Gun-related eye injuries: A primer.

Gun-related eye injuries are relatively common in the context of gunshot wounds to the head and neck. Many of the fundamental principles of gunshot wound management apply to the care of these patients, but the complex anatomy and functional relationships of the periocular region do pose special challenges. We provide a focused primer for physicians seeking a more in-depth understanding of gun-related eye injuries and present 3 representative cases outlining the spectrum of pathology, provide a focused review of the relevant ballistics concepts, and discuss the management of injuries to the periocular soft tissues, orbital structures, and globe. We found that good cosmetic and functional results can often be achieved with appropriate early intervention, but visual prognosis may remain guarded despite optimal treatment.

The Flip-Back Myocutaneous Advancement Flap for Periocular Reconstruction.

PURPOSE: To present a novel myocutaneous flap for anterior lamellar reconstruction. METHODS: Retrospective interventional case series of consecutive patients who underwent Mohs reconstruction using the flip-back flap. Operations were performed by a single surgeon (DTT) between January 2012 and May 2016. For lower eyelid defects, an extended subciliary incision was made and a skin-muscle flap developed and suspended in the manner of lower eyelid blepharoplasty. A back-cut was used to develop a pedicle from the overlapping tissue, which was then rotated 180 degrees into the defect. A similar method was employed in an inverted manner for upper eyelid defects. Postoperative eyelid function, cosmesis, complications, and need for further interventions were assessed. RESULTS: Ten patients-8 with lower and 2 with upper eyelid defects-were reconstructed using this method. Mean follow up was 18.3 ± 15.5 months with a minimum interval of 4 months. Despite the 180-degree rotation of a relatively narrow pedicle, none of the patients experienced flap necrosis. Postoperative function and cosmesis was satisfactory, with no tissue puckering, notching, or symptomatic retraction. No antimetabolite/steroid injection or surgical revision was required. CONCLUSIONS: The flip-back flap expands the armamentarium of the periocular reconstructive surgeon. Its particular forte is in addressing broad and relatively shallow anterior lamellar defects where sufficient tissues are not available for transposition via a uni- or bipedicle flap. By leveraging the robust periocular vascular plexus and defying traditional guidelines governing pedicle formation and rotation, it permits creation of a local flap in cases where skin grafts or extensive Mustarde-style flaps might otherwise be required.The flip-back myocutaneous flap offers a novel alternative to skin grafting or more extensive cheek rotational flaps for reconstruction of challenging anterior lamellar defects involving the eyelids and adjacent periocular tissues.

A Prospective Randomized Comparative Clinical Trial to Analyze Pain and Surgical Outcomes Between Frontal Nerve Blocks and Subconjunctival Anesthesia for Conjunctival Mullerectomy Resection.

PURPOSE: Conjunctival Müller's muscle resection (CMMR) is a posterior approach surgical technique to correct blepharoptosis. The purpose of this study is to compare patient-reported pain scores and surgical outcomes for patients who received 2 different anesthetic techniques during CMMR, frontal nerve block and subconjunctival injection. METHODS: A prospective randomized comparative clinical trial enrolled 33 CMMR subjects from one tertiary eye center. Patients undergoing unilateral CMMR were randomized to receive either frontal nerve block or subconjunctival injection. For patients undergoing bilateral CMMR, each side was randomized to one of the injection techniques. Upper eyelid margin reflex distance was measured and recorded for each eye before and after surgery. Patients' pain scores were quantified using the Wong Baker Pain Scale. Subjects quantified their pain during, immediately after, 12 and 24 hours after surgery. RESULTS: Twenty-four bilateral and 9 unilateral cases were enrolled in the study. Twenty-two (92%) subjects were female, and the mean patient age was 69 ± 12 years. The mean margin reflex distance was 1.1 mm preoperatively, which increased to 3.5 and 3.6 mm 2 months postoperatively in frontal nerve block and subconjunctival injection groups, respectively (p value <0.0001). Both paired and nonpaired analyses demonstrated no significant difference in the pain score reported by the patients or the surgical outcomes between the 2 anesthesia techniques at any time during or after the surgery. There were no anesthetic-related complications. CONCLUSION: There was no statistically significant difference in pain scores or surgical outcomes in patients receiving frontal nerve block compared with those receiving subconjunctival injection during CMMR surgery.

Advanced single-stage eyelid reconstruction: anatomy and techniques.

BACKGROUND: Skin cancers of the periocular tissue present formidable reconstructive challenges because of anatomic complexity, vital function, and cosmetic significance. OBJECTIVE: To review eyelid anatomy and reconstructive techniques from an oculoplastic surgery perspective. RESULTS: Eyelid structure and function are intimately linked, and good working knowledge is a prerequisite for successful reconstructive efforts. We discuss periocular anatomy, patient evaluation, and single-stage repair of both anterior lamellar and full-thickness defects. CONCLUSION: Despite the challenges of periocular skin cancer reconstruction, excellent cosmetic and functional results can be achieved with appropriate technique.

Transitional cell-type papillary carcinoma of the lacrimal sac manifesting as a medial canthal skin lesion.

A 61-year-old man presented with a 2.5 cm fungating skin lesion above the right medial canthus, accompanied by fluctuance and subtle inferotemporal globe displacement. The tumor had erupted 2 months previously and grown rapidly. Computed tomography (CT) revealed a 4.2 × 2.8 × 2.1 cm exophytic mass of the right orbit, superimposed on chronic dacryocystitis. Incisional biopsy disclosed faulty epithelial maturation sequence with possible basement membrane invasion. The patient underwent wide excision with medial maxillectomy, inferior turbinectomy, ethmoidectomy, and partial rhinectomy. The orbital floor was then reconstructed; a paramedian forehead flap and myocutaneous cheek advancement flap were used to fill cutaneous defects. All surgical margins were negative on both frozen and permanent sections. Definitive histopathology was consistent with transitional cell type papillary carcinoma of the lacrimal sac. Adjuvant radiotherapy was recommended, but the patient has declined further treatment. He remains recurrence-free at one year.

Orbital fractures: national inpatient trends and complications.

PURPOSE: The present study aimed to examine cost, demographics, and short-term complications associated with orbital fractures and their surgical repair in the inpatient population in the United States over a 7-year period. METHODS: A retrospective cohort study was performed by using the Nationwide Inpatient Sample from 2002 to 2008 and searching the database for discharges classified with International Classification of Disease-9 diagnosis codes of orbital fractures, orbital fracture repair, and associated diagnoses. RESULTS: There was nearly a 50% increase in the annual number of orbital fracture admissions from 2002 to 2008. Demographics for patients with orbital fractures showed that 68% of them were male, most commonly between 18 and 44 years of age, with 69% of cases at large teaching hospitals. Associated ocular diagnoses included eyelid laceration, commotio retinae, and globe rupture. Approximately 25% of patients underwent surgical repair. Surgical patients were younger than nonsurgical patients by approximately 10 years. An overall complication rate of 15.8% was noted, including: pulmonary complications, diplopia, renal impairment, venous thromboembolism, and wound complications. Orbital fracture repair was associated with approximately 1 extra day of hospitalization and $22,000 in-hospital charges. The rates of pulmonary, wound, and ocular motility complications were significantly higher in the patients undergoing orbital fracture repair (p<0.05). CONCLUSIONS: The number of orbital fractures and associated cost has dramatically increased over the past decade. Acute repair of orbital fractures is common and is associated with a longer hospital course, increased cost, and higher rate of complications.