Publications by authors named "Keith D Carter"

49 Publications

Misdiagnosis of fungal infections of the orbit.

Can J Ophthalmol 2022 May 4. Epub 2022 May 4.

From the Department of Ophthalmology and Visual Sciences, Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa. Electronic address:

Objective: To evaluate the accuracy of the initial diagnosis in the case of fungal infections of the orbit and identify factors that may influence patient outcomes.

Methods: An institutional review board-approved retrospective chart review was conducted across 2 large academic centres to identify cases of fungal infections involving the orbit from January 1, 1998, to November 15, 2019. Data collected included patient demographics, past medical history, examination findings, diagnosis, treatment, imaging, and outcomes.

Results: Fifty cases of fungal infection involving the orbit were identified. Of these, 33 (66.0%) were initially misdiagnosed as nonfungal diagnoses. Sixteen patients (32.0%) received multiple initial diagnoses. The most common diagnoses on presentation were bacterial cellulitis (n = 12 of 50; 24.0%) and bacterial sinusitis (n = 12 of 50; 24.0%). These were followed by vascular and orbital inflammatory conditions (n = 9 of 50; 18.0%): 5 patients (10.0%) were clinically diagnosed with giant cell arteritis, 3 (6.0%) with nonspecific orbital inflammation, and 1 (2.0%) with optic neuritis. In this subset of patients, 77.8% (n = 7 of 9) were treated initially with systemic steroids. Additional initial diagnoses included neoplastic mass lesions, mucocele, dacryocystitis, cavernous sinus thrombosis, hemorrhage, tick-borne illness, allergic rhinitis, and allergic conjunctivitis. Misdiagnosis was significantly correlated with involvement of the masticator space on imaging (p = 0.04).

Conclusion: Fungal infections of the orbit are misdiagnosed in 2 of 3 cases. Nearly 15% of patients who are later diagnosed with fungal disease of the orbit were initially treated with systemic steroids. Misdiagnosis is more frequent when the masticator space is involved.
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http://dx.doi.org/10.1016/j.jcjo.2022.04.007DOI Listing
May 2022

Advancing Inclusive Research: Establishing Collaborative Strategies to Improve Diversity in Clinical Trials.

Ethn Dis Winter 2022;32(1):61-68. Epub 2022 Jan 20.

Genentech Inc., South San Francisco, CA.

Well-characterized disparities in clinical research have disproportionately affected patients of color, particularly in underserved communities. To tackle these barriers, Genentech formed the External Council for Advancing Inclusive Research, a 14-person committee dedicated to developing strategies to increase clinical research participation. To help improve the recruitment and retention of patients of color, this article chronicles our efforts to tangibly address the clinical research barriers at the system, study, and patient levels over the last four years. These efforts are one of the initial steps to fully realize the promise of personalized health care and provide increased patient benefit at less cost to society. Instead of simply acknowledging the problem, here we illuminate the collaborative and multilevel strategies that have been effective in delivering meaningful progress for patients.
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http://dx.doi.org/10.18865/ed.32.1.61DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8785867PMC
February 2022

Trends in horizontal periocular asymmetry.

Can J Ophthalmol 2021 Dec 16. Epub 2021 Dec 16.

Department of Ophthalmology and Visual Sciences, University of Iowa, Iowa City, Iowa. Electronic address:

Objective: To determine whether there is laterality predominance in the horizontal dimensions of the periocular region.

Design: Retrospective study.

Participants: Patients >18 years of age who presented to a single academic ophthalmology department. Exclusion criteria included history of facial trauma or surgery, aesthetic injections, or other periocular-altering processes.

Methods: Standardized digital photographs were obtained, and periocular structures were measured with Image J software. The midline was defined as the midpoint between the medial canthi, and the distances measured include midline to medial canthus, pupil centre, lateral canthus, and lateral zygoma. The palpebral fissure width was calculated as the distance between the lateral canthus and medial canthus. Data analysis was done for the full cohort and subsequently according to patient-identified gender.

Results: Periocular structures were measured in 83 patients (50 female and 33 male) with a mean age of 57.0 ± 16.2 years (range, 22-84 years). Right-sided predominance was found to be increasingly significant for the following variables: midline to pupil centre (31.34 mm vs 31.08 mm, p < 0.01), midline to lateral canthus (42.57 mm vs 42.23 mm, p < 0.005), and midline to lateral zygoma (65.70 mm vs 64.01 mm, p < 0.001).

Conclusions: Photographic analysis of adults with no periocular-altering history demonstrates that there is a right-sided predominance in the horizontal dimension of the midline to the pupil, lateral canthus, and zygoma with increasing significance. Asymmetry of horizontal periocular measurements was more prevalent in males.
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http://dx.doi.org/10.1016/j.jcjo.2021.11.004DOI Listing
December 2021

The Effect of Sleep Position Preference on Eyelid and Eyebrow Symmetry.

Ophthalmic Plast Reconstr Surg 2022 May-Jun 01;38(3):266-269. Epub 2021 Oct 13.

Department of Ophthalmology and Visual Sciences, University of Iowa Health Care, Iowa City, Iowa, U.S.A.

Purpose: To investigate the relationship between sleep position preference and eyebrow and eyelid position and degree of upper eyelid dermatochalasis.

Methods: A prospective study evaluating the impact of sleep position on facial asymmetry was conducted at an academic ophthalmology department. Eligibility criteria included the absence of periocular-altering trauma or surgery, contact lens use, or other periorbital disease processes. Patients reported their sleep position preference on a questionnaire. Standardized digital photographs of patients were obtained, and Image J software was used for measurements and converted into millimeters based on a standard corneal limbus-to-limbus ratio. Upper and lower eyelid position, upper eyelid dermatochalasis, and eyebrow position were assessed by the following image-derived measurements: marginal reflex distance 1 (iMRD1), marginal reflex distance 2 (iMRD2), tarsal platform show (iTPS), and central brow position (iBP). These results were compared with the patient reported sleep position preference to determine correlation.

Results: Seventy-one patients were enrolled and reported the following sleep position preferences: 28 (right), 24 (left), 13 (both), and 6 (supine). Patients with a right- or left-sided preference demonstrated lower iMRD1 measurements for the preferred sleep side (p < 0.0004) with no other significant difference in periorbital measurements. A larger degree of upper eyelid height (iMRD1) asymmetry was observed among patients with a sleep side preference.

Conclusion: Patients with a predominant sleep side preference demonstrate a significant increase in ipsilateral upper eyelid asymmetry and an inferior upper eyelid position on the sleep side. There were no differences noted in lower eyelid position, central eyebrow position, or amount of upper eyelid dermatochalasis.
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http://dx.doi.org/10.1097/IOP.0000000000002066DOI Listing
May 2022

Scleral Contact Lens as Initial Management in a Neonate With a Large Upper Eyelid Coloboma.

Ophthalmic Plast Reconstr Surg 2022 Jan-Feb 01;38(1):e10-e13

From the Department of Ophthalmology and Visual Sciences, Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA.

A neonate presented with a large full-thickness upper eyelid coloboma with near-complete exposure of the cornea. After failing lubrication and a moisture chamber, he was fit with a customized scleral contact lens that protected the ocular surface. It was tolerated well, and ocular surface health was maintained for 13 months to permit the growth of eyelid tissue for future oculoplastic surgery. Delaying reconstruction by using scleral contact lenses as management for large eyelid colobomas has not been previously described. A temporizing measure such as this could be considered for large eyelid colobomas in neonates.
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http://dx.doi.org/10.1097/IOP.0000000000002057DOI Listing
January 2022

Revision orbital decompression for thyroid eye disease.

Am J Otolaryngol 2022 Jan-Feb;43(1):103196. Epub 2021 Sep 2.

Department of Otolaryngology - Head and Neck Surgery, University of Iowa Hospitals and Clinics, United States of America.

Objective: To compare the indications, surgical techniques and outcomes for revision orbital decompression surgery for thyroid eye disease in open, endoscopic, and combined open and endoscopic approaches.

Methods: A retrospective review of all revision orbital decompression procedures for thyroid eye disease from a single large academic institution over a 17-year period (01/01/2004-01/01/2021) was performed. Patient demographics, as well as indications and types of surgery were reviewed. Outcome measures included changes in proptosis, intraocular pressure, visual acuity and diplopia.

Results: Thirty procedures were performed on 21 patients. There was a median of 9.4 months between primary orbital decompression and revision decompression surgery. There were 6 bilateral procedures, and 2 of these patients underwent additional revision surgeries due to decreased visual acuity with concern for persistent orbital apex compression or sight-threatening ocular surface exposure in the setting of proptosis. Twenty-five procedures were performed as open surgeries with 5 endoscopic/combined cases. Combined Ophthalmology/Otolaryngology surgery via combined open/endoscopic approaches was favoured for persistent orbital apex disease. Visual acuity remained preserved in all patients. The overall median reduction in proptosis was 2 mm and intraocular pressure change was 1 mmHg regardless of surgical approach. The overall rate of new onset diplopia after surgery was 15%. These patients had open approaches. All endoscopic/combined approach patients had pre-existing diplopia. There were no statistically significant differences between the open and endoscopic/combined groups in regard to change in visual acuity, reduction in proptosis or intraocular pressure.

Conclusion: Revision orbital decompression is an uncommon procedure indicated for those patients with progressive symptoms despite previous surgery and intensive medical management. Both endoscopic and non-endoscopic techniques offer favourable outcomes with respect to visual acuity, decrease in intraocular pressure, and improvement in proptosis and overall lead to a low incidence of new onset diplopia.

Level Of Evidence: Level IV.
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http://dx.doi.org/10.1016/j.amjoto.2021.103196DOI Listing
February 2022

Challenging the current treatment of residual postoperative ptosis: safety and efficacy of repeat Müller's muscle conjunctival resection.

Can J Ophthalmol 2022 08 29;57(4):247-252. Epub 2021 May 29.

Department of Ophthalmology and Visual Sciences, University of Iowa, Carver College of Medicine, Iowa City, Iowa. Electronic address:

Objective: To determine if repeat Müller's muscle conjunctival resection (MMCR) is a viable approach in the treatment of recurrent or residual eyelid ptosis.

Methods: A retrospective review of patients who underwent repeat MMCR was performed using external photos obtained preoperatively, postoperatively, and at last follow-up. The marginal reflex distances (MRD1 and MRD2), brow position (BP), and tarsal platform show (TPS) were evaluated with digital image analysis. The change in upper eyelid height (MRD1) and TPS following repeat ptosis repair were the outcome measures.

Results: Repeat MMCR was performed on 12 eyelids of 11 patients. Mean MRD1 elevation after initial MMCR was 1.6 mm (standard deviation [SD] = 1.0mm, p < 0.00001). Mean decrease in TPS was 1.9 mm (p = 0.04). There was no significant change in MRD2 (p = 0.36) or BP (p = 0.33) with initial MMCR. Mean interval between procedures was 12.8 months (range 2.3-48.0) and follow-up after repeat MMCR was 2.3 months. Total average follow-up after initial MMCR was 15.1 months. Mean elevation in MRD1 after repeat MMCR was 1.0 mm (SD = 0.8 mm, p < 0.002). Mean decrease in TPS was 1.0 mm (p = 0.03). There was no difference in MRD2 (p = 0.90) or BP (p = 0.53). There were no complications of repeat MMCR noted clinically or spontaneously reported, including no entropion, fornix foreshortening, or development of dry eye signs or symptoms.

Conclusion: Repeat MMCR significantly improves recurrent or residual ptosis after initial MMCR without significant adverse consequences. The degree of elevation with repeat MMCR was diminished when compared with initial MMCR.
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http://dx.doi.org/10.1016/j.jcjo.2021.04.021DOI Listing
August 2022

A direct transcutaneous approach to infraorbital nerve biopsy.

Orbit 2022 Feb 6;41(1):130-137. Epub 2021 May 6.

Department of Ophthalmology and Visual Sciences, University of Iowa, Iowa City, Iowa, USA.

Purpose: To describe a novel transcutaneous infraorbital nerve biopsy technique which can be performed to aid in the diagnosis of perineural invasion (PNI) of facial cutaneous squamous cell carcinoma (SCC).

Methods: A single-center retrospective chart review was performed. Patients diagnosed with SCC with PNI via an infraorbital nerve biopsy between February 2019 and February 2020 were included. Data collected consisted of patient demographics, medical history, clinical presentation and exam, histologic and radiographic findings, treatment, and outcomes.

Results: Four patients (3 male, 1 female) met inclusion criteria. The mean age at diagnosis was 79.5 years (range 66-85 years). Three of the four patients had a history of facial skin lesions, including actinic keratosis and SCC, involving the nose, cheek, or ear. One patient had no history of cutaneous malignancy. All patients presented with cranial neuropathies, including total V2 hypoesthesia. The most common presenting symptom was facial pain, followed by diplopia, unilateral facial weakness, and hypoesthesia in the V1 and/or V2 distribution. Transcutaneous infraorbital nerve biopsy in all patients revealed squamous cell carcinoma with no biopsy complications.

Conclusion: Definitive diagnosis of PNI can be challenging but is important to minimize tumor-related morbidity. Infraorbital nerve biopsy can establish this diagnosis, especially in the context of negative or indeterminate imaging findings. This work comprises the first description of a transcutaneous approach to infraorbital nerve biopsy, which is a minimally invasive technique that can be performed in an outpatient procedure suite with limited to no sedation.
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http://dx.doi.org/10.1080/01676830.2021.1920041DOI Listing
February 2022

The Effect of Photographic Visual Aids in Preoperative Patient Counseling in Oculoplastic Surgery.

Ophthalmic Plast Reconstr Surg 2021 May-Jun 01;37(3S):S70-S75

Department of Ophthalmology and Visual Sciences, University of Iowa, Iowa City, Iowa.

Purpose: To investigate the effect of visual supplementation and its mode of delivery in preoperative counseling of patients undergoing oculoplastic surgery.

Methods: A prospective randomized controlled trial of consecutive patients undergoing oculoplastic eyebrow and eyelid surgery was conducted. Patients were randomized to an "oral only" group receiving routine preoperative oral counseling or an "oral and visual" group receiving identical counseling visually supplemented with photographs demonstrating common postoperative physical findings. Patients in the "oral and visual" group were further randomized to receive education from the medical team in person versus prerecorded video. Patient emotions and expectations regarding postoperative healing were assessed preoperatively and at 1 week and 2 months postoperatively.

Results: 103 patients were included: 32 received in-person oral education, 33 received in-person oral education with photographs, and 38 received education with photographs via video. There were no significant differences in demographics or preoperative patient fear, anxiety, or preparedness. The "oral and visual" group expected more severe postsurgical discomfort and physical findings at postoperative day 1 and week 1. There were no significant differences between groups in surgery signup, cancellation, or triage call rates; patient expectations of postoperative months 2 and 4; or in anxiety, preparedness, or satisfaction.

Conclusions: Visual supplementation in preoperative counseling increases patient expectations of postoperative physical findings without escalating fear or anxiety, and has no significant impact on patient emotions, triage call rates, and satisfaction throughout their surgical experience. Preoperative education via video is perceived by patients to be equivalent to counseling in person by the surgeon.
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http://dx.doi.org/10.1097/IOP.0000000000001817DOI Listing
May 2021

Closure Technique and Antibiotics in Frontalis Sling Infection and Exposure.

Ophthalmology 2021 03 16;128(3):480-482. Epub 2020 Jul 16.

Department of Ophthalmology and Visual Sciences, University of Iowa, Iowa City, Iowa. Electronic address:

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http://dx.doi.org/10.1016/j.ophtha.2020.06.066DOI Listing
March 2021

Upper Eyelid Splitting to Facilitate the Insertion of Glaucoma Drainage Devices.

J Glaucoma 2017 Nov;26(11):e249-e251

*Department of Ophthalmology and Visual Sciences, The University of Iowa Hospitals and Clinics, Iowa City, IA †Cincinnati Eye Institute, Cincinnati, OH.

Purpose: To describe a new application for vertical splitting of the upper eyelid, a technique traditionally used for orbital access, to facilitate glaucoma drainage device (GDD) implantation in patients with poor surgical exposure.

Methods: Case series.

Cases: We present a case of Möbius syndrome with complete restriction of the extraocular muscles, followed by a case of cicatricial narrowing of the palpebral fissures due to chronic allergic dermatitis. Both patients had severe, medically uncontrolled glaucoma, but poor surgical exposure precluded implantation of a GDD. Both cases underwent vertical splitting of the upper eyelid, which allowed for adequate exposure of the superior globe quadrants and successful implantation of a GDD.

Conclusions: A variety of congenital or acquired conditions result in narrowing of the palpebral fissure or restriction of extraocular motility. When these patients have concurrent advanced glaucoma, inadequate surgical exposure can impede necessary surgical intervention. Use of a vertical upper eyelid split technique allows for access to the superior globe and facilitates implantation of a GDD.
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http://dx.doi.org/10.1097/IJG.0000000000000789DOI Listing
November 2017

Hering's Law in Congenital Ptosis: Evaluation of the Contralateral Response to Unilateral Congenital Ptosis Repair.

Ophthalmic Plast Reconstr Surg 2018 May/Jun;34(3):284-290

Department of Ophthalmology and Visual Sciences, Carver College of Medicine, University of Iowa.

Purpose: To determine the applicability and clinical relevance of Hering's law for the eyelids in cases of congenital ptosis.

Methods: A retrospective chart review and digital photograph analysis of patients who underwent unilateral congenital ptosis repair at a tertiary, university-based, Oculoplastics clinic was conducted. Pre- and postoperative eyelid height (marginal reflex distance), upper eyelid symmetry, and brow position were determined using ImageJ analysis software. Changes in these values, and the relationship between the change in ipsi- and contralateral eyelid heights and brow positions, were determined.

Results: In 51 patients, the mean change in contralateral upper eyelid position (marginal reflex distance) following unilateral repair was -0.5 mm with 29% (n = 15) demonstrating a greater than 1 mm contralateral descent. The contralateral brow position remained stable with a mean change of +0.1 mm. No significant differences were seen between the 15 patients who demonstrated a contralateral upper eyelid descent greater than 1 mm and the remainder of the cohort in terms of amblyopia rate (p = 0.71), mean preoperative marginal reflex distance (p = 0.14), mean change in ipsilateral marginal reflex distance (p = 0.32), mean change in contralateral brow position (p = 0.44), or mean postoperative upper eyelid asymmetry (1.3 mm vs. 1.2 mm). Overall, the mean upper eyelid asymmetry improved from 2.6 mm preoperatively to 1.2 mm postoperatively. None of the 51 patients underwent subsequent contralateral ptosis repair.

Conclusions: Hering's law for the eyelids applies to cases of congenital ptosis but has little clinical significance due to improved upper eyelid asymmetry following unilateral surgery.
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http://dx.doi.org/10.1097/IOP.0000000000000951DOI Listing
July 2018

Scleral Contact Lenses in an Academic Oculoplastics Clinic: Epidemiology and Emerging Considerations.

Ophthalmic Plast Reconstr Surg 2018 May/Jun;34(3):231-236

Department of Ophthalmology and Visual Sciences, Carver College of Medicine, University of Iowa Hospitals and Clinic, Iowa City, Iowa.

Purpose: To describe the role and efficacy of scleral contact lenses (SCLs) in the treatment of progressive keratopathy in patients who have undergone periocular surgical procedures, to investigate the financial impact of these surgical interventions, and to demonstrate the role of oculoplastic surgery in improving scleral contact lens fit.

Methods: A retrospective medical record review was performed to identify patients who both received SCLs and were examined by the oculoplastics service at the University of Iowa between January 1990 and December 2015. Inclusion criteria also required a minimum of 12 months of patient follow up after being fit with a SCL. The indication for SCL use, as well as clinical outcomes and cumulative relative value units (RVUs) of prior oculoplastic treatments and SCL therapy were recorded for each patient.

Results: Six hundred and fifty-nine patients were fitted with SCLs at the authors' institution during the 25-year study period, 43 of whom were examined by the oculoplastics service for reasons related to their SCL. Patients who were fitted for SCLs before (27 patients) or after (16 patients) evaluation in the oculoplastics clinic presented with a variety of corneal and periocular pathology. Corneal indications for SCLs in patients seen secondarily in the oculoplastics clinic included decreased corneal sensation (from CN V palsy or neurotrophic keratopathy), decreased corneal healing from limbal stem cell deficiency, exposure keratopathy, and keratoconjunctivitis sicca secondary to Sjogren's syndrome or orbital radiation. Indications for oculoplastic clinic evaluation in current scleral lens patients included lagophthalmos, trichiasis, epiphora, cicatricial changes in the eyelids or fornices, and eyelid or eyebrow malposition affecting SCL centration. In all 27 patients, surgical intervention resulted in improved SCL centration. Sixteen patients (5 with CN VII palsy, 4 with CN V and CN VII palsy, 4 with neurotrophic keratitis, and 3 with cicatricial entropion) had progressive corneal decompensation despite primary oculoplastics procedures to protect the cornea and ultimately benefitted from SCL treatment secondarily. Fourteen of these 16 patients demonstrated an improved visual acuity of 1 line or more using SCLs. Procedures performed before referral for SCLs included tarsorrhaphies, gold weights, ectropion repair with lateral tarsal strip, retraction repair with spacer grafts, full-thickness skin grafts, cheek lifts, and punctal occlusion. The total RVUs of these procedures performed per patient were tabulated. The RVU range was 10.47-33.96 with an average of 19.5 RVUs (standard deviation = 9.4 RVUs) per patient.

Conclusions: Scleral contact lenses may offer a useful alternative to stabilize the ocular surface, improve vision, and minimize the financial impact and morbidity of multiple periocular procedures in select patients with progressive keratopathy of varying etiologies. The therapeutic indications and utilization of SCLs are likely to increase in oculoplastic practices with optometric support, particularly in academic settings. Surgical correction of eyelid and eyebrow malposition, as well as epiphora, may also be useful adjunctive procedures to optimize SCL fit.
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http://dx.doi.org/10.1097/IOP.0000000000000929DOI Listing
July 2018

Rethinking Our Definition of Postoperative Success: A Comparative Analysis of Three Upper Eyelid Retraction Repair Techniques Using Novel Metrics to Capture Functional and Aesthetic Outcomes.

Ophthalmic Plast Reconstr Surg 2018 Jan/Feb;34(1):55-63

Purpose: To compare 3 upper eyelid retraction repair techniques and introduce novel metrics, which enhance the analysis of postoperative aesthetic outcomes.

Methods: Retrospective review with Image J 1.48 digital analysis of patients who underwent repair of thyroid-related upper eyelid retraction at the University of Iowa from 1996 to 2014 via 1 of 3 surgical techniques, septum-opening levator recession with Muellerectomy, modified septum-preserving levator recession with Muellerectomy, and modified septum-preserving full-thickness blepharotomy, was conducted. Photographs were obtained preoperatively, 3 to 6 months postoperatively, and at last follow up (>6 months) and evaluated by digital image analysis (denoted by "i"). Outcome measures assessed were marginal reflex distance (iMRD1), temporal-to-nasal ratio, tarsal platform show (iTPS), pupil to visible eyelid crease, brow fat span (iBFS), tarsal platform show to brow fat span ratio (iTPS:iBFS), and tarsal platform show minimizing power (iTPS-minimizing power).

Results: A total of 121 eyelids (28 septum-opening levator recession with Muellerectomy, 66 septum-preserving levator recession with Muellerectomy, and 27 septum-preserving full-thickness blepharotomy) from 74 patients were evaluated with a mean follow up of 24.2 months. There were no statistically significant differences between techniques in terms of iMRD1 or temporal-to-nasal ratio reduction at either time point (intertechnique p values of 0.17 to >0.99). The percentage of eyelids from subjects undergoing bilateral intervention that achieved a final iMRD1 between 2.50 mm and 4.50 mm was similar (intertechnique p value of 0.23), with no difference regarding the number of subjects demonstrating iMRD1 symmetry within 1 mm (intertechnique p value of 0.15). Though iTPS elongation was greater at 3 to 6 months with septum-opening compared with the combined septum-preserving techniques (p value of 0.04), this difference was not maintained at final follow up (p value of >0.99). There was no difference in terms of iTPS symmetry at time of final follow up (intertechnique p value of 0.69). The pupil to visible eyelid crease was unchanged in all techniques (p values >0.99). Mean changes in iBFS at final follow up were -1.27 mm, -0.44 mm, and +0.55 mm for septum-opening levator recession with Muellerectomy, septum-preserving levator recession with Muellerectomy, and septum-preserving full-thickness blepharotomy (p values of 0.01, 0.49, and >0.99, respectively). Mean iTPS:iBFS ratios at final follow up were not statistically different between techniques (intertechnique p value of 0.10) and no difference in symmetry was demonstrated (intertechnique p value of 0.47). Median values for iTPS-minimizing power were: -0.83, -0.93, and -1.01 for septum-opening levator recession with Muellerectomy, septum-preserving levator recession with Muellerectomy, and septum-preserving full-thickness blepharotomy, respectively (intertechnique p value of 0.54).

Conclusions: Each technique appropriately lowered the eyelid and improved contour without intertechnique variability. Septum-preserving techniques demonstrated less iTPS elongation initially, but this difference was not maintained. The visible eyelid crease height (pupil to visible eyelid crease) remained stable in all techniques, indicating that the iTPS elongation seen with each technique was secondary to reduction in iMRD1 and the iBFS reduction seen with septum-opening levator recession with Muellerectomy was due to brow descent. No intertechnique differences in the amount of iTPS elongation relative to iMRD1 reduction (i.e., the novel iTPS-minimizing power) were seen. Given that each procedure evaluated yielded similar results, technique selection may be guided by surgeon experience and preference.
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http://dx.doi.org/10.1097/IOP.0000000000000868DOI Listing
February 2018

Perception of patient appearance following various methods of reconstruction after orbital exenteration.

Orbit 2016 Aug 24;35(4):187-92. Epub 2016 Jun 24.

c University of Iowa Hospitals and Clinics , Iowa City , Iowa , USA.

This article compares the perception of health and beauty of patients after exenteration reconstruction with free flap, eyelid-sparing, split-thickness skin graft, or with a prosthesis. Cross-sectional evaluation was performed through a survey sent to all students enrolled at the University of Iowa Carver College of Medicine. The survey included inquiries about observer comfort, perceived patient health, difficulty of social interactions, and which patient appearance was least bothersome. Responses were scored from 0 to 4 for each method of reconstruction and an orbital prosthesis. A Friedman test was used to compare responses among each method of repair and the orbital prosthesis for each of the four questions, and if this was significant, then post-hoc pairwise comparison was performed with p values adjusted using Bonferroni's method. One hundred and thirty two students responded to the survey and 125 completed all four questions. Favorable response for all questions was highest for the orbital prosthesis and lowest for the split-thickness skin graft. Patient appearance with an orbital prosthesis had significantly higher scores compared to patient appearance with each of the other methods for all questions (p value < 0.0001). Second highest scores were for the free flap, which were higher than eyelid-sparing and significantly higher compared to split-thickness skin grafting (p value: Question 1: < 0.0001; Question 2: 0.0005; Question 3: 0.006; and Question 4: 0.019). The orbital prosthesis was the preferred post-operative appearance for the exenterated socket for each question. Free flap was the preferred appearance for reconstruction without an orbital prosthesis. Split-thickness skin graft was least preferred for all questions.
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http://dx.doi.org/10.1080/01676830.2016.1176207DOI Listing
August 2016

Epidemiology and Prognosis of Primary Periocular Sweat Gland Carcinomas.

Ophthalmic Plast Reconstr Surg 2017 Mar/Apr;33(2):101-105

*Department of Ophthalmology and Visual Sciences, University of Iowa Hospitals and Clinics, Iowa City, Iowa; †Orbital Oncology and Ophthalmic Plastic Surgery, Department of Plastic Surgery, and ‡Department of Pathology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, U.S.A.

Purpose: To characterize the clinical presentation, management, and outcomes of patients with sweat gland carcinoma of the periocular region. To review the pathologic classification scheme, compare the clinical behavior between subtypes, and discuss treatment recommendations for periocular sweat gland carcinomas.

Methods: Retrospective study from 2 tertiary centers, which are part of the American Society of Ophthalmic Plastic and Reconstructive Surgery Oncology Database.

Results: Twenty-two patients, of whom 13 (59%) were female, were included in the study. The median age was 69 years. The median follow-up time was 23 months. Twenty (91%) patients had lesions that were slow growing and were present for several months to years before diagnosis. Presentation was varied, and pathology included mucinous carcinoma (7; 32%), microcystic adnexal carcinoma (4; 18%), endocrine mucin-producing sweat gland carcinoma (4; 18%), eccrine carcinoma (2; 9%), apocrine carcinoma (2; 9%), poorly differential adnexal carcinoma (2; 9%), and hidroadenocarcinoma (1; 5%). Microcystic adnexal carcinoma tended to present with the largest tumor dimension (range: 25-32 mm) and mucinous carcinoma the smallest (range: 5-13 mm). Treatments included Mohs micrographic excision in 10 patients (45.5%), wide local excision in 10 patients (45.5%), and orbital exenteration in 2 patients (9%). No lesions ≤T2b (by AJCC 7th edition classification for eyelid carcinomas) had local recurrence or nodal metastasis. No patients had distant metastasis.

Conclusions: Sweat gland carcinomas tend to grow slowly and be present for several months to years before diagnosis. Overall, microcystic adnexal carcinoma subtype showed more aggressive clinical behavior than mucinous subtypes. Eyelid carcinomas AJCC category T2b or less were associated with better outcomes.
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http://dx.doi.org/10.1097/IOP.0000000000000658DOI Listing
March 2017

An Analysis of Conjunctival Map Biopsies in Sebaceous Carcinoma.

Ophthalmic Plast Reconstr Surg 2017 Jan/Feb;33(1):17-21

*Department of Ophthalmology and Visual Sciences, †Department of Statistics, Carver College of Medicine, University of Iowa, Iowa City, Iowa; and ‡Cincinnati Eye Institute, Cincinnati, Ohio, U.S.A.

Purpose: To evaluate the need for standardized conjunctival map biopsies in periocular sebaceous carcinoma and to formulate recommendations regarding map biopsy number, location, size, and utility based on analysis of biopsy locations, results, and outcomes.

Methods: Retrospective consecutive series of patients with sebaceous carcinoma treated at a tertiary care hospital from 1988 to 2013. Main outcome measures included conjunctival biopsy locations, number, size, and pathology.

Results: A diffuse eyelid pattern was evident on presentation in 28/51 patients (54.9%) versus a solitary eyelid nodule in 23/51 (45.1%). Forty-five patients underwent a total of 429 conjunctival biopsies. The conjunctiva was negative in 277 specimens (64.6%), positive in 121 (28.2%), suspicious in 26 (6.1%), and nondiagnostic in 5 (1.2%). Intraepithelial conjunctival involvement was present in 36 patients (70.6%) of whom 23 (63.9%) presented with a diffuse eyelid appearance. There was no statistically significant correlation between primary tumor location and sites of positive biopsies or biopsy size. The pattern at presentation and location of primary tumor did not correlate with biopsy results. Clinical assessment regarding conjunctival involvement was incorrect in 10 of 23 patients (43.5%) with a solitary nodule. Despite primary tumor resection with clear margins confirmed on pathology, 5 of 45 (11%) patients had locally recurrent sebaceous carcinoma.

Conclusions: Conjunctival biopsy size does not correlate with the presence of tumor in the biopsy. Primary tumor location and pattern of tumor at presentation do not correlate with conjunctival biopsy results. Irrespective of the clinical tumor features, standardized conjunctival map biopsies are essential in staging periocular sebaceous carcinoma.
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March 2017

Optic Nerve Sheath Fenestration: Current Preferences in Surgical Approach and Biopsy.

Ophthalmic Plast Reconstr Surg 2015 Jul-Aug;31(4):310-2

*Department of Ophthalmology and Visual Sciences; †Department of Pathology; and ‡Department of Otolaryngology-Head and Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A.

Purpose: Optic nerve sheath fenestration (ONSF) has evolved since its inception in 1872. Surgical approaches include a lateral orbitotomy, a medial orbitotomy, or a superomedial lid crease. The actual fenestration can be done with slits or a window excision with biopsy. Each variation has its advantages and disadvantages. We describe the current preferences in surgical approach and biopsy for ONSF and examine the value of biopsy in patients who have undergone ONSF.

Design: Eight-question survey and retrospective, noncomparative case review.

Subjects: All American Society of Ophthalmic Plastic and Reconstructive Surgeons (ASOPRS) members are invited to participate in a survey and ONSFs from 1998 to 2013 at the University of Iowa Hospital and Clinics.

Methods: Data from the survey was analyzed and patient records were reviewed.

Main Outcome Measures: Preferred surgical approach, type of fenestration, and biopsy results.

Results: Sixty-four percent of responding ASOPRS members (150/236) have not performed an ONSF in the last year. One third of that group has performed an ONSF in the last 5 years. Fifty-nine percent perform a medial; 10%, a lateral and 31%, a superomedial approach. Seventy-three percent perform a window fenestration, and about half of those surgeons send the specimen for pathologic evaluation. Anecdotally, some biopsies from surgeons who were surveyed have revealed new diagnoses. In a chart review of 90 cases of ONSF, no biopsy gave an unexpected result.

Conclusion: The medial approach for ONSF is most common in our respondents; however, the superomedial lid crease incision is gaining popularity for its efficiency and elegance. Three quarters of surgeons remove a window and a quarter fenestrate with slits. Optic nerve sheath biopsy has limited diagnostic value. In the absence of any evidence to suggest a diagnosis other than idiopathic intracranial hypertension, the usefulness of biopsy during fenestration is low.
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http://dx.doi.org/10.1097/IOP.0000000000000326DOI Listing
February 2016

Factors affecting eyelid crease formation before and after silicone frontalis suspension for adult-onset myogenic ptosis.

Ophthalmic Plast Reconstr Surg 2015 May-Jun;31(3):227-32

*Department of Ophthalmology and Visual Sciences; †Department of Otolaryngology - Head and Neck Surgery; and ‡Department of Biostatistics, University of Iowa Hospitals and Clinics, Iowa City, Iowa; §Department of Neurology, University of New Mexico School of Medicine, Albuquerque, New Mexico; and ‖Cincinnati Eye Institute, Cincinnati, Ohio, U.S.A.

Purpose: To evaluate factors that affect eyelid crease formation before and after frontalis suspension.

Design: Nonrandomized, comparative, interventional case series.

Methods: Sixty-three patients (125 eyes) with myogenic ptosis were included. Data collected included age, gender, previous surgeries, follow up, as well as pre- and postoperative margin reflex distance, palpebral fissure height, and levator function. Intraoperative maneuvers of incorporation of the levator aponeurosis into the skin closure, conservative fat excision, and conservative skin excision were recorded. Pre- and postoperative eyelid creases were graded by 2 masked, independent observers as "good," "fair," or "poor."

Results: The weighted κ coefficient between the graders was 0.68 (95% CI, 0.58-0.79) preoperatively and 0.70 (95% CI, 0.61-0.79) postoperatively. Evaluating preoperative eyelid crease grades, there was no significant difference with regard to age or gender (p = 0.83 or 0.69, respectively). Eyelid crease grade correlated with margin reflex distance (p = 0.0004) and palpebral fissure height (p = 0.002). There was no significant correlation of eyelid crease with levator function (p = 0.104). After frontalis sling, intraoperative maneuvers of incorporation of the levator aponeurosis into the incision, skin preservation, and fat preservation correlated with postoperative eyelid crease (p = 0.0004, 0.059, and 0.033, respectively).

Conclusions: Preoperative levator function in patients with adult onset myogenic ptosis may be an inaccurate measure of true levator palpebrae strength. Reliance on levator function alone in decision making for surgical intervention in these patients may be misguided. The inclusion of the intraoperative maneuvers of incorporation of the levator aponeurosis into the skin incision and preservation of fat and skin results in a stronger eyelid crease after frontalis sling surgery.
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http://dx.doi.org/10.1097/IOP.0000000000000272DOI Listing
February 2016

Salivary gland dysfunction and nasolacrimal duct obstruction: stenotic changes following I-131 therapy.

Ophthalmic Plast Reconstr Surg 2015 May-Jun;31(3):e50-2

*Carver College of Medicine, University of Iowa, Iowa City; †Department of Ophthalmology, Boston University, Boston, Massachusetts; and Departments of ‡Otolaryngology-Head and Neck Surgery, §Ophthalmology and Visual Sciences, and ‖Oral Pathology, University of Iowa, Iowa City, Iowa, U.S.A.

Radioactive iodine has long been used in the treatment of cancers of the thyroid. While salivary complications secondary to I-131 therapy in association with xerophthalmia are well documented, there is little in the literature addressing simultaneous nasolacrimal duct obstruction with salivary gland dysfunction. The authors present 2 patients with epiphora from bilateral nasolacrimal duct obstruction and concurrent sialadenitis following I-131 ablation therapy for papillary thyroid carcinoma. These cases highlight the lacrimal and salivary duct complications resulting from I-131 therapy, introduce the possibility of a shared mechanism of damage, and demonstrate the availability of effective treatments for both conditions. Ophthalmologists see patients with epiphora from I-131 therapy and should be aware of the possible concurrent symptoms caused by salivary duct stenosis to make timely and appropriate referrals.
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http://dx.doi.org/10.1097/IOP.0000000000000066DOI Listing
February 2016

Intimate partner violence: an underappreciated etiology of orbital floor fractures.

Ophthalmic Plast Reconstr Surg 2014 Nov-Dec;30(6):508-11

*Carver College of Medicine, University of Iowa, Iowa City, Iowa; †School of Social Work, University of Minnesota, St. Paul, Minnesota; ‡Department of Ophthalmology, Boston University School of Medicine, Boston, Massachusetts; §Department of Ophthalmology and Visual Sciences, Carver College of Medicine, University of Iowa, Iowa City, Iowa; and ‖Department of Ophthalmology, Cincinnati Eye Institute, Cincinnati, Ohio, U.S.A.

Purpose: To evaluate the prevalence of intimate partner violence (IPV) in a large population of female orbital floor fracture patients and provide recommendations on effectively identifying and referring IPV survivors.

Methods: Retrospective review of facial fracture patients examined at the University of Iowa Hospitals and Clinics between January 1995 and April 2013. International Classification of Diseases, Ninth Revision, codes and medical record review were used to determine the prevalence of IPV victimization and clinical outcomes.

Results: A total of 1,354 women and 4,296 men sustained facial fractures. Of these, 405 women and 1,246 men sustained orbital floor fractures. Leading mechanisms of orbital floor fractures in women were motor vehicle collisions (29.9%) and falls (24.7%). Twenty percent had no etiology documented. Intimate partner violence-associated assault was the third leading documented cause of orbital floor fractures in women (7.6%) followed by non-IPV-associated assault (7.2%). Among women with orbital floor fractures due to assault, leading patterns of injury included the following: isolated orbital floor fractures (38.7%, 12/31 in IPV patients; 55.2%, 16/29 in non-IPV patients), zygomaticomaxillary complex fractures (35.5%, 11/31 in IPV patients; 17.2%, 5/29 in non-IPV patients), and orbital floor plus medial wall fractures (16.1%, 5/31 in IPV patients; 24.1%, 7/29 in non-IPV patients). Involvement of ancillary services was documented in 20.0% (7 law enforcement and 5 social service agencies, 12/60) of assault-related orbital floor fracture cases. Ascertainment of patient safety was documented in 1.7% (1/60) of these cases.

Conclusions: Ophthalmologists treating orbital floor fracture patients should maintain a high index of suspicion for IPV and screen accordingly. Following IPV disclosure, patient safety should be assessed and referral provided.
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May 2015

Limited Wegener's Granulomatosis Presenting with an Isolated Abduction Deficit.

Neuroophthalmology 2014 25;38(3):145-148. Epub 2014 Apr 25.

Department of Ophthalmology and Visual Sciences; Department of Neurology, University of IowaIowa City, IowaUSA; Department of Neurology, Veterans Affairs Medical CenterIowa City, IowaUSA.

Wegener's granulomatosis often affects the orbit, typically presenting with painful proptosis. The authors describe a 14 year-old girl, with limited Wegener's granulomatosis, who initially presented with an isolated painless abduction deficit that spontaneously resolved over several weeks. She subsequently developed painful proptosis and diplopia, followed by facial and oral nodules. This case demonstrates that limited Wegener's granulomatosis can rarely present with an isolated painless abduction deficit.
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http://dx.doi.org/10.3109/01658107.2014.894086DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5122943PMC
April 2014

Limited Wegener's Granulomatosis Presenting with an Isolated Abduction Deficit.

Neuroophthalmology 2014 25;38(3):145-148. Epub 2014 Apr 25.

Department of Ophthalmology and Visual Sciences; Department of Neurology, University of IowaIowa City, IowaUSA; Department of Neurology, Veterans Affairs Medical CenterIowa City, IowaUSA.

Wegener's granulomatosis often affects the orbit, typically presenting with painful proptosis. The authors describe a 14 year-old girl, with limited Wegener's granulomatosis, who initially presented with an isolated painless abduction deficit that spontaneously resolved over several weeks. She subsequently developed painful proptosis and diplopia, followed by facial and oral nodules. This case demonstrates that limited Wegener's granulomatosis can rarely present with an isolated painless abduction deficit.
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http://dx.doi.org/10.3109/01658107.2014.894086DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5122943PMC
April 2014

Bilateral lacrimal drainage obstruction and its association with secondary causes.

Ophthalmic Plast Reconstr Surg 2014 Mar-Apr;30(2):152-6

Departments of *Ophthalmology and Visual Sciences, and †Otolaryngology-Head and Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A.

Purpose: Etiologies of lacrimal obstruction requiring a dacryocystorhinostomy (DCR) have been reviewed previously but most commonly are thought to result from "primary acquired" nasolacrimal duct obstruction, a process of chronic inflammation in a narrowed duct. The authors have observed that secondary causes are frequently associated with bilateral lacrimal outflow disease. The purpose of this study is to investigate this relationship to help the clinician prioritize which patients to evaluate for secondary causes.

Methods: This is a retrospective case-controlled review of patients who underwent bilateral DCR from 1986 to 2012 at this institution. They are compared with an age and gender-matched control group who underwent unilateral DCR. Statistical analysis was undertaken using the Pearson chi-square test for p value, except for age, which used the Wilcoxon rank sum test. Logistic regression was used for comparing prevalence of secondary issues in bilateral disease versus unilateral disease, with age as covariate.

Results: Two hundred thirty-five patients underwent bilateral (91) or unilateral DCR (144). Twice as many patients undergoing bilateral DCR had an underlying secondary cause compared with the patients undergoing unilateral DCR. (38%, 19%, p= 0.001, odds ratio 2.59). In patients <50, the odds ratio of a secondary cause in bilateral disease would be 5.34 compared with patients older than 80. (p = 0.0002) Patients in the bilateral DCR group underwent revisions at more than twice the rate as patients in the unilateral DCR group (26%, 12%, p = 0.007).

Conclusions: Ophthalmologists should have a high index of suspicion for secondary conditions underlying bilateral lacrimal outflow obstruction, especially in patients <50. These patients should undergo laboratory workup and intraoperative biopsy. They should also be counseled regarding a higher failure rate.
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September 2014

In vivo examination of meibomian gland morphology in patients with facial nerve palsy using infrared meibography.

Ophthalmic Plast Reconstr Surg 2012 Nov-Dec;28(6):396-400

Department of Ophthalmology & Visual Sciences, University of Iowa Hospitals and Clinics, Iowa City, Iowa 52242, USA.

Purpose: The aim of this study was to investigate the effect of orbicularis oculi weakness on meibomian gland morphology using infrared meibography.

Methods: This was a cross-sectional study. Patients were recruited from the University of Iowa Hospitals and Clinics. Inclusion criteria required the patient to be at least 18 years of age and have a unilateral facial nerve palsy. A total of 32 affected eyelids from 20 patients were studied. The aforementioned participant group was examined using infrared video meibography. The contralateral unaffected eyelids served as control. Eyelids with previous surgery were excluded. Data collected included age and gender in addition to laterality, duration, and cause of the palsy. Each eyelid was assigned a "meibograde" based on morphological changes of the meibomian glands.

Results: The main outcome measure was the "meibograde" based on infrared morphology of the meibomian glands. Fourteen upper and 18 lower eyelids affected by facial nerve palsies of various durations were examined. Mean patient age was 57.6 years (range 20-86). The affected lower eyelid meibograde (n = 12) was significantly different than the control (p = 0.001) in patients with weakness for more than 3 months. No difference was found in the upper eyelids at less than (n = 6) or more than (n = 8) 3 months duration. Similarly, the lower eyelids affected for less than 3 months (n = 6) showed no statistically significant difference.

Conclusions: Over time, weakness of the orbicularis oculi is associated with morphological changes in the lower lid representing increased meibomian gland dysfunction. This may represent an overlooked cause of ocular surface disease in patients with facial nerve weakness.
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March 2013

Periorbital edema: a puzzle no more?

Curr Opin Ophthalmol 2012 Sep;23(5):405-14

Department of Ophthalmology and Visual Sciences, University of Iowa Hospitals and Clinics, Iowa City, Iowa 52242, USA.

Purpose Of Review: Periorbital edema is a common problem that deserves scrutiny. Although a variety of healthcare providers may see this clinical entity, ophthalmologists are often consulted along the way toward diagnosis. It can challenge even the most astute clinicians. A diagnosis may reveal merely a bothersome issue or potentially a sight-threatening or life-threatening problem.

Recent Findings: Comprehensive reviews on this topic are scarce. Textbooks are brief. There are, however, many studies in the scientific literature of notable cases of periorbital edema. The causes generally fall into the categories of infectious, inflammatory or tumors, medication related, and postsurgical or trauma.

Summary: This article synthesizes the current literature on the topic with a case series from our institution. It aims to provide a thorough resource for all practitioners to make the prospect of triaging, diagnosing, and treating periorbital edema less daunting.
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September 2012

Primary bilateral silicone frontalis suspension for good levator function ptosis in oculopharyngeal muscular dystrophy.

Br J Ophthalmol 2012 Jun 4;96(6):841-5. Epub 2012 Apr 4.

Department of Surgery, Division of Ophthalmology, University of New Mexico School of Medicine, Albuquerque, New Mexico USA.

Aim: To evaluate outcomes of patients with oculopharyngeal muscular dystrophy (OPMD) with levator function (LF) ≥ 10mm who underwent primary bilateral silicone frontalis suspension.

Methods: 31 patients with OPMD satisfied the following inclusion criteria: LF ≥ 10 mm; no previous eyelid surgery; and pre-operative measurements, silcone frontalis suspension and post-operative measurements performed by a single individual. The following data were collected: age; gender; pre-operative margin reflex distance (MRD), palpebral fissure height (PF), and LF; post-operative MRD, PF and lagophthalmos; follow-up; and complications.

Results: Mean age at surgery was 61.5 ± 5.8 years. Pre-operative measurements for MRD, PF and LF were -0.05 ± 0.82 mm (OD), -0.13 ± 0.91 mm (OS); 5.2 ± 1.2 mm (OD), 5.2 ± 1.3 mm (OS); 11.6 ± 1.3 mm (OD), and 11.7 ± 1.3 mm (OS), respectively. Post-operative measurements for MRD and PF were 2.23 ± 0.97 mm (OD), 2.10 ± 1.09 mm (OS), 7.9 ± 1.4 mm (OD), and 7.7 ± 1.6 mm (OS), respectively (all p < 0.0001). The mean follow-up period was 22.8 ± 22.4 months. There was no sling (infection or extrusion) or ophthalmic (significant corneal compromise) complication after the surgery. Six patients (19%) underwent early (within 3 months) tightening of their slings for under correction. Three patients (10%) underwent late (> 39 months) tightening of their frontalis slings for recurrent ptosis after their initial surgery.

Conclusions: Primary bilateral silicone frontalis suspension for good LF ptosis secondary to OPMD appears to be an effective, safe treatment which gives symmetrical upper lid elevation. Early sling adjustment may be required to attain optimal eyelid height and late tightening for expectant loosening of the sling is safe and effective.
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http://dx.doi.org/10.1136/bjophthalmol-2011-300667DOI Listing
June 2012
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