Sheri L. DeMartelaere

Use of the Boston Ocular Surface Prosthesis in the Management of Severe Periorbital Thermal Injuries: A Case Series of 10 Patients

PURPOSE To report the use of the Boston Ocular Surface Prosthesis (BOSP) in patients with severe periorbital thermal injuries. DESIGN Retrospective, interventional case series. PARTICIPANTS Patients with severe periorbital thermal injuries treated with the BOSP. METHODS Chart review of 10 consecutive patients (16 eyes) who sustained severe periorbital thermal injuries during combat missions in Iraq and Afghanistan and were treated for exposure keratopathy with the BOSP, a Food and Drug Administration-approved gas-permeable, scleral contact lens. MAIN OUTCOME MEASURES Corneal epithelial defect healing, uncorrected and best-corrected visual acuity, and BOSP wear time. RESULTS Exposure keratopathy occurred after severe periorbital thermal injuries and followed a predictable course of scar contracture. In all patients, vision-threatening ocular surface disease developed as a result of chronic ocular exposure. Rehabilitation of the ocular surface was accomplished using the BOSP, with 10 of the 16 treated eyes achieving a corrected visual acuity of 20/70 or better. Five eyes achieved a best-corrected visual acuity of 20/40 or better. The BOSP also was used as a drug-delivery vehicle to treat corneal ulcers successfully in 6 eyes. The only eye that required penetrating keratoplasty was an early intervention believed to be a direct sequelae of the original thermal burn, rather than a failure of the BOSP regimen. The mean BOSP wear time was 16 hours per day. CONCLUSIONS The BOSP can play an important role in rehabilitation of the ocular surface for patients with severe periorbital thermal injuries and resultant exposure keratopathy. Use of the BOSP should be considered as a treatment option for these difficult cases of severe periorbital thermal injuries.

Light-activated sutureless closure of wounds in thin skin†

Closing lacerations in thin eyelid and periorbital skin is time consuming and requires high skill for optimal results. In this study we evaluate the outcomes after single layer closure of wounds in thin skin with a sutureless, light‐activated photochemical technique called PTB.

Sealing of Corneal Lacerations Using Photo-Activated Rose Bengal Dye and Amniotic Membrane

Purpose: Watertight closure of perforating corneoscleral lacerations is necessary to prevent epithelial ingrowth, infection, and potential loss of the eye. Complex lacerations can be difficult to treat, and repair with sutures alone is often inadequate. In this study, we evaluated a potentially sutureless technology for sealing complex corneal and scleral lacerations that bonds the amniotic membrane (AM) to the wound using only green light and rose bengal dye. Methods: The AM was impregnated with rose bengal and then sealed over lacerations using green light to bond the AM to the deepithelialized corneal surface. This process was compared with suture repair of 3 laceration configurations in New Zealand White rabbits in 3 arms of the study. A fourth study arm assessed the side effect profile including viability of cells in the iris, damage to the blood–retinal barrier, retinal photoreceptors, retinal pigment epithelium, and choriocapillaris in Dutch Belted rabbits. Results: Analyses of the first 3 arms revealed a clinically insignificant increase in polymorphonuclear inflammation. In the fourth arm, iris cells appeared unaffected and no evidence of breakdown of the blood–retinal barrier was detected. The retina from green light laser-treated eyes showed normal retinal pigment epithelium, intact outer segments, and normal outer nuclear layer thickness. Conclusions: The results of these studies established that a light-activated method to cross-link AM to the cornea can be used for sealing complex penetrating wounds in the cornea and sclera with minimal inflammation or secondary effects.

Five Tips for Endoscopic Brow Lift

We present tips for endoscopic brow lifting. Preoperative botulinum toxin promotes wound healing. Tumescent injection helps with dissection. Transection of procerus and corrugator muscles is not recommended as it increases risk of hematomas. Intravenous fluid given at the end of the case can help reduce nausea.

Lower Eyelid Blepharoplasty Evaluation: Avoid the Cookie-Cutter Approach

The cookie cutter approach to lower eyelid blepharoplasty should be discouraged. Abnormal anatomic relationships should first be determined before an appropriate surgical plan can be established. Each individual patient will have characteristic anatomic problems that require different surgical techniques to correct.

Incisional Guidelines When Marking the Skin in Upper Eyelid Blepharoplasty

For those patients without a discernable lid crease (Figure 16.1), the following measurements can provide a good incisional guideline: 7–9 mm above the mid-eyelid margin for men and 8–10 mm for women 6 mm above the medial eyelid margin at the level of the punctum 6–8 mm above the lateral eyelid margin at the level of the lateral canthus Lateral eyelid crease incision then swings upwards at the lateral canthus to end 15–18 mm from the lateral canthus at a 45° angle Open image in new window Figure 16.1 Artist’s sketch depicting incision guidelines for upper eyelid blepharoplasty. (A) Preoperative sketch of upper eyelid dermatochalasis. (B) Castrovierjo calipers are used to measure the eyelid

The Treatment of Festoons in Lower Blepharoplasty

Festoons or “malar bags” are thought to be involutional attenuation of the skin and underlying orbital orbicularis oculi muscle. Edema often accumulates in this area. Standard blepharoplasty techniques will not address festoons, if present, and may make them worse for a time due to persistent edema in this area. In severe cases of festoons, one approach is direct excision.

Spontaneous subconjunctival abscess because of Haemophilus influenzae.

Purpose: To report a case of a spontaneous subconjunctival abscess in a patient with no previous ocular surgery or trauma. Method: Case report. Results: We report a case of a subconjunctival abscess caused by Haemophilus influenzae after several days of worsening conjunctivitis. Computed tomography scans of the orbits confirmed an abscess cavity adjacent to the globe without orbital extension. The abscess was spontaneously draining at presentation and resolved completely with topical and oral antibiotic therapy. Conclusions: To our knowledge, this is the first-described case of spontaneous subconjunctival abscess formation in an immunocompetent individual unrelated to preexisting ocular pathology, previous ocular surgery, or trauma. H. influenzae species may possess the ability to penetrate an intact conjunctiva and develop subconjunctival abscess. We recommend that patients presenting with bacterial conjunctivitis be closely examined to rule out subconjunctival abscess, which may require additional aggressive medical or surgical management.

Tarsal Switch Levator Resection for the Treatment of Myopathic Blepharoptosis

Progressive myopathic ptosis is often associated with fair to poor levator function. These patients usually adopt a head-back/chin-up position with heavy recruitment of the frontalis muscle to see, resulting in chronic neck pain and visual fatigue. In addition, these patients often have a poor Bell’s phenomenon and the orbicularis muscle can be weak, resulting in poor eye protective mechanisms. Surgical procedures to correct blepharoptosis in patients with poor eye-protective mechanisms are associated with an increased incidence of postoperative lagophthalmos and corneal exposure.