Naresh Joshi

Orbital volume augmentation with autologous micro-fat grafts.

Purpose: The purpose of this study is to present an alternative procedure for rehabilitation of the volume deficient anophthalmic or enophthalmic socket. Methods: A retrospective review of clinical and photographic records of 12 patients with either an anophthalmic or enophthalmic orbit (14 orbits) undergoing volume augmentation by micro-fat grafting, or lipostructure, as initially described by Coleman. Patients with orbital volume deficiency seen in the oculoplastic clinic at Chelsea and Westminster Hospital, London, UK, were invited to participate in the study. The technique is discussed in detail. Results: The volume of fat injected ranged from 0.8 mL to 4.5 mL (median, 3.05 mL) per orbit, with a median increase in exophthalmometry measurements (available in 9 patients) of 2 mm (range, 0–7.5 mm). Subjective improvement in cosmetic outcome was experienced in all patients. Repeat grafting was required in 1 patient, and will be required in another patient. There were no embolic complications. The procedure was well tolerated in all patients. Median follow-up was 14.5 months (range,12–30 months). Conclusions: Micro-fat grafting to the anophthalmic or enophthalmic socket appears to be a safe alternative technique for orbital volume enhancement. It has the advantages of avoiding alloplastic infectious complications, ease of technique, minimal donor site morbidity, acceptable graft take rate, low embolic complication rate, and good cosmetic outcome.

Early Cure Rates with Narrow-Margin Slow-Mohs Surgery for Periocular Malignant Melanoma

BACKGROUND Staged excision with rush-processed paraffin-embedded tissue sections (Slow-Mohs) is an effective treatment for periocular melanoma. Although there is no consensus on initial margins of excision, narrower margins in the eyelids have the functionally and cosmetically important consequence of smaller postoperative wounds. OBJECTIVES To report early cure rates for periocular melanoma using Slow-Mohs surgery with en-face margin sectioning. METHODS Retrospective, multicenter, noncomparative case series. Slow-Mohs surgery in 14 patients with periocular melanoma from 2000 to 2006. RESULTS Fourteen patients underwent 14 Slow-Mohs procedures for eight lentigo maligna, one nodular, and one superficial spreading melanoma, and four lentigo maligna, 12 primary, and two recurrent tumors. The most common site was the lower eyelid (8/14, 57.1%). Breslow thickness ranged from 0.27 to 1.70 mm, with four cases less than 0.76 mm and one case greater than 1.5 mm. Five cases were a Clark level II or greater. Complete excision was achieved with one level (6 cases) or two or three levels (8 cases), with 2- to 3-mm margins at each level in all but one case. With median follow-up of 36 months, there were two local recurrences (2/14, 14.3%). CONCLUSION Slow-Mohs with en-face sections achieves similar early cure rates to previously published margin-controlled excision techniques. Narrow margins of excision can optimize tissue preservation without compromising outcome.

Endoscopic removal of periorbital lesions

In this article, the authors describe the technique, indications and contra-indications for removing various periorbital lesions with an endoscope. The principal reason for using this technique is the excellent postoperative cosmesis. Seven patients in total had lesions removed in this manner. The only complication noted was some leakage of the contents of a dermoid cyst intraoperatively. Cosmesis postoperatively was excellent in all cases. None of the cases had to be converted to an ‘open’ procedure.

Re-thinking 3D printing: A novel approach to guided facial contouring

Rapid prototyped or three dimensional printed (3D printed) patient specific guides are of great use in many craniofacial and maxillofacial procedures and are extensively described in the literature. These guides are relatively easy to produce and cost effective. However existing designs are limited in that they are unable to be used in procedures requiring the 3D contouring of patient tissues. This paper presents a novel design and approach for the use of three dimensional printing in the production of a patient specific guide capable of fully guiding intraoperative 3D tissue contouring based on a pre-operative plan. We present a case where the technique was used on a patient suffering from an extensive osseous tumour as a result of fibrous dysplasia with encouraging results.

The use of autologous autoclaved bone in orbital reconstruction after exenteration for invasive cutaneous carcinoma.

PURPOSE To describe a technique for reconstructing the orbital bony architecture after invasion by tumour. METHODS Orbital bone invaded by tumour was osteotomized (post-exenteration), autoclaved to remove tumour cells, and then refixated in order to re-establish the normal orbital anatomy. RESULTS Despite some shrinkage of the bone fragment in the autoclaving process, after refixation the contour and topography of the bony orbit was essentially normal. CONCLUSION Autoclaved bone can be used to reconstruct the exenterated orbit; it is a fast and technically simple strategy for maintaining orbital anatomy when faced with bony invasion by tumour.

Eye Care in the Critically Ill: A National Survey and Protocol

Sedated and ventilated critically ill patients often have inadequate eyelid closure and are susceptible to developing exposure keratopathy and microbial keratitis. Preventative measures reduce the risk of complications and visual loss. A telephone survey of all intensive care units in England was performed to elucidate the measures being used and their prevalence. Of 267 units, 217 participated (81%). Of these, 130 (60%) had an eye care protocol and 143 (66%) of all participating units formally assessed eyelid closure. The presence of an eye care protocol did not improve the likelihood of a unit assessing eyelid closure, a key component of the detection of patients at risk of ophthalmic complications; 66% of units with eye care protocols assessed eyelid closure formally, compared to eyelid closure assessment occurring in 65% of units that did not employ an eye care protocol. Most units used at least two protective methods per unit, the most popular being Geliperm application and Lacrilube. Self-reported complication rates in the last year were low, but only 13% of units audited eye-related complications. To improve eye care and replace current protocols, we propose a simple protocol encouraging vigilant eyelid closure assessment, administration of preventative therapy where indicated and referral if there is any corneal opacity or continuous exposure.

The transnasal advancement flap: A technique for medial canthal area defects

AIM . To illustrate an alternative technique for reconstructing defects in the medial canthal area following tumour removal. MATERIALS AND METHODS . Eight consecutive patients who underwent Mohs¹ micrographic surgery for removal of a basal cell carcinoma in the medial canthal area were prospectively recruited. An experienced dermatologist trained in Mohs¹ micrographic surgery removed the tumour, and subsequently an oculoplastic surgeon reconstructed the defect. An incision is made from the superior end of the defect superomedially towards the midline of the dorsum of the nose following one of the natural lines of the skin (spec name). The incision runs in arcuate fashion just medial to the eyebrow and then reaches the dorsum of the nose and extends on the contralateral aspect of the nose towards the medial canthal area. The skin is then undermined to free up the newly formed flap. The flap is advanced towards the lesion and fixed intra-dermally with Vicryl Rapide® sutures to ensure anchoring into the concavity of the medial canthal region. The skin is then sutured with prolene sutures. RESULTS . The defects presented were oval or round in shape with diameters ranging from 0.5 to 2 cm. In all cases the transnasal flap covered the entire area and the defect was successfully reconstructed. Mean follow-up is 10.8 months (±4.5 SD) (range 4–17 months); all patients had an excellent cosmetic result and were subjectively satisfied. CONCLUSIONS . The transnasal advancement flap seems to have some advantages over the usual reconstruction techniques in use to repair medium defects in the medial canthal area. These are the avoidance of vertical scars in the glabellar area, eyebrow hair is not transposed into the medial canthal area, the skin match is excellent, both in colour and thickness, and surgical scars are hidden within the natural lines of the nasal bridge. We advocate the use of this technique for all minor to medium skin defects.

Inferior oblique schwannoma: diagnosis and management.

Introduction: Orbital schwannoma accounts for less than 5% of orbital tumours and few cases arising in the superior orbit are reported in the literature. Purpose: To present, to our knowledge, the first report of inferior oblique-associated orbital schwannoma. Methods: Interventional case report with clinical photographs, MRI imaging, intra-operative photographs and histology. Results: A 68 year-old man presented with decreased right vision and double vision in downgaze. Examination revealed a right 3 mm ptosis, hypertropia and limitation of depression. Exploration and excision, via anterior orbitotomy, and histological examination confirmed a schwannoma located within the right inferior oblique muscle. Vision normalised post-operatively and there has been no clinical or radiological recurrence of the lesion at 2 years. Conclusions: This rare case highlights that schwannoma may occur in association with the inferior oblique complex and we suggest that schwannomas should now be considered in the differential diagnosis when patients present with a clinically-suspected or radiologically-proven orbital mass.

Undiagnosed Type 2 Diabetes Mellitus Presenting with Orbital Cellulitis

The authors describe the case of a 48 years old woman who presented with a one week history of a painful, swollen left eye with proptosis and diplopia. A computed tomography (CT) scan showed features of left orbital cellulitis, and blood tests and urinalysis confirmed the diagnosis of diabetes mellitus. The infection resolved following a course of intravenous antibiotics and with glycaemic control. To our knowledge, undiagnosed diabetes mellitus presenting with orbital cellulitis has not previously been reported.

Gold in the balance: How does patient posture affect eyelid closure?

ABSTRACT A retrospective audit was conducted of four patients with upper eyelid gold weights (inserted >5 years ago) as treatment for facial nerve palsy-related lagophthalmos. Each patient was presently examined for lagophthalmos (“opened” or “closed”) at three different patient inclinations (lying flat at 0º, lying back at 45º, and sitting upright at 90º). In all four cases at 0º inclination, the upper eyelid remained “open” with significant lagophthalmos, and therefore the ocular surface was vulnerable. At other inclinations, 45º and 90º, the eyes were substantially “closed” and the ocular surface was protected. We discuss the mechanism by which this occurs. We suggest that patients fitted with upper eyelid gold weight implant who do not show adequate closure during postoperative clinical examination or signs of corneal show should try sleeping in a slightly upright position to aid ocular surface protection.