25 YEARS IN

Developments in oculoplastic 25 surgery years

BY ROD MCNEIL

study of NHS practice few studies published were described as demonstrated significant encouraging, with transient ptosis the most patient-reported quality-of-life common reported complication. Aimprovements from commonly performed oculoplastic operations: Periocular hyaluronic acid filler entropion repair, ectropion repair, ptosis treatment for volume restoration repair and dacrocystorhinostomy (DCR) Hyaluronic acid is a glycosaminoglycan that [1]. In recent years, surgical and non- is present in body tissues, such as in skin surgical approaches to functional and and cartilage. It is able to combine with aesthetic oculoplastic surgery have water and swell when in gel form, causing advanced considerably with the adoption of a smoothing / filling effect. Sources of innovative minimally-invasive techniques, hyaluronic acid used in dermal fillers can be novel procedures and newer technologies. from bacteria or rooster combs (avian). In In an interview with Rod McNeil, Consultant some cases, hyaluronic acid used in dermal Ophthalmic and Oculoplastic Surgeon fillers is chemically modified (crosslinked) Mr Raman Malhotra, Corneoplastic Unit, to make it last longer in the body. The Queen Victoria NHS Trust, East Mr Raman Malhotra, effects of this material last approximately 12 Grinstead, UK, shares his experience in months but in the periorbital region can last Consultant Ophthalmic and Oculoplastic Surgeon, oculoplastic surgery and highlights practice Corneoplastic Unit, Queen Victoria Hospital NHS Trust, for three to five years. developments. , UK. “The use of hyaluronic acid fillers has “A major trend has been the introduction revolutionised the place for aesthetic of non-surgical options in oculoplastic eyelid surgery with the development of surgery,” explained Mr Malhotra. “The range rejuvenation strategies for lower eyelid of off-label uses of botulinum toxin injection bags,” continued Mr Malhotra. “Restoring (e.g. Botox, Allergan) in ophthalmology volume with filler treatment often achieves has continued to expand. In , a more youthful softer appearance than that botulinum toxin injection may be used for obtained following an eyebag operation. blepharospasm, therapeutic ptosis and “Hyaluronic acid filler is an effective watery eyes. Botulinum toxin injection is means of rejuvenating the upper eyelid and used to treat crocodile tears after facial is particularly successful in patients with palsy, but even more recently, patients who are not suitable for lacrimal surgery medial / generalised upper eyelid hollowing, often are treated with botulinum toxin or significant post-blepharoplasty upper injection to the lacrimal gland as a simple eyelid show [4]. Surgical experience further non-surgical method to reduce symptoms confirms the effective use of hyaluronic acid and maintain quality of life. This trend gel (Perlane) for tear-trough rejuvenation reflects a greater emphasis on maintaining as an alternative to lower eyelid surgery quality of life and improving the efficiency [5]. We published results of a consecutive and effectiveness of care by customising interventional case series (n=198 eyes of non-surgical interventions to better address 100 patients) using hyaluronic acid gel as a individual needs.” tear-trough filler over an 18-month period A report on experience and outcomes [5]. The gel was placed preperiosteally, using botulinum toxin injection for the deep to orbicularis, anterior to the inferior treatment of epiphora due to lacrimal orbital rim, with a mean volume of 0.59ml “The use of hyaluronic acid outflow obstruction found epiphora per eye. High patient satisfaction with completely resolved in one fifth, improved minimal complications was noted, with 8% fillers has revolutionised by up to 60-90% in a half and only ‘a little requesting additional hyaluronic acid gel the place for aesthetic better’ in a further fifth [2]. Temporary within three months. bruising and diplopia (lasting two weeks) “Tear-trough filling offers a minimally- eyelid surgery with was reported in 12% (2/17). A review by invasive, non-surgical alternative to Singh et al. noted that botulinum toxin blepharoplasty, with a reduced risk of the development of injection into the lacrimal gland is a complications and minimal recovery time. rejuvenation strategies for minimally invasive alternative in cases of We use a clear hyaluronic acid gel filler, to refractory epiphora secondary to lacrimal create volume and smoother contours. The lower eyelid bags.” drainage disorders [3]. Outcomes from the treatment comprises a series of micro-

Eye News | JUNE/JULY 2018 | VOL 25 NO 1 | www.eyenews.uk.com 25 YEARS IN OPHTHALMOLOGY

(A) (B) (C) (D)

Figure 1: The right nasal cavity view during endoscopic DCR with a large osteotomy, full marsupialisation of the lacrimal sac, creation of mucosal flaps and edge-to-edge mucosal apposition for maximum primary intention healing. No mucosa is excised. A mucosal incision with a small angled crescent blade is made on the lateral nasal wall, at the roof of the nose, at least 8mm above the insertion of the middle turbinate extending down to just below the body of the middle turbinate. A parallel vertical incision made 8mm anterior to this creates the tramline. A superior incision joining the two lines completes the anterior nasal flap (A). The flap is blunt dissected off bone and reflected inferiorly (B). Following reflection of the posterior nasal flap the maxillary bone is more widely exposed (C). Following lacrimal sac marsupialisation, all four flaps are positioned with edge-to-edge apposition. The probe is seen in between the lacrimal flaps (D). Anterior nasal flap (ANF); posterior nasal flap (PNF); anterior lacrimal flap (ALF); posterior lacrimal flap (PLF). injections along the line of the hollow. The and their use reflects the shift to temporary 80.3% overall, 81.5% in the non-visible iris area is then gently massaged to ensure even (absorbable) and reversible filler treatment sign (VIS) group and 78% in the VIS group. distribution of the gel. Results are instant as opposed to permanent fillers such as These outcomes are comparable to, and and last well over 12 months. polymethylmethacrylate beads. possibly better than, anterior approach “Restoring volume in the aging periorbital surgery in eyelids with severe ptosis and a area with filler treatment has transformed Ptosis correction VIS. oculoplastic practice, and led to a marked A review of surgical management of ptosis Favourable long-term outcomes have decrease in the need for endoscopic brow and the use of phenylephrine by British nonetheless been reported in patients lifts. Hollows can make brows extended Oculoplastic Surgery Society (BOPSS) undergoing anterior approach white and heavy, and filler treatment can also consultants showed that the majority line advancement for correction of effectively address brow temple volume.” of consultants will switch from anterior blepharoptosis [10]. As Lee and Yen note, an understanding to posterior approach surgery when the of the changes in the upper and lower phenylephrine test is strongly positive Posterior approach levatorpexy periocular area due to aging, the meticulous and will also perform bilateral surgery Posterior approach levatorpexy is a safe identification of focal hollows, and the when a contralateral ptosis is induced with and effective procedure for correction of precise delivery of filler to these areas can phenylephrine [8]. congenital ptosis. This minimally invasive smooth contours and restore a rejuvenated “Müller muscle-conjunctiva resection or surgical procedure involves exposing the periorbital area [6]. white line advancement have become two posterior surface of the levator muscle Periocular hyaluronic acid filler treatment of the most popular ways of performing through a transconjunctival approach. The is increasingly used as an alternative ptosis surgery using a posterior approach,” levator muscle is advanced and plicated to traditional surgical procedures for explained Mr Malhotra. “The predictability using a suture passed through its posterior non-aesthetic indications, including of correcting height is probably the same surface, partial-thickness, to tarsal plate lagophthalmos, eyelid malpositions and as an anterior approach, but the value of and tied on the skin. No tissue (conjunctiva, orbital volume deficiency [7]. Filler injections posterior approach ptosis surgery is the Muller’s muscle, levator) are excised [11]. are minimally invasive, repeatable, predictability of the contour.” “We undertook a retrospective review titratable and, depending on the product Antus et al. recently reported encouraging of levatorpexy for congenital ptosis with used, may be reversible. Filler treatment outcomes from a single-centre case reduced levator function and found may also be used for treating epipheron for series of patients with severe involutional posterior approach levatorpexy to be a volume loss as a non-surgical alternative aponeurotic ptosis undergoing posterior useful first-line choice for congenital ptosis to orbital implants. Hyaluronic acid fillers approach white-line advancement ptosis for all ranges of levator function [12]. It is provide an effective option for volume surgery [9]. Involving a mean postoperative popular among parents due to avoidance restoration with good efficacy and safety follow-up of 28 weeks, success rates were of a skin incision or any resection and no

Eye News | JUNE/JULY 2018 | VOL 25 NO 1 | www.eyenews.uk.com 25 YEARS IN OPHTHALMOLOGY

excision of tissue. In my mind, I cannot see a [14]. Endoscopic DCR is usually considered sequelae of acute inflammation [17]. justification for doing an anterior approach for patients who have been refractory to Antiproliferative immunosuppression for congenital ptosis repair when similar conventional treatment such as warm with azathioprine may possibly confer outcomes can be achieved using a posterior compresses, massage and probing of additional benefit in adults with active approach without the need for skin incision the nasolacrimal duct. If NLDO is left moderate-to-severe thyroid eye disease or tissue removal.” untreated, the symptoms persist and may be associated with proptosis or ocular distressing for the patient. motility restriction, according to results Platinum chains for upper eyelid Mr Malhotra continued: “Outcomes from from CIRTED, a multicentre, double-blind, loading a multicentre series demonstrate that DCR randomised controlled trial conducted at six “Over the past five years, our Corneoplastic is a safe operation, with an overall success UK centres [18]. Unit and Trust have expanded considerably rate of 90% for paediatric nasolacrimal duct “Perhaps the most exciting breakthrough and we are now one of the largest facial obstruction. Complete symptom resolution is the inhibition of the insulin-like nerve palsy services in the UK. The big was observed in 78% (90/116), significant growth factor I receptor (IGF-IR) as a new mantra is achieving effective closure and improvement in 12% (14/116), partial therapeutic strategy to attenuate the a natural appearance for eyelid and facial improvement in 2% (2/116) [15]. The main underlying autoimmune pathogenesis appearance. This is particularly important advantage of powered-type endoscopic of thyroid-associated ophthalmopathy,” for lower eyelid position, upper eyelid DCR over external DCR is faster recovery continued Mr Malhotra [19]. Teprotumumab appearance, and the shape of the eye. My rate without skin incision or muscle trauma. is a human monoclonal antibody inhibitor preference is to use platinum chains instead External DCR involving nasal incision is of IGF-IR that blocks the induction of of gold weights for upper eyelid loading associated with a slight risk of permanently proinflammatory cytokines. Results of in the management of lagophthalmos. weakening the blink. a multicentre, randomised, placebo- Platinum is denser than gold and therefore “There is still a role for external DCR in controlled trial demonstrated that less bulky. Moreover, platinum chains appropriately selected patients, for example teprotumumab was more effective than contour the eyelid better than gold weights.” in those who have a very narrow nasal placebo in reducing proptosis and the A review of late outcomes over a 10-year space and who are therefore unsuitable for Clinical Activity Score [19]. This may prove to period to 2013 showed that gold weights septoplasty, those not suitable for a general be a major change in the way active thyroid were associated with a higher rate of anaesthetic, or occasionally in those with eye disease will be managed in the near complications and twice more likely to canalicular disease. Other than that, an future. require long-term revision surgery compared endonasal approach to DCR is definitely the with platinum chains [13]. Gold weights procedure of choice and is now established Expansion of advanced had a significantly higher rate of weight practice. It has to be carried out according to oculoplastic cadaveric courses prominence and migration compared with the surgical principles of full sac exposure, Brow lifts, blepharoplasty, ptosis correction, platinum chains. complete osteotomy and creating nasal removal of benign eyelid or skin lesions and “There are now many more procedures flaps for primary intention mucosal healing. procedures to treat watering eyes are often available for achieving an aesthetically A practice audit of my endonasal DCR cases included on lists of procedures for which natural appearance. For facial palsy, performed over the previous two years Clinical Commissioning Groups do not recession of eyelid retractors helps to showed, in the absence of patients with routinely provide funding. According to the elevate the lower eyelid to address eyelid canalicular disease, a 100% success rate.” Royal College of Ophthalmologists, prompt malposition. Most of the time I am recessing Simultaneous nasal procedures may assessment and treatment is needed when retractors in ectropion surgery, particularly be required in a significant proportion of there is a likelihood of malignancy, or where for facial palsy. I would hope surgeons start patients undergoing endoscopic DCR [16]. A eyelid malposition threatens the ocular questioning that old dogma of advancing multicentre evaluation reported that 14.1% surface. There should also be provision or plicating retractors, as this contributes of a total cohort of 576 patients required a for treatment where brow droop or ptosis to retraction long term. Also, by using trans concomitant endonasal procedure during reduce the field of vision to the point where (or retro) caruncular medial eyelid fixation endoscopic DCR (11.9% required septoplasty, the ability to drive is compromised. approaches I also rarely need to perform 1.5% middle turbinate surgery and 0.34% Oculoplastic centres should be medial canthoplasties that create a rounded polypectomy). photographing all cases pre- and canthus. postoperatively in a standardised manner “We also have an established Thyroid eye disease and record baseline and post-treatment multidisciplinary approach for facial palsy, Most cases of thyroid eye disease visual acuity, said Mr Malhotra. “Many with a large physiotherapy support service are managed effectively in the active oculoplastic procedures now require helping transform patient outcomes inflammatory phase with systemic low priority applications for funding and through to rehabilitation and recovery and corticosteroids, and intervenous pulsed oculoplastic surgery case numbers overall preventing the development and impact of methyl predinisolone regimes have in NHS-funded care have declined as a synkinesis.” now transformed steroid management, result. Ophthalmic trainees often voice reducing steroid-related side effects in concerns that they are not getting sufficient Endoscopic lacrimal surgery these patients. Orbital decompression exposure to ptosis surgery cases for training Powered-endoscopic DCR is an endonasal- nowadays is commonly performed in the purposes. Training under supervision in approach procedure used to bypass the inactive phase for non-sight threatening ptosis surgery, while no longer a curriculum nasolacrimal duct. Endoscopic DCR indications such as exophthalmos-related requirement for general ophthalmologists, is is indicated for patients with lacrimal exposure or congestion in addition to sight- a good exercise in developing global skills in sac obstruction or nasolacrimal duct threatening compressive optic neuropathy. oculoplastics.” obstruction (NLDO). NLDO is common, Immunosuppression in the active Oculoplastic cadaveric courses offer and presenting symptoms include watering inflammatory phase of thyroid eye disease is advanced surgical training opportunities of the eye and dacryocystitis (infection) paramount in order to reduce the long-term for oculoplastic fellows, senior trainees

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with an interest in oculoplastic surgery and TAKE HOME MESSAGE consultants with an interest in oculoplastic surgery. The Manchester Oculoplastic, • Non-surgical options in oculoplastic surgery have expanded significantly. Lacrimal and Orbital Dissection Course, at • Restoring volume in the ageing periorbital area with hyaluronic acid gel filler Central Manchester University treatment has transformed oculoplastic practice. NHS Foundation Trust, is hugely popular and • Müller muscle-conjunctiva resection or white line advancement have become usually oversubscribed. It is one of the most two of the most popular ways of performing ptosis surgery using a posterior technologically advanced surgical skills approach. labs in the UK. The course is focused on • Posterior approach levatorpexy is a safe and effective procedure for correction of anatomy, dissection and surgical techniques, congenital ptosis. with a high expert faculty to delegate ratio. • Platinum chains contour the eyelid better than gold weights. Course contents include enucleation, • An endonasal approach to dacryocystorhinostomy is the procedure of choice. evisceration and exenteration, techniques • Inhibition of the insulin-like growth factor I receptor (IGF-IR) represents a that all trainees should master. Similar promising new therapeutic strategy for the management of active thyroid eye disease. courses exist nationwide, for example, the Coventry Ophthalmic Surgery Skills Cadaver Course at University Hospitals Coventry and Warwickshire NHS Trust. Details of these courses can be found on the BOPSS website (www.bopss.co.uk). 9. Antus Z, Salam A, Horvath E, Malhotra R. Outcomes for 18. Rajendram R, Taylor PN, Wilson VJ, et al. Combined severe aponeurotic ptosis using posterior approach immunosuppression and radiotherapy in thyroid eye white-line advancement ptosis surgery. Eye (Lond) disease (CIRTED): a multicentre, 2 × 2 factorial, double- References 2018;32(1):81-6. blind, randomised controlled trial. Lancet Diabetes 1. Smith HB, Jyothi SB, Mahroo OA, et al. Patient- 10. Schulz CB, Nicholson R, Penwarden A, Parkin B. Anterior Endocrinol 2018;6(4):299-309. reported benefit from oculoplastic surgery.Eye (Lond) approach white line advancement: technique and long- 19. Smith TJ, Kahaly GJ, Ezra DG. Teprotumumab for 2012;26(11):1418-23. term outcomes in the correction of blepharoptosis. Eye thyroid-associated ophthalmopathy. N Engl J Med 2. Ziahosseini K, Al-Abbadi Z, Malhotra R. Botulinum (Lond) 2017;31(12):1716-23. 2017;376(18):1748-61. toxin injection for the treatment of epiphora in lacrimal 11. Al-Abbadi Z, Sagili S, Malhotra R. Outcomes of posterior- outflow obstruction.Eye (Lond) 2015;29(5):656-61. approach ‘levatorpexy’ in congenital ptosis repair. Br J 3. Singh S, Ali MJ, Paulsen F. A review on use of botulinum Ophthalmol 2014;98(12):1686-90. toxin for intractable lacrimal drainage disorders. Int 12. Feldman I, Brusasco L, Malhotra R. Improving outcomes Ophthalmol 2017 [Epub ahead of print]. of posterior approach levatorpexy for congenital ptosis 4. Morley AM, Taban M, Malhotra R, Goldberg RA. Use with reduced levator function. Ophthal Plast Reconstr AUTHOR of hyaluronic Acid gel for upper eyelid filling and Surg 2018 [Epub ahead of print]. contouring. Ophthal Plast Reconstr Surg 2009;25(6): 13. Siah WF, Nagendran S, Tan P, et al. Late outcomes of gold 440-4. weights and platinum chains for upper eyelid loading. Br J Ophthalmol 2018;102(2):164-8. 5. Morley AM, Malhotra R. Use of hyaluronic acid filler for tear-trough rejuvenation as an alternative to 14. National Institute for Health and Care Excellence. lower eyelid surgery. Ophthal Plast Reconstr Surg Endoscopic dacryocystorhinostomy Interventional procedures guidance 113. 2005. https://www.nice.org. 2011;27(2):69-73. uk/guidance/ipg113 Last accessed May 2018. 6. Lee S, Yen MT. Nonsurgical rejuvenation of the eyelids 15. Chan W, Wilcsek G, Ghabrial R, et al. Pediatric endonasal with hyaluronic acid gel injections. Semin Plast Surg dacryocystorhinostomy: A multicenter series of 116 2017;31(1):17-21. cases. Orbit 2017;36(5):311-6. 7. Tan P, Kwong TQ, Malhotra R. Non-aesthetic indications 16. Figueira E, Al Abbadi Z, Malhotra R, et al. Frequency for periocular hyaluronic acid filler treatment: a review. of simultaneous nasal procedures in endoscopic Rod McNeil, Br J Ophthalmol 2017 [Epub ahead of print]. dacryocystorhinostomy. Ophthal Plast Reconstr Surg Independent Journalist and Consultant 8. Mota PM, Norris JH. Review on surgical management of 2014;30(1):40-3. E: [email protected] ptosis and the use of phenylephrine: A national survey 17. Verity DH, Rose GE. Acute thyroid eye disease (TED): of British Oculoplastic Surgery Society (BOPSS) UK principles of medical and surgical management. Eye Consultants. Orbit 2016;35(6):339-42. (Lond) 2013;27(3):308-19.

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