Eyelid Pathology Research Articles

Wingtip Flap for Reconstruction of Full-Thickness Upper and Lower Eyelid Defects.

Pentagonal wedge resection is a technique used to address a wide variety of eyelid pathology. This procedure frequently results in excess skin at the apex of the wound, commonly known as a "dog ear." A variety of methods have been described to address the cutaneous redundancy, the most classic of which is the Burow's triangle repair. The authors present a technique to address the anterior lamellar excess that avoids placement of a vertical scar traversing the pretarsal and preseptal portion of the affected eyelid. The repair moves the preseptal closure of the wound temporally, away from the moving portion of the eyelid. The horizontal incision that transposes the vertical closure temporally is concealed in the eyelid crease. A retrospective review of all patients undergoing this technique for eyelid reconstruction was undertaken. The surgical technique is described in detail. The procedure has been performed on 7 patients (8 eyelids). Patients were followed for an average of 12 weeks. Indications for surgery were floppy eyelid syndrome requiring horizontal shortening of the upper eyelid and neoplastic lesions involving the upper or lower eyelid. There were no complications. All patients had a satisfactory outcome with regard to function and cosmesis. Full-thickness excision of the central two-thirds of the lower and upper eyelid is used extensively to manage a wide variety of conditions. The authors present a technique for addressing the anterior lamellar closure with notable advantages over previously described methods. The major advantages of this technique are that it results in a vertical closure that is horizontally displaced from the primary action of the levator aponeurosis and avoids anterior and midlamellar scarring of the upper and lower eyelid that may inhibit vertical movement. In addition, the cutaneous scar is more easily concealed.

Development of Strabismus in Children Initially Diagnosed with Pseudostrabismus

ABSTRACTPurpose: To evaluate the incidence of strabismus in children initially diagnosed with pseudostrabismus and to identify risk factors for the development of strabismus.Methods: The medical records of patients who were diagnosed with pseudostrabismus at initial examinations in outpatient clinic were reviewed retrospectively. Follow-up examinations were made at the strabismus department. Age at first examination, gender, family and developmental history, ophthalmic and orthoptic findings including orbit, and eyelid pathologies were investigated.Results: Sixty-five patients with the diagnosis of pseudostrabismus were identified; 2 patients (3.1%) had pseudoexotropia, and 63 patients (96.9%) had pseudoesotropia. The mean age at the initial exam was 29.26±26.68 months (range; 4–120 months). Epicanthal skin folds (n=35), flat broad nasal bridge (n=17), blepharophimosis syndrome (n=1), hypertelorism (n=1), telecanthus (n=1), and multiple pathologies (n=10) were the reasons for pseudostrabismus. Six patients (9.2%) had clinically significant hypermetropia. Anisometropia and amblyopia were detected in 1 (1.5%) and 3 patients (4.6%), respectively, at the initial examination. The mean follow-up period was 25.2±23.28 months (range; 1–154 months). During the follow-up period, true strabismus was detected in 8 cases (12%); of these, 5 cases had non-refractive esotropia, 2 cases had refractive accommodative esotropia, and 1 case had exotropia. Binocular single vision was not developed following amblyopia therapy and refractive correction in esotropic cases. Binocular single vision and best corrected visual acuity were statistically significant risk factors for the development of strabismus (P=0.001).Conclusion: The pseudostrabismic children with subnormal binocular single vision or low visual acuity require follow-up for the risk of development of true strabismus.

Surgical outcome of involutional lower eyelid entropion correction using transcutaneous everting sutures in Chinese patients

To evaluate the clinical efficacy of transcutaneous everting sutures for lower eyelid involutional entropion in Chinese patients. A retrospective, non-comparative, interventional case series. This retrospective study consecutively reviewed the medical records of all patients with involutional lower eyelid entropion who underwent transcutaneous everting suture for entropion correction at the Department of Ophthalmology, Caritas Medical Centre, from 1st January 2010 to 31st October 2013. Exclusion criteria included concurrent eyelid pathologies such as malignant tumor, infection, cicatricial entropion, post-operative follow-up period of <3 months, significant horizontal lid laxity, and aged <60 years at the time of surgery. The primary outcome measures were recurrence rate and complications. Secondary outcome measures included patient demographic data, type and number of everting sutures, duration of operation, timing of stitch removal, duration of follow-up, as well as each patient's medical history and current medications. Thirty-four eyelids of 28 patients were included. The average age was 78.2 ± 7.3 years and the male to female ratio was 4:3. In this series, 26.5 and 2.9 % of eyelids underwent entropion correction whilst receiving aspirin and warfarin, respectively. The mean duration of post-operative follow-up was 13.2 ± 10.5 months. The recurrence rate was 11.8 % at a mean of 9.0 ± 6.0 months. There were no peri-operative or post-operative complications observed. A transcutaneous everting suture was found to be a quick and effective means to correct senile involutional lower lid entropion in Chinese patients with no complications despite the continued use of anti-coagulation therapy in >25 % of our cases.

No histological evidence of orbicularis oculi muscle hypertrophy in congenital epiblepharon

To analyse the microscopic anatomy of the orbicularis oculi muscle in patients with congenital epiblepharon and to determine whether hypertrophy of the orbicularis oculi muscle, which is considered as a possible cause of this eyelid malposition, exists. Sixty-seven eyelids with congenital epiblepharon of 41 Japanese patients, as well as 30 control eyelids of 24 Japanese patients with other eyelid pathologies (upper eyelid: fourteen blepharoptosis, one trichiasis and two retractions; lower eyelid: five involutional entropions, one trichiasis and seven retractions) were analysed. These controls contained no orbicularis pathology such as cicatrization or orbitopathy. The muscle specimens were obtained from the central part of the pretarsal orbicularis oculi muscle during surgery. The specimens were stained with haematoxylin & eosin. Only specimens with cross-sectional areas that included large muscle fibres were selected. In each section, 10 muscle fibres were measured across their smallest diameter, thereby avoiding inaccurate measurements of muscle kinking occurring during the processing or by any obliquity of the plane of section. Measurements of the muscle fibre diameter were made with a digital measure. There were no significant differences in the average diameter of the muscle fibres between the patients with congenital epiblepharon and the control group. There was no evidence of orbicularis oculi muscle hypertrophy in congenital epiblepharon.

Ocular motor function in relation to gross motor function in congenital and childhood myotonic dystrophy type 1

To assess ocular motor function in congenital and childhood myotonic dystrophy type 1 (DM1) and correlate the results with cytosine-thymine-guanine (CTG) repeat size, severity of the disease, myotonia and skeletal muscle function. A cross-sectional investigation into strabismus, versions/ductions, saccades, smooth pursuit movements and ptosis was performed on 49 individuals with a confirmed diagnosis of DM1, all diagnosed at <18 years of age and with >40 CTG expansion repeats. The results were correlated with myotonia as well as Hammersmith motor ability scale (HMA). In addition, the ocular results were compared to results from an age and- sex-matched control group. Ocular motor abnormalities were seen in 82%; the most frequent findings were altered conjugate eye movements and 'pseudoptosis' while blepharoptosis was rare. Strabismus was most common in the severe congenital subgroup, with a frequency 14 times higher than in the control group. Positive correlations were seen between CTG repeat size and affected eyelids, and between myotonia and affected eyelids; both these findings were most prominent in the mild congenital group. CTG repeat size was also correlated with version/duction defects, and most obviously in the childhood group. Low HMA scores were associated with high occurrence of strabismus and version/duction defects. Abnormalities of ocular motor function are frequently present. CTG repeat size correlates positively with altered versions/ductions and eyelid pathology. Gross motor dysfunction correlates with strabismus and defect versions/ductions, and eyelid pathology indicates involvement of myotonia.

Şarbon: Preseptal Sellülitin Nadir Bir Sebebi

Anthrax, caused by the spore-forming bacterium Bacillus anthracis, is rarely seen in industrial nations but is common in developing countries. In this case report, a 36-year-old male farmer who was diagnosed with preseptal cellulitis initially, was presented. Gram-positive rods were found in the microscopic examination of the scraped material obtained from the lower edge of the necrotic area. The patient was managed with high dose intravenous penicillin G. On the third day of treatment, edema began to decrease on the right eyelids. A patch of black necrotic eschar tissue developed on the whole surface of left eyelids. At the final examination of the case, six months after the completion of the treatment, the cutaneous lesion was healed without any eyelid pathology. Despite its rarity in developed parts of the world, anthrax should be considered in the differential diagnosis of preseptal and orbital cellulitis.

Lateral Wedge Resection: A Simple Technique for Repairing Involutional Lower Eyelid Entropion

Lower lid involutional entropion is a common eyelid pathology affecting the elderly population. Most of the reported surgical techniques are mainly based on a lateral tarsal strip anchored to the orbital rim. To report the surgical outcome using a simple single-stitch lateral wedge technique to repair involutional lower entropion. This single-surgeon, retrospective, noncomparative cases series included all patients with involutional lower eyelid entropion who were operated on using the lateral wedge technique. Fifty-eight eyelids of 52 patients (46 unilateral, 6 bilateral; 27 men, 25 women; age, mean 67 ± 10; range 50-85) underwent surgical repair. Immediate resolution of entropion and associated ocular symptoms was achieved in 55 eyelids (94.9%). One case had postoperative ectropion that completely resolved spontaneously after 4 weeks, and one had wound dehiscence that healed completely without any intervention. Another patient had residual entropion that resolved after an additional surgical repair. No other cases of recurrence were noted during a mean follow-up period of 16 months (range 6-24 months). This minimally invasive single-stitch lateral wedge technique is a simple and effective procedure for repairing involutional lower eyelid entropion and is associated with low recurrence and complication rates. Igal Leibovitch, MD, has indicated no significant interest with commercial supporters.

Long-term Success Rate of Perforated Punctal Plugs in the Management of Acquired Punctal Stenosis

To give the long-term success rates of punctal dilatation with insertion of perforated punctal plugs (PPP) for the management of acquired punctal stenosis. A series of 44 eyes of 26 patients who underwent PPP implantation for the management of acquired punctal stenosis were retrospectively evaluated in terms of the severity of acquired punctal stenosis, associated eyelid disorders, implantation technique of PPP, and long-term success rate of PPP for the treatment of epiphora. In all patients, punctal dilation was performed prior to the insertion of plugs. Patients demonstrating moderate or severe horizontal eyelid laxity underwent a lateral tarsal strip procedure before PPP implantation. Complete stenosis of the punctum was treated with the radiofrequency unit before PPP implantation. The plugs were extracted at 2 months in every patient. The mean age of the patients was 63.6 +/- 10.5 years. The median interval between the onset of epiphora and PPP implantation was 15 months. There were 14 complete stenoses, 29 partial punctal stenoses, and 1 squamous papilloma involving the inferior punctum causing epiphora. Associated eyelid laxity was detected in 14 of 44 eyes (31.8%), and 8 eyes underwent a lateral tarsal strip procedure before PPP implantation. The mean follow-up time was 19.0 +/- 13.4 months. Success was achieved in 37 of 44 eyes (84.1%), with relief of epiphora. Of the 7 eyes with continued epiphora, 3 eyes demonstrated recurrent punctal stenosis and 4 eyes demonstrated mild horizontal eyelid laxity. The long-term success rate of PPP implantation for the treatment of acquired punctal stenosis is satisfactory. Associated eyelid pathologies should be evaluated for their contribution to epiphora and be treated before PPP implantation.

Donor site morbidity in free tarsal grafts

Purpose To determine if harvesting free tarsal grafts from the upper eyelids is associated with significant morbidity. Design Prospective case series. Methods Consecutive patients managed with free tarsal grafts by three of the authors (D.S., D.G., R.G.) over a 4-year period. Results Ninety-one eyelids in 75 patients were operated on using the free tarsal graft for various eyelid pathologies. Mean follow-up period was 14.83 ± 8.45 months (range, 4 to 42 months). Contour peaking in donor upper eyelid appeared in two eyelids (2.2%), lash ptosis in four eyelids (4.4%) of three patients, and donor site infection in one eyelid (1.1%). Four patients (5.3%) complained of a transient ocular discomfort. There were no cases of postoperative changes on the eyelid height, entropion, or keratopathy in the donor site eye. Most of the donor site complications were mild or transient and required no further surgery. In three patients who underwent subsequent surgery to treat preexisting ptosis or retraction of the donor eyelid, the results were less predictable and further procedures were required. Conclusion Free tarsal grafts harvested from the upper eyelids, with preservation of at least 4 mm of the tarsal plate inferiorly, do not lead to significant donor site morbidity. However, subsequent procedures to alter the position of the donor eyelid may be less predictable.

Lower eyelid medial canthal tendon laxity grading: an interobserver study of normal subjects

Objective To describe a simple grading system for medial canthal tendon (MCT) laxity and measure its reproducibility. Study design Observational case series and interobserver variability study. Participants Fifty subjects (100 lower eyelids) without eyelid disease. The age range was 19 to 98 years. Methods Subjects without eyelid pathology or previous surgery were selected. Two ophthalmologists assessed the position of the inferior punctum in relation to the cornea with the patient in primary gaze. Two measurements were made, the first with the lower eyelid at rest and then with the lateral distraction test. Both observers were masked to the other observer’s measurements. Main outcome measures Kappa statistics to show the strength of agreement between the two observers for the resting and lateral distraction eyelid positions. Results High kappa values were found for resting position (agreement in 92 of 100 eyelids) and for lateral distraction testing (agreement in 85 of 100 eyelids). The range of resting positions was from position –1 to position 1. The range of laterally distracted positions was from position 0 to position 5. Overall, a very high level of agreement was achieved between observers. Conclusions This grading system for MCT laxity is simple, easy to learn and reproducible, easier than measuring in millimeters, and has an advantage over merely saying the tendon is “lax” or “not lax.” We propose this standardized grading system in the evaluation of patients with entropion and ectropion to identify those patients who may benefit from MCT stabilization/plication.

Plastic Surgical Techniques in the Fifteenth Century by Şerafeddin Sabuncuoğlu

Serafeddin Sabuncuoğlu (A.D. 1385-1468) is the author of the first illustrated surgical textbook in the Turkish-Islamic literature, namely, Cerrahiyet-ül Haniyye (Imperial Surgery). A pioneer in all fields of surgery. Sabuncuoğlu developed numerous original techniques. He was a keen observer and inventor and a prolific writer who combined his fortune with knowledge of his era. He described a mass reduction procedure for the management of gynecomastia, probably one of the first attempts at reduction mammaplasty. He gave detailed descriptions of different eyelid pathologies and their surgical managements. The aim of this study is to investigate the contributions of this remarkable pioneer to the field of plastic surgery.

Transcutaneous lower blepharoplasty.

Transcutaneous lower blepharoplasty as a standard procedure for cosmetic lower blepharoplasty is being replaced by transconjunctival blepharoplasty and laser resurfacing techniques. Nevertheless, there remain specific indications for the transcutaneous approach and its modifications. The accomplished facial plastic surgeon will be able to choose the appropriate technique based on the patient's concerns, the eyelid pathology, and his or her clinical experience.

Ophthalmological complications as a manifestation of burn injury

Facial burns are a frequent component of the presentation of victims who have sustained thermal trauma, reportedly occurring in 20 per cent of burn patients. Even apparently ‘minor’ facial injuries might well be associated with significant ocular trauma. A retrospective review of 865 patients admitted to our burn centre showed 22 per cent (192) with facial burns. Ocular involvement, defined as globe or eyelid pathology, was present in 15 per cent (127) of these patients. The aetiology and spectrum of ocular injuries is reviewed with lid burns and subsequent lid contractures, accounting for over 50 per cent of ocular complications. Serious ocular pathology necessitating enucleation occurred in only two patients. The difficulties encountered in performing a complete ophthalmological examination in the presence of facial burns are presented in conjunction with a recommended therapeutic plan.

The significance of ophthalmological symptoms in idiopathic blepharospasm.

Two hundred and seventy-two patients with idiopathic blepharospasm were reviewed to establish the role of local eye disease in their illness. The majority of patients (57%) had symptoms at the onset of their illness such as dryness of the eyes, grittiness, irritation or photophobia suggesting eye lid or ocular surface disease. Detailed ophthalmological examination at the time of presentation had been carried out in 170 of the 272 cases; 64% of these patients had ocular symptoms, and 40% had demonstrable ocular surface or eye lid pathology. Such pathology was usually bilateral, chronic and resistant to local treatment. Blepharospasm developed in these patients after a long latent period, often of many years. Unilateral pathology was acute, normally responded well to local treatment, but was followed by the development of bilateral blepharospasm usually within six months. Amongst all 272 patients, those without ocular symptoms at presentation rarely developed them subsequently; if they did, there were no abnormal signs. The data suggest that ophthalmological disorders may trigger idiopathic blepharospasm in a substantial proportion of cases predisposed to develop this condition.