James H. Oestreicher

Complications of Hydroxyapatite Orbital Implants: A Review of 100 Consecutive Cases and a Comparison of Dexon Mesh (Polyglycolic Acid) with Scleral Wrapping

PURPOSE The authors analyzed all the complications associates with the first 100 hydroxyapatite orbital implants performed by one surgeon, and compare scleral wrapping versus Dexon mesh (polyglycolic acid, Davis & Geck, Manati, Puerto Rico) wrapping in light of these complications. BACKGROUND Prior studies have not included the full range of complications that can occur with hydroxyapatite orbital implants. Dexon mesh implant wrapping is a promising substitute for sclera and avoids the risks involved in using donor tissue. METHODS A retrospective analysis of 100 consecutive cases was performed. RESULTS Many minor complications occurred, but the rate of exposure was low (3%) and no implant was lost. Dexon mesh wrapping was similar to scleral wrapping with respect to complications, although more posterior implant placement was necessary to avoid exposure in the Dexon-wrapped group. CONCLUSIONS Surgeons and patients must be prepared for many minor complications when using hydroxyapatite orbital implants, but these can be readily overcome. Dexon mesh wrapping of the implant is recommended to avoid using donor tissue.

Complications of Orbital Implants: A Review of 542 Patients Who Have Undergone Orbital Implantation and 275 Subsequent Peg Placements

Purpose: To inform patients and physicians of the complications associated with three commonly used orbital implants, as well as associated anophthalmic socket issues. Methods: A retrospective chart review of 542 patients who underwent eviscerations, enucleations and secondary procedures by one surgeon (Dr. James Oestreicher) was completed, paying special attention to complications in the follow-up period prior to pegging, as well as those that occurred post-pegging. Results: Approximately 60% of patients experienced complications prior to implant drilling, with discharge being the most prevalent (15.9%). Secondary procedures were associated with significantly greater complication rates prior to implant drilling. Silicone implants had significantly less pre-pegging pyogenic granuloma (P = 0.011) and hypo-ophthalmos (P = 0.042) than the other implant types. Seven implants had to be removed due to exposure. Implant drilling and peg placement were performed in 275 patients. Implant drilling complications were experienced by 67.4% of pegged patients, with a change in discharge from prior to pegging (27.2%) being the most prevalent. Plastic peg systems had a significantly higher incidence of complications than titanium systems. Conclusions: The majority of orbital implantations involve complications, these being largely minor ones which resolve spontaneously or are easily treated. Secondary implant procedures involve a higher likelihood of complications. Silicone implants have the smallest amount of complications. Should patients decide to undergo pegging, evidence sides strongly for the use of a titanium peg and sleeve system over the other peg types. Implant removal is a rare event; occurring in 1.3% (n = 7) of the study population.

Treatment of exposed coral implant after failed scleral patch graft.

A case of a coral orbital enucleation implant that exposed and failed two closure attempts, by scleral patch grafting and by simple tissue advancement, is presented. The method used to overcome this problem is detailed. This unique case sheds light on the factors that are etiologically important in coral implant exposure and those relevant to covering that exposure successfully.

Clinical Spectrum of Leber's Congenital Amaurosis in the Second to Fourth Decades of Life

Lebers congenital amaurosis is a type of congenital retinitis pigmentosa in which the fundus abnormalities are extremely variable and to some extent age dependent. Most cases are seen in infancy. The retinal, electroretinogram, and fluorescein angiographic findings are described in ten patients with Lebers congenital amaurosis who ranged in age from 13 to 36 years when first seen. All of the patients were from Honduras and were unrelated except for one pair (a brother and sister). The polymorphic appearance of the fundus is emphasized and is particularly striking in the siblings. A macular lesion (a bulls-eye maculopathy) not previously associated with Lebers congenital amaurosis is reported as a variant fundus appearance in this entity.

Fasanella-Servat procedure: indications, efficacy, and complications.

BACKGROUND The Fasanella-Servat procedure is used for the repair of mild to moderate ptosis. The purpose of this study was to determine the efficacy of the Fasanella-Servat procedure for the repair of several forms of ptosis. METHODS The authors retrospectively reviewed 169 charts of 2 surgeons from 1988 to 1996. All patients had undergone a Fasanella-Servat procedure for ptosis. Patients with less than a 1-month follow-up were excluded, leaving 153 eyelids of 144 patients. Surgical success was defined as lid symmetry within 0.5 mm or correction of eyelid contour abnormality from previous surgery or trauma. RESULTS Ptosis was classified as involutional, occurring after intraocular surgery, congenital, due to Horners syndrome present after levator surgery, and myogenic/other. With a mean follow-up of 7 months, success was achieved in 89.5% of cases (137/153). Among subgroups, success was highest at 100% in Horners syndrome (8/8) and post-levator surgery (11/11), and lowest in congenital ptosis at 76.4% (13/18). Postoperative problems included dry eye symptoms (6/144 patients), contour abnormalities in 12 lids, and dermatochalasis in 10 lids. INTERPRETATION The Fasanella-Servat operation is effective for mild to moderate ptosis from a variety of causes and for contour abnormality correction in patients with little or no ptosis. Despite the long-held belief that excision of the accessory lacrimal glands of Wolfring leads to dry eye symptoms, our study found this to be the exception. This procedure has the advantage of high reliability when reasonable preoperative criteria are applied and is minimally invasive.

Adrenergic receptors in the ptotic human eyelid: correlation with phenylephrine testing and surgical success in ptosis repair.

Purpose: To investigate the relationship between adrenergic receptors in Müller muscle and response to phenylephrine testing in patients undergoing ptosis surgery. This study also compares outcomes of Fasanella and Putterman approaches to posterior ptosis repair. Methods: Prospective analysis of 71 patients undergoing posterior ptosis surgery. Eyelid height was measured before and after phenylephrine. Müller muscle was examined for alpha-1D, alpha-2C, beta-1, and beta-2 receptors. Specimens were graded on receptor staining intensity. Patients were seen 1 week and 6 weeks following surgery. Surgical outcomes were scored on a scale of 1 (most favorable) to 3 (least favorable). Results: Adrenergic receptors were found in decreasing order: alpha-1D, beta-1, alpha-2C, and beta-2. Receptor grade significantly predicted eyelid height for alpha-2C receptors (p = .03). Mean outcome scores for 36 Putterman (1.10) and 35 Fasanella (1.27) procedures were not significantly different. Conclusions: Alpha 1D, alpha-2C, and beta-2 receptors are documented within human Müller muscle. Human eyelid elevation response to phenylephrine is inversely related to the amount of alpha-2C receptor staining in Müller muscle. Fasanella and Putterman procedures have equal outcomes, independent of adrenergic receptors.

Treatment of post-blepharoplasty lower lid retraction by free tarsoconjunctival grafting.

BACKGROUND Blepharoplasty is probably the most commonly performed facial cosmetic procedure. Despite attempts to prevent its occurrence, post-blepharoplasty lower eyelid malposition with inferior scleral show and corneal exposure can occur, particularly with nonophthalmologist surgeons. Since a repair must oppose the force of gravity and recurrent scarring, it is often difficult to achieve functional and esthetically pleasing surgical correction. A variety of authors have documented methods to correct post-blepharoplasty lower eyelid malposition. A review of such methods is presented. This is the first paper to analyze results from free tarsoconjunctival grafting specifically in cases of post-blepharoplasty lower lid retraction. METHODS The present case-series report attempts to examine the efficacy of free tarsoconjuctival grafting in patients with postblepharoplasty lower lid malposition.Ten patients, ranging in age from 48-75 years (mean = 58.7 years), presented with varied amounts of inferior scleral show and ocular symptoms, including epiphora, dry eye and ocular irritation. Varied amounts of lagophthalmos and superficial punctate keratitis were detected in five eyes and ten eyes, respectively. As described, each patient (20 eyes) underwent bilateral free conjunctival grafting from upper to lower eyelids. RESULTS After a follow-up interval of 3-32 months (mean = 15 months), all patients experienced a decrease in inferior scleral show and symptomatology.The decrease in inferior scleral show ranged from 0.75 to 3mm, with an average decrease of 1.61mm; symptoms of epiphora, dry eye or discomfort persisted in only four eyes.The amount of lagophthalmos and superficial punctate keratitis also decreased postoperatively. Side effects were minimal. INTERPRETATION We conclude that in the specific case of postblepharoplasty lower lid retraction, free tarsoconjunctival grafting is both safe and effective.

Treatment of lower eyelid retraction by retractor release and posterior lamellar grafting: an analysis of 659 eyelids in 400 patients.

Purpose: To review one surgeons experience with posterior lamellar grafting for lower eyelid elevation over a 15-year period, comparing the success of different posterior lamellar grafts used in 4 etiology groups. Methods: A retrospective chart review of 400 patients (659 eyelids) was conducted. Patients were grouped into thyroid ophthalmopathy, previous surgery, trauma, and idiopathic causes. Three graft types were used: hard palate mucosa, free tarsoconjunctival, and free scleral. Objective measurements of lagophthalmos, scleral show, and superficial punctate keratopathy, and subjective patient symptoms, preoperatively and postoperatively were compared between graft types and etiologic groups. Complications were tabulated and compared between groups, as was any need for further surgery. The mean follow-up interval was 16.5 months. The main outcome measures were objective measurements of lagophthalmos, scleral show, and superficial punctate keratopathy. Results: A mean reduction in lagophthalmos (∼0.5 mm), superficial punctate keratopathy (mean score reduction = 0.2, on a scale of 1–3), and scleral show (∼1.3 mm) was demonstrated for all etiology groups and graft types. Furthermore, 90% of patients subjectively reported a reduction of 1 to 3 symptoms. Hard palate mucosa grafts were more likely to be used than tarsoconjunctival grafts in cases with one or more previous surgeries (p < 0.001). Complications were more common with tarsoconjunctival grafts (except for bleeding), but the difference was statistically significant only for wound dehiscence (p = 0.004). Conclusions: Lower eyelid retraction repair with posterior lamellar grafting and lateral eyelid tightening can be recommended with confidence for eyelid retraction patients because most improved subjectively and by objective examination.

Distribution of adrenergic receptor subtypes in the retractor muscles of the upper eyelid

PURPOSE To identify adrenergic receptor subtypes and their relative distribution in the retractor muscles of the upper eyelid, the levator palpebrae superioris, and the Müller muscle. The pattern of distribution of these receptors in the Müller muscle was further compared in patients with dysthyroid eyelid retraction and in normal subjects. METHODS Müller muscle specimens were collected from 19 patients undergoing ptosis correction and from 8 patients undergoing repair of dysthyroid eyelid retraction. Immunohistochemical staining for alpha 1-, alpha 2-, beta 1-, and beta 2-adrenergic receptors was performed using antihuman rabbit polyclonal antibodies. RESULTS alpha 2-Adrenergic receptors were the predominant subtype in the Müller muscle, and beta 1-adrenergic receptors were the predominant subtype in the levator muscle. There was no significant difference in the staining pattern between specimens collected from patients with dysthyroid eyelid retraction and those from normal subjects. CONCLUSIONS The interaction between the alpha 2 and beta 1 receptors in the upper eyelid retractor muscles may be important in the control of the upper eyelid position and may contribute to the development of dysthyroid eyelid retraction. Specific alpha 2 antagonists could be developed and may be effective pharmacologic agents for the treatment of eyelid retraction.

Aspergillus mycetoma in a secondary hydroxyapatite orbital implant: a case report and literature review.

OBJECTIVE The authors describe the first case report of a fungal abscess within a hydroxyapatite orbital implant in a patient who had undergone straightforward secondary hydroxyapatite implant surgery. DESIGN Case report and literature review. INTERVENTION Four months postoperatively after pegging and 17 months after original implant placement, chronic discharge and socket irritation became evident. Recurrent pyogenic granulomas were a problem, but no obvious area of dehiscence was present over the implant. The peg and sleeve were removed 31 months after pegging (44 months after original placement of the implant). The pain and discharge did not resolve, and the entire hydroxyapatite orbital implant was removed 45 months after sleeve placement and 58 months after initial implant placement. The pain and discharge settled rapidly. MAIN OUTCOME MEASURES Cultures and histopathology. RESULTS Results of bacterial cultures were negative. Results of histopathologic examination of the implant disclosed intertrabecular spaces with multiple clusters of organisms consistent with Aspergillus. CONCLUSIONS Persistent orbital discomfort, discharge, and pyogenic granulomas after hydroxyapatite implantation should cause concern regarding potential implant infection. The authors have now shown that this implant infection could be bacterial or fungal in nature. This is essentially a new form of orbital Aspergillus, that of a chronic infection limited to a hydroxyapatite implant.