Biomedical subjects
Publications and source records attributed to John B Holds.
Cosmetic rejuvenation of the periorbital area has been an area of continual advancement in surgical knowledge over the past century. It is anticipated that some new currently described advances will be incorporated into continuing practice patterns, with advances in nonsurgical rejuvenation and surgical techniques.
BACKGROUND: Many common oculoplastic surgical procedures can be performed in an office-based setting. OBJECTIVE: To describe a system of local anesthetic use that provides superb anesthesia administered in a nearly painless manner. METHODS: Combined conjunctival, topical, and injected local anesthesia is used in outpatient oculoplastic surgical procedures. The use of optional adjuvant oral sedation can decrease pain and anxiety in selected patients. RESULTS: We have successfully employed our described system of local anesthesia for office-based oculoplastic surgery. CONCLUSION: In suitable patients, the shifting of operative location from the hospital or ambulatory surgery center to the office provides many benefits to both the patient and the surgeon.
PURPOSE OF REVIEW: The surgical correction of blepharoptosis, both congenital and acquired, has been intensively examined and reported on for many years. This paper reviews recent publications on basic science, evaluation, technique modifications, and innovative materials in the care of ptosis patients. RECENT FINDINGS: The frontalis suspension technique is a commonly performed surgical correction of congenital blepharoptosis, used widely in the repair of ptosis with poor levator function. The repair typically includes using either tissue such as autologous or banked fascia lata or permanent suture material. The procedure involves connecting the motor unit (frontalis muscle) and the upper eyelid. Authors have recently reintroduced the technique of a dynamic frontalis muscle flap tunneled into the eyelid that directly attaches to the tarsal plate.Patients presenting with symptomatic blepharoptosis due to disinsertion or thinning of the levator aponeurosis require surgical repair. Multiple groups have tended toward a minimally invasive approach directed specifically at the levator aponeurotic defect. Proposed advantages of a small eyelid incision (8-13 mm) include less local anesthetic and tissue distortion, less ecchymosis and edema, decreased operative times, a shortened recovery period, and improved surgical results. SUMMARY: Surgical correction of congenital blepharoptosis may be performed with autologous fascia lata, cadaveric allograft, or permanent suture material. The use of a frontalis muscle advancement flap is elegantly designed; however, its role in clinical practice remains to be defined. Advancement of the levator aponeurosis for senile blepharoptosis may be preformed via a minimally invasive small incision approach. Patients benefit with decreased operative time, edema, ecchymosis, and recovery times.
A 50-year-old woman with a clinically negative breast examination was diagnosed with metastatic breast cancer only after pathologic evidence of an orbital metastasis. She presented with pressure and pain above the right eye associated with enophthalmos and pseudo-Brown syndrome. The diagnosis of breast cancer based on initial ophthalmic findings requires a strong level of suspicion. Multiple reports show that survival in these cases is limited, usually only 1 year after diagnosis. We present a case of 10-year survival after the diagnosis of breast cancer presenting as an orbital mass. These new findings provoke us to continue aggressive systemic and ophthalmic treatment for such patients.
PURPOSE: Evaluate the use of sentinel lymph node biopsy (SLNB) in staging and directing treatment of patients with conjunctival malignancy. DESIGN: Retrospective, noncomparative, interventional case reports. METHODS: Two patients with conjunctival melanoma underwent SLNB, which consisted of lymphoscintigraphy with injection of sulfur colloid technetium-99m. Lymphazurin blue was injected intraoperatively into the area of prior excision. The combination of a signal through the sulfur colloid technetium-99m and blue staining identified SLNs. RESULTS: In both patients, the SLNs containing metastatic disease were identified and biopsies obtained, aiding staging and optimal therapy. CONCLUSION: Sentinel lymph node biopsy has been recently reported as an aid in evaluating patients with periocular malignancies. These reports of patients with tumor-positive SLNs arising from the lymphatic metastasis of conjunctival malignancies underscore the utility of this important technique in evaluating patients with periocular malignancies.
PURPOSE: To evaluate the tarsal strip procedure in the treatment of tearing related to lacrimal pump failure. METHODS: A retrospective chart review of all tearing patients undergoing the tarsal strip procedure was done. Patients with ectropion, nasolacrimal duct obstruction, and punctal eversion and stenosis were excluded. Data collected included patient age, sex, procedures performed, follow-up, and resolution of tearing. The main outcome measure is resolution of tearing. RESULTS: Thirty-four eyelids of 21 patients underwent a tarsal strip procedure for the correction of tearing. Complete resolution of tearing was noted in 14 eyes. Seventeen eyes were partially improved and required no further intervention. Three eyes were unimproved over the follow-up period. Two eyes eventually required another procedure. CONCLUSIONS: Patients undergoing tarsal strip for tearing caused by presumed lacrimal pump failure showed a significant rate of improvement in their tearing symptom after the procedure. The tarsal strip procedure appears to be effective in the surgical treatment of tearing secondary to laxity of the lower eyelid.
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PURPOSE: Patients presenting with blepharoptosis due to disinsertion or thinning of the levator aponeurosis require surgical repair. A minimally invasive approach directed specifically at the levator aponeurotic anatomic defect may provide benefits to the patient. Proposed advantages of a small eyelid incision (8-13 mm) include less local anesthetic and tissue distortion, less ecchymosis and edema, decreased operative times, a shortened recovery period, and improved surgical results. We describe our results with the use of a small incision ptosis repair in select patients. SUBJECT AND METHODS: A retrospective chart review between January 2000 and September 2001 included 91 patients and 118 eyelids with blepharoptosis due to aponeurotic disinsertion, corrected by a minimally invasive approach. The small incision technique comprised levator aponeurotic resection and advancement. Pre- and postoperative upper eyelid marginal reflex distances (MRD1), eyelid contour, need for reoperation, and complications (overcorrection, undercorrection, hematoma, and infection) were recorded. RESULTS: The average preoperative MRD1 measured 0.5 +/- 1.1 mm, with a range of -2.0 to 2.5 mm. The average postoperative MRD1 measured 2.6 +/- 0.8 mm, with a range of 1 to 5.5 mm (P < 0.0001). Of the 118 eyelids corrected by a small incision technique, there were 4 overcorrections, 3 undercorrections, 1 failure, 1 postoperative ptosis procedure of the contralateral upper eyelid secondary to Hering's law ptosis, and 4 patients requesting surgical treatment of dermatochalasis. No symptomatic dry eye, exposure keratopathy, or other complication resulted in association with the overcorrections. No contour abnormalities, infections, hematomas, or other complications were noted. CONCLUSION: Our experience suggests that utilization of a small skin incision is safe, precise, and efficient and allows for more rapid recovery from surgery. The authors note a decreased incidence of reoperation and postoperative complaints compared with historical larger-incision cases.
PURPOSE: To determine the rate of infection in patients who underwent blepharoplasty with and without carbon dioxide laser resurfacing. DESIGN: A retrospective, nonrandomized, consecutive case series. PARTICIPANTS: Eighteen hundred sixty-one patients who underwent upper or lower blepharoplasty, with or without carbon dioxide laser resurfacing. METHODS: Charts of patients who underwent blepharoplasty, with or without laser resurfacing, were analyzed for the presence of postoperative infection, method of treatment, and possible sequelae. MAIN OUTCOME MEASURES: The rate of infection (%) was determined for each group of patients. RESULTS: Infection occurred in 0.2% of patients who underwent blepharoplasty without laser resurfacing and 0.4% of patients who had adjunctive laser resurfacing. No permanent functional or cosmetic sequelae resulted from the episodes of infection. CONCLUSIONS: Infection after blepharoplasty without laser resurfacing is uncommon, indicating that topical antibiotic ointment prophylaxis is a sufficient postoperative regimen. The use of adjunctive laser resurfacing may increase the infection rate slightly.
PURPOSE: To evaluate the penetration resistance of common spectacle and safety lenses to high-velocity projectiles and to examine the current recommendations regarding the use of such lenses. METHODS: The penetration threshold of glass, high-index, and polycarbonate spectacle and safety lenses was determined by firing BBs, pellets, and 0.22-caliber projectiles. The mass, diameter, velocity, and energy of each projectile were measured, and the center thickness, mass, and refractive power of each lens were recorded. The penetration threshold for each lens type was calculated, and a comparison of impact resistance was made. RESULTS: The maximum velocity of the BB was measured at 221 m/s; pellets at 210 m/s; CB.22 rimfire projectiles at 204 m/s; and 0.22 rimfire projectiles at 290 m/s. The BB penetration thresholds were as follows: glass lenses = 84.0 m/s (2.4 J) and high-index lenses = 107.7 m/s (4.09 J). Polycarbonate spectacle and safety lenses were not penetrated by BBs regardless of their velocity; however, these lenses were penetrated by CB.22 rimfire projectiles (89.2 J). Review of the penetrated lenses showed that center thickness and refractive power was comparable between the various groups of projectiles. CONCLUSIONS: Polycarbonate offers a vastly superior degree of penetration resistance compared with other commonly used lens materials. The current recommendations regarding the use of polycarbonate in prescription and protective lenses, as endorsed by the American Academy of Ophthalmology and the American Academy of Pediatrics, must be reevaluated.
PURPOSE: To present 3 cases of melanoma metastatic to the orbit treated with various traditional modalities including surgery and chemotherapy and being treated with melanoma vaccines and to present background information on immunotherapy. METHODS: Retrospective review of 3 patients with melanoma metastatic to the orbit who were treated with melanoma vaccines along with conventional treatments. One patient had known orbital involvement before vaccine treatment; 2 patients had orbital metastases subsequent to vaccine administration. RESULTS: Patients survived at least 13 months after the diagnosis of metastatic melanoma, with 1 patient surviving 51 months after the onset of metastases and administration of melanoma vaccine. CONCLUSIONS: Although still unproven, immunotherapy with melanoma vaccines is a promising new treatment modality for metastatic melanoma with few side effects.
OBJECTIVE: To describe the management of patients with necrotizing fasciitis of the eyelids. DESIGN: Retrospective, noncomparative interventional case series. PARTICIPANTS: Seven patients with necrotizing fasciitis limited to the eyelids. METHODS: Retrospective review of the charts and photographs of seven patients with necrotizing fasciitis limited to the eyelids. MAIN OUTCOME MEASURES: Eyelid function and appearance, mortality, and morbidity. RESULTS: Seven of seven patients had good eyelid function and adequate appearance without reconstruction after healing. No deaths occurred. CONCLUSIONS: Eyelid necrosis due to necrotizing fasciitis can be a devastating condition. The morbidity and mortality of selected cases are reduced with prompt and appropriate antimicrobial therapy and nonaggressive debridement of necrotic tissue after autodemarcation of the necrotic zone.
PURPOSE: To report the results of the surgical repair of lower eyelid reverse ptosis. METHODS: Retrospective case series. Eight patients ranging in age from 31 to 77 years underwent surgical repair of lower eyelid reverse ptosis. The pupillary axis of the affected eye(s) in each patient was obscured in downgaze, interfering with reading. The lower eyelid reverse ptosis resulted from involutional changes in 3 patients, previous orbital decompression in 3 patients, multiple prior retinal and extraocular muscle operations in 1 patient, and previous orbital floor fracture and repair in 1 patient. Transcutaneous advancement of the lower eyelid retractors was performed in 12 eyelids of the 8 patients. RESULTS: The mean preoperative vertical eyelid fissure was 6.2 mm (median, 6 mm; range, 3-9 mm), increasing after surgery to a mean of 7.7 mm (median, 8 mm; range, 5-11 mm). The mean preoperative distance between the central light reflex and the lower eyelid margin was 1.7 mm (median, 1.25 mm; range, 1-4 mm); this distance increased to a mean of 3.3 mm (median, 3.25 mm; range, 2.5-4.5 mm) after surgery. Symptoms improved in all patients, and there were no perioperative complications. Follow-up intervals ranged from 2 months to 24 months (mean, 9 months; median, 13 months). CONCLUSIONS: Analogous to upper eyelid ptosis repair by advancement of the levator aponeurosis, lower eyelid reverse ptosis may be corrected effectively and safely by advancing the lower eyelid retractors.
PURPOSE: To evaluate postoperative edema and ecchymosis after blepharoplasty surgery with or without autologous platelet gel. METHODS: In this prospective, randomized, controlled trial, patients received autologous platelet concentrate in the eyelid incisions of one side during bilateral blepharoplasty surgery. The opposing eye was not treated and was used as a control. Autologous platelet concentrate was prepared by the Harvest system (Harvest Technologies, Plymouth, MA, U.S.A.). The blood was centrifuged and platelet-rich plasma isolated. Platelet-rich plasma was mixed with thrombin and instilled in the wound on a randomly selected side before wound closure. Patients were examined and completed a questionnaire at postoperative days 1, 3, 7, and 30. Photographs were taken at each visit and were graded by masked, trained observers for edema and ecchymosis. RESULTS: Significantly less edema (p<0.05) was noted by the photograders at day 1 and by the patients at day 30. There were non-statistically significant trends toward decreased ecchymosis and edema in the treated group. Questionnaire data showed no significant difference in postoperative pain between the treated and untreated sides. Photographic and questionnaire data showed no clinically meaningful difference between the treated and control sides. CONCLUSIONS: Although there were statistically significant differences in edema using autologous platelet gel in blepharoplasty surgery, trends toward improvement in postoperative edema and ecchymosis did not achieve clinical significance.
PURPOSE: To review injection techniques and patient satisfaction with injection of Restylane in various facial areas by American Society of Ophthalmic Plastic and Reconstructive Surgery members. METHODS: Data from 286 patients treated with Restylane in nine American Society of Ophthalmic Plastic and Reconstructive Surgery practices were abstracted to a spreadsheet for analysis. RESULTS: Nine practices performed Restylane injections for 8.8 months on average (range, 2 to 28 months). Average practice volume per patient was 1.2 ml (range, 0.7 to 2.1 ml). Nine of nine practices injected the nasolabial and melolabial folds, 9 of 9 practices injected the lips, and 6 of 9 injected the glabella. Only 2 of 9 practices injected other fillers concurrently. Botox was injected concurrently by 8 of 9 practices. On a scale of 1 to 10, physicians rated average patient discomfort during Restylane injection 4.6 with topical anesthesia and 2.1 with injectable lidocaine, with or without topical anesthesia. The end point for injection was determined by visual cues, volume of injection, extrusion of the product, and palpation. "Problematic" complications, including bruising, swelling, bumpiness, and redness each had an incidence of 5% or less. Patient satisfaction on a scale of 1 to 10 had an average rating of 8.1, compared with that of Botox injection (8.9), upper blepharoplasty (8.9), and collagen injection (6.6). The source of Restylane patients was estimated to be existing Botox patients (45%); existing non-Botox patients (18%); word of mouth (14%); and new patients for other services (13%). CONCLUSIONS: Injection techniques, volume, end points, and anesthesia vary for different facial areas and between practices. Patients experience mild to moderate injection discomfort that is lessened with injectable lidocaine. Self-limited problems occur in about 5% of patients. Physician-determined patient satisfaction is perceived to be higher than that of collagen injection but slightly lower than that of botulinum toxin injection. The major source of Restylane patients was from existing practice patients, especially botulinum toxin patients.
PURPOSE: To describe the spectrum and treatment of orbital Rosai-Dorfman disease and to review previously documented cases. METHODS: Retrospective, interventional case series of seven patients and literature review. RESULTS: Each patient with Rosai-Dorfman disease had unique disease expression requiring aggressive therapy, such as chemotherapy, radiation, and/or surgical excision. One systemically aggressive case presented with intraocular and choroidal invasion, a previously unreported finding. Response to therapy was variable and unpredictable. CONCLUSIONS: Rosai-Dorfman disease, although historically described as benign and self-limiting, may cause significant morbidity and mortality involving multiple organ systems. Available treatment options may not control the disease. Further research and long-term clinical correlation is necessary.
PURPOSE: To describe a novel surgical technique for lower eyelid blepharoplasty with fat repositioning in an intrasuborbicularis oculi fat (intra-SOOF) plane. METHODS: Description of surgical technique and outcome of a retrospective, interventional case series of 66 consecutive patients who underwent surgery. RESULTS: Sixty-six patients with an average age of 56 years underwent bilateral transconjunctival lower eyelid blepharoplasty with fat repositioning in an intra-SOOF plane. Surgery was most commonly done in an office-based operating or procedure room under local anesthetic only. Patients were observed for an average of 6 months. Complications and revisions were few. Surgical outcomes and subjective patient satisfaction rate were excellent. CONCLUSIONS: Lower eyelid fat repositioning blepharoplasty in an intra-SOOF plane is an alternative technique to address the tear trough deformity. This technique provides excellent surgical results and high patient satisfaction. Convenient for both patient and surgeon, this technique is readily performed in an office-based procedure room under local anesthetic. Further follow-up will determine long-term outcomes.