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There has been an increased recognition for the role volume deflation plays in the aging periorbital area, and as such, rejuvenation strategies to augment and restore volume have developed and evolved. Hyaluronic acid fillers provide an efficient option for volume augmentation with good efficacy, longevity, and safety. An understanding of the changes in the upper and lower periocular area due to aging, the meticulous identification of focal hollows, and the precise delivery of filler to these areas can smooth contours and restore a rejuvenated periorbital area.

Surgery of the orbit entails a firm understanding of complex bony and soft tissue anatomy, as the orbit consists of important neurovascular structures that are compressed into a small, confined space with often challenging visualization. Approaches are numerous and are governed by the lesion, size, location (anterior, mid-orbit, apex), and relationship to adjacent soft tissue and bone.

Complications are an inevitable part of surgery and, despite the best preparative efforts, events may not unfold as planned and unanticipated complications inescapably occur. A thorough knowledge of potential complications in order of likelihood and importance is paramount in achieving the best possible outcome, not simply to minimize the occurrence of these events but also to provide the capacity to optimally evaluate and manage such events should they arise. This review summarizes the evaluation and management of complications associated with commonly performed surgical procedures in the field of ophthalmic plastic and reconstructive surgery.

Purpose To compare functional and surgical outcomes of a subperiosteal midface lift with and without the placement of a hard palate mucosal graft (HPMG) in patients with lower eyelid retraction. Design Retrospective, comparative, interventional case series. Participants Thirty-four patients with lower eyelid retractions who underwent surgery at the Jules Stein Eye Institute in a 5-year period. Methods Medical record review of all patients who underwent surgery for lower eyelid retraction by a subperiosteal midface lift with or without an HPMG. Preoperative and postoperative digital photographs were taken in all patients. Main Outcome Measures Change in margin reflex distance 2 (MRD 2 ), measured from the pupillary margin to the upper margin of the lower eyelid; patient discomfort; and surgical complications. Results Thirty-four patients (20 female; mean age, 64 years) participated in the study; 11 underwent bilateral surgery, with overall 43 surgeries performed. Eighteen patients (42%) had lower eyelid retraction secondary to previous transcutaneous lower eyelid blepharoplasty. Postoperatively, patients attained a better lower eyelid position, with improvement of lower eyelid height of 1.4 mm ( P t test). Patients operated using an HPMG (12 surgeries) achieved a greater reduction in MRD 2 postoperatively as compared with patients operated by subperiosteal midface lift alone (31 surgeries; 2.2 mm vs. 1.1 mm, respectively; P = 0.02, Wilcoxon Mann–Whitney). One patient needed reoperation secondary to symptomatic lower eyelid retraction postoperatively. Conclusions The subperiosteal midface lift is effective in correction of lower eyelid retraction of various causes. The use of an HPMG spacer may enhance surgical outcomes and results in a better lower eyelid position.

Purpose To determine whether existing Systemized Nomenclature of Medicine (SNOMED) terminology adequately describes aesthetic concepts commonly encountered in the oculoplastic and facial plastic surgery setting. Methods This was a noncomparative case series. A panel of three oculoplastic surgeons compiled a list of unique concepts describing specialized aesthetic terminology commonly encountered in the oculoplastic and facial plastic surgery setting, with a specific focus on anatomic structures and descriptive findings. A standard electronic browser was used to manually search for the existence of equivalent matching concepts in SNOMED. A quality of match score from 1 to 3 was used with values of (1) no match, (2) partial match, and (3) equivalent match. Results An assessment of the existing aesthetic terminology revealed that a majority of concepts were not represented. Of 62 total concepts, 68% had no match, 13% had a partial match, and 19% had a complete match. Conclusions SNOMED coverage of aesthetic terminology was less than in previous studies examining content representation for other medical topics. Such findings underscore a need for further development and refinement of aesthetic content.

Purpose To evaluate the effect of deep lateral wall orbital decompression with intraconal fat debulking on strabismus in thyroid-related orbitopathy (TRO) patients using automated Hess screen (AHS). Design Prospective nonrandomized clinical study. Participants Eleven TRO patients (19 surgeries) operated on at the Jules Stein Eye Institute from January, 2004, through December, 2004. Methods Automated Hess screen testing was performed in all patients before surgery and 3 months after surgery; all patients received surgery in the nonactive phase of the disease. Main Outcome Measures Amplitude of horizontal and vertical deviations (prism diopters) in all standard positions of gaze. Results Eleven TRO patients (7 females; mean age, 47 years) were included in the study; 8 patients underwent bilateral surgery. After surgery, exophthalmos decreased an average (±standard deviation) of 2.7 mm (±2.5 mm; P = 0.003). Before surgery, 7 patients (63%) reported primary gaze diplopia, whereas only 2 patients (18%) showed diplopia in primary gaze after surgery ( P = 0.03, chi-square analysis). Orbital decompression had no statistically significant effect on horizontal and vertical ocular deviations measured by AHS. Mean amplitude of deviation in primary gaze was 1.2 prism diopters (PD) esotropia and 0.07 PD hypotropia before surgery, and 2.5 PD exotropia with 0.6 PD hypertropia after surgery (δ = 3.7 PD for horizontal deviation and −0.7 for vertical deviation; P = 0.051, paired samples t test for horizontal difference and P not significant for vertical difference). Nonsignificant P values were obtained in all 9 positions of gaze. Most patients had periocular numbness that resolved spontaneously 2 to 6 months after surgery. Conclusions Deep lateral wall orbital decompression with intraconal fat debulking had no statistically significant effect on horizontal and vertical deviations measured by the AHS. Patients may demonstrate small angle exotropia shift, but this finding was not clinically significant.

Purpose To report the clinical and pathophysiologic features of two patients with Mikulicz's disease and to further characterize recommendations for diagnosis and management with a review of the literature. Methods Retrospective nonrandomized consecutive case series, Jules Stein Eye Institute, David Geffen School of Medicine at UCLA. Results Mikulicz's disease is characterized by symmetric lacrimal, parotid, and submandibular gland enlargement with associated lymphocytic infiltrations. The authors noted two cases of Mikulicz's disease. The diagnosis of Mikulicz's disease was based on the following criteria: 1) symmetric and persistent swelling of the lacrimal glands and either or both of the major salivary glands (parotid and submandibular); and 2) the exclusion of other diseases that may mimic this presentation, such as sarcoidosis, viral infection, or lymphoproliferative disorders. Conclusions Mikulicz's disease is a condition in which there is bilateral lacrimal and salivary gland swelling that is not associated with other systemic conditions. The condition is self-limiting and most often, the diagnosis is a clinical one. Previously, Mikulicz's disease was often considered as a subtype of Sjogren's syndrome (SS). Clinical and immunologic differences between Mikulicz's disease and SS may warrant further consideration of Mikulicz's disease as a specific autoimmune phenomenon separate from SS, and Mikulicz's disease may be amenable to different treatment modalities than those employed in patients with SS.

In the setting of facial trauma with fracture of one or more orbital walls, clinically significant enophthalmos is a possible undesirable outcome after primary repair. In this article, the evaluation of patients presenting with acquired enophthalmos and the available minimally invasive and surgical management options are discussed.

Objective To evaluate the efficacy of onabotulinumtoxinA injection for the treatment of refractory filamentary keratitis. Methods A retrospective review of treatment response of 33 eyes of 17 patients with filamentary keratitis resistant to conventional medical therapy who were treated with onabotulinumtoxinA injection was performed. Ocular surface findings, symptom improvement, and the number and location of filaments before and after the injections were recorded. All eyelids were injected subcutaneously with onabotulinumtoxinA (10 U/0.1 mL). All treatments were performed in accordance with an individualized treatment plan using precise localizing treatment maps, with adjustments to dosage based on treatment response. Results Objective and subjective improvement was noted after the initial onabotulinumtoxinA injection in all patients. Filaments completely resolved after the onabotulinumtoxinA injection in 29 eyes (88%). In 20 of these eyes, filaments and punctate fluorescein staining resolved, whereas in 9 eyes, filaments resolved but punctate fluorescein staining persisted. Three eyes (9%) had partial improvement: 2 residual microfilaments were noted in one eye and 1 in the other eye. In 1 eye, filaments resolved after initial and subsequent injections but recurred within 8 weeks of each injection. Although 14 treated eyes (42%) showed sustained improvement after 1 onabotulinumtoxinA injection, additional injections were necessary in 19 eyes (58%) during the follow-up period because of the recurrence of symptoms and filaments on the cornea. Conclusions OnabotulinumtoxinA injection should be considered an effective option for treating refractory filamentary keratitis. Because of the likelihood of recurrence, serial onabotulinumtoxinA injections may be necessary in some cases.

Primary tumors of the lacrimal sac are extremely rare and predominantly epithelial in origin. We report a unique case of fibromyxoma of the lacrimal sac in an 86-year-old Caucasian woman who presented with 3 months of lower eyelid edema and 1 week of purulent discharge, epiphora, and acute pain. Examination revealed right lower eyelid erythema/edema and a tender, firm, palpable mass of the right lacrimal sac, which self-expressed a yellow, purulent discharge. On surgical exploration, a firm, rubbery, yellow mass was encountered and excised. Histopathologic analysis identified a nonencapsulated mass composed of loose interlacing fascicles and bundles of spindle-shaped cells with prominent myxoid changes; immunostaining was strongly positive for vimentin, weakly for smooth muscle actin, and negative for S-100 and muscle-specific actin. These findings were consistent with the diagnosis of a fibromyxoma of the lacrimal drainage system. After excision, the patient did well, with resolution of dacryocystitis.

We report a case of a 37-year-old male with a conjunctival melanocytic nevus presenting in a rare, peripunctal location with preservation of the lacrimal canaliculus and punctum.

A 50-year-old woman presented with a 2-week history of diplopia and right-sided orbital pain with eye movement. Examination revealed an edematous, ptotic right upper eyelid with conjunctival hyperemia, proptosis, and significant limitation to upward and downward ductions on the right. MRI was significant for a homogeneously enhancing lesion within the superior rectus muscle. A laboratory evaluation seeking an infectious, inflammatory, or autoimmune process was nonrevealing. A diagnosis of orbital myositis was made, and the patient experienced significant improvement with oral corticosteroids. The patient's symptoms, however, recurred after attempts at a slow taper of the corticosteroids. An orbital biopsy of the lesion revealed fibroadipose tissue containing irregularly shaped yellow-white deposits birefringent under polarized light, suggestive of silica crystals. The patient denied any history of trauma or prior surgery. An intraorbital triamcinolone injection to the superior orbit allowed resolution of symptoms and a successful taper off systemic corticosteroids.

The surgical aims of midface lifting are to restore the inferiorly displaced midfacial tissues to their youthful anatomic position through vertical elevation and repositioning. Lifting of these tissues along with concurrent lower eyelid blepharoplasty and repositioning of fat over the orbital rim may provide added benefi t in camoufl age of the doubleconvexity facial profi le of the aging face.

The modulation of wound healing in the postoperative setting is a vital component of aesthetic eyelid and periorbital surgery, particularly in situations of disorganized wound healing and exuberant scar formation. While surgical approaches that minimize scar formation continue to evolve, the management of wound healing and scar formation is limited by biologic considerations. Use of nonsurgical treatment modalities that target the underlying biologic process continues to evolve. While the field awaits introduction of specific modulators that interrupt these mechanisms, the adjunct use of anti-metabolites, anti-inflammatory agents, and tissue volume expansion can provide substantial benefit with minimal risk.

Orbital cellulitis describes an infection involving the soft tissues posterior to the orbital septum, including the fat and muscle within the bony orbit. This condition may be associated with severe sight and life-threatening complications. Despite significant advances in antimicrobial therapies and diagnostic technologies, the management of orbital cellulitis often remains challenging, and rapid diagnosis and prompt initiation of therapy are important in minimizing complications and optimizing outcomes. This review summarizes the distinctive characteristics of preseptal and orbital cellulitis, with a focus on anatomic considerations, predisposing conditions, approaches to evaluation, and management strategies.

Dermoid cysts are common tumors resulting from entrapped ectodermal elements at fetal suture lines. Management is conceptually straightforward, with surgical excision of the mass in its entirety without rupture. The conspicuous location and potential scarring from direct excision can be objectionable, particularly in children. The authors describe 2 cases using a hidden hairline incision and an endoscopic approach to remove dermoid cysts in the nasoglabellar region.

Lemierre's syndrome is characterized by acute oropharyngeal infection with secondary internal jugular vein thrombophlebitis and subsequent metastatic infections. 1 The anaerobe Fusobacterium necrophorum is the usual etiologic agent, although other microorganisms, including Streptococcus , Staphylococcus , Enterococcus , Bacteroides , and Lactobacilli , may be present alone or in combination with F. necrophorum . 1-3 Common sites of metastatic infection include the lungs and joints. Thromboembolic complications, such as septic pulmonary embolism, persistent jugular vein occlusion, hepatic abscesses, and nephropathy, may occur. 1,2 We report a case of Lemierre's syndrome in a 3-year-old Caucasian boy who subsequently presented with manifestations of a fourth (trochlear) nerve palsy.

To evaluate the outcome of Müller's muscle-conjunctival resection (MMCR) for correction of upper eyelid ptosis and to explore the relationship between phenylephrine testing, muscle resection, and surgical outcome.Medical records were reviewed for all patients who underwent MMCR at the Jules Stein Eye Institute, Los Angeles, California, from January 1, 1999, through June 30, 2005. Outcome measures were margin reflex distance-1, ptosis correction after instillation of phenylephrine drops, extent of MMCR, ptosis correction, and eyelid symmetry.In 80 patients who underwent 131 MMCR procedures for correction of upper eyelid ptosis, margin reflex distance-1 increased on average by 1.6 mm (P.001). In 106 patients (81%), eyelid symmetry equal to or less than 1 mm was achieved (P = .02). Phenylephrine testing underestimated the extent of ptosis correction achieved with MMCR. A weak correlation was found between the extent of MMCR and ptosis correction (r = 0.2; P = .04).Müller's muscle-conjunctival resection is effective for ptosis correction in patients with good levator muscle function; good eyelid symmetry is achieved in most patients. Phenylephrine testing underestimated the ptosis correction achieved with MMCR by 40%. The relationship between MMCR and ptosis correction is complex.

Purpose To report our preliminary experience utilizing a nonsurgical alternative in the treatment of lower eyelid retraction: expansion and reinforcement of the lower eyelid with hyaluronic acid gel. Methods Retrospective review of patients with lower eyelid retraction treated with hyaluronic acid gel. Pretreatment, post-treatment, and follow-up photographs were digitized and overall outcomes assessed. Measurements of inferior scleral show were standardized and compared. Results Sixty-five procedures (31 patients; 14 male; mean age 58 years, range, 33-78 years) with lower eyelid retraction of various etiologies were treated with hyaluronic acid gel. A mean change in scleral show of 1.04 mm was found when pre- and post-treatment measurements were compared. The overall mean follow-up period was 6.2 months (range, 1-12 months). During the interval from initial treatment to follow-up visit (mean 4.6 months, range, 1-12 months), the effect of the hyaluronic acid gel diminished, with a mean increase in inferior scleral show of 0.52 mm. Twelve patients underwent a second, and 6 patients underwent a third, maintenance treatment with an improvement in scleral show of 0.87 mm and 1.13 mm, respectively. Complications were minor and included swelling, redness, bruising, and tenderness at the sites of injection. Conclusions Based on our preliminary results, hyaluronic acid gel shows promise as a treatment modality for the management of lower eyelid retraction. Long-term follow-up will better clarify the required frequency of maintenance injections, the degree of hyaluronic acid gel retention, and the position of the lower eyelid over time.

Basal cell carcinoma (BCC) is the most common non-melanoma skin cancer, and its incidence continues to rise. Current management options are numerous and focus on tumour eradication while maximising cosmetic and functional capacity. Although surgery continues to be considered the main treatment modality, new pharmacological agents, such as immunomodulators, topical chemotherapeutic agents and photodynamic therapy, have emerged and show promising results. Pharmacological agents offer the potential for lower morbidity and improved tissue preservation compared with surgery and radiotherapy. However, pharmacological treatments possess higher failure rates when compared with surgery, and most studies have investigated only low-risk lesions. Several prospective, randomised, double-blind, vehicle-controlled studies have established the efficacy of imiquimod for superficial BCC. This review summarises the evidence regarding the mechanism, efficacy and safety of pharmacological agents based on the literature from the past 10 years. Experimental treatments that have been successfully utilised in the treatment of BCC are also discussed. Treatment of BCC with other agents, such as tazarotene, glycoalkaloid (BEC-5) cream, cidofovir and calcium dobesilate have been reported, but further studies are needed to ascertain the efficacy and adverse-effect profiles of these treatments.

Objective: To describe a modified technique for conjunctivodacryocystorhinostomy (CDCR) and to compare this technique with the standard transcaruncular placement of the glass tube. Methods: Patients with upper lacrimal system obstructionunderwentCDCRattheJulesSteinEyeInstituteduring a 3-year period. Thirteen patients underwent modified CDCR leaving the caruncle intact, while 7 patients underwent Jones glass tubes placement through a caruncular incision (conventional CDCR). Data regarding ocular and tearing history were recorded and analyzed. Successrates,definedascompleteimprovementintearing,were comparedbetweenpatientswhounderwentstandardCDCR and those who underwent modified CDCR. Main outcome measures included symptom relief, patients’ tolerance of the Jones tube, and surgical complications. Results:Nineteenpatients(12menand7women;mean age, 66 years) underwent 20 CDCR surgical procedures with Jones tube placement. Previous lacrimal history included malignancy of the ocular adnexa, trauma, chemotherapy, and previous failed dacryocystorhinostomy. Success was found in 13 surgical cases (65%) and partial improvement was found in 4, giving a qualified success rate of 85%. Patients who underwent modified CDCR were more likely to undergo a successful surgery compared with patients who underwent conventional CDCR,with11(85%)of13casesachievingcompleteimprovement vs 2 (29%) of 7 cases in the conventional CDCR group (P=.03, Fisher exact test). Complications included 1 case of migration and loss of the Jones tube. Conclusion: Modified CDCR results in partial or complete resolution of tearing in nearly 92% of cases, allowing for an improved outcome both functionally and cosmetically compared with conventional CDCR.

To compare external levator advancement and Müller's muscle-conjunctival resection (conjunctivomullerectomy, or CJM) for correction of upper eyelid involutional ptosis.Retrospective, nonrandomized, comparative interventional case series.Review of medical records of 159 patients (272 surgical procedures) who underwent external levator advancement or CJM was performed.Functional and cosmetic outcome, marginal reflex distance one (MRD1), and surgical complications.A total of 159 patients (51 men, 108 women, mean age 70 years) underwent 272 surgical procedures for upper eyelid ptosis; concurrent blepharoplasty was performed in 141 cases. MRD1 increased an average of 1.6 (+/-1.5) mm, from 0.8 mm (+/-1.2) preoperatively to 2.3 mm (+/-1.2) postoperatively (P.001). Fifteen patients (5.5%) underwent reoperation for residual ptosis, nine (18%) in the external levator advancement group, two (3%) in the CJM group, three (8%) in the external plus blepharoplasty group, and one (1%) in the CJM plus blepharoplasty group (P.001). Patients who underwent external levator advancement had significantly more severe ptosis preoperatively but attained similar eyelid position postoperatively as compared with CJM patients. Complications included overcorrection in four cases (1.4%), lagophthalmos of 1 mm in 10 (3.6%), and pyogenic granuloma in two (1%).External levator advancement and CJM performed alone or with concurrent blepharoplasty are effective treatments for upper eyelid ptosis. Residual ptosis or postoperative eyelid retraction occurs in up to 20% of cases and can be addressed successfully with a second operation.

Purpose To compare success rates of external dacryocystorhinostomy (DCR) and endoscopic endonasal DCR for acquired nasolacrimal duct obstruction (NLDO). Design Retrospective, comparative, nonrandomized clinical study. Participants One hundred forty-three patients (176 surgeries) operated for acquired NLDO. Methods A review of electronic medical records of patients with acquired NLDO who underwent DCR at the Jules Stein Eye Institute from 1999 to 2004 was performed. Data regarding the lacrimal drainage system, comprehensive eye examination, surgical outcome, and postoperative nasal endoscopy were analyzed. Main Outcome Measures Surgery failure was defined as (1) no marked improvement in tearing or any episode of postoperative dacryocystitis, (2) inability to irrigate the lacrimal system postoperatively, and (3) postoperative nasal endoscopy with scarring in the intranasal osteotomy or no visualization of fluorescein dye. Postoperative nasal endoscopy was performed in all failed cases and in >50% of all patients. Results One hundred forty-three patients (48 male and 95 female; mean age, 63 years) underwent 176 DCR surgeries for acquired NLDO. Success was achieved in 135 cases (76.7%), and failure in 41 (23.3%). Of the 41 failed cases, anatomical obstruction at the fistula site was found in 20 (49% of failed cases), whereas functional failure with no evidence of obstruction was found in 21 (51%). Surgery revision was performed in 22 cases (12.5%), but it was successful in only 9 (5.1%); patients who failed the first revision were likely to fail additional revisions ( P = 0.02). History of facial trauma was associated with surgery failure. In our patients, endoscopic DCR (86 cases) had a significantly higher success rate than external DCR (90 cases), 84% versus 70% ( P = 0.03). Complications included 1 patient with nose bleeding on the first postoperative day that resolved with nasal packing and 2 patients with sump syndrome that resolved after endoscopic revision. Conclusions The success rate of DCR for acquired NLDO in our group of patients was 77%, lower than reported in previous studies, with endoscopic surgery showing better results. Success rates of revision surgery were relatively low (

Purpose To evaluate the outcome of eyelid retraction surgery in thyroid-related orbitopathy (TRO) patients in 2 different surgical settings: done simultaneously with orbital decompression or as a staged procedure after orbital decompression. Design Retrospective, comparative, nonrandomized clinical study. Participants Ninety-six patients (158 eyes). Methods A review of electronic medical records of TRO patients who underwent surgery for upper eyelid retraction and orbital decompression at the Jules Stein Eye Institute in 1999 to 2003 was performed. Data regarding eyelid position, comprehensive eye examination, surgical outcome, and complications were analyzed. Main Outcome Measures Anatomical and functional success based on margin reflex distance (MRD1; ≤5 mm was graded as mild retraction; >5 mm and 7 mm, severe), and patients' discomfort. Results One hundred fifty-eight eyelid retraction surgeries were performed on 96 TRO patients (18 male and 78 female; mean age, 48 years); mean follow up time was 15 (±12) months. Group 1 consisted of patients undergoing simultaneous eyelid retraction surgery and orbital decompression and comprised 97 cases (surgeries). Group 2 included 61 cases of staged surgery: orbital decompression and eyelid retraction at a later stage. The groups had similar surgical outcomes, and >85% had a better eyelid position postoperatively. Reoperation rates for residual or recurrent eyelid retraction were similar, overcorrection was higher in group 2 (5% vs. 0%, P = 0.03). Changes in MRD1, lagophthalmos, and exophthalmos were similar ( P >0.05, independent samples t test). Correction of eyelid retraction was effective in treating patients' discomfort and exposure keratopathy ( P = 0.04, χ 2 ). No severe complications occurred after orbital decompression or eyelid retraction surgery in this group of patients. Conclusions Transconjunctival Muller's muscle recession for correction of eyelid retraction in mild to moderate TRO patients, performed simultaneously with deep lateral wall orbital decompression, resulted in acceptable eyelid position in two thirds of our patients. Overcorrection and consecutive ptosis occurred less often after combined orbital decompression and eyelid retraction surgery than after isolated eyelid repositioning surgery. If confirmed in prospective controlled studies, eyelid-repositioning surgery performed at the time of orbital decompression may decrease the number of total procedures and compress the time needed for surgical rehabilitation.

Orbital varices are vascular malformations consisting of abnormal venous channels. Indications for intervention include loss of vision, elevated orbital pressure with motility deficit, and intractable pain. We present a case of a 65-year-old woman with an orbital varix, who underwent embolization via endovascular coiling. This treatment resulted in an intralesional thrombosis with subsequent enlargement of the varix, leading to a compressive optic neuropathy and severe vision loss. If an intervention is to be contemplated, the possibility of this rare but serious complication should be carefully considered and patients appropriately counseled.

Background To describe an episode of thyroid associated orbitopathy (TAO) following the initiation of thiazolidinedione (TZD). Case presentation We report a female patient with a history of Graves' disease and stabilised thyroid associated orbitopathy for 2.5 years, who experienced rapid progression of TAO after the initiation of thiazolidinedione for glycemic control. Following the discontinuation of TZD, the patient experienced subsequent stabilisation of disease and normalization of vision. The medical history, ophthalmic findings, and clinical course are discussed. Conclusion Thiazolidinediones may exacerbate TAO, and this should be taken into consideration when selecting treatment for diabetic patients with a history of autoimmune thyroid disorders.