Ophthal Plast Reconstr Surg, Vol. 30, No. 2, 2014
Letters to the Editor
recent nodal mapping technique of Lymphoscintigraphy and sentinel lymph node biopsy (SLNB) to challenge the classically accepted notion that the lateral two-thirds of the upper eyelid, the lateral third of the lower eyelid, and lateral half of the conjunctiva drain in the parotid (preauricular) lymph nodes, and the medial third of the upper eyelid, the medial two-thirds of the lower eyelid, and the medial half of the conjunctiva drain in the submandibular and deep cervical nodes. The authors divided 28 subjects into 1 of 5 radioactive colloid injection sites of the eyelid including the upper lateral, upper medial, medial canthus, lower medial, and lower lateral and found that regardless of injection site, the sentinel node was most commonly the preauricular node.1 Moreover, in 3 subjects, there was no identifiable sentinel node, and in 11 patients, there was >1 sentinel node.1 This expands on the prior studies put forth by Cook et al.4,5 using histochemical analysis (and later Lymphoscintigraphy in cynomolgus monkeys) to suggest that ocular lymphatic drainage patterns in the human may be more variable and nuanced than previously believed. Our patients were under general anesthesia with a laryngeal mask airway (LMA), and the images were taken after indirect ophthalmoscopy was performed, and digital images were obtained. The authors anticipated cryotherapy would lower the local temperature of the immediately surrounding conjunctiva but instead observed an interesting extension of freeze that was not confined to the conjunctiva but extended inferolaterally toward the ear (the preauricular area) in both children. This observation indicates not only that the freeze from cryotherapy travels, possibly via lymphatics, but also that its extension may parallel the lymphatic drainage of the orbit as described by Nijhawan, Marriott, and Harvey.1 If preauricular nodes are the first to drain the conjunctiva, regardless of cryotherapy site, it may change our classic understanding of lymphatic drainage patterns. In the future, thermal imaging may be utilized as an adjunct tool to better understand the lymphatic drainage pattern of the individual’s eye and potentially aid in sentinel node mapping (Fig. 2).
Kendra A. Klein, Jasmine Francis, David H. Abramson, Brian Marr, Paul Dalecki,
M.D. M.D. M.D. M.D. M.D.
Correspondence: Kendra Klein, M.D., Memorial Sloan Kettering Cancer Center, 502 East 73rd St., Apt 4B New York, NY 10021. ([email protected]) The authors have no financial or conflicts of interest to disclose.
REFERENCES 1. Nijhawan N, Marriott C, Harvey JT. Lymphatic drainage patterns of the human eyelid: assessed by lymphoscintigraphy. Ophthal Plast Reconstr Surg 2010;26:281–5. 2. Ring EF, Ammer K. Infrared thermal imaging in medicine. Physiol Meas 2012;33:R33–46. 3. Shih SR, Li HY, Hsiao YL, et al. The application of temperature measurement of the eyes by digital infrared thermal imaging as a prognostic factor of methylprednisolone pulse therapy for Graves’ ophthalmopathy. Acta Ophthalmol 2010;88:e154–9. 4. Cook BE Jr, Lucarelli MJ, Lemke BN, et al. Eyelid lymphatics I: histochemical comparisons between the monkey and human. Ophthal Plast Reconstr Surg 2002;18:18–23. 5. Cook BE Jr, Lucarelli MJ, Lemke BN, et al. Eyelid lymphatics II: a search for drainage patterns in the monkey and correlations with human lymphatics. Ophthal Plast Reconstr Surg 2002;18: 99–106.
Reply re: “Lymphatic Drainage Patterns of the Human Eyelid: Assessed by Lymphoscintigraphy” To the Editor: I suspect on reading the letter by Klein et al.1 that they are looking at conjunctival drainage, which is slightly different than our article,2 which looked at eyelid lymphatic drainage, but nevertheless it is interesting that their results show a similar outcome. The figures show a change in color gradient extending inferotemporally whether the cryoprobe was placed medially or temporally on the bulbar conjunctiva. First of all it is gratifying that their results tend to confirm our results. Secondly, they are to be commended for using such an innovative technique to evaluate lymphatic drainage in the periocular area.
John Harvey, M.D., F.R.C.S.C. for Drs. Nijhawan and Marriott Correspondence: John T. Harvey, M.D., Hamilton Regional Eye Institute, 2757 King Street East, Hamilton, Ontario L8G 5E4, Canada ([email protected]) The author has no financial or conflicts of interest to disclose.
REFERENCES 1. Klein KA, Francis J, Abramson DH, et al. Re: “Lymphatic drainage patterns of the human eyelid: assessed by lymphoscintigraphy” [letter]. Ophthal Plast Reconstr Surg 2014;30. 2. Nijhawan N, Marriott C, Harvey JT. Lymphatic drainage patterns of the human eyelid: assessed by lymphoscintigraphy. Ophthal Plast Reconstr Surg 2010;26:281–5.
Re: “Scleral Necrosis Secondary to Nonabsorbable Suture Following Ptosis Surgery” To the Editor: Greetings to the author for publishing a rare case report. We would like to share a few points of interest. We in our institute also follow the external levator advancement with 6-0 Prolene suture. But we take extreme care while anchoring the LPS to Tarsus. Only partial thickness bite is taken in the tarsus, and after each suture, the eyelid is everted to see for any suture through the palpebral conjunctiva or seen subconjunctivally. By this simple examination, we can avoid these complications.
Dayakar Yadalla, M.D. JayaGayatri Rajagopalan, M.B.B.S, D.O., D.N.B. Correspondence: Dayakar Yadalla, M.D., Aravind Eye Hospital, Tavalakuppam, Pondicherry 605007, India (drdayakaryadalla@ gmail.com) The authors have no financial or conflicts of interest to disclose.
REFERENCES 1. Meghpara B, Lee S, Yen MT. Scleral necrosis secondary to nonabsorbable suture following ptosis surgery. Ophthal Plast Reconstr Surg 2013;29:e115–e6.
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
193
Ophthal Plast Reconstr Surg, Vol. 30, No. 2, 2014
Letters to the Editor
2. Spoor TC. Atlas of oculoplastic and orbital surgery. Informa Health care 2010;52–54. 3. Berlin AJ, Vestal KP. Levator aponeurosis surgery. A retrospective review. Ophthalmology 1989;96:1033–6; discussion 1037.
Reply re: “Scleral Necrosis Secondary to Nonabsorbable Suture Following Ptosis Surgery” To the Editor: I thank Drs. Yadalla and Rajagopalan1 for their interest and insight regarding our recent report on scleral necrosis after ptosis surgery.2 I agree that the best way to avoid these types of complications after ptosis surgery is with meticulous attention to detail when placing the tarsal sutures during the operative procedure. However, patients often present with unusual clinical signs and symptoms after having procedures performed by other surgeons. As in our presented case, this presentation may be quite some time after their initial surgery. While we hope that all surgeons use extreme care when placing their tarsal sutures, our case demonstrates that complications can result from a retained nonabsorbable suture even if an exposed suture is not readily visualized on the palpebral conjunctiva. Physicians should have a high degree of suspicion for the presence of a retained suture when patients present with persistent conjunctival or scleral necrosis in the setting of prior eyelid surgery.
Michael T. Yen, M.D. Correspondence: Michael T. Yen, M.D., Cullen Eye Institute, Department of Ophthalmology, Baylor College of Medicine, 1977 Butler Blvd, Houston, TX 77030 ([email protected]) Supported in part by an unrestricted educational grant from Research to Prevent Blindness, Inc., New York, NY. The author has no financial or conflicts of interest to disclose.
REFERENCES 1. Yadalla D, Rajagopalan J. Re: “scleral necrosis secondary to nonabsorbable suture following ptosis surgery”[letter]. Ophthal Plast Reconstr Surg 2014;30. 2. Meghpara B, Lee S, Yen MT. Scleral necrosis secondary to nonabsorbable suture following ptosis surgery. Ophthal Plast Reconstr Surg 2013;29:e115–7.
Re: “Inverting Sutures for Tarsal Ectropion (The Leicester Modified Suture Technique)” To the Editor: The authors describe a less invasive variant of lower eyelid “suture-driven” marginal rotation for tarsal ectropion, without the need for tissue incision/excision.1 I commend the authors on this procedural modification and on their excellent results in 20 patients, which clearly validates the technique as described. Tarsal ectropion is primarily seen in the elderly, as this reported series verifies. This demographic often has medical problems or takes medication, such as blood thinners, which makes the least invasive intervention most appropriate. For this reason, I read the article with interest.
194
The 1 finding not described in the article, which would help bring clarity to the procedure, is what the palpebral conjunctiva and fornix look like after healing has occurred. In previous descriptions of similar techniques, the reattachment of the retractors and often associated small shortening of the posterior lamella by conjunctival resection2 have been important steps to invert the eyelid. Besides a small clinically irrelevant conjunctival cicatrix or mild symblepheron, I have not noted consequences from conjunctival wedge excision. In the most similar description to the authors’ technique, Burroughs et al.3 also use a marginal rotation suture, which is passed through a subciliary incision and then subconjunctivally along the posterior surface of the eyelid before engaging the retractors at the fornix and exiting the skin. In this procedure, the skin incision and internalized eyelid suture passage can lead to an “inverting directed cicatrix,” which seems critical to the success of the procedure. In this current article, the authors note a shortened posterior lamella as a potential drawback of surgery, when in fact, it may play a vital role in allowing long-term correction from a mechanical standpoint. The mechanism for correction of eyelid malposition from suture rotation is clear, but without forming a raw surface on the retractors or conjunctiva for adhesion or inducing a more aggressive internal eyelid cicatrix with buried sutures, I am uncertain as to why the authors’ procedure has lasting power. The presence of an external divot (scar) at the suture egress clearly indicates that the inflammatory reaction of the polyfilament suture used (5-0 Vicryl) plays a role in creating a cicatrix. The question is what does the suture do to the internal surface of the lower eyelid? Does the conjunctiva bunch up like an accordion? Does the reaction from the suture lead to a conjunctival erosion with subsequent adhesions, which may aid in eyelid inversion? Is there an internal scar similar or different than what is seen externally? Can the authors elaborate on these questions and provide perspective, based on their experience, as to why they think that the procedure creates the needed adhesions to lead to more than short-term stability of eyelid position?
Guy G. Massry, M.D. Correspondence: Guy G. Massry, M.D., Ophthalmic Plastic and Reconstructive Surgery, Beverly Hills Ophthalmic Plastic Surgery, 150 North Robertson Blvd. No. 314, Beverly Hills, CA 90211 ([email protected]) The author has no financial or conflicts of interest to disclose.
REFERENCES 1. Berry-Brincat A, Burns J, Sampath R. Inverting sutures for tarsal ectropion (the leicester modified suture technique). Ophthal Plast Reconstr Surg 2013;29:400–2. 2. Wesley RE. Tarsal ectropion from detachment of the lower eyelid retractors. Am J Ophthalmol 1982;93:491–5. 3. Burroughs JR, Soparkar CN, Patrinely JR. Rotation mattress suture: a powerful adjunct for ectropion correction. Ophthal Plast Reconstr Surg 2003;19:404–6.
Re: “Inverting Sutures for Tarsal Ectropion (The Leicester Modified Suture Technique)” To the Editor: We read the article on “Inverting sutures for tarsal ectropion (the leicester modified suture technique)” with great interest.
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
Letters to the Editor
recent nodal mapping technique of Lymphoscintigraphy and sentinel lymph node biopsy (SLNB) to challenge the classically accepted notion that the lateral two-thirds of the upper eyelid, the lateral third of the lower eyelid, and lateral half of the conjunctiva drain in the parotid (preauricular) lymph nodes, and the medial third of the upper eyelid, the medial two-thirds of the lower eyelid, and the medial half of the conjunctiva drain in the submandibular and deep cervical nodes. The authors divided 28 subjects into 1 of 5 radioactive colloid injection sites of the eyelid including the upper lateral, upper medial, medial canthus, lower medial, and lower lateral and found that regardless of injection site, the sentinel node was most commonly the preauricular node.1 Moreover, in 3 subjects, there was no identifiable sentinel node, and in 11 patients, there was >1 sentinel node.1 This expands on the prior studies put forth by Cook et al.4,5 using histochemical analysis (and later Lymphoscintigraphy in cynomolgus monkeys) to suggest that ocular lymphatic drainage patterns in the human may be more variable and nuanced than previously believed. Our patients were under general anesthesia with a laryngeal mask airway (LMA), and the images were taken after indirect ophthalmoscopy was performed, and digital images were obtained. The authors anticipated cryotherapy would lower the local temperature of the immediately surrounding conjunctiva but instead observed an interesting extension of freeze that was not confined to the conjunctiva but extended inferolaterally toward the ear (the preauricular area) in both children. This observation indicates not only that the freeze from cryotherapy travels, possibly via lymphatics, but also that its extension may parallel the lymphatic drainage of the orbit as described by Nijhawan, Marriott, and Harvey.1 If preauricular nodes are the first to drain the conjunctiva, regardless of cryotherapy site, it may change our classic understanding of lymphatic drainage patterns. In the future, thermal imaging may be utilized as an adjunct tool to better understand the lymphatic drainage pattern of the individual’s eye and potentially aid in sentinel node mapping (Fig. 2).
Kendra A. Klein, Jasmine Francis, David H. Abramson, Brian Marr, Paul Dalecki,
M.D. M.D. M.D. M.D. M.D.
Correspondence: Kendra Klein, M.D., Memorial Sloan Kettering Cancer Center, 502 East 73rd St., Apt 4B New York, NY 10021. ([email protected]) The authors have no financial or conflicts of interest to disclose.
REFERENCES 1. Nijhawan N, Marriott C, Harvey JT. Lymphatic drainage patterns of the human eyelid: assessed by lymphoscintigraphy. Ophthal Plast Reconstr Surg 2010;26:281–5. 2. Ring EF, Ammer K. Infrared thermal imaging in medicine. Physiol Meas 2012;33:R33–46. 3. Shih SR, Li HY, Hsiao YL, et al. The application of temperature measurement of the eyes by digital infrared thermal imaging as a prognostic factor of methylprednisolone pulse therapy for Graves’ ophthalmopathy. Acta Ophthalmol 2010;88:e154–9. 4. Cook BE Jr, Lucarelli MJ, Lemke BN, et al. Eyelid lymphatics I: histochemical comparisons between the monkey and human. Ophthal Plast Reconstr Surg 2002;18:18–23. 5. Cook BE Jr, Lucarelli MJ, Lemke BN, et al. Eyelid lymphatics II: a search for drainage patterns in the monkey and correlations with human lymphatics. Ophthal Plast Reconstr Surg 2002;18: 99–106.
Reply re: “Lymphatic Drainage Patterns of the Human Eyelid: Assessed by Lymphoscintigraphy” To the Editor: I suspect on reading the letter by Klein et al.1 that they are looking at conjunctival drainage, which is slightly different than our article,2 which looked at eyelid lymphatic drainage, but nevertheless it is interesting that their results show a similar outcome. The figures show a change in color gradient extending inferotemporally whether the cryoprobe was placed medially or temporally on the bulbar conjunctiva. First of all it is gratifying that their results tend to confirm our results. Secondly, they are to be commended for using such an innovative technique to evaluate lymphatic drainage in the periocular area.
John Harvey, M.D., F.R.C.S.C. for Drs. Nijhawan and Marriott Correspondence: John T. Harvey, M.D., Hamilton Regional Eye Institute, 2757 King Street East, Hamilton, Ontario L8G 5E4, Canada ([email protected]) The author has no financial or conflicts of interest to disclose.
REFERENCES 1. Klein KA, Francis J, Abramson DH, et al. Re: “Lymphatic drainage patterns of the human eyelid: assessed by lymphoscintigraphy” [letter]. Ophthal Plast Reconstr Surg 2014;30. 2. Nijhawan N, Marriott C, Harvey JT. Lymphatic drainage patterns of the human eyelid: assessed by lymphoscintigraphy. Ophthal Plast Reconstr Surg 2010;26:281–5.
Re: “Scleral Necrosis Secondary to Nonabsorbable Suture Following Ptosis Surgery” To the Editor: Greetings to the author for publishing a rare case report. We would like to share a few points of interest. We in our institute also follow the external levator advancement with 6-0 Prolene suture. But we take extreme care while anchoring the LPS to Tarsus. Only partial thickness bite is taken in the tarsus, and after each suture, the eyelid is everted to see for any suture through the palpebral conjunctiva or seen subconjunctivally. By this simple examination, we can avoid these complications.
Dayakar Yadalla, M.D. JayaGayatri Rajagopalan, M.B.B.S, D.O., D.N.B. Correspondence: Dayakar Yadalla, M.D., Aravind Eye Hospital, Tavalakuppam, Pondicherry 605007, India (drdayakaryadalla@ gmail.com) The authors have no financial or conflicts of interest to disclose.
REFERENCES 1. Meghpara B, Lee S, Yen MT. Scleral necrosis secondary to nonabsorbable suture following ptosis surgery. Ophthal Plast Reconstr Surg 2013;29:e115–e6.
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
193
Ophthal Plast Reconstr Surg, Vol. 30, No. 2, 2014
Letters to the Editor
2. Spoor TC. Atlas of oculoplastic and orbital surgery. Informa Health care 2010;52–54. 3. Berlin AJ, Vestal KP. Levator aponeurosis surgery. A retrospective review. Ophthalmology 1989;96:1033–6; discussion 1037.
Reply re: “Scleral Necrosis Secondary to Nonabsorbable Suture Following Ptosis Surgery” To the Editor: I thank Drs. Yadalla and Rajagopalan1 for their interest and insight regarding our recent report on scleral necrosis after ptosis surgery.2 I agree that the best way to avoid these types of complications after ptosis surgery is with meticulous attention to detail when placing the tarsal sutures during the operative procedure. However, patients often present with unusual clinical signs and symptoms after having procedures performed by other surgeons. As in our presented case, this presentation may be quite some time after their initial surgery. While we hope that all surgeons use extreme care when placing their tarsal sutures, our case demonstrates that complications can result from a retained nonabsorbable suture even if an exposed suture is not readily visualized on the palpebral conjunctiva. Physicians should have a high degree of suspicion for the presence of a retained suture when patients present with persistent conjunctival or scleral necrosis in the setting of prior eyelid surgery.
Michael T. Yen, M.D. Correspondence: Michael T. Yen, M.D., Cullen Eye Institute, Department of Ophthalmology, Baylor College of Medicine, 1977 Butler Blvd, Houston, TX 77030 ([email protected]) Supported in part by an unrestricted educational grant from Research to Prevent Blindness, Inc., New York, NY. The author has no financial or conflicts of interest to disclose.
REFERENCES 1. Yadalla D, Rajagopalan J. Re: “scleral necrosis secondary to nonabsorbable suture following ptosis surgery”[letter]. Ophthal Plast Reconstr Surg 2014;30. 2. Meghpara B, Lee S, Yen MT. Scleral necrosis secondary to nonabsorbable suture following ptosis surgery. Ophthal Plast Reconstr Surg 2013;29:e115–7.
Re: “Inverting Sutures for Tarsal Ectropion (The Leicester Modified Suture Technique)” To the Editor: The authors describe a less invasive variant of lower eyelid “suture-driven” marginal rotation for tarsal ectropion, without the need for tissue incision/excision.1 I commend the authors on this procedural modification and on their excellent results in 20 patients, which clearly validates the technique as described. Tarsal ectropion is primarily seen in the elderly, as this reported series verifies. This demographic often has medical problems or takes medication, such as blood thinners, which makes the least invasive intervention most appropriate. For this reason, I read the article with interest.
194
The 1 finding not described in the article, which would help bring clarity to the procedure, is what the palpebral conjunctiva and fornix look like after healing has occurred. In previous descriptions of similar techniques, the reattachment of the retractors and often associated small shortening of the posterior lamella by conjunctival resection2 have been important steps to invert the eyelid. Besides a small clinically irrelevant conjunctival cicatrix or mild symblepheron, I have not noted consequences from conjunctival wedge excision. In the most similar description to the authors’ technique, Burroughs et al.3 also use a marginal rotation suture, which is passed through a subciliary incision and then subconjunctivally along the posterior surface of the eyelid before engaging the retractors at the fornix and exiting the skin. In this procedure, the skin incision and internalized eyelid suture passage can lead to an “inverting directed cicatrix,” which seems critical to the success of the procedure. In this current article, the authors note a shortened posterior lamella as a potential drawback of surgery, when in fact, it may play a vital role in allowing long-term correction from a mechanical standpoint. The mechanism for correction of eyelid malposition from suture rotation is clear, but without forming a raw surface on the retractors or conjunctiva for adhesion or inducing a more aggressive internal eyelid cicatrix with buried sutures, I am uncertain as to why the authors’ procedure has lasting power. The presence of an external divot (scar) at the suture egress clearly indicates that the inflammatory reaction of the polyfilament suture used (5-0 Vicryl) plays a role in creating a cicatrix. The question is what does the suture do to the internal surface of the lower eyelid? Does the conjunctiva bunch up like an accordion? Does the reaction from the suture lead to a conjunctival erosion with subsequent adhesions, which may aid in eyelid inversion? Is there an internal scar similar or different than what is seen externally? Can the authors elaborate on these questions and provide perspective, based on their experience, as to why they think that the procedure creates the needed adhesions to lead to more than short-term stability of eyelid position?
Guy G. Massry, M.D. Correspondence: Guy G. Massry, M.D., Ophthalmic Plastic and Reconstructive Surgery, Beverly Hills Ophthalmic Plastic Surgery, 150 North Robertson Blvd. No. 314, Beverly Hills, CA 90211 ([email protected]) The author has no financial or conflicts of interest to disclose.
REFERENCES 1. Berry-Brincat A, Burns J, Sampath R. Inverting sutures for tarsal ectropion (the leicester modified suture technique). Ophthal Plast Reconstr Surg 2013;29:400–2. 2. Wesley RE. Tarsal ectropion from detachment of the lower eyelid retractors. Am J Ophthalmol 1982;93:491–5. 3. Burroughs JR, Soparkar CN, Patrinely JR. Rotation mattress suture: a powerful adjunct for ectropion correction. Ophthal Plast Reconstr Surg 2003;19:404–6.
Re: “Inverting Sutures for Tarsal Ectropion (The Leicester Modified Suture Technique)” To the Editor: We read the article on “Inverting sutures for tarsal ectropion (the leicester modified suture technique)” with great interest.
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
