James R. Patrinely

Complications Associated with Alloplastic Implants used in Orbital Fracture Repair

BACKGROUND The treatment of orbital wall fractures involves observation and/or surgical reduction with repositioning of herniated orbital tissues. To prevent reherniation of tissue and development of enophthalmos, the orbital floor or wall defect is commonly covered with an alloplastic implant. Complications associated with these implants are infrequent and generally appear as isolated case reports. METHODS The authors reviewed the files of four consultative oculoplastic surgeons and searched for individuals with complications secondary to their alloplastic implants used during orbital fracture repair. FINDINGS Seventeen patients were identified with a variety of complications related to their alloplastic implant. CONCLUSION Although these implants are relatively inert and develop a fibrous capsule walling them off from the surrounding orbit, they remain foreign bodies and are thus subject to possible complications at any time. The authors review the spectrum of complications occurring with various alloplastic implants.

Congenital Dacryocele: A Collaborative Review

Fifty-four cases of congenital dacryocele from several medical centers were reviewed retrospectively. There was strong female preponderance (73%) and unilateral involvement (88%). Lacrimal sac contents could be expressed by local massage through the puncta in 21% of cases. Probing and irrigation were done under general (27.8%) or local (55.6%) anesthesia, while in other cases (16.7%), the cyst resolved before intervention. Recurrence of the dacryocele occurred in 10 patients (22%) after probing. Nasal cysts were visualized in six cases. Marsupialization of nasal cysts was necessary in four cases. In one center, after conservative therapy, 80% of cysts resolved spontaneously and 20% developed dacryocystitis. Surgical intervention is indicated in cases of dacryocystitis, cellulitis, breathing difficulty from large nasal cysts, recurrent dacryocele, and lack of its resolution after a short trial of digital massage.

Orbital Involvement in Allergic Fungal Sinusitis

BACKGROUND Although allergic fungal sinusitis is a relatively common, noninvasive form of paranasal sinus mycosis, and despite frequent orbital involvement, there have been few reports of this condition in the ophthalmic literature. METHODS Two cases of allergic fungal sinusitis having orbital symptoms are described. The current classification, typical presentation, and ideal management of fungal sinusitis are reviewed. RESULTS Distinguishing radiologic and pathologic features were present in both patients. Aspergillus flavus was cultured in one case, and Bipolaris spicifera was cultured in the other. CONCLUSIONS Allergic fungal sinusitis is a unique subset of sino-orbital disease with highly characteristic clinical, radiologic, and pathologic features. Unlike invasive forms of mycotic disease, allergic fungal sinusitis may be managed adequately with surgical debridement, aeration of the involved sinuses, and systemic and topical corticosteroids.

The Perils of Permanent Punctal Plugs

PURPOSE To describe previously unreported complications associated with permanent lacrimal punctal plugs. METHOD Five oculoplastic practices reviewed patients referred to them over the preceding 2 years for permanent lacrimal punctal plug complications. RESULTS In 12 patients, 14 lacrimal punctal plugs migrated distally within the lacrimal drainage system, causing symptoms and necessitating surgical removal. CONCLUSION Luxation of permanent punctal plugs into the distal lacrimal drainage system can occur, sometimes requiring complex surgical intervention.

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.

Combined transconjunctival/intranasal endoscopic approach to the optic canal in traumatic optic neuropathy.

Surgical decompression of the optic canal is indicated in patients with traumatic optic neuropathy who fail to respond to corticosteroids. Traditional surgical approaches to the orbital apex have been effective in achieving optic nerve decompression but require either a craniotomy, provide limited exposure with late identification and protection of the optic nerve, or require external incisions. The combined transconjunctival/intranasal endoscopic approach to the optic canal offers sufficient exposure, allows early identification and protection of the optic nerve, provides space for the use of multiple surgical instruments, obviates a craniotomy and external incisions, and can be performed quickly with minimal morbidity. The technique of combined transconjunctival/intranasal endoscopic optic nerve decompression will be described and the experience with nine cases will be presented.

Primary Optic Nerve Sheath Meningioma in Children

Primary optic nerve sheath meningioma represents a proliferation of meningothelial cap cells of the arachnoid villi within the optic nerve sheath. Patients younger than 20 years of age make up less than 5% of all cases of pediatric primary optic nerve meningiomas. Histopathologically, the most common subtypes in children are transitional (54%) and meningotheliomatous (38%). This tumor has been called aggressive in the pediatric population, with surgical excision recommended. However, the tumor may spread intraorbitally, intracranially, or intraocularly after subtotal surgical resection. Recent studies examined the use of fractionated, stereotactic radiation in children with this tumor; however, follow-up is limited. Neurofibromatosis type 2 is concomitantly diagnosed in 28% of patients with pediatric primary optic nerve sheath meningioma. There have been no known deaths attributed primarily to this tumor.

Adjunctive Hyperbaric Oxygen in the Treatment of Bilateral Cerebro-rhino-orbital Mucormycosis

Survival is uncommon in bilateral cerebro-rhino-orbital mucormycosis treated surgically and medically. A 66-year-old man in previously good health had bilateral cerebro-rhino-orbital mucormycosis and newly diagnosed nonketotic diabetes mellitus at initial examination. Total loss of vision, proptosis, and ophthalmoplegia of both eyes were present. The patient was treated with aggressive surgical and medical therapies that included bilateral orbital exenteration, intravenous and local amphotericin B, hyperbaric oxygen, and control of the diabetes mellitus. One and one-half years after onset of the illness, the patient is alert and clinically stable. The importance of prompt diagnosis and aggressive treatment of this disease is emphasized by this case. Additionally, we suggest that adjunctive hyperbaric oxygen is a reasonable modality in the treatment of this often fatal disease.

Skin flaps in periorbital reconstruction

Soft tissue defects of the periorbital region are best repaired with local skin or skin-muscle flaps. Flaps have functional and aesthetic advantages over skin grafts in that they provide a better color and texture match to the thick periorbital skin. The general physiological and biomechanical principles of skin flap survival and orientation are discussed with modification according to peculiarities of the periorbital area. The four basic groups of skin flaps are the sliding flap, advancement flap, rotation flap, and transposition flap. Selected standard and modified designs of each group are illustrated, and each surgical technique is described in stepwise fashion. The specific applications of the flaps to periorbital reconstruction are emphasized. The indications for use of various skin flaps, the local factors involved in flap selection, and proper preoperative planning are also discussed.

Correction of lower eyelid retraction with high density porous polyethylene: The Medpor® Lower Eyelid Spacer

PURPOSE . To describe the use of a new alloplastic implant for the correction of complex lower eyelid retraction. METHODS . A retrospective review of patient charts and photographs was performed to evaluate the efficacy of the first 50 porous polyethylene lower eyelid spacers (LES) used in the correction of complex eyelid retraction. RESULTS . Fifty LES were implanted in 38 patients. Follow-up ranged from 18 to 32 months. The average number of surgical procedures attempted for eyelid retraction repair prior to referral to our practice and implantation of the LES was 5, range 0 to 16. After LES implantation, all patients had improvement of their lower eyelid retraction. Three LES implants were revised for eyelid contour deformity (‘lateral winging’) and one for exposure through the anterior eyelid margin. In two cases, full-thickness skin grafts were placed directly over the porous implants with good success. DISCUSSION . Lower eyelid spacers (LES) constructed of porous polyethylene provide a rigid, bio-integrated support for eyelids with severe malposition that are recalcitrant to other corrective efforts.