Repeat posterior lamellar grafting for recalcitrant lower eyelid retraction is effective.

PURPOSE: To review one surgeon's (J.H.O.) experience with repeat retractor release and posterior lamellar grafting in patients with residual lower eyelid retraction. To quantify the amount of eyelid elevation expected from each procedure. METHOD: Retrospective chart review of patients with repeat posterior lamellar grafting between 1992 and 2010. Patients were grouped into thyroid associated orbitopathy (TAO) and other causes. Hard palate mucosa or free tarsoconjunctiva grafts were used. Preoperative and postoperative inferior scleral show, lagophthalmos, superficial punctate keratopathy, and patient symptoms were recorded. Outcome measures were changes in scleral show and lagophthalmos with each procedure. Combined results were examined.Results in patients with TAO were analysed separately and compared with other etiologies. RESULTS: In this series, a single procedure is expected to reduce scleral show by a mean of 1.63 mm (76%) and lagophthalmos by a mean of 0.48 mm (55%). A second procedure can further reduce residual scleral show by a mean of 0.71 mm (80%) and residual lagophthalmos by a mean of 0.43 mm (76%). Patients with TAO were more likely to have larger measurements of preoperative scleral show (1.40 mm versus 0.46 mm, p < 0.001). Patients with other etiologies were more likely to have larger measurements of preoperative lagophthalmos (1.25 mm versus 0.47 mm, p = 0.004). CONCLUSIONS: This is the first study to evaluate outcomes of recalcitrant lower lid retraction requiring repeat posterior lamellar grafting. Mean reductions in scleral show and lagophthalmos can be used as a guide in the preoperative evaluation and counseling of patients with lower lid retraction.

Aspergillus mycetoma in a secondary hydroxyapatite orbital implant: a case report and literature review.

OBJECTIVE: The authors describe the first case report of a fungal abscess within a hydroxyapatite orbital implant in a patient who had undergone straightforward secondary hydroxyapatite implant surgery. DESIGN: Case report and literature review. INTERVENTION: Four months postoperatively after pegging and 17 months after original implant placement, chronic discharge and socket irritation became evident. Recurrent pyogenic granulomas were a problem, but no obvious area of dehiscence was present over the implant. The peg and sleeve were removed 31 months after pegging (44 months after original placement of the implant). The pain and discharge did not resolve, and the entire hydroxyapatite orbital implant was removed 45 months after sleeve placement and 58 months after initial implant placement. The pain and discharge settled rapidly. MAIN OUTCOME MEASURES: Cultures and histopathology. RESULTS: Results of bacterial cultures were negative. Results of histopathologic examination of the implant disclosed intertrabecular spaces with multiple clusters of organisms consistent with Aspergillus. CONCLUSIONS: Persistent orbital discomfort, discharge, and pyogenic granulomas after hydroxyapatite implantation should cause concern regarding potential implant infection. The authors have now shown that this implant infection could be bacterial or fungal in nature. This is essentially a new form of orbital Aspergillus, that of a chronic infection limited to a hydroxyapatite implant.

Sensitivity and specificity of the diagnosis of periocular lesions by oculoplastic surgeons.

BACKGROUND: A few studies have assessed the sensitivity of ophthalmologists in diagnosing periocular lesions. However, no study has assessed their diagnostic specificity or the degree to which they overdiagnose various lesions. We performed a study to determine the sensitivity and specificity of oculoplastic surgeons' preoperative diagnoses of common and uncommon periocular lesions. METHODS: Using the patient records of four oculoplastic ophthalmologists, we reviewed all charts documenting periocular surgery in which lesions were excised and sent for biopsy. For each of 358 cases we recorded the preoperative diagnosis as listed by the surgeon and the postoperative diagnosis as reported by the pathologist. Each preoperative diagnosis was then scored as correct or incorrect. The relative number of each type of lesion was determined, and the ophthalmologists' sensitivity and specificity were calculated. RESULTS: The sensitivity and specificity for the eight most frequently lesions were (in order of frequency) basal cell carcinoma 92.1% and 81.6% respectively, papilloma 81.6% and 66.0%, cyst 66.7% and 69.7%, nevus 53.6% and 75.0%, seborrheic keratosis 27.8% and 71.4%, chalazion 93.3% and 100.0%, squamous cell carcinoma 33.3% and 55.6%, and xanthelasma 100.0% and 76.9%. The values for melanoma were 50.0% and 28.6%, for sebaceous gland carcinoma 0.0% and 100.0%, and for uncommon lesions (nonspecific inflammation, actinic keratosis, granuloma, cavernous hemangioma, folliculitis, benign sweat gland tumour, eccrine hidrocystoma and collagenous tissue) 27.8% and 57.1%. The overall accuracy in lesion identification was 70.0%. INTERPRETATION: Although ophthalmologists have excellent diagnostic sensitivity and specificity for some types of lesion, such as basal cell carcinoma and chalazion, the identification of other lesion types, such as cyst, squamous cell carcinoma and possibly melanoma and sebaceous gland carcinoma, is less optimal.

Complications of hydroxyapatite orbital implants. A review of 100 consecutive cases and a comparison of Dexon mesh (polyglycolic acid) with scleral wrapping.

PURPOSE: The authors analyzed all the complications associates with the first 100 hydroxyapatite orbital implants performed by one surgeon, and compare scleral wrapping versus Dexon mesh (polyglycolic acid, Davis & Geck, Manati, Puerto Rico) wrapping in light of these complications. BACKGROUND: Prior studies have not included the full range of complications that can occur with hydroxyapatite orbital implants. Dexon mesh implant wrapping is a promising substitute for sclera and avoids the risks involved in using donor tissue. METHODS: A retrospective analysis of 100 consecutive cases was performed. RESULTS: Many minor complications occurred, but the rate of exposure was low (3%) and no implant was lost. Dexon mesh wrapping was similar to scleral wrapping with respect to complications, although more posterior implant placement was necessary to avoid exposure in the Dexon-wrapped group. CONCLUSIONS: Surgeons and patients must be prepared for many minor complications when using hydroxyapatite orbital implants, but these can be readily overcome. Dexon mesh wrapping of the implant is recommended to avoid using donor tissue.

Ruptured globes following radial and hexagonal keratotomy surgery.

OBJECTIVE: To ascertain if cases of radial keratotomy wound rupture were occurring and whether the globes ruptured through the corneal incisions. DESIGN: Cases of traumatic ruptured globe after incisional corneal refractive surgery were collected from ophthalmologists and from peer-reviewed and other ophthalmic literature. RESULTS: Twenty-eight human eyes (eight previously unreported) are known to have ruptured through refractive corneal incisions in activities of daily living (n = 12), assault (n = 7), motor vehicle accidents (n = 5), and sports (n = 4). Two patients died of their injuries. Of the remaining 26 ruptured eyes, eight (31%) recovered 20/40 or better visual acuity. Six eyes (23%) were totally blinded, six (23%) were legally blinded, and six (23%) had best corrected visual acuity of 20/40 to 20/100 despite multiple surgical procedures. CONCLUSIONS: As radial keratotomy becomes more popular the pool of patients who may experience traumatic ruptured globe will grow. Every patient who has had radial keratotomy should be aware that the surgery has weakened the eye(s).

Carotid-cavernous fistula mimicking Graves' eye disease.

We encountered two patients referred for treatment of Graves' eye disease who had atypical features and were found to have carotid-cavernous fistulae. The relevant clinical findings and investigations used to make this important distinction are described, and the factors involved in the initial diagnostic confusion are analyzed. A correct diagnosis leading to proper treatment was made once atypical features were taken note of and alternative diagnoses considered, despite the context of presumed Graves' eye disease. We conclude that these two entities are quite different but have enough similarities to overlap in certain clinical contexts.

Elastic modulus of orbicularis oculi muscle in normal humans, humans with Graves' eye disease, and cynomolgus monkeys.

We built an experimental apparatus to investigate the passive elastic characteristics of orbicularis oculi muscle and examined specimens from normal humans, humans with stable Graves' eye disease, and cynomolgus monkeys. Stress-strain curves were determined and found to be exponential. The elastic modulus (Young's modulus), analogous to the stiffness of the material, was calculated as a function of strain. Elastic modulus as a function of instantaneous stress was linear. Monkey elastic modulus values were determined, but did not allow meaningful interspecies comparison because of the small sample size. No significant difference was found between normal humans and humans with Graves' eye disease with respect to elastic modulus values.

Periocular granuloma annulare, nodular type. Occurrence in late middle age.

We describe the two oldest individuals with nodular granuloma annulare (pseudorheumatoid nodules) in the ophthalmologic literature and propose a unified classification scheme that recognizes pseudorheumatoid nodules to be granuloma annulare, nodular type. All lesions in both cases revealed so-called necrobiotic granulomas, characterized by an acellular central area containing mucin (hyaluronic acid) surrounded by palisading histiocytes (macrophages), diagnostic of granuloma annulare. These features are identical to those reported in the ophthalmologic and older general pathology literature as pseudorheumatoid nodules and the contemporary general and dermatologic pathology literature as granuloma annulare. We believe the diagnosis of nodular granuloma annulare should be employed for necrobiotic lesions displaying distinctive clinicopathologic features to unite the ophthalmologic, general, and dermatologic pathology literature. Granuloma annulare, nodular type, must also be considered in the differential diagnosis of ocular and periocular lesions at any age.

Treatment of exposed coral implant after failed scleral patch graft.

A case of a coral orbital enucleation implant that exposed and failed two closure attempts, by scleral patch grafting and by simple tissue advancement, is presented. The method used to overcome this problem is detailed. This unique case sheds light on the factors that are etiologically important in coral implant exposure and those relevant to covering that exposure successfully.

Prophylactic lacrimal intubation for protection of the nasolacrimal apparatus during elective orbital osteotomies.

The lacrimal excretory system may be damaged after midface trauma or tumor resection, or injured in association with elective osteotomies involving the medial and inferior orbital walls and rims. Epiphora or problems of recurrent purulent ocular discharge and dacryocystitis may arise. Using the technique described by Crawford, we recently began to intubate at the time of surgery the lacrimal systems of our patients undergoing total midface and orbital osteotomy. Examples of the outcome of this procedure are presented. There were no cases of worsened epiphora or dacryocystitis. We detailed the use of lacrimal intubation in patients who are at high risk for postoperative obstruction of the lacrimal excretory system. Although our study was small and uncontrolled, our intention is to draw attention to the potential of intubation as an adjunct to the craniofacial surgeon's usual procedures.

The position of the eyebrow.

The position of the eyebrow, which varies from person to person, is an important factor determining the final result of blepharoplasty, ptosis, and other aesthetic surgery. We developed a new instrument for measuring the position of the eyebrow--a clear, curved, plastic face mask with inscribed distance gradations in millimeters and a sliding horizontal step to catch the superior orbital rim for measurement.