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PURPOSE: To describe a simplified technique for ptosis repair using a single adjustable suture. DESIGN: Retrospective noncomparative series. PARTICIPANTS: Fifty-one cases of ptosis repair performed or supervised by the same surgeon between 1993 and 1995. INTERVENTION: The surgical approach consisted of using a single adjustable "hang-back" 5-0 silk suture for plication of the superior portion of the levator aponeurosis. Lid height was then reassessed within the first 4 postoperative days and permanently readjusted by fixating the adjustable suture. Excluded were patients with history of unstable ptosis as a result of systemic disease or congenital, mechanical, and traumatic ptosis resulting from a mass or trauma. The follow-up period ranged from 3 to 31 months. MAIN OUTCOME MEASURE: Lid position. RESULTS: All eyelids included in this study were corrected to 1 mm of the desired result. There were no incidents of peaking or recurrence on long-term follow-up. Complications included one case of hematoma and a case of slight tenting of the eyelid margin. CONCLUSIONS: This procedure combines the physiologic approach of levator aponeurosis surgery with the simplicity and flexibility of a single adjustable "hang-back" type suture. It may readily be combined with other procedures such as blepharoplasty. It is also useful when the "ideal" lid level may not be determined until the postoperative period, such as eyes subject to ptosis by Hering's law, levator dehiscence, or those at increased potential risk for corneal exposure.

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The use of collagen shields to enhance comfort and facilitate recovery after eyelid surgery was studied. Thirty-two patients undergoing various eyelid procedures were studied. In 10 patients, bilateral surgery was performed and the contralateral eye was used as a control. In patients with unilateral surgery, 20 of 22 patients exhibited comfortable postoperative courses, and in patients with bilateral surgery, eight of 10 patients had less conjunctival injection, chemosis, corneal staining, or lid edema on the side with the collagen shield. The only complications occurred with the 72-h lens, which tended to irritate the cornea and have a variable dissolution time.

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To evaluate whether intracranial spreading of a local anesthetic might occur after a peribulbar injection, we did simulated peribulbar anesthetic injections with radiopaque dye into two cadaver heads. Using a standard and modified peribulbar injection with a 25-gauge needle, the four orbits were injected with 8 mL of dye. Computed tomography revealed that the dye spread intraconally and intracranially. In one case the dye was seen tracking along the optic nerve sheath. Since intracranial spreading of a local anesthetic may be associated with adverse sequelae (i.e., brainstem anesthesia), we urge caution and vigilance after both peribulbar and retrobulbar anesthetic injections to prevent cardiopulmonary compromise.

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A case of endogenous Klebsiella pneumoniae endophthalmitis, cryptogenic in origin, is presented. It was treated initially with success, only to recur three months later with loss of the eye. Common sites of Klebsiella infection are reviewed. This organism rapidly destroys retinal photoreceptors. A link between Klebsiella and acute anterior uveitis has been suggested but is not supported by prospective data.

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The lazy-T procedure described by Smith corrects medial ectropion of the lower lid by combining a horizontal full-thickness shortening of the lid with excision of conjunctiva and tarsus inferior to the punctum to invert the lid. However, some cases of senile medial ectropion involve an element of vertical traction on the skin as well as horizontal lid laxity. A new procedure is described that makes use of skin gained from horizontal lower lid shortening in the form of a medially based transposition flap to produce vertical skin lengthening. It is useful to treat medial ectropions that have horizontal laxity along with cicatricial components and has successfully relieved this condition in eight patients.

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We examined 52 consecutive patients who underwent autogenous dermis-fat implantation in anophthalmic sockets during the past five years. The results of the study show that 81% of the cases had no change in the volume of the graft during a mean follow-up period of 2 1/2 years, ranging from a minimum of six months to a maximum of five years. The remaining 19% underwent graft resorption to a varying degree. We consider dermis-fat graft a procedure of choice in cases of extruded or migrated implants, an alternative to a synthetic allograft in primary enucleations, and a useful procedure in selected cases of enophthalmic and contracted socket.

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Various methods of surgical correction of lid retraction are discussed. Retraction secondary to overcorrected ptosis surgery is more amenable to correction by various stretching techniques, incising of the levator or recession of the lid elevators. Endocrine lid retraction poses a more difficult problem. Because of the many facets to the problem, a multidisciplined team approach is advised with surgery planned in a stepwise fashion to suit the many interrelated ocular problems of each individual patient.

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A new procedure has been devised to deepen the inferior fornix of anophthalmic sockets. It is useful when there is fore-shortening due to shifting or relaxation of tissues rather than contracted scar tissue or absence of mucosal lining.

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Over the course of nine years a young man sustained repeated recurrences of a squamous papillary epithelial tumor of the conjunctiva and canaliculus. Treatment had included repeated surgical excisions, fulguration, cryotherapy, and localized applications of Thiotepa. When we examined him in 1972 he had a recurrent lesion measuring about 1 cm in diameter. Because of past failures with the above-noted therapeutic modalities, we decided to treat him with immunotherapy using the immunological adjuvant DNCB (dinitrochlorobenzene). We sensitized him systemically to DNCB by applying 2,000 microng of this agent to the skin of his forearm. A spontaneous "flare" reaction, indicative of delayed hypersensitivity, developed. Delayed hypersensitivity to DNCB was confirmed by in vitro testing of his lymphocytes for their ability to produce migration inhibitory factor (MIF) in response to DNCB. Subsequent localized application of DNCB to the conjunctival tumor resulted in rapid regression of the lesion and there has been no recurrence during a follow-up period of three years. We believe this is the first time a conjunctival tumor has been successfully treated with immunotherapy.

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This case report describes a chronic medically-refractory corneal ulcer which eventually yielded Herellea vaginicola from resected corneal tissue. A review of the literature cites the occurrence of this organism as an inhabitant of normal conjunctiva, as an infrequent cause of conjunctivitis, and as the causative agent in two previous cases of corneal ulcers. This case illustrates the difficulty in the isolation of the organism and indicates the need for diagnostic and therapeutic keratectomy in conjunction with a conjunctival flap.

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