Richard L. Scawn

Customised 3D Printing: An Innovative Training Tool for the Next Generation of Orbital Surgeons

ABSTRACT Additive manufacturing or 3D printing is the process by which three dimensional data fields are translated into real-life physical representations. 3D printers create physical printouts using heated plastics in a layered fashion resulting in a three-dimensional object. We present a technique for creating customised, inexpensive 3D orbit models for use in orbital surgical training using 3D printing technology. These models allow trainee surgeons to perform ‘wet-lab’ orbital decompressions and simulate upcoming surgeries on orbital models that replicate a patients bony anatomy. We believe this represents an innovative training tool for the next generation of orbital surgeons.

Spontaneous superior ophthalmic vein thrombosis: a rare entity with potentially devastating consequences.

PurposeSpontaneous superior ophthalmic vein thrombosis (SOVT) is a rare entity. We describe three patients with spontaneous ophthalmic vein thrombosis, each with various risk factors.Patients and MethodsA retrospective review of three patients with a diagnosis of superior ophthalmic vein thrombosis. Clinical characteristics, radiographic features, management techniques and outcomes are described.ResultsAll patients presented with unilateral painful proptosis. Two patients had intact light perception, whereas one patient presented with absent light perception. All patients had identifiable risk factors for thrombosis, which included sickle cell trait, hereditary hemorrhagic telangectasia and colon cancer with recurrent deep vein thrombosis. Anticoagulation was initiated in two patients. Resolution of proptosis was seen in all patients, with no recovery of vision in one patient.ConclusionsRisk factors for spontaneous superior ophthalmic vein thrombosis are multifactorial. MRI and MRV confirm the diagnosis of SOVT. Despite urgent intervention devastating visual loss may occur.

Secondary Orbital Reconstruction in Patients with Prior Orbital Fracture Repair.

Purpose: To evaluate clinical characteristics, preoperative imaging findings, pre- and post-operative outcomes, and satisfaction of patients requiring secondary reconstruction after inadequate primary orbital fracture repair. Methods: Retrospective review of 13 patients requiring secondary orbital reconstruction following unsatisfactory primary repair. Primary outcomes were postoperative changes in enophthalmos, hypo- or hyper-globus, superior sulcus deformity, and restrictive strabismus. Secondary outcomes included patient satisfaction. Results: Of 13 patients, 9 patients had primary orbital implants, and 4 patients did not. Of the 9 with implants, 6 had inferior displacement posteriorly, 2 had superior displacement posteriorly, and 1 had good position but had entrapped orbital tissues beneath it. Findings from primary surgery included enophthalmos (12/13), hypoglobus (10/13), hyperglobus (1/13), superior sulcus deformity (9/13), restricted supraduction (12/13), and restricted infraduction (7/13). Mean preoperative enophthalmos and hypoglobus were 4.4 ± 2.6 mm and 2.9 ± 1.4 mm, respectively. Secondary reconstruction resulted in mean reduction of enophthalmos by 3.4 ± 1.4 mm (p < 0.001), of hypoglobus by 2.9 ± 1.5 mm (p < 0.001), and of hyperglobus by 1 mm (n = 1). All 9 patients had resolution of their superior sulcus deformity. Of 12 cases with restricted ocular motility, all had improvements in postoperative motility following secondary surgery. Mean improvement in supraduction and infraduction was 1.8 ± 1.0 points (p < 0.001) and 1.4 ± 1.3 points (p = 0.025), respectively. Twelve patients reported being very satisfied or satisfied with secondary surgery; 1 patient was neutral. Conclusions: This study demonstrates that secondary orbital reconstruction can achieve excellent functional and cosmetic results with high patient satisfaction and minimal complications. Secondary reconstruction of previously repaired orbital fractures should be considered when clinically indicated.

Outcomes of Orbital Blow-Out Fracture Repair Performed Beyond 6 Weeks After Injury.

Purpose: Blow-out fractures cause expansion of the bony orbital walls and prolapse of orbital contents in the sinuses. This can result in diplopia, enophthalmos, and hypoglobus. Early surgical repair has been previously recommended, however, recent reports show that delayed surgery can also be effective. In this study, the clinical and functional outcome of patients with delayed presentation and blow-out fracture repair beyond 6 weeks after injury are described. Methods: This is a noncomparative retrospective study. Medical records of adult patients with late orbital floor fracture repair performed by 4 surgeons from April 2008 to January 2014 at 3 tertiary referral centers were reviewed. All repairs were performed more than 6 weeks from the time of injury. Patients with prior orbital fracture repair surgery were excluded. Results: Twenty patients were included in the study. The duration from time of injury to surgery ranged from 7 weeks to 21 years with a mean of 19 months. Follow up ranged from 6 weeks to 56 months (mean 8 months). Mean age was 48 years (range, 25–80). Male to female ratio was 11:9. Surgery was performed on 10 right eyes and 10 left eyes. CT imaging demonstrated 10 patients had isolated floor fractures, while the remaining 10 patients had combined floor and medial wall fractures. Four patients also had associated facial fractures that did not require surgery. Indications for surgery included enophthalmos of 2 mm or more (18 of 20) and/or significant diplopia within 30° of primary gaze (6 of 20). Mean pre- and postoperative enophthalmos was 2.4 ± 0.9 mm and 0.3 ± 0.2 mm, respectively, corresponding to a mean reduction in enophthalmos of 2.1 ± 1.2 mm (range, 1–5 mm). Four of 7 patients with hypoglobus ranging from 1.5 mm to 8 mm preoperatively had complete resolution postoperatively, the remaining 3 patients showed reduced hypoglobus. Of the 12 patients that had diplopia preoperatively in any position of gaze, 6 patients had complete resolution of diplopia postoperatively, 4 patients had reduced but residual diplopia in extreme gaze, and 2 patients had persistent diplopia, in primary position and down gaze, respectively. Two patients had poor vision that precluded the manifestation of diplopia. None of the 6 patients without preoperative diplopia developed symptoms post operatively. Conclusion: Surgical repair of blow-out fractures of the orbit occurring more than 6 weeks or more from injury can achieve marked improvement in both the functional and cosmetic aspects. The likelihood of induced diplopia is low. Orbital floor fracture repair should be considered to successfully treat enophthalmos or diplopia in patients with delayed clinical presentation, even decades postinjury.

Commentary on: Lower Eyelid Retraction Surgery Without Internal Spacer Graft

“Lower Eyelid Retraction Surgery Without Internal Spacer Graft” is a retrospective case series in 11 patients (17 eyelids), that challenges a traditional perceived necessity for routine spacer graft placement in successfully elevating a retracted lower eyelid.1 A clinical diagnosis of eyelid retraction encompasses a broad spectrum of periocular conditions, occurring as the sequelae to cicatricial anterior, middle, posterior lamellae, eyelid fat pad deficiency, canthal laxity, or midface pathophysiology that yields a relative deficiency in the vertical lid-cheek continuum.2-4 Taban’s published series comprises three causations of lower lid retraction: thyroid eye disease, facial palsy, and post-blepharoplasty syndrome; the latter etiology predominates in this cohort and probably reflects the relative prevalence of post-blepharoplasty syndrome as a cause of lower eyelid retraction in contemporary urban periocular clinical practice. This commentary will focus on the surgical treatment of post-blepharoplasty eyelid retraction. The author cites surgical series from the 1980s and 1990s in which up to one in five patients may experience varying degrees of eyelid retraction following lower eyelid blepharoplasty.5,6 Subsequent literature from that era, not only describes revision techniques for elevating the lid, but in the spirit of “prevention is better than cure” bestows the merits of prophylactic intraoperative lateral canthal support, even in the absence of any detectable preoperative lower lid or lateral canthal tendon laxity.7-9 Although several contemporary lower lid blepharoplasty surgical series with routine canthal support demonstrated excellent postoperative eyelid retraction incidence of ≤1.2% with mean follow-up ≤6 months.10-13 Long-term follow-up of 12 months or more beyond the date of lower lid blepharoplasty surgery is understandably often lacking. However, one can infer that the problem of post-blepharoplasty eyelid retraction is not completely conquered, as evidenced by a 21-month retrospective series by Griffin et al from California. This series yielded 46 patients, 81 eyelids, that presented with post-blepharoplasty lower eyelid retraction. All patients had undergone prior transcutaneous blepharoplasty with the authors identifying six etiologic factors of eyelid retraction: orbicularis strength, middle lamella scar, anterior lamella shortage, volume deficiency, negative vector, and lower eyelid laxity. Most patients requiring revision surgery had four or more factors indicating a summation of effect and highlighting the importance of recognizing and addressing these factors to mitigate the risk of post-blepharoplasty eyelid retraction. Augmenting the anterior lamella in postblepharoplasty lower lid retraction is problematic Typically patients have undergone a prior upper lid blepharoplasty, so the absence of an excess upper lid skin, means any skin graft would need to be obtained from secondary choice sites, such as retro or pre-auricular region where a suboptimal color-thickness-texture match is often not well received in this aesthetically sensitive, post-cosmetic surgery patient cohort. In common with many authors, our surgical preference for addressing anterior lamella deficiency in post-blepharoplasty in lower lid retraction (without available upper lid

Blepharoplasty basics for the dermatologist

Blepharoplasty is amongst the more frequently performed aesthetic procedures with surgery performed by physicians and surgeons across a variety of sub-specialities. This paper, aimed at a dermatology audience, describes patient selection, eyelid anatomy, clinical examination and surgical steps to achieve successful upper and lower lid blepharoplasty outcomes. Recommendations for minimising complications are made and photographs used to illustrate important clinical and surgical features.

Psychological Disturbances in Thyroid Eye Disease

Patients with thyroid-associated eye disease (TED) are at increased risk of psychological disturbances such as anxiety and depression, resulting in impaired quality of life. Several standardized instruments, ranging from generic health-related questionnaires to those specific to TED, have been used to measure psychological changes and impact on quality of life. Altered appearance caused by TED seems to be most significant in decreasing quality of life by negatively influencing facial expression, communication, self-perception, and social interactions. However, deficits in visual functioning and the subsequent limitations in daily activities can also contribute. Diminished work productivity and healthcare costs may cause financial strain. Changes in quality of life scores do not always correlate with objective measures of clinical disease burden, supporting the argument for incorporating independent quality of life assessments into routine care. We propose that quality of life and psychological assessment be a routine component of multidisciplinary TED management.

Management of Severe Thyroid Eye Disease and Use of Biological Agents

Multiple classification and grading systems exist for thyroid eye disease (TED) but for the purpose of this chapter, severe disease broadly includes severe inflammatory orbitopathy, sight-threatening disease, and/or proptosis greater than 25 mm.

Mastication Induced Retrobulbar Hemorrhage

Abstract Retrobulbar hemorrhage is a feared potentially sight threatening complication after orbital decompression surgery. We present a patient, 36 hours after surgery, while forcefully biting, suddenly developed a retrobulbar hemorrhage arising from the temporalis muscle causing an orbital compartment syndrome. Rapid intervention with canthotomy and cantholysis was associated with recovery of vision from absent light perception to 20/20. A mastication induced retrobulbar hemorrhage has not been previously described.