Medial Canthal Tendon Research Articles

Clinical efficacy of improved method of inverted L-shaped incision combined with medial canthal tendon plication for moderate and severe epicanthus correction

Objective To explore the clinical effect of inverted L-shaped incision combined with medial canthal tendon plication for moderate and severe epicanthus correction. Methods Improved method of inverted L-shaped incision combined with medial canthal tendon plication were performed in 42 cases of moderate and severe epicanthus. The epicanthus covered more than 50% lacrimal caruncle with single-fold eyelids or unconspicuous double-fold eyelids. Among them, 40 cases received double-eyelid plasty simultaneously. Results The follow-up time of 38 cases ranged from 6 to 24 months. 37 cases received double-eyelid plasty simultaneously. All the patients obtained satisfactory results aesthetically, the contours of two eyelid fissures and the double-eyelid radian looked more natural postoperatively. There was no reoccurrence of epicanthus. Mild scar proliferation was observed in all of the patients in the early 1-2 months of postoperative period and then would fade within three months. Conclusions It is effective to correct epicanthus by improved method of inverted L-shaped incision combined with medial canthal tendon placation. Key words: Medial epicanthus; Double eyelid plasty

Medial canthal support structures: the medial retinaculum: a review.

The medial canthus is supported by several structures with a complicated 3-dimensional arrangement in a narrow space. Although the medial canthal tendon occupies a major portion of the area, the medial canthal support structures include the following entities: Horner's muscle, the medial rectus capsulopalpebral fascia including the medial check ligament, the medial horn of the levator aponeurosis, the medial horn supporting ligament, the medial horn of the lower eyelid retractors, the preseptal part of the orbicularis oculi muscle, and 3 variations of the Lockwood's ligament. We named the composite of these structures the "medial retinaculum," which is similar to the "lateral retinaculum" of the lateral canthus. Profound comprehension and consideration of the medial retinaculum warrants safe and effective surgery in the medial canthal region.

Modified auricular cartilage sling for paralytic ectropion

To evaluate the outcomes of a modified auricular cartilage sling for paralytic ectropion. We treated 17 eyelids of 17 patients (average 67 years old) with an auricular cartilage sling between 2004 and 2012. All patients had paralytic ectropion with lower eyelid ptosis. Cartilage was harvested via an incision just inside the anterior rim of the helix. Skin incisions were made at the subciliary, medial and lateral canthal regions. The auricular cartilage graft was sutured to the medial canthal tendon medially, lateral orbital rim laterally, inferior tarsus superiorly, and lower eyelid retractors inferiorly. Average follow-up period was 40 months (range 16-60months). The median L-MRD (mm) was improved from 8.4 preoperatively (interquartile range 7.5-8.9) to 5.2 postoperatively (4.8-5.3). The median lagophthalmos (mm) was improved from 5.8 preoperatively (4.7-7.0) to 2.2 postoperatively (1.6-2.6). 16 patients had corneal exposure preoperatively and this resolved completely in 12 patients. All patients experienced good anatomical and functional results with relief of their preoperative pain/discomfort symptoms without complications. No patients required reoperation and none experienced infection, exposure of the cartilage graft, or recurrence of lower eyelid malpositions. Postoperatively, all lower eyelids moved downward with down-gaze. The auricular scar left no significant cosmetic deformity. The modified auricular cartilage sling with 4 point fixation for paralytic ectropion appears to maintain normal eyelid mobility with down-gaze and avoids the problem of lower eyelid fixation.

Surface landmark of the facial vein for the dermal fillers injection

ObjectiveThe purpose of this study was to describe the course of the facial vein and identification of surface landmark of the facial vein for dermal fillers injections. MethodsThirty flaps of hemiface were turned over to measure the distance between the facial vein and ala of the nose and oral commissure. The vertical distance was measured from the inferior orbital rim to the facial vein. The diameter of the facial vein and the depth from skin surface to the facial vein were measured. Anatomical relationships of the facial vein to its surrounding structure were observed. ResultsThe course of the facial vein is a large curved course without tortious from the medial canthal tendon downward along the medial orbital rim. The mean vertical distance from the facial vein to the inferior orbital rim was 6.87±1.14mm. The average horizontal distance from the facial vein to ala of nose was 21.57±3.95mm. The average horizontal distance from the facial vein to oral commissure was 27.55±3.97mm. The average depth values from skin surface to the facial vein at the level of ala of nose and oral commissure were 14.44±2.90 and 15.38±2.40mm, respectively. ConclusionsThe course of the facial vein at the level of ala of nose and the oral commissure were approximately 2 and 3cm, respectively at the depth of 1.5cm.

Outcome of Y to V Medial Canthoplasty With Medial Canthal Tendon Plication for the Correction of Blepharophimosis- Ptosis-Epicanthus Inversus Syndrome

AIM: Evaluation of the results of Y to V medial canthoplasty with medial canthal tendon (MCT) plication for the correction of blepharophimosis syndrome. MATERIALS AND METHODS: Prospective interventional case series which included 15 cases of blepahrophimosis syndrome. Two stages management was used in all cases. The first stage was Y to V medial canthoplasty with MCT plication. 3 months later, ptosis was corrected by bilateral frontalis suspension or maximum levator resection in the more ptotic eyelid in patients with asymmetric ptosis. Data regarding margin reflex distance 1 (MRD1), horizontal palpebral fissure length (HPFL), inner intercanthal distance (IICD), and the ratio of IICD to HPFL were recorded before and after surgery and were statistically analyzed. RESULTS: The mean age of patients was 3.7±0.8 years. According to the postoperative IICD/HPFL, 12 patients (80%) had successful outcome. The preoperative IICD had a mean of 37.6±1.5 mm, which was reduced post operative to a mean of 33.0±2.3 mm. The HPFL improved from preoperative mean 21±1.2 mm to postoperative mean 24.2±1.4 mm. The mean preoperative IICD/HPFL ratio was 1.8±0.2 which was reduced post operative to a mean of 1.37±0.2. The MRD1 improved from preoperative mean of 1±0.4 mm to 3.6±0.3 mm post operative. The main complication recorded was undercorrection which was observed in 3 patients (20%). CONCLUSION: The two stage management using simple procedures as Y to V medial canthoplasty with MCT plication followed by frontalis suspension or maximum levator resection yielded satisfactory results in the correction of complicated deformity as the blepharophimosis syndrome.

Hypertelorism Correction With Facial Bipartition and Box Osteotomy

Hypertelorism may be corrected by either transcranial box osteotomy or facial bipartition. Despite radical bony resection, the associated soft tissue translation often seems disproportionate. The purpose of this study was to review bony and soft tissue movements in a series of 15 consecutive hypertelorism correction cases. Two surgical residents in training independently analyzed preoperative and postoperative axial and three-dimensional reconstructed computed tomography data from 15 consecutive patients undergoing facial bipartition (n = 7) or transcranial box osteotomy correction (n = 8) between 2001 and 2010. Anterior interorbital distance, lateral interorbital distance, midpoint globe distance, and globe protrusion were measured along with intercanthal distance and palpebral fissure width. The mean preoperative anterior interorbital distance was 35.5 mm; postoperatively, there was a mean reduction of 9.5 mm, to 26 mm. The mean preoperative intercanthal distance was 48.1 mm; there was a mean reduction of 10.3 mm, to 37.8 mm. The mean preoperative midpoint globe distance was 69.5 mm; there was a mean reduction of 9.6 mm, to 59.9 mm. The mean preoperative globe protrusion was 17.6 mm; there was a mean reduction of 5 mm, to 12.6 mm (28.5%). The mean interclass correlation (a measurement of interrater congruency with 1 being complete agreement) was 0.85 CONCLUSIONS: Transcranial box osteotomy and facial bipartition correct hypertelorism. The medial canthal tendons, lateral canthal tendons, and globes move in proportion to the bony attachments. We observed a reduction in globe protrusion an average of 29%, therefore risking enophthalmos.

Caruncular fixation in medial canthal tendon repair: the minimally invasive purse string suture for tendinous laxity and medial ectropion.

To describe a surgical technique for repair of medial ectropion that simply and reliably addresses tendinous laxity and punctal eversion. Prospective, single-blind, consecutive case study of 54 patients (79 eyes) by 3 surgeons. The subject population consisted of 33 males and 21 females, with a mean age of 81 years (SD = 9, range = 64-97). The presenting mechanisms of ectropion were as follows: cicatricial (n = 10), paralytic (n = 1), involutional (n = 62), mechanical (n = 3), and congenital (n = 3). Ectropion and punctal eversion was surgically addressed by use of a purse string suture that incorporated closure of a medial spindle incision and deep fixation to the base of the caruncle. The average postoperative follow-up period was 147 days (SD = 291, range 8-2,352). Sixty-four eyes had a presenting complaint of tearing (81%), with 50 eyes (78%) achieving complete resolution (p = 0.0001). Eyelid malposition was determined to be anatomically corrected in 34 of 35 eyes (97%, p = 0.0001). Four of the 79 operated eyelids had recurrence of ectropion (5%). All other reported complications were minor, resolved without sequalae. The technique demonstrated safety, efficacy, and reproducibility, regardless of ectropion mechanism. Incorporation of a purse string suture between the lower eyelid portion of the medial canthal tendon and the caruncle produces a reliable posterior-superior fixation parallel to the vectors of the posterior limb of the medial canthal tendon. This technique is equally effective as a primary correction method or when used in combination with other procedures.

En bloc resection of lacrimal sac tumors and simultaneous orbital reconstruction: surgical and functional outcomes.

To describe a surgical technique of en bloc resection of lacrimal sac tumors by the shared expertise of 2 specialists to achieve optimal tumor margin clearance and the simultaneous reconstruction of the bony defect to preserve ocular functions and cosmesis. All patients who had resection of malignant nasolacrimal drainage system tumors using the combined technique and posttreatment protocol between 1997 and 2011 were studied in this retrospective, noncomparative, interventional case series. A combined medial maxillectomy and medial orbitotomy for en bloc resection of the lacrimal sac tumor was followed by reconstruction with a tailored contoured titanium mesh to support the globe and eyelid. Disease relapse, disease survival, ocular functions (vision loss, motility, globe dystopia, and diplopia), and cosmesis (medial canthal tendon dystopia and eyelid retraction) were documented. Fourteen patients with malignant lacrimal sac tumors underwent en bloc resection. Postoperative radiation was ultimately administered to 9 patients. All patients but one were alive at last follow up. Tumor recurred locally in 2 patients with a regional recurrence in a third patient. Complications from radiation therapy included skin breakdown over the mesh (9/14 patients) with nasocutaneous fistula, medial canthal tendon dystopia (2/14 patients), and corneal perforation in a patient with recurrent disease. Despite removal of the tear drainage system, only 7 of 14 patients reported epiphora. None of the patients developed diplopia after resection and radiation therapy. The combined sinus-orbit approach is an effective method of managing lacrimal sac tumors to achieve optimal tumor clearance from the orbit and nasal cavity. Simultaneous reconstruction of the bony defect with a contoured titanium mesh provides a fixation anchor for the medial canthal tendon and globe support and serves as a supporting platform for the lower eyelid and cheek to minimize midface collapse. Postoperative radiation is associated with skin flap breakdown and nasocutaneous fistula formation.

Anatomy of anterior ethmoidal foramen, medial canthal tendon, and lacrimal fossa for transcutaneous anterior ethmoidal nerve block in Japanese individuals.

To examine the anatomical relationships of the anterior ethmoidal foramen (AEF), medial canthal tendon (MCT), and lacrimal fossa (LF) in Japanese individuals. Thirty-eight orbits from 19 Japanese cadavers (7 men and 12 women; average age at death, 89.3 years) were used in this experimental anatomical study. The AEF, MCT, and superior border of the LF were exposed. The following distances were then measured: 1) from the point at the medial orbital rim directly anterior to the AEF to the superior border of the MCT (AEF-MCT), and 2) from the superior border of the LF to the superior border of the MCT (LF-MCT). (AEF-MCT) and (LF-MCT) distances were 9.40±1.92 (mean±standard deviation) and 4.21±1.18 mm, respectively. No values of (LF-MCT) exceeded the mean (AEF-MCT) (9.40 mm). The transcutaneous anterior ethmoidal nerve block can be reliably performed without injury to the lacrimal sac by inserting a needle approximately 9 mm superior to the superior border of the MCT.

Adjunctive Techniques to Traditional Advancement Procedures for Treating Severe Blepharoptosis

To create a more physiologic eyelid opening in patients with severe blepharoptosis, the authors used lamina propria mucosa of conjunctiva, which continues to the check ligament of the superior fornix, in addition to levator aponeurosis and Müller's muscle as a composite flap. In patients with epicanthal folds with associated telecanthus, the authors also performed epicanthoplasty with medial canthal tendon shortening. Fifty blepharoptosis patients (85 eyelids) with a degree of ptosis of greater than 4 mm underwent the advancement technique using the levator aponeurosis-Müller's muscle-lamina propria mucosa of conjunctiva as a composite flap. Twenty-one (42 percent) of those patients also underwent split V-W epicanthoplasty and plication of the medial canthal tendon for epicanthal folds with associated telecanthus. Degree of ptosis and levator function were measured preoperatively and postoperatively. Complete or near-complete correction of ptosis (degree of ptosis, <1 mm) was achieved in 54 eyelids (63.5 percent) and mild residual ptosis (degree of ptosis, 1 to 2 mm) was observed in 22 eyelids (25.9 percent) in postoperative follow-up after 6 months. The most common complication was reoperation, which was done in 15 eyelids (17.6 percent) because of incomplete correction. The advancement technique using the levator aponeurosis- Müller's muscle-lamina propria mucosa of conjunctiva composite was effective in the treatment of severe blepharoptosis with levator function of 2 to 7 mm. The technique produced elevating motion of the physiologic eyelid in a superior-posterior direction. There were no serious complications, such as long-term lagophthalmos or lid lag. Therapeutic, IV.

English

Background: Dacryocystitis is the inflammation of the lacrimal sac due to nasolacrimal duct obstruction. Chronic dacryocystitis is a constant threat to cornea and orbital soft tissue & always dictates surgery for correction of symptomatology. The gold standard procedure of choice for the treatment of epiphora is Dacryocystorhinostomy. This study proposes to evaluate and compare the surgical outcome of external DCR and endoscopic endonasal DCR. METHODS: A Retrospective, comparative, randomized interventional study was conducted from January 2012 to December 2013. 40 diagnosed cases of chronic dacryocystitis were randomized into two groups. Group A included 20 patients who underwent external Dacryocystorhinostomy and group B included the rest of the 20 patients who underwent endoscopic endonasal Dacryocystorhinostomy. RESULTS: In group A patients, 9 cases had bleeding during surgery, tearing of the anterior nasal flap was seen in 5 cases and punctal laceration in 4 cases. In group B patients 3 cases had bleeding, 5 cases had Trauma to the middle turbinate while accidental entry into anterior ethmoidal cells was in 4 cases. In 8 cases there was difficulty in making a bone window. In group A patients, duration of surgery is comparatively more than in group B. In post-operative period group A patients, had epistaxis, rhinostomy site closure, hypertrophied external scar and medial canthi damage as its complication while group B epistaxis, nasal Synechea, intra nasal granulation at the ostium are major complication. After a period of 3months by syringing the lacrimal sac of the patients in group A patients, 18 patients had a patent sac (success rate is 90%). In group B patients, 16 patients had a patent sac (success rate being 80%). CONCLUSION: DCR either by external or endonasal route can be considered for treatment of nasolacrimal duct obstruction. The external route has an easy and short learning curve with reduced cost of equipment. Whereas endoscopic DCR is time saving, avoids a facial scar and injury to the neighboring structures like the medial palpebral ligament and the angular facial vessels. In our study, the success rate of Endonasal DCR and External DCR are almost equal and comparable. This indicates that these two different DCR techniques are acceptable alternatives. However it's the preference of the patient, resource available and the surgeon himself to decide the right surgical option to axe the disease.

Endoscopic Ultrasonic Dacryocystorhinostomy for Recurrent Dacryocystitis Following Rhinoplasty

The lacrimal sac is the structure most vulnerable to injury when performing rhinoplastic osteotomies. When performed in a low lateral position or along the frontal process of the frontal-maxillary suture, osteotomies can potentially tear the medial canthal tendon and injure the underlying lacrimal sac, possibly resulting in dacryocystitis. In this case report, the authors discuss a case of dacryocystitis following primary rhinoplasty; this injury was repaired with endoscopic dacryocystorhinostomy (DCR) using a Sonopet ultrasonic bone aspirator (Stryker, Kalamazoo, Michigan) at a single institution. This method achieved nasolacrimal duct patency, and the patient continued to be symptom-free at an 18-month follow-up. This is the first reported case of recurrent dacryocystitis following rhinoplasty as treated by endoscopic DCR. 5.

Transcaruncular Medial Canthal Tendon Plication with Lower Eyelid Suture Sling in Facial Nerve Palsy

Purpose: To report a technique for correcting lower eyelid punctal ectropion with an inferiorly displaced or retracted medial eyelid due to facial nerve palsy, by extending a suture sling along the pre-tarsal lower eyelid when performing transcaruncular medial canthal tendon plication.Methods: Single-centre retrospective, non-comparative review of patients with facial nerve palsy who underwent medial canthal tendon plication with lower eyelid suture sling (MCT suture sling). Outcome measures included: the presence of lower eyelid ectropion, medial eyelid height, punctal position, inferior marginal reflex distance (MRD) and inferior scleral show measured both pre-operatively and at the last follow-up visit.Results: Thirty-three patients with facial nerve palsy with a mean age of 59, underwent MCT suture sling for lagophthalmos and/or ectropion. Then, 66% (21/32) of cases had punctal ectropion pre-operatively and 9% (3/32) had punctal ectropion at the last follow-up. Medial eyelid height was deemed to improve in 66% (21/32) of cases at the last follow up visit. Follow-up was mean 13.5 months. Six (18%) patients were deemed failures due to inferior MRD and inferior scleral showing worse than pre-operative measurements.Discussion: We report a technique for incorporating a suture sling to transcaruncular-approach MCT plication when the medial canthus has retracted or descended thus requiring support and a posterior vector. It avoids rounding of the medial canthal angle that may occur with traditional medial canthoplasty. Transcaruncular MCT plication is well described. Incorporating a suture sling to potentially reduce single point-fixation cheese-wiring and early dehiscence is minimally invasive, non-excisional and repeatable.

Medial Canthopexy Using Y-V Epicanthoplasty Incision in the Correction of Telecanthus

Telecanthus occurs because of the disruption of the medial canthal tendon (MCT). The deformity of medial canthus can result from nasoorbitoethmoid fractures, tumor resection, craniofacial exposure, congenital malposition, or aging. Repair of the MCT using transnasal wiring is regarded as a method of choice to treat telecanthus. We have introduced an oblique transnasal wiring using Y-V epicanthoplasty incision rather than the well-known classical bicoronal approach. Eight patients with telecanthus were treated with this method. Through the medial canthal horizontal and periciliary incision, we could have an access to the medial orbital wall and the MCT. An oblique transnasal wiring was performed with the following steps: (1) after slit skin incision on the nasal recession of the contralateral frontoglabella area, 2 drill holes were made from this point to the superior and posterior region of the lacrimal fossa of the affected orbit; (2) a 2-0 wire was passed through the MCT and the holes; (3) the wire was pulled and tightened until the MCT was ensured and was twisted in the contralateral side. After the repositioning of the MCT, the skin was simply sutured. The excess skin was trimmed, and then the skin was sutured with nylon 7-0. The remaining "dog ear" in the lateral portion can be removed by additional periciliary skin incision and excision. All the patients achieved an improvement and a prompt recovery. The interepicanthal distance was decreased by 6.3 mm on average compared with that in the preoperative condition. All patients had no complication associated with surgeries. Of posttraumatic telecanthus, 5 patients were much satisfied with the outcomes, and 1 patient had recurrence on postoperative month 3. In cases of congenital anomaly or neoplasm, the telecanthus was also improved. An oblique transnasal wiring using Y-V epicanthoplasty incision could be a simple, safe method to correct the telecanthus with the following advantages: first, we could fix the MCT to the appropriate position with oblique transnasal wiring; second, a horizontal incision and a periciliary incision could be acquired with enough operative fields; third, Y-V epicanthoplasty incision is an effective method for minimizing unsightly scar formation.

Calcium Hydroxyl-Apatite (Radiesse) for the Correction of Periorbital Hollows, Dark Circles, and Lower Eyelid Bags

To describe the authors experience with calcium hydroxyl-apatite (CaHa) injections for the aesthetic correction of tear trough, infraorbital hollows, deep upper sulcus, dark circles and lower eyelid bags. The records of 63 patients (127 eyelids) injected with CaHa for aesthetic rejuvenation of the periocular region between March 2012 and March 2013 were retrospectively evaluated. All injections were carried out using a 25-gauge cannula after adding 0.5 ml of 2% lidocaine to 1.5 ml vials of the original product. Postoperative visits were scheduled at 1 week and 1 month. Any previous treatment was recorded, and necessity of retreatments and side effects was evaluated. Patient satisfaction was recorded at 1 month with self-evaluation of the treatment result as "worsened," "unchanged," or "improved." Standard pre- and postinjection photographs were taken and compared to analyze the success of the procedure. Pictures were retrospectively graded by the authors on a similar improvement scale of 1 (worse), 2 (no change), and 3 (improvement). Fifty-eight/sixty-three patients were women (92%), with an average age of 42 years (range; 18-57 years). Chief complaints were "hollows" in 94% of patients, "dark circles" in 33%, lower eyelid "bags" in 17%, and deep upper sulcus in 4.7%. Twenty-three patients (36.5%) required an additional correction 1 month after the primary treatment. Satisfaction was as high as 98% among patients treated primarily for hollowness, and the overall satisfaction rate was 92%. Associated dark circles were satisfactorily treated in 68% of the patients. Temporary side effects involved mild erythema and swelling for 2 to 3 days and pseudoxanthalesma effect in 22 eyelids (17.4%) lasting <6 weeks. In 2 patients, erythema lasted longer than 4 weeks. The 2 worse complications in this series were migration of the product above the medial canthal tendon in 1 patient and overcorrection in another patient. These complications were all managed conservatively and resolved spontaneously within 6 to 8 weeks. No case of irregular contour, palpable lumpiness, or unevenness were encountered. In the end, only 1 patient thought she was worsened after the treatment. Treatment of the periocular region with CaHa injections is a safe and effective treatment with high patient satisfaction and low complication rate. Advanced technical skills may have to be acquired for the specific treatment of this area using this particulate material.

Ethmoidal Sinus Mucocele as a Cause of Acquired Brown Syndrome

Dear Editor, A mucocele is composed of a respiratory epithelial lined mucus-containing lesion with accumulation of mucoid secretion. Sometimes, it produces remodeling of the bony structure and influences the adjacent tissues [1]. In this case, extension of the ethmoid sinus mucocele and remodeling of the orbital structure were major causes of acquired Brown syndrome. Although various causes of acquired Brown syndrome have been described, this is the first reported case of acquired Brown syndrome due to ethmoidal sinus mucocele in Korea. A 69-year-old male presented to our institution with a newly-developed diplopia. There was no history of trauma or any medical illness. At initial examination, visual acuity was 20 / 30 in both eyes. The intraocular pressure was 17 mmHg in the right and 20 mmHg in the left eye. There was no relative afferent pupillary defect and color vision was normal. A soft compressible tender mass measuring 2 × 2 mm on the superonasal aspect of the left upper lid extending from the trochlea to the medial canthal tendon was noted. A motility examination showed an underelevation in adduction of the left eye mimicking Brown syndrome (Fig. 1A). A left hypotropia of 2 prism diopters (PD) to 4 PD in primary gaze, which increased to 6 PD in right and upgaze, was present. Forced duction testing indicated a restriction of elevation in adduction of the left eye. Computed tomography (Fig. 1B) revealed an expansile nonenhancing 30 × 25 mm mass of the left ethmoidal sinus having an intraorbital extension consistent with a mucocele. The mass appeared to be pressing on the globe causing effacement of the left medial rectus and superior oblique tendon with anterolateral displacement of the trochlea. The patient underwent endoscopic ethmoidectomy and evacuation of the mucocele by an otolaryngologist. Postoperatively at two months, there was complete resolution of the diplopia and the patient was asymptomatic. A forced duction test revealed no restrictions. Fig. 1 (A) Preoperative versions of subject in nine diagnostic positions of gaze, demonstrating underelevation in adduction of the left eye. (B) Orbital computed tomography scan showing the nonenhancing 30 × 25 mm mass (arrow) of the left ethmoidal sinus ... Brown syndrome is characterized by limited elevation in adduction with positive forced duction testing [2]. The mechanism of acquired Brown syndrome in this case was thought to be the ethmoidal sinus mass preventing anterior tendon movement through the trochlea or the spread of inflammation from an adjacent sinus disease [3]. Complete resolution of symptoms after surgery suggests that mechanical effects were the main cause in this case. Although acquired Brown syndrome is rare, ethmoidal sinus mucocele should be considered in differential diagnosis of acquired Brown syndrome.

Classification and management of ectropion with medial canthal tendon laxity

Purpose Lower eyelid ectropion is usually accompanied by a variable degree of medial and lateral eyelid laxity. This work investigates a clinical evaluation scheme and a surgical plan to repair ectropion associated with different stages of such associated laxity. Patients and methods Forty-two procedures on 30 patients with lower eyelid ectropion associated with variable degree of medial palpebral ligament laxity were performed on the basis of the ectropion classification and management protocol described in this work. Patients were followed up for at least 6 months postoperatively. Results Firm medial eyelid fixation against lateral traction and correction of ectropion were achieved in all cases. Epiphora was cured in 26 eyes. The planned cosmetic outcome was achieved in 28 cases. Conclusion Individualizing the surgical repair for involutional ectropion on the basis of the clinical findings is cosmetically and functionally rewarding.

Location and Tension of the Medial Palpebral Ligament

The aim of this study was to elucidate the precise anatomic location and tension of the medial palpebral ligament (MPL). Eleven hemifaces of 10 fresh Korean adult cadavers were used in this study. Nine specimens were used for measurement of dissection and tension, and 2 were used for histologic study. Measurements of tensile strength of each part of the MPL and Horner muscle were performed using a force gauge.The MPL consisted of 2 layers in all specimens dissected. The superficial layer of the palpebral ligament (SMPL) was observed from the anterior lacrimal crest to the upper and lower tarsal plates. The deep layer of the palpebral ligament (DMPL) lay from the anterior lacrimal crest to the posterior lacrimal crest, covering the lacrimal sac. The Horner muscle was observed at the posterior lacrimal crest just lateral to the attachment of the DMPL and ran laterally to the tarsal plate deep to the SMPL. The SMPL began at 4.5 ± 2.3 mm lateral to the nasomaxillary suture line to the upper and lower tarsal plates. Its transverse length was 9.6 ± 1.5 mm, and vertical width was 2.4 ± 0.7 mm, and its thickness was 4.5 ± 2.3 mm. The transverse length of the DMPL was 3.7 ± 0.4 mm, and its vertical width was 2.9 ± 1.3 mm, with a thickness of 0.3 ± 0.1 mm. The transverse length of the Horner muscle was 7.6 ± 1.9 mm, and its vertical width was 4.06 ± 1.5 mm, with a thickness of 0.4 ± 0.1 mm. The tensile strength of the SMPL was 13.4 ± 3.2 N, that of the DMPL was 4.1 ± 1.7 N, and that for Horner muscle was 9.0 ± 3.1 N. The tensile strength of the SMPL was significantly higher than that of the DMPL (P = 0.003).We reconfirmed that the MPL consisted of 2 layers: superficial layer and deep layer. Our results might be of use in surgeries of the medial canthi.

Bilateral Squamous Cell Carcinoma of the Lacrimal Sac

A 42-year-old man presented with right-sided epiphora, a fleshy lesion emanating from the right inferior punctum and a painless mass below the medial canthal tendon. Biopsy of the lacrimal sac mass disclosed papillary squamous cell carcinoma in situ. The patient underwent wide local excision with clear surgical margins and remained disease free until 28 months later when he returned with hemorrhagic epiphora of the OS and fullness overlying the left lacrimal sac. Biopsy confirmed papillary squamous cell carcinoma in situ. He underwent similar excision and has remained disease free for 6 months. To the best of the authors' knowledge, this is the first report of bilateral squamous cell carcinoma of the lacrimal sac.

Genetic diseases affecting the eyelids

The molecular basis of a number of inherited diseases that affect the eyelids has been elucidated over the last two decades. Due to the vast number of these diseases, a clinician may become overwhelmed by the volume of data, making it difficult to incorporate newer information into his or her clinical practice. This article intends to review the recent developments of inherited diseases that affect the eyelids that a typical oculoplastic surgeon will encounter. This review proposes categorizing genetic diseases affecting the eyelids on rarity and whether the disease manifests itself at birth or later in life. Based on this classification system the following 10 diseases (the first five manifesting at birth, the last five later in life) are considered more likely to be encountered by the typical oculoplastic surgeon and reviewed in detail: blepharophimosis-ptosis-epicanthus inversus syndrome, congenital fibrosis of the extraocular muscles, lymphedema-distichiasis syndrome, neurofibromatosis type 1, congenital myasthenic syndrome, oculopharyngeal muscular dystrophy, chronic progressive external ophthalmoplegia, myotonic dystrophy, neurofibromatosis type 2, and basal cell nevus syndrome. The remaining known genetic disorders that affect the eyelids are considered less likely to be encountered by the typical oculoplastic surgeon and are listed in tabular form. It is prudent for the oculoplastic surgeon to be knowledgeable of inherited disorders that affect the eyelids to aid in accurate diagnosis, counseling, and treatment. The development of future therapies may at some point make treatment of these diseases no longer surgical. http://links.lww.com/COOP/A4.