Search

Purpose: This study aims to report a case series of upper eyelid cicatricial margin entropion with retraction, corrected through a grey-line approach only. We remind readers of the grey-line approach to levator recession (LR) and lamellar repositioning surgery. Methods: A retrospective review of clinic notes and photographs of patients who underwent grey-line split (GLS), LR, release of orbital septum, recession of levator, advancement of posterior lamella and anterior lamellar repositioning without a skin crease incision, from December 2015 to December 2016. Indications for surgery included mild-to-moderate cicatricial margin upper eyelid entropion, tarsal curling, and meibomian gland inversion. Patients requiring spacer interposition to lengthen the posterior lamella were excluded from the study. Parameters of the study included lid margin position, lid height, ocular surface health and symptom improvement. Results: Eleven eyelids of eight patients were included in the study, and underwent the procedure described. Lid margin position measured as the marginal reflex distance lowered (improved) in 72.7% of patients. Lid margin eversion was achieved in all eyes (100%). Corneal punctate epithelial erosions markedly improved, being present in 72.7% of patients preoperatively, and only 9.1% of patients postoperatively. Eight of eleven eyes showed symptomatic improvement, with six (54.5%) being completely asymptomatic and two achieving partial relief. An added observation was a pretarsal show asymmetry in some patients which improved in 36.4% of surgeries postoperatively. Conclusion: Upper eyelid LR with GLS and anterior lamella repositioning can all be performed through the plane of the split, avoiding a skin incision. Normal lid margin apposition was achieved in all eyes with 91% demonstrating a clear cornea and 72% having symptomatic improvement.

The aim of this study was to reveal the histomorphological connections among the suborbicularis oculi fat (SOOF), the orbicularis oculi muscle (OOM), the superficial musculoaponeurotic system (SMAS), the infraorbital fat and the skin.Full graft tissue blocks of the infraorbital region with the skin, SMAS, OOM and SOOF were collected post mortem from one female and two male formalin-fixed body donors. Serial histological sections were made, stained and digitized. Digitalization and three-dimensional (3D) reconstruction of the histological meshwork were performed.SOOF was revealed as a fibro-adipose tissue underlying the OOM, which was strictly separated from the intraorbital fat pad by the orbital septum. SOOF, OOM and SMAS were connected by fibrous septa derived from the SOOF, traversing the OOM with division into multiple muscular bundles, continuing above the muscular plane by forming the SMAS and ending with skin insertion. In the infraorbital region, two different types of SMAS bordering the infraorbital fold have been recognized. Muscle cells have been demonstrated in the SMAS fibrous septa of both SMAS types.Together with the OOM, the SMAS and the skin, SOOF forms an anatomical functional unit. Muscular contraction of the OOM could be transferred by the SMAS to the skin level, producing periorbital mimic expression. The 3D reconstruction facilitates the comprehension of the morphological structure, its connections and space correlations in the infraorbital area. The morphological and topographical peculiarities of the infraorbital structures make it possible to conclude that surgical interventions in this area need to be elaborated and individualized. Keywords: Suborbicularis oculi fat, SOOF plastic surgery, Subcutaneous musculoaponeurotic system, SMAS, 3D reconstruction, Infraorbital soft tissue

INTRODUCTION: Orbit is a sterile closed compartment surrounded by bony walls on all sides and anteriorly by orbital septum. The orbit houses the eyeball and has the major function of protection of eyeball and helps in its motility in extreme degrees. Orbit has many potential spaces that make it a primary site of infections. It may present either as a secondary site for infections from the adjacent structures or intermediary site for infection to other vital sites. Orbital anatomy and its relation with other adjacent structures are important in the pathogenesis of orbital infections. These relationships also explain its devastating consequences and influence therapeutic decisions. Orbital and periorbital infections may be caused by variety bacterial, fungal and parasitic agents. Appropriate management depends on appreciation of topography of the process within the orbit and periorbital tissues using Radioimaging and identification of responsible organisms and its sensitivity to antibiotics using Microbiological study. Appropriate management by either medical or surgical treatment helps in prevention of complications.1e Integration of history, physical and ocular examination and ancillary testing allow achievement of these primary goals. AIM OF THE STUDY: To evaluate orbital infections and analyse the role of Radioimaging and Microbiological study in early diagnosis, management and outcome. OBJECTIVES: To analyse the prevalence, etiopathogenesis and various clinical presentations of orbital infections and role of Radioimaging and Microbiological study in its early diagnosis, treatment and outcome. METHODS OF EVALUATION: This prospective study was conducted at Orbit and Oculoplasty department, RIOGOH, Egmore, Chennai for a period of 12 months during when 30 patients with Orbital infections were evaluated RESULTS: Out of 30 patients, 16 patients (53.4%) were diagnosed to have Preseptal cellulitis, 8 patients (26.7%) and 4 patients (13.3%) were diagnosed with Orbital cellulitis and Orbital abscess respectively. Rest of the 2 patients were diagnosed with Subperiosteal abscess and Cavernous sinus thrombosis. Radiological and Microbiological investigations were done in patients according to their needs Out of the 20 medically treated with appropriate antibiotics, all patients improved. Out of the 10 surgically treated, 2 patients (20%) deteriorated. CONCLUSION: Orbital infections are more common in paediatric age group and preseptal cellulitis is the commonest infection encountered. Periocular infections are the most common causative factor for the orbital infections. Bacteria is the major causative organism for orbital infections. Among it, gram positive organisms predominate the cause. Fungi constituted the second major cause. Radioimaging like X Ray, B scan, CT Scan and MRI help in diagnosis, identification of complications and in assessment of response of treatment in orbital infections. They are complimentary to one another. Microbiological study with Gram Staining, Culture and Sensitivity and Fungal culture help in the identification of Strain of Organism and in Correct choice of antibiotics that is important in the complete cure of infections. Most of the orbital infections resolve with the prompt treatment. Surgical approach forms the treatment of choice in abscess and it should be followed by medical treatment according to the microbiological study. Radioimaging and Microbiological study play a significant role in the choice of treatment. Radioimaging is used to assess, response to treatment and to modify treatment for a better outcome.

Compared to the traditional transcutaneous approach, a safe and effective lower eyelid blepharoplasty has been recognized. In 2007, Sadove first reported a series of patients treated with transconjunctival septal suturing, but the inferior orbitopalpebral sulcus was not totally improved. Orbital septal fat release and preservation through the transconjunctival approach was used to treat 20 young patients with bulging bags and inferior orbitopalpebral sulcus. The orbital septal fat was released and transferred to infraorbital rim to be a base for the inferior orbitopalpebral sulcus. Obvious bulging fat was released, and the orbitopalpebral sulcus was flattened by released and excessive orbital septal fat. Satisfactory results were achieved. The results achieved from this series of patients indicate that orbital septal fat release and preservation through the transconjunctival approach for reducing the orbitopalpebral sulcus is a safe and effective treatment for bulging fat and orbitopalpebral sulcus in young 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 .

Filler injections for sunken upper eyelid correction and glabellar augmentation at the orbitoglabellar region need to be performed correctly. Precise knowledge of the emerging sites of all terminal branches of the ophthalmic artery is essential for these procedures to be conducted safely. The terminal branches of the ophthalmic artery were studied in both periorbital and intraorbital dissections. The aim of this study was to verify the critical positions of the emerging sites at the orbital septum that may act as potential retrograde channels for filler emboli. In the 40 eyes examined, the branches of the ophthalmic artery were found to emerge from four different sites. Two substantial emerging sites were situated on both sides of the trochlea of the superior oblique muscle. These sites were located at the superior part of the medial orbital rim (SMOR) and are alternatively named as the epitrochlear and the subtrochlear emerging sites. The other two sites can be regarded as accessory emerging sites due to the comparably smaller artery. Dissection of the intraorbital region revealed small periosteal branches of the infraorbital artery which coursed anteriorly on the orbital floor to form anastomoses with the lacrimal artery. In other areas of the orbital floor, no branches extended from the infraorbital artery. In front of the lacrimal gland, very minute branches descended and coursed along both margins of the superior tarsus but did not course outside the lateral orbital rim. A danger zone was located at the SMOR, where the ophthalmic branches emerge to form anastomotic channels. Compression at the trochlea guarantees safe injection of filler, reducing the risk of complication. 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 .

Purpose: To report the characteristics of lacrimal gland prolapse among the patients who underwent upper blepharoplasty.Materials and Methods: In a retrospective study, consecutive upper blepharoplasty patients with significant lacrimal gland prolapse were included. The degree of prolapse was measured as anterior protrusion of lacrimal gland from the orbital rim. Reposition of the lacrimal gland was performed by using non-absorbable sutures to fixate the gland to the periosteum of lacrimal fossa. In cases with unusually large lacrimal glands, an incisional biopsy of the gland was obtained. The orbital septum was left unsutured.Results: Twenty patients (19 females and one male) out of a total of 198 patients who underwent upper blepharoplasty (10.1%) had clinically significant lacrimal gland prolapse. Mean age was 54.8 ± 9.4 years (range, 31-69). Fourteen patients (70%) were asymptomatic. Anterior protrusion of lacrimal gland was measured to be 6.4 ± 1.2 mm (range, 5-10 mm) from the orbital rim. Incisional biopsy of the lacrimal gland was obtained in 10 patients (50%). Nine biopsies showed mild chronic inflammation and one revealed only normal lacrimal gland tissue. Postoperative course was uncomplicated in 15 patients (75%), with mild symptoms in the others and only one instance of mild unilateral recurrence of lacrimal gland prolapse.Conclusions: Reposition of a prolapsed lacrimal gland is a safe and effective adjunctive procedure in upper blepharoplasty, with minimal complications and acceptable postoperative outcome. Prolapsed lacrimal glands showed mild inflammation which could be due to repetitious movements of a lax gland, although various other etiologies can be involved.

PURPOSE Congenital ptosis can threaten visual function and is usually treated with surgical correction. This study tests the hypothesis that congenital ptosis involves not only the levator muscle but also the orbital septum, which may tether the eyelid in the primary position. METHODS A retrospective chart review was performed on 30 patients (41 eyelids) with congenital ptosis who underwent surgical correction that included partial septum excision. Histologic analysis was performed by a masked pediatric pathologist, with grading of septal tissue disorganization and fibrosis based on standard histologic criteria. An independent comparison of histologic grading with clinical ptosis measures was then performed. RESULTS Fifteen eyelids demonstrated significant septal fibrosis, 19 were mild, and 7 were not fibrotic. Thirty-six eyelids demonstrated histologic disorganization. Mildly fibrotic eyelids were found to have reduced preoperative levator function than those that were not fibrotic (2.84 ± 1.92 vs. 9.57 ± 4.76 mm; p < 0.0001). Samples that demonstrated significant fibrosis were also found to have reduced preoperative levator function (4.67 ± 2.12 vs. 9.57 ± 4.76 mm; p = 0.0007). Histologically disorganized samples were also found to have a lower preoperative levator function (9.50 ± 6.04 vs. 3.99 ± 2.49; p = 0.0052). CONCLUSIONS Orbital septae in patients with congenital ptosis demonstrate histologic disorganization and fibrosis. When decreased levator function is observed clinically, septal fibrosis and/or disorganization is likely present. These observations suggest that debulking the fibrotic septum during congenital ptosis surgery may improve outcomes by releasing the eyelid from its congenitally tethered position, improving eyelid elasticity.

To study the anatomical location of retro-orbicularis oculi fat (ROOF) in the upper eyelid and to investigate how ROOF affects the appearance of the upper eyelid. Twenty-eight Chinese hemifacial cadaver specimens were used (14 male cadavers; age range 52–82 years). In 28 hemifaces, the eyelids were dissected from the superficial to deep layers, and the appearance, location, extent, and surrounding tissue of ROOF were observed. Additionally, we observed the relationship between the upper eyelid morphology and ROOF of the upper eyelid in surgical patients who were treated in the plastic surgery department of Tongji Hospital affiliated with Huazhong University of Science and Technology in 2018. ROOF is a type of fascia adipose tissue that is located in a fat compartment between the muscles (the orbicularis oculi and frontalis muscles) and the orbital septum/frontalis fascia. In patients with hypertrophic ROOF, the upper eyelid appears as a heavy eyelid and as a drooping eyelid. And in patients with atrophic ROOF, the upper eyelid appears as a sunken eyelid. ROOF is located in the fat compartment between the orbicularis muscle and the orbital septum/frontalis fascia. ROOF covers the entire upper eyelid and appears thinner medially and thicker laterally. It is continuous with the fat under the frontalis muscle and affects the appearance of the upper eyelid. It represents an important factor in upper 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.

Sinonasal-related orbital infections (SROIs) are typically pediatric diseases that occur in 3–4% of children with acute rhinosinusitis. They are characterised by various clinical manifestations, such as peri-orbital and orbital cellulitis or orbital and sub-periosteal abscesses that may develop anteriorly or posteriorly to the orbital septum. Posterior septal complications are particularly dangerous, as they may lead to visual loss and life-threatening events, such as an intracranial abscess and cavernous sinus thrombosis. Given the possible risk of permanent visual loss due to optic neuritis or orbital nerve ischemia, SROIs are considered ophthalmic emergencies that need to be promptly recognised and treated in an urgent-care setting. The key to obtaining better clinical outcomes in children with SROIs is a multi-disciplinary assessment by pediatricians, otolaryngologists, ophthalmologists, radiologists, and in selected cases, neurosurgeons, neurologists, and infectious disease specialists. The aim of this paper is to provide an overview of the pathogenesis, clinical manifestations, diagnosis, and treatment of pediatric SROIs, and to make some practical recommendations for attending clinicians.

Lower blepharoplasty has evolved significantly over the last several decades from a volume-depleting procedure to a volume-preserving procedure. In the days past, the surgeon would remove significant amounts of fat with aggressive skin-muscle resection utilizing the skin-muscle flap approach. This led to a hollowed, surgical look that soon began to fall out of favor not to mention an unacceptably high incidence of lower eyelid retraction [1]. In the last two decades, lower eyelid blepharoplasty has progressed to a volume conservation procedure with more conservative resection of fat or repositioning of fat using a transconjunctival approach with skin maintenance using a separate method such as laser resurfacing, skin pinch, lateral orbicularis muscle or lateral canthal tightening, or excising skin laterally [2–4]. This maximally preserves orbital septum and infraciliary orbicularis muscle minimizing the risk of lower eyelid retraction and ectropion.

Slight alterations in the intricate anatomy of the upper and lower eyelid or their underlying structures can have pronounced consequences for ocular esthetics and function. The understanding of periorbital structures and their interrelationships continues to evolve and requires consideration when performing complex eyelid interventions. Maintaining a detailed appreciation of this region is critical to successful cosmetic or reconstructive surgery. This article presents a current review of the anatomy of the upper and lower eyelid with a focus on surgical implications.

Background: Orbital cellulitis refers to the inflammation or infection of the soft tissues of the orbit located behind the orbital septum. Aim: To determine the current trends in the outcomes following the management of orbital cellulitis in a tertiary hospital in Southern Nigeria. Patients and Methods: A retrospective review of medical records of patients with orbital cellulitis from January 2008 to December 2014 was conducted. The age, sex, duration of symptoms, predisposing factors, clinical findings, laboratory/radiological investigations, treatment provided, complications, and follow‑up were recorded. Results were analyzed with SPSS Version 21 program. Results: Forty‑two patients were seen made of 17 (40.5%) males and 25 (59.5%) females with a mean age of 18.2 ± 18.7 years of which children 6/18 at presentation, 38 (82.6%) and at discharge, 39 (84.8%). The mean duration of presenting complaints was 15.5 ± 31.6 days. Patients who presented early were less likely to develop complications, P = 0.003. The most common complication was exposure keratopathy in 8 (44.4%) eyes. The only surgical intervention performed was incision and drainage of abscess in 3 (7.1%) eyes. No patient came for follow‑up. Conclusion: Prompt institution of effective antibiotics and management of complications that may arise improves prognosis of orbital cellulitis.Keywords: Antibiotics, orbital cellulitis, Southern Nigeria

Objective This study was performed to evaluate a novel method of constructing double eyelids by fixation of the orbicularis oculi muscle and orbital septum to the pretarsal fascia and correction of blepharoptosis. Methods In total, 285 patients requesting aesthetic construction of double eyelids were divided into three groups: those treated by the modified method (Group A, n = 108), those treated by traditional construction of the upper eyelid (Group B, n = 85), and those treated by the Park method (Group C, n = 92). The patients were followed up for 3 to 12 months (average, 6 months). The surgical effects and degree of satisfaction were compared among the three groups. Results In Group A, the mean operative time was 1.0 ± 0.2 hours. The degree of satisfaction with the surgical effect was significantly different between Group A (95.37%) and Group B (87.06%). However, no significant difference in satisfaction was noted between Group A (95.37%) and Group C (91.30%) or between Group B (87.06%) and Group C (91.30%). Conclusions The modified technique is simple and effective for construction of double eyelids and correction of blepharoptosis. All patients were satisfied with the surgical and aesthetic effects.

Background: Orbital cellulitis is an infectious involvement of the tissues posterior to the orbital septum causing severe local and general complications. Material and methods: The aim of our work was to study the clinical, paraclinical and therapeutic characteristics of orbital cellulitis through a retrospective study of 89 cases collected between 2015 and 2019. The diagnosis of orbital cellulitis was based on clinical and imaging elements. Results: The average age was 17.5 years. Exophthalmos was noted in 33% of cases, ophthalmoplegia in 18% of cases, diplopia in 4.5% of cases and ocular hypertonia in 11% of cases. Orbital CT scan allowed the diagnosis of subperiosteal abscess in 20% of cases and orbital abscess in 10% of cases. Sinusitis was the main infectious origin in children, while dacryocystitis predominated in adults. All patients received parenteral antibiotherapy combined with corticotherapy after 48 hours. Complications occurred in 10 cases, dominated by exposure keratitis, panophthalmitis and optic atrophy with permanent blindness. Conclusions: We emphasize the importance of rapid diagnosis and urgent treatment of orbital cellulitis.

Summary Background Lower blepharoplasty is one of the most common cosmetic rejuvenation procedures. Occasionally, adverse effects of the operation, ranging from operated and somewhat flattened unnatural look of the lower eyelid region to more severe cases of ectropion, retraction leading to functional disabilities, further compound the problem. The author has developed a technique focusing on two aspects in terms of the outcome of the operation in developing a technique that ensures a uniformly consistent and esthetically perceptible result. Methods The anatomic basis for the technique is reviewed and described. We performed lower blepharoplasty using the septo-capsulopalpebral fascial recession flap. The procedure requires skin incision, maintenance of pretarsal muscular roll, skin-muscle flap elevation, orbital septum release, orbital fat removal, septo-capsulopalpebral recession flap, skin excision, and closure. Results No complications have occurred in 453 patients, including hematoma and dry eye. Lid malposition such as entropion or lagophthalmos was not seen in any patient. Regardless of the preoperative variations in the lower lid, the method corrected the prolapsed lower eyelid and provided satisfactory esthetic result after the operation. Recurrences have not been observed during the follow-up period. Conclusion Lower blepharoplasty using the septo-capsulopalpebral fascial recession flap is effective to correct baggy eyelid, with minimal risk of cicatricial ectropion or tarsal capsize and retraction. Further, the esthetic result is enhanced by the author's method of making the pretarsal muscular roll with prevention of its loss.

Double-eyelid blepharoplasty is one of the most popular aesthetic surgeries in China. But the traditional method produces a hidebound double eyelid due to its rigid suturing between the skin and the tarsus. The authors of this article concluded a novel technique of “flexible suspension technique” compared with traditional blepharoplasty which is considered as a “rigid fixation technique.” This is a retrospective study of two groups of 100 Chinese Han females, on whom double-eyelid blepharoplasty was performed, 50 cases by “flexible suspension technique” and the other 50 by “rigid fixation technique.” The basic procedure of “flexible suspension technique” is suturing the orbicularis oculi muscle to the septal extension. Thus, the surgical connection between skin and tarsus is flexible. The surgical results were evaluated and compared using the Global Aesthetic Improvement Scale and Visual Analogue Scale/Score. The “very much improved” rate in the “flexible suspension technique” group was higher than that in the “rigid fixation technique” group (p

Infective sinusitis is a condition that many of us will have suffered from at some time in our lives during the course of a severe head cold. However, sometimes the infection may escalate to cause an acute complication. Complications of infective sinusitis occur in both children and adults, but children have always been much more prone to developing periorbital cellulitis. Periorbital cellulitis is a term used to encompass all infections within the orbit. The orbital septum is a fibrous sheet that effectively acts as a barrier to spread of infection, and infections are therefore categorised as pre-septal or post-septal. A subperiosteal abscess is most likely to affect the medial part of the orbit, but in older children and adults, it can occur in the superior aspect. This will cause proptosis and possible limitation of eye movement and should be clearly visible on Magnetic resonance imaging (MRI) scan of the sinuses.

The aim of this study was to measure the location of the septoaponeurosis junction relative to the tarsal plate in the upper eyelids of Koreans through a histologic study.Thirty-four upper eyelids from 34 Korean adult cadavers (mean age, 77.8 years) were used. Sagittal sections on the midpupillary line were made, and 10-μm-thick sections were prepared and stained with hematoxylin-eosin and Masson trichrome. Under a magnifying loupe with a scale, the height of the tarsal plate (HTP), thickness of the tarsal plate (TTP), distance from the lid margin to the septoaponeurosis junction (MJD), and distance from the upper border of the tarsal plate to the septoaponeurosis junction (TJD) were measured.The mean HTP was 8.09 ± 1.68 mm (range: 4.0-0.8 mm). The mean TTP was 1.52 ± 1.56 mm (range: 0.8-3.0 mm). The mean MJD was 9.18 ± 2.69 mm (range: 2.5-13.0 mm). The mean TJD was 1.1 ± 2.6 mm (range: -5.5-7.0 mm). In 25 (73.5%) of the 34 eyelids, the SAJ (1.1 ± 2.6 mm) was above the upper border of the tarsal plate (UTP); however, in 9 (26.5%) of the 34 eyelids, below the UTP. The greater the HTP, the greater the MJD was (y=0.620x+4.166, P = 0.024 [linear regression analysis]). However, there was no significant correlation between the HTP and TJD (P = 0.155 [correlation analysis]).The results of this study provide a useful guide for performing operations involving the orbital septum and levator aponeurosis.

1. Aesthetic ideals differ between various Asian cultures. The preferred aesthetic enhancement is typically a highlighting of natural ethnic features rather than complete transformation. 2. Fullness, sharp angles, and epicanthal folds uniquely characterize eyelids in persons of Asian ancestry. 3. Anatomic differences in the orbital septum, levator palpebrae aponeurosis, and distribution of adipose tissues explain the varying configurations of creases that are seen in persons of Asian ancestry. 4. The surgeon should have a detailed preoperative discussion to elicit the patient's preference with regard to the height and configuration of the eyelid crease and any epicanthal fold or volume alterations. 5. Both open and closed surgical techniques have been described for crease fixation, aimed at creating adhesions between the levator aponeurosis and the skin-orbicularis complex at the desired crease location. 6. Our preferred surgical approach is the open technique, which typically yields a more physiologic and dynamic crease. The open technique also allows for more precise crease fixation and modification of the orbital fat, if desired. 7. Most common postoperative concerns relate to eyelid crease asymmetry and poor longevity.

Key Clinical Message Orbital involvement occurs in 85% of complicated acute sinusitis and is more prevalent in children. Prompt differentiation between the more common periorbital (preseptal) cellulitis and infections, posterior to the orbital septum (including orbital cellulitis/abscess), is essential due to the latter's risk of irreversible optic neuropathy, intracranial spread and death.

Superficial subcutaneous lipomas are benign, slow-growing neoplasms comprised mature adipose cells that may be surrounded by a fibrous tissue capsule. While found commonly on the body, simple lipomas are rarely described in the eyelids. Reports of two eyelid lipomas in the literature describe the anatomy to be posterior to the orbital septum. The presenting authors report the case of a simple lipoma of the eyelid found fully in the preseptal plane. Lipomas can occur anterior to the orbital septum and should be considered in the differential when presented with a painless, slow-growing eyelid mass in adults.

The final esthetic result is a common concern of patients with eyelid tumors, especially young patients and those with tumors affecting the medial edge of the lower eyelid. The procedure herein described combines two lateral flaps: one tarsoconjunctival and the other from the periosteum. The first step is removal of the tumor lesion. Preseptal dissection is then performed through a subciliary incision on both the lateral and medial halves of the eyelid up to the orbital rim. Next, the lateral canthal tendon, lateral attachment of the orbital septum, capsulopalpebral fascia, and conjunctiva are cut. This allows the medial displacement of the tarsoconjunctival flap, which is sutured to the defect area. The second flap, a periosteal strip, is used to reconstruct the tarsus and lateral canthal tendon, providing firm support for the posterior lamella. The orbicularis muscle is anchored to the orbital rim, and the skin of the lower eyelid is directly sutured to the subciliary incision and periosteal strip. The author successfully carried out this procedure on nine patients. None of the patients developed ocular irritation or postoperative epiphora. The defects that can be repaired by this technique are equivalent in size to those repaired by the Tenzel procedure. Unlike the semicircular flap procedure, this technique allows eyelid reconstruction with no vertical scarring and a smaller lateral incision, and it ensures soft contact between the palpebral rim and surface of the eyeball. This procedure confers an attractive eyelid appearance that may be crucial for some 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 .

Introduction Even though orbital complications in acute rhinosinusitis are not very common, they can be very severe complications, with high mortality rates, due to infection spreading to orbital and intracranial tissues (1). Especially due to intracranial complications, acute rhinosinusitis is considered in the life-threatening disease group. As per Chandler et al. (2), orbital complications are classified into five groups according to the severity of complications: preseptal cellulitis, orbital cellulitis, subperiosteal abscess, orbital abscess, and cavernous sinus thrombosis. Although orbital complications are clinically rare, they are more common in children than in adults. Orbital septum acts as a barrier that prevents the spread of inflammation from the preseptal region towards the orbital space. Along with proptosis, limitation of eye movements, and decrease in vision, the presence of redness, edema, and local temperature increase in the eyelids, i.e., infectious pathology of orbital region, suggest intraorbital propagation. Especially in the childhood period, compared to adult age groups, infections in the preseptal region that did not receive proper treatment can spread easily in the orbits and cause serious complications such as brain abscess, meningitis, and cavernous sinus thrombosis (1-4). Although antibiotic use reduces the incidence of sinus infections and complications, acute sinusitis is still the leading cause of orbital inflammation and impaired vision. Particularly after frequent upper respiratory infections during the childhood, the infection that spreads easily to the nose and sinuses sets the ground for orbital complications (4-6). In our study, accompanied by diagnosis, treatment, and follow-up symptoms of 11 patients who developed orbital complications of rhinosinusitis, treatment and follow-up algorithm of orbital complications have been revised with literature data. 131

The purpose of this paper is to report the outcome of retrotarsal tucking of Muller muscle-levator aponeurosis for the correction of borderline to moderate ptosis in conjunction with esthetic blepharoplasty in Asian eyelids and to explore the relationship between the extent of advancement and change in the eyelid position (MRD1). The medical records of 290 consecutive patients who underwent retrotarsal tucking of Muller muscle-levator aponeurosis from February 2005 to November 2011 were reviewed. Of those, 26 patients (51 eyelids) were statistically analyzed. The correction was performed through an external upper blepharoplasty approach. Once the orbital septum was opened, the Muller muscle-levator aponeurosis was advanced and tucked under the posterior surface of the tarsus by a single lifting suture. The average follow-up period was 20.6 months, with a range of 3–68 months. In 26 patients (51 eyelids), satisfactory results were recorded for 49 of 51 eyelids (96.1 %). The margin reflex distance-1 (MRD1) increased from 1.56 ± 0.70 mm preoperatively to 3.86 ± 0.94 mm postoperatively (p

Importance Blepharoplasty is one of the most commonly performed facial aesthetic surgeries. While myriad techniques exist to improve the appearance of the lower eyelids, there is no clear consensus on the optimal management of the orbital septum. Objectives To evaluate the safety and feasibility of the use of the holmium:yttrium aluminum garnet (Ho:YAG) laser for orbital septal tightening, and to determine whether modest use of this laser would provide some degree of clinical efficacy. Design, Setting, and Participants Direct laser irradiation of ex vivo bovine tissue was used to determine appropriate laser dosimetry using infrared thermal imaging and optical coherence tomography before conducting a pilot clinical study in 5 patients. Laser irradiation of the lower eyelid orbital septum was performed through a transconjunctival approach. Standardized preoperative and postoperative photographs were taken for each patient and evaluated by 6 unbiased aesthetic surgeons. Exposure Use of the Ho:YAG laser for orbital septal tightening. Main Outcome and Measure To determine appropriate laser dosimetry, infrared thermal imaging and optical coherence tomography were used to monitor temperature and tissue shape changes of ex vivo bovine tissue that was subjected to direct laser irradiation. For the clinical study, preoperative and postoperative photographs were evaluated by 6 surgeons on a 10-point Likert scale. Results Optical coherence tomography demonstrated that laser irradiation of bovine tissue to a temperature range of 60°C to 80°C resulted in an increase in thickness of up to 2-fold. There were no complications or adverse cosmetic outcomes in the patient study. Patient satisfaction with the results of surgery averaged 7 on a 10-point Likert scale. For 3 patients, 3 (50%) of the evaluators believed there was a mild improvement in appearance of the lower eyelids after surgery. The remaining patients were thought to have no significant changes. Conclusions and Relevance Transconjunctival Ho:YAG laser blepharoplasty is a safe procedure that may ameliorate mild pseudoherniation of lower eyelid orbital fat and is a first step toward the development of percutaneous techniques. Level of Evidence 4.

Recently, the public has developed a growing interest in aesthetic surgery. Middle-aged individuals in Northeastern Asia have have shown particular interest in undergoing blepharoplasty to reduce bulging eyelid fat. However, those who present for aesthetic surgery usually have not considered the possibility of an eyelid tumor, and thus, have not taken time to undergo evaluation for this possibility. Here, the authors describe a case of mucosaassociated lymphoid tissue (MALT) lymphoma that was diagnosed by a thorough physical examination in a man requesting lower blepharoplasty. A 58-year-old man visited out aesthetic center to alleviate bulging of both lower eyelids, which had begun approximately 5 years previously. The patient had no underlying disease at presentation, and chest X-ray and electrocardiography findings were normal. Physical examination confirmed bulging of both lower eyelids to a similar extent, and the unidentified tumor was palpated on the left side (Fig. 1). A biopsy was recommended for evaluation purposes, but the patient requested cosmetic surgery only, and thus, we began lower blepharoplasty after informing the patient that a biopsy might be needed during surgery and that if so, additional treatment might be required. Initially, we elevated a musculocutaneous flap by subciliary incision, and then began dissection to the extent of the inferior orbital rim. After exposing the preseptal space, an incision was performed on the orbital septum to expose the orbital fat for removal and transposition. However, we encountered a pinkish, hard, highly vascularized mass-like lesion between the orbital septum and orbital fat, which is not normally found during lower blepharoplasty. After resecting the 1.8 cm × 1.5 cm × 1.2 cm mass, lower blepharoplasty was performed in the usual manner (Fig. 2). The pathologic examination result indicated MALT lymphoma with an immunoprofile of CD20 (+), bcl-2 (+), CD3 (–), CD10 (–), CD38 (–), and CD138 (–) (Fig. 3). The patient was sent to another hospital for a systematic workup, and subsequent orbital computed tomography (CT) and positron emission tomography (PET)-CT indicated a possibility of residual lymphoma localized in the extraocular area (Fig. 4). As a result, he was treated using involved-field radiation therapy at the origin of the lymphoma at 2 Gy for 20 days based on a 1AE Ann Arbor staging. Orbital CT and PET-CT at 6 months postoperatively revealed no evidence of lymphoma and a good cosmetic outcome was achieved at 6 months after surgery (Fig. 5). The patient was very satisfied with the discovery of the mass at an early stage and the sufficient biopsy.

Hereditary angioedema is an autosomal dominant and life-threatening disorder characterized by recurrent episodes of non-pitting edema affecting the skin, respiratory system and digestive tracts and caused by a congenital deficiency or function defect of the C1 esterase inhibitor. Preseptal cellulitis is defined as an infection of the tissues of the anterior orbital septum. It is generally caused by complications from an upper respiratory tract infection, dacryocystitis, dermal infection, and, rarely, sinusitis. The disease presents with orbital pain, edema on the eyelids, erythema, and fever. In this case, a child with hereditary angioedema type 2 who presented as mimicking a complication of acute sinusitis is discussed.

Upper blepharoplasty (or double eyelid surgery) is one of the most commonly performed cosmetic surgical procedures for Asians.1 Just like any other cosmetic surgical procedure, careful evaluation of patient anatomy, proper selection of the procedure, precisely performing the procedure, and suitable postoperative care are key for an optimal outcome after Asian upper blepharoplasty.2 This Special Topic article, entitled “Visual, Physiological and Aesthetic Factors and Pitfalls in Asian Blepharoplasty,” is a good example of an article written by an experienced Asian blepharoplasty surgeon.3 It starts by emphasizing the importance of upper eyelid anatomy in Asian patients, followed by analyzing some of the common problems in Asian upper blepharoplasty, including the less optimal height of the upper eyelid skin crease, the wrong placement of non-absorbable suture in the upper eyelid that changes its normal anatomy, and the careless closure of the upper eyelid incision, causing functional and anatomic disturbance of the upper eyelid. In general, the upper eyelid is a 7-layer structure that contains skin, orbicularis muscle, orbital septum, preaponeurotic fat pads, the levator muscle, the Mueller's muscle, and upper tarsus, and conjunctiva. One should always pay attention to the differences between Asian and Caucasian upper eyelids in terms of the anatomy, especially preseptal fat, which does not exist in Caucasians.2,4 A schematic diagram clearly demonstrates the distinctive anatomy of the Asian upper eyelid in comparison with that of a Caucasian (Figure 1). Figure 1. A schematic diagram showing the differences of anatomic structures between Asian and Caucasian upper eyelid. Adapted from Park DD.2 We agree with the author that levator function should always be evaluated as one of the important preoperative evaluations for any potential Asian upper blepharoplasty patients. As a matter of fact, levator plication during an open Asian upper blepharoplasty may enhance cosmetic …

Inflammatory pseudotumor (IPT)—known as the "great mimicker"—is a rare, benign condition mimicking other benign or malignant tumors. It may be found in almost any organ system. Confirmation of a diagnosis of IPT involves a process of exclusion because IPT mimics other malignant or benign tumors. The mainstay treatment of IPT is corticosteroids. However, in cases of orbital pseudotumor presenting with an eyelid mass, excision of the mass with combined lower or upper blepharoplasty is an aesthetically favorable and appropriate diagnostic option. In the present report, we describe a case of lower eyelid IPT excision combined with lower blepharoplasty. A 57-year-old man presented to our outpatient clinic with mass-like lesions in the right lower eyelid area (Fig. 1). He first noticed the mass 4 months before his outpatient visit. The mass was non-tender and highly movable. Our first clinical impression was that the lesion was an epidermal cyst; however, following ultrasonography, a highly vascularized mass with no definite fluid or abscess pocket formation and nonspecific soft tissue inflammation was detected (Fig. 2). Because the patient also complained of baggy lower eyelids, surgical exploration and excision of the mass in combination with lower blepharoplasty was planned. Through a subciliary approach, two tiny masses were identified in the medial fat pad of the right lower eyelid (Fig. 3). The masses were excised, and biopsy specimens were obtained (Fig. 4A). Openings were made at the orbital septum, and fat was partially removed for the correction of the bulging of the lower eyelid. Lower blepharoplasty was then performed for the opposite side in a similar manner (Fig. 5). The patient was discharged 1 day after surgery. The patient seemed very satisfied with the results, and the stitches were removed on postoperative day 6. Biopsy results showed chronic sclerosing inflammation with fibrosis, plasma cell infiltration, and lymphoid aggregates with multinucleated giant cells and several Immunoglobulin G (IgG)4+ plasma cells (Fig. 4B). Based on these findings, the presence of IPT was suspected, and immunohistochemistry was performed to confirm this diagnosis. Immunohistochemistry confirmed that the mass was an IPT, with no evidence of IgG4-related disease. The patient did not report any complications during the follow-up period. Fig. 1 A 57-year-old man presented to the outpatient center with a palpable mass around the right lower eyelid. Because he complained of baggy lower eyelids, we decided to confirm our diagnosis with an excisional biopsy combined with lower blepharoplasty of ... Fig. 2 The preoperative ultrasound images revealed a highly vascularized mass with no definite fluid or abscess pocket formation and nonspecific soft tissue inflammation. Fig. 3 Intraoperative image showing two tiny masses in the medial fat pad of the right lower eyelid. Biopsy specimens were obtained to confirm the diagnosis. Fig. 4 (A) Two tiny masses were excised. The excised masses underwent a pathology examination for analysis. (B) Histopathology showed chronic sclerosing inflammation with fibrosis, plasma cell infiltration, and lymphoid aggregates with multinucleated giant cells ... Fig. 5 Immediate postoperative image of the patient. Also known as idiopathic orbital inflammation, IPT is a non-infectious, benign condition that is often misdiagnosed as another benign or malignant tumor or other type of ophthalmopathy. It is the third most common disorder of the orbit following Graves' ophthalmopathy and lymphocytopathy. It accounts for almost 10% of all cases of orbital masses [1]. In 2007, Chirapapaisan et al. [2] reviewed the medical records of 49 patients with orbital pseudotumor (24 males and 25 females; mean age, 43.75 years), most of whom were in their mid-40s or 50s. In terms of chief complaints, 49% presented with proptosis, 22.4% presented with lid swelling or a lid mass, and 12.2% presented with orbital pain; the remaining patients showed diplopia, visual loss, or ptosis [2]. The etiology of IPT is unknown, but many studies suggest a strong relationship between IPT and the immune system. Many rheumatologic disorders are associated with IPT, such as Wegener granulomatosis, giant cell arteritis, and systemic lupus erythematosus. Therefore, many different immunosuppressive therapies can be administered in cases involving IPT. Garrity et al. [3] treated idiopathic orbital inflammation with infliximab, and Hatton et al. [4] successfully treated orbital pseudotumor with mycophenolate mofetil. These findings suggest that orbital IPT is strongly related to autoimmune disease. Many studies indicate that the pathogenesis of IPT involves tissue damage and fibrosis mediated by cytokines and growth factors, which may be associated with various viral infections, a genetic predisposition, or environmental factors [5]. No flowchart exists to diagnose this disease, and the diagnosis of orbital IPT involves a process of exclusion. Other ophthalmopathies, such as Graves' ophthalmopathy, must be excluded before the diagnosis of orbital IPT. Moreover, various rheumatoid disorders should be excluded, because these disorders can present as orbital IPTs. Orbital cellulitis, metastatic carcinomas, dermoid cysts, and epidermal cysts should be excluded on the basis of radiographic characteristics on ultrasonography, computed tomography, or magnetic resonance imaging. Orbital IPTs typically show diffuse infiltration of the orbit or inflammation of the adjacent orbital tissue. Orbital pseudotumors related to orbital masses typically have poorly defined margins. When there is a discrete mass or mass-like lesion, surgical excision with tissue biopsy is an option; however, due to the prompt and marked response to corticosteroids observed in such cases, surgery is not suggested as a first-line treatment. The mainstay of treatment for orbital IPT is corticosteroids. In most cases, patients treated with corticosteroids show a marked improvement in symptoms. A good response to corticosteroid treatment is often viewed as pathognomonic for orbital IPT. In cases of incomplete response to steroids or in patients who cannot receive steroid treatment, radiotherapy can be used as second-line therapy. Many immunosuppressive agents, such as cyclosporin A, methotrexate, azathioprine, and mycophenolate mofetil, are currently being used in clinical practice. Infliximab, a suppressor of tumor necrosis factor (TNF)-alpha, can be indicated in cases of intractable or recurrent orbital IPT. Hence, medical treatment is considered the first-line treatment, and surgical excisional biopsy is not suggested routinely. This is because only approximately 20% of cases of orbital IPT present as an eyelid mass, and medical treatment is very effective in most cases. However, in cases with obvious mass-like lesions, surgical excision and pathology results can be considered for confirmation of diagnosis and treatment. The histopathologic findings of orbital IPT include nonspecific polymorphic, lymphocytic infiltrates with macrophages, polymorphonuclear leukocytes, and eosinophils. Increased connective tissue with fibrosis and edema is also commonly seen. In the case presented here, we could grossly recognize the well-defined mass in the subcutaneous layer, which was not very deep from the skin layer. Therefore, diagnostic excision was one of the best options. Moreover, the patient's needs were considered, and surgical excision with lower blepharoplasty was performed. A diagnosis of orbital IPT was confirmed on the basis of the histopathology results, and during the follow-up period, the patient did not report any complications or recurrence. Both the medical team and the patient were highly satisfied with the surgical results. We present a case of orbital IPT that was excised in combination with lower blepharoplasty. Because most orbital IPTs develop in patients who are in their 40s and 50s, aesthetic surgical procedures for the eyelid can be considered in combination with tumor excision. Therefore, in cases of orbital IPT presenting with an eyelid mass, excision combined with lower or upper blepharoplasty is an aesthetically favorable and appropriate diagnostic option.

Orbital cellulitis is an infection of soft tissue behind the orbital septum. Common pathogens isolated include Staphylococcus aureus, Staphylococcus epidermidis, and Streptococcus pneumoniae. It is a straightforward diagnosis and usually responds to empirical treatment without any sequela. We report a case of orbital cellulitis caused by Enterococcus faecalis, which was complicated by myositis of levator palpebrae superioris. To the best of our knowledge, only one case report exists dating way back to 1986.

The authors innovated the levator aponeurosis and Muller muscle plication reinforced with levator sheath advancement (AMPSA) for blepharoptosis correction. The orbital septum was opened 1 mm above its fusion with the levator aponeurosis. The preaponeurotic fat was retracted and the thickened part of the levator sheath was identified. Two plication sutures were made: medial suture at the medial border of the pupil and lateral between the lateral border of the pupil and the lateral limbus. A needle with 6-0 nylon thread first bit the tarsal plate approximately 1 mm below its upper border, then bit the levator aponeurosis and the Muller muscle together at 3 to 6 mm above the upper border of the tarsal plate. The needle bit 1 to 3 mm of the thickened part of the levator sheath and the suture was tied. A total of 116 eyes were operated on using levator aponeurosis and Muller muscle plication (AMP), and 79 eyes using AMPSA. The mean follow-up period was 11.4 months. In the AMP group, the postoperative marginal reflex distance-1 (MRD-1) (3.8 ± 0.2 mm) was significantly greater than the preoperative MRD-1 (2.7 ± 0.3 mm) (P < 0.001). In the AMPSA group, the postoperative MRD-1 (3.5 ± 0.3 mm) was also significantly greater than the preoperative MRD-1 (1.7 ± 0.4 mm) (P < 0.001). The improvement in MRD-1 was greater in the AMPSA group (1.7 ± 0.4 mm) than in the AMP group (1.1 ± 0.3 mm) (P < 0.001). The difference in the MRD-1 outcome between AMPSA and AMP (0.6 mm) was obtained by advancing the thickened part of the levator sheath. AMPSA may be an effective procedure for correcting blepharoptosis.

Periorbital cellulitis is a very common disease in pediatric population, it describes an infection involving the adjacent soft tissues anterior to the orbital septum. Pathogens involved are generally Gram-positive cocci after introduction of Haemophilus influenzae vaccine. We report a case of Neisseria gonorrhoeae periorbital cellulitis associated with bacterial conjunctivitis in a child. There are few cases reported in the literature with this microorganism as the causal agent. With this case, we would like to emphasize the importance to do a culture of the ocular secretion (if it exists) because this allowed us to determine an infrequent agent of this disease.

Ocular adnexal smooth muscle masses/neoplasms are extremely rare. Such lesions are comparatively more common in the conjunctiva than in the orbit and are most unusual in the eyelid. A 58-year-old woman slowly developed over 4 months a firm, movable sausage-shaped lesion in the deep lateral half of the right lower eyelid. The lesion ran parallel to and above the orbital rim. At surgery, the lesion was located between the orbicularis muscle and the inferior orbital septum. The term ellipsoid is used descriptively and does not imply any particular biologic behavior. Immunohistochemical evaluation revealed smooth muscle actin and desmin positivity. Due to the ubiquity of small blood vessels and the absence of smooth muscle bundles in the potential space between the orbicularis striated muscle and the inferior orbital septum, venular smooth muscle emerges as a highly likely source for the lesion.

Orbital cellulitis is a severe and sight-threatening infection of orbital tissues posterior to the orbital septum. The most common causes of orbital cellulitis are rhinosinusitis, orbital trauma, and surgery. Infective endocarditis (IE) is a systemic infection that begins on cardiac valves and spreads by means of the bloodstream to peripheral organs. Septic emboli can spread to any organ including the eyes and can cause focal or diffuse ophthalmic infection. Ocular complications of IE classically include Roth's spots, subconjunctival hemorrhages, chorioretinitis, and endophthalmitis. IE as a cause of orbital cellulitis has been described by only one author in the literature. Here, we present a very rare case of bilateral orbital cellulitis caused by IE. Through this case, we aim to create awareness of the potential for serious ocular complications in IE and provide an overview of the management.

We evaluated the relationship between infraorbital fat herniation and age-related changes in the bony orbit and orbital fat density using computed tomography. Two hundred and sixty-five patients were enrolled (60 patients were evaluated for changes in the bony orbit and 205 for changes in orbital fat density). Five measurements using parasagittal sections and one measurement using three-dimensional images were obtained. Intraorbital fat herniation length was positively correlated with orbital rim inclination. Lowering of the inferior orbital rim, which is connected to the orbicularis retaining ligament, tear trough ligament and orbital septum, can cause mechanical stretching of the lower eyelid and may contribute to infraorbital fat herniation. A strong and significant negative correlation was observed between orbital fat density and age, indicating that existing orbital fat can accommodate an enlargement in bony orbit volume without orbital fat hyperplasia/hypertrophy. In other words, an increased orbital fat volume may be a by-product of the adaptation of orbital fat to changes in bony orbit volume. Mechanical stretching of the lower eyelid due to ageing of the bony orbit and weakening of the lower eyelid due to age-related factors such as dermal/fat/muscle atrophy and loss of muscle tone can together result in anterior drooping of the lower eyelid. Therefore, age-related changes in the bony orbit contribute to intraorbital fat herniation.

Introduction: Brow-lift and upper blepharoplasty are often done sequentially to achieve adequate rejuvenation of the upper face. We describe the feasibility of a novel method of addressing both the aged forehead and upper eyelid fat pseudoherniation via an open brow-lift approach. Materials and Methods: We performed our technique on 6 cadaver and 3 human subjects. A brow-lift was performed in open fashion followed by upper eyelid fat excision through the superiorly exposed orbital septum. Position of the orbital fat from this approach and its ease of excision were recorded. Results: In all cases, the medial and central fat compartments were medial and lateral to the supraorbital nerve, respectively. Fat was accessible and amenable to excision from this approach. There were no complications related to this technique. Conclusions: When upper eyelid dermatochalasia is resolved when an open brow-lift is performed, this technique addresses upper eyelid fat pseudoherniation through the same brow-lift incision. Although this procedure is feasible and safe, long-term results in a greater number of patients are needed to confirm its role in aesthetic surgery.

Purpose To evaluate the use of hyaluronic acid gel in the management of lagophthalmos in sunken superior sulcus syndrome. Introduction Lagophthalmos associated with orbital fat atrophy and deep superior sulcus is a known entity described previously. Orbital fat atrophy results in deep superior sulcus where skin, orbicularis muscle, and orbital septum retract posteriorly in the deep superior sulcus, leading to lagophthalmos from suboptimal orbicularis function and effective skin shortening. The authors define this condition as sunken superior sulcus syndrome (SSSS) when the deep superior sulcus leads to exposure keratopathy. Thus, the syndrome consists of deep superior sulcus, lagophthalmos, and exposure keratopathy. Although the use of hyaluronic acid gel has been proposed as a management option for paralytic lagophthalmos, its application in the treatment of lagophthalmos in SSSS has not been reported. Methods In this study, 5 patients (10 eyelids) with SSSS were injected with hyaluronic acid gel in the superior sulcus of the upper eyelid. Injected amount was titrated until the desired point was reached: complete or nearly complete eyelid closure. Results After an average follow up of 9.5 months, lagoph thalmos improved by 2 mm or 69% (p = 0.02) on the right side and by 1 mm or 71% (p = 0.01) on the left side. Most patients also reported significantly improved ocular comfort and appearance of the superior sulcus. The only complications noted were bruising and temporary uneven contour of the upper eyelid sulcus. Conclusions Management of lagophthalmos in SSSS with hyaluronic acid gel is an effective and safe alternative to surgery.

Fulminant thyroid eye disease arises where gross inflammatory expansion of the orbital fat and/or muscles leads to a major rise in the intraorbital pressure. The rising pressure often leads to significant exophthalmos that, in turn, may cause marked corneal exposure or ulcerative keratitis – this exposure being exacerbated by marked upper eyelid retraction and lagophthalmos. Exophthalmos is prevented from occurring where the orbital septum does not yield, and this exacerbates the rise in orbital pressure which, when extreme, leads to an ischaemic compressive optic neuropathy. Treatment of fulminant thyroid eye disease should be directed to controlling thyroid gland function, stopping smoking and protecting the cornea by medical and, if necessary, surgical means. Systemic glucocorticoids form the mainstay of medical therapy for this serious condition, but B-lymphocyte depletion with rituximab may prove a valuable adjunct for difficult cases. Early orbital decompression should be considered where optic neuropathy continues despite adequate medical therapy and where there is gross proptosis complicating upper eyelid retraction.

Preseptal and orbital cellulitis, both more common in the pediatric population, are important bacterial infections of the orbit. Preseptal cellulitis refers to infection anterior to the orbital septum, while orbital cellulitis describes an infection involving the soft tissues posterior to the orbital septum, involving the soft tissue and muscle in the confined bony orbit. It is important to differentiate these two entities as early diagnosis, aggressive medical treatment, and timely surgical intervention are important to avoid irreversible visual loss and intracranial spread in the case of orbital cellulitis. Periorbital necrotizing fasciitis, though rare, progresses rapidly and is associated with significant morbidity and mortality. Clinicians should be aware of characteristic features and act promptly to save life and vision.

Background: The orbital septum is a membranous sheet acting as the anterior boundary of the orbit. Preseptal cellulitis is a kind of an infection of the eyelid and portions of skin around the eye, anterior to the orbital septum. Preseptal cellulitis is different from orbital cellulitis in epidemiology, etiology and treatment of choice. The current study aimed to evaluate the frequency of major risk factors of preseptal cellulitis. Methods: This descriptive prospective study was conducted on 40 patients with preseptal cellulitis admitted to two educational hospitals in Tehran, Iran, during 2014 - 2015. Epidemiologic and clinical findings of the patients with CT scan documented preseptal cellulitis were recorded as risk factors and complete history of trauma. All the patients were scanned for sinus involvement (axial and coronal paranasal sinus CT scan). Complete physical exam for cutaneouse lesions predisposing to preseptal cellulitis as varicella was performed. Blood samples were cultured. Data were analyzed using the SPSS Software version 20. Results: During the study period, 40 patients including 21 females and 19 males with preseptal cellulitis were studied. The mean age of the patients was 38.95 ± 16.20 years. The most common underlying factors was trauma (57.5% of the patients) following sinusitis (25%) with the ethmoid sinus being the most common involved sinus. Ophtalmic Zoster, dacryocystitis and hordeolum were predisposing factors in 17.5% of the cases. Most cases occurred in spring (47.5%) and the least in summer (5%). Conclusions: Sinusitis was the most common predisposing factor of preseptal cellulitis in previous studies, but in this study trauma was the most common one. Recognition of major risk factors of preseptal cellulitis can be effective in planning the treatment of choice in preseptal cellulitis in different communities.

A single convex line without signs of bony landmarks presents a youthful contour appearance of the eyelid-cheek complex.1 Gradually, midcheek aging is characterized by progressive anatomic landmark changes, such as eye bags and lower lid orbitomalar sulcus depression (tear trough and lid-cheek junction),2–4 which present a tired appearance. The correction of those landmarks is very important in improving facial rejuvenation.5,6 In the history of lower blepharoplasty technique advances, there have been many surgical techniques designed to improve the most effective aesthetic results and to prevent postoperative complications.7 Surgical fat removal with lower lid skin excision was first performed in the early evolution of prominent lower eyelid fat management.8–11 Further, Loeb has popularized the fat sliding technique to achieve a more natural and comprehensive rejuvenation of the lower eyelid region.1,12–14 De la Plaza and Arroyo have been interested in fat preservation and tightening of the orbital septum techniques,15–17 because they described their capsulopalpebral fascia (CPF) repair technique for lower eyelid herniation in 1988. Although several surgical techniques are available, the correction of orbital malar sulcus depression is still a challenge. In this article, the downward rotation technique of the capsulopalpebral fascia, orbital septum, and orbital fat complex to orbitomalar sulcus depression can address a change of eyelid contour and create a more youthful and pleasing appearance. We describe this new surgical technique for lower eyelid blepharoplasty to preserve the lower eyelid fat and to more fully correct orbitomalar sulcus depression. In particular, this technique decreases the recurrence rate of palpebral bags.