Faculty Bibliography

PURPOSE/OBJECTIVE:To compare success rates of external dacryocystorhinostomy (DCR) and endoscopic endonasal DCR for acquired nasolacrimal duct obstruction (NLDO). DESIGN/METHODS:Retrospective, comparative, nonrandomized clinical study. PARTICIPANTS/METHODS: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/METHODS: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.

PURPOSE/OBJECTIVE:To evaluate the efficacy of transconjunctival Müller muscle recession and graded levator disinsertion for eyelid retraction in patients with thyroid-related orbitopathy (TRO). DESIGN/METHODS: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/CONCLUSIONS: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.

PURPOSE/OBJECTIVE:To evaluate the safety and efficacy of intralesional triamcinolone acetonide (TA) injection in primary and recurrent chalazia. DESIGN/METHODS:Retrospective, interventional, consecutive case series. PARTICIPANTS/METHODS: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/METHODS: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.

PURPOSE/OBJECTIVE: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/METHODS:Retrospective, comparative, nonrandomized clinical study. PARTICIPANTS/METHODS: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/METHODS: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.

PURPOSE/OBJECTIVE: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/METHODS:Interventional case series. PARTICIPANTS/METHODS: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/METHODS: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/CONCLUSIONS: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.

PURPOSE/OBJECTIVE:To compare surgical outcomes of internal (transconjunctival) vs external (subciliary) involutional entropion repair. DESIGN/METHODS: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/METHODS: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.

PURPOSE/OBJECTIVE: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/METHODS: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.