2009

+ Early versus late repair of orbital blowout fractures

Simon GJ, Syed HM, McCann JD, Goldberg RA
BACKGROUND AND OBJECTIVE: To compare early and late surgical repair of orbital blowout floor fractures. PATIENTS AND METHODS: A retrospective, comparative interventional case series reviewed medical records of 50 consecutive patients who underwent unilateral orbital floor fracture repair in a 4-year period. Comparative analysis was performed between patients operated on within 2 weeks of injury and those operated on at a later stage. RESULTS: Assault, motor vehicle accidents, and sports injuries were the most common causes of injury. Surgery was performed due to inferior rectus muscle entrapment and limitations in up gaze in 20 (40%) patients or to prevent enophthalmos in cases with significant bony orbital expansion in 30 (60%) patients. After surgery, enophthalmos improved an average of 0.8 mm. Limitation in ocular motility improved after surgery but was statistically significant only in up gaze. Patients who underwent early repair (within 2 weeks) achieved less improvement in enophthalmos versus patients who underwent late repair (delta enophthalmos of 0.2 +/- 1.1 vs 1.3 +/- 1.9 mm, respectively; P = .02). CONCLUSION: In these patients, postoperative vertical ductions and postoperative enophthalmos improved after fracture repair. Surgery was associated with a low rate of postoperative complications. No apparent difference in surgical outcome was seen between early (within 2 weeks) and late surgical repair.

+ Facial nerve injury during external dacyocystorhinostomy

Vagefi MR, Winn BJ, Lin CC, Sieres BS, LauKaitis SJ, Anderson RL, McCann JD
OBJECTIVE: To describe weakness of the orbicularis oculi muscle after external dacryocystorhinostomy (DCR) and propose an anatomic explanation for the complication. DESIGN: Retrospective, observational study. PARTICIPANTS: Sixteen patients (13 female, 3 male) with a mean age of 60 years (median, 61 years; range, 34-85 years). METHODS: A retrospective chart review was performed of consecutive patients who had nasolacrimal duct obstruction repair by external DCR. Patients were identified who developed postoperative orbicularis oculi muscle weakness that manifested as hypometric blink or lagophthalmos with or without punctate keratopathy on the operated side. Patient parameters collected included demographic data, type of incision, incision length, use of lacrimal stent, length of follow-up, intraoperative and postoperative complications, and time to resolution of clinical findings. Statistical analysis was performed using a 2-tailed Fisher exact test with clinical significance designated at alpha = 0.05. MAIN OUTCOME MEASURES: Identification of patients with orbicularis oculi muscle weakness after external DCR, documentation of incision type, clinical findings, and recovery of function. RESULTS: Among 215 patients and 247 surgeries, 16 individuals (7.4%) were identified who demonstrated abnormalities of eyelid closure in the postoperative period after external DCR. Of these, 13 patients had lagophthalmos with or without hypometric blink and 3 patients had hypometric blink alone. Eleven patients underwent surgery through a nasojugal incision, 4 patients underwent surgery through a vertical incision, and 1 patient underwent surgery through an eyelid margin incision. The degree of postoperative lagophthalmos was on average 1.5 mm. Four patients developed punctate keratopathy. Follow-up ranged from 3 to 50 weeks (mean, 20 weeks). Resolution of lagophthalmos was seen on average by 14 weeks with the longest time to resolution of 32 weeks. Three individuals continued to have residual hypometric blink at the time of last follow-up. CONCLUSIONS: Damage to peripheral fibers of the zygomatic and buccal branches of the facial nerve as they course through the medial canthal area to innervate the upper eyelid orbicularis oculi muscle may occur during external DCR surgery. Such injury may be responsible for orbicularis oculi muscle weakness manifesting as postoperative abnormal eyelid closure and lagophthalmos. In our cohort of patients, these findings were temporary and typically resolved in several months.

+ The lateral tarsal strip mini-tarsorrhaphy procedure

Vagefi MR, Anderson RL
The lateral canthus normally sits 1 to 2 mm higher than the medial canthus. With time, aging and gravity produce inferior displacement of the canthus. Numerous eyelid disorders can also result in lower eyelid or lateral canthal tendon laxity or malposition, requiring horizontal eyelid tightening or canthal repositioning. The lateral tarsal strip procedure has proven to be a useful technique in addressing these problems. Care must be taken when suspending the tarsal strip to the lateral orbital rim to preserve the almond shape of the lateral canthal angle. If mild to moderate upper eyelid laxity is present, suspension of the strip can result in upper eyelid overhang with lower eyelid and eyelash imbrication. We describe the lateral tarsal strip mini-tarsorrhaphy procedure that overcomes this problem. The technique provides excellent functional and aesthetic results and adds to the versatility of a time-tested procedure

2008

+ Acquired port wine stain of the upper eyelid after cluster headache

Vagefi MR, Florell SR, Lin CC, McCann JD, Anderson RL
A 69-year-old white man with a medical history of left-sided cluster headaches presented for evaluation of dermatochalasis. The left upper eyelid demonstrated red-pink, blanchable macules that coalesced in a patch. The lesion appeared after an episode of a cluster headache. Upper eyelid blepharoplasty permitted en bloc removal of most of the lesion. Histopathologic evaluation demonstrated aggregates of telangiectatic blood vessels in the papillary dermis consistent with the diagnosis of an acquired port wine stain. The authors report, to their knowledge, the first description of an acquired port wine stain associated with cluster headaches.

+ Autologous dermis graft at the time of evisceration or enucleation.

Vagefi MR, McMullan TF, Burroughs JR, Isaacs DK, Tsirbas A, White GL Jr, Anderson RL, McCann JD.
AIM: To present a new technique using autologous dermis graft at the time of enucleation or evisceration to replace the ocular surface area lost when the corneal scleral button is excised. METHODS: A retrospective, interventional, non-comparative case series of patients who had an autologous dermis graft placed to assist in closure of Tenon's capsule and conjunctiva at the time of enucleation or evisceration. Medical records were reviewed and the following variables were recorded: age, sex, history of previous ocular surgery or radiation treatment, indication for surgery, type of surgery, laterality, type of orbital implant, size of implant, length of follow up, and complications. RESULTS: Nine patients were identified (three male, six female) Five had enucleation with implant placement and four had evisceration with implant placement. Four individuals received unwrapped porous polyethylene spherical implants, three received silicone implants, and two received hydroxylapatite implants. Follow up ranged from 30 to 112 weeks (mean (SD), 61 (28) weeks). No operative or early complications were observed. One patient who had enucleation after two rounds of brachytherapy for uveal melanoma developed subsequent late exposure of the implant. There were no complications involving the graft donor site. CONCLUSIONS: This small series shows that the use of a dermis graft is a safe and effective new technique to facilitate orbital rehabilitation. It is hypothesised that the extra surface area produced with a dermis graft preserves the fornices and allows a larger implant. It may also allow the implant to be placed more anteriorly which assists with both implant and prosthesis motility.

+ Bump thermoplasty as a simple treatment for lateral incision closure artifacts after upper eyelid blepharoplasty

Vagefi MR, McMullan TF, McCann JD, Anderson RL


+ Cosmetic eyelid and facial surgery

Ben Simon GJ, McCann JD
The goal of cosmetic surgery is to reverse anatomical changes that occur in the face with aging. It is a rapidly growing subdiscipline of ophthalmic plastic surgery and includes forehead, eyelid, mid-face, lower face, and neck surgery, most performed by ophthalmic plastic surgeons. The current article reviews updates in cosmetic eyelid and facial surgery, including minimally invasive techniques such as cable suspensions, injections, and fillers.

+ Epidermoid cyst of the upper eyelid tarsal plate

Vagefi MR, Lin CC, McCann JD, Anderson RL
A 78-year-old white man presented with a painless, right upper eyelid mass causing mechanical ptosis. There was no prior history of trauma, surgery, or eyelid inflammation. Examination revealed a firm, globular mass that was fixed to the tarsal plate of the upper eyelid. Excisional biopsy performed through an upper eyelid crease incision revealed a mass securely attached to the tarsal plate which upon separation leaked cheesy, malodorous material. Histopathologic sections demonstrated a cyst lined by squamous epithelium containing laminated keratin consistent with a diagnosis of an epidermoid cyst. The authors report, to their knowledge, the first description of an epidermoid cyst of the tarsal plate. As with epidermoid cysts in other locations, surgical excision is the treatment of choice.

+ Exacerbation of blepharospasm associated with craniocervical dystonia after placement of bilateral globus pallidus internus deep brain stimulator

Vagefi MR, Lin CC, McCann JD, Anderson RL
To report a case of exacerbation of blepharospasm after bilateral globus pallidus internus (GPi) deep brain stimulator (DBS) placement. A 69-year-old male presented after bilateral GPi DBS placement for blepharospasm and craniocervical dystonia with worsening eyelid spasms and associated apraxia of lid opening (ALO). Numerous attempts to adjust DBS parameters were ineffective. Consequently, bilateral upper eyelid myectomy was performed. Myectomy surgery was free of complications. The patient had significant improvement of blepharospasm and ALO. Although early success has been reported with DBS placement in a small number of patients with focal dystonias, further studies and longer follow-up are needed to demonstrate whether this will prove to be a useful approach in the treatment of blepharospasm. Upper eyelid myectomy can provide an effective means for treating blepharospasm and associated ALO. 2008 Movement Disorder Society

+ Facial Nerve Injury during External Dacryocystorhinostomy

Vagefi MR, Winn BJ, Lin CC, Sires BS, Laukaitis SJ, Anderson RL, McCann JD
OBJECTIVE: To describe weakness of the orbicularis oculi muscle after external dacryocystorhinostomy (DCR) and propose an anatomic explanation for the complication. DESIGN: Retrospective, observational study. PARTICIPANTS: Sixteen patients (13 female, 3 male) with a mean age of 60 years (median, 61 years; range, 34-85 years). METHODS: A retrospective chart review was performed of consecutive patients who had nasolacrimal duct obstruction repair by external DCR. Patients were identified who developed postoperative orbicularis oculi muscle weakness that manifested as hypometric blink or lagophthalmos with or without punctate keratopathy on the operated side. Patient parameters collected included demographic data, type of incision, incision length, use of lacrimal stent, length of follow-up, intraoperative and postoperative complications, and time to resolution of clinical findings. Statistical analysis was performed using a 2-tailed Fisher exact test with clinical significance designated at alpha = 0.05. MAIN OUTCOME MEASURES: Identification of patients with orbicularis oculi muscle weakness after external DCR, documentation of incision type, clinical findings, and recovery of function. RESULTS: Among 215 patients and 247 surgeries, 16 individuals (7.4%) were identified who demonstrated abnormalities of eyelid closure in the postoperative period after external DCR. Of these, 13 patients had lagophthalmos with or without hypometric blink and 3 patients had hypometric blink alone. Eleven patients underwent surgery through a nasojugal incision, 4 patients underwent surgery through a vertical incision, and 1 patient underwent surgery through an eyelid margin incision. The degree of postoperative lagophthalmos was on average 1.5 mm. Four patients developed punctate keratopathy. Follow-up ranged from 3 to 50 weeks (mean, 20 weeks). Resolution of lagophthalmos was seen on average by 14 weeks with the longest time to resolution of 32 weeks. Three individuals continued to have residual hypometric blink at the time of last follow-up. CONCLUSIONS: Damage to peripheral fibers of the zygomatic and buccal branches of the facial nerve as they course through the medial canthal area to innervate the upper eyelid orbicularis oculi muscle may occur during external DCR surgery. Such injury may be responsible for orbicularis oculi muscle weakness manifesting as postoperative abnormal eyelid closure and lagophthalmos. In our cohort of patients, these findings were temporary and typically resolved in several months. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

+ Gouty tophus of the upper eyelid

Yang CC, Vagefi MR, Davis D, Mamalis N, Anderson RL, McCann JD
A 64-year-old man with gout presented with history of an enlarging mass in the left upper eyelid causing mechanical ptosis. The patient underwent excisional biopsy. The histopathologic findings confirmed the diagnosis of gouty tophus of the eyelid.

+ Injectable calcium hydroxylapatite for orbital volume augmentation

Vagefi MR, McMullan TF, Burroughs JR, White GL Jr, McCann JD, Anderson RL
OBJECTIVE: To describe a new method of augmenting orbital volume for anophthalmic enophthalmos correction. METHODS: A retrospective medical record review was conducted of 4 consecutive patients who had injectable calcium hydroxylapatite (Radiesse) placed in the extraconal space to augment orbital volume. RESULTS: Four patients were treated with 1 to 2 vials (1.3 mL per vial) of injectable calcium hydroxylapatite. The mean amount of preoperative enophthalmos measured by Hertel exophthalmometry was 4 mm (range, 2-7 mm). The mean follow-up was 57 weeks (range, 45-71 weeks). A reduction of enophthalmos, ranging from 2 to 5 mm (mean, 2.75 mm), was observed when comparing preoperative with postoperative measurements of the anophthalmic orbit with prosthesis in place. All patients demonstrated clinical and aesthetic improvement that was observed to continue at almost 1 year or more postoperatively. In one patient, injection was complicated by a peribulbar hemorrhage related to local anesthesia administration, which resolved without incident. CONCLUSIONS: Injectable calcium hydroxylapatite provides a new, safe, simple, cost-effective technique to treat volume deficiency in the anophthalmic orbit. Augmentation achieved with this semipermanent filler has demonstrated a lasting effect in the orbit of 1 year or more with little volume loss. The filler seems to last longer in areas with less movement, blood supply, and lymphatic drainage. Injection can even be performed in an office setting using local anesthesia. The amount of volume replacement can be titrated, and the procedure is repeatable until adequate volume is obtained.

+ Local anesthesia in oculoplastic surgery: precautions and pitfalls

Vagefi MR, Lin CC, McCann JD, Anderson RL


+ Low-cost headlamps for facial and oculoplastic surgery

Wu AY, Vagefi MR, Georgescu D, McCann JD, Anderson RL


+ Muller's muscle-conjunctival resection for correction of upper eyelid ptosis: relationship between phenylephrine testing and the amount of tissue resected with final eyelid position.

Ben Simon GJ, Lee S, Schwarcz RM, McCann JD, Goldberg RA
OBJECTIVES: To evaluate the outcome of Müller's muscle-conjunctival resection (MMCR) for correction of upper eyelid ptosis and to explore the relationship between phenylephrine testing, muscle resection, and surgical outcome. METHODS: Medical records were reviewed for all patients who underwent MMCR at the Jules Stein Eye Institute, Los Angeles, California, from January 1, 1999, through June 30, 2005. Outcome measures were margin reflex distance-1, ptosis correction after instillation of phenylephrine drops, extent of MMCR, ptosis correction, and eyelid symmetry. RESULTS: In 80 patients who underwent 131 MMCR procedures for correction of upper eyelid ptosis, margin reflex distance-1 increased on average by 1.6 mm (P < .001). In 106 patients (81%), eyelid symmetry equal to or less than 1 mm was achieved (P = .02). Phenylephrine testing underestimated the extent of ptosis correction achieved with MMCR. A weak correlation was found between the extent of MMCR and ptosis correction (r = 0.2; P = .04). CONCLUSIONS: Müller's muscle-conjunctival resection is effective for ptosis correction in patients with good levator muscle function; good eyelid symmetry is achieved in most patients. Phenylephrine testing underestimated the ptosis correction achieved with MMCR by 40%. The relationship between MMCR and ptosis correction is complex.

+ Osteoplasty using calcium hydroxylapatite filler

Vagefi MR, McMullan TF, McCann JD, Anderson RL
PURPOSE: To describe a novel method using injectable calcium hydroxylapatite (Radiesse) for aesthetic correction of small bony defects in the skull. METHODS: A prospective, small interventional case series was performed. Three patients were identified with bony defects of the frontal bone from prior trauma or surgery. Calcium hydroxylapatite filler was injected locally to fill the bony defects. The procedure was performed in an ambulatory surgical center with monitored anesthesia care in conjunction with eyelid surgery. RESULTS: Three patients were treated with 1 to 3 vials (1.3-ml vial) of injectable calcium hydroxylapatite with improvement of volume deficiency and cosmesis. There were no complications associated with the procedure. Follow-up ranged from 2 months to 7 months. CONCLUSIONS: This preliminary report demonstrates that injectable calcium hydroxylapatite filler provides a new, simple, semipermanent technique for aesthetic correction of small bony defects in the skull. The amount of volume replacement is easily titrated, and the procedure can be repeated if necessary until adequate volume is obtained. Although these cases were performed in a surgery center, the technique could easily be done as an office procedure with local anesthesia. A larger cohort and longer follow-up is necessary to establish the duration of effect and success of the procedure.

+ Re: "Correction of anophthalmic enophthalmos with injectable calcium hydroxylapatite (Radiesse)"

Burroughs JR, Anderson RL, Vagefi MR, McCann JD


+ Treatment of lower eyelid retraction by expansion of the lower eyelid with hyaluronic Acid gel.

Goldberg RA, Lee S, Jayasundera T, Tsirbas A, Douglas RS, McCann JD
PURPOSE: To report our preliminary experience utilizing a nonsurgical alternative in the treatment of lower eyelid retraction: expansion and reinforcement of the lower eyelid with hyaluronic acid gel. METHODS: Retrospective review of patients with lower eyelid retraction treated with hyaluronic acid gel. Pretreatment, post-treatment, and follow-up photographs were digitized and overall outcomes assessed. Measurements of inferior scleral show were standardized and compared. RESULTS: Sixty-five procedures (31 patients; 14 male; mean age 58 years, range, 33-78 years) with lower eyelid retraction of various etiologies were treated with hyaluronic acid gel. A mean change in scleral show of 1.04 mm was found when pre- and post-treatment measurements were compared. The overall mean follow-up period was 6.2 months (range, 1-12 months). During the interval from initial treatment to follow-up visit (mean 4.6 months, range, 1-12 months), the effect of the hyaluronic acid gel diminished, with a mean increase in inferior scleral show of 0.52 mm. Twelve patients underwent a second, and 6 patients underwent a third, maintenance treatment with an improvement in scleral show of 0.87 mm and 1.13 mm, respectively. Complications were minor and included swelling, redness, bruising, and tenderness at the sites of injection. CONCLUSIONS: Based on our preliminary results, hyaluronic acid gel shows promise as a treatment modality for the management of lower eyelid retraction. Long-term follow-up will better clarify the required frequency of maintenance injections, the degree of hyaluronic acid gel retention, and the position of the lower eyelid over time.

+ Upper eyelid myectomy in blepharospasm with associated apraxia of lid opening

Georgescu D, Vagefi MR, McMullan TF, McCann JD, Anderson RL.
PURPOSE: To assess the impact of upper eyelid myectomy surgery on blepharospasm with associated apraxia of lid opening (ALO), dry eye, photophobia, and daily functioning in patients who are refractory to botulinum toxin treatment. DESIGN: Noncomparative, consecutive, interventional case series. METHODS: A retrospective chart review was performed to identify 100 consecutive patients beginning on January 1, 2000, who underwent upper eyelid myectomy surgery for blepharospasm and fulfilled the inclusion criteria. A survey was sent to all patients. Data were entered in an anonymous manner into a spreadsheet and analysis was performed using the Student t test with significance set at P<.05. RESULTS: Forty-five (88%) patients experienced ALO before surgery, among which 15 (33%) patients stated they were completely cured and 20 (44%) others had more than 50% improvement in ALO with surgery. In 20 of 30 patients who continued botulinum toxin treatment after surgery, the effect lasted longer. Twelve (29%) of 42 patients who experienced dry eyes before surgery improved. Eighteen (41%) of the 44 patients who experienced light sensitivity before surgery improved. Thirty-seven (82%) patients noted their cosmetic appearance to be better after surgery. The cumulative preoperative disability score was 14.11+/-5.78 (59%), whereas the cumulative postoperative disability score was 5.20+/-8.25 (22%; P<.01). CONCLUSIONS: Upper eyelid myectomy surgery appears to be effective in treating blepharospasm with associated ALO in most patients who are refractory to botulinum toxin injections and can provide improvement in the quality of life.

2007

+ Asynchronous blepharospasm, facial and cervical dystonia, and bilateral asynchronous hemifacial spasm.

Katz BJ, Burroughs JR, Anderson RL, Bownds S, McCann JD
We present a patient with a facial movement disorder that has characteristics of both blepharospasm and bilateral asynchronous hemifacial spasm. Because of the increased incidence of blepharospasm in patients with hemifacial spasm, our patient's clinical presentation is probably not a chance occurrence, but rather a manifestation of some predisposition for these two movement disorders. This unusual constellation of signs and symptoms challenges the current diagnostic criteria and suggests that some of these facial movement disorders may lie on a spectrum, rather than represent distinct entities.

+ Autologous dermis graft at the time of evisceration or enucleation

Vagefi MR, McMullan TF, Burroughs JR, Isaacs DK, Tribas A, Whit GL Jr, Anderson RL, McCann JD
AIM: To present a new technique using autologous dermis graft at the time of enucleation or evisceration to replace the ocular surface area lost when the corneal scleral button is excised. METHODS: A retrospective, interventional, non-comparative case series of patients who had an autologous dermis graft placed to assist in closure of Tenon's capsule and conjunctiva at the time of enucleation or evisceration. Medical records were reviewed and the following variables were recorded: age, sex, history of previous ocular surgery or radiation treatment, indication for surgery, type of surgery, laterality, type of orbital implant, size of implant, length of follow up, and complications. RESULTS: Nine patients were identified (three male, six female) Five had enucleation with implant placement and four had evisceration with implant placement. Four individuals received unwrapped porous polyethylene spherical implants, three received silicone implants, and two received hydroxylapatite implants. Follow up ranged from 30 to 112 weeks (mean (SD), 61 (28) weeks). No operative or early complications were observed. One patient who had enucleation after two rounds of brachytherapy for uveal melanoma developed subsequent late exposure of the implant. There were no complications involving the graft donor site. CONCLUSIONS: This small series shows that the use of a dermis graft is a safe and effective new technique to facilitate orbital rehabilitation. It is hypothesised that the extra surface area produced with a dermis graft preserves the fornices and allows a larger implant. It may also allow the implant to be placed more anteriorly which assists with both implant and prosthesis motility

+ Injectable calcium hydroxylapatite for orbital volume augmentation

Vagefi MR, McMullan TF, Burroughs JR, White GL Jr, McCann JD, Anderson RL
OBJECTIVE: To describe a new method of augmenting orbital volume for anophthalmic enophthalmos correction. METHODS: A retrospective medical record review was conducted of 4 consecutive patients who had injectable calcium hydroxylapatite (Radiesse) placed in the extraconal space to augment orbital volume. RESULTS: Four patients were treated with 1 to 2 vials (1.3 mL per vial) of injectable calcium hydroxylapatite. The mean amount of preoperative enophthalmos measured by Hertel exophthalmometry was 4 mm (range, 2-7 mm). The mean follow-up was 57 weeks (range, 45-71 weeks). A reduction of enophthalmos, ranging from 2 to 5 mm (mean, 2.75 mm), was observed when comparing preoperative with postoperative measurements of the anophthalmic orbit with prosthesis in place. All patients demonstrated clinical and aesthetic improvement that was observed to continue at almost 1 year or more postoperatively. In one patient, injection was complicated by a peribulbar hemorrhage related to local anesthesia administration, which resolved without incident. CONCLUSIONS: Injectable calcium hydroxylapatite provides a new, safe, simple, cost-effective technique to treat volume deficiency in the anophthalmic orbit. Augmentation achieved with this semipermanent filler has demonstrated a lasting effect in the orbit of 1 year or more with little volume loss. The filler seems to last longer in areas with less movement, blood supply, and lymphatic drainage. Injection can even be performed in an office setting using local anesthesia. The amount of volume replacement can be titrated, and the procedure is repeatable until adequate volume is obtained

+ Thiazolidinedione induced thyroid associated orbitopathy.

Lee S, Tsirbas A, Goldberg RA, McCann JD.
BACKGROUND: To describe an episode of thyroid associated orbitopathy (TAO) following the initiation of thiazolidinedione (TZD). CASE PRESENTATION: We report a female patient with a history of Graves' disease and stabilised thyroid associated orbitopathy for 2.5 years, who experienced rapid progression of TAO after the initiation of thiazolidinedione for glycemic control. Following the discontinuation of TZD, the patient experienced subsequent stabilisation of disease and normalization of vision. The medical history, ophthalmic findings, and clinical course are discussed. CONCLUSION: Thiazolidinediones may exacerbate TAO, and this should be taken into consideration when selecting treatment for diabetic patients with a history of autoimmune thyroid disorders.

+ To patch or not to patch? That is the question.

Anderson RL, Georgescu D, Vagefi MR, McMullan TF, Burroughs JR, McCann JD.
An editorial on eye patching and post operative bleeding after surgery.

2006

+ Clinical manifestations and treatment outcome of optic neuropathy in thyroid-related orbitopathy.

Ben Simon GJ, Syed H, Douglas R, Schwartz R, Goldberg RA, McCann JD.
BACKGROUND AND OBJECTIVE: To investigate the incidence and outcome of optic neuropathy associated with thyroid-related orbitopathy. PATIENTS AND METHODS: All patients diagnosed as having optic neuropathy associated with thyroid-related orbitopathy who underwent treatment for optic neuropathy between January 1, 1999, and March 1, 2003, were reviewed. Demographic and clinical data were extracted from the oculoplastic registry (electronic medical record). RESULTS: Optic neuropathy occurred in 20 of 595 patients with thyroid-related orbitopathy (3.4%). All patients received systemic steroids, 7 patients received orbital steroid injections, and 2 patients were treated with orbital radiotherapy. Orbital decompression was performed in all 26 orbits. Visual acuity improved from a mean of 20/150 to 20/30 (P < .001). Color vision improved from a mean of 5.2/14 to 11/14 (P = .001). The afferent pupillary defect disappeared shortly after treatment for all but 1 case, and improved in all cases. Exophthalmos decreased from 26.4 +/- 2.5 to 21.5 +/- 2.1 mm (P< .001; 95% confidence interval, 3.8 to 5.7). CONCLUSIONS: Optic neuropathy manifests rarely in patients with thyroid-related orbitopathy. Monitoring visual acuity or afferent pupillary response may be a reliable way of assessing and monitoring optic neuropathy. In this study, patients had improved visual acuity and optic nerve function after a combination of medical and surgical treatment.

+ Clinical manifestations of orbital mass lesions at the Jules Stein Eye Institute, 1999-2003.

Ben Simon GJ, Yoon MK, Atul J, Nakra T, McCann JD, Goldberg RA
BACKGROUND AND OBJECTIVE: To describe the clinical manifestations, diagnoses, treatments, and outcomes of orbital mass lesions at a tertiary care referral center. PATIENTS AND METHODS: All cases of newly diagnosed or referred orbital tumors at the Jules Stein Eye Institute from 1999 to 2003 were reviewed retrospectively. Demographic and clinical data were extracted from the electronic oculoplastics registry of the Division of Orbital and Ophthalmic Plastic Surgery. RESULTS: Three hundred sixty-nine cases of orbital mass lesions were evaluated (167 males and 202 females; mean age = 48 years). The most common presenting symptoms were mass/proptosis, pain, swelling, inflammation, and diplopia. The most common categories of diagnosis were cystic or structural lesions, benign tumors, inflammatory processes, neuronal processes, and fibrous processes. Increasing age was associated with an increased incidence of primary and metastatic malignant tumors. Half of all cases required surgical intervention consisting of excision, debulking, or exenteration; 20% to 30% of cases were managed conservatively. CONCLUSIONS: The differential diagnosis of orbital mass lesions differs across age groups. No clinical sign or symptom is specific for the underlying diagnosis and the biological behavior of the abnormal process may be misleading. Therefore, a careful diagnostic approach that considers the benefit of imaging studies must be undertaken. Almost 50% of these mass lesions can be managed with nonsurgical intervention.

+ Comparing Outcomes of Enucleation and Evisceration.

Nakra T, Simon GJ, Douglas RS, Schwarcz RM, McCann JD, Goldberg RA
PURPOSE: To compare clinical outcomes of enucleation and evisceration by functional and aesthetic measures. DESIGN: Retrospective, nonrandomized, comparative analysis. PARTICIPANTS: Eighty-four patients who underwent enucleation or evisceration. METHODS: The medical records of the participants were retrospectively reviewed. Clinical photographs were graded by blinded observers for qualitative measures. MAIN OUTCOME MEASURES: Postoperative eyelid and motility measurements, as well as subjective grades of various aesthetic and functional outcomes. RESULTS: There is no statistically significant difference in the overall aesthetic outcome of enucleation and evisceration, although several specific comparisons were found to be significant. Implant motility score is higher in eviscerated eyes (5.58+/-2.08) than in enucleated eyes (4.35+/-1.69) (P = 0.05). Adduction of the implant is significantly less than abduction in eviscerated eyes (1.34 vs. 1.44; P = 0.02). Implant motility is greater than prosthesis motility. Both enucleation and evisceration result in enophthalmos and a sulcus defect. Seven of 32 patients (21.9%) who underwent enucleation experienced a complication, whereas only of 7 of 52 patients (13.5%) who underwent evisceration experienced a complication (P = 0.0002). The 2 most common complications were implant exposure and formation of a pyogenic granuloma. CONCLUSIONS: Although enucleation and evisceration produce aesthetically similar outcomes, eviscerated eyes have better implant motility and experience fewer complications. Both enucleation and evisceration result in enophthalmos, sulcus contour defects, and incomplete transfer of implant motility to the prosthesis.

+ Congenitally enlarged extraocular muscles: can congenital thyroid eye disease exist in a euthyroid infant?

Burroughs JR, Bearden WH, Anderson RL, Hoffman RO, Elliot RL, McCann JD.
A 2-month-old boy presented with hypotropia, eyelid retraction, and proptosis of the left eye. CT and ultrasound demonstrated enlarged extraocular muscles. Both the infant and mother were euthyroid. The patient underwent inferior rectus recession, lower eyelid retractor disinsertion, and entropion repair. Biopsy of the inferior rectus and oblique muscles was normal. The clinical presentation and workup appear to be most consistent with thyroid eye disease, which, to our knowledge, would be the first reported case of euthyroid congenital thyroid eye disease with a euthyroid mother.

+ Correction of congenital blepharoptosis in oculomotor-abducens synkinesis.

Burroughs JR, Anderson RL, Elliot RL
A 4-year-old boy was referred for blepharoptosis. Examination revealed the presence of oculomotor-abducens synkinesis (right upper eyelid elevation with right gaze). Reports of congenital oculomotor-abducens synkinesis syndromes are rare. Two surgeries required more levator resection than anticipated to obtain the first, to our knowledge, reported successful result in this condition.

+ Inferior rectus muscle transection: a cause of diplopia after non-penetrating orbital trauma.

Yip CC, Jain A, McCann JD, Demer JL
BACKGROUND: Vertical diplopia after blow out fracture repair is not uncommon; we report an unusual case of inferior rectus muscle (IR) transection presenting as a persistent infra-duction deficit after uncomplicated blow out fracture repair. METHODS: We used multi-positional MRI to diagnose a transected IR with a contracted and posteriorly displaced muscle belly. RESULTS: Infra-duction improved after surgical repair of the transected IR. CONCLUSION: Multi-positional MRI is a novel technology that can be used to assist in the decisive management of persistent post-operative infra-duction deficits and avoid prolonged periods of observation.

+ Internal brow elevation at blepharoplasty.

Burroughs JR, Bearden WH, Anderson RL, McCann JD
OBJECTIVE: To present data on a transblepharoplasty technique that provides a safe and reliable brow elevation and glabellar furrow reduction by releasing inferior tethering and weakening the brow depressor muscles. DESIGN: Nonrandomized retrospective case series and surgical technique description. RESULTS: One thousand patients who underwent internal brow elevation for cosmesis associated with upper blepharoplasty over the past 9 years were reviewed. Follow-up ranged from 6 months to 9 years. There were no serious long-term complications. All patients experienced forehead hypesthesia, which was temporary in most patients. Only 2 patients complained of prolonged and bothersome forehead hypesthesia lasting longer than 2 years. CONCLUSION: The internal brow elevation at blepharoplasty is a reproducibly safe and effective technique to improve eyebrow appearance without fixation.

+ Medial wall decompression for optic neuropathy but lateral wall decompression with fat removal for non vision-threatening indications.

McCann JD
Editorial on orbital decompression surgery.

+ Mikulicz's disease: a new perspective and literature review.

Lee S, Tsirbas A, McCann JD, Goldberg RA
PURPOSE: To report the clinical and pathophysiologic features of two patients with Mikulicz's disease and to further characterize recommendations for diagnosis and management with a review of the literature. METHODS: Retrospective nonrandomized consecutive case series, Jules Stein Eye Institute, David Geffen School of Medicine at UCLA. RESULTS: Mikulicz's disease is characterized by symmetric lacrimal, parotid, and submandibular gland enlargement with associated lymphocytic infiltrations. The authors noted two cases of Mikulicz's disease. The diagnosis of Mikulicz's disease was based on the following criteria: 1) symmetric and persistent swelling of the lacrimal glands and either or both of the major salivary glands (parotid and submandibular); and 2) the exclusion of other diseases that may mimic this presentation, such as sarcoidosis, viral infection, or lymphoproliferative disorders. CONCLUSIONS: Mikulicz's disease is a condition in which there is bilateral lacrimal and salivary gland swelling that is not associated with other systemic conditions. The condition is self-limiting and most often, the diagnosis is a clinical one. Previously, Mikulicz's disease was often considered as a subtype of Sjögren's syndrome (SS). Clinical and immunologic differences between Mikulicz's disease and SS may warrant further consideration of Mikulicz's disease as a specific autoimmune phenomenon separate from SS, and Mikulicz's disease may be amenable to different treatment modalities than those employed in patients with SS.

+ Periocular and orbital amyloidosis: clinical characteristics, management, and outcome.

Leibovitch I, Selva D, Goldberg RA, Sullivan TJ, Saeed P, Davis G, McCann JD, McNab A, Rootman J
OBJECTIVE: To present the clinical features and management outcome in a large series of patients with periocular and orbital amyloidosis. DESIGN: Retrospective, noncomparative, interventional case series. PATIENTS: All patients diagnosed with periocular and orbital amyloidosis in 6 oculoplastic and orbital units. METHODS: Clinical records of all patients were reviewed. MAIN OUTCOME MEASURES: Clinical presentation, radiological and histological findings, treatment modalities, and outcome. RESULTS: The study included 24 patients (15 female, 9 male) with a mean age of 57+/-17 years. Nineteen cases were unilateral, and 5 were bilateral. Clinical signs and symptoms included a visible or palpable periocular mass or tissue infiltration (95.8%), ptosis (54.2%), periocular discomfort or pain (25%), proptosis or globe displacement (21%), limitations in ocular motility (16.7%), recurrent periocular subcutaneous hemorrhages (12.5%), and diplopia (8.3%). Seven cases had orbital involvement, and 17 were periocular. Immunohistochemistry in 7 patients showed B cells or plasma cells producing monoclonal immunoglobulin chains that were deposited as amyloid light chains. Only 1 patient was diagnosed with systemic amyloid light chain amyloidosis. Treatment modalities were mainly observation and surgical debulking. During a mean follow-up period of 39 months, 21% showed significant progression after treatment, whereas 79% were stable or showed no recurrence after treatment. CONCLUSION: Periocular and orbital amyloidosis may present with a wide spectrum of clinical findings and result in significant ocular morbidity. Complete surgical excision is not feasible in many cases, and the goal of treatment is to preserve function and to prevent sight-threatening complications.

+ Standardized terminology for aesthetic ophthalmic plastic surgery.

Lee S, Tsirbas A, Goldberg RA, McCann JD
PURPOSE: To determine whether existing Systemized Nomenclature of Medicine (SNOMED) terminology adequately describes aesthetic concepts commonly encountered in the oculoplastic and facial plastic surgery setting. METHODS: This was a noncomparative case series. A panel of three oculoplastic surgeons compiled a list of unique concepts describing specialized aesthetic terminology commonly encountered in the oculoplastic and facial plastic surgery setting, with a specific focus on anatomic structures and descriptive findings. A standard electronic browser was used to manually search for the existence of equivalent matching concepts in SNOMED. A quality of match score from 1 to 3 was used with values of (1) no match, (2) partial match, and (3) equivalent match. RESULTS: An assessment of the existing aesthetic terminology revealed that a majority of concepts were not represented. Of 62 total concepts, 68% had no match, 13% had a partial match, and 19% had a complete match. CONCLUSIONS: SNOMED coverage of aesthetic terminology was less than in previous studies examining content representation for other medical topics. Such findings underscore a need for further development and refinement of aesthetic content.

+ Strabismus after deep lateral wall orbital decompression in thyroid-related orbitopathy patients using automated hess screen.

Ben Simon GJ, Syed HM, Lee S, Wang DY, Schwarcz RM, McCann JD, Goldberg RA
PURPOSE: To evaluate the effect of deep lateral wall orbital decompression with intraconal fat debulking on strabismus in thyroid-related orbitopathy (TRO) patients using automated Hess screen (AHS). DESIGN: Prospective nonrandomized clinical study. PARTICIPANTS: Eleven TRO patients (19 surgeries) operated on at the Jules Stein Eye Institute from January, 2004, through December, 2004. METHODS: Automated Hess screen testing was performed in all patients before surgery and 3 months after surgery; all patients received surgery in the nonactive phase of the disease. MAIN OUTCOME MEASURES: Amplitude of horizontal and vertical deviations (prism diopters) in all standard positions of gaze. RESULTS: Eleven TRO patients (7 females; mean age, 47 years) were included in the study; 8 patients underwent bilateral surgery. After surgery, exophthalmos decreased an average (+/-standard deviation) of 2.7 mm (+/-2.5 mm; P = 0.003). Before surgery, 7 patients (63%) reported primary gaze diplopia, whereas only 2 patients (18%) showed diplopia in primary gaze after surgery (P = 0.03, chi-square analysis). Orbital decompression had no statistically significant effect on horizontal and vertical ocular deviations measured by AHS. Mean amplitude of deviation in primary gaze was 1.2 prism diopters (PD) esotropia and 0.07 PD hypotropia before surgery, and 2.5 PD exotropia with 0.6 PD hypertropia after surgery (delta = 3.7 PD for horizontal deviation and -0.7 for vertical deviation; P = 0.051, paired samples t test for horizontal difference and P not significant for vertical difference). Nonsignificant P values were obtained in all 9 positions of gaze. Most patients had periocular numbness that resolved spontaneously 2 to 6 months after surgery. CONCLUSIONS: Deep lateral wall orbital decompression with intraconal fat debulking had no statistically significant effect on horizontal and vertical deviations measured by the AHS. Patients may demonstrate small angle exotropia shift, but this finding was not clinically significant.

+ Subperiosteal midface lift with or without a hard palate mucosal graft for correction of lower eyelid retraction.

Ben Simon GJ, Lee S, Schwarcz RM, McCann JD, Goldberg RA.
PURPOSE: To compare functional and surgical outcomes of a subperiosteal midface lift with and without the placement of a hard palate mucosal graft (HPMG) in patients with lower eyelid retraction. DESIGN: Retrospective, comparative, interventional case series. PARTICIPANTS: Thirty-four patients with lower eyelid retractions who underwent surgery at the Jules Stein Eye Institute in a 5-year period. METHODS: Medical record review of all patients who underwent surgery for lower eyelid retraction by a subperiosteal midface lift with or without an HPMG. Preoperative and postoperative digital photographs were taken in all patients. MAIN OUTCOME MEASURES: Change in margin reflex distance 2 (MRD2), measured from the pupillary margin to the upper margin of the lower eyelid; patient discomfort; and surgical complications. RESULTS: Thirty-four patients (20 female; mean age, 64 years) participated in the study; 11 underwent bilateral surgery, with overall 43 surgeries performed. Eighteen patients (42%) had lower eyelid retraction secondary to previous transcutaneous lower eyelid blepharoplasty. Postoperatively, patients attained a better lower eyelid position, with improvement of lower eyelid height of 1.4 mm (P<0.001, 1-sample t test). Patients operated using an HPMG (12 surgeries) achieved a greater reduction in MRD2 postoperatively as compared with patients operated by subperiosteal midface lift alone (31 surgeries; 2.2 mm vs. 1.1 mm, respectively; P = 0.02, Wilcoxon Mann-Whitney). One patient needed reoperation secondary to symptomatic lower eyelid retraction postoperatively. CONCLUSIONS: The subperiosteal midface lift is effective in correction of lower eyelid retraction of various causes. The use of an HPMG spacer may enhance surgical outcomes and results in a better lower eyelid position.

+ Suture midface suspension.

Ugurbas SH, Goldberg RA, McCann JD, Shorr N, Murthy R, Ben Simon GJ
OBJECTIVE: To describe a simple and effective facelift technique useful as an adjunct to other oculoplastic procedures METHODS: Retrospective, non-comparative case series. Thirty five patients undergoing suture midface suspension from 1998 to 2000. Suspension sutures were passed from the nasolabial fold to the temporalis fascia to elevate the midface and the corner of the mouth. RESULTS: A satisfactory and stable outcome is obtained in 2 years of follow up. CONCLUSION: Suture midface suspension is a safe and effective technique for the management of midface descent.

+ Temporary suture tarsorrhaphy.

McInnes AW, Burroughs JR, Anderson RL, McCann JD
PURPOSE: To describe a technique for performing a bolsterless temporary tarsorrhaphy. DESIGN: Retrospective analysis and surgical technique description. METHODS: Temporary suture tarsorrhaphy (TST), which consists of a suture through the upper and lower eyelid posterior lamella, was performed after eyelid or socket surgery. RESULTS: Over 15 years, >1000 patients in the practice of one of the authors (R.L.A.) had TST that successfully maintained corneal coverage without complications in all but four eyes. In two patients, replacement was required because of tissue erosion; in two patients, the suture was placed too posteriorly and caused corneal irritation that required replacement. CONCLUSION: The TST is functionally equivalent to, or superior to, traditional bolster temporary tarsorrhaphy. The TST is faster and simpler, requires fewer materials, and avoids the risks of bolsters, which include eyelid margin necrosis, irregularities, and lash loss from vascular compromise.

+ The evaluation of light sensitivity in benign essential blepharospasm.

Adams WH, Digre KB, Patel BC, Anderson RL, Warner JE, Katz BJ
PURPOSE: To test light sensitivity thresholds rigorously in patients with benign essential blepharospasm (BEB) compared with patients who have known light sensitivity (migraineurs) and to normal control subjects. DESIGN: Prospective, observational, case control study. METHODS: We recruited a total of 87 subjects into each of three groups: BEB, migraine, and normal control subjects. A modified slit-lamp chin rest, heat shield, light meter, and halogen light that was modulated by a rheostat were used to measure light sensitivity thresholds. Participants were tested without spectacles, with gray-tinted spectacles, and with FL-41-tinted spectacles. RESULTS: Light discomfort thresholds for subjects with BEB were significantly lower compared with normal control subjects (P < or = .009) and similar to the migraine group. Both gray and FL-41-tinted lenses improved light sensitivity thresholds in all groups (P < or = .0005). There was no observed difference in the improvement in light sensitivity when the gray and FL-41-tinted lenses were compared. CONCLUSION: Patients with BEB are considerably more sensitive to light than control subjects and as sensitive to light as patients with migraine. Physicians who care for patients with BEB should consider using tinted lenses to help ameliorate symptoms.

2005

+ Benign essential blepharospasm.

Ben Simon GJ, McCann JD.
A review article on Benign Essential Blepharospasm.

+ Cold urticaria: an under-recognized cause of postsurgical periorbital swelling.

Burroughs JR, Patrinely JR, Nugent JS, Soparkar CN, Anderson RL, Pennington JH
PURPOSE: To report cold urticaria as an under-recognized cause of potential periorbital and facial edema after elective oculofacial plastic surgery. METHODS: Retrospective case series of three patients with primary acquired cold urticaria with review of the clinical aspects of each of the cases. RESULTS: Two of the patients had significant postoperative swelling attributed to primary acquired cold urticaria after the routine use of cool compresses to their surgical sites. The third patient had known primary acquired cold urticaria and required special perioperative management. All three patients ultimately had a good surgical outcome with no long-term sequelae. CONCLUSIONS: Although primary acquired cold urticaria is generally not a serious condition, it can be easily overlooked and misdiagnosed as a localized adverse reaction to injected anesthetic, topical antibiotic ointments, or early preseptal cellulitis after eyelid or facial surgery. Rarely, this condition can be fatal and should be recognized by the surgeon to ensure both optimal surgical results and general medical management. Three simple screening questions should identify most patients with this disorder.

+ Corrugator superciliaris muscle excision for tension and migraine headaches.

Bearden WH, Anderson RL
PURPOSE: This study investigates the effect of corrugator superciliaris muscle excision on patients with frequent tension or chronic migraine headaches emanating from the glabellar or frontal regions. METHODS: We present a prospective study of 12 patients with chronic and frequent tension and/or migraine headaches. Patients who had already elected to undergo corrugator excision for cosmesis (n = 64) were given questionnaires to evaluate for the presence of chronic, recurrent migraine and/or tension headaches. Patients who answered in the affirmative went on to answer questions such as onset, location, frequency, severity, and duration of their headaches. Patients were grouped by types of headaches: tension, migraine, and combined headaches. Twelve patients who met all criteria were entered into the study and underwent corrugator excision in combination with blepharoplasty. Postoperative questionnaires and interviews were administered to evaluate the response of the patients' headaches to corrugator excision. RESULTS: All 12 patients had less frequent headaches and said they would have the procedure performed again for headache. Eleven of 12 patients (92%) had less intense headaches after corrugator superciliaris excision. Overall, 58% noted complete relief of their headaches. Follow-up ranged from 6 to 19 months. CONCLUSIONS: Corrugator superciliaris muscle excision provides significant relief for headaches emanating from or localizing to the frontal and glabellar regions. Although improvement of migraine headaches has been previously described with this technique, this is the first report, to our knowledge, of effective surgical treatment of tension headaches by corrugator excision.

+ External (subciliary) vs internal (transconjunctival) involutional entropion repair.

Ben Simon GJ, Molina M, Schwarcz RM, McCann JD, Goldberg RA
PURPOSE: To compare surgical outcomes of internal (transconjunctival) vs external (subciliary) involutional entropion repair. DESIGN: Retrospective, consecutive case series. METHODS: Electronic medical record review of all patients who underwent involutional entropion repair at the Jules Stein Eye Institute over a 4-year period was performed. MAIN OUTCOME MEASURES: Anatomic and functional success, recurrence rate, and complications. RESULTS: Forty-nine eyes (39 patients) were operated. Twenty-nine eyes underwent subciliary incision repair; 20 eyes underwent transconjunctival repair, both with lower lid retractors reinsertion. Good correlation was found between two masked observers in grading surgical outcome (on a scale of 1 to 4) (r = .76, P < .001). Forty-two cases (84%) achieved good surgical repair and improvement in symptoms. Recurrence was noticed in 4 eyes (8.2%). Recurrence was higher with the internal approach (15% vs 3% with subciliary incision), but this was not statistically significant (P = .14). Complications included: three cases (8.2%) with mild eyelid retraction that were treated conservatively, three cases with postoperative ectropion (all in the external approach, two of which lateral canthal resuspension was not performed), and two cases (4.1%, one case in each group) with pyogenic granuloma. CONCLUSIONS: Surgical correction of involutional entropion by reinsertion of lower eyelid retractors has similar outcome with internal (transconjunctival) and external (subcilliary) approaches. Although not statistically significant, internal repair may result in a higher recurrence rate, whereas external repair may show more postoperative ectropion, most probably attributable to scarring of the anterior lamella. Lateral canthal resuspension, when needed, may reduce the rate of postoperative ectropion.

+ External levator advancement vs Muller's muscle-conjunctival resection for correction of upper eyelid involutional ptosis.

Ben Simon GJ, Lee S, Schwarcz RM, McCann JD, Goldberg RA
PURPOSE: To compare external levator advancement and Müller's muscle-conjunctival resection (conjunctivomullerectomy, or CJM) for correction of upper eyelid involutional ptosis. DESIGN: Retrospective, nonrandomized, comparative interventional case series. METHODS: Review of medical records of 159 patients (272 surgical procedures) who underwent external levator advancement or CJM was performed. MAIN OUTCOME MEASURES: Functional and cosmetic outcome, marginal reflex distance one (MRD1), and surgical complications. RESULTS: A total of 159 patients (51 men, 108 women, mean age 70 years) underwent 272 surgical procedures for upper eyelid ptosis; concurrent blepharoplasty was performed in 141 cases. MRD1 increased an average of 1.6 (+/-1.5) mm, from 0.8 mm (+/-1.2) preoperatively to 2.3 mm (+/-1.2) postoperatively (P < .001). Fifteen patients (5.5%) underwent reoperation for residual ptosis, nine (18%) in the external levator advancement group, two (3%) in the CJM group, three (8%) in the external plus blepharoplasty group, and one (1%) in the CJM plus blepharoplasty group (P < .001). Patients who underwent external levator advancement had significantly more severe ptosis preoperatively but attained similar eyelid position postoperatively as compared with CJM patients. Complications included overcorrection in four cases (1.4%), lagophthalmos of 1 mm in 10 (3.6%), and pyogenic granuloma in two (<1%). CONCLUSIONS: External levator advancement and CJM performed alone or with concurrent blepharoplasty are effective treatments for upper eyelid ptosis. Residual ptosis or postoperative eyelid retraction occurs in up to 20% of cases and can be addressed successfully with a second operation.

+ External versus endoscopic dacryocystorhinostomy for acquired nasolacrimal duct obstruction in a tertiary referral center.

Ben Simon GJ, Joseph J, Lee S, Schwarcz RM, McCann JD, Goldberg RA.
PURPOSE: To compare success rates of external dacryocystorhinostomy (DCR) and endoscopic endonasal DCR for acquired nasolacrimal duct obstruction (NLDO). DESIGN: Retrospective, comparative, nonrandomized clinical study. PARTICIPANTS: One hundred forty-three patients (176 surgeries) operated for acquired NLDO. METHODS: A review of electronic medical records of patients with acquired NLDO who underwent DCR at the Jules Stein Eye Institute from 1999 to 2004 was performed. Data regarding the lacrimal drainage system, comprehensive eye examination, surgical outcome, and postoperative nasal endoscopy were analyzed. MAIN OUTCOME MEASURES: Surgery failure was defined as (1) no marked improvement in tearing or any episode of postoperative dacryocystitis, (2) inability to irrigate the lacrimal system postoperatively, and (3) postoperative nasal endoscopy with scarring in the intranasal osteotomy or no visualization of fluorescein dye. Postoperative nasal endoscopy was performed in all failed cases and in >50% of all patients. RESULTS: One hundred forty-three patients (48 male and 95 female; mean age, 63 years) underwent 176 DCR surgeries for acquired NLDO. Success was achieved in 135 cases (76.7%), and failure in 41 (23.3%). Of the 41 failed cases, anatomical obstruction at the fistula site was found in 20 (49% of failed cases), whereas functional failure with no evidence of obstruction was found in 21 (51%). Surgery revision was performed in 22 cases (12.5%), but it was successful in only 9 (5.1%); patients who failed the first revision were likely to fail additional revisions (P = 0.02). History of facial trauma was associated with surgery failure. In our patients, endoscopic DCR (86 cases) had a significantly higher success rate than external DCR (90 cases), 84% versus 70% (P = 0.03). Complications included 1 patient with nose bleeding on the first postoperative day that resolved with nasal packing and 2 patients with sump syndrome that resolved after endoscopic revision. CONCLUSIONS: The success rate of DCR for acquired NLDO in our group of patients was 77%, lower than reported in previous studies, with endoscopic surgery showing better results. Success rates of revision surgery were relatively low (<50%), and patients who fail the first revision are not likely to benefit from additional revisions.

+ Frontalis suspension for upper eyelid ptosis: evaluation of different surgical designs and suture material.

Ben Simon GJ, Macedo AA, Schwarcz RM, Wang DY, McCann JD, Goldberg RA
PURPOSE: To compare two sling designs (single loop or double pentagon) and a variety of suture material that was used in frontalis suspension surgery for correction of upper eyelid ptosis. DESIGN: Retrospective, nonrandomized, comparative interventional case series. METHODS: Medical record review of 99 patients (164 surgeries) who underwent frontalis suspension surgery for upper eyelid ptosis was conducted at the Jules Stein Eye Institute in 1996 to 2002. Functional and cosmetic success, margin reflex distance (MRD) and lagophthalmos were evaluated. RESULTS: MRD increased an average of 1.1 mm after the operation (P < .001). Ptosis recurrence was noticed in 42 cases (26%); polytetrafluoroethylene achieved the lowest recurrence rate (15%), although not statistically significant. No difference in functional success, ptosis recurrence, or change in MRD was noticed between single loop and double pentagon design. A better cosmetic outcome was noted in cases in which nylon suture was used. Complications included four cases (2.4%) of over-correction, three cases (1.8%) of suture infection (all in polytetrafluoroethylene), two cases of pyogenic granuloma (1.2%), and two cases (1.2%) of suture exposure. CONCLUSION: Frontalis suspension for upper eyelid ptosis resulted in 26% ptosis recurrence after a mean of 12 months from first surgery. Polytetrafluoroethylene showed the lowest incidence of ptosis recurrence. No statistically significant difference was found between different suture materials or loop shape that was used in the surgical technique. A better cosmetic outcome, as graded by different observers, was noted in cases in which a nylon sling was used.

+ Intralesional triamcinolone acetonide injection for primary and recurrent chalazia: is it really effective?

Ben Simon GJ, Huang L, Nakra T, Schwarcz RM, McCann JD, Goldberg RA
PURPOSE: To evaluate the safety and efficacy of intralesional triamcinolone acetonide (TA) injection in primary and recurrent chalazia. DESIGN: Retrospective, interventional, consecutive case series. PARTICIPANTS: One hundred forty-seven patients with primary or recurrent chalazia (155 cases) treated at the oculoplastic clinic at the Jules Stein Eye Institute between January 1, 2000, and December 31, 2003. METHODS: Patients received an intralesional injection of 0.1 to 0.2 ml TA (40 mg/ml). Data regarding lesion size, including digital color photography, lesion regression or recurrence, and complete ophthalmic examination, were recorded at the time of injection and at different intervals until resolution or surgical excision. Success was defined as at least an 80% decrease in size with no recurrence. If the lesion recurred or regression was minimal (<50%), further injections were given as needed. Patients who declined injection or who did not respond to 2 to 3 injections were referred for surgical excision and drainage. MAIN OUTCOME MEASURES: Lesion size, clinical resolution, time to resolution, recurrence, and complications. RESULTS: Most of the patients received 1 injection (93 patients; 60%) or 2 injections (31 patients; 20%) with resolution of the lesion (more than 80% decrease in size), with an average time to resolution of 2.5 weeks. Patients who did not respond to 2 injections were more likely to fail treatment (minimal or no regression), to respond to further injections, or to undergo surgical excision and drainage (P = 0.0001, chi-square test). Patients with blepharitis required more injections to resolution (2+/-1.3 vs. 1.4+/-1; P = 0.05, independent samples t test). Intraocular pressure and visual acuity remained stable after treatment. No complications, such as visual loss, subcutaneous fat atrophy, or skin depigmentation changes, were noted with steroids injections; assuming a complication rate of 2%, our power was adequate to rule out these complications. CONCLUSIONS: Intralesional TA injection in primary and recurrent chalazia is effective in achieving lesion regression. Most cases resolve with an average of 1 to 2 injections. Chalazia that fail to respond to 2 or 3 injections are more likely to benefit from surgical excision. It may be considered as a first treatment in cases where diagnosis is straightforward.

+ Lagophthalmos in enophthalmic eyes.

Yip CC, Gonzalez-Candial M, Jain A, Goldberg RA, McCann JD.
AIMS: To report a case series of enophthalmic patients with lagophthalmos. METHODS: A retrospective review of the electronic medical records at a tertiary health care centre of all patients with the diagnoses of "enophthalmos" and "lagophthalmos". Patients who had a history of diseases (such as Graves' orbitopathy), trauma or surgery of the orbit and eyelid were excluded. Enophthalmos was defined as exophthalmometric reading of 14 mm or less in both eyes. RESULTS: Seven patients (14 eyes) with bilateral enophthalmos were found to have concomitant lagophthalmos. All patients had deep superior sulci bilaterally. The upper eyelids were seen to be severely retro-placed behind the superior orbital rim. The extraocular motilities were full with no focal neurological deficit. The orbicularis oculi function was normal with no facial paralysis. The orbits were soft on retropulsion and no facial asymmetry was noted. The mean exophthalmolmetry reading measured 12.6 (SD 1.1) mm. The lagophthalmos varied from 1-5 mm. One patient (one eye) with 3 mm lagophthalmos developed a corneal ulcer and was treated with topical antibiotics and gold weight placement in the upper eyelid. CONCLUSION: Enophthalmic patients with deep superior sulci and retro-placed upper eyelids may present with lagophthalmos and exposure keratopathy.

+ Minimally invasive orbital decompression: local anesthesia and hand-carved bone.

Ben Simon GJ, Schwarcz RM, Mansury AM, Wang L, McCann JD, Goldberg RA
OBJECTIVE: To investigate the safety and efficacy of a conservative orbital decompression using sharp-curette bony decompression and intraconal fat debulking through a transconjunctival incision in patients with thyroid-related orbitopathy and mild to moderate proptosis. DESIGN: Retrospective, noncomparative, interventional case series. PARTICIPANTS AND METHODS: Data from all patients undergoing minimal orbital decompression at the Jules Stein Eye Institute, Los Angeles, Calif, over a period of 4(1/4) years were collected and analyzed. Data included visual acuity, exophthalmometry measurements, intraocular pressure, complete slitlamp examination results, ocular ductions, new-onset primary or downgaze diplopia, and patient satisfaction. Conservative decompression was performed through a transconjunctival incision using a manual curette and by removing cortical bone from the zygomatic marrow space on the anterior rim of the inferior orbital fissure; intraconal fat was bluntly dissected and excised or suctioned with a Frasier tip aspirator. MAIN OUTCOME MEASURES: Patient perception of pressure pain and ocular discomfort, proptosis, visual acuity, intraocular pressure, postoperative complications, and new-onset primary or downgaze diplopia. RESULTS: Eighty minimally invasive orbital decompression surgeries were performed in 48 patients (6 male, 42 female). Six surgeries (4 patients) were performed for prominent globes with relative proptosis and no thyroid-related orbitopathy (non-Graves proptosis). All patients had improvement in congestive orbitopathy and pressure pain associated with thyroid-related orbitopathy. Exophthalmos decreased by a mean +/- SD of 2.4 +/- 2.6 mm from 22.7 +/- 2.5 mm (range, 17-29 mm) to 20.3 +/- 2.3 mm (range, 14-25 mm) (P<.001 [95% confidence interval, 1.8-3.0]). Mean visual acuity improved after surgery (P = .02). One patient (2.1%) developed postoperative primary or downgaze diplopia; he underwent successful eye muscle surgery at a later stage. No complications were associated with orbital decompression. CONCLUSIONS: Minimally invasive orbital decompression surgery with intraconal fat debulking in this group of patients was effective in proptosis reduction; improvement in subjective pressure pain and high patient satisfaction were noticed. Surgery was associated with a low rate (2.1%) of new-onset primary or downgaze diplopia. Proptosis reduction using a graded approach accounting for 4 mm of retrodisplacement was achieved.

+ Orbital exenteration: one size does not fit all.

Ben Simon GJ, Schwarcz RM, Douglas R, Fiaschetti D, McCann JD, Goldberg RA
PURPOSE: To evaluate the clinical indications for orbital exenteration in a tertiary referral center and to compare clinicopathologic correlation and cosmetic outcome with previously reported data. DESIGN: Retrospective, nonrandomized, consecutive case series. METHODS: Review of Electronic Medical Record system, Orbital Clinic, Jules Stein Eye Institute, between January 1999 and December 2003. main outcome measures: Surgery type, clear margins histologically, survival, and wearing an eye patch. RESULTS: Thirty-four patients (mean age 67 years) underwent orbital exenteration; mean follow-up 1.2 +/- 1.5 years (6 months to 6 years). Diagnosis included orbital, ocular, and adnexal malignancies, with squamous and basal cell carcinoma being the most common. Twenty-one patients (62%) underwent total or extended orbital exenteration, and 13 patients (38%) underwent subtotal exenteration including tissue reconstruction. Clear surgical margins were obtained in 23 cases (68%), whereas positive margins were left in 11 cases (32%). Many of the patients preferred an eye patch to cover the surgical region regardless of surgical reconstruction. Only 4 patients (11.8%) who underwent subtotal exenteration with orbital prosthesis did not use a patch. During follow-up period 3 patients expired, only 1 of which was tumor-related. CONCLUSIONS: Clinical indications for orbital exenteration remain similar over the last four decades with a higher prevalence of squamous cell carcinoma in our institute. Orbital exenteration is considered curative in cases of basal or squamous cell carcinoma but not in cases of malignant infiltrative processes such as adenoid cystic carcinoma of the lacrimal gland. Patients are likely to wear an eye patch regardless of any attempt at surgical reconstruction.

+ Paradoxical use of frontalis muscle and the possible role of botulinum a toxin in permanent motor relearning.

Ben Simon GJ, Blaydon SM, Schwarcz RM, Nakra T, Goldberg RA, McCann JD
PURPOSE: To report 7 patients with paradoxical use of the frontalis muscle despite postsurgical correction of ptosis with good postoperative eyelid position. Successful treatment with botulinum A toxin facilitated motor relearning and cessation of muscle contraction. DESIGN: Interventional case series. PARTICIPANTS: Seven patients, in 2 eye-plastic clinics, who underwent successful surgical correction of upper eyelid ptosis. METHODS: Review of clinical history, clinical photographs, treatment, and follow-up. MAIN OUTCOME MEASURES: Frontalis muscle contraction and upper eyelid position. RESULTS: Patients underwent successful surgical correction of ptosis but continued using the frontalis muscle despite good eyelid position postoperatively. Frontalis contraction ceased spontaneously in 2 patients, but required botulinum A toxin injection in 5. The effects of a single treatment of botulinum A toxin lasted from 3 months to 2 years, longer than the expected effect of the toxin. CONCLUSION: Patients with long-standing eyelid ptosis may paradoxically continue utilizing the frontalis after successful surgical correction and despite good postoperative eyelid position. Cessation of frontalis contraction can be achieved with a single injection of botulinum A toxin. We hypothesize that chemodenervation, achieved with the toxin, may influence the central nervous system to relearn the set point for muscle contraction and may be associated with permanent motor relearning. Spontaneous resolution of muscle contraction can occur in the first months after surgery.

+ Rethinking orbital imaging establishing guidelines for interpreting orbital imaging studies and evaluating their predictive value in patients with orbital tumors.

Ben Simon GJ, Annunziata CC, Fink J, Villablanca P, McCann JD, Goldberg RA
PURPOSE: To establish guidelines for interpretation of orbital imaging by magnetic resonance imaging (MRI) and/or computed tomography (CT), and to apply these guidelines and examine their predictive value in 131 patients with biopsy-proven orbital tumors. DESIGN: Prospective evaluation of imaging studies. PARTICIPANTS: Imaging studies (CT and/or MRI) from 131 cases with biopsy-proven orbital tumors. METHODS: Guidelines for reviewing orbital imaging studies (MRI and/or CT) were established based on 5 major characteristics: (1) anatomic location, (2) bone and paranasal sinuses involvement, (3) content, (4) shape, and (5) associated features. In total, 84 features were established by an experienced orbital surgeon and a neuroradiologist. Applying these 84 features, imaging studies of 131 biopsy-proven orbital tumors were evaluated by 3 physicians. MAIN OUTCOME MEASURES: Imaging features: characteristics, sensitivity, specificity, and positive and negative predictive values in various groups of orbital tumors and kappa values. RESULTS: One hundred thirty-one cases of biopsy-proven orbital tumors were evaluated. Benign lesions were more likely to be smaller in size, round or oval in shape (29% of all benign tumors, 0% in malignant and inflammatory, P<0.001), and associated with hyperostosis (22% of all benign lesions, P<0.001). They were also more likely to be hyperdense or hypodense on CT imaging (15% and 11%, respectively; P<0.05 in comparison with inflammatory and malignant tumors). Inflammatory processes showed panorbital involvement (23% vs. 3%, and 0% in benign and malignant tumors, respectively; P<0.001). Orbital fat involvement and fat stranding were noticed only in inflammatory lesions (19% and 16%, respectively; P<0.001). None of the features occurred only in malignant tumors, but they tend to involve the anterior orbit more commonly (54% vs. 20%, and 29% in benign and malignant; P = 0.002), and were more likely to show bone erosion (31% vs. 6%, and 16% in benign and inflammatory tumors, respectively; P = 0.004) and molding around orbital structures (29% vs. 3% in benign, and 0% in inflammatory tumors, respectively; P<0.001). Features such as panorbital involvement, orbital fat, frontal sinus opacity, molding around orbital structures, perineural involvement, and fat stranding had specificity of 97% to 100%, but low sensitivity. CONCLUSIONS: Guidelines for analysis of orbital imaging studies (CT or MRI) are suggested. Based on these guidelines several imaging features showed significantly different occurrences in benign, malignant, and inflammatory processes; although this can help in differential diagnosis, tissue diagnosis may still be required.

+ Simultaneous orbital decompression and correction of upper eyelid retraction versus staged procedures in thyroid-related orbitopathy.

Ben Simon GJ, Mansury AM, Schwarcz RM, Lee S, McCann JD, Goldberg RA
PURPOSE: To evaluate the outcome of eyelid retraction surgery in thyroid-related orbitopathy (TRO) patients in 2 different surgical settings: done simultaneously with orbital decompression or as a staged procedure after orbital decompression. DESIGN: Retrospective, comparative, nonrandomized clinical study. PARTICIPANTS: Ninety-six patients (158 eyes). METHODS: A review of electronic medical records of TRO patients who underwent surgery for upper eyelid retraction and orbital decompression at the Jules Stein Eye Institute in 1999 to 2003 was performed. Data regarding eyelid position, comprehensive eye examination, surgical outcome, and complications were analyzed. MAIN OUTCOME MEASURES: Anatomical and functional success based on margin reflex distance (MRD1; < or = 5 mm was graded as mild retraction; > 5 mm and < 7 mm, moderate; and > 7 mm, severe), and patients' discomfort. RESULTS: One hundred fifty-eight eyelid retraction surgeries were performed on 96 TRO patients (18 male and 78 female; mean age, 48 years); mean follow up time was 15 (+/-12) months. Group 1 consisted of patients undergoing simultaneous eyelid retraction surgery and orbital decompression and comprised 97 cases (surgeries). Group 2 included 61 cases of staged surgery: orbital decompression and eyelid retraction at a later stage. The groups had similar surgical outcomes, and > 85% had a better eyelid position postoperatively. Reoperation rates for residual or recurrent eyelid retraction were similar, overcorrection was higher in group 2 (5% vs. 0%, P = 0.03). Changes in MRD1, lagophthalmos, and exophthalmos were similar (P > 0.05, independent samples t test). Correction of eyelid retraction was effective in treating patients' discomfort and exposure keratopathy (P = 0.04, chi2). No severe complications occurred after orbital decompression or eyelid retraction surgery in this group of patients. CONCLUSIONS: Transconjunctival Muller's muscle recession for correction of eyelid retraction in mild to moderate TRO patients, performed simultaneously with deep lateral wall orbital decompression, resulted in acceptable eyelid position in two thirds of our patients. Overcorrection and consecutive ptosis occurred less often after combined orbital decompression and eyelid retraction surgery than after isolated eyelid repositioning surgery. If confirmed in prospective controlled studies, eyelid-repositioning surgery performed at the time of orbital decompression may decrease the number of total procedures and compress the time needed for surgical rehabilitation.

+ Suture tarsorrhaphy.

Yen MT, Anderson RL
Comment on prior paper.

+ Transconjunctival Muller muscle recession with levator disinsertion for correction of eyelid retraction associated with thyroid-related orbitopathy.

Ben Simon GJ, Mansury AM, Schwarcz RM, Modjtahedi S, McCann JD, Goldberg RA
PURPOSE: To evaluate the efficacy of transconjunctival Müller muscle recession and graded levator disinsertion for eyelid retraction in patients with thyroid-related orbitopathy (TRO). DESIGN: Retrospective consecutive case series. METHODS: Medical record review of 78 TRO patients (107 eyelids) who underwent surgery for upper eyelid retraction in a 5-year period was performed. Main outcome measures were anatomic and functional success, minimal reflex distance (MRD), lagophthalmos, eyelid asymmetry, and patient discomfort. RESULTS: One hundred seven eyelid retraction surgeries were performed on 78 TRO patients (63 women, mean age 49 years); mean follow-up time was 16.7 months. Upper eyelid position, lagophthalmos, exposure keratopathy, and patients' discomfort markedly improved after surgery (P < .001). Marginal reflex distance (MRD1) decreased an average of 2.6 mm from 6 mm pre-operatively to 3.4 mm post-operatively (P < .001); lagophthalmos decreased an average of 0.6 mm from 1.3 mm pre-operatively to 0.4 mm post-operatively (P = .006) Failure rate was 8.4%, most improved with a second surgery. Overcorrection was noticed in three cases (2.8%). Eyelid asymmetry improved from a mean of 1.0 mm pre-operatively to 0.4 mm post-operatively (P = .001); more than 80% of patients showed eyelid asymmetry of 1 mm or less. CONCLUSION: Transconjunctival Müller muscle and levator recession is safe and effective in correction of mild, moderate, or severe eyelid retraction in TRO patients. The failure rate is less than 10% and may be addressed by a second surgery.

+ What causes eyelid bags? Analysis of 114 consecutive patients.

Goldberg RA, McCann JD, Fiaschetti D, Ben Simon GJ
BACKGROUND: The purpose of this study was to identify the anatomical basis for perception of lower eyelid bags in patients seeking aesthetic surgery and to evaluate the cumulative contribution of different anatomic characteristics before surgery. METHODS: The histories and photographs of patients whose motivation for aesthetic consultation was lower eyelid bags were analyzed. Six categories of anatomic basis for the lower eyelid bags were identified. For each patient, a score from 0 to 4 was given in each category. The cumulative contribution score for each category was calculated as total points for that category for all patients, divided by the 456 total available points. The authors also developed a "uniqueness score" to reflect the percentage contribution of the worst identified anatomic problem compared with the other problems. This was calculated for each patient as the maximum score in one category, divided by total points for that patient. RESULTS: A total of 114 consecutive cases were evaluated (67 men and 47 women; mean age, 52 +/- 11 years; age range, 23 to 76 years). The cumulative contribution score for each anatomic variable was as follows: cheek descent and hollow tear trough, 52 percent; prolapse of orbital fat, 48; skin laxity and sun damage, 35; eyelid fluid, 32; orbicularis hyperactivity, 20; and triangular cheek festoon, 13. Prolapsed orbital fat and tear trough deformity both received the higher score and were more common in men as compared with women. The average uniqueness score was 38 percent, with a range of 20 to 75 percent. No one category played a dominant role for most patients. Tear trough depression, skin laxity, and triangular malar mound were significantly more common in patients older than 50 years. Linear regression analysis showed that recommendation for surgery is based on the extent of fat prolapse, skin elasticity, and midface descent. Significant positive correlations were found in all six categories and in uniqueness scores calculated by different observers (r values ranged from 0.31 to 0.73; p < 0.001, Pearson correlation), with the highest score in agreement with the contribution of eyelids fat (r = 0.73) and skin laxity (r = 0.66); the uniqueness score correlation was r = 0.45 (p < 0.001). CONCLUSIONS: Eyelid bags do not have a single anatomic basis. For different anatomic problems, different treatments are recommended.

2004

+ Bilateral decompression retinopathy after orbital decompression surgery.

Ben Simon GJ, Goldberg RA, McCann JD.
A short report on a rare complication of orbital decompression surgery.

+ Cerebral vasospasm and ischemia after orbital decompression for graves ophthalmopathy.

McCormick CD, Bearden WH, Hunts JH, Anderson RL
PURPOSE: We describe the first reported cases of cerebral vasospasm, ischemia, and infarct after orbital decompression surgery for Graves disease-related ophthalmopathy. METHODS: We present two patients who had inadvertent penetration of the dura mater during orbital decompression surgery. One case was recognized at surgery; the other was not. All patient data were gathered and relayed in accordance with state and U.S. laws. RESULTS: Postoperative cerebrospinal fluid leak, radiographic evidence of subarachnoid hemorrhage, and severe neurologic morbidity occurred in each case. Cerebral ischemia and infarction resulting from subarachnoid hemorrhage-induced cerebral vasospasm occurred in each case. CONCLUSIONS: The risk of dural penetration, cerebral vasospasm, and ischemia should be considered during preoperative evaluation for orbital decompression surgery. The diagnosis, treatment, and prevention of this previously unreported serious complication of this procedure is paramount.

+ Extraocular muscle enlargement with tendon involvement in thyroid-associated orbitopathy.

Ben Simon GJ, Syed HM, Douglas R, McCann JD, Goldberg RA
PURPOSE: To evaluate the configuration of extraocular muscle and tendon enlargement in patients with thyroid-associated orbitopathy (TAO). DESIGN: Retrospective, noncomparative case series. METHODS: We retrospectively evaluated the preoperative computed tomography (CT) or magnetic resonance imaging (MRI) scans, or both, of 125 consecutive patients with previously diagnosed TAO. Axial CT (n = 88) or MRI (n = 37) slices of the orbits were examined for tendon involvement of enlarged medial or lateral recti muscles. A ratio of tendon to muscle width greater than 0.5 was considered as tendon involvement. RESULTS: Eight patients (6.4%) with TAO demonstrated tendon involvement on axial CT or MRI. These patients had significantly greater diplopia in primary gaze than patients with no tendon involvement or patients with no muscle enlargement. CONCLUSION: The configuration of extraocular muscle enlargement on imaging studies has traditionally been used to differentiate TAO from other inflammatory processes because the tendon is typically spared (fusiform configuration) in TAO. However, we found that the configuration of tendon involvement (cylindrical configuration) can occasionally be noted in TAO and may be more frequently associated with primary gaze diplopia. Tendon involvement does not eliminate the diagnostic possibility of TAO.

+ Idiopathic orbital inflammatory disease.

Goldberg RA, McCann JD, Shorr N
A short report on orbital pseudoturmor.

+ Incision-less frontalis suspension.

Yip CC, Goldberg RA, Cook TL, McCann JD
A short report on a new technique of repairing congenital ptosis of the eyelids.

+ Partial resolution of acute ascending motor polyneuropathy after enucleation of an eye with metastatic melanoma.

Ben Simon GJ, McCann JD, Barth N, Goldberg RA, Glasgow BJ, Straatsma BR
Report of a case.

+ Perivascular dermatitis of the eyelid secondary to chronic epiphora.

Yen MT, Yen KG, Anderson RL
A short report.

+ Prevalence of asymmetric exophthalmos in Graves orbitopathy.

Soroudi AE, Goldberg RA, McCann JD
PURPOSE: To report the prevalence and the degree of significant asymmetric orbital involvement secondary to thyroid-related (Graves) orbitopathy in a large patient population. METHODS: The prevalence of exophthalmometric differences of > or =2 mm was determined in 391 consecutive patients diagnosed with Graves orbitopathy from the Jules Stein Eye Institute Division of Ophthalmic Plastic and Reconstructive Surgery patient registry. RESULTS: Thirty-six of 391 patients (9%) in this cohort had asymmetric proptosis with a difference of > or =2 mm, based on single-observer Hertel measurements before orbital decompression surgery. This finding was similar among men (11/95, 12%) and women (25/296, 8%) but was not statistically significant (P= 0.358; 95% CI, 0.6% to 7.8%). Also, we found no racial variations in the incidence of unilateral disease. CONCLUSIONS: Clinically, unilateral or asymmetric Graves orbitopathy is common and can lead to misdiagnosis or to unnecessary testing. Thyroid-related orbitopathy must be considered in the differential diagnosis for any case of asymmetric exophthalmos.

+ Primary-gaze diplopia in patients with thyroid-related orbitopathy undergoing deep lateral orbital decompression with intraconal fat debulking: a retrospective analysis of treatment outcome.

Ben Simon GJ, Wang L, McCann JD, Goldberg RA.
Our goal was to investigate the incidence of postoperative primary gaze diplopia in patients with thyroid-related orbitopathy (TRO) undergoing deep lateral wall orbital decompression surgery with intraconal fat debulking in the Jules Stein Eye Institute over a period of 4(1/4) years. Overall 201 orbital decompression surgeries were performed in 116 patients (23 males, 93 females). All surgeries were performed by two of the authors (R.A.G. and J.D.M.) and in the noninflammatory phase of the disease. Exophthalmos decreased by an average of 3.4 +/- 2.7 mm from 23.8 +/- 3.2 mm (17-31) to 20.4 +/- 2.5 mm (14-29), p < 0.001, 95% confidence interval (CI) (3.0:3.8). 31% of patients had preoperative primary gaze diplopia and 28.4% had postoperative primary gaze diplopia. Thirty (83%) of the 36 patients with preoperative diplopia had also postoperative diplopia; 6 (16.7%) of the 36 patients had improvement in diplopia following deep lateral wall decompression. Of the 80 (69%) of patients without preoperative double vision 3 developed postoperative double vision in primary gaze (2.6% of all patients). These 3 patients were older (56 versus 46 years, p = 0.047), had more limitation in ocular movements (p = 0.017) and achieved more decrease in proptosis with surgery (6 versus 3.1 mm, p = 0.024). No complications were associated with orbital decompression. In conclusion deep lateral wall orbital decompression surgery with intraconal fat debulking is associated with a low rate (2.6%) of new-onset primary gaze diplopia. Some patients (5.2%) with preoperative diplopia actually had improvement in diplopia postoperatively. This surgery is effective in reduction of congestion and exophthalmos, and is not associated with detrimental effects on visual acuity.

+ Reverse ptosis-induced corneal steepening and decreased vision after LASIK surgery.

Ben Simon GJ, Goldberg RA, McCann JD
PURPOSE: To report a patient with a past history of LASIK who had decreased vision and induced corneal steepening after lower eyelid ptosis. Surgical correction of lower eyelid ptosis decreased the corneal steepening and improved visual acuity. METHODS: Interventional case report. RESULTS: A 37-year-old woman had a history of bilateral LASIK, childhood strabismus surgery, and multiple surgeries to release scarring and improve motility in her left eye. Last surgery to release scar tissue resulted in reverse ptosis (lower eyelid ptosis) and decreased visual acuity from induced corneal steepening. Correction of lower eyelid ptosis by reinsertion of the retractor complex resulted in decreasing corneal steepening, improved visual acuity, and good anatomic position of the lower eyelid. CONCLUSION: Lower eyelid ptosis may induce corneal steepening and decreased vision after LASIK. Surgical correction of ptosis can decrease the extent of steepening and improve visual acuity.

+ The role of midface lift and lateral canthal repositioning in the management of euryblepharon.

Yip CC, McCann JD, Goldberg RA
Report of a new surgical technique to manage children with eurybleparon.

2003

+ Orbicularis oculi muscle graft augmentation after protractor myectomy in blepharospasm.

Yen MT, Anderson RL, Small RG
PURPOSE: To evaluate the effectiveness of free orbicularis oculi muscle grafts in correcting volume deficit deformities after protractor myectomy in patients with essential blepharospasm. METHODS: Prospective case series. During the 13-month period from October 2000 through November 2001, all patients with essential blepharospasm undergoing primary eyelid protractor myectomy received an orbicularis oculi muscle graft to replace the volume deficit deformity created by the myectomy. Only patients who had at least 6 months of postoperative follow-up were included in the analysis. RESULTS: Forty-six patients underwent primary eyelid protractor myectomy and had a free orbicularis oculi muscle graft for volume replacement. All patients had significant functional improvement of their eyelid spasms after the myectomy. Of the 38 patients who underwent upper eyelid myectomy, 3 patients were overcorrected and no patients were undercorrected with the orbicularis muscle graft. Two of the overcorrected patients underwent surgical debulking of their muscle grafts. Of the 8 patients who underwent lower eyelid myectomy, no patients were overcorrected and 1 patient was undercorrected. None of the patients were observed to have any spasms, contractions, or other signs of muscular activity or aberrant innervation of the muscle graft.CONCLUSIONS: The orbicularis oculi muscle graft is a useful adjunct to protractor myectomy in improving the aesthetic outcomes for blepharospasm patients. Our study demonstrates the viability of the orbicularis oculi muscle graft and may lead to future applications of the graft in facial aesthetics.

+ Orbital volume augmentation for late enophthalmos using the deep lateral wall.

Goldberg RA, Saulny S, McCann JD, Yuen VH
Orbital volume augmentation to address enophthalmos and hollowing of the superior sulcus has been described with a variety of materials and from a variety of approaches.(1-4) A common location for volume augmentation is the inferomedial orbital wall; this surface is often the one that was expanded related to orbital trauma, and it is easily accessed through hidden conjunctival or caruncular incisions.

+ Treatment of prominent eyes with orbital rim onlay implants: four-year experience.

Goldberg RA, Soroudi AE, McCann JD
PURPOSE: Different approaches have been proposed to address the aesthetic or reconstructive challenge associated with relatively prominent eyes. Operations that address the soft tissues alone are prone to failure if the underlying orbital bony relationships are not addressed. Orbital rim advancement can serve as a supplement to orbital decompression in this setting or as an alternative for patients who may not maximally benefit from decompression surgery. METHODS: We report our 4-year experience with porous polyethylene orbital rim onlay grafts used to address relative proptosis in 24 patients. RESULTS: All patients had some degree of subjective and objective improvement. Proptosis decreased an average of 4.65 mm, with a range of 3 to 9 mm, based on single-observer Hertel exophthalmometry measurements (5.2 mm in those with concomitant decompression). Lagophthalmos was also improved in all patients with preoperative inadequacy in eyelid closure. Interpalpebral fissure size was reduced 1.3 mm on average, with a range of 0.5 to 6 mm (2 mm in those with concomitant decompression). Average follow-up was 41 months, with a range of 7 to 70 months. In 3 cases, we noted postoperative lower eyelid retraction with eyelid adhesion to the implant; possible risk factors for this complication included reoperative cases and simultaneous eyelid reconstruction with hard palate grafts. CONCLUSIONS: The porous polyethylene orbital rim onlay implant offers a relatively simple and effective surgical technique for the treatment of symptomatic relative proptosis. It can be used alone or in combination with other techniques including midface lift, lower eyelid retractor recession, and orbital decompression. To be effective, the implant should be placed so that it is flush with or overlapping the orbital rim; lateral displacement negates the effect of the implant in improving the eyelid/globe relationship. Postoperative eyelid retraction with tethering to the implant is a potential risk of the onlay implant, and although it may not be possible to avoid this in all cases, surgeries should be designed to minimize postoperative eyelid retraction.

+ Upper eyelid skin grafting: an effective treatment for lagophthalmos following blepharoplasty.

Shorr N, Goldberg RA, McCann JD, Hoenig JA, Li TG
Patients who have undergone upper blepharoplasty occasionally develop anterior lamellar insufficiency, which can result in lagophthalmos, corneal decompensation, and even blindness. Historically, skin grafts in the upper eyelid have been considered a last-resort procedure because of poor cosmetic outcomes. Poor cosmetic outcomes result from the traditional practice of placing the skin graft above the eyelid crease. This article describes a surgical technique for upper eyelid skin grafting in which the graft is placed in a supraciliary position. Presented are results of a retrospective study of 20 patients (31 eyelids) who underwent supraciliary upper eyelid skin grafting. The postoperative results were evaluated by examining the improvement in lagophthalmos, the improvement of keratopathy and comfort of the patient, and the cosmetic appearance of the graft. Upper eyelid skin grafting using this surgical technique is an effective and cosmetically acceptable method to improve corneal integrity and comfort in patients who have corneal exposure from insufficient anterior lamella after upper eyelid or eyebrow surgery.

2002

+ Alternating ptosis associated with intermittent exotropia.

Yen KG, Yen MT, Elliot RL, Anderson RL
A unique case of alternating, poorly controlled, intermittent strabismus that improved after repair of bilateral, alternating congenital ptosis is described. A 7-year-old boy with bilateral, alternating congenital ptosis and poorly controlled, intermittent exotropia underwent bilateral frontalis suspensions. After surgery, the patient demonstrated improved control of his exotropia. We conclude that an alternating ptosis may lead to sensory deprivation of the occluded eye and decreased fusion, causing an intermittent strabismus to be poorly controlled. Repair of the ptosis to a sufficient eyelid height bilaterally may improve control of the strabismus, obviating strabismus surgery.

+ Benign essential blepharospasm.

McCann JD, Ugurbas SH, Goldberg RA.
A review of benign essential blepharospasm.

+ Bovine hydroxyapatite orbital implant: a preliminary report.

Perry JD, Goldberg RA, McCann JD, Shorr N, Engstrom R, Tong J
PURPOSE: To determine the safety and efficacy of bovine hydroxyapatite as an orbital implant material. METHODS: Prospective, consecutive case series of patients undergoing enucleation, evisceration, or secondary orbital implantation. A motility peg was placed in all consenting candidates. Patients were followed 1 week, 1 month, and several months after surgery for signs of inflammation, infection, extrusion, or other complication. RESULTS: Twenty-seven patients received a bovine hydroxyapatite orbital implant. Magnetic resonance imaging was obtained in 3 patients (3 orbits) approximately 4 weeks after surgery and showed signs of peripheral fibrovascular ingrowth in all three cases. Magnetic resonance imaging was obtained in 9 patients (9 orbits) 4 to 12 months after surgery and showed signs of incomplete fibrovascular ingrowth in 1 of 9 (11%) cases, subtotal fibrovascular ingrowth in 2 of 9 (22%) cases, and complete fibrovascular ingrowth in 6 of 9 (67%) of cases. Complications included postoperative chemosis in 3 cases (11%) and exposure requiring reoperation in 2 cases (7%). Motility peg placement was performed successfully in 5 patients (5 orbits). CONCLUSIONS: Bovine hydroxyapatite appears to be a safe and effective orbital implant material. The material appears to be biocompatible and nonallergenic. Bovine hydroxyapatite allows for fibrovascular integration and motility peg placement.

+ Capsular calcification of alloplastic orbital implants.

Yen MT, Anderson RL.
PURPOSE: To report calcification of the capsule surrounding alloplastic orbital implants and postulate this calcification as a possible cause of poor implant motility. DESIGN: Interventional case reports. METHODS: Two patients with alloplastic spherical implants after enucleation presented with poor implant motility. Both patients underwent orbital implant exchange with a quasi-integrated porous polyethylene orbital implant. RESULTS: During removal of the original alloplastic orbital implant, a hard, thick shell adherent to the surrounding orbital tissues was encountered. After complete excision of the shell, microscopic evaluation confirmed a dense, fibrous capsule with calcification. No evidence of inflammation or malignancy was associated with either capsule. Postoperatively, both patients had significant improvement in motility of their new orbital implant. CONCLUSIONS: Although calcification of the fibrous capsule surrounding alloplastic orbital implants is an unusual finding, it may result in poor implant motility. Capsule excision and implant exchange may significantly improve the motility of the orbital implant.

+ Laser madness in facial plastic surgery.

Anderson RL, Yen MT
An editorial on the user of lasers on plastic surgery.

+ No-scar Asian epicanthoplasty: a subcutaneous approach.

Yen MT, Jordan DR, Anderson RL
PURPOSE: The epicanthal fold is a normal finding in the medial portion of the upper eyelid in many Asians. We describe a simple technique of removing the excess muscle and softening or eliminating the epicanthal fold without making incisions in the medial canthal region, thus avoiding complications such as scarring or web formation METHODS: Interventional case series. The subcutaneous epicanthoplasty was performed on all Asian patients undergoing concurrent upper eyelid blepharoplasty or aponeurotic ptosis repair. RESULTS: Thirty-eight Asian patients underwent epicanthal fold correction between January 1996 and December 2000. All patients had softening of the epicanthal fold; however, some cases of mild undercorrection were noted. CONCLUSIONS: Softening or elimination of the Asian epicanthal fold can be accomplished without making skin incisions in the medial canthal region. Our technique is a simple, graded procedure that can be performed in conjunction with upper blepharoplasty or ptosis repair.

+ The quasi-integrated porous polyethylene orbital implant.

Anderson RL, Yen MT, Lucci LM, Caruso RT
PURPOSE: To describe a new quasi-integrated porous polyethylene orbital implant that combines the advantages of host tissue incorporation and improved motility with a single-stage surgery. METHODS: Twenty-four consecutive patients undergoing primary or secondary orbital implantation received the quasi-integrated porous polyethylene implant. Approximately 6 weeks after implantation, a custom-fitted prosthesis was made by an impression technique to provide a "lock-and-key" fit with the orbital implant. Postoperative complications and motility of the prosthetic shell were evaluated. RESULTS: During the 27-month period between December 1998 and March 2001, 24 patients received the quasi-integrated porous polyethylene implant as a buried orbital implant. Thirteen patients received the implant as a primary orbital implant after either evisceration or enucleation and 11 patients received the implant as a secondary orbital implant. Follow-up ranged from 3 months to 30 months, with an average of 16.9 months. All patients were considered to have good motility of their prosthetic shell at their final follow-up visit. No cases of implant extrusion or migration were noted. Two patients required deepening of their inferior fornix to accommodate the increased motility of their prosthesis. CONCLUSIONS: The new quasi-integrated porous polyethylene orbital implant provides improved motility without the need for secondary placement of pegs or screws. It has the advantage of biocompatibility, allowing host tissue incorporation to resist implant migration and extrusion. The implant is available in three sizes: small, medium, and large, approximating the volume of a 16-, 18-, and 20-millimeter sphere, respectively.

+ Use of vinyl polysiloxane impression material to protect and identify the nasolacrimal sac in endonasal dacryocystorhinostomy.

Goldberg RA, Beizai P, Kim J, McCann JD
PURPOSE: To determine the role of vinyl polysiloxane impression material (trade name Reprosil) in endonasal dacryocystorhinostomy. METHODS: Case series of 15 consecutive endonasal dacryocystorhinostomies in which vinyl polysiloxane material was used to mark and protect the nasolacrimal sac. Vinyl polysiloxane is mixed from two tubes, then immediately injected in the sac through a preplaced 21-gauge cannula. It is important to be sure the cannula is in the sac to avoid false injection and extravasation. We have found it best to inject a small amount, usually 0.2 to 0.3 mL. RESULTS: A patent osteum was successfully created in 13 of the 15 cases (87%). Complications included two cases of retained vinyl polysiloxane that necessitated removal through an external excision. CONCLUSIONS: Endonasal dacryocystorhinostomy has several advantages compared with the external approach. There is no external scar and the bruising and swelling are substantially reduced, allowing patients to return to work more quickly. In addition, the adjacent nasal anatomy is directly visualized, allowing for simultaneous treatment of any relevant nasal pathology and precise manipulation of the nasal tissues.

2001

+ A new groove director for simplified nasolacrimal intubation.

Anderson RL, Yen MT, Hwang IP, Lucci LM
Silicone intubation is commonly performed to maintain patency of the lacrimal drainage system. We describe a new lacrimal groove director, designed to simplify retrieval of the metal Crawford probe with minimal trauma to the nasal mucosa. This instrument can also be used to infracture or medialize the inferior turbinate in both pediatric and adult populations during nasolacrimal duct intubation or external or endoscopic dacryocystorhinostomy.

+ Inferior oblique muscle location after enucleation and evisceration.

Goldberg RA, McCann JD, Truong S, Yuen VH
PURPOSE: To report the location of the inferior oblique muscle after enucleation without primary attachment of the muscle to the orbital implant and after evisceration. METHODS: Interventional case series. Retrospectively, eight orbital magnetic resonance imaging (MRI) studies were analyzed, four after enucleation and four after evisceration, to assess the position of the inferior oblique muscle relative to the orbital implant and the point of insertion. RESULTS: In the enucleation patients, the inferior oblique muscle was anteriorly displaced and the muscle appeared to insert into an inferior subconjunctival scar mass in three of the four patients. In all four of the evisceration patients, the inferior oblique muscle appeared normally positioned and inserted onto the implant in the normal location. CONCLUSION: Enucleation without suturing of the inferior oblique muscle to the implant is associated with healing in an abnormal anterior location and into an inferior subconjunctival scar mass. Evisceration does not appear to disrupt the normal position or insertion of the inferior oblique muscle.

+ Management of eyelid anomalies associated with Blepharo-cheilo-dontic syndrome.

Yen MT, Lucci LM, Anderson RL
PURPOSE: To describe the previously unreported management of the eyelid anomalies associated with blepharocheilo-dontic syndrome. Blepharo-cheilo-dontic syndrome is a syndrome of congenital cleft lip/palate, oligodontia, euryblepharon, eyelid ectropion, and lagophthalmos. METHODS: Case report. A 3-month-old male presented with bilateral upper and lower eyelid ectropion with eyelid retraction, marked euryblepharon, severe lagophthalmos, and a right side cleft lip/palate. Lateral tarsal strips, lower eyelid retractor disinsertion, myocutaneous advancement of the cheek and eyelids, and lateral tarsorrhaphy were performed. RESULTS: Correction of the ectropion, eyelid retraction, euryblepharon, and marked improvement in his lagophthalmos were achieved postoperatively. No recurrence of the ectropion or euryblepharon has been noted after 6 months of follow-up. CONCLUSION: Appropriate reconstructive surgery of the eyelids reduces the morbidity associated with the eyelid anomalies and provides an excellent cosmetic result for patients with blepharo-cheilo-dontic syndrome.

+ Nodular cutaneous amyloid tumors of the eyelids in the absence of systemic amyloidosis.

Pelton RW, Desmond BP, Mamalis N, Pratt DV, Patel BC, Anderson RL
A patient was referred with recurrent bilateral, slow-growing, painless, nodular tumors of the upper eyelid margins. The tumors were excised and the base of each lesion was ablated with the CO2 laser. Histological examination of the excised tissue revealed amyloid. Despite the fact that cutaneous, amyloid lesions of the eyelid have been previously described as essentially pathognomonic for systemic amyloid disease, no evidence of systemic amyloidosis was found in this patient. We believe that this represents only the second reported case of bilateral cutaneous amyloid of the eyelids without systemic involvement. We agree with previous authors that this lesion be added to the list of painless slow-growing bilateral eyelid tumors.

+ Orbicularis myectomy with levator advancement in Schwartz-Jampel syndrome.

Lucci LM, Yen MT, Anderson RL, Hwang IP, Black RE
PURPOSE: Schwartz-Jampel syndrome is a disorder of continuous myotonia causing blepharospasm, acquired ptosis, and blepharophimosis. We report the management of the associated eyelid anomalies with orbicularis oculi myectomy, levator aponeurosis resection, and lateral canthopexy. METHODS: Interventional case reports. Two patients with Schwartz-Jampel syndrome presented with blepharospasm, acquired ptosis, and blepharophimosis. Orbicularis myectomy, levator aponeurosis resection, and lateral canthopexy were performed to relieve the blepharospasm and to correct the ptosis and blepharophimosis. RESULTS: Significant functional and cosmetic improvements were achieved by increasing the palpebral fissure height and length while greatly decreasing the blepharospasm of the patients. No recurrence of the blepharospasm or eyelid anomalies has been noted after 1 and 15 years of follow-up, respectively. CONCLUSION: The blepharospasm and eyelid alterations caused by Schwartz-Jampel syndrome should be treated to provide functional and cosmetic improvements. Our technique of myectomy, levator resection, and lateral canthopexy provides an excellent, long-lasting result.

+ Solitary fibrous tumor of the orbit in a child.

Lucci LM, Anderson RL, Harrie RP, Mamalis N, Coffin C, Crandall DC.
PURPOSE: Solitary fibrous tumor is a rare spindle-cell tumor that usually is seen in the pleura. The orbit is one of the most common extrapleural sites. It is frequently misdiagnosed as hemangiopericytoma and is seen in older patients. We present the youngest case of this tumor, which was apparent in family photographs by age 10 and removed at age 15. The first reported echography findings are presented. METHODS: Case report and literature review. RESULTS: Solitary fibrous tumor was diagnosed by microscopy and immunohistochemical study that showed cells reactive with vimentin and CD34. CONCLUSIONS: Solitary fibrous tumor of the orbit has been diagnosed with increasing frequency in recent years as the result of improved methods of pathologic examination. It is important to be aware of this tumor and recognize that it must be included in the differential diagnosis of highly vascular spindle-cell tumors even in young children.

+ Systemic corticosteroid use in orbital lymphangioma.

Sires BS, Goins CR, Anderson RL, Holds JB.
PURPOSE: To describe the clinical results of systemic corticosteroid use in a series of patients with orbital lymphangioma. METHODS: Four patients (two adults and two children) were treated with corticosteroids using intravenous, oral, or both routes for 2 days to a month. Corticosteroids were used with and without other therapies for symptomatic exacerbations. RESULTS: The adults showed more improvement with pain than with swelling, whereas the children had improvement with both the signs and symptoms. There were no complications in any patient. CONCLUSIONS: Systemic corticosteroids are a useful therapeutic option for patients with orbital lymphangioma and can be used as an adjuvant treatment to surgery and other modalities. Resolution of symptoms with corticosteroids was expedited compared with the natural history of the disease in the patients studied.

2000

+ Burn scar malignancies of the eyelids.

Pratt DV, Pelton RW, Patel BC, Anderson RL
PURPOSE: To study the clinicopathologic characteristics and treatment of eyelid carcinomas developing in thermal burn scars. METHODS: A review of eight cases of eyelid burn scar malignancies: two from our own experience and six from published reports. RESULTS: Reported cases of burn scar malignancy of the eyelid are short-latency basal cell carcinomas. All carcinomas arose from small superficial burns. These potentially aggressive tumors respond well to local excision. CONCLUSION: As with other areas of the body, eyelid burn scars may undergo neoplastic degeneration. These carcinomas are predominately short latency basal cell carcinomas, rather than long-latency squamous cell carcinomas that are more common elsewhere in the body, including the head and neck region. Clinicians should be diligent in the long-term surveillance of all eyelid burns.

+ Early results of the frontalis muscle flap technique for the treatment of congenital ptosis.

Tong JT, Goldberg RA, Perry JD, McCann JD
Report of a technique for correcting congenital ptosis.

+ Orbital decompression.

Jordan DR, Anderson RL
A report on orbital decompression surgery for patients with thyroid eye disease.

1999

+ A novel mechanism for benign essential blepharospasm.

McCann JD, Gauthier M, Morschbacher R, Goldberg RA, Anderson RL, Fine PG, Digre KB
PURPOSE: The purpose of this study is to test the hypothesis that the photophobia of benign essential blepharospasm (BEB) is caused by sympathetically maintained pain. METHODS: Nineteen patients with photophobia and BEB were enrolled in an unblinded prospective treatment trial. The intervention was blockade of the superior sympathetic ganglion with local anesthetic. Outcome measures included the patient's subjective report of ocular surface dryness, foreign body sensation, and eyelid spasm. We also obtained video recordings of eyelid movements. RESULTS: Of the 19 patients, 13 reported subjective improvement in BEB symptoms after cervical sympathetic blockade (CSB). Thirteen of 19 patients also had objective evidence of decreased light-induced eyelid spasm after CSB. Ocular surface disease was present in 18 of 19 patients. CONCLUSION: These data support the hypothesis that in many patients with BEB there is a sympathetically maintained pain syndrome associated with external ocular disease. We speculate on a neurologic circuit that may explain these findings.

+ Management of severe cicatricial entropion using shared mucosal grafts.

Goldberg RA, Joshi AR, McCann JD, Shorr N
OBJECTIVE: To retrospectively analyze our experience using nasal turbinate and hard palate mucosal grafts as shared buttress grafts between the upper and lower eyelid for reconstruction in severe cicatricial entropion. SURGICAL TECHNIQUES: A horizontal tarsectomy is performed in the upper and lower eyelid approximately 2 mm posterior to the gray line. The distal tarsal segments are then dissected and rotated 180 degrees. A graft of nasal turbinate mucosa or hard palate mucosa measuring 1.5 x 3 cm is harvested. The graft is sutured to the cut edge of tarsus in the upper and lower eyelid. The rotated distal tarsal segment is stabilized against the graft using 5 mattress sutures. After 3 weeks, the graft is split by sharp dissection between the upper and lower eyelids. METHODS: The medical records of 12 consecutive patients, representing 15 shared buttress grafts, were reviewed. There were 5 hard palate and 10 nasal turbinate mucosal grafts placed. Follow-up ranged from 2 months to 7 years. RESULTS: The amount of corneal stipple, as well as subjective patient comfort, improved after eyelid margin reconstruction in 12 of the 15 eyes. One patient's visual acuity improved by more than 2 lines after surgery. There were no cases of failure of graft survival and no complications directly related to the shared graft technique. Recurrent entropion and trichiasis were noted in 3 eyelids more than a year after graft placement, reflecting ongoing cicatrization in these eyelids. Hard palate mucosal grafts were irritating to the corneal surface, requiring removal of the epithelium using a diamond burr and bandage contact lens wear. Nasal turbinate mucosal grafts were better tolerated by the corneal surface and had the added benefit of mucous production. CONCLUSIONS: Eyelid reconstruction using nasal turbinate and hard palate mucosal tissues as a shared buttress graft is a viable treatment option for patients with severe cicatricial entropion. Resolution of trichiasis and mechanical corneal abrasion was noted in 13 (86%) of 15 patients with no specific complications related to the technique. The shared buttress technique successfully autostents the healing eyelid margins, makes good use of the large turbinate mucosal graft, and minimizes trips to the operating room. When the mechanical requirements of eyelid margin reconstruction do not require the sturdiness of hard palate mucosa, nasal turbinate mucosa is a preferable graft tissue because it is better tolerated by the corneal surface and produces mucous.

+ Nodular fasciitis of the lower eyelid in a pediatric patient.

Hymas DC, Mamalis N, Pratt DV, Scott MH, Anderson RL, Langer PD
PURPOSE: To describe a 14-year-old boy with a 1-month history of a rapidly growing, nontender, lower eyelid mass. METHODS: The specimen was studied using light microscopy. RESULTS: Although magnetic resonance imaging suggested a chronic vascular lesion, histopathologic analysis after excisional biopsy was consistent with nodular fasciitis. CONCLUSIONS: Nodular fasciitis is a relatively common soft-tissue lesion and represents a benign, reactive process. Lesions in the head and neck develop more frequently in children and adolescents than in adults, but periorbital lesions are uncommon. This is the first reported case of nodular fasciitis of the lower eyelid in a pediatric patient.

+ The tarsal tuck procedure: avoiding eyelid retraction after lower blepharoplasty.

Anderson RL, Jordan DR
A new technique to avoid complications with cosmetic lower eyelid blepharoplasty surgery.

1998

+ Blepharospasm: past, present, and future.

Anderson RL, Patel BC, Holds JB, Jordan DR
To investigate causes, associations, and results of treatment with blepharospasm, 1,653 patients were evaluated by extensive questionnaires to study blepharospasm and long-term results of treatment with the full myectomy operation, botulinum-A toxin, drug therapy, and help from the Benign Essential Blepharospasm Research Foundation (BEBRF). The percent of patients improved by the BEBRF was 90%, full myectomy 88%, botulinum-A toxin 86%, and drug therapy 43%. The patient acceptance rate for the BEBRF was 96%, full myectomy 82%, botulinum-A toxin 95%, and drug therapy 57%. Blepharospasm is multifactorial in origin and manifestation. A vicious cycle and defective circuit theory to explain in origin and direct treatment rather than a defective specific locus is presented. All four forms of therapy evaluated are useful and must be tailored to the patient's needs. Mattie Lou Koster and the BEBRF have helped blepharospasm sufferers more than any other modality, and all patients should be informed of this support group. The full myectomy is reserved for botulinum-A toxin failures, and the limited myectomy is an excellent adjunct to botulinum-A toxin.

+ Cutaneous malignant melanoma and oculodermal melanocytosis (nevus of Ota): report of a case and review of the literature.

Patel BC, Egan CA, Lucius RW, Gerwels JW, Mamalis N, Anderson RL
A 29-year-old white man, with oculodermal melanocytosis, had a rapidly enlarging, erythematous, painful nodule over his left brow, within the nevus. The lesion was excised and diagnosed as a malignant melanoma. Systemic evaluation showed no evidence of distant disease. This is the tenth case reported of a cutaneous melanoma developing in a nevus of Ota. Melanoma arising in the choroid, brain, orbit, iris, ciliary body, or optic nerve in association with a nevus of Ota is well documented. Careful observation is necessary in patients with a nevus of Ota, particularly in white patients, in whom malignant degeneration seems to occur with a disproportionate frequency.

+ Laser mania in medicine.

Anderson RL, Pratt DV, Patel BC
A short report.

+ Ruptured globe during orbital decompression surgery.

Mawn LA, Jordan DR, Anderson RL
A 74-year-old patient sought treatment for visual obscuration and clinically had signs of Graves orbitopathy. Past medical history was unremarkable except for the use of antihypertensive medication. During the hospital admission, a fluorescent treponemal antibody absorption test was reactive, indicating infection with syphilis at some time in the past. Visual deterioration despite oral corticosteroid therapy prompted orbital decompression. At the time of surgery, she sustained a globe rupture. Presumably, syphilitic scleritis was responsible, in part, for scleral thinning and weakening, predisposing her to this complication. To the authors' knowledge, globe rupture has not been previously reported during orbital decompression.

+ Sarcoidosis with orbital tumor outside the lacrimal gland: initial manifestation in 2 elderly white women.

Peterson EA, Hymas DC, Pratt DV, Mortenson SW, Anderson RL, Mamalis N
Two elderly white women (aged 72 and 87 years) were first seen with painless, unilateral orbital swelling. Orbital scanning revealed masses infiltrating the soft tissue around the eye. Biopsy results showed nodular, noncaseating granulomas consistent with sarcoidosis. One patient's workup revealed systemic manifestations of sarcoidosis at the time of examination with hilar lymphadenopathy noted on gallium scan; the other refused a complete systemic workup. The orbital tumors resolved with systemic prednisone therapy. To our knowledge, our 87-year-old patient is the oldest to be seen with orbital sarcoidosis. These 2 patients demonstrate that this diagnosis must be considered with orbital tumors in the elderly and in unusual locations, such as these which occurred outside the lacrimal gland.

1997

+ "Pneumofornix" (air under the eyelid): a normal finding.

Patel BC, Elahi E, Anderson RL, Harnsberger HR.
Normal pockets of air under the eyelids have not been previously described in the literature. To assess the incidence and patterns of normal air bubbles in the region of the eyelid, computed tomography (CT) scans of 126 normal orbits and 36 orbits of patients with thyroid orbitopathy were assessed. Twenty-eight (22%) of the normal orbits and 14 (39%) of the thyroid orbits had a well-defined medial or lateral air bubble (or both) on axial views (.1 > P > .05). Oval central or paracentral air bubbles in sections through the superior or inferior fornix were seen in 19 (15%) of the normal orbits and 10 (28%) of the thyroid orbits (.1 > P > .05). It is important to be aware of the incidence and patterns of these normal air bubbles to ensure their accurate differentiation from pathologic air bubbles.

+ An orbital abscess secondary to acute dacryocystitis.

Ntountas I, Morschbacher R, Pratt D, Patel BC, Anderson RL, McCann JD.
An orbital abscess is an ophthalmic surgical emergency that is typically caused by the spread of bacteria from adjacent structures, such as the sinuses, eyelids, or teeth. Although acute dacryocystitis is commonly associated with preseptal cellulitis, it rarely causes orbital infection. Infection of the lacrimal sac will typically localize in the preseptal space because the lacrimal sac lies anterior to the orbital septum. To the authors' knowledge, this is the first report of an intraconal abscess secondary to acute dacryocystitis. The key points in the surgical management of this entity are discussed.

+ Atypical lymphoid hyperplasia of the eyelids manifesting as xanthelasma-like lesions.

Egan CA, Patel BC, Morschbacher R, Gerwels JW, Anderson RL.
We describe a patient who had bilateral, yellow papules of the upper eyelids. This proved to be the clinical manifestation of an atypical lymphoid hyperplasia of the orbits. We describe this clinical presentation as a new sign of this condition. This finding serves to broaden the differential diagnosis of yellow papules on the eyelids. Atypical lymphoid hyperplasia of the orbits poses a challenging problem. Their benign or malignant nature cannot usually be determined by clinical and radiologic criteria. Most of these infiltrates result in extraocular lymphoma. We describe a patient with bilateral, yellow papules of the upper eyelids that proved to be a manifestation of an atypical lymphoid hyperplasia of the orbits.

+ Eyelid reconstruction with irradiated human tarsal plate and aorta.

Jordan DR, Anderson RL.
Reconstruction of posterior lamellar eyelid defects requires a tissue substitute that is either identical to the tissue lost (ex. surrounding or nearby tarsus) or donor tissue from another site that serves the same supportive role. Irradiated homologous tarsal plate and irradiated homologous aorta are potential posterior lamellar substitutes. Each provides a structural framework for the surrounding lid tissues to grow upon and are incorporated into the normal eyelid anatomy. Both the tarsal plate and aorta can be harvested, irradiated and stored in a refrigerator, ready to be utilized in those selected cases with severe tissue loss. They may also be utilized as a donor material in more routine lid reconstruction as an alternative. We discuss our experience with these materials.

+ Management of postblepharoplasty lower eyelid retraction with hard palate grafts and lateral tarsal strip.

Patel BC, Patipa M, Anderson RL, McLeish W.
Lower eyelid malposition is the most common long-term complication following transcutaneous lower eyelid blepharoplasty. The malposition may include rounding of the lateral canthal angle, lower eyelid retraction with inferior scleral show, or frank ectropion. The result is cosmetically unacceptable and may be associated with tearing, irritation, and other exposure keratitis symptoms. Multiple factors, including lower eyelid laxity, shortage of skin, and scarring of the middle lamella, may be responsible for this malposition. A systematic examination of the lower eyelid, as presented, helps to assess the degree to which each of these factors is responsible for the malposition. Patients with the most severe degree of lower eyelid malposition generally have middle lamella scarring. If this abnormality is not addressed, lower eyelid procedures aimed at correcting the malposition are doomed to failure. In the presence of significant middle lamella scarring, a spacer is required to provide vertical height and stiffness to support the lower eyelid following release of the cicatrix. A systematic approach aimed at addressing the underlying abnormalities was developed. In patients with significant middle lamella scarring, hard palate mucosa grafts were used as spacers in 29 eyelids (17 patients). A lateral canthotomy and transconjunctival incision allow access to the scarring in the lower eyelid retractors and septum. After careful release of all cicatrix, a hard palate mucosa graft is inserted between the lower border of the tarsal plate and the recessed conjunctiva, lower eyelid retractors, and septum. Horizontal lower eyelid laxity, when present, is corrected by performing a lateral tarsal strip. Most patients do not have a true deficiency of the anterior lamella (skin and orbicularis oculi muscle). When a moderate amount of anterior lamella deficiency is present with significant scarring of the middle lamella, the technique we describe allows correction of the lower eyelid malposition without a skin graft. After a follow-up interval of 6 to 30 months (mean 14 months), excellent results were obtained in all eyelids. Complications included corneal abrasions in two eyes before routine use of bandage cornea contact lenses at the end of surgery and a secondary bleed from the roof of the mouth in one patient. Palate mucosa closely resembles tarsus and provides excellent vertical support to the eyelid. It is stiff enough to maintain eyelid contour without causing a cosmetically unacceptable bump. Tissue can be obtained with ease. The technique, as described, addresses the underlying causes of lower eyelid malposition and gives excellent functional and cosmetic results.

+ The universal implant for evisceration surgery.

Jordan DR, Anderson RL.
The Universal implant is a quasi-integrated buried orbital implant designed to provide the same motility advantages as does an Iowa implant, but is simpler to implant and associated with fewer complications. The protruding mounds on the implant are keyed to corresponding indentations on the posterior prosthetic surface, allowing more life-like motility. We describe a straight-forward technique for its use as an evisceration implant and report the results in 24 patients. The Universal implant is simple to use and the lock-and-key mechanism obtained between implant and prosthesis provides the patient with a high degree of life-like motility. Its cost is significantly lower than the more popular hydroxyapatite implant and it does not require a drilling procedure for coupling.

+ Transcanalicular neodymium: YAG laser for revision of dacryocystorhinostomy.

Patel BC, Phillips B, McLeish WM, Flaharty P, Anderson RL.
BACKGROUND: Laser-assisted dacryocystorhinostomy (DCR) has failed to match the success rates of external DCR. It has been suggested that this technology may be best suited for revision of failed DCR cases. The authors prospectively evaluated the efficacy of transcanalicular laser-assisted revision DCR (TCLARDCR). METHODS: A neodymium:YAG (Nd:YAG) laser was used for transcanalicular revision of 24 failed DCRs. Failure had followed one (n = 15), two (n = 7), or three (n = 2) previous external DCRs. RESULTS: Mean duration of the surgery was 78.2 minutes. Success was achieved in 11 cases (46%; mean follow-up, 20 months). There was no correlation between early loss of stents and failure. Three cases had partial relief of symptoms. Three of the failures unsuccessfully underwent further TCLARDCR. CONCLUSIONS: The authors' success rate of 46% with TCLARDCR compares poorly with the 85% success for external revision DCR. With TCLARDCR, specific anomalies like the sump syndrome cannot be addressed adequately. There is a theoretical risk of canalicular injury. Laser lacrimal surgery also is equipment dependent and more costly than external DCR. The TCLARDCR cannot be recommended for revision DCR using the Nd:YAG laser (Lasersonics, Milpitas, CA).

+ Transcanalicular removal of silastic nasolacrimal tubes.

Patel BC, Anderson RL.
Publication

1996

+ Benign orbital fibrous histiocytoma simulating a lacrimal gland tumor.

al-Hazzaa SA, Specht CS, McLean IW, Holds JB, Anderson RL.
The case of a patient with a lacrimal fossa mass that was believed to be a primary lacrimal gland tumor is reported. However, at lateral orbitotomy the tumor was found within the lacrimal fossa, but distinct from the lacrimal gland. Histopathology revealed a benign fibrous histiocytoma. The tumor was totally excised, has not recurred over a 3-year follow-up period. This mesenchymal tumor should be included in the differential diagnosis of lacrimal fossa mass in adults.

+ History of oculoplastic surgery (1896-1996).

Patel BC, Anderson RL.
Publication

+ Transconjunctival blepharoplasty.

Patel BC, Anderson RL.
Publication

+ Use of hard palate grafts for treatment of postsurgical lower eyelid retraction: a technical overview.

Patipa M, Patel BC, McLeish W, Anderson RL.
Lower eyelid retraction occasionally occurs following the repair of fractures involving the orbital rims, orbital floor, or complex zygomatic maxillary complex fractures. The surgical repair of these scarred eyelids has been historically difficult. The authors have utilized the principle of releasing the scar tissue and attempting to reposition the eyelid in its normal anatomic position by employing a hard palate mucosal graft spacer to correct the eyelid malposition. In this article, the authors discuss the excellent success they have experienced utilizing hard palate autologous grafts as spacers performing revision of scarred contracted lower eyelid retractors and tightening of the lateral canthal tendon complex. Adherence to the principles delineated in the article can yield excellent functional and cosmetic results.

1995

+ A sensitive and specific polymerase chain reaction-based assay for the diagnosis of cytomegalovirus retinitis.

McCann JD, Margolis TP, Wong MG, Kuppermann BD, Luckie AP, Schwartz DM, Irvine AR, Ai E.
PURPOSE: To develop a sensitive and specific laboratory assay for the diagnosis of cytomegalovirus retinitis. METHOD: We used a polymerase chain reaction-based assay for detection of cytomegalovirus DNA in vitreous samples. We attempted to detect cytomegalovirus DNA in 19 vitreous samples from patients with the acquired immunodeficiency syndrome (AIDS) who had untreated cytomegalovirus retinitis and in 40 vitreous samples from patients with AIDS who had been treated with systemic ganciclovir or foscarnet, or both. We also attempted to detect cytomegalovirus DNA in vitreous samples from 54 immunocompetent patients, including 32 with retinal detachment or macular hole, 11 with vitreous inflammation, and 11 with vitreous hemorrhage. Additionally, we attempted to detect cytomegalovirus DNA in 15 vitreous samples from patients with AIDS who had vitreoretinal inflammation not caused by cytomegalovirus. RESULTS: Cytomegalovirus DNA was detected in 18 of 19 eyes with untreated cytomegalovirus retinitis. We detected cytomegalovirus DNA in 19 of 40 vitreous samples from patients with previously treated cytomegalovirus retinitis. Cytomegalovirus DNA was not detected in any of 69 patients who did not have a clinical diagnosis of cytomegalovirus retinitis. Thus, the assay had an estimated sensitivity of 95% in detecting untreated cytomegalovirus retinitis and a sensitivity of 48% in detecting cytomegalovirus retinitis that had been treated with systemic ganciclovir or foscarnet, or both. The assay did not give false-positive results in patients with vitreous hemorrhage or vitreous inflammation. Most important, the assay did not give false-positive results in AIDS patients with vitreous inflammation from causes other than cytomegalovirus retinitis. CONCLUSION: We have developed a sensitive and specific diagnostic assay that will assist in the diagnosis of cytomegalovirus retinitis.

+ Blepharospasm and related facial movement disorders.

Patel BC, Anderson RL.
The variable clinical features and the relatively good response of blepharospasm to botulinum-toxin type A are now well established. The etiology and pathophysiology of blepharospasm and related facial movement disorders are still poorly understood. Genetic and histopathologic studies over the last year have contributed to our understanding of this disease. The most significant progress has been made in the electromyographic studies of the the levator palpebrae and orbicularis oculi muscles. Subclassification based on the electromyographic abnormalities of these two muscles have begun to improve our understanding of the variable responses to botulinum-toxin type A. Further electromyographic studies may help identify the best sites of injection for optimal response and differentiate patients requiring limited or complete myectomy. The development of the limited myectomy has provided excellent functional and cosmetic results with quick recovery times in selected patients.

+ Microcystic adnexal carcinoma of the eyebrow and eyelid.

Hunts JH, Patel BC, Langer PD, Anderson RL, Gerwels JW.
Publication

+ Modification of Mustarde technique for correction of epicanthus in Asian patients.

Patel BC, Langer P, Anderson RL.
Publication

1994

+ Embryonal rhabdomyosarcoma of the orbit in a 35-year-old man.

Mamalis N, Grey AM, Good JS, McLeish WM, Anderson RL.
A 35-year-old man had rapidly progressive proptosis of the right eye with associated chemosis over a period of several weeks. Computed tomography demonstrated a solid extraconal mass in the inferior anterior right orbit. Pathologic examination revealed the lesion to be an embryonal rhabdomyosarcoma. Consistent with the diagnosis, immunohistochemical assays demonstrated positive staining with myoglobin, desmin, and muscle-specific actin. The lesion grew rapidly and was further surgically excised. Subsequently, treatment with radiation and chemotherapy was initiated. Primary embryonal rhabdomyosarcoma of the orbit is an extremely rare tumor in adults, and, to our knowledge, this patient represents the oldest individual reported to have developed such a tumor, as documented by immunohistochemical analysis.

+ Irradiated homologous aorta in eyelid reconstruction. Part 1: Technique and animal research.

Jordan DR, McDonald H, Addison DJ, Anderson RL.
Reconstruction of full thickness eyelid defects requires the correction of posterior lamella (tarsus, conjunctiva) and anterior lamella (skin, muscle). Various tarsal substitutes--conchal and nasal cartilage, banked sclera, hard palate, irradiated homologous tarsal plates, periosteum, temporalis fascia, and composite grafts from the opposite eyelid--have been used for posterior lamellar replacement over the years. Eyelid-sharing procedures and full thickness flaps have also been described. At times, because of extensive tissue loss, the eyelid reconstruction can be particularly challenging because of the shortage of tissue. We describe a new posterior lamellar technique using irradiated homologous aorta. The experimental surgical procedure in rabbits, the clinical response, and the histological fate of the donor aorta are described in Part 1 followed by our experience with four patients in Part 2.

+ Irradiated homologous aorta in eyelid reconstruction. Part II. Human data.

Jordan DR, McDonald H, Anderson RL.
Reconstruction of posterior lamellar eyelid defects requires a tissue substitute that is either identical to the tissue lost (i.e., surrounding or nearby tarsus) or donor tissue that serves the same supportive role. With extensive lid defects, at times an alternative tissue to tarsus may be required. Irradiated homologous aorta is available as a posterior lamellar substitute. It provides a structural framework for the surrounding lid tissues to grow on and is incorporated into the normal eyelid anatomy. It is available to the reconstructive ophthalmic surgeons as an alternative donor tissue in the presence of extensive lid defects.

+ Orbital emphysema. Staging and acute management.

Hunts JH, Patrinely JR, Holds JB, Anderson RL.
BACKGROUND: Orbital emphysema is usually a benign, transient phenomenon. Rarely, the intraorbital air mass can cause central retinal artery occlusion. Because of the potential for severe visual loss, the rapid diagnosis and management of this condition are essential. Currently, there is no standard protocol for the treatment and management of severe orbital emphysema. To develop a management algorithm, the authors reviewed the records of eight patients with orbital emphysema, in addition to nine other reported patients with ocular dysfunction. METHODS: Retrospective review of patients with orbital emphysema who have proptosis, diplopia, or loss of vision. RESULTS: Orbital emphysema is associated with small orbital fractures. The location of the intraorbital air mass usually correlates with the fracture location. A four-stage classification system of orbital emphysema is developed. This staging system is helpful in constructing an acute diagnostic and management algorithm for orbital emphysema. CONCLUSION: Understanding the pathophysiology of orbital emphysema is important in developing a rational approach to manage this potentially sight-threatening condition. Treatment using a needle-coupled open syringe filled with saline allows direct monitoring of the air mass during decompression.

+ Primary adenoid cystic carcinoma of the lacrimal sac: report of a case.

Parnell JR, Mamalis N, Davis RK, Flaharty PM, Anderson RL.
A 41-year-old white woman presented with a 1-month history of epiphora and a painless medial canthal mass on the left that was unresponsive to antibiotic treatment. Computerized tomography (CT) and magnetic resonance imaging (MRI) scans delineated a soft tissue mass with bony destruction originating in the area of the left lacrimal sac with extension into the maxillary and ethmoid sinuses and inferomedial orbit. Open biopsy of the mass revealed adenoid cystic carcinoma (ACC). On surgical exploration, the tumor was found to originate from the lacrimal sac wall. Radical surgery with wide excision of surrounding bone and periorbital tissue was performed in light of the histological diagnosis and tumor extension. Orbital exenteration was not performed in order to preserve the patient's left eye. A 6-week course of adjunctive radiotherapy was applied without complication. The patient was clinically and radiologically free of tumor at 1-year follow-up. This case represents only the third time that primary ACC arising from the lacrimal sac has been reported.

+ Silent sinus syndrome.

Langer PD, Patel BC, Anderson RL.
Comment on prior paper.

+ Traumatic neuropathies of the optic nerve, optic chiasm, and ocular motor nerves.

McCann JD, Seiff S.
This review focuses on traumatic chiasmal syndrome and traumatic neuropathies of cranial nerves II, III, IV, and VI. The review highlights common anatomical sites of injury to the above structures. Special emphasis is placed on review of recent literature. Other review of related material include.

1993

+ Aneurysmal bone cyst of the orbit and ethmoid sinus.

Patel BC, Sabir DI, Flaharty PM, Anderson RL.
A brief report.

+ Auditory brain-stem responses in blepharospasm.

Creel DJ, Holds JB, Anderson RL.
The auditory brain-stem response (ABR) has been reported to detect abnormalities in both the auditory pathways and in adjacent structures. Ten of 35 consecutive patients with blepharospasm were found to have abnormal ABRs involving poor form and delayed peak latency of positive components III or V. Abnormal ABRs in approximately 30% of patients with essential blepharospasm suggest pathology in the brain-stem of a substantial proportion of patients with this form of cranial-cervical dystonia.

+ Hydraulic orbital injection injuries.

Holds JB, Patrinely JR, Zimmerman PL, Anderson RL.
BACKGROUND: A high-pressure stream from mechanical equipment may inject gas or liquids deep into the orbit with few initial clinical signs. Aggressive surgical debridement as used in the extremities for the treatment of injection injuries is not possible in the orbit. METHODS: Four patients with orbital injection injuries from farm or industrial equipment are presented. Previously reported cases of high-pressure injection injury are reviewed. RESULTS: Two patients suffered localized anterior orbital inflammation partially responsive to steroidal and nonsteroidal anti-inflammatory agents. Late debridement was required in one patient for a persistent lipogranuloma. Two patients suffered more dramatic and diffuse injections of hydrocarbon mixtures, requiring emergent early surgical debridement and decompression for compressive orbital signs. All patients attained an adequate functional outcome, with one patient's vision limited by a coexisting ocular injury. CONCLUSIONS: High-pressure orbital injection injuries manifest a spectrum of signs ranging from acute inflammation with tissue necrosis and compressive visual loss to late chronic inflammation with a pseudotumor-like course. The authors recommend the initial treatment of orbital injection injuries with systemic antibiotics followed by prompt neuroradiologic imaging. Systemic corticosteroids should be added for confirmed injection injuries with surgical debridement of discrete masses and orbital decompression when indicated. Continued therapy with anti-inflammatory medication may be required to suppress chronic inflammation with selective late surgical debridement of lipogranulomas.

+ Invasive squamous cell carcinoma arising from asymptomatic choristomatous cysts of the orbit. Two cases and a review of the literature.

Holds JB, Anderson RL, Mamalis N, Kincaid MC, Font RL.
BACKGROUND: Epithelial choristomatous cysts are common orbital lesions, the most frequent of which are dermoid or epidermoid tumors. Massive enlargement or extraorbital extension of these benign lesions may occur. Malignant transformation of the epithelial lining of epidermoid cysts is rarely reported. METHODS: Two patients are presented in whom the epithelial lining of a previously asymptomatic choristomatous cyst of the orbit underwent malignant transformation to produce invasive squamous cell carcinoma. The unusual origin and clinical presentation of the lesions caused a delay in the diagnosis and therapy in both patients. Metastatic workup was negative in both patients, who underwent resection of their tumors via orbital exenteration with craniofacial resection. Reported cases of malignant transformation in analogous choristomatous cysts elsewhere in the cranium are reviewed. RESULTS: One patient is alive and well without recurrent disease 40 months postoperatively. The second patient died of a pulmonary embolus 2 months postoperatively. Autopsy showed no residual tumor. Overall, only 3 of 18 reported patients with epidermoid choristoma of the head and orbit with malignant transformation were alive when reported. CONCLUSIONS: Malignant squamous metaplasia is believed to be a rare complication of orbital dermoid or epidermoid cysts, with only two previously reported cases. However, malignant transformation is relatively frequent in analogous epidermoid cysts found elsewhere in the cranial vault, especially after incomplete excision. These reports encourage the complete removal of epithelial choristomas of the orbit.

+ Medial canthotomy and cantholysis in eyelid reconstruction.

Holds JB, Anderson RL.
Combined medial canthotomy and cantholysis is a quick, technically simple, single-stage reconstructive technique for use in the reconstruction of the upper or lower eyelid. This technique, which transects one lacrimal canaliculus, provides up to 20% of the horizontal eyelid dimension for closure. Medial canthotomy and cantholysis is most frequently used in combination with other eyelid reconstructive techniques for difficult reconstructions, which would otherwise require more extensive surgical procedures. The surgical technique is readily performed with the patient under general anesthesia and entails the transection of one lacrimal canaliculus, lysis of one crus of the medial canthal tendon, and lateral advancement of the medial eyelid stump. We used medial canthotomy and cantholysis in the reconstruction of 29 eyelid defects (21 upper eyelids and eight lower eyelids) over a 12-year period with adequate reconstructive results in all cases. Eleven of the patients underwent simultaneous lateral canthotomy and cantholysis. Complications of the medial canthotomy and cantholysis technique include anterior displacement of the medial portion of the eyelid, epiphora, notching of the medial portion of the eyelid, medial ectropion, and blepharoptosis. If used with appropriate case selection, this technique allows an optimal reconstructive result to be achieved with a minimum of operative time and morbidity.

+ Morbidity after gold weight insertion.

Patel BC, Flaharty P, Anderson RL.
Comment on a prior paper on eyelid reconstruction for facial nerve palsy.

+ Orbital meningoencephalocele manifesting as a conjunctival mass.

Terry A, Patrinely JR, Anderson RL, Smithwick W.
Orbital meningoencephalocele is a rare congenital abnormality caused by a defect of the cranio-orbital bones that usually manifests soon after birth as a soft, cystic fullness in the superomedial canthal area with associated exophthalmos. We managed an unusual case of congenital orbital meningoencephalocele that manifested as a cystic conjunctival mass without proptosis or periorbital changes. Preoperative computed tomographic scans failed to demonstrate a bone defect. After suture ligature of the posterior stalk, excision of the lesion yielded an ependymal cyst surrounded by neuroglial and meningeal tissue and filled with cerebrospinal fluid. The patient had normal results of ophthalmic and neurologic examinations after transconjunctival resection of the lesion after three years of follow-up. An orbital approach may be appropriate for a few selected cases in which no bone defect is found on computed tomography. Orbital meningoencephalocele should be included in the differential diagnosis of isolated congenital conjunctival cystic masses.

+ Primary T-cell immunoblastic lymphoma of the orbit in a pediatric patient.

Leidenix MJ, Mamalis N, Olson RJ, McLeish WM, Anderson RL.
BACKGROUND: The authors report a case of an 8-year-old pediatric patient with a 2-week history of painless periorbital swelling unresponsive to antibiotic treatment. METHODS: Computed tomography (CT) showed a large, lateral, anterior left orbital soft tissue mass with bony erosion into the anterior cranial fossa through the roof of the orbit laterally. Surgical exploration showed a hard white mass that had eroded through the roof of the left orbit and into the anterior cranial fossa, with herniation of the brain and associated dura through the defect. Results of a complete evaluation of the child for systemic lymphoma, including a lumbar puncture, chest x-ray, bone scan, bone marrow aspirate, and chest/abdomen CT, were negative. RESULTS: Results of histopathologic and immuno-histochemical evaluation showed a primary orbital T-cell immunoblastic lymphoma. The patient was treated with intrathecal ara-C (Cytosar-U) and methotrexate, 16.2 Gy of whole brain irradiation, and a chemotherapeutic protocol consisting of cyclophosphamide (Cytoxin), vincristine (Oncovin), methotrexate, daunomycin, and prednisone. The patient remains free of lymphoma 33 months after diagnosis, with 20/20 visual acuity in both eyes. CONCLUSION: The authors believe that this is the youngest documented case of a primary T-cell immunoblastic lymphoma of the orbit.

+ Re: Reconstruction of a medial canthus defect with a myocutaneous flap.

Patel BC, el Gazayerly E, Anderson RL.
Comment on a prior paper concerning reconstructive eyelid surgery.

+ Single suture ptosis tuck.

Jordan DR, Anderson RL.
Comment on a prior paper concerning eyelid reconstruction.

+ The use of fibrin glue in mucous membrane grafting of the fornix.

Patel BC, Flaharty P, Anderson RL.
Comment on a prior paper concerning eyelid reconstruction surgery.

+ Whitnall's sling with superior tarsectomy for the correction of severe unilateral blepharoptosis.

Holds JB, McLeish WM, Anderson RL.
The management of severe unilateral blepharoptosis is problematic. In the presence of poor levator function, conventional surgical techniques frequently do not adequately elevate a ptotic eyelid. From May 1988 through July 1991, we used 4- to 5-mm external resections of the superior tarsus in conjunction with a maximal aponeurectomy (Whitnall's sling procedure) to augment blepharoptosis correction in selected cases of severe unilateral blepharoptosis. Seventeen (68%) of 25 patients with poor levator function blepharoptosis who underwent this new surgical procedure achieved a lid height within 1 mm of the opposite lid with good or excellent ocular function, cosmesis, and eyelid crease formation. Mild to moderate degrees of exposure keratopathy developed early in the postoperative period in all patients. This exposure keratopathy ultimately resolved in most patients. Superior tarsectomy safely augments the blepharoptosis correction of a Whitnall sling procedure in severe blepharoptosis, improving the results of aponeurotic surgery in patients with severe unilateral blepharoptosis.

1992

+ Complications associated with alloplastic implants used in orbital fracture repair.

Jordan DR, St Onge P, Anderson RL, Patrinely JR, Nerad JA.
BACKGROUND: The treatment of orbital wall fractures involves observation and/or surgical reduction with repositioning of herniated orbital tissues. To prevent reherniation of tissue and development of enophthalmos, the orbital floor or wall defect is commonly covered with an alloplastic implant. Complications associated with these implants are infrequent and generally appear as isolated case reports. METHODS: The authors reviewed the files of four consultative oculoplastic surgeons and searched for individuals with complications secondary to their alloplastic implants used during orbital fracture repair. FINDINGS: Seventeen patients were identified with a variety of complications related to their alloplastic implant. CONCLUSION: Although these implants are relatively inert and develop a fibrous capsule walling them off from the surrounding orbit, they remain foreign bodies and are thus subject to possible complications at any time. The authors review the spectrum of complications occurring with various alloplastic implants.

+ Cosmetic eyelid surgery and the problem eyelid.

McLeish WM, Anderson RL.
The human eyelid is an amazingly complex structure that is responsible for protecting, moisturizing, and reconstituting the external surface of the eye. Compromise of any of the tarsoligamentous supporting structures of the eyelids can result in eyelid malposition, corneal compromise, and even blindness. Failure to recognize these abnormalities in patients seeking cosmetic eyelid surgery can lead to disastrous results. The most common structural eyelid abnormalities encountered in patients seeking cosmetic eyelid surgery and prophylactic and reconstructive surgical techniques to deal with these difficult problems are discussed.

+ Modifications to the semicircular flap technique in eyelid reconstruction.

Jordan DR, Anderson RL, Holds JB.
The most common reconstructive procedure in the upper and lower eyelid is direct closure of the lid margin. When additional mobilization of tissue is needed to close a defect, lateral canthotomy and cantholysis is suggested. Mobilization of tissue beyond the lateral orbital rim is occasionally required. We have found that in the lower eyelid the mobilized tissue is much better supported if the initial incision is made vertically toward the eyebrow rather than temporally, as is suggested with the semicircular flap technique. We describe modifications to this technique, which we refer to as the vertical-temporal advancement flap, and present the results in 28 consecutive patients followed for 8 months to 3 years.

+ The pigtail probe protected by silicone intubation: a combined approach to canalicular reconstruction.

McLeish WM, Bowman B, Anderson RL.
We have devised a method of single-eyelid canalicular reconstruction using the pigtail probe to facilitate identification of the proximal canalicular segment following silicone stent intubation of the normal, uninjured canaliculus. A series of seven acute and two long-standing canalicular lacerations were successfully reconstructed using this technique, which minimizes the risks associated with the use of the pigtail probe.

+ Treatment of pseudotumor cerebri by primary and secondary optic nerve sheath decompression.

Anderson RL, Flaharty PM.
A comment on an orbital surgery technique.

1991

+ Botulinum-induced alteration of nerve-muscle interactions in the human orbicularis oculi following treatment for blepharospasm.

Alderson K, Holds JB, Anderson RL.
To assess longstanding alterations in human muscle innervation induced by botulinum toxin, we studied motor axons in the orbicularis oculi of nine patients previously injected with botulinum toxin for treatment of benign essential blepharospasm (BEB). Compared with untreated BEB and normal orbicularis oculi, muscle exposed to botulinum toxin developed persistent and cumulative alterations of innervation, including (1) thin, unmyelinated axonal collaterals that contact muscle end plates, (2) an increased number of muscle fibers innervated by individual terminal motor axons, (3) a profusion of unmyelinated axonal sprouts that end blindly, (4) an increased range of end plate sizes, and (5) multiple end plates on individual muscle fibers. The findings suggest that axonal sprouts which develop after botulinum-toxin-induced functional denervation can form new end plates. A single muscle fiber may then be innervated at separate sites by more than one axon.

+ Diffuse malignant melanoma of iris with metastases.

Kersten RC, Tse DT, Anderson RL.


+ Facial dystonia, essential blepharospasm and hemifacial spasm.

Holds JB, White GL, Thiese SM, Anderson RL.
Movement disorders, or dyskinesias, in the facial region may be categorized in several ways. Dystonic movement disorders in the cranial-cervical region, including essential blepharospasm, Meige syndrome and spasmodic torticollis, are characterized by uncontrollable squeezing movements in the face and neck. These disorders typically present in the fifth and sixth decades of life. Essential blepharospasm is particularly debilitating, as the involuntary eyelid closure that accompanies this condition may result in functional blindness with an otherwise normal visual pathway. Hemifacial spasm is an intermittent, unilateral, spasmodic contraction of the muscles innervated by the facial nerve. This disorder usually presents in the third or fourth decade and has a different underlying pathophysiology than the dystonias. Botulinum A toxin therapy has largely supplanted surgical intervention in the treatment of essential blepharospasm and hemifacial spasm.

+ Histologic features of human orbicularis oculi treated with botulinum A toxin.

Harris CP, Alderson K, Nebeker J, Holds JB, Anderson RL.
To evaluate muscle histologic features in humans following therapeutic botulinum toxin injections, we studied orbicularis oculi from 11 patients with blepharospasm; nine had previously received botulinum toxin injections and two had not. All muscles had comparable variability in muscle fiber diameter, with no necrosis, inflammation, denervation, or consistent alterations in muscle fiber internal architecture. Botulinum toxin produces no persistent histologic changes in human muscle fibers.

1990

+ Acquired oculomotor-abducens synkinesis.

Jordan DR, Miller DG, Anderson RL.
The authors present a rare case of bilateral aberrant oculomotor regeneration following severe head trauma with the unusual finding of unilateral palpebral fissure widening on abduction with normal lateral rectus function (oculomotor-abducens synkinesis). The findings do not match the usual syndromes of either acquired oculomotor synkinesis or acquired Duane's retraction syndrome and seem to represent a unique case of aberrant regeneration involving the third and sixth cranial nerves.

+ Amelanotic malignant melanoma of the conjunctiva with local metastasis to the eyelid.

Jordan DR, Mamalis N, White GL, Hansen SO, Anderson RL.
Conjunctival melanomas are uncommon. The amelanotic variety is extremely rare. We describe a patient with an amelanotic melanoma of the superior conjunctiva that was primarily excised, followed by extensive conjunctival resection and liquid nitrogen cryotherapy applied to the tumour bed. Eight months later a local metastatic lesion was noted in the lower eyelid. Eyelid metastasis in conjunctival melanoma is uncommon but may occur owing to the rich lymphatic vasculature within the conjunctiva.

+ Apical membrane Cl- channels in airway epithelia: anion selectivity and effect of an inhibitor.

Li M, McCann JD, Welsh MJ.
Previous work has investigated the anion selectivity of transepithelial Cl- secretion by airway epithelia and its inhibition by the Cl(-)-channel blocker 5-nitro-2-(3-phenylpropylamino)benzoate (NPPB). Here we report the anion selectivity of the apical membrane and of the outwardly rectifying Cl- channel and the effect of NPPB on the Cl- channel. The anion selectivity sequence of the apical membrane determined with conventional microelectrodes in the native epithelium was SCN- greater than I- greater than Br- greater than NO3- approximately Cl- much greater than SO(4)2- approximately gluconate-. This contrasts with the observation that Cl- and Br- support transepithelial secretion but that I- does not. Thus the anion selectivity of transepithelial transport is determined by the basolateral membrane Cl- entry step. The anion selectivity of the outwardly rectifying Cl- channel studied in excised patches was the same as that of the apical membrane. We also found that NPPB reversibly blocked the outwardly rectifying Cl- channel from both the internal and external surfaces of the patch. NPPB, 10 microM, completely blocked the channel; lower concentrations caused a decrease in the probability of finding the channel in the open state. NPPB also caused the appearance of a subconductance state of the channel, an occurrence which is rarely observed in the absence of NPPB. These data provide further support for the conclusion that the outwardly rectifying Cl- channel is responsible for Cl- exit from the cell across the apical membrane.

+ Apraxia of lid opening in blepharospasm.

Jordan DR, Anderson RL, Digre KB.
Apraxia of lid opening is a nonparalytic motor abnormality characterized by difficulty in initiating the act of lid elevation. It has been reported with extrapyramidal disorders, including Parkinson's disease, Huntington's chorea, progressive supranuclear palsy, and Shy-Drager syndrome. We found seven cases (7%) of functionally disabling apraxia of lid opening in 100 consecutive blepharospasm patients studied. It is important for physicians treating blepharospasm to be aware of the association between these two visually debilitating disorders.

+ Avoiding complications of orbital surgery: the orbital branches of the infraorbital artery.

Coulter VL, Holds JB, Anderson RL.
Adequate exposure in surgery along the orbital floor requires recognition and often division of the orbital branches of the infraorbital artery. Failure to recognize this orbital vascular bundle may lead to severe complications, including visual loss.

+ Basolateral K+ channels in airway epithelia. I. Regulation by Ca2+ and block by charybdotoxin.

McCann JD, Matsuda J, Garcia M, Kaczorowski G, Welsh MJ.
In airway epithelia, adenosine 3',5'-cyclic monophosphate (cAMP) stimulates Cl- secretion by activating apical membrane Cl- channels and basolateral membrane K+ channels. Cl- channels are regulated by cAMP-dependent phosphorylation, whereas K+ channels are regulated by the cytosolic Ca2+ concentration, [Ca2+]c. Our recent observation that cAMP increases [Ca2+]c suggested that cAMP might indirectly regulate K+ channels by increasing [Ca2+]c. To study regulation of K+ channels we measured 86Rb efflux, single K+ channels in membrane patches, and [Ca2+]c with the fluorescent indicator fura-2. Isoproterenol and Ca2+ ionophore, A23187, transiently increased [Ca2+]c and transiently stimulated 86Rb efflux. Stimulation of 86Rb efflux resulted from release of intracellular Ca2+ stores. 86Rb efflux was blocked by Ba2+ or charybdotoxin, but not by tetraethylammonium. Charybdotoxin prevented all of the 86Rb efflux that was stimulated by A23187 or by forskolin. Charybdotoxin also blocked the low-conductance inwardly rectifying K+ channel (KCLIC) in membrane patches. These results indicate that the KCLIC channel is responsible for the Ca2(+)-dependent increase in K+ permeability in airway epithelial cells. They also indicate that cAMP-induced release of intracellular Ca2+ is sufficient to activate K+ channels.

+ Basolateral K+ channels in airway epithelia. II. Role in Cl- secretion and evidence for two types of K+ channel.

McCann JD, Welsh MJ.
We previously described a Ca2(+)-activated K+ channel (KCLIC) in airway epithelial cells [J. D. McCann, J. Matsuda, M. Garcia, G. Kaczorowski, and M. J. Welsh. Am. J. Physiol 258 (Lung Cell. Mol. Physiol. 2): L334-L342, 1990]. To determine whether the KCLIC channel is a basolateral membrane channel and to understand its role in Cl- secretion, we studied airway epithelial cells grown on permeable supports. When cells were stimulated with A23187, charybdotoxin (ChTX) inhibited Cl- secretion and 86Rb efflux at the same concentrations, indicating that the KCLIC channel is required for Ca2(+)-stimulated Cl- secretion. We also investigated the function of K+ channels in adenosine 3',5'-cyclic monophosphate-stimulated secretion. Addition of isoproterenol caused a biphasic increase in Cl- secretion; the time course of the transient component correlated with the time course of the isoproterenol-induced increase in Ca2+ concentration [( Ca2+]c). ChTX inhibited the transient component, but not the prolonged component of secretion; Ba2+ inhibited the sustained component. These results suggest that when cells are grown on permeable supports isoproterenol-induced secretion depends on activation of two types of K+ channel: the KCLIC channel that is stimulated initially and a ChTX-insensitive K+ channel that is stimulated during sustained secretion. This conclusion was supported by measurement of 86Rb efflux from cell monolayers.

+ Bilateral hemifacial spasm.

Holds JB, Anderson RL, Jordan DR, Patrinely JR.
A description of a rare case of hemifacial spasm that effects both sides of the face.

+ Blepharospasm-oromandibular dystonia associated with a left cerebellopontine angle meningioma.

Persing JA, Muir A, Becker DG, Jankovic JJ, Anderson RL, Edlich RF.
Blepharospasm-oromandibular dystonia is characterized by the presence of spasms of the orbicularis oculi (blepharospasm) and of the lower facial or oromandibular muscles. A patient with this syndrome is presented in which a left cerebellopontine angle meningioma appeared to act as a triggering mechanism for the development of this disorder. On the basis of this report, we recommend that physicians search for this tumor in patients with this disorder.

+ Botulinum A toxin injection. Failures in clinical practice and a biomechanical system for the study of toxin-induced paralysis.

Holds JB, Fogg SG, Anderson RL.
Botulinum A toxin injection has great utility in the treatment of essential blepharospasm and other facial spasm disorders. Several investigators have noted the failure of botulinum toxin injections to relieve lid spasm in occasional patients and a decrease in effectiveness or duration of effect following multiple injections in other patients. We reviewed the charts of 30 consecutive patients presenting for the evaluation or treatment of facial dystonia. Of 20 patients who had received multiple injections of botulinum toxin, 10 patients were felt to be treatment failures. A new biomechanical system was developed to investigate the duration and degree of paralysis induced in the gastrocnemius muscle of the rat. Animals were treated with four sequential injections at 6-week intervals to the same muscle, resulting in muscle atrophy and an increase in the duration and degree of muscle paralysis, contrary to clinical findings in humans. The review of patient data confirms that, for many patients, repeated injection of botulinum toxin results in a decrease in duration and degree of effect despite an increased toxin dose. An opposite effect was noted in our experimental model because of progressive muscle atrophy.

+ Bradykinin stimulates airway epithelial Cl- secretion via two second messenger pathways.

Smith JJ, McCann JD, Welsh MJ.
In canine airway epithelial cells, bradykinin increases intracellular concentrations of D-myo-inositol 1,4,5-trisphosphate [Ins(1,4,5)P3], cytosolic calcium concentration ([Ca2+]c), and adenosine 3',5'-cyclic monophosphate (cAMP). To determine the role of these second messengers in bradykinin-stimulated Cl- secretion, we studied the secretory response to this peptide using canine tracheal monolayers mounted in Ussing chambers. Bradykinin stimulated Cl- secretion [measured as short-circuit current (Isc)] when added to submucosal or mucosal surfaces; however, secretory responses differed substantially. Submucosal addition of bradykinin induced a biphasic increase in secretion; mucosal addition induced a monophasic increase in secretion. Both responses were mediated by B2 receptors. We show that activation of bradykinin receptors can stimulate Cl- secretion in two ways. 1) Bradykinin added to either surface stimulates prostaglandin synthesis and release at the basolateral surface. This leads to activation of prostaglandin E2-sensitive receptors on the basolateral surface that are coupled to cAMP production and an increase in apical membrane Cl- conductance. 2) In addition, bradykinin added to the submucosal surface increases Ins(1,4,5)P3 and [Ca2+]c levels, which enhance basolateral K+ conductance and the electrical driving force for apical Cl- exit. Whereas secretion requires activation of apical Cl- channels, the data show that Cl- secretion can also be modulated by activation of basolateral K+ channels. These data indicate that bradykinin-induced transepithelial Cl- secretion is mediated by two independent, second messenger pathways. These results provide the first evidence for expression of both pathways in a polar fashion in an epithelial monolayer.

+ Calcium-dependent regulation of airway epithelial chloride channels.

Clancy JP, McCann JD, Li M, Welsh MJ.
To determine how cell calcium ([Ca2+]c) regulates apical Cl- channels, we measured the rate of 125-Iodide (125I-) efflux to assay Cl- channel activity in intact cells and examined cell-free membrane patches from cultured canine tracheal epithelial cells. The Ca2+ elevating agonist bradykinin and the calcium ionophore A23187 increased 125I- efflux. This response did not require prostaglandin production. Under several conditions, changes in [Ca2+]c were temporally dissociated from changes in channel activation: a transient increase in [Ca2+]c caused a prolonged stimulation of 125I- efflux. Neither Cl- channel activation nor open-channel probability was affected by varying internal [Ca2+] in excised membrane patches. Adenosine 3',5'-cyclic monophosphate (cAMP)- and Ca2(+)-dependent channel activation may be independent: cAMP-stimulated 125I- efflux did not require an increase in [Ca2+]c, Ca2(+)-stimulated efflux did not require an increase in cAMP, and simultaneous addition of A23187 and isoproterenol produced additive effects on 125I- efflux. The data suggest that an increase in [Ca2+]c activates Cl- channels, however, the effect of Ca2+ appears to be indirect, not involving a ligand-type interaction with the channel.

+ Does anyone know how to differentiate a 'functional' defect from a cosmetic one?

Anderson RL, Holds JB.
Comment on a prior publication on reconstructive and cosmetic eyelid surgery.

+ Evidence that Ca2(+)-dependent activation of airway epithelia Cl- channels is not dependent on phosphorylation.

Clancy JP, McCann JD, Welsh MJ.
Previous studies have shown that an increase in the cytosolic Ca2+ concentration [( Ca2+]c) activates Cl- channels in airway epithelia but that the effect is indirect. Because adenosine 3',5'-cyclic monophosphate (cAMP) and phorbol myristate acetate (PMA) activate Cl- channels via phosphorylation by cAMP-dependent protein kinase and protein kinase C, respectively, we asked whether Ca2(+)-dependent Cl- channel activation is phosphorylation dependent. We measured 125I- efflux as an assay of Cl- channel activation in the intact cell. We found that depletion of cellular ATP prevented cAMP- and PMA-induced activation but did not alter activation produced by the Ca2+ ionophore A23187. Moreover, addition of high concentrations of staurosporine (5 microM), to nonspecifically inhibit kinase activity, blocked cAMP- and PMA-stimulated 125I- efflux but had no effect on A23187-induced efflux. These results suggest that elevation of [Ca2+]c does not activate Cl- channels via phosphorylation.

+ Expression of cystic fibrosis transmembrane conductance regulator corrects defective chloride channel regulation in cystic fibrosis airway epithelial cells.

Rich DP, Anderson MP, Gregory RJ, Cheng SH, Paul S, Jefferson DM, McCann JD, Klinger KW, Smith AE, Welsh MJ.
The cystic fibrosis transmembrane conductance regulator (CFTR) was expressed in cultured cystic fibrosis airway epithelial cells and Cl- channel activation assessed in single cells using a fluorescence microscopic assay and the patch-clamp technique. Expression of CFTR, but not of a mutant form of CFTR (delta F508), corrected the Cl- channel defect. Correction of the phenotypic defect demonstrates a causal relationship between mutations in the CFTR gene and defective Cl- transport which is the hallmark of the disease.

+ Granulomatous acne rosacea of the eyelids.

Patrinely JR, Font RL, Anderson RL.
We describe the clinicopathologic features of the papular form of granulomatous acne rosacea of the eyelids. This unusual cutaneous disorder is typified by painless eruptions of reddish to yellowish brown, occasionally ulcerative papules symmetrically distributed around the eyelids, lower part of the forehead, nasolabial folds, and upper lip. Histopathologically, the lesions display caseating and noncaseating dermal granulomas that mimic those seen in tuberculosis, tuberculoid leprosy, sarcoidosis, and other diseases. The disorder responds well to systemic tetracycline therapy but may involute spontaneously during a period of months to years. The distinction of this disorder from other dermal granulomatous diseases, such as tuberculosis, leprosy, syphilis, and foreign bodies, is important because of the different therapeutic implications.

+ Irradiated homologous tarsal plate banking: a new alternative in eyelid reconstruction. Part I. Technique and animal research.

Jordan DR, Tse DT, Anderson RL, Hansen SO.
Reconstruction of full thickness eyelid defects requires the correction of both posterior lamella (tarsus, conjunctiva) and anterior lamella (skin, muscle). Tarsal substitutes including banked sclera, nasal cartilage, ear cartilage, and periosteum can be beneficial for posterior lamellar repair, while anterior lamellar replacement, including skin grafts, pedicle flaps, advancement flaps, etc., is important to cover the posterior reconstructed portion. At times, due to extensive tissue loss, the eyelid reconstruction can be particularly challenging. We have found an alternative posterior lamellar reconstructive technique utilizing irradiated homologous tarsal plate that can be particularly useful in selected cases of severe tissue loss. The experimental surgical procedure in monkeys and the histological fate of the implanted tarsus is described in Part I, and followed in Part II by our experience with this tissue in six human patients.

+ Irradiated homologous tarsal plate banking: a new alternative in eyelid reconstruction. Part II. Human data.

Jordan DR, Tse DT, Anderson RL, Hansen SO.
Reconstruction of full thickness eyelid defects requires the correction of both posterior lamella (tarsus, conjunctiva) and anterior lamella (skin, muscle). Irradiated homologous tarsal plate provides a structured framework for the lid reconstruction, and is incorporated nicely into the normal lid anatomy.

+ Lacrimal gland prolapse in craniosynostosis syndromes and poor function congenital ptosis.

Jordan DR, Germer BA, Anderson RL, Morales L.
Lacrimal gland prolapse is an important, though uncommon, feature found in craniofacial abnormalities as well as in cases of poor function congenital ptosis. It occurs secondary to a number of conditions, including increased posterior pressure secondary to decreased orbital volume; also, supportive structures of the gland often may be weak in conjunction with a poor function ptosis or as a result of trauma at the time of major reconstruction. Recognition of the prolapsed gland and its replacement into the lacrimal gland fossa in craniosynostosis syndromes, as well as in cases of poor function congenital ptosis in general, allows the temporal eyelid to approach a more normal position, yielding an improved functional and cosmetic result.

+ Lower eyelid retraction: a minimal incision surgical approach to retractor lysis.

Holds JB, Anderson RL, Thiese SM.
Lower eyelid retraction associated with prior blepharoplasty, trauma, or other conditions is a challenging problem for the ophthalmic surgeon. We describe a procedure involving tightening the lower eyelid and supraplacing the lateral canthus in combination with in-glove lysis of the lower eyelid retractors and scar tissue. This is accomplished through a small lateral incision. To date, we have treated over 200 eyelids using this technique with excellent results. We recommend this technique for the treatment of mild to moderate degrees of lower eyelid retraction.

+ Motor nerve sprouting in human orbicularis muscle after botulinum A injection.

Holds JB, Alderson K, Fogg SG, Anderson RL.
The paralytic properties of botulinum A toxin have led to its use in humans in the treatment of strabismus and facial dystonias such as essential blepharospasm. Examination of orbicularis muscle from 10 patients with essential blepharospasm who received 2-18 injections of botulinum toxin 6 weeks to 3 years prior to surgery revealed characteristic nodal, terminal and ultraterminal "sprouting" of the motor axons. Orbicularis muscle from five individuals never exposed to botulinum failed to demonstrate these changes. The significance of persistent motor nerve sprouting in response to botulinum exposure remains to be elucidated.

+ Mucinous adenocarcinoma of the orbit arising from a stable, benign-appearing eyelid nodule.

Holds JB, Haines JH, Mamalis N, Anderson RL, Wolin MJ.
Mucinous adenocarcinoma is a rare eyelid tumor which should be considered in the differential diagnosis of a nodular or cystic lesion of the eyelid. This lesion may be locally aggressive and requires complete excision to prevent local recurrence or regional metastases. We present what we believe is the first report of a mucinous adenocarcinoma manifesting as a stable, benign-appearing nodule that has already given rise to a much larger secondary lesion. This case underscores the importance of performing a biopsy on even benign-appearing eyelid nodules.

+ Multiple orbital tumors were cavernous hemangiomas.

Wolin MJ, Holds JB, Anderson RL, Mamalis N.
Two distinct masses in the left orbit were incidentally found in a 48-year-old woman during a computed tomographic scan done to evaluate neurologic complaints. Initial diagnostic considerations focused on a lymphoproliferative disorder or other systemic disease. Orbitotomy revealed two discrete tumors, both cavernous hemangiomas. Although uncommon, cavernous hemangioma should be considered in the differential diagnosis of the patient with multiple orbital lesions.

+ Nodular fasciitis presenting as a rapidly enlarging episcleral mass in a 3-year-old.

Holds JB, Mamalis N, Anderson RL.
A rapidly enlarging periocular mass in a child obligates the treating physician to rule out a malignancy, especially a rhabdomyosarcoma. A 3-year-old girl presented with a 5-day history of a rapidly growing episcleral mass superonasal to the globe, adjacent to the superior rectus muscle insertion. The lesion was locally excised. A sarcoma could not be excluded on frozen sections. Permanent sections and electron microscopy revealed nodular fasciitis, a benign lesion with a pseudosarcomatous histologic appearance. No recurrence has been noted at 9 months follow-up. Nodular fasciitis is a benign proliferation which should be considered in the differential diagnosis of a rapidly enlarging subconjunctival or orbital mass in a child.

+ Regulation of Cl- and K+ channels in airway epithelium.

McCann JD, Welsh MJ.
Stimulation of transepithelial Cl- secretion by the airway epithelium requires activation of channels at the two opposite sides of the cell: the apical and basolateral membranes. At the apical membrane, the Cl- channel is regulated by phosphorylation with PKA and PKC. At the basolateral membrane, the KCLIC channel is regulated by [Ca2+]c. Addition of a secretagogue that increases cellular levels of cAMP also causes release of Ca2+ from intracellular stores. The Ca2+ may then regulate basolateral membrane KCLIC channels. The cAMP-induced increase in [Ca2+]c and activation of the KCLIC channel is transient, however, whereas activation of the Cl- channel and stimulation of secretion is a more sustained response. Those results suggest that the presence of a second Ca2(+)-independent K+ channel located at the basolateral membrane, which is only expressed in cells grown on permeable supports.

+ The aponeurotic approach to congenital ptosis.

Jordan DR, Anderson RL.
Using a surgical technique directed at the levator aponeurosis, we successfully corrected 228 cases of congenital ptosis. The advantages of this approach are: normal anatomic planes and structures of the eyelid are maintained; basic and reflex tear secretion, goblet cells, or meibomian glands remain undisturbed, allowing maintenance of the three-layered tear film; any aponeurotic defects may be explored and repaired relatively easily; all elevating structures are preserved (aponeurosis rather than muscular levator is removed, Mueller's muscle is left intact, Whitnall's ligament is not violated); posterior sutures, which may irritate the cornea, are avoided; no tarsus or conjunctiva are removed.

+ The medial tarsal strip.

Jordan DR, Anderson RL, Thiese SM.
Medial canthal malpositions and marked medial ectropion due to laxity, scarring, or trauma can be difficult to correct. Medial canthal tendon publications have been advocated but they do not achieve adequate posterior and medial placement of the medial canthal angle and they lack permanence. One of us (R.L.A.) has developed a surgical technique for correcting these problems that is a modification of the lateral tarsal strip procedure used to correct lateral canthal tendon laxity and malposition. The medial tarsal strip procedure repositions and tightens the medial lower or upper eyelid, establishing a normal anatomic appearance. Its use is indicated in cases of medial canthal malposition or marked medial ectropion associated with a nonfunctioning canalicular system or in those cases in which loss of function of a patent canaliculus is acceptable or desirable. The advantages of the medial tarsal strip are as follows: (1) surgery is directed at the site of the defect; (2) recurrence of canthal tendon laxity and elongation is avoided; (3) a more medial and posterior positioning of the medial eyelid can be obtained; (4) any amount of eyelid laxity can be corrected simultaneously; (5) the almond-shaped canthal angle is preserved or reestablished; and (6) the procedure is fast and easily performed.

+ The tarsal tuck procedure: avoiding eyelid retraction after lower blepharoplasty.

Jordan DR, Anderson RL.
Eyelid retraction and ectropion are the most common complications of lower blepharoplasty. These complications often occur as a result of removing excessive skin and muscle in the face of a lax lower eyelid. The tarsal tuck technique tightens and stabilizes the lower eyelid, thereby minimizing these complications. The lateral canthus and lower eyelid are elevated with the tarsal tuck, which reduces the amount of skin removal required and avoids the "round eye" appearance.

+ The universal orbital implant: indications and methods.

Anderson RL, Thiese SM, Nerad JA, Jordan DR, Tse D, Allen L.
Major criticisms of quasi-integrated implants, such as the Iowa Implant, have been the time-consuming surgical technique needed to implant the prosthesis, and the high rate of extrusion. The Universal Implant (Oculo-Plastik, Montreal) is designed with these concerns in mind. In addition, those qualities that produce the motility advantages of a quasi-integrated implant and the ease of placement of a sphere have been incorporated into the design of the Universal Implant. The Universal Implant also (1) uses a faster implantation technique at surgery, (2) avoids cleaning the muscles, (3) has smaller mounds that are lower and more rounded, and should decrease the late extrusion rate, (4) can be used as an evisceration implant, enucleation implant, or secondary implant, and (5) has a larger girth and radius on the posterior surface that, in turn, helps support orbital fat and tissues and results in a more natural superior sulcus. It is recommended that the Universal Implant be used by surgeons who were pleased with the Iowa Implant, as the Universal implant represents an excellent alternative with major advantages over most other enucleation implants.

+ Whitnall's sling for poor function ptosis.

Anderson RL, Jordan DR, Dutton JJ.
Severe unilateral ptosis with poor levator function has previously been treated with maximal levator muscle resection or bilateral or unilateral frontalis suspension. One of us (R.L.A.) has developed a technique called "Whitnall's sling," where only the levator aponeurosis is resected, preserving Whitnall's ligament and its attachments. Whitnall's ligament and the underlying resected levator muscle are sutured to the superior portion of the tarsal plate. This surgery preserves levator muscle, Müller's muscle, and Whitnall's ligament without altering the structures that produce the three-layer tear film. In 69 eyelids operated on between July 1976 and July 1986, in which a minimum of 1 year of follow-up by one of use was obtained, results have been satisfactory and directly related to levator function. We believe this technique to be anatomically and physiologically superior to "maximal levator resection" with similar long-term results. More recent results have shown that the addition of a 5-mm superior tarsectomy provides an additional elevation of 1 to 1.5 mm. Whitnall's sling is best suited for cases where the opposite fissure height is 9 mm or less and levator function of the ptotic eyelid is 3 to 5 mm.

1989

+ Activation of normal and cystic fibrosis Cl- channels by voltage, temperature, and trypsin.

Welsh MJ, Li M, McCann JD.
In cystic fibrosis (CF) phosphorylation-dependent activation of outwardly rectifying apical membrane Cl- channels is defective. To further understand regulation of this channel we examined several other mechanisms of channel activation in normal and CF cells. Previous studies have shown that strong membrane depolarization can activate channels in excised cell-free membrane patches. Here we show that such activation is dependent on both the absolute membrane voltage and the duration of depolarization. Moreover, activation was reversible by membrane hyperpolarization. In some cases, excising patches of membrane from the cell caused channel activation, even in the absence of depolarization. However, the frequency of channel activation with patch excision increased when bath temperature was increased from 23 to 37 degrees C. Although the channel remained in the activated state when temperature was reduced to 23 degrees C, subsequent hyperpolarization inactivated the channel. In cell-attached patches, neither depolarization nor increasing bath temperature to 37 degrees C activated channels, suggesting that neither is physiologically important in regulation of the channel. Thus changes in membrane voltage and bath temperature appear to cause a nonenzymatic change in the channel's conformation; the interactions between voltage and temperature suggest that they may affect the same process. To determine if a proteolytic alteration of the channel could also cause activation, we added trypsin to the cytosolic surface of excised membrane patches. Trypsin activated channels, which could not then be inactivated by either hyperpolarization or phosphorylation with PKC, suggesting that trypsin removed or altered a region of the channel involved in inactivation. All of these interventions activated Cl- channels from both normal and CF cells. Thus many aspects of Cl- channel activation are normal in CF; only phosphorylation-dependent activation is defective.

+ Acute visual loss due to a calcified optic nerve glioma.

Jordan DR, Anderson RL, White GL Jr, Mamalis N.
Optic nerve gliomas are slow-growing tumours most commonly seen in children under 10 years of age. Rapidly progressive proptosis and rapid visual deterioration are uncommon but may occur owing to accumulation of mucoid material, necrosis or hemorrhage. We describe a patient with an optic nerve glioma who manifested sudden proptosis and blindness caused by hemorrhage within the optic nerve sheath. The visual acuity returned to 20/25 after surgical decompression of the nerve and high-dose steroid therapy. Histopathological examination was required to establish the diagnosis of optic nerve glioma with extensive calcification. Optic nerve decompression or short-term high-dose steroid therapy, or both, may be helpful in recovering visual function in selected patients with optic nerve gliomas who have acute visual loss.

+ Computed tomographic features of nonthyroid extraocular muscle enlargement.

Patrinely JR, Osborn AG, Anderson RL, Whiting AS.
While Graves' disease is the most common cause of enlarged extraocular muscles, other disorders may masquerade as dysthyroid orbitopathy. The authors conducted a retrospective analysis of the computed tomographic (CT) scans of 60 patients with nonthyroid enlarged extraocular muscles to establish the differential radiographic features of these disorders. The diseases were classified as primary or local invasion of neoplasm (26%), inflammatory (25%), metastatic tumor (20%), vascular (13%), infection (12%), and acromegaly (3%). The inflammatory cases demonstrated more bilateral involvement (40%) and less involvement of the tendons (47%) than previously appreciated. The relatively high incidence of these features in the inflammatory group is important because both features have been considered pathognomonic for Graves' disease. Primary and metastatic tumors produced a nodular muscle enlargement with sharp borders and frequent bone changes. Certain tumors showed a predilection for certain muscle groups. Vascular cases involved multiple unilateral muscles and usually enlarged the superior ophthalmic vein. Infectious cases usually demonstrated fusiform muscle enlargement with blurred margins, whereas acromegaly caused moderate enlargement of all recti. Although certain diagnosis-specific radiographic patterns are described, no feature is pathognomonic for any disorder.

+ Dacryocystectomy for the treatment of dacryocystitis patients with Wegener's granulomatosis.

Holds JB, Anderson RL, Wolin MJ.
We evaluated a woman with Wegener's granulomatosis who was experiencing recurrent dacryocystitis. Nasolacrimal duct obstruction had been present for many years and epiphora was not a significant concern. Our experience with the development of nasalcutaneous fistulas following dacryocystorhinostomy in several patients with Wegner's granulomatosis led us to perform a dacryocystectomy. The functional result was good, and there were no problems with wound healing. Dacryocystectomy should be considered as an alternative to dacryocystorhinostomy for dacryocystitis in patients with Wegener's granulomatosis and similar disorders in whom epiphora is not a major complaint.

+ Dysthyroid optic neuropathy without extraocular muscle involvement.

Anderson RL, Tweeten JP, Patrinely JR, Garland PE, Thiese SM.
We present three atypical cases of dysthyroid optic neuropathy. The unique feature was progressive visual field loss with normal-sized or minimally enlarged extraocular muscles. Other atypical findings included optic nerves that appeared to be linearly on stretch with only moderate proptosis, good ocular motility, and only mildly reduced central visual acuity and color vision despite severe field loss. These cases responded rapidly to decompressive surgery after failing high-dose corticosteroid therapy. While marked enlargement of the extraocular muscles with apical optic nerve compression has been documented to cause dysthyroid optic neuropathy, another etiology such as short optic nerves on stretch appears to be at work in these atypical cases. Although extraocular muscle enlargement is the most important diagnostic feature and indicator of the severity of Graves' ophthalmology, our atypical cases demonstrate that this sign alone is an inadequate basis for diagnosis and visual prognosis.

+ Epicanthal folds. A deep tissue approach.

Jordan DR, Anderson RL.
Epicanthal folds are seen in infants and young children of all races, and they appear as a normal finding in Orientals of all ages. The formation of these folds seems to be related to tension from excessive underlying muscle in many cases. Surgically, a number of techniques have been suggested for their correction, but many of these techniques result in unsightly scars. A technique has been devised for the correction of epicanthal folds that involves an incision on the fold and removes muscle beneath the fold while attaching the skin edges to deep tissues in an attempt to create a crease, which may extend into normal creases. This technique has delivered good functional and cosmetic results in 9 of 10 consecutive cases treated in this manner.

+ Essential blepharospasm and related dystonias.

Jordan DR, Patrinely JR, Anderson RL, Thiese SM.
Essential blepharospasm is an idiopathic disorder of progressive involuntary spasms of the orbicularis oculi and upper facial (corrugator, procerus) muscles. Blepharospasm literally means spasm of the eyelids; however, most patients with blepharospasm also have or will develop squeezing in the lower face and neck muscles (Meige's syndrome, orofacial dystonia, or oromandibular dystonia). Some patients develop dystonic, uncontrolled movements in areas outside the facial nerve distribution (segmental cranial dystonia or craniocervical dystonia). Chronic, forceful squeezing by the periocular muscles becomes debilitating for the patient and leads to functional and cosmetic eyelid deformities. Treatment has included a variety of modalities and oral medications that are of limited efficacy. Botulinum-A toxin injections have delivered the best temporary relief from this disorder, while the periorbital myectomy operation has been shown to give the best long-term results.

+ Fashionable patches.

Wolin MJ, Holds JB, Anderson RL.
Publication

+ Fibrous histiocytoma. An uncommon eyelid lesion.

Jordan DR, Addison DJ, Anderson RL.
Publication

+ Identification and regulation of whole-cell chloride currents in airway epithelium.

McCann JD, Li M, Welsh MJ.
We used the whole-cell patch-clamp technique to study membrane currents in human airway epithelial cells. The conductive properties, as described by the instantaneous current-voltage relationship, rectified in the outward direction when bathed in symmetrical CsCl solutions. In the presence of Cl concentration gradients, currents reversed near ECl and were not altered significantly by cations. Agents that inhibit the apical membrane Cl conductance inhibited Cl currents. These conductive properties are similar to the conductive properties of the apical membrane Cl channel studied with the single-channel patch-clamp technique. The results suggest that the outwardly rectifying Cl channel is the predominant Cl-conductive pathway in the cell membrane. The steady-state and non-steady-state kinetics indicate that current flows through ion channels that are open at hyperpolarizing voltages and close with depolarization. These Cl currents were regulated by the cAMP-dependent protein kinase: when the catalytic subunit of cAMP-dependent protein kinase was included in the pipette solution, Cl channel current more than doubled. We also found that reducing extracellular osmolarity by 30% increased Cl current, suggesting that cell-swelling stimulated Cl current. Studies of transepithelial Cl transport in cell monolayers suggest that a reduction in solution osmolarity activates the apical Cl channel: reducing extracellular osmolarity stimulated a short-circuit current that was inhibited by Cl-free solution, by mucosal addition of a Cl channel antagonist, and by submucosal addition of a loop diuretic. These results suggest that apical membrane Cl channels may be regulated by cell volume and by the cAMP-dependent protein kinase.

+ Intractable orbicularis myokymia: treatment alternatives.

Jordan DR, Anderson RL, Thiese SM.
Orbicularis myokymia frequently occurs in young, otherwise health individuals. The intermittent muscle fasciculations are transient and generally disappear with time. If the myokymia is persistent or progressive, neurologic assessment and investigation may be necessary. Muscle relaxants, botulinum-A toxin, and surgical myectomy are methods of treatment that only occasionally need to be considered. We present limited orbicularis myectomy and botulinum-A toxin injections as efficacious treatments in five selected intractable cases of orbicularis myokymia.

+ Malignant lesions of the eyelid.

Mamalis N, White GL Jr, Pedersen DM, Holds J, Anderson RL.
Malignant tumors of the eyelid and ocular adnexa are often detected during routine examinations. Basal cell carcinoma is the most common of these tumors, followed by squamous cell carcinoma. Sebaceous gland carcinoma and malignant melanoma are seen less frequently. Malignant eyelid tumors may mimic a number of benign conditions. Early diagnosis requires a high index of suspicion, and biopsy of the lesion is often necessary.

+ Merkel cell tumor of the eyelid: a review and report of an unusual case.

Mamalis N, Medlock RD, Holds JB, Anderson RL, Crandall AS.
We describe a case of a Merkel cell tumor of the eyelid that manifested as a recurrent chalazion. This tumor had the classic characteristics of a Merkel cell neoplasm by light microscopy. Electron microscopy showed dense-core neurosecretory granules and perinuclear microfilaments consistent with the diagnosis. Because a Merkel cell tumor may manifest as a chalazion, pathologic evaluation of all atypical chalazia is essential. Merkel cell tumors are malignant, and they must be treated aggressively to minimize recurrence or metastasis.

+ Phosphorylation-dependent regulation of apical membrane chloride channels in normal and cystic fibrosis airway epithelium.

Welsh MJ, Li M, McCann JD, Clancy JP, Anderson MP.
The observations described herein allow us to make several inferences about PKC and regulation of normal and CF Cl- channels. FIGURE 5 shows a model that summarizes these observations. In this model, for the sake of clarity, we refer to the channel as a single entity, but note that it may consist of multiple subunits and associated proteins. FIGURE 5A shows the channel in an inactivated state following excision from the cell. The channel can be activated by strong membrane depolarization, via an unknown mechanism, or by phosphorylation with PKA or PKC at a low [Ca2+] We speculate that PKA and PKC may phosphorylate and activate the channel at the same site, or region of the channel, because phosphorylation-dependent activation by both is defective in CF. This result suggests that the CF defect might lie in a defective phosphorylation site on the channel, or associated protein, or in the mechanism that converts phosphorylation into a change in channel conformation, such as activation. Activated channels can be inactivated by PKC at a high [Ca2+]. At high [Ca2+], PKC maintains the channel in an inactivated state and it inactivates channels that have been activated by PKC at low [Ca2+], by depolarization, or by PKA. Both activation and inactivation appear to result from phosphorylation; neither can be explained by down-regulation of the channel. There are several possible ways to explain the two opposite effects of PKC on the Cl- channel: different responses may be due to an effect of Ca2+ on the channel, on PKC, or on the interaction between the two.

+ Photo essay. Avoiding inferior oblique injury during lower blepharoplasty.

Jordan DR, Anderson RL, Thiese SM.
Publication

+ Primary vs delayed implant in evisceration.

Holds JB, Anderson RL.
Publication

+ Regulation of chloride channels by protein kinase C in normal and cystic fibrosis airway epithelia.

Li M, McCann JD, Anderson MP, Clancy JP, Liedtke CM, Nairn AC, Greengard P, Welsch MJ.
Apical membrane chloride channels control chloride secretion by airway epithelial cells. Defective regulation of these channels is a prominent characteristic of cystic fibrosis. In normal intact cells, activation of protein kinase C (PKC) by phorbol ester either stimulated or inhibited chloride secretion, depending on the physiological status of the cell. In cell-free membrane patches, PKC also had a dual effect: at a high calcium concentration, PKC inactivated chloride channels; at a low calcium concentration, PKC activated chloride channels. In cystic fibrosis cells, PKC-dependent channel inactivation was normal, but activation was defective. Thus it appears that PKC phosphorylates and regulates two different sites on the channel or on an associated membrane protein, one of which is defective in cystic fibrosis.

+ Release of intracellular calcium by two different second messengers in airway epithelium.

McCann JD, Bhalla RC, Welsh MJ.
To better understand regulation of Cl- secretion by airway epithelia, we measured the intracellular Ca2+ concentration ([Ca2+]c) using the Ca2+ indicator fura-2 and a fluorescent microscope imaging system. We examined receptor-mediated changes in [Ca2+]c in response to two Cl- secretagogues: the beta-adrenergic agonist isoproterenol and the peptide hormone bradykinin. Isoproterenol increased cell adenosine 3',5'-cyclic monophosphate (cAMP) levels but did not alter cellular accumulation of inositol phosphates. Bradykinin stimulated inositol phosphate accumulation but, in the presence of indomethacin, did not alter cAMP levels. Despite the difference in second messenger pathways, both bradykinin and isoproterenol transiently increased [Ca2+]c. Bradykinin stimulated inositol phosphate accumulation and increased [Ca2+]c with similar potencies, suggesting that bradykinin elevated [Ca2+]c by stimulating inositol phosphate production. The response to isoproterenol was inhibited by a beta-adrenergic antagonist, but not an alpha-adrenergic antagonist, and was mimicked by a membrane permeant analogue of cAMP. Isoproterenol also increased [Ca2+]c and cAMP at similar potencies. These results suggest that isoproterenol increased [Ca2+]c via cAMP. Both agonists increased [Ca2+]c when the extracellular [Ca2+] was reduced, suggesting that they release Ca2+ from intracellular stores. The ability of cAMP to increase [Ca2+]c suggests a mechanism by which cAMP- and Ca2+-activated membrane transport processes can be regulated in a coordinating manner.

+ Tarsoconjunctival flap for upper eyelid reconstruction.

Jordan DR, Anderson RL, Nowinski TS.
Reconstruction of large, full-thickness upper eyelid defects is a challenge to the ophthalmic plastic surgeon. Ideally, the defect should be reconstructed with tissues similar or identical to those that have been lost. We present a procedure similar to the Hughes tarsoconjunctival flap technique for lower eyelid reconstruction. However, our technique was used for upper eyelid reconstruction. A remnant of tarsus at least 3 mm wide must be available to be advanced inferiorly in the upper eyelid. We have performed this procedure on 13 patients over ten years (1977 to 1987) with good to excellent results.

+ The facial nerve in eyelid surgery.

Jordan DR, Anderson RL.
Publication

+ The five-flap technique for blepharophimosis.

Anderson RL, Nowinski TS.
The correction of epicanthus associated with blepharophimosis is a difficult surgical problem. Most commonly used techniques, such as the Mustardé technique, require meticulous measurements, and their theoretical geometric basis and flap designs are often confusing. We present the five-flap technique utilizing logical flap design, which is a combination of a Y-to-V flap with double opposing Z-plasties on the apex, that is well suited to this difficult problem. It is important to remove excess muscle and deep tissues underlying the flaps in the medial canthal region, which are present in blepharophimosis cases and contribute to the deformity in these patients. Medial canthal tendon resection and tucks or transnasal wiring are then performed. The technique has been utilized in 14 patients with a minimum of one year of follow-up over the past six years with good results.

+ The lateral tarsal strip revisited. The enhanced tarsal strip.

Jordan DR, Anderson RL.
The lateral tarsal strip procedure was originally designed for the treatment of upper and lower eyelid laxity, or lateral canthal tendon laxity or malposition. Despite the excellent results with a standard tarsal strip procedure for those eyelids with laxity and excess skin, we have encountered a number of patients with lower eyelid or canthal malpositions or both who would benefit from a tarsal strip, but who do not have lax tissues (especially skin), and may in fact have a shortage of skin. These include cases of lower lid retraction or canthal malposition following trauma, blepharoplasty, or other operations, and patients with tendency toward or having cicatricial ectropion. Any anterior lamella removal in such patients would aggravate the lid malposition and weaken the lateral canthal tissues to be sutured. We suggest a modification of the tarsal strip (developed by one of us [R.L.A.]) to treat many such patients without requiring additional anterior lamella (skin graft) or more formidable procedures. We refer to this technique as the "enhanced tarsal strip" technique, and we use this technique more frequently than the original tarsal strip procedure.

+ Unicanalicular stent for nasolacrimal duct obstruction.

Jordan DR, Anderson RL, Patrinely JR.
The authors describe a method for silicone intubation of a single patent canaliculus associated with a nasolacrimal duct obstruction. Although bicanalicular intubation is always preferable when possible, unicanalicular stenting is necessary when only one canaliculus is patent. A chief advantage of this technique is that the lacrimal stent is inaccessible to the child and thus cannot be accidentally pulled out.

1988

+ Anatomy of the orbicularis oculi and other facial muscles.

Patrinely JR, Anderson RL.
Publication

+ CO2 laser treatment of eyelid syringomas.

Nerad JA, Anderson RL.
Syringomas are benign epithelial tumors of the sweat glands. The diffuse nature of these raised tumors makes surgical treatment difficult. Three patients with eyelid syringomas were successfully treated with CO2 laser vaporization. CO2 laser therapy appears to be a safe and effective mode of treatment for these benign superficial eyelid tumors.

+ Cyclic AMP-dependent protein kinase opens chloride channels in normal but not cystic fibrosis airway epithelium.

Li M, McCann JD, Liedtke CM, Nairn AC, Greengard P, Welsh MJ.
Chloride (Cl-) secretion by the airway epithelium regulates, in part, the quantity and composition of the respiratory tract fluid, thereby facilitating mucociliary clearance. The rate of Cl- secretion is controlled by apical membrane Cl- channels. Apical Cl- channels are opened and Cl- secretion is stimulated by a variety of hormones and neurotransmitters that increase intracellular levels of cyclic AMP (cAMP). In cystic fibrosis (CF), a common lethal genetic disease of Caucasians, airway, sweat-gland duct, secretory-coil and possibly other epithelia are anion impermeable. This abnormality may explain several of the clinical manifestations of the disease. The Cl- impermeability in CF-airway epithelia has been localized to the apical cell membrane, where regulation of Cl- channels is abnormal: hormonal secretagogues stimulate cAMP accumulation appropriately but Cl- channels fail to open. Here we report that the purified catalytic subunit of cAMP-dependent protein kinase plus ATP opens Cl- channels in excised, cell-free patches of membrane from normal cells, but fails to open Cl- channels in CF cells. These results indicate that in normal cells, the cAMP-dependent protein kinase phosphorylates the Cl- channel or an associated regulatory protein, causing the channel to open. The failure of CF Cl- channels to open suggests a defect either in the channel or in such an associated regulatory protein.

+ Full-thickness unipedicle flap for lower eyelid reconstruction.

Anderson RL, Jordan DR, Beard C.
We developed a technique for lower eyelid reconstruction using a full-thickness unipedicle flap from the upper tarsal portion of the upper eyelid. The lost tissue is replaced with identical tissue from the ipsilateral upper eyelid. The technique is best suited to shallow defects of the temporal lower eyelid. The levator aponeurosis and Müller's muscle are recessed to avoid upper eyelid retraction. The key to performing this operation is a thorough knowledge of eyelid anatomy and preservation of its microvascular supply. This procedure has produced satisfactory to excellent results in 17 patients and offers the reconstructive surgeon several advantages over other techniques.

+ Hemangioblastoma of the optic nerve. Report of a case and review of literature.

Nerad JA, Kersten RC, Anderson RL.
The authors present a case of an optic nerve hemangioblastoma in a young woman with von Hippel-Lindau disease. The initial diagnosis was made by incisional biopsy. Tumor growth led to progressive proptosis and loss of light perception. Excision was carried out by lateral orbitotomy. Clinically and radiographically, the tumor resembled an optic nerve meningioma or glioma. Review of the other known cases offers no information as to the potential spread of this benign tumor from the intraorbital optic nerve to the optic canal. Optic nerve hemangioblastoma must be considered in the differential diagnosis of optic nerve tumors in patients with or without von Hippel-Lindau disease.

+ Local side effects of botulinum toxin injections.

Patrinely JR, Whiting AS, Anderson RL.
Publication

+ Monocanalicular silicone intubation.




+ Optic nerve involvement as the initial manifestation of sarcoidosis.

Jordan DR, Anderson RL, Nerad JA, Patrinely JR, Scrafford DB.
Sarcoidosis is a multisystem granulomatous disease of unknown cause. It may have several diverse manifestations that may be progressive yet develop slowly. Ocular disease may occur with inactive systemic disease. We describe two patients in whom optic nerve involvement was the first manifestation of sarcoidosis and clinically mimicked an optic nerve tumour. Sarcoidosis involving the optic nerve should be considered when an optic nerve tumour is suspected.

+ Optic nerve sheath fenestration in pseudotumor cerebri. A lateral orbitotomy approach.

Tse DT, Nerad JA, Anderson RL, Corbett JJ.
In patients with pseudotumor cerebri accompanied by loss of vision, optic nerve sheath fenestration is an effective route to prompt recovery of vision. A lateral orbitotomy approach to decompression of the optic nerve is appropriate for the ophthalmologist with adequate orbital experience. A rectangular window of dura and arachnoid, measuring approximately 3 X 5 mm, is excised from the bulbous portion of the optic nerve. It is important that the arachnoid within the window is excised because an intact arachnoid is an effective barrier to cerebrospinal fluid egress. The use of operating microscope, microsurgical instrument, and microdissecting techniques are emphasized. Twenty-eight patients (40 eyes) with progressive visual loss were treated by surgical nerve sheath fenestration. A study of the indications, results, and complications of this procedure is presented in a companion article.

+ Orbital emphysema: a potentially blinding complication following orbital fractures.

Jordan DR, White GL Jr, Anderson RL, Thiese SM.
A case of visual loss due to orbital emphysema secondary to a blow-out fracture of the orbit is presented. Because vision returned to 20/20 following an optic nerve decompression procedure, we hypothesize that our patient developed a compressive optic neuropathy with ischemia due to the emphysema. Essential instructions concerning the injury that the emergency physician should give the patient suffering an orbital blow-out are also presented.

+ Results of optic nerve sheath fenestration for pseudotumor cerebri. The lateral orbitotomy approach.

Corbett JJ, Nerad JA, Tse DT, Anderson RL.
Twenty-eight patients with pseudotumor cerebri underwent 40 optic nerve sheath fenestrations for relief of visual loss or to preserve vision. Twenty women and eight men underwent 16 unilateral fenestrations and 12 bilateral operations. Papilledema disappeared or was strikingly reduced in 24 of 28 patients. The other four patients had gliotic discs (two patients) or were followed up for only a short time. Visual acuity improved in 12 of 40 eyes and remained the same in 22 of 40 eyes. Seventeen eyes had preoperative visual acuity of 20/30 or better. In six eyes visual acuity decreased. Of eight eyes operated on that had visual acuity of 20/200 or worse, only three showed improvement. Visual fields improved in 21 of 40 eyes and remained the same in ten eyes. Five of the ten eyes that did not change had poor vision before surgery. Eight eyes in five patients continued to lose acuity postoperatively. Each of these eight eyes had a concomitant loss of visual field. An additional two eyes developed visual field loss with preserved visual acuity. The indications for surgery are early evidence of progressive loss of visual field or acuity in a patient with pseudotumor cerebri. Severe vision loss presents little opportunity for improvement but fenestration may be used in a last effort to preserve or restore vision.

+ Simultaneous bilateral conjunctival and orbital lymphoma presenting as a conjunctival lesion.

Mamalis N, Mackman G, Holds JB, Anderson RL, Apple DJ, Scholes G.
A 44-year-old man with the diagnosis of a conjunctival lymphoma in the left eye was also found on further evaluation to have a lymphoma in the opposite orbit. The patient had no systemic signs of the disease, and was treated with localized radiation therapy. Although simultaneous presentation of lymphoma affecting the conjunctiva in one eye and the orbit on the opposite side is rare, any patient with an isolated conjunctival lymphoma should have a careful evaluation of the opposite eye and orbit, including an orbital computed tomographic scan to rule out simultaneous involvement.

+ Surgical management of blepharospasm.

Anderson RL, Patrinely JR.
Publication

+ The diagnosis of sarcoidosis.

Jordan DR, Anderson RL, Nerad JA, Scrafford DB.
The diagnosis of sarcoidosis depends on the clinical and radiologic features along with histologic evidence of epithelioid-cell granulomas on biopsy. The amount of histologic support required varies inversely with the certainty with which the pattern of clinical features is recognized. It is essential to exclude other recognized causes of granulomatous disease. On the basis of our experience and that of other workers, we believe that sarcoidosis must be considered in the differential diagnosis when optic nerve thickening is encountered on CT, MRI or echography. Chest roentgenography is the easiest way to confirm the diagnosis. However, as many as 15% of patients will have a normal x-ray film, and other tests may be needed to help confirm the diagnosis. Biopsy of the involved tissues may be the only way to make the diagnosis. Once a provisional diagnosis is made, investigation for systemic sarcoidosis should include chest roentgenography, determination of the serum ACE level, 67Ga scanning, pulmonary function studies, testing for delayed skin reactions (with tuberculin, C. albicans, Trichophyton and mumps virus) and blood studies (determination of the erythrocyte sedimentation rate and levels of immunoglobulins, albumin, calcium and alkaline phosphatase). Finally, conjunctival biopsy is simple to do and is quite useful in supporting the diagnosis if no other tissue is readily available.

+ Water balloon orbitopathy.

Holds JB, Anderson RL, Teske M.
Publication

1987

+ A preliminary report on the Universal Implant.

Jordan DR, Anderson RL, Nerad JA, Allen L.
Extrusion and time-consuming surgical techniques required of implantation have been the major criticisms of quasi-integrated implants such as the Iowa Implant. With these concerns in mind, the Universal Implant (Oculo-Plastik, Montreal) has been designed to offer the motility advantages seen with quasi-integrated implants and the ease of placement of a sphere. The Universal Implant incorporates most of the advantages seen in the Iowa Implant and other quasi-integrated implants. In addition, the Universal Implant (1) utilizes a faster surgical technique for implantation; (2) avoids cleaning the muscles; (3) has lower, more rounded, smaller mounds that should decrease the late extrusion rate; (4) can be used as an enucleation implant, evisceration implant, or secondary implant; and (5) has a greater girth and larger radius of the posterior surface that helps support orbital fat and tissues, resulting in a more natural superior sulcus. Considering that the Iowa Implant is presently not available, the Universal Implant should be used by those surgeons who were pleased with the former implant and should be considered as a reasonable alternative to other enucleation implants.

+ A simple procedure for adjusting eyelid position after aponeurotic ptosis surgery.

Jordan DR, Anderson RL.
An aponeurotic approach to ptosis surgery elevates the eyelid without sacrificing the elevating and supporting structures or the tear-producing glands. With this preservation of normal anatomy, reoperation by the technique described herein for the adjustment of overcorrections or undercorrections and contour abnormalities is simple to carry out in the first three weeks after surgery and has yielded good to excellent results in 32 of 34 patients.

+ Carbon dioxide (CO2) laser therapy for conjunctival lymphangioma.

Jordan DR, Anderson RL.
Lymphangiomatous tissue involving the ocular adnexa may be difficult to manage because this highly vascular, unencapsulated tissue intermingles freely with normal adnexal structures. Hemostasis is difficult to obtain, and important ocular and periocular structures are damaged easily. We have successfully treated two individuals who had extensive conjunctival involvement of their lymphangioma with the carbon dioxide (CO2) laser. The CO2 laser permits a precise form of treatment with the ultimate form of hemostasis (tissue vaporization), resulting in minimal trauma, edema, and scarring, and thus offers a safe alternative to surgical excision of these lesions.

+ Full-thickness bipedicle flap for total lower eyelid reconstruction.

Anderson RL, Weinstein GS.
We describe a technique for total lower eyelid reconstruction utilizing a full-thickness bipedicle flap from the upper eyelid. The levator aponeurosis and Müller's muscle are recessed to avoid upper eyelid retraction. The key to performing this operation is a thorough knowledge of eyelid anatomy and techniques for preserving its microvascular blood supply. The bipedicle flap requires meticulous surgical technique but has many advantages over standard types of total lower eyelid reconstruction, including the following: excellent tissue match and cosmesis are obtained with single-stage reconstruction; distal flaps and grafts are avoided; open palpebral fissure is maintained, resulting in rapid rehabilitation; posterior lamella of tarsus, rather than substitute, is utilized; anterior lamella of functional orbicularis is utilized for support and closure; pedicles suspend and support the eyelid, decreasing lower eyelid retraction, laxity, and ectropion; allows simultaneous reconstruction of canthal defects; and is faster than other forms of total lower eyelid reconstruction. The results of 14 total lower eyelid reconstructions are presented. Minor canthal deformities, the most frequent complication, are easily corrected. This technique should be considered as an alternative to other procedures in cases of total lower eyelid reconstruction.

+ Hemifacial spasm. Results of unilateral myectomy.

Garland PE, Patrinely JR, Anderson RL.
Hemifacial spasm (HFS) is a disorder characterized by unilateral involuntary spasm of the muscles innervated by the facial nerve (cranial nerve VII). The etiology is often a redundant or ectatic artery in the cerebellopontine angle that compresses the facial nerve. Neurosurgical decompression with implantation of a sponge between the ectatic artery and the facial nerve produces good results, but has a high complication rate and a poor patient acceptance rate. Various modes of peripheral neurectomy have also been advocated, but the recurrence rate is high and the preexisting functional and cosmetic eyelid deformities are exacerbated. The results of unilateral periorbital myectomy in 21 HFS patients are presented. Follow-up ranging from 1 to 7 years was available on 16 patients. Excellent or good results were obtained in 94% of these cases, and postoperative complications were minor. Transient lymphedema and forehead anesthesia are the most common complications. An unforseen benefit of periorbital myectomy surgery is the improvement or relief of lower facial contractions that occurred in 75% of patients. The authors believe the myectomy procedure is a safe, effective, predictable therapy for those HFS patients unwilling to risk a neurosurgical operation, and allows simultaneous reconstruction of associated eyelid and eyebrow deformities.

+ Macrocystic enlargement of orbital dermis-fat grafts.

Patrinely JR, Anderson RL, Shore JW.
Acquired cysts represent an unusual but significant complication of orbital dermis-fat grafts. We report two cases of late postoperative enlargement of dermis-fat grafts: First, macrocystic enlargement occurring in both orbits with severe microphthalmia; second, cystic enlargement occurring in a dermis-fat graft for anophthalmia following an earlier evisceration. Both graft enlargements were due to epithelial-lined cysts that developed within the graft tissue. These cysts were treated by excising the cysts walls and allowing the resultant cavity to heal spontaneously. Light microscopy of the excised tissue revealed that the clear cysts were lined by a non-keratinizing, stratified squamous epithelium. The histogenesis of the cysts is unclear, but most likely they are the result of incompletely removed or implanted conjunctival or corneal epithelium. Several other possibilities are discussed. Due to the difficulty of removing all corneal and conjunctival epithelium, cystic complications of dermis-fat grafts make unattractive their use for volume enhancement in patients with microphthalmia or following evisceration.

+ Metastatic disease first presenting as eyelid tumors: a report of two cases and review of the literature.

Morgan LW, Linberg JV, Anderson RL.
We present two unusual cases in which an eyelid tumor was the first sign of metastatic disease. The first involved a 53-year-old man with pulmonary carcinoma and the second a 71-year-old man with malignant lymphoma. Fifteen similar cases from the literature are reviewed. The most frequent primary lesion is breast carcinoma in women, which appears as a diffuse lesion of one or two eyelids. Metastatic lung carcinoma in men appears as solitary nodules, representing the second-most common type of lesion. The questions of left- or right-side predominance, age and sex of patients, types of tumors, and prognosis are discussed.

+ Neuroleptics antagonize a calcium-activated potassium channel in airway smooth muscle.

McCann JD, Welsh MJ.
We examined the effect of neuroleptics on Ca-activated K channels from dog airway smooth muscle cells. Because these agents inhibit a variety of other Ca-mediated processes, it seemed possible that they might also inhibit Ca-activated K channels. In excised, inside-out patches, several neuroleptics potently and reversibly inhibited the K channel from the internal but not the external surface of the patch. Measurements of the effect on open probability and open- and closed-state durations support a simple kinetic model in which neuroleptics bind to and block the open channel. Inhibition by neuroleptics was moderately voltage dependent, with blockers less potent at hyperpolarizing voltages. The relationship between voltage and the dissociation constant for the blocker suggests that the binding site is one-third of the way across the channel's electrical field. Equilibrium dissociation constants for the drug-channel complex were: haloperidol, 1.0 +/- 0.1 microM; trifluoperazine, 1.4 +/- 0.1 microM; thioridazine, 2.4 +/- 0.1 microM; and chlorpromazine, 2.0 microM. This rank-order potency is different from their potency as calmodulin inhibitors, which suggests that neuroleptics bind to the channel rather than a calmodulin-channel complex.

+ Obtaining fascia lata.

Jordan DR, Anderson RL.
The surgical procedure for obtaining fascia lata can be easily carried out by the ophthalmic surgeon. However, anatomy related to obtaining the tissue, as outlined in standard surgical textbooks, is not entirely accurate and should be clarified. The tissue necessary for strong frontalis slings should come from a thick band of fascia lata referred to as the "iliotibial tract." If one attempts to obtain fascia lata by directing a fascia stripper along an imaginary line directed from the head of the fibula to the anterior iliac spine, as suggested in most textbooks, an inadequate specimen may be obtained. The iliotibial tract of fascia lata actually runs from the lateral tibial condyle to the iliac crest. The fascia stripper, therefore, needs to be directed along an imaginary line from the lateral tibial condyle to the iliac crest to obtain the strongest fascia lata and avoid transecting the longitudinal fibers.

+ Orbital cyst formation associated with Gelfilm use.

Loftfield K, Jordan DR, Fowler J, Anderson RL.
Two patients developed cystic lesions in the anterior orbit 21 and 26 months after repair of blow-out fracture with orbital floor Gelfilm implants. Both patients had associated motility disturbances. Both lesions were surgically excised and found to be cystic in nature and filled with glistening gelatinous material consistent with partially absorbed, encysted gelatin film (Gelfilm). Histologically, a fibrous capsule was present; the contents of the cyst were not pathologically identifiable since they dissolved during fixation. Postoperatively, the motility disturbances improved in each patient.

+ Paranasal sinusitis, orbital abscess, and inflammatory tumors of the orbit.

Reidy JJ, Giltner J, Apple DJ, Anderson RL.
We present the clinical, radiological, and histopathological findings from a case of unilateral inflammatory mass of the right orbit, originating in the ipsilateral paranasal sinuses. A connection between inflammatory tumors of the orbit and paranasal sinusitis has been suspected for many years. This case shows a definite association between chronic paranasal sinusitis, orbital cellulitis, subperiosteal abscess, and formation of an inflammatory orbital tumor. Early diagnosis combined with appropriate therapeutic measures is essential in order to prevent adverse consequences, which can include severe visual loss.

+ Prevention of prolapsed silicone stents in dacryocystorhinostomy surgery.

Jordan DR, Anderson RL.
Publication

+ Skin flaps in periorbital reconstruction.

Patrinely JR, Marines HM, Anderson RL.
Soft tissue defects of the periorbital region are best repaired with local skin or skin-muscle flaps. Flaps have functional and aesthetic advantages over skin grafts in that they provide a better color and texture match to the thick periorbital skin. The general physiological and biomechanical principles of skin flap survival and orientation are discussed with modification according to peculiarities of the periorbital area. The four basic groups of skin flaps are the sliding flap, advancement flap, rotation flap, and transposition flap. Selected standard and modified designs of each group are illustrated, and each surgical technique is described in stepwise fashion. The specific applications of the flaps to periorbital reconstruction are emphasized. The indications for use of various skin flaps, the local factors involved in flap selection, and proper preoperative planning are also discussed.

+ The treatment of advanced choroidal melanoma with massive orbital extension.

Rini FJ, Jakobiec FA, Hornblass A, Beckerman BL, Anderson RL.
Four patients, each with a history of choroidal melanoma for more than ten years, became increasingly proptotic secondary to massive extraocular extension of their tumors. Because no metastases were detected during thorough systemic examinations, two patients underwent orbital exenteration. These patients suffered fulminant local orbital regrowth of their tumors at three and six months after surgery and died of distant metastases within ten months of exenteration. A third patient, who underwent a biopsy of the orbital mass via a lateral orbitotomy and received postoperative radiotherapy, died two years afterward. A fourth patient who refused any surgical treatment was followed up for five years after massive orbital disease developed. She died of disseminated disease. The patients who survived the longest had minimal or no surgery.

+ Unilateral blepharochalasis.

Langley KE, Patrinely JR, Anderson RL, Thiese SM.
We present two unique cases of unilateral blepharochalasis. Blepharochalasis is an idiopathic disorder of young adults manifested by intermittent, recurrent episodes of eyelid edema. After repeated episodes of swelling, the periorbital tissue develops premature aging with thinned, redundant skin and stretching of the eyelid tendons. Blepharochalasis is considered bilateral; unilateral cases are extremely rare. Ptosis surgery in these cases may be unpredictable due to alterations in the levator aponeurosis. Simple reattachment of the apparent edge of the disinserted levator aponeurosis may cause significant overcorrection and variations in postoperative eyelid heights. Our two unilateral cases demonstrated proptosis on the affected side, and prominent vessels in the levator aponeurosis and suborbicularis muscle planes, plus vascular changes in orbital fat in one case. Blepharochalasis therefore may be an orbital rather than a periorbital disease, as suggested previously. Proptosis is probably overlooked in the usual bilateral cases. When all other causes of unilateral swelling have been ruled out and the findings are consistent with blepharochalasis, this diagnosis should be considered.

+ Whitnall's sling, not a "new procedure".

Anderson RL.
Publication

+ Wound necrosis following dacryocystorhinostomy in patients with Wegener's granulomatosis.

Jordan DR, Miller D, Anderson RL.
Two patients with Wegener's granulomatosis underwent dacryocystorhinostomy (DCR) for nasolacrimal duct obstruction and epiphora. Wound necrosis occurred in each individual with the formation of a nasal-cutaneous fistula. A pedicle flap was the treatment of choice in one case, while direct closure of the necrotic incision site and high-dose steroid therapy was used in the other. Both did well with complete wound healing. The tearing persisted in one and resolved in the other. Dacryocystorhinostomy should be avoided whenever possible in patients with Wegener's granulomatosis, and steroid dosage should be increased if surgery is necessary in the presence of active inflammation.

1986

+ A review of lacrimal drainage surgery.

Patrinely JR, Anderson RL.
The advent of improved silicone intubation sets, increased understanding of lacrimal and nasal anatomy and physiology, and refinements in surgical instrumentation and technique have led to higher success rates in lacrimal surgery. Recent clinical studies, combined with new techniques in canalicular reconstruction, have helped identify which patients will benefit from surgical intervention and which techniques are indicated. Fortunately, this has greatly reduced the number of CDCRs necessary.

+ Acquired blepharophimosis in a patient with juvenile blepharospasm.

Patrinely JR, Anderson RL.
At 4 years of age, a young girl with Schwartz-Jampel syndrome developed blepharospasm with resultant blepharophimosis. Her eyelids and facial features had been normal until that time. While these rare ocular abnormalities may be present together in patients with this syndrome, the relationship between them has not been explained. We theorize that constant orbicularis squeezing in the pediatric age group retards full eyelid development and leads to acquired blepharophimosis.

+ Calcium-activated potassium channels in canine airway smooth muscle.

McCann JD, Welsh MJ.
Airway smooth muscle cells from canine trachealis muscle were dispersed by treatment with collagenase and elastase. Cells were identified as smooth muscle by their binding of anti-smooth muscle gamma-isoactin monoclonal antibodies and by their contraction in response to acetylcholine. The patch-clamp technique was used to study single channel currents in cell-attached and isolated patches of membrane. The most common single channel currents had a conductance of 266 +/- 12 pS (mean +/- S.D., n = 7) in symmetrical 135 mM-K solutions. The reversal potential of the channel was unaltered by large chemical gradients for Cl, Na and Ca and was determined exclusively by the chemical K gradient. Thus, the channel is highly selective for K. In both cell-attached and isolated patches of membrane, depolarization increased the frequency of channel opening and the duration of the open state. In isolated patches of membrane, increasing [Ca] on the cytoplasmic side of the membrane from 10(-8) to 10(-6) M increased both the frequency of channel opening and the duration of the open state. Tetraethylammonium, tetramethylammonium, or Cs (10 mM) on the cytoplasmic side of the membrane caused a voltage-dependent decrease in conductance of the open channel while having no obvious effect on channel kinetics. These blocks were completely reversible. Ba (10 mM) on the cytoplasmic side of the membrane slightly decreased inward currents and completely blocked outward currents through the channel. External Ba (10 mM) caused a voltage-dependent decrease in inward current. External tetraethylammonium (10 mM) completely blocked single channel currents.

+ Mohs' micrographic technique.

Anderson RL.
Publication

+ Tarsal rotational flap for upper eyelid reconstruction.

Kersten RC, Anderson RL, Tse DT, Weinstein GL.
Reconstruction of full-thickness defects in the upper eyelid presents a special challenge to the oculoplastic surgeon. We present and discuss a new, surgically simple technique for posterior lamella reconstruction of the upper eyelid, which can also be used with other procedures. The surgical technique calls for a vertical strip of tarsus (tarsal flap) to be rotated horizontally and sutured to canthal tendon remnants or periosteum at the orbital rim. This procedure has produced satisfactory to excellent results in our test group, and presents the reconstructive surgeon with several advantages over other techniques.

+ The septal pulley in frontalis suspension.

Patrinely JR, Anderson RL.
We present a modification of the frontalis suspension for blepharoptosis, first described in 1937, that eliminates many of the drawbacks of traditional brow suspension techniques. Functional and cosmetic problems with standard suspension procedures are related to the superficial location of the sling in the eyelid, which leads to unsatisfactory geometric tenting of the pretarsal and preseptal skin, obliteration of the lid crease, and a pulling away of the upper lid from the globe with brow elevation. Eyelid height is also limited by the upper lid being pulled away from the globe. By anchoring the suspensory material behind the superior orbital septum near the arcus marginalis, more physiologic vectors of elevation are transmitted to the upper eyelid. This modification has yielded good cosmetic and functional results in 96 cases of frontalis suspension using both autogenous and allosplastic materials, and it deserves to be more widely used.

1985

+ Advances in eyelid malpositions.

Nowinski T, Anderson RL.
Publication

+ Advances in orbital surgery.

Nowinski T, Anderson RL.
Advances in diagnostic modalities, orbital anatomy, pathophysiology of orbital disorders, and surgical techniques have allowed a more functional and safer approach to orbital surgery. Recent and future research commitments to orbital disease will continue to advance our knowledge in this complex, rapidly evolving field.

+ Age of aponeurotic awareness.

Anderson RL.
Publication

+ Delayed socket granuloma formation following evisceration.

Weinstein GS, Anderson RL.
We report a rare granuloma of the socket that simulated a conjunctival squamous cell carcinoma in a patient treated with evisceration six and a half years earlier. An excisional biopsy revealed loose connective tissue with marked capillary proliferation and lymphocytic infiltration. The cut end of a silicone exoplant, used to treat a preceding traumatic retinal detachment, was found at the base of the lesion. Prior operative procedures should be reviewed in patients presenting with socket lesions to exclude the presence of an iatrogenic foreign body.

+ Eyelid tattooing. A sign of the times.

Anderson RL.
Publication

+ Idiopathic inflammatory perioptic neuritis simulating optic nerve sheath meningioma.

Dutton JJ, Anderson RL.
Between 1976 and 1982, we examined 13 patients with clinical and radiographic findings consistent with optic nerve sheath meningioma. All patients had visual loss, evidence of optic nerve dysfunction, centrocecal visual field defects, and echographic and computed tomographic evidence of optic nerve or sheath enlargement. All underwent surgery for biopsy or excision of their presumed tumors. However, adequate histologic sampling of all lesions failed to demonstrate meningioma in four patients; two of these four showed inflammatory infiltration of the dural sheath, whereas the other two showed only edematous or dense fibrous tissue. There was no evidence of other systemic disease in any of these cases. We conclude that optic nerve or sheath enlargement, probably induced by an idiopathic inflammatory perioptic neuritis, may simulate a sheath meningioma. Proper diagnosis requires biopsy confirmation.

+ Intracellular calcium regulates basolateral potassium channels in a chloride-secreting epithelium.

Welsh MJ, McCann JD.
The two individual cell membranes of epithelia are functionally coupled, so that changes in apical membrane conductance are paralleled by changes in basolateral K+ conductance. However, the signal that regulates basolateral K+ conductance, thereby coupling the two membranes, is unknown. We tested the hypothesis that the cellular calcium concentration, [Ca2+]c, may regulate basolateral K+ conductance in canine tracheal epithelium, a Cl- -secreting epithelium that shows marked membrane coupling. Three findings support the hypothesis. First, the intracellular Ca2+ antagonist 8-(diethylamino)octyl 3,4,5-trimethoxybenzoate hydrochloride (TMB-8) attenuated the secretory response. Second, the secretagogue epinephrine increased [Ca2+]c, as measured with quin-2. Third, we found a K+ channel that was activated by Ca2+ on the cytosolic side of the membrane. Thus, cytosolic Ca2+ regulates the basolateral K+ conductance and may be the signal responsible for functional coupling of the two cell membranes.

+ The medial spindle procedure for involutional medial ectropion.

Nowinski TS, Anderson RL.
Involutional medial ectropion responds poorly to traditional ectropion procedures. Eversion of the lacrimal punctum must be functionally corrected to reestablish normal corneal wetting physiology as well as tear-lake drainage. We describe our retropunctal approach with emphasis on a new, enhanced closure that utilizes the lower eyelid retractors. This stabilizes the medial eyelid margin in order to obtain and maintain good functional and cosmetic results. This procedure allows a predictable anatomic approach that is easily performed and can be combined with other procedures, such as a lateral tarsal strip, medial canthal tendon plication, or skin graft or flap, when required.

+ The role of orbital exenteration in choroidal melanoma with extrascleral extension.

Kersten RC, Tse DT, Anderson RL, Blodi FC.
The management of choroidal melanoma with extrascleral extension has been a subject of controversy with some proposing orbital exenteration whenever extrascleral extension is demonstrated and others feeling it to be of no value in increasing survival. We reviewed the cases of 43 patients with extrascleral extension of choroidal melanoma. Although five-year survival had previously been demonstrated to be significantly improved in patients undergoing early orbital exenteration at our institution, extended follow-up in 16 consecutive cases revealed ultimate tumor related mortality to approach that of patients refusing exenteration. Only in cases with nonencapsulated or surgically transected extension did exenteration appear to improve survival. In ten cases with delayed recurrence of tumor in the orbit, exenteration proved to be palliative rather than curative.

+ The use of a periosteal strip for eyelid reconstruction.

Weinstein GS, Anderson RL, Tse DT, Kersten RC.
Strips of periosteum from the zygoma were used to reconstruct very extensive lateral canthal and temporal eyelid defects in 11 patients. The strips were reflected nasally, sutured to residual tarsal stumps, and covered anteriorly with myocutaneous flaps. After a minimum follow up of one year, cosmesis was excellent in five patients, satisfactory in five, and poor in one. Minor complications related to this procedure included ectropion and low lateral contour (one patient each), blunting of the lateral canthal angle (three patients), eyelid notching and dehiscence (one patient each), and symblepharon formation (one patient). However, only one patient had a complication that was significant enough to require a second surgery. This technique allows for one-stage reconstruction, an open palpebral fissure, and the ability to reconstruct extensive loss of the temporal portion of two adjacent eyelids when sharing techniques are not possible.

1984

+ Canalicular cystocele.

Weinstein GS, Tse DT, Reese PD, Anderson RL.
We report a rare case of acquired canalicular cystocele in a patient with obstructions at both the proximal and distal ends of the inferior canaliculus. Histopathologic examination revealed a dilated tubule lined with nonkeratinizing squamous epithelium that measured 19 mm long and 7 mm wide. No mucous secreting goblet cells were observed in any sections. The fibrotic, thickened wall was infiltrated with epithelioid, lymphoid, and occasional plasma cells.

+ Combined clinical and computed tomographic diagnosis of orbital glioma and meningioma.

Jakobiec FA, Depot MJ, Kennerdell JS, Shults WT, Anderson RL, Alper ME, Citrin CM, Housepian EM, Trokel SL.
The clinical information on 22 patients with orbital optic nerve gliomas and 47 patients with meningiomas was correlated with computed tomographic findings obtained in both axial and coronal studies. Most of the gliomas occurred in children, although 7 patients presented after 20 years of age. Among the patients with meningiomas, the majority were women in early middle age, although two tumors occurred in children less than 20 years of age. Low grades of proptosis (median, 2 mm for both tumors), frequent significant visual field obscurations with eye movements, and opto-ciliary shunt vessels pointed toward the diagnosis of an optic nerve tumor. Patients with gliomas generally manifested massively swollen fusiform optic nerves with clear-cut margins due to circumscription by an intact dura. Kinks and bucklings of the optic nerve as well as infarctive cysts distinguished the glioma CT-scan patterns from the meningiomas. Distinctive axial CT-scan features of the meningiomas not shared by the gliomas were narrowly and diffusely enlarged nerves with polar expansions either at the orbital apex or immediately behind the globe; calcification; irregular excrescent margins signifying extradural invasion into the orbital soft tissues; a negative optic nerve shadow running down the center of the lesion; and bone erosion near the orbital apex. Coronal studies often revealed irregular margins signifying transgression of the dura. A diffusely and narrowly enlarged optic nerve shadow with regular margins (intrasheath lesions) was the one morphologically overlapping pattern displayed by 11 meningiomas and three gliomas. In these cases there tended to be more profound visual loss in the gliomas compared with the meningiomas, as well as the more frequent presence of opto-ciliary vessels in the meningiomas. Arteriography may be helpful in this particular category by demonstrating a tumor blush for the meningiomas, whereas this finding is typically absent with optic nerve gliomas. Meningiomas may be very closely simulated by dural or intraneural inflammations.

+ Combined surgery and cryotherapy for scleral invasion of epithelial malignancies.

Dutton JJ, Anderson RL, Tse DT.
Three patients with epithelial malignancies of the ocular adnexa, a basal cell carcinoma, a squamous cell carcinoma, and a malignant melanoma, are presented. All three had invasive tumors with scleral involvement. In an attempt to preserve the globe, treatment consisted of local surgical excision without lamellar or full thickness sclerectomy , followed by cryotherapy utilizing a double cycle freeze-thaw- refreeze technique to the underlying scleral bed and areas of suspected residual tumor. All three patients have been followed from 24 to 37 months without change in their initial visual acuity and without clinical recurrence of tumor. Although this combined surgical and cryosurgical approach cannot be advocated as a primary mode of therapy, it may offer a useful alternative to enucleation or exenteration in selected patients with ocular invasion of tumor in whom more radical surgery may be visually incapacitating or not otherwise feasible.

+ Cyanoacrylate adhesive used to stop CSF leaks during orbital surgery.

Tse DT, Panje WR, Anderson RL.
Butyl-2-cyanoacrylate (Histoacryl Blue) tissue adhesive successfully sealed three cases of CSF leaks encountered during orbital surgery. The application of tissue adhesive was followed by prompt cessation of leak. We have found this tissue adhesive to be a valuable technical adjunct in the intraoperative management of this difficult problem and have not seen any general or local toxic reaction to the material.

+ Hematoporphyrin derivative photoradiation therapy in managing nevoid basal-cell carcinoma syndrome. A preliminary report.

Tse DT, Kersten RC, Anderson RL.
Hematoporphyrin derivative (HpD) is a photodynamically active dye that is preferentially retained by malignant tissues and initiates a cytotoxic reaction when exposed to red light. Normal tissues adjacent to a tumor retain HpD to a lesser degree and are thus spared damage from the light-induced reaction. We describe the treatment of 40 basal-cell carcinomas in three patients with nevoid basal-cell carcinoma syndrome. All treated lesions showed disappearance of clinically apparent tumor within four to six weeks, and there was no damage to surrounding skin. Thirty-three lesions (82.5%) showed complete response on biopsy findings, while seven showed residual tumor cells. The recurrence rate was 10.8%, with the follow-up ranging from 12 to 14 months. Tumor response was related to the total light dose delivered and the size and location of the tumor.

+ Levator myectomy in synkinetic ptosis.

Dillman DB, Anderson RL.
A procedure for obliterating levator palpebrae superioris function is useful in stopping synkinetic movements of the upper lid in jaw winking and related disorders. The central element of the procedure is division of the levator muscle above Whitnall's ligament. This process obliterates the synkinetic movement completely without extensive dissection and injury to eyelid structures. Eight patients observed for up to five years have had complete and permanent resolution of synkinesis with no complications.

+ Orbital malignant melanoma and oculodermal melanocytosis: report of two cases and review of the literature.

Dutton JJ, Anderson RL, Schelper RL, Purcell JJ, Tse DT.
Oculodermal melanocytosis is a congenital melanoblastic hamartoma affecting ocular tissues and facial skin. It is seen more commonly in oriental and black patients. Malignant degeneration, once believed to be rare in this syndrome, occurs in 4.6% of all reported cases, and is more frequent in whites. The actual incidence of malignant melanoma in this syndrome is difficult to determine as many uncomplicated cases go unreported. The most common site of malignant melanoma associated with this entity is in the choroid. Four previously described orbital tumors represent the second most frequent area of presentation. A review of the literature in this disease is discussed as well as a new case of orbital malignant melanoma associated with it. A second case of presumed orbital melanoma associated with oculodermal melanocytosis is also discussed.

+ Oriental eyelids. An anatomic study.

Doxanas MT, Anderson RL.
Dissection of the eyelids and sagittal sections of the orbital blocks identified the anatomic features of the oriental eyelids responsible for their unique appearance. The basic distinction involves the formation of the eyelid crease and fold. In the occidental eyelid, the orbital septum fuses with the levator aponeurosis below the superior tarsal border. However, in the oriental eyelid, the orbital septum fuses with the levator aponeurosis below the superior tarsal border. The accompanying preaponeurotic or orbital fat is allowed to proceed to the anterior tarsal surface, resulting in a full or thickened eyelid. The inferior extension of the orbital septum, beyond the superior tarsal border, prevents anterior aponeurotic fibers from fanning toward the subcutaneous tissues to produce the normal eyelid crease. Appreciation of the unique anatomic features of oriental eyelids is important for those persons who evaluate or surgically explore these eyelids.

+ Petriellidium (Allescheria) boydii orbital and brain abscess treated with intravenous miconazole.

Anderson RL, Carroll TF, Harvey JT, Myers MG.
A previously healthy 4-year-old boy suffered a penetrating injury to his left orbit and left frontal lobe, which resulted in an infection by Petriellidium boydii. The patient was successfully treated with intravenous miconazole and multiple debridements.

+ Trochleitis with superior oblique myositis.

Tychsen L, Tse DT, Ossoinig K, Anderson RL.
Thirteen patients complained of recent fluctuating aching of one orbit, punctuated by stabbing pains. All had exquisite point tenderness over the trochlea and in half of the patients the pain was aggravated by eye movement. Standardized A-scan echography demonstrated swelling of the peritrochlear tissue and thickening of the superior oblique muscle with low internal acoustic reflectivity, typical of myositis. CT scan showed a soft tissue density in the region of the trochlea. Biopsy, performed on two patients, revealed peri-trochlear inflammation. In all patients the symptoms resolved within a period of weeks or months: indomethacin or naproxen were not effective, but oral or locally injected corticosteroids shortened the course compared to no treatment. None of the patients had ptosis, proptosis, Brown's syndrome, or a click, nor did they have echographic or radiographic signs of sinusitis or inflammation away from the trochlea. This probably represents a highly localized subtype of idiopathic orbital inflammation ("pseudotumor").

1983

+ A new modification of the standard lacrimal groove director for nasolacrimal intubation.

Tse DT, Anderson RL.
We devised a new lacrimal groove director, designed for the atraumatic and easy retrieval of the Crawford metal probe. This instrument alleviates many of the problems encountered with the use of the Crawford hook.

+ Aponeurosis disinsertion in congenital entropion.

Tse DT, Anderson RL, Fratkin JD.
Lower lid retractor aponeurosis disinsertion is a well-recognized etiologic factor in many involutional entropion cases, but to our knowledge it has not previously been reported as a cause of congenital entropion. Four congenitally entropic lower eyelids in three patients with no history of birth trauma were all found to have retractor disinsertion during exploratory procedures. All four eyelids were surgically corrected by reinserting the retractors to the inferior tarsal margin. Detailed histologic studies of orbicularis oculi muscle fibers in two cases showed no evidence of fiber hypertrophy. This finding refutes the commonly accepted concept of orbicularis muscle hypertrophy as an etiologic mechanism of congenital entropion.

+ Bilateral congenital lacrimal sac mucoceles with nasal extension and drainage.

Divine RD, Anderson RL, Bumsted RM.
A newborn infant with bilateral mucoceles of the lacrimal sacs also had submucosal masses along the floor of the nose beneath the inferior turbinates communicating with the mucoceles. Drainage of the mucoceles was performed by needle aspiration and wide marsupialization of the nasal masses into the nose under direct visualization. To our knowledge, this is the first time that intranasal extension of mucoceles has been reported, and the first time that lacrimal sac mucoceles have been successfully treated via direct nasal drainage. We advocate careful nasal evaluation in cases of congenital lacrimal sac mucoceles to determine whether intranasal extension is common and whether intranasal drainage can be curative.

+ Compressive optic neuropathy following use of intracranial oxidized cellulose hemostat.

Dutton JJ, Tse DT, Anderson RL.
A 35-year-old white male sustained head injuries in a motor vehicle accident. He underwent neurosurgical repair of a frontotemporal skull fracture and lacerated left frontal lobe; regenerated oxidized cellulose (Surgicel) was placed into the anterior cranial fossa for hemostasis. Forty-eight hours after surgery he suffered rapid deterioration of vision to no light perception from optic nerve compression. Radiologic and echographic evaluation demonstrated a subperiosteal soft tissue density in the orbital apex consistent with hematoma. At surgery for optic canal decompression, the cellulose hemostat was found in the apex of the left orbit, having migrated through orbital roof fractures, and had apparently caused the compressive optic neuropathy. Decompression resulted in return of vision to the level of counting fingers.

+ Necrobiotic xanthogranuloma of the eyelid.

Codère F, Lee RD, Anderson RL.
Necrobiotic xanthogranuloma with paraproteinemia is characterized by multiple nodules or plaques that involve the periorbital area along with other parts of the body. A dysproteinemia due to an IgG paraprotein is associated with the condition; low serum complement, cryoglobulinemia, leukopenia, and hyperlipemia are also sometimes seen. Multiple myeloma is present in some cases. Two cases of necrobiotic xanthogranuloma with IgG monoclonal gammopathy were seen. Both initially had ocular symptoms and in the second case, the ocular manifestations have dominated the clinical picture. Histologically, these granulomas are characterized by collagen necrobiosis and by the presence of many foamy histiocytes and Touton giant cells. Because necrobiotic xanthogranuloma with monoclonal gammopathy frequently has prominent manifestations in the orbital region, may result in dysfunction of the eyelids or extraocular muscles, and is associated with potentially life-threatening systemic conditions, its recognition by the ophthalmologist is important.

+ Nitrous oxide cryotherapy for intraepithelial epithelioma of the conjunctiva.

Divine RD, Anderson RL.
Nine patients were treated with the nitrous oxide eyelid cryoprobe for large or recurrent intraepithelial epithelioma of the conjunctiva or cornea. Nitrous oxide cryotherapy is more convenient for ocular cryosurgery than liquid nitrogen therapy and seems to be as effective for intraepithelial epithelioma. Surgical debulking of the lesion is recommended before cryosurgery. An obvious advantage of cryosurgery over surgical modalities for intraepithelial epithelioma is that large areas of tumor as well as surrounding tissues can be treated. This procedure results in a higher cure rate and avoids grafting and symblepharon formation. The complications of light cryosurgery seem to be minor even when the cornea is treated. Heavy cryosurgery may result in severe iritis, posterior synechiae, and corneal scarring. A biopsy-proved diagnosis of intraepithelial epithelioma can be misleading and does not rule out the presence of underlying malignant disease.

1982

+ A periorbital approach to blepharospasm.

Anderson RL.
Publication

+ Bilateral Candida albicans dacryocystitis with facial cellulitis.

Codère F, Anderson RL.
Candida albicans rarely infects the lacrimal drainage system. This paper describes a case of bilateral C. albicans dacryocystitis following midfacial trauma. The patient presented with recurrent facial cellulitis and a fistula opening onto the cheek. The condition was controlled only after bilateral dacryocystorhinostomy along with amphotericin B therapy. This appears to be the first reported case in which the lacrimal sacs acted as a reservoir for microorganisms causing recurrent facial cellulitis.

+ Cryosurgery of the ocular adnexa.

Anderson RL.
Publication

+ Dominantly inherited blepharoptosis, high myopia, and ectopia lentis.

Gillum WN, Anderson RL.
A previously undescribed syndrome of bilateral blepharoptosis, ectopia lentis, and high myopia apparently was dominantly inherited and originated from a spontaneous genetic mutation. The syndrome seems to be caused by a decrease in the tensile strength of the levator aponeurosis, the zonules, and the sclera.

+ External dacryocystorhinostomy. A prospective study comparing the size of the operative and healed ostium.

Bumsted RM, Linberg JV, Anderson RL, Barreras R.
This study compares the size of the operative anastomosis with the size of the healed intranasal ostium resulting from 22 external dacryocystorhinostomies. The area of the healed intranasal ostium was approximately 2% of the area of the surgical anastomosis. No correlation was found between the size of the surgical anastomosis and the size of the healed ostium. In all cases, excellent functional results were obtained, regardless of the size of the healed ostium. This study suggests the size of the surgical anastomosis is not directly related to the success of the procedure, although it must be large enough to technically perform the procedure.

+ Metastatic carcinoid unresponsive to radiation therapy presenting as a lacrimal fossa mass.

Divine RD, Anderson RL, Ossoinig KC.
A case of metastatic carcinoid tumor presenting as a lacrimal fossa mass is described. This appears to be only the fourth case report of metastatic carcinoid to the orbit and the first to include ultrasound evaluation. the tumor mass did not regress despite radiation therapy as documented on serial ultrasound examinations. Therapeutic implications of this finding are discussed. Metastatic carcinoid tumors are reviewed.

+ Metastatic small cell carcinoma masquerading as orbital myositis.

Divine RD, Anderson RL.
A case of discrete metastases to an extraocular muscle from a silent small cell carcinoma is described. Clinically, diagnostically, and pathologically this masqueraded as orbital myositis. It was not until a full thickness muscle biopsy was obtained that the diagnosis was realized. The need for deep biopsy is stressed. Discrete metastases to an extraocular muscle without other orbital soft tissue involvement is rarely reported. This is the first reported case from a small cell primary tumor. Metastatic orbital disease is discussed.

+ Optic nerve blindness following blunt forehead trauma.

Anderson RL, Panje WR, Gross CE.
Publication

+ Orbital decompression in Graves ophthalmopathy.

Anderson RL.
Publication

+ Results in eyelid malignancies treated with the Mohs fresh-tissue technique.

Anderson RL.
Publication

+ Study of intranasal ostium external dacryocystorhinostomy.

Linberg JV, Anderson RL, Bumsted RM, Barreras R.
A rigid endoscope was used to directly examine, measure, and photograph the intranasal ostium created by an external dacryocystorhinostomy (DCR). This technique was used to examine 19 patients who underwent 22 standard external DCRs. All patients had clinically successful results, documented by a positive Jone I dye test following surgery. The dimension of the bony opening created at surgery was measured and averaged 11.84 mm in diameter. The average diameter of the healed intranasal ostium was only 1.80 mm. No statistically valid correlation between the size of the bony opening and the final size of the healed intranasal ostium could be established. Thus, a large surgical anastomosis did not necessarily result in a large healed intranasal ostium. Excellent functional results were obtained even when the intranasal ostium was quite small. Other indications for the use of this technique are discussed.

+ Techniques in eyelid wound closure.

Divine RD, Anderson RL.
While one of the most basic techniques in eyelid surgery is the repair of an eyelid defect that involves the margin, many eyelid defects are still poorly repaired; and much confusion still exists in this area. Based upon sound anatomic and surgical principles, we suggest several modifications of classically described techniques: (1) The greyline suture is replaced by a tarsal suture through the meibomian gland orifices to provide a stronger closure and better alignment. (2) All tension of closure is supported by the deep tarsal sutures rather than by the margin sutures to avoid notch formation or unsightly scars. (3) A two-layered closure where orbicularis and tarsus is closed in a single layer is technically easier and gives results comparable to the classically taught three-layered closure. Conjunctival sutures in the tarsal portion of the eyelid are unnecessary and frequently cause corneal irritation. (4) When lid resection is performed, a pentagonal excision rather than a "V" or wedge resection should be used to minimize tension on the margin when closed. We present in an illustrated step-by-step fashion our preferred technique which gives consistently good results.

+ The management of meibomian gland carcinoma.

Harvey JT, Anderson RL.
We present nine cases of sebaceous adenocarcinoma seen on the Oculoplastic Service at the University of Iowa over the past five years. It is essential to make the biopsy-proven diagnosis of meibomian gland adenocarcinoma promptly, using multiple full thickness eyelid biopsies. We recommend the Mohs' fresh-frozen technique in patients with surgically resectable lesions, exenteration in those with orbital extension, and radical neck dissection for cases with nodal involvement. Radiotherapy may be indicated in patients with extensive tumors who cannot tolerate or refuse surgery or as an adjunct to surgery in others.

+ The tarsal strip.

Anderson RL.
Publication

1981

+ Bilateral visual loss after blepharoplasty.

Anderson RL.
Publication

+ Blepharospasm surgery. An anatomical approach.

Gillum WN, Anderson RL.
Essential blepharospasm is an idiopathic, progressively debilitating disease leading to blindness. Years of forceful spasms result in brow ptosis, dermatochalasis, and, frequently, levator aponeurosis and lateral canthal tendon defects. Following standard neurectomy procedures, the facies droop, brow ptosis and dermatochalasis worsen, and ptosis and canthal tendon laxity suddenly become more evident. We describe a procedure involving meticulous extirpation of all accessible orbicularis oculi, procerus, corrugator superciliaris, and facial nerves in postorbicular fascia. This extirpation of eyelid protractors is combined with browplasty with fixation to frontalis and reinforcement of the levator aponeurosis to strengthen the retractors. Our technique opens the eye just as effectively as standard facial neurectomy procedures, simultaneously corrects associated anatomical deformities, and avoids facial paralysis. Gratifying results were obtained in 15 patients followed up for six to 38 months.

+ Complications of cryosurgery.

Wood JR, Anderson RL.
We describe 70 patients who underwent cryosurgery to the lids during a two-year period. Of the 58 receiving adequate follow-up, approximately one fourth had complications thought to be directly caused by cryosurgery. These include visual loss, lid notching, corneal ulcer, acceleration of symblepharon formation, xerosis, cellulitis, activation of herpes zoster, skin depigmentation, and severe soft-tissue reaction. In addition, 9% of the lids showed possible induction of trichiasis in areas adjacent to treatment. More than two thirds of patients with conjunctival shrinkage or grafted or irradiated lids had adverse effects, with one case of permanent visual loss. Misdirected lashes were successfully eliminated with a single double freeze-thaw technique in 90% of lids treated. Cryosurgery for aberrant lashes and some benign lid lesions is the most effective method of therapy presently available, but one must be aware of its potential complications. It has a low complication rate in "normal" lids, but should be used with caution in patients with conjunctival shrinkage or in those with grafted and/or irradiated lids.

+ Giant cell (reparative) granuloma of the orbit.

Hoopes PC, Anderson RL, Blodi FC.
Clinically and histologically, there exists considerable controversy as to what constitutes a giant cell tumor. There is an increasing awareness that the term giant cell tumors should not be used indiscriminately in describing lesions of the mandible, maxilla, and facial bones which contain multinucleated giant cells. This paper reports a rare case of giant cell reparative granuloma of the orbit. The differentiation between giant cell reparative granuloma and the true giant cell tumor is discussed and a description of the visual symptomatology associated with these lesions of th sphenoid bone is presented. These tumors must be removed completely to prevent recurrence.

+ Lid lag and lagophthalmos: a clarification of terminology.

Harvey JT, Anderson RL.
Lid lag, lagophthalmos and von Grafe's sign are useful terms which refer to important clinical signs. Despite the fact that they have discrete meanings, they are often used interchangeably and incorrectly by many ophthalmologists and, therefore, their value has been degraded. We provide definitions for these commonly used (but often confused) ophthalmic terms: Lagophthalmos is the inability to completely close the eyes; Lid lag is the static situation in which the eyelid is higher than normal with the globe in downgaze; and von Grafe's sign is a dynamic sign describing the retarded descent of the eyelid during movement of the globe from primary position to downgaze. It is our hope that these terms will be adopted by the ophthalmic community so that precision in definition will lead to clarity of thought and communication.

+ Lid splitting and posterior lamella cryosurgery for congenital and acquired distichiasis.

Anderson RL, Harvey JT.
Congenital distichiasis is a rare condition with an accessory row of lashes at the Meibomian gland orifices. We suggest "acquired distichiasis" as an appropriate term for the accessory row of lashes in or near the Meibomian gland orifices, occurring as a result of such conditions as Stevens-Johnson syndrome, ocular pemphigoid, or chemical and physical injuries. We report a new treatment technique in which the eyelid is divided along the gray line then followed by cryotherapy to the posterior lid lamella. This removes the distichiatic lashes without damaging the normal lashes in the anterior lid lamella and avoids depigmentation. Histologic examination demonstrates the aberrant lashes result from a metaplasia of tissues in or around the Meibomian glands. Thirteen eyelids with acquired distichiasis and four eyelids with congenital distichiasis have been followed up for eight to 48 months. All have been greatly improved.

+ Reversible visual loss in subperiosteal hematoma of the orbit.

Gillum WN, Anderson RL.
A 19-year-old white male developed blindness in the left eye following a motor vehicle accident. Orbital echography and computerized axial tomography established the diagnosis of subperiosteal hematoma of the orbit. Emergency medical therapy and lateral canthotomy resulted in slight visual improvement but rebleeding occurred 12 hours after injury with visual loss. An emergency surgical decompression of the orbit was performed. Vision returned to 6/7.5 following decompression. This is the first report illustrating that orbital decompression can reverse complete visual loss from a subperiosteal hematoma of the orbit.

+ Sinus involvement in inflammatory orbital pseudotumor.

Eshaghian J, Anderson RL.
Orbital pseudotumor is a difficult diagnosis to establish preoperatively. The relationship between sinus disease and orbital pseudotumor is controversial. We describe two patients with unilateral proptosis, diplopia, palpable orbital masses, ocular discomfort, and sinus problems of short duration. Echographically, both had low reflective masses in the orbit and the adjacent sinuses. Roentgenograms and echograms were interpreted as showing erosion of the bony orbital wall. A presumptive diagnosis of sinus malignant neoplasm with orbital extension was made. Sinus histopathologic examination in one case and nasal histopathologic examination in the other showed chronic inflammatory changes compatible with the diagnosis of pseudotumor. At orbitotomy, one patient had vessels communicating between the orbital and sinus lesions, and both patients had irregular pitting of the bone next to the histologically proved orbital pseudotumors. The lytic erosive changes predicted preoperatively were not present. Simultaneous orbital and sinus pseudotumors seem to be a distinct clinicopathologic entity. Those concerned with the diagnosis and management of orbital disease should be aware of this entity.

+ Sudden blindness following facial trauma.

Panje WR, Gross CE, Anderson RL.
Blindness following facial trauma may occur with what appears to be a minor insult to the periorbital area. This report deals with our experience in treating five patients who had sudden blindness following frontal head trauma. Unselected optic nerve decompression was in general unrewarding in reversing blindness. However, the early administration of pharmacologic doses of corticosteroids does appear effective in reversing blindness in this select patient population and may indicate which patient is a good candidate for decompression. Examination of holographic experiments performed on dried skulls, in addition to clinical findings, appears to suggest that the cause of blindness associated with frontal head trauma may be related to stretching of the optic nerve and not necessarily to compression.

+ Tarsal strip procedure for correction of eyelid laxity and canthal malposition in the anophthalmic socket.

Anderson RL.
Surgically anophthalmic sockets commonly have laxity of the lower eyelid, inferior displacement of the lower eyelid and lateral canthus, shallowing of the inferior fornix, and a deep superior sulcus. These deformities result in difficulty in prosthesis retention, pooling of tears and mucus, epiphora and lower eyelid irritation, and poor cosmesis with an appearance of facial asymmetry. The causes of these problems are numerous, but the main anatomic deformity is a marked laxity and elongation of the lateral canthal tendon. The tarsal strip procedure is ideal for correcting or improving these deformities simultaneously with one simple procedure. We are very pleased with our results in 26 patients with surgically anophthalmic sockets in which this procedure was utilized. We highly recommend the tarsal strip procedure not only to correct these conditions in anophthalmic sockets but in almost any condition where laxity of the eyelids or canthal malposition requires surgical correction.

+ The aponeurotic approach to eyelid retraction.

Harvey JT, Anderson RL.
A technique for the upper lid retraction that involves an anterior approach similar to aponeurotic ptosis surgery is presented. Instead of advancing the aponeurosis, it is recessed and Müller's muscle is completely extirpated. The lateral horn of the levator must be cut to relieve the marked temporal elevation of the eyelid. Lid height and contour are adjusted intraoperatively with patient cooperation. In the lower lid, the retractors are recessed via a conjunctival approach unless simultaneously performed with orbital decompression. Any amount of lid retraction may be corrected by this technique in the upper lid and up to 3 mm of lower lid retraction can be corrected. Lid height in both the upper and lower lid is lasting and predictable. Thirty-one patients (63 eyelids) have been operated on using this technique with good results. Results in 17 patients (35 eyelids) with follow-up ranging from 8 to 42 months are presented.

+ Transorbital approach to decompression in Graves' disease.

Anderson RL, Linberg JV.
Patients with Graves' disease have an increased volume of orbital tissue that sometimes results in serious functional and cosmetic problems. Visual loss may result from optic nerve compression in the orbital apex. Surgical decompression provides space for expansion of orbital tissues and often results in dramatic improvement. A transorbital approach to decompression of the orbit, appropriate for the ophthalmologist with adequate orbital experience, is presented. A lower eyelid incision is used in the manner of exploring a blow-out fracture. The majority of the orbital floor and the entire ethmoidal complex are removed. Removal of bone to the orbital apex is emphasized in cases of optic neuropathy. A comparative study of the indications, results, and complications of this procedure vs other techniques of decompression for Graves' disease is presented in a companion article.

+ Transorbital decompression. Indications and results.

Linberg JV, Anderson RL.
In a few patients with Graves' disease, visual loss related to an optic neuropathy develops. Clinical and radiologic evidence suggests that the mechanism of visual loss is optic nerve compression in the orbital apex. Steroids may offer improvement, but often the condition recurs unless high doses are maintained. Orbital decompression provides dramatic visual and cosmetic improvement in most cases. A transorbital approach suitable to the experienced orbital surgeon for decompression of the orbital floor and medial wall has been presented in a companion article. Results of this approach in 12 eyes with visual loss unmanageable by steroid therapy indicate a gratifying improvement in vision. Strabismus is the most frequent complication. Results with follow-up ranging from six to 18 months are encouraging and comparable to the results obtained with other methods of surgical decompression.

1980

+ Adenoid cystic carcinoma of the lacrimal gland in a child.

Dagher G, Anderson RL, Ossoinig KC, Baker JD.
An unusual case of adenoid cystic carcinoma of the lacrimal gland occurred in an 11-year-old child. Clinical, echographic, and histopathologic characteristics, as well as the management of this usually fatal disease, are discussed. The subtle signs and symptoms of this tumor were noted at the age of 9 years. A review of the literature reveals this to be the youngest patient in whom this tumor has been reported.

+ Amblyopia in ptosis.

Anderson RL, Baumgartner SA.
Amblyopia can result from strabismus, anisometropia, media opacities, and congenital disorders such as nystagmus. Complicated forms of ptosis (ie, associated with neurofibroma or hemangioma) are also known to cause amblyopia. A previously unconfirmed cause of amblyopia is uncomplicated ptosis. We carefully examined 123 consecutive surgical ptosis patients with uncomplicated congenital or early acquired ptosis. Twenty-five cases of amblyopia (20%) were seen. Four cases (3.2%) were thought to be caused by the ptosis. In two of these cases (1.6%), the amblyopia was directly attributed to the ptosis. In one of the remaining two cases, exotropia and amblyopia developed on the ptotic side while the patient was being observed for the ptosis. In another patient, a progressively increasing cylindrical refractive error and amblyopia developed, which were attributed to the ptosis. We recommend careful evaluation of cases of congenital ptosis for the detection and treatment of amblyopia.

+ Bilateral visual loss after blepharoplasty.

Anderson RL, Edwards JJ.
Blindness following blepharoplasty is a well-documented complication. Removal of orbital fat is common to most cases in which such blindness occurs. We present a patient who was referred to us following blepharoplasty involving orbital fat removal in all four lids with subsequent onset of bilateral visual loss. Visual acuity in the right eye has remained no light perception and in the left eye improved from 20/400 to 20/20 following bilateral orbital decompression. An electroretinogram was within normal limits in both eyes. A normal response from the visual evoked response in the left eye and an abnormal response from the visual evoked response in the right eye indicate ganglion cell damage or visual pathway disruption in the right eye, probably secondary to optic nerve ischemia. We conclude that the small nutrient vessels to the optic nerve are more easily compromised than the central retinal artery and are responsible for the visual loss in many of these cases. We believe this to be the first documented case of bilateral visual loss following blepharoplasty and the first electrophysiological study demonstrating the pathophysiology of blindness following blepharoplasty. We advocate rapid orbital decompression to treat this catastrophic complication.

+ Loxoscelism of the eyelids.

Edwards JJ, Anderson RL, Wood JR.
Loxoscelism is a reaction to the bite of spiders of the genus Loxosceles. Several species have been found in the United States; the most commonly encountered is L reclusus, the small brown recluse spider. Two types of reactions occur from the bite. In the localized type, necrotic loxoscelism, a cutaneous lesion with extensive gangrene develops. About 25% of patients have systemic manifestations of viscerocutaneous loxoscelism. There is the same local reaction, but, in addition, fever, chills, vomiting, joint pain, and hematologic abnormalities occur. Hemoglobinemia and hemoglobinuria suggest severe involvement. Deaths are believed to be caused by massive intravascular hemolysis. We describe a 61-year-old man who was bitten on the periorbital region; viscerocutaneous loxoscelism with gangrenous involvement of the eyelids developed. Severe laryngeal edema from regional, massive swelling of his neck was life threatening.

+ Orbicularis oculi muscle in chronic progressive external ophthalmoplegia.

ghian J, Anderson RL, Weingeist TA, Hart MN, Cancilla PA.
Orbicularis oculi muscle biopsies were performed in 38 patients (ten with chronic progressive external ophthalmoplegia and 28 controls) to determine whether ragged red fibers were present and, if so, whether they were specific to progressive external ophthalmoplegia. To our knowledge, the orbicularis muscle has not been previously studied in this regard. Ragged red fibers were seen in the orbicularis oculi in patients with and without ophthalmoplegia, although they were more abundant in patients with ophthalmoplegia. The limb muscles of patients with ophthalmoplegia showed ragged red fibers. Electron microscopy demonstrated that these fibers contain either abnormal or increased numbers of normal mitochondria. Thus, the presence of ragged red fibers in the orbicularis oculi muscle is not limited to patients with chronic progressive external ophthalmoplegia, and the diagnosis of this disorder with ragged red fibers should be based on a combination of clinical and laboratory findings, including those from a limb muscle biopsy.

+ Phospholine iodide toxicity and Jones' tubes.

Wood JR, Anderson RL, Edwards JJ.
A 72-year-old man with epiphora secondary to bilateral canalicular stenosis resulting from long-term treatment with 0.125% to 0.25% echothiophate iodide (phospholine iodide) drops for glaucoma underwent bilateral conjunctivodacryocystorhinostomies with Jones' tubes. Within days after undergoing this surgery, he experienced severe unexplained diarrhea, fatigue, weight loss, and prostration. He cancelled his postoperative ophthalmic appointment because of "medical illness." He required admission to his local hospital where extensive studies were done in an attempt to establish the cause of this life-threatening condition. After stopping the echothiophate iodide drops, all symptoms disappeared within two days. Drug toxicity is a previously unreported complication of conjunctivodacryocystorhinostomy, and this case demonstrates that topical medications have enhanced systemic absorption after lacrimal surgery with placement of fistulizing prosthetic devices. One must be aware of this possible complication, not only with long-acting anticholinesterases, but with topical sympathomimetic drugs (especially in cardiac patients) as well as cycloplegic agents in children.

+ Preserved irradiated homolgous cartilage for orbital reconstruction.

Linberg JV, Anderson RL, Edwards JJ, Panje WR, Bardach J.
Human costal cartilage is an excellent implant material for orbital and periorbital reconstruction because of its light weight, strength, homogeneous consistency and the ease with which it can be carved. Its use has been limited by the necessity of a separate surgical procedure to obtain the material. Preserved irradiated homologous cartilage has been shown to have almost all the autogenous cartilage and is concenient to use. Preserved irradiated homologous cartilage transplants do not elicit rejection reactions, resist infection and rarely undergo absorption.

+ Strabismus in ptosis.

Anderson RL, Baumgartner SA.
Two hundred twenty-six consecutive surgical ptosis cases were carefully evaluated to establish the incidence of strabismus in ptosis. The overall incidence of strabismus in surgical ptosis patients was found to be 36%. Most remarkable were the findings in 113 congenital ptosis patients; 32% of these patients were found to have strabismus. Only 44% of these patients had entities previously described associating strabismus with ptosis. It is postulated that in four of the congenital ptosis patients (3.5%), strabismus developed as a result of their ptosis. In one of these patients, strabismus and amblyopia developed while the patient was being observed prior to ptosis surgery. This study demonstrates the need for careful ocular motility evaluation in all patients with ptosis. Ocular motility evaluation and follow-up is especially important in congenital ptosis, where the ptotic lid may, in fact, precipitate strabismus and amblyopia.

1979

+ Aponeurotic defects in congenital ptosis.

Anderson RL, Gordy DD.
Levator aponeurosis disinsertion is an accepted etiologic factor in some acquired ptosis cases, but it has not previously been reported as a cause of congenital ptosis. Forty-six congenitally ptotic eyelids in 36 patients with no history of birth trauma were surgically explored and three eyelids were found to have levator disinsertions. All three cases were treated by aponeurotic repair with excellent results. These cases and suggestions that help to preoperatively identify congenitally ptotic eyelids with levator disinsertions are presented. We feel the aponeurotic approach to ptosis correction is applicable to cases of congenital ptosis with at least 5 mm of function.

+ Aponeurotic ptosis surgery.

Anderson RL, Dixon RS.
The recognition of defects in the levator aponeurosis associated with a renewed interest in eyelid anatomy has led to a revival of aponeurotic surgery. We describe our approach with emphasis on techniques that help obtain and maintain avascular planes throughout surgery. The advantages of this approach include preservation of (1) tear-producing structures, (2) Müller's muscle and Whitnall's ligament, and (3) normal anatomical planes and structures of the eyelid. Our results indicate that this technique is the procedure of choice for acquired ptosis cases. It also gives good results in congenital ptosis cases with at least 5 mm of function. Overcorrection at surgery is necessary in all cases. Tucking of the aponeurosis is to be avoided as no raw healing surfaces are obtained. Results in 60 eyelids with a minimum follow-up of one year are presented.

+ Indications, complications and results with silicone stents.

Anderson RL, Edwards JJ.
Fifty-two patients with complicated lacrimal problems were treated with silicone stents. Our overall success rate, judging from a minimum 6-month follow-up, was 40% in these complicated cases, accepting only positive dye tests as our criteria for success. We divided these cases into six groups with successes ranging from 0--68%. Twenty-nine percent of patients had complications related to their stents. While silicone stents are probably the most important recent advance in lacrimal surgery, one must be aware of their indications, limitations and complications.

+ Medial ectropion. A new technique.

Anderson RL, Hatt MU, Dixon R.
Medial ectropion of the lower lid responds poorly to standard ectropion procedures. This region contains the initial parts of the nasolacrimal excretory system, which must be functionally reestablished. A new surgical approach to medial ectropion consists of a Z-plasty transposition skin flap from the upper to the lower lid, a plication of the lower crus of the medial canthal tendon, and a punctoplasty. The posterior and superior contraction forces in the transposition flap enhance and maintain the result. Seven lids have been successfully operated on with this technique from the functional and cosmetic point of view.

+ Modified lacrimal groove director for nasolacrimal intubation.

Anderson RL, Edwards JJ.
Publication

+ Neuromyopathic ptosis: a new surgical approach.

Anderson RL, Dixon RS.
Neuromyopathic ptosis is a progressive disorder frequently associated with other ocular abnormalities. These include dry eyes, absent Bell's phenomenon, protractor weakness, and heterotropia. Thus, correction of this ptosis has not been well described and is avoided by many surgeons. Since ptosis usually occurs early in life, correction is of functional, economic, and cosmetic importance. Clinical and histologic findings suggest that degeneration and defects of the levator aponeurosis contribute to the ptosis. During the past two years, we have used the aponeurotic approach to correct neuromyopathic ptosis. We describe 19 eyelids with a minimum one-year follow-up. Most eyelids were purposely undercorrected. A mean lid elevation of 3.3 mm with good symmetric results was obtained. Procedures were performed under local anesthesia. Advantages of this technique are (1) patient cooperation for adjustment of lid height and contour at surgery; (2) preservation of other suspensory structures (Müller's muscle and Whitnall's ligament); (3) easy adjustment of lid height postoperatively; (4) preservation of all tear-producing structures; (5) avoidance of corneal irritation from posterior sutures; and (6) maintenance of anatomic planes, which simplifies reoperation, if necessary. We believe this conservative approach corrects most eyelids with neuromyopathic ptosis.

+ Reconstruction by myocutaneous eyelid flaps.

Anderson RL, Edwards JJ.
The combined loss of skin and deeper tissues of the eyelids and periorbital regions can frequently be reconstructed with use of an eyelid myocutaneous flap. This technique alone can be used for most eyelid defects not involving the lid margin, or it can be used in conjunction with other procedures when the lid margin is involved. Defects, sometimes quite large, in 37 patients have been reconstructed with good results. The technique provides one-stage reconstruction, avoids volume loss and depressed scars, provides an excellent blood supply to the flap, gives an optimum tissue match, decreases patient morbidity, and increases the likelihood of a good cosmetic result. The generalized applications of this technique make it valuable for reconstructive surgery of the orbital region.

+ The role of Whitnall's ligament in ptosis surgery.

Anderson RL, Dixon RS.
Whitnall's ligament has been described functionally as a check ligament of the levator. Our anatomic dissections and operative findings indicate that this ligament is primarily a support for the upper eyelid and superior orbit. Whitnall's ligament is frequently confused with the levator horns and is unfortunately cut during many ptosis procedures. This is to be avoided because much larger levator resections are required when this ligament's support to the upper lid and the fulcrum effect for the levator are lost. Preserving and enhancing the function of Whitnall's ligament improves the efficiency of the levator, making large levator resections rarely necessary. We have noted no more lid lag than that seen with other forms of levator surgery.

+ The tarsal strip procedure.

Anderson RL, Gordy DD.
We have developed a procedure that is particularly useful for (1) paralytic or senile upper and lower eyelid laxity, (2) lateral canthal tendon laxity or malposition, and (3) iatrogenic phimosis associated with recurrent entropion or ectropion after traditional lid-shortening procedures. Lateral canthal tendon laxity or elongation is the primary problem in the majority of these cases, and eyelid tightening with use of lateral tarsal strips corrects this deformity. The midtarsal portion of the eyelid, which is usually resected in traditional lid-shortening procedures, is seldom elongated, and recurrences of laxity are common secondary to further stretching of lax tendons. The technique involves a lateral canthotomy and transection of the appropriate crus of the lateral canthal tendon. The eyelid is then split into anterior and posterior lamellae, and tarsal strips are fashioned from the posterior lamella. The tarsal strips are sutured to periosteum at the lateral orbital wall, adjusting the height and tension of the lateral canthus. This technique gives a normal appearance to the lateral canthal angle and has yielded good results in 51 cases.

+ The use of phenylephrine in eyelid cryosurgery.

Anderson RL, Edwards JJ.
Publication

+ The use of thymoxamine in eyelid retraction.

Dixon RS, Anderson RL, Hatt MU.
We observed substantial narrowing in 75% of fissures in patients with various types of lid retraction after topical application of aqueous 0.5% thymoxamine (moxisylyte). Even contralateral normal-appearing fissures in thyroid patients responded in this manner. The nonresponders in the lid retraction group included a patient with an orbital pseudotumor and patients with long-standing and stable euthyroid eye disease. No normal subjects' fissures responded greatly to thymoxamine. A substantial reduction in palpebral fissures was seen in all patients with thick extraocular muscles and in 14 of 18 (78%) of all fissures of thyroid patients; the average response was 2.3 mm. This effect may last for five hours after thymoxamine administration. Thymoxamine may be of use as a diagnostic test for thyroid eye disease, and if it can be modified to cause less ocular irritation

+ [Microscopically controlled excision of malignant eyelid tumors and subsequent reconstruction (author's transl)]

Hatt M, Anderson RL, Ceilley RI.
35 patients, most of whom had recurrent or large malignant eyelid tumors (33 basal cell carcinomas and 2 squamous cell carcinomas), underwent microscopically controlled excision (Mohs' fresh tissue technique). This approach guarantees a complete removal of the tumor, while conserving as much healthy tissue as possible. Short time follow-up studies have shown that plastic reconstruction gave good functional and cosmetic results.

+ [Ptosis surgery: anterior approach for levator aponeurosis shortening (author's transl)]

Hatt M, Anderson RL.
A simplified method for ptosis surgery has been used in 33 patients. The levator aponeurosis is exposed by the anterior approach. It is folded or excised and reattached to the anterior surface of the tarsus, matching the level and the contour of the two upper lids. The cosmetic appearance of the lid is improved by the skin closure technique. This method for ptosis surgery meets the anatomical and physiological needs best. It has given very satisfactory functional and cosmetic results.

1978

+ A multispecialty approach to the excision and reconstruction of eyelid tumors.

Anderson RL, Ceilley RI.
An ongoing study indicates that the Mohs' fresh tissue technique of tumor removal followed by eyelid reconstruction may be the most efficacious management of eyelid malignancies. Forty-seven recurrent, invasive or large eyelid and canthal tumors were excised by this method followed by eyelid reconstruction. The advantages of this approach are (1) a high cure rate, (2) conservation of tissue, (3) reduced operating room time, and (4) maximum utilization of specialty training.

+ Helminthosporium corneal ulcers.

Krachmer JH, Anderson RL, Binder PS, Waring GO, Rowsey JJ, Meek ES.
We studied four cases of Helminthosporium corneal ulcers from four different institutions. One case occurred in an immune-deficient infant, another in a patient three months after removal of a foreign body; the third case occurred in a patient with a corneal dystrophy who was wearing soft contact lenses and using topical corticosteroids; and the fourth occurred in a patient with a history of multiple foreign bodies. Antifungal sensitivities were performed in three cases and showed relatively good sensitivity to available antifungal medications; even though all four patients improved, there was poor correlation between in vitro sensitivities and clinical response.

+ Microscopically controlled excision of malignant neoplasms on and around eyelids followed by immediate surgical reconstruction.

Ceilley RI, Anderson RL.
Mohs' fresh-tissue technique of ablating malignant neoplasms is a highly reliable, yet conservative method of treating cutaneous cancers. Removal of such lesions on eyelids by this technique, followed by immediate reconstruction is a most efficacious way to manage them. Forty-seven cases of recurrent, invasive, or large carcinomas on eyelids and canthi were excised by this method followed by immediate reconstruction. The excisions were done by dermatologists specializing in Mohs' techniques and the reconstruction by an oculoplastic surgeon. The advantages of the combined procedures are: 1) high cure rate, 2) conservation of tissue, 3) reduced operating time, and 4) maximum utilization of specialized competence.

+ The blepharocardiac reflex.

Anderson RL.
The oculocardiac reflex is described as the triad of bradycardia, nausea, and faintness evoked by the stretching of ocular muscles, or by pressure on or within the eyeball. The trigeminal nerve is the afferent limb of this reflex; the efferent limb is the vagus nerve to the heart. This reflex was noted to occur from traction on the levator aponeurosis in five of 36 patients with ptosis, and from traction on the retractors of the lower eyelid in three of 11 patients with entropion. To our knowledge, this is the first documentation of eliciting this reflex by stretching the muscles of the eyelid. Electrocardiogram monitoring for early recognition of these cases, and the availability of an intravenous line with atropine for prompt treatment are strongly recommended. Careful manipulation of the upper and lower eyelid retractors and preoperative atropine therapy may help to reduce the incidence of this reflex.

+ The rubber glove graft for mucous membrane reconstruction.

Anderson RL.
Publication

1977

+ Gelfoam packing after dacryocystorhinostomy.

Anderson RL.
Publication

+ Medial canthal tendon branches out.

Anderson RL.
A previously undescribed, superior supporting branch of the medial canthal tendon has been found by careful cadaver dissection. This branch unites the common tendon to the frontal bone; thus, it provides a superior support to the medial canthus. The posterior portion of the medial canthal tendon is a thin and weak structure, as compared with its anterior companion. It inserts on the posterior lacrimal crest. While most surgeons contend that the posterior limb of the medial canthal tendon maintains the position of the medial canthus after either accidental or surgical disinsertion of the anterior tendon, it is likely that this superior supporting branch maintains the canthal position in these clinical conditions.

+ Surgical repair for distichiasis.

Anderson RL.
Publication

+ The levator aponeurosis. Attachments and their clinical significance.

Anderson RL, Beard C.
A detailed knowledge of the anatomy of the levator aponeurosis is required for the aponeurotic approach to ptosis. Yet, many misconceptions regarding the insertional attachments of this important structure are found in the literature. The levator aponeurosis inserts via a fan of fibers. The first insertional attachment curves anteriorly around the orbital septum to form the lid crease. Approximately the anterior half of the aponeurosis inserts into pretarsal orbicularis and the overlying subcutaneous tissue. The remaining posterior half inserts firmly on the lower portion of the tarsus.