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Purpose: To examine with histology the anatomical location of hyaluronic acid gel injected to the infraorbital hollows of cadaver specimens., Methods: The authors dissected 5 fresh hemifacial cadaver specimens following preperiosteal injection of hyaluronic acid gel to the infraorbital hollows. Following tissue fixation, full-thickness soft tissue sections were obtained along the medial, central, and lateral lower eyelid/midface of each specimen. Histologic examination of the anatomical location of hyaluronic acid gel was performed using hematoxylin and eosin and Hale colloidal iron stains., Results: Histologic examination of the central and lateral lower eyelid/midface sections revealed a significant portion of hyaluronic acid gel in either a postorbicularis or a subcutaneous plane in 8 of 10 sections. Only 2 sections displayed hyaluronic acid gel solely within a preperiosteal plane. The medial sections revealed hyaluronic acid gel resting in either a preperiosteal or an intraorbicularis plane. Soft tissue structures such as deep fat compartment septa and the orbicularis oculi muscle appeared to play a significant role in influencing the resting position of hyaluronic acid gel., Conclusions: In most specimens, the location of a significant portion of hyaluronic acid gel following injection to the infraorbital hollows differed from the intended injection plane. Soft tissue structures including fat compartment septa and the orbicularis oculi muscle appear to influence the resting position of hyaluronic acid gel. Careful attention should be used to avoid overfilling the thin soft tissue layers of the medial infraorbital hollows or tear trough.

Controversy persists in surgical eyelid anatomy despite the routine use of microanatomical examination in modern eyelid research. The aim of our study was to facilitate visualisation of upper eyelid anatomy by optimising the orientation of cadaveric specimens. We studied the anatomy of everted eyelids, providing an excellent histological view of the posterior approach to the eyelid commonly used in surgery. Non-traumatic separation of the eyelid lamellae provides a new view of the eyelid's lamellar nature. Further application of this model may enhance understanding of the multilayered aspect of the levator aponeurosis. The technique may improve intraoperative understanding of critical eyelid anatomy and promote safer and more effective eyelid surgery.

Purpose: To assess for alterations in the microscopic anatomy that occur as a result of the Müller muscle-conjunctival resection (MMCR) ptosis procedure and to better understand the mechanisms by which MMCR elevates the eyelid., Methods: Sixteen orbits from 8 fresh frozen Caucasian cadaver heads, ranging from 38 to 100 years of age were used. For each head, MMCR was performed on one side. The contralateral, unoperated orbit served as an anatomic control. Each exenterated orbital contents and excised MMCR specimen was evaluated. The histopathology of the eyelids and MMCR specimens were studied microscopically by staining with hematoxylin-eosin, elastic, and Verhoeff-Masson trichrome., Results: Müller muscle and conjunctiva were present in all 8 of the excised MMCR specimens. Elastic fibers consistent with Müller muscle tendon or among the smooth muscle fibers were seen within all excised MMCR specimens. The levator aponeurosis was intact in 8 of 8 operated eyelids; however, the aponeurosis was plicated in all. The accessory lacrimal gland tissues were intact in all of the operated and unoperated eyelids., Conclusions: MMCR works by shortening the posterior lamella, which results in advancement of the levator palpebrae superioris muscle and plication of the levator aponeurosis. Plication of the levator aponeurosis likely contributes to the increased volumetric effect seen clinically after MMCR. Phenylephrine testing can help in fine-tuning the amount of resection, but given the mechanism of action of MMCR, adequate levator muscle function remains a critical factor in the success of the surgery. Moreover, MMCR preserves accessory lacrimal gland tissues.

The authors present 2 cases of eyelid dermoid cyst attached to tarsus in pediatric patients. Both patients were infants who presented with a firm, nontender upper eyelid mass firmly adherent to tarsus. In both cases, the lesion was excised en bloc, and histopathology revealed a dermoid cyst. To the authors' knowledge, there are no previously reported cases of tarsal dermoid cyst. These cases demonstrate the importance of including dermoid cyst in the differential diagnosis of a tarsus-based eyelid mass. Misdiagnosis may lead to incision and curettage, resulting in spillage of cyst contents and the risk of severe inflammation and scarring.

Purpose: To perform a quantitative analysis of adipocyte viability after fat processing during autologous fat transfer, comparing the processing methods of washing, centrifuging, and sedimentation., Methods: An experimental study was conducted in which 24 fat samples were obtained after processing from 22 patients undergoing autologous fat transfer. Histologic analysis of periodic acid-Schiff-stained specimens was then performed., Results: Cell counts per high-powered field of intact adipocytes and nucleated adipocytes and adipocyte cross-sectional area were significantly greater in samples processed by sedimentation, compared with those by centrifuging or washing., Conclusions: Of the various processing techniques currently used during autologous fat transfer, sedimentation appears to yield a higher proportion of viable adipocytes than does washing or centrifuging.

Purpose: To describe the demographics, symptoms, and findings of acquired lax eyelid syndrome and to assess the efficacy of the 4-eyelid tarsal strip-periosteal flap technique to treat horizontally lax upper and lower eyelids., Methods: A retrospective, case-series review of 80 patients (320 eyelids) evaluated from January 2000 to April 2004 for lax upper and lower eyelids causing chronic irritation was performed. Ten patients with diagnosed floppy eyelid syndrome or obstructive sleep apnea were excluded. Height and weight of all patients were recorded to calculate body mass index. Lateral tarsal strip fixation of all 4 eyelids to periosteal flaps based inside the orbital rim was performed to achieve horizontal tightening. Postoperative follow-up ranged up to 52 months. Preoperative/postoperative symptoms and examination findings of upper and lower eyelid distraction, keratopathy, and conjunctival inflammation were compared., Results: The most common presenting symptoms were epiphora (85.7%) and irritation (80%). The most common examination findings were upper and lower eyelid horizontal laxity and palpebral conjunctival injection (100% patients). Thirteen of 70 patients (18.6%) were obese, based on body mass index; 26 of 70 patients (37.1%) were mildly overweight; 29 of 70 patients (41.4%) were normal weight; and 2 of 70 patients (2.9%) were underweight. After surgery, 91% of patients had improved or resolved symptoms and signs; 2.5% of dehiscences occurred with the use of the 4-eyelid technique. Gradual continued improvement was observed for up to 1 year., Conclusions: Evaluation of patients presenting with chronically irritated eyes should include distraction of both the upper and lower eyelids and examination for conjunctival inflammation. Acquired lax eyelid syndrome is similar to floppy eyelid syndrome; however, 43.3% of patients were normal weight or underweight. The 4-eyelid tarsal strip-periosteal flap fixation is a rapid and effective technique for correction of this syndrome.

Background: Ocular sebaceous carcinoma (SC) is a rare tumor of the eyelids. Clinically it frequently involves the upper lid in older women. Microscopically it tends to extend far beyond its assessed clinical margins. SC is characterized by a variety of tissue invasion mechanisms. It may spread by direct extension, be multifocal in advanced cases, and develop "skip areas" after trauma. Despite its ability to develop discontinuity, over the past two decades there have been several favorable case reports of SC treated by Mohs micrographic surgery (MMS)., Objective: To illustrate by case report the clinical presentation and management of patients with SC and to document our series of SC patients treated by MMS over the last 14 years., Methods: A retrospective study was conducted of all cases of sebaceous carcinoma involving the ocular adnexa treated at the University of Wisconsin Mohs Surgery Clinic from 1987 to 2001. We also reviewed the accumulated medical literature of SC treated by MMS., Results: In our series, there were nine cases of periocular SC. Five cases originated on the upper lid and four on the lower lid. Five of nine patients (55%) showed epithelial invasion. One patient developed a local recurrence 1.5 years later and was treated by orbital exenteration. This patient has had no evidence of disease for 5 years. Eight of nine patients (88%) had no evidence of local recurrence with a follow-up of 1-14 years. In our literature review we found 40 additional cases of orbital SC treated by MMS. Intraepithelial spread of SC was found in 50% of patients (24 of 48). Six patients developed local recurrence. The overall local cure rate following MMS is 87.8% (43 of 49), with a mean follow-up of 3.1 years. The regional metastatic rate was 8% (4 of 49). There were no deaths reported., Conclusion: We present nine new cases of SC. The age, sex, and site distribution are compatible with other SC cases reported in the literature. We reviewed the medical literature and compiled 49 cases of SC treated by Mohs surgery. Intraepithelial spread was discovered in 50% of the cases. Multifocal disease or discontinuity was present in 6% (3 of 49). Mohs surgery appears to be an effective method for excising the microscopic ramifications of primary SC. When feasible, we recommend in SC cases where intraepithelial pagetoid spread has been observed, that removal of another Mohs layer should be considered in order to provide an additional assurance layer against local tumor recurrence.

Purpose: To investigate the Cynomolgus monkey eyelid as an experimental model for oculoplastic surgery, Methods: Eyelid and periocular tissue were removed from Cynomolgus monkeys being euthanized. After fixation, the macroscopic and microscopic characteristics of the Cynomolgus monkey eyelid were studied., Results: Macroscopic and microscopic characteristics of the Cynomolgus monkey eyelids were described. The Cynomolgus monkey eyelid bears resemblance to the human eyelid in its compartmentalization and complexity., Conclusions: The Cynomolgus monkey eyelid is a suitable experimental research model. Its compartmentalization resembles that of the human eyelid both microscopically and macroscopically.

Purpose: To study the lymphatic drainage of the cynomolgus monkey through the use of lymphoscintigraphy., Methods: Lymphoscintigraphy with 500 microCi of 99mTechnetium sulfur colloid injected at specific sites around the eyelids was performed with five cynomolgus monkeys in lateral and ventral positions., Results: Lymphoscintigraphy of the monkey eyelid and periocular tissue revealed lymphatic drainage to the parotid lymph nodes from the entire upper eyelid, medial canthus, and lateral lower eyelid and drainage to the submandibular lymph nodes from the medial and central lower eyelid. In addition to draining to the parotid lymph nodes, the central upper eyelid was also seen to drain to the submandibular lymph nodes., Conclusions: Lymphoscintigraphy of the cynomolgus monkey eyelids reveals discrete lymphatic drainage pathways for the upper and lower eyelids and a dual pathway for the central upper eyelid. Future studies will help to clarify the lymphatic drainage pathways of human eyelids.

Purpose: To study the lymphatic drainage of the cynomolgus monkey and human eyelid and periocular tissue by means of histochemistry., Methods: Eyelid and periocular tissue from three cynomolgus monkeys undergoing sacrifice for glaucoma and retina research purposes and discarded tissue from a wedge resection of one human eyelid were used for histochemical analysis. Lymphatic capillaries were distinguished histochemically in monkey and human eyelids by light microscopy with a 5'-nucleotidase (5'-Nase) staining method. Identification of lymphatic vessels was based on strict morphologic criteria combined with specific 5'-Nase staining., Results: Histochemical analysis with 5'-nucleotidase revealed a subcutaneous and pretarsal lymphatic plexus in both the human and monkey., Conclusions: Histochemical results demonstrate similar lymphatic plexi in the monkey and human. Future studies will help to clarify the lymphatic drainage pathways of monkey and human eyelids.

Purpose: To describe the gross and microscopic anatomy of the depressor supercilii muscle and to discuss its cosmetic implications., Methods: The depressor supercilii muscle was studied in detail with the use of gross anatomic dissections carried out on eight sides of four fresh cadaver heads and ten sides of five preserved cadaver heads. Histological analysis was performed on parasagittal sections of one side of a preserved cadaver head. Measurements were taken on cadaver specimens to determine the insertion point of the depressor supercilii muscle on the undersurface of the skin., Results: The depressor supercilii muscle is distinct from the corrugator supercilii muscle and the medial head of the orbital portion of the orbicularis oculi muscle. The depressor supercilii muscle was noted to be superior in orientation and redder in color than the orbicularis oculi muscle. The depressor supercilii muscle arose from the frontal process of the maxilla approximately 1 cm above the medial canthal tendon and appeared to originate from two distinct heads in most specimens, a novel finding. In specimens containing two heads of the depressor supercilii muscle, the angular vessels passed between the two muscle heads. In specimens containing one muscle head, the angular vessels were found anterior to the muscle. The insertion of the depressor supercilii muscle in the dermis lay approximately 13 to 14 mm superior to the medial canthal tendon., Conclusions: The origin, insertion, and anatomy of the depressor supercilii muscle help it to act as a depressor of the eyebrow. Histologically, the depressor supercilii muscle arises distinctly from bone and has a unique insertion. The depressor supercilii muscle appears to be distinct from the corrugator supercilii and the orbicularis oculi muscles.

Purpose: To describe a novel surgical technique for lower eyelid ectropion repair that avoids canthotomy and cantholysis and can be used in combination with external levator repair and/or in combination with blepharoplasty., Methods: A retrospective analysis of lower eyelid procedures with the use of the canthus-sparing technique between January 1, 1998, and December 31, 1999, was performed. The canthus-sparing approach was used in 198 eyelid procedures for the correction of lower eyelid ectropion. Seventy-four (37.4%) procedures involved the correction of lower eyelid ectropion alone and 25 (12.6%) procedures involved the correction of lower eyelid ectropion during upper eyelid small-incision external levator repair. In these cases, an incision was made lateral to the lateral canthus and a periosteal flap was created at the lateral orbital rim. The inferior crus of the lateral canthal tendon was then attached to this full-thickness elevated periosteum. Twenty (10.1%) procedures involved the correction of ectropion during upper blepharoplasty and 79 (39.9%) procedures involved the correction of ectropion during combined upper eyelid ptosis repair and blepharoplasty. In these cases, the inferior crus of the lateral canthal tendon was attached to a periosteal flap created through the lateral portion of the blepharoplasty incision., Results: The mean age of patients undergoing ectropion repair was 74.3+/-9.3 years (range, 42-93 years). The average duration of symptoms (most commonly tearing and/or ocular irritation) was 20+/-14 months (range, 3-84 months). Recurrences of lower eyelid ectropion or symptoms occurred in 4 (2%) eyelids. The average follow-up interval was 54+/-65 days (range, 3-330 days)., Conclusions: The canthus-sparing approach to ectropion repair promotes a secure adhesion to the lateral orbital wall with minimal violation of normal anatomic structures and relations. It is time-efficient and reduces postoperative morbidity.

Purpose: Lower eyelid involutional entropion is a significant disorder of the aging population resulting from horizontal eyelid laxity, overriding orbicularis oculi muscle, and attenuation of the lower eyelid retractors. The purpose of this study is to describe the long-term results of transconjunctival entropion repair., Design: Interventional noncomparative case series., Participants: Thirty-six eyelids in 31 patients., Methods: Charts were reviewed of all transconjunctival entropion repairs, which included myectomy, retractor fixation, and horizontal shortening performed by three oculoplastic surgeons between January 1993 and January 1999. Cases with less than 12 months follow-up were excluded., Main Outcome Measures: Entropion recurrence., Results: Thirty-six lids in 31 patients were followed for mean of 31.5 months (12.5-79). Six of 36 lids (16.7%) had postoperative complications. Recurrent entropion occurred in 3 of 36 lids (8.3%) an average 16.3 months (7-35) after surgery. An average of 6 trichiasis lashes (1-10) occurred in 4 of 36 lids (11.1%) at a mean of 2.25 months (1-4) after surgery. There were no overcorrections. Three of 36 lids (8.3%) required additional surgery., Conclusions: Entropion recurrence after three-step transconjunctival repair is within the 0% to 30% reported recurrence for other repair techniques but more frequent than reported for a similar transcutaneous procedure. The 8.3% recurrence rate might have resulted from inadequate myectomy, inadequate retractor fixation, cicatricial changes directly related to the transconjunctival incision, or progressive involutional changes. Trichiasis was the most frequent complication. Transconjunctival entropion repair may be slightly less effective than transcutaneous repair.

Objective: Granular cell tumors are rare tumors of the periorbital region, and we present the second such case in the lacrimal sac. The natural history and clinical behavior of these tumors is reviewed., Design: Case report., Methods: The clinical presentation, workup, surgical approach, and pathology of a case of granular cell tumor of the lacrimal sac are presented., Results: There has been no recurrence of the lacrimal sac tumor with incomplete resection., Conclusions: This case history further adds to the understanding of the biologic behavior of granular cell tumors in the periorbital region.

Purpose: To investigate the anatomic and histologic changes present in midfacial ptosis., Methods: Experimental study applying gross anatomic and histologic techniques to formalin-preserved and fresh-frozen cadaver heads with and without midfacial ptosis. High-resolution surface coil magnetic resonance imaging (MRI) was performed to obtain radiologic correlations., Results: The orbitomalar ligament was further characterized by identification of a well-developed lateral component in the sub-superficial musculoaponeurotic plane; abnormalities of this important supporting structure were present in the subcutaneous plane in 8 of 10 specimens with midfacial ptosis. The zygomatic and masseteric cutaneous ligaments also were further characterized on a gross anatomic level, and histologic evidence of these two structures was produced. The subcutaneous components of the zygomatic and masseteric cutaneous ligaments were attenuated or not identifiable in 40% and 30% of specimens with midfacial ptosis, respectively. High-resolution surface coil MRI provided exquisite correlations of midfacial anatomy., Conclusions: The lateral component of the orbitomalar ligament provides major osteocutaneous midfacial support. Subcutaneous attenuation of the orbitomalar, masseteric cutaneous, and zygomatic ligaments was associated with midfacial ptosis.

Postoperative upper lid asymmetry is a common problem following ptosis surgery. Recently we performed multiple ptosis operative procedures to correct lid asymmetry in the management of a patient with bilateral acquired upper eyelid ptosis. The patient's eyelids were corrected successfully after five procedures. We retrospectively reviewed the treatment of this patient with unsatisfactory results. The medical literature was reviewed for further insight into the common problem of reoperation after ptosis surgery.

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

Purpose: To identify lymphatic vessels in the human orbit., Methods: Lymphatic and blood capillaries were distinguished histochemically by light microscopy using a 5'-nucleotidase (5'-Nase) and alkaline phosphatase (ALPase) double staining method. Identification of lymphatic vessels was based on strict morphologic criteria combined with specific 5'-Nase staining., Results: The presence of conjunctival lymphatics was confirmed and used as a control tissue. Lymphatic vessels were identified in the lacrimal gland and in the dura mater of the optic nerve. Structures demonstrating positive 5'-Nase staining at the orbital apex were highly suggestive of lymphatics but did not meet the morphologic criteria established. Lymphatic vessels were not identified in the extraocular muscles or orbital fat., Conclusion: To the authors' knowledge, this study presents the first evidence for lymphatic capillaries in the dura mater of the human optic nerve and lacrimal gland.

Purpose: To describe a new surgical technique and early results of external levator repair performed through a small skin incision., Methods: A chart review of consecutive patients undergoing small incision external levator repair was conducted. This modified external levator repair was performed through an 8-mm eyelid crease incision. Patients with unilateral or bilateral aponeurogenic blepharoptosis were candidates for the technique. Patients with excessive horizontal upper eyelid laxity and those requiring blepharoplasty in addition to blepharoptosis surgery did not undergo this technique. Patients who underwent previous upper eyelid surgery or concurrent brow surgery were excluded from the review. Preoperative measurements included upper eyelid margin reflex distance, levator function, and degree of dermatochalasis, as well as Goldmann visual field results. Outcome measures included incidence and type of intraoperative complications, postoperative upper eyelid position (including margin reflex distance, eyelid contour, and symmetry), incidence and type of postoperative complications, and revisions or additional necessary surgery., Results: Twenty-eight eyelids of 17 patients met study inclusion criteria. Preoperative margin reflex distance +/- SD averaged 0.8 +/- 0.4 mm. Average length of follow-up was 28 +/- 5 weeks (range, 15 to 52 weeks). No significant intraoperative complications occurred. Postoperative margin reflex distance averaged 3.7 +/- 0.3 mm. Two eyelids were mildly undercorrected, and one demonstrated moderately peaked contour postoperatively. Satisfactory eyelid position and contour were achieved in 25 of 28 treated eyelids. No patient elected reoperation., Conclusions: Early results demonstrated that small incision levator repair is safe and generally effective. This minimally invasive external levator repair is useful for a carefully selected subset of patients with aponeurogenic blepharoptosis.

Purpose: To determine the efficacy of using a scaffold of hydroxyapatite blocks within the maxillary sinus to treat patients with large orbital floor fractures and secondary vertical globe dystopia., Methods: Case series of five patients. Hydroxyapatite blocks were stacked within the maxillary antrum to support the reconstructed orbital floor., Results: All patients had good results, though mild residual enophthalmos persisted in three patients. The orbital floor implants and globe positions remained stable during follow-up intervals ranging from 46 to 65 months. No adverse postoperative complications, such as sinusitis, developed., Conclusions: Hydroxyapatite block scaffolding is a useful alternative to metallic floor implants and autologous bone grafts in the reconstruction of large traumatic orbital floor defects associated with vertical globe dystopia.

Lateral canthal fixation is widely used. This article sought to determine if a periosteal flap used routinely in conjunction with a tarsal strip provides lasting lateral canthal fixation. This consecutive clinical series from two ambulatory surgery centers followed 79 patients who underwent 141 lateral canthal fixation procedures. Outcome was measured by the position of the lateral canthus. Correct positioning of the lateral canthus was achieved in 78 of 79 patients representing 139 of 141 procedures (98%). The failed case was a patient with floppy eyelid syndrome in whom the sutures tore through the tarsal strips. The tarsal strip-periosteal flap technique is a successful, technically direct method of lateral canthal fixation. It is promoted as an enhancement of the tarsal strip technique, and is especially helpful in patients with prominent eyes.

The eye is convergent from the orbital axis when in the primary gaze position; greater projection of the lateral sclera results from the posterior location of the lateral orbital rim relative to the medial orbital rim. If the horizontal tarsal ligamentous band cannot lengthen to accommodate an increasingly exophthalmic globe in thyroid ophthalmopathy, a horizontally tight eyelid with increased exposure of the lateral sclera will result; thus, temporal flare is accentuated. Lateral canthal advancement was developed as an adjuvant procedure to reduce temporal flare in the surgical repair of thyroid-related eyelid retraction. Lateral canthal advancement is a theoretically rational and effective adjunct to retractor recession when horizontal tightness of the eyelid is present. In the horizontally tight eyelid, lateral canthal advancement is effective in enhancing the effect of retractor recession and in reducing temporal flare.

The ancient schwannoma is a rare variant of a neurilemoma with a course typical of a slow-growing benign neoplasm. Histologically, it can be confused with a malignant mesenchymal tumor because of increased cellularity, nuclear pleomorphism, and hyperchromatism. Despite the degree of nuclear atypia, mitotic figures are absent. We describe the clinical and histopathologic features of an ancient schwannoma of the orbit.

This study was designed to evaluate the characteristics of human orbital fat and connective tissue. Two exenteration specimens were studied by light microscopy with special stains. Four distinct regions were identified on the basis of their connective tissue septa, which contained blood vessels and were composed of elastin and collagen types I, III, and IV. Transmission electron microscopy was performed on the opposite orbits. The fibroblasts and adipocytes appeared metabolically inactive and showed no regional differences. The fat was phase extracted from the connective tissue and subjected to biochemical analysis. No regional differences were found in the content of fatty acids and protein. The fatty acids included palmitic acid (22-24.6%), oleic acid (45-51.5%), and linoleic acid (15-18.6%). Despite demarcation of the orbital fat into distinct regions by the connective tissue septa, ultrastructural and biochemical analysis revealed no regional variations in the fat. The diagnostic and therapeutic implications of these findings are discussed.

A 78-year-old man underwent ectropion repair with a monopolar electrosurgical unit. A flash fire occurred, resulting in a loss of eyelashes of the left upper and lower eyelids. A retrospective analysis of the case was conducted, including a review of the relevant literature. Although rare, the possibility of a flash fire should be considered when performing surgery with an electrosurgical unit. Minimizing supplemental oxygen and electrosurgical power settings may help to avoid such an incident.

Background: Human cysticercosis is secondary to an infestation by cysticercus cellulosae, the larval form of Taenia solium. Cysticercosis is endemic to regions with poor sanitation. The purpose of this report is to present a large series of patients with orbital cysticercosis and to discuss the current treatment., Methods: A retrospective chart analysis of all patients with orbital cysticercosis from an urban practice in southern India was performed. The clinical features, the results of investigations, the therapies instituted, and the outcomes realized were recorded., Results: Twenty patients diagnosed with orbital cysticercosis were identified (11 female and 9 male). Their ages ranged from 5 to 25 years with a mean age of 12.5 years. Nine patients manifested subconjunctival cysts. Eight were excised and 5 of these were densely adherent to the adjacent extraocular muscle (EOM). The remaining 11 patients had a cyst in a single EOM. The EOM cysts had proptosis, restricted motility, recurrent inflammation, and blepharoptosis. Two of the EOM cysts were excised surgically and four extruded spontaneously. Six patients with EOM cysts were treated medically: they all received oral corticosteroids and, additionally, five were given oral albendazole and one was given oral praziquantel., Conclusions: Excisional biopsy is recommended for subconjunctival cysticercosis. Idiopathic cystic myositis can present like EOM cysticercosis, but is differentiated by resolution with corticosteroid treatment. Medical therapy in orbital cysticercosis with oral albendazole and corticosteroids can arrest recurrent inflammation and improve ocular motility.

The use of hard palate mucosal grafts (HPG) in eyelid surgery is becoming increasingly popular. We present two palatal donor site complications that have not been previously reported. The first is an oro-nasal fistula discovered 1 week following surgery. The second is oral candidiasis, which compromised healing of the palatal donor site. With appropriate treatment, both complications resolved shortly after surgery. Careful preoperative evaluation and postoperative follow-up is recommended to recognize and manage these complications.

Distichiasis is a rare congenital or acquired condition in which an accessory row of eyelashes arises from the posterior lamella of the eyelid margin. Previously described surgical techniques to treat distichiasis can result in complications including trichiasis, loss of normal eyelashes, cicatricial entropion, and eyelid margin deformities. We describe a new technique in which the eyelid margin is split to expose the distichiasis eyelash follicles. Each aberrant eyelash follicle is individually excised or microhyfrecated and then removed. Seventeen eyelids in 5 patients with congenital or acquired distichiasis have been treated. We have achieved excellent functional and cosmetic results using this new technique.

Objective: To measure any sex size differences in the bony nasolacrimal drainage systems in a normal, age-matched population., Methods: A retrospective study of axial cut maxillofacial computed tomographic scans was conducted. Three levels of the bony nasolacrimal duct (NLD) system on the right and left sides were measured along the anteroposterior diameter. The data were analyzed using 2-tail t test, analysis of variance, and linear regression methods., Results: Scans from 71 adult patients (36 men and 35 women) were reviewed. Women were found to have a smaller bony diameter at the level of the lower fossa (P = .01) and the middle NLD (P = .06) compared with those of men. The adult inferior bony fossa increased in size with age in both men and women, while the middle NLD increased in size in men only. No significant size difference was found between the right and left side at any level., Conclusions: Size differences are found in measurements of bony nasolacrimal excretory systems in men vs women. Women have significantly smaller dimensions in the lower nasolacrimal fossa and the middle NLD. The anteroposterior dimension of the bony nasolacrimal canal at the fossa level enlarged in both sexes, with age co-inciding with osteoporotic changes throughout the body. These quantitative anatomical observations provide a contributory factor to explain the increased prevalence of primary acquired NLD obstruction in women.

Objectives: To define the lateral extension of the Müller muscle and to elucidate its involvement in the development and surgical treatment of Graves (thyroid) eye disease., Methods: Twelve lateral halves of orbits exenterated from patients with medial or posterior orbital neoplasms were fixed, embedded, and step sectioned at 250-microns intervals to produce histological sections. Gross anatomical dissections of human cadaver heads were also used to corroborate the histological findings., Results: Histological analysis revealed that the Müller muscle extended laterally between the orbital and palpebral lobes of the lacrimal gland in all specimens. The smooth muscle fibers were found to interdigitate with lacrimal ducts passing from the orbital to palpebral lobe and to extend close to the ductal orifices at the conjunctival surface. Gross dissections confirmed that the Müller muscle accompanied the levator aponeurosis lateral extension, which is known to pass between the orbital and palpebral lobes of the lacrimal gland., Conclusions: Our anatomical findings suggest that the Müller muscle may contribute to the temporal flare frequently seen in eyelid retraction associated with thyroid eye disease. They may also explain the difficulty of treating lateral eyelid retraction in thyroid eye disease and indicate the need for new surgical approaches for severe lateral eyelid retraction.

Cystic lesions of the extraocular muscles (EOMs) are uncommon. Six patients with a cystic lesion in an extraocular muscle, as observed by computerized tomography (CT) scanning, were retrospectively identified from the practice of one of the authors (G.C.S.), and their clinical course was reviewed. All the patients were treated initially with oral corticosteroids. Those who did not respond to this therapy underwent surgical exploration. Four patients demonstrated complete resolution of clinical signs and symptoms with oral steroid therapy. Posttreatment CT scans performed in two of these patients showed resolution of the cystic lesion with residual muscle thickening in one. The two patients not responding to steroids underwent surgical excision and histopathology confirmed the diagnosis of cysticercosis. Cysticercosis is a previously reported cause of a cystic lesion in an EOM. To the best of our knowledge, cystic lesions of the EOMs resolving with steroids have not been previously reported. Response to oral steroids in four of our patients is suggestive of myositis with a cystic change in the muscle. We recommend a trial of oral steroid therapy in patients with a cystic EOM lesion before surgical exploration is performed.

The orbital and eyelid relationships of the superficial musculoaponeurotic system (SMAS) were studied in human cadavers. Using gross and microscopic techniques, the SMAS was found to be intimately related to the eyelids and orbicularis oculi muscle, and to have distinct orbital bony attachments. Sub-SMAS fat in the malar region was found to be continuous with the submuscular fat in the eyebrow region. The malar sub-SMAS fat continued superiorly into the lower eyelid above the inferior orbital rim, as a postorbicularis layer. A bony attachment emanating from the inferior orbital rim, the orbitomalar ligament, traveled through the orbicularis oculi muscle in a lamellar fashion prior to inserting into the dermis. The cutaneous insertion of this attachment corresponds to the malar and nasojugal skin folds. With aging, relaxation of the orbitomalar ligament allows inferior migration of orbital fat, in addition to the anterior migration that occurs through an attenuated orbital septum. These findings have implications not only in cosmetic surgery but also in the understanding of facial soft tissue changes that occur with aging.

Traumatic blow-out fractures of the orbital floor are a common injury that can lead to significant morbidity. Accepted indications for surgical repair include displaced fractures consisting of a defect > 50% of the orbital floor, extraocular muscle entrapment, and clinically significant enophthalmos. Although infraorbital nerve hypesthesia has been reported as an indication for repair of fractures of the zygomatic complex and is often encountered as an associated finding in fractures of both the orbital floor and inferior orbital rim, it has not been generally regarded as a primary indication for blow-out fracture repair. We report two patients in whom severe, progressive infraorbital nerve hypesthesia served as the primary indication for surgical repair. Both patients experienced improvement in infraorbital nerve function following surgical repair, accompanied by persistent pain and paresthesias in the distribution of the infraorbital nerve. We suggest that progressive infraorbital nerve hypesthesia should be considered a primary indication for blow-out fracture repair in selected patients in whom hypesthesia is both severe and progressive.

Botulinum toxin has recently been used as a nonsurgical treatment for blepharospasm and other facial dyskinesias. This report describes four patients between the ages of 32 and 37 years who failed to respond to botulinum injections for severe blepharospasm. Other than age, no other features could be identified in these patients that would differentiate this group. Particularly early age of onset for essential blepharospasm might be an indicator of failure to respond to the injections.

Background: Endonasal laser-assisted dacryocystorhinostomy has been a subject of much interest since its introduction in 1990, offering the potential advantages of decreased postoperative morbidity and the lack of a cutaneous scar. In this study, the authors report the results of 46 endonasal laser-assisted dacryocystorhinostomy procedures performed on 42 patients between February 1991 and July 1992., Methods: The medical records of all patients undergoing endonasal laser-assisted dacryocystorhinostomy procedures were reviewed retrospectively in detail. Patients undergoing laser-assisted external dacryocystorhinostomies or conjunctivo-dacryocystorhinostomies and those with follow-up periods less than 4 months were not included in the study., Results: A total of 46 endonasal laser-assisted dacryocystorhinostomy procedures were performed. Of these, 32 were successful and 14 failed after a single attempt, yielding a success rate of 70% (32/46). Of the 14 patients with failed procedures, 6 underwent a second endonasal laser-assisted dacryocystorhinostomy. Of these, five were successful. The success rate calculated on the basis of one or two attempts was 80% (37/46)., Conclusions: The science and technology of endonasal laser-assisted dacryocystorhinostomy is undergoing a continuous process of evolution as a number of modifications are introduced, including better patient selection, more complete tissue removal at the osteotomy site, and the adjunctive use of mitomycin C. As this process continues, it is likely that the success rates in this modality will improve, making it an increasingly attractive alternative to external dacryocystorhinostomy.

We studied the relationship between eye dominance (Scobee test) and upper lid level (MRD) in 54 patients with unilateral ptosis or asymmetric bilateral ptosis (> or = 2 mm difference in MRD) using the phenylephrine test. A contralateral lid drop was measured in 12/54 patients after instillation of 2.5% phenylephrine in the more ptotic eye and occurred in both congenital (3) and acquired (9) ptosis cases. A contralateral lid drop was seen in 7/14 (50%) patients whose ptosis was greater in the dominant eye and in 5/40 (12.5%) patients whose ptosis was greater in the nondominant eye (p = .01). Contralateral lid drops > or = 1 mm were present in 7/54 patients, and 6/14 (43%) of them had greater ptosis on the dominant side and 1/40 (2.5%) on the non-dominant side (p = .001). There was no association between contralateral pseudoretraction and either visual acuity or severity of ptosis. These results suggest that levator muscle tone is influenced by eye dominance when ptosis is present. The preoperative evaluation of unilateral or asymmetrical bilateral ptosis cases should include the Scobee and phenylephrine tests to unmask contralateral upper lid pseudoretraction.

The presence of orbital lymphatics in the primate model is demonstrated using light and electron microscopic enzyme histochemistry. In addition, strictly morphological definitions of lymphatics, such as discontinuous basal lamina, thin and irregular walls, anchoring filaments, and attenuated endothelial cell cytoplasm, were applied. This study confirmed the presence of conjunctival lymphatics reported by others. It also clearly demonstrated the presence of orbital arachnoid and lacrimal gland lymphatics that have not been previously described. A few areas of the extraocular muscles and connective tissue at the orbital apex also showed evidence of the presence of lymphatic vessels. Additional work is needed to define the nature and extent of orbital lymphatics as well as their connection to the extraorbital lymphatic system.

This light and electron microscopic study demonstrates an elastic fiber network (EFN) for the levator palpebrae superioris muscle complex, which forms an intricate insertion into the upper eyelid. The EFN is examined in the monkey, in a fresh exenteration specimen, and in fresh frozen cadaver specimens from both sexes of different age groups. Multiple elastic insertions of the levator aponeurosis and Muller's muscle attachment with well-organized elastic fibers are demonstrated using special staining techniques and serial microscopic sectioning. Transmission electron microscopy (TEM) confirms the ultrastructure of "mature" elastin fibers in Muller's muscle tendon and their close relationship with the elastin-related fiber, oxytalan. Current thinking concerning the nature of elastic fibers and their possible implications in acquired involutional blepharoptosis is discussed. This microscopic study of the EFN of the upper eyelid focuses attention on the multiple elastic fiber insertions of the levator muscle complex that includes the levator aponeurosis, the conjoined fascia, the lid crease area, and Muller's muscle tendon, which have not been previously described.

We present new information regarding the sympathetic nerve anatomy in the cavernous sinus and retrobulbar orbit of the cynomolgus monkey. Postganglionic sympathetic nerves were identified using an immunoperoxidase technique in which the primary antiserum was directed against tyrosine hydroxylase, the rate-limiting enzyme in norepinephrine synthesis. Our work is unique in adapting this staining method to paraffin-embedded tissue. This technique allows sympathetic nerve fibers to be distinguished from other autonomic, sensory, and motor nerves. A large sympathetic nerve bundle lateral to the internal carotid artery in the cavernous sinus gave off one or more branches that leave the artery to encircle the abducens nerve. Further division occurs within the cavernous sinus, but all sympathetic nerve fibers destined for the orbit entered it through the superior orbital fissure. None pass through the optic canal. In the orbit, sympathetics were associated with the ophthalmic artery and some of its branches and with the sensory root to the ciliary ganglion. After entering the ganglion, the sympathetic fibers were lost to detection in most specimens, but they were again seen in a single short ciliary nerve in one instance. Sympathetic nerve fibers were not detected adjacent to several structures identified in the human anatomy literature, such as the intracranial and intracanalicular segments of the ophthalmic artery, the nasociliary nerve, the long ciliary nerves, the nerve to the inferior oblique muscle, or the lacrimal artery and nerve.

Fifty-eight patients (69 eyes) underwent conjunctivodacryocystorhinostomy for lacrimal canalicular obstruction. The cause of lacrimal obstruction and the results and complications of the operation were analyzed. Trauma and idiopathic disease were the most common causes of lacrimal canalicular obstruction in 24 of 69 (34.8%) eyes each. Relief of epiphora was achieved in 68 of the 69 eyes (98.5%). The complications included tube displacement in 40 of the 69 eyes (57.9%), tube obstruction in 19 of the 69 eyes (27.5%), and infection of the lacrimal sac in four of the 69 eyes (5.8%). Despite frequent complications, most Jones tubes can be made to function satisfactorily. Conjunctivodacryocystorhinostomy remains the best surgical treatment at this time for permanent loss of canalicular function.