Christopher T. Westfall

Results of Buccal Mucosal Grafting for Patients with Medically Controlled Ocular Cicatricial Pemphigoid

Eyelid surgery for patients with ocular cicatricial pemphigoid is risky when there is unchecked perioperative inflammation. The authors performed buccal mucosal grafts on 42 eyelids (23 eyes) of 17 patients with ocular cicatricial pemphigoid whose disease was controlled by systemic immunosuppression. Results were graded as: improved (12 cases, 16 eyes); satisfactory (2 cases, 2 eyes); or poor (5 patients, 5 eyes). Complications included breakthrough trichiasis, surface keratinization of the graft, blepharoptosis, phimosis, depressed eyelid blink, incomplete eyelid closure, submucosal abscess formation, and persistent nonhealing epithelial defects of the cornea. Technical errors at surgery accounted for two complications. Secondary corneal ulceration developed in two patients. The immunologic aspect of the disease flared or progressed in five patients in the postoperative period and necessitated an increase or change in systemic medication for immunosuppression. Buccal mucosal grafting shows promise in temporarily rehabilitating eyelids of some ocular cicatricial pemphigoid patients whose disease is controlled by immunosuppressive therapy.

Operative Complications of the Transconjunctival Inferior Fornix Approach

The transconjunctival inferior fornix incision provides access to the floor, rim, lateral, and inferior medial walls of the orbit. Complications of this surgical approach to the orbit are known to be rare but heretofore have not been clearly defined. Over an 8-year period, in an estimated 1200 cases, the authors have encountered cicatricial entropion, lower eyelid retraction, canthal dehiscence, lower eyelid avulsion, canalicular laceration, buttonhole laceration of the lower eyelid, conjunctival chemosis, and lacrimal sac laceration. Attention to anatomic landmarks and sound surgical execution will prevent these complications in most patients.

Management of orbital and periorbital arteriovenous malformations

Arteriovenous malformations (AVMs) of the orbit are progressively enlarging communications between arteries and veins that bypass normal capillary beds. In contrast to arteriovenous fistulas (AVFs), AVMs are congenital lesions with multiple large feeding arteries, a central nidus, and numerous dilated draining veins. Management of AVMs of the orbit may be difficult due to the threat of hemorrhage, vascular occlusion during treatment, and collateral damage to surrounding organs. We managed AVM of the orbit and periorbital tissues in four patients. Neuroimaging studies, clinical decision making, operative experience, and long-term postoperative results were retrospectively reviewed. Four cases of AVM of the orbit and periorbital tissues were successfully treated with preoperative embolization and subsequent excision of the central nidus of the AVM. There was no evidence of recurrence in any of the cases over follow up ranging from 2 to 5 years. We conclude that identification of all arterial feeders, from both internal and external carotid systems, is critical in developing a therapeutic plan. AVMs may be treated by surgical excision alone, or embolization alone. However, in the hands of an experienced interventional neuroradiologist and an appropriately chosen surgical team, most AVMs can and should be treated by a combined approach of preoperative embolization followed by surgical excision of the vascular mass. The goal of therapy is closure of the low-resistance shunt.

Chronic exposure keratopathy complicating surgical correction of ptosis in patients with chronic progressive external ophthalmoplegia

PURPOSE To report chronic exposure keratopathy related to surgical ptosis correction in patients with chronic, progressive, external ophthalmoplegia. METHODS Case reports of three patients with chronic exposure keratopathy following blepharoptosis surgery. RESULTS We report three patients with chronic progressive external ophthalmoplegia with chronic corneal complications after surgical ptosis repair. All three gave a history of blepharoptosis and extraocular muscle dysfunction. Each presented with chronic corneal ulceration. All had histories suggestive of ophthalmoplegia. Treatment of corneal ulceration necessitated hospitalization and surgical intervention. CONCLUSION Patients with chronic, progressive, external ophthalmoplegia have little ability to properly protect the eye from exposure and are at risk for corneal damage. A thorough ophthalmic history and examination before ptosis surgery may prevent the corneal complications resulting from surgical intervention.

Isolated fractures of the orbital floor : risk of infection and the role of antibiotic prophylaxis

The application of antibiotic prophylaxis to fractures of the orbital floor is controversial. The incidence of infection following this injury remains undefined. We report a case of orbital cellulitis following orbital floor fracture, and attempt to define guidelines for the appropriate use of antibiotics in the setting of an isolated blowout fracture.

Brown recluse spider bite to the eyelid

PURPOSE To present a photographically documented case of a known brown recluse spider bite to the eyelid. DESIGN Interventional case report. METHODS The wound was photographed daily during an 11-day hospitalization and at 1 month and 6 months after the injury. Treatment included canthotomy and cantholysis; administration of dapsone, antibiotics, and steroids; and hyperbaric oxygen therapy. MAIN OUTCOME MEASURES Clinical presentation and course of a known brown recluse spider bite. RESULTS Complete recovery with cicatrization at the site of the bite. CONCLUSIONS We present a case of a brown recluse spider bite to the left lower eyelid with a discussion of management and outcome of this rarely reported injury.

Prophylactic use of antibiotics in oculoplastic surgery.

Since the times of antiquity, surgeons have attempted to balance those factors that ultimately determine risk of infection. Increased risk is associated with certain host characteristics that tend to lower resistance to infection. These include extremes of age, debilitating diseases (e.g., diabetes and systemic cancers), concomitant immunosuppressive therapy, malnutrition, poor vascularity, prior tissue irradiation, severe obesity [ 13, and even cigarette smoking in certain cardiac surgical patients [2]. Other factors that influence infectious risk include the size and virulence of the microbial inoculum, the amount of associated local tissue inflammation or injury (e.g., hypoxia, pH, hematoma), and the presence of a foreign material [3]. Prior to the antibiotic era, the surgeon’s armamentarium was largely limited to strict aseptic technique and gentleness in tissue handling. The development of antibiotics provided a powerful new tool in the fight against perioperative infection. The widespread introduction of antibiotics in the 1940s was a major surgical advance [4]. Originally introduced to treat active infections, antibiotics have become increasingly important as a preventive measure. It is now estimated that up to 50% of all antibiotics used in the United States are used for prophylaxis in surgical patients [5 ] . Hildebrand and colleagues [6] believe they are used inappropriately as often as 93% of the time. It is no wonder that prophylactic antibiotic usage has sparked a great deal of interest. Traditionally, attempts to document the effectiveness of prophylactic antibiotics in various surgical settings have been based on comparisons of

Sinus histiocytosis with massive lymphadenopathy (SHML) prednisone resistant but dexamethasone sensitive

Sinus histiocytosis with massive lymphadenopathy (SHML) is a histiocytic disorder affecting children and adults. It usually presents as markedly enlarged lymph nodes that require surgical biopsy for confirmation. This lesion is usually self‐limited but can present in areas that can cause significant morbidity or disfigurement. We report a case that required therapy due to the severe disfigurement but was resistant till treated with dexamethasone. This case illustrates that SHML may be resistant to prednisone but still be sensitive to dexamethasone.

Occupational protein contact dermatitis to cornstarch in a paper adhesive.

BACKGROUND Protein contact dermatitis is better known in food-service and health-care workers than in industrial workers. Cornstarch has seldom been a problem, although it can cause contact urticaria to glove powder. OBJECTIVE To present the case of a paper-bag maker who developed severe occupational (protein) contact dermatitis within two-three hours after returning to work. She lacked any evidence of urticaria and demonstrated largely negative patch-test results. METHODS Following a history of occupational exposure to a cornstarch-based adhesive, the patient was patch-tested to materials with which she had worked, which she contacted, and with which she had attempted treatment. Following patch testing, she was prick-tested to cornstarch, the principal ingredient in the adhesive. RESULTS Patch testing was negative except for a very mild reaction to the adhesive. Prick testing to cornstarch was more severe than the histamine control. The test site became eczematous and remained so for more than ten weeks. Avoidance of cornstarch and the adhesive was followed by clearing. CONCLUSION Workup for prominent occupational contact dermatitis without urticaria may sometimes require testing for type 1 allergy.

Miniplate Reconstruction of the Lateral Orbital Rim after Orbital Decompression for Graves Disease

BACKGROUND Removal of lateral orbital bone with or without simultaneous removal of the lateral orbital rim is an accepted method of orbital decompression for Graves disease. Once removed, the bone is no longer available for reconstruction and secondary complications such as rounding of the canthal angle, canthal dystopia, and globe dystopia may result. METHODS The authors replaced the excised bone with a titanium miniplate to protect the globe and fixate the lateral canthal tendon in 18 patients (33 orbits). The orbital rim and lateral orbital wall were completely removed, and the inner aspect of the orbit was enlarged with a cutting burr. A standard titanium miniplate was then anchored to remaining bone, and soft tissue was secured to the miniplate to reconstruct the lateral canthus. RESULTS The results, as manifest by appearance of the lateral canthus and position of the eyelid in apposition to the globe, were graded as excellent in all patients and orbits. There were no early or late complications. CONCLUSION Miniplate reconstruction of the lateral orbital rim after decompression for Graves disease allows the beneficial affect of lateral decompression and preserves the functional aspect of the lateral orbital wall.