Lacrimal Gland Prolapse Research Articles

Prevalence of Lacrimal Gland Prolapse in the Functional Blepharoplasty Population

Traditional functional blepharoplasty has focused on the excision of variable amounts of skin, muscle, and fat, with little attention given to the finding of the lacrimal gland prolapse (LGP). The reported incidence of LGP found on clinical examination, on patients of all ages presenting for blepharoplasty, is 15%. The author's experience with the procedure in the older age group (older than 60), is that this percentage is much lower than that found at surgery. To verify whether this is correct, the author evaluated lacrimal gland position intraoperatively in a group of patients undergoing functional upper blepharoplasty. In those patients who had LGP, the author routinely repositioned the gland and evaluated surgical outcomes. The author evaluated the presence of an intraoperatively displaced lacrimal gland in his functional blepharoplasty population over a 2.5-year period (2008-2010). Patients with a history of previous eyelid surgery, trauma, or who had concurrent ptosis or other eyelid malpositions were excluded from the study. When present, the degree of prolapse was graded as mild (0-2 mm), moderate (3-5 mm), or severe (6 mm or more). The author arbitrarily suture-repositioned the gland in all patients with 4 mm or more of prolapse. In cases with less prolapse, light cautery to the tip of the gland capsule and surrounding soft tissue allowed adequate repositioning without suture fixation. Pertinent patient demographics and postoperative complications were documented. Patients were seen consistently to 6 months after surgery with an average follow up of 12 months. Fifty-seven patients were included in the study. Thirty-four patients (60%) had some degree of LGP. Of these, 8 patients (24%) had mild prolapse, 23 patients (67%) had moderate prolapse, and 3 patients (9%) had severe prolapse. Nineteen patients (56%) with LGP had the gland suture-repositioned, and 15 patients (44%) received cautery to retro-place the gland. In one patient (3%), transient dry-eye symptoms developed after surgery. Otherwise, there were few benign and self-limiting postoperative complications, consisting of prolonged upper eyelid swelling and transient mild pain. Lacrimal gland prolapse is a common finding during functional upper blepharoplasty surgery and appears to be a normal involutional periorbital aging change. Most cases are moderate in degree (as defined in the article), and not associated with specific preoperative symptoms or complaints, except lateral hooding with concomitant visual field deficit. Repositioning the gland intraoperatively is generally complication free and typically not associated with increased morbidity or healing time. The clinical significance of LGP in the elderly undergoing blepharoplasty surgery is unknown and requires further study.

Lacrimal Gland Prolapse: Management During Aesthetic Blepharoplasty: Review of the Literature and Case Reports

Prolapse of the lacrimal gland is an acquired clinical condition caused mainly by relaxation of the local suspending ligaments. Before an aesthetic blepharoplasty, there should be a preoperative clinical suspicion of lacrimal gland pathology for patients with bulging lateral thirds of the upper eyelids. It should be borne in mind that inadvertent removal of the lacrimal gland can lead to important alterations in ocular lubrication. This report describes two clinical cases of patients with lacrimal gland prolapse associated with dermatochalasis and their treatment.

A pilot study of ocular diseases screening for neonates in China

To explore the clinical strategies for the screening of newborn eye diseases and obtain information concerning the incidence of newborn ocular diseases. Newborns in a baby-friendly nursery were evaluated for mass screening of eye diseases 2 to 7 days after birth (including reaction to light stimulation, external ocular examination and test for pupil red reflex) and those with abnormalities were subjected to diagnostic examination (external ocular examination with a hand-held slit-lamp, pupil red reflex and mydriatic examination). Newborns in neonatal intensive care unit (NICU) were subjected to screening 5 to 14 days after birth and then, together with those with high risk factors, received a comprehensive examination for screening and diagnostic purposes. The suspected cases were referred to department of ophthalmology for definite diagnosis. Among the 15,398 (91.65%) newborns who were enrolled the screening program, 12 different eye diseases (involving 1266 cases) were detected, with a prevalence of 8.22%. Of these eye diseases, 7 were congenital ocular diseases, involving 809 cases (5. 254%) and including congenital ptosis in 2 cases (0.013%), congenital corneal opacity in 6 cases (0.039%), persistent pupillary membrane in 724 cases (4.702%), congenital cataract in 15 cases (0.097%), persistent hyaloid artery in 54 cases (0.351%), obstruction of nasolacrimal duct in 7 cases (0.046%) and lacrimal gland prolapse in 1 cases (0.007%). Five different diseases (457 cases, 2. 968%) detected were acquired in nature, including neonatal conjunctivitis in 391 case (2.539%), vitreous hemorrhage in 6 cases (0.039%), retinal hemorrhage in 34 cases (0.221%), and neonatal dacryocystitis in 23 cases (0.149%). Of 27 premature babies with body weight lower than 1500 g, 3 had retinopathy of prematurity (ROP, 6 eyes involved). Early intervention is of great importance for the prevention and treatment of neonatal ocular diseases. The screening of newborn ocular diseases is not only feasible but also effective in the monitoring and control of the eye diseases in neonates.

Diagnostic Challenge

A 5-year-old pet rabbit with a history of severe acquired dental disease and rhinitis was presented for unilateral prolapse of the deep lacrimal gland of the third eyelid. The prolapse was believed to be due to abnormalities of the alveolar bullae secondary to severe dental disease and rhinitis. The prolapse was successfully replaced using a combination of techniques used in canine ophthalmology: the creation of a pocket or envelope in adjacent mucosa to cover the gland, and anchoring the nictitans to the periosteum. Correction was successful and the gland remained in place without complications until the rabbit’s death 4.5 years later.

Periorbital and midfacial rejuvenation via blepharoplasty and sub-periosteal midface rhytidectomy

The stigmata of midfacial ageing are the malar descent, lateral orbital festoon formation, tear-through deformity, deep melojugal sulcus, buccal fat pad and sub-orbicularis oculi fat (SOOF) prolapse, deep nasolabial folds and cutaneous and muscular descent. The signs of periorbital ageing include dermatochalasis, skin hooding of the upper eyelids, lacrimal gland prolapse, adipose prolapse, and lateral canthal descent and orbital septum diastasis. All of these deformities can be addressed through upper and lower blepharoplasties with arcus marginalis release, lateral canthopexy, sub-periosteal midface rhytidectomy with temporal suspension of the malar mound and SOOF repositioning. The same technique can be utilized for the restoration of facial symmetry after Bell's palsy. In the following report the technique and the authors’ experience in the rejuvenation of the periorbital and midface region are presented. There were a total of 20 patients in this series. Sixteen were female and 4 were male. All the patients were followed-up on a monthly basis after surgery for the first 6 months. They were then seen at 1 year post-surgery. All of the patients were evaluated by the senior author. In the beginning of the study there was 1 Asian female patient with mild postoperative ectropion, which resolved and did not require operative intervention. The patients experienced prolonged postoperative oedema. The patients were satisfied with their postoperative outcomes. In all patients, the goals of periorbital and midfacial rejuvenation were achieved with the above technique. Simultaneous periorbital and midfacial rejuvenation can be achieved via upper and lower blepharoplasties, lateral canthopexies and sub-periosteal midface rhytidectomy.

Ocular manifestations of head injury: a clinical study

This prospective study aimed to clinically correlate the various ocular findings with the neurological status in cases of closed head injury. A total of 200 consecutive cases of closed head injury admitted to a major teaching hospital underwent a thorough ophthalmic assessment. The Glasgow coma scale (GCS) and the Revised trauma score (RTS) were applied to grade the severity of injury and assess the prognosis. Kendall's tau-b and Fisher's exact test were used in the analysis. The main causes of head injury were road traffic accidents 52.5% followed by assaults in 34%. Ocular involvement was found in 167(83.5%) cases. These included corneal and scleral tears in 2%, subconjunctival haemorrhage or ecchymosis in 46%, orbital fractures 12%, pupillary involvement 6.5%, papilloedema 5.5%, intraocular trauma 5.5%, proptosis 3%, lateral rectus palsy 2%, lacrimal gland prolapse 1%, and optic nerve trauma 0.5%. All 21 patients (10.5%) who died had eye involvement. In all, 150 cases (75%) with a RTS of 12 had a good prognosis. Of these 124 (82.6%) had ocular involvement of no neurological significance. Although sophisticated imaging techniques are available to localize lesions, early ophthalmic assessment in correlation with the GCS aids in prognosticating outcomes. Pupillary involvement, papilloedema, and ocular motor paresis pointed to a more severe head injury. To our knowledge, this is the only prospective study recording ocular findings in the first few hours and attempting a correlation with the final outcome.

Reconstructive blepharoplasty

Neuromodulation, filling agents, non-ablative lasers and therma-lifting can non-invasively rejuvenate the peri-orbital tissues, but eyelid skin redundancy and loss of elasticity, fatty prolapse, levator aponeurotic disinsertion, lacrimal gland prolapse, lateral canthal tendon and lower lid margin laxity need to be addressed surgically. Carbon dioxide laser techniques allow us to perform skin and skin-muscle resections, levator aponeurotic repairs, lacrimal gland suspensions, lateral canthal plications, lipo-vaporization, fat ransposition and eyelid skin resurfacing efficiently, with great accuracy and minimal downtime, in a virtually bloodless field.

THE SURGICAL TREATMENT OF GRAVES' ORBITOPATHY: A Decade of Progress

The total rehabilitation of the patients with Graves' ophthalmopathy is sometimes possible only with sequential surgical procedures. Elective surgical treatment is normally delayed until the inflammatory phase subsides and stability is established, usually 1 to 3 years after onset. Additionally, the metabolic status should be well controlled before elective surgical treatment. Generally, eyelid and motility measurements should remain stable for a period of 6 months before any surgical intervention. 44 Exceptions to delaying surgical repair until stability are severe exposure keratopathy requiring eyelid surgery or progressive optic neuropathy unresponsive to corticosteroid or radiation therapy, which prompts orbital decompression. The overall risk of the need for surgery was estimated as 2.5 times greater in patients older than 50 years than in younger patients. 3 This may be related to the presence of more severe ophthalmopathy in older patients. 33 A systematic surgical approach was introduced in 1986. 75 The usual sequence of reconstruction of the Graves' patient with severe orbitopathy is orbital decompression and strabismus surgery followed by eyelid retraction surgery and other eyelid surgery. Orbital decompression may influence the muscle function and eyelid position. In addition, muscle surgery especially if it involves the vertical rectus muscles; may change eyelid retraction. Despite the usefulness of a systematic conceptual approach, the treatment must be individualized to each patient, as the disease does not follow a uniform course, and the manifestations differ in severity. The first stage of surgical rehabilitation, when necessary, is the orbital decompression. It is indicated to reduce excessive proptosis, to relieve orbital congestion, and to treat compressive optic neuropathy. 6,31,53,74 The goal of strabismus surgery in Graves' orbitopathy is usually to achieve single binocular vision in the primary and reading positions. Stable motility measurements should be achieved muscle surgery. Many patients have restriction of the inferior rectus muscles and benefit from some degree of bilateral inferior rectus recessions. Adjustable sutures frequently are used. Surgery for eyelid retraction and other abnormalities follows strabismus surgery. There are numerous eyelid abnormalities described in dysthyroid ophthalmopathy. The most frequent are upper and lower eyelid retraction, lagophthalmos, ptosis, dermatochalasis, lacrimal gland prolapse and mechanical medial lower eyelid entropion. The eyebrow fat pad may also be enlarged in patients with Graves' orbitopathy. In selected cases, the brow fat may need to be debulked when performing a blepharoplasty to achieve the desired aesthetic result. 21 Cosmetic reduction of herniated fat pads and eyebrow fat pads is generally performed last.

Eyelid, conjunctival, and corneal findings in sleep apnea syndrome

Objective To determine the prevalence of eyelid, conjunctival, and corneal findings in patients with sleep apnea syndrome (SAS). Design Case series. Participants Seventy-two white patients referred for evaluation of suspected SAS. Intervention Complete examination of eyelids, conjunctiva, and cornea, including videokeratography. Main outcome measures Spearman rank correlations were determined between the respiratory disturbance index (RDI) during night sleep, a value used to diagnose and grade SAS, and tear film break-up time, eyelid distraction distance, presence or absence of ocular irritation symptoms, blepharoptosis, floppy eyelids, lacrimal gland prolapse, keratoconus, and endothelial dystrophy. Each correlation was controlled for age and body mass index. Results According to the RDI, 44 (61%) of the 72 patients had SAS. The RDI correlated positively with the eyelid distraction distance ( P = 0.05), presence or absence of floppy eyelids ( P = 0.01), and lacrimal gland prolapse ( P = 0.01), and correlated negatively with tear film break-up time ( P = 0.02). None of our patients with floppy eyelids had corneal abnormalities. One patient with SAS had bilateral keratoconus; another had bilateral Fuch endothelial dystrophy. Conclusions Sleep apnea syndrome was significantly associated with reduced tear film break-up time, floppy eyelids, and lacrimal gland prolapse. However, ocular irritation symptoms and corneal involvement were rare among patients with SAS. These findings do not confirm previous studies that reported a high prevalence of corneal involvement in floppy eyelid syndrome.

Aesthetic and Functional Outcomes of Dacryoadenopexy

Forty patients underwent bilateral lacrimal gland suspension concomitant with upper and lower lid blepharoplasty. All surgery was performed by the same surgeon (BG). Twenty-eight (70%) patients were available for a mean follow-up period of 19.9 months, and 12 (30%) patients were available only for an early follow-up period (mean = 3.6 months). Of the 40 patients, 20 underwent both preoperative and postoperative Schirmer’s testing. Two patients exhibited “dry eye” symptoms preoperatively. Two (5%) patients had epiphora develop postoperatively, which resolved spontaneously and six (15%) patients complained of “dry eyes,” four of whom had complete resolution of their symptoms within 6 months postoperatively. Only two (5%) patients had persistent mild “dry eye” symptoms. Overall, 38 (95%) of the 40 patients were asymptomatic at their final follow-up evaluations. A correlation between Schirmer’s scores and patients’ symptoms could not be established. No recurrences of lacrimal gland prolapse were found in any of the 28 patients who were available for long-term follow-up.

A new technique for the treatment of lacrimal gland prolapse in blepharoplasty. Aesthetic Plast

A new technique for the treatment of lacrimal gland prolapse in blepharoplasty. Aesthetic Plast

A new technique for the treatment of lacrimal gland prolapse in blepharoplasty

The lateral temporal fullness of the upper eyelid in patients presenting for a blepharoplasty is sometimes due to a prolapse of the lacrimal gland. The operative procedures that attempt to reposition the migrated lacrimal gland have been either dangerous in that they cause a dry-eye syndrome or unsatisfactory in that they have a high rate of recurrence or other complications. A new and different operative approach to a herniated or prolapsed lacrimal gland deals with an extraglandular concept of repositioning the gland that corresponds to the general principles of hernial surgery.

Blepharochalasis A Review of 30 Cases

This paper presents the findings in a series of 30 patients with blepharochalasis, including the age of onset, sex, predisposing factors, symptoms and signs, frequency and duration of attacks, and length of the history. There were 16 bilateral and 14 unilateral cases. The condition can be divided into an active (early) and a quiescent (late) stage. The active stage is further subdivided into intumescent (hypertrophic) and atrophic forms. The sequelae included excess thin skin, fat herniation, lacrimal gland prolapse, ptosis, blepharophimosis, pseudoepicanthic fold, proptosis, conjunctival injection and cysts, entropion, and ectorpion. Surgery primarily involved blepharoplasty, ptosis correction, and lateral canthal reattachment alone or in combination. The pathology showed a variable picture of epithelial atrophy, vasculitis, and loss of elastic fibers, which did not greatly help to differentiate blepharochalasis from angioedema, lymphedema, dermatochalasis, tumors and infiltrations, and floppy lid syndromes. Blepharochalasis is probably a localized angioedema. The diagnosis depends on the clinical features of intermittent attacks of localized swelling affecting one or more eyelids associated with thinning of the skin giving either an intumescent (hypertrophic) or atrophic appearance in the active stage of the condition and progressing to atrophic changes in the quiescent (late) stage.

The treatment of lacrimal gland prolapse in blepharoplasty.

Careful evaluation of the patient undergoing blepharoplasty should include an assessment of lacrimal gland position. Lacrimal gland prolapse, if uncorrected at the time of surgery, will result in lid asymmetry. The purpose of this article is to review the anatomy of the lacrimal gland, the causes of herniation, and the surgical management in conjunction with blepharoplasty.

The prolapsed lacrimal gland in blepharoplasty

Evaluation of the patient for blepharoplasty should include an assessment of lacrimal gland position. Lacrimal gland prolapse, if not corrected at the time of blepharoplasty surgery, will result in lid asymmetry. Prolapse of the gland can occur spontaneously or in conjunction with certain disease processes including blepharochalasis and thyroid ophthalmopathy.Surgical correction of the condition may be accomplished through the standard blepharoplasty incision. Careful attention to hemostasis during surgery and a working knowledge of the bilobed anatomy of the gland are prerequisites to the successful resuspension of the gland into the lacrimal fossa.