Biomedical subjects
Publications and source records attributed to A M Putterman.
Full-thickness eyelid defects are created in the resection of eyelid carcinomas. These eyelid colobomas can be satisfactorily reconstructed with remaining eyelid tissue in the majority of cases. Procedures are described for resection of varying portions of the eyelids.
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The tarsal-conjunctival-margin portion of a composite graft can be covered with a temporal semicircular flap to ensure its survival. The procedure provides a method of reconstructing full-thickness upper or lower eyelid defects in which there is loss of approximately 33% to 66% of the eyelid. The technique is especially valuable in reconstructing the temporal half of the eyelids, for which major reconstructive procedures are usually required. The procedure has been successful in 21 cases.
The treatment for severe unilateral blepharoptosis is controversial. Sixteen consecutive cases of severe unilateral blepharoptosis were studied: eight had a super-maximum levator muscle resection (30 mm or more) and eight had a bilateral brow suspension with excision of the normal levator. Cosmetically acceptable results were achieved in six of eight cases undergoing a super maximum levator resection. Disparity in the palpebral fissure in downgaze ranged from 3 to 6 mm and was not bothersome to either patient or parent. Postoperative complications such as hypotropia and conjunctival prolapse can be minimized with careful technique. Four to eight cases undergoing bilateral brow suspension with excision of the normal levator had residual ptosis. Brow scars were occasionally noticeable. Overall cosmesis was considered better in the super-maximum levator resection group compared to the frontalis sling group by unbiased observers. Super-maximum levator resection is a good alternative in the treatment of severe unilateral blepharoptosis for selected cases, particularly for those who fear manipulation of the normal eyelid.
Abnormal, thin, crinkly, or pigmented nasal lower eyelid skin is sometimes associated with dermatochalasis (excessive skin). In these cases, excision of temporal lower eyelid skin by conventional cosmetic blepharoplasty draws and diffuses this abnormal skin temporally and worsens the appearance of the lower eyelid skin. A new procedure in which excessive abnormal skin is excised nasally rather than temporally draws and diffuses the more normal temporal skin nasally and improves the appearance of the lower eyelid skin. This approach simultaneously resolved dermatochalasis and abnormal-appearing lower eyelid skin in six eyelids of three patients without complications.
Sebaceous adenocarcinoma is a rare neoplasm of the eyelid that often masquerades as a chalazion, blepharitis, or blepharoconjunctivitis. Controversy exists as to the proper mode of therapy for patients with a tumor confined to the eyelid. We believe that wide local excision (5 to 6 mm of normal tissue) with frozen section analysis and eyelid reconstruction is the preferred treatment. Only 1 of 11 patients had a recurrence with this technique. No regional or distant metastasis has occurred in an average of 68 months of follow-up.
Two patients were treated for a previously unreported disorder believed to be related to Marcus Gunn jaw-winking. The first, a 9-month-old infant with left congenital blepharoptosis without jaw-winking and with normal ocular motility had an up and down movement of the left globe synchronous with nursing movements of the jaw. The second was a 5-year-old girl with left blepharoptosis, jaw-winking, and left double elevator palsy who had up and down movements of both the left upper lid and the left globe synchronous with chewing. The left globe movements were most prominent in the field of vertical action of the superior rectus muscle and persisted after levator excision and fascia lata sling procedures. The possible etiology of the Marcus Gunn jaw-winking phenomenon is discussed and related to our cases of eye bobbing. The eye bobbing probably is caused by abnormal innervation to the superior rectus muscle produced by jaw movements in a manner analogous to the abnormal stimulation of the levator muscle in jaw-winking. The similar embryologic development and innervation of the levator and superior rectus muscles add credence to this theory.
Five patients (eight eyelids) had acquired blepharoptosis after using contact lenses. The ages (26 to 55 years) of these patients was not consistent with idiopathic senile blepharoptosis, and we excluded all other possible causes. All patients had disinsertion and recession of the aponeurosis of the levator palpebrae superioris muscle, and the blepharoptosis improved in each case after reattachment of the aponeurosis to the superior tarsal border. We believe there is a cause-and-effect relationship between the use of contact lenses and the acquisition of secondary blepharoptosis. The most likely explanation of this type of blepharoptosis is difficulty in inserting and removing the lenses. Thus, excessive eyelid manipulation may disinsert the aponeurosis of the levator palpebrae superioris muscle from the tarsus.
A 24-year-old woman sustained a blow-out fracture of the orbital floor with prolapse of the globe into the maxillary sinus. This was treated by replacing the globe in the orbit surgically and reconstructing the orbital floor. Postoperatively, the eye retained normal visual acuity.
Six patients underwent combined Jones tube-canalicular intubation and conjunctival dacryocystorhinostomy. These patients had epiphora secondary to partial obstruction of the upper and lower canaliculi, complete obstruction of the common canaliculus or a single canaliculus, or paresis of the orbicularis oculi muscle. In these patients we would have performed a dacryocystorhinostomy with silicone elastic intubation, risking recurrent obstruction, or a conjunctival dacryocystorhinostomy with placement of a Jones tube, risking failure of the procedure and complete obstruction of patent canaliculi by placement of the tube. The combined Jones tube-canalicular silicone elastic intubation and conjunctival dacryocystorhinostomy ensured successful treatment of epiphora for this group of patients. Intubating the canaliculi with Bowman probes during placement of the Jones tube avoids injury and subsequent postoperative canalicular obstruction. After several months, the silicone elastic tubing is removed and the Jones tube is plugged. If the patient is asymptomatic and the canaliculi are patent and can be irrigated freely to the nasal cavity, the Jones tube can be removed. However, if epiphora occurs, the plug can be removed and the tube left in place to drain the tears without additional surgery.
A graded, controlled excision of Müller's muscle with or without recession of the levator aponeurosis using sensory without motor anesthesia is an excellent technique for releasing thyroid-related upper eyelid retraction. The procedure has provided statistically significant success rates in the first 53 upper eyelids treated by this technique that were carefully analyzed postoperatively. It has continued to provide consistently good results in an additional 49 upper eyelids. The six complications in the first 53 cases included nasal ptosis (4), diffuse ptosis (1), and residual eyelid retraction (1). These were easily rectified with a second simple surgical procedure. The operation described is considered superior to other techniques in treating thyroid-related upper eyelid retraction because other procedures have not been analyzed in large enough numbers to demonstrate as high a degree of success as this operation. The procedure is simple, based on anatomic and physiologic principles, tailored to the individual patient intraoperatively, and yields consistently good results.
A combined Z-plasty and horizontal shortening procedure to treat ectropions with cicatricial and horizontal laxity components successfully relieved ectropions in six patients. If the cicatricial changes are localized to one third or less of the eyelid, a skin Z-plasty to vertically lengthen the eyelid can be combined with a full-thickness pentagonal resection to horizontally tighten the eyelid.
Fifteen years ago a 47-year-old man underwent an evisceration for an unsuspected choroidal melanoma. A bulky recurrence required exenteration. The patient is currently alive and has no evidence of metastatic disease.
Four tarsorrhaphy sutures are placed through the lower eyelid and brow following ptosis surgery in a system designed for patients with external ophthalmoplegia, third nerve paralysis, and myashenia gravis. Three of the sutures connect the lower eyelid to the forehead, and the fourth suture is passed through the lower eyelid and taped to the cheek. The three lid-brow sutures are released during the first two postoperative weeks, one by one, and topical ointment instillations are gradually tapered. The tarsorrhaphy system allows the cornea to adapt gradually to the lagophthalmos that follows ptosis surgery. It also keeps the eyelids partially closed during the first two postoperative weeks in patients with frontalis sling surgery who have marked difficulty lowering their eyebrow and closing their eyelids because of early postoperative forehead edema and pain. The tarsorrhaphy system has prevented serious keratopathy in six patients with ptosis associated with abnormal ocular motility and in one patient with lagophthalmos following trauma. It also allowed the six ptosis patients to have full, rather than partial, correction of their ptosis.
Upper eyelid retraction secondary to thyroid disease can be relieved in a controlled manner by a graded detachment and excision of Müller's muscle and stripping and recession of the levator aponeurosis. This improves cosmesis, lessens the exophthalmic appearance, and relieves ocular irritation secondary to exposure keratopathy and conjunctivopathy. Recessing the lower eyelid retractors and placing a scleral graft between them and the tarsus can relieve lower eyelid retraction. Edema and inflammation of orbital fat secondary to thyroid disease cause separation of the orbital septum from the capsulopalpebral fascia, allowing fat to prolapse into the orbit as in a true hernia. To prevent full fledged lower eyelid retraction and to relieve slight amounts that already exist, the lower eyelid retractors are recessed when orbital fat is excised.
A 62-year-old black man had is left socket reconstructed to permit the wearing of a prosthesis following an injury to the left eye with hot metal. Between six and seven months after the socket surgery and within several weeks after removing the temporary conformer, he developed depigmentation of his eyelid skin, which is slowly improving. We feel that either a hypersensitivity reaction to chloramphenicol ointment or traumatic insult to the eyelid tissues is responsible for the loss of pigment.
Intradermal nevi of the eyelid may be found on the eyelid margin, but occasionally occur on the eyelid skin. Excision of the tumor is performed to substantiate the diagnosis and to improve cosmesis. If the tumor involves the skin alone, an elliptical resection of tumor is recommended. If the tumor appears on the eyelid margin only, it is sliced off parallel with the lid margin. This provides a simple technique to obtain a specimen for diagnosis. It spares the cilia, requires no sutures, and provides a good cosmetic result. If the tumor involves eyelid margin and skin simultaneously, a combination of the elliptical excision and slicing technique is used. When the tumor is more extensive, a full-thickness pentagonal resection of the eyelid with or without canthotomy and cantholysis is performed.
An aberrant opening of the lacrimal gland duct into the temporal upper eyelid skin caused troublesome epiphora in a patient. This occurred either as a congenital anomaly or by blunt trauma to the eyelid. The epiphora was relieved by redirecting the flow of tears from the external to the internal eyelid. This treatment prevented the recurrence of the fistula and preserved the flow of tears to the eye.