Ophthalmological outcome following orbital resection in anterior and anterolateral skull base surgery.

OBJECT: Partial resection of the orbital bones is not uncommon during the excision of anterior and anterolateral skull base tumors. Controversy exists regarding the need for and extent of the reconstruction necessary following this resection. The authors studied this factor in a series of patients. METHODS: The authors conducted a retrospective review of 56 patients in whom resection of 57 anterior or anterolateral skull base tumors and partial excision of the orbital bone were performed. Adverse ophthalmological outcomes were noted in 16 patients, in nine of whom adverse outcomes were believed to be directly related to resection of the orbital walls. Some degree of orbital reconstruction was performed during 23 of the 57 procedures. An adverse orbit-related outcome was strongly associated with resection of the orbital floor and with resection of two thirds or more of two or more orbital walls but not with the presence of absence or orbital reconstruction. The latter finding, however, is likely a function of selection bias. CONCLUSIONS: In most patients after partial excision of the orbital bones, elaborate reconstruction is not necessary. Isolated medial and lateral orbital wall defects or combined superior and lateral orbital wall defects, especially in cases in which the periorbita is intact, probably do not require primary reconstruction. In cases of orbital floor defects, whether isolated or part of a multiple wall resection, primary reconstruction is recommended.

Porous polyethylene implant fibrovascularization rate is affected by tissue wrapping, agarose coating, and insertion site.

PURPOSE: Often used in facial and ocular reconstruction, biointegratable materials, such as hydroxyapatite and high density porous polyethylene, can be associated with migration, exposure, and infection. Complications are less likely after implants become fibrovascularly integrated. A model was sought to study the influence of multiple factors on the rate of fibrovascular ingrowth into porous implants. METHODS: High density porous polyethylene cubes were implanted into paraspinous skeletal muscles in rabbits. The cubes were explanted at weekly intervals using survival surgery. The number of fibroblasts at the center of each cube was counted, generating a time-dependent standard curve of cell accumulation. Porous polyethylene cubes uncoated, coated with agarose (a plant-derived carbohydrate), or coated with nonperforated sclera (human or rabbit) were implanted into suprascapular adipose and paraspinous skeletal muscle in other rabbits. RESULTS: Fibrovascular ingrowth occurred more rapidly with cube implantation into skeletal muscle versus adipose, with increased surface area contact between implants and muscle, and with removal of muscle capsules. While the rate of fibroblast accumulation decreased in cubes coated with sclera, coating the cubes with agarose increased the fibrous capsule formation without altering the rate of biointegration. CONCLUSIONS: This study provides a novel approach for the study of fibrovascular ingrowth into implants treated under a variety of conditions. Modification of current surgical techniques may increase the rate of porous polyethylene implant biointegration.

Epidermal and fibroblast growth factors enhance fibrovascular integration of porous polyethylene implants.

PURPOSE: Porous implants used in functional and aesthetic reconstruction of the orbit, face, and cranium are less likely to develop complications after they become biointegrated. We investigated whether the administration of exogenous growth factors could increase the rate of implant integration. METHODS: High-density porous polyethylene cubes were placed in dorsal paraspinal muscles of rabbits, and daily transcutaneous injections of saline, epidermal growth factor, or basic fibroblast growth factor were administered directly over the cubes for 10 days. At serial time points up to 10 weeks, cubes were explanted and the fibroblasts present at the center of the cubes were counted. RESULTS: Injections of epidermal growth factor and basic fibroblast growth factor increased the rate at which fibroblasts accumulated in porous polyethylene implants and decreased the time required to achieve a maximal rate of cellular accumulation within the cubes. At 4 weeks, when all cell populations had attained a linear rate of accumulation, cubes previously injected with saline, epidermal growth factor, or basic fibroblast growth factor contained an average of 10, 40, and 80 cells per 0.0156 mm2, at their centers, respectively. CONCLUSIONS: Enhancement of the rate of biointegration of porous polyethylene cubes in rabbits is achievable by repeated, transcutaneous administration of exogenous growth factors.

Growth factors embedded in an agarose matrix enhance the rate of porous polyethylene implant biointegration.

PURPOSE: Repeated injections of epidermal and basic fibroblastic growth factors have been shown to enhance the biointegration rate of implanted porous polyethylene. A study was done to determine whether agarose, introduced at the time of implant placement, might serve as an adequate "single dose" delivery system for endogenous and exogenous growth factors. METHODS: Polyethylene cubes coated with agarose-containing growth factors were implanted into fat and muscle in rabbits. Factors studied included autogenous whole blood, autogenous serum, ascorbic acid, epidermal growth factor, basic fibroblast growth factor, transforming growth factor alpha, and transforming growth factor beta. The rate and character of the fibrovascular ingrowth into implants and surrounding capsule thickness were assessed. RESULTS: Fibroblast infiltration enhanced two- to sixfold with the use of autogenous or allogenic factors introduced in an agarose matrix at the time of cube implantation. CONCLUSIONS: Growth factors studied altered the thickness of the capsule surrounding implants as well as both the vascularity and stromal density within implants.

Visual loss associated with fibrous dysplasia of the anterior skull base. Case report and review of the literature.

The authors present a case of visual loss associated with fibrous dysplasia of the anterior skull base and the surgical management of this case. Preoperative computerized tomography scanning in this patient demonstrated a patent optic foramen and a rapidly growing cystic mass within the orbit, which was responsible for the patient's visual loss. A literature review revealed that this case is typical, in that cystic mass lesions of various types are frequently responsible for visual loss associated with fibrous dysplasia. The authors did not find significant evidence in the literature to support the notion that visual loss associated with fibrous dysplasia is the result of progressive optic canal stenosis, thus raising questions about the value of prophylactic optic canal decompression. Instead, as demonstrated by this case and those uncovered in the literature review, most instances of visual loss result from the rapid growth of mass lesions of cystic fibrous dysplasia, mucoceles, or hemorrhage. Findings of the literature review and the present case of fibrous dysplasia of the anterior skull base support a role for extensive surgical resection in these cases and indicate a need for additional prospective analysis of a larger number of patients with this disease.

Total upper eyelid reconstruction with mucosalized tarsal graft and overlying bipedicle flap.

Total or near-total upper eyelid reconstruction with a mucosalized tarsal graft and overlying bipedicled myocutaneous flap was performed on 12 patients. This technique offers several advantages over other reconstructive methods: (1) the opportunity for immediate visual rehabilitation through a single-staged procedure without obscuration of the visual axis, (2) preservation of eyelid blinking and closure by relocation of functional orbicularis muscle, (3) excellent eyelid contour, and (4) use of tissue physiologically similar to that removed. The technique and clinical results are presented herein.

Bilateral optic disk edema caused by sarcoidosis mimicking pseudotumor cerebri.

PURPOSE: To present a case of retrobulbar optic nerve and chiasm sarcoidosis that mimicked pseudotumor cerebri. METHODS: A 34-year-old, thin, black woman presented with transient visual obscurations, normal visual acuity, bilateral optic disk edema, and enlarged blind spots. Clinical, medical, and radiologic evaluations were consistent with pseudotumor cerebri. The patient improved while taking acetazolamide, but 6 months later her symptoms worsened. Neuroimaging disclosed enhancement of the optic nerve and chiasm. RESULTS: Despite administration of intravenous corticosteroids, the patient's vision worsened. Bilateral optic nerve sheath fenestrations were performed, and pathology disclosed sarcoidosis. CONCLUSION: Sarcoidosis of the optic nerves and chiasm may mimic pseudotumor cerebri.

The ocular complications of periocular laser surgery.

Laser periocular surgery has achieved an increased popularity, especially since recent technical developments in the carbon dioxide and erbium:yttrium-aluminum-garnet lasers. Despite the relative safety of these procedures in experienced hands, postoperative complications affecting the periocular region, and the eye itself, may follow laser surgery. Common complications include persistent erythema, hyper- and hypopigmentation, and hypertrophic scarring. Skin infection (viral, bacterial, or fungal) may also jeopardize the postoperative period after periocular laser treatment. Severe burns, transitory or permanent, lower lid ectropion, and even corneal injuries or ocular perforation are among the most severe hazards. A thorough preoperative evaluation, appropriate training, and a cautious and conservative approach are reinforced to minimize such problems.

Tarsal patch-flap for orbital implant exposure.

The authors determine the efficacy of a new technique, the tarsal patch-flap, in the management of postenucleation and postevisceration porous orbital implant exposures that are recalcitrant to other surgical approaches. All patients treated during a 30-month period with recurrent orbital implant exposures who failed at least one surgical attempt at defect closure were treated using a tarsal patch-flap, a fornix-based tarsoconjunctival flap from the upper eyelid. Eight patients, six after enucleation and two after evisceration, were treated with a tarsal patch-flap. Five implants were porous polyethylene and three were hydroxyapatite. The defect size ranged from 4 mm to 12 mm (largest dimension). All eight patients have maintained closure of their defects for a mean follow-up of 13.8 months (range, 4-30 months). The vascularized tarsal patch-flap provides an excellent alternative surgical approach to the management of recurrent orbital implant exposures recalcitrant to Tenon-conjunctival advancement and autologous fascia grafting.

Conjunctival cysts of the orbit.

OBJECTIVE: This study reviews functionally and anatomically disruptive features of simple conjunctival orbital cysts. DESIGN: A case series review from four oculoplastic practices over 6 years. PARTICIPANTS: Eleven patients with simple conjunctival cysts of the orbit were identified. INTERVENTION: All cysts were excised and evaluated histopathologically. MAIN OUTCOME MEASURES: Assessment was made of the length of time from inciting event to presentation, preoperative and postoperative refractive state and ocular motility, the presence or absence of discomfort, and radiographic or clinical evidence of bone remodeling. RESULTS: Six of 11 cysts were presumed to be primary, unrelated to antecedent surgery or trauma. Four of 11 cysts were associated with pain or tenderness, 5 cysts induced ocular motility disturbance, 6 cysts caused observable globe distortion or refractive error change, and 6 cysts remodeled bone. CONCLUSIONS: Simple conjunctival cysts of the orbit, traditionally regarded as low-pressure lesions with minimal structural impact, may induce considerable anatomic and functional disruption.