John L. Wobig

Anatomy of the orbital septum and associated eyelid connective tissues : Implications for ptosis surgery

The anatomy of the orbital septum and associated eyelid connective tissues was examined using cadaver dissection, histologie sections, surgical observations, and special radiologie imaging. The embryologie development of the eyelid connective tissues was also reviewed. Examination revealed a distinct layer of fibroadipose tissue in the eyelid and eyebrow posterior to the orbicularis and frontalis muscles, and anterior to the orbital septum. Fibrous septa within the submuscular fibroadipose tissue become contiguous with more compact lamellae of the orbital septum posteriorly imparting a multilayered quality to the orbital septum. Fat within the fibroadipose layer anterior to the orbital septum may be mistaken for the preaponeurotic fat pad by the unwary surgeon and may lead to surgical error. The orbital septum and the levator aponeurosis were found to join 2 to 5 mm above the superior tarsal border (average, 3.4 mm). Recommendations for ptosis surgery based on these anatomic principles are given.

Severe ocular and orbital toxicity after intracarotid etoposide phosphate and carboplatin therapy

PURPOSE To report severe ocular and orbital toxicity after administration of intracarotid etoposide phosphate and carboplatin. METHOD Case report. RESULTS A 52-year-old man with glioblastoma multiforme underwent left intracarotid administration of eto poside phosphate and carboplatin inferior to the ophthalmic artery. Within 7 hours, a nonpupillary block angle-closure glaucoma developed secondary to uveal effusion in the ipsilateral eye, which was relieved by cycloplegia. Four days later, severe orbital inflammation resulted in a visual acuity of counting fingers, proptosis, optic neuropathy, and total external ophthalmoplegia in the eye. The patients condition improved after a lateral cantholysis and administration of high-dose intravenous corticosteroids. Two weeks later, an anterior uveitis occurred in the left eye, which responded to topical corticosteroids. During a 2-month period, the patient recovered to a visual acuity of 20/70, near normal motility, and normal intraocular pressure, and the ocular and orbital inflammation resolved. Preexisting ipsilateral chemotherapy-induced maculopathy became more pronounced. CONCLUSION Ocular and orbital toxicity after intracarotid etoposide phosphate and carboplatin therapy is infrequently reported.

Glucocorticoid impact on cochlear function and systemic side effects in autoimmune C3.MRL-Faslpr and normal C3H/HeJ mice

Glucocorticoids are effective in reversing hearing loss, but their severe side effects limit long term management of many ear disorders. A clearer understanding of these side effects is critical for prolonged therapeutic control of hearing and vestibular dysfunction. Therefore, this study characterized the impact of the glucocorticoid prednisolone on cochlear dysfunction and systemic organ systems in C3.MRL-Fas(lpr) autoimmune mice and their normal C3H/HeJ parent strain. Following 3 months of treatment, autoimmune mice had better auditory thresholds and improved hematocrits, anti-nuclear antibodies, and immune complexes. Steroid treatment also lowered body and spleen weights, both of which rise with systemic autoimmune disease. Steroid treatment of the normal C3H/HeJ mice significantly elevated their blood hematocrits and lowered their body and spleen weights to abnormal levels. Thus, systemic autoimmune disease and its related hearing loss in C3.MRL-Fas(lpr) mice are steroid-responsive, but normal hemopoiesis and organ functions can be significantly compromised. This mouse model may be useful for studies of the detrimental side effects of steroid treatments for hearing loss.

The Bubble Test: An Atraumatic Method for Canalicular Laceration Repair

Summary: Canalicular lacerations need to be correctly identified before surgical repair. Methods to find the medial cut end are numerous. With the use of direct sight or the bubble test or both, the identification and repair of the medial cut end of the lacerated canaliculus should be achievable in the majority of cases.

Lacrimal Probing Complications

Probing can be accomplished at any age with extreme care. Whenever an individual believes he has developed a false passage, he should stop and come back at a later date to accomplish opening of the obstructed nasolacrimal duct.

Bilateral Localized Orbital Neurofibromas

BACKGROUND The authors report on a 30-year-old man who presented with progressive bilateral exophthalmos over a 2-year period. FINDINGS Computed tomography showed large heterogeneous masses in the superior aspect of both orbits. Excisional biopsy via bilateral lateral orbitotomies showed the tumors to be well-circumscribed, relatively avascular, localized neurofibromas. The patient had several features suggestive of multiple endocrine neoplasia type IIB, including Marfanoid habitus, enlarged corneal nerves, thickened lips, and mucosal neuromas. CONCLUSION Localized neurofibromas are rare in the orbit and, unlike plexiform neurofibromas, are not typically associated with von Recklinghausens neurofibromatosis. Bilaterality of such localized neurofibromas has not been previously reported. Recognition of ophthalmic lesions suggestive of multiple endocrine neoplasia IIB should prompt evaluation for systemic manifestations of this disorder.

Secondary fractures of Le Fort I osteotomy.

Purpose To report the ophthalmic complications of Le Fort I osteotomy for the correction of dentofacial deformities and to determine the maximal compressive loads applied during pterygomaxillary separation in a cadaver model. Methods Two cases of ophthalmic complications arising after Le Fort I osteotomy are reported. Le Fort I osteotomy was performed on five cadavers. The maximal compressive load applied during pterygomaxillary separation was recorded with a 10 kN (3,000 lbf) load cell of a MTS Mini-Bionix servohydraulic machine (MTS, Eden Prairie, MN, U.S.A.). A paired t test was used to compare forces applied to the right and left sides. Computed tomography scans of each specimen were obtained after Le Fort I osteotomy to document secondary fractures. The skulls were subsequently stained with 1% fuschin red to highlight secondary fractures. Results Maximum compressive loads during pterygomaxillary separation ranged from 22 N (5.0 lbf) to 162 N (36.5 lbf), with an average of 106 N (23.8 lbf) (SD 47.6 N [10.7 lbf]). Forces applied on the first operative side were significantly greater than forces applied on the second operative side (p = 0.0034). Secondary fractures were found in three specimens by computed tomography and in two specimens by 1% fuschin red. All secondary fractures occurred on the second operative side. Conclusion Secondary fractures in the Le Fort I osteotomy procedures occurred on the side opposite the greater maximal compressive load and on the second operative side.

Surgical debulking of eyelid and anterior orbital plexiform neurofibromas by means of the carbon dioxide laser

PURPOSE To present the carbon dioxide laser as an effective tool for surgical debulking of eyelid and orbital neurofibromas. METHOD Two patients with neurofibromatosis underwent surgical debulking of their eyelid and orbital plexiform neurofibromas by means of the carbon dioxide laser. RESULTS Acceptable cosmetic results were obtained with the removal of eyelid and orbital neurofibromas with improved hemostasis and minimal destruction of surrounding tissue when compared with conventional methods of removal. CONCLUSIONS The carbon dioxide laser may allow significant improvement in the removal of plexiform neurofibromas.

Infection of a Porous Polyethylene Orbital Implant With capnocytophaga

Summary: A 68-year-old woman experienced an infection of a porous polyethylene orbital implant caused by Capnocytophaga after a dental procedure. The infection was unresponsive to both topical and oral antibiotics and required removal of the porous polyethylene orbital implant. Capnocytophaga is a capnophilic, gram-negative bacillus. Capnocytophaga is a normal commensal of the mouth and is responsible for both gingivitis and periodontal disease. Capnocytophaga is a rare cause of ocular infections. This is the first reported patient with an infection of a porous polyethylene orbital implant caused by Capnocytophaga. The authors believe infected integrated orbital implants must be removed because neither topical or systemic therapy provide effective treatment.

Transconjunctival frontalis suspension: a clinical evaluation.

PURPOSE To determine the effectiveness of transconjunctival frontalis suspension in patients with blepharoptosis and poor levator function (eyelid excursion less then 5 mm). METHODS The medical records of 29 patients (50 ptotic eyelids) were reviewed. RESULTS Four patients (eight eyelids) had blepharophimosis syndrome, ten patients (27 eyelids) had congenital ptosis, seven patients (14 eyelids) had myogenic ptosis, and one patient (one eyelid) had neurogenic ptosis. Surgical results were good and complications were minimal during follow-up intervals ranging from six months to seven years. CONCLUSIONS Transconjunctival frontalis suspension is technically simpler than traditional external frontalis suspension and yields satisfactory functional and cosmetic results in patients with poor levator function.