital septum, with or without inferior drooping of fat tissue., Results: The orbicularis muscle was thinner at the skin crease of a double eyelid than at 10 mm from the eyelid margin in the single eyelid group (p = 0.029). In 3 specimens the skin crease of double eyelid was at the tip of the bending orbicularis muscle, which was thick. Although the skin crease in the region of a double eyelid was thinner than in other parts of the skin, excluding the simple crease regions, other outcome measures were not shown as definite causative factors in creating the Asian double eyelid., Conclusions: The thickness of orbicularis oculi muscle or its bending shape, and the thickness of the skin at the skin crease, are major causative factors in Asian double eyelid formation. more...

Purpose: To examine the junctional variations of the levator palpebrae superioris (LPS) muscle, the levator aponeurosis, and Müller muscle in Asians., Methods: Postmortem specimens of 17 upper eyelids and orbits of 13 Asians (9 right and 8 left; average age, 78.5 years old) were used. Full-thickness sagittal sections of the central part of the upper eyelids and orbits were microscopically examined using Masson trichrome staining., Results: Peripheral branching of the LPS muscle was demonstrated in 12 specimens. Five of these showed that the complete origin of Müller muscle was from the inferior branch, whereas the levator aponeurosis originated from the superior branch. In the other 7 specimens, part of the Müller muscle origin was from the orbital smooth muscle network. The superior branch was significantly thicker (average: 340.8 μm) than the inferior branch (average: 247.5 μm) (p = 0.014). Two specimens did not demonstrate any branching structures, and most areas of the distal end of the LPS muscle was connected to Müller muscle. The other 3 specimens also did not demonstrate these branching structures, and Müller muscle was seen originating from the orbital smooth muscle network and from the inferior aspect of the LPS muscle., Conclusions: The authors demonstrated variations of the junctional anatomy of the LPS muscle, the levator aponeurosis, and Müller muscle. These new anatomical findings may help better understanding of the anatomy of the upper eyelid and the relations to the orbital smooth muscle network. more...

Purpose: To analyze the distribution and characteristics of upper eyelid skin elastic fibers in different areas of skin thickness and in relation to the eyelid crease., Methods: We used 12 postmortem eyelids (6 right, 6 left) of 10 Asian cadavers (mean age: 77.1 years at death), fixed in 10% buffered formalin. Full-thickness sagittal sections of the upper eyelids were dehydrated, embedded in paraffin, and cut in 7-μm-thick sections. The sliced sections were stained with elastica van Gieson., Results: The upper eyelid skin was divided in 2 areas; the thinner and thicker areas. The average distance from the eyelid margin to the border between the 2 areas was 17.8 mm (range, 12.8-24.0 mm). Ten eyelids showed a small amount of elastic fibers in the thinner skin area, and 2 eyelids were rich in elastic fibers in the same area. The volume of elastic fibers multiplied in the thicker skin area. The elastic fibers in the eyelid margin area were fine and nonfragmented, whereas in other areas they were thicker and more fragmented. A part below the skin creases showed the same concentration of elastic fibers to other areas of the upper eyelid skin., Conclusions: Most upper eyelids demonstrated a small amount of elastic fibers in the thinner skin area and a larger amount in the thicker area. The eyelid margin elastic fibers had a normal morphology, whereas in other areas they were more disintegrated, thicker, and fragmented. The eyelid creases and the elastic fiber concentration were unrelated. more...

Purpose: To describe the anatomic characteristics of Müller's muscle tendon., Materials and Methods: Twelve postmortem, buffered formalin (10%)-fixed eyelids (6 right, 6 left) of 10 Asians (aged 62 to 92 years at death; mean age: 77.1 years) were used. Full-thickness sagittal sections of the upper eyelid specimens were dehydrated and embedded in paraffin and cut in 7-μm-thickness sagittal sections. Sliced sections were stained with elastica van Gieson. The concentration of the elastic fibers in Müller's muscle tendon was analyzed and compared with the concentration in the levator aponeurosis. Fat deposition and the dimensions of Müller's muscle tendon were also analyzed., Results: Both Müller's muscle tendon and the levator aponeurosis contained elastic fibers, which were more abundant in Müller's muscle tendon. Fat deposition in Müller's muscle tendon was demonstrated only in one specimen from an 84-year-old male. The average length of Müller's muscle tendon was 2.56 mm (range: 1.40-5.64 mm), and the average thickness of the tendon was 0.27 mm (range: 0.08-0.88 mm). There was no correlation between cadaver age and muscle length or thickness., Conclusions: Müller's muscle tendon is rich in elastic fibers with minimal age-related fat deposition. more...

Purpose: To analyze the distribution of tarsal elastic fibers, with special emphasis on the meibomian duct area., Methods: Nine postmortem orbits (5 right, 4 left) of 7 Asian cadavers (mean age at death: 82 years, age range: 73-94 years), fixed in 10% buffered formalin, were used. Full-thickness sagittal sections of the upper eyelid specimens were dehydrated and embedded in paraffin and cut in 7-μm-thick sagittal sections. Sliced sections were stained with elastica van Gieson., Results: Elastic fibers were demonstrated in all tarsal plates. They were mostly distributed around the meibomian ducts and much less around the acini or in the tarsal stroma. These elastic fibers were also seen in the area of the muscle of Riolan. The outer part of the meibomian acini was less surrounded by elastic fibers., Conclusions: Tarsal elastic fibers are distributed mainly around the meibomian ducts, and much less around the acini or in the tarsal stroma. The fibers were also shown to extend to the area of the muscle of Riolan. These anatomical findings may help clarify the mechanisms involved in meibomian secretion. more...

Purpose: To present the anatomical characteristics of the superior border of the lateral orbital wall and thereby reduce the risk of inadvertent dural damage during deep lateral orbital wall decompression., Methods: Twenty-five orbits (13 right and 12 left) of 13 Asian cadavers (6 men and 7 women) aged 61 to 93 years at death (average, 79.5 years) were used. After removing the orbital content, the lateral orbital wall, and the skull and brain, the superior border of the lateral orbital wall was exposed, which was analyzed from an orbital cavity view and an intracranial cavity view., Results: The anterior part of the superior border of the lateral orbital wall is parallel with the orbital roof; however, more posteriorly, as the orbital roof curves inferiorly, they become perpendicular. The cortical bone conspicuously separates the thin superior border from the orbital roof. In the junction between the superior and the posterior borders, a thick bone marrow exists. Complete removal of this bone marrow resulted in penetration in the junction of the anterior and middle cranial fossae., Conclusion: The authors documented the anatomy of the superior border of the lateral orbital wall, including the different relative positions between the superior border and the orbital roof in the anterior and posterior parts of the orbit. To avoid dural exposure, the cortical bone should not be exposed at the junction between the superior and posterior borders of the lateral orbital wall, which corresponds to the junction of the anterior and middle cranial fossae. more...

Purpose: To present the microscopic lateral tarsal fixation findings in Caucasians, focusing on the lateral rectus capsulopalpebral fascia (lrCPF), lateral canthal band (LCB), and the tarsus., Materials and Methods: Seven Caucasian cadavers (13 eyelids: 7 right and 6 left; age range, 78-101 years) were used. Microscopic axial sections parallel to the eyelid margin were made and stained with Masson's trichrome. The first and second sections of the upper eyelids were obtained at 1 mm and 5 mm, respectively, superior to the upper eyelid margin. The first and second sections of the lower eyelid were obtained at 1 mm and 3 mm, respectively, below the lower eyelid margin., Results: All first sections of the upper eyelids (7 specimens: 3 right and 4 left) showed continuity of the lrCPF with the tarsus. The LCB merged with the lrCPF and connected to the tarsus (3 eyelids) or the muscle of Riolan (4 eyelids). All second sections of the upper eyelids (9 specimens: 4 right and 5 left) showed direct communication of the lrCPF, intermingling with the LCB, with the tarsus. All first sections of the lower eyelids (4 specimens: 2 right and 2 left), showed direct insertions of the lrCPF on the tarsus. The LCB, merging with the lrCPF, communicated with the tarsus and the muscle of Riolan (all 4 eyelids). All second sections of the lower eyelids (7 specimens: 2 right and 5 left) showed direct insertion of the lrCPF, intermingling with the LCB, on the tarsus., Conclusions: The lateral aspect of the tarsal plate in Caucasians is supported by the lrCPF and the LCB, similar to that in Asians. more...

A detailed understanding of the relationship between the ethmoidal sinus and the intracranial cavity is essential to prevent intracranial penetration during orbital surgery. The authors analyzed 10 postmortem orbits with their adjacent skull bases of 5 Asian cadavers (3 males and 2 females; mean age of 80 years at death). After removing all orbital contents, skull and brain, the medial orbital wall, ethmoidal cells, and ethmoidal roof were also removed. From the intracranial cavity view, the ethmoidal roof was situated just lateral to the cribriform plate. From the orbital view, the location of the roof was close to the superior border of the medial orbital wall. These anatomical observations may be useful to prevent intracranial penetration and cerebrospinal fluid leakage during medial orbital wall decompression. more...

Purpose: To characterize the attachment site of the orbital septum on the levator aponeurosis and the anatomic level of the inferior end of the preaponeurotic fat pad, both in Asians and whites., Materials and Methods: Full-thickness sagittal sections of upper eyelids, fixed in 10% buffered formalin, were microscopically examined in 18 postmortem upper eyelids of 10 Asian cadavers (mean death age, 78 years; age range, 68-89 years) and 11 postmortem upper eyelids of 7 whites (mean death age, 88 years; age range, 78-101 years). We measured the distance from the superior tarsal border to the attachment site of the orbital septum on the levator aponeurosis based on the position of the distal end of the anterior layer of the levator aponeurosis. In addition, the position of the inferior end of the preaponeurotic fat pad was simultaneously measured from the superior tarsal border., Results: The average distance from the superior tarsal border to the distal end of the anterior layer of the levator aponeurosis was 4.44 mm in Asians and 3.71 mm in whites (p = 0.412). The average distance from the superior tarsal plate border to the preaponeurotic fat pad was 1.90 mm in Asians and 3.17 mm in whites (p = 0.173)., Conclusions: The distance from the orbital septum attachment site on the levator aponeurosis to the superior tarsal border is similar in Asians and whites. However, there is some tendency, although not statistically significant, to a lower extension of the preaponeurotic fat pad in Asians. more...

A 56-year-old man who underwent surgical clipping of a cerebral aneurysm via a bifrontal craniotomy in a Jack-knife position complained of bilateral blindness immediately after surgery. Examinations 14 hours later revealed marked bilateral proptosis with eyelid edema and conjunctival chemosis. MRI demonstrated severe bilateral globe tenting with marked orbital tissue edema. Despite emergent lateral canthotomy and cantholysis, there was no visual recovery. This is a rare case of bilateral irreversible blindness after cerebrovascular surgery caused by orbital compartment syndrome and resulting in severe globe tenting and ocular ischemia. Attention to factors such as direct ocular pressure from skin flaps, congestion from head positioning, and adequate intraoperative eye protection and monitoring may reduce the risk of this complication or allow faster management when diagnosed. more...

A 56-year-old healthy man underwent left medial rectus recession and lateral rectus resection for esotropia. The next day he developed severe left periocular pain with decreased vision, an afferent pupillary defect, periorbital edema, limited ocular motility, and proptosis. Computed tomography showed fat stranding and less than 90 degrees of posterior globe tenting. Despite intravenous antibiotics to treat orbital cellulitis, and a lateral canthotomy and cantholysis to decompress the orbit, visual acuity worsened to no light perception. The patient underwent emergent orbital decompression including release of the superior and inferior septum and outfracturing of the orbital floor and medial wall; however, there was no recovery of vision. Blinding orbital cellulitis is a rare complication after strabismus surgery. Despite poor prognosis, prompt diagnosis and aggressive treatment may maximize visual potential. more...

Purpose: Esthesioneuroblastoma is a rare malignancy arising from the olfactory mucosa in the nasal fossa, which can invade the orbit producing ophthalmic symptoms and signs. The purpose of this study was to present a case series and review the literature to assess the characteristics of orbital involvement by esthesioneuroblastoma., Methods: Retrospective case series of all patients treated for biopsy-proven esthesioneuroblastoma at the Royal Adelaide Hospital between 1992 and 2004., Results: Nine patients (5 male, 4 female) with a mean age of 50 years (range, 20 to 66 years) were reviewed. One case was classified as Kadish stage A, 1 as Kadish stage B, and 7 as Kadish stage C. Mean time from onset of symptoms to diagnosis was 17 months (range, 2 to 24 months). Radiologic orbital invasion was present in 4 cases and was associated with ophthalmic symptoms or signs in 3 of these cases. These included proptosis (2 cases), periorbital pain (1 case), decreased visual acuity (1 case), extraocular muscle restriction (1 case), and chemosis (1 case). One patient with symptoms secondary to orbital invasion was initially referred to and assessed by an ophthalmologist. All patients who had or went on to have development of orbital invasion had advanced disease at diagnosis. Treatment was surgical (9/9), with the addition of radiotherapy (6/9) and chemotherapy (2/9). Mean follow-up was 3.6 years (range, 0.5 to 8.5 years). Six of 9 patients had tumor recurrence. Two had metastasis. Five of 9 patients remained alive., Conclusions: Orbital invasion by esthesioneuroblastoma is not uncommon. It is important to be aware of this malignancy because a significant proportion of patients will present with ophthalmic signs and symptoms. more...

Purpose: To report the use of autologous pericranium grafts to cover exposed orbital implants., Methods: A two-center consecutive case series of exposed orbital implants covered with autologous pericranium grafts. A patch of pericranium was harvested from the parieto-occipital region and was placed over the implant within a pocket between the implant and the Tenon capsule, followed by layered closure of Tenon and conjunctiva., Results: Four patients (2 women, 2 men) with a mean age of 37 years (range, 26 to 45 years) were included in the study. The mean follow-up period was 9.5 months (range, 7 to 12 months). In all cases, there was no recurrence of exposure and no donor site morbidity. A small pyogenic granuloma, arising from the conjunctival suture line, developed in one case., Conclusions: Autologous pericranium is a useful covering material for exposed orbital implants and may be used as an alternative to frontal periosteum. more...