Ramin Mostafavi

Infection after insertion of alloplastic orbital floor implants.

Ten patients developed infections after alloplastic implantation (nine silicone, one gelatin film [Gelfilm] implant) for orbital floor fracture repair. Infection resulted from the following: (1) dental surgery, (2) upper respiratory infection, (3) inferior extrusion of a retained implant into the maxillary sinus with a fistulous tract into the inferior conjunctival fornix, (4) rhinoplasty, (5) snorting cocaine and other drugs, (6) postoperative infection after orbital floor repair, and (7) medial implant migration resulting in chronic dacryocystitis. In all ten patients, implants were removed because of orbital abscess, recurrent infection, or chronic low-grade infections. Microbiologic culture of removed implants disclosed Staphylococcus aureus, S. epidermidis, Serratia marcescens, and Pseudomonas aeruginosa as the offending organisms. The main complication of infection included severe cicatricial ectropion of the lower eyelid in three patients. The final globe position was not adversely affected by implant removal performed from five months to 20 years after insertion. Guidelines for prevention and management of orbital implant infections based on these ten patients are presented.

Treatment choices of 119 patients with hemifacial spasm over 11 years

A retrospective study of patients with hemifacial spasm (HFS) was performed in order to determine long-term treatment choices: local botulinum toxin, type A, injections, oral pharmacologic agents, and surgery (neurosurgical decompression of the seventh nerve at the brainstem level and upper eyelid blepharoplasty). Of 119 patients with diagnosed hemifacial spasm in the Oculoplastics Division of the Department of UMD-New Jersey Medical School, Newark, NJ from September, 1983, to June 1, 1994, 108 were initially treated with 735 botulinum toxin injections. Forty-seven of the 108 patients (43.5%) initially treated at our institution received 459 injections for a median treatment period of 59 months per patient. Eight patients (7.4%) continued treated elsewhere and four other patients were injected at our institution until their death from other causes. Twenty-two patients (20.4%) were lost to followup after receiving 117 injections. Five patients (4.6%) had spontaneous resolution of their condition after botulinum toxin therapy and nine patients (8.3%) chose not to receive any additional injections or other treatment. Thirteen patients (12.0%) did not respond adequately to botulinum injections and 10 such patients obtained relief from treatments other than botulinum toxin: oral pharmacologic agents (two patients), neurosurgical decompression of the seventh nerve (two patients), and upper eyelid blepharoplasty (one patient). In addition to botulinum injections, 15 patients required adjunctive minor tranquilizers and/or antiseizure medications. Botulinum A toxin is an excellent long-term treatment of hemifacial spasm. This condition may occasionally spontaneously resolve after botulinum therapy.

Combined paresis and restriction of the extraocular muscles after orbital fracture: a study of 16 patients.

Sixteen patients with combined paresis and restriction of extra-ocular muscle(s) orbital fracture repair were studied before and after in order to determine the clinical features and management of such patients. All 16 patients showed limited ductions of the involved eye in the field of action of the entrapped, paretic muscle and of the antagonist muscle after orbital fracture. Single extraocular muscles (13 patients) and two extraocular muscles (three patients) were demonstrated adjacent to the fracture site on orbital computed tomography (CT). In three patients prior to orbital surgery, a deviation in primary position was present. After fracture repair with release of the entrapped muscle in all patients, evidence of paresis of the muscle was demonstrated by underaction in its field of action and overaction in the field of its antagonist. There was a resultant manifest tropia or phoria in the primary position. In seven patients, the paresis gradually improved with no tropia and little diplopia in the functional fields of gaze. Three patients had minimal deviations and required no further treatment. Six patients with significant deviations required prisms (three patients) or strabismus surgery (three patients). The latter three patients had two muscles involved. Results of this study demonstrate that the ophthalmologist must appropriately diagnose patients with paresis and restriction of an extraocular muscle and counsel them that “new” diplopia may occur after orbital fracture repair and that this diplopia may require additional therapy.

Bilateral nasolacrimal duct obstruction associated with Crohn's disease successfully treated with dacryocystorhinostomy

Summary A 41-year-old woman developed epiphora due to bilateral nasolacrimal duct obstruction 1 year after a definitive diagnosis of Crohns disease. Treatment with systemic and topical antibiotic therapy resulted in resolution of the left-sided obstruction but epiphora persisted on the right side. The patient underwent standard dacryocystorhinostomy with insertion of silicone tubes. Six months after surgery, she remains free of symptoms. To our knowledge, this is the first report of bilateral nasolacrimal duct obstruction that occurred in a patient with active Crohns disease.

The role of proliferating cell nuclear antigen (PCNA) in differentiating idiopathic orbital inflammatory disease and lymphoid proliferations

Summary The purpose of the present study was to determine whether proliferating cell nuclear antigen (PCNA), an immunohistochemical marker for a nuclear protein abundant in actively proliferating (dividing) cells, is useful as an aid in differentiating idiopathic orbital inflammatory syndrome (IOIS) from lymphoproliferative lesions (LLs). Records of all patients with IOIS and LLs were studied retrospectively. Tissue biopsy specimens from four patients with IOIS and nine patients with LLs were examined. The diagnosis in each case was based on presenting signs and symptoms, orbital computed tomography (CT) and/or magnetic resonance (MR) scans, histopathologic criteria, and follow-up data consistent with the entity. These findings were correlated with the percentage of B- and T-cells in the lesions as well as with the number of cells that demonstrated staining for PCNA in formalin-fixed tissue. PCNA activity was markedly increased in the higher grade (HG) lymphoma group as compared to that in the low grade (LG) lymphoma and idiopathic inflammatory group. Lymphoma cases showed a significantly increased B-/T-cell ratio compared to IOIS lesions. PCNA activity in conjunction with the ratio of B-/T-cells may be a helpful immunohistologic adjunct for differentiating purely inflammatory lesions of the orbit from lymphoid tumors. Further studies are necessary to compare PCNA activity in fresh frozen tissue with that in formalin-fixed tissue.

Medial Canthoplasty for Optimum Support of the Lower Eyelid in 14 Patients

BACKGROUND AND OBJECTIVES Medial canthoplasty surgically fuses the upper and lower lids medial to the puncta. The authors modified the procedure by inserting a temporary lacrimal stent in order to avoid kinking and scar contracture of the canaliculi. PATIENTS AND METHODS A medial canthoplasty successfully corrected lower eyelid laxity in 14 patients with the following conditions: (1) exposure and/or neurotrophic keratitis with medial ectropion and/or retraction of the lower eyelid (11 patients), and (2) inability to retain a prosthesis because of lower eyelid ectropion and contracture of the inferior conjunctival fornix (3 anophthalmic patients). RESULTS All patients had a satisfactory cosmetic result despite minimal vertical and horizontal narrowing of the palpebral fissure. Complications included partial wound dehiscence and pyogenic granuloma. CONCLUSION The modified medial canthoplasty described in this article corrects medial ectropion with minimal cosmetic deformity.

Hinged silicone covered metallic implant for repair of large fractures of the internal orbital skeleton.

Summary The objective of this study was to determine the effectiveness of hinged silicone covered metallic implant for the repair of large fractures of the internal orbital skeleton. Twelve patients underwent reconstruction of the orbital floor (and medial wall) with a hinged silicone covered metallic implant that was fixated at or just inside the inferior orbital rim with screws. The surgical technique permits intraoperative graded overcorrection because the implant is secured at the orbital rim and bent at its “hinge” to elevate the entire implant to the desired height. Nine of 12 patients had late repairs (≥4 weeks after injury); 3 patients had early repairs ≤3 weeks of injury. All 12 patients had acceptable results with regards to enophthalmos and hypoophthalmos. One patient underwent secondary soft tissue upper eyelid augmentation for a residual superior sulcus deformity. The hinged silicone covered metallic implant is a useful technique for reconstruction of large orbital floor and medial wall defects. Long-term complications of this implant are unknown.