Richard Hart

Orbital Adherence with Titanium Mesh Floor Implants: A Review of 10 Cases

Abstract Background: Multiple materials have been used in the repair of orbital floor fractures. We report 10 cases of complications relating to the use of titanium mesh orbital floor implants. Method: A retrospective review of 10 cases in 2 centres in New Zealand. Patients presented with diplopia or eyelid retraction following repair of an orbital floor fracture with titanium mesh implants. Results: Ten patients (7 male, 3 female) aged between 15–78 years old (mean 39 years) presented with significant restriction of eye movement and/or eyelid retraction following repair of an orbital floor fracture with a titanium mesh implant. Seven patients presented with restriction of eye movement alone. Three patients had lower lid retraction in addition to restriction of eye movement. One patient presented with epiphora following erosion of the implant through the nasolacrimal duct. Seven patients underwent surgical removal of the implant with all patients showing improvement of extraocular movement post-operatively. Three cases did not undergo implant removal with one case showing mild improvement over 9 months, and 2 cases showing no improvement. The mean interval between the initial surgery and removal of the implant was 7.1 months. Discussion: In our series, 7 cases required explantation of the original titanium implant. In these cases a vigorous fibrotic reaction had taken place between the orbital contents and the titanium mesh implant. We postulate that the fibrous reaction between the implant and the orbital contents caused the eye movement restriction and the lid retraction. Implant materials used in orbital floor fracture surgery should be inert with a flat profile rather than a mesh to prevent adhesions through the mesh that may cause cicatricial eye movement restriction and eyelid retraction.

Orbital crossbow injury

luscum contagiosum in patients with human immunodeficiency virus infection. Orbit 1999; 18: 75–81. 6. Leahey AB, Shane JJ, Listhaus A, Trachtman M. Molluscum contagiosum eyelid lesions as the initial manifestation of acquired immunodeficiency syndrome. Am J Ophthalmol 1997; 124: 240–1. 7. Pelaez CA, Gurbindo MD, Cortes C, Munoz-Fernandez MA. Molluscum contagiosum, involving the upper eyelids, in a child infected with HIV-1. Pediatr AIDS HIV Infect 1996; 7: 43–6. 8. Brown J, Janniger CK, Schwartz RA, Silverberg NB. Childhood molluscum contagiosum. Int J Dermatol 2006; 45: 93–9. 9. Cattelan AM, Sasset L, Corti L, Stiffan S, Meneghetti F, Cadrobbi P. A complete remission of recalcitrant molluscum contagiosum in an AIDS patient following highly active antiretroviral therapy (HAART). J Infect 1999; 38: 58–60.

In vivo ocular biomechanical compliance in thyroid eye disease

Background/aims To compare the ocular biomechanical properties in patients with thyroid eye disease (TED) and healthy participants using a non-contact Scheimpflug-based tonometer (CorVis ST). Methods All eyes were examined by slit lamp biomicroscopy, corneal tomography and the CorVis ST (CST). Patients with TED were examined by a fellowship trained oculoplastics specialist to determine status and assess severity. The outputs from CST and additionally derived parameters, including maximum orbital deformation (MOD), were compared between healthy participants and patients with TED using Students t-test. Furthermore, a multiple linear regression analysis was used to control for various factors known to influence ocular biomechanical responses to an air pulse. Results This study included 20 patients with TED and compared them with a cohort of 152 healthy participants. The mean age of patients with TED was 46.7±19.0 years and the mean age of healthy participants was 35.9±13.8 years (p=0.03). There were no statistically significant differences in gender distributions between both groups (p>0.05). Several CST parameters were significantly different between groups (p<0.05). Of note, however, MOD was significantly lower in patients with TED (0.16±0.04 mm) compared with the healthy participants (0.25±0.05 mm, p<0.001). This dissimilarity remained even after controlling for the various cofactors. Receiver-operating characteristic analysis revealed an area under the curve of 0.91±0.04 (95% CI 0.84 to 0.98, p<0.001) for MOD. Conclusions The in vivo ocular biomechanics as measured by the CST reflects a reduced orbital compliance. This method of ocular biomechanical assessment may aid in the categorisation of TED severity and assist in monitoring and/or diagnosing TED.

Use of x-ray film implant for the repair of orbital fractures.

Purpose: To evaluate the experience with sterilized x-ray film in the repair of orbital blow-out fractures (BOFs). Methods: A retrospective review of case notes from 56 patients with orbital BOF repaired using sterilized x-ray film onlay implants at 2 institutions between November 2004 and December 2010. Patient demographics, timing of surgery, surgical approach, postoperative complications, and length of follow up were recorded. Results: Fifty-six patients (44 men, 12 women) received sterilized x-ray film implants during the 6-year study period. Mean age at the time of repair was 29 years (range 4–85 years). For 68% of patients, surgical repair was performed within 2 weeks of injury. Average length of postoperative follow up was 5.5 months (range 1–36 months), 48% had follow up >3 months. Following surgical repair, diplopia in primary or down gaze reduced from 98% to 4% and enophthalmos ≥2 mm reduced from 21% to 5% cases. One patient required a second operation for repositioning of an incompletely reduced fracture. A second patient presented 9 months postoperatively with recurrent episodes of proptosis, and the implant and its surrounding pseudocapsule were subsequently removed. There were no cases of visual loss, implant infection, or migration. Conclusions: This series has demonstrated that in selected orbital fractures sterilized x-ray film can provide a safe, effective, and low-cost onlay implant.

Reply re: "Use of sterilized x-ray film implant for the repair of orbital blow-out fractures".

1. The implant can be sterilized using ethylene oxide. This was the method employed at our hospital until our sterile supply department switched to the use of hydrogen peroxide gas. 2. No implant migration occurred in our study population. 3. We have not used holes to fixate this type of implant, but they could easily be drilled into the film prior to insertion to allow fixation with either screws or sutures.

Concordance of congenital ptosis in monozygotic twins.

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Partnering to develop a continuing professional development program in a low-resource setting: Cambodia

OBJECTIVE To design and implement a continuing professional development (CPD) program for Cambodian ophthalmologists. DESIGN Partnering (twinning) between the Royal Australian and New Zealand College of Ophthalmologists (RANZCO) and the Cambodian Ophthalmological Society (COS). PARTICIPANTS Practicing ophthalmologists in Cambodia. METHODS A conjoint committee comprising 4 ophthalmologists from RANZCO and 3 ophthalmologists from COS was established, supported by a RANZCO administrative team experienced in CPD administration. CPD requirements and recording were adapted from the RANZCO CPD framework. Cambodian ophthalmologists were surveyed during program implementation and after handover to COS. RESULTS At the end of the 3-year program at handover to COS, a CPD program and online recording system was established. All 47 (100%) practicing ophthalmologists in Cambodia were registered for CPD, and 21/47 (45%) were actively participating in the COS CPD program online recording. Surveys of attitudes toward CPD demonstrated no significant change. CONCLUSIONS Partnering was moderately effective in establishing a CPD program for Cambodian ophthalmologists. Uptake of CPD may have been limited by lack of a requirement for CPD for continuing medical licensure in Cambodia. Follow-up will be necessary to demonstrate CPD program longevity.

Re: Atomic force microscopy and scanning electron microscopy analysis of daily disposable limbal ring contact lenses.

EDITOR: Lorenz and colleagues attempted to use atomic force microscopy (AFM) and scanning electron microscopy (SEM) to evaluate and compare the pigment location and surface roughness in commercially available limbal ring or ‘circle’ contact lenses. They report that, of seven lens brands analysed, only one, 1-Day AcuvueDefine (1DAD; Johnson& Johnson, New Brunswick, New Jersey, USA) did not have surface pigment; however, major shortcomings in experimental technique warrant questioning of the study’s results and the authors’ conclusions. Lorenz and colleagues used a SEM operated at 10kV accelerating voltage in backscattered electron imaging mode (BEI) for all SEM analyses. SEM at 10 kV, especially with BEI (detection depth up to approximately one micron), is affected by electron beam penetration artefacts, which can

In vivo confocal microscopy of climatic droplet keratopathy

We describe the corneal microstructural changes in a patient with spheroidal degeneration using in vivo confocal microscopy. Multiple hypo‐ and hyper‐reflective spherical lesions were observed in the anterior corneal stroma and Bowmans layer ranging from 45 to 220 μm in size. The corneal epithelium, posterior stroma and endothelium were otherwise unaffected. In vivo confocal microscopy demonstrates good correlation with excised histological samples in climatic droplet keratopathy. It provides a non‐invasive technique to examine the living cornea for degenerative disease and acts as a bridge between clinical and laboratory observations.

Evaluation and management of mechanical globe injury: response

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