John B. Holds

Exposed hydroxyapatite orbital implants : report of six cases

Six patients with complications of primary or secondary hydroxyapatite implants were studied. Complications included socket infection and/or conjunctival dehiscence. Complications were detected during regular follow-up examinations, and various treatment approaches were used. The hydroxyapatite implant exposure occurred 4 to 6 weeks (mean, 4.5 weeks) after implantation. Three of the six implants were wrapped in preserved donor sclera before implantation. One of the implants showed wide exposure and chronic infection and was removed. In two cases, scleral patch grafts with a conjunctival pedicle graft were performed, resulting in successful coverage of the implant without further conjunctival dehiscence. In one of the patients, a Tenons conjunctival flap was advanced to cover the defect, and was unsuccessful with the spicules of the hydroxyapatite eroding through the vascular flap after 1 month. Three of the patients demonstrate a persistent conjunctival epithelial defect. These three patients with chronically exposed hydroxyapatite have remained stable with follow-up intervals ranging from 8 to 12 months. Early exposure of hydroxyapatite orbital implants is a potential problem despite meticulous technique. Implant coverage is difficult, although chronic exposure seems to be tolerated often in the hydroxyapatite orbital implant without migration or extrusion.

Botulinum‐induced alteration of nerve‐muscle interactions in the human orbicularis oculi following treatment for blepharospasm

To assess longstanding alterations in human muscle innervation induced by botulinum toxin, we studied motor axons in the orbicularis oculi of nine patients previously injected with botulinum toxin for treatment of benign essential blepharospasm (BEB). Compared with untreated BEB and normal orbicularis oculi, muscle exposed to botulinum toxin developed persistent and cumulative alterations of innervation, including (1) thin, unmyelinated axonal collaterals that contact muscle end plates, (2) an increased number of muscle fibers innervated by individual terminal motor axons, (3) a profusion of unmyelinated axonal sprouts that end blindly, (4) an increased range of end plate sizes, and (5) multiple end plates on individual muscle fibers. The findings suggest that axonal sprouts which develop after botulinum-toxin-induced functional denervation can form new end plates. A single muscle fiber may then be innervated at separate sites by more than one axon.

Blepharospasm: past, present, and future.

Summary: To investigate causes, associations, and results of treatment with blepharospasm, 1,653 patients were evaluated by extensive questionnaires to study blepharospasm and long-term results of treatment with the full myectomy operation, botulinum-A toxin, drug therapy, and help from the Benign Essential Blepharospasm Research Foundation (BEBRF). The percent of patients improved by the BEBRF was 90%, full myectomy 88%, botulinum-A toxin 86%, and drug therapy 43%. The patient acceptance rate for the BEBRF was 96%, full myectomy 82%, botulinum-A toxin 95%, and drug therapy 57%. Blepharospasm is multifactorial in origin and manifestation. A vicious cycle and defective circuit theory to explain origin and direct treatment rather than a defective specific locus is presented. All four forms of therapy evaluated are useful and must be tailored to the patients needs. Mattie Lou Koster and the BEBRF have helped blepharospasm sufferers more than any other modality, and all patients should be informed of this support group. The full myectomy is reserved for botulinum-A toxin failures, and the limited myectomy is an excellent adjunct to botulinum-A toxin.

Conservative management of necrotizing fasciitis of the eyelids.

OBJECTIVE To describe the management of patients with necrotizing fasciitis of the eyelids. DESIGN Retrospective, noncomparative interventional case series. PARTICIPANTS Seven patients with necrotizing fasciitis limited to the eyelids. METHODS Retrospective review of the charts and photographs of seven patients with necrotizing fasciitis limited to the eyelids. MAIN OUTCOME MEASURES Eyelid function and appearance, mortality, and morbidity. RESULTS Seven of seven patients had good eyelid function and adequate appearance without reconstruction after healing. No deaths occurred. CONCLUSIONS Eyelid necrosis due to necrotizing fasciitis can be a devastating condition. The morbidity and mortality of selected cases are reduced with prompt and appropriate antimicrobial therapy and nonaggressive debridement of necrotic tissue after autodemarcation of the necrotic zone.

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.

Evisceration with scleral modification

Purpose To describe an evisceration technique that combines scleral modification with optic nerve release for coverage of any sized orbital implant. Methods The medical records of 70 patients who underwent the described evisceration procedure were reviewed. Results The average implant was 20 mm in diameter, with 50 patients (71%) receiving a solid polymethylmethacrylate sphere. Fifty-eight patients (83%) had a history of at least one previous ocular surgery, and 12 patients (17%) had phthisical eyes preoperatively with moderate to severe scleral cicatrization. Postoperatively, there were two cases of new or worsened ptosis, no cases of worsened motility, and no cases of implant extrusion. Conclusion Evisceration with scleral modification is a simple and effective procedure that allows placement of any size orbital implant. Surgical results are excellent with few complications.

Hyaluronic acid gel (Restylane) filler for facial rhytids: Lessons learned from American Society of Ophthalmic Plastic and Reconstructive Surgery member treatment of 286 patients

Purpose: To review injection techniques and patient satisfaction with injection of Restylane in various facial areas by American Society of Ophthalmic Plastic and Reconstructive Surgery members. Methods: Data from 286 patients treated with Restylane in nine American Society of Ophthalmic Plastic and Reconstructive Surgery practices were abstracted to a spreadsheet for analysis. Results: Nine practices performed Restylane injections for 8.8 months on average (range, 2 to 28 months). Average practice volume per patient was 1.2 ml (range, 0.7 to 2.1 ml). Nine of nine practices injected the nasolabial and melolabial folds, 9 of 9 practices injected the lips, and 6 of 9 injected the glabella. Only 2 of 9 practices injected other fillers concurrently. Botox was injected concurrently by 8 of 9 practices. On a scale of 1 to 10, physicians rated average patient discomfort during Restylane injection 4.6 with topical anesthesia and 2.1 with injectable lidocaine, with or without topical anesthesia. The end point for injection was determined by visual cues, volume of injection, extrusion of the product, and palpation. “Problematic” complications, including bruising, swelling, bumpiness, and redness each had an incidence of 5% or less. Patient satisfaction on a scale of 1 to 10 had an average rating of 8.1, compared with that of Botox injection (8.9), upper blepharoplasty (8.9), and collagen injection (6.6). The source of Restylane patients was estimated to be existing Botox patients (45%); existing non-Botox patients (18%); word of mouth (14%); and new patients for other services (13%). Conclusions: Injection techniques, volume, end points, and anesthesia vary for different facial areas and between practices. Patients experience mild to moderate injection discomfort that is lessened with injectable lidocaine. Self-limited problems occur in about 5% of patients. Physician-determined patient satisfaction is perceived to be higher than that of collagen injection but slightly lower than that of botulinum toxin injection. The major source of Restylane patients was from existing practice patients, especially botulinum toxin patients.

Tarsal strip procedure for the correction of tearing

Purpose To evaluate the tarsal strip procedure in the treatment of tearing related to lacrimal pump failure. Methods A retrospective chart review of all tearing patients undergoing the tarsal strip procedure was done. Patients with ectropion, nasolacrimal duct obstruction, and punctal eversion and stenosis were excluded. Data collected included patient age, sex, procedures performed, follow-up, and resolution of tearing. The main outcome measure is resolution of tearing. Results Thirty-four eyelids of 21 patients underwent a tarsal strip procedure for the correction of tearing. Complete resolution of tearing was noted in 14 eyes. Seventeen eyes were partially improved and required no further intervention. Three eyes were unimproved over the follow-up period. Two eyes eventually required another procedure. Conclusions Patients undergoing tarsal strip for tearing caused by presumed lacrimal pump failure showed a significant rate of improvement in their tearing symptom after the procedure. The tarsal strip procedure appears to be effective in the surgical treatment of tearing secondary to laxity of the lower eyelid.

Systemic corticosteroid use in orbital lymphangioma

Purpose To describe the clinical results of systemic corticosteroid use in a series of patients with orbital lymphangioma. Methods Four patients (two adults and two children) were treated with corticosteroids using intravenous, oral, or both routes for 2 days to a month. Corticosteroids were used with and without other therapies for symptomatic exacerbations. Results The adults showed more improvement with pain than with swelling, whereas the children had improvement with both the signs and symptoms. There were no complications in any patient. Conclusions Systemic corticosteroids are a useful therapeutic option for patients with orbital lymphangioma and can be used as an adjuvant treatment to surgery and other modalities. Resolution of symptoms with corticosteroids was expedited compared with the natural history of the disease in the patients studied.

Maxillary Sinus Atelectasis with Enophthalmos

Chronic maxillary sinusitis may present as atelectasis of the sinus with changes to surrounding structures. Several mechanisms have been proposed for this problem. Chronic obstruction of the sinus ostium, with resultant retention of secretions and osteitic bone resorption, may account for these changes. Enophthalmos is one manifestation that may require corrective treatment. Titanium micromesh reconstruction of the orbital floor, with or without onlay concha cartilage, has reliably resolved the enophthalmos. Reconstruction of the orbital floor and ventilation of the obstructed sinus ostium may be carried out relatively safely in a single operation. The standard endoscopic technique of uncinate removal and middle meatal antrostomy should be modified to prevent orbital penetration. This report reviews our series of 6 patients with this problem, as well as a comprehensive review of the literature. Recommendations for management of both the obstruction and the secondary orbital manifestations are presented.