Michael T. Yen

Effect of Corticosteroids in the Acute Management of Pediatric Orbital Cellulitis With Subperiosteal Abscess

Purpose: To determine the effect of intravenous corticosteroids in the acute management of pediatric orbital cellulitis with subperiosteal abscess. Methods: The inpatient records of all patients treated for orbital cellulitis with subperiosteal orbital abscess between January 2001 and August 2003 were reviewed. The use of corticosteroids, length of hospital stay, need for surgical drainage, treatment course, and clinical outcomes were reviewed. A t test and Fisher exact test analysis were calculated to evaluate statistical significance. Results: Twelve patients received intravenous corticosteroids and 11 patients did not receive corticosteroids. All patients had complete resolution of their abscess without complications. Length of hospitalization between the patients treated with and without intravenous corticosteroids was not significantly different (p = 0.26). Four of 12 patients treated with intravenous corticosteroids underwent orbitotomy for drainage of the abscess, and 6 of 11 patients treated without intravenous corticosteroids underwent surgical drainage (p = 0.20). Two of 12 patients treated with corticosteroids received intravenous antibiotics after discharge, whereas 7 of 11 in the group not treated with corticosteroids received intravenous antibiotics after discharge (p = 0.03). Conclusions: The use of intravenous corticosteroids does not appear to adversely affect clinical outcomes and may be beneficial in the treatment of pediatric orbital cellulitis with subperiosteal abscess. Review of our data suggests that a prospective, randomized trial is warranted to further clarify the role of corticosteroids in the acute management of pediatric orbital cellulitis with subperiosteal abscess.

Inflammatory disorders of the orbit in childhood: A case series

PURPOSE To describe a series of cases of orbital inflammatory disorders in children. DESIGN Retrospective case series. METHODS The medical records of pediatric patients diagnosed with orbital inflammation between September 1, 2002, and December 31, 2008, at Texas Childrens Hospital were reviewed. Data collected included age at presentation, final diagnosis, treatment, workup and evaluation, need for biopsy and biopsy results, and involvement of lacrimal gland and muscles. RESULTS Twelve cases were identified. Six cases were males and 6 were females with age at presentation ranging from 1.3 to 16.2 years (mean, 11.9 years). The most common presentation was lacrimal gland enlargement, which was bilateral in 3 cases. Other common presenting signs were proptosis, extraocular motility limitation, and pain on eye movement. Half of our patients had systemic complaints at presentation, the most common of which was fever. Four patients were diagnosed as having a systemic cause and 2 of these patients had systemic symptoms. CONCLUSIONS Idiopathic orbital inflammatory conditions in children are uncommon, but can be associated with systemic conditions. Patients typically have lacrimal gland involvement, pain with eye movement, proptosis, and motility deficits at presentation. Bilateral cases may have a higher incidence of systemic disease.

No-scar Asian epicanthoplasty: a subcutaneous approach.

Purpose: The epicanthal fold is a normal finding in the medial portion of the upper eyelid in many Asians. We describe a simple technique of removing the excess muscle and softening or eliminating the epicanthal fold without making incisions in the medial canthal region, thus avoiding complications such as scarring or web formation Methods: Interventional case series. The subcutaneous epicanthoplasty was performed on all Asian patients undergoing concurrent upper eyelid blepharoplasty or aponeurotic ptosis repair. Results: Thirty-eight Asian patients underwent epicanthal fold correction between January 1996 and December 2000. All patients had softening of the epicanthal fold; however, some cases of mild undercorrection were noted. Conclusions: Softening or elimination of the Asian epicanthal fold can be accomplished without making skin incisions in the medial canthal region. Our technique is a simple, graded procedure that can be performed in conjunction with upper blepharoplasty or ptosis repair.

Orbicularis oculi muscle graft augmentation after protractor myectomy in blepharospasm.

Purpose To evaluate the effectiveness of free orbicularis oculi muscle grafts in correcting volume deficit deformities after protractor myectomy in patients with essential blepharospasm. Methods Prospective case series. During the 13-month period from October 2000 through November 2001, all patients with essential blepharospasm undergoing primary eyelid protractor myectomy received an orbicularis oculi muscle graft to replace the volume deficit deformity created by the myectomy. Only patients who had at least 6 months of postoperative follow-up were included in the analysis. Results Forty-six patients underwent primary eyelid protractor myectomy and had a free orbicularis oculi muscle graft for volume replacement. All patients had significant functional improvement of their eyelid spasms after the myectomy. Of the 38 patients who underwent upper eyelid myectomy, 3 patients were overcorrected and no patients were undercorrected with the orbicularis muscle graft. Two of the overcorrected patients underwent surgical debulking of their muscle grafts. Of the 8 patients who underwent lower eyelid myectomy, no patients were overcorrected and 1 patient was undercorrected. None of the patients were observed to have any spasms, contractions, or other signs of muscular activity or aberrant innervation of the muscle graft. Conclusions The orbicularis oculi muscle graft is a useful adjunct to protractor myectomy in improving the aesthetic outcomes for blepharospasm patients. Our study demonstrates the viability of the orbicularis oculi muscle graft and may lead to future applications of the graft in facial aesthetics.

Botulinum Toxin Injection for the Management of Refractory Filamentary Keratitis

OBJECTIVE To evaluate the efficacy of onabotulinumtoxinA injection for the treatment of refractory filamentary keratitis. METHODS A retrospective review of treatment response of 33 eyes of 17 patients with filamentary keratitis resistant to conventional medical therapy who were treated with onabotulinumtoxinA injection was performed. Ocular surface findings, symptom improvement, and the number and location of filaments before and after the injections were recorded. All eyelids were injected subcutaneously with onabotulinumtoxinA (10 U/0.1 mL). All treatments were performed in accordance with an individualized treatment plan using precise localizing treatment maps, with adjustments to dosage based on treatment response. RESULTS Objective and subjective improvement was noted after the initial onabotulinumtoxinA injection in all patients. Filaments completely resolved after the onabotulinumtoxinA injection in 29 eyes (88%). In 20 of these eyes, filaments and punctate fluorescein staining resolved, whereas in 9 eyes, filaments resolved but punctate fluorescein staining persisted. Three eyes (9%) had partial improvement: 2 residual microfilaments were noted in one eye and 1 in the other eye. In 1 eye, filaments resolved after initial and subsequent injections but recurred within 8 weeks of each injection. Although 14 treated eyes (42%) showed sustained improvement after 1 onabotulinumtoxinA injection, additional injections were necessary in 19 eyes (58%) during the follow-up period because of the recurrence of symptoms and filaments on the cornea. CONCLUSIONS OnabotulinumtoxinA injection should be considered an effective option for treating refractory filamentary keratitis. Because of the likelihood of recurrence, serial onabotulinumtoxinA injections may be necessary in some cases.

Laser-assisted dacryocystorhinostomy: a viable treatment option?

Purpose of review Improvements in endoscopic instrumentation and evolving laser technologies have renewed interest in laser-assisted endonasal applications, and an increasing number of lacrimal surgeons have focused on laser-assisted approaches to dacryocystorhinostomy (DCR). The purpose of this review was to assess the clinical efficacy of laser-assisted DCR techniques with a particular focus on the endocanalicular approach and to describe various laser systems and their associated tissue effects. Recent findings Recent studies of endocanalicular laser DCR suggest favorable success rates that are comparable with external and endonasal endoscopic DCR, although there is a shortage of robust, prospective, randomized studies. Summary Recent evidence suggests that endocanalicular laser DCR is a well tolerated, viable treatment option for nasolacrimal duct obstruction in selected patients with favorable results and shorter operative times. More recent studies seem to suggest improvements in success rates compared with older studies, although additional, well designed, comparative studies are needed.

Optic Neuropathy Following Endovascular Coiling of an Orbital Varix

Orbital varices are vascular malformations consisting of abnormal venous channels. Indications for intervention include loss of vision, elevated orbital pressure with motility deficit, and intractable pain. We present a case of a 65-year-old woman with an orbital varix, who underwent embolization via endovascular coiling. This treatment resulted in an intralesional thrombosis with subsequent enlargement of the varix, leading to a compressive optic neuropathy and severe vision loss. If an intervention is to be contemplated, the possibility of this rare but serious complication should be carefully considered and patients appropriately counseled.

Nonsurgical Rejuvenation of the Eyelids with Hyaluronic Acid Gel Injections

Abstract There has been an increased recognition for the role volume deflation plays in the aging periorbital area, and as such, rejuvenation strategies to augment and restore volume have developed and evolved. Hyaluronic acid fillers provide an efficient option for volume augmentation with good efficacy, longevity, and safety. An understanding of the changes in the upper and lower periocular area due to aging, the meticulous identification of focal hollows, and the precise delivery of filler to these areas can smooth contours and restore a rejuvenated periorbital area.

Localized Immunoglobulin Light Chain Amyloid of the Conjunctiva Confirmed by Mass Spectrometry Without Evidence of Systemic Disease

Current guidelines recommend a thorough systemic workup in patients with newly diagnosed immunoglobulin amyloid light chain (AL) amyloidosis because of a close association with an underlying plasma cell proliferative disorder. Rarely, however, AL amyloidosis may present as a localized, benign disease without systemic involvement. Few previous reports have documented localized AL amyloid of the conjunctiva, and all these used immunohistochemistry for amyloid typing, which can be inaccurate. The authors identified 2 cases of AL amyloidosis confirmed by mass spectrometry localized to the conjunctiva and without evidence of systemic disease as determined by thorough systemic workup. Despite the very sensitive diagnostic technique of mass spectrometry, AL amyloidosis of the conjunctiva may not have an association with systemic plasma cell proliferative disorder. It is important to recognize conjunctiva as a site where localized amyloidosis can occur, even with the AL subtypes, as this entity usually exhibits a benign course and may be managed conservatively.

Secondary Repair of Acquired Enophthalmos

In the setting of facial trauma with fracture of one or more orbital walls, clinically significant enophthalmos is a possible undesirable outcome after primary repair. In this article, the evaluation of patients presenting with acquired enophthalmos and the available minimally invasive and surgical management options are discussed.