Alison B. Callahan

Infantile hemangiomas: A review

Infantile hemangiomas (IH) are the most common eyelid and orbital tumors of childhood. Although they are considered benign lesions that have a generally self-limited course, in the periocular region, they have the potential to cause amblyopia, strabismus, and severe disfigurement. The decision for treatment can be a source of anxiety for patients, parents, and physicians alike. There are numerous treatment modalities, including emerging therapies that may make treatment safer and more effective than ever before. This review discusses our current understanding of this disease, its management, and future therapies.

Plus Disease in Retinopathy of Prematurity: Quantitative Analysis of Standard Published Photograph

dose group. At the visit 10±2 weeks after stopping the levodopa treatment, the mean change in visual acuity in the amblyopic eye from baseline was 5 (±4) letters in the lowerdose group and 4 (±5) letters in the higher-dose group. Levodopa-carbidopa was not discontinued by any subject during the 9-week dosing regimen. Adverse events were reported for 8 of 16 subjects (29 events) in the lowerdose group and 11 of 17 subjects (26 events) in the higherdose group (eTable 2). No adverse events were considered serious. Headaches were reported by 6 subjects; a cold, upper respiratory tract infection, and cough were reported by 6; rash was reported by 4; and nausea and vomiting were reported by 3.

Prophylactic Postoperative Antibiotics for Enucleation and Evisceration

Purpose:To investigate the necessity and usefulness of prophylactic postoperative antibiotics in patients undergoing enucleation or ocular evisceration. Methods:A retrospective, multicenter, comparative case series was designed. After obtaining Institutional Review Board authorization, a medical records’ review was conducted. Demographics, indication for surgery, surgical technique, postoperative antibiotic dosing, and postoperative course were evaluated. Records were grouped according to antibiotic protocols, and presence or absence of postoperative wound infection (orbital cellulitis) was recorded. Rates of postoperative infection were analyzed statistically. Results:Between 1996 and 2011, 666 evisceration or enucleation surgeries were conducted at 4 institutions. Six hundred forty-eight records were available for analysis, of which 4 were excluded due to insufficient follow-up data. All the remaining 644 patients received a single, perioperative, intravenous dose of antibiotics. Five hundred seventy-eight patients (90%) received an orbital implant, while 66 (10%) did not. Three hundred eighty-one patients (59%) received postoperative antibiotics, and 263 patients (41%) did not. Two cases were identified with signs suggestive of infection, but no culture-positive infections were found, and no patient was admitted to the hospital for management. Of the 2 suspicious cases, 1 was found in the group that received postoperative antibiotics (group 1) and 1 in the group that did not receive postoperative antibiotics (group 2). No statistically significant difference in postoperative infection rate was noted between the 2 groups (p = 0.52). While patients with infectious indications for surgery were more likely to receive postoperative antibiotics (p < 0.001), there was no statistically significant difference in rates of infection among patients with infectious indications for surgery based on receiving or not receiving postoperative antibiotics (p = 0.79), and no patients with infectious indications for surgery not receiving postoperative antibiotics developed a postoperative infection. Conclusions:This study demonstrates the clinical safety of withholding postoperative prophylactic antibiotics in orbital surgery even when implanting alloplastic material in a sterile field. Furthermore, Centers for Disease Control and Prevention guidelines mandate cessation of postoperative antibiotics within 24 hours of surgery. Surgeons are cautioned not to generalize these results to nonsterile surgery such as sinonasal or nasolacrimal surgery.

Malignant rhabdoid transformation of a longstanding, aggressive, and recurrent orbital angiomyxoma.

A 47-year-old woman presented with a medial orbital tumor initially diagnosed as either a myxoid neurofibroma or myoepithelioma. Over 30 years the tumor recurred seven times and was serially debulked. Careful histopathologic analysis coupled with immunohistochemical studies performed on the last two biopsies established the rare diagnosis of a locally aggressive angiomyxoma (because of its local infiltrative growth) with myofibroblastic features (smooth muscle actin and calponin positivity and desmin negativity). The last recurrence manifested at a shorter interval than the earlier ones, suggesting an accelerating clinical course. By this late stage there was complete blindness, a frozen globe, and extreme, unmeasurable proptosis accompanied by massive chemosis and eyelid fullness. An exenteration was performed, and the orbital contents contained a persistent angiomyxoma, but additionally, another cellular population had emerged-mitotically active cells with a malignant rhabdoid phenotype (round shape, cytoplasmic hyaline/globoid inclusions composed of whorls of compact vimentin filaments as well as epithelial membrane antigen and focal cytokeratin positivity). This is the first orbital case of a rhabdoid transformation of a benign orbital mesenchymal tumor. Shortly after the exenteration, multifocal metastases, notably to the lungs, were found, leading to the introduction of chemotherapy, which was discontinued because of non-responsiveness of the tumor and patient intolerance. After 1 year of follow up, the patient is still alive, but has persistent active disease with widespread metastases and a guarded prognosis.

Intraorbital foreign bodies: retrospective chart review and review of literature.

An uncommon, yet highly morbid, form of ocular trauma is foreign body penetration of the orbit. Management depends on a variety of factors including composition of the foreign body, location, present or future need for magnetic resonance imaging (MRI), and patient preference. Although organic materials, such as wood, are almost universally removed immediately due to their potential for inflammation and infection, metal foreign bodies may be managed more conservatively if their location and composition are innocuous. However, metal foreign bodies also may have late sequelae including local and systemic infection, inflammation, and toxicity. Surgical removal of orbital foreign bodies is commonly recommended, but exposes the patient to risk of harm to the visual apparatus. When foreign bodies lie in particularly high-risk locations, surgery may cause more damage than observation. In some cases, patients with metal foreign bodies may present in need of MRI many years after initial trauma. Although considered a contraindication for MRI, data exist in cautious support of imaging despite known metal foreign body. To better understand orbital foreign bodies and their management, a retrospective chart review was performed, examining their incidence, composition, location, patient demographics, management, and complications at an academic tertiary care center. The relevant literature on observation, surgery, and imaging in relation to intraorbital foreign bodies was analyzed in the context of our findings.

Low-Cost 3D Printing Orbital Implant Templates in Secondary Orbital Reconstructions

PURPOSE Despite its increasing use in craniofacial reconstructions, three-dimensional (3D) printing of customized orbital implants has not been widely adopted. Limitations include the cost of 3D printers able to print in a biocompatible material suitable for implantation in the orbit and the breadth of available implant materials. The authors report the technique of low-cost 3D printing of orbital implant templates used in complex, often secondary, orbital reconstructions. METHODS A retrospective case series of 5 orbital reconstructions utilizing a technique of 3D printed orbital implant templates is presented. Each patients Digital Imaging and Communications in Medicine data were uploaded and processed to create 3D renderings upon which a customized implant was designed and sent electronically to printers open for student use at our affiliated institutions. The mock implants were sterilized and used intraoperatively as a stencil and mold. The final implant material was chosen by the surgeons based on the requirements of the case. RESULTS Five orbital reconstructions were performed with this technique: 3 tumor reconstructions and 2 orbital fractures. Four of the 5 cases were secondary reconstructions. Molded Medpor Titan (Stryker, Kalamazoo, MI) implants were used in 4 cases and titanium mesh in 1 case. The stenciled and molded implants were adjusted no more than 2 times before anchored in place (mean 1). No case underwent further revision. CONCLUSIONS The technique and cases presented demonstrate 1) the feasibility and accessibility of low-cost, independent use of 3D printing technology to fashion patient-specific implants in orbital reconstructions, 2) the ability to apply this technology to the surgeons preference of any routinely implantable material, and 3) the utility of this technique in complex, secondary reconstructions.

Reactivation of Thyroid Associated Orbitopathy Following Trauma with Intraorbital Foreign Body

Abstract A 63-year-old female with mild, bilateral, stable thyroid-associated orbitopathy sustained trauma resulting in glass foreign bodies embedded on the left ocular surface and left lateral orbital extraconal and intraconal space. After 2 orbitotomies including a failed attempt to remove the intraconal foreign body and poor response to oral steroids, she developed severe, progressive left periorbital edema and 9 mm of relative proptosis. Serial, post-operative imaging demonstrated worsening inflammatory changes along the surgical tract, which slowly improved over several months, with simultaneously worsening proptosis and enlargement of the left inferior and medial rectus muscles consistent with worsening thyroid orbitopathy. She subsequently underwent unilateral 3-wall orbital decompression with improvement in her symptoms. Periorbital trauma with orbital foreign bodies and related surgical trauma may result in reactivation of thyroid-associated orbitopathy.

Microdebrider Use in Orbital Surgery

Abstract Purpose: To report the novel use of a sinus microdebrider for the removal of tissue during orbital surgery. Methods: This retrospective study reviewed the logs of 3 surgeons to identify patients who required orbital surgery during which the surgeon chose to use a sinus microdebrider with an open sky technique as a means of removing portions of the orbital tissue. Collected data included patient demographics, clinical examinations, pathologic diagnoses, radiologic studies, operative reports and, when available, photographs and intra-operative video. Results: Three patients were identified as having undergone orbital surgery assisted by the use of a sinus microdebrider. The first patient had an extensive, recurrent left orbital myxoid tumor. Debulking of this gelatinous, infiltrative mass was aided by the combined suction and cutting action of the microdebrider. Two cases involved orbital exenteration for infiltrative sino-orbital fungus infection resulting in a blind eye and frozen globe. Removal of orbital apical tissue during exenteration surgery was facilitated with the microdebrider. Conclusions: The characteristics of the sinus microdebrider make it a useful adjunct for orbital surgery, particularly in situations where tissue may be difficult to grasp and excise. Caution should be exercised whenever using this electrically powered tool due to its potential for rapid tissue destruction. Therefore, the microdebrider should only be used in cases in which there is little risk of damage to essential orbital structures.

Cauda equina involvement in Susac's syndrome.

Susacs syndrome is a rare autoimmune microangiopathy characterized by the clinical triad of encephalopathy, branch retinal artery occlusions, and sensorineural hearing loss. In many cases, the clinical triad is not fully present at the onset of symptoms. MRI studies often show characteristic punched out lesions of the central fibers of the corpus callosum, and leptomeningeal enhancement and deep gray matter lesions may also be seen. Here we present a case of Susacs syndrome in a middle aged man with the unique clinical finding of cauda equina syndrome and spinal MRI showing diffuse lumbosacral nerve root enhancement. Biopsy specimens of the brain, leptomeninges, and skin showed evidence of a pauci-immune endotheliopathy, consistent with pathology described in previous cases of Susacs syndrome. This case is important not only because it expands the clinical features of Susacs syndrome but also because it clarifies the mechanism of a disorder of the endothelium, an important target for many disorders of the nervous system.

Minimally invasive approaches to eyebrow lifting.

Brow lifting has become an important part of rejuvenation of the face, as surgeons have begun to think of the entire face as a unit, rather than individual parts. Proper positioning of the forehead is critical for overall facial synergy. In addition, the brow is a fundamental part of the upper face-eyelid continuum, as good brow position is necessary to achieve desired upper eyelid position and contour.