Outpatient Surgical Management of Orbital Blowout Fractures.

There is ample investigation into the optimal timing and approach to orbital blowout fracture (OBF) repair; however, less attention has been directed toward postoperative care. This is a multicenter IRB-approved retrospective review of patients with OBF presenting to our study sites between November 2008 and August 2016. Those with isolated OBF, over 18 years of age, and who had not suffered additional facial injuries or globe trauma were included. A total of 126 surgical cases of isolated OBF repair were identified that met our inclusion and exclusion criteria; 42.1% were outpatient repairs while the remaining 57.9% were admitted for overnight monitoring. Time elapsed prior to repair differed between the two groups at a mean of 8.4 days versus 5.2 days for the outpatient and inpatient cohorts, respectively ( p = 0.001). A majority of inpatient cases underwent immediate repair, while a majority of outpatient cases were delayed. There were two cases of RBH in the outpatient cohort resulting in an overall incidence of 1.6%. In both instances, a significant change in clinical exam including decreased visual acuity, diplopia, and eye pain prompted repeat evaluation and immediate intervention for hematoma evacuation. Estimated hospital charges to the patient's insurance for key components of an inpatient versus outpatient isolated OBF repair amounted to a total cost of $9,598.22 for inpatient management and $7,265.02 for outpatient management without reflexive postoperative imaging. Reflexive postoperative CT scans were obtained in 76.7% of inpatient cases and only two led to a reoperation. No outpatient repairs included reflexive postoperative imaging. Outpatient OBF repair is an attractive alternative to inpatient management. The potential cost savings of outpatient management of OBF, which do not detract from quality or safety of patient care, should not be ignored. Our results will hopefully contribute to updated shared practice patterns for all subspecialties that participate in the surgical management of OBF.

Correction of Lower Eyelid Retraction with En Glove Placement of Porcine Dermal Collagen Matrix Implant.

The authors conducted a retrospective case series of patients undergoing a lateral tarsal strip procedure with "en glove" placement of an acellular porcine dermal collagen matrix for correction of mild to moderate lower eyelid retraction. A detailed description of this minimally invasive technique with retrospective analysis of outcomes is provided. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, IV.

Diagnosing Distensible Venous Malformations of the Orbit With Diffusion-weighted Magnetic Resonance Imaging.

PURPOSE: To compare the diffusion-weighted imaging of nonthrombosed distensible venous malformations of the orbit with that of other histologically-proven orbital tumors. DESIGN: Retrospective case-control study. METHODS: Patients with nonthrombosed distensible venous malformations of the orbit and patients with other histologically-proven orbital tumors were selected for chart review. The main outcome measure was the apparent diffusion coefficient of these lesions. RESULTS: Sixty-seven patients qualified for chart review; 9 patients had nonthrombosed distensible venous malformations and 58 patients had other histologically-proven tumors. Three of the 9 patients with nonthrombosed distensible venous malformations were initially misdiagnosed as having had solid orbital tumors. The mean apparent diffusion coefficient of distensible venous malformations was 2.80 ± 0.48 × 10-3 mm2/s, whereas the mean apparent diffusion coefficient of other histologically-proven tumors was 1.18 ± 0.39 × 10-3 mm2/s (P < .001). The mean apparent diffusion coefficient ranged from 2.42 to 3.94 × 10-3 mm2/s in the distensible venous malformation group, whereas other histologically-proven tumors ranged from 0.53 to 2.08 × 10-3 mm2/s. Therefore, in this single-institution series, a threshold value of 2.10 × 10-3 mm2/s was 100% sensitive and 100% specific for distensible venous malformations. CONCLUSION: Certain nonthrombosed distensible venous malformations can evade diagnostic suspicion and mimic solid orbital tumors on standard magnetic resonance imaging sequences. In this single-institution series, diffusion-weighted imaging effectively distinguished these nonthrombosed distensible venous malformations from other orbital tumors.

Primary hepatoid adenocarcinoma of the orbit.

PURPOSE: To report a case of primary hepatoid adenocarcinoma of the orbit. OBSERVATIONS: An adult patient was referred for evaluation of an orbital mass. Histopathology of the orbital biopsy indicated a carcinoma with hepatoid features. Laboratory studies revealed normal liver function tests, elevated serum alpha-fetoprotein, and whole-body positron emission tomography/computed tomography scan showed no evidence of liver involvement or an alternative primary origin. CONCLUSIONS AND IMPORTANCE: To the authors' knowledge, this is the first reported case of primary hepatoid adenocarcinoma of the orbit.

Restrictive Strabismus Following Frontotemporal-orbitozygomatic Craniotomy.

The frontotempotal-orbitozygomatic craniotomy (FTOZ) is a standard approach for large sphenoid wing meningiomas (SWMs). Nevertheless, resection of these tumors is not without ophthalmologic risks. This series presents two patients with acute postoperative restrictive strabismus following tumor resection and orbital wall reconstruction. Forced duction testing and postoperative imaging revealed impingement of the lateral rectus muscle caused by an alloplastic implant and/or residual bone, prompting immediate orbitotomy and restoration of normal extraocular muscle function. This report highlights the intricacies of orbital reconstruction, as well as the need for intraoperative forced duction testing.

Paranasal Sinus Mucocele as a Late Complication of Dacryocystorhinostomy.

A 50-year-old female presented with a slowly enlarging painless mass of the right medial canthus. The past surgical history is significant for external dacryocystorhinostomy for acquired nasolacrimal duct obstruction 10 years prior and subsequent endoscopic and external revisions. Imaging revealed a large fronto-ethmoidal sinus mucocele extending into the right medial orbit. On surgical exploration, the right middle turbinate was found to have lateralized, obstructing sinus outflow. The mucocele was evacuated and ethmoidectomy and middle turbinectomy were performed. The patient did well postoperatively without recurrence at 6 months of follow-up. Sinus mucocele formation is a rare, late complication of lacrimal surgery.

Lacrimal Sac Smooth Muscle Tumor of Uncertain Malignant Potential.

A 13-year-old male presented with recurrent left nasolacrimal duct obstruction following endoscopic dacryocystorhinostomy 4 years prior at an outside institution. The past medical history was significant for stage IV neuroblastoma, diagnosed at age 2, requiring surgical resection, induction chemotherapy, autologous bone marrow transplantation and radiation, currently in remission. Preoperative CT scan demonstrated a 2 cm ovoid mass centered in the left lacrimal fossa, consistent with dacryocystocele; however, a solid tumor could not be ruled out. Subsequent surgical exploration of the lacrimal sac revealed a friable, solid mass filling the lacrimal sac, and extending into the duct. The mass was grossly resected with preservation of the lacrimal drainage system and placement of indwelling silicone stents. Histopathology confirmed the diagnosis of smooth muscle tumor of uncertain malignant potential. The patient remained free of epiphora and showed no clinical or radiographic evidence of recurrence at 6 months of follow up.

Persistent Upgaze Restriction after Orbital Floor Fracture Repair.

Here we present two cases of marked postoperative upgaze restriction after successful repair of orbital floor fracture and release of inferior rectus entrapment. In both cases, follow-up imaging showed enlargement of the inferior rectus, and gradual resolution of gaze limitation was observed over several months of conservative management. Thus, in patients with postoperative findings suggestive of residual inferior rectus entrapment, follow-up imaging is indicated prior to returning to the operating room. With a markedly swollen inferior rectus muscle but no radiographic evidence of residual muscle entrapment in the fracture, a trial of conservative management may be warranted.

Delayed periocular hemorrhage after upper blepharoplasty.

Periocular and orbital hemorrhage are rare complications of blepharoplasty, with a reported incidence of 0.055%. These complications are even less common more than 48 h after surgery. The authors report 2 cases of postoperative hemorrhage 5 and 8 days following uncomplicated upper blepharoplasty in which the initiating factor seems to have been uncontrolled hypertension. Details of the presentation, management and follow-up of each patient are described. These cases serve as an important reminder that patients must be appropriately counseled regarding the postoperative implications of their systemic conditions.

An aggressive sphenoid wing meningioma causing foster kennedy syndrome.

Foster Kennedy syndrome is a rare neurological condition with ophthalmic significance that can manifest as acute visual loss. It is classically characterised by unilateral optic nerve atrophy and contralateral papilledema resulting from an intracranial neoplasm. Physicians should consider Foster Kennedy syndrome in patients who present with visual loss and who have a history of intracranial neoplasm. In addition to ophthalmologic examination, neuroimaging is essential for the diagnosis of Foster Kennedy syndrome.

Clinical, radiographic, and audiometric predictors in conservative management of vestibular schwannoma.

OBJECTIVE: Vestibular schwannomas (VS) can be managed by observation. The goals were to examine clinical, radiographic, and audiometric variables at presentation and during observation that may predict which patients fail conservative management. METHODS: A retrospective chart review was performed of 202 patients who elected observation primarily. Data collection included presenting symptoms, symptom progression, tumor size, audiologic measures, and global clinical outcomes. Univariate and multivariate analyses were performed. RESULTS: Follow-up ranged from 1 month to 16 years (mean, 2.48 yr). Nineteen patients (9.4%) in the study group failed. Disequilibrium as a presenting symptom appeared more often in patients who failed observation (58% versus 32%; p = 0.039), as did new-onset disequilibrium. Presenting tumor size differed for patients who failed conservative management, with a mean of 14.0 versus 8.4 mm (p = 0.0006). Neurotologic complications compared favorably to those treated with primary surgery or radiotherapy. CONCLUSION: Patients with subjective disequilibrium at presentation and subjective disequilibrium developed during observation may be more likely to fail conservative management. Increased tumor size at presentation also may indicate the same, although no threshold could be achieved.