Late proptosis following orbital floor fracture repair.

OBJECTIVE: Late proptosis is an unusual complication of orbital floor fracture repair. We report 12 cases and propose a classification scheme and differential diagnosis for this rare complication. DESIGN: Retrospective multi-institutional case review. SETTING: Two tertiary referral centers. RESULTS: We report 12 cases of late proptosis following orbital floor fracture repair. Causes of late proptosis include peri-implant inflammation, capsular hemorrhage, gelatin film cyst, implant infection, sino-orbital fistula, intraorbital sinus mucocele, and carotid-cavernous fistula. We describe the treatment of each case individually; in most cases, the implant was removed. All 12 patients had a satisfactory outcome after treatment. CONCLUSIONS: Proptosis presenting 2 months or more after orbital floor fracture is rare. We classify the origin of late proptosis into three groups: implant, sinus, and neurovascular. We describe the diagnosis and management of this unusual complication.

Transconjunctival approach vs subciliary skin-muscle flap approach for orbital fracture repair.

OBJECTIVE: To compare the transcutaneous and transconjunctival approaches for repair of orbital rim and floor fractures. DESIGN: We conducted a retrospective study of the occurrence of eyelid retraction following the repair of 63 orbital fracture, 27 with the subciliary skin-muscle flap approach and 36 with the transconjunctival preseptal approach. SETTING: Academic tertiary referral medical center. PARTICIPANTS: Fifty-nine patients underwent 63 orbital explorations. INTERVENTIONS: Of the 27 transcutaneous explorations, 24 were done early within the first 2 weeks of injury and three were performed for correction of late posttraumatic enophthalmos. Of the 36 transconjunctival explorations, 25 were done early and 11 were performed for correction of late posttraumatic enophthalmos. OUTCOME MEASURE: Clinically noted complications. RESULTS: We found a 12% rate of transient ectropion and a 28% rate of permanent scleral show with the subciliary skin-muscle flap approach compared with no transient ectropion and a 3% rate of permanent scleral show with the transconjunctival approach. CONCLUSIONS: We believe that the transconjunctival approach provides excellent exposure with less risk of postoperative eyelid retraction and ectropion.

Adjunctive hyperbaric oxygen in the treatment of bilateral cerebro-rhino-orbital mucormycosis.

Survival is uncommon in bilateral cerebro-rhino-orbital mucormycosis treated surgically and medically. A 66-year-old man in previously good health had bilateral cerebro-rhino-orbital mucormycosis and newly diagnosed nonketotic diabetes mellitus at initial examination. Total loss of vision, proptosis, and ophthalmoplegia of both eyes were present. The patient was treated with aggressive surgical and medical therapies that included bilateral orbital exenteration, intravenous and local amphotericin B, hyperbaric oxygen, and control of the diabetes mellitus. One and one-half years after onset of the illness, the patient is alert and clinically stable. The importance of prompt diagnosis and aggressive treatment of this disease is emphasized by this case. Additionally, we suggest that adjunctive hyperbaric oxygen is a reasonable modality in the treatment of this often fatal disease.

Synergistic enhancement of type I and III collagen production in cultured fibroblasts by transforming growth factor-beta and ascorbate.

Transforming growth factor-beta (TGF-beta) is a prototype of a family of polypeptides that regulates cellular growth and phenotypic differentiation [(1986) Science 233, 532-534; (1987) Cell 49, 437-438]. TGF-beta injection induces angiogenesis and fibrosis locally [(1986) Proc. Natl. Acad. Sci. USA 83, 4167-4171; (1987) Science 237, 1333-1336] and stimulates the synthesis of extracellular matrix proteins, fibronectin, collagens, and proteoglycans in vitro in many cell types [(1986) J. Biol. Chem. 261, 4337-4345; (1987) Biochem J. 247, 597-604]. Ascorbate is also known to induce collagen synthesis and to promote wound healing [(1988) J. Invest. Dermatol. 90, 420-424; (1986) Coll. Rel. Res. 6, 455-466]. We report that in cultured human skin fibroblasts, ascorbate and TGF-beta synergistically enhance the biosynthesis of type I and III collagens and their steady-state mRNAs. TGF-beta alone has no enhancing effect on type III collagen synthesis. The cooperation between ascorbate and TGF-beta may be of significance in wound healing and in disorders of fibrosis.

Septal perforation closure utilizing the external septorhinoplasty approach.

Nasal septal perforations can be technically difficult to close permanently, particularly if they are large, located posteriorly, or associated with little residual septal cartilage and bone. By allowing direct access to the usually undisturbed dorsal septum, septal flaps are easier to elevate with the external septorhinoplasty approach. Also, better visualization and more room in which to work are afforded by this approach, enabling the surgeon to close perforations that might be more technically difficult to close using standard intranasal incisions. The technique of external septorhinoplasty combined with septal mucoperichondrial advancement flaps and a supporting graft of mastoid periosteum, cartilage, or ethmoid bone was used to close perforations up to 4 cm in diameter in 22 patients from 1981 to 1983 with a 77% (17/22) complete closure rate. Symptomatic improvement was noted by all patients.