David B. Samimi

Microbiologic trends and biofilm growth on explanted periorbital biomaterials: a 30-year review.

Purpose: To investigate microbiologic trends and role of biofilm on periorbital biomaterials surgically explanted for recalcitrant infection. Methods: A search of the Bascom Palmer Eye Institute, University of Miami Miller School of Medicine microbiology laboratory electronic database was conducted from 1980 to 2010. Culture results were analyzed from submitted periorbital biomaterials explanted for nonresolving infections or exposure. Random select samples cultured during the study were sent for electron microscopy. Results: Twenty-one explanted biomaterials were identified from 18 patients. Five orbital plate implants included 2 made of nylon, 1 of porous polyethylene, 1 of silicone, and 1 metallic. Of 4 anophthalmic socket sphere implants, 2 were silicone, 1 was porous polyethylene, and 1 was poly-2-hydroxyethyl methacrylate. Lacrimal intubation devices included 10 silicone stents and 2 pyrex glass Jones tubes. All biomaterials were culture positive with 40 total isolates identified. The most common organisms overall were Mycobacterium chelonae (N = 9), Staphylococcus aureus (N = 8), and Pseudomonas aeruginosa (N = 3). One hundred percent of orbital spheres had Gram-positive organisms, 90% of lacrimal silicone stents grew atypical mycobacterium, and 60% of orbital plates were culture positive for yeast species. Mixed organism growth was documented on 58% of the specimens. Ten of 12 implants (83%) examined with electron microscopy exhibited organisms encased in glycocalyx, suggestive of biofilm. Conclusions: A diverse array of microorganisms can colonize biomaterials implanted within the orbit and lacrimal drainage system. The authors’ study showed that the majority of infected periocular and orbital alloplastic implants display biofilm when studied with electron microscopy (83%). The cultured organism type depended on the implant location and composition. Most infected silicone lacrimal stents grew atypical mycobacterium, whereas infected orbital fracture repair plates demonstrated yeast species. Biofilms are known to be antibiotic resistant, explaining the need to explant most infected alloplastic implants. Further research concerning treatment of biofilms may prevent explantation and improve surgical outcomes.

The hydrogel lacrimal stent for dacryocystorhinostomy: preliminary experience.

Purpose: To present the results of dacryocystorhinostomy with the use of a newly designed hydrogel lacrimal stent for repair of acquired nasolacrimal duct obstruction. Methods: Noncomparative interventional case series. Twenty-three cases of acquired nasolacrimal duct obstruction confirmed by probing and irrigation underwent dacryocystorhinostomy using the hydrogel lacrimal stent. Tearing symptoms, functional endoscopic dye test, and anatomic appearance of ostia were noted at follow-up. Results: Five of 23 ostia closed during the postoperative period (1–3 months), translating to a late success rate of 78.3%. The 5 failed cases were treated successfully with ostium revision, 1 case requiring 2 revisions. All patients had endoscopic follow-up with a minimum follow-up of 6 months after stent removal. In the successful cases we noted a large, quiet ostium with good separation of the nasal septum and middle turbinate. Eleven cases (47.8%) had history of previously failed dacryocystorhinostomy surgery, chronic sinusitis, deviated septum, or maxillofacial surgery. There were no complications or reports of unusual pain or symptoms associated with the stent itself. Conclusions: Early experience suggests the hydrogel lacrimal stent is a well-tolerated, effective tool for dacryocystorhinostomy surgery after acquired nasolacrimal duct obstruction. The device may serve as a useful surgical tool by holding open the ostium, maintaining apposition of the mucosal edges, and decreasing the incidence of nasal adhesions.

The Modified Fasanella-Servat Procedure: Description and Quantified Analysis

Purpose: To describe a modified Fasanella-Servat procedure and nomogram for the correction of minimal amounts of ptosis. Methods: Retrospective review of this modified Fasanella-Servat procedure was performed on 118 eyelids in 86 consecutive patients over 2, 4-year periods by 1 surgeon (S.C.D.). The amount of tarsectomy was based on the amount of ptosis. Results: Mean pre- and postoperative margin-to-reflex distance 1 were +0.7 mm and +2.4mm, respectively. One hundred and twelve eyelids (95%) had satisfactory results with postoperative margin-to-reflex distance 1 ≥ 1.5 mm. Eyelid symmetry was achieved in 92% of eyelids to within 0.5 mm. There was no incidence of overcorrection, tarsal buckling, or corneal abrasion. One eyelid had a contour deficit. Tarsectomy amount ranged from 2 mm to 5 mm. Average amount of tarsectomy to eyelid elevation was 2.4:1. Conclusions: The modified Fasanella-Servat procedure is technically easy, time-efficient, and has a low complication rate for the treatment of minimal blepharoptosis (< 2.5 mm) with good levator function and negative phenylephrine test. In the authors’ hands, the ratio of tarsectomy to eyelid elevation is approximately 2:1. In addition to other techniques such as levator advancement and Müller’s muscle conjunctival resection, the modified Fasanella-Servat technique is a useful adjunct to the modern ptosis surgeon’s armamentarium.

Orbital Tumors Excision without Bony Marginotomy under Local and General Anesthesia

To present our experience of removing middle to deep orbital tumors using a combination of minimally invasive soft tissue approaches, sometimes under local anesthesia. Methods. In this retrospective case series, 30 patients (13 males and 17 females) underwent tumor removal through eyelid crease (17 eyes), conjunctival (nine eyes), lateral canthal (two eyes), and transcaruncular (two eyes) approaches. All tumors were located in the posterior half of the orbit. Six cases were removed under monitored anesthesia care with local block, and 24 were under general anesthesia. Results. The median (range) age and follow-up duration were 48.5 (31–87) years old and 24.5 (4–375) weeks, respectively. Visual acuity and ocular motility showed improvement or no significant change in all but one patient at the latest followup. Confirmed pathologies revealed cavernous hemangioma (15 cases), pleomorphic adenoma (5 cases), solitary fibrous tumor (4 cases), neurofibroma (2 cases), schwannoma (2 cases), and orbital varix (1 case). None of the patients experienced recurrence. Conclusions. Creating a bony marginotomy increases intraoperative exposure of the deep orbit but adds substantial time and morbidity. Benign orbital tumors can often be removed safely through small soft-tissue incisions, without bone removal and under local anesthesia.

An anatomically based approach to intralesional corticosteroid injection for eyelid capillary hemangiomas

BACKGROUND AND OBJECTIVE To describe a corticosteroid injection technique for eyelid capillary hemangiomas that minimizes the risk of a central retinal artery occlusion and is based on anatomic, physiologic, and pharmacologic rationales. PATIENTS AND METHODS In this retrospective, non-comparative, interventional case series, the medical records of 50 eyes of 50 patients over a 10-year period were reviewed for retinal complications associated with the described injection technique. RESULTS Ophthalmoscopy showed no retinal complications in the 50 eyes treated with this injection technique. CONCLUSION The risk of central retinal artery occlusion from retrograde embolization can be minimized by using an anatomically based injection technique that prevents canalization of an artery and avoids injection pressures exceeding the mean systemic arterial pressure.

Microbiology and Biofilm Trends of Silicone Lacrimal Implants: Comparing Infected Versus Routinely Removed Stents

Purpose: To investigate the pathogens and biofilms responsible for clinically significant infection of silicone stents implanted within the lacrimal system. Methods: Retrospective review of culture results and patient demographics for all silicone lacrimal stents removed early for clinically significant infection and sent to the Bascom Palmer Microbiology Laboratory through the end of year 2010. As a control, routinely removed, clinically noninfected stents from the same institution were prospectively sent for culture over a 6-month period. Four clinically infected and 6 clinically noninfected stents showing mucus within the lumen at removal were sent for scanning electron microscopy. Images were randomized and graded by a microbiologist for the presence of organisms, matrix deposits, organisms within matrix, and overall impression of significant biofilm formation. Results: Nineteen stents were included in the study; 100% of clinically infected (n = 10) and noninfected (n = 9) stents were culture positive. Culture positivity for nontuberculous mycobacterium was found in 90% of infected stents and none of the noninfected stents (p < 0.001). Of infected stents, 50% grew Gram-positive organisms compared with 89% of noninfected stents (p = 0.07). Fifty percent of infected versus 67% of noninfected stents were culture positive for Gram-negative organisms (p = 0.46). Electron microscopy of stents revealed organisms consistent with culture results (size, shape) in planktonic and biofilm form. Masked observer image grading revealed a statistically significant higher amount of organism and biofilm on infected versus noninfected specimen. Conclusion: Nontuberculous mycobacteria comprise the primary pathogens responsible for clinically significant infection of silicone stents in the lacrimal system in South Florida. Robust biofilm production by this organism likely plays a role in pathogenesis. Further research into biofilm-related lacrimal implant infection may aid in the development of useful prevention and treatment strategies.

PROSE scleral lens: a novel aid for staged eyelid reconstruction.

A 50-year-old man presented with a papillomatous tarsoconjunctival tumor involving the medial two-thirds of the left upper eyelid. Office biopsy revealed papillary squamous cell carcinoma (SCCA). Rapid tumor growth with caruncular and forniceal conjunctival involvement continued, despite a trial of weekly interferon-α2b intralesional injection therapy. Surgical excision with clear margins resulted in a large upper eyelid defect. The suspicion for recurrence remained, given the aggressive nature of the tumor. A temporary prosthetic replacement of the ocular surface ecosystem (PROSE) scleral lens was fit for preservation of the ocular surface and visual function during a 1-month observation period. No evidence of recurrence was noted, and the eyelid defect was successfully reconstructed with a Cutler-Beard procedure. Local disease was controlled; unfortunately, metastatic disease was found in the ipsilateral parotid gland 1 year later. Aggressive surgical removal is recommended in interferon-α2b nonresponsive SCCA tumors. The PROSE scleral contact lens may serve as a useful adjunct for the maintenance of a healthy ocular surface and visual function during delayed eyelid defect repair.

Hemorrhagic Complications of Rivaroxaban After Eyelid Surgery.

rivaroxaban 8 hours after the procedure, and 2 hours after the dose, she experienced active bleeding from the left lower eyelid unrelieved with holding pressure. By the time she presented 12 hours after that dose, she had pulsatile bleeding externally across the entire wound. There was no evidence of orbital compartment syndrome, and hemostasis was achieved, with difficulty, with electrocautery and oxidized cellulose polymer (Surgicel). Her recorded hemoglobin drop was 1 U, however likely greater since she bled for hours prior to the first sample. There is currently no antidote for any of the factor Xa inhibitors. Monitoring with the standard coagulation labs (prothrombin time/international normalized ratio, partial thromboplastin time) is not recommended. Anti-factor Xa activity can be measured in some centers, but may have limited utility since normal parameters may not correlate to reversal of anticoagulation. Activated charcoal can theoretically prevent further absorption of agents if given within 3 to 8 hours after dose. Rivaroxaban is likely not dialyzable due to the high plasma protein binding. In cases of severe, uncontrollable bleeding, activated or unactivated prothrombin complex concentrations are options, although systemic thrombosis may be a risk. Data on efficacy of these therapies on factor Xa inhibitors-associated bleeding is limited to animal models and small series of healthy, nonbleeding volunteers. A 4-factor prothrombin complex concentration was able to reverse PT prolongation and impaired thrombin generation in 10 to 12 nonbleeding volunteers, although a rabbit hemorrhage model did not reverse bleeding. The clinical relevance is unclear. Thankfully, both of our patients recovered without permanent sequalae, but we share these experiences with rivaroxaban given the current limited data. Unlike older medications, these newer anticoagulants may have a more rapid and more profound effect on clotting after surgery. An anti-factor Xa antidote is under development (andexanet alfa recombinant protein that binds factor Xa inhibitor), but until this becomes readily available, therapy should be reinstated with caution after eyelid surgery. Further research is necessary to clarify the best practices for stopping and restarting factor Xa inhibitors after oculofacial surgery. Catherine Y. Liu, M.D., Ph.D. David B. Samimi, M.D. Jeremiah P. Tao, M.D., F.A.C.S.

On-Q pump for pain control after orbital implant surgery.

Purpose: To introduce an elastomeric continuous infusion pump for pain control after outpatient orbital implant surgery. Methods: Retrospective, noncomparative consecutive case series of all patients undergoing enucleation, evisceration, or secondary orbital implantation using the On-Q pain system between August 2004 and January 2006. Postoperative pain score, need for narcotics, and adverse events were recorded. The On-Q catheter is inserted intraoperatively through the lateral lower eyelid into the muscle cone under direct visualization, prior to the orbital implant placement. The On-Q system continually infuses anesthesia (bupivacaine) to the retrobulbar site for 5 days. Results: Among 20 patients, mean postoperative period pain score, with On-Q in place, was 1.3 (scale of 0 to 10). Nine patients (45%) did not need any adjunctive oral narcotics. Two patients experienced postoperative nausea. One catheter connector leaked, thereby decreasing delivery of retrobulbar anesthetic resulting a pain level of 6, the highest level in the study. There were no postoperative infections. No systemic toxic effects from bupivacaine were observed clinically. Conclusion: The On-Q pain pump is widely available, low cost, and requires minimal patient manipulation for the use in orbital implant surgery. The device was safe and appeared to minimize postoperative pain in the authors’ case series.