Aesthetic surgery journal / the American Society for Aesthetic Plastic surgery, 2015
Botulinum toxin type A (BTX-A; Botox) is supplied as individual freeze-dried preparations that sh... more Botulinum toxin type A (BTX-A; Botox) is supplied as individual freeze-dried preparations that should be administered within 24 hours after reconstitution. To avoid wasting this expensive drug, some physicians have resorted to storing vials of reconstituted BTX-A beyond the recommended duration. However, there is insufficient evidence to indicate that the sterility of previously reconstituted BTX-A is maintained during storage. The authors sought to determine whether bacterial and/or fungal proliferation occurred in vials of reconstituted BTX-A and subsequent storage of the remaining solution under refrigeration for 4 weeks. A portion of the contents of 88 consecutive 100-U vials of BTX-A was administered aseptically to 108 patients for essential blepharospasm, hemifacial spasm, or facial rejuvenation. The vials were then stored for 4 weeks in a refrigerator, after which the contents were transferred to various media (blood agar, chocolate agar, Sabouraud agar, brain-heart infusion ...
Aesthetic surgery journal / the American Society for Aesthetic Plastic surgery, 2015
Botulinum toxin type A (BTX-A; Botox) is supplied as individual freeze-dried preparations that sh... more Botulinum toxin type A (BTX-A; Botox) is supplied as individual freeze-dried preparations that should be administered within 24 hours after reconstitution. To avoid wasting this expensive drug, some physicians have resorted to storing vials of reconstituted BTX-A beyond the recommended duration. However, there is insufficient evidence to indicate that the sterility of previously reconstituted BTX-A is maintained during storage. The authors sought to determine whether bacterial and/or fungal proliferation occurred in vials of reconstituted BTX-A and subsequent storage of the remaining solution under refrigeration for 4 weeks. A portion of the contents of 88 consecutive 100-U vials of BTX-A was administered aseptically to 108 patients for essential blepharospasm, hemifacial spasm, or facial rejuvenation. The vials were then stored for 4 weeks in a refrigerator, after which the contents were transferred to various media (blood agar, chocolate agar, Sabouraud agar, brain-heart infusion ...
To analyze the ocular wavefront aberrations in patients with facial dystonia treated with botulin... more To analyze the ocular wavefront aberrations in patients with facial dystonia treated with botulinum toxin A. Patients with benign essential blepharospasm and hemifacial spasm in activity underwent slit lamp examination and bilateral wavefront analysis under pharmacologic mydriasis using Alcon LADARvision wavefront aberrometry system. After that, all patients were treated with botulinum toxin A injections performed by the same ophthalmologist. After one month, the wavefront analysis was performed in the same way and by the same examiner. The main outcome measure was the change in ocular wavefront aberrations. Paired T-test was used to compare pre and post-injection numeric wavefront values. From a total of 11 patients enrolled in this study, 6 (54.5%) had essential blepharospasm and 5 (45.5%) had hemifacial spasm. The fellow eyes of patients with hemifacial spasm were not included, totalizing 17 eyes with spasm. Eight patients were female (72.7%) and three were male (27.3%), the male...
Ectropion is characterized by the eversion of the eyelid margin and the consequent exposure of th... more Ectropion is characterized by the eversion of the eyelid margin and the consequent exposure of the conjunctiva and cornea. The shortening of the anterior lamella of the lid causes cicatricial ectropion. We described a case of skin pathology causing cicatricial ectropion. The case is about a 68-year-old woman with a 2-year history of psoriatic arthritis. She complained of eyelid tearing and redness for two years. Due to the psoriasis, she presented a very dry skin, also in the periocular region, resulting in cicatricial ectropion. A skin graft was indicated to correct the eyelid malposition. Careful investigation should be performed in patients who have a skin disease that can lead to cicatricial ectropion.
Ophthalmic Plastic and Reconstructive Surgery, 2013
The rate at which the orbit matures is not well-documented. Limiting this pursuit are the difficu... more The rate at which the orbit matures is not well-documented. Limiting this pursuit are the difficulties inherent in measuring orbital volumes accurately. This study compared 3 common methods of determining orbital volume and sought to identify an accurate, practical manner for doing so. The volume of 1 orbit of 8 human cadaver heads was independently measured using 3 different methods: 1) CT was performed, and images were analyzed with 3-dimensional (3D) volumetric software; 2) The same orbits were then exenterated and a silicone cast was taken. The cast volumes were measured by water displacement; 3) The orbits were then filled with 1-mm glass beads that were transferred to a graduated cylinder where their volume was determined. The data were analyzed statistically. Intraobserver agreements were good for both beads and casts. Interobserver agreements were good for both beads and CT (p > 0.05). Values obtained using the bead method were equal to values obtained using the cast method (p > 0.05). However, agreement between direct (orbital fillers and casts) and indirect measurements (radiographic techniques) was not satisfactory (p < 0.05). Independent of method, determining orbital volume is inherently difficult owing to the hyperbolic parabola that is the orbit entrance; all methods require estimation. Glass beads and casts yielded more reproducible values but can only be used in cadavers. CT measurement is prone to error due to the variability of methodologies used but allows access to enormous testing populations. Interstudy comparison is currently not possible. CT volumetric software with strict universal standards for estimating the anterior limit of the orbit appears to be the best method of studying human orbital volumes.
To describe the results of a conservative and reversible technique for the treatment of progressi... more To describe the results of a conservative and reversible technique for the treatment of progressive myopathic blepharoptosis in cases when surgery is not indicated, using octyl-2-cyanoacrylate liquid bandage. Ten consecutive patients with progressive myopathic blepharoptosis were studied. Octyl-2-cyanoacrylate liquid bandage was applied to the upper eyelid to create a deeper eyelid crease. Margin reflex distance, photographs, and visual fields were obtained prior to and after treatment. All patients described a better appearance after application of the product, and none had an allergic response. All cases had an increase in the margin reflex distance and improvement in visual fields. Octyl-2-cyanoacrylate liquid bandage is an alternative method that is simple, safe, and effective in the management of severe blepharoptosis. Moreover, it can be used in patients without systemic conditions or those who are unwilling to undergo a surgical procedure.
Ophthalmic Plastic and Reconstructive Surgery, 2013
Immunohistochemical studies have begun to advance knowledge regarding the pathogenesis of vascula... more Immunohistochemical studies have begun to advance knowledge regarding the pathogenesis of vascular anomalies in many anatomical regions. However, the immunohistochemical features of most orbital tumors have been overlooked. Therefore, a comparative immunohistochemical study of a series of the 2 most common orbital vascular lesions- infantile hemangioma (IH) and encapsulated cavernous venous lesion (ECVL), the latter also termed cavernous hemangioma or venous malformation-was undertaken. Twenty surgically excised orbital tumors diagnosed clinically and histopathologically as IHs (10 cases) or "cavernous hemangioma" (10 cases) were evaluated pathologically and immunohistochemically using hematoxylin and eosin, Alcian blue, Masson trichrome, GLUT-1, CD31, CD34, D2-40, smooth muscle actin (SMA), desmin, and Ki-67 probes. All cases reacted strongly with the traditional blood vessel endothelial markers CD31 and CD34 and were negative for D2-40, a selective marker for lymphatic endothelium. All IH were positive for GLUT-1, and all ECVL were negative for GLUT-1. In IH, SMA (but not desmin) stained a monolayer of pericytes and in ECVL multilaminar smooth muscle vascular mural cells and intravascular (interstitial) stromal cells. Nuclear Ki-67 immunostaining was strongly positive in IH (average of 16.3%) and close to zero in ECVL. Immunophenotypic results for ECVL and IH demonstrated no overlapping staining patterns. Infantile hemangioma had the classical architecture of capillaries. Because of the constant presence of mural smooth muscle, it was concluded that ECVL is an accurate and descriptive term. However, desmin negativity in ECVL indicates myofibroblastic differentiation rather than full-fledged smooth muscle differentiation. Infantile hemangioma may display ectatic channels as the lesion ages but does not acquire multilaminar smooth muscle walls. Its pericytes lack cytoplasmic filaments and desmin reactivity but are SMA-positive because of the presence of poorly polymerized actin in the cytosol. In IH, Ki-67 positivity was observed in the endothelial cells of the solid and more ectatic regions. In contrast, the virtual absence of Ki-67 positivity in ECVL lends further support for the interpretation that it is more closely related to a malformation than a benign neoplasm.
Ophthalmic Plastic and Reconstructive Surgery, 2013
Orbital osteotomy risks injury to the eyeball and orbit soft tissues. Used extensively in oral an... more Orbital osteotomy risks injury to the eyeball and orbit soft tissues. Used extensively in oral and maxillofacial surgery, piezoelectric technology offers a greater margin of safety than traditional bone cutting instruments. The authors describe the novel use of this system in a variety of orbital surgeries. This interventional case series was performed in accordance with institutional review board regulations. The medical records of all patients who had undergone orbital surgery using the piezoelectric blade at 3 institutions were reviewed. Indication for surgery, gender, age, duration of follow up, intraoperative complications, surgical result, and postoperative course was recorded. Sixteen patients underwent surgery on 18 orbits using the piezoelectric system between August 2011 and June 2012. Surgeries performed included orbital decompression (8), lateral orbitotomy (5), cranio-orbitotomy (4), and external dacryocystorhinostomy (1). Eight were female and 8 were male patients. Mean age was 55 years old (standard deviation 15 years). Mean follow up was 82 days. The osteotomy created by the blade was narrow and smooth in every case. The surgeons uniformly appreciated the precision and safety of the instrument compared with traditional electric saw blades. There were no soft tissue lacerations or intraoperative complications and reconstructions were uniformly uneventful. Postoperative healing was rapid with no unexpected inflammation, and no palpable bony defects were appreciated in the reconstructed cases. Because it does not cut soft tissue and cuts a narrow trough, the self-irrigating piezoelectric saw blade appears safer and more precise than traditional electric saw blades in and around the orbit.
Ophthalmic Plastic and Reconstructive Surgery, 2013
Infants with orbital hemangiomas and vascular malformations often develop expanded orbits or regi... more Infants with orbital hemangiomas and vascular malformations often develop expanded orbits or regional hyperostosis. Treatment in these cases depends, in part, on the stage of orbital development at the time of intervention; yet, orbital development with respect to age is not well-known. The authors sought to determine the rate of orbital development and the age of orbital maturation in a single ethnic population. Skeletons recovered in North America and housed at the Peabody Museum of Archaeology and Ethnology, Harvard University, were inspected. The age of specimen was determined by dentition. Orbital volume was measured using 1-mm glass beads and a graduated cylinder. Linear measurements were taken with calipers and paper rulers. The measurements were plotted against age, and statistical analysis was performed. Relevant literature was reviewed. Of the hundreds of skeletons examined, 42 were sufficiently intact for orbital measurement. The specimens represented a period of up to 1000 years. Thirty-two were pediatric (defined prenatal to 18 years) and 10 were adults. Mean adult orbital volume was 26.2 ml. Based on the regression analysis, 60% of adult orbital volume was achieved at 4.35 years, 75% at 9.36 years, and 90% at 17.13 years of age. Linear dimensions progressively increased with age. This largest direct-measure study of pediatric orbital volume suggests that orbital growth continually decelerates from birth until maturity at 22 years. With 50% of orbital growth occurring by 16 months of age, surgeons removing periocular vascular anomalies after that age should consider concurrent skeletal management.
To determine disease severity in glaucoma patients who presented to a tertiary care service for t... more To determine disease severity in glaucoma patients who presented to a tertiary care service for the first time and to determine the prevalence of different types of glaucoma. Retrospective analysis of data of patients referred to the Glaucoma Service at the Santa Casa de Misericórdia de São Paulo, Brazil in 2007. A complete chart review from 448 patients was done; data regarding age, gender, ethnicity, family history, duration of the disease, previous treatment, best corrected visual acuity, cup-to-disc ratio, intraocular pressure, diagnosis and treatment were collected. Glaucoma was diagnosed by the presence of typical optic disk abnormalities, disregarding IOP values. 52.3% of patients presented visual acuity less than or equal to 20/200 and 67.7% presented cup-to-disc ratio between 0.8 and 1.0 in the worse-seeing eye; 13.4% of patients were considered legally blind. Primary open angle glaucoma was the most prevalent form of glaucoma (54.2%, 95% CI: 48.5-59.5) and chronic angle closure glaucoma was the second most frequent (11.5%, 95% CI: 8.25-15.5). A considerable rate of patients (almost 60% in the better-seeing eye and 70% in the worse-seeing eye) presented with advanced glaucoma. Strategies that create conditions for early diagnosis are deemed necessary to reduce glaucoma-related blindness in the Brazilian population.
To analyze the influence of thermal partial punctal occlusion on the ocular surface of dry eye re... more To analyze the influence of thermal partial punctal occlusion on the ocular surface of dry eye related to Sjögren syndrome. Thirty-seven eyes of 19 patients (3 male and 16 female; 49.11 ± 14.33 years old) with keratoconjunctivitis sicca were enrolled in this study. Superior and inferior partial occlusion were performed in both eyes under topical anesthesia using thermal cautery with a sterile tip to obtain lacrimal punctum smaller than 0.5 mm. Schirmer I, break-up-time, diameter of lacrimal puncta, corneal fluorescein, and rose Bengal staining scores were analyzed before and after 24 weeks and after 24 months of the procedure. All measurements were performed under controlled climate. The average lacrimal punctum diameter before the procedure was 0.65 ± 0.134 mm. All lacrimal puncta were successfully reduced to less than 0.5 mm after 4 weeks of the procedure. The average Schirmer I test values improved statistically after 24 weeks and maintained stable after 24 months. Average break-up-time, rose Bengal, and fluorescein staining score values improved statistically after 24 weeks and improved even more after 24 months. Average Schirmer I test, break-up-time, rose Bengal, and fluorescein staining scores showed significant improvement (p < 0.0001) after 24 months of partial thermal punctal occlusion. Our study showed that reducing the punctum diameter to 0.5 mm can improve vital staining scores, break-up-time, and Schirmer I test in dry eye related to Sjögren syndrome.
To evaluate the effects of oral azithromycin in patients with posterior blepharitis. Twenty-six e... more To evaluate the effects of oral azithromycin in patients with posterior blepharitis. Twenty-six eyes of 13 patients with posterior blepharitis diagnosed by a qualified ophthalmologist were enrolled in this study. Patients were instructed to use oral azithromycin 500 mg per day for 3 days in 3 cycles with 7-day intervals. Subjective clinical outcomes were graded and scored 1 day before and 30 days after the end of the treatment (53 days after initiating the treatment) based on severity scores of: (1) eyelid debris; (2) eyelid telangiectasia; (3) swelling of the eyelid margin; (4) redness of the eyelid margin; and (5) ocular mucus secretion. For the assessment of global efficacy, patients were asked by the investigator to rate the subjective symptoms (eyelid itching, ocular itching, eyelid hyperemia, ocular hyperemia, ocular mucus secretion, photophobia, foreign body sensation, and dry eye sensation) on a scale of 0 (no symptoms) to 5 (severe symptoms). Break-up time, Schirmer I test, corneal fluorescein staining score, and rose bengal staining score were also performed in all patients. All clinical outcomes scoring showed statistically significant improvement after oral azithromycin, except for eyelid swelling. Average subjective symptom grading improved statistically after treatment with oral azithromycin, except for eyelid hyperemia, photophobia, and foreign body sensation. Average tear film break-up time values showed statistically significant improvement after the treatment with oral azithromycin. No statistically significant improvement was observed on average values of Schirmer I test, corneal fluorescein staining score, and rose bengal staining score. The combination of multiple clinical parameters shown in this study supports the clinical efficacy of pulsed oral azithromycin therapy for the management of posterior blepharitis.
To evaluate the use of octyl-2-cyanoacrylate liquid bandage (Band-Aid liquid, Ethicon, Johnson &a... more To evaluate the use of octyl-2-cyanoacrylate liquid bandage (Band-Aid liquid, Ethicon, Johnson & Johnson, New Jersey, USA) as a temporary treatment in patients awaiting surgical repair for involutional entropion. Thirteen patients (15 eyelids) with involutional entropion were evaluated while they waited for surgical intervention. The lids were repositioned by the application of octyl-2-cyanoacrylate liquid bandage in the malar fold. Patients were followed-up at days 1, 7 and 15. Assessment and duration of correction were recorded. All the patients presented successful correction at day 1, with significant improvements in signs and symptoms. The mean duration of action of the octyl2-cyanoacrylate liquid bandage was three days. No ocular or dermatological reactions were noted. Octyl-2-cyanoacrylate liquid bandage showed to be a simple, safe and effective option to temporarily treat involutional entropion, while patients waited for surgical intervention.
Volume loss and muscular hyperactivity are two major components of the aging process that contrib... more Volume loss and muscular hyperactivity are two major components of the aging process that contribute to the formation of the folds and wrinkles. Tear trough deformity is one of the most difficult depressions to correct surgically. The authors evaluate the results of periorbital filling with hyaluronic acid (HA) in a small series of patients. Between June 2008 and December 2009, 25 patients were treated with HA to correct tear trough deformities. The HA was administered into the preperiosteal tissues with a serial puncture technique and approximately 0.1 mL was injected at each pass. Each patient's before and after photographs were reviewed by three surgeons; to objectively assess the outcomes, a quantitative scale was used to grade the pre- and postinjection results. The significance of subjective aesthetic evaluation of the photographs was evaluated with the Mann-Whitney U-test. Differences were regarded as significant if probabilities were less than 0.05. The mean (SD) volume per side needed to achieve correction was 0.54 (0.27) mL on the right and 0.61 (0.30) mL on the left. Complications included some degree of bruising, erythema, and local swelling. Most patients (88%) had cosmetic improvement according to the independent evaluation. All patients were very satisfied with their results. During the course of the study, the authors determined that the ideal candidates for this treatment are young, with thick skin and a definite hollow.
Antibiotic stewardship is important in controlling resistance, adverse reactions, and cost. The l... more Antibiotic stewardship is important in controlling resistance, adverse reactions, and cost. The literature regarding antibiotic use for eyelid surgery is lacking. To determine standard care and assess factors influencing antibiotic prescribing practices for eyelid surgery. A survey study was conducted from February 2, 2014, to March 24, 2014. The survey was distributed to 2397 oculoplastic surgeons in private and academic oculoplastic surgery practices in 43 countries. All surgeons were members of ophthalmic plastic and reconstructive surgery societies. Data were analyzed by geographic location. Linear regression was performed to quantify contributions to rates of prescribing postoperative antibiotics for routine eyelid surgical procedures. Rates of prescribing prophylactic intravenous, oral, and topical antibiotics as well as factors that influence surgeons' prescribing practices. A total of 782 responses were received from 2397 surgeons (average response rate, 36.7%; 2.5% marg...
Aesthetic surgery journal / the American Society for Aesthetic Plastic surgery, 2015
Botulinum toxin type A (BTX-A; Botox) is supplied as individual freeze-dried preparations that sh... more Botulinum toxin type A (BTX-A; Botox) is supplied as individual freeze-dried preparations that should be administered within 24 hours after reconstitution. To avoid wasting this expensive drug, some physicians have resorted to storing vials of reconstituted BTX-A beyond the recommended duration. However, there is insufficient evidence to indicate that the sterility of previously reconstituted BTX-A is maintained during storage. The authors sought to determine whether bacterial and/or fungal proliferation occurred in vials of reconstituted BTX-A and subsequent storage of the remaining solution under refrigeration for 4 weeks. A portion of the contents of 88 consecutive 100-U vials of BTX-A was administered aseptically to 108 patients for essential blepharospasm, hemifacial spasm, or facial rejuvenation. The vials were then stored for 4 weeks in a refrigerator, after which the contents were transferred to various media (blood agar, chocolate agar, Sabouraud agar, brain-heart infusion ...
Aesthetic surgery journal / the American Society for Aesthetic Plastic surgery, 2015
Botulinum toxin type A (BTX-A; Botox) is supplied as individual freeze-dried preparations that sh... more Botulinum toxin type A (BTX-A; Botox) is supplied as individual freeze-dried preparations that should be administered within 24 hours after reconstitution. To avoid wasting this expensive drug, some physicians have resorted to storing vials of reconstituted BTX-A beyond the recommended duration. However, there is insufficient evidence to indicate that the sterility of previously reconstituted BTX-A is maintained during storage. The authors sought to determine whether bacterial and/or fungal proliferation occurred in vials of reconstituted BTX-A and subsequent storage of the remaining solution under refrigeration for 4 weeks. A portion of the contents of 88 consecutive 100-U vials of BTX-A was administered aseptically to 108 patients for essential blepharospasm, hemifacial spasm, or facial rejuvenation. The vials were then stored for 4 weeks in a refrigerator, after which the contents were transferred to various media (blood agar, chocolate agar, Sabouraud agar, brain-heart infusion ...
To analyze the ocular wavefront aberrations in patients with facial dystonia treated with botulin... more To analyze the ocular wavefront aberrations in patients with facial dystonia treated with botulinum toxin A. Patients with benign essential blepharospasm and hemifacial spasm in activity underwent slit lamp examination and bilateral wavefront analysis under pharmacologic mydriasis using Alcon LADARvision wavefront aberrometry system. After that, all patients were treated with botulinum toxin A injections performed by the same ophthalmologist. After one month, the wavefront analysis was performed in the same way and by the same examiner. The main outcome measure was the change in ocular wavefront aberrations. Paired T-test was used to compare pre and post-injection numeric wavefront values. From a total of 11 patients enrolled in this study, 6 (54.5%) had essential blepharospasm and 5 (45.5%) had hemifacial spasm. The fellow eyes of patients with hemifacial spasm were not included, totalizing 17 eyes with spasm. Eight patients were female (72.7%) and three were male (27.3%), the male...
Ectropion is characterized by the eversion of the eyelid margin and the consequent exposure of th... more Ectropion is characterized by the eversion of the eyelid margin and the consequent exposure of the conjunctiva and cornea. The shortening of the anterior lamella of the lid causes cicatricial ectropion. We described a case of skin pathology causing cicatricial ectropion. The case is about a 68-year-old woman with a 2-year history of psoriatic arthritis. She complained of eyelid tearing and redness for two years. Due to the psoriasis, she presented a very dry skin, also in the periocular region, resulting in cicatricial ectropion. A skin graft was indicated to correct the eyelid malposition. Careful investigation should be performed in patients who have a skin disease that can lead to cicatricial ectropion.
Ophthalmic Plastic and Reconstructive Surgery, 2013
The rate at which the orbit matures is not well-documented. Limiting this pursuit are the difficu... more The rate at which the orbit matures is not well-documented. Limiting this pursuit are the difficulties inherent in measuring orbital volumes accurately. This study compared 3 common methods of determining orbital volume and sought to identify an accurate, practical manner for doing so. The volume of 1 orbit of 8 human cadaver heads was independently measured using 3 different methods: 1) CT was performed, and images were analyzed with 3-dimensional (3D) volumetric software; 2) The same orbits were then exenterated and a silicone cast was taken. The cast volumes were measured by water displacement; 3) The orbits were then filled with 1-mm glass beads that were transferred to a graduated cylinder where their volume was determined. The data were analyzed statistically. Intraobserver agreements were good for both beads and casts. Interobserver agreements were good for both beads and CT (p > 0.05). Values obtained using the bead method were equal to values obtained using the cast method (p > 0.05). However, agreement between direct (orbital fillers and casts) and indirect measurements (radiographic techniques) was not satisfactory (p < 0.05). Independent of method, determining orbital volume is inherently difficult owing to the hyperbolic parabola that is the orbit entrance; all methods require estimation. Glass beads and casts yielded more reproducible values but can only be used in cadavers. CT measurement is prone to error due to the variability of methodologies used but allows access to enormous testing populations. Interstudy comparison is currently not possible. CT volumetric software with strict universal standards for estimating the anterior limit of the orbit appears to be the best method of studying human orbital volumes.
To describe the results of a conservative and reversible technique for the treatment of progressi... more To describe the results of a conservative and reversible technique for the treatment of progressive myopathic blepharoptosis in cases when surgery is not indicated, using octyl-2-cyanoacrylate liquid bandage. Ten consecutive patients with progressive myopathic blepharoptosis were studied. Octyl-2-cyanoacrylate liquid bandage was applied to the upper eyelid to create a deeper eyelid crease. Margin reflex distance, photographs, and visual fields were obtained prior to and after treatment. All patients described a better appearance after application of the product, and none had an allergic response. All cases had an increase in the margin reflex distance and improvement in visual fields. Octyl-2-cyanoacrylate liquid bandage is an alternative method that is simple, safe, and effective in the management of severe blepharoptosis. Moreover, it can be used in patients without systemic conditions or those who are unwilling to undergo a surgical procedure.
Ophthalmic Plastic and Reconstructive Surgery, 2013
Immunohistochemical studies have begun to advance knowledge regarding the pathogenesis of vascula... more Immunohistochemical studies have begun to advance knowledge regarding the pathogenesis of vascular anomalies in many anatomical regions. However, the immunohistochemical features of most orbital tumors have been overlooked. Therefore, a comparative immunohistochemical study of a series of the 2 most common orbital vascular lesions- infantile hemangioma (IH) and encapsulated cavernous venous lesion (ECVL), the latter also termed cavernous hemangioma or venous malformation-was undertaken. Twenty surgically excised orbital tumors diagnosed clinically and histopathologically as IHs (10 cases) or "cavernous hemangioma" (10 cases) were evaluated pathologically and immunohistochemically using hematoxylin and eosin, Alcian blue, Masson trichrome, GLUT-1, CD31, CD34, D2-40, smooth muscle actin (SMA), desmin, and Ki-67 probes. All cases reacted strongly with the traditional blood vessel endothelial markers CD31 and CD34 and were negative for D2-40, a selective marker for lymphatic endothelium. All IH were positive for GLUT-1, and all ECVL were negative for GLUT-1. In IH, SMA (but not desmin) stained a monolayer of pericytes and in ECVL multilaminar smooth muscle vascular mural cells and intravascular (interstitial) stromal cells. Nuclear Ki-67 immunostaining was strongly positive in IH (average of 16.3%) and close to zero in ECVL. Immunophenotypic results for ECVL and IH demonstrated no overlapping staining patterns. Infantile hemangioma had the classical architecture of capillaries. Because of the constant presence of mural smooth muscle, it was concluded that ECVL is an accurate and descriptive term. However, desmin negativity in ECVL indicates myofibroblastic differentiation rather than full-fledged smooth muscle differentiation. Infantile hemangioma may display ectatic channels as the lesion ages but does not acquire multilaminar smooth muscle walls. Its pericytes lack cytoplasmic filaments and desmin reactivity but are SMA-positive because of the presence of poorly polymerized actin in the cytosol. In IH, Ki-67 positivity was observed in the endothelial cells of the solid and more ectatic regions. In contrast, the virtual absence of Ki-67 positivity in ECVL lends further support for the interpretation that it is more closely related to a malformation than a benign neoplasm.
Ophthalmic Plastic and Reconstructive Surgery, 2013
Orbital osteotomy risks injury to the eyeball and orbit soft tissues. Used extensively in oral an... more Orbital osteotomy risks injury to the eyeball and orbit soft tissues. Used extensively in oral and maxillofacial surgery, piezoelectric technology offers a greater margin of safety than traditional bone cutting instruments. The authors describe the novel use of this system in a variety of orbital surgeries. This interventional case series was performed in accordance with institutional review board regulations. The medical records of all patients who had undergone orbital surgery using the piezoelectric blade at 3 institutions were reviewed. Indication for surgery, gender, age, duration of follow up, intraoperative complications, surgical result, and postoperative course was recorded. Sixteen patients underwent surgery on 18 orbits using the piezoelectric system between August 2011 and June 2012. Surgeries performed included orbital decompression (8), lateral orbitotomy (5), cranio-orbitotomy (4), and external dacryocystorhinostomy (1). Eight were female and 8 were male patients. Mean age was 55 years old (standard deviation 15 years). Mean follow up was 82 days. The osteotomy created by the blade was narrow and smooth in every case. The surgeons uniformly appreciated the precision and safety of the instrument compared with traditional electric saw blades. There were no soft tissue lacerations or intraoperative complications and reconstructions were uniformly uneventful. Postoperative healing was rapid with no unexpected inflammation, and no palpable bony defects were appreciated in the reconstructed cases. Because it does not cut soft tissue and cuts a narrow trough, the self-irrigating piezoelectric saw blade appears safer and more precise than traditional electric saw blades in and around the orbit.
Ophthalmic Plastic and Reconstructive Surgery, 2013
Infants with orbital hemangiomas and vascular malformations often develop expanded orbits or regi... more Infants with orbital hemangiomas and vascular malformations often develop expanded orbits or regional hyperostosis. Treatment in these cases depends, in part, on the stage of orbital development at the time of intervention; yet, orbital development with respect to age is not well-known. The authors sought to determine the rate of orbital development and the age of orbital maturation in a single ethnic population. Skeletons recovered in North America and housed at the Peabody Museum of Archaeology and Ethnology, Harvard University, were inspected. The age of specimen was determined by dentition. Orbital volume was measured using 1-mm glass beads and a graduated cylinder. Linear measurements were taken with calipers and paper rulers. The measurements were plotted against age, and statistical analysis was performed. Relevant literature was reviewed. Of the hundreds of skeletons examined, 42 were sufficiently intact for orbital measurement. The specimens represented a period of up to 1000 years. Thirty-two were pediatric (defined prenatal to 18 years) and 10 were adults. Mean adult orbital volume was 26.2 ml. Based on the regression analysis, 60% of adult orbital volume was achieved at 4.35 years, 75% at 9.36 years, and 90% at 17.13 years of age. Linear dimensions progressively increased with age. This largest direct-measure study of pediatric orbital volume suggests that orbital growth continually decelerates from birth until maturity at 22 years. With 50% of orbital growth occurring by 16 months of age, surgeons removing periocular vascular anomalies after that age should consider concurrent skeletal management.
To determine disease severity in glaucoma patients who presented to a tertiary care service for t... more To determine disease severity in glaucoma patients who presented to a tertiary care service for the first time and to determine the prevalence of different types of glaucoma. Retrospective analysis of data of patients referred to the Glaucoma Service at the Santa Casa de Misericórdia de São Paulo, Brazil in 2007. A complete chart review from 448 patients was done; data regarding age, gender, ethnicity, family history, duration of the disease, previous treatment, best corrected visual acuity, cup-to-disc ratio, intraocular pressure, diagnosis and treatment were collected. Glaucoma was diagnosed by the presence of typical optic disk abnormalities, disregarding IOP values. 52.3% of patients presented visual acuity less than or equal to 20/200 and 67.7% presented cup-to-disc ratio between 0.8 and 1.0 in the worse-seeing eye; 13.4% of patients were considered legally blind. Primary open angle glaucoma was the most prevalent form of glaucoma (54.2%, 95% CI: 48.5-59.5) and chronic angle closure glaucoma was the second most frequent (11.5%, 95% CI: 8.25-15.5). A considerable rate of patients (almost 60% in the better-seeing eye and 70% in the worse-seeing eye) presented with advanced glaucoma. Strategies that create conditions for early diagnosis are deemed necessary to reduce glaucoma-related blindness in the Brazilian population.
To analyze the influence of thermal partial punctal occlusion on the ocular surface of dry eye re... more To analyze the influence of thermal partial punctal occlusion on the ocular surface of dry eye related to Sjögren syndrome. Thirty-seven eyes of 19 patients (3 male and 16 female; 49.11 ± 14.33 years old) with keratoconjunctivitis sicca were enrolled in this study. Superior and inferior partial occlusion were performed in both eyes under topical anesthesia using thermal cautery with a sterile tip to obtain lacrimal punctum smaller than 0.5 mm. Schirmer I, break-up-time, diameter of lacrimal puncta, corneal fluorescein, and rose Bengal staining scores were analyzed before and after 24 weeks and after 24 months of the procedure. All measurements were performed under controlled climate. The average lacrimal punctum diameter before the procedure was 0.65 ± 0.134 mm. All lacrimal puncta were successfully reduced to less than 0.5 mm after 4 weeks of the procedure. The average Schirmer I test values improved statistically after 24 weeks and maintained stable after 24 months. Average break-up-time, rose Bengal, and fluorescein staining score values improved statistically after 24 weeks and improved even more after 24 months. Average Schirmer I test, break-up-time, rose Bengal, and fluorescein staining scores showed significant improvement (p < 0.0001) after 24 months of partial thermal punctal occlusion. Our study showed that reducing the punctum diameter to 0.5 mm can improve vital staining scores, break-up-time, and Schirmer I test in dry eye related to Sjögren syndrome.
To evaluate the effects of oral azithromycin in patients with posterior blepharitis. Twenty-six e... more To evaluate the effects of oral azithromycin in patients with posterior blepharitis. Twenty-six eyes of 13 patients with posterior blepharitis diagnosed by a qualified ophthalmologist were enrolled in this study. Patients were instructed to use oral azithromycin 500 mg per day for 3 days in 3 cycles with 7-day intervals. Subjective clinical outcomes were graded and scored 1 day before and 30 days after the end of the treatment (53 days after initiating the treatment) based on severity scores of: (1) eyelid debris; (2) eyelid telangiectasia; (3) swelling of the eyelid margin; (4) redness of the eyelid margin; and (5) ocular mucus secretion. For the assessment of global efficacy, patients were asked by the investigator to rate the subjective symptoms (eyelid itching, ocular itching, eyelid hyperemia, ocular hyperemia, ocular mucus secretion, photophobia, foreign body sensation, and dry eye sensation) on a scale of 0 (no symptoms) to 5 (severe symptoms). Break-up time, Schirmer I test, corneal fluorescein staining score, and rose bengal staining score were also performed in all patients. All clinical outcomes scoring showed statistically significant improvement after oral azithromycin, except for eyelid swelling. Average subjective symptom grading improved statistically after treatment with oral azithromycin, except for eyelid hyperemia, photophobia, and foreign body sensation. Average tear film break-up time values showed statistically significant improvement after the treatment with oral azithromycin. No statistically significant improvement was observed on average values of Schirmer I test, corneal fluorescein staining score, and rose bengal staining score. The combination of multiple clinical parameters shown in this study supports the clinical efficacy of pulsed oral azithromycin therapy for the management of posterior blepharitis.
To evaluate the use of octyl-2-cyanoacrylate liquid bandage (Band-Aid liquid, Ethicon, Johnson &a... more To evaluate the use of octyl-2-cyanoacrylate liquid bandage (Band-Aid liquid, Ethicon, Johnson & Johnson, New Jersey, USA) as a temporary treatment in patients awaiting surgical repair for involutional entropion. Thirteen patients (15 eyelids) with involutional entropion were evaluated while they waited for surgical intervention. The lids were repositioned by the application of octyl-2-cyanoacrylate liquid bandage in the malar fold. Patients were followed-up at days 1, 7 and 15. Assessment and duration of correction were recorded. All the patients presented successful correction at day 1, with significant improvements in signs and symptoms. The mean duration of action of the octyl2-cyanoacrylate liquid bandage was three days. No ocular or dermatological reactions were noted. Octyl-2-cyanoacrylate liquid bandage showed to be a simple, safe and effective option to temporarily treat involutional entropion, while patients waited for surgical intervention.
Volume loss and muscular hyperactivity are two major components of the aging process that contrib... more Volume loss and muscular hyperactivity are two major components of the aging process that contribute to the formation of the folds and wrinkles. Tear trough deformity is one of the most difficult depressions to correct surgically. The authors evaluate the results of periorbital filling with hyaluronic acid (HA) in a small series of patients. Between June 2008 and December 2009, 25 patients were treated with HA to correct tear trough deformities. The HA was administered into the preperiosteal tissues with a serial puncture technique and approximately 0.1 mL was injected at each pass. Each patient's before and after photographs were reviewed by three surgeons; to objectively assess the outcomes, a quantitative scale was used to grade the pre- and postinjection results. The significance of subjective aesthetic evaluation of the photographs was evaluated with the Mann-Whitney U-test. Differences were regarded as significant if probabilities were less than 0.05. The mean (SD) volume per side needed to achieve correction was 0.54 (0.27) mL on the right and 0.61 (0.30) mL on the left. Complications included some degree of bruising, erythema, and local swelling. Most patients (88%) had cosmetic improvement according to the independent evaluation. All patients were very satisfied with their results. During the course of the study, the authors determined that the ideal candidates for this treatment are young, with thick skin and a definite hollow.
Antibiotic stewardship is important in controlling resistance, adverse reactions, and cost. The l... more Antibiotic stewardship is important in controlling resistance, adverse reactions, and cost. The literature regarding antibiotic use for eyelid surgery is lacking. To determine standard care and assess factors influencing antibiotic prescribing practices for eyelid surgery. A survey study was conducted from February 2, 2014, to March 24, 2014. The survey was distributed to 2397 oculoplastic surgeons in private and academic oculoplastic surgery practices in 43 countries. All surgeons were members of ophthalmic plastic and reconstructive surgery societies. Data were analyzed by geographic location. Linear regression was performed to quantify contributions to rates of prescribing postoperative antibiotics for routine eyelid surgical procedures. Rates of prescribing prophylactic intravenous, oral, and topical antibiotics as well as factors that influence surgeons' prescribing practices. A total of 782 responses were received from 2397 surgeons (average response rate, 36.7%; 2.5% marg...
Uploads
Papers by Tammy Osaki