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PURPOSE: To evaluate the efficacy and safety of a bilayer dermal regenerative matrix for primary or complex/recurrent eyelid retraction. METHODS: Retrospective review of patients undergoing eyelid retraction repair using the bilayer dermal regenerative matrix from 2005 to 2019. Nineteen eyelid surgeries from 15 patients were identified. Collected data included patient demographics, symptoms, preoperative/postoperative lower eyelid position, inferior scleral show, lagophthalmos, etiology of retraction, history of prior retraction surgeries, major/minor complications, and follow-up duration (minimum 6 months). Postoperative measurements were taken at a minimum of 1 week, 3-6 weeks, 2-4 months, and 6 months. RESULTS: Postoperatively, 90% of cases had good improvement of lower eyelid retraction (defined as 1 mm or less below the inferior limbus). Postoperative elevation of the lower eyelid ranged 1-3.5 mm compared with preoperative measurements. When used in the upper eyelid for conjunctival scarring, the implant improved the superior fornix depth. Complications were minimal and included transient conjunctival injection, eyelid edema, and foreign body sensation. No patients requested early removal of the silicone layer due to ocular pain. CONCLUSIONS: The bilayer dermal regeneration matrix template may be considered a reasonable alternative to other spacers to reduce the vertical palpebral fissure and eyelid malposition in primary, complex, or recurrent cases. It also worked well for first-line correction of thyroid retraction, which tend to be more challenging due to globe proptosis. Suboptimal results may have occurred due to active cicatrizing conjunctival disease, or residual negative vector of the cheek and orbit. High cost may be a consideration, and the bilayer dermal regeneration matrix template was not studied directly against hard palate and other spacer materials.

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A 70-year-old Korean female with a history of Klebsiella pneumonia liver abscess was presented to the authors' service with signs of endophthalmitis and orbital cellulitis. Vitreous biopsy confirmed K. pneumonia as the causative organism. With prolonged intravenous antibiotics and steroids, orbital symptoms resolved, but visual acuity remained at light perception. This is the first case in the literature to report on endophthalmitis and orbital cellulitis from K. pneumonia liver abscess.

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PURPOSE: Dacryocystorhinostomy (DCR) is the standard procedure for the treatment of acquired nasolacrimal duct obstruction (NLDO) that can be performed through an external or endonasal approach. Both techniques create a fistula from the lacrimal sac into the nasal cavity via a bony osteotomy. Historically, external DCR has been considered the gold standard; however, recent reports suggest endonasal DCR is an effective alternative. There are numerous variations of endonasal DCR described in the literature that report variable success rates. The purpose of this study is to describe the approach and success rate with endonasal DCR in which nasal mucosa, bone, and lacrimal sac mucosa are sequentially removed. METHODS: The authors retrospectively reviewed cases of endonasal DCR from 2004 to 2011 from 2 institutions (the University of California, San Diego, California, and the Fante Eye and Face Center in Denver, Colorado, U.S.A.). Patients with a history of epiphora and NLDO confirmed with punctal irrigation were included. Exclusion criteria were the presence of canalicular obstruction, history of orbital trauma, and prior DCR surgery. Success was defined as subjective relief of epiphora and confirmation of ostium patency with irrigation. RESULTS: A total of 324 patients (74 men, 250 women; mean age 59.3) encompassing 407 endonasal DCR cases were included in the study. The total case success rate was 92.2% with an average follow-up time of 91.5 days. Revision surgery was performed in 7 of the failed cases and resulted in success in 6 of these cases. CONCLUSIONS: Endonasal DCR is a simple and effective approach to surgically treat NLDO and offers success rates comparable with external DCR.

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A 55-year-old white woman with severe thyroid eye disease developed marked orbital edema following the administration of intravenous contrast media with complete loss of vision over a 10-minute period while in the radiology waiting room. She was immediately treated with intravenous methylprednisolone with recovery of precontrast visual acuity and resolution of orbital edema. She underwent orbital decompression 2 weeks later and is currently doing well. This potential complication, although rare, should be recognized and treated immediately.

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PURPOSE: To review injection techniques and patient satisfaction with injection of Restylane in various facial areas by American Society of Ophthalmic Plastic and Reconstructive Surgery members. METHODS: Data from 286 patients treated with Restylane in nine American Society of Ophthalmic Plastic and Reconstructive Surgery practices were abstracted to a spreadsheet for analysis. RESULTS: Nine practices performed Restylane injections for 8.8 months on average (range, 2 to 28 months). Average practice volume per patient was 1.2 ml (range, 0.7 to 2.1 ml). Nine of nine practices injected the nasolabial and melolabial folds, 9 of 9 practices injected the lips, and 6 of 9 injected the glabella. Only 2 of 9 practices injected other fillers concurrently. Botox was injected concurrently by 8 of 9 practices. On a scale of 1 to 10, physicians rated average patient discomfort during Restylane injection 4.6 with topical anesthesia and 2.1 with injectable lidocaine, with or without topical anesthesia. The end point for injection was determined by visual cues, volume of injection, extrusion of the product, and palpation. "Problematic" complications, including bruising, swelling, bumpiness, and redness each had an incidence of 5% or less. Patient satisfaction on a scale of 1 to 10 had an average rating of 8.1, compared with that of Botox injection (8.9), upper blepharoplasty (8.9), and collagen injection (6.6). The source of Restylane patients was estimated to be existing Botox patients (45%); existing non-Botox patients (18%); word of mouth (14%); and new patients for other services (13%). CONCLUSIONS: Injection techniques, volume, end points, and anesthesia vary for different facial areas and between practices. Patients experience mild to moderate injection discomfort that is lessened with injectable lidocaine. Self-limited problems occur in about 5% of patients. Physician-determined patient satisfaction is perceived to be higher than that of collagen injection but slightly lower than that of botulinum toxin injection. The major source of Restylane patients was from existing practice patients, especially botulinum toxin patients.

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BACKGROUND: A chief morbidity of facial nerve palsy is ocular exposure, which is largely due to lower lid retraction and ectropion. OBJECTIVE: To assess the role of midfacial elevation in the comprehensive surgical treatment of paralytic lower lid malposition and ocular exposure. METHODS: Eleven patients with chronic facial nerve palsy causing symptomatic ocular exposure were treated with subperiosteal midface elevation as a component of comprehensive lower lid elevation. Other procedures were performed concomitantly to treat lower lid ligament laxity and reduced lower lid rigidity, as required. Preoperative and postoperative ocular exposure symptoms, visual acuity, lower lid position, lagophthalmos, and keratopathy were compared. RESULTS: At an average of 17 months of follow-up, all patients reported improvement in symptoms. Visual acuity was maintained or improved in all patients. Lower eyelid position (P =.003), lagophthalmos (P =.07), and keratopathy (P<.001) were also improved. CONCLUSIONS: Midfacial elevation is a safe and effective surgical adjunct in the treatment of lower eyelid retraction in chronic facial palsy. Its use reduces the need for tarsorrhaphy, which limits the binocular visual field and negatively impacts cosmesis.

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PURPOSE: To report 18 cases of unusually large, early conjunctival breakdown occurring with the use of bovine pericardium wrapping material for orbital implants. METHODS: Retrospective case series. The clinical course and histopathologic features of 18 cases of early conjunctival breakdown in patients who had undergone orbital implantation of bovine pericardium-wrapped hydroxyapatite or porous polyethylene are reviewed. RESULTS: Eighteen patients presented with unusually large (average 13.44 mm) conjunctival defects over bovine pericardium-wrapped implants. The average time from enucleation to exposure was approximately 4 months. Implants had to be removed in 8 of 18 cases. There was clinical and histologic evidence of tissue inflammation and conjunctival melting. CONCLUSIONS: The conjunctival melting phenomenon we report herein is alarming. We have abandoned the use of bovine pericardium as a wrapping material for implants after enucleation because of the unfavorable results.

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