MR imaging of orbital inflammatory syndrome, orbital cellulitis, and orbital lymphoid lesions: the role of diffusion-weighted imaging

BACKGROUND AND PURPOSE

Orbital inflammatory syndrome (OIS) has clinical features that overlap with orbital lymphoid lesions and orbital cellulitis. Prompt diagnosis is needed in all 3 conditions because the management of each one differs greatly. CT and MR imaging, though useful, do not always distinguish among these conditions. The aim of this study was to identify the role of diffusion-weighted imaging (DWI) in differentiating these 3 diagnoses.

MATERIALS AND METHODS

A retrospective analysis of orbital MR imaging was conducted. T1- and T2-weighted and postcontrast images were analyzed. Region-of-interest analysis was performed by using measurements in areas of abnormality seen on conventional MR imaging sequences and measurements of the ipsilateral thalamus for each patient. The DWI signal intensity of the lesion was expressed as a percentage of average thalamic intensity in each patient. Similarly, lesion apparent diffusion coefficients (ADCs) and lesion-thalamus ADC ratios were calculated. Statistical significance was determined by the Kruskal-Wallis test, and post hoc pairwise comparisons, by the Mann-Whitney U test for DWI-intensity ratio, ADC, and ADC ratio.

RESULTS

A significant difference was noted in DWI intensities, ADC, and ADC ratio between OIS, orbital lymphoid lesions, and orbital cellulitis (P < .05). Lymphoid lesions were significantly brighter than OIS, and OIS lesions were significantly brighter than cellulitis. Lymphoid lesions showed lower ADC than OIS and cellulitis. A trend was seen toward lower ADC in OIS than in cellulitis (P = .17).

CONCLUSIONS

DWI may help differentiate OIS from lymphoid lesions and cellulitis and may allow more rapid management.

Internal levator advancement by Müller's muscle-conjunctival resection: technique and review

BACKGROUND

Müller's muscle-conjunctival resection surgery presumably works by advancing the levator aponeurosis of the upper eyelid. The amount of blepharoptosis and the lid's response to the instillation of phenylephrine hydrochloride onto the superior ocular fornix are used to determine the extent of surgery needed.

OBJECTIVES

To demonstrate the procedure developed and popularized by Allen M. Putterman, MD, performed by Michael Mercandetti, MD, MBA, and to describe the relationship between the amount of Müller's muscle-conjunctival resection performed and the amount of elevation achieved.

METHODS

Data were retrospectively analyzed based on surgical cases done over a 5-year period by one surgeon (A.M.P.).

RESULTS

A linear regression model was developed. From this regression a simple table correlating the amount of resection with the amount of elevation desired was derived.

CONCLUSION

The surgeon will need to modify the table based on his or her clinical experience and postoperative results.

Glabellar rhytids in thyroid-associated orbitopathy

PURPOSE

To correlate the presence and severity of glabellar rhytids with disease severity in patients with thyroid-associated orbitopathy (TAO).

METHODS

Retrospective, noncomparative medical record review of 113 consecutive new patient visits with the clinical diagnosis of TAO. Ocular examination features studied included assessment of visual acuity, optic nerve appearance and function, proptosis, strabismus, eyelid position, and exposure keratopathy. These features were correlated with graded clinical photographs evaluating rhytid severity using the Fisher exact text.

RESULTS

Eighty of 97 patients included in the study (82.5%) had glabellar rhytids. Eyelid retraction was present in 95 of the 97 patients (98%). Patients with diplopia had more severe rhytids (p < 0.05). Patients with at least three abnormal clinical findings tended to have more severe rhytids.

CONCLUSIONS

Glabellar rhytids are a common finding in patients with TAO, and tend to be present in patients with diplopia and multiple stigmata of the disease.

The effect of upper blepharoplasty on eyelid position when performed concomitantly with Müller muscle-conjunctival resection

PURPOSE

To determine the effect on eyelid elevation of excising excess skin, orbicularis oculi muscle, and herniated orbital fat and reconstructing the upper eyelid crease (blepharoplasty) concomitant with a Müller muscle-conjunctival resection.

METHODS

The charts of 202 patients who had undergone Müller muscle-conjunctival resection during an 8-year interval were reviewed. Three hundred forty-five eyelids were divided into two groups. Group 1 (n = 162) underwent a Müller muscle-conjunctival resection only, and group 2 (n = 183) had this procedure combined with excision of skin, orbicularis muscle, and herniated orbital fat with upper eyelid crease reconstruction. Each group was divided into three subgroups based on the amount of Müller muscle-conjunctival resection. Subgroup A had resection less than 7.75 mm; subgroup B, resection of 7.75 to 8.75 mm; and subgroup C, resection greater than 8.75 mm. The change in margin reflex distance-1 (MRD1) measurements of the upper eyelid levels (postoperative MRD1 minus preoperative MRD1) were calculated and compared between groups.

RESULTS

The mean (+/- standard deviation) change in MRD1 was, respectively, 2.3 +/-1.0 mm and 1.9+/-1.0 mm for groups 1A and 2A; 3.1+/-1.3 mm and 2.1+/-1.2 mm for groups 1B and 2B; and 3.4+/-1.2 mm and 2.8+/-1.3 for groups 1C and 2C.

CONCLUSIONS

Blepharoplasty performed concomitant with a Müller muscle-conjunctival resection reduced the anticipated postoperative eyelid elevation by as much as 1 mm. Surgeons who perform these procedures together should be aware that a larger Müller muscle-conjunctival resection may be required to obtain the desired increase in eyelid height postoperatively.

Upper blepharoplasty: a novel approach to improving progressive myopathic blepharoptosis

OBJECTIVE

To describe the results of upper blepharoplasty for the treatment of progressive myopathic upper eyelid blepharoptosis.

DESIGN

Retrospective, noncomparative case series.

PARTICIPANTS

Six consecutive patients treated bilaterally.

INTERVENTION

Upper blepharoplasty in 6 patients (12 eyelids) with progressive myopathic ptosis.

MAIN OUTCOME MEASURES

Subjective visual improvement, ocular comfort, preoperative and postoperative margin reflex distances, lagophthalmos, and degree of corneal keratopathy at last follow-up date.

RESULTS

All patients had subjective visual improvement and denied ocular discomfort. Upper eyelid ptosis, measured by margin reflex distances, was improved. No worsening of lagophthalmos or corneal keratopathy was noted.

CONCLUSIONS

Upper blepharoplasty may be an excellent alternative for ptosis treatment in patients with progressive myopathies. Improvement in ptosis, margin reflex distance, without concomitant lagophthalmos, and corneal keratopathy can be achieved.

Age-related changes in type-I collagen synthesis in human eyelid skin

PURPOSE

This study was to determine whether age-related decrements in type I collagen synthesis occur in human eyelid skin.

METHODS

Using an antibody to procollagen I, we investigated collagen synthetic activity in skin removed for cosmetic purposes from 10 white patients between the ages of 4 and 77 years. Eleven masked referees graded the immunostaining on a scale of 1 (most intense) to 10 (least intense).

RESULTS

The multiple range test for rank by group demonstrated more intense staining in younger patients compared with older patients. An average correlation coefficient of 0.8432 (p < 0.05) existed between each of the referee's rankings.

CONCLUSION

Type I collagen synthesis diminishes with age in eyelid skin.

The effect of hyperthyroidism on Müller's muscle contractility in rats

The objective of this study was to determine if hyperthyroidism affects the responses of Müller's muscle to alpha-1 adrenoceptor agonists and consequently, if these responses might explain thyroid eyelid retraction. Sprague-Dawley adult rats (n = 37) were divided into control and treated groups and given either placebo or intraperitoneal triiodothyronine (250 micrograms/kg/d) for 1, 2, or 3 weeks. A suture was passed through their upper eyelid and connected to a force transducer that measured Müller's muscle contractions. Responses to phenylephrine (0.015-0.61 mmol) were compared with respect to peak amplitude and 50% duration of action. Mean maximum force values [+/-1 standard error of the mean (SEM)] in response to phenylephrine were 1.254 +/- 0.071 gr for controls and 0.963 +/- 0.062 gr for thyroid-treated subjects (p = 0.005). Mean 50% duration of response values (+/-1 SEM) were 9.143 +/- 1.108 min for controls and 5.763 +/- 0.973 min for thyroid-treated subjects (p = 0.014). Hyperthyroid rats had a significantly lower Müller's muscle response amplitude than control rats; however, duration of response was not significantly different between the groups. We believe that hyperthyroidism caused intrinsic changes in Müller's muscle that resulted in eyelid retraction. Based on hypotheses discussed in this article, we expect that further studies will localize these changes to the thyroid hormone receptor on Müller's muscle or calcium-triggered intracellular second messengers. Clinical significance would then be the ability to treat hyperthyroid eyelid retraction with drugs. This study provides the first evidence of functional impairment of Müller's muscle due to hyperthyroidism in an animal model.

Intraoperatively controlled small-incision forehead and brow lift

Placement of screws at the posterior aspect of the incision sites and the gradual placement and removal of staples behind the screws allow for a controlled and titrated elevation of the forehead and brows. This technique does require the patient's acceptance of the temporary placement of screws and staples into the scalp, which in my experience has not been a problem. By seating the patient upright on the operating table, the surgeon can intraoperatively make a direct evaluation and adjustments (removal or addition of staples). This approach leads to a more controlled elevation of the forehead and brows and the potential of a more symmetrical and satisfactory result.

Predictability of magnetic resonance imaging in differentiation of orbital lymphoma from orbital inflammatory syndrome

Twenty-two patients with clinical presentations of either orbital lymphoma or orbital inflammatory syndrome (OIS) involving 25 orbits were examined by magnetic resonance imaging (MRI) before biopsy. To determine whether MRI adds specificity to radiographic diagnosis, the MRI signal characteristics of all tumors were examined. Attention was focused on the signal intensity of each tumor on T1- and T2-weighted images. In nine of 12 (75%) orbital lymphomas, the tumors appeared hyperintense to fat on T2-weighted images and became brighter relative to their appearance on T1-weighted images. In 11 of 13 (85%) orbital infiltrates with OIS, the tumors appeared isointense to fat on T2-weighted images and became slightly darker or unchanged relative to their appearance on T1-weighted images. Tumor density and homogeneity were fairly similar in all 25 lesions and were therefore not useful for further differentiation. Similarly, the presence of moderate enhancement with gadopentetate dimeglumine was seen in all but one tumor, and it was therefore not useful for further differentiation.

Multiple periorbital cutaneous myxomas progressing to scleromyxedema

Myxomas are rare cutaneous tumors that have been associated with a variety of other abnormalities including atrial myxomas, endocrine abnormalities, and bone malformations. We describe a 38-year-old white man with multiple periorbital myxomas in whom myalgias, fatigue, and more diffuse cutaneous involvement developed. These findings were consistent with scleromyxedema. He also had an associated left subclavian deep venous thrombosis. The patient responded well to therapy with cyclophosphamide.

Solitary fibrous tumor of the orbit

PURPOSE

We studied a case of solitary fibrous tumor of the orbit in a 75-year-old man.

METHODS

The patient had painless, slowly progressive proptosis of eight months' duration. He underwent magnetic resonance imaging, which showed a well-circumscribed retrobulbar mass. The tumor was excised.

RESULTS

Examination of the tumor disclosed haphazardly arranged spindle cells alternating with collagenous, hypocellular areas in a richly vascular background without necrosis. Immunoperoxidase stains showed characteristic expression of CD34 and vimentin.

CONCLUSION

Solitary fibrous tumor can infrequently involve the orbit and may recur locally and metastasize, necessitating long-term follow-up.

Wedge resection of eyelid margin in the treatment of abnormal eyelid margins

Widened, hypertrophic, erythematous eyelid margins occasionally occur secondary to congenital anomalies or previous surgical procedures. When a full-thickness resection of the eyelid is not possible because of horizontal tightness of the lid, it is possible to excise a wedge of the eyelid margin itself. This procedure was successful in decreasing widened, hypertrophic, erythematous eyelid margins in three patients.

A minor modification of the Hughes' operation for lower eyelid reconstruction

PURPOSE/METHODS

We modified the Hughes' technique to decrease the frequency of persistent conjunctival hyperemia on the reconstructed lower eyelid margin.

RESULTS/CONCLUSION

When the conjunctival flap is divided at the second stage of the operation, the tissue is trimmed flush with the reconstructed lower eyelid margin rather than advancing the flap over the eyelid margin. This minor modification has yielded satisfactory functional and aesthetic results in 70 patients.

Lid crease and capsulopalpebral fascia repair in congenital entropion and epiblepharon

Forty-one eyelids of 21 patients with congenital entropion or epiblepharon underwent transcutaneous reconstruction of the eyelid crease and retractor (capsulopalpebral fascia). All of the patients demonstrated lack of cutaneous-capsulopalpebral fascia attachment. In contrast with the patients with epiblepharon, those with congenital entropion also had partial or complete absence of tarsal-capsulopalpebral fascia attachment. Surgical treatment included anastomosis of the capsulopalpebral fascia, tarsal border, and eyelid skin crease; no skin or muscle was removed. With a minimum follow up of 1 year, malposition recurred in 3 of the 33 (9%) eyelids with epiblepharon, and in none of the 8 eyelids with entropion.

Acquired blepharoptosis secondary to essential blepharospasm

We treated four patients with essential blepharospasm, receiving botulinum A toxin, in whom, although they had no preexisting blepharoptosis, a concurrent bilateral acquired blepharoptosis developed. Since the blepharoptosis did not improve after the period of time during which the effects of botulinum A toxin would have been expected to resolve (2 to 10 weeks), we judged that its development was unrelated to the toxin. We propose, rather, that the stretching, attenuation, disinsertion, or dehiscence of the upper eyelid levator muscle caused by the blepharospasm were at least partly responsible for the onset of the blepharoptosis. To ensure appropriate treatment in these cases, careful clinical evaluation is required to differentiate the two conditions.

Composite grafting for eyelid reconstruction

Viable composite grafting is a technique used in eyelid reconstruction in which the graft is obtained from the contralateral eyelid. We reviewed the charts of 51 patients who underwent composite grafting of the eyelid since 1983. The average horizontal length of the defect repaired with this technique was 17.3 mm, and the most common indication for its use was basal cell carcinoma. Postoperatively, 39 (91%) of the 43 patients with available measurements had within 2.0 mm of palpebral fissure symmetry. Furthermore, this method of reconstruction allows survival of the eyelid margin and eyelid margin cilia. Composite grafting of the eyelid is a valuable method for eyelid reconstruction that provides acceptable cosmetic results.

Postoperative mydriasis after repair of orbital floor fracture

Mydriasis after operative repair of orbital floor fracture has been attributed to manipulation of the inferior oblique muscle. We treated two patients with mydriasis, one with an isolated mydriatic pupil and the other with a tonic pupil, which followed posterior orbital floor injuries and repair. The posterior location of the fractures suggests that surgical manipulation of or near the ciliary ganglion may account for these phenomena. Patients should be warned before posterior orbital floor repair about possible mydriatic or tonic pupils as a complication.

Surgical treatment of thyroid-related lower eyelid retraction: a modified approach

A 15-year retrospective study was performed in 68 patients who underwent scleral implantation for correction of lower eyelid retraction related to Graves' disease. Three variations of the scleral implantation procedure were used over three time periods. Scleral grafting alone ("old" procedure) was performed in 53 patients from 1974 to 1985. Because of persistent lower lid retraction postoperatively, this procedure was modified. Beginning in 1986, a lateral canthal suspension consisting of either a lateral tarsal strip or a lateral tarsorrhaphy was added to the scleral implantation ("intermediate" procedure) and was performed in seven patients. Since 1988, the procedure has been further modified to include both a lateral tarsal strip and a lateral tarsorrhaphy ("new" procedure). Eight patients underwent this procedure. Analysis with Student's t test indicated a statistically significant reduction in lower lid retraction when using the new procedure, as measured by a reduction in the margin reflex distance-2, the distance from the corneal light reflex to the central lower lid (p = 0.02), and by a reduction in inferior central scleral show, the distance from the central lower lid to the inferior limbus (p = 0.02). An analysis of covariance, controlling for age, Hertel exophthalmometry readings, and length of follow-up, also indicated that the reduction in the postoperative margin reflex distance-2 was significant (p = 0.04).

Bilateral dacryocystitis after punctal occlusion with thermal cautery

A 61-year-old woman developed acute bilateral dacryocystitis secondary to Staphylococcus aureus 3 weeks after undergoing punctal occlusion with thermal cautery for keratoconjunctivitis sicca. The dacryocystitis resolved with intravenous antibiotics, aspiration of the lacrimal sacs, injection of sulfacetamide into the lacrimal sacs, and bilateral dacryocystorhinostomy. Preexisting bilateral nasolacrimal duct obstruction was postulated as the underlying cause. In these cases, irrigation of the lacrimal system is recommended before proceeding with punctal occlusion.

Treatment and Prognosis of Orbital Non-Hodgkinʼs Lymphomas

Twenty patients with orbital lymphomas were treated and followed over a 14-year period. Ten of these patients had well-differentiated lymphocytic lymphoma (WDL), and all of them were clinical stage IE. Five patients had nodular poorly differentiated lymphocytic lymphomas (NPDL), three patients had diffuse histiocytic lymphomas (DHL), one had nodular mixed-cell lymphoma, and one had diffused mixed-cell lymphoma. The patients with WDL received local radiation therapy, and all of them entered completed remissions. The projected survival at 10 years was 100% for these patients. The patients with low-grade lymphomas with advanced disease were treated with chlorambucil and prednisone or cytoxan and vincristine. The patients with high-grade lymphomas received treatment with methotrexate, cyclophosphamide, doxorubicin, vincristine, bleomycin, dexamethasone (mBACOD) or cyclophosphamide, vincristine, methotrexate, cytosine arabinoside, leucovorin (COMLA). The overall survival estimate for all patients was 63% at 10 years. The disease-free survival was 49% at 10 years. The patients with high-grade lymphomas had a poor prognosis, with no survivors after 4 years. This study suggests that patients with WDL usually present with localized disease to the involved orbit, and have an excellent prognosis with radiation therapy alone. Patients with high-grade orbital non-Hodgkin's lymphomas have a poor outcome despite use of aggressive combination chemotherapy regimens.

Conventional frozen sections in periocular basal-cell carcinoma: a review of 236 cases

Two hundred thirty-six periocular basal-cell carcinomas were resected under conventional frozen-section control. Only two tumors recurred, yielding a success rate of 99.2%. The mean follow up was 56 months. Eighty-one of the 236 patients were followed for at least 5 years; the 5-year cure rate was 97.5%. To our knowledge, this is the largest reported series of periocular basal-cell carcinoma resected under conventional frozen-section control; also, we believe the follow-up data are superior to those of previous series. The high success rates with conventional frozen-section techniques in this and other series are comparable to those reported for the Mohs micrographic techniques.

Canaliculectomy in the treatment of keratitis sicca

In patients with keratitis sicca (exposure keratopathy) in whom treatment with topical tear solutions and ointments is not effective, closure of the lacrimal puncta is performed with insertion of plugs or by cautery, hypercation, or laser. If punctal occlusion fails with these modalities, surgical excision of the canaliculi is recommended. Canaliculectomy successfully relieved ocular irritation and keratopathy in three patients with keratitis sicca, with no complications (follow-up, 10 to 26 months).

The domed dermis-fat graft orbital implant

Dermis-fat grafts have been widely used in the reconstruction of the anophthalmic socket, both primarily after enucleation and secondarily after extrusion or migration of an existing implant. The dermis-fat graft is an effective means of replacing orbital volume and affording motility of the ocular prosthesis with both low morbidity and a satisfactory cosmetic result. We present a modification to the dermis-fat graft technique. Our modification creates a domed shape to the anterior surface of the graft that simulates the curvature of the eye. The dome-shaped graft creates deeper fornices than a standard flat-surfaced dermis-fat graft. It also allows better contact between the prosthesis and the dermis as the graft moves. The prosthesis can be thinner centrally and lighter than a prosthesis fabricated for a socket with a standard dermis-fat graft or spherical implant. This results in better motility of the prosthesis while also replacing orbital volume. There is no additional morbidity associated with this technique. We have used this procedure successfully in 18 patients; 10 were primary grafts and eight secondary grafts. Motility of the prosthesis was satisfactory in all cases. There was no abnormal graft shrinkage. All grafts maintained their domed shape. Follow-up ranged from 6 to 21 months.

Adrenal suppression and growth retardation after injection of periocular capillary hemangioma with corticosteroids

Adrenal suppression and/or growth retardation were noted in two patients after injection of periocular capillary hemangiomas with corticosteroids. Parents should be warned of these two potential complications of intralesional corticosteroid therapy. Baseline and posttreatment adrenal function should be monitored. If iatrogenic adrenal suppression occurs, supplemental systemic corticosteroids may be necessary in situations involving systemic stress such as infection or surgery.

Dacryocystorhinostomy in Wegener's granulomatosis

Dacryocystorhinostomy was performed on two patients with Wegener's granulomatosis that had been quiescent for many years. Excellent results were attained, with elimination of dacryocystitis, complete relief from epiphora, and maintenance of a patent outflow tract. No wound necrosis occurred postoperatively, in contrast to a previous report in the literature. Our experience suggests that nasolacrimal duct obstruction in the setting of quiescent Wegener's granulomatosis can be treated safely and effectively with dacryocystorhinostomy.

Recurrent conjunctival papilloma causing nasolacrimal duct obstruction

We treated two patients who had recurrent conjunctival papillomas that invaded the nasolacrimal sac and caused complete canalicular and nasolacrimal duct obstruction. The ophthalmologist should be aware of the possibility of a conjunctival papilloma invading the lacrimal sac when treating patients with conjunctival papillomas. Excision should be complete, and adjunctive therapy such as cryotherapy should be considered to reduce the chance of tumor recurrence.

Scalpel neodymium:YAG laser in oculoplastic surgery

In a three-year study, the scalpel Nd:YAG laser was compared with conventional surgery in 18 patients who underwent oculoplastic surgery. The postoperative follow-up was at least eight months. The contact Nd:YAG laser had distinct advantages over conventional surgery in the treatment of vascular orbital tumors, including less perioperative bleeding and a shorter operating time. In other oculoplastic procedures, ten of the 18 patients underwent surgery with the scalpel Nd:YAG laser on one side and conventional surgery on the other side. There was less bleeding, a shorter operating time, and less pain on removal of orbital fat on the laser-treated side. The postoperative scarring was initially more noticeable on the Nd:YAG laser-treated side, but after three months there was no appreciable difference in scar formation between the two sides. The amount of postoperative edema and ecchymosis did not appear to be significantly different with the Nd:YAG laser compared with conventional surgery. Additionally, microscopic evaluation showed minimal charring of tissues with the Nd:YAG laser.

A 16-year study of conjunctival dacryocystorhinostomy

We reviewed a consecutive series of 79 conjunctival dacryocystorhinostomies performed over a 16-year period in 75 patients. Thirty-eight of 75 patients with canalicular blockage between the common canaliculus and the first 5 mm of the canaliculus as well as patients with common canalicular blockage who had failed previous dacryocystorhinostomy were treated with combined canalicular reconstruction, nasal lacrimal intubation, and conjunctival dacryocystorhinostomy. In 37 patients, less than 5 mm of proximal canaliculus remained open. These patients were treated with conjunctival dacryocystorhinostomy alone, including four patients who had bilateral procedures. Two of 38 patients who underwent combined canalicular and conjunctival procedures required further surgery for a successful outcome compared with 14 of 37 patients who underwent conjunctival dacryocystorhinostomy without canalicular reconstruction (P = .002). Overall, 71 of 74 patients (96%) had a successful outcome, and five patients were lost to follow-up.

Comparison of 2.5% and 10% phenylephrine in the elevation of upper eyelids with ptosis

The Mueller's muscle-conjunctival resection procedure has been effective in treating ptosis in eyelids that elevate upon instillation of topical 10% phenylephrine (Neo-Synephrine). The small risk of an adverse systemic reaction to phenylephrine could be even further decreased by using 2.5% phenylephrine instead of 10% phenylephrine. In order to assess the feasibility of using 2.5% phenylephrine instead of 10% phenylephrine in ptosis evaluation, we compared the amount of upper eyelid elevation produced by the two solutions. Thirty ptotic upper eyelids in 20 patients exposed to 10% phenylephrine rose an average of 0.2 mm higher than the same lids exposed to 2.5% phenylephrine. Although this difference was statistically significant, we suspect that the small magnitude of this difference would have little effect on the decision to perform a Mueller's muscle-conjunctival resection procedure or on the calculation of the amount of tissue to resect.

Patient satisfaction in oculoplastic surgery

Patient satisfaction in oculoplastic surgery was evaluated through questionnaires sent to patients, referring physicians, and oculoplastic surgeons. Two oculoplastic surgical procedures, cosmetic blepharoplasty and acquired blepharoptosis treatment, were analyzed. One hundred forty-five patients and 85 referring physicians of the practices of five oculoplastic surgeons were questioned. Sixty-nine additional oculoplastic surgeons were also surveyed. The results of treatment were consistently emphasized as the most important factor in patient satisfaction, a finding that contrasted greatly with the decreased emphasis on the cost of treatment. This implies that patients value the quality of medical care and are willing to pay for it. The preference of patients contrasts sharply with the trend of government and third-party payers to emphasize cost containment at the possible sacrifice of quality of care. The surveys also showed that pain and discomfort and office waiting time are more important to patient satisfaction than oculoplastic surgeons realize and that the surgeons will have to address these issues in order to improve satisfaction. Also, there is a falloff of surgeon-patient communication postoperatively which is less satisfying to patients and recognized, but not acted on, by surgeons. Therefore, more postoperative surgeon-patient communication by telephone is also likely to improve patient satisfaction.

Conjunctival flap-cosmetic shell-ptosis procedure. Treatment of blepharoptosis in severe keratopathy

The correction of marked blepharoptosis in patients with severe or potential keratopathy will worsen the keratopathy and possibly lead to the complications of corneal ulceration and endophthalmitis. The conjunctival flap--cosmetic shell--ptosis procedure is well suited to this difficult management problem. Patients are initially treated with a conjunctival flap to protect their cornea. Subsequently they are fit with a cosmetic shell, and finally they undergo surgery to correct their ptosis. This three-stage procedure has produced excellent cosmetic and functional results in two patients, one of whom had ptosis and severe radiation-induced keratopathy following the treatment of a rhabdomyosarcoma; the other patient had severe ptosis associated with lack of corneal sensation and orbicularis function following removal of a cerebral meningioma.

Recurrent Jones tube extrusions successfully treated with a modified glass tube

Displacement or extrusion of the standard glass Jones tube causes conjunctivodacryocystorhinostomy to fail in many cases. Patients who have had trauma, a tumor excised, or have received radiation therapy in the medial canthal area are particularly susceptible to this complication. Gladstone and Putterman developed a modified glass tube that has a second flange 3 to 6 mm from the top flange. The second flange anchors the tube and reduces its mobility. Eleven patients who could not retain a standard Jones tube were fitted with a modified glass tube. Seven of these patients were able to wear the originally placed modified tube comfortably. Two additional patients extruded the originally placed modified tube but were able to retain a shorter modified tube. Follow-up ranged from 3 weeks to 49 months (average, 22.4 months).

Custom orbital implant in the repair of late posttraumatic enophthalmos

We repaired late, posttraumatic enophthalmos in 21 patients by inserting a large, soft, Silastic block through a lower eyelid flap and transconjunctival approach to the orbit. These blocks were hand carved at the time of surgery to match bony defects as characterized by hypocycloidal tomographic biometry. Enophthalmos and hypo-ophthalmos were ameliorated with acceptable appearance in all cases. No implant rejections, migrations, or infections were found. Complications included upper eyelid blepharoptosis, lower eyelid retraction, and conjunctival prolapse. The improvements were stable over a median follow-up of 13 months.

Cicatricial entropion: an analysis of its treatment with transverse blepharotomy and marginal rotation

Transverse blepharotomy with marginal rotation is a simple and effective procedure to treat cicatricial entropion of diverse etiology in upper and lower eyelids. The surgeon can vary the site of incision and suture placement to control the amount of marginal rotation required. We treated 152 eyelids (98 patients) with this technique, obtaining an 85% overall success rate. Eleven recurrences were found in 7 of 18 lids with ocular pemphigoid; the success rate for this subgroup was 39% compared with 92% for all others. We recommend this procedure as a technically easy treatment for cicatricial entropion not caused by ocular pemphigoid.

Reconstruction of nasal fistulas of the medial canthus

Invasive carcinomas of the medial canthus may require the removal of skin, subcutaneous tissue, and nasal bone, which can result in a nasal fistula of the medial canthus. I applied a nasolabial flap on the inside of the fistula and a forehead flap on the outside to reconstruct such a fistula. This technique was successful in three patients.

Combined viable composite grafting and eyelid sharing techniques to prevent blepharoptosis after extensive tumor excision

Five patients underwent tumor excision involving either the entire upper eyelid and temporal lower eyelid (three patients) or the entire lower eyelid and temporal upper eyelid (two patients), followed by reconstruction with an eyelid sharing procedure combined with viable composite grafting to the upper eyelid and a temporal semicircular flap. None of the five patients developed postoperative blepharoptosis, and all had excellent functional and cosmetic results. Follow-up ranged from 23 to 94 months.