Benjamin P. Erickson

Orbital Cellulitis and Subperiosteal Abscess: A 5-year Outcomes Analysis.

Abstract Purpose: Orbital cellulitis and subperiosteal abscess (SPA) are historically associated with poor outcomes. We seek to characterize current associations with abscess formation, surgical failure and vision loss. Methods: All cases of orbital cellulitis presenting to an affiliated hospital between April 2008 and 2013 were critically reviewed. Results: Thirty patients met inclusion criteria. Average age was 28.7 ± 24.4. The male to female ratio was 2:1. Abscesses were identified in 56.7% of patients. Adults were less likely than children to present with abscesses (28.6% vs. 81.3%, p = 0.008). Of the other factors analyzed, only antibiotic use before admission (70.5% vs. 23.1%, p = 0.03) and maximum restriction (−2.5 ± 1.2 vs. −0.9 ± 0.7, p = 0.008) were associated with SPA. Temperature at presentation (37.9 ± 0.9 vs. 37.1 ± 0.4, p = 0.04), relative proptosis (5.8 ± 3.3 mm vs. 2.1 ± 1.1, p = 0.002) and abscess volume (4.3 ± 1.3 mm3 vs. 0.7 ± 0.5 mm3, p = 0.0004) were associated with progression to surgery. Reoperation was required in 26.7% of patients. Of these, two-thirds had combined superior/medial abscesses that re-accumulated after isolated endonasal surgery. Two of the 3 patients with profound vision loss had a dental etiology. Conclusions: Only young age, prior antibiotics and degree of restriction predicted the presence of an abscess. Re-accumulation was more common than anticipated, and drainage of superior/medial abscesses by endoscopic surgery alone had the strongest association with surgical failure. Patients with odontogenic abscesses must be treated with particular caution.

The BLICK mnemonic for clinical-anatomical assessment of patients with epiphora.

Purpose: Evaluation of the tearing patient is often distilled to a search for ocular surface problems causing reflex hypersecretion versus lacrimal drainage problems. The literature does not typically emphasize conditions affecting the function of the tear distribution system, but neglect of these important factors can lead to suboptimal treatment outcomes. The intent of this review is to provide a systemic evaluation of frequently overlooked conditions that can influence the distribution system and to offer a mnemonic to ensure an orderly sequence of inspection during clinical examination. Methods: Review of clinical literature and experience from 1957 to 2014. Results: Tearing complaints attributable to problems with the distribution system can be evaluated, classified, and managed according to the mnemonic BLICK, which stands for Blink dynamics, Lid malposition, Imbrication, Conjunctivochalasis, and Kissing puncta. Conclusion: The BLICK mnemonic is a useful adjunct to the workup of epiphora.

Zone 3 ruptured globe from a dog bite.

Periocular injuries from dog bites are relatively common in school-age children, but intraocular trauma is exceedingly rare. We present a 7-year-old boy who sustained a zone 3 ruptured globe injury after attack by a Perro de Presa Canario. At presentation, visual acuity in the injured eye was counting fingers. Surgical exploration revealed an inferotemporal corneoscleral laceration extending 15 mm posterior to the limbus, with protrusion of uveal tissue, which was repaired. Visual acuity improved to 20/40 by the first postoperative month.

Management of neonatal proptosis: A systematic review

Gross proptosis presenting at birth is an uncommon manifestation of a variety of lesions that can compromise vision and result in disfigurement or even loss of life. Notably, many disease entities have different presentations and prognoses in neonates compared to older children. A structured mental framework is essential to an efficient and coordinated response. We present three challenging cases of neonatal proptosis and discuss the clinical presentation and biological behavior of the lesions that are most often implicated.

Delayed sclerotomy wound dehiscence after lensectomy and vitrectomy in Marfan syndrome

Marfan syndrome (MFS) is associated with abnormal fibrillin development that can cause morbidity and mortality. A case of acute onset hypotony due to sclerotomy wound dehiscence 13 years after 20-gauge pars plana vitrectomy and lensectomy is reported in a patient with MFS. Slit lamp examination revealed a leaking sclerotomy wound and intraoperatively the source was noted to be the prior sclerotomy site. On postoperative follow-up, the patients vision returned to baseline, and intraocular pressure normalized. Twenty-gauge sclerotomy wound dehiscence may occur years after surgery, especially in patients with abnormal collagen as in MFS.

A 32-year-old man with delayed onset post-traumatic proptosis and diplopia.

BACKGROUND Proptosis and motility deficits are common findings in the setting of craniofacial trauma, but can indicate the presence of vision and even life-threatening pathology. OBJECTIVE Our aim was to identify presentations consistent with traumatic carotid cavernous fistula (CCF) and to review the appropriate initial work-up and management. CASE REPORT A 32-year-old man came to our emergency department with proptosis, ocular motility deficits, and decreased vision 1 month after a restrained motor vehicle accident. An orbital bruit was auscultated and four-vessel angiography revealed a CCF. Covered stents and an embolic agent were used to abolish the arteriovenous communication and the patient rapidly returned to his premorbid baseline. CONCLUSIONS CCF is a relatively rare but important consequence of craniofacial trauma that must be recognized promptly in order to minimize the likelihood of serious sequelae. It should be suspected in patients with antecedent trauma presenting with exophthalmos, arterialized conjunctival vessels, and orbital bruit.

Novel Pigtail Cannula for a Canalicular-Involving Eyelid Laceration.

An 89-year-old woman presented with a canalicular-involving laceration/avulsion of the right lower eyelid after a fall. The inferior canaliculus was severed deep within the wound, and the ends were difficult to identify. Novel pigtail cannulas, designed by the authors, were used for lacrimal system intubation and suture passage. Satisfactory cosmetic and functional results were achieved. These cannulas facilitate repair by integrating multiple functionalities in a single instrument. Once a cannula has been inserted and rotated, the location of fluid egress provides important clues. If injected saline appears in the nasopharynx but not in the wound, absence of a common canaliculus can be suspected. Injection of viscoelastic, air or fluorescein-impregnated saline also permits easier identification of the cut end of the canaliculus within the wound and facilitates appropriate rotation of the pigtail.

Idiopathic unilateral enlargement of the extraocular muscles in an infant

A 6-month-old boy presented with a unilateral motility deficit of the right eye in all fields of gaze. Neuroimaging revealed unilateral enlargement of the medial, lateral, and inferior rectus muscles with sparing of the tendons. An evaluation for thyroid eye disease, idiopathic orbital inflammation, myositis, inflammatory and neoplastic infiltration of the muscle, vascular anomalies, and metastatic neuroblastoma was unrevealing. Biopsy of the muscle revealed normal architecture with an absence of inflammation, infiltration, or fibrosis. A review of the literature reveals the exceptionally rare nature of this finding. While the authors cannot rule out an atypical case of congenital euthyroid eye disease, this constellation of findings is not consistent with thyroid eye disease and may represent previously described cases of idiopathic enlargement of the extraocular muscles.

Split face evaluation of long‐pulsed non‐ablative 1,064 nm Nd:YAG laser for treatment of direct browplasty scars

To investigate 1,064 nm long‐pulse Nd:YAG laser for postoperative treatment of direct browplasty scars.

Transitional Cell-Type Papillary Carcinoma of the Lacrimal Sac Manifesting as a Medial Canthal Skin Lesion

Abstract 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.