Julian D. Perry

Transcaruncular approach to the medial orbit and orbital apex.

OBJECTIVE To present a versatile approach to the medial orbit and orbital apex through the caruncle. DESIGN Retrospective, noncomparative, case series with description of surgical technique. PARTICIPANTS Twenty-five consecutive patients underwent orbital surgery by use of a transcaruncular approach. INTERVENTION Inferior and medial wall fracture repair or orbital decompression by means of a transcaruncular or combined transfornix-transcaruncular approach. MAIN OUTCOME MEASURES The surgical indications and complications were recorded for each patient. RESULTS Ten patients (10 orbits) underwent combined inferior and medial orbital wall fracture repair through a combined transfornix-transcaruncular approach. In 8 of 10 (80%) orbits, the inferior oblique muscle was disinserted during surgery. Fifteen patients (24 orbits) underwent orbital decompression surgery for dysthyroid orbitopathy. An isolated transcaruncular approach was used in 5 of 24 orbits, and a combined transfornix-transcaruncular approach was used in 19 of 24 orbits. There were no complications related to either approach. CONCLUSIONS Orbital bone removal and fracture reduction may be safely completed through a combined transfornix-transcaruncular approach. The transcaruncular approach provides excellent and safe exposure of the medial orbital wall, and it avoids scarring associated with the Lynch approach.

Strabismus after balanced medial plus lateral wall versus lateral wall only orbital decompression for dysthyroid orbitopathy

Purpose This study aimed to determine the relative incidence and time course of new-onset strabismus after balanced medial plus lateral wall orbital decompression versus decompression of the lateral wall alone for dysthyroid orbitopathy. Methods The study design was a retrospective nonrandomized comparative case series. Thirty-two consecutive patients underwent balanced medial plus lateral wall orbital decompression or lateral wall orbital decompression for dysthyroid orbitopathy. The incidence, duration, and treatment of postoperative strabismus was recorded for each patient. Results Significant preoperative strabismus was present in 31% (4/13 patients) of the balanced decompression group and in 26% (5/19 patients) of the lateral wall decompression group. Only 25% (1/4) of cases of preexisting strabismus in the balanced decompression group resolved postoperatively without muscle surgery, whereas 60% (3/5) of cases in the lateral wall decompression group resolved postoperatively without surgery. Preoperative strabismus was absent in 69% (9/13) of patients in the balanced decompression group and in 74% (14/19) of patients in the lateral wall decompression group. New-onset, persistent postoperative strabismus developed in 33% (3/9) of patients in the balanced decompression group and in 7% (1/14) of patients in the lateral wall decompression group. Conclusion Lateral wall orbital decompression may produce less new-onset, persistent postoperative strabismus than balanced medial plus lateral wall orbital decompression for dysthyroid orbitopathy.

The safety and applications of acellular human dermal allograft in ophthalmic plastic and reconstructive surgery: a preliminary report.

Purpose To describe the uses and determine the safety of a commercially available acellular dermal allograft in ophthalmic plastic and reconstructive surgery. The existing literature regarding current applications and results using acellular dermal allograft is reviewed. Methods The study design was a retrospective, noncomparative case series. Participants consisted of 63 consecutive patients undergoing ophthalmic plastic and reconstructive surgery using an acellular dermal matrix graft. The main intervention was placement of a dermal allograft. Outcome measures included the degree of clinical improvement and complications for each patient. Results We used AlloDerm (LifeCell Corporation, The Woodlands, TX, U.S.A.) as a posterior lamellar conjunctival spacer graft, a soft tissue interpositional graft, and an orbital implant wrapping material. Clinical improvement was noted in all cases. There were no complications attributable to the acellular dermal matrix material. Conclusions We describe several novel ophthalmic plastic and reconstructive surgical applications using acellular dermal allograft tissue. This material may be used safely as a posterior lamellar conjunctival spacer graft, a soft tissue interpositional graft, and a wrapping material. Clinically, the allograft appears to be biocompatible, nontoxic, and nonallergenic in the orbit, eyelid, and midfacial tissues. Long-term data and studies comparing the efficacy of acellular dermal allograft with conventional materials are necessary.

Botulinum toxin type a for dysthyroid upper eyelid retraction.

Purpose:To evaluate the safety and efficacy of botulinum toxin type A for treatment of eyelid retraction resulting from thyroid eye disease (TED) during the inflammatory phase of the condition.Methods:In this prospective, nonrandomized case series, 18 patients with inflammatory eyelid retraction cau

Transcaruncular orbital decompression for dysthyroid optic neuropathy.

Purpose To determine the efficacy of transcaruncular approach orbital apex decompression for treatment of dysthyroid optic neuropathy. Methods In this retrospective noncomparative interventional case series, charts for all patients undergoing orbital decompression surgery for dysthyroid optic neuropathy performed by one author between October 1999 and September 2001 were included in the study. Primary outcome measures included visual acuity, static perimetry, pupillary testing, and color plate testing before and after surgery. Records were also reviewed for changes in extraocular motility and proptosis after surgery and for surgical complications. Results Sixteen consecutive patients (6 unilateral, 10 bilateral, for a total of 26 cases) underwent orbital apex decompression for dysthyroid optic neuropathy through a transcaruncular approach. In each orbit, the optic neuropathy was refractory to oral corticosteroid therapy. Preoperative visual acuity remained stable or improved in each case. Preoperative Humphrey visual field testing revealed an average mean deviation of −10.3 ± 6.5 (range, +0.76 to −25.45). Average postoperative mean deviation was −2.79 ± 2.4 (range, +0.94 to −9.82). Before surgery, 7 of 23 eyes (30%) had full color plates. After surgery, 22 of 23 eyes (96%) had full color plates. Follow-up ranged from 2 to 26 months (mean, 10 months). New-onset diplopia developed in 2 of 10 (20%) patients without preexisting diplopia. Conclusions Transcaruncular approach orbital apex decompression effectively treats dysthyroid optic neuropathy.

Paranasal sinus mucoceles with skull-base and/or orbital erosion: Is the endoscopic approach sufficient?

Objective The objective of this study was to review the management of paranasal sinus mucoceles with skull-base and/or orbital erosion in the endoscopic era. Study Design A retrospective data analysis. Methods A chart review was performed on 57 patients treated from January 2001 to March 2007. Results The average age at the time of presentation was 50.6 years with a 1:1 male: female ratio. The most common site was the frontal sinus (54.4%), followed by frontoethmoid (29.8%) and sphenoid (8.8%). Areas of erosion included skull base (40.4%), orbit (50.9%), and both orbit and skull base (8.8%). Endoscopic drainage using image guidance was used in all 57 patients without complications. Fifty-six cases (98.2%) had a functionally patent mucocele opening with a median follow-up of 15 months. Conclusions The endoscopic approach can be safely used for the management of mucoceles with skull-base and/or orbital erosion. Open adjunct approaches can be avoided in most cases.

Safety of unwrapped spherical orbital implants.

Purpose: To determine the exposure rate of unwrapped spherical orbital implants after enucleation surgery. Methods: Retrospective review of consecutive case series. All patients undergoing orbital implantation during enucleation surgery from October 1999 to September 2003 were included. Charts were reviewed for preoperative diagnoses, type and size of implant, use of a wrapping material, and complications. Results: Twenty-six consecutive patients underwent enucleation surgery without wrapping material. Nineteen patients received porous polyethylene, 5 patients received polymethylmethacrylate, and 2 received hydroxyapatite. Mean implant diameter was 21.03 mm. Mean follow-up was 17.1 months (range, 2 to 43 months). There were no complications of implant extrusion, exposure, infection, or migration. Conclusions: The use of unwrapped spherical orbital implants may be associated with a low rate of early exposure. Careful choice of implant type may help reduce the risk of implant exposure.

Lower eyelid position after transconjunctival lower blepharoplasty with versus without a skin pinch.

Purpose: To evaluate the effect of transconjunctival lower blepharoplasty with or without a skin pinch on lower eyelid position. Methods: Retrospective analysis of patients undergoing bilateral lower blepharoplasty using a transconjunctival approach with or without a skin pinch. Patients undergoing other surgical procedures that could affect lower eyelid position were excluded. Twenty-five patients (50 eyes) underwent transconjunctival blepharoplasty without skin pinch and 20 patients (40 eyes) underwent transconjunctival blepharoplasty with a skin-pinch technique. Preoperative and postoperative photographs were measured for the horizontal corneal diameter and distance from light reflex to lower eyelid margin (MRD2). The ratio of MRD2 to corneal diameter was multiplied by 11 to standardize to a corneal diameter of 11 mm. Student t test was used for statistical analysis. Results: There were 8 male and 37 female patients. Average follow-up was 4 months. Mean preoperative standardized MRD2 was 4.68 mm and 4.65 mm for transconjunctival blepharoplasty without and with skin pinch, respectively. Mean postoperative standardized MRD2 was 4.73 mm and 4.70 mm for transconjunctival blepharoplasty without and with skin pinch, respectively. The mean change in lower eyelid position was 0.05 mm after each technique. The change in lower eyelid position was not statistically significant for either group (p > 0.5). There was no significant difference in lower eyelid position change between the 2 groups (p > 0.99). Conclusions: Transconjunctival lower blepharoplasty with or without a skin pinch yields a stable postoperative lower eyelid position.

Fibrin sealant for Müller muscle-conjunctiva resection ptosis repair.

Purpose: To determine the safety and efficacy of fibrin sealant for use in Müller muscle–conjunctiva resection ptosis repair. Methods: This was a retrospective review of a consecutive case series. All patients underwent Müller muscle–conjunctiva resection ptosis repair with fibrin sealant used for wound closure. Surgery was performed in a manner similar to a previously described technique, using fibrin tissue sealant rather that suture for wound closure. Postoperative symmetry was defined as MRD1 of each eyelid within 0.5 mm. Results: Müller muscle–conjunctiva resection ptosis repair with fibrin sealant used for wound closure was performed on 53 eyelids of 33 patients. There were 27 female patients and 6 male patients. Twenty patients underwent bilateral ptosis repair and 13 patients underwent unilateral ptosis repair. Average follow-up was 17 weeks (range, 3 to 45 weeks). Mean preoperative MRD1 was 1.22 mm (range, –1.5 to 2.5 mm) in the right upper eyelid and 1.50 mm (range, 0 to 2 mm) in the left upper eyelid. Mean postoperative MRD1 was 3.11 mm (range, 2 to 4.5 mm) in the right upper eyelid and 3.12 mm (range, 1 to 4.5 mm) in the left upper eyelid. Postoperative symmetry was found in 32 of 33 patients (97%). We found no evidence of keratopathy or other complications attributable to the fibrin sealant. Conclusions: Müller muscle–conjunctiva resection ptosis repair with fibrin sealant used for wound closure may allow for predictable results with few complications and appears to be an acceptable alternative to traditional suture techniques.

Bovine hydroxyapatite orbital implant: A preliminary report

Purpose To determine the safety and efficacy of bovine hydroxyapatite as an orbital implant material. Methods Prospective, consecutive case series of patients undergoing enucleation, evisceration, or secondary orbital implantation. A motility peg was placed in all consenting candidates. Patients were followed 1 week, 1 month, and several months after surgery for signs of inflammation, infection, extrusion, or other complication. Results Twenty-seven patients received a bovine hydroxyapatite orbital implant. Magnetic resonance imaging was obtained in 3 patients (3 orbits) approximately 4 weeks after surgery and showed signs of peripheral fibrovascular ingrowth in all three cases. Magnetic resonance imaging was obtained in 9 patients (9 orbits) 4 to 12 months after surgery and showed signs of incomplete fibrovascular ingrowth in 1 of 9 (11%) cases, subtotal fibrovascular ingrowth in 2 of 9 (22%) cases, and complete fibrovascular ingrowth in 6 of 9 (67%) of cases. Complications included postoperative chemosis in 3 cases (11%) and exposure requiring reoperation in 2 cases (7%). Motility peg placement was performed successfully in 5 patients (5 orbits). Conclusions Bovine hydroxyapatite appears to be a safe and effective orbital implant material. The material appears to be biocompatible and nonallergenic. Bovine hydroxyapatite allows for fibrovascular integration and motility peg placement.