Primary implant placement with evisceration in patients with endophthalmitis.

OBJECTIVE: To evaluate the efficacy of primary orbital implant placement with evisceration in patients with endophthalmitis and blind eyes. DESIGN: Retrospective noncomparative case series. PARTICIPANTS: Eleven patients with endophthalmitis and blind eyes underwent evisceration by two surgeons between 1994 and 1998. INTERVENTION: Evisceration and primary orbital implant placement. MAIN OUTCOME MEASURES: All patients were evaluated for implant exposure and successful fitting of their prostheses. RESULTS: Ten of 11 patients had uneventful postoperative courses and successful prosthetic fitting. One patient with Pseudomonas aeruginosa endophthalmitis had an implant exposure successfully treated with a fascia lata patch. CONCLUSIONS: Primary orbital implant placement with evisceration in patients with endophthalmitis is an acceptable treatment, eliminating the need for open evisceration and subsequent delayed orbital implant placement.

Intravascular papillary endothelial hyperplasia: collection of four cases and a review of the literature.

Intravascular papillary endothelial hyperplasia is a benign tumor that rarely presents in the orbit and ocular adnexa. Generally, it occurs as an isolated eyelid mass, not associated with systemic or local disease. Histopathologically, it can be easily confused with angiosarcoma or Kimura's disease. We present our experience with four cases of this tumor in the ocular adnexa, along with a literature review.

High-density porous polyethylene (Medpor) as a successful anophthalmic socket implant.

BACKGROUND: High-density porous polyethylene (Medpor) has been used successfully as an implant in orbital fracture repair and in the management of both cosmetic and post-traumatic facial deformities. The material is well tolerated, resists infection, is nonantigenic, and promotes tissue ingrowth. Additionally, sutures can be passed through it. These characteristics led to its use as an implant in anophthalmic socket surgery. METHODS: Twenty-one patients with anophthalmia underwent implantation of spherically shaped high-density porous polyethylene implants. The implant was used in six primary enucleations with direct extraocular muscle attachment, ten secondary implant insertions, one repeat secondary implant insertion, and five eviscerations. RESULTS: Postoperative follow-up averaged 19 months. During this period, there were no extrusions, infections, significant inflammatory responses, or implant exposures. One implant was removed 4 months after insertion due to inadequate initial placement secondary to a severe post-traumatic orbital deformity. Successful re-implantation was performed without complication. Postoperatively, all sockets showed good to excellent motility. Results of histologic examination of the removed implant demonstrated minimal inflammatory response and extensive fibrovascular ingrowth involving 60% of the implant substance. CONCLUSIONS: This initial report indicates that high-density porous polyethylene can be used successfully as an implant in anophthalmic socket surgery. Its advantages over other similar implants include a significantly lower material cost and the ability to suture the extraocular muscles directly to it without the need for a covering material such as fascia or sclera. Experimental studies are in progress to determine if this implant can be integrated with an ocular prosthesis to promote improved motility and cosmesis.

Animal model of porous polyethylene orbital implants.

Ophthalmologists continue to search for the ideal orbital implant for the anophthalmic socket. The successful long-term clinical performance of an implantable prosthesis is highly dependent on the materials from which the device is fabricated. Among the materials issues are chemistry, surface texture, and porosity. Polyethylene, a polymer comprised of simple hydrocarbon chains, is highly resistant to biological degradation and possesses mass and fabrication properties that would be favorable in an orbital implant. In this report, our early experimental experience with porous polyethylene orbital enucleation implants is reported. Our findings are sufficiently encouraging to warrant further exploration and refinement of the polyethylene device examined.

Transconjunctival entropion repair.

Involutional lower-eyelid entropion has three underlying correctable causes: eyelid laxity, overriding of the orbicularis oculi muscle, and attenuation of the lower-eyelid retractors. We describe a new technique for correcting this problem. A transconjunctival approach is used to advance or fortify the lower-eyelid retractors. The orbicularis oculi muscle can also be addressed through this approach. Combining this technique with lateral canthal resuspension anatomically corrects the entropion by addressing all three correctable causes. Transconjunctival blepharoplasty can also be performed in conjunction with this technique. Twenty-three eyelids of 18 patients successfully underwent this procedure. Six patients underwent simultaneous transconjunctival blepharoplasty. Follow-up ranged between 9 and 18 months. There were no postoperative recurrences, overcorrections, or lower-eyelid retraction. This approach yields a stable and definitive repair of involutional entropion with excellent postoperative cosmesis.

Outpatient dacryocystorhinostomy.

We report 105 dacryocystorhinostomy procedures in 87 patients performed on an outpatient basis. Seventy-six patients received local, and 29 received general, anesthesia. The patients left the hospital an average of 2.6 hours after surgery, but 14 were admitted after surgery--9 immediately, and 5 after some delay, primarily for epistaxis. There were no serious complications related to the outpatient nature of the surgery. The success rate was 94%. We conclude that outpatient dacryocystorhinostomy is successful, well accepted by patients, and safe, provided that inpatient care facilities are readily available should they be needed.

Autogenous fascial grafts for exposed retinal buckles.

Three patients with exposed scleral buckling elements received autogenous fascial grafts as an alternative to buckle removal. All three patients had successful coverage of their scleral buckles. There were no redetachments or infections. One patient had a postoperative ptosis that required repair. Autogenous fascial grafts are useful procedures in patients with exposed retinal buckles who have a significant risk of retinal redetachment with buckle removal.

Further modifications of the Müller's muscle-conjunctival resection procedure for blepharoptosis.

A modified Müller's muscle-conjunctival resection procedure was performed to correct minimal to mild blepharoptosis with good levator function. A semilinear formula was used to excise specific amounts of Müller's muscle for different amounts of blepharoptosis. This formula was modified by less than adequate responses with the phenylephrine test. The phenylephrine test was also used to unmask contralateral ptosis so that bilateral surgery or less resection on the primarily ptotic eye could be planned. This modified technique and formula provides an approach to better quantitate minimal to mild ptosis surgery and yield more predictable results.

Orbital volume augmentation with adjustable prefabricated methylmethacrylate subperiosteal implants.

Prefabricated right and left subperiosteal implants were used in nine anophthalmic sockets to correct superior sulcus deformities. The advantages of these implants include increased stability, easy insertion under direct visualization and the possibility of easy retrieval if necessary, and custom modification for volume and shape intraoperatively, with the addition of methylmethacrylate. There were no extrusions, implant migrations, or infections. Complications included mild undercorrection, upper eyelid blepharoptosis, and transient ectropion.

Carbon dioxide laser treatment of the conjunctiva and the cornea.

Carbon dioxide (CO2) laser treatment was applied to the cornea and conjunctiva of 16 eyes from eight young pigs at power levels of 2.5 to 20.0 W, an exposure time of 0.1 seconds and different numbers of overlapping burns. Four animals were euthanatized at 30 minutes, one at 36 hours and three from 18 to 21 days after the treatment. Nitrous oxide (N2O) cryotherapy also was applied in a double freeze-thaw fashion to three of the eyes to compare the effects of the CO2 laser and cryotherapy at each of the time intervals. Epithelial destruction was achieved with CO2 laser power levels of 5.0 W and one or more superimposed burns. At 5.0 W, Bowman's membrane was destroyed while the conjunctival substantia propria protected the underlying sclera. The anterior chamber reaction was minimal and appeared to be less intense than with cryotherapy after 36 hours. At high energy levels (20.0 W), corneal and scleral perforation occurred. Furthermore, we have treated five human patients with the CO2 laser for bulbar conjunctival epithelial proliferative disorders. Minimal scarring occurred and local control of the disease was obtained in four patients. The CO2 laser may offer advantages over other modalities of treatment for bulbar conjunctival epithelial disorders. Its use is not recommended for lesions of the cornea and forniceal or palpebral conjunctiva.

Dysthyroid orbitopathy.

Dysthyroid orbitopathy often presents with the classical signs and symptoms of hyperthyroidism with or without pretibial myxedema. However, it may start insidiously without a history of thyroid disease and without clinical signs of hyperthyroidism. The signs or symptoms may be confusing and mimic neurologic disease. The therapy of dysthyroid orbitopathy is becoming more accurately individualized, but is not yet directed at the immunologic cause.

Lacrimal drainage system inflammatory masses from retained silicone tubing.

In two cases studied we found inflammatory masses of the lacrimal system associated with retained silicone material. We saw the first patient two years after a failed dacryocystorhinostomy. A mass of the superior punctum mimicking a lacrimal sac or canalicular neoplasm consisted of chronic granulomatous inflammation centered around retained silicone tubing. In the second patient, a foreign body giant cell inflammatory reaction occurred in the lacrimal sac in which there were retained knots of silicone tubing. We believed the inflammation in these patients to be caused by the knots and the cut ends of the silicone tubing present in the lacrimal drainage system.

The nonspecific orbital inflammatory syndromes.

The nonspecific orbital inflammatory syndromes are a peculiar group of inflammations that may occur in acute or subacute forms and can become chronic. They may be diffuse or primarily localized to a specific tissue of the orbit. The nonspecific inflammations that are targeted toward specific tissues are myositis, dacryoadenitis, perineuritis, and periscleritis. Each of these syndromes has definite signs, symptoms, ultrasonic and radiologic findings. Therefore, this group of nonspecific inflammations should be more clearly classified for purposes of better understanding and better management. All of these inflammatory syndromes in the acute form respond well to high doses of oral corticosteroids tapered gradually over a period of months, but may be reoccurrent or become chronic. The subacute form responds less well. Occasionally, patients require radiation to stop the inflammation in the subacute or chronic state, but these patients are often left with a functional deficit. The cause, although presumed to be an immune disorder involving the orbital tissues, remains unknown.

Computed tomography of orbital myositis.

The computed tomographic (CT) scans of 11 consecutive patients with orbital myositis were reviewed to better characterize the CT appearance of this condition. The findings in this series differed from those of previous reports in several ways. Multiple muscle involvement predominated. Bilateral involvement was more frequent than previously reported. Enlargement of the tendon as well as the muscle was a frequent finding, but a normal tendinous insertion did not preclude the diagnosis of orbital myositis. Although the CT appearance of orbital myositis is often helpful, the findings are not pathognomonic; correlation with history, clinical findings, and therapeutic response must be considered in making the diagnosis.