Philip L. Custer

Orbital implants in enucleation surgery: A report by the american academy of ophthalmology☆

OBJECTIVE To compare prosthetic and implant motility and the incidence of complications associated with porous and nonporous enucleation implants. METHODS Literature searches conducted in January 2002 for 1985 to 2001 and May 2002 for October 2001 to 2002 retrieved relevant citations. The searches were conducted in MEDLINE and limited to articles published in English with abstracts. Panel members reviewed the articles for relevance to the assessment questions, and those considered relevant were rated according to the strength of the evidence. RESULTS A randomized clinical trial and a longitudinal cohort study detected no difference in implant or prosthetic movement between nonpegged hydroxyapatite porous and spherical alloplastic nonporous implants. No controlled studies were retrieved that investigated whether pegging porous implants improves prosthetic movement. Several case series indicate that patients with pegged hydroxyapatite implants have some degree of improved prosthetic motility. Longitudinal cohort studies show that sclera-covered hydroxyapatite implants have higher exposure rates than sclera-covered silicone implants, and unwrapped porous polyethylene implants have higher exposure rates than unwrapped acrylic implants. There are numerous case series that document a wide range of implant exposure rates in patients with various enucleation implants. It is difficult to compare complication rates among implant types because patient populations vary, surgical techniques differ, and follow-up periods are often limited. CONCLUSIONS Based on one randomized clinical trial, spherical alloplastic nonporous and nonpegged porous enucleation implants provide similar implant and prosthetic motility when they are implanted using similar surgical techniques. Coupling the prosthesis to a porous implant with a motility peg or post appears to improve prosthetic motility, but there are few available data in the literature that document the degree of the improvement. There is a widely variable incidence of porous implant exposure, but certain surgical techniques and the type of wrapping material seem to reduce the exposure rate. Additional research is needed to document the long-term incidence of complications related to porous enucleation implants and associated surgical techniques. This includes the use of wrapping materials and what procedural modifications, both surgical and prosthetic, are most effective in reducing these complications.

Porous implant exposure: Incidence, management, and morbidity.

Purpose: To identify what factors may predispose patients to exposure of porous anophthalmic implants and to determine the outcome of exposed porous implants. Methods: Examination of pooled data obtained through a PubMed literature search of English-language publications from 1989 through 2004 using the key words enucleation, evisceration, and socket reconstruction. Results: Porous implants were inserted in 80% (3012 of 3777) of the cases identified from 49 publications. The difference in exposure rate between coralline hydroxyapatite (4.9%) and porous polyethylene (8.1%) implants is primarily related to a higher reported complication rate of uncovered porous polyethylene implants, particularly in retinoblastoma patients. Other techniques associated with increased exposures include wrapping implants with bovine pericardium or polyglactin mesh. Evisceration and secondary procedures did not have statistically different complication rates compared with enucleation. There are more late exposures of porous polyethylene than coralline hydroxyapatite implants. Spontaneous healing of exposures occurred in 13% (19 of 145) of cases. Covering exposures with patch grafts underneath vascularized conjunctival flaps was the most successful method of surgical repair. Implant removal was necessary after 29% (42 of 145) of exposures. Conclusions: Although the published literature between 1989 and 2004 reports higher complication rates for uncovered porous implants and implants wrapped with bovine pericardium or polyglactin mesh, pooling data from different studies may mask very good or poor results obtained by individual surgeons. Spontaneous healing of exposed porous implants is relatively uncommon. However, many exposed porous implants can be salvaged with secondary repair.

Enucleation : Past, present, and future

The technique of enucleation is constantly evolving. The last decade has witnessed a resurgence of interest in this procedure. Numerous researchers have investigated this subject, attempting to identify ways to refine the operation. New implant designs have been introduced. Various covering materials are now available. Methods of reducing anophthalmic volume deficit have been suggested. These innovations have increased the variables that may be modified by the individual surgeon. Although the surgical options have expanded, there is little consensus about what technique is most ideal. As we start the next decade, it seems appropriate to review the accomplishments of the 1990s, attempting to synthesize what we have learned and determine where the technique of enucleation may be headed.

Surgical Excision of Periorbital Capillary Hemangiomas

BACKGROUND Periorbital capillary hemangiomas of childhood can produce ptosis, strabismus, and anisometropia, resulting in amblyopia. Traditional therapy with either systemic or local corticosteroids occasionally yields incomplete resolution of these lesions and may be associated with numerous adverse complications. The authors report their experience performing surgical resection of periorbital capillary hemangiomas. METHODS Twelve children with periorbital capillary hemangiomas were treated surgically. Six of these children had previously failed to adequately respond to steroid injections and six were primarily treated with surgical resection. All lesions were believed to be localized and did not appear to be infiltrative on preoperative computed tomographic scans. RESULTS All lesions were completely resected, except for two in which there was a small area of residual hemangioma surrounding the lacrimal drainage system that was left intact. Controlled intraoperative hemorrhage in two patients required intraoperative directed-donor blood transfusion. Perioperatively, in one patient a wound dehiscence developed, which required minor repair. This same patient elected to have surgical scar revision postoperatively. The patients have been followed up to 5 years. All did well with improved cosmesis, and they have good lid function. No recurrences have been noted. CONCLUSION Surgical resection of pediatric capillary hemangiomas should be considered a treatment option in those that fail to respond to corticosteroids and/or are isolated and noninfiltrative in nature.

Magnetic resonance imaging and computed tomography in a model of wooden foreign bodies in the orbit.

Wooden foreign bodies in the orbit are not detectable by standard roentgenography. Reports in the literature on the ability of computed tomography (CT) to detect orbital wooden foreign bodies have varied. To evaluate whether magnetic resonance imaging (MRI) would offer any advantage over CT in detecting wood in the orbit, MRI and CT were performed on an in vitro model of wooden foreign bodies in the orbit. Woods of different types and sizes were studied in vegetable fat backgrounds chosen to simulate orbital fat. On CT, most types of wood were hypodense to fat. Appropriate window settings were critical in the detection of wood by CT: in this model, a window width of 1000 Hounsfield units was optimal. On MRI. all types of wood were hypointense to fat. Small pieces of wood were surrounded by an MRI truncation artifact consisting of hyperintense spots. TI-weighted images demonstrated wood better than T2-weighted images and required less scanning time than either proton density or T2-weighted images. MRI was superior to CT in detecting the smallest pieces of wood. The role of MRI in the detection of orbital wooden foreign bodies in clinical practice remains to be determined.

Enucleation of blind, painful eyes.

Purpose To determine the demographics and results of treatment in patients undergoing enucleation of blind, painful eyes. Methods Medical records were reviewed to determine the precipitating cause, preoperative symptoms, prior therapy, and results of treatment in 58 patients in whom enucleation was performed to relieve ocular discomfort. Patient perception of symptoms and treatment was assessed by a follow-up mail survey. Results Forty-five percent of patients had sustained prior trauma. Ocular discomfort was attributed to phthisis (43%), elevated intraocular pressure (40%), or corneal decompensation (10%). Preoperative symptoms included ocular pain (91%), periocular headache (17%), tearing (26%), and ipsilateral photophobia (26%). Eight patients experienced contralateral photophobia. Enucleation provided complete symptomatic relief in 54 patients (93%). Two of the four patients with persistent discomfort experienced painful facial paresthesias, attributed to prior retrobulbar alcohol injections. Ninety-one percent of the 32 patients who completed the follow-up survey reported pain relief after surgery, whereas 94% would recommend enucleation to others with blind, painful eyes. Conclusions Trauma is the most common precipitating condition in patients undergoing enucleation of blind, painful eyes. These patients experience a variety of symptoms, including ocular pain, facial pain or paresthesias, tearing, and photophobia. Contralateral photophobia is not uncommon. Enucleation is highly effective in relieving these symptoms and should be considered in patients unresponsive to topical therapy. Facial paresthesias in patients who have received prior retrobulbar alcohol injections are not relieved by enucleation.

Management and prognosis of merkel cell carcinoma of the eyelid

OBJECTIVE To evaluate the clinical presentation, treatment, and long-term follow-up of eyelid Merkel cell carcinoma. DESIGN Retrospective noncomparative interventional case series. PARTICIPANTS Fourteen patients with primary eyelid Merkel cell carcinoma. METHODS Cases of Merkel cell carcinoma for which long-term follow-up was available were solicited from members of the American Society of Ophthalmic Plastic and Reconstructive Surgery through an on-line e-mail/news group. MAIN OUTCOME MEASURES Follow-up period, treatment history, presence and type of recurrence, and mortality. RESULTS Average follow-up was 33.4 months. Of the 14 cases identified, only 2 patients (14%) received prophylactic therapy beyond wide surgical excision. Three patients (21%) had recurrences, none of whom initially received prophylactic therapy (i.e., radiation therapy, lymph node dissection, and/or chemotherapy) beyond wide surgical excision. One patient (7%) died of metastatic Merkel cell carcinoma. CONCLUSIONS Merkel cell carcinoma is a rare skin malignancy that occasionally affects the eyelid, with the potential for regional and distant metastasis. Consideration should be given to the use of prophylactic adjunctive therapies beyond wide surgical excision while simultaneously considering the morbidity of these therapies.

Postcataract Ptosis: A Randomized, Double-masked Comparison of Peribulbar and Retrobulbar Anesthesia

PURPOSE A randomized, double-masked study of 317 patients was conducted to determine if the incidence of postcataract ptosis is greater with retrobulbar or two-injection peribulbar injection anesthesia. METHODS Surgery consisted of a planned extracapsular extraction with posterior chamber lens implantation, and no superior rectus bridle suture was used. Ptosis was quantitatively documented preoperatively and postoperatively at 1, 2, 5, and 90 days by the surgeon, photographically at 90 days by a masked observer, and subjectively by the patients. Postcataract ptosis was defined as a drop in the lid margin of 2 mm or greater after correcting for any change in the fellow eye. RESULTS The incidence of ptosis at 90 days in patients given peribulbar anesthesia was 5.8% and in patients given retrobulbar anesthesia 5.5%, and this difference was not statistically significant (P = 0.90). Eighteen percent of patients in both groups reported a change in the appearance of their eyelids. There was a moderate, positive correlation among patients who reported a change in their lid position and objective measurements of ptosis. Preoperative clinical measurements of vertical lid fissure width and levator function, and the appearance of the lid crease or superior sulcus were not predictive for the development of postoperative ptosis at 90 days; the best predictor was the presence of ptosis in the immediate postoperative period. CONCLUSION The incidence of postcataract ptosis is the same whether two injection peribulbar or retrobulbar anesthesia is used.

Repair of cicatricial ectropion in an infant with harlequin ichthyosis using engineered human skin

PURPOSE To report the use of an Apligraf (Organogenesis, Inc., Canton, Massachusetts, USA) human skin equivalent for repair of cicatricial ectropion in a patient with harlequin ichthyosis. DESIGN Interventional case report. METHODS A 6-week-old male child with harlequin ichthyosis and severe bilateral upper eyelid cicatricial ectropion underwent repair with Apligraf grafts. RESULTS After the initial repair with Apligraf grafts, recurrent bilateral upper eyelid ectropion developed, requiring repeat Apligraf grafting at age 61 days. After the second graft, the eyelids remained well positioned until the childs sudden death from respiratory failure at age 6 months. CONCLUSION Apligraf human skin equivalent facilitated the repair of cicatricial ectropion in a child with harlequin ichthyosis.

Functional Indications for Upper Eyelid Ptosis and Blepharoplasty Surgery: A Report by the American Academy of Ophthalmology

OBJECTIVE To evaluate the functional indications and outcomes for blepharoplasty and blepharoptosis repair by assessing functional preoperative impairment and surgical results. METHODS Literature searches of the PubMed and Cochrane Library databases were conducted on July 24, 2008, with no age or date restrictions, and they were limited to articles published in English. These searches retrieved 1147 citations; 87 studies were reviewed in full text, and 13 studies met inclusion criteria and were included in the evidence analysis. RESULTS The 13 studies reported the functional effects or treatment results of simulated ptosis; several types of blepharoptosis repair, including conjunctiva-Müllers muscle resection, frontalis suspension, and external levator resection; and upper eyelid blepharoplasty. CONCLUSIONS Repair of blepharoptosis and upper eyelid dermatochalasis provides significant improvement in vision, peripheral vision, and quality of life activities. Preoperative indicators of improvement include margin reflex distance 1 (MRD(1)) of 2 mm or less, superior visual field loss of at least 12 degrees or 24%, down-gaze ptosis impairing reading and other close-work activities, a chin-up backward head tilt due to visual axis obscuration, symptoms of discomfort or eye strain due to droopy lids, central visual interference due to upper eyelid position, and patient self-reported functional impairment. FINANCIAL DISCLOSURE(S) The author(s) have no proprietary or commercial interest in any materials discussed in this article.