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The double-eyelid operation is the most requested cosmetic surgery in Asians. The incision is usually located at the pretarsal skin 6 mm to 8 mm above palpebral margin. The purpose of this paper is to report a novel approach of double-eyelid operation through a supraciliary incision (SCI). Three transverse curved lines were drawn on the upper lid skin. The location of line 1 (SCI) was 1.5 mm above the eyelash, line 2 according to the amount of redundant skin excised and line 3 at 3 mm to 4 mm above line 2. After the incisions were made between line 1 and line 2, the subcutaneous dissection is carried out over 5 mm the line 3. Then, the redundant skin and a strip orbicularis oculi muscle were removed to open the orbital septum and to explore underside levator aponeurosis. Along the line 3, the internal buried fixation sutures between dermal tissue and the fusion line of the orbital septum and levator aponeurosis were placed. Finally, the wounds were closed between line 2 and line 1. There were 528 patients who underwent the double-eyelid operation through the supraciliary approach. In long-term follow-up, 288 patients were evaluated at 6 months to 78 months postoperatively. Of those, 266 patients were satisfactory for the result (92.36%) with natural shape and invisible surgical scar. In another 22 patients (7.63%), a revised blepharoplasty was performed in 22 eyelids. The double-eyelid surgery using the SCI has several advantages including less visibility of the incision, the protected subdermal vascular network, the intact continuity of the upper eyelid skin, the combination of the SCI and internal dermal buried suture method. The approach can be considered an efficient technique for Asian patients. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Background In order to correct upper lid laxity, upper blepharoplasty, subbrow excision, and forehead lift have been utilized. Our newly developed subbrow excision attaches the orbicularis oculi muscle to the frontalis muscle. This improves the longevity of the result without inhibiting the gliding plane of the periorbita. Method From January 2016 to July 2018, 564 patients were operated on using this technique. Among them, 41 were male and 523 were female with the average age of 59.5 years. The average size of the subbrow excision was 55 mm × 8 mm. From the upper skin incision site, the upper dissection proceeded cephalad in the subcutaneous plane just above the orbicularis oculi muscle to the point where the frontalis muscle was seen. The lower flap was created by incising the orbicularis oculi muscle 5 mm cephalad to the distal skin incision. From this 5-mm orbicularis muscle stump, the dissection proceeded caudally in a plane between the orbicularis muscle and the orbital septum. Once this flap was created, the 5-mm muscle stump was attached to the exposed frontalis muscle in a horizontal mattress fashion in three areas. The skin incision was then closed. Three months after the operation, a satisfaction survey was conducted using the Likert scale. Results The patients were followed postoperatively for at least 6 months. In all but two cases, the orbital laxity improved. However, in the brow’s lateral third where the frontalis muscle does not exist, a slight lowering of the brow had occurred. The incision healed well without any keloid or hypertrophic scars. There were no significant complications such as superior orbital nerve entrapment-related sensory problems. Conclusions Subbrow lift utilizing the frontalis muscle attachment to the lower flap orbicularis muscle is a novel method of correcting upper eyelid skin hooding. The technique does not rely on periosteal fixation. Therefore, the eyebrow gliding plane is not violated. Thus, the natural eyebrow movement is maintained. There were no cases of injury to the deep branch of the supraorbital nerve, poor wound healing, or other significant complications. Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

The lower eyelid changes with aging include atrophy of the orbital septum with subsequent forward herniation of orbital fat, descent of the sub-orbicularis oculi muscle fat, ptosis of the orbicularis oculi muscle, weakening of the orbito-malar ligament and the development of laxity of the eyelid skin, the tarsus and the canthal tendons. In this article we aim at describing our experience of using a modified lower lid blepharoplasty with fat repositioning in patients with lower lid fat prolapse and tear trough deformity. A retrospective, non-randomised non-comparative interventional consecutive case series of patients seeking surgical treatment. Patients underwent surgery between April 2010 and October 2019 by a single surgeon (BL). Patient demographics, clinical examination, preoperative and postoperative clinical photography, outcomes and complications were recorded. Follow-up was initially at 2 weeks and finally at 16–20 weeks. Outcomes were recorded as subjective improvement and degree of patient satisfaction. A total of 150 patients were recruited in the study period. The mean age at the time of surgery was 49. One hundred forty-one (94%) patients were very satisfied with the final outcome of their surgery, 5 were satisfied and 4 were dissatisfied. One patient developed a bilateral lower lid infection requiring abscess drainage. Seventeen other patients experienced minor complications in the postoperative period, including 2 with a unilateral lower lid infection requiring oral antibiotics, 3 with a temporary inferior oblique palsy, 1 with temporary unilateral infraorbital nerve dysfunction, 3 with residual prolapses of the lateral fat pads, 1 with a medial lower lid lump, 2 with a conjunctival granuloma, 2 with a temporary medial ectropion, 1 with persistent unilateral lower lid oedema, 1 with persistent bilateral lower lid oedema and 1 with unilateral lower lid retraction. We report a high patient satisfaction with a low rate of significant complications following our modified lower lid transconjunctival blepharoplasty with fat repositioning. Level of evidence: Level III, therapeutic study

Purpose To examine the fine anatomic structures between levator aponeurosis and Muller muscle in front of the tarsus. Materials and methods Postmortem specimens of 6 Chinese males (5 elderly men, aging from 68 to 86 years; 1 child, 10 years old) were used. A 3-μm thickness sagittal section of the central part of the upper eyelid was prepared, and the samples were examined microscopically by using hematoxylin-eosin, Masson trichrome, and anti-smooth muscle actin antibodies staining. Results There are 2 new findings in this study, one is the posterior layer of the levator aponeurosis and the other is the extensions of Muller muscle. The posterior levator aponeurosis had different insertion patterns that approximately paralleled the extension line of the levator aponeurosis at the confluence of attachment site of the orbital septum on the levator superioris. Below the confluence, it took the form of a layered insertion, and then extended to the orbicularis oculi muscle and subcutaneous tissue rather than inserting directly into tarsus. The Muller muscle was a multilayered structure at the upper border of tarsus. The superior Muller muscle extended above the peripheral arcade, and the inferior Muller muscle tendon was attached to the surface of tarsus with an Umbrella-shaped fiber. Conclusions The authors discovered that the levator aponeurosis had different insertion patterns of the posterior layers. The Muller muscle gave branches at the peripheral arcade: the anterior one crossed the peripheral arcade and extended to the tarsus, and the posterior one attached and extended to the tarsus.

Background Nowadays, a sharp, well-defined supratarsal fold and appropriate fullness of the upper eyelid tissue are considered important features of beautiful and youthful eyes. Individuals with thin upper eyelid tissue are at high risk of developing multiple upper eyelid folds and/or sunken appearance after upper blepharoplasty. Innovatively, the authors propose the application of free orbital fat grafting to the postorbicularis oculi space during upper blepharoplasty in order to achieve better aesthetic results. Methods Fifty Chinese patients with congenital single eyelids combined with mildly sunken upper eyelid tissue were operated on between June 2017 and October 2018. During blepharoplasty, the lateral portion of the orbital septum was dissected, and appropriate lateral orbital fat was harvested. When the double-eyelid fold was formed and skin was interruptedly sutured, the harvested fat was divided into several pieces each side according to the sunken depth, and they were used to replace a layer on two-thirds of the central region of the supraseptal skin-muscle flap through the zipping gaps. Results Forty-five patients underwent the follow-up interview for 6 to 18 months with a mean period of 10 months. The satisfaction rate was 82%. No significant asymmetry, irregularities, and sunken upper eyelid and multiple upper eyelid folds occurred. Conclusion The lateral orbital fat grafting to the central region of the supraseptal skin-muscle flap during upper blepharoplasty is an effective and simple method to correct or prevent multiple upper eyelid folds and/or sunken upper eyelid in Asians.

Background: Microfocused ultrasound (MFU) causes tissue tightening by producing thermal injury zones and is used to treat various age-related changes including lower eyelid fat bulging.Objective: To investigate the efficacy of a new treatment protocol of MFU for lower eyelid fat bulging.Methods and materials: We reviewed the medical records of all patients who began MFU for lower eyelid fat bulging from March 2017 to September 2018. MFU was performed in two steps to tighten the lower eyelid dermis and orbital septum. Data on age, sex, bulging severity, and the number of treatment sessions were obtained. Associations of these variables with treatment response were determined through an ordinal logistic regression analysis.Results: Among 191 enrolled patients, 119 (62.3%) and 47 (24.6%) achieved fair and good responses, respectively. In the multivariable analysis, multiple treatment sessions (odds ratio (OR) 6.618; 95% confidence interval (CI) 3.242-13.513; p < .001), moderate bulging (OR 4.328; 95% CI 1.755-10.671; p = .001), and severe bulging (OR 7.570; 95% CI 2.537-22.585; p < .001) were associated with greater treatment response. There were no serious adverse events.Conclusions: The new treatment protocol of MFU is an effective and safe strategy for lower eyelid fat bulging.

We report an unusual case of a young male patient who presented with severe pain and swelling of his left eyelid following an air compressor tip accident. He suffered extensive facial edema accompanied by deep tissue emphysema and an elevated intraocular pressure. On noncontrast CT scan, air was detected in the intraconal and extraconal orbital compartments, and intracranially within the subarachnoid spaces as well as in the suprasellar and perimesencephalic cisterns. There were no detectable fractures. We presume that by perforating the orbital septum, Tenon's capsule, and the optic nerve sheath, air had managed to penetrate the cranium through the optic nerve subarachnoid space and into the intracranial subarachnoid space.

Highlights • Subperiosteal orbital abscess is a rare complication of a dental infection. • Antibiotics alone are ineffective and do not guarantee arrest of the infection spread. • The possible route of infection spread should be determined, and is illustrated in this report. • Postseptal infections require a more aggressive approach compared to preseptal infections. • In case of an orbital infection, intraoral examination and dental radiography may not be overlooked., Introduction Subperiosteal orbital abcess is a rarely reported complication of odontogenic infections and can be associated visual impairment and neurological symptoms. Because of fast infection spreading, delay in diagnosis and treatment can result in permanent damage. Presentation of case A 55-year old presented with a right-sided subperiosteal orbital abscess originating from a decayed first upper molar. The associated loss of vision improved only after a extraoral surgical drainage. Three years later, recurrent headaches, photobia and ptosis still persist. Discussion Our case demonstrates a rare but potentially hazardous complication of untreated dental infections. The effect of antibiotics is often overestimated, and lack of treatment may lead to serious sequelae, certainly when the orbital infection is located posterior to the orbital septum. When intraoral drainage is insufficient, the infection should be accessed extraorally. Conclusion Orbital infections require a thorough clinical evaluation, including the oral cavity as dental infections may be overlooked. Dental radiograpy plays a major role. Prompt and adequate treatment is crucial in preventing further spreading of odontogenic infections.

Orbital cellulitis (OC) refers to acute infection of soft tissues of the orbit behind orbital septum. As many as 11% cases of OC result in visual loss. Here, we report a 60-year-old female who is a known case of Type 2 diabetes mellitus presented with complaints of right-sided headache, unable to open right eyelid, and unable to move eyeball for 1 month. Magnetic resonance imaging brain with orbit contrast done showed right-sided OC with forming abscess. Nasal endoscopy was done and nasal swab culture showed growth of Staphylococcus aureus. The patient was kept on antibiotics and was discharged after improvement. Prompt diagnosis and proper management are essential for curing the patient with OC. This is particularly important to prevent visual loss and other severe life-threatening complications.

Preseptal and orbital cellulitis are two types of infection surrounding the orbital septum with very different potential outcomes. Our aim was to describe key differential features of both conditions, laying special emphasis on diagnostic and therapeutic tools.A retrospective review of patients admitted to a tertiary hospital over a 15-year period (January 2004-October 2019) was conducted. We included 198 patients with preseptal and 45 with orbital cellulitis. Descriptive statistics were performed to examine the available information.Statistically significant differences were found between patients with preseptal and orbital cellulitis regarding age (3.9 ± 2.14 vs. 7.5 ± 4.24 years), presence of fever (51.5% vs. 82.2%), and preexisting sinusitis (2% vs. 77.8%) (all P0.001). Diplopia, ophthalmoplegia and proptosis were only present in orbital cellulitis (P0.001). Median values of C-reactive protein were significantly higher among children with orbital involvement [136.35 mg/L (IQR 74.08-168.98) vs. 17.85 (IQR 6.33-50.10), P0.0001]. A CRP120 mg/L cut-off point for orbital cellulitis was obtained. Early CT scans were performed in 75.6% of suspected orbital cellulitis and helped detecting complications at an early stage. Abscesses were revealed in 70.6% of cases, especially medial subperiosteal abscesses (58.8%). All patients received intravenous antibiotics, whereas corticosteroids were preferred in patients with orbital implication (8.6% vs. 73.3%, P0.001). Only 26.7% of patients required additional surgery.Clinical presentation and CRP are extremely sensitive for differential diagnosis of preseptal and orbital cellulitis. Prompt initiation of intravenous antibiotics is mandatory and can prevent surgical procedures even in cases with incipient abscesses.

BACKGROUND Sunken upper eyelid makes people's eyes look gaunt and aging. At present, more and more people are paying attention to eye rejuvenation, and more and more people are asking for correction of sunken upper eyelid. Orbital septum fat plays an important role in the display of eye contour. Therefore, the position of orbital septum fat can be adjusted surgically to improve the upper eyelid depression. OBJECTIVE This article discusses the clinical effect of orbital septum fat flap transfer in the upper eyelid depression of mild to moderate. METHODS Thirty patients with single eyelid depression in our hospital from April to September 2020 were selected. After blepharoplasty, the orbital septum fat was fully released and the lateral orbital fat transfer was fixed to the mid-medial upper eyelid depression. RESULTS After the operation, 29 patients were satisfied with the results, with good incision healing, bilateral basic symmetry no obvious scar, and negative effect of non-convex and concave eyelid inequality. One patient did not achieve the expected results and was treated with a second autologous fat filling. CONCLUSIONS For patients with mild to moderate sunken upper eyelid, orbital septal fat flap metastasis during blepharoplasty has not only good effect, natural appearance, and smooth upper eyelid skin, but also only 1 incision for upper eyelid formation, which has high acceptance and satisfaction of patients and can be widely used in clinical practice.

A 46-year-old man with refractory migraine headache was treated with decompressive migraine surgery of the supraorbital and supratrochlear nerves. Postoperatively, he reported diplopia that got better on left head tilt. After ophthalmological examination, a diagnosis of right superior oblique palsy was made. The aim is to report the first case of superior oblique muscle or trochlea damage that may have occurred because of inadvertent entry through the orbital septum into the right superior orbit.

Purpose: Orbital cellulitis is an infectious pathology affecting fat and muscles behind the orbital septum. Retinopathy of prematurity (ROP) is an abnormal retinal blood vessel proliferation affective preterm low birth weight infants. Here we report the first case report of a 4-month-old infant who presented to our outpatient setting with orbital cellulitis and bilateral ROP sequelae. Case report: A 4-month-old female infant was brought by her mother to the OPD with sudden onset redness, discharge, and swelling in the right eye accompanied by fever for 1 day. The child was born preterm at 8 months gestational age with a birth weight of 1.3 kg. Ocular examination revealed orbital cellulitis. Bruckner’s reflex revealed an altered red glow. Ultrasound B scan confirmed bilateral localized highly reflective peripheral anterior looping membranes suggestive of retinal detachment as sequelae of ROP. The child was treated with topical eyedrops 0.5% Moxifloxacin 2 hourly and was referred to a tertiary hospital for higher management in the form of intravenous injections of Cefixime 50 mg/kg in two divided cases with Vancomycin 60 mg/kg/day in two divided doses for 5 days in a critical care unit (CCU). Conclusion and importance: Orbital cellulitis is an emergency ocular condition that should be promptly treated with a multidisciplinary approach. There is a high probability of missing the posterior segment pathology in such cases. Meticulous history taking, detailed ocular examination along with Bruckner’s reflex help in immediately clinching the correct diagnosis in such cases and safeguards the clinician from any medicolegal issues in the future.

The orbital septum prevents both superficial eyelid infection and the spread of bleeding into the orbit. The fusion point between the upper eyelid orbital septum and the levator aponeurosis or the tarsal plate plays an important role in determining the width of the natural double eyelid. We observed a number of unsatisfactory upper eyelid blepharoplasty outcomes resulting from improper handling of the orbital septum—such as excessive destruction of orbital septum tissue and failure to form a firm attachment point between the orbital septum and the levator aponeurosis or palpebrae plate—during primary surgery. The three most common types of unsatisfactory upper blepharoplasty outcomes include abnormally high double eyelid creases, multiple creases, and disappearance of creases. In the repair operation, we try to determine the remaining orbital septum tissue for reconstruction and form a firm attachment between the orbital septum and the levator aponeurosis or tarsal plate. Follow-up after surgery was performed to observe whether our technique can ensure effective and favorable long-term natural-looking upper eyelid blepharoplasty outcome. From January 2018 to January 2020, secondary blepharoplasty involving the above-mentioned unsatisfactory double eyelid results was performed in 83 patients, including 63 patients (141 eyes) with abnormally high skin creases, 6 patients (8 eyes) with multiple creases, and 14 patients (24 eyes) with double eyelid disappearance. The outcomes were assessed 6 months to 2 years after the surgery by reviewing the photographs to evaluate the esthetic outcomes including stability of double eyelid, double fold curve, symmetry, patient satisfaction, and the incidence of complications. After an average follow-up of 12 months, most patients achieved a better double eyelid appearance. The esthetic outcome was graded as good in 80 patients, poor due to recurrence of double eyelid disappearance in 2, and poor because of asymmetry of the double eyelid curve in length or width in 1 patient. All patients had acceptable scars. No cases of infection or ptosis were observed. Reconstructing the orbital septum and ensuring a firm fixation with the levator aponeurosis or tarsal plate is an effective method to repair unsatisfactory upper eyelid blepharoplasty. Moreover, it is very important to protect the orbital septum and proper treatment during the initial surgery. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Introduction and importance: Mucoceles are expansive pseudocystic formations, developed from the sinuses of the face, affecting mainly adults. Evolving at low noise, they are most often revealed by neurological or ophthalmological complications. We report a rare case of a bilateral frontal mucocele with orbito-cerebral extension following nasal sinus polyposis. Case presentation This was a 35-year-old patient with a history of Widal syndrome, who presented frontal headaches and left proptosis evolving for 4 months, in whom clinical examination revealed a left superomedial eyelid swelling, left proptosis and stage 2 nasosinus polyposis. Computed tomography and craniofacial magnetic resonance imaging were in favor of a bilateral frontal mucocele with left orbital and bilateral cerebral extensions. The patient was bilaterally operated by a combined approach including external Jacques eyebrow and endonasal Draf IIa procedure in addition to a radical total ethmoidectomy. The outcomes were favorable with regression of headaches and resolution of exophthalmos. Clinical discussion The frontal mucocele, although benign, has an aggressive potential in the absence of treatment either towards the endocranium or the orbit behind the orbital septum causing intra-orbital extension, or in front of it; causing the dominant upper palpebral form as in the case of our patient. The treatment is still based on surgical excision of the cyst with drainage of the causal sinus, which was carried out for our patient. Conclusion Despite its benign behavior, frontal mucocele may become serious by compression of neighboring organs which require an early and appropriate surgical management., Highlights • Mucoceles are rare benign sinus tumors of the frontoethmoid complex. • They rarely extend to the endocranial anatomical structures. • Imaging is of capital importance for its multidisciplinary management. • Surgery is the standard treatment of mucocele based on external and endonasal routes.

Purpose: To describe an unusual case of fulminant orbital cellulitis with complete vision loss despite timely medical and surgical management. Observation: Orbital cellulitis is an infective condition of the ocular adnexal structures (fat, periorbita, and muscles) behind the orbital septum. A 22-year-old female presented with rapidly progressing orbital cellulitis and was started on empirical intravenous antibiotics. Orbital imaging showing marked proptosis with optic nerve stretching and an extraconal abscess in the medial aspect of left orbit. Emergency lateral canthotomy and orbital decompression was done. Streptococcus pyogenes was isolated on culture and antibiotics changed according to the sensitivity pattern. Lid edema, proptosis, and extraocular movements improved but vision deteriorated to absent light perception. Fundus showed disc pallor on follow up. A case of fulminant orbital cellulitis with compartment syndrome and ischemic necrosis of optic nerve is reported, which led to permanent vision loss despite timely antibiotics and surgical management. Conclusion: Despite prompt surgical intervention and administration of intravenous antibiotics, the patient may develop compartment syndrome, ischemic necrosis or infiltration of the optic nerve leading to complete vision loss.Orbital cellulitis is an infective condition of the ocular adnexal structures (fat, periorbita, and muscles) behind the orbital septum. This condition is more common in children and young adults and usually results from a paranasal sinus or any facial infection. 1 The majority of the organisms isolated are Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae B and Moraxella catarrhalis. Beta-hemolytic streptococci are rarely implicated. Bacterial cellulitis usually responds well to antibiotics but rarely may result in vision or life-threatening complications. Keywords: Abscess, Compartment syndrome, Orbital cellulitis, Orbit, Pain, Streptococcus pyogenes.

Background In patients with mild superior sulcus deformity, pseudoptosis, or multiple eyelid folds, several bulky fibers can be found anterior to the orbital septum. These fibers, called preorbital septum fibers, may constrict protrusion of the fat pad and movement of the levator palpebrae muscle. Objectives In this study, the authors illustrated the anatomy of these fibers and described the double-eyelid procedure to correct pseudoptosis, mild superior sulcus deformity, and multiple eyelid folds, which may be caused by these fibers. Methods The bulky preorbital septum fibers were dissected and severed during upper blepharoplasty to release the orbital septum fat pad and levator palpebrae muscle. This procedure was performed between January 2016 and January 2018 in 56 patients with distinct preorbital septum fibers. Results Of the 56 patients, 38 displayed mild to moderate upper eyelid depression and multiple eyelids, and 18 displayed pseudoptosis. Bulky fibers that existed in the superficial layer of the orbital septum were all dissected and removed. After 6 months’ recovery, the superior sulcus deformity improved in all patients. No recurrence of multiple eyelids was observed. Patients with pseudoptosis showed a notable release of their upper eyelids. Conclusions This is the first time to our knowledge that the preorbital septum fibers are described as a distinct anatomical structure. They are clinically important in upper eyelid anatomy and the improvement of sunken upper eyelids or pseudoptosis. The combination of blepharoplasty with release of these fibers is easy to perform and promote. Level of Evidence: 4

BACKGROUND The classic pterional, pretemporal, and orbitozygomatic approaches achieve large areas of exposure with easy maneuverability. In select cases (eg, some anterior circulation aneurysms), the minimally invasive fronto-orbital craniotomy can yield adequate exposure that must be balanced with its risk of frontalis injury. OBJECTIVE To detail a 10-yr experience using the transpalpebral approach, characterized by an incision whose camouflage is the natural eyelid crease, notably the effectiveness and outcomes of this exposure for anterior circulation aneurysms. METHODS In this retrospective review, 82 patients with 88 aneurysms underwent a supraorbital frontal minicraniotomy via the eyelid incision performed by a single neurosurgeon and closure by an oculoplastic surgeon (2007-2016). Incision of the orbiculi oculi developed a plane between the muscle and orbital septum superiorly. Outcomes recorded included aneurysm occlusion or residual, treatment modality (clipping/wrapping), postoperative hemorrhage or stroke, postoperative wound healing, and overall cosmesis. RESULTS Of 85 (97%) aneurysms treated by clipping, postoperative and follow-up imaging showed complete obliteration in 81 (95%) aneurysms and residuals in 4 (5%). Cosmetic outcomes for the eyelid incision were excellent: 81 (99%) patients noted excellent wound healing at follow-up and no scarring; 1 patient developed significant temporalis wasting and upper eyelid scarring after posterior communicating artery aneurysm clipping. Overall, 13 minor and 8 major complications affected 19 patients. CONCLUSION Our findings confirm the versatility of the eyelid supraorbital frontal minicraniotomy for common anterior circulation aneurysms. This large series found that postoperative complication risks were similar to traditional techniques and cosmetic results were excellent.

In recent years, because the formation mechanism of double eyelids in Asians is still controversial, many techniques for double-eyelid plasty have been developed. However, the removal of large amounts of pretarsal tissue and the obvious scars in those techniques make patients dissatisfied with the appearance. Thus, we have devised a novel surgical approach named the kiss technique. The method is to create a physiological double-eyelid fold on the basis of the formation mechanism of double-eyelid creases. From January 2017 to March 2019, the novel blepharoplasty was performed on 386 Chinese patients (769 eyes) in our department. Patients were evaluated at 3–24 months after surgery. Instead of dividing the orbital septum all the way to the orbital margin both medially and laterally, all that is required is to dissect the pretarsal orbicularis oculi muscle inferiorly to the lower border of the tarsus and to incise the pretarsal extension of the aponeurosis to expose the white line. Then, the white line is sutured to the orbicularis oculi muscle. Finally, the skin incisions are sutured interruptedly, and a vivid fold is created. The general satisfaction rate was 97.5%. The edema period for most patients ended within 2 weeks. The scars became unnoticeable after 3–6 months. Disappearance of the fold was not found in any case. The kiss technique is a simple and effective method, which can not only create a natural double crease but also reduce the complications of double-eyelid surgery. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Background: Orbital cellulitis is an infection of the ocular adnexal and orbital tissues behind the orbital septum. The complications are poor prognosis. This paper is to describe some severe rare complications of orbital cellulitis. Case presentation: A case of 32-year-old female presented with acute severe progressive orbital cellulitis on the right eye after a black fly (Simuliidae spp.) bite. Orbital imaging with computed tomography and magnetic resonance imaging showed eyelid abscess with orbital abscess formation and superior ophthalmic vein thrombosis. She was promptly treated with intravenous vancomycin, piperacillin and had surgical procedures to release orbital pressure including lateral canthotomy, lateral cantholysis, and eyelid with orbital abscess drainage. Pus collection culture was positive for Staphylococcus aureus. Even though she responded well to antibiotics treatment, progression involved severe orbital inflammation with marked increased orbital pressure, and her visual acuity was such that she had no light perception. Combined central retinal vein, central retinal artery and cilioretinal artery occlusion were identified. Fundus examination showed retinal whitening at the posterior pole and a few scattered flame-shaped retinal hemorrhages. The cilioretinal artery presented with perivascular retinal whitening. A fundus fluorescein angiogram revealed cilioretinal and retinal artery filling delay and also delayed arteriovenous transit time. She also developed an ischemic macular hole after a week of treatment. We demonstrate an optical coherence tomography image showing the intact posterior hyaloid membrane that represents no traction on the macula to support the ischemic cause. Conclusion: Multiple retinal vascular occlusion and ischemic macular hole could be an early complication of severe orbital cellulitis from increased orbital pressure; therefore, close monitoring of visual acuity with IOP, and prompt treatment when indicated might reduce the risk of consequent blindness.

This study aimed to evaluate techniques for repairing previously failed double-eyelid surgeries based on different anatomical structure injuries. A total of 120 patients with failed double-eyelids in our hospital were enrolled and classified into four types according to their anatomical structure damage: type I, unsmooth radians of the double-eyelid line; type II, upper socket depression; type III, iatrogenic ptosis; and type IV, comprehensive damage. Accordingly, methods of restoration included orbital septum fat supplement, repair of levator palpebrae superioris, and treatment of scar. Postoperative follow-up time points were 1 week, 1 month, and 6 months. Outcome observations were binocular symmetry, fluency of double-eyelid, scar recovery, height and contour profile of the upper eyelid margin, and plumpness of the upper eyelid. The eyelid morphological score was evaluated using photographs of preoperative and 6-month postoperative data, and the effect of eyelid repair was evaluated objectively by statistical analysis. At 1 month after surgery, the height of the upper palpebral margin was maintained in most patients and located at 1–2 mm below the superior limbus. At 6 months after surgery, most patients had better restorative effects. Comparison of mean eyelid morphological scores showed a statistically significant improvement following surgery (P

This article presents a new method using orbital septum for double-eyelid blepharoplasty.During double-eyelid blepharoplasty, we incised the orbital septum horizontally. Using the attachment site of the levator aponeurosis as a pedicle, the lower part of the dissected orbital septum was turned downward and then sutured to the upper border of the lower orbicularis oculi muscle and posterior pretarsal fascia. We evaluated the efficacy of this double-eyelid surgical procedure in patients undergoing the procedure from December 2015 to October 2017.We included 462 eyes of 231 patients in the final analysis. Sutures were removed 7 days after surgery. All double-eyelid creases were well formed, and the eyelids closed well. Six-month follow-up results revealed that the double-eyelid shape was natural looking, and no patients experienced upper eyelid retraction or incomplete eye closure. Notched scars did not occur, and patient satisfaction was achieved in all cases. Two hundred eleven patients were fully satisfied with the surgical results, and 20 were basically satisfied with the surgical results.Using the orbital septum is a good approach for double-eyelid blepharoplasty.

Background Periorbital and orbital cellulitis are infections of the tissue anterior and posterior to the orbital septum, respectively, and can be difficult to differentiate clinically. Periorbital cellulitis can also progress to become orbital cellulitis. Orbital cellulitis has a relatively high incidence in children and adults, and potentially serious consequences including vision loss, meningitis, and death. Complications occur in part due to inflammatory swelling from the infection creating a compartment syndrome within the bony orbit, leading to elevated ocular pressure and compression of vasculature and the optic nerve. Corticosteroids are used in other infections to reduce this inflammation and edema, but they can lead to immune suppression and worsening infection. Objectives To assess the effectiveness and safety of adjunctive corticosteroids for periorbital and orbital cellulitis, and to assess their effectiveness and safety in children and in adults separately. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2020, Issue 3); Ovid MEDLINE; Embase.com; PubMed; Latin American and Caribbean Health Sciences Literature Database (LILACS); ClinicalTrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). We did not use any date or language restrictions in the electronic search for trials. We last searched the electronic databases on 2 March 2020. Selection criteria We included studies of participants diagnosed with periorbital or orbital cellulitis. We excluded studies that focused exclusively on participants who were undergoing elective endoscopic surgery, including management of infections postsurgery as well as studies conducted solely on trauma patients. Randomized and quasi-randomized controlled trials were eligible for inclusion. Any study that administered corticosteroids was eligible regardless of type of steroid, route of administration, length of therapy, or timing of treatment. Comparators could include placebo, another corticosteroid, no treatment control, or another intervention. Data collection and analysis We used standard methodological procedures recommended by Cochrane. Main results The search yielded 7998 records, of which 13 were selected for full-text screening. We identified one trial for inclusion. No other eligible ongoing or completed trials were identified. The included study compared the use of corticosteroids in addition to antibiotics to the use of antibiotics alone for the treatment of orbital cellulitis. The study included a total of 21 participants aged 10 years and older, of which 14 participants were randomized to corticosteroids and antibiotics and 7 participants to antibiotics alone. Participants randomized to corticosteroids and antibiotics received adjunctive corticosteroids after initial antibiotic response (mean 5.13 days), at an initial dose of 1.5 mg/kg for three days followed by 1 mg/kg for another three days before being tapered over a one- to two-week period. We assessed the included study as having an unclear risk of bias for allocation concealment, masking (blinding), selective outcome reporting, and other sources of bias. Risk of bias from sequence generation and incomplete outcome data were low. The certainty of evidence for all outcomes was very low, downgraded for risk of bias (-1) and imprecision (-2). Length of hospital stay was compared between the group receiving antibiotics alone compared to the group receiving antibiotics and corticosteroids (mean difference (MD) 4.30, 95% confidence interval (CI) -0.48 to 9.08; 21 participants). There was no observed difference in duration of antibiotics between treatment groups (MD 3.00, 95% CI -0.48 to 6.48; 21 participants). Likewise, preservation of visual acuity at 12 weeks of follow-up between group was also assessed (RR 1.00, 95% CI 0.82 to 1.22; 21 participants). Pain scores were compared between groups on day 3 (MD -0.20, 95% CI -1.02 to 0.62; 22 eyes) along with the need for surgical intervention (RR 1.00, 95% CI 0.11 to 9.23; 21 participants). Exposure keratopathy was reported in five participants who received corticosteroids and antibiotics and three participants who received antibiotic alone (RR 1.20, 95% CI 0.40 to 3.63; 21 participants). No major complications of orbital cellulitis were seen in either the intervention or the control group. No side effects of corticosteroids were reported, although it is unclear which side effects were assessed. Authors' conclusions There is insufficient evidence to draw conclusions about the use of corticosteroids in the treatment of periorbital and orbital cellulitis. Since there is significant variation in how corticosteroids are used in clinical practice, additional high-quality evidence from randomized controlled trials is needed to inform decision making. Future studies should explore the effects of corticosteroids in children and adults separately, and evaluate different dosing and timing of corticosteroid therapy.

Blepharoptosis is an unpleasant complaint of the patients referring to oculoplastic clinics. Following a thorough medical and neurologic work-up, the surgical correction is the main treatment strategy in many cases. Levator muscle function is a measure of maximal lid excursion and crucial for selecting the best surgical approach. Once the levator muscle function is measured as reasonable, along with a good Bell’s phenomenon, the strengthening of the muscle by the shortening or resection techniques through an external approach can favorably elevate the eyelid.

The anatomy of the eyelids is divided into two lamellae, the anterior and the posterior. The anterior lamella consists of the skin and orbicularis muscle, while the posterior lamella consists of the tarsal plate and conjunctiva. Some authors also consider a third lamella, the middle lamella, where the orbital septum and the capsulopalpebral fascia (CPF) are located.

Treatment of ocular trauma commonly involves repair of eyelid lacerations, both superficial and deep. Superficial eyelid lacerations involving just skin and orbicularis usually only require skin sutures. Occasionally, lacerations may extend deep into the eyelid or orbit, requiring more extensive tissue reapposition and repair. Repair of these lacerations should involve debridement of the wound with sterile saline +/− antibiotic solution, as well as removal of all foreign bodies/particulate matter before wound closure. Laceration depth should be carefully noted, as lacerations that violate the orbital septum need to be treated with care and meticulously closed.

Eyelids are usually contributing two to three questions in ophthalmology basic exams, where examiners usually focus on common topics. For example, the cross-sectional anatomy and the relation of the internal structures to each other are among the highest yield topics. An example of such questions is the relation of muscles to the orbital septum, as the orbicular oculi muscle lies anterior, while the levator muscle lies posterior to the orbital septum.

Differences between Oriental and Caucasian eyelids have been explained in great detail in several reports in the past. The purpose of this article is to discuss the functional aspects of Asian double fold upper blepharoplasty and to present techniques that help to improve both the functional and cosmetic outcomes and satisfaction after surgery. The eyes of Asians are relatively small with thick skin in the eyelids and periorbital area. They typically lack the upper eyelid crease (creating the so-called double eyelid) due to burden factors like thick skin, hypertrophied orbicularis oculi muscle (OOM), submuscular fibroadipose tissue, thick orbital septum, abundant preaponeurotic fat, and lower positioned transverse ligament. Asian eyes may also have a superior visual field defect due to skin overriding the upper lid margin (skin–OOM–fat complex slide down). These burden factors result in the eyelashes appearing short and becoming misdirected and pressed toward the globe, causing functional discomfort. As a compensatory mechanism, Asian people tend to engage the frontalis muscle to lift the eyebrow to help them open their eyes. Along with aesthetic enhancement, double-eyelid surgery in Asian burden lids can improve the functional deficiencies helping the patients to open the eyes more easily. In addition, treatment of the Mongolian fold (medial epicanthal fold), caused by medial hypertrophy of preseptal OOM, augments the surgical results. In this report, we present the appropriate preoperative assessment, surgical technique, and postoperative care that should be employed to achieve consistently good functional and aesthetic outcomes in these patients.

The area covered by the orbicularis oculi (OOc) m. is called the “periorbital region.” The territory extends from the upper and lower eyelids to the eyebrows. The OOc m. is the muscle that determines the shape of the eyes and facial expressions. The OOc m. is an elliptically broad and flat muscle that acts in closing the eyelid, which protects the eyeballs. The component of the OOc m. can be subdivided as the orbital and the palpebral part by its location. More in detail, the palpebral portion can be classified by preseptal and pretarsal portions (Fig. 4.1). These portions are positioned in the superficial layer of both the tarsal plate and the orbital septum. The palpebral part of the muscle involuntarily closes the eyelids by making vertical wrinkles in the area of the medial canthus.

Upper eyelid aging results from comprehensive changes, and studies have failed to comprehensively address these changes. This study proposes a comprehensive approach to the surgical treatment of aging upper eyelids. Data of 116 patients with aging upper eyelids were analyzed. Each eye was scored on upper eyelid laxity, degree of blepharoptosis, and upper eyelid socket depression at preoperation and 6 months after surgery. Based on average scores of both eyes, three degrees of aging were considered: mild, moderate, and severe. All patients underwent comprehensive surgical treatments. Depending on its condition, loose skin was appropriately removed, and the levator palpebrae superioris (LPS) was corrected in patients with degenerative ptosis. Meanwhile orbital septum fat was released or periumbilical fat mass was used as a filler to correct upper eyelid socket depression. All cases were summarized based on a classification and grading system. Scores were reassessed, and satisfaction survey was conducted after 6 months follow-up. The preoperative and postoperative scores of the three groups were significantly different (p

Surgical management of thyroid eye disease (TED) has two general aims: (1) relieve symptoms of orbital congestion and fibrosis, including possibly compressive optic neuropathy, and (2) reconstruct the periocular region to reduce deformity and renormalize appearance. Surgical management follows a sequence that is tailored to individual patient needs. The signs and symptoms of TED that can be addressed surgically include proptosis, orbital pressure/pain, orbital inflammatory signs, diplopia secondary to restrictive strabismus, ocular surface exposure secondary to lagophthalmos, and eyelid retraction. Because orbital decompression surgery can improve lagophthalmos and eyelid retraction, and can affect strabismus (positively or negatively), these issues are traditionally addressed sequentially by orbital decompression first, followed by strabismus surgery, and finally eyelid retraction repair, as needed. In this chapter, we focus primarily on orbital decompression surgery and eyelid surgery, although key aspects of strabismus surgery are also discussed.

PURPOSE To compare the thickness of the retro- and sub-orbicularis oculi fat (ROOF and SOOF) between patients with thyroid eye disease (TED) and controls via MRI and to determine factors influencing fat thickness. METHODS This retrospective, comparative, case-control study included 136 patients (272 sides) with TED and 50 control patients (50 sides). The thickness of the ROOF and SOOF was measured on the quasi-sagittal plane through the optic nerve (the central plane) and 6 mm lateral and medial to the central plane at the level through the superior orbital rim and at the level just below the orbital septum in the lower eyelid, respectively. RESULTS The ROOF and SOOF were thickest on the lateral plane (p < 0.050; Tukey Kramer post hoc test) and were significantly thicker in patients with TED than controls on all planes (p < 0.050; Student t test). Multivariate stepwise analysis showed that age, sex, clinical activity score, Hertel exophthalmometric values, and number of enlarged extraocular muscles are significant predictors of the ROOF and SOOF thickness in patients with TED (p < 0.050). CONCLUSIONS Patients with TED had thicker ROOF and SOOF on all planes than controls with various factors influencing the thickness. These results may be helpful in planning rehabilitative blepharoplasty with removal of the ROOF and SOOF for correction of eyelid fullness in TED.

Background Double eyelid operation has become the most popular cosmetic procedure in China, while how to make sure the acquired double eyelids the same as congenital ones is still a problem. Objective This study aimed to explore a design and operation procedure to obtain natural and dynamic double eyelids, which are accordant with the congenital double eyelids both in appearance and movement. Methods The authors conducted a retrospective review of 352 patients who underwent our operation from October 2012 to October 2018. The procedures were performed by one senior surgeon. First, design the incision line 7 to 8 mm distance parallel to the ciliary margin. Then, cut down the skin and orbicularis muscle, and dissect the orbicularis myocutaneous flap from the anterior surface of the tarsal plate. Next, expose the orbital septum transversely in the lowest site from lateral to medial direction, and dispose of the fat tissue herniated spontaneously. Subsequently, suture the upper margin of pretarsal orbicularis myocutaneous flap to the levator aponeurosis. Finally, the skin edge of incision was closed interruptedly. The patients were followed up from 6 to 30 months after surgery by 2 surgeons to evaluate the long-term results. Results A total of 352 patients with 704 eyes were operated on and followed up in our study. There were 29 patients (8.2%) that showed slight asymmetry, and 7 eyes (2.0%) showed shallow creases. Besides that, all the creases were symmetry, parallel and natural. Just as congenital double eyelids, when opening eyes there was no sausagelike appearance, and when closing eyes there were no depressed scars. Conclusions By reconstructing the physiological structure of upper eyelids, our double eyelid operation creates dynamic double eyelids, which are accordant with the congenital ones both in appearance and movement.

Thyroid Eye Disease (TED) (also called Thyroid Orbitopathy, Graves Orbitopathy, Thyroid-Related Inflammatory Orbitopathy) is a relatively common condition, yet poorly recognized and frequently mismanaged. Compared to the Western world, there exist several variations in the knowledge, attitude, and practice of Thyroid Orbitopathy in Asians with patient, general physician, and ophthalmologist-related factors. These factors have direct implications on the diagnosis, management, and clinical outcomes. Moreover, the clinical presentation may also be frequently different owing to inherent variation of orbital bony anatomy, soft tissue involvement (extraocular muscles, fat, fibrous connective tissue—intermuscular septum, orbital septum, retaining ligaments, etc.), and tissue response to medical and surgical intervention [1].

The anatomy of the orbit includes, the bony cavities that contain the globes, extraocular muscles, nerves, fat, and blood vessels. The orbital walls are perforated by several important apertures. The periorbita, also called the orbital periosteum or orbital fascia, covers the bones of the orbit. This dense connective tissue membrane serves as an attachment site for muscles, tendons, and ligaments and is a support structure for the blood supply to the orbital bones. The extraocular muscles are responsible for the movement of the eye and for synchronous movements of the eyelids. The eyelids form a soft-tissue protection to the globe and the anterior entrance to the orbit. The orbital septum separates the bony orbit from the eyelid and represents the anterior most orbital structure.

Summary Background Approximately 50% of Asians do not have upper eyelid creases. Full-incision methods may leave obvious scars and buried-suture methods cannot remove excess tissues to create a double eyelid. The new palpebral marginal incision technique masked the incision at the upper palpebral margin and removed the excess tissue, thereby achieving scarless and natural double eyelids. Methods The modified technique involved the incision site and positioning processes. The incision line is 1.0–1.5 mm above the palpebral margin. A strip of orbicularis muscle beneath the positioned double eyelid must be removed. The orbital septum is then exposed, and a certain amount of orbital fat is removed. Next, the dermis and tarsal plate are sutured in an orderly manner. Finally, a strip of the redundant skin located approximately 1–3 mm above the incision is excised to correct blepharochalasis before the skin is closed. Results This new technique was performed in 212 patients including 56 patients with blepharochalasis who had their skin excised during the surgery. The follow-up period ranged from 6 months to 3 years. Ninety-five percent of the patients rated excellent and good and that they were satisfied with their surgery, and no significant complications occurred. Conclusions The following are the advantages of the authors' technique: (1) minimal or even no surgical scarring is discernible on the eyelids even when they are closed; (2) solves the problem of excessive tissue and correct blepharochalasis; and (3) the double eyelid fold is stable and natural for a long time.

IntroductionSkin and soft tissue infections of the eye can be classified based on anatomic location as either anterior to the orbital septum (ie, periorbital cellulitis) or posterior to the orbital septum (ie, orbital cellulitis). These two conditions are often considered together in hospitalised children as clinical differentiation is difficult, especially in young children. Prior studies have identified variation in management of hospitalised children with orbital cellulitis; however, they have been limited either as single centre studies or by the use of administrative data which lacks clinical details important for interpreting variation in care. We aim to describe the care and outcomes of Canadian children hospitalised with periorbital and orbital cellulitis.Method and analysisThis is a multisite retrospective cohort study including previously healthy children aged 2 months to 18 years admitted to hospital with periorbital or orbital cellulitis from 2009 to 2018. Clinical data from medical records from multiple Canadian hospitals will be collected, including community and academic centres. Demographic characteristics and study outcomes will be summarised using descriptive statistics, including diagnostic testing, antibiotic therapy, adjunctive therapy, surgical intervention and clinical outcomes. Variation will be described and evaluated using χ² test or Kruskal-Wallis test. Generalised linear mixed models will be used to identify predictors of surgical intervention and longer length of stay.Ethics and disseminationApproval of the study by the Research Ethics Board at each participating site has been obtained prior to data extraction. Study results will be disseminated by presentations at national and international meetings and by publications in high impact open access journals. By identifying important differences in management and outcomes by each hospital, the results will identify areas where care can be improved, practice standardised, unnecessary diagnostic imaging reduced, pharmacotherapy rationalised and where trials are needed.

Summary: The inferior orbitopalpebral sulcus deformity is challenging during lower eyelid blepharoplasty. Plastic surgeons are currently addressing each case individually, depending on the patient’s unique circumstances. Nevertheless, patients with large orbital grooves often complain that the inferior orbitopalpebral sulcus is not sufficiently improved. Altogether, 189 patients underwent transcutaneous blepharoplasty. According to their local anatomy, 98 underwent transcutaneous blepharoplasty surgery only, 59 had it combined with arcus marginalis release, and 32 had it combined with orbital septum fat flap stuffing. For the latter 32 patients, the orbital fat was trimmed and flipped to roll over the edge 10 mm from the infraorbital rim to form a base to repair the tear trough deformity and palpebromalar groove. Excessive dermatochalasis was removed, excrescent bulging fat was released, and the sulcus deformity was flattened using the orbital fat flap. The cosmetic results were satisfactory. Releasing the orbital septal fat helped restructure the deformity. The lower eyelid bags and lower orbital sulcus deformities were well corrected, allowing recovery with a convex-type facial contour. Using an orbital fat flap to treat a tear trough deformity and palpebromalar groove is effective and safe. Careful performances by surgeons can avoid serious complications. This operation satisfies both patients and surgeons.

Background Numerous techniques have been used for lower blepharoplasty. The techniques can be classified into four principles: excision of excess fat, septal reset, orbital fat repositioning, and reinforcement of the attenuated orbital septum. Objectives We modified the conventional approach of septal reinforcement to utilize an inverted T-shaped plication with preservation of the orbital fat, repositioning the septum below the arcus marginalis to refine tear-trough deformity. Methods From April 2010 to September 2015, 93 individuals underwent bilateral lower blepharoplasty. Retrospective chart reviews were performed, and the results and complications during the follow-up period were recorded and photographed. Results The patients comprised 76 women and 17 men. Thirteen, 33, and 47 patients exhibited mild, moderate, and severe fat herniation, respectively, accompanied by tear-trough deformity. A total of 70 and 23 patients underwent lower blepharoplasty via subciliary and transconjunctival approaches, respectively. We performed inverted T-shaped plication of the orbital septum in mild and moderate cases and X-shaped plication in severe cases, and in moderate and severe cases, we performed septal repositioning simultaneously. The mean follow-up period was 25 months. When immediate mild lid retraction or lid malposition was observed, it recovered without specific treatment within 1 to 2 weeks. No permanent lid malposition or ectropion was observed in any of the patients. Conclusions Septal plication with inverted T-shape or X-shape can minimize the downward forces that affect postoperative eyelid malposition and ectropion. Further, these procedures provide sufficiently strong reinforcement of the orbital septum to restore infraorbital fat herniation.

Highlights • Acute dacryocystitis presents as a pre-septal cellulitis, responds to systemic antibiotic and drainage without permanent visual loss. • We describe a healthy man presenting with complete visual loss following orbital cellulitis and abscess formation due to acute dacryocystitis. • The clinical, radiological, intraoperative and postoperative findings are discussed with review of all similar reported cases. • Our aim is to stress on prompt recognition of these cases for appropriate treatment to avoid catastrophic visual loss., Introduction Acute dacryocystitis usually presents as a pre-septal cellulitis since the lacrimal sac lies anterior to the orbital septum. Orbital cellulitis secondary to acute dacryocystitis is very rare due to a variety of anatomic barriers to the orbit but can occur and result in abscess formation with risk of visual compromise. Presentation of case We describe a case of otherwise healthy adult who presented with complete visual loss following orbital cellulitis and abscess formation secondary to acute dacryocystitis. The clinical, radiological, intraoperative and postoperative findings are discussed. Discussion Typically, orbital cellulitis responds well to systemic antibiotic and surgical drainage without permanent visual loss. There are 7 cases reported in the literature of acute dacryocystitis complicated by permanent visual loss. Conclusion Patients with acute dacryocystitis need to be carefully monitored for signs of orbital cellulitis. Prompt recognition and appropriate treatment of this condition are essential.