Superior Sulcus Deformity Research Articles

Anatomic and Magnetic Resonance Imaging-Based Correction of Upper-Eyelid Depression and Blepharoptosis in Senile Patients.

In senile patients with sunken superior sulcus, involutional ptosis, and higher eyelid crease, a single operation to correct depression or ptosis cannot achieve good results. We demonstrated the anatomy of periorbital septum fibers, which may contribute to the levator muscle's volume depletion and dynamic power transmission disorder, and described a procedure for correcting upper-eyelid depression and blepharoptosis in senile patients. The fibrous webs in these patients connected the posterior aspect of the orbicularis and the orbital septum and extended to the orbital fat and levator aponeurosis. These fibers were dissected to release the periorbital septal fibers, and the orbital septal fat flap was transferred to the depressed region. Advancement or plication of the levator aponeurosis was performed in patients with uncorrected blepharoptosis after the procedures described above. The technique was applied to 13 Chinese patients (25 eyes) between May 2021 and April 2022. Postoperative magnetic resonance imaging revealed that the preaponeurotic fat was displaced forward and down to the upper margin of the tarsus, and the curvature of the upper-eyelid depression was significantly improved. Moreover, the superior sulcus deformity improved, the ptosis was corrected, and the uppermost crease decreased in all patients. No recurrence of ptosis or abnormal adhesion was observed. We believe this is the first study using magnetic resonance imaging to evaluate eyelid anatomy and the effects of surgery in this patient group. Releasing periorbital septum fibers is crucial for correcting a portion of the sunken eyelid and ptosis in Asians.

Long-term efficacy of enucleation combined with primary orbital implantation in children with retinoblastoma histopathological invasion of optic nerve.

ObjectiveThis study aimed to observe the long-term effect of enucleation combined with primary orbital implantation in children with histopathologic optic nerve invasive retinoblastoma (RB).MethodsWe retrospectively analyzed the clinical data and outcomes of children with RB optic nerve invasion confirmed by histopathology who underwent enucleation combined with primary orbital implantation between March 2010 and April 2014 in Beijing Tongren Hospital. The follow-up time ranged from 81 to 129 months, with a mean follow-up of 96 ± 14 months.ResultsA total of 59 children were included in this study. There were 32 males and 27 females; 52 children were affected in one eye and seven children in both eyes. The time from onset of symptoms to visit was between 3 days and 16 months, with a mean of 2.2 ± 2.8 months. The age at the of surgery was between 2 and 65 months, with an average of 24 ± 13 months. Patients were classified based on the degree of optic nerve invasion into four grades: grade 1 (invasion of prelaminar) in 28 cases, grade 2 (invasion of laminar) in 14 cases, grade 3 (invasion of retrolaminar but not reaching the optic nerve transection) in 16 cases, and grade 4 (invasion of the optic nerve transection) in 1 case. Post-operatively, all children were treated with 0–9 cycles of intravenous chemotherapy based on histopathology results from the removed eye. Of the 59 children, 13 had postoperative complications, and one died from recurrence. The survival rate was 98% (58/59). There was one case of orbital implant exposure, one of orbital cellulitis, six of enophthalmos and superior sulcus deformity, two of blepharoptosis, one of granuloma complicated with blepharoptosis, and one with a subconjunctival cyst.ConclusionFor children with RB histopathologic invasion of the optic nerve, enucleation combined with primary orbital implantation reveals future potential treatment options when combined with a full course of intravenous chemotherapy.

Post enucleation reconstruction of orbit using silicone orbital implant and dermis fat graft

The aim of this study was to study the cosmetic appearance of patients after Post-enucleation reconstruction of the orbit with silicone implant and dermis fat graft. this is a prospective interventional study conducted at the department of Oculoplasty and Orbital disorder of a tertiary care eye hospital between 2014 and 2016. 30 cases of which 16 were males and 14 females were included in the study. Patients between the age group 10- 40 years who had painful blind eye, anterior staphyloma and Pthisis bulbi were included in the study. Patients who had enucleation because of malignancies like retinoblastoma and malignant melanoma were excluded from study. Informed consent obtained from the adult patients and consent of one of the parent was obtained from patients who were under 18 years of age after explaining the procedure in patients own language. All patients included were examined by an experienced ophthalmologist using slit lamp, transparent scale, exophthalmometer, A scan, B scan. In single sitting enucleation was done, silicon spherical orbital implant was placed in orbit in posterior sub tenon’s space. Dermis fat harvested from upper and outer quadrant of buttock was placed over the Orbital implant in the posterior sub tenon’s space. Recti muscles were sutured to the edge of dermis fat and conjunctiva sutured to the edge of dermis fat. Conformer placed and Suture tarsorraphy done. Cases followed post operatively on day one, and after 2 week and after 3 months. After 3rd month prosthetic eye was placed. Palpebral aperture height, enophthalmos and superior orbital sulcus deformity and cosmetic appearance was noted. 20 cases had 1mm difference in palpebral aperture height when compare to normal eye. 9 cases had 2mm, and one case had 4mm difference in palpebral aperture height. Enophthalmos with prosthesis was measured by exophthalmometer. 20 cases had 1mm of enophthalmos when compared to normal eye. 9 cases had 2 mm of Enophthalmos and one case had 4 mm of enophthalmos. 20 cases had fullness of superior orbital sulcus. 10 cases had 1-3 mm of superior orbital sulcus deformity.Cosmetic appearance was judged by doctors and attenders of patient. 20 cases had good cosmetic appearance. Whereas, 9 had fair cosmetic appearance and one had poor cosmetic appearance. It is concluded that doing enucleation and implanting orbital implant primarily along with Dermis fat graft reduces implant exposure to nil, and gives good cosmetic results as shown by measurement of Palpebral aperture height, Enophthalmos and Superior orbital sulcus deformity.

Modified impression tray and iris positioning ocular prosthesis of post enucleation socket syndrome: case report

The cosmetic disfigurements which arise due to loss of orbital volume after enucleation of an eye include enophthalmus, superior sulcus deformity, upper eyelid ptosis, and lower eyelid laxity. The treatment can be either conservative or surgical. For patients who does not want to undergo further surgical procedures, the conservative treatment is simple, non-invasive, and appropriate. This case report describes modified impression tray and iris positioning technique of post enucleation socket syndrome to achieve aesthetics and function. A 65-year-old male patient reported to the Dental Hospital Universitas Sumatera Utara with the chief complaint of facial disfigurement due to loss of the right eye. Patient had enucleation 6 months ago and using conformer after surgery. The diagnosis was post enucleation socket syndrome. Clear acrylic sclera as a tray without handgrip will precisely records of the palpebre con- vexity and specified socket. The use of eyebrow ruler helps accurately determine the symmetrical iris position com- pared to only visually determining which is subjective with the possibility of interobserver errors. It was concluded that clear acrylic sclera as a tray and eyebrow ruler to determine the position of iris resulting in patient satisfaction due to aesthetics and function.

Outcomes and complications of evisceration with primary implant: an electronic medical record driven analytics of 1800 cases

ABSTRACT Purpose To describe the surgical outcomes and implant complications in 1,800 patients undergoing evisceration with primary implant Methods An Electronic Medical Record-driven analysis of 1,800 patients undergoing evisceration with primary implant between 2013 and 2019. Implant sizing was performed intra-operatively to place the largest implant without tension on the wound closure. Outcome measures included implant complications, prosthesis measurements, and incidence of a good aesthetic outcome. Good outcome was defined as <2 mm enophthalmos and grade 1 or less superior sulcus deformity with a custom ocular prosthesis. Results Eighteen hundred eyes of 1800 patients were included. The mean age at surgery was 36 ± 21 years (median 32 years). Implants used were poly(methyl methacrylate) (PMMA) in 1737 (97%) and porous polyethylene in 63 (3%) patients. Two-petal sclerotomy was performed in 1512 (88%) and four-petal sclerotomy in 165 (10%) patients. The mean diameter of the implant used was 19.35 ± 1.18 mm (median 20, range 10–22 mm). The implant extrusion rate was 3% (56) and implant displacement was seen in none. The mean prosthesis volume and thickness were 2.22 ± 0.67 ml (median 2, range 1–6.5 ml) and 6 ± 1 mm (median 6, range 2–9 mm). The mean difference in prosthesis projection on Hertel’s exophthalmometer was 0.28 ± 1 mm (median 0, range 0–1 mm). Good outcome was observed in 93%. The mean follow-up period was 351 ± 386 days (median 194). Conclusion Evisceration with empirically selected primary orbital implant placement is associated with minimal implant complications and gives a good aesthetic outcome in 93% of the patients.

Sagging eye syndrome.

The pulley is the functional origin of the extraocular muscles and prevents their dislocation from the muscle cone. The pulley degenerates with age and may progress to cause the sagging eye syndrome (SES). Divergence paralysis, a type of distance esotropia, occurs when the lateral rectus muscle pulley and lateral rectus-superior rectus (LR-SR) band show degenerated symmetry OU. Cyclovertical strabismus of a small angle occurs when the lateral rectus muscle pulley and LR-SR band show degenerated asymmetry OU. Patients with SES have distinctive features, such as baggy eyelids, deep superior sulcus deformity, and aponeurotic ptosis. SES is the leading cause of non-paralytic diplopia, and its rate increases with age, with 60% of the patients being women. One-third of the cases of SES are distance esotropia of 9Δ on average, and two-third of the cases are small-angle hypertropia of 4Δ on average. Diplopia is cured with surgery, and each case needs to be differentiated from the heavy eye syndrome for diagnosis and treatment.

Evisceration with acrylic spherical implant: An evaluation

Purpose: The purpose of this study is to assess the acceptance, of non-integrated acrylic implant in terms of cosmesis, patient comfort, socket component as well as the comparison of these parameter between eyes with and without implant. Materials and Methods: A total of 25 eyes with specific indications for sacrificing the eye were randomly divided with 2 groups of with and without implant. Ocular parameters were taken before and after surgery. Results: Follow up assessment was done post operatively, at 2nd week, 4th week and 6 months after surgery. In the immediate post operative period, the symptoms of pain, discharge and discomfort were present in all patient belonging to either group. However, on future follow up of 1st week these complaints were significantly less in the group without implant. At 6 months serous, non infectious discharge was present in 20% of the study population of both the groups. Evaluation of the post operative socket in terms of infection, superior sulcus deformity revealed comparable (with implant 13.3% and without implant 20%) data in terms of post operative infection, all of which were well controlled after administering appropriate antibiotics whereas, superior sulcus deformity was present in 100 ?ses without implant compare to only 13% at 6 months follow up. Assessment of the complications associated with lid showed that in the group without implants ptosis was present in all cases compared to only 13% (2 cases) in the group with implant. At 6 months, lid complications in the group without implants comprised of 2 cases of entropion and 4 cases of ectropion compared to only one case of ectropion in those with implants. The results in both the group were comparable in terms of occurrence of conjunctival dehiscence and giant papillary conjunctivitis. Conclusion: The placement of an acrylic spherical implant was associated with cosmesis with a much better amplitude of movements at the cost of a relatively more prolonge

Volumetric Versus Empirical Determination of Enucleation Implant Size.

To compare the use of sizing implants versus intraoperative volume measurements for individualization of enucleation implant size, and to identify preoperative factors affecting the choice of implant. In this retrospective observational cohort study, 2 implant sizing methods were compared using clinical records and photographs in 139 patients who underwent enucleation between 2007 and 2016. There was no difference in mean implant (p = 0.6562) or prosthetic (p = 0.1990) enophthalmos between the 2 methods, or when comparing patients with and without conjunctival-Tenons fibrosis. The incidence and severity of superior sulcus deformity was similar between the methods (p = 0.6394). Preoperative phthisis (p < 0.0001) and intraoperative conjunctival-Tenons fibrosis (p = 0.0010) were more common in the sizing implant group. Among all study patients, mean implant size was larger in males (21.3 mm, n = 80) than females (20.7 mm, n = 59) (p = 0.0027). Implants >20 mm were more frequently inserted in patients with a wider Hertel exophthalmometry base (80% of males >95 mm; 77% of females >97 mm). Approximately 21.0% of patients demonstrated ≥8 mm of implant enophthalmos, suggesting an undersized implant. The authors estimate that 11% of patients could have received a sphere larger than 22 mm. Individualization of enucleation implant size can reduce the incidence of anophthalmic socket syndrome. The empirical use of sizing implants provided similar results as intraoperative volumetric measurements, when evaluated by postoperative superior sulcus depth and prosthetic or implant enophthalmos. Preoperative exophthalmometry may facilitate selection of implant size. Preexisting conjunctival-Tenon fascial fibrosis often did not limit implant size and was not associated with a higher prevalence of wound breakdown or implant exposure.

Transcutaneous approach for orbital augmentation with alloplastic implants in acquired anophthalmia

ABSTRACT Purpose: To report the outcomes of a transcutaneous surgical technique for orbital volume augmentation with secondary alloplastic implants in acquired anophthalmia. Methods: Retrospective case note review of patients who underwent secondary orbital implant insertion through a subciliary incision between January 2006 and December 2017. Collected data included age, gender, type and cause of primary surgery, time interval before secondary implantation, and details of secondary implantation surgery. The main outcome parameters included postoperative appearance, grade of superior sulcus deformity (SSD), implant centration, and prosthesis function. Results: Thirty-eight patients ranging from 2 to 54 years had undergone secondary alloplastic orbital implant placement through the subciliary approach. The mean follow-up was 5.3 years (range: 1–10 years). All the patients showed satisfactory orbital volume with the average SSD was grade 0.74. There were no cases with implant exposure or extrusion. Implant migration occurred in six cases (15.8%). Fitting a prosthesis was possible in all cases. Conclusion: Subciliary secondary orbital implantation is proved to be effective in correcting volume deficiency in acquired anophthalmia with rapid rehabilitation while avoiding anterior surface breakdown and implant exposure.

Rejuvenation of periocular region in Koreans: A multimodal approach combining botulinum toxin, fillers, and micro-focused ultrasound with visualization for optimal results.

Periorbital aging involves all layers of the skin, fat, and the bony orbit. Therefore, a multimodal approach is necessary. Twenty Korean subjects who required periorbital rejuvenation were enrolled in this study. First, micro-focused ultrasound with visualization (MFU-V) was performed across the supra-brow area, lateral canthus, and the infraorbital area. Next, the filler was injected into the sunken upper eyelid, lateral eyebrow, and the infraorbital area. Lastly, botulinum toxin was administered into the forehead, glabella, crow's feet, and the lateral orbital rim below the brow on the same day. Photographs were taken at baseline; immediately after treatment; and at 1, 4, and 12 weeks of follow-up. The average eyebrow height was increased by 3.5 mm, and the maximum height was elevated by 3.9 mm at week 12. Physician visual analogue scale (VAS) scores regarding the whole periorbital area and eyebrow ptosis were continuously improved throughout the observation period. Physician VAS scores for infraorbital hollow and superior sulcus deformity improved immediately after the procedure and were maintained at week 12. Adverse events were mild and transient. We believe that a multimodal approach combining MFU-V, fillers, and botulinum toxin results in significant periocular rejuvenation.

The Anatomy and Clinical Application of Preorbital Septum Fiber.

In patients with mild superior sulcus deformity, pseudoptosis, or multiple eyelid folds, several bulky fibers can be found anterior to the orbital septum. These fibers, called preorbital septum fibers, may constrict protrusion of the fat pad and movement of the levator palpebrae muscle. In this study, the authors illustrated the anatomy of these fibers and described the double-eyelid procedure to correct pseudoptosis, mild superior sulcus deformity, and multiple eyelid folds, which may be caused by these fibers. The bulky preorbital septum fibers were dissected and severed during upper blepharoplasty to release the orbital septum fat pad and levator palpebrae muscle. This procedure was performed between January 2016 and January 2018 in 56 patients with distinct preorbital septum fibers. Of the 56 patients, 38 displayed mild to moderate upper eyelid depression and multiple eyelids, and 18 displayed pseudoptosis. Bulky fibers that existed in the superficial layer of the orbital septum were all dissected and removed. After 6 months' recovery, the superior sulcus deformity improved in all patients. No recurrence of multiple eyelids was observed. Patients with pseudoptosis showed a notable release of their upper eyelids. This is the first time to our knowledge that the preorbital septum fibers are described as a distinct anatomical structure. They are clinically important in upper eyelid anatomy and the improvement of sunken upper eyelids or pseudoptosis. The combination of blepharoplasty with release of these fibers is easy to perform and promote.

Evaluation of Cosmetic Appearance and Ocular Motility Following Evisceration Surgery

AbstractBackground: Evisceration is a surgical technique that is used for cosmetic and curative reasons in many ocular diseases such as phthisis bulbi.Aim of the Study: Evaluation of the cosmetic results and motility of the artificial prosthesis after two techniques of evisceration with insertion of prosthesis.Patients and Methods: The study was carried out in ophthalmology department in Tanta University Hospital included 20 patients divided randomly into 2 equal groups. We underwent full history taking and acquired ophthalmolog-ical examination.Operation and Follow-up: Evisceration of the eye with scleral quadrisection and insertion of an implant inside sclera in 10 patients (the first group) and addition of relaxing circumferential incision at posterior sclera in another 10 patients (the 2nd group). Follow-up was carried out in 1st day after operation, 1 week, 3 weeks and 6 weeks.Results: Postoperative superior sulcus deformity difference between 2 groups was statistically significant (p-value=0.031) and it was markedly deformed in 40% of cases in group 1 and 20% in group 2. Palpebral fissure height had also statistically significant difference between 2 groups (p-value=0.030). enophthalmos was significantly reduced in the 2nd group (mean=0.700±0.483) in comparison to the 1st group (mean= 1 .700± 1 .059).Conclusion and Recommendations: Performing relaxing posterior sclerotomies with evisceration surgeries allows insertion of larger implant with no increased risk of extrusion and this technique improves cosmetic appearance and motility of the prosthesis.

Correction of superior sulcus deformity and dermatochalasis with autologous fat transferto retro-orbicularis oculi fat (ROOF) through upper blepharoplasty incision

Objective To investigate an operative method of autologous fat transfer to retro-orbicularis oculi fat (ROOF) through upper blepharoplasty incision for correction of superior sulcus deformity and dermatochalasis, and to evaluate the efficacy and safety of the method. Methods ROOF lies in the lateral supraorbital area. Autologous fat transfer to ROOF through upper blepharoplasty incision was performed in patients selected by examination. The efficacy and safety were evaluated by follow-up study. Results From March 2013 to June 2017, 23 selected patients received the treatment with 3 months to 50 months (mean, 20.4 months) follow-up. The amount of fat graft for each palpebra was 0.6 to 2.0 ml, and the mean graft amount was 1.4 ml. The superior sulcus deformity improved significantly in 22 (95.7%) cases. All 23 cases achieved significant improvement of dermatochalasis. 22 (95.7%) cases were satisfied with the result. No major complications occurred. Conclusions Autologous fat transfer to ROOF through upper blepharoplasty incision is effective and safe in correction of superior sulcus deformity and dermatochalasis, The operative method should be a good choice for selected patients. Key words: Skin; Relaxation; Blepharoplasty; Autografts; Fat; Sunken; Retro-orbicularis oculus fat

In Vivo Effects of Retrobulbar Bimatoprost Injection on Orbital Fat.

Recent publications have reported the adverse effects of prostaglandin analogues on the periocular tissues. These medications may cause periorbital lipodystrophy, enophthalmos, and deepening of the superior sulcus deformity. While these effects may have adverse consequences for some patients, the atrophy of the periorbital fat may have a useful role in diseases that lead to orbital and periorbital fat hypertrophy such as thyroid eye disease. In this pilot study, the authors investigated the effects of retrobulbar bimatoprost injection on the intraocular pressure and orbital fat in a rat animal model. Three rats were sedated and intraocular pressure was measured. A 0.1 ml aliquot of bimatoprost was injected into the right orbit of all rats. In the left orbit, 0.1 ml of phosphate-buffered saline was injected as a control. Three weeks later, all rats were sedated and intraocular pressure was measured before euthanizing. Routine histologic staining was performed and thin sections through the intraconal orbital fat were obtained. Density of intraconal adipocytes was measured and adipocyte heterogeneity was determined using a computer image analysis algorithm. The specimens injected with bimatoprost demonstrated atrophy of orbital fat with significantly increased adipocyte density (p = 0.009) and heterogeneity (p = 0.008) when compared with control. Intraocular pressure was not significantly decreased at 3 weeks after injection of retrobulbar bimatoprost. In this pilot study, orbital injection of bimatoprost demonstrated atrophy of intraconal adipocytes when compared with control orbits injected with saline. The orbits injected with bimatoprost were noted to have smaller, more heterogeneous adipocytes that were densely packed in the intraconal space. The study limitations include the small sample size, which limited the ability for us to make conclusions about the effect on intraocular pressure. Nevertheless, the findings presented suggest that retrobulbar bimatoprost may present a nonsurgical alternative to induce atrophy of the orbital fat without inducing inflammation or hypotony.

Porous Versus Nonporous Orbital Implants After Enucleation for Uveal Melanoma: A Randomized Study

To compare hydroxyapatite with acrylic implants after enucleation for uveal melanoma with respect to eyelid position, ocular motility, implant complications, and patient satisfaction. Patients undergoing primary enucleation for uveal melanoma between May 2005 and November 2012 at the Liverpool Ocular Oncology Centre, United Kingdom, were randomized between hydroxyapatite and acrylic implants. Questionnaires were sent to patients and ocularists to comment on the main outcomes. A total of 416 patients were recruited in the study, of whom 281 were included, with 49.5% (139/281) and 50.5% (142/281) receiving a hydroxyapatite (HA) or acrylic (AC) implant. Mailed questionnaires completed at ≥18 months by patients showed no significant differences between the groups in eyelid position, prosthetic motility, socket complications, and patient satisfaction. Complications included implant extrusion (1% vs 4%), enophthalmos (26% vs 26%), and superior sulcus deformity (24% vs 24%) with HA and AC implants, respectively, (Fisher exact test p > 0.0125 in all, Bonferroni correction). Questionnaires completed by ocularists indicated no significant differences in eyelid opening, prosthetic motility, and other complications at 6 months (Fisher exact test, p > 0.05 in all); there was a higher prevalence of ptosis with AC than HA implants (46% vs 25%, p = 0.03) and a greater need for ocularists' treatment with HA than AC (50% vs 28%, p = 0.03). Patient-reported outcomes after enucleation for uveal melanoma indicate no major differences between hydroxyapatite and acrylic implants in surgical outcomes and patient satisfaction. There was a higher prevalence of ptosis with AC and a greater need of ocularists' visits with HA at around 6 months observed by ocularists.

Four Petal Evisceration : Pros and Cons

purpose: To evaluate four petals evisceration as one of the best modifications in evisceration surgery, allowing the use of large orbital implant with low incidence of complications. Methods: We conducted a retrospective, interventional study on evisceration with placement of spherical non porous orbital implant after four petal evisceration. Preoperative examination included full history, ophthalmological examination, indication for surgery, B-scan ultrasonography, axial length in cases of atrophic and socket surface in secondary cases. All patients were operated a four petal evisceration with spherical non porous implant of size 18 to 22. Postoperative, all patients were followed for at least 6 months for presence of complications, implant and prosthesis motility and the final cosmetic results. Results: 18 eyes were included. Diagnosis necessitating evisceration was atrophia bulbi in 8 patients, endophthalmitis in 2 patients, and implant exposure in 4 patients, corneoscleral melting due to caustic exposure in 1 patient, self-eviscerated globe due to severe trauma in 1 patient and anopthalmic socket following evisceration without implant in 2 patients. Implant size was 18 in 1 patient, 20 in 6 patients, and 22 in 11 patients. No implant exposure occurred; superior sulcus deformity occurred in 3 patients, downward implant migration occurred in 1 patient. Regarding implant motility, it was good with mean of 75% in 14 patients; moderate with mean of 66% in 4 patients. The prosthesis motility was fair with mean of 35% in 12 patients (66.6%) and poor with mean (10%) in 6 patients. Conclusion: Four petals evisceration facilitates the use of large sized implant in all cases even in implant exposure with deficient sclera with good post-operative final cosmetic results, very low rate of complications and moderate prosthesis motility.

Secondary Orbital Reconstruction in Patients with Prior Orbital Fracture Repair.

To evaluate clinical characteristics, preoperative imaging findings, pre- and post-operative outcomes, and satisfaction of patients requiring secondary reconstruction after inadequate primary orbital fracture repair. Retrospective review of 13 patients requiring secondary orbital reconstruction following unsatisfactory primary repair. Primary outcomes were postoperative changes in enophthalmos, hypo- or hyper-globus, superior sulcus deformity, and restrictive strabismus. Secondary outcomes included patient satisfaction. Of 13 patients, 9 patients had primary orbital implants, and 4 patients did not. Of the 9 with implants, 6 had inferior displacement posteriorly, 2 had superior displacement posteriorly, and 1 had good position but had entrapped orbital tissues beneath it. Findings from primary surgery included enophthalmos (12/13), hypoglobus (10/13), hyperglobus (1/13), superior sulcus deformity (9/13), restricted supraduction (12/13), and restricted infraduction (7/13). Mean preoperative enophthalmos and hypoglobus were 4.4 ± 2.6 mm and 2.9 ± 1.4 mm, respectively. Secondary reconstruction resulted in mean reduction of enophthalmos by 3.4 ± 1.4 mm (p < 0.001), of hypoglobus by 2.9 ± 1.5 mm (p < 0.001), and of hyperglobus by 1 mm (n = 1). All 9 patients had resolution of their superior sulcus deformity. Of 12 cases with restricted ocular motility, all had improvements in postoperative motility following secondary surgery. Mean improvement in supraduction and infraduction was 1.8 ± 1.0 points (p < 0.001) and 1.4 ± 1.3 points (p = 0.025), respectively. Twelve patients reported being very satisfied or satisfied with secondary surgery; 1 patient was neutral. This study demonstrates that secondary orbital reconstruction can achieve excellent functional and cosmetic results with high patient satisfaction and minimal complications. Secondary reconstruction of previously repaired orbital fractures should be considered when clinically indicated.

One-stage bone strip reconstruction technique with balloon sinus dilatation surgery for chronic maxillary atelectasis.

PurposeChronic maxillary atelectasis is characterized by unilateral spontaneous enophthalmos and hypoglobus due to increased orbital volume secondary to maxillary sinus inward deformation. Reformation of the sinus architecture and reconstruction of the orbit are key to a successful outcome. Here, we introduce a one-staged surgery that addresses both these goals.Patients and methodsWe retrospectively reviewed 11 patients treated with one-stage orbital and sinus surgery. A transconjunctival subperiosteal approach was used to create slats in the thinned orbital floor. A nasal endoscopic approach was utilized to access the maxillary sinus and place a modified Foley catheter balloon through the enlarged maxillary ostium. A bridge graft of nasal septal, ear cartilage, or LactSorb was placed on the reconstructed and balloon-supported orbital floor. The balloon was deflated and removed at 10–14 days. All patients underwent complete ophthalmic and orbital evaluation, including standardized photography and radiologic imaging.ResultsEleven patients, mean age 39.5 years, presented with diplopia in upgaze, superior sulcus deformity, and at least 2 mm of relative enophthalmos. After initial overcorrection, enophthalmos improved in all cases. Symmetry within 1 mm was accomplished in 10 of 11 cases. Follow-up time was 259±320 days. Full motility was recovered in all patients.ConclusionWe describe a one-staged surgery consisting of cutting slats in the orbital floor, dilating the maxillary sinus with a balloon, and stabilizing the orbital floor with a cartilage graft placement. Our anecdotal experience suggests that this surgical approach can safely achieve normalization of the pathologic sinus outflow and restoration of the orbit anatomy. The balloon ensures orbital floor stability during the healing process, and it may act to stent open the sinus ostium during early mucosal healing.

Unilateral Prostaglandin-Associated Periorbitopathy: A Syndrome Involving Upper Eyelid Retraction Distinguishable From the Aging Sunken Eyelid.

To study the effects of prostaglandin analogue drops on the eyelids and adnexa in unilaterally treated subjects with the intention of qualifying, quantifying, and categorizing the characteristics of prostaglandin-associated periorbitopathy (PAP). Patients using prostaglandin analogue drops in only 1 eye for at least 1 year were evaluated by masked examiners. Orbital and eyelid measurements were obtained for each patient, and adnexal photographs were taken. PAP was divided into 3 grades based on the presence and severity of fat atrophy and the existence and depth of superior sulcus deformity. Statistical analysis was performed comparing data between treated and untreated eyes. Thirty-three patients meeting eligibility criteria were enrolled, with equal numbers of subjects using latanoprost, travoprost, and bimatoprost. Treated eyes had a statistically significant increase in lagophthalmos (0.62 mm, p < 0.001), superior sulcus deformity/PAP grade (0.72, p < 0.001), and eyelid redness (1.08, p < 0.001). Treated eyes had significantly greater marginal reflex distance 1 measurements (0.89 mm, p = 0.02), highest with bimatoprost and moderate PAP. Treated eyes had relatively greater enophthalmos than untreated eyes. Very few patients noticed or complained about eyelid changes. Prostaglandin analogue drops cause adnexal changes and orbital fat atrophy leading to eyelid redness, superior sulcus deformity, higher eyelid crease, and enophthalmos. In contrast to previous studies showing ptosis in PAP, relative upper eyelid retraction was seen in most of our treated eyes. Our novel PAP grading scale may help objectify and categorize this syndrome. Awareness of these signs is critical, as the eyelids and eyes may be affected even in the absence of patient recognition.

The effect and applications of acellular dermal allograft (AlloDerm®) in ophthalmic plastic surgery

PurposeTo describe the use and efficacy of AlloDerm® in ophthalmic plastic and reconstructive surgery. MethodsA retrospective review was conducted of 31 eyes of 25 patients who underwent an AlloDerm® graft procedure for correction of lower lid retraction, anophthalmic socket contraction, superior sulcus deformity, implant exposure, or skin defect. Clinical outcomes were measured by the degree of improvement and incidence of complications. Operation success and reoperation rates were also evaluated. ResultsThere were 15 cases of lower lid retraction, 10 anophthalmic socket contractions, 2 superior sulcus deformities, 2 orbital implant exposures, and 2 periorbital skin defects. The mean age of the patients was 44.7 (±2.8) years. The mean follow-up period was 16.7 (±2.5) months. Twenty-seven eyes (87.1%) had successful outcomes and 4 eyes of 4 patients required further surgery. Three of those were due to undercorrection, and the other was due to severe adhesion. Applications of AlloDerm® skin substitute were satisfactory at the 6-month follow-up examination. There were no statistically significant factors, such as underlying causes or degrees and locations of defects that impacted on outcome. ConclusionsAlloDerm® is an excellent material for correction of lid retraction, contracted socket, superior sulcus deformity, and implant exposure. In patients for whom periorbital skin grafts or flaps are inappropriate or difficult to perform, the use of AlloDerm® to cover skin defects may be a good option.