Kelly R. Everman

Age-Matched, Case-Controlled Comparison of Clinical Indicators for Development of Entropion and Ectropion

Purpose. To analyze the clinical findings associated with involutional entropion and ectropion and compare them to each other and to age-matched controls. Methods. Prospective, age-matched cohort study involving 30 lids with involutional entropion, 30 lids with involutional ectropion, and 52 age-matched control lids. Results. The statistically significant differences associated with both the entropion and ectropion groups compared to the control group were presence of a retractor dehiscence, presence of a “white line,” occurrence of orbital fat prolapse in the cul-de-sac, decreased lower lid excursion, increased lid laxity by the snapback test, and an increased lower lid distraction. Entropion also differed from the control group with an increased lid crease height and decreased lateral canthal excursion. Statistically significant differences associated with entropion compared to ectropion were presence of a retractor dehiscence, decreased lateral canthal excursion, and less laxity in the snapback test. Conclusion. Entropic and ectropic lids demonstrate clinically and statistically significant anatomical and functional differences from normal, age-matched lids. Many clinical findings associated with entropion are also present in ectropion. Entropion is more likely to develop with a pronounced retractor deficiency. Ectropion is more likely to develop with diminished elasticity as measured by the snapback test.

Uveal melanoma with massive extrascleral extension via pars plana vitrectomy sites.

A 74-year-old man underwent cataract extraction and 4 months later developed a macula-off retinal detachment. The retinal detachment was repaired via pars plana vitrectomy. Postoperatively, hyphema and dense vitreous hemorrhage developed. The hyphema recurred after anterior chamber washout. The hemorrhage was evacuated via a second pars plana vitrectomy, during which profuse, uncontrollable hemorrhage from the vitreous cavity prevented intraocular visualization; the sclerotomy sites were closed without identification of the bleeding source. One month later, the patient presented with complete loss of vision and pain on the affected side. Examination revealed extensive rubeosis and conjunctival injection, a vascularized mass filling the retrolental space, and subconjunctival nodules at the sclerotomy sites. Enucleation was performed, and a mass was note to involve 95% of the posterior chamber without gross optic nerve invasion. Histopathologic examination confirmed malignant melanoma. The rapid, massive extrascleral extension of uveal melanoma through surgical sclerotomy sites demonstrated in this case has not been previously described.

Piezoelectric-Assisted Removal of The Lateral Orbital Rim in Lateral Orbital Rim Advancement

Dear Sir, Lateral orbital decompression is a key component in the treatment of Thyroid Eye Disease (TED), either alone or in combination with additional surgical procedures. For surgeons who prefer advancement of the lateral orbital rim, a high-speed oscillating saw is often used for removal of this bony area. Operation of the oscillating saw poses direct surgical risk, namely thermal injury to the surrounding bone and tissues. Other risks include mechanical damage to surrounding soft tissues, especially those composing the neurovaculature supply. Recently, piezoelectric ultrasound technology has been used to remove bone with precision and a decreased risk of soft tissue injury as reported in the neurosurgical, otologic, maxillofacial, orthopedic and oculoplastic literature. Other surgeons have described the use of piezoelectric instruments to burr the internal orbital wall structures. We have recently incorporated this technology to safely remove the lateral orbital rim using the Mectron Piezosurgery system (Mectron Technology, Carasco, Genova, Italy) with a saw attachment (MT1s-10). Constant sterile, aerosolized irrigation at the tip of the handpiece functions to cool the blade and thus reduces thermal injury to surrounding bone. Cavitation of the fluid provides for blood-free incisions while the operating frequency of 25–29 kHz ensures that only mineralized structures are cut while soft tissues are spared even upon direct contact with these delicate structures. This is a useful adjunct for efficacious and safe lateral orbital rim advancement in lateral orbital decompression surgery. Orbit, 31(1), 63, 2012 Copyright

Addition of dermis-fat graft to diminish cable visibility in frontalis suspension for patients with pre-existing deep superior sulci.

Purpose: To propose and demonstrate a technique modification for frontalis suspension to simultaneously address ptosis and diminish abnormalities related to deep superior sulcus defect. Methods: Six patients underwent simultaneous frontalis suspension and placement of a superior sulcus dermis-fat graft. Results: Postoperative visibility of the cables, anticipated in patients with deep superior sulci, was prevented in these 6 patients. Conclusions: Dermis-fat grafting may be added to improve cosmesis after frontalis suspension in patients at risk for postoperative cable visibility.

Risk of ocular blood splatter during oculofacial plastic surgery.

Purpose: To assess intraoperative blood splatter to the ocular surface and adnexa during oculofacial surgery. Methods: Four surgeons and multiple assistants at three separate locations wore a total of 331 protective eye shields during 131 surgeries. Postoperatively, a luminol blood detection system was used to identify blood splatter on the shields. In the event of positive blood splatter, the total number of blood spots was counted. Controls were used to verify the blood detection protocol. A postoperative questionnaire was given to all surgeons and assistants after each case, and they were asked whether intraoperative blood splatter was noticed. Results: Blood was detected on 61% of eye shields and in a total of 80% of surgical cases. However, only 2% of blood splatters were recognized intraoperatively by the surgical participants. There was no significant difference in the splatter rate between surgeons (64%), assistants (60%), and surgical technicians (58%) (p = 0.69). Shields worn during full-thickness eyelid procedures, direct brow lifting, orbitotomy with bony window, and orbital fracture repairs were more likely to be splattered (p = 0.03), and there was a significant difference between splatter rates among different surgeons (range, 29–90%; p = 0.0004), suggesting that blood splatter rate may be both procedure dependent and surgeon dependent. Conclusions: Mucocutaneous and transconjunctival transmission of human immunodeficiency virus and viral hepatitis has been documented. These results suggest that oculofacial plastic surgeons should consider eye protection for patients with known blood-borne diseases and in cases where blood splatter is expected. This precautionary practice is supported by the high incidence (98%) of undetected, intraoperative blood splatter.

Hydrogel explant extrusion masquerading as a malignant eyelid lesion.

Hydrogel was a commonly used material for scleral buckling in the early 1980s to the mid-1990s. Use of hydrogel ceased due to a high complication rate, including frequent migration. Various symptoms and clinical findings have been reported with hydrogel migration. There have been no published reports of hydrogel migration to the eyelid anterior to the orbital septum with erosion of the orbicularis and bleeding as a presenting symptom. The authors describe a patient with hydrogel migration to the upper eyelid, with symptomology and clinical findings consistent with a malignant eyelid lesion. Excisional biopsy of extraorbital hydrogel is recommended in these cases.

Piezosurgery in External Dacryocystorhinostomy.

BACKGROUND Dacryocystorhinostomy (DCR) can be performed via an external or endoscopic approach. The use of ultrasonic or piezosurgery has been well described for endoscopic DCRs but is lacking for external DCRs. This study presents a case series of external DCRs performed using piezosurgery evaluating results and complications. METHODS Prospective, consecutive case series of patients undergoing primary external DCR for lacrimal drainage insufficiency. A standard external DCR technique was used using 1 of 2 piezosurgery systems for all bone incision. All patients received silicone intubation to the lacrimal system. Surgical outcome was measured in terms of patient-reported epiphora as follows: 1) complete resolution, 2) improvement >50%, 3) improvement <50%, and 4) No improvement. Intra and postoperative complications were also recorded. RESULTS Fifty-two patients, 14 male and 38 female, were included in the study, with 2 patients having bilateral surgery. The average age of the patients was 55.8 years. The average length of follow up was 221 days. Surgical outcomes showed 72% of patients with complete resolution of epiphora and 21% with >50% improvement. There were 4 patients (7%) who had <50% improvement. There was 1 (2%) intraoperative complication and 2 (4%) postoperative complications recorded. CONCLUSIONS Piezourgery is a viable modality for performing external DCRs. The lack of surgical complications shows a potential for decreased soft tissues damage. The surgical success rate based on patient-reported epiphora is similar to those published for mechanical external DCRs. This modality may benefit the novice surgeon in the reduction of soft and mucosal tissue damage.

Coronal Brow Lift

Patients should have been evaluated and deemed appropriate for surgical intervention. The procedure should be considered for patients with bilateral brow ptosis. Coronal approach may be modified to a pretrichial approach if forehead length is greater than 60 mm. Patients should have been educated about the risks and benefits of the procedure, including the alternatives.

Zygomaticomaxillary Complex (ZMC) Fracture Repair

Patients should have been evaluated and deemed appropriate for such surgical intervention. The procedure should be considered for patients with unilateral or bilateral displacement of the zygomaticomaxillary complex with malar flattening, trismus, canthal dystopia, diplopia, globe malposition, or enophthalmos. Surgical treatment should be completed within 2 weeks from the time of injury. Patients with inferior rectus incarceration or entrapment require more emergent repair with age further directing interventional timing. However, patients with concurrent orbital hemorrhage and/or globe injury usually undergo delayed repair once vision-threatening issues have resolved. All patients should undergo CT imaging of the orbits and facial bones prior to surgical planning. Patients should have been educated about the risks and benefits of the procedure, including alternatives.

Infection Rates after Periocular Surgery Utilizing New versus Re-Processed Monopolar Electrocautery.

BACKGROUND To determine if there is a difference in periocular post-operative infection rates when utilizing new versus re-processed monopolar electrocautery tips. METHODS Retrospective cohort study of 4,976 consecutive surgical cases involving 17,149 procedures. Post-operative infections were identified using chart review, facility infection surveillance records, and surgeon reporting. The main outcome measure was the presence or absence of infection within 30 post-operative days. The Fischer exact test was used to compare infection rates between cautery modalities. All statistical analysis was conducted at the 0.05 α level. RESULTS There was no statistically significant difference between new and re-processed monopolar cautery infection rates (p=0.3879). CONCLUSIONS Post-operative infection rates are similar for periocular surgery using both new and re-processed monopolar cautery. These findings suggest that re-processed cautery is a viable option for periocular surgery to decrease cost and reduce material waste without affecting the quality of care.