Periocular Area Research Articles

Effects of the Nd:YAG 1320-nm laser on skin rejuvenation: Clinical and histological correlations

The neodymium:yttrium-aluminum-garnet (Nd:YAG) laser is a popular non-ablative treatment used for skin rejuvenation. The purpose of this prospective study was to evaluate the clinical effects, coupled with a quantitative assessment, of the histological changes in response to Nd:YAG 1320-nm laser treatment of periocular wrinkles. Six volunteers with Fitzpatrick skin types III and IV and Glogau class I–II wrinkles were subjected to 3 months of Nd:YAG 1320-nm treatment in the periocular area (six sessions at 2-week intervals). Volunteers were photographed, and skin biopsies were obtained at baseline as well as 3 and 6 months after the start of treatments. Quantitative evaluation of total elastin, newly synthesized tropoelastin, collagen types I, III and VII, and newly synthesized collagen was performed using a computerized morphometric analysis. A noticeable clinical and histological improvement was observed after Nd:YAG 1320-nm treatment. Collagen types I, III and VII, as well as newly synthesized collagen, together with tropoelastin showed a statistically significant increase in response to treatment, while the mean level of total elastin was significantly decreased after treatment. Our data suggest that Nd:YAG 1320 nm is an effective treatment for skin rejuvenation as it stimulates the repair processes, and reverses the clinical, as well as the histopathological, signs of skin aging.

Infantile haemangioma: Part II. Risks, complications and treatment

Because of their spontaneous involution, most infantile haemangiomas (IH) do not require therapeutic intervention. However, in 10 to 15% of cases such as segmental and multifocal IH, locations in the periocular, airway and perineal areas, or complications of ulceration, treatment is necessary. Moreover, the risk of permanent scarring and disfigurement associated with IH, even if involution is complete, has been increasingly recognized as a rationale for treatment. Treatments for IH currently include topical, intralesional, systemic therapies, laser and surgical modalities depending on the clinical scenario. However, clinicians must carefully weigh the risks and benefits for each treatment. Recently, the efficacy of propranolol, a non-cardioselective beta-blocker, was reported and has been revolutionary in the management of IH.

Commentary: Predicting Efficacy of Fractional Carbon Dioxide Laser Treatment for Resurfacing

is an impor-tant advancement in our knowledge of in vivo der-mal modeling after fractional ablative lasertreatment. Maximizing clinical response and mini-mizing adverse events are the ultimate goal of everylaser surgeon. We have all had patients who pre-operatively presented as excellent candidates forablative treatment only to have suboptimal responseto multiple sessions. Conversely, other patients havean outstanding response to identical parameters andend up as an example of success on our lecture slides.This type of rigorous scientific work adds to ourunderstanding of the factors that may differentiatethese two types of patient responses.The objective nature of this work challenges usto reassess our assumptions regarding clinical results.The finding that midfacial areas such as forehead,lip, and chin had a statistically significantly greaterincrease in dermal collagen than cheeks and neckis surprising. In practice, patient satisfaction istypically higher in the thinner skin of the cheeks,particularly in the periocular area. This may be afunction of the thicker skin in this central area, re-quiring a larger increase in collagen to confer asimilar clinical response.The future for fractional ablative lasers will probablyinclude real-time adjustment of fluence and pulseduration from ultrasound feedback of ablation depthas a ratio to tissue depth. This may be coupledwith feedback on tissue temperature and othermeasurements to optimize results. Perhaps aninterface will also have information such as patientage, retinoid use, and other variables to adjustparameters accordingly.

A woman with severe lupus nephritis and difficult to control diabetes mellitus

A woman with severe lupus nephritis and difficult to control diabetes mellitus

Case report: the use of a modified Tenzel-type flap to reconstruct two separate peri-ocular defects

Basal cell carcinomas in the peri-ocular area account for about 20% of head and neck carcinomas [1], and synchronous non-melanoma skin cancers are a frequent occurrence, in one study occurring in 39% of patients [2]. A well-recognised and excellent way of bringing thin, texture and colour-matched skin to cover lower lid defects which cannot be closed are cheek rotation flaps [3, 4]. However, normally, the presence of a second lesion on the ipsilateral lateral canthus would prevent such flaps from being possible. Here we describe a novel modification of the Tenzel-type flap to simultaneously reconstruct two defects arising from the excision of basal cell carcinomas—one on the inferior eyelid and one on the lateral canthus. Both carcinomas were completely excised, and the patient had a good cosmetic result. The underlying concept is the integration of what may initially appear to be two mutually exclusive local flaps.

Ophthalmic Artery Obstruction and Cerebral Infarction Following Periocular Injection of Autologous Fat

We report a case of ophthalmic artery obstruction combined with brain infarction following periocular autologous fat injection. The patient, a 44-year-old woman, visited our hospital for decreased visual acuity in her left eye and dysarthria one hour after receiving an autologous fat injection in the periocular area. Her best corrected visual acuity for the concerned eye was no light perception. Also, a relative afferent pupillary defect was detected in this eye. The left fundus exhibited widespread retinal whitening with visible emboli in several retinal arterioles. Diffusion-weighted magnetic resonance imaging of the brain showed a hyperintense lesion at the left insular cortex. Therefore, we diagnosed ophthalmic artery obstruction and left middle cerebral artery infarction due to fat emboli. The patient was managed with immediate ocular massage, carbon dioxide, and oxygen therapy. Following treatment, dysarthria improved considerably but there was no improvement in visual acuity.

Childhood Granulomatous Periorificial Dermatitis

Childhood granulomatous periorificial dermatitis (CGPD), also known as facial Afro-Caribbean childhood eruption (FACE), is a distinctive granulomatous form of perioral dermatitis. It is a condition of unknown etiology, characterized by monomorphous, small, papular eruptions around the mouth, nose and eyes that histopathologically show a granulomatous pattern. It affects prepubescent children of both sexes and typically persists for several months but resolved without scarring. We report a 9 year-old girl with multiple, discrete, monomorphic, papular eruptions of 2-months duration on the perioral and periocular areas. Histopathological examination demonstrated upper dermal and perifollicular granulomatous infiltrate.

Malherbe′s calcifying epithelioma (pilomatrixoma): An uncommon periocular tumor

Benign calcifying epithelioma of Malherbe or pilomatrixoma or pilomatricoma is an uncommon lesion of the periocular tissues, arising from the matrix cells at the base of the hair. In the periocular area, it usually arises from the lids and eyebrows. Pilomatrixoma has certain characteristic clinical and histopathologic features, but since it is not commonly suspected preoperatively, certain distinctive clinical features of tumor should suggest clinical diagnosis followed by histopathologic confirmation.

Venous malformation: update on aetiopathogenesis, diagnosis and management.

The aim of this review was to discuss the current knowledge on aetiopathogenesis, diagnosis and therapeutic management of venous malformations (VMs). VMs are slow-flow vascular anomalies. They are simple, sporadic or familial (cutaneomucosal VMs or glomuvenous malformations), combined (e.g. capillaro-venous and capillaro-lymphaticovenous malformations) or syndromic (Klippel-Trenaunay, blue rubber bleb naevus and Maffucci). Genetic studies have identified causes of familial forms and of 40% of sporadic VMs. Another diagnostic advancement is the identification of elevated D-dimer level as the first biomarker of VMs within vascular anomalies. Those associated with pain are often responsive to low-molecular-weight heparin, which should also be used to avoid disseminated intravascular coagulopathy secondary to intervention, especially if fibrinogen level is low. Finally, development of a modified sclerosing agent, ethylcellulose-ethanol, has improved therapy. It is efficient and safe, and widens indications for sclerotherapy to sensitive and dangerous areas such as hands, feet and periocular area.

Successful treatment of canine necrolytic migratory erythema (superficial necrolytic dermatitis) due to metastatic glucagonoma with octreotide

Necrolytic migratory erythema (NME; also known as superficial necrolytic dermatitis) is a syndrome most often associated with certain chronic liver diseases or pancreatic glucagonomas. In humans with glucagonoma-associated NME, skin lesions usually respond to octreotide, a somatostatin analogue that inhibits glucagon release. In this report an 11-year-old golden retriever dog with pancreatic glucagonoma and metastasis to the regional lymph nodes, spleen and liver was diagnosed with NME. The dog exhibited erosions, ulcers and crusts on the paws, pressure points, muzzle, periocular area and prepuce. The dog was also anorexic and had difficulty walking. Because metastasis precluded surgery, treatment was initiated with subcutaneous octreotide (2 μg/kg twice daily). Skin lesions and systemic clinical signs improved markedly within 5 days. The dosage was increased to nearly 3 μg/kg twice daily and signs almost completely resolved within 10 days. Anorexia was the major adverse effect observed. During the following month, both dosage (1-3.7 μg/kg) and frequency (two to four times daily) of the octreotide injections were adjusted to permit control of clinical signs while maintaining adequate appetite. Temporary cessation of octreotide administration resulted in the rapid recurrence of skin lesions. Resuming injections led to improvement of clinical signs within 48 h. The dog was later euthanized because of progressive metastatic disease. In conclusion, subcutaneous octreotide injections were beneficial in this dog with glucagonoma-associated NME. This somatostatin analogue could be a valuable option to treat canine patients with non-resectable or relapsing pancreatic glucagonoma-associated NME.

Incidência das dermatopatias auto-imunes em cães e gatos e estudo retrospectivo de 40 casos de lupus eritematoso discóide atendidos no serviço de dermatologia da Faculdade de Medicina Veterinária e Zootecnia da UNESP – Botucatu

The objectives of this study were to do a survey of the autoimmune skin diseases and update the records regarding the occurrence of discoid lupus erythematosus in canine and feline populations attended at the Dermatology Service of the College of Veterinary Medicine and Animal Science of UNESP - Botucatu, including species, gender, breed, age, location and characteristic of the lesions. Results have shown that the order of occurrence, regarding the number of cases of autoimmune skin diseases in the animals attended by the Dermatology Service in the period from 1988 to 2007 was: discoid lupus erythematosus, pemphigus folliaceus, uveo-dermatologic syndrome, pemphigus vulgaris, systemic lupus erythematosus, necrolytic migratory erythema, multiforme erythema and plasmacytic pododermatitis. All the animals with discoid lupus erythematosus were dogs and most of them were mongrel females. More frequently breeds affected by discoid lupus erythematosus were german shepherd and akita and the mean age was 56 months. Most lesions were located in nasal planum, narines and periocular area and were characterized by crusting, depigmentation and erythema.

Periocular cosmesis

Abstract Purpose Facial nerve paralysis is one of the most devastating peripheral nerve injuries which implies severe functional, cosmetic and psychological consequences to the patients. The periocular area can be improved cosmetically by raising the tissues that have been drooped. These techniques are brow lift for the forehead‐ brow area, midface lift for the mid part of the face and face lift for restoring the contour of the tissues of the lower face. These are static techniques and support the tissues that are not any more innervated and are atrophied and drooped by the force of gravity. Methods In particular brow lift can be achieved by direct incision over the brow, by endoscopic forehead‐brow lift using anchoring systems or alternatively by small incision non endoscopic forehead brow lift through an eyelid incision. Midface lift can be achieved by subperiosteal or pre‐periosteal lift of the tissues or by using a suspension system. Face lift can be achieved with a deep planar rhytidectomy which can lift the tissues of the mid and lower face. Combination of forehead, midface and face lift can be necessary for the maximal possible symmetry of the face in a static position. There is a limitation of these techniques in regards to the dynamic reanimation of the face. There are several dynamic procedures helping at this direction. Results In particular, in case of a transected facial nerve, the disrupted facial nerve can be restored by α) direct end–to‐end coaptation or by β) cable nerve graft interposition Other techniques include: • Temporalis muscle transfer • Free nerve‐muscle grafts • Ipsilateral nerve transposition • Facial nerve‐cross face anastomosis. Conclusion The above available dynamic procedures may provide some degree of facial tone or voluntary facial movement.

Paederus-Induced Keratitis

To report the clinical picture and management of 4 cases of presumed paederus-induced keratitis. The clinical characteristics of the anterior segment and periocular area were presented. The outcomes and healing course of the corneal lesions were recorded. Each patient sustained an accidental eye injury from a beetle while riding a motorcycle. Three cases were complicated by periocular dermatitis. All patients had diffuse punctate epithelial erosions or large epithelial defects on the unilateral cornea. Prolonged corneal epithelialization was noted after lubrication with artificial tears and wearing a contact lens. Reepithelialization was promoted after topical supplementation with 20% autologous serum. All 4 patients had good visual outcomes. Two patients healed with a faint corneal scar. Paederus-induced keratitis could result in extensive involvement of the corneal surface. Keratitis with a large epithelial defect mimicking the corrosive lesion of a chemical burn requires aggressive therapy, such as autologous serum combined with a bandage contact lens. Avoiding contact with the crushed body of the beetle while rubbing the eye is mandatory to prevent this type of keratitis.

Technical note: Applicability of infrared thermography as a non invasive measurements of stress in rabbit.

Among the main physiological stress indicators, the temperature evaluation is very important and innovative because it may be monitored without directly interacting with the animal. The use of a thermographic system, which is based on the detection of infrared radiation emitted by a subject, is a suitable method in order to measure temperature without any contact. In this research, a thermographic system was employed in order to single out the rabbit skin's zones most suitable for the temperature monitoring during stress challenges. Six hybrid rabbits were observed during induced stress; the areas selected as reference were: the ocular area (globe and periocular area), the internal auricle pavilion, and a shaved area of the head. The results of this pilot study show that the thermographic technique is a suitable method for the evaluation of temperature on rabbit. The best areas singled out were the eye bulb, the periocular area and the ear skin. The results concerning the effect of stress on cutaneous temperature showed that during stress condition a decrease in temperature occurs with respect to the basal condition (AT~1°C) and this trend is more evident for the auricle pavillion. In fact, this reaction is more evidenced in the ear skin, where a vasoconstriction process occurs. Moreover, corticosterone levels slightly increase (P=0.08) following the stressor's challenge due to tonic immobility test. In this research, both temperature and the change in corticosterone level show that the stress reaction induced by tonic immobility test is stronger than the one due to the other stressors applied to rabbits.

Rejuvenation of the Lower Lid and Periocular Area from Above

Rejuvenation of the periocular region, specifically the lower eyelid region, can be performed with a variety of methods. One finding of the aging lower eyelid region is the "Y-deformity." Elevation of the midface is a powerful tool that can significantly improve the appearance of the lower eyelid. This article addresses the elevation of the midface through two approaches: the meloplication and the subperiosteal midface-lift. In addition to midface elevation, a short discussion on canthopexy is included. Although the lower eyelid can be addressed in a variety of ways, rejuvenation of the periocular region from above should be considered in all patients, as these approaches yield good results.

Steroid-sparing effect of mycophenolate mofetil in the treatment of a subepidermal blistering autoimmune disease in a dog : clinical communication

A 7-year-old female Cocker spaniel-cross was referred with an 8-month history of mucocutaneous erosive dermatitis. On physical examination, skin lesions affected the eyelids and periocular area, lips and vulva. Lesions were symmetrical with small diffuse superficial ulcers, haemorrhagic crusts, adherent purulent exudation in haired skin, and alopecia with hyperpigmentation and scarring. Histopathologic evaluation showed multiple, non-intact dermoepidermal junction vesicles and ulceration associated with a dermal lichenoid infiltrate. Immunohistochemistry showed strong to moderate reactivity in the dermoepidermal junction for the antibodies directed against canine IgG, human IgG lambda light chains and C3, respectively. A diagnosis of autoimmune subepidermal blistering dermatosis was made. Treatment with oral prednisone at 2 mg/kg and mycophenolate mofetil (MMF) at 20 mg/kg twice daily was initiated and after 4 weeks the ulcers and erosions were cured. During the rest of treatment, MMF was maintained at 10 mg/kg twice daily and prednisone could be tapered to 0.25 mg/kg once every other day without recurrences. In conclusion, this case report shows that MMF was well tolerated and might be effective as steroid-sparing agent in the long-term treatment of this autoimmune subepidermal blistering disease.

Periocular granuloma annulare in four children

Subcutaneous granuloma annulare is a skin condition that occurs on the lower extremities, hands, and scalp of healthy children. It rarely occurs in the periocular area, and when it does, the annular pattern is often absent. Histopathology is diagnostic and shows palisading histiocytes around areas of necrobiosis. Although benign in nature, the lesions tend to multiply, grow in size, and often recur. They usually resolve spontaneously and do not require treatment. Four cases of periocular subcutaneous granuloma annulare, from four different geographical areas, were identified through on-line postings on the worldwide mailing list of the Organization for Pediatric Ophthalmology and Strabismus (http://lists.ucsd.edu/mailman/listinfo/ped-ophth-1). These 4 patients are reported here, and a brief review of the literature is presented.

Headache Attributable to Disorders of the Eye

Sensory innervation to the eye and periocular area arises from the ophthalmic branch of the trigeminal nerve. Thus, ocular, orbital, and systemic disorders may produce head pain with ocular signs and symptoms. Whereas some of these entities have characteristic diagnostic features, others mimic primary headache disorders such as migraine and cluster headache. This article reviews common ocular and neuro-ophthalmic conditions that are accompanied by pain in or near the eye.

A rare case of orbital apex syndrome with herpes zoster ophthalmicus in a human immunodeficiency virus-positive patient

We report a rare instance of favorable outcome in orbital apex syndrome secondary to herpes zoster ophthalmicus (HZO) in a human immunodeficiency virus (HIV)-positive patient. The patient complained of pain and decrease in vision in one eye (20/640) for 2 weeks accompanied with swelling, inability to open eye, and rashes around the periocular area and forehead. The presence of complete ophthalmoplegia, ptosis, relative afferent pupillary defect, and anterior uveitis with decreased corneal sensation prompted a diagnosis of HZO with orbital apex syndrome. The enzyme-linked immunosorbent assay test and a low CD4 count confirmed HIV. Highly active antiretroviral therapy (HAART), systemic acyclovir, and systemic steroids were started. Visual acuity and uveitis improved within 10 days. By the end of the fourth week, ocular motility also recovered and the final visual acuity was 20/25. We highlight the role of HAART, used in conjunction with systemic steroid and acyclovir therapy, in improving the outcome.

Sebaceous gland carcinoma of the eyelid

Sebaceous gland carcinoma, commonly arises in the periocular area, is an uncommon condition. It represents 1–5.5% of eyelid malignancies and is considered to be the third most common eyelid malignancy after basal cell and squamous cell carcinomas, although few reports placed this tumor as second most common after basal cell carcinoma. It usually affects elderly women and characterized by high rate of local recurrence, regional, and distant metastases. A delay in diagnosis, which can be attributed primarily to ability of this tumor to masquerade as more benign conditions, often leads to inappropriate management with increased morbidity and mortality rates. In this study, the authors discuss key elements of the primary disease and therapeutic options available to treat such devastating problem.