Michael J. Hawes

Operative Complications of the Transconjunctival Inferior Fornix Approach

The transconjunctival inferior fornix incision provides access to the floor, rim, lateral, and inferior medial walls of the orbit. Complications of this surgical approach to the orbit are known to be rare but heretofore have not been clearly defined. Over an 8-year period, in an estimated 1200 cases, the authors have encountered cicatricial entropion, lower eyelid retraction, canthal dehiscence, lower eyelid avulsion, canalicular laceration, buttonhole laceration of the lower eyelid, conjunctival chemosis, and lacrimal sac laceration. Attention to anatomic landmarks and sound surgical execution will prevent these complications in most patients.

Effectiveness of bicanalicular silicone intubation in the repair of canalicular lacerations.

Abstract In this series of 24 patients with 28 canalicular lacerations, bicanalicular silicone intubation is found to be an effective technique with 95% anatomic success. No statistically significant difference is noted in successful repair when comparing proximal, mid, and distal lacerations. There are no recognized cases of iatrogenic injury to either the injured or the uninjured canaliculus in this series. The repair of all canalicular lacerations is advocated.

Mucinous eccrine adenocarcinoma of the periocular region

Purpose: To report 4 patients with mucinous eccrine adenocarcinoma of the periocular region. Methods: Interventional case series of 4 patients with mucinous eccrine adenocarcinoma of the periocular region treated at 2 centers. Results: Two patients with mucinous eccrine adenocarcinoma of the upper eyelid, 1 with mucinous eccrine adenocarcinoma of the lower eyelid, and 1 with mucinous eccrine adenocarcinoma of the eyebrow were included in this report. The lower eyelid lesion and the eyebrow lesion recurred after Mohs micrographic surgery. Both recurrent lesions were treated with Mohs micrographic surgery and postoperative adjuvant external-beam radiation therapy. The other 2 primary tumors were treated with wide local excision with frozen section control of margins and did not recur. The follow-up time after the most recent surgical procedure ranged from 8 to 17 months (median, 12 months). Conclusions: Mucinous eccrine adenocarcinoma is a rare ocular adnexal neoplasm that can involve the eyelid and periocular skin, can be locally invasive, and has a high risk of local recurrence despite Mohs surgery.

The dacryolithiasis syndrome

A syndrome of the typical patient with a dacryolith in the lacrimal sac or nasolacrimal duct is described, based on review of 107 consecutive patients undergoing dacryocystorhinostomy (DCR) and 43 patients with a history of dacryocystitis. The incidence of dacryolithiasis was 14% of all patients having a DCR. The typical patient with a dacryolith was 45 years old, had a 4.8 year history of intermittent epiphora, had at least one episode of acute dacryocystitis, and could be irrigated with some fluid getting into the nasopharynx. Patients undergoing DCR with a history of acute dacryocystitis had a nine times higher likelihood of having a dacryolith than DCR patients without a history of acute dacryocystitis. DCR was curative in all 15 patients with a dacryolith.

From eyelid bumps to thyroid lumps: report of a MEN type IIb family and review of the literature.

Purpose We present a two-generation family with multiple endocrine neoplasia (MEN) type IIb diagnosed by their ophthalmologists based on characteristic ophthalmic findings. Methods A family consisting of a 33-year-old female proband and her 8-and 7-year-old children had prominent corneal nerves; eyelid, lip, and tongue nodules; and a characteristic facies. A polymerase chain reaction-based genetic assay was obtained to detect the genetic mutation most commonly associated with MEN type IIb. Serum calcitonin and urine catecholamine studies were obtained. Results Molecular genetic studies detected in all 3 patients a mutation at codon 918 of the RET proto-oncogene known to be present in 95% of the cases of MEN type IIb. Serum calcitonin was elevated in the proband and her son. Urine catecholamine levels were elevated in the proband. Surgical treatment and histologic analysis confirmed pheochromocytoma and medullary thyroid carcinoma (MTC) in the proband. Surgical exploration revealed the MTC to be metastatic to the liver. Conclusions This family demonstrates the characteristic findings of MEN type IIb: prominent corneal nerves in a clear stroma and multiple submucosal neuromas of the conjunctiva, eyelids, lips, and tongue. Ophthalmologists have a critical role to play in recognizing these signs, because the early diagnosis of medullary thyroid carcinoma and pheochromocytoma may be life saving.

Complications of tarsoconjunctival grafts

Summary: The authors reviewed 44 tarsoconjunctival grafts performed from 1983 to 1993 to determine the nature and severity of complications related to these grafts. Follow‐up ranged from 3 weeks to 10 years, with a mean of 23 months. The complications were categorized as none, minor, or major. A complication was deemed major if it required a second surgical procedure for treatment. Eleven percent (5/44) of patients had major complications, including marked upper lid retraction after upper lid reconstruction (1), wound dehiscence (2), cicatricial ectropion (1), and excessive lower lid laxity (1). Seventy‐three percent (32/44) of patients had minor complications. Minor complications included trichiasis (5), notching of the donor and/or recipient lid margin (9), mild lid retraction (3), contour deformity (2), granuloma (2), prolonged edema or erythema (4), symblepharon (1), mild ectropion (2), punctate keratitis (1), minimal ptosis (1), and epiphora (1). Sixteen percent (7/44) had no complications. Despite the frequent minor complications and the occasional major complications, the use of free tarsoconjunctival grafts remains a valuable procedure in the surgeons armamentarium for reconstruction of major eyelid defects. Knowledge and early recognition of the possible complications may result in better patient care.

Cherubism and its orbital manifestations

Cherubism is a rare, fibroosseous lesion of the jaws that may have orbital manifestations of proptosis, lower eyelid retraction, superior globe displacement, and visual loss. Management of the orbital tumors in two cases from the same family is described. The original description of the disorder is reviewed. The inheritance pattern is autosomal dominant. Pathology findings show multinucleated giant cells in a vascular fibrous stroma. Teeth are often missing or displaced. Radiographic studies show symmetric cystic lesions in the jaws and sometimes involvement of the orbital floor and lateral orbital wall. Fibrous dysplasia is in the differential diagnosis, but can be distinguished by clinical characteristics. Treatment may involve curettement or recontouring of the bony lesions.

Magnetic resonance imaging versus bone scan for assessment of vascularization of the hydroxyapatite orbital implant

Summary We prospectively studied 10 patients who were status postenucleation and primary placement of the hydroxyapatite orbital implant. Both the technetium-99m bone scan and gadolinium-enhanced magnetic resonance images (MRI) were obtained on the same day at variable time points in the postoperative period in order to assess the degree of vascularization. Up to 78% of the bone scans were interpreted as being completely vascularized, while only 10% of the corresponding MRI scans were consistent with complete vascularization. Cost analysis showed that MRI was a cost-effective imaging modality. We conclude that contrast-enhanced MRI provides a more accurate assessment of vascularization of the hydroxyapatite orbital implant when compared to bone scan.

Re: "Comparison of free tarsoconjunctival grafts and Hughes tarsoconjunctival grafts for lower eyelid reconstruction"

Purpose: To review the use of free autogenous tarsoconjunctival (TC) grafts and Hughes TC flaps in the practice of one of the authors (MJH) and compare complications and outcomes and develop a rationale for the selection of surgical technique. Methods: Retrospective comparative case series of 70 patients who underwent reconstructive surgery for a major full-thickness lower eyelid defect using a free autogenous TC graft or Hughes TC pedicle flap by one of the authors (MJH). Rates of complications, including erythema of the eyelid margin, eyelid position abnormalities, and need for additional surgeries, were reviewed. Results: During a 15-year period, 70 patients with full-thickness lower eyelid defects were treated with autogenous TC grafts and flaps. The average age of the patients receiving a free TC graft was younger than the average age of patients receiving a Hughes TC graft (63 versus 73 years, p < 0.001). Patients with a free TC graft were more likely to have a smaller eyelid defect than the patients receiving a Hughes TC graft (52% versus 72%, p < 0.001). Patients receiving a free TC graft were less likely to require surgery to repair eyelid margin erythema than those in receiving a Hughes TC flap (one patient [2%] versus 5 patients [19%], respectively [odds ratio = 0.10, confidence interval = 0.01 to 0.95]). The average follow up was 22 months. Conclusions: Free TC flaps associated with mycocutaneous advancement flaps are less likely to lead to complications of eyelid margin erythema and subsequent revision surgery than Hughes TC flaps with full-thickness skin grafts.

Pediatric Golf-Related Ophthalmic Injuries

OBJECTIVES To document ophthalmic morbidity of golf-related injuries in children and to report specific injury patterns. DESIGN A noncomparative, interventional, retrospective case series of 11 pediatric patients treated at 2 institutions for ophthalmic trauma resulting from golf-related injuries during 15 years. RESULTS Eleven eyes of 11 patients were injured. There were 6 boys and 5 girls, with a mean age of 10.2 years (age range, 7-14 years). Ten patients were injured by golf clubs and 1 patient by a golf ball. One injury occurred on a golf course. At the initial ophthalmic examination, visual acuity was 20/20 in 4 eyes (36%), 20/25 to 20/80 in 3 eyes (27%), no light perception in 3 eyes (27%), and undeterminable in 1 eye (9%). Nine of 11 patients required surgery. Follow-up ranged from 0 to 66 months (mean follow-up, 12 months). Three of 11 subjects had permanent deficits, including blindness, decreased vision, and anophthalmia. Final visual acuity was no light perception in 2 eyes (18%), 20/70 in 1 eye (9%), and 20/20 or better in 8 eyes (73%). CONCLUSIONS The findings from this series reveal that pediatric ophthalmic golf injuries, although rare, may be devastating to the eye, periocular adnexa, and visual system. Among our cases, most injuries occurred off the golf course, many required surgery, and some resulted in permanent loss of vision.