Faculty Bibliography

PURPOSE: : The purpose of this study was to investigate the prevalence of a common canalicular entrance in the lacrimal sac and to investigate the anatomy of the canalicular/lacrimal sac junction with direct visualization using a novel cadaveric dissection technique. METHODS: : Preserved cadavers were dissected to allow direct visualization of the canalicular entrance(s) to the lumen of the lacrimal sac. The prevalence of a common canaliculus and the anatomical variations of the canalicular/lacrimal sac mucosal fold of tissue were recorded. RESULTS: : One hundred twenty-four lacrimal systems (95 cadavers; 43 female, 52 male) were included in the study analysis. Overall, 123 lacrimal systems demonstrated a common canaliculus entering the lacrimal sac. Only one demonstrated 2 separate orifices (right orbit; male) in the sac (0.08%; 95% confidence interval, 0.1%-4.4%). Seventy-four lacrimal systems had some variation of a canalicular/lacrimal sac mucosal fold (59.7%). The remaining 50 (40.3%) had no visible canalicular/lacrimal sac mucosal fold. CONCLUSIONS: : This study provides direct anatomical evidence that the prevalence of separate canalicular orifices in the lacrimal sac is lower than previously reported (<1%). Additionally, the presence of a valve-like structure at the canalicular/lacrimal sac junction is common. These observations can potentially play a role in evaluating and treating lacrimal system pathology

The effectiveness of orbital decompression has been enhanced by the use of endoscopes in orbital decompressive surgery. In patients with severe proptosis and visual compromise, surgical intervention provides definitive therapy. Endoscopes have allowed for more complete removal of the bone posteriorly to the orbital apex under direct visualization, which has led to a decrease in morbidity. Two-wall decompression is now the minimum procedure that successfully achieves release of contents at the orbital apex. Whether the endoscope is used as an adjunct surgically or postoperatively to facilitate debridement, it has become an important tool in the armamentarium for the successful management of proptosis. The endoscopic view of posterior ethmoidal sinuses and the sphenoid sinuses enables the surgeon to successfully carry out a posterior decompression, and provides the opportunity to decompress the optic nerve if the need arises. 2011 Elsevier Inc

PURPOSE:: Canalicular stenosis is a frequent cause of epiphora. Patients with canalicular stenosis often require timely insertion of bicanalicular silicone stents to prevent permanent and complete closure of the canaliculi. This study reports the use of balloon canaliculoplasty in conjunction with silicone tube intubation in selected cases of canalicular stenosis. METHODS:: Patients with canalicular stenosis noted upon probing of the upper and lower lacrimal systems were included in the study. Patients with punctal stenosis underwent concurrent punctoplasty. Patients with complete canalicular obstruction were excluded from the study. The procedure was as follows. Canalicular dilation was achieved with 2 successive dilations of 90 seconds with a 2-mm-diameter balloon dilator, followed by probing and intubation of the lacrimal system with bicanalicular Crawford tubes. RESULTS:: Twenty-one eyes (41 canaliculi) of 12 patients (10 females, 2 males) with canalicular stenosis were included in this study. The average age was 64.5 +/- 7.5 years. Silicone tubes were left in place for an average 5.5 +/- 2.6 (range: 2 to 12) months. Mean follow up after tube removal was 6.2 +/- 1.1 months. Improvement within 1 week of the procedure was recorded in 20 out of 21 canaliculi (95.2%). Final clinical outcomes were successful or acceptable in 16 out of 21 eyes (76.2%). CONCLUSIONS:: Balloon canaliculoplasty with silicone tube intubation is simple and safe and appears to be an effective alternative treatment in patients with canalicular stenosis

Treating unilateral ptosis can be challenging and a proper preoperative evaluation may help prevent unexpected outcomes on the contralateral lid. Preoperative evaluation should include testing for Hering's law, which remains useful in understanding the phenomenon of induced contralateral eyelid retraction in the context of ptosis. Approximately 10% to 20% of patients with unilateral ptosis have some degree of induced retraction on clinical evaluation in the contralateral lid. When there is a positive Hering's test on preoperative examination, the surgeon should consider a bilateral ptosis procedure. The surgical approach to unilateral ptosis depends on the severity of the ptosis and its etiology, and the surgeon should be aware of which procedure is most likely to provide the best outcome in selected instances

BACKGROUND:: Postoperative complications of blepharoplasty range from cutaneous changes to vision-threatening emergencies. Some of these can be prevented with careful preoperative evaluation and surgical technique. When complications arise, their significance can be diminished by appropriate management. This article addresses blepharoplasty complications based on the typical postoperative timeframe when they are encountered. METHODS:: The authors conducted a review article of major blepharoplasty complications and their treatment. RESULTS:: Complications within the first postoperative week include corneal abrasions and vision-threatening retrobulbar hemorrhage; the intermediate period (weeks 1 through 6) addresses upper and lower eyelid malpositions, strabismus, corneal exposure, and epiphora; and late complications (>6 weeks) include changes in eyelid height and contour along with asymmetries, scarring, and persistent edema. CONCLUSIONS:: A thorough knowledge of potential complications of blepharoplasty surgery is necessary for the practicing aesthetic surgeon. Within this article, current concepts and relevant treatment strategies are reviewed with the use of the most recent and/or appropriate peer-reviewed literature available

A 40-year-old man presented with bradycardia, left eye pain, and intermittent nausea 1 day after blunt trauma to the left orbit. Imaging revealed a large orbital floor fracture with significant herniation of orbital contents but no obvious extraocualar muscle entrapment. Oculocardiac reflex was suspected, and the fracture was repaired surgically within 24 hours of presentation. His bradycardia resolved immediately postoperatively. This case is a unique presentation of the oculocardiac reflex in a large orbital floor fracture with significant herniation of orbital contents but without extraocualar muscle entrapment

PURPOSE: To describe and evaluate an office-based technique to adjust the Fasanella-Servat procedure in the first postoperative week. METHODS: This retrospective case series reviewed all consecutive eyelids undergoing the Fasanella-Servat procedure between July 1, 2006, and July 1, 2007, by a single surgeon (R.D.L.). Charts were reviewed to determine the frequency, timing, safety, and efficacy of postoperative adjustment. Postadjustment photographs were reviewed by a blinded ophthalmic plastic surgeon for eyelid contour, height, symmetry, overall cosmesis, and picture quality as excellent, satisfactory, or poor. RESULTS: The Fasanella-Servat procedure was performed on a total of 102 eyelids in 54 patients over the 12-month interval. Postoperative adjustments at the time of suture removal were performed to improve mild eyelid asymmetries for 22 eyelids (22%) in 19 patients. Postadjustment photographs, available for 17 patients, showed excellent eyelid contour (53%), height (88%), symmetry (82%), and cosmesis (65%). Satisfactory results were obtained in all remaining photographed eyelids. CONCLUSIONS: The Fasanella-Servat procedure should be viewed as an adjustable ptosis correction with the adjustment as a standard component of postoperative suture removal. This manipulation takes only a few moments with minimal to no patient discomfort. It allows for improvements in eyelid height and contour. This series demonstrates a procedure that is simple, highly successful, and safe