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Objective To evaluate the differences between Asian and Caucasian upper eyelid anatomy through cadaver dissection, histopathological study, and magnetic resonance imaging. Materials and Methods Upper eyelids of 9 Korean and 5 Caucasian cadavers were dissected, and then were studied microscopically with hematoxylin-eosin, Masson trichrome, and elastin stains. Four healthy young Korean men were studied by dynamic high-resolution magnetic resonance imaging with regard to demonstration of upper eyelid structure. Results More subcutaneous and suborbicularis fat, with a pretarsal fat component, is present in Asian eyelids. The Asian double eyelids showed an amount of fat intermediate between Asian single eyelids and Caucasian eyelids. Asian single eyelids showed fusion of the orbital septum to the levator aponeurosis below the superior tarsal border, while fusion is above the superior tarsal border in Caucasians. The preaponeurotic fat pad descends anteriorly to the tarsal plate in the Asian single eyelid, but not in the Caucasian eyelid. A pretarsal fat pad is identified in the Asian single eyelids. Conclusions The causes of absent or lower crease in the Asian upper eyelid are as follows: (1) the orbital septum fuses to the levator aponeurosis at variable distances below the superior tarsal border; (2) preaponeurotic fat pad protusion and a thick subcutaneous fat layer prevent levator fibers from extending toward the skin near the superior tarsal border; and (3) the primary insertion of the levator aponeurosis into the orbicularis muscle and into the upper eyelid skin occurs closer to the eyelid margin in Asians. Structural differences relating to increased fat in the Asian upper eyelid include the presence of a pretarsal fat pad and a moderate fat increase in the double Asian eyelid.

In reply Meyer, who with coworkers ' recently described the septal relationships of the suborbicularis fat pad, is entirely correct in pointing out a labeling error; the arrowhead on the figure indicates not the suborbicularis fat pad but rather the subcutaneous fat (which lies beneath the dermis and anterior to the orbicularis). However, I do not believe that the posterior shadow along the orbital rim in the Asian volunteer is a posteriorly located arcus marginalis. This posterior shadow is an orbital fibrous condensation that is occasionally seen on these images. On MRI we have noted that the orbital septum sometimes blends into the fibrous septa of the postorbicularis fat pad and is not always visualized as a discrete fibrous sheet, just as it is sometimes less distinct surgically. In this Asian eyelid, the orbital septum that separates the prominent suborbicularis fat and preaponeurotic fat is not well imaged, and the curved

To the Editor. —Congenital upper eyelid eversion is a rare disorder of unknown etiology. The condition is typically bilateral, with a higher incidence observed in black newborns, infants with trisomy 21, and children of multiparous mothers.1-3Proposed pathophysiologic mechanisms of this anomaly include failure of the orbital septum and levator aponeurosis to fuse, orbicularis muscle hypotony, vertical shortening of eyelid skin, vertical elongation of posterior eyelid structures, and canthal abnormalities.2,3Although the condition is self-limited, complications of conjunctival desiccation, progressive chemosis, and secondary infection are relative contraindications to waiting several weeks for spontaneous resolution. Conservative treatment of lid eversion by applying moisture chambers or topical lubricants can take weeks to months for resolution; taping the eyelids closed is technically difficult and often unsuccessful. Instead, most recently published reports recommend early surgical treatment, such as suture tarsorrhaphy, skin grafting, horizontal lid shortening, and full-thickness sutures applied between the superior

We report a case of mycosis fungoides metastatic to the anterior orbit in an 83-year-old woman. The patient had a history of several years' duration of well-controlled primary mycosis fungoides with localized dermatologic T-cell lymphomas, mainly on the lower extremities. She developed gradual proptosis, hyperophthalmos, and vertical diplopia. Computed tomography demonstrated a solid, extraconal mass in the right lower anterior orbit. Biopsy revealed a gristly, yellowish, infiltrating mass at the level of the inferior orbital septum. Pathologic examination revealed anaplastic T lymphocytes with multiloculated, cerebriform nuclei that matched those of the primary mycosis fungoides skin tumors. Mycosis fungoides rarely spreads to the ocular and periocular structures, and this case was unique in that it presented as a pure orbital lesion with sparing of the overlying lids and adnexal structures.

At the Southern Regional Scientific meeting of the American Academy of Facial Plastic and Reconstructive Surgery, Dr Ira D. Papel, Baltimore, Md, White Sulfur Springs, WVa, described several of the most common undesirable appearances of the eyelids after lower blepharoplasty. Scleral show, rounded palpebral fissure, and ectropion in the senile lower eyelid can be minimized by careful preoperative evaluation and selection of one of several procedures designed to tighten or suspend the lower eyelid. The lower blepharoplasty procedure preferred by the author for the senile lower eyelid is the combined transconjunctival and lateral strip technique. A 1-cm lateral can-thotomy is performed, transecting the inferior crus of the lateral canthal tendon. Fat removal is accomplished by incising the conjunctiva and approaching the orbital fat either through the orbital septum or behind the septum. The conjunctiva is then closed with a running 6-0 mild chromic suture in a subconjunctival plane. The

BAGGY LOWER EYELIDS are most commonly caused by an attenuation of either or both the septum orbitale and the orbicularis oculi muscle, which results in a forward extension of the peripheral intraocular fat through the orifices adipeux of Charpy 1,2 (Fig 1). The occurrence of these fat hernias in association with a variety of conditions has been reported. These include degenerative changes in the epidermis and subcutaneous tissues resulting in skin redundancy; 3 allergic conditions, myxedema, or nephrosis that cause intermittent edema and thickening of the lids; 3-5 and pathological states such as neoplastic disease, lipoidosis, and exophthalmic goiter, in which intraorbital pressure is increased. 3,5,6 The present report records a case of bags beneath the eyes caused by either the absence of or hypoplasia of the septum orbitale, or orbicularis oculi, or both, an anomaly which permitted the intraocular fat to extend into the subcutaneous tissues of the lower

• The semicircular flap of Tenzel has proved to be an excellent reconstructive procedure for central eyelid defects. Although originally described for defects measuring half of the eyelid, we have found that it may be used for defects greater than 60% in the lower eyelid, if the lower eyelid retractors and inferior orbital septum are identified and severed from their attachments. This is the key factor in the mobilization and advancement of this flap. It may, in many circumstances, obviate the need for a more complicated reconstructive procedure.

In Reply. —We thank Dr Silver for his comments, and he is correct in suggesting that it is safer to pass the needle from inferior to superior while placing an eyelid plate between the lid and globe. However, while these maneuvers may be safer for some surgeons, we have noted the following difficulties in obtaining the desired effect when using these procedures: We place fascia in a base-down triangle fashion in the eyelids. Maneuvering the needle superiorly would involve its passage with fascia in the eyelet. This is a very difficult and traumatic pass that sometimes results in a tear in the fascia. It is virtually impossible to make the near right-angle turn necessary to change the direction of a needle that is behind the orbital septum at the arcus marginalis to a position anterior to the supraorbital rim and behind the frontalis muscle when passing from inferior

In the reply to his critics G. Levinsohn 1 repeats his assertions that myopia is due to the effect of gravity in the bent forward position of the head. The eyeball is said to protrude in this posture and to assume a pearlike shape, being similar to a bag of water suspended from a hook, the optic disk being the punctum fixum. Indeed, the protrusion of the eyeball can be easily verified in many cases. However, this protrusion indicates a forward movement of the eyeball in toto and by no means an alteration of the shape of the eye. It is due to the congestion of the orbital veins. The extent of the protrusion depends on the size of the aperture between the lids, on the resistance of the orbital septum, ligaments, muscles and other structures and on the degree of filling of the orbital veins. If the protrusion were

• Dividing the orbital septum from the levator aponeurosis is a major problem for the surgeon who does an occasional ptosis operation. The modification described here is devised to aid identification of the septum-aponeurosis relationship.

• The technique of removing both the scarred tarsal plate and orbital septum is described for correction in cases of severe trachomatous entropion. The procedure gave about 90% satisfactory results in a series of which 35 eyes were operated. The combined technique is simple and can be performed as an office procedure.

• Dissection of the eyelids and sagittal sections of the orbital blocks identified the anatomic features of the oriental eyelids responsible for their unique appearance. The basic distinction involves the formation of the eyelid crease and fold. In the occidental eyelid, the orbital septum fuses with the levator aponeurosis above the superior tarsal border. However, in the oriental eyelid, the orbital septum fuses with the levator aponeurosis below the superior tarsal border. The accompanying preaponeurotic or orbital fat is allowed to proceed to the anterior tarsal surface, resulting in a full or thickened eyelid. The inferior extension of the orbital septum, beyond the superior tarsal border, prevents anterior aponeurotic fibers from fanning toward the subcutaneous tissues to produce the normal eyelid crease. Appreciation of the unique anatomic features of oriental eyelids is important for those persons who evaluate or surgically explore these eyelids.

To the Editor: —Recently, Bayard (Unilateral Glaucoma Following Resection of a Tumor of the Superior Fornix,Arch Ophthal70:647 [Nov] 1963) described an interesting case of unilateral open-angle glaucoma detected about one year after removal of a tumor in the upper fornix and aggravated after resection of almost 50% of the subconjunctival and episcleral tissue from a point 6 mm behind the limbus to the orbital septum. The unilaterality was supported by provocative and tonographic tests, but the mechanism is said to be a matter of speculation. The author rightly assumed that the surgery may have affected the episcleral vessels in half the circumference of the globe. During the first third of our century, when the aqueous humor was believed to be stagnant, an explanation of this case might well have been difficult; Leber's theory of a continuous circulation of the aqueous humor was in disrepute until it was reconfirmed