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PubMed2000

[Merkel cell tumor of the eyelids: review of the literature and report of 2 patients].

BACKGROUND: The Markel cell carcinoma is a rare malignant skin tumor. The tumor was first described in 1972 by Toker and he named it trabecular carcinoma. We had the opportunity to treat two patients with a Merkel cell carcinoma of the upper and lower eyelid and reviewed the literature using the "Medline" database concerning Merkel cell carcinomas of the ocular adnexa. HISTORY AND SIGNS: A 76-year-old female patient was referred to our hospital because of an inflammatory tumor of the left upper eyelid present for two months. A 91-year-old male patient noticed for four weeks a painless itching lesion at the left lower eyelid. The remaining ophthalmologic examination in these patients was unremarkable. THERAPY AND OUTCOME: Both tumors were excised. Histological and immunohistochemical examination verified a Merkel cell carcinoma in both cases. The 76-year-old female patient exhibited no recurrent tumor after a follow-up of 18 months. The 91-year-old male patient had a recurrent tumor inferior to the temporal lower eyelid 7 months after tumor excision, however, lymph node metastasis is not present as of yet. The patient underwent radiation therapy with cobalt of the left orbit with a total dose of 60 Gy. CONCLUSION: Merkel cell carcinomas can occur everywhere on the skin; the eyelids are affected in 10% of all cases. Best histochemical markers are cytokeratin 20 and neurospecific enolase. A review of the literature revealed 31 patients with Merkel cell carcinomas involving the eyelids. Female patients were more often affected than male patients. The upper eyelid was more frequently involved than the lower eyelid. Recurrent disease is frequent.

Aged↗
PubMed2004

[Treatment of eyelid retraction in Grave's disease by recession of the levator complex].

BACKGROUND: The chronic stage in Grave's orbitopathy is characterised by fibrotic changes within the orbital soft tissues, especially the extraocular muscles. Retraction of the eyelids is a common clinical feature of this phenomenon. To solve this problem several techniques for lengthening the upper eyelid have been described with variable rates of success. In this report we describe our modified Harvey's technique for the correction of upper eyelid retraction which includes a complete recession of the Muller's muscle/levator complex from the tarsal plate without the interposition of a spacer. Finally only the skin and the superficial orbicularis muscle are sutured. We also report about our results with this procedure. METHODS: 8 patients (1 male, 7 female) with lid retraction in Grave's ophthalmopathy were recorded who had undergone the modified lengthening technique by an external approach between 2001 and 2004. Four patients underwent a bilateral procedure and 1 patient showed a significant under-correction, necessitating reoperation. So a total of 13 procedures were included in this follow-up study. Beside the common ophthalmological examination, special interest was put in the difference of the two eyelid apertures in primary position pre- and postoperatively. RESULTS: Within a follow-up period of at least 3 months we recorded an averaged lengthening of the upper eyelid of 3.1 mm. The difference of the two eyelid apertures in primary position improved from 2.2 mm preoperatively to 1.0 mm postoperatively. Only 1 patient needed reoperation because of a significant under-correction. There were no late over-corrections observed. CONCLUSIONS: The modified Harvey's technique to lengthen the upper eyelid is a safe and effective method to reduce upper eyelid retraction in Grave's disease. An eventually required orbital decompression or extraocular muscle surgery has to be done before the lid surgery.

Adult↗
PubMed1991

Anatomic considerations in upper eyelid retraction.

A series of anatomically correct orbital drawings are created to examine the major integrating factors that determine upper eyelid position on the eye. The principal upper eyelid force planes can be identified as (1) the eyelid vertical retractor plane slightly divergent from the orbital axis, (2) the eyelid protractor plane nearly tangent to the orbital aperture, and (3) the upper eyelid tarsalligamentous plane swinging from within the horizontal orbital rims. These forces are governed by variation in orbital size and shape, globe size and position, and the length-tension characteristics of the eyelid retractors, protractors, and lamellae. Enhanced lateral upper eyelid retraction occurs in part because the eye in primary position looks away from the orbital axis and projects more lateral sclera. When the eye gazes laterally, coincident with the orbital axis, enhanced lateral upper eyelid retraction disappears.

Exophthalmos↗
PubMed1999

Distribution of adrenergic receptor subtypes in the retractor muscles of the upper eyelid.

PURPOSE: To identify adrenergic receptor subtypes and their relative distribution in the retractor muscles of the upper eyelid, the levator palpebrae superioris, and the Müller muscle. The pattern of distribution of these receptors in the Müller muscle was further compared in patients with dysthyroid eyelid retraction and in normal subjects. METHODS: Müller muscle specimens were collected from 19 patients undergoing ptosis correction and from 8 patients undergoing repair of dysthyroid eyelid retraction. Immunohistochemical staining for alpha 1-, alpha 2-, beta 1-, and beta 2-adrenergic receptors was performed using antihuman rabbit polyclonal antibodies. RESULTS: alpha 2-Adrenergic receptors were the predominant subtype in the Müller muscle, and beta 1-adrenergic receptors were the predominant subtype in the levator muscle. There was no significant difference in the staining pattern between specimens collected from patients with dysthyroid eyelid retraction and those from normal subjects. CONCLUSIONS: The interaction between the alpha 2 and beta 1 receptors in the upper eyelid retractor muscles may be important in the control of the upper eyelid position and may contribute to the development of dysthyroid eyelid retraction. Specific alpha 2 antagonists could be developed and may be effective pharmacologic agents for the treatment of eyelid retraction.

Eyelid Diseases↗
PubMed1999

Congenital, paradoxical lower eyelid retraction on upgaze.

PURPOSE: Active lower eyelid retraction on upgaze is a rarely described finding. The purpose of this study is to describe the clinical and operative findings in two patients with this unique eyelid movement disorder. METHODS: The authors identified active, unilateral lower eyelid retraction on upgaze in two patients who had no other ocular or systemic abnormalities. RESULTS: Surgical extirpation of the lower eyelid retractor complex was carried out in both cases. During one of the procedures, performed under local anesthesia, the lower eyelid retractors were observed to retract actively on upgaze. Postoperatively, lower eyelid retraction on upgaze was not present in either case. CONCLUSIONS: The authors are aware of only one other case report describing active, paradoxical lower eyelid retraction on upgaze. The mechanism of eyelid retraction in this previous report and in the two patients described herein is not known. The authors postulate that these unique cases may represent a previously unrecognized form of congenital, aberrant innervation of the oculomotor nerve.

Adolescent↗
PubMed1999

Tarsal switch procedure for the surgical rehabilitation of the eyelid and socket deficiencies of the anophthalmic socket.

PURPOSE: To describe a tarsal transfer procedure, which we have named the "tarsal switch," to correct the eyelid malpositions and camouflage the socket defects of acquired anophthalmos. METHODS: The technique consists of an upper eyelid tarsectomy, with transfer of the autologous tarsoconjunctival graft to the posterior lamella of the lower eyelid. RESULTS: The operation was performed in 21 anophthalmic patients. In 16 patients with eyelid malpositions, excellent results (within 1 mm of the fellow eye) were attained in 100% of the patients with ptosis, and in 88% of patients with lower eyelid retraction. In the remaining 5 patients, orbital volume loss with secondary implant migration, inferior prosthetic displacement and eyelid asymmetry predominated. In these patients the anophthalmic orbital defects and eyelid asymmetry were masked well. Patient satisfaction was high and complications were few during an average follow-up interval of 16 months. CONCLUSION: The tarsal switch procedure is useful in managing the eyelid malpositions and masking the orbital deficiencies of the anophthalmic socket.

Adult↗
PubMed2002

Eyelid sensation after supratarsal lid crease incision.

PURPOSE: To determine the severity and duration of the loss of eyelid sensation after upper eyelid crease incision. METHODS: This clinic-based case study was performed by analyzing observational measurements of patients undergoing upper blepharoplasty or ptosis surgery. Eighty-three eyelids of 50 patients were studied. A Cochet-Bonnet filament-type aesthesiometer was used to obtain all measurements. Preoperative and postoperative measurements were recorded at 1 week, 1 month, and final (2-6 months) time periods. Statistical analysis evaluated the degree and duration of the sensory loss and the extent of recovery during the evaluation period. Recovery of sensation was defined as a numerical reading within one point of baseline. RESULTS: The mean aesthesiometry reading was calculated at the preoperative (3.45), 1-week (1.20), 1-month (1.56), and final postoperative (2.56) periods. Paired t testing showed a decreased but significant difference in sensation measurement at each comparison. Recovery of sensation to within one point occurs at the preoperative to late time period comparison. All but 4 of the 68 eyelids tested at the 1-week postoperative time period had a measured loss of sensation. Of the 44 eyelids tested at the final time period, all but 1 had regained some or all of this sensory loss. CONCLUSIONS: Loss of skin sensation in the eyelid after upper eyelid crease incision blepharoplasty or blepharoptosis repair occurs in most patients and should be considered an expected outcome of the procedure. Partial to complete recovery of eyelid sensation over 2 to 6 months should also be expected, though in rare instances this does not occur.

Adolescent↗
PubMed2004

Eyelid involvement in paracoccidioidomycosis.

PURPOSE: To describe a series of patients with eyelid lesions caused by paracoccidioidomycosis and to estimate the prevalence of eyelid involvement in this disease METHODS: The medical records of 439 patients with paracoccidioidomycosis admitted to our hospital from 1992 to 2002 were reviewed. Age, sex, and clinical forms of the disease were recorded. All patients with eyelid involvement had a skin biopsy positive for paracoccidioidomycosis and were examined by an ophthalmologist with oculoplastic training. RESULTS: Of 439 patients with acute, subacute, or chronic paracoccidioidomycosis, 11 (2.5%) had eyelid involvement. Active lesions ranged from erythematous patches of madarosis to frank destructive ulcers indistinguishable from malignancies. Healed lesions were characterized by a high degree of fibrosis. Cicatricial changes induced eyelid malpositions (entropion or ectropion) and fusion of eyelid tissues to the globe. Madarosis was a constant finding in the inactive lesions. CONCLUSIONS: The prevalence of eyelid involvement in paracoccidioidomycosis is low. Isolated active lesions are usually diagnosed as malignant tumors. Cicatricial changes are characterized by a high degree of fibrosis. If not treated, the mycosis can destroy the eyelid.

Acute Disease↗
PubMed2005

Free tarsus autogenous graft struts for lower eyelid elevation.

PURPOSE: Free tarsus autogenous graft (FTG) has emerged as a useful biological spacer in lower eyelid elevation. However, it has limited use where a spacer of greater than 4 mm height is required, because at least 4 mm of upper tarsal height must be preserved to maintain upper eyelid rigidity. We describe an augmentation of FTG in its use as a spacer, by way of creating 2 parallel-placed vertical FTG struts, in contrast to interpositioning the FTG horizontally. METHODS: This case series describes the technique of harvesting and interpositioning FTG struts. Nine eyelids in 6 patients in whom FTG struts were used for lower eyelid elevation are reported. The patients ranged in age from 41 to 80 years. Underlying diagnoses included thyroid orbitopathy, previous blepharoplasty, and previous facial and eyelid thermal burns. RESULTS: FTG struts achieved an effective spacer height of up to 7 mm, and follow-up of 9 to 20 months revealed a good outcome in all 3 cases, with no complications. CONCLUSIONS: FTG struts provide an effective and lasting lower eyelid elevation when used as a spacer. A spacer graft of up to 7 mm in vertical height may be harvested from a long strip of upper eyelid tarsus that is 4 mm in vertical height. This technique would allow autogenous upper eyelid tarsus to be harvested with maximum conservation of tissue.

Adult↗
PubMed2005

Modification of the Cutler-Beard procedure using donor achilles tendon for upper eyelid reconstruction.

PURPOSE: Large upper eyelid defects are typically repaired by the two-stage Cutler-Beard procedure. Replacing the tarsal plate is integral in reconstructing the upper eyelid. Currently, autogenous cartilage is the most frequently used tarsal substitute. We propose using donor Achilles tendon as an alternative for increased stability of the upper eyelid when repairing large defects by the Cutler-Beard procedure. METHODS: We present a retrospectively reviewed case series of four patients with large upper eyelid defects. Each had the traditional Cutler-Beard procedure with the variation of using donor Achilles tendon as the tarsal replacement. Patients were examined and photographed in follow-up ranging from 6 months to 4 years. RESULTS: All cases were successful in recreating the upper eyelid without complication. The tendon graft supplied structure, motility, and cosmesis throughout follow-up. The human Achilles tendon was investigated by literature review and compared with currently available posterior lamellar substitutes. CONCLUSIONS: The replacement of upper eyelid tarsus with Achilles tendon as part of the Cutler-Beard procedure was successful in repairing large upper eyelid defects in four patients. The tendon graft is easily placed and incorporated in the normal eyelid anatomy. It is pliable and mobile yet stable. Repair is not limited by the size of the defect, as the tissue is readily available. The modification produced excellent functional and cosmetic results.

Achilles Tendon↗
PubMed2005

[Eyelid measures before and after upper blepharoplasty--quantitative evaluation].

PURPOSE: To evaluate eyelid measures before and after upper blepharoplasty surgery using a digital image system. METHODS: Eighteen eyelids of 9 patients with dermatochalasis were evaluated at the Hospital das Clínicas de Botucatu-UNESP regarding eyelid measures before and after upper blepharoplasty. All patients were female, aged between 40 and 75 years. The images were acquired by a photographic camera, transferred to a computer and then analyzed by the Scion Image Frame Grabber program. The evaluated parameters were upper eyelid position in primary gaze position, upper palpebral sulcus and lateral eyelid angle. The measures were obtained before and after 60 days of upper dermatochalasis surgery. RESULTS: After the surgery, there was an increase of upper eyelid position and upper palpebral sulcus; the lateral palpebral angle did not show any alteration. CONCLUSION: Eyelid position changes after blepharoplasty and digital image processing provides quantitative measures of the eyelid, allowing a better quantification of the surgical results.

Adult↗
PubMed1993

Retinoic acid, cortisone, or thyroxine suppresses the mutant phenotype of the eyelid development mutation, lgMl, in mice.

The development of the mammalian eyelid is one of the last major morphogenetic events during prenatal development. The eyelids originate as outgrowths of epithelium and mesenchyme above and below the eye; they grow and flatten across the eyes, and meet and fuse firmly but temporarily until several days after birth in mice. In mouse lidgap mutants, eyelid development fails. Previously, we have shown that normal eyelid development can be induced in lidgap mutants by maternal treatment with cortisone or thyroxine. These hormones have been reported to interact with members of a receptor superfamily, and their response elements have been shown to induce transcription of hormone-regulated genes; retinoic acid also interacts with members of this superfamily. The purposes of our study were to examine the joint effect of thyroxine and cortisone on induced eyelid development in lidgap-Miller mutant fetuses (lgMl/lgMl), to test for synergism, and also to test whether retinoic acid also induces eyelid development in this mutant. We found that the combined effect of thyroxine and cortisone was significantly greater than that of either hormone alone, but that the dose-response slopes (log dose, probit scale) for eyelid development induced by cortisone alone or by cortisone preceded by 0.1 mg thyroxine were parallel, suggesting that their action is additive, not synergistic. We found that retinoic acid administered on day 14 of gestation induced eyelid development in lgMl/lgMl mutant fetuses, with a significant dose response and ED50 of 24 +/- 6 mg/kg. The response was treatment-time dependent, with optimal responses after day 14 or 11 treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed2005

Reconstruction of seventeen full-thickness defects of the eyelids with twenty-two Hübner tarsomarginal grafts.

In 1976, Hübner described a new technique to repair full-thickness defects of the eyelids. In 1993, we decided to adopt this simple and easily reproducible technique that guarantees restoration of the normal aspect of the margin. Subsequently, 17 eyelid reconstructions were performed on 13 patients, requiring the harvesting of 22 tarsomarginal grafts. No cosmetic or functional sequelae in the donor eyelids were observed. One or several functional complications were present in seven out of 17 reconstructed eyelids, including two cases of epiphora, one case of lagophtalmos and two cases of lid notch. Loss of the eyelids was observed in three cases out of six upper eyelid reconstructions and in nine cases out of 11 lower eyelid reconstructions. In all cases, the margin integrity was otherwise preserved. Very few simple techniques achieve that level of quality in the eyelid reconstruction process.

Adult↗
PubMed1988

The effect of omitting botulinum toxin from the lower eyelid in blepharospasm treatment.

We randomly selected 26 patients with essential blepharospasm to receive either botulinum toxin or saline injection in their lower eyelids to evaluate the necessity of lower eyelid injection to relieve blepharospasm. As diplopia may occur from botulinum toxin injections for blepharospasm, most commonly from injection of the lower eyelid, and surgical relief of blepharospasm is often achieved by excision of only the upper eyelid protractors, omission of toxin from the lower eyelid seemed both desirable and possible. All patients received botulinum toxin in the upper eyelids, above the eyebrows, across the glabella, and near the lateral canthus. Thirteen of 15 patients who received saline in their lower eyelids had relief of spasm, with the same spasm-free interval as those who received toxin. We recommend avoiding injection of toxin in the medial two thirds of the lower eyelid in order to diminish the likelihood of diplopia from inferior oblique muscle paresis.

Blepharitis↗
PubMed2003

Eyelid tumors in southern Taiwan: a 5-year survey from a medical university.

This retrospective case analysis investigated the epidemiology of eyelid tumors in a subtropical area. The study assessed the proportion of all eyelid tumors that were malignancies, the accuracy of diagnosis, and surgical results. We retrospectively collected all cases of eyelid tumors in the Department of Ophthalmology, Kaohsiung Medical University, Taiwan, between January 1994 and December 1998. Among the 144 cases collected, about half of the tumors were located in the upper eyelids and the other half in the lower eyelids. Nearly 50% of cases underwent tumor resection with eyelid reconstruction. When followed up to April 1999, 97% of patients were satisfied with the surgical results. There were 18 cases (12.5%) of malignant tumors, including 14 basal cell carcinomas, three sebaceous carcinomas, and one squamous cell carcinoma. Before surgery, two malignancies were presumed to be benign tumors while another two were thought to be different malignant tumors. The benign tumors included 38 nevi, 15 squamous papillomas, 13 cysts, 11 verrucae, 10 seborrheic keratoses, four hemangiomas, and others. All tumors that were thought to be malignancies were treated using complete resection with margin monitoring by frozen section. At the end of follow-up, no recurrence was noted. More than 10% of cases of eyelid tumors in this subtropical teaching hospital were malignant. All surgeons should be alert to this phenomenon when they operate on an eyelid tumor. The best policy is to send all specimens for pathologic examination.

Adenocarcinoma, Sebaceous↗
PubMed2001

Botulinum-A toxin treatment of the lower eyelid improves infraorbital rhytides and widens the eye.

Botulinum-A exotoxin (BTX-A) can be used cosmetically to improve rhytides, particularly of the upper one-third of the face. In this study, fifteen women had BTX-A (BOTOX, Allergan, Inc.) injected into the orbicularis oculi muscle. One lower eyelid received two units just subdermally in the midpupillary line three millimeters below the ciliary margin. The opposite periocular area received two units BTX-A in the lower eyelid with 12 units BTX-A injected into the lateral orbital ("crow's foot") area. Three injections of four units each were placed 1.5 cm from the lateral canthus, each 1 cm apart. Patients and physicians independently evaluated the degree of improvement (grade 0 = no improvement, grade 1 = mild improvement, grade 2 = moderate improvement, and grade 3 = dramatic improvement). An independent photographic analysis was performed. Patients reported a grade of 0.73 when two units were injected alone into the lower lid, and a grade of 1.9 when the lower eyelid and the lateral orbital areas were injected. Physician assessment was grade 0.7 with injection of the eyelid alone and grade 1.8 with injection of the lower eyelid and lateral orbital area. Single investigator photographic analysis demonstrated that 40% of the subjects who had injection of the lower eyelid alone had an increased palpebral aperture (IPA), while 86% of the subjects who had injection of the lower eyelid and lateral orbital area had an IPA. Subjects receiving two units alone had an average 0.5 mm IPA and a mean 1.3 mm IPA at full smile. Concomitant treatment of the lateral orbital area produced a mean 1.8 mm IPA at rest and a mean 2.9 mm IPA at full smile. The results were more notable in the Asian eye. Two units of BTX-A injected into the lower eyelid orbicularis oculi muscle improves infraorbital wrinkles, particularly when used in combination with BTX-A treatment of the lateral orbital area.

Adolescent↗
PubMed1998

A prefabricated free flap for eyelid reconstruction.

Patients with severe soft-tissue trauma to the ipsilateral upper and lower eyelid and surrounding structures represent a reconstructive challenge. The authors present a new approach to eyelid reconstruction, by creating a prefabricated free flap from the contralateral lower eyelid. New Zealand white rabbits were anesthetized, and the central artery and vein of the ear were mobilized and placed in a subcutaneous tunnel in the lower eyelid. After a delay procedure, flaps were made that measured 50 percent of the lower lid area. In an initial group (n = 9), the flaps were harvested at 3 weeks, and injected with Microfil, to demonstrate visual and radiologic patency and perfusion from the neopedicle. In a subsequent group of animals (n = 6), full-thickness defects of 50 percent of the left upper lid were created. Prefabricated free flaps from the right lower lid were transferred, anastomosing to the central artery and vein on the side of the eyelid being reconstructed. Tissue removed from the upper eyelid was placed in the defect of the lower lid donor site to serve as a control. Flaps were followed for periods of up to 6 months, documenting results photographically and by injection. Prefabricated free flaps from the lower eyelid maintained long-term patency and full-thickness perfusion from the pedicle, and also maintained size, shape, and accessory skin appendages better than composite graft controls. The authors concluded that prefabricated free flaps may be used to reconstruct eyelid defects; a surgical technique for application to human subjects is proposed.

Animals↗
PubMed1992

Innervation of the feline eyelids.

The innervation of the eyelids is incompletely understood. This is a particular problem for those who wish to develop animal models of eyelid dysfunction in humans. Blepharospasm, for example, is a disease of uncontrolled eyelid spasm that is difficult to manage clinically because the aetiology is not understood. The anatomical literature on eyelid innervation is sparse and even conflicting. We attempted to study eyelid innervation, both sensory and motor, with injection of horseradish peroxidase (HRP) into the superior eyelid, inferior eyelid, and bulbar conjunctiva. We used 13 anesthetized weanling cats. Shape and structure of the facial nucleus varied along its rostrocaudal extent, but there was a clear demarcation of lateral and medial division. HRP-filled facial nucleus cells were ipsilateral to the injection site, and label appeared throughout the rostrocaudal length. All injection sites, including bulbar conjunctiva, labelled facial nucleus neurons located with overlapping distribution, predominantly in the dorsal part of the lateral division. Likewise, heavy labelling occurred throughout the entire ipsilateral cranial cervical ganglion and the trigeminal ganglion in all kittens. Injection of upper or lower eyelids caused some labelling in the second through the fourth cervical spinal ganglia.

Animals↗