Craig D. Lewis

Exposed porous orbital implants treated with simultaneous secondary implant and dermis fat graft.

Purpose: To describe a technique for simultaneous secondary orbital implantation and dermis fat graft placement for exposed porous implants with significant conjunctival insufficiency. Design: Retrospective review of 4 consecutive cases. Methods: Charts were reviewed for type and size of exposed porous implant, size of conjunctival defect, history of previous reconstruction for exposure, size and type of implant placed, follow-up interval, complications, ability to retain prosthesis, and cosmesis. Results: Four patients underwent simultaneous dermis fat graft placement and secondary implantation for exposed and completely avascular orbital implants. The rectus muscles were advanced over the new implant to act as the host bed for the dermis fat graft. All patients tolerated a new prosthesis well, with adequate motility and cosmesis. Conclusions: Simultaneous secondary implantation and dermis fat graft placement may adequately address avascular porous implant exposure with significant conjunctival insufficiency.

External dacryocystorhinostomy outcomes in sarcoidosis patients

Purpose: To determine surgical outcomes after external dacryocystorhinostomy (DCR) surgery in patients with sarcoidosis. Methods: We retrospectively reviewed the charts of all patients with sarcoidosis who underwent external DCR surgery between January 2001 and January 2010. Clinical data reviewed included patient demographics, immunosuppressive therapies, biopsy results, use of intraoperative triamcinolone, and postoperative outcomes and complications. Success was defined as resolution of epiphora. Results: External DCR was performed on 13 sides of 9 patients with sarcoidosis. Four patients were systemically immunosuppressed with methotrexate or plaquenil, and 4 patients used inhaled corticosteroids only. Intraoperative biopsy in 10 cases (9 patients) revealed non-necrotizing granulomatous inflammation (8 cases) and chronic inflammation (2 cases). Silicone stents were removed at a mean of 2.9 months. Initial DCR surgery was successful in 10 of 13 (87%) surgeries with an average follow up of 31 months (range, 14 to 48 months). None of the 5 surgeries (4 patients) with intralesional triamcinolone injections failed, compared with 3 of 8 (38%) surgeries without intralesional triamcinolone. Of the 3 failures, 2 early failures (3 months) were successfully treated with balloon catheter dilation. In the one patient with a late failure (47 months), subsequent balloon catheter dilation failed. All 3 patients who experienced failures used inhaled corticosteroids only. In contrast, 4 of the 6 patients with successful surgery were systemically immunosuppressed. Complications such as punctal erosion, wound necrosis, or cerebrospinal fluid leak did not occur. Conclusions: External DCR surgery successfully treats nasolacrimal duct obstruction associated with sarcoidosis. Intralesional triamcinolone may improve the success rate without added complications. Long-term success may be less in patients not receiving systemic immunosuppressive therapy.

External dacryocystorhinostomy surgery in patients with Wegener granulomatosis.

Purpose: To determine surgical outcomes after external dacryocystorhinostomy (DCR) surgery in patients with Wegener granulomatosis (WG). Methods: The authors retrospectively reviewed the charts of consecutive patients with WG who underwent primary or secondary external DCR surgery between January 2001 and January 2010. Clinical data reviewed included patient demographics, systemic disease involvement and immunosuppression therapy, intraoperative biopsy findings, and postoperative outcomes and complications. Success was defined as resolution of epiphora. Results: Sixteen primary external DCRs were performed on 9 patients with WG, and 2 secondary external DCRs were performed on 2 patients. At the time of surgery, all patients with WG were on systemic immunosuppressive agents including methotrexate, rapamycin, sirolimus, tacrolimus, azathioprine, cyclophosphamide, rituximab, and prednisone, and no patients received increased corticosteroids after surgery. Intraoperative biopsy in patients with WG revealed chronic inflammation (4 patients) and fibrosis (1 patient). Silicone stents were removed at an average of 5.8 months (range, 3–12 months). All surgeries were successful in resolving epiphora with an average follow up of 3.5 years (range, 10 months–6 years) and no complications. Conclusions: Primary and secondary external DCR surgery successfully treats nasolacrimal duct obstruction in patients with WG on systemic immunosuppression.

Transconjunctival lateral cantholysis for closure of full-thickness eyelid defects.

Purpose: To report a novel technique for closure of full-thickness eyelid defects too large for primary closure that avoids an external lateral canthotomy. Methods: Retrospective review of a consecutive case series of all patients undergoing transconjunctival lateral cantholysis. Results: Thirteen eyelids of 12 patients underwent transconjuctival lateral cantholysis for closure of a full-thickness eyelid defect. Each defect occurred after excision of an eyelid cutaneous malignancy. Each defect would not close primarily without undue wound tension. Average horizontal defect size measured 13.7 mm (range, 11-20 mm). Average follow-up interval was 2.3 months (range, 0.5-5 months). All defects healed well with no evidence of dehiscence, notching or other complication related to closure. No patient requested or required further surgery for any reason. Conclusion: Transconjunctival lateral cantholysis allows for closure of larger full-thickness eyelid defects and avoids morbidity from lateral canthotomy/cantholysis.

A paradigm shift: volume augmentation or 'inflation' to obtain optimal cosmetic results.

Purpose of review In the last several years, surgeons have increasingly realized the importance of volume loss as a central mechanism of facial aging. New, innovative techniques incorporate volume augmentation, or inflation, to improve cosmetic outcomes. Recent findings Previous rejuvenative facial surgical techniques focused on the removal of excess, lax tissues. In addition to tissue laxity and descent, volume loss significantly contributes to the appearance of facial aging in most patients. Volume loss, or deflation, affects all facial layers, including the skin, deep soft tissue, and bone. A variety of new, innovative surgical and nonsurgical techniques specifically address volume deficiencies in the brow, periorbita, and midface. Volume augmentation directly counteracts volume loss, a key feature of facial aging, and offers surgeons a powerful tool to improve cosmetic results. Summary In addition to the excision or repositioning of lax or prolapsed tissues, surgeons must assess and treat facial volume loss to optimize cosmetic outcomes.

Internal Cantholysis for Repair of Moderate and Large Full-Thickness Eyelid Defects

PURPOSE To determine the safety and efficacy of internal cantholysis for closure of larger full-thickness eyelid defects. DESIGN Retrospective review of a consecutive case series. PARTICIPANTS Eighteen patients (18 eyelids) underwent internal cantholysis for repair of a moderate or large full-thickness eyelid defect during the study period. METHODS Retrospective review of a consecutive case series of all patients undergoing transconjunctival lateral cantholysis for repair of moderate and large full-thickness eyelid defects between October 2008 and November 2010. Moderate was defined as ≥ 14 mm in horizontal length, and large was defined as ≥ 20 mm in horizontal length. MAIN OUTCOME MEASURES Charts were reviewed for patient demographics; indication for surgery; defect size, type, and location; other concomitant repair; follow-up interval; and complications. RESULTS Eighteen patients (18 eyelids) underwent internal cantholysis for repair of a moderate or large full-thickness eyelid defect during the study period. Average patient age was 73 years (range, 45-94 years), and there were 10 male and 8 female patients. Average defect size was 19.0 mm (range, 14-25 mm). Average follow-up interval was 4.6 months (range, 1-12 months). Complications included eyelid margin notch (3 cases), persistent canthal dystopia (3 cases), trichiasis (2 cases), pyogenic granuloma (2 cases), eyelid margin nodule (1 case), lower eyelid elevation of 1 mm (1 case), and mild resolving medial lagophthalmos (1 case). No patient requested or required further surgery on the operated eyelid for any reason during the study period. CONCLUSIONS Internal cantholysis allows for closure of moderate and large full-thickness eyelid defects. Complications are acceptable in light of the morbidity of other therapeutic options, such as semicircular flap or shared eyelid flap procedures.

Xerophthalmia and intracranial hypertension in an autistic child with vitamin A deficiency

The authors present a 10-year-old boy with autism and idiopathic intracranial hypertension referred for evaluation of dry eyes. When questioned, the patients parents reported that he had a restricted diet. Laboratory testing revealed hypovitaminosis A. The symptoms and signs of xerophthalmia rapidly resolved with oral and topical vitamin A supplementation.

Use of Tegaderm™ for postoperative eye dressing in children

Creating a secure postoperative eye dressing after pediatric surgery can be challenging. Children frequently attempt to remove dressings, especially those covering their face and eyes. Any dressing or tape with loose ends may be pulled and dislodged. We report a fast and simple method to create a secure postoperative eye dressing using transparent Tegaderm dressing.

Primary dermatofibrosarcoma protuberans invading the orbit.

A 38-year-old man presented with a slow-growing, firm cutaneous mass beneath his left eyebrow. Histopathology and immunohistochemistry confirmed the diagnosis of dermatofibrosarcoma protuberans. The mass infiltrated the medial canthal tendon and anterior orbital fat and could not be completely excised with Mohs micrographic surgery. The patient underwent exenteration and dacryocystectomy with margin-controlled excision and remained free of disease 9 months after surgery. To our knowledge, no prior case of primary dermatofibrosarcoma protuberans involving the orbit has been reported.

Rotational Flap Repair of Full Thickness Eyelid Defects without a Posterior Lamellar Graft or Flap

ABSTRACT Background: To determine the safety and effectiveness of full thickness eyelid reconstructions using a semicircular rotational flap without reconstructing the posterior lamella. Methods: The charts of all patients undergoing semicircular flap closure of full thickness eyelid defects by one surgeon (JDP) at the Cole Eye Institute between March 2000 and October 2012 were reviewed. Charts were reviewed for patient demographic information, as well as for the size of the defect, the type of flap used, length of follow-up and complications. Results: Fifty eyelids of 50 patients underwent a semicircular flap repair without posterior lamellar reconstruction during the study period, and 41 charts were available for review. Average patient age was 74 years (range, 40–92 years). Average follow-up was 9.8 months (range, 1–84 months). Average defect size was 19.1 mm (range, 14–30 mm, SD 4.6). Complications included pyogenic granuloma (10 patients, 24.4%), exposure keratopathy (7 patients, 17.1%) lagophthalmos (5 patients, 12.2%), ectropion (6 patients, 14.6%), lateral canthal dystopia (2 cases, 4.9%), eyelid notch (2 cases, 4.9%) and trichiasis (4 cases, 9.8%). Two patients underwent subsequent tarsorrhaphy and one patient underwent ectropion repair. There were no cases of wound dehiscence, diplopia or fornix inadequacy, and the recruited aspect of the eyelid healed well in each case. No case required reconstruction of the eyelid margin or fornix. Conclusions: Semicircular flap repair of full thickness eyelid defects without flap or graft repair of the posterior lamella results in an adequate fornix and a low rate of secondary surgery.