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PURPOSE: To evaluate the ability of preoperative phenylephrine testing to predict postoperative upper eyelid tarsal platform show in patients undergoing Müller muscle-conjunctival resection (MMCR) ptosis repair without concurrent blepharoplasty. METHODS: A retrospective chart review was performed on 52 eyelids of patients who underwent MMCR without external skin incision. Photographs were reviewed to objectively and subjectively compare the results of phenylephrine testing to postoperative appearance. Only patients who underwent successful MMCR were included in the study. The authors defined successful MMCR as having a resulting marginal reflex distance within 1 mm of that predicted by phenylephrine testing. For objective analysis, the tarsal platform show was measured using computer software. For subjective analysis, 2 experienced examiners were asked to grade the correlation in appearance on a scale of 1-5 (1 being poor correlation and 5 being excellent correlation). RESULTS: The mean tarsal platform show in the phenylephrine test photographs and the postoperative photographs was 3.8 and 3.63 mm, respectively (mean = 0.17; standard deviation = 0.71). The difference between the means was not statistically significant (p > 0.05). The mean difference in tarsal platform show between phenylephrine testing and postoperative was 0.17 mm (standard deviation = 0.71). The difference was not statistically significant (t[51] = 0.09; p > 0.05; 2 tailed). The mean subjective correlation score comparing phenylephrine testing photographs to postoperative photographs was 4.4 out of possible 5. CONCLUSIONS: Phenylephrine testing exhibits good predictability with regard to eyelid appearance after successful MMCR without external skin incision and, therefore, may assist the surgeon when trying to decide if blepharoplasty or eyelid crease formation is necessary at the time of MMCR.

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Aging changes to the lower eyelids and midface include pseudoherniated orbital fat, tear trough deformity, lid laxity, and dermatochalasis. Surgical repair often aims at treating redundant skin or orbital fat malposition with a lower eyelid blepharoplasty. Either a transcutaneous or transconjunctival approach may be used, though recent trends have favored the transconjunctival technique if procedures require more than simple skin excision. In manipulating the inferior orbital fat pads, a surgeon has many options including excision, repositioning, or augmentation with synthetic dermal filler, autologous fat grafts, or acellular dermal allografts. The authors review and detail indications, preoperative evaluation, techniques, and complications of lower lid blepharoplasty.

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PURPOSE: To investigate the presence and microbiology of bacterial biofilms on Jones tubes (JTs) by direct visualization with scanning electron microscopy and polymerase chain reaction (PCR) of representative JTs, and to correlate these findings with inflammation and/or infection related to the JT. METHODS: In this study, prospective case series were performed. JTs were recovered from consecutive patients presenting to clinic for routine cleaning or recurrent irritation/infection. Four tubes were processed for scanning electron microscopy alone to visualize evidence of biofilms. Two tubes underwent PCR alone for bacterial quantification. One tube was divided in half and sent for scanning electron microscopy and PCR. Symptoms related to the JTs were recorded at the time of recovery. RESULTS: Seven tubes were obtained. Five underwent SEM, and 3 out of 5 showed evidence of biofilms (60%). Two of the 3 biofilms demonstrated cocci and the third revealed rods. Three tubes underwent PCR. The predominant bacteria identified were Pseudomonadales (39%), Pseudomonas (16%), and Staphylococcus (14%). Three of the 7 patients (43%) reported irritation and discharge at presentation. Two symptomatic patients, whose tubes were imaged only, revealed biofilms. The third symptomatic patient's tube underwent PCR only, showing predominantly Staphylococcus (56%) and Haemophilus (36%) species. Two of the 4 asymptomatic patients also showed biofilms. All symptomatic patients improved rapidly after tube exchange and steroid antibiotic drops. CONCLUSIONS: Bacterial biofilms were variably present on JTs, and did not always correlate with patients' symptoms. Nevertheless, routine JT cleaning is recommended to treat and possibly prevent inflammation caused by biofilms.

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PURPOSE: To evaluate the efficacy of dermis fat graft (DFG) as a primary implant technique in pediatric patients requiring unilateral enucleation due to retinoblastoma. METHODS: A retrospective chart review of 14 consecutive pediatric patients who underwent dermis fat graft implantation after unilateral enucleation for retinoblastoma by 1 surgeon (E.A.S.) was performed to evaluate graft efficacy with regard to orbital volume growth and any associated morbidity. Patients who received chemotherapy or external beam radiation were excluded. Demographic information was recorded. Serial MRIs were used to measure orbital volumes to compare the surgical and contralateral orbits over time. The main outcome measure was the difference in bony orbital volume between enucleated and contralateral, uninvolved orbits. Mann-Whitney U test was used to compare orbital volume measurements between surgical and nonsurgical orbits. Correlation testing was performed to determine the effect of age, sex, and follow-up time on the orbital volume changes. RESULTS: There was no statistical difference between the MRI volume measured for surgical and nonsurgical orbits over time. This was the case at all measured time points and for all ages and genders. All patients were under the age of 4 years at the time of surgery. The median difference in orbital volumes between surgical and nonsurgical orbits was -0.095 cm (range -1.26 to 1.01 cm; quartiles -0.32 to 0.07 cm; mean ± SD, -0.144 ± 0.0522 cm; 95% confidence interval, -0.247 to -0.0419 cm). The median follow-up time from surgery date to the most recent clinical examination was 38.5 months (range, 13 to 70 months; quartiles, 28.75 to 45.5 months; mean ± standard deviation [SD], 38.43 ± 17.21 months; 95% confidence interval, 29.41 to 47.45 months). CONCLUSIONS: In pediatric patients below 4 years of age with unilateral retinoblastoma treated with enucleation and primary dermis fat graft implantation, there was no statistically significant difference in bony orbital volume between the surgical and nonsurgical orbits during the follow-up period.

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Acquired blepharoptosis presents as both a functional and cosmetic problem commonly encountered by facial plastic surgeons. Ptosis repair can be both challenging and frustrating, especially given ever-increasing demands for an optimal cosmetic surgical result. The authors present a brief overview of key points to consider when attempting to achieve excellent blepharoptosis repair outcomes.

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Orbital tumor, trauma, and necrosis require the orbital contents to be resected and the patient is left with a cosmetic deformity that affects a patient's self-image and those around him or her. Careful planning between the oral and maxillofacial surgeon and/or oculoplastic surgeon and the maxillofacial prosthodontist will result in a secure and accurate esthetic reconstruction using an implant-supported prosthesis. The multiple steps involved in this process require the commitment of doctors and patient. This article reviews surgical and prosthetic considerations in providing a satisfactory esthetic reconstruction of a variety of orbital defects.

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PURPOSE: The surgical approach to the medial orbit allows superior exposure of the medial orbital wall and nasal bones, extending to the orbital apex, with excellent cosmetic results. METHODS: This is a retrospective database study of all patients (N = 98) undergoing a transcutaneous medial canthal tendon incision in practice during 2009. This 1.5- to 2.0-cm incision is made just anterior to, in the same plane as, and shaving the anterior ramus of the medial canthal tendon. After exposing the origin of the anterior ramus of the medial canthal tendon, the periorbita along with the attached medial canthal tendon is elevated, exposing the entire medial orbital wall from the orbital strut to the trochlea. Anterior dissection allows access to the nasal bones to the dorsum of the nasal bridge. The parameters studied in this report were the complication rates (including scarring requiring revision, telecanthus, diplopia related to the technique, and injury to the optic nerve or other orbital structures) and photographic evidence of the final cosmetic result of this approach. RESULTS: During 2009, 173 surgical procedures were performed through the transcutaneous medial canthal tendon incision. The procedures comprised 89 fracture repairs of the nasal or ethmoid complex, 2 naso-orbito-ethmoid fracture repairs, 4 cases of isolated nasal fracture repair, 37 medial wall decompressions for ophthalmic Graves disease, 13 cases of subperiosteal abscess drainage, and 28 dacyrocystorhinostomies using a slightly modified incisional position. The inferior oblique was not cut or released in any of these cases. There were no observed cases of medial canthal webbing, injury to orbital structures, telecanthus, optic neuropathy, or iatrogenically induced diplopia related to the technique. By definition, the authors' follow-up time is limited to less than 2 years in each case; however, all complications, which the authors have considered for this report, would have been readily observable in this postoperative period. CONCLUSIONS: The small incision, transcutaneous medial canthal approach offers excellent and safe exposure of the medial wall, nose, and the orbital apex. The authors differentiate this transcutaneous medial canthal tendon incision from the less cosmetically acceptable, larger and more anterior Lynch incision. This medial canthal tendon incision has, and continues to be, a workhorse in the authors' approach to the medial orbit and nose while offering unparalleled exposure with an excellent safety and complication profile.

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An 80-year-old woman with a painful, poorly seeing right eye underwent retrobulbar chlorpromazine injection for pain control. After the injection, the patient's symptoms improved; however, a neurotrophic ulcer developed within 2 weeks after the procedure. It is postulated that chlorpromazine may lead to sensory denervation to the cornea with the subsequent development of neurotrophic keratopathy, as observed in this case. Awareness of this potential adverse effect is important for proper patient safety, education, and postinjection management.

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Exophthalmometry is an important clinical tool used in evaluating many orbital diseases. The authors evaluated whether or not exophthalmometry readings obtained from computed tomography (CT) correlate with traditional Hertel measurements. Patients with orbital disease who had undergone clinical and CT examination were identified, and CT exophthalmometry readings were obtained digitally using a GE PACS radiograph viewing system in 53 orbits (44 thyroid-associated ophthalmopathy and 9 post-trauma). Exophthalmometry data obtained with CT were compared with Hertel readings obtained by an experienced examiner. CT data and clinical data were obtained by separate and masked observers. 46 of 53 CT exophthalmometry measurements were within 2 mm of the value recorded from Hertel testing. The CT metrics, on average, provided exophthalmometry that was 0.03 mm shorter than Hertel (95% CI). The intraclass correlation coefficient was 0.95 (95% CI) for the two forms of measurement. The authors conclude that CT exophthalmometry correlates well with Hertel exophthalmometry.

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Exophthalmometry is an important clinical tool used in evaluating many orbital diseases. The authors evaluated whether or not exophthalmometry readings obtained from computed tomography (CT) correlate with traditional Hertel measurements. Patients with orbital disease who had undergone clinical and CT examination were identified, and CT exophthalmometry readings were obtained digitally using a GE PACS radiograph viewing system in 53 orbits (44 thyroid-associated ophthalmopathy and 9 post-trauma). Exophthalmometry data obtained with CT were compared with Hertel readings obtained by an experienced examiner. CT data and clinical data were obtained by separate and masked observers. 46 of 53 CT exophthalmometry measurements were within 2 mm of the value recorded from Hertel testing. The CT metrics, on average, provided exophthalmometry that was 0.03mm shorter than Hertel (95% CI). The intraclass correlation coefficient was 0.95 (95% CI) for the two forms of measurement. The authors conclude that CT exophthalmometry correlates well with Hertel exophthalmometry.

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PURPOSE: To describe clinical outcomes of patients who underwent implantation of the AlphaCor keratoprosthesis, without the second stage of the procedure, in which the central anterior layer of the corneal stromal pocket is excised to expose the keratoprosthesis optic to the exterior of the eye. METHODS: Outcomes of 6 consecutive cases of AlphaCor implantation without the second stage of the procedure were retrospectively reviewed. The cases were performed at 1 tertiary referral center between February 2005 and December 2006. RESULTS: Each of the 6 treated eyes had experienced failure of 2-5 human donor grafts before AlphaCor implantation. With a mean follow-up of 22 months (range, 14-38 months), all devices remained in situ at time of review. All patients had decreased pain compared with what they experienced preoperatively, and preoperative bullous keratopathy resolved after AlphaCor implantation. Two patients developed retroprosthetic membranes. Five patients developed elevated intraocular pressure requiring additional medication or surgery in the postoperative course, but 4 of them had preexisting glaucoma. No patients developed breakdown of the ocular surface, increased ocular surface disease, stromal melting, aqueous leakage, infection, or extrusion. CONCLUSIONS: Omitting stage 2 surgery of the AlphaCor implantation may decrease the incidence of complications and provide patients with a comfortable eye and improved cosmetic appearance in cases of bullous keratopathy from corneal graft failure and can be useful when there is little chance of a successful repeat graft and no urgency or possibility of restoring visual acuity better than approximately 20/200. Resolution of bullous keratopathy and reduction of pain was achieved despite the lack of functional endothelium.

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