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Purpose: To directly compare margin-reflex distance 1, margin-reflex distance 2, and palpebral fissure in the upright versus supine positions in nonsurgical patients., Methods: A total of 43 patients (31 female, 12 male, and age range 26-96) were enrolled. Photos were taken in the clinic in the upright and supine position with a ruler placed vertically in the same plane as the eyelid, and the above computer-analyzed measurements were obtained., Results: Among the 86 eyes observed, the average upright margin-reflex distance 1 was 2.97 mm (95% confidence interval [CI], 2.70-3.24), while the average supine margin-reflex distance 1 was 2.38 mm (95% CI, 2.13-2.63). These differences were statistically significant ( p < 0.001). Similarly, statistically significant differences were seen with margin-reflex distance 2 ( p < 0.001), where upright measurements averaged 5.57 mm (95% CI, 5.33-5.81), and supine measurements averaged 5.01 mm (95% CI, 4.73-5.28). Finally, palpebral fissure showed similar significance ( p < 0.001). Upright measurements averaged 8.54 mm (95% CI, 8.19-8.90), while supine measurements averaged 7.38 mm (95% CI, 7.00-7.76)., Conclusions: Supine positioning provides a decrease in margin-reflex distance 1, margin-reflex distance 2, and palpebral fissure when compared with upright positioning in nonsurgical patients. This contradicts a previous study on intraoperative patients when lidocaine with epinephrine was used. This study helps us better understand the normal physiologic response to position changes with regard to eyelid height in the nonsurgical patient. As such, this study may function as a control for future studies comparing anesthetic/surgical parameter effects on intra- and post-operative eyelid heights., Competing Interests: The authors have no financial or conflicts of interest to disclose., (Copyright © 2024 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Purpose : To directly compare an algorithmic external levator resection technique with the choice of intraoperative adjustment to the same technique without intraoperative adjustments. Methods : A sequential controlled prospective comparative cohort study. Two cohorts were compared: a historical control adjustment, and an experimental non-adjustment group. Fourteen patients, 25 eyelids, were in the historical cohort; and 15 patients, 23 eyelids, were in the non-adjustment cohort. Primary acquired ptosis patients who met inclusion criteria were considered. All patients underwent a standardized external levator resection technique. Intraoperative adjustments were performed only in the historical cohort. Age, follow-up time, surgical time, and marginal reflex distance 1 (MRD1) were collected. Statistical analysis was performed using the Mann-Whitney U test. Statistical significance was p < 0.05. Primary and secondary outcome measures were postoperative MRD1 minus goal MRD1, and surgical time, respectively. Results : Twenty-five historical eyelids were compared with 23 non-adjusted eyelids. The average patient age was 68.4 years (range 19-84) and 59.3 years (range 24-83) for the adjusted and non-adjusted groups. Six-month postoperative (postoperative minus goal) MRD1 was -0.1 mm (95% CI -0.3-0.1) and -0.2 mm (95% -0.5-0.0) ( p = 0.33), and surgical time was 13.8 min (95% CI 12.6-15.1) and 9.5 min (95% CI 9.0-10.1) ( p < 0.001) for the adjusted and non-adjusted cohort, respectively. Conclusions : The external levator resection, utilizing a standardized algorithm approach, is an efficacious technique for involutional eyelid ptosis. With sound technique, this method can be performed without the need for intraoperative adjustment, thereby saving operative time and achieving similar results.

Introduction: Trans-lamina cribrosa pressure has been postulated to be a contributor in the development of a glaucomatous optic nerve versus optic nerve edema, depending on the pressure gradient. Uncertainty remains in the therapeutic outcome of adjusting this gradient., Case Report: We discuss a unique case of idiopathic intracranial hypertension presenting as asymmetric optic disc edema following trabeculectomy. It was treated via optic nerve fenestration due to the patient remaining symptomatic on maximum tolerated acetazolamide. Intraocular pressure stabilized into target range and the optic nerve edema resolved., Conclusions: Rarely, intraocular pressure reduction can unmask elevated intracranial pressure, leading to optic nerve edema. Optic nerve sheath fenestration is a practical therapeutic modality to consider when treating this occurrence.

Ocular adnexal lymphoma and intraocular lymphoma, whether occurring simultaneously or sequentially, are often similar to associated systemic lymphoma. We describe 4 cases of ocular adnexal lymphoma or intraocular lymphoma with a dissimilar systemic lymphoma. Two of the cases represent Richter transformation of chronic lymphocytic leukemia/small-cell lymphoma into diffuse large B-cell lymphoma. In the third patient, conjunctival extranodal marginal zone lymphoma developed following treatment for Hodgkin lymphoma. The fourth patient had a remote history of systemic diffuse large B-cell lymphoma with a subsequent diagnosis of orbital extranodal marginal zone lymphoma. Clinical-pathological correlation is reported for all cases in addition to pertinent review of the literature., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose: To investigate the effects of performing a previously described algorithmic levator resection for involutional ptosis with a blepharoplasty instead of through a small incision., Methods: Eyelids with involutional ptosis and normal levator function were included in the study. An upper blepharoplasty was performed first. An external levator resection was then performed based on a described technique involving 2 mm resection of aponeurosis for 1 mm of desired lift, consistent tension on the aponeurosis between surgical cases, and standardized suture placement., Results: Forty-one eyelids of 25 patients were included. Mean postoperative margin to reflex distance 1 (MRD1) was 2.98 mm, which was significantly higher than preoperative MRD1 (0.67 mm), but lower than the predetermined goal MRD1 (3.35 mm). Eight eyelids did not meet primary outcome of MRD1 within 1 mm of goal MRD1, with 5 undercorrections. There was no difference between the postoperative MRD1 compared with the same ptosis technique performed through a small incision only, but there were more intraoperative suture adjustments and fewer eyelids meeting the primary outcome when a concurrent blepharoplasty was performed., Conclusions: The addition of blepharoplasty with a previously described algorithmic approach external levator resection has an 80% success rate in achieving the primary outcome. When compared with a small-incision ptosis repair, concurrent blepharoplasty results in a less predictable outcome and an increased need for intraoperative adjustment. Performing an algorithmic technique for external levator resection with a blepharoplasty has less predictable outcomes, which raises the question of separating the procedures to improve patient care.

Importance: External surgical treatment of involutional ptosis with normal levator function is challenging owing to lack of an established algorithm. Developing an algorithm-based technique could improve postoperative results while limiting intraoperative inefficiencies., Objective: To investigate the postoperative success of an algorithmic external levator aponeurosis resection technique for aponeurotic ptosis with good levator function., Design, Setting, and Participants: This retrospective cohort study included patients with involutional ptosis and normal levator function who were treated from July 1, 2015, through November 30, 2016, at a private ophthalmic plastic surgery clinic., Interventions: The technique involved a small incision in the eyelid crease, with dissection through the orbital septum to expose the levator aponeurosis. The leading edge of the aponeurosis was then clamped to a medical-grade spring scale to standardize the stress on the eyelid between patients. Two millimeters of aponeurosis were resected for every 1 mm of desired ptosis correction. Two sutures were then placed to connect the aponeurosis to the tarsus at predetermined locations., Main Outcomes and Measures: Preoperative predicted (goal) vs actual margin reflex distance-1 (MRD1)., Results: Twenty-six eyelids of 15 patients (6 men and 9 women; mean [SD] age, 65 years [range, 17-84 years]) met inclusion criteria. The mean follow-up was 189 days (range, 63-343 days). The mean preoperative MRD1 was 0.44 mm (range, -0.5 to 2 mm; 95% CI, 0.18-0.70 mm) compared with the final mean MRD1 of 3.2 mm (range, 2.5-4.0 mm; 95% CI, 3.1-3.4 mm; P < .001). The mean predicted goal MRD1 was 3.4 mm (range, 2.5-4.0 mm; 95% CI, 3.2-3.5 mm). The final MRD1 of all eyelids was within 1 mm of the goal MRD1. The mean surgical time per eyelid was 14.6 minutes (range, 10.5-34.0 minutes). Twelve eyelids (46%) did not have intraoperative suture adjustments., Conclusions and Relevance: In correcting aponeurotic ptosis, a small-incision levator aponeurectomy incorporating an algorithm and consistent stress on the aponeurosis during resection achieves the goal MRD1 efficiently. The algorithm closely estimates the desired height intraoperatively such that only small intraoperative suture height revisions, if any, are needed. No intraoperative adjustments were made in 12 eyelids, necessitating future studies to determine whether any adjustments are needed., Level of Evidence: 3.

Purpose: To investigate biomechanical properties of the levator aponeurosis., Methods: Patients undergoing external levator resection for primary or revision correction of acquired ptosis were analyzed as primary and revision groups. Immediately postoperatively, the resected segments of the levator aponeurosis were stressed by adding sequential masses to the tissue. Specimen length was recorded at each stress level. Stress-strain diagrams were used to summarize how the tissue elongated in response to the external forces, because these diagrams correct for differences in specimen size. Representative specimens were analyzed histologically., Results: Twenty-two specimens from 14 patients in the primary group and 10 specimens from 7 patients in the revision group met inclusion criteria. In the primary group, the mean age was 66 years; 8 patients were women. In the revision group, the mean age was 69 years; 6 patients were women. Levator aponeurosis specimens in both the primary and revision group demonstrated proportional increases in length with increasing stress, demonstrating that the levator aponeurosis is extensile. Given the same amount of stress, the levator aponeurosis from primary specimens elongated more than revision specimens. Histologically, revision specimens exhibited increased collagen and haphazard, tangled elastin fibers., Conclusions: The levator aponeurosis obtained during surgical correction of acquired ptosis elongates in response to nominal external forces. This biomechanical property is important because the length of the aponeurosis may vary intraoperatively if variable forces are applied to the eyelid. This property might be related to connective tissue architecture and, specifically, fibrosis. Surgeons performing levator aponeurosis resection should be mindful to maintain a consistent amount of force on the levator aponeurosis when performing the resection to maximize intercase consistency.

A 32-year-old female who underwent scleral buckle removal presented 5 weeks postoperatively with a red, fluctuant subconjunctival mass. CT scan identified an irregularly bordered, hypoattenuated lesion next to the globe with the density of air. Ophthalmic plastic and reconstructive surgeons were consulted to evaluate orbital cellulitis with intraorbital gas, at which point it was deemed that the hypoattenuated mass was likely a retained sponge element based on its radiological features. Additional surgical exploration identified the retained silicone sponge. This clinical photographic-radiological correlation of retained silicone sponges presenting as orbital inflammation reminds surgeons to meticulously explant buckle material.

Purpose: The purpose of this study was to determine whether a localized full-thickness eyelid excision results in a proportional decrease in the total number of eyelashes or whether a full complement of visible lashes persists, thus suggesting a compensatory increase in the anagen/telogen ratio among the remaining follicles., Methods: A retrospective chart review was performed on 38 patients who underwent full-thickness eyelid resections repaired with primary eyelid closure for either benign or malignant eyelid lesions. Demographic and surgical data were collected, postoperative eyelid photographs were reviewed, and eyelashes were counted., Results: There were 10 upper eyelids and 28 lower eyelids in 10 men and 28 women, with an average age of 57.9 years (range, 14-86 years). The lesion pathology was benign in 21 cases (55%) and malignant in 17 cases (45%). The full-thickness defect involved <25% of the eyelid in 16 cases (42%) and >25% of the eyelid in 22 cases (58%). The follow-up period ranged from 50 to 319 days, with an average of 94 days. In contralateral controls, upper eyelids had an average of 72.1 lashes and lower eyelids had an average of 38.2 lashes, and there was no statistical significance between men and women. In lower lids that underwent <25% resection, control lids had an average of 37.3 lashes and operative lids had 37.1 lashes. In lower lids that underwent >25% resection, control lids had an average of 38.7 lashes and operative lids had 34.2 lashes. This represents an 11.6% decrease and was statistically significant. In upper eyelids that underwent <25% resection and >25% resection, control eyelids had an average of 74.9 lashes and 69.3 lashes and operative eyelids had 77.6 lashes and 69.1 lashes, respectively. Finally, lash count was compared by benign versus malignant pathologic diagnosis. In upper eyelids with benign lesions and malignant lesions, control eyelids had an average of 73.8 lashes and 65.3 lashes and operative eyelids had 74.6 lashes and 68.3 lashes, respectively. In lower eyelids with benign pathology and malignant lesions, control eyelids had an average of 34.5 lashes and 41.4 lashes and operative eyelids had 33.8 lashes and 36.8 lashes. This represents an 11.1% decrease and was statistically significant., Conclusions: Full-thickness excision of eyelid margin tissue including lashes does not usually affect postoperative lash numbers. Because the total number of follicles is reduced, the percentage of lashes in the anagen versus the resting or telogen phase apparently increases compared with the preoperative state. This eyelash study contributes to the growing body of literature on the poorly understood topic of hair follicle cycle regulation.

A retrospective case report of an orbital hematoma resulting from balloon sinus dilation during functional endoscopic sinus surgery is presented. The authors propose that this event may be because of shearing of venules that drain in the superior periorbital channels related to microfractures caused by the balloon dilation. To the authors' knowledge, this is the first report of orbital hematoma in the setting of balloon sinus dilation.

This is a report of a 57-year-old female patient who sought treatment for multiple episodes of bloody epiphora. A CT of her orbits revealed enhancement and enlargement of her left lacrimal sac and duct. A biopsy was then performed, which showed a varix involving the wall of the lacrimal sac. To the authors' knowledge, this is the first reported case of a lacrimal sac varix causing bloody epiphora.

Importance: Empirically determined doses of onabotulinum toxin A for aesthetic treatments are as much as 5 times higher for the upper than for the lower facial muscles., Objective: To use electromyography (EMG) to determine objectively whether the disparity between doses is due to intrinsic differences between the muscle groups' responses to onabotulinum toxin A or to variable amounts of paralysis required to achieve the desired aesthetic outcomes., Design: We collected EMG data before and at 2 to 4 weeks and 3 months after 8- and 2-U onabotulinum toxin A injections to the corrugator and depressor anguli oris muscles, respectively., Setting: A private oculofacial plastic surgery practice., Participants: Twenty-six subjects recruited from February 1 through April 1, 2009., Interventions: Electromyography recordings and cosmetic onabotulinum toxin A injections., Main Outcome Measures: Mean motor unit (MU) durations and maximal amplitudes at baseline and 2 to 4 weeks and 3 months after injection., Results: Baseline mean MU amplitudes were similar for the corrugator and depressor anguli oris muscles. At 2 to 4 weeks after injection, 78% MU and 64% maximal amplitude reduction for the corrugator muscle were detected, but only 54% MU and 18% maximal amplitude reduction for the depressor anguli oris (P = 2.7 × 10-8 and P = 1.3 × 10-14, respectively). At 3 months, function was partially recovered for both muscle groups., Conclusions and Relevance: Onabotulinum toxin A causes a similar dose-dependent reduction in MU and maximal voluntary amplitudes for muscles of the upper and lower face. The dose disparity appears to result from differences in the amount of paralysis required to achieve desirable aesthetic results., Level of Evidence: 2.

Objective: To report a refinement of small-incision external levator advancement with a standardized method for suture placement for correction of acquired blepharoptosis and 1 surgeon's results with this technique., Methods: Retrospective medical record review of data from all patients with unilateral or bilateral acquired blepharoptosis who underwent small-incision external levator advancement from October 1, 2007, through January 31, 2011., Results: Ninety-two eyelids from 66 patients with acquired blepharoptosis were treated with small-incision external levator advancement with uniform suture placement. Forty patients underwent unilateral surgery and 26 underwent bilateral surgery. The mean preoperative margin-to-reflex distance was 0.70 mm. The mean postoperative margin-to-reflex distance was 2.95 mm. Symmetry was achieved in 49 patients (74%) on the basis of a less than 1-mm difference in margin-to-reflex distance. When stratified by unilateral ptosis repair vs bilateral ptosis repair, bilateral ptosis repair achieved greater symmetry on average (81% vs 70%). Nine patients underwent revision. There were only 2 postoperative complications: one was postoperative upper eyelid bleeding and the other was exposure keratopathy., Conclusion: The simplified method of suture placement for small-incision external levator advancement is an effective, safe, and efficient option for acquired ptosis correction.

A 43-year-old woman (Case 1), 63-year-old man (Case 2), and a 67-year-old man (Case 3) presented with diplopia (Cases 1, 2, and 3) and upper-eyelid ptosis (Cases 1 and 3). The cases had preceding cranial nerve V1 disturbances ranging from 3 months to 8 years. Each demonstrated complete internal ophthalmoplegia and external ophthalmoplegia. No case had a cutaneous squamous cell carcinoma (SCC) on presentation or by history. Imaging revealed isolated orbital apex masses. Tumor biopsies revealed SCCs of various differentiations. Systemic workup revealed no extraorbital malignancy. All received radiation therapy, and 2 patients underwent adjuvant chemotherapy. One patient is alive since diagnosis (49 months). In Case 2, SCC developed in the contralateral orbit, and the patient died 19 months after diagnosis; and Case 3 died 12 months after diagnosis. These isolated cases of orbital SCC may have arisen from orbital choristomatous squamous epithelium, may represent de novo or metastatic tumors, or may be manifestations of occult perineural spread.

Neurofibromas of the eyelid are a well-recognized manifestation of neurofibromatosis. Several different presentations have been described. The authors present a case of a 52-year-old man with an unusual eyelid neurofibroma that presented as sudden vision loss from obstruction secondary to prolapse of the palpebral conjunctiva.

A 47-year-old woman presented with a painful mass below her left medial canthus. Examination revealed a 1-cm tender, smooth, pulseless, mobile mass inferior to the level of the anterior lacrimal crest. CT imaging was performed. Excision of the involved angular vein revealed a smooth, intralumenal lesion. Histopathologic examination demonstrated intravenous pyogenic granuloma (IVPG). There are approximately 30 reported cases of IVPG in the English literature, 2 of which arise in the periocular angular vein. The ultrasound and MRI characteristics of IVPG have been previously described. We describe the CT profile of this rare, benign tumor as a mildly heterogeneic, contrast-enhancing cylindrical lesion within, and conforming to the shape of, the angular vein. There is dilatation of the vein proximal to the lesion with marked narrowing distal to it secondary to obstruction of flow. On noncontrast imaging, the lesion is isodense with nasal mucosa and without calcifications.

Objective: To describe weakness of the orbicularis oculi muscle after external dacryocystorhinostomy (DCR) and propose an anatomic explanation for the complication., Design: Retrospective, observational study., Participants: Sixteen patients (13 female, 3 male) with a mean age of 60 years (median, 61 years; range, 34-85 years)., Methods: A retrospective chart review was performed of consecutive patients who had nasolacrimal duct obstruction repair by external DCR. Patients were identified who developed postoperative orbicularis oculi muscle weakness that manifested as hypometric blink or lagophthalmos with or without punctate keratopathy on the operated side. Patient parameters collected included demographic data, type of incision, incision length, use of lacrimal stent, length of follow-up, intraoperative and postoperative complications, and time to resolution of clinical findings. Statistical analysis was performed using a 2-tailed Fisher exact test with clinical significance designated at alpha = 0.05., Main Outcome Measures: Identification of patients with orbicularis oculi muscle weakness after external DCR, documentation of incision type, clinical findings, and recovery of function., Results: Among 215 patients and 247 surgeries, 16 individuals (7.4%) were identified who demonstrated abnormalities of eyelid closure in the postoperative period after external DCR. Of these, 13 patients had lagophthalmos with or without hypometric blink and 3 patients had hypometric blink alone. Eleven patients underwent surgery through a nasojugal incision, 4 patients underwent surgery through a vertical incision, and 1 patient underwent surgery through an eyelid margin incision. The degree of postoperative lagophthalmos was on average 1.5 mm. Four patients developed punctate keratopathy. Follow-up ranged from 3 to 50 weeks (mean, 20 weeks). Resolution of lagophthalmos was seen on average by 14 weeks with the longest time to resolution of 32 weeks. Three individuals continued to have residual hypometric blink at the time of last follow-up., Conclusions: Damage to peripheral fibers of the zygomatic and buccal branches of the facial nerve as they course through the medial canthal area to innervate the upper eyelid orbicularis oculi muscle may occur during external DCR surgery. Such injury may be responsible for orbicularis oculi muscle weakness manifesting as postoperative abnormal eyelid closure and lagophthalmos. In our cohort of patients, these findings were temporary and typically resolved in several months.

Purpose: To determine pathways of sympathetic nerves from the orbital apex to the eyelids in human cadaver tissue using immunohistochemistry., Methods: Human cadaver orbit tissue was sectioned and immunolabeled with a monoclonal antityrosine hydroxylase antibody., Results: In the orbital apex, the nasociliary, frontal, lacrimal, and maxillary branches of the trigeminal nerve demonstrated intense staining upon entering the orbit. Immunoreactive axons from the nasociliary and frontal nerves were observed to join the extraocular motor nerves in the posterior orbit. A plexus of immunolabeled nerves was observed to accompany the ophthalmic artery as it entered the orbital apex. The ophthalmic artery and its branches throughout the orbit demonstrated staining of nerve fibers in the peripheral muscularis. The nasociliary nerve contributed sympathetic branches to the ciliary ganglion. Nerves passing through the ciliary ganglion and a few ganglion cell bodies demonstrated mild to moderate tyrosine hydroxylase reactivity. Axons within the short and long ciliary nerves demonstrated strong tyrosine hydroxylase reactivity and were observed to enter the posterior sclera and the suprachoroidal space. The lacrimal gland demonstrated mild pericapillary staining and occasional stromal nerve fibers reactive to the antityrosine hydroxylase antibody. Müller muscle and the inferior tarsal muscle possessed a strong tyrosine hydroxylase-reactive nerve supply that appeared to originate from the anterior terminal branches of the nasociliary and lacrimal nerves., Conclusions: Sympathetic nerves enter the orbit via the first and second divisions of the trigeminal nerve and a plexus of nerves surrounding the ophthalmic artery. Extraocular motor nerves receive a sympathetic nerve supply from the sensory nerves in the posterior orbit. Some ciliary ganglion cell bodies demonstrated tyrosine hydroxylase-like reactivity, suggesting a sympathetic modulatory role for the ciliary ganglion. Sympathetics innervate ocular structures via the posterior ciliary nerves. Sympathetic axons travel anteriorly in the orbit via the nasociliary and lacrimal nerves to innervate the sympathetic eyelid muscles. Sympathetic nerves also travel with the frontal branch of the ophthalmic nerve to innervate the forehead skin. The ophthalmic artery and all of its branches contain a perivascular sympathetic nerve supply that may be involved in regulation of blood flow to ocular and orbital structures.

Purpose: To identify clinical characteristics of burn patients requiring emergent orbital decompression for vision-threatening orbital compartment syndrome., Methods: A retrospective review of 28 burn patients at a trauma center provided data regarding demographics, physical examination findings, and resuscitation fluid volumes. Patients requiring orbital decompression were compared with those who did not, using t tests and Fisher exact test. Linear regression was used to test for an association between peak intraocular pressure and fluid volume. Logistic regression was used to assess associations between need for orbital decompression and fluid volume., Results: Eight of 28 patients required emergent orbital decompression, which immediately reduced intraocular pressure from 59.4 +/- 15.9 mm Hg to 28.6 +/- 8.2 mm Hg (p < 0.001). There was a positive relationship between fluid volume in the first 24 hours and peak intraocular pressure (p < 0.001). Patients who were treated with orbital decompression were resuscitated with a higher fluid volume in the first 24 hours than those who were not (37,218 +/- 14,405 ml versus 24,649 +/- 12,339 ml, p = 0.015). This was no longer statistically significant when adjusted for periocular burns. The relative risk for undergoing orbital decompression in patients receiving > or =8.6 ml/kg/% total body surface area burned in the first 24 hours was 4.4 (p = 0.03)., Conclusions: Risk factors for vision-threatening orbital compartment syndrome include fluid volume and periocular burns. Signs of vision-threatening orbital compartment syndrome should be addressed early with orbital decompression.

A 34-year-old immunocompetent woman sought treatment for a 6-week history of right inferior medial canthal swelling and discharge consistent with canaliculitis. Symptoms persisted after conservative medical therapy. After canaliculotomy and removal of a dacryolith, the patient experienced resolution of signs and symptoms. Although Actinomyces has been a frequently reported cause of canaliculitis, we report a unique case of canaliculitis caused by Mycobacterium chelonae.

Objective: To evaluate the successes and challenges of endoscopic orbital floor fracture repairs., Methods: We analyzed 53 orbital floor repairs and recorded the indications for surgery, factors that complicated the endoscopic repair or necessitated conversion to an open approach, and outcomes for each., Results: Forty-five procedures were completed endoscopically. Repairs of smaller injuries confined entirely to the medial floor were readily accomplished, particularly when entrapment was the primary indication for surgery. Endoscopic repair became very difficult and often not possible when a large amount of soft tissue was herniated through the floor defect and when dissection medially onto the lamina papyracea and lateral to the infraorbital nerve was required for implant placement. Duration of follow-up was short for some patients, but no adverse trends in outcomes were identified., Conclusions: Blowout fractures can be approached endoscopically. However, the technical challenge of working from below with a telescope tends to increase the difficulty of many repairs without improving results. Most blowout fractures are probably still best treated through an open approach, assuming that the lower eyelid incision is correctly performed.

A case of chronic Actinomyces canaliculitis with associated pyogenic granuloma formation and bloody tears is described. Although Actinomyces is a well-known cause of canaliculitis, the authors are not aware that it has been reported in association with pyogenic granulomas.

Background: Fluid resuscitation remains a fundamental component of early burn care management. However, recent studies suggest that excessive volumes of resuscitation are being administered. Overresuscitation results in negative sequelae including abdominal and extremity compartment syndromes. Elevated intraocular pressure (IOP) has been described as another potentially devastating effect of massive fluid resuscitation in trauma patients. The orbit, similar to the abdomen and extremity, is a compartment, limited to expansion from edema anteriorly by the eyelids and orbital septum, and posteriorly by the bony orbital walls. The purpose of this study was to review the incidence of elevated IOP in a series of patients with major burn injury., Methods: We retrospectively reviewed the charts of 13 consecutive patients admitted to our burn center with burn sizes >25% total body surface area (TBSA). All patients underwent serial IOP measurements for the first 72 hours following admission. Medical records were reviewed for fluid resuscitation volume, IOP measurements, need for canthotomy, and results of canthotomy procedures., Results: Five of 13 patients had IOP >30 mm Hg and required lateral canthotomy. Canthotomy immediately reduced IOP (p = 0.009). Patients who developed elevated IOP received a significantly larger fluid resuscitation (9.0 cc/kg/%TBSA versus 6.0 cc/kg/%TBSA, p = 0.02). Elevated IOP was significantly associated with delivery of larger fluid resuscitation volume (p = 0.027)., Conclusions: Massive fluid resuscitation following burn injury can result in orbital compartment syndrome requiring lateral canthotomy. Early diagnosis and treatment of orbital compartment syndrome should be incorporated into the management of patients with major burn injury receiving large fluid resuscitation volume.

The histologic findings of a pegged hydroxyapatite orbital implant removed due to chronic inflammation and pain are described. A 44-year-old woman underwent explantation of a hydroxyapatite sphere and polycarbonate motility peg due to chronic redness, swelling, discharge, and pain. Histology revealed complete fibrovascularization of the implant, with approximately 90% ossification. No bone marrow was identified. Histologic sections revealed fibrous connective tissue at the periphery of a sclerotic bony mass with a granulomatous inflammatory infiltrate at the motility peg aperture. There were no bacterial, mycobacterial, or fungal organisms identified histologically or by culture. Consistent with previous reports, hydroxyapatite orbital implants are amenable to fibrovascular ingrowth and bony transformation. The presence of a granulomatous inflammatory reaction around the polycarbonate motility peg in this case may have prevented complete osseous transformation of the hydroxyapatite implant.

Persistent conjunctival chemosis in patients who have undergone cosmetic eyelid surgery is an uncommon but aesthetically undesirable and potentially debilitating postoperative complication. We attempted to determine if a regional conjunctivoplasty can effectively reduce signs and symptoms of chronic postoperative chemosis in these patients. Three patients with iatrogenic chemosis resistant to conservative management (ie, lubrication, pressure patching, and steroid drops) and persisting for more than 6 months after the initial surgery were included. A limbal peritomy followed by subconjunctival and sub-Tenon's fascia dissection was performed in regions of clinically detectable chemosis. Patients were followed postoperatively for 3 to 9 months to assess clinical response. All patients demonstrated significant objective improvement in clinically observable chemosis as well as symptoms related to ocular surface dryness.

Blindness caused by ischemic optic neuropathy in the hospital setting occurs perioperatively and in critically ill patients, but its etiology remains ill defined. We describe four critically ill patients who developed blindness within 1 mo of one another. Three cases occurred outside of the operative arena. Potential risk factors for the development of ischemic optic neuropathy, such as use of vasopressors, venous congestion, and hypotension, are described.

Purpose: The underlying cause of involutional blepharoptosis is unknown. The carotenoid content of preaponeurotic and nasal orbital fat among patients with and without involutional ptosis was evaluated to investigate the hypothesis that development of ptosis may be related to low carotenoid content of preaponeurotic orbital fat., Methods: Through a case-control design, the carotenoid content of preaponeurotic and nasal fat of 10 patients with ptosis and 11 patients without ptosis was measured by spectrophotometry analysis. Differences in carotenoid content between patients with and without ptosis were evaluated in unadjusted analyses and in multivariate models adjusted for age, sex, race, and presence of thyroid eye disease as potential confounders., Results: The total carotenoid content of the preaponeurotic fat of patients with ptosis was 59% lower than patients without ptosis (2.98 versus 7.26 absorbance/mg, p = 0.005). When adjustments were made for age, sex, race, and presence of thyroid eye disease, this difference was attenuated, but there was still a trend toward lower preaponeurotic fat carotenoid content among patients with ptosis (p = 0.09). The carotenoid content of the nasal fat was not significantly different among patients with and without ptosis (2.69 versus 3.40 absorbance/mg, p = 0.33). A lower ratio of preaponeurotic to nasal carotenoid content was demonstrated among patients with ptosis compared with patients without ptosis (1.4 versus 2.1; p = 0.06 unadjusted, p = 0.10 adjusted)., Conclusions: Patients with involutional ptosis show trends toward having lower carotenoid content in preaponeurotic fat. Further investigation of the potential role of orbital fat carotenoids in the development of involutional ptosis is warranted.

Purpose: To determine the significance of flash visual evoked potentials (FVEP) in the evaluation of patients with traumatic optic neuropathy (TON)., Methods: Eleven head-injured patients admitted to our center were diagnosed with unilateral TON. For every patient, FVEPs were obtained in both the affected eye and the unaffected eye. The normal eye thus functioned as each subject's internal control. We determined the amplitudes of FVEP waveforms for each eye and calculated an amplitude ratio of the affected/normal side for all individuals. The best-corrected visual acuity was obtained for each eye 2 weeks after acute hospitalization. We then determined the relation between best-corrected visual acuity in TON and the FVEP amplitude ratio., Results: In 4 patients in whom the amplitude ratio was at least 0.5, visual acuity in the affected eye was 20/30 or better. In 7 patients, the amplitude ratio was less than 0.5, and visual acuity in the eye with TON did not exceed 20/300 (Pearson r = -0.93, p = 0.0001)., Conclusions: Flash visual evoked potentials are highly predictive of the degree of visual function in unilateral TON. Finding FVEP amplitudes that are at least 50% of the normal eye appears to be critical in anticipating good, long-term visual outcome.

Purpose: To report a case of transient bilateral vision impairment with external ophthalmoplegia and internal ophthalmoplegia after blepharoplasty under local anesthesia., Design: Interventional case report., Methods: A 70-year-old man underwent bilateral upper blepharoplasty under local anesthesia. During orbital fat removal additional anesthetic was injected into both medial fat pads for pain control., Results: Immediate postoperative examination revealed bilateral decreased visual acuity and internal ophthalmoplegia in the right eye. An exotropia was present with marked limitation of right eye adduction. These findings resolved completely 3 hours postoperatively., Conclusions: Local anesthesia during blepharoplasty can enervate the optic nerve, ciliary ganglion, and extraocular muscle nerves. Local anesthesia should be injected judiciously during orbital fat removal to avoid this reversible but alarming event., (Copyright 2003 by Elsevier Science Inc.)

Purpose: To describe and present the results of a modified surgical technique to repair floppy eyelids., Methods: A case series of 5 patients who were treated with the modified technique is presented. This technique uses the relaxed skin tension lines to tighten the lids in an aesthetically minded reconstruction., Results: All patients had relief of symptoms and good cosmetic and functional results. Average follow-up was 39 months. Complications were minor and easily treated., Conclusions: This modified surgical technique provides excellent long-term structural integrity of the wound with a potentially more acceptable camouflaged scar.

Objective: To identify and quantify carotenoids found in white and yellow orbital fat., Methods: Specimens of nasal (white) and preaponeurotic (yellow) orbital fat were obtained from patients during upper eyelid blepharoplasty. Carotenoids and retinoids were extracted and subjected to spectral and high-performance liquid chromatography analyses., Results: The chromophore content of extracts from unsaponified fat, as measured by absorbance at 425 nm per gram of fat, was 2- to 4-fold higher in preaponeurotic fat than in nasal fat. High-performance liquid chromatography analysis from enzymatically digested fat revealed large amounts of lutein, beta-carotene, and retinol and small amounts of other unidentified carotenoids. The amount of beta-carotene and lutein in preaponeurotic fat was approximately 4-fold higher than in nasal fat., Conclusions: The higher carotenoid content of preaponeurotic fat might cause it to be more yellow than other orbital fat, and lutein and beta-carotene might be selectively absorbed from plasma by preaponeurotic fat., Clinical Relevance: The results provide baseline information for studies of the physiological features of orbital fat in normal and diseased conditions.

Purpose: To describe the clinical results of systemic corticosteroid use in a series of patients with orbital lymphangioma., Methods: Four patients (two adults and two children) were treated with corticosteroids using intravenous, oral, or both routes for 2 days to a month. Corticosteroids were used with and without other therapies for symptomatic exacerbations., Results: The adults showed more improvement with pain than with swelling, whereas the children had improvement with both the signs and symptoms. There were no complications in any patient., Conclusions: Systemic corticosteroids are a useful therapeutic option for patients with orbital lymphangioma and can be used as an adjuvant treatment to surgery and other modalities. Resolution of symptoms with corticosteroids was expedited compared with the natural history of the disease in the patients studied.

Purpose: We report the histological findings of a hydroxyapatite orbital implant 5.5 years after implantation., Methods: The hydroxyapatite orbital implant was excised from the left orbit of a 17-year-old female, and it was decalcified and processed for routine light microscopic evaluation., Results: The implant showed complete fibrovascularization with nearly complete osteogenesis with hematopoiesis., Conclusion: Bone may biointegrate throughout the pores of hydroxyapatite orbital implants.