Ophthal Plast Reconstr Surg, Vol. 30, No. 5, 2014
Letters to the Editor
was a suspected foreign body that might be embedded in deep tissues. Conventional x-ray of anteroposterior and lateral views of the head (with plastering of three syringe needles on forehead) were taken (Fig. B). There was a foreign body on the superior border of the orbit. The foreign body can be seen in an x-ray image (Fig. C) medially to the entry site (under the medial injector, not under the central one). The patient was taken to the surgical theatre, and an incision was made medial to the entry site under local anesthesia. Dissection was made, and foreign body was found as embedded into the inferior portion of the frontal bone (Fig. D). Most of the studies concerning with the removal of GPs are related with intraorbital and retroorbital GPs and not with the periorbital ones.1–5 In one of these studies, fluoroscopy was used for removal of intraorbital foreign bodies and claimed that this method was effective both for shortening of the duration of surgery and facilitating the orbital manipulations.2 In another study, it was reported that such foreign bodies may not be treated.3 In our case, we also offered the patient that the foreign body may not be removed, but as above mentioned, patient did not accept leaving the foreign body. Surgeons usually make an incision in the site of puncture and search the foreign body with blind dissection. Both superficial and deep tissues expose more tissue trauma. As a cheap and easy accessible diagnostic method, conventional radiographs can be used. Although ultrasound, CT, and metal detectors6 are advanced imaging/detecting modalities, they are not always available, especially in rural areas or developing countries. Stockmann et al.7 claimed that conventional radiographs might be still the standard in localization of projectiles. They used spherical radiopaque reference markers. In our case, reference markers were syringe needles that can be found in every health institutes. Placement of the needles can be done with a plaster. One needle was usually placed on the entry point, and two or more needles were placed on both sides. Anteroposterior and lateral views of the head radiographs were used to localize the GP. In our case, foreign body was medial to the entry point and extracted with a small incision. We report this technique as it has not appeared in the ophthalmic literature.
Adem Gul, M.D. Ertugrul Can Hakkı Birinci
6. Muensterer OJ, Joppich I. Identification and topographic localization of metallic foreign bodies by metal detector. J Pediatr Surg 2004;39:1245–8. 7. Stockmann P, Vairaktaris E, Fenner M, et al. Conventional radiographs: are they still the standard in localization of projectiles? Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104:e71–5.
Botox Enhancing Eyebrow Elevation in External Ophthalmoplegia Ptosis To the Editor: External ophthalmoplegia can lead to upper eyelid ptosis and limitation in extraocular muscle movements. Patients compensate for the ptosis by raising their eyebrows with their frontalis muscle, and this then elevates the upper eyelids so that they can see better. Upper blepharoplasties can decrease the effort needed for eyebrow elevation by shortening the amount of skin in the upper eyelids.1,2
CASE REPORT I have been following a patient with external ophthalmoplegia for 14 years. Due to difficulty in seeing because of his upper eyelid ptosis, I treated him with a left functional blepharoplasty, which was successful in decreasing his left upper eyelid ptosis and improving his vision with neither secondary keratopathy nor ocular irritation (Figs. 1 and 2). He also complained cosmetically of the wrinkles in his forehead from the overaction of his frontalis muscle for which I treated him several times with Juvederm (hyaluronic acid) injections in his forehead crease lines, which minimally lessened the deep wrinkles. Recently, I treated him with Botox (2.5 units/ ml; Allergan, Inc, Irvine, CA) with 2 injections in each procerus muscle, 4 in each corrugator muscle, and 1 on each side of the temporal superior orbicularis muscle. The weakening of these muscles from the Botox led to the antagonistic frontalis muscle lifting the eyebrows with less patient effort. It also led to almost complete resolution of the forehead deep wrinkles, because the patient stopped forcibly raising his eyebrows to see (Fig. 3). Further study of the use of Botox in the treatment of upper eyelid ptosis in external ophthalmoplegia will be needed to determine if this is a consistent addition to our treatment armamentaria. Also, there is the possibility that Botox injections in the procerus, corrugator, and orbicularis muscles might be
Correspondence Adem Gul, M.D., Ondokuz Mayis University, Samsun, Turkey ([email protected]) The authors have no financial or conflicts of interest to disclose.
REFERENCES 1. Ho VH, Wilson MW, Fleming JC, et al. Retained intraorbital metallic foreign bodies. Ophthal Plast Reconstr Surg 2004;20:232–6. 2. Yoganathan P, Conti SM, Kavalec C. The use of intraoperative fluoroscopy as an aid for removal of radiopaque intraorbital foreign bodies. Ophthalmic Surg Lasers Imaging 2008;39:436–7. 3. Jewsbury H, O’Duffy D. The best treatment can be no treatment: retained retro-orbital air gun pellet following attempted suicide. BMJ Case Rep 2011;2011:pii. 4. Mendes PD, Fariña EG, de Aguiar GB, et al. Changes in management strategies after spontaneous migration of a retained intraorbital metallic foreign body. J Craniofac Surg 2010;21:1295–6. 5. Finkelstein M, Legmann A, Rubin PA. Projectile metallic foreign bodies in the orbit: a retrospective study of epidemiologic factors, management, and outcomes. Ophthalmology 1997;104:96–103.
444
FIG. 1. Patient with external ophthalmoplegia with secondary left upper eyelid ptosis and strabismus preoperatively.
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
Ophthal Plast Reconstr Surg, Vol. 30, No. 5, 2014
FIG. 2. Patient after treatment with a left upper blepharoplasty that allows him to raise his eyebrows and thereby his eyelids to see better. (Photograph taken 3 weeks after Juvederm [hyaluronic acid] injections in forehead wrinkles.)
helpful in the treatment of upper eyelid ptosis in patients without external ophthalmoplegia.
Allen M. Putterman, M.D. Correspondence: Allen M. Putterman, M.D., University of Illinois College of Medicine, 111 N. Wabash, Chicago, IL 60602 ([email protected])
Letters to the Editor
FIG. 3. Patient after injection of Botox in his procerus, corrugator, and orbicularis muscles, which allowed him to raise his eyebrows with less effort and also significantly decreased his forehead wrinkles. (Photograph taken 1 year after last Juvederm [hyaluronic acid] injections in forehead wrinkles.)
This report was sponsored by a grant from the Illinois Society for the Prevention of Blindness. The author has no conflicts of interest to disclose.
REFERENCES 1. Burnstein MA, Putterman AM. Upper blepharoplasty: a novel approach to improving progressive myopathic blepharoptosis. Ophthalmology 1999;106:2098–100. 2. Putterman AM. Functional ptosis blepharoplasty diagnostic clamp. Ophthal Plast Reconstr Surg 2012;28:311–2.
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
445
Letters to the Editor
was a suspected foreign body that might be embedded in deep tissues. Conventional x-ray of anteroposterior and lateral views of the head (with plastering of three syringe needles on forehead) were taken (Fig. B). There was a foreign body on the superior border of the orbit. The foreign body can be seen in an x-ray image (Fig. C) medially to the entry site (under the medial injector, not under the central one). The patient was taken to the surgical theatre, and an incision was made medial to the entry site under local anesthesia. Dissection was made, and foreign body was found as embedded into the inferior portion of the frontal bone (Fig. D). Most of the studies concerning with the removal of GPs are related with intraorbital and retroorbital GPs and not with the periorbital ones.1–5 In one of these studies, fluoroscopy was used for removal of intraorbital foreign bodies and claimed that this method was effective both for shortening of the duration of surgery and facilitating the orbital manipulations.2 In another study, it was reported that such foreign bodies may not be treated.3 In our case, we also offered the patient that the foreign body may not be removed, but as above mentioned, patient did not accept leaving the foreign body. Surgeons usually make an incision in the site of puncture and search the foreign body with blind dissection. Both superficial and deep tissues expose more tissue trauma. As a cheap and easy accessible diagnostic method, conventional radiographs can be used. Although ultrasound, CT, and metal detectors6 are advanced imaging/detecting modalities, they are not always available, especially in rural areas or developing countries. Stockmann et al.7 claimed that conventional radiographs might be still the standard in localization of projectiles. They used spherical radiopaque reference markers. In our case, reference markers were syringe needles that can be found in every health institutes. Placement of the needles can be done with a plaster. One needle was usually placed on the entry point, and two or more needles were placed on both sides. Anteroposterior and lateral views of the head radiographs were used to localize the GP. In our case, foreign body was medial to the entry point and extracted with a small incision. We report this technique as it has not appeared in the ophthalmic literature.
Adem Gul, M.D. Ertugrul Can Hakkı Birinci
6. Muensterer OJ, Joppich I. Identification and topographic localization of metallic foreign bodies by metal detector. J Pediatr Surg 2004;39:1245–8. 7. Stockmann P, Vairaktaris E, Fenner M, et al. Conventional radiographs: are they still the standard in localization of projectiles? Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104:e71–5.
Botox Enhancing Eyebrow Elevation in External Ophthalmoplegia Ptosis To the Editor: External ophthalmoplegia can lead to upper eyelid ptosis and limitation in extraocular muscle movements. Patients compensate for the ptosis by raising their eyebrows with their frontalis muscle, and this then elevates the upper eyelids so that they can see better. Upper blepharoplasties can decrease the effort needed for eyebrow elevation by shortening the amount of skin in the upper eyelids.1,2
CASE REPORT I have been following a patient with external ophthalmoplegia for 14 years. Due to difficulty in seeing because of his upper eyelid ptosis, I treated him with a left functional blepharoplasty, which was successful in decreasing his left upper eyelid ptosis and improving his vision with neither secondary keratopathy nor ocular irritation (Figs. 1 and 2). He also complained cosmetically of the wrinkles in his forehead from the overaction of his frontalis muscle for which I treated him several times with Juvederm (hyaluronic acid) injections in his forehead crease lines, which minimally lessened the deep wrinkles. Recently, I treated him with Botox (2.5 units/ ml; Allergan, Inc, Irvine, CA) with 2 injections in each procerus muscle, 4 in each corrugator muscle, and 1 on each side of the temporal superior orbicularis muscle. The weakening of these muscles from the Botox led to the antagonistic frontalis muscle lifting the eyebrows with less patient effort. It also led to almost complete resolution of the forehead deep wrinkles, because the patient stopped forcibly raising his eyebrows to see (Fig. 3). Further study of the use of Botox in the treatment of upper eyelid ptosis in external ophthalmoplegia will be needed to determine if this is a consistent addition to our treatment armamentaria. Also, there is the possibility that Botox injections in the procerus, corrugator, and orbicularis muscles might be
Correspondence Adem Gul, M.D., Ondokuz Mayis University, Samsun, Turkey ([email protected]) The authors have no financial or conflicts of interest to disclose.
REFERENCES 1. Ho VH, Wilson MW, Fleming JC, et al. Retained intraorbital metallic foreign bodies. Ophthal Plast Reconstr Surg 2004;20:232–6. 2. Yoganathan P, Conti SM, Kavalec C. The use of intraoperative fluoroscopy as an aid for removal of radiopaque intraorbital foreign bodies. Ophthalmic Surg Lasers Imaging 2008;39:436–7. 3. Jewsbury H, O’Duffy D. The best treatment can be no treatment: retained retro-orbital air gun pellet following attempted suicide. BMJ Case Rep 2011;2011:pii. 4. Mendes PD, Fariña EG, de Aguiar GB, et al. Changes in management strategies after spontaneous migration of a retained intraorbital metallic foreign body. J Craniofac Surg 2010;21:1295–6. 5. Finkelstein M, Legmann A, Rubin PA. Projectile metallic foreign bodies in the orbit: a retrospective study of epidemiologic factors, management, and outcomes. Ophthalmology 1997;104:96–103.
444
FIG. 1. Patient with external ophthalmoplegia with secondary left upper eyelid ptosis and strabismus preoperatively.
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
Ophthal Plast Reconstr Surg, Vol. 30, No. 5, 2014
FIG. 2. Patient after treatment with a left upper blepharoplasty that allows him to raise his eyebrows and thereby his eyelids to see better. (Photograph taken 3 weeks after Juvederm [hyaluronic acid] injections in forehead wrinkles.)
helpful in the treatment of upper eyelid ptosis in patients without external ophthalmoplegia.
Allen M. Putterman, M.D. Correspondence: Allen M. Putterman, M.D., University of Illinois College of Medicine, 111 N. Wabash, Chicago, IL 60602 ([email protected])
Letters to the Editor
FIG. 3. Patient after injection of Botox in his procerus, corrugator, and orbicularis muscles, which allowed him to raise his eyebrows with less effort and also significantly decreased his forehead wrinkles. (Photograph taken 1 year after last Juvederm [hyaluronic acid] injections in forehead wrinkles.)
This report was sponsored by a grant from the Illinois Society for the Prevention of Blindness. The author has no conflicts of interest to disclose.
REFERENCES 1. Burnstein MA, Putterman AM. Upper blepharoplasty: a novel approach to improving progressive myopathic blepharoptosis. Ophthalmology 1999;106:2098–100. 2. Putterman AM. Functional ptosis blepharoplasty diagnostic clamp. Ophthal Plast Reconstr Surg 2012;28:311–2.
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
445
![[Lower eyelid extension-plasty in patients with ptosis in chronic progressive external ophthalmoplegia].](/assets/img/hold.png)
