Ophthal Plast Reconstr Surg, Vol. 30, No. 1, 2014
Letters to the Editor
Correspondence: Ved Prakash Gupta, M.B.B.S., M.D., D.N.B., Department of Ophthalmology, University College of Medical Sciences and G.T.B. Hospital, Delhi-110095, India (vpg275gv@ yahoo.co.in) The authors have no financial or conflicts of interest to disclose.
REFERENCES 1. Yoon MK, McCulley TJ. Secondary tarsoconjunctival graft: a modification to the Cutler-Beard procedure. Ophthal Plast Reconstr Surg 2013;29:227–30. 2. Cutler NL, Beard C. A method for partial and total upper lid reconstruction. Am J Ophthalmol 1955;39:1–7. 3. Wesley RE, McCord CD Jr. Transplantation of eyebank sclera in the Cutler–Beard method of upper eyelid reconstruction. Ophthalmology 1980;87:1022–8. 4. Carrol RP. Entropion following the Cutler-Beard procedure. Ophthalmology 1983;90:1052–5. 5. Hsuan J, Selva D. Early division of a modified Cutler-Beard flap with a free tarsal graft. Eye (Lond) 2004;18:714–7.
Dr. Gupta and colleagues also note that, in our initial report,1 the second patient had paralytic blepharotosis postoperatively, and therefore, “eyelid retraction would not be expected.” We stand behind our initial assertion that the lack of retraction, even in the setting of preoperative blepharoptosis, is noteworthy. Retraction seen following Cutler-Beard procedures is mechanical in nature, resulting from posterior lamellar contraction. Thus, even though ptotic, a reconstructed eyelid could be retracted evidenced by entropion and lack of complete closure, neither of which were seen in this patient. Again we thank Drs. Gupta for their interest in our recent article “Secondary tarsoconjunctival graft: a modification to the Cutler-Beard procedure.”1 Their thoughts are insightful and interesting and bring to light the opportunity for us to add clarity to our initial work. Perhaps in time, an appropriately designed prospective study comparing various nuances in technique will help determine the truly optimal approach to these challenging reconstructions.
Michael K. Yoon, M.D. Timothy J. McCulley, M.D.
Reply Re: “Secondary Tarsoconjunctival Graft: A Modification to the Cutler-Beard Procedure” To the Editor: We would like to thank Drs. Gupta, Gupta, and Gupta for their interest in our recent article “Secondary tarsoconjunctival graft: a modification to the Cutler-Beard procedure.”1 In this manuscript, we describe our experience with the placement of a tarsoconjunctival graft at the second stage of the Cutler-Beard procedure, when the initial flap is divided. This provides structural stability, reducing the occurrence of postoperative eyelid retraction and entropion. This technique also provides additional conjunctiva for the posterior lamella (and in turn the fornix) and, possibly more importantly, allows for the eyelid margin to be covered with mucosa. We place the graft with the formerly superior edge positioned inferiorly to allow for draping of the conjunctiva over the eyelid margin. Dr. Gupta et al. make an insightful observation. They point out that the contour of the reconstructed eyelid of the first patient in our report was uneven, and they are somewhat correct; an irregularity can be seen medially in the photo, looking straight ahead. In our experience, the contours of the reconstructed eyelids have been adequate but less than perfect; however, this has compared well to our experiences with other techniques. In our published figure (Figure 3B),1 the second panel shows with gentle eyelid closure; the upper eyelid margin contour is visible (due to the lack of upper eyelashes) and reasonably smooth. The assertion made by Dr. Gupta and colleagues remains valid; with our technique, perfect contour is not guaranteed, particularly when reconstructing very large defects. The contour of the graft does not match the natural curvature of an upper eyelid. Perhaps as suggested, reshaping the tarsoconjunctival graft could aid the creation of a more natural eyelid contour. A shortcoming of tarsoconjunctival grafts is their limited vertical height. Thus, we make efforts to avoid wasting tissue, especially in upper eyelid reconstruction, that would occur with “trimming” of the graft as suggested by Gupta et al. Perhaps, 1 or more small vertical incisions in the graft would allow for reshaping without loss of tissue.
74
Correspondence: Michael K. Yoon, M.D., Massachusetts Eye and Ear Infirmary, Department of Ophthalmology, Harvard Medical School, Boston, MA, U.S.A. ([email protected]) The authors have no financial or conflicts of interest to disclose.
REFERENCES 1. Yoon MK, McCulley TJ. Secondary tarsoconjunctival graft: a modification to the Cutler-Beard procedure. Ophthal Plast Reconstr Surg 2013;29:227–30.
Re: “A Modified Lacrimal Sac Implant for High-Risk Dacryocystorhinostomy” To the Editor: I read with interest the article by De Castro et al.1 on modified lacrimal sac implant using Rains frontal sinus stent as an alternative to the conventional dacyrocystorhinostomy (DCR) in high-risk cases. I congratulate the authors on this good work. However, I would like to articulate few of my observations. Although I agree with the use of Rains stents in the exceptional pediatric case, the heterogeneity of the remaining etiologies do not stand on the same platform. A good number of studies on Sacroidosis and Wegener’s granulomatosis have shown excellent results with the traditional DCR.2,3 Most patients are usually on long-term systemic immunosuppression to manage the disease systemically, and Lee et al.3 in their series have shown excellent results in Wegener’s granulomatosis with external DCR without additional immunosuppression. Although the authors did not find much anatomical disruption while revising failed DCR’s, it may not be the same experience for many surgeons worldwide. In the more likely event of scarred lacrimal sac with intrasac synechiae and fibrosis, I wonder how easy it would be to place the Rains stents? Another concern is the closure of the bony osteotomy. It is a well-known fact in literature that there is a significant decrease in the size of the ostium, specially in the first 4 weeks.4 With a small osteotomy of just 4 mm and a pliable stent with luminal flow, did the authors observe any focal strangulation
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
Letters to the Editor
Correspondence: Ved Prakash Gupta, M.B.B.S., M.D., D.N.B., Department of Ophthalmology, University College of Medical Sciences and G.T.B. Hospital, Delhi-110095, India (vpg275gv@ yahoo.co.in) The authors have no financial or conflicts of interest to disclose.
REFERENCES 1. Yoon MK, McCulley TJ. Secondary tarsoconjunctival graft: a modification to the Cutler-Beard procedure. Ophthal Plast Reconstr Surg 2013;29:227–30. 2. Cutler NL, Beard C. A method for partial and total upper lid reconstruction. Am J Ophthalmol 1955;39:1–7. 3. Wesley RE, McCord CD Jr. Transplantation of eyebank sclera in the Cutler–Beard method of upper eyelid reconstruction. Ophthalmology 1980;87:1022–8. 4. Carrol RP. Entropion following the Cutler-Beard procedure. Ophthalmology 1983;90:1052–5. 5. Hsuan J, Selva D. Early division of a modified Cutler-Beard flap with a free tarsal graft. Eye (Lond) 2004;18:714–7.
Dr. Gupta and colleagues also note that, in our initial report,1 the second patient had paralytic blepharotosis postoperatively, and therefore, “eyelid retraction would not be expected.” We stand behind our initial assertion that the lack of retraction, even in the setting of preoperative blepharoptosis, is noteworthy. Retraction seen following Cutler-Beard procedures is mechanical in nature, resulting from posterior lamellar contraction. Thus, even though ptotic, a reconstructed eyelid could be retracted evidenced by entropion and lack of complete closure, neither of which were seen in this patient. Again we thank Drs. Gupta for their interest in our recent article “Secondary tarsoconjunctival graft: a modification to the Cutler-Beard procedure.”1 Their thoughts are insightful and interesting and bring to light the opportunity for us to add clarity to our initial work. Perhaps in time, an appropriately designed prospective study comparing various nuances in technique will help determine the truly optimal approach to these challenging reconstructions.
Michael K. Yoon, M.D. Timothy J. McCulley, M.D.
Reply Re: “Secondary Tarsoconjunctival Graft: A Modification to the Cutler-Beard Procedure” To the Editor: We would like to thank Drs. Gupta, Gupta, and Gupta for their interest in our recent article “Secondary tarsoconjunctival graft: a modification to the Cutler-Beard procedure.”1 In this manuscript, we describe our experience with the placement of a tarsoconjunctival graft at the second stage of the Cutler-Beard procedure, when the initial flap is divided. This provides structural stability, reducing the occurrence of postoperative eyelid retraction and entropion. This technique also provides additional conjunctiva for the posterior lamella (and in turn the fornix) and, possibly more importantly, allows for the eyelid margin to be covered with mucosa. We place the graft with the formerly superior edge positioned inferiorly to allow for draping of the conjunctiva over the eyelid margin. Dr. Gupta et al. make an insightful observation. They point out that the contour of the reconstructed eyelid of the first patient in our report was uneven, and they are somewhat correct; an irregularity can be seen medially in the photo, looking straight ahead. In our experience, the contours of the reconstructed eyelids have been adequate but less than perfect; however, this has compared well to our experiences with other techniques. In our published figure (Figure 3B),1 the second panel shows with gentle eyelid closure; the upper eyelid margin contour is visible (due to the lack of upper eyelashes) and reasonably smooth. The assertion made by Dr. Gupta and colleagues remains valid; with our technique, perfect contour is not guaranteed, particularly when reconstructing very large defects. The contour of the graft does not match the natural curvature of an upper eyelid. Perhaps as suggested, reshaping the tarsoconjunctival graft could aid the creation of a more natural eyelid contour. A shortcoming of tarsoconjunctival grafts is their limited vertical height. Thus, we make efforts to avoid wasting tissue, especially in upper eyelid reconstruction, that would occur with “trimming” of the graft as suggested by Gupta et al. Perhaps, 1 or more small vertical incisions in the graft would allow for reshaping without loss of tissue.
74
Correspondence: Michael K. Yoon, M.D., Massachusetts Eye and Ear Infirmary, Department of Ophthalmology, Harvard Medical School, Boston, MA, U.S.A. ([email protected]) The authors have no financial or conflicts of interest to disclose.
REFERENCES 1. Yoon MK, McCulley TJ. Secondary tarsoconjunctival graft: a modification to the Cutler-Beard procedure. Ophthal Plast Reconstr Surg 2013;29:227–30.
Re: “A Modified Lacrimal Sac Implant for High-Risk Dacryocystorhinostomy” To the Editor: I read with interest the article by De Castro et al.1 on modified lacrimal sac implant using Rains frontal sinus stent as an alternative to the conventional dacyrocystorhinostomy (DCR) in high-risk cases. I congratulate the authors on this good work. However, I would like to articulate few of my observations. Although I agree with the use of Rains stents in the exceptional pediatric case, the heterogeneity of the remaining etiologies do not stand on the same platform. A good number of studies on Sacroidosis and Wegener’s granulomatosis have shown excellent results with the traditional DCR.2,3 Most patients are usually on long-term systemic immunosuppression to manage the disease systemically, and Lee et al.3 in their series have shown excellent results in Wegener’s granulomatosis with external DCR without additional immunosuppression. Although the authors did not find much anatomical disruption while revising failed DCR’s, it may not be the same experience for many surgeons worldwide. In the more likely event of scarred lacrimal sac with intrasac synechiae and fibrosis, I wonder how easy it would be to place the Rains stents? Another concern is the closure of the bony osteotomy. It is a well-known fact in literature that there is a significant decrease in the size of the ostium, specially in the first 4 weeks.4 With a small osteotomy of just 4 mm and a pliable stent with luminal flow, did the authors observe any focal strangulation
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
