15.6.1Upper Eyelid Loading

Paralytic lagophthalmos with secondary exposure keratopathy is most commonly treated by upper eyelid load- 15 ing techniques, involving implantation of either a gold or platinum weight. Complications of this procedure include extrusion of the weight, allergy, poor cosmesis, ongoing lagophthalmos, blepharoptosis, and induced astigmatism.

In addition, a return of orbicularis oculi function, as in Bell’s palsy, can demand removal of the weight. Upper eyelid loading using an injection of hyaluronic acid gel o ers several advantages including immediate application in the o ce, a titratable weight to reduce over/under correction, improved cosmesis and a duration of 6–9 months [45].

Injections are performed using a 30-gauge needle after application of ice or EMLA cream to anesthetize the upper eyelid. The filler is placed deep to the orbicularis oculi in the pre-tarsal and/or pre-levator aponeurosis regions by means of 3–4 injections, avoiding the area adjacent to the upper canaliculus [45]. Due to the relatively superficial placement of the filler and lack of an adjacent bony surface for molding, a feathered “haystack” approach is recommended with multiple passes of the needle tip to distribute the filler for each injection [45].

In general anything up to 1 ml of filler is required although the volume used will depend on severity of lagophthalmos, lid height, and desired esthetic outcome [45]. The mean reported improvement in lagophthalmos is 4.8 mm, (ranging from 0.9 to 11.9 mm), with 80% of cases maintaining this improvement over four months. Complications from this technique are minimal and include transient edema, erythema, pain, and tenderness that settle within a few days [45].

15.6.2Lower Eyelid Elevation

Lagophthalmos and exposure keratopathy can also be the result of lower eyelid retraction. Causes of this are numerous and include malar volume deficiency, globe proptosis (also causing a negative facial vector) and lower eyelid cicatrization. Definitive management for this has traditionally been through surgical intervention, which, as well as the usual complications of hemorrhage, infection, and tissue malposition, can cause further scarring or volume depletion which exacerbates the lagophthalmos. Once again, soft-tissue fillers o er a less invasive, alternative treatment that e ectively expands and reinforces the tissues of the lower eyelid, acting as a temporary spacer. This serves to elevate the lower eyelid reducing scleral show. To date, one study has been pub-

lished on this, using NASHA filler (Restylane®) administered to the lower eyelid [32].

The injection technique is as described above for upper eyelid loading, using the “haystack” approach and with filler placed in the sub-orbicularis plane in the preseptal region and adjacent to the orbitomalar ligament [32]. For 0.9 ml of filler placed in this manner, to the lower eyelid inferior scleral show typically improves by 1 mm in patients whose baseline scleral show is in the order of 1.2 mm. The e ects of the filler are temporary, with one third of patients requiring a top-up by four months. Patient satisfaction with this procedure, however, is high and reported complications are limited to mild bruising and minimal discomfort [32].

15.6.3 Treatment of Cicatricial Ectropion

Lower eyelid cicatricial ectropion, caused by shortage of the anterior lamella, has also traditionally been managed surgically. This has included release of scarring, recruitment of additional skin in the form of a flap, cheek lift or full-thickness skin graft, and simultaneous lid tightening. Soft-tissue fillers o er an alternative treatment for mild cases by acting as a temporary lower eyelid tissue expander, stretching the deficient anterior lamella in that region [24].

The area for injection is numbed using ice or topical anesthetic cream. In this case, the desired placement of filler is subcutaneous to try and stretch the deficient skin as much as possible. Once again, a “haystack” or “linear threading” method is used to deliver the filler as smoothly as possible in this superficial location. Filler is placed along the inferior orbital rim, pre-septally, and pre-tar- sally. Posttreatment upward massage of the lower eyelid by the patient is recommended [24].

Results have been very encouraging with 70% of patients maintaining a fully corrected lower eyelid position for over twelve months. Bruising can occur in over 90% of cases and a bluish discoloration in two thirds. The author reports that lumpiness is rare using the linear threading method. No patients required dissolution of filler [24].

15.7Future Developments

Soft-tissue fillers are becoming key contributors to the management of orbital and periorbital volume deficiency. This is due to their exemplary safety record, biocompatibility, high tolerability, ease of administration, titratability, reversibility, and excellent results. It is likely that the

demand for such products will rise as physician and patient awareness of their potential applications increases. This will also reflect the growing preference for patients to undergo minimally invasive treatments, as well as an increased demand for correction of orbital and periorbital asymmetries and contour abnormalities that may have previously been considered too minor for surgical intervention. The versatility of these products has also been shown in the ever expanding range of orbital and periorbital pathologies that they have been successfully used for.

Future developments in this field are likely to reflect biomedical research into increased stability and longevity of hyaluronic acid products, whilst maintaining easy injectability as well as reversibility with the application of hyaluronidase. Novel compounds with longer tissue persistence or collagen-promoting characteristics may also emerge on the market. It is also hoped that FDA approval will be obtained for the orbital and periorbital application of existing products to remove the need for such treatments to occur o -label. In the meantime, increased use of soft-tissue fillers by oculoplastic surgeons will add to the current literature and improve the documentation of existing treatment outcomes.

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64.Zimbler MS, Kokoska MS, Thomas JR (2001) Anatomy and pathophysiology of facial aging. Facial Plast Surg Clin North Am 9:179–187

Adenoid cystic carcinoma, 134, 135 Angiography, 164

Anophthalmos, congenital. See Congenital clinical anophthalmos

Azithroprine, 58

Bacterial canaliculitis, 70 Beta-blockers, 169

Blepharoplasty. See Lower blepharoplasty; Upper blepharoplasty

Breast carcinoma, 54, 55, 178

Brow suspension, unilateral ptosis. See also Levator muscle recession

compensatory eyebrow elevation, 117–118 congenital dystrophic ptosis, 118

fascia implantation, 122–123

frontalis muscle, innervation patterns, 118 harvesting autogenous fascia lata, 121–122 levator muscle recession, 119–121 materials, 121

mechanical principals, 122

partial or total levator muscle recession planning, 118–119

surgical technique, 121–123 upper lid approach, 122

Canalicular inflammation anatomy, 67–68 bacterial canaliculitis, 70

chemotherapeutic agents, 71–72 dacryocystorhinostomy and retrograde

canaliculostomy, 74–75 drug eruptions, 71 embryology, 67

etiology, 67, 68 histology, 68

iatrogenic causes, 71–73 infective causes, 69, 70

Jones canalicular bypass tube placement, 75 lacrimal stents and plugs, 73

lichen planus (LP), 70 microbial canaliculitis, 69

ocular cicatricial pemphigoid, 70–71 pathophysiology, 68–69

physiology, 68 radiotherapy, 72–73 surgical management, 74–75

systemic inflammatory disease, 70–71

topical ophthalmic treatments, 73 Carcinoid tumor, 179–180 Cavernous hemangioma, 134, 135 Collagen fillers, 216

Computed tomography (CT)

bone window CT scan, 126–127, 128 diagrammatic representation, 125–126 iodinated intravenous contrast agents, 127, 128 orbital and periorbital structures, 126

orbital diseases, 126, 127 scanners, 127–128

Congenital clinical anophthalmos age, 106

associated systemic and ocular diseases, 107–110 birth, 107

examination, 106 family history, 106–107

nasolacrimal system findings, 111–112, 114–115 neuroradiological findings, 111, 113–114 patient data, 106

patients, 106 pregnancy history, 107 systemic diseases, 114

unilateral microphthalmos, 113 Conjunctival MALT lymphoma, 3 Corticosteroids, 54–55

Cosmetic oculofacial plastic surgery endoscopic brow lift, 23, 25–29 facial analysis, 22–25

lower blepharoplasty, 33–43 upper blepharoplasty, 29–33

Dacryocystorhinostomy, 74–75

Dermoid cyst, 134–135, 136

Docetaxel (Taxotere), 72

Endoscopic brow lift anesthesia, 26

eyebrow elevation, 25–26 frontalis contraction, 23, 26 postoperative care, 27–29

retro orbicularis oculi fat (ROOF) deflation, 23, 25 surgical procedure, 26–27

Esophageal carcinoma, 176 Etanercept, 59

Eyelid blepharoplasty. See Lower blepharoplasty; Upper blepharoplasty

Facial analysis aging, 22 facial layers, 22 fat loss, 22, 23

workup sheet, 23, 24–25 Fibrous dysplasia, 135, 136 5-Fluorouracil (5-FU), 71–72 Follicular lymphoma

cytogenesis, 6 imaging findings, 8 incidence, 2 pathogenesis, 3 pathology, 5 treatment, 11, 12

Hemangioma. See Infantile hemangioma (IH) Hyaluronic acid fillers, 216

Hydroxyapatite (HA) implants. See also Orbital implants advantages, 196–197

vs. aluminum oxide (Bioceramic) implant, 198, 199 Bio-Eye, 197

complication, 197 FCI3 implants, 197

vs. porous polyethylene implants, 197

Idiopathic orbital inflammatory syndrome (IOIS), 57 alkylating agents, 58–59

anatomic location, 48 anatomic site, 49 antimetabolites, 58 biologic agents, 59 corticosteroids, 57–58 orbital biopsy, 56 differential diagnosis, 48, 50 management algorithm, 57 neoplasm, 53–54, 55 orbital cellulites, 50–52 pediatric IOIS, 60 radiation, 58

sarcoidosis, 52

sclerosing pseudotumor, 60–61 T-cell inhibitors, 59

thyroid eye disease (TED), 49–50 Tolosa–Hunt syndrome (THS), 62–63 Wegener granulomatosis, 52–53

Infantile hemangioma (IH)

active nonintervention, 164–165 beta-blockers, 169 classification, 162

clinical phases, 161 differential diagnosis, 162–163 embolization, 168

etiology, 161–162 histology, 162 interferon-alfa, 166–167 investigation, 163–164 ocular complications, 163

pulsed-dye laser (PDL), 167–168 steroids, 165–166

surgery, 168–169 treatment indications, 165 vincristine, 167

Infliximab, 59

Injectable soft-tissue fillers advantages, 215 collagen fillers, 216 complications, 215–216

hyaluronic acid fillers, 216 lower eyelid elevation, 226 orbit, 217, 219

preorbital volume loss (see Preorbital volume loss) semipermanent injectable soft-tissue fillers, 216–217 tear trough, 220–223, 224

temple and brow, 223–224 types, 216–217

upper eyelid and brow, 220, 221 volume replacement, 215

Interferon-alfa, 166–167

Iodinated intravenous contrast agents, 127, 128

Jones canalicular bypass tube placement, 75

Lacrimal canalicular inflammation and occlusion. See Canalicular inflammation

Lacrimal drainage system

DCR, lacrimal sac biopsy, 97–99 diagnosis, 95, 96

lacrimal sac lesions, 99–103 lacrimal sac tumors, 95, 96

lesions, treatment and prognosis, 99–103 malignant melanoma, 100, 101 oncocytoma, 100, 102

primary non-Hodgkin B-cell lymphoma (MALT), 99, 100

pyogenic granuloma, 101, 102 sarcoidosis, 101, 103

squamous cell carcinoma, 99, 100 surgical anatomy, 96–97

Wegener granulomatosis, 101, 103 Lacrimal stents and plugs, 73 Levator muscle recession

approach, 119

eyelid level evolution, 121 partial levator recession, 119, 120 principle, 119

total levator muscle recession, 119, 121 undercorrection and overcorrection, 121

Lichen planus (LP), 70 Lower blepharoplasty

fat protrusion and infraorbital hollowness, 35–36 fat removal vs. fat preservation, 36–37

inferior orbital rim and bony midface, 36, 37 infralash muscle plication blepharoplasty, 38, 39 lid retraction and ectropion, 35

lower eyelid and midface, 33, 34 lower eyelid fillers, 39–41, 42 midface implants, 41, 42–43 midface retrusion, 36, 37

skin excess, 33, 35

transconjunctival blepharoplasty, 35, 36 transconjunctival fat repositioning, 38–40

Lung carcinoma, 178–179 Lymphangioma, 136, 137 Lymphoma, 136, 137

Magnetic resonance imaging (MRI) components, 129

image creation, 131–134 Larmor frequency, 129–130 spinning tops, 129, 130

T1 constant, 130–131

T2 constant, 132, 133

Malignant peripheral nerve sheath tumors, 81 Malignant schwannomas. See Malignant peripheral

nerve sheath tumors Mantle cell lymphoma

clinical features, 7 cytogenesis, 6, 7 histology, 4–6

Melanoma, 100, 101, 179 Metastatic orbital tumors

biopsy, 177–178 breast carcinoma, 178

carcinoid tumor, 179–180 chemotherapy, 180 clinical features, 175–176 differential diagnosis, 180 epidemiology, 173–174

hormonal therapy, 180–181 imaging and patterns, 176–177 lateralization, 174 localization, 174–175

lung carcinoma, 178–179 melanoma, 179

metastasis, biological behavior and timing, 174 prognosis and survival, 181

prostatic cancer, 179 radiotherapy, 180 surgery, 181

Methicillin-resistant Staphylococcal aureus (MRSA) infection, 153–154

Methotrexate, 58 Microbial canaliculitis, 69 Mitomycin C therapy, 73

Mucosa-associated lymphoid tissue (MALT) chronic antigen stimulation, 3

clinical features, 7 imaging findings, 8 lymphoepithelial unit, 4 pathology, 4

PET scan, 10, 11 radiotherapy, 12

Myositis, 136, 138

Neurofibromas, 80–81

Neurofibromatosis type 1 (NF1). See also Orbitofacial neurofibromatosis type 1 (NF1)

clinical manifestations, 79–80 diagnostic criteria, 80 genetics, 83

malignant peripheral nerve sheath tumors, 81 medical management, 84

neurofibromas, 80–81 nomenclature, 79

optic pathway gliomas, 81–82 surgical management, 84–90

Index 233

Nonporous spherical implants, 199–200 Non-surgical volume enhancement. See Injectable

soft-tissue fillers

Ocular adnexal lymphoproliferative disease (OALD) chemotherapy, 12

chronic antigen stimulation, 3 classification, 2

clinical features, 7

cluster of differentiation (CD), 2 cytogenetics, 4–6, 7

follicular lymphoma, 11 imaging findings, 8, 9 immunosuppression, 3–4 immunotherapy, 12–13 incidence, 1

mantle cell lymphoma, 11 outcome, 13 pathogenesis, 2–3 pathology, 4–6

positron emission tomography, 9 radioimmunotherapy, 13 radiotherapy, 11–12

staging, 9 treatment, 9–11

Ocular cicatricial pemphigoid, 70–71 Oncocytoma, 100, 102

Optic pathway gliomas (OPGs) anterior approach, 88 blind proptotic left eye, 81

imaging and chemotherapy, 82 lateral approach, 87

orbital imaging, 138 progression, 82

proptosis, surgical intervention, 87–88 remission, 82

superior approach, 88

Orbital and periorbital malignancies cetuximab, 191–192

imatinib mesylate, 190–191 rituximab, 188–189

yttrium-90-labeled ibritumomab tiuxetan, 189–190 Orbital cellulitis, 50–52

evaluation, 154–155 medical therapy, 155–156

prevention, orbital fracture, 158 surgical treatment, 156–158

Orbital imaging

adenoid cystic carcinoma, 134, 135 cavernous hemangioma, 134, 135 computed tomography (CT) (see Computed

tomography (CT)) dermoid cyst, 134–135, 136

diffusion MRI (diffusion-weighted imaging), 140–141 fibrous dysplasia, 135, 136

lymphangioma, 136, 137 lymphoma, 136, 137

magnetic resonance imaging (see Magnetic resonance imaging (MRI))

myositis, 136, 138

optic nerve gliomas, 138

positron emission tomography, 141–142

pseudotumor, 139 rhabdomyosarcoma, 139 three-dimensional images, 129

ultrasound (echography) (see Ultrasound (echography)) Orbital implants. See also Hydroxyapatite (HA) implants

adults, 199–200 children, 200–201

extraocular muscle attachment, 202–203 implant wrapping, 202

peg and sleeve implants (see Peg and sleeve implant–prosthesis coupling systems)

porous orbital implants, 197–199 (see also Porous orbital implants)

volume considerations, 201

wrapping materials (see Wrapping materials) Orbital volume loss. See also Injectable soft-tissue fillers

etiology, 213, 214 features, 214–215

Orbitofacial neurofibromatosis type 1 (NF1). See also Optic pathway gliomas (OPGs)

malignant peripheral nerve sheath tumors, 81 neurofibromas, 80–81

optic pathway gliomas, 81–82 orbital involvement, 86–90 periorbital involvement, 85 progression, 90–92

surgery timing, 84–85 surgical management, 84–90

Parry–Romberg syndrome, 220 Pediatric IOIS, 60

Peg and sleeve implant–prosthesis coupling systems FCI peg–sleeve coupling system, 205 fibrovascularization, 205

MEDPOR Motility Coupling Post (MCP), 205 polycarbonate peg, 205

titanium peg systems, 205 Periocular herpes simplex infection, 69 Periorbital cellulitis

CA-MRSA vs. hospital-acquired MRSA, 152–153 etiology, 151

infection, 149–150 microbiology, 151–152 orbital MRSA, 153–154

pathogens and resistance, 152–154 symptomatology and presentation, 149–150

PHACE syndrome, 162, 163 Plexiform neurofibroma

malignant peripheral nerve sheath tumors, 80 upper eyelid, 80–81

Porous orbital implants aluminum oxide, 198–199 bio-eye implant, 197 FCI3 implants, 197

fibrovascular ingrowth, 196–197 polyethylene implants (MEDPOR), 197–198

Porous spheres, 199

Pre-and postoperative internal ptosis repair, 33 Preorbital volume loss

cicatricial ectropion, 226 etiology, 213–214

features, 215

injectable soft -tissue fillers, 225–226 lower eyelid elevation, 226

upper eyelid loading, 226 volume enhancement, 225

Preservative-related chronic conjunctivitis, 73

Primary non-Hodgkin B-cell lymphoma (MALT), 99, 100 Proptosis

anterior approach, 88 lateral approach, 87 superior approach, 88

Prostatic cancer, 179 Pseudotumor, 139

Pulsed-dye laser (PDL), 167–168 Pyogenic granuloma, 101, 102

Quasi-integrated implant, 199

Retro orbicularis oculi fat (ROOF) deflation, 23, 25, 26 Rhabdomyosarcoma, 139

Rituximab

B-cell lymphomas, 189 CD20, 188–189

cyclophosphamide, adriamycin, vincristine, and prednisone (CHOP), 189

Sarcoidosis, 52, 54, 101, 103 Sclerosing pseudotumor, 60–61

Semipermanent injectable soft-tissue fillers, 216–217 Soft-tissue fillers. See Injectable soft-tissue fillers SPRED1 mutation, 83

Squamous cell carcinoma, 63, 99, 100 Steroids

intralesional corticosteroid injection, 165–166 oral corticotherapy, 166

topical steroid, 165 Stevens–Johnson syndrome (SJS), 71

T-cell inhibitors, 59

Thyroid eye disease (TED), 49–50 Tolosa–Hunt syndrome (THS), 62–63 Typical idiopathic orbital inflammatory

syndrome (IOIS), 57

Ultrasound (echography) extraocular muscle, 145 kinetic echography, 143, 145 optic nerves, 146 quantitative echography, 143

topographic echography, 143–146 Unilateral ptosis, brow suspension

compensatory eyebrow elevation, 117–118 congenital dystrophic ptosis, 118

frontalis muscle, innervation patterns, 118 levator muscle recession, 119–121

partial or total levator muscle recession planning, 118–119

surgical technique, 121–123

Upper blepharoplasty anesthesia, 30

brow volumizing, 30–32 crease formation, 30, 31

excess lateral skin, management, 30, 32 marking, 30

patient evaluation, 29–30

preand postoperative internal ptosis repair, 31, 33 skin/muscle excision, 30

Wegener granulomatosis, 52–54, 101, 103 Wrapping materials

human donor sclera, 203

microporous expanded polytetrafluoroethylene (e-PTFE), 203

polyester-urethane like e-PTFE, 203–204 polyglactin 910 mesh, 204

vicryl mesh-wrapped implants, 204