Ophthalmic Plastics and Reconstructive Surgery

OBJECTIVE:
The authors noted that many of their patients with the floppy eyelid syndrome had a unique finding of eyelash ptosis and lashes that curled in many directions. The purpose of this study was to determine how many of these patients had this physical finding.

DESIGN:
Case series.

PARTICIPANTS:
The authors retrospectively reviewed the charts and photographs of eight consecutive patients with the floppy eyelid syndrome. They also examined four new patients with floppy eyelid syndrome.

INTERVENTION:
Surgical tightening of 13 upper lids was performed in 9 patients.

MAIN OUTCOME MEASURES:
Relief of symptoms and normalization of eyelash position.

RESULTS:
All of the 12 consecutive patients with floppy eyelid syndrome demonstrated eyelash ptosis with loss of eyelash parallelism. All patients treated with surgical shortening of the affected eyelid were asymptomatic at follow-up.

CONCLUSIONS:
The authors have identified a new physical finding in the floppy eyelid syndrome: eyelash ptosis with loss of eyelash parallelism. The authors believe that this new physical finding is characteristic of the floppy eyelid syndrome, and will aid in the timely diagnosis and treatment of this sometimes obscure syndrome.

Authors' abstract, Ophthalmol
Department of Ophthalmology,
West Virginia University,
Morgantown, WV

Ophthalmic Plastics and Reconstructive Surgery

OBJECTIVE: This study examines the long-term follow-up of all patients treated with doxorubicin injections in the eyelids. DESIGN: Nonrandomized clinical trial.

PARTICIPANTS: Eighteen patients with blepharospasm (12 female; 6 male) and nine patients with hemifacial spasm (4 female; 5 male).

INTERVENTION: Eyelids were repeatedly injected at intervals of 10 or more weeks until the spasms were ameliorated or the patient requested discontinuation.

MAIN OUTCOME MEASURE: Clinical "cure" defined as sufficient symptomatic relief to defer further paralytic treatment. All patients have been followed for more than 1 year since the last injection.

RESULTS: Nine of 18 patients with blepharospasm completed the full course of treatment and are considered "cured" for more than 1 year (median, 3 years; maximum, 6 years). Six of nine patients with hemifacial spasm completed treatment. Five of these six patients are considered "cures," lasting for more than 4.5 to 6 years. Two additional patients, one with blepharospasm and one with hemifacial spasm, had significant amelioration and were untreated for more than 3 years after the last doxorubicin injection, but occasionally request botulinum toxin supplementation. The minimum effective dose per treated eyelid ranged from 1.0 to 4.2 mg (median, 2.25 mg). The treatment-related discontinuations and complications were related to skin inflammation. Four of the 14 "cured" patients required some surgical "touch-up" on 1 eyelid. However, all the patients who completed treatment are either cured or have had significant amelioration of symptoms.

CONCLUSIONS: Doxorubicin chemomyectomy is an evolving technique and an effective treatment for essential blepharospasm and hemifacial spasms symptomatically localized to the eyelids. Sixteen (59%) of the initial series of 27 patients completed the treatment. Of these, all are apparently cured or their symptoms significantly ameliorated. In the future, an even higher proportion would be expected to complete the treatment due to improvements in the selection criteria and treatment protocols developed during this 8-year trial. While the treatment appears to be reasonably safe compared with surgical myectomy in its present form, the authors are continuing to explore and introduce additional cotreatments to minimize the acute skin changes and maximize the long-term effectiveness of the myectomy.

Authors' abstrat, Ophthalmol
University of Minnesota Medical School,
Minneapolis, MN

Ophthalmic Plastics and Reconstructive Surgery

The main thrust of this paper is to make us aware that fibrous dysplasia is as much an adult disease as a pediatric disease. The authors review 20 patients, 9 less than 18 years old and 11 over 18 years old at presentation. These two age groups are separated in the paper and compared to each other.

The introduction gives an excellent overview and summary of fibrous dysplasia. It also makes the point that it is generally characterized as a disease of children and adolescents.

METHODS
The Methods section tells us that they reviewed twenty charts of patients with biopsy proven fibrous dysplasia from the records of their department from 1967 through to 1996. It is not stated whether this was the whole number of patients with this condition seen over this time, and if not, if the process of picking out these particular charts from all the fibrous dysplasia charts was random. So we are left with uncertainty as to what proportion of fibrous dysplasia truly occurs in adults as opposed to children. Of the 20 charts 13 had radiologic charts for review.

RESULTS
The Results section contains Table 1, which provides a good summary of the chart findings for each of the cases. It is noted that facial asymmetry is the most common presenting complaint, followed by vision loss. Pain was uncommon (Figure 1); the most common presenting sign was a cheek mass (Figure 2). Review of the 13 radiologic files shows that suture lines were crossed by the disease more often than not, and that the maxilla was the most commonly involved facial bone (Figure 2). Also it is noted that almost all the radiology showed that the bone involved had a pagetoid appearance. The authors then go on to present eight of the cases, which clearly illustrate the wide spectrum of presentations and pathology possible.

DISCUSSION
In the Discussion the authors emphasize that their observation of a significant number of adult patients with ophthalmic complications of fibrous dysplasia is in agreement and supports the recent trend to consider the disease a life span disease and not pediatric solely. They give a good discussion of the possible causes of visual loss in the disease with a good review of the literature. They recommend both CT and MRI to evaluate the etiology.

The authors note that their finding that the maxilla was most often involved contrasts with Rootman et al who found the frontal bone was involved and attribute this to possible referral bias. They also note that they also had a contrast with Rootman et al in that their radiological findings showed a pagetoid appearance whereas Rootman et al found a 50/50 distribution between ground glass and pagetoid appearances. The authors then discuss the radiologic differential diagnosis from meningioma and conclude that MRI is the most useful method of distinction.

The concluding paragraphs are tightly written and summarize the paper well.

Mounir Bashour, MD, CM
Montreal, Canada