Louise A. Mawn

The bioceramic implant: evaluation of implant exposures in 419 implants.

Purpose: To compare the rate of exposure in the immediate 3-month postoperative follow-up period with the rate of exposure after the immediate postoperative period in 419 anophthalmic patients with a bioceramic (aluminum oxide) orbital implant. Methods: This is a retrospective, clinical case series of 419 patients who received a bioceramic orbital implant. All patients who presented to five oculofacial surgeons (D.J., S.G., J.D., S.K., L.M.) from January 1, 2000, to June 1, 2007, who received a bioceramic orbital implant and had a minimum of 3 months of follow-up were included in this study. The authors analyzed age, gender, type of surgery, implant size, peg system, follow-up duration, time of pegging, and problems encountered. The data from the patients with greater than 3 months of follow-up with exposure of the bioceramic implant are detailed in this report. Results: There were 353 patients followed for 3 to 96 months with an average of 30 months of follow-up (median 23 months). Implant exposure occurred in 32/353 bioceramic implants (9.1%). Six of the 32 (19%) exposures occurred during the 90-day postoperative period (average 2.1 months). Twenty-six (81%) exposures occurred outside of the 90-day postoperative period (average 27.5 months, range 4–82 months). Conclusions: Implant exposures can occur anytime postimplant placement. This review discovered an implant exposure rate of 9.1%, with the majority of the exposures occurring after the postoperative follow-up period. Patients with porous orbital implants should be followed on a long-term basis to detect this complication.

Pathogenesis of Canalicular Lacerations

Purpose: To assess the pathogenesis of canalicular lacerations. Methods: This is a retrospective, clinical case series of 236 patients who sustained a canalicular laceration. All patients who presented to the oculoplastic service of 3 individuals (D.R.J., S.M.G., L.A.M.) from May 1, 1998 to September 30, 2007, with a canalicular laceration were included in the study. Case histories were carefully reviewed in an attempt to classify the mechanism of injury as: “direct (penetrating) injury,” “indirect (avulsive),” or “diffuse (avulsive).” Associated injuries (floor fractures, soft tissue lacerations, etc.) were also recorded. Results: Of the 236 patients reviewed, direct canalicular injuries were detected in 128 (54.2%), indirect injuries were detected in 60 (25.4%), and diffuse injuries were detected in 48 (20.3%). Avulsive blunt injuries (due to indirect or diffuse trauma) therefore accounted for 45.7% of the lacerations whereas direct penetrating injuries accounted for 55.2% of the canalicular lacerations. Other injuries associated with the trauma occurred in 152 of the 236 patients (64%). Lacerations involving other portions of the eyelids, periocular area, and face made up the greatest number of associated injuries, and occurred with equal frequency in the direct penetrating group and the indirect/diffuse (avulsive injury) group. Associated injuries more serious in nature including orbital fractures, globe rupture, other body injuries, and head trauma were more commonly seen when diffuse trauma was involved. Conclusions: Direct, indirect, or diffuse forces may injure canaliculi but direct penetrating injuries were more common than avulsive injuries. More serious injuries (orbital fractures, globe rupture, other body injuries, and head trauma) were more commonly seen when diffuse trauma was involved.

The round-tipped, eyed pigtail probe for canalicular intubation: a review of 228 patients.

Purpose: To assess the effectiveness and outcomes of canalicular intubation with the use of a round-tipped, eyed pigtail probe. Methods: Retrospective interventional case series of 228 patients requiring intubation of the canalicular system. Patients were treated surgically with attempted repair of the canalicular system with the round-tipped, eyed pigtail probe. The main outcome measures were successful intubation of the lacrimal system, symptoms of tearing, clinical functional evaluation of lacrimal system, complications, and need for further lacrimal surgery. Results: Of 228 patients, 222 (97.4%) had their canalicular systems successfully intubated with silicone tubing using the round-tipped, eyed pigtail probe. Follow-up was obtained in 191 (86%) of the 222 patients. One-hundred sixty of 191 (83.8%) patients were irrigated and found to be anatomically patent (of the remainder, one was blocked whereas 30 were too young to be irrigated). One hundred fifty-two of the 191 (79.6%) patients had no tearing by history. Thirty-two (16.7%) had occasional tearing on some days that was not bothersome. Seven (3.7%) had intermittent or persistent tearing on a daily basis. Sixty-seven of the 191 (35%) had their lacrimal system more extensively assessed using the dye disappearance test, Jones I test, Jones II test, and canalicular probing. Anatomic patency in this subgroup was demonstrated in 66 of 67 (98.5%) of patients. The dye disappearance test, however, revealed slight asymmetry in 24 of 53 patients (45%) with canalicular lacerations yet only 14 of these 24 (58%) had any symptoms of tearing, indicating some discrepancy between subjective and objective assessment of tearing postcanalicular repair. Fifty-three of the repaired trauma patients underwent probing of the involved and uninvolved canalicular systems. In no patient was a stricture or blockage involving the uninvolved canaliculus identified. Additional lacrimal surgery (dacryocystorhinostomy) was performed on 2 of 191 (1%) patients with greater than 3 months follow-up. Conclusion: The round-tipped, eyed pigtail probe can help safely and effectively identify and repair canalicular lacerations. Symptomatic tearing was infrequent; the lacrimal systems showed complete anatomic patency in the majority of patients tested, and need for further lacrimal surgery was rare following pigtail probe intubation.

Juvenile Pilocytic Astrocytoma Masquerading as Amblyopia

PURPOSEnA healthy 13-year-old girl, previously diagnosed with amblyopia in her right eye, was seen in consultation after her vision continued to decrease.nnnMETHODSnA complete ophthalmologic examination including visual field testing and optic nerve photography was performed in the neuro-ophthalmologic clinic. Magnetic resonance imaging study was also obtained.nnnRESULTSnVisual sensory deficits and pale optic nerves were noted on clinical examination. Visual field testing showed a chiasmatic junctional defect. Magnetic resonance imaging verified a large chiasmatic mass, histologically proven to be a juvenile pilocytic astrocytoma.nnnCONCLUSIONnEarly recognition of signs and symptoms of chiasmatic lesions is essential for preventing visual loss.

Integra Bilayer Matrix Wound Dressing Closure of Large Periorbital Traumatic Wound

We report the first use of the Integra Bilayer Matrix Wound Dressing (Integra LifeSciences Corp), a collagen sheet with glycosaminoglycans and a silicone layer, in an innovative reconstruction approach to devastating traumatic tissue loss in the periocular area. A 36-year-old woman was involved in a motor vehicle crash with a resultant large defect from the medial canthus to the temporal fossa and from the pretarsal skin to the brow. There was denudation of skin and soft tissue to the bone at the superolateral orbital apex. The severity of tissue loss precluded placement of an autograft or allograft; thus, a skin substitute was instead used, with a successful reconstructive outcome. Application of the newer bioengineered skin products for full-thickness skin wounds should be considered for reconstruction of the periocular area.

Primary ocular presentation of sinonasal undifferentiated carcinoma.

The authors describe 2 consecutive patients who presented to Vanderbilt University Medical Center with primary orbital presentation of sinonasal undifferentiated carcinoma and were treated from July 2005 to April 2009. The patients were a 39-year-old woman and 54-year-old woman who both presented to the ophthalmology service due to complaints of diplopia. Imaging studies demonstrated large soft tissue masses originating in the sinuses with extension in the orbit in both cases. Both patients were treated with carboplatin, paclitaxel, and dexamethasone as induction chemotherapy followed by concurrent chemoradiation with intensity-modulated radiation therapy. This treatment regimen resulted in significant tumor shrinkage, resolution of symptoms, and no evidence of recurrence while avoiding surgical intervention and allowing orbital preservation.

A Survey of Current Blepharospasm Treatment Patterns Among Oculoplastic Surgeons.

Purpose: To determine the current practice pattern of ASOPRS members injecting onabotulinumtoxinA for Blepharospasm. Methods: An invitation to participate in a web-based, anonymous survey was sent to current members of American Society of Ophthalmic Plastic and Reconstructive Surgeons (ASOPRS) via e-mail. The survey consisted of 9 questions and used the Research Electronic Data Capture online application. Institutional Review board approval was obtained for this study. Results: Forty-one percent of ASOPRS members invited responded to the survey. The mean initial dose of onabotulinumtoxinA used was 22.5 units per side and the most common number of injection sites was greater than 7 per side. Only 12 of the 247 responding surgeons who treat benign essential blepharospasm with onabotulinumtoxinA reported that their initial injection pattern is with 3 or fewer sites per side as per the Food and Drug Administration (FDA)–approved recommendations. Conclusions: Survey of current trends in the management of blepharospasm with onabotulinumtoxinA by ASOPRS members showed that the mean initial dose used to treat blepharospasm patients was 22.5 (standard deviation ± 9.5 units, range 2.5 to 50 units per side). There is significant variation in the treatment doses. The majority of ASOPRS members do not follow the FDA-approved recommendation for dosing.

Periorbital Necrotizing Fasciitis Secondary to Candida parapsilosis and Streptococcus pyogenes.

Necrotizing fasciitis is most often caused by either polymicrobial bacterial infections or by Gram-positive organisms, such as Streptococcus or Staphylococcus; however, rare cases of fungal necrotizing fasciitis have been reported. Candida parapsilosis is an emerging fungal pathogen. This fungus grows in either a yeast or pseudohyphal form. C. parapsilosis has been reported to cause keratitis, intraocular infection, and seeding of frontalis slings. C. parapsilosis is a commensal of human skin and can be acquired by nosocomial spread. Necrotizing fasciitis due to Candida has rarely been reported, but to date C. parapsilosis has not been identified as the causative organism in necrotizing fasciitis. This is the first documented case of human periocular soft tissue infection by C. parapsilosis, and also the first report providing evidence of mycotic infection in a necrotizing fasciitis concurrently infected by Streptococcus pyogenes.

Repair of Canalicular Lacerations

7 ccurred with choroidal lymphoid proliferations, which are ery different from vitreoretinal lymphomas and which are ow known to consist of EMZL. Similar to Jakobiec, I ust emphasize that mucosa-associated lymphoid tissue MALT) lymphomas are not synonymous with EMZLs: hey are a subgroup of EMZLs characterized by mucosal ocation and lymphoepithelial lesions (ie, infiltration of djacent epithelium, such as conjunctiva or lacrimal gland cini). Prognostication, research, and patient care would be nhanced if OALs were: 1) subtyped using the WHO lassification; 2) staged using the novel TNM system; and ) graded using biomarkers such as Ki-67 and, possibly, s-yet-to-be-determined genotypic features. SARAH E. COUPLAND Liverpool, United Kingdom

Orbital Myositis as Both a Presenting and Associated Extraintestinal Sign of Crohn's Disease.

Orbital myositis is a rare extraintestinal manifestation of inflammatory bowel disease and has been reported to occur at variable times relative to gastrointestinal symptoms, including years before, concurrently to, and years after the gastrointestinal diagnosis. Here, the authors report 3 cases of Crohns disease associated orbital myositis, adding to the 18 previously reported cases. The authors describe 2 cases of middle-aged females presenting with orbital myositis during clinical remission of Crohns disease. The authors also describe the first reported case of orbital myositis-associated Crohns disease diagnosed prior to any gastrointestinal symptoms in a teenage male presenting with corticosteroid responsive intermittent eyelid swelling. These cases underscore the importance of the Ophthalmic Plastic Surgeon in initiating a thorough systemic workup for cases of orbital inflammatory disease.