Jeffrey A. Nerad

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.

Medial and lateral orbital wall surgery for balanced decompression in thyroid eye disease.

Objectives/Hypothesis Diplopia remains a major potential complication of orbital decompression performed for thyroid eye disease. We sought to examine the effect of medial and lateral wall surgery with sparing of the orbital floor on the incidence of postoperative diplopia.

Intraorbital Wood: Detection by Magnetic Resonance Imaging

The authors present two cases in which intraorbital wooden foreign bodies remained undetected after initial ophthalmologic examination and radiologic investigation which included plain orbital x-rays, orbital computed tomography (CT) scans, and, in one case, orbital ultrasound. In each case, subsequent magnetic resonance imaging (MRI) showed a well-delineated low-intensity lesion suggestive of a retained foreign body. Investigation of a case of suspected wooden foreign body in the orbit should include an MRI scan if there is no contraindication, and no foreign body has been defined on CT scan, ultrasound, or plain orbital films.

Clinical Characteristics Associated With Orbital Invasion of Cutaneous Basal Cell and Squamous Cell Tumors of the Eyelid

Over a six-year period, between 1984 and 1990, 622 patients with basal cell and squamous cell carcinoma of the eyelids were examined at our institution. Thirteen patients had orbital invasion at initial examination. The average age of patients at orbital invasion was 75.8 years. Ten patients were men, eight of whom had basal cell carcinoma and two of whom had squamous cell carcinoma. Most patients had an orbital mass and incomitant strabismus at initial examination. Invasive basal cell carcinoma developed in 11 patients, and squamous cell carcinoma developed in two patients. Ten patients were treated for cutaneous carcinoma at the site of invasion before examination at our institution. The average duration between onset of a cutaneous lesion and our examination for orbital invasion was 9.8 years for basal cell carcinoma and one year for squamous cell carcinoma. Radiologic and histopathologic features were reviewed. The clinical characteristics of these patients were reviewed and orbital exenteration was recommended to all 13 patients. Nine patients underwent exenteration and four refused the operation.

Orbital Complications in Endoscopic Sinus Surgery Using Powered Instrumentation

Objectives/Hypothesis Powered dissection is increasingly used in endoscopic sinus surgery. Although it has certain clear advantages over conventional instrumentation, powered dissection also presents special liabilities. The objectives of the report are to highlight the special dangers of powered instrumentation near the orbit, to suggest techniques that might minimize these risks, and to review the management of orbital injuries.

Sebaceous cell carcinoma of the ocular adnexa: clinical presentations, histopathology, and outcomes.

Purpose: To investigate the clinical features, time to diagnosis, histopathology, treatment, and mortality rates of patients with sebaceous cell carcinoma. Methods: This was a retrospective, consecutive series of patients with sebaceous cell carcinoma at a tertiary referral medical center. Between January 1984 and January 2006, 31 patients with sebaceous cell carcinoma were evaluated at the Department of Ophthalmology and Visual Sciences, University of Iowa Hospitals and Clinics. The main outcome measures were clinical presentations, treatments, reconstructive procedures, and outcomes. Results: Thirty-one patients were diagnosed with sebaceous cell carcinoma of the ocular adnexa on histopathology. Twenty (65%) of the patients were women and 11 were men. The upper eyelid was involved in 18 patients, lower eyelid in 10, both upper and lower eyelids in 1, and caruncle in 2. Twenty-three patients had in situ disease, pagetoid disease, or both. Eight patients reported symptoms for <6 months and 22 had symptoms for ≤12 months before the diagnosis of sebaceous cell carcinoma was made. Local surgical excision of the tumor as initial treatment was performed in 25 patients. Exenteration was the initial surgery performed in 4 patients. Two patients died from metastatic sebaceous cell carcinoma. Conclusions: Sebaceous cell carcinoma has varied presentations and is commonly misdiagnosed. Tumor-related deaths occurred in only 2 patients (6.7%), which is lower than previous reports and may be related to earlier detection or improved surgical excision techniques.

The transcaruncular approach to the medial orbital wall.

Objective To demonstrate the safety and use of the transcaruncular approach as a surgical technique that provides rapid exposure of the medial orbital wall and apex through a small cosmetic conjunctival incision.

Vascular Lesions of the Orbit: More than Meets the Eye

Vascular lesions of the orbit may be classified on the basis of their natural history, growth pattern, and histologic composition as capillary hemangiomas, venous vascular malformations, venous lymphatic malformations, arterial and arteriovenous lesions, or neoplasms. Most follow a characteristic pattern of clinical development and have one or more specific imaging features that allow diagnosis. Hemangiomas typically manifest at or soon after birth and subsequently involute. They are nonencapsulated, poorly circumscribed, often lobulated, and largely extraconal in location. Cavernous malformations are septate and well circumscribed, may exhibit progressive enhancement on delayed images, and do not involute. Orbital varices appear distended on images obtained with the patient prone or during the Valsalva maneuver. Venous lymphatic malformations show multiple fluid-fluid levels, enlarge during viral infections, and may manifest as chocolate-colored cysts after an acute hemorrhage. Arteriovenous malformations, fistulas, and aneurysms have typical angiographic features. Hemangiopericytomas arise from the paranasal sinuses and show early tumor blush and persistent staining on angiographic images. Hemangioblastomas appear as enhancing mural nodules with associated cysts and serpentine flow voids on magnetic resonance (MR) images. Choroidal hemangiomas and melanomas can be differentiated on the basis of their appearances on T2-weighted MR images. Patients with vascular orbital and ocular metastases commonly have a history of breast or lung primary tumors.

Management of the orbital floor in silent sinus syndrome.

Background Enophthalmos in a patient with an opacified hypoplastic maxillary sinus, without sinus symptomatology, describes the silent sinus syndrome. A current trend is to perform endoscopic maxillary antrostomy and orbital floor reconstruction as a single-staged operation. A two-staged approach is performed at our institution to avoid placement of an orbital floor implant in the midst of potential infection and allow for the possibility that enophthalmos and global ptosis may resolve with endoscopic antrostomy alone, obviating the need for orbital floor reconstruction. Methods A retrospective review identified four patients with silent sinus syndrome evaluated between June 1999 and August 2001. Patients presented to our ophthalmology department with ocular asymmetry, and computerized tomography (CT) scanning confirmed the diagnosis in each case. Results There were three men and one woman, with ages ranging from 27 to 40 years. All patients underwent endoscopic maxillary antrostomy. Preoperative enophthalmos determined by Hertels measurements ranged from 3 to 4 mm. After endoscopic maxillary antrostomy, the range of reduction in enophthalmos was 1–2 mm. Case 2 had a preoperative CT scan and a CT scan 9 months after left endoscopic maxillary antrostomy. Volumetric analysis of the left maxillary sinus revealed a preoperative volume of 16.85 ± 0.06 cm3 and a postoperative volume of 19.56 ± 0.07 cm3. This represented a 16% increase in maxillary sinus volume postoperatively. Orbital floor augmentation was avoided in two patients because of satisfactory improvement in enophthalmos. In the other two patients, orbital reconstruction was performed as a second-stage procedure. There were no complications. Conclusion Orbital floor augmentation can be offered as a second-stage procedure for patients with silent sinus syndrome. Some patients’ enophthalmos may improve with endoscopic antrostomy alone.

Surgical Excision of Periorbital Capillary Hemangiomas

BACKGROUND Periorbital capillary hemangiomas of childhood can produce ptosis, strabismus, and anisometropia, resulting in amblyopia. Traditional therapy with either systemic or local corticosteroids occasionally yields incomplete resolution of these lesions and may be associated with numerous adverse complications. The authors report their experience performing surgical resection of periorbital capillary hemangiomas. METHODS Twelve children with periorbital capillary hemangiomas were treated surgically. Six of these children had previously failed to adequately respond to steroid injections and six were primarily treated with surgical resection. All lesions were believed to be localized and did not appear to be infiltrative on preoperative computed tomographic scans. RESULTS All lesions were completely resected, except for two in which there was a small area of residual hemangioma surrounding the lacrimal drainage system that was left intact. Controlled intraoperative hemorrhage in two patients required intraoperative directed-donor blood transfusion. Perioperatively, in one patient a wound dehiscence developed, which required minor repair. This same patient elected to have surgical scar revision postoperatively. The patients have been followed up to 5 years. All did well with improved cosmesis, and they have good lid function. No recurrences have been noted. CONCLUSION Surgical resection of pediatric capillary hemangiomas should be considered a treatment option in those that fail to respond to corticosteroids and/or are isolated and noninfiltrative in nature.