Charles N. S. Soparkar

Medial rectus muscle injuries associated with functional endoscopic sinus surgery: Characterization and management

Objective To characterize and evaluate treatment options for medial rectus muscle (MR) injury associated with functional endoscopic sinus surgery (FESS). Design Retrospective interventional case series Participants A total of 30 cases were gathered from 10 centers. Methods Cases of orbital MR injury associated with FESS surgery were solicited from members of the American Society of Ophthalmic Plastic & Reconstructive Surgery (ASOPRS) through an e-mail discussion group. Main Outcome Measures Variables assessed included patient demographics, computerized tomography and operative findings, extent of MR injury and entrapment, secondary orbital/ocular injuries, initial and final ocular alignment and ductions, and interventions. Results A spectrum of MR injury ranging from simple contusion to complete MR transection, with and without entrapment, was observed. Four general patterns of presentation and corresponding injury were categorized. Conclusions Medial rectus muscle injury as a complication of FESS can vary markedly. Proper characterization and treatment are important, particularly with reference to the degree of direct MR injury (muscle tissue loss) and entrapment. Patients with severe MR disruption can benefit from intervention but continue to show persistent limitation of ocular motility and functional impairment. Prevention and early recognition and treatment of these injuries are emphasized.

Orbital solitary fibrous tumor: radiographic and histopathologic correlations.

OBJECTIVE To correlate the clinicopathologic and radiographic features characteristic of orbital solitary fibrous tumor (SFT). METHODS The diagnostic features and clinical outcome of seven adults with orbital SFT are retrospectively outlined. Orbital imaging was performed by ultrasonography, computed tomography, or magnetic resonance imaging. Some cases were imaged by multiple modalities. Histopathologic examination of each tumor specimen included standard light and immunohistochemical stains. RESULTS Heterogeneous internal composition was better appreciated on magnetic resonance imaging than on computed tomography. All cases undergoing magnetic resonance imaging showed T1 isointensity and T2 hypointensity relative to gray matter. Strong, generalized immunohistochemical reactivity to vimentin and CD34 validated the diagnosis of SFT and differentiated the specimens from other spindle cell neoplasms. After complete tumor resection, our patients remain tumor free with postoperative intervals of 15 to 45 months. CONCLUSIONS Solitary fibrous tumor has now been reported in 26 orbits. No physical finding is pathognomonic, but several imaging traits are highly characteristic. Intralesional image heterogeneity and a predominantly low T2 signal intensity are distinctive of SFT. Complete tumor resection and immunohistologic specimen evaluation are emphasized. Clinicians should consider the diagnosis of SFT when confronted with an adult patient having an orbital soft tissue mass demonstrating the distinctive magnetic resonance imaging findings.

Porous polyethylene implant fibrovascularization rate is affected by tissue wrapping, agarose coating, and insertion site

Purpose Often used in facial and ocular reconstruction, biointegratable materials, such as hydroxyapatite and high density porous polyethylene, can be associated with migration, exposure, and infection. Complications are less likely after implants become fibrovascularly integrated. A model was sought to study the influence of multiple factors on the rate of fibrovascular ingrowth into porous implants. Methods High density porous polyethylene cubes were implanted into paraspinous skeletal muscles in rabbits. The cubes were explanted at weekly intervals using survival surgery. The number of fibroblasts at the center of each cube was counted, generating a time-dependent standard curve of cell accumulation. Porous polyethylene cubes uncoated, coated with agarose (a plant-derived carbohydrate), or coated with nonperforated sclera (human or rabbit) were implanted into suprascapular adipose and paraspinous skeletal muscle in other rabbits. Results Fibrovascular ingrowth occurred more rapidly with cube implantation into skeletal muscle versus adipose, with increased surface area contact between implants and muscle, and with removal of muscle capsules. While the rate of fibroblast accumulation decreased in cubes coated with sclera, coating the cubes with agarose increased the fibrous capsule formation without altering the rate of biointegration. Conclusions This study provides a novel approach for the study of fibrovascular ingrowth into implants treated under a variety of conditions. Modification of current surgical techniques may increase the rate of porous polyethylene implant biointegration.

Conjunctival cysts of the orbit

OBJECTIVE This study reviews functionally and anatomically disruptive features of simple conjunctival orbital cysts. DESIGN A case series review from four oculoplastic practices over 6 years. PARTICIPANTS Eleven patients with simple conjunctival cysts of the orbit were identified. INTERVENTION All cysts were excised and evaluated histopathologically. MAIN OUTCOME MEASURES Assessment was made of the length of time from inciting event to presentation, preoperative and postoperative refractive state and ocular motility, the presence or absence of discomfort, and radiographic or clinical evidence of bone remodeling. RESULTS Six of 11 cysts were presumed to be primary, unrelated to antecedent surgery or trauma. Four of 11 cysts were associated with pain or tenderness, 5 cysts induced ocular motility disturbance, 6 cysts caused observable globe distortion or refractive error change, and 6 cysts remodeled bone. CONCLUSIONS Simple conjunctival cysts of the orbit, traditionally regarded as low-pressure lesions with minimal structural impact, may induce considerable anatomic and functional disruption.

Misdiagnosis of Silent Sinus Syndrome

Purpose To review cases of spontaneous enophthalmos erroneously diagnosed as silent sinus syndrome to identify other inflammatory disorders with a similar clinical presentation. Methods Retrospective observational case series. Chart reviews were performed covering encounters over a 5-year period, searching for patients referred to two physicians with an incorrect diagnosis of silent sinus syndrome. Only cases of acquired enophthalmos of reported nontraumatic or nonneoplastic cause were included. Particular attention was directed toward noting clinical features of upper eyelid position and periocular atrophy. Results Nineteen cases of erroneous referral for silent sinus syndrome were identified. Fourteen of these cases were due to tumor, trauma, congenital facial asymmetry, or diffuse facial lipodystrophy. Among the remaining cases, four were diagnosed as Parry-Romberg syndrome and one as linear scleroderma. Conclusions Parry-Romberg syndrome and linear scleroderma must be distinguished from silent sinus syndrome as causes of inflammatory-mediated, spontaneous enophthalmos.

Efficacy of botulinum toxin type A after topical anesthesia

Purpose: To determine whether the use of topical anesthesia has an impact on botulinum toxin type A (BTX-A) efficacy. Methods: Forty patients (20 receiving BTX-A for facial cosmetic rhytid reduction and 20 for benign essential blepharospasm) were evaluated in a double-blind, randomized, triple-crossover study at 2.5- to 4.5-month intervals. The discomfort and efficacy of BTX-A injections after betacaine application to half the face (random assignment) were compared against the discomfort and efficacy of a placebo ointment on the other half of the face. This was followed by cryoanalgesia to the entire face. Results: Patients ranged from 27 to 81 years of age (mean, 53 years), and 34 were female. Of the 120 total injection comparisons, a better BTX-A effect on one side of the face was reliably identified by 80% and 77% of blepharospasm and cosmetic patients, respectively, with the placebo-treated side providing better BTX-A effect approximately 90% of the time (p < 0.001). Patients reported a more painful side during injection in just 18 of the 120 trials, and only 1 of 40 patients believed the administration of analgesia was worth the trouble. Conclusions: Pretreatment with topical betacaine followed by skin cooling seems to have a deleterious impact on BTX-A effect without a significantly beneficial patient-perceived reduction in injection discomfort.

The eye examination in facial trauma for the plastic surgeon

Summary: Fifteen to 20 percent of patients with major facial trauma suffer vision-threatening injuries. Not only does the early identification and management of such ophthalmic insults frequently carry a better visual prognosis, but manipulations during facial fracture repair may exacerbate unrecognized eye trauma. In addition, ophthalmic problems not documented before facial reconstruction may be interpreted as direct complications of surgery. Thus, all physicians who treat patients with trauma above the mandible should appreciate the fundamentals of ophthalmic evaluation and emergency management. This article strives to provide a simplified, practical guide, but it should not be viewed as a substitute for consultation by a qualified eye care provider when an ocular injury is strongly suspected.

Pearls of Orbital Trauma Management

Orbital fractures account for a significant portion of traumatic facial injuries. Although plastic surgery literature is helpful, additional pearls and insights are provided in this article from the experience of an oculoplastic surgeon. The fundamentals remain the same, but the perceptions differ and provide a healthy perspective on a long-standing issue. The most important thing to remember is that the optimal management plan is often variable, and the proper choice regarding which plan to choose rests upon the clinical scenario and the surgeon having an honest perception of his or her level of expertise and comfort level.

Giant cell reparative granuloma of the orbit associated with cherubism.

PURPOSE To report a case of cherubism with extensive, bilateral orbital involvement occurring in a 27-year-old woman who had the diagnosis established at the age of 4 years. DESIGN Single interventional case report. INTERVENTION Ophthalmologic examination and computed tomography were performed. The patient underwent multiple surgical excisions using a bicoronal and transorbital approach. The excised orbital tissues were studied histopathologically. RESULTS Computed tomography showed bilateral inferior lateral masses involving the orbital floors and producing marked superior displacement of the orbital contents. The intrinsic expansile bone lesions involved the inferior and lateral orbital walls with apical compression of the optic nerves. Histopathologic examination of the masses revealed scattered giant cells in a fibroblastic stroma containing small vascular channels. The lesion was interpreted as giant cell reparative granuloma. CONCLUSIONS Giant cell reparative granuloma is an uncommon bone lesion that might involve the orbit. Cherubism should be included in the differential diagnosis of lesions that show the histopathologic features of giant cell reparative granuloma.

Monitored anesthesia care for enucleations and eviscerations

OBJECTIVE To report the technique and success of using monitored anesthesia care instead of general anesthesia for ocular enucleation and evisceration surgeries. DESIGN Retrospective, noncomparative interventional case series. PARTICIPANTS Twelve enucleated patients (Soparkar and Patrinely) and 146 eviscerated patients (Kulwin and Kersten). METHODS Surgical logs of two oculoplastic practices were reviewed searching for cases of ocular enucleations and eviscerations performed under monitored anesthesia care between 1990 and 2001. Identified hospital and clinic charts were then reviewed. MAIN OUTCOME MEASURES Monitored anesthesia care was deemed successful if (1) there were hemodynamic stability and complete analgesia intraoperatively; (2) there was absence of any chart documentation regarding patient or family psychological distress over the anesthesia method used; and (3) patients were discharged from the hospital without the need for observation or treatment > or = 23 hours. RESULTS Between 1990 and 2001, 146 eviscerations were performed under local anesthesia with monitored anesthesia care by two surgeons (RCK, DRK) as their routine practice pattern. In 1996, Drs. Soparkar and Patrinely began performing enucleations under monitored anesthesia care in selected cases, and from 1996 to 2001, these surgeons enucleated 12 patients under monitored anesthesia care. Four of the enucleated patients requested surgery without general anesthesia. The remaining eight patients had been refused surgery by at least one other specialist because of the patients perceived high medical risk for complications under general anesthesia. In all 158 patients, the procedures were deemed successful by the preceding criteria. CONCLUSIONS This four-surgeon case series reports the successful use of local anesthesia with monitored care for ocular enucleation and evisceration procedures, offering several potential advantages over the traditional use of general anesthesia.