Brett W. Davies

Predicting the Need for Surgical Intervention in Pediatric Orbital Cellulitis

PURPOSE To investigate the predictive value of the complete ophthalmic examination at first presentation in foreseeing the need for surgery in patients with pediatric orbital cellulitis. DESIGN Retrospective observational case series. METHODS We reviewed 136 cases of radiographically confirmed orbital cellulitis between 2004 and 2012 at Childrens Hospital Colorado. The presenting ophthalmic examinations, imaging results, medical and surgical interventions, and clinical complications were recorded. The main outcome measures were ophthalmic examinations on presentation, medical or surgical interventions, and complications. RESULTS The median age was 6.5 years. Of the patients, 56 (41%) underwent surgical intervention, and 80 patients (59%) were managed medically. Patients requiring surgery had higher rates of extraocular motility (EOM) restriction (78.6% vs 38.8% P<0.01), proptosis (64.3% vs 21.2%, P<0.01), elevated intraocular pressure (IOP) (35.7% vs 12.5%, P<0.01), and age over 9 years (58.9% vs 20.0%, P<0.01). Using any combination of the above risk factors at presentation, the probability of surgical intervention increases from 7% (95% confidence interval [CI] 1%-13%) with zero risk factors to 95% (95% CI 89%-100%) with 4 risk factors. CONCLUSIONS In pediatric orbital cellulitis, the likelihood of surgical intervention can be estimated accurately based on the ophthalmic examination on initial presentation to the hospital. Risk factors for surgery include age older than 9 years, proptosis, EOM restriction, and elevated IOP. These factors may be used to identify patients at high risk for failure of medical management early in the clinical course.

Combined orbital floor and medial wall fractures involving the inferomedial strut: repair technique and case series using preshaped porous polyethylene/titanium implants.

Background Combined orbital floor and medial wall fractures can be technically challenging to repair, particularly when the inferomedial strut is involved. A surgical repair technique is described utilizing a single preshaped porous polyethylene/titanium implant to span both defects. Methods Retrospective interventional case series. Results Fracture repair was performed on 17 orbits (16 patients) between October 2009 and February 2012. Subsequent surgical revision was required in three cases (18%). Visual acuity was stable or improved in all cases. Of 7 patients with preoperative diplopia, 5 improved and 2 remained stable postoperatively, and there were no cases of new or worsened diplopia following surgery. Postoperative asymmetry in Hertel exophthalmometry averaged 1.0 mm (range 0 to 2 mm). Preoperatively, average orbital volume was 122.7% compared with control (range 109 to 147%, standard deviation [SD] 9.6), which improved to 100.3% postoperatively (range 92 to 110%, SD 5.7). The average decrease in orbital volume was 22.5% (range 10 to 54%, SD 11.4, p < 0.001). Conclusions With careful preoperative planning and meticulous surgical technique, combined orbital floor and medial wall fractures involving the inferomedial strut can be successfully repaired with a preshaped porous polyethylene/titanium implant through a transconjunctival/transcaruncular approach with inferior oblique disinsertion.

Analysis of pediatric facial dog bites.

The aim of this study was to characterize and report the epidemiological data regarding pediatric facial dog bites. For this study, a retrospective chart review was used. This study was performed at a large tertiary pediatric hospital. All children younger than 18 years who sought medical attention after a facial dog bite between January 1, 2003, and December 31, 2008, were included. Demographic and epidemiologic data were collected and analyzed. A total of 537 children were identified. The average age was 4.59±3.36 years, with a slight male preponderance (52.0%). The majority of dog bites occurred in children 5 years of age or younger (68.0%). Almost all (89.8%) of the dogs were known to the children. When circumstances surrounding the bite were documented, over half (53.2%) of the cases were provoked. The most common breeds were mixed breed (23.0%), Labrador retriever (13.7%), Rottweiler (4.9%), and German shepherd (4.4%). Inpatient treatment was required in 121 (22.5%) patients with an average length of stay of 2.96±2.77 days. Children 5 years or younger were more likely to be hospitalized than older children. Children 5 years old and younger are at high risk for being bitten in the face by a familiar dog and are more likely to require hospitalization than older children. Certain dog breeds are more likely to bite, and there is often a history of provocation. There is a tremendous financial and psychosocial burden associated with dog bites, and prevention strategies should focus on education with the aid of public policies and better documentation and reporting systems.

C-Reactive Protein As a Marker for Initiating Steroid Treatment in Children With Orbital Cellulitis.

Purpose: To determine both the benefit of systemic steroids in pediatric patients with orbital cellulitis and to assess the usefulness of C-reactive protein (CRP) levels as a marker for starting steroids. Methods: Prospective, comparative interventional study. Pediatric patients aged 1 to 18 years admitted to a tertiary care children’s hospital with a diagnosis of orbital cellulitis from October 2012 to March 2014 were included in the study. All patients were treated with intravenous antibiotics, and patients with subperiosteal abscess who met previously published criteria for surgical decompression underwent combined transorbital drainage and/or endoscopic sinus surgery. CRP was measured daily as a biomarker of inflammation, and when below 4 mg/dl, patients were started on oral prednisone 1 mg/kg per day for 7 days. Patients whose families did not consent to steroid treatment served as the control group. Patients were followed after discharge until symptoms resolved and all medications were discontinued. Results: Thirty-one children were diagnosed with orbital cellulitis during the study period. Of these 31 children, 24 received oral steroids (77%) and 7 did not (23%). There were 19 males and 5 females in the steroid group with an average age of 8.1 years, and 6 males and 1 female in the nonsteroid group with an average age of 7.1 years (p = 0.618). Thirteen patients (54%) in the steroid group and 2 patients (29%) in the nonsteroid group underwent sinus surgery with or without orbitotomy (p = 0.394). The average CRP at the onset of steroid treatment was 2.8 mg/dl (range: 0.5–4). Patients who received oral steroids were admitted for an average of 3.96 days. In comparison, patients who did not receive steroids were admitted for an average of 7.17 days (p < 0.05). Once CRP was ⩽4 mg/dl, patients treated with steroids remained in the hospital for another 1.1 days, while patients who did not receive steroids remained hospitalized for another 4.9 days (p < 0.01). In the steroid group, 2 families reported increased hyperactivity in their children while on steroids. There was 1 case in each group of recurrence of symptoms after discharge from the hospital. Average follow-up time was 2.4 months in the steroid group and 2 months in the nonsteroid group (p = 0.996). At last visit, all patients returned to their baseline ophthalmic examination. There were no cases of vision loss or permanent ocular disability in either group. Conclusions: Our results give further evidence of the safety and benefit of systemic steroids in children with orbital cellulitis. Futhermore, this is the first study to suggest a standardized starting point (CRP ⩽ 4 mg/dl) and dosing schedule (oral prednisone 1 mg/kg for 7 days) for children with orbital cellulitis. Patients who received systemic steroids after CRP dropped below 4 mg/dl were discharged from the hospital earlier than patients who did not receive systemic steroids.

Pediatric Idiopathic Orbital Inflammation: Clinical Features of 30 Cases.

Purpose: Pediatric idiopathic orbital inflammation (IOI) is a rare entity with little known about the clinical presentation and natural history. The authors report the demographics, clinical presentations, radiographic and histopathologic characteristics, and treatment outcome of 30 children with IOI. Methods: Retrospective chart review of 30 patients 18 years and younger diagnosed with IOI and statistical analysis using analysis of variance and Fisher’s exact test. This study was reviewed and approved by the Institutional Review Board of SUNY Downstate Medical Center. Results: There were 9 males (30%) and 21 females (70%) with pediatric IOI who presented at a median age of 11 years (range 2–18 years). Primary IOI was found in 19 patients (63%) and recurrent IOI in 11 patients (37%). Overall, 26 patients (87%) had unilateral IOI while 4 patients (13%) had bilateral disease at presentation. There were 12 patients (40%) with systemic constitutional signs. The most common ophthalmic findings included periorbital edema (n = 20, 67%) and blepharoptosis (n = 17, 57%). All patients had orbital radiography with common findings of dacryoadenitis (n = 12, 40%), orbital mass (n = 12, 40%), or myositis (n=10, 33%). The presence of a radiographic orbital mass was significantly related to the clinical presence of blepharoptosis (p = 0.03). The most common treatment was oral glucocorticoids in 24 patients (80%). Over mean follow up of 19 months (range 6–64 months), females were more likely to display recurrent disease (p = 0.01). Conclusions: Idiopathic orbital inflammation is an uncommon but important cause of acute orbital syndrome in children, manifesting as a bilateral condition in 13% and with constitutional symptoms in 40%. Posttreatment recurrence is found in 37% of cases.

Axial Globe Position Measurement: A Prospective Multicenter Study by the International Thyroid Eye Disease Society.

Purpose: Identify a reproducible measure of axial globe position (AGP) for multicenter studies on patients with thyroid eye disease (TED). Methods: This is a prospective, international, multicenter, observational study in which 3 types of AGP evaluation were examined: radiologic, clinical, and photographic. In this study, CT was the modality to which all other methods were compared. CT AGP was measured from an orthogonal line between the anterior lateral orbital rims to the cornea. All CT measurements were made at a single institution by 3 individual clinicians. Clinical evaluation was performed with exophthalmometry. Three clinicians from each clinical site assessed AGP with 3 different exophthalmometers and horizontal palpebral width using a ruler. Each physician made 3 separate measurements with each type of exophthalmometer not in succession. All photographic measurements were made at a single institution. AGP was measured from lateral photographs in which a standard marker was placed at the anterior lateral orbital rim. Horizontal and vertical palpebral fissure were measured from frontal photographs. Three trained readers measured 3 separate times not in succession. Exophthalmometry and photography method validity was assessed by agreement with CT (mean differences calculation, intraclass correlation coefficients [ICCs], Bland-Altman figures). Correlation between palpebral fissure and CT AGP was assessed with Pearson correlation. Intraclinician and interclinician reliability was evaluated using ICCs. Results: Sixty-eight patients from 7 centers participated. CT mean AGP was 21.37 mm (15.96–28.90 mm) right and 21.22 mm (15.87–28.70 mm) left (ICC 0.996 and 0.995). Exophthalmometry AGP fell between 18 mm and 25 mm. Intraclinician agreement across exophthalmometers was ideal (ICC 0.948–0.983). Agreement between clinicians was greater than 0.85 for all upright exophthalmometry measurements. Photographic mean AGP was 20.47 mm (10.92–30.88 mm) right and 20.30 mm (8.61–28.72 mm) left. Intrareader and interreader agreement was ideal (ICC 0.991–0.989). All exophthalmometers’ mean differences from CT ranged between −0.06 mm (±1.36 mm) and 0.54 mm (±1.61 mm); 95% confidence interval fell within 1 mm. Magnitude of AGP did not affect exophthalmometry validity. Oculus best estimated CT AGP but differences from other exophthalmometers were not clinically meaningful in upright measurements. Photographic AGP (right ICC = 0.575, left ICC = 0.355) and palpebral fissure do not agree with CT. Conclusions: Upright clinical exophthalmometry accurately estimates CT AGP in TED. AGP measurement was reliably reproduced by the same clinician and between clinicians at multiple institutions using the protocol in this study. These findings allow reliable measurement of AGP that will be of considerable value in future outcome studies.

Perioperative pregabalin for attenuation of postoperative pain after eyelid surgery.

Purpose: To examine the effect of a 1-time dose of pregabalin (Lyrica) on the perception of pain and analgesic consumption after oculofacial plastic surgery. Methods: In this prospective, randomized, double-blind, placebo-controlled trial, patients presenting to the oculofacial plastic surgery service at University of Colorado Eye Center for functional eyelid surgery and who met the study criteria were consecutively enrolled between October 2011 and September 2012. Subjects were randomized to either placebo or 150 mg pregabalin administered 15 minutes to an hour prior to the procedure. The procedure was then performed under the usual standard of care. Postoperatively, study subjects recorded pain scores on visual analog scales (range 0–100) at 1 to 2 hours, 2 to 4 hours, 8 to 12 hours, 20 to 28 hours, and 36 to 48 hours and the amount of acetaminophen consumed. Data were analyzed with Statistical Analysis System software using mixed-effects linear models. Results: Fifty-two patients were enrolled. Three patients were excluded due to incomplete follow up (n = 2) and postoperative course requiring early unblinding (n = 1). Twenty-six subjects were men. Average age was 68 years (range, 25–89). Eyelid procedures performed included blepharoplasty (18), canthoplasty (11), ptosis repair (15), eyelid retraction repair (2), pentagonal wedge resection (1), and MOHS reconstruction (2). Twenty-six patients were randomized to receive pregabalin, while the remainder received placebo. There was no significant difference in demographics between the 2 groups. The pregabalin group reported pain scores that were 5.5 points lower on average compared with the placebo group (p = 0.0307). Patients in the pregabalin group also consumed half as much acetaminophen (1.3 g) on average as the placebo group (2.6 g) during the postoperative period. Conclusions: Pregabalin is effective in reducing postoperative pain after oculoplastic procedures when compared with placebo. It may be a useful adjunct for pain control in selected patients.

Radiation-induced dedifferentiated chondrosarcoma with orbital invasion

Purpose: To report 2 interventional cases of dedifferentiated chondrosarcoma with orbital involvement after radiotherapy performed in childhood and to review the literature on chondrosarcoma in the orbit following radiation treatment. Methods: Retrospective analysis of medical records of 2 patients with chondrosarcoma of the orbits with review of the literature. Results: The first patient developed chondrosarcoma of the orbital and maxillary sinus 36 years after external beam radiation therapy to the OS to treat retinoblastoma. The second patient developed a large orbital chondrosarcoma 35 years after external beam radiation therapy in the treatment of craniofacial fibrous dysplasia. Conclusions: These cases highlight the risk of secondary chondrosarcoma in patients following radiotherapy and the importance of lifetime monitoring.

Bilateral Candida and atypical mycobacterial infection after frontalis sling suspension with silicone rod to correct congenital ptosis.

In this case report, the authors describe an unusual complication of a frontalis sling suspension with silicone rods. A 5-year-old girl with blepharophimosis syndrome underwent frontalis sling suspension using an open sky technique. Four weeks after surgery, she was noted to have pustules over both upper eyelids and eyebrows. Cultures from the surgical sites grew Mycobacterium chelonae and Candida parapsilosis. Intravenous antibiotics and antifungals and sling explantation were curative. One month after sling explantation, the patient maintained an adequate marginal reflex distance 1. Atypical mycobacterial and Candida infection should be considered in the differential diagnoses of postoperative infection after frontalis sling suspension with silicone rods.

Dacryocystitis As the Initial Presentation of Invasive Fungal Sinusitis in Immunocompromised Children

Sino-orbital fungal infection is a rare, but life-threatening disease seen mainly in immunocompromised patients. While initial clinical impression may vary, dacryocystitis has rarely been described as the initial presenting sign. The authors present 2 pediatric cases of dacryocystitis as the initial sign of invasive fungal sinusitis. To their knowledge, this presenting sign has not been previously reported in the pediatric population. Management strategies and outcomes are discussed.