The Hook and Release Technique During Enucleation Surgery.

PURPOSE: To describe the results and potential benefit of direct muscle release from the globe during enucleation surgery without identifying sutures in the rectus muscle insertion sites, a technique referred to as the hook and release technique. METHODS: Single center, retrospective chart review of patients who underwent enucleation with direct removal of the rectus muscles without identifying sutures in their insertion sites between January 2011 and September 2015 was carried out. The inclusion criteria were primary enucleation without previous strabismus surgery, retinal detachment surgery, or orbital surgery that entered the fibrous connective tissue framework. Forty charts of enucleated patients that had direct release of their extraocular muscles without identifying sutures before releasing them from the globe were identified and reviewed. The primary outcome measure was intraoperative or immediate postoperative complications. This retrospective chart review was performed with research ethics board approval and in compliance with the Declaration of Helsinki. RESULTS: Data show that following the hook and release technique, the rectus muscles were easily located and reconnected to the orbital implant wrap. The oblique muscles were not reattached. In each of the 40 patients, the 4 rectus muscles were easily located by gently applying traction anteriorly at the conjunctiva/Tenons' edge using double-pronged skin hooks. There was no instance of a lost or slipped muscle following the hook and release technique. CONCLUSION: The hook and release technique is a simple and efficient method to remove the 4 rectus muscles from the globe and still easily locate them. They are not "lost" and do not "slip out of position" but held in place by the orbital connective tissue framework and the extraocular muscle pulley system. This technique has been very helpful teaching resident staff how to do enucleation surgery as it avoids the more time consuming placement of double-armed locking sutures through the rectus muscle insertions and the potential risk of globe penetration while the muscles remain attached to the eye. If the surgeon desires to attach the muscles to the orbital implant, then sutures are passed after the eye is removed, thus eliminating the worry of globe penetration and avoiding accidentally cutting preplaced extraocular muscle sutures during the remaining enucleation procedure.

Localizing the Lost Rectus Muscle Using the Connective Tissue Framework: Revisiting the Tunnel Technique.

PURPOSE: To describe a technique for localizing a lost rectus muscle during strabismus or retinal surgery or following trauma. METHODS: In this single center, retrospective chart review, 5 patients were identified between January 2012 and June 2016 with a lost rectus muscle; 3 during strabismus surgery and 2 post trauma. The inclusion criteria included a lost rectus muscle during strabismus surgery, or a disinserted/lacerated rectus muscle following ocular/orbital trauma. The primary outcome measure was successful reattachment of the rectus muscle. RESULTS: The lost rectus muscle was identified in each patient and reattached to the globe by gently applying traction anteriorly at the conjunctiva/Tenon edge using double-pronged skin hooks and following the path of the rectus muscle through its Tenon capsule tunnel where it remained attached by suspensory ligaments. There was no instance where orbital fat was obscuring or blocking the view of the lost rectus muscles. There were no other complications associated with the procedure. CONCLUSIONS: The authors describe a simple and effective method in 5 patients to localize a lost rectus muscle based on knowledge of the orbital connective tissue framework.

Balanced (endoscopic medial and transcutaneous lateral) orbital decompression in Graves' orbitopathy.

BACKGROUND: To determine the clinical outcomes and morbidity of endoscopic medial wall combined with transcutaneous lateral orbital wall decompression in Graves' orbitopathy. METHODOLOGY: A retrospective noncomparative case series of patients who underwent surgical decompression for Graves' orbitopathy at Hospital Universitario de Fuenlabrada between 2004 and 2014 was performed. We reviewed the patients' charts and analyzed before and after the decompression, the visual acuity (Snellen chart), optic nerve compression (fundoscopy and optic coherence tomography), exophthalmometry (Hertel measurement), ocular motility, diplopia, eyelid surgery needed after decompression and its possible complications. RESULTS: A total of 20 patients (36 orbits) were operated. The mean follow-up was 44 months (range 18-84). Vision improved dramatically in all compressive optic neuropathy cases (5 cases). Hertel measurements improved on average 3.5 mm (range 1.5-4.5). Diplopia was cured in eight patients (40%) and nine patients with severe preoperative diplopia required strabismus surgery after decompression. Eyelid surgery was further needed in 13 patients. Hyaluronic acid injection was the most used technique for the treatment of eyelid retraction (6 out of 13 patients). Only two major complications were observed: one case had a major post-operative epistaxis and another a cerebrospinal fluid leak. Both were resolved without further sequelae. CONCLUSIONS: These results suggest that endoscopic medial wall combined with transcutaneous lateral wall orbital decompression is an effective and safe treatment for the symptomatic dysthyroid eye disease with important proptosis or compressive optic neuropathy.

The Gracillimus Orbitis Muscle.

The gracillimus orbitis muscle is an anomalous, accessory, or supernumerary extraocular muscle that, although is rarely seen clinically in the human orbit, has been identified in 5% to 14% of dissected cadaver orbits. It arises from the medial surface of the levator near its origin and runs forward between the levator and superior oblique muscles resembling one of the other extraocular muscles. More anteriorly, it becomes thinner, less well defined, and mostly fibrous. Its major insertion is into the fascia surrounding the trochlea, while other fibers may travel to the supratrochlear artery, intermuscular septum, the levator or medial rectus muscle, and the fascia surrounding the superior ophthalmic vein. The function of this anomalous muscle remains unknown in most cases. Knowledge of its presence is important as the oculoplastic/orbital surgeon may encounter it during an eyelid or orbital procedure.

Current indications for pegging in the anophthalmic socket: are there any?

PURPOSE OF REVIEW: To highlight the development, problems, and current status of coupling porous orbital implants to the overlying prosthetic eye. RECENT FINDINGS: Although increasing the risk of complications, pegging significantly contributes to prosthesis motility and satisfies the cosmetic expectations of some patients. Patients should be counseled regarding the increased risks in approximately one-third of individuals and that complications can occur even 10 years following implantation. SUMMARY: Although implant peg placement has declined dramatically over the past decade, a precise and meticulous technique under intravenous anesthesia in the appropriately selected patient can be a successful outpatient procedure. Fortunately, most problems are of a minor nature, and over 85% of patients are able to retain their pegs following proper management and timely intervention. Additional visits to the ophthalmic plastic surgeon or ocularist are required that may not be necessary if a peg had not been placed.

Evisceration With Implant Placement Posterior to Posterior Sclera.

PURPOSE: To describe the results and potential benefit of placement of a porous orbital implant (aluminum oxide) posterior to posterior sclera and compare the exposure rate with a former evisceration technique involving a posterior sclerotomy with placement of a porous implant partly within the scleral shell and partly within the intraconal space. METHODS: Single-center, retrospective, interventional case series. A chart review of 93 patients undergoing evisceration with placement of an aluminum oxide orbital implant in conjunction with 2 different posterior sclerotomy techniques between 1999 and 2013 was carried out. Seventy-one patients met the inclusion criteria having 1 of 2 posterior sclerotomy techniques with an aluminum oxide orbital implant, a normal or near normal size eye and at least 6 months follow-up. Retrospective data analysis included demographic profile and treatment outcomes of the different posterior sclerotomy techniques. This study was performed with Institutional Review Board Approval and in compliance with the Declaration of Helsinki. RESULTS: Thirty patients underwent the posterior radial sclerotomy technique, while 41 patients underwent implant placement posterior to posterior sclera technique. The average size implant used in the posterior radial sclerotomy technique was 18 mm versus 20 mm in the implant placement posterior to posterior sclera technique (p < 0.001) with the implant placed posterior to posterior sclera. The exposure rate with the posterior radial sclerotomy technique was 5 of the 30 patients (16.7%) and 0 of 41 (0%) for the implant placement posterior to posterior sclera technique (p = 0.006). CONCLUSION: Placement of an aluminum oxide orbital implant posterior to posterior sclera allowed the placement of larger implants which allowed enhancement of socket volume. In addition, it appeared to have a decreased risk of implant exposure during the study period. Porous implant placement posterior to posterior sclera is an alternate posterior sclerotomy technique that allows coverage of the implant surface with 3 layers of autogenous sclera.

Filler Migration: A Number of Mechanisms to Consider.

PURPOSE: To report 3 representative cases of soft tissue filler identified in locations other than their intended injected sites (possible migration) and review the literature on pathogenesis of filler migration. INTRODUCTION: Soft tissue fillers are continuing to increase in popularity throughout North America and worldwide as a means of volume restoration and contour enhancement. With increasing recognition of their value in restoring a more youthful appearance and the ease of office injection, soft tissue fillers have become one of the most commonly performed nonsurgical cosmetic procedures. Soft tissue fillers are also foreign bodies in our system and therefore have the potential for a myriad of complications both immediately after the injection and potentially months or years later. Filler migration is one such complication and has a number of potential mechanisms. METHODS: The authors reviewed the medical records of 3 patients with filler located in areas other than their intended injected sites possibly as a result of migration. All patients were from the practice of 1 individual (DRJ). A MEDLINE search of the English-language literature on filler migration was conducted to investigate the various causes responsible for migration of filler. RESULTS: Clinical manifestations of the possible filler migration in the 3 cases included eyelid swelling in 2 patients and a noninflammatory mass adjacent to the area of filler injection in the third patient. Surgery was performed on 1 patient, and filler was visualized in the tissue and dissolved with hyaluronidase. Hyaluronidase was also used to dissolve the suspected filler in a second patient, and the third patient has elected to continue with observation. CONCLUSIONS: Filler migration is one of the potential complications associated with the injection of soft tissue fillers. It is important all physicians assessing nodules/masses/swelling in the facial area be aware that soft tissue fillers may migrate to a location away from their intended site of injection by several mechanisms and persist in the tissue even years later. A delayed reaction to the filler may occur months to years later and at times subject the patient to unnecessary investigations in attempt to identify it.

Diplopia from pleomorphic lipoma of the orbit with lateral rectus muscle involvement.

A-55-year-old man with a 2-year history of left proptosis with painless swelling of the upper and lateral bulbar conjunctiva was referred. He had developed diplopia in left gaze. Orbital CT showed left proptosis with a mass measuring 2 × 1 cm in the superolateral and lateral left orbit, with lateral rectus muscle infiltration. The lesion was excised and was found to be diffuse, and an infiltrative mass affecting the anterior portion of the lateral rectus muscle was also removed. The histopathologic diagnosis was pleomorphic lipoma. Only 7 cases of pleomorphic lipomas occurring in ocular adnexal tissues or in the orbit have been previously reported, but in none of the cases had an infiltration of the lateral rectus muscle or diplopia been described before. The histopathologic features and differential diagnosis of this type of soft tissue tumor are also described.