Reich, Shani S. M.D.; Null, Robert C. M.D.; Timoney, Peter J. M.D.; Sokol, Jason A. M.D
Purpose: To assess current members of the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) regarding preference in surgical techniques for orbital decompression in Graves’ disease.
Methods: A 10-question web-based, anonymous survey was distributed to oculoplastic surgeons utilizing the ASOPRS listserv. The questions addressed the number of years of experience performing orbital decompression surgery, preferred surgical techniques, and whether orbital decompression was performed in collaboration with an ENT surgeon.
Results: Ninety ASOPRS members participated in the study. Most that completed the survey have performed orbital decompression surgery for >15 years. The majority of responders preferred a combined approach of floor and medial wall decompression or balanced lateral and medial wall decompression; only a minority selected a technique limited to 1 wall. Those surgeons who perform fat decompression were more likely to operate in collaboration with ENT. Most surgeons rarely remove the orbital strut, citing risk of worsening diplopia or orbital dystopia except in cases of optic nerve compression or severe proptosis. The most common reason given for performing orbital decompression was exposure keratopathy. The majority of surgeons perform the surgery without ENT involvement, and number of years of experience did not correlate significantly with collaboration with ENT.
Conclusions: The majority of surveyed ASOPRS surgeons prefer a combined wall approach over single wall approach to initial orbital decompression. Despite the technological advances made in the field of modern endoscopic surgery, no single approach has been adopted by the ASOPRS community as the gold standard.
Briceño, César A. M.D.; Elner, Victor M. M.D., Ph.D.; Demirci, Hakan M.D.
Purpose: The aim of this study was to evaluate expression patterns of known lymphangiogenic growth factors and chemokines in conjunctival melanoma, and to describe patterns of lymphatic vessel growth in these tumors.
Methods: This was a retrospective chart review comprising 5 participants (6 tumor specimens) and the main outcome measures were expression of growth factors, chemokines, and their receptors known to be important in tumor lymphangiogenesis as well as patterns of lymphatic vessel growth on immunohistochemical sections.
Results: Tumor cells in all specimens expressed lymphangiogenic growth factors VEGFC, VEGFD, and their receptor VEGFR3. Chemotactic factors CXCL12 and CCL21 and their receptors, CXCR4 and CCL21, were also expressed in tumor cells and lymphatic endothelial cells. Staining was most intense for these proteins at the invasive tumor edge, suggesting increased lymphangiogenic activity at this location. In addition, lymphatic vessels clustered near the invasive edge of the tumors.
Conclusions: VEGFC, VEGFD, and VEGR3 are diffusely expressed by conjunctival melanoma cells, most intensely at the invasive tumor edge. CXCL12, CXCR4, CCL21, and CCR7 were also most intensely expressed at the invasive edge, where the highest density of lymphatic vessels was also observed. These expression patterns suggest that these mediators of tumor-associated lymphangiogenesis warrant further investigation as potential therapeutic targets in conjunctival melanoma.
Ali, Mohammad Javed F.R.C.S.; Singh, Swati M.D.; Naik, Milind N. M.D.
Aims: The aims of this study were to illustrate the techniques and usefulness of a new rigid, variable-view endoscope in lacrimal surgeries.
Methods: A 4-mm continuously variable view rigid endoscope (EndoCAMeleon) was used to assess 4 intraoperative scenarios in lacrimal surgeries. The endoscope offers variable views from 15° to 90° in one single plane while remaining shape invariant. Multiple planes were assessed after changing the direction of the endoscopic shaft. The ease of handling and optical performance was noted in each plane.
Results: Enhanced visualization over a wide angle range without moving the endoscope was found to be very beneficial intraoperatively. Accurate assessment of extent of cicatrization or synechiae causes of dacryocystorhinostomy failure, monitoring of internal common opening during trephination, and postoperative ostium evaluation was possible with wider and superior visualization. A complete endoscopic overview in one plane without the need of multiple angled endoscopes made the inspections detailed and less time consuming. Because the tip of the endoscope does not move, it was found to be effective in narrow working spaces without causing any collision with the tissues in the vicinity.
Conclusion: Enhanced field of vision, quicker assessment, and ability to optimize visualization in a continuous mode are advantages of using a variable-view endoscope in lacrimal surgeries.
Armstrong, Blair K. M.D.; Sobti, Deepak M.D.; Mancini, Ronald M.D., F.A.C.S.
Purpose: Brow ptosis commonly occurs with aging. Minimally invasive techniques are varied and include neurotoxin paralysis of eyebrow depressors and internal brow pexy. The authors present a modification of the traditional brow-pexy surgery which incorporates weakening of the lateral eyebrow depressor, the orbicularis oculi muscle, to synergistically influence brow position.
Methods: This retrospective review includes 44 brows in 22 patients treated over a 14-month period. All patients underwent surgery by a single surgeon (RM) at UT Southwestern Medical Center. The surgical technique includes partial orbicularis resection to augment the traditional internal brow pexy. Preoperative and postoperative photographs were analyzed using ImageJ software.
Results: This procedure has been successfully performed on 44 brows in 22 patients with no complications and a high satisfaction rate. ImageJ analysis demonstrates an average elevation of 2.42 mm of the lateral tail of the brow with improved brow contour, volume, and symmetry.
Conclusions: The “Tuck and Rise” has proven a simple, minimally invasive, and effective technique to volumize and elevate the lateral tail of the eyebrow.
Memarzadeh, Khashayar M.D.; Gustafsson, Lotta M.D., M.Sc., Ph.D.; Blohmé, Jonas M.D., Ph.D.; Malmsjö, Malin M.D., Ph.D.
Purpose: For the modified Hughes procedure, a tarsoconjunctival flap from the upper eyelid is used to reconstruct large, full-thickness, lower eyelid defects. The conjunctival pedicle is divided once vascularization is deemed to be adequate. The importance of maintaining a flap pedicle to ensure adequate perfusion of the graft has been questioned. The purpose of the study was to investigate the microvascular blood flow, oxygenation, and survival of a tarsoconjunctival flap in an experimental porcine model of the modified Hughes procedure.
Methods: The modified Hughes procedure was performed in 9 pigs. Microvascular blood flow was measured by laser Doppler velocimetry. Tissue oxygenation was measured using a Licox system, and tissue survival was determined by analyzing histologic sections of biopsy specimens from the lower edge of the flap.
Results: Blood flow and the oxygenation of the tissue decreased gradually during dissection and advancement of the tarsoconjunctival flap. At the time when the flap was sutured into place, there was virtually no blood flow or oxygenation of the tissue. However, flap survival did not seem to be compromised, as shown by the absence of pyknotic cell nuclei necrosis in the biopsy specimens, 12 hours after the procedure.
Conclusions: The pedicle of the tarsoconjunctival flap does not seem to contribute to the nourishment of the tarsoconjunctival flap. Nourishment may be supplied by the rich vascularization of the remaining eyelid and tear film. If this is the case, single-stage grafting of a free tarsal plate may be performed, thus avoiding the eyelid-sharing stage of the procedure, without compromising the survival of the graft.
Moore, Grant H. M.D.; Rootman, Dan B. M.D., M.Sc.; Yeganeh, Amir B.A.; Goldberg, Robert A. M.D.
Purpose: To evaluate the long-term transformation of lateral eyebrow soft tissue in a group of patients with known thyroid eye disease.
Methods: A retrospective review of all patients with a known diagnosis of thyroid eye disease with clinical photos available from both their initial diagnosis visit and at least 7 years following their initial visit was performed. Age at diagnosis, sex, disease activity, previous orbital, and eyelid surgery were noted, as was history of treatment with radioactive iodine, steroids, and external beam radiation. The area between the upper eyebrow and upper eyelid crease was evaluated in standardized photographs by a panel of 4 expert, independent, masked observers utilizing a previously published visual grading key.
Results: One hundred and four patients met inclusion criteria. Fifteen participants were male and 89 were female. The mean patient age was 50.6 years (±1.21 years), and the mean follow up duration was 10.0 years (±0.23 years). The mean initial photo grade (1.24) was significantly higher than the mean follow up photo grade (1.00; p < 0.01). In logistic regression analyses, only the initial photograph grade was significantly associated with improvement in eyebrow soft tissue appearance (p < 0.01). Medical and surgical treatments were not significantly associated with changes in eyebrow soft tissue appearance (all p > 0.05).
Conclusions: Expansion of eyebrow soft tissue may improve over time in patients with thyroid eye disease. This change was not affected by age, sex, disease activity, surgery, or medical therapy.
Tawfik, Hatem A. M.D.; Abdulhafez, Mohamed H. F.R.C.S.; Fouad, Yousef A. M.B.B.S.; Dutton, Jonathan J. M.D., Ph.D., F.A.C.S.
Purpose: To review the recent data about eyelid morphogenesis, and outline a timeline for eyelid development from the very early stages during embryonic life till final maturation of the eyelid late in fetal life.
Methods: The authors extensively review major studies detailing human embryologic and fetal eyelid morphogenesis. These studies span almost a century and include some more recent cadaver studies. Numerous studies in the murine model have helped to better understand the molecular signals that govern eyelid embryogenesis. The authors summarize the current findings in molecular biology, and highlight the most significant studies in mice regarding the multiple and interacting signaling pathways involved in regulating normal eyelid morphogenesis.
Results: Eyelid morphogenesis involves a succession of subtle yet strictly regulated morphogenetic episodes of tissue folding, proliferation, contraction, and even migration, which may occur simultaneously or in succession.
Conclusions: Understanding the extraordinary process of building eyelid tissue in embryonic life, and deciphering its underlying signaling machinery has far reaching clinical implications beyond understanding the developmental abnormalities involving the eyelids, and may pave the way for achieving scar-reducing therapies in adult mammalian wounds, or control the spread of malignancies.