A Technique for Severe Lower Eyelid Retraction: The Fascia Lata Sling with Lateral Burr Hole.

BACKGROUND: Lower eyelid retraction is a common and feared complication of both disease processes and aesthetic and cosmetic surgical procedures. A four-finger approach has been previously described to determine adequate treatment of lid retraction. In the authors' experience, they have found that even the most aggressive treatment approach-subperiosteal cheek lift with canthopexy and interpositional graft-is inadequate to address severe lower lid retraction. METHODS: The authors propose a technique of a lower lid fascial sling with a lateral burr hole for support to be used when all five fingers are needed to correct the lower lid retraction. Review of 134 patients who underwent the fascia lata sling with lateral burr hole for severe lower lid retraction was performed. RESULTS: The fascia lata sling with lateral burr hole adequately corrected the lid retraction in all but one patient in one procedure. This patient had persistent lateral ectropion and underwent revision canthoplasty, resulting in resolution of the lateral ectropion. CONCLUSION: The fascia lata sling with lateral burr hole is a reliable procedure to correct lid retraction from a wide variety of causes.

Managing a long-recurring primary orbital hemangiopericytoma.

Hemangiopericytomas are uncommon vascular neoplasms that originate from the pericytes lining capillaries and postcapillary venules. Few cases of primary orbital hemangiopericytoma have been reported. We present a 61-year-old woman with longstanding, recurrent benign orbital hemangiopericytoma and results of its successful removal.

Superior Ophthalmic Vein Access for Embolization of an Indirect Carotid Cavernous Fistula.

Carotid cavernous fistulae (CCF) are defined as abnormal connections between the carotid circulation and cavernous sinus. CCFs can be categorized as being direct or indirect. Direct CCFs are usually associated with trauma, whereas indirect CCFs are associated with revascularization following cavernous sinus thrombosis. We present a case of a 53-year-old male who presented with tinnitus, proptosis, conjunctivitis, and blurry vision. The patient had a recent endovascular transvenous embolization that was only partially successful, with a residual carotid cavernous fistula draining to the left superior ophthalmic vein and multiple cortical veins. A physical examination of the patient showed elevated intraocular pressures bilaterally. The patient had a high-flow indirect carotid cavernous fistula with bilateral superior ophthalmic vein (SOV) and retrograde cortical vein drainage. The SOV was punctured with a micropuncture needle and was used to successfully gain access to the cavernous sinus. Multiple coils were placed in the posterior aspect of the sinus until there was complete occlusion of venous flow. Coils were packed up to the posterior aspect of the orbit near the junction of the cavernous sinus with the SOV, and the embolization was successful. Indirect CCFs have gradual onset and are usually low-flow. Low-flow CCFs might improve with medical management.Some CCFs may cause ocular manifestations and can be symptomatically managed with prism therapy or ocular patching for diplopia, lubrication for keratopathy, or topical agents for elevated intraocular pressures. However, patients presenting with persistent ocular morbidity may require surgical or endovascular intervention.

Effect of optic nerve sheath fenestration for idiopathic intracranial hypertension on retinal nerve fiber layer thickness.

The objective of the study was to evaluate whether optic nerve sheath fenestration in patients with idiopathic intracranial hypertension was associated with improvement in visual field pattern deviation and optical coherence tomography retinal nerve fiber layer thickness.The records of 13 eyes of 11 patients who underwent optic nerve sheath fenestration were reviewed. The subjects were patients of a clinical practice in Dallas, Texas. Charts were reviewed for pre- and postoperative visual field pattern deviation (PD) and retinal nerve fiber layer thickness (RNFL).PD and RNFL significantly improved after surgery. Average PD preoperatively was 8.51 DB and postoperatively was 4.80 DB (p = 0.0002). Average RNFL preoperatively was 113.63 and postoperatively was 102.70 (p = 0.01). The preoperative PD and RNFL did not correlate strongly.Our results demonstrate that PD and RNFL are improved after optic nerve sheath fenestration. The pre- and postoperative RNFL values were compared to the average RNFL value of healthy optic nerves obtained from the literature. Post-ONSF RNFL values were significantly closer to the normal value than preoperative. RNFL is an objective parameter for monitoring the optic nerve after optic nerve sheath fenestration. This study adds to the evidence that OCT RNFL may be an effective monitoring tool for patients with IIH and that it continues to be a useful parameter after ONSF.

Effect of resection of an orbital arteriovenous malformation on central venous pressure.

We report the first utilization of intraoperative central venous pressure (CVP) monitoring in the resection of an orbital arteriovenous malformation. A 24-year-old woman with a history of a left orbital mass who had previously undergone resection of a cranio-orbital arteriovenous malformation presented with gradual recurrence in the left orbit. She visited the emergency department with sudden vision loss, which resolved over several hours. This transient vision loss was thought to be due to a steal phenomenon from the ophthalmic artery due to the residual vascular malformation. Further surgical resection was undertaken. A preoperative angiogram identified residual feeding vessels, and the larger vessels were embolized. At the start of the procedure, her CVP was elevated (29 mm Hg), as measured by a central venous line. The remaining feeding vessels were surgically ligated, and an intraoperative arteriogram confirmed their successful ablation. At the conclusion of the procedure, the CVP had decreased to 9 mm Hg.

Periorbital cellulitis due to cutaneous anthrax.

Virgil's plague of the ancient world, Bacillus anthracis, is rare in developed nations. Unfortunately rural communities across the globe continue to be exposed to this potentially lethal bacterium. Herein we report a case of periorbital cutaneous anthrax infection in a 3-year-old girl from the rural area surrounding Harare, Zimbabwe with a brief review of the literature.

Use of an ultrasonic bone curette (Sonopet) in orbital and oculoplastic surgery.

The use of the Sonopet Omni, an ultrasonic bone curette, has been discussed for ear, nose, and throat, neurosurgical, and maxillofacial procedures. Its use in oculoplastic and orbital surgery has not been extensively described. The Sonopet has a number of advantages that impart particular utility when operating in the orbit. We present three illustrative cases highlighting the unique advantages of the Sonopet: 1) the ability to spare critical soft tissues; 2) the facility to sculpt and restore the complex contour of the orbit; 3) the capability to biopsy infiltrative lesions that may not be as amenable to manipulation with conventional drills; and 4) a small footprint ideal for small operative fields such as the orbit.

Orbital liposarcoma masquerading as a hemangioma.

Liposarcomas are the most common soft tissue sarcomas in adulthood, comprising approximately 20% of all sarcomas; most present in the extremities and retroperitoneum (1). Despite the large amount of adipose tissue in the orbit, orbital liposarcomas are rare. Diagnosis can be challenging due to the rarity of the entity and the pathological similarity to benign adipose tumors (2, 3). Fortunately, the advent of immunohistochemical staining has aided in diagnosis. Management of orbital liposarcoma also can be challenging, as illustrated by the case described herein (4).

A novel solution for superficially placed calcium hydroxylapatite (Radiesse) in the inferior eyelid.

Injectable fillers such as calcium hydroxylapatite (Radiesse) have become increasingly prevalent given their availability as an office procedure as well as their satisfying results. Calcium hydroxylapatite is well suited for use along bony structures in the face such as the inferior orbital rim and zygoma. On the other hand, it is not well suited for injection into the soft periorbital tissues and eyelid. In this case series we describe two cases of misplaced calcium hydroxylapatite in the inferior periorbita and eyelid; with a successful and relatively quick resolution of the complication using saline injections and erbium laser treatments.

Timing of return to normal activities after orbital floor fracture repair.

BACKGROUND: Orbital floor fractures are among the most common facial fractures, and patients and surgeons often ask when the patient can resume normal activities after surgical treatment. This study attempted to address this basic issue by examining wound strength and histologic characteristics after orbital floor fracture repair with three commonly used materials. METHODS: Twenty-one female goats were anesthetized under general anesthesia. A systematic approach was used to fracture both orbits (n = 42 orbits) and measure the energy required to create the fractures. The orbits were repaired with one of three different materials. One-third of the orbits were then refractured at 10, 24, or 45 days after the initial injury. The energy required to fracture the orbit was measured, and histopathologic samples were taken. RESULTS: Preoperative fracture strength was largely regained after 10 days and before 24 days following the initial injury and repair, regardless of fracture repair material. LactoSorb and polyamide sheeting were associated with a lower incidence of postoperative seroma formation and thicker capsule formation than was Silastic sheeting. Wound strength in orbits repaired with Silastic sheeting during the initial postoperative period was inferior compared with orbits repaired with LactoSorb or polyamide sheeting. However, in the longer term, wound strength was not statistically different for any of the materials used in fracture repair. CONCLUSIONS: Orbital floor strength is regained 24 days after repair. The authors now let patients resume normal activities approximately 3 weeks after uncomplicated orbital floor fracture repair. This is one of many clinical factors in assessing the return to normal activities. In addition, LactoSorb and polyamide sheeting are adequate for the repair of simple floor fractures.

Beveled osteotomy with lateral wall advancement and interpositional bone grafting for severe thyroid orbitopathy.

PURPOSE: To present a new technique for orbital decompressions for patients with severe thyroid orbitopathy that minimizes complications while maximizing the amount of decompression. This method involves advancing the lateral orbital wall in such a way as to promote osseous union and minimize cosmetic deformities. METHODS: This paper represents a case series (42 eyes from 26 patients) of orbital decompressions for severe thyroid related orbitopathy. All patients were treated via a graded balanced orbital decompression with advancement of the lateral orbital wall with interpositional bone grafts. Preoperative and postoperative measurements were tabulated and statistically analyzed. RESULTS: All patients demonstrated significant improvement in proptosis with an average Hertel exophthalmometry reduction of 8 mm. In addition, 22 patient orbits with preoperative elevation of intraocular pressure demonstrated an average 7 mm Hg improvement in postoperative intraocular pressure. Seven patients required strabismus surgery postoperatively and no patient developed new onset strabismus after surgery. Of all patients, 54% demonstrated improvement of visual acuity of greater than 1 line and no patient experienced a decrease in visual acuity. Postoperative computed tomography scan demonstrated osseous union of the lateral wall after advancement with this new technique. No patient complained of a palpable deformity of the lateral orbital wall. CONCLUSIONS: The graded balanced orbital decompression with interpositional bone grafts effectively decompressed the orbit with significant improvement in final visual acuity, exophthalmometry measurements, and final intraocular pressure. In addition, this technique promotes osseous union with minimal cosmetic deformities.

Assessment of biomechanics of orbital fracture: a study in goats and implications for oculoplastic surgery in humans.

PURPOSE: To determine the biophysical characteristics of energy absorption of the various orbital structures and the amount of force/energy required to produce an orbital fracture in goats, and to interpret results in terms of human clinical applicability. DESIGN: Experimental animal study. METHODS: The energy required to fracture the orbit on direct globe impact was measured. We used a variety of other measurements, including high-speed videography, intraocular pressure, and intraorbital pressure measurements to describe the biophysics of floor fracture. Twenty-one goats and 42 orbits were studied in this single institutional site study. RESULTS: Our measurements determined the fracture threshold for the caprine orbit averaged 26.5 N (SE 3.1 N) with a total energy threshold for fracture of 2600 mJ (SE 280 mJ). Eye deformation measured 6 mm with deformation energy dissipation measuring 100 to 180 mJ (SE 10 mJ). Eye displacement measured 10 mm with dissipation measuring 50 to 75 mJ (SE 4.0 mJ). The deconvoluted bone fracture energy averaged 2350 mJ (SE 260 mJ). CONCLUSIONS: Impact energy applied to the orbit through the eyeball is absorbed and dissipated by three primary mechanisms: (1) globe deformation, (2) globe displacement, and (3) orbital fracture. Excess energy (above the energy required for deformation and displacement) >or=2350 mJ will result in an orbital fracture.

Improved prosthetic motility with placement of a second coupling PEG.

PURPOSE: Integrated coupled orbital implants have been shown to improve prosthetic motility over noncoupled orbital implants. Some patients are limited in prosthetic motility despite this coupling for various mechanical and physiological reasons. A common limitation of motility in anophthalmic rehabilitation is forniceal constriction or scarring. Anophthalmic patients with coupled integrated implants who were noted to have limited prosthetic motility because of conjunctival scarring, improperly placed coupling pegs, rotation of the prosthesis, or contracture in the fornices underwent placement of a second coupling peg with the aim of improving prosthetic motility. METHODS: Six patients were selected who fit the criteria of poor prosthetic motility despite excellent implant motility. All patients had previously placed hydroxyapatite implants followed by motility peg placement several months later. Titanium motility peg placement was only placed after gadolinium-enhanced magnetic resonance imaging neuroimaging studies were performed to assess proper vascularization of the integrated implant. After determining the direction of motility limitation caused by conjunctival dysfunction, a second titanium motility peg was placed in the standard fashion to improve prosthetic motility. RESULTS: All six patients had improvement of prosthesis motility, as noted by both the patient and surgeon, after second motility coupling peg placement. No complications were encountered. CONCLUSIONS: In select patients with poor translation of implant motility to prosthesis motility, placement of a second motility coupling peg may improve prosthetic motility.