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PubMed2002

A histologic analysis and three-dimensional reconstruction of the muscle of Riolan.

PURPOSE: To describe the anatomic and histologic relations of the muscle of Riolan in the eyelid margin. METHODS: Serial microscopic sections of the eyelid were prepared, digitally scanned, and then reconstructed with computer software to create a 3-dimensional profile of this muscle group in two planes. RESULTS: The muscle of Riolan is a distinct subdivision of striated muscle that is separate from the pretarsal orbicularis muscle. In parasagittal eyelid sections, the muscle appears to be composed of two separate bundles, the pars ciliaris, located anterior to the tarsal plate, and a second smaller bundle, the pars subtarsalis, located posterior to the orifices of the meibomian glands. Coronal sections, however, demonstrate numerous muscle fibers that traverse the tarsus, connecting the two muscle groups that we describe for the first time as the pars fascicularis. CONCLUSIONS: The three muscle subdivisions are therefore physically joined together and appear to act as a single functional entity that should be collectively referred to as the muscle of Riolan.

Adult↗

PubMed2002

A new algorithm for ptosis repair using conjunctival Müllerectomy with or without tarsectomy.

PURPOSE: To determine the predictability of a new algorithm for determining the amount of tissue resection for conjunctival Müllerectomy with or without tarsectomy blepharoptosis repair. METHODS: Consecutive case series of all patients undergoing conjunctival Müllerectomy with or without tarsectomy ptosis repair from October 1999 to September 2001. Each patient underwent excision according to a new algorithm for determining the amount of tissue excision. The amount resected was determined by the following formula: 9 mm of conjunctiva and Müller muscle + x mm of tarsus, where x = distance of undercorrection after phenylephrine testing. RESULTS: Sixty-eight consecutive patients underwent 70 cases of conjunctival Müllerectomy with or without tarsectomy ptosis repair on 117 eyelids, using a new algorithm for tissue excision. Forty-seven cases were bilateral and 23 were unilateral. Postoperative symmetry was found in 58 of 67 patients (87%) after 1 surgery. Patient satisfaction based on symmetry, contour, and height after 1 repair was achieved in 64 of 67 patients. There were no overcorrections. Two patients underwent successful reoperation with a second conjunctival Müllerectomy with or without tarsectomy operation. CONCLUSIONS: This modified algorithm and technique quantifies conjunctival Müllerectomy with or without tarsectomy ptosis surgery and yields predictable results.

Algorithms↗

PubMed1994

Corneal disorders in floppy eyelid syndrome.

The corneal findings in 60 patients with floppy eyelid syndrome seen at the Bascom Palmer Eye Institute over a 10-year period were determined by review of their medical records. Punctate epithelial keratopathy (45%), and both clinical (10%) and subclinical keratoconus were the most commonly encountered corneal disorders. Two patients developed progressive endotheliopathy (Chandler's syndrome and nonguttate endothelial dystrophy) during the period of observation. In contrast to previous reports in which almost all patients were obese men, 37% (n = 22) of our patients were women and only 29% of all patients were obese. All patients slept face down, usually on the most severely affected eye. Treatment by lid shortening surgery and/or an eye shield provided symptomatic relief. A pathogenetic theory is advanced that the degenerative changes in the tarsus result from the combination of local pressure-induced lid ischemia and systemic hypoventilation followed by reperfusion oxidation injury.

Adult↗

PubMed1977

Correction of entropion in the elderly: a muscle flap procedure.

A method for surgical correction of entropion in the elderly has been described, utilizing a medially-based muscle flap of the orbicularis oculi muscle. The flap is sutured to the periosteum over the lateral orbital rim, thus holding the tarsus and lower lid in a correct position against the globe. The repair is supported further by excising the excess lower lid skin and anchoring the remaining skin to the lateral canthal ligament. The key to this procedure is the ease and accuracy with which the correction can be accomplished.

Aged↗

PubMed1978

Tarsal fixation in lower blepharoplasty.

Proceeding from the premise that a "youthful" eyelid has a pretarsal bulge while a "senile" eyelid has a pretarsal flatness, the tarsal fixation technique for lower blepharoplasty has been introduced--to reposition part of the orbicularis in front of the tarsus to produce a pretarsal bulge. The technique is presented as a suggested adjunct to the usual types of lower blepharoplasty.

Adult↗

PubMed1985

Palatal grafts for eyelid reconstruction.

A full-thickness graft of hard palate mucosa was used as the lining tissue for eyelid reconstruction in 11 patients over a 7-year period. An orbicularis musculocutaneous flap supplied cover and support. In all cases the mucosal graft was easily removed, convenient to handle, and took completely. The palate donor site reepithelialized by about 3 weeks postoperative and has remained healed and asymptomatic in all cases. In follow-up averaging 3 years, all the reconstructed lids have retained a stable and comfortable lid margin, with no instance of entropion or irritation. The outstanding virtue of palate mucosa for eyelid reconstruction is that it appears to retain most of its original size and stiffness over the long term and thus in a single layer can serve to replace both tarsus and conjunctiva.

Adult↗

PubMed1986

Pathways of sympathetic innervation to the superior and inferior (Müller's) tarsal muscles.

Fluorescent staining and fluorescent microscopy were used to evaluate the pathways which the sympathetic nerves followed to reach the smooth muscles of the eyelids. Selected structures from fresh orbits were removed, sectioned, and fluorescently stained utilizing glyoxylic acid. Photographic results from the fresh orbits showed fluorescence accompanying the oculomotor, trochlear, and abducent nerves and branches of the ophthalmic division of the trigeminal (lacrimal, supraorbital, and nasociliary) nerves. The eyelids exhibited intense fluorescence within the tarsus and throughout adjacent connective tissue. The principal paths of the sympathetic nerves are the sensory (first dimension of the trigeminal) and the motor nerves to the orbit. The arteries (in contrast to previous descriptions) do not appear to be a major pathway.

Eyelids↗

PubMed1987

Experience with tarsal suspension as a factor in lower lid blepharoplasty.

The bowed lower eyelid, with scleral show, is a common but untoward result following blepharoplasty with even minimal skin excision. A number of conditions, unrecognized preoperatively, can predispose a patient to scleral show. These include eyelid laxity with or without atrophic orbicularis muscle tone, lax canthal tendons, hypoplastic malar eminences, unrecognized Graves' ophthalmopathy, unilateral high myopia, or the secondary blepharoplasty. Suspension of the tarsus of the lower eyelid, concomitant with or following blepharoplasty, can straighten bowed lids and provide 2 to 3 mm of elevation, if desired. A classification of patients likely to develop scleral show is presented along with a revised technique of tarsal suspension.

Adolescent↗

PubMed1990

The prevention and treatment of lower lid ectropion following blepharoplasty.

Ectropion and scleral show are the most common complications following lower lid blepharoplasty. Certain conditions predispose patients to ectropion, and these should be evaluated. In some cases, the addition of a wedge tarsectomy or tarsal strip procedure to a blepharoplasty in association with careful technique and postoperative measures is important in prevention of postblepharoplasty ectropion. Postoperative ectropion should initially be treated conservatively with massage. This may be effective up to 6 months postoperatively. If conservative measures fail, the etiology of the ectropion should be addressed. Laxity of the tarsus and canthal ligaments benefit from a horizontal lid-shortening procedure. Where there is vertical shortening from excessive skin resection or scarring of the orbital septum, there should be release and grafting of the deficiency.

Ectropion↗

PubMed1997

Management of postblepharoplasty lower eyelid retraction with hard palate grafts and lateral tarsal strip.

Lower eyelid malposition is the most common long-term complication following transcutaneous lower eyelid blepharoplasty. The malposition may include rounding of the lateral canthal angle, lower eyelid retraction with inferior scleral show, or frank ectropion. The result is cosmetically unacceptable and may be associated with tearing, irritation, and other exposure keratitis symptoms. Multiple factors, including lower eyelid laxity, shortage of skin, and scarring of the middle lamella, may be responsible for this malposition. A systematic examination of the lower eyelid, as presented, helps to assess the degree to which each of these factors is responsible for the malposition. Patients with the most severe degree of lower eyelid malposition generally have middle lamella scarring. If this abnormality is not addressed, lower eyelid procedures aimed at correcting the malposition are doomed to failure. In the presence of significant middle lamella scarring, a spacer is required to provide vertical height and stiffness to support the lower eyelid following release of the cicatrix. A systematic approach aimed at addressing the underlying abnormalities was developed. In patients with significant middle lamella scarring, hard palate mucosa grafts were used as spacers in 29 eyelids (17 patients). A lateral canthotomy and transconjunctival incision allow access to the scarring in the lower eyelid retractors and septum. After careful release of all cicatrix, a hard palate mucosa graft is inserted between the lower border of the tarsal plate and the recessed conjunctiva, lower eyelid retractors, and septum. Horizontal lower eyelid laxity, when present, is corrected by performing a lateral tarsal strip. Most patients do not have a true deficiency of the anterior lamella (skin and orbicularis oculi muscle). When a moderate amount of anterior lamella deficiency is present with significant scarring of the middle lamella, the technique we describe allows correction of the lower eyelid malposition without a skin graft. After a follow-up interval of 6 to 30 months (mean 14 months), excellent results were obtained in all eyelids. Complications included corneal abrasions in two eyes before routine use of bandage cornea contact lenses at the end of surgery and a secondary bleed from the roof of the mouth in one patient. Palate mucosa closely resembles tarsus and provides excellent vertical support to the eyelid. It is stiff enough to maintain eyelid contour without causing a cosmetically unacceptable bump. Tissue can be obtained with ease. The technique, as described, addresses the underlying causes of lower eyelid malposition and gives excellent functional and cosmetic results.

Adult↗

PubMed1997

Island mucochrondrocutaneous flap for reconstruction of total loss of the lower eyelid.

The methods usually employed for reconstruction of total lower eyelid loss include (1) tarsoconjunctival flaps from the upper eyelid and skin-graft cover and (2) chondromucosal grafts and local skin-flap cover. We report a technique for coverage of these defects with an island flap involving the full thickness of the ipsilateral nasal wall based on the dorsal (external) nasal vessels, terminal branches of the ophthalmic vessels. The advantages of this method are (1) the main components of the eyelid (skin, tarsus, conjunctiva) are reconstructed in a single short operation, even under local anesthesia, (2) there is one donor area that can be closed primarily without significant deformity, (3) the upper lid remains intact, and ectropion is improbable, and (4) the procedure involves a short hospitalization. As disadvantages we might mention bulkiness of the new eyelid and difficult dissection of the (subcutaneous) pedicle.

Aged↗

PubMed1999

Long-term comparison of a newly designed gold implant with the conventional implant in facial nerve paralysis.

Patients with complete facial nerve palsy are at risk for eye complications resulting from exposure of the cornea and loss of the blinking reflex. Failure of protection predisposes the patient to exposure keratitis, corneal abrasion and, in rare cases, blindness. The mainstays of non-surgical therapy are cumbersome, obscure vision, and are mostly helpful in patients with acute facial paralysis in whom recovery of orbicularis oculi function is expected. Methods of lid-loading using metal implants and gold eyelid weights have been reported in the literature. Between October of 1988 and March of 1995, 32 patients with lagophthalmos due to facial nerve palsy underwent a total of 34 procedures for the insertion of a gold eyelid weight. Each patient had a gold weight inserted into a small pocket between the orbicularis oculi and the tarsal plate of the upper eyelid. The gold implant is curved to fit the curvature of the eye and contains holes for fixation to the tarsus with sutures. Ingrowth of fibrous tissue through the holes may also help fix the weight in position. Between 1988 and 1991, 10 patients received 10 commercially available rectangular gold implants with 2 holes; these implants resulted in adverse effects, such as infection and exposure in up to 30 percent of the cases. Because of the high complication rate with the rectangular gold implant, the authors began using a new, elliptical gold implant with 3 holes, which is longer, thinner, wider in the center, and narrower in the peripheral portion. This new elliptical implant was used on 22 patients (24 implants) from December of 1991 through March of 1995. The mean follow-up time for the 32 patients in the study was 41.3 months (range, 6 to 63 months), 49.8 months for patients with rectangular implants and 32.8 months for patients with elliptical implants. The elliptical gold implant resulted in dynamic closure of the eyelid and in excellent protection and cosmesis. Lagophthalmos and exposure keratitis resolved, visual acuity significantly improved without complications, and most patients could dispense with eyedrops and salves. A lower eyelid supporting procedure (conchal cartilage graft) should be performed simultaneously in patients with lagophthalmos of a moderate or severe degree to achieve complete closure of the eyelid. Use of a tall pillow decreased the incidence of eyelid opening during sleep. Double eyelid fold operations'were performed on the contralateral eyelid after 6 months, resulting in a symmetrical and beautiful eyelid.

Adolescent↗

PubMed1998

Superior oblique tendon resection or inferior oblique muscle recession in vertical deviations.

This study reports the results on patients undergoing superior oblique (SO) tendon resections with or without inferior oblique (IO) muscle recession to correct vertical deviations. The design of this study was nonrandomized, baseline-controlled, and postsurgical versus presurgical and was performed in a solo practice affiliated with a university ophthalmology department. One hundred ninety-five patients underwent surgery. Patients were evaluated presurgically and postoperatively in the major fields of muscle action. Resections were based on measurements at 14 inches in the field of major function of the SO. The surgical approach was a radial, rather than circumferential, incision extending from the limbus to the tarsus parallel to the lateral border of the superior rectus, followed by resection of the SO tendon. Surgery resulted in improved fusion in 78% of the cases. Average deviation in the left superior oblique field in SO tendon resection only (n = 14) was reduced from 11.0 to 1.7 prism diopters, and fusion improved 85% after treatment. In 181 cases of SO tendon resection or IO recession, the left superior oblique field was reduced from 15.8 to 3.6 diopters. SO tendon resection was successfully utilized to treat underacting SO muscle and vertical deviations. A radial incision facilitated the surgical procedure, and its use is recommended to those performing the surgery.

Adolescent↗

PubMed2006

Sebaceous carcinoma of the caruncle.

PURPOSE: To report a case of sebaceous carcinoma of the caruncle. METHODS: A 68-year-old woman developed a slowly enlarging mass of her left caruncle. Incisional biopsy elsewhere was interpreted histopathologically as invasive squamous cell carcinoma. On the basis of the clinical findings, however, we suspected sebaceous carcinoma. Excisional biopsy with frozen section control was undertaken and the lesion was studied histopathologically. RESULTS: Histopathological examination disclosed infiltration of the caruncular stroma by lobules of a malignant neoplasm that had prominent cytoplasmic vacuoles, typical of sebaceous carcinoma. CONCLUSION: Although it is best known to arise in the meibomian glands of the tarsus, sebaceous carcinoma can rarely arise in the caruncle and can be misinterpreted histopathologically as squamous cell carcinoma.

Adenocarcinoma, Sebaceous↗

PubMed2004

Cutaneous benign mixed tumor (chondroid syringoma) of the eyelid: clinical presentation and management.

PURPOSE: To describe the clinical presentation of cutaneous benign mixed tumor of the eyelid and its management options. METHODS: Periocular cases of cutaneous benign mixed tumor were gathered from members of an oculoplastics specialty Internet discussion group. A total of 9 patients are described in this retrospective, interventional case series. The clinical presentation, histopathology, and management of these lesions is reviewed. RESULTS: Patients were typically asymptomatic, presenting with a slowly enlarging, nontender nodule of 2 to 8 years' duration. The lesions ranged from 4 mm to 17 mm in greatest dimension. Four of the lesions were on the eyelid margin, three in the sub-brow area of the upper eyelid, and two in the central lids. All six cases not involving the brow were fixed to the tarsus; one brow lesion was believed to be adherent to the skin. None of the lesions was associated with significant changes of the overlying epidermis, although one lesion showed overlying pigmentation. All patients underwent excisional biopsy for diagnostic or cosmetic reasons. On histopathologic examination, the tumors were biphasic, with an epithelial component exhibiting apocrine or hair follicle differentiation and a myxoid, adipocytic, chondroid, and/or fibrous stroma. The pathologic diagnoses were all consistent with cutaneous benign mixed tumor (chondroid syringoma, pleomorphic adenoma). Follow-up ranged from 2 weeks to 12 months, although several patients failed to keep scheduled follow-up appointments. No clinical recurrences were identified. CONCLUSIONS: Cutaneous benign mixed tumor may occur in the eyelid, and, although uncommon, should be included in the differential diagnosis of firm, nodular eyelid tumors. The histopathologic features are similar to those seen in this tumor type arising in other areas of the body. Preoperative consideration of this diagnostic possibility may allow the surgeon to plan for complete excision, thereby reducing the possibility of recurrence or malignant transformation.

Adenoma, Pleomorphic↗

PubMed2004

Microscopic anatomy of the lower eyelid in asians.

PURPOSE: To study the microscopic anatomic relation of the capsulopalpebral fascia, orbital septum, and tarsus of the lower eyelid in Asians. The anatomic differences between the Asian and non-Asian upper eyelid have been well described by various authors, but the differences of the lower eyelid have not been well characterized microscopically. The microscopic anatomy of the lower eyelid in non-Asians was well studied, but in Asians, despite the presence of gross differences, there were very limited studies on the microscopic anatomy. A thorough knowledge of the Asian lower eyelid anatomy is essential for surgical exploration of the eyelid. It may also explain the higher prevalence of eyelid disorders such as epiblepharon and entropion in Asians. METHODS: Ten normal Asian lower eyelids from 10 formalin-fixed cadavers (mean age, 67.5 years) were harvested and studied with light microscopy after staining with Masson trichrome. RESULTS: There was no fusion of the orbital septum and the capsulopalpebral fascia at the lower border of the tarsal plate in 7 specimens and a very limited fusion of these tissues in 3 specimens. The average distance from the inferior tarsal border to the first observable smooth muscle nuclei of the inferior retractors was 1.44 mm. The average tarsal plate thickness was 1.36 mm and the average tarsal plate height was 4.12 mm. CONCLUSIONS: The Asian lower eyelid anatomy differs from its non-Asian counterpart. There was no consistent fusion between the capsulopalpebral fascia and the orbital septum inferior to the inferior tarsal border. No extension of the capsulopalpebral fascia to the skin was observed. The average distance between the inferior retractors and the inferior tarsal plate was 1.44 mm in the normal Asian lower eyelid.

Aged↗

PubMed2004

Ultrasound biomicroscopy of the levator aponeurosis in congenital and aponeurotic blepharoptosis.

PURPOSE: To evaluate and measure the thickness of the levator aponeurosis by ultrasound biomicroscopy in congenital dysmyogenic and aponeurotic blepharoptosis. METHODS: Forty-four upper eyelids of 22 patients who had unilateral blepharoptosis were evaluated by ultrasound biomicroscopy. The patients ranged in age from 13 to 69 years (mean, 35.4 +/- 20.2 years). Fourteen patients were male and 8 patients were female. Seven patients had congenital dysmyogenic blepharoptosis and 15 patients had aponeurotic blepharoptosis. Imaging was performed with a 50-MHz transducer. The thickness of the levator aponeurosis was measured centrally at the upper border of the tarsus. RESULTS: The levator aponeurosis was imaged in all eyelids except for one eyelid with aponeurotic blepharoptosis. The mean thickness of the levator aponeurosis was 0.39 +/- 0.10 mm in the ptotic eyelid and 0.42 +/- 0.09 mm in the control eyelid of the patients with congenital dysmyogenic blepharoptosis (p = 0.043). The mean thickness of the levator aponeurosis was 0.26 +/- 0.05 mm in the ptotic eyelid and 0.36 +/- 0.04 mm in the control eyelid of the patients with aponeurotic blepharoptosis (p = 0.001). The thickness of the levator aponeurosis was correlated with the palpebral fissure height (p = 0.013, r = 0.644) in aponeurotic blepharoptosis. The thickness of the levator aponeurosis was correlated with the levator function (p = 0.033, r = 0.795) in congenital dysmyogenic blepharoptosis. CONCLUSIONS: The thickness of the levator aponeurosis can be measured with ultrasound biomicroscopy. The most common pathology in aponeurotic blepharoptosis is thinned-out aponeurosis. The levator aponeurosis of the ptotic eyelid is thinner than the normal eyelid in congenital ptosis.

Adolescent↗

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↗