John R. Burroughs

Misdiagnosis of Silent Sinus Syndrome

Purpose To review cases of spontaneous enophthalmos erroneously diagnosed as silent sinus syndrome to identify other inflammatory disorders with a similar clinical presentation. Methods Retrospective observational case series. Chart reviews were performed covering encounters over a 5-year period, searching for patients referred to two physicians with an incorrect diagnosis of silent sinus syndrome. Only cases of acquired enophthalmos of reported nontraumatic or nonneoplastic cause were included. Particular attention was directed toward noting clinical features of upper eyelid position and periocular atrophy. Results Nineteen cases of erroneous referral for silent sinus syndrome were identified. Fourteen of these cases were due to tumor, trauma, congenital facial asymmetry, or diffuse facial lipodystrophy. Among the remaining cases, four were diagnosed as Parry-Romberg syndrome and one as linear scleroderma. Conclusions Parry-Romberg syndrome and linear scleroderma must be distinguished from silent sinus syndrome as causes of inflammatory-mediated, spontaneous enophthalmos.

Monitored anesthesia care for enucleations and eviscerations

OBJECTIVE To report the technique and success of using monitored anesthesia care instead of general anesthesia for ocular enucleation and evisceration surgeries. DESIGN Retrospective, noncomparative interventional case series. PARTICIPANTS Twelve enucleated patients (Soparkar and Patrinely) and 146 eviscerated patients (Kulwin and Kersten). METHODS Surgical logs of two oculoplastic practices were reviewed searching for cases of ocular enucleations and eviscerations performed under monitored anesthesia care between 1990 and 2001. Identified hospital and clinic charts were then reviewed. MAIN OUTCOME MEASURES Monitored anesthesia care was deemed successful if (1) there were hemodynamic stability and complete analgesia intraoperatively; (2) there was absence of any chart documentation regarding patient or family psychological distress over the anesthesia method used; and (3) patients were discharged from the hospital without the need for observation or treatment > or = 23 hours. RESULTS Between 1990 and 2001, 146 eviscerations were performed under local anesthesia with monitored anesthesia care by two surgeons (RCK, DRK) as their routine practice pattern. In 1996, Drs. Soparkar and Patrinely began performing enucleations under monitored anesthesia care in selected cases, and from 1996 to 2001, these surgeons enucleated 12 patients under monitored anesthesia care. Four of the enucleated patients requested surgery without general anesthesia. The remaining eight patients had been refused surgery by at least one other specialist because of the patients perceived high medical risk for complications under general anesthesia. In all 158 patients, the procedures were deemed successful by the preceding criteria. CONCLUSIONS This four-surgeon case series reports the successful use of local anesthesia with monitored care for ocular enucleation and evisceration procedures, offering several potential advantages over the traditional use of general anesthesia.

The buried vertical mattress: A simplified technique for eyelid margin repair

We describe a new approach for the closure of eyelid margin defects. We conducted a prospective evaluation of patients undergoing the buried vertical mattress technique for full-thickness eyelid margin repair and found that 90 patients (follow-up, 3 to 18 months; average, 6 months) had eyelid margin defects closed with the use of a buried vertical mattress technique. There were no cases of dehiscence, and only 5 (5.5%) patients had minor notch formation. We conclude that the buried vertical mattress suture technique can be a safe and effective method to close eyelid margin defects while saving postoperative time and the cost of multiple sutures.

Cold urticaria: An underrecognized cause of postsurgical periorbital swelling

Purpose: To report cold urticaria as an underrecognized cause of potential periorbital and facial edema after elective oculofacial plastic surgery. Methods: Retrospective case series of three patients with primary acquired cold urticaria with review of the clinical aspects of each of the cases. Results: Two of the patients had significant postoperative swelling attributed to primary acquired cold urticaria after the routine use of cool compresses to their surgical sites. The third patient had known primary acquired cold urticaria and required special perioperative management. All three patients ultimately had a good surgical outcome with no long-term sequelae. Conclusions: Although primary acquired cold urticaria is generally not a serious condition, it can be easily overlooked and misdiagnosed as a localized adverse reaction to injected anesthetic, topical antibiotic ointments, or early preseptal cellulitis after eyelid or facial surgery. Rarely, this condition can be fatal and should be recognized by the surgeon to ensure both optimal surgical results and general medical management. Three simple screening questions should identify most patients with this disorder.

Rotation mattress suture: A powerful adjunct for ectropion correction

We describe an effective adjunctive suture technique for severe forms of both tarsal and marginal ectropion in a case series of 28 patients undergoing the rotation mattress suture technique for ectropion repair. Forty eyelids, followed for 1 to 5 years (average, 2.5 years), underwent tarsal or marginal ectropion repair, using the rotation mattress suture technique. Transient notching was noted in 31 eyelids (78%) but persisted in only 1 case (3%). Twenty-five eyelids (63%) had 0.5 to 1.0 mm of eyelid retraction. There were only 2 cases (5%) of recurrent ectropion. We found that excluding transient changes and predictable, mild lower eyelid retraction, the rotation mattress suture provides a powerful adjunctive reparative option for difficult cases of ectropion with low complication and failure rates.

Transblepharoplasty Internal Brow Elevation with Corrugator Removal

To yield optimal results, we strongly encourage our patients to undergo adjunctive transblepharoplasty procedures to the standard upper blepharoplasty. Our most common adjunctive procedure is internal brow elevation, which we suggest to any patient who has less than 10 mm of skin between the upper eyelid crease and the inferior brow cilia, is not interested in more aggressive brow elevation, and is ideal for heavy ptotic brow fat pads.

Cosmetic Botulinum Toxin Applications: General Considerations and Dosing

Cosmetic applications of botulinum toxin continue to expand beyond the FDA-approved use for glabellar furrows. Patients should sign an informed consent for off-label cosmetic uses. Not only do the eyelid injections improve current rhytids, but the future development of mimetic rhytids is prevented. It is paramount to understand the anatomy of the eyelid and facial muscles and that the rhytid-inducing musculature is the injection site rather than the actual wrinkles.

Management of intractable postoperative blepharoplasty bleeding after thrombolysis for a pulmonary embolism.

A 61-year-old man underwent uneventful upper blepharoplasty but suffered a life-threatening pulmonary embolism requiring complex management for intractable bleeding following thrombolysis.

Preoperative Assessment of the Eye and Periocular Region

Proper preoperative assessment of the eye and periocular region is essential to verify ocular health and vision and to obtain an optimal surgical result. A systematic approach to reviewing the ocular history, review of systems, and pertinent physical exam will be discussed. This is important to identify not only underlying ocular conditions but also potentially serious systemic conditions with ocular manifestations that can impact the patients overall health. A thorough exam by a qualified provider is needed if there are any management issues regarding the presence of a condition(s) that can impact the surgical outcome.

Asynchronous blepharospasm, facial and cervical dystonia, and bilateral asynchronous hemifacial spasm

We present a patient with a facial movement disorder that has characteristics of both blepharospasm and bilateral asynchronous hemifacial spasm. Because of the increased incidence of blepharospasm in patients with hemifacial spasm, our patients clinical presentation is probably not a chance occurrence, but rather a manifestation of some predisposition for these two movement disorders. This unusual constellation of signs and symptoms challenges the current diagnostic criteria and suggests that some of these facial movement disorders may lie on a spectrum, rather than represent distinct entities.