Dale R. Meyer

Orbital implants in enucleation surgery: A report by the american academy of ophthalmology☆

OBJECTIVE To compare prosthetic and implant motility and the incidence of complications associated with porous and nonporous enucleation implants. METHODS Literature searches conducted in January 2002 for 1985 to 2001 and May 2002 for October 2001 to 2002 retrieved relevant citations. The searches were conducted in MEDLINE and limited to articles published in English with abstracts. Panel members reviewed the articles for relevance to the assessment questions, and those considered relevant were rated according to the strength of the evidence. RESULTS A randomized clinical trial and a longitudinal cohort study detected no difference in implant or prosthetic movement between nonpegged hydroxyapatite porous and spherical alloplastic nonporous implants. No controlled studies were retrieved that investigated whether pegging porous implants improves prosthetic movement. Several case series indicate that patients with pegged hydroxyapatite implants have some degree of improved prosthetic motility. Longitudinal cohort studies show that sclera-covered hydroxyapatite implants have higher exposure rates than sclera-covered silicone implants, and unwrapped porous polyethylene implants have higher exposure rates than unwrapped acrylic implants. There are numerous case series that document a wide range of implant exposure rates in patients with various enucleation implants. It is difficult to compare complication rates among implant types because patient populations vary, surgical techniques differ, and follow-up periods are often limited. CONCLUSIONS Based on one randomized clinical trial, spherical alloplastic nonporous and nonpegged porous enucleation implants provide similar implant and prosthetic motility when they are implanted using similar surgical techniques. Coupling the prosthesis to a porous implant with a motility peg or post appears to improve prosthetic motility, but there are few available data in the literature that document the degree of the improvement. There is a widely variable incidence of porous implant exposure, but certain surgical techniques and the type of wrapping material seem to reduce the exposure rate. Additional research is needed to document the long-term incidence of complications related to porous enucleation implants and associated surgical techniques. This includes the use of wrapping materials and what procedural modifications, both surgical and prosthetic, are most effective in reducing these complications.

Anatomy of the orbital septum and associated eyelid connective tissues : Implications for ptosis surgery

The anatomy of the orbital septum and associated eyelid connective tissues was examined using cadaver dissection, histologie sections, surgical observations, and special radiologie imaging. The embryologie development of the eyelid connective tissues was also reviewed. Examination revealed a distinct layer of fibroadipose tissue in the eyelid and eyebrow posterior to the orbicularis and frontalis muscles, and anterior to the orbital septum. Fibrous septa within the submuscular fibroadipose tissue become contiguous with more compact lamellae of the orbital septum posteriorly imparting a multilayered quality to the orbital septum. Fat within the fibroadipose layer anterior to the orbital septum may be mistaken for the preaponeurotic fat pad by the unwary surgeon and may lead to surgical error. The orbital septum and the levator aponeurosis were found to join 2 to 5 mm above the superior tarsal border (average, 3.4 mm). Recommendations for ptosis surgery based on these anatomic principles are given.

Localized lymphedema (elephantiasis): a case series and review of the literature

Background:  Lymphedema typically affects a whole limb. Rarely, lymphedema can present as a circumscribed plaque or an isolated skin tumor.

Lacrimal sac dacryoliths: predictive factors and clinical characteristics.

OBJECTIVE Lacrimal sac dacryoliths are often diagnosed during dacryocystorhinostomy (DCR), although their cause is unclear. Several factors have been suggested to predispose to dacryolith formation. The clinical presentation of nasolacrimal duct obstruction (NLDO) may differ if associated with a dacryolith. Our study evaluated specific risk factors related to dacryolith formation and how the clinical presentation of patients with dacryoliths differs from patients with primary acquired NLDO who undergo DCR. DESIGN Retrospective, comparative, interventional case series. PARTICIPANTS/INTERVENTION One hundred thirty-eight consecutive patients with NLDO who underwent DCR (163 total DCR cases) between 1993 and 1998. MAIN OUTCOME MEASURES We evaluated the frequency of dacryolith formation for all DCR cases. For 115 patients with primary acquired NLDO, we statistically compared the patients with dacryoliths (n = 12) to those without (n = 103) for several variables related to clinical history and presentation. RESULTS The overall frequency of dacryoliths was 12 of 163 (7.4%) for all DCR cases and 12 of 138 (8.7%) for all patients. All patients with dacryoliths were in the subgroup of 115 patients with primary acquired NLDO, and the frequency in that subgroup was 12 of 115 (10.4%). There was no statistical difference between the group of patients with dacryoliths and those without dacryoliths for age, duration of epiphora, history of acute dacryocystitis, or previous use of antiglaucomatous topical medications. Male gender was more likely to be associated with dacryoliths (P = 0.004), as was initial presentation with lacrimal sac distension (P < 0.001). Partial nasolacrimal obstruction on lacrimal irrigation approached statistical significance for dacryolith formation (P = 0.08), as did a history of cigarette smoking (P = 0.09). CONCLUSIONS In patients with primary acquired NLDO who require DCR, male gender and presence of sac distension are more frequently associated with dacryoliths. Partial NLDO and history of cigarette smoking may also be relative risk factors for dacryolith formation. These observations may be helpful in the evaluation and surgical planning for patients with lacrimal obstruction.

Stepwise treatment paradigm for congenital nasolacrimal duct obstruction.

Purpose: To compare the outcomes achieved by a series of patients treated in a stepwise fashion who presented with congenital nasolacrimal duct obstruction. Methods: In this retrospective interventional case series, 127 patients, ranging in age from 1 month to 81 months, with 173 lacrimal systems diagnosed with congenital nasolacrimal duct obstruction, were treated in a stepwise fashion. A treatment paradigm was evaluated that prescribed probing as an initial procedure regardless of age. Those who failed probing received balloon catheter dilation. Those who failed probing and balloon catheterization received silicone intubation. Dacryocystorhinostomy was reserved for patients failing the above treatments. Clinical success was defined as complete resolution of symptoms. Success rates at each step were evaluated, and a cost analysis was performed. Results: Lacrimal probing was successful in 134 of 173 (76.9%) cases. Of the 39 probing failures, 32 (82.1%) were cured with balloon catheterization. All 7 cases (100%) that failed probing and balloon catheterization were cured with silicone intubation. No patient in this series required dacryocystorhinostomy. Conclusions: A stepwise approach to the treatment of congenital nasolacrimal duct obstruction is a clinically and financially effective model for treatment.

Silicone Intubation Without Intranasal Fixation for Treatment of Congenital Nasolacrimal Duct Obstruction

PURPOSE We assessed the efficacy and morbidity of silicone intubation without intranasal fixation to treat congenital nasolacrimal duct obstruction. METHODS Forty eyes of 30 consecutive patients underwent silicone intubation to treat congenital nasolacrimal duct obstruction. The ends of the silicone tubing were tied together with a single square knot and were allowed to retract into the nose without intranasal fixation. Tubing removal was performed in the office via the medial canthus in all patients. No attempt was made to reposition prematurely dislodged tubing. RESULTS The success rate for this series was 38 (95%) of 40 eyes in 29 (97%) of 30 patients. Of seven eyes that required unplanned early tubing removal for dislocated tubing, five eyes nevertheless showed complete resolution of nasolacrimal duct obstruction. Only one patient underwent a second silicone intubation under general anesthesia. CONCLUSIONS Silicone intubation without the use of intranasal fixation is an effective strategy for treating congenital nasolacrimal duct obstruction. It spares most patients from a second procedure under general anesthesia and achieves success rates comparable to previous studies in which more complex techniques were used.

Management and prognosis of merkel cell carcinoma of the eyelid

OBJECTIVE To evaluate the clinical presentation, treatment, and long-term follow-up of eyelid Merkel cell carcinoma. DESIGN Retrospective noncomparative interventional case series. PARTICIPANTS Fourteen patients with primary eyelid Merkel cell carcinoma. METHODS Cases of Merkel cell carcinoma for which long-term follow-up was available were solicited from members of the American Society of Ophthalmic Plastic and Reconstructive Surgery through an on-line e-mail/news group. MAIN OUTCOME MEASURES Follow-up period, treatment history, presence and type of recurrence, and mortality. RESULTS Average follow-up was 33.4 months. Of the 14 cases identified, only 2 patients (14%) received prophylactic therapy beyond wide surgical excision. Three patients (21%) had recurrences, none of whom initially received prophylactic therapy (i.e., radiation therapy, lymph node dissection, and/or chemotherapy) beyond wide surgical excision. One patient (7%) died of metastatic Merkel cell carcinoma. CONCLUSIONS Merkel cell carcinoma is a rare skin malignancy that occasionally affects the eyelid, with the potential for regional and distant metastasis. Consideration should be given to the use of prophylactic adjunctive therapies beyond wide surgical excision while simultaneously considering the morbidity of these therapies.

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.

Success of balloon catheter dilatation as a primary or secondary procedure for congenital nasolacrimal duct obstruction

PURPOSE To determine the efficacy of lacrimal balloon catheter dilatation in treating congenital nasolacrimal duct obstruction (CNLDO) as a primary procedure in children more than 18 months of age and in children who have failed lacrimal probing or silicone intubation. DESIGN Retrospective, interventional case series. PARTICIPANTS Fifty-nine patients, ranging in age from 15 months to 9 years (mean, 35.6 months), with 73 lacrimal systems diagnosed with CNLDO who underwent nasolacrimal balloon catheter dilatation. Thirty-four lacrimal systems (46.5%) had no previous procedures, whereas 39 lacrimal systems (53.5%) had failed probing, silicone intubation, or both. INTERVENTION Balloon catheter dilatation was performed following standard protocol, with a simplified regimen in most patients. MAIN OUTCOME MEASURES Clinical patency of the nasolacrimal duct after balloon dilatation was the main outcome measure and was defined as complete resolution of signs and symptoms (crusting, discharge, and increased tear meniscus). Age, inferior turbinate infracture, and Downes syndrome as related to the main outcome measure were also analyzed. RESULTS Overall, 56 of the 73 lacrimal systems (76.7%) had complete resolution of symptoms. Twenty-seven of all 34 primary balloon catheter dilatations (79.4%) remained clinically patent, whereas 29 of all 39 secondary balloon catheter dilatations (74.4%) remained clinically patent after surgery (P = 0.8165). Thirty-nine of 47 lacrimal systems (82.9%) in children older than 24 months remained clinically patent, whereas 17 of 26 lacrimal systems (65.4%) in children younger than 24 months remained clinically patent (P = 0.1573). The mean age of patients with successful outcomes was 37 months, whereas the mean age of patients with failed balloon catheter dilatations was 32 months (P = 0.3924). In the secondary procedure group, analysis showed that the mean age of success (32 months) was greater than the mean age of failure (18 months; P = 0.0491). Within the secondary group, 16 of 17 lacrimal systems (94.1%) older than 24 months were successful, whereas 13 of 22 lacrimal systems (59.1%) younger than 24 months were successful (P = 0.0344). CONCLUSIONS Balloon catheter dilatation is an effective treatment for congenital nasolacrimal duct obstruction. In particular, balloon catheter dilatation in older children who failed previous probing is highly successful.

Margins of excision for cutaneous melanoma of the eyelid skin - The collaborative eyelid skin melanoma group report

Purpose To evaluate the practice patterns among surgeons who treat melanomas of the eyelid skin with respect to margins of excision and to look for possible correlation between margins of excision and the incidence of local and regional recurrence and distant metastasis. Methods A retrospective survey of the members of the American Society of Ophthalmic Plastic & Reconstructive Surgery and the European Society of Ophthalmic Plastic & Reconstructive Surgery yielded 44 cases. The patients’ age, sex, date of diagnosis, histologic classification of melanoma, Breslow thickness, Clark level, location of melanoma, size of margins of excision, and findings of local or regional recurrence or distant metastasis were recorded in each case. Patients were stratified on the basis of margins of excision: ≤5 mm; >5 mm but <10 mm; and ≥10 mm. Patients were also stratified by Breslow thickness. A Cox regression model was used to evaluate the predictive value of each factor for recurrence. Main outcome measures were the incidences of local and regional recurrence and distant metastasis as a function of margins of excision and Breslow thickness. Results The majority of patients for whom reliable information was available had excision margins of ≤5 mm. The Breslow thickness of most of the tumors was ≤1 mm. Eleven patients (25%) had local recurrence. Five patients (11%) had regional lymph node metastasis. All patients with regional nodal metastasis were men. Distant metastasis developed in 3 patients (7%)—2 men and 1 woman. The follow-up times ranged from 10 to 108 months (mean, 34 months; median, 21 months). The incidence of local recurrence was higher among patients with melanomas at least 2 mm thick and margins of excision ≤5 mm than among patients with melanomas at least 2 mm thick but with margins ≥10 mm, but this difference was not statistically significant because very few patients had melanomas at least 2 mm thick. Breslow thickness was the only statistically significant predictor of local, regional, and distant metastasis. Margins of excision did not have a statistically significant effect on local, regional, or distant recurrence. Conclusions Breslow thickness is an important prognostic indicator for eyelid skin melanomas. A 5-mm margin of excision may be adequate for thin melanomas of the periocular skin, but because of the small number of patients in this series who had >5-mm margins, a definitive comparison of outcome with larger margins of excision cannot be made. For melanomas ≥2 mm, wider margins of excision may be prudent, and careful surveillance for local and regional recurrence is indicated.