Arthur L. Millman

Prediction of Late Enophthalmos by Volumetric Analysis of Orbital Fractures

The purpose of this study was to determine whether orbital volume assessment by computerized tomography (CT) could provide additional information for the initial evaluation of orbital blowout fractures and guide optimal treatment. The medical records of 30 patients with orbital blowout fractures, either surgically or conservatively managed, were retrospectively reviewed. Orbital volumetric analysis was then determined from digitized CT scans. Fracture-related volume expansion relative to the unaffected fellow orbit was correlated with motility deficits and location and degree of enophthalmos. Early Hertels measurements (< 4 weeks) were available in 21 patients and did not correlate with the computer volumetric values or with subsequent late enophthalmos. Late Hertels measurements (> 4 weeks) were obtained in 13 of 15 nonrepaired fractures and in 5 of 15 surgically repaired patients (late presentation; 18 patients). When seen at more than 4 weeks, 11 (92%) of 12 patients with > or = 13% orbital volume expansion manifested significant enophthalmos (> 2 mm) compared with 1 (17%) of 6 patients with < 13% orbital expansion (p = 0.004). Fractures presenting with enophthalmos on initial examination had extensive medial wall involvement in addition to the floor fracture (p = 0.003). CT measurements of orbital volume can predict the final degree of late enophthalmos and may facilitate the planning of surgical intervention.

Herpes Zoster Ophthalmicus in Patients at Risk for the Acquired Immune Deficiency Syndrome (AIDS)

In a prospective investigation of 54 consecutive cases of herpes zoster ophthalmicus, conducted over a two-year period, immunologic evaluations included enumeration of T lymphocyte subsets and serum immunoglobulin levels. Herpes zoster ophthalmicus occurred with frequent ocular complications in a subgroup of adults distinguishable by their young age, the presence of AIDS-risk factors, alterations in T-cell subpopulations, and polyclonal increases of serum gammaglobulin. Over the study duration, 21% (three of 14) of the AIDS-risk subgroup patients have developed AIDS with a 14% (two of 14) mortality. Herpes zoster ophthalmicus in AIDS-risk group members appeared to be an early clinical marker for the immune deficiency induced by AIDS retroviral infection.

Custom orbital implant in the repair of late posttraumatic enophthalmos

We repaired late, posttraumatic enophthalmos in 21 patients by inserting a large, soft, Silastic block through a lower eyelid flap and transconjunctival approach to the orbit. These blocks were hand carved at the time of surgery to match bony defects as characterized by hypocycloidal tomographic biometry. Enophthalmos and hypo-ophthalmos were ameliorated with acceptable appearance in all cases. No implant rejections, migrations, or infections were found. Complications included upper eyelid blepharoptosis, lower eyelid retraction, and conjunctival prolapse. The improvements were stable over a median follow-up of 13 months.

Septal-myocutaneous flap technique for lower lid blepharoplasty

Lower lid blepharoplasty can present a significant challenge to the facial plastic surgeon. Routine findings of periorbital fat herniation and dermatochalasia of the lower lid are often associated with the presence of more occult findings, e.g., tarsoligamentous laxity and ectropion. Traditional surgical approaches to the aging lower eyelid utilize the skin flap, the skin-muscle flap, and the transconjunctival technique. The limitation of any one of these procedures alone is that of not addressing the multiple problems of the aging eyelid; this may lead to common postoperative problems of lower lid blepharoplasty, including lid retraction, lagopthalmos, scleral show, rounding of the lateral canthus, and ectropion. We present an integrated surgical solution to the functional and anatomical defects of both the anterior and posterior lamellae, and, when indicated, lateral canthal support. The procedure incorporates a small lateral subciliary and lateral canthal incision with a myocutaneous advancement flap developed in a plane deep to the orbital septum, combined with transconjunctival blepharoplasty for removal of herniated orbital fat. It allows for simultaneous management of the multiple defects of the aging lower eyelid and complete restoration of the relevant anatomy, while avoiding the common pitfalls of lower lid blepharoplasty. We present our experience of 64 patients who underwent bilateral combined septal-myocutaneous advancement flap and transconjunctival blepharoplasty. Indications and postoperative results are reviewed. No complications, including scleral show or ectropion, have been noted over the 4-year postoperative period.

Cicatricial Entropion: An Analysis of its Treatment with Transverse Blepharotomy and Marginal Rotation

Transverse blepharotomy with marginal rotation is a simple and effective procedure to treat cicatricial entropion of diverse etiology in upper and lower eyelids. The surgeon can vary the site of incision and suture placement to control the amount of marginal rotation required. We treated 152 eyelids (98 patients) with this technique, obtaining an 85% overall success rate. Eleven recurrences were found in 7 of 18 lids with ocular pemphigoid; the success rate for this subgroup was 39% compared with 92% for all others. We recommend this procedure as a technically easy treatment for cicatricial entropion not caused by ocular pemphigoid.