Christopher J. Compton

Recession and Extirpation of the Lower Eyelid Retractors for Paralytic Lagophthalmos.

Purpose:To describe a technique to correct lower eyelid malposition and lagophthalmos due to facial nerve palsy. Methods:Chart review was performed and identified 13 patients with facial nerve palsy, who presented with paralytic eyelid malposition and were treated with recession and extirpation of the lower eyelid retractors between September 2012 and March 2014 by 1 surgeon (HBL). Results:A total of 12 eyelids in 11 patients met inclusion criteria. Mean preoperative MRD2 was 10 mm (range, 9.0–12.0 mm) and the mean postoperative MRD2 was 7 mm (range, 5.0–9.0 mm). The MRD2 improved an average of 3.0 mm in each patient (range, 2.0–4.0 mm). Patients had an average of 6.9 mm (range, 4.0–10.0 mm) of lagophthalmos preoperatively, which improved to 2.1 mm (range, 0.0–4 mm). The amount of lagophthalmos improved an average of 4.8 mm in the patients. There were no complications encountered in the patients. All patients had a subjective improvement in ocular comfort. Conclusions:The authors’ surgical technique is effective in addressing lower eyelid malposition and ocular surface disease in paralytic lagophthalmos.

A novel surgical technique for the treatment of giant fornix syndrome.

Purpose: To describe a novel surgical treatment for patients with chronic relapsing conjunctivitis, corneal epitheliopathy, and ptosis secondary to giant fornix syndrome. Methods: A retrospective case series was performed looking at the presence or absence of preoperative symptoms of eye irritation, tearing, blurry vision, and discharge in 6 patients diagnosed with giant fornix syndrome. Their examination findings were noted, and all patients underwent an extensive conjunctivoplasty with resection of redundant forniceal conjunctiva with subconjunctival antibiotics. Final visual acuity, symptoms, and examination findings were noted with a minimum follow up of 9 months. Results: Six patients were treated from November 2009 to November 2011. Duration of symptoms ranged from 3 to 40 months. Four patients were women while 2 were men, with age ranging from 61 to 85 years. Common symptoms were severe mucopurulent discharge, eye redness, tearing, and irritation with examination findings of severe conjunctival discharge and injection, corneal epitheliopathy, upper eyelid ptosis, and a deep upper and lower eyelid fornix. Most patients had undergone previous treatments with topical and/or oral antibiotics or steroids. All patients underwent surgical intervention using the surgical technique to be described with resolution of their symptoms, and even an improvement of 2 or more lines of best corrected visual acuity (3 of 5 patients). Conclusions: The authors’ novel surgical technique helps restore the abnormal anatomy found in patients with giant fornix syndrome and thus, helps resolve chronic relapsing conjunctivitis and surface disease associated with this often underdiagnosed condition. Further studies are needed to evaluate the risk of entropion and dry eye syndrome due to the modification of the posterior lamella.

Nodular Fasciitis of the Orbit.

A 13-month-old boy was presented with new onset proptosis of the right eye. CT scan and MRI showed an enhancing mass in the right superior orbit with local bone remodeling and erosion. A craniotomy was performed for biopsy and sub-total resection. Histopathology and immunohistochemistry confirmed the lesion to be nodular fasciitis. Nodular fasciitis lesions are classically found in the anterior ocular adnexa, especially in pediatric patients. This is the first reported case of nodular fasciitis arising in the posterior orbit of a child younger than 16.

Foreign Body Granuloma Following Orbital Reconstruction with Porous Polyethylene.

Porous polyethylene is commonly used in the orbit for fracture repair and anophthalmic reconstruction; it reportedly has a good safety profile and integrates well into host tissue. Foreign body reaction to porous polyethylene has been reported in facial tissue, but to our knowledge, not in the orbit. The authors report 2 cases of foreign body inflammatory giant cell reaction in patients who underwent orbital fracture repairs with porous polyethylene implants.

The Prevalence of Air Regurgitation and Its Consequences After Conjunctivodacryocystorhinostomy and Dacryocystorhinostomy in Continuous Positive Airway Pressure Patients.

Purpose:To describe the prevalence of air regurgitation into the periocular region in continuous positive airway pressure (CPAP) patients with a history of conjunctivodacryocystorhinostomy with a Lester Jones tube and a dacryocystorhinostomy with silicone intubation, as well as problems caused by this regurgitation and methods to cope. Methods:A retrospective chart review of patients who either underwent a conjunctivodacryocystorhinostomy or dacryocystorhinostomy was performed. Patients were contacted via phone interview. Demographic information, history of sleep apnea, use of CPAP, and presence of air regurgitation and associated complications were recorded. Institutional review board/ethics committee approval was obtained. Results:Two patients who underwent a conjunctivodacryocystorhinostomy with Lester Jones tube and were on CPAP were identified. Both complained of air regurgitation, sensation of Lester Jones tube moving due to regurgitation, and periodic eye pain. Twenty-two patients who underwent a dacryocystorhinostomy with silicone stent and used CPAP were identified. Of these, 16 (72.7%) complained of air regurgitation. Difficulty sleeping (56.2%), dry eye symptoms upon waking (68.8%), eye pain upon waking (31.3%), and blurry vision upon waking (12.5%) were the commonest complaints due to air regurgitation. A total of 7 (43.7%) patients had to discontinue their CPAP at some point due to symptoms. Conclusions:This study brings to light the prevalence of air regurgitation in dacryocystorhinostomy procedures, and its associated symptoms. Given that this procedure is much more common than conjunctivodacryocystorhinostomy, surgeons should consider asking patients before performing surgery whether they use CPAP. Patients should be consented regarding the risk of air regurgitation and associated dry eye, foreign body sensation, and eye pain.

Lateral tarsoconjunctival onlay flap lower eyelid suspension in facial nerve paresis.

Purpose: To evaluate the efficacy of a lateral tarsoconjunctival flap suspension procedure to improve paralytic eyelid malposition. Methods: Retrospective chart review (with photograph and videographic data) of consecutive patients between 2008 and 2013 with permanent unilateral paralytic eyelid malposition treated with a far lateral tarsoconjunctival flap lower eyelid suspension alone or in conjunction with lateral canthoplasty. Upper and lower eyelid position, lagophthalmos, ocular surface disease, patient satisfaction, and cosmesis were recorded before and after intervention. Postoperative complications and subsequent management were also recorded. Results: A total of 110 patients were identified. Lagophthalmos, ocular surface exposure, exposure keratopathy, and eyelid retraction (both upper and lower) improved in all cases. All patients described an improvement in eye irritation, epiphora, and cosmesis. Patients with a good Bell’s reflex exhibited some dynamic function to the lower eyelid on videography. Three (2.7%) eyelids had flap dehiscence that was successfully treated with repeat suturing. Seven (6.4%) patients had symptomatic temporal peripheral vision requiring partial flap takedown. Five (4.5%) patients had pyogenic granulomas excised. Seven (6.4%) patients later had a supplemental medial tarsorrhaphy for medial lagophthalmos. Conclusions: The lateral tarsoconjunctival flap suspension was highly effective in this series of patients with paralytic eyelid malposition. Improved eyelid position and cosmesis were universal although some patients benefitted from an additional medial tarsorrhaphy. Return of natural upward lower eyelid movement upon eyelid closure was a further benefit in some patients. Temporal vision obstruction was an infrequent side effect and flap dehiscence and granulomas were rare complications.

Orbital cellulitis and corneal ulcer due to Cedecea: First reported case and review of the literature

ABSTRACT Cedecea is a gram-negative bacterium from the family Enterobacteriaceae, rarely associated with human infection. We report the first case of an orbital cellulitis and corneal ulcer due to Cedecea in a patient who sustained a motor vehicle accident and was then found to have a retained wooden orbital foreign body.

Orbital Floor and Medial Wall Fractures

Fractures to the orbit and midface are a significant source of ocular morbidity. The safe and effective repair of these fractures hinges on the approach that provides optimal exposure and implant selection with low complication rates. The lateral and medial canthal approach to the orbit is discussed, along with the use of nonadherent orbital implants.

Ophthalmic considerations in patients with Pfeiffer syndrome

Purpose We report here a newborn male infant with striking features consistent with severe Pfeiffer syndrome type II, including cloverleaf skull deformity with pansynostosis, extreme proptosis, upper extremity contractures, broad big toes and thumbs with varus deviation and genetic mutation in the FGFR2 gene. The authors review the ophthalmic complications in Pfeiffer syndrome and discuss the unique surgical strategies used for obtaining adequate corneal coverage in these unique patients. Observations Ophthalmic considerations in Type 2 Pfeiffer Syndrome include vision loss secondary to increased intracranial pressure, and extreme proptosis as a result of orbitostenosis and midfacial retrusion. Our patient has undergone multiple ophthalmic/oculoplastic, neurosurgical, and midfacial surgeries as a result of corneal deterioration due to extreme exorbitism. Conclusions and importance It is important for ophthalmologists to be aware of the ophthalmic complications associated with patients with craniosynostosis syndromes. Our case identifies the importance of close communication between ophthalmology and plastic reconstructive surgery to help formulate the most successful plan in treating corneal decompensation and proptosis in Pfeiffer Syndrome patients.