Marc Yonkers

Orbital Injury From Needlefish Impalement.

Ophthal Plast Reconstr Surg, Vol. 31, No. 6, 2015 Through the medial bulbar conjunctiva, a needlefish (Fig. 1A) beak impaled the orbit of a 28-year-old man surfing in South America. He was initially treated conservatively with removal of subconjunctival and anterior orbital foreign material. Progressive eye irritation and pain prompted CT that demonstrated nonspecific hyperintense lesions (arrows) in the deep superior orbit (Fig. 1B) coronal and (Fig. 1C) sagittal images. After a superior orbitotomy through an eyelid crease incision, 19 fragments of foreign cartilaginous material were removed, shown in an unmagnified gross photo (Fig. 2A). A 20.5× magnified photomicrograph (Fig. 2B) demonstrates finer detail from the boxed portion of Fig. 2A. The needlefish, of the family Belonidae, has a long teeth-studded beak and a slender body capable of growing up to 2 meters. This anatomy enables needlefish to leap and skip at speeds of up to 40 miles per hour across the water surface. Needlefish rarely cause facial trauma, and more commonly injure extremities and the trunk. While infrequent, facial needlefish injuries have been associated with disfigurement, facial paralysis and death; vigorous irrigation, debridement and tetanus prophylaxis may forestall secondary infections. DOI: 10.1097/IOP.0000000000000400 Accepted for publication December 9, 2014. The authors have no financial or conflicts of interest to disclose. Address correspondence and reprint requests to Asghar Haider, B.S., 850 Health Sciences Road, Irvine, CA 92697-4375. E-mail: asgharh@uci.edu Orbital Injury From Needlefish Impalement

Baby Shampoo Versus Povidone-Iodine or Isopropyl Alcohol in Reducing Eyelid Skin Bacterial Load.

PURPOSE Baby shampoo is used as an alternative surgical skin preparation, but the evidence supporting its use is scarce with no descriptions of efficacy in the periocular region. The authors compare the efficacy of baby shampoo, povidone-iodine (PI, Betadine) and isopropyl alcohol (IA) in reducing eyelid skin bacterial load. METHODS Prospective, randomized, comparative, and interventional trial. Bacterial load on adult, human eyelid skin was quantitated before and after cleansing with 1) dilute baby shampoo, 2) 10% PI, or 3) 70% IA. Paired skin swabs were collected from a 1 cm area of the upper eyelid of subjects before and after a standardized surgical scrub technique. Samples were cultured on 5% sheep blood agar for 24 hours. The number of colony forming units (CFU) was assessed and bacterial load per square centimeter of eyelid skin was quantified. RESULTS Baseline and postcleansing samples were assessed from 42 eyelids of 42 subjects (n = 14 for each of baby shampoo, PI, and IA). Before cleansing, similar amounts of bacterial flora were grown from all specimens (median log CFU/cm = 2.04 before baby shampoo, 2.01 before PI, 2.11 before IA; p > 0.05). All 3 cleansing agents significantly reduced the bacterial load (p < 0.01 for each). There was no statistically significant difference in postcleansing bacterial load between the 3 cleansing agents (median log CFU/cm = 0.48 after baby shampoo, 0.39 after PI, 0.59 after IA; p > 0.05). Change from baseline in bacterial load was statistically similar for all 3 agents (median reduction in log CFU/cm = 1.28 with baby shampoo, 1.57 with PI, 1.40 with IA; p > 0.05). These corresponded to bacterial load reductions of 96.3%, 96.6%, and 98.4% for baby shampoo, PI, and IA, respectively. CONCLUSIONS Baby shampoo achieved comparable diminution in eyelid skin bacterial load to PI or IA. These data suggest baby shampoo may be an effective preoperative cleansing agent.

A case of attempted bilateral self-enucleation in a patient with bipolar disorder

Attempted and completed self-enucleation, or removal of one’s own eyes, is a rare but devastating form of self-mutilation behavior. It is often associated with psychiatric disorders, particularly schizophrenia, substance induced psychosis, and bipolar disorder. We report a case of a patient with a history of bipolar disorder who gouged his eyes bilaterally as an attempt to self-enucleate himself. On presentation, the patient was manic with both psychotic features of hyperreligous delusions and command auditory hallucinations of God telling him to take his eyes out. On presentation, the patient had no light perception vision in both eyes and his exam displayed severe proptosis, extensive conjunctival lacerations, and visibly avulsed extraocular muscles on the right side. An emergency computed tomography scan of the orbits revealed small and irregular globes, air within the orbits, and intraocular hemorrhage. He was taken to the operating room for surgical repair of his injuries. Attempted and completed self-enucleation is most commonly associated with schizophrenia and substance induced psychosis, but can also present in patients with bipolar disorder. Other less commonly associated disorders include obsessive-compulsive disorder, depression, mental retardation, neurosyphilis, Lesch-Nyhan syndrome, and structural brain lesions.

Lazy Pentagonal Wedge Resection of Eyelid Margin Lesions

Full-thickness pentagonal wedge resection and repair is a mainstay in the treatment of eyelid neoplasms, trichiasis, and other eyelid pathologic abnormalities.1-3 Traditionally, when performed on the lower eyelid, incisions are made in a symmetric pentagon surrounding the lesion. The parallel vertical medial and lateral incision design offers structural integrity of the reconstructed tarsus and margin and forestalls eyelid margin distortion and notching. Fullthickness resection may also more reliably eradicate basal cell carcinoma (BCC) and other carcinomas. However, the largely vertical wound may leave a conspicuous scar as it crosses normal horizontal or oblique relaxed skin tensions lines. The triangular inferior aspect of the defect may add to the resultant deformity since it induces skin redundancy, known as a dog-ear deformity, that usually requires additional surgical treatment.3-6 A modified curvilinear or “lazy” pentagonal wedge resection technique may achieve the tarsal alignment associated with the pentagonal wedge, yet minimize scarring and dog-ear deformity. In this procedure, this curved pattern—in lieu of a linear incision—may minimize cutaneous excess and keep the resultant wound aligned with the relaxed facial skin tension lines. Herein, we describe this surgical technique in detail and retrospectively assess safety outcomes and cosmetic results.

Vascular Steal Syndrome, Optic Neuropathy, and Foreign Body Granuloma Reaction to Onyx-18 Embolization for Congenital Orbito-Facial Vascular Malformation.

A 34-year-old patient presented with a right orbito-facial mass since childhood, consistent with a congenital arteriovenous (AV) malformation. Prior to presentation, she had multiple incomplete surgical resections and embolizations with N-butyl acetyl acrylate and Onyx-18. The patient reported gradual, progressive vision loss shortly after Onyx-18 embolization. Five months after embolization, she presented with decreased vision, disfigurement and mechanical ptosis relating to a large subcutaneous mass affecting the medial right upper eyelid and forehead. Significant exam findings included a visual acuity of 20/400 (20/60 prior to embolization), an afferent pupillary defect, and optic disc pallor. MRI and angiography revealed a persistent AV malformation with feeders from the ophthalmic artery and an absent choroidal flush to the right eye. Pathology from surgical resection showed a significant foreign body giant cell reaction to the embolization material adjacent to the vessels. We suggest that an incomplete embolization with Onyx-18 may have caused vascular steal syndrome from the ophthalmic artery.