Stephen R. Klapper

Orbital Involvement in Allergic Fungal Sinusitis

BACKGROUND Although allergic fungal sinusitis is a relatively common, noninvasive form of paranasal sinus mycosis, and despite frequent orbital involvement, there have been few reports of this condition in the ophthalmic literature. METHODS Two cases of allergic fungal sinusitis having orbital symptoms are described. The current classification, typical presentation, and ideal management of fungal sinusitis are reviewed. RESULTS Distinguishing radiologic and pathologic features were present in both patients. Aspergillus flavus was cultured in one case, and Bipolaris spicifera was cultured in the other. CONCLUSIONS Allergic fungal sinusitis is a unique subset of sino-orbital disease with highly characteristic clinical, radiologic, and pathologic features. Unlike invasive forms of mycotic disease, allergic fungal sinusitis may be managed adequately with surgical debridement, aeration of the involved sinuses, and systemic and topical corticosteroids.

A new titanium peg system for hydroxyapatite orbital implants

Purpose To evaluate a new hydroxyapatite-coated titanium sleeve and titanium peg system for HA orbital implants. Methods The authors followed 54 patients receiving an HA-coated titanium sleeve and peg system and analyzed the complications associated with this peg system. The following data were recorded: type of surgery performed, size of implant used, type of HA used, time of pegging, follow–up duration, problems encountered, and treatment. Results Fifty-seven patients received the HA-coated titanium peg and sleeve system. The average duration of follow-up was 15 months (range, 3–30 months). Three patients were lost to follow-up after 1 month. Complications associated with peg placement in 54 patients included: discharge (9.2%), pyogenic granulomas (14.8%), peg falling out during prosthesis removal (9.2%), poor transfer of movement (1.8%), clicking (3.7%), conjunctiva overgrowing peg (1.8%), part of sleeve shaft visible (9.2%), peg drilled on an angle (1.8%), HA visible around peg hole (3.7%), and loose sleeve (3.7%). Conclusion The HA-coated titanium sleeve and titanium peg is a new peg system available for HA orbital implants. Many of the complications associated with this peg system are similar to the commonly used polycarbonate peg system. Pyogenic granulomas and discharge, however, appear to be less frequently encountered with this new system. The HA-coated titanium sleeve and titanium pegs were well tolerated and appeared quieter in the socket than most polycarbonate pegs.

Wrapping hydroxyapatite implants.

Hydroxyapatite (HA) implants currently are most commonly wrapped in fresh unprocessed human donor sclera before implantation to facilitate entry into the orbital space and allow extraocular muscle attachment. Autologous temporalis fascia or autologous fascia lata are alternatives, but prolong surgery time and require a second operative site. Recently, a number of other wraps, such as processed human pericardium, processed human fascia lata, processed human sclera, bovine pericardium and expanded polytetrafluoroethylene [e-PTFE], have being marketed. Although they also facilitate implant placement, they can be costly. Polygalactin (Vicryl, Ethicon, Somerville, NJ) mesh is another readily available wrap that is easy to use and cost effective. To obtain a high success rate with this wrap, the polygalactin mesh wrapped HA implant must be moistened and seated into the orbit properly. If it is not, exposure may occur, which may explain why some surgeons shy away from its use. The proper technique is reviewed in this paper.

The bioceramic implant: evaluation of implant exposures in 419 implants.

Purpose: To compare the rate of exposure in the immediate 3-month postoperative follow-up period with the rate of exposure after the immediate postoperative period in 419 anophthalmic patients with a bioceramic (aluminum oxide) orbital implant. Methods: This is a retrospective, clinical case series of 419 patients who received a bioceramic orbital implant. All patients who presented to five oculofacial surgeons (D.J., S.G., J.D., S.K., L.M.) from January 1, 2000, to June 1, 2007, who received a bioceramic orbital implant and had a minimum of 3 months of follow-up were included in this study. The authors analyzed age, gender, type of surgery, implant size, peg system, follow-up duration, time of pegging, and problems encountered. The data from the patients with greater than 3 months of follow-up with exposure of the bioceramic implant are detailed in this report. Results: There were 353 patients followed for 3 to 96 months with an average of 30 months of follow-up (median 23 months). Implant exposure occurred in 32/353 bioceramic implants (9.1%). Six of the 32 (19%) exposures occurred during the 90-day postoperative period (average 2.1 months). Twenty-six (81%) exposures occurred outside of the 90-day postoperative period (average 27.5 months, range 4–82 months). Conclusions: Implant exposures can occur anytime postimplant placement. This review discovered an implant exposure rate of 9.1%, with the majority of the exposures occurring after the postoperative follow-up period. Patients with porous orbital implants should be followed on a long-term basis to detect this complication.

Management of Cosmetic Eyelid Surgery Complications

There is a broad spectrum of complications that can occur following cosmetic eyelid surgery. The experienced eyelid surgeon should be able to avoid most serious complications through proper patient selection, a comprehensive preoperative assessment and surgical plan, meticulous surgical technique, and appropriate postoperative care. The aesthetic eyelid surgeon must counsel a patient contemplating blepharoplasty surgery regarding typical expectations including edema, eyelid numbness, dry eyes, and mild blurred vision. Patients must also be aware of the risks and the signs of serious complications such as infection, hematoma, or severe vision loss. Oculofacial surgeons must be capable of managing these adverse outcomes. The management of these urgent complications as well as other significant postoperative problems including diplopia, lagophthalmos, eyelid malposition, severe chemosis and edema, crease abnormalities, and wound dehiscence is outlined in this review.

Jones tube insertion in children with canalicular agenesis.

The purpose of this report is to describe a simplified method of Jones tube insertion in the management of pediatric patients with symptomatic upper and lower punctal and canalicular agenesis. A 5-year-old female with bilateral upper and lower canalicular agenesis, and a 4-year-old male with agenesis of the right upper and lower canaliculi, underwent placement of Jones tubes without performing standard external conjunctivodacryocystorhinostomy. The first child requiring bilateral Jones tube insertion has remained asymptomatic for 24 months. The Jones tube dislodged in the second patient 6 weeks postoperatively. The tube was replaced, and the child has been asymptomatic for 16 months. The technique of Jones tube insertion without a previous or concomitant external dacryocystorhinostomy may be a useful modification in the management of pediatric patients with symptomatic upper and lower canalicular agenesis.

Management of Experimental Globe Perforation During Strabismus Surgery

BACKGROUND The incidence of potentially vision-threatening globe perforation during strabismus surgery is reportedly between less than 1% and 12% of cases. Optimal treatment of globe perforation is not known; however, traditionally it has been treated with cryotherapy at the time of surgery or observation without treatment. The indirect-ophthalmoscope-directed diode laser may provide a safe and effective alternative treatment. METHODS We perforated the globes of six adult Dutch rabbits (12 eyes) and treated four eyes with cryotherapy and four with diode laser; the remaining four were not treated. RESULTS Histologic examination of the untreated eyes revealed a cellular reaction around the polyglactin suture that formed a non-uniform chorioretinal adhesion. The cryotherapy eyes had a tenuous chorioretinal adhesion and retinal pigment epithelium (RPE) cells in the vitreous on several sections. The laser-treated eyes had a firm, wide chorioretinal adhesion, with minimal tissue disruption and no release of RPE cells. No complications occurred. CONCLUSION We conclude that indirect-ophthalmoscope-directed diode laser retinopexy was safe and efficacious for globe perforation during strabismus surgery on rabbits and could be expected to be useful in humans.

Surgical techniques in enucleation: the role of various types of implants and the efficacy of pegged and nonpegged approaches.

Loss of an eye to tumor, trauma, or end-stage ocular disease is devastating to persons of any age. Not only is there a loss of binocular vision with reduced peripheral visual field and loss of depth perception with various job restrictions, there may also be a sense of facial disfigurement. One’s self-image, self-esteem, and self-confidencemay be affected. Because eye contact is such an essential part of human interaction, it is extremely important for the artificial eye patient to maintain a natural, normalappearing prosthetic eye. This has always been challenging, and although there have been numerous breakthroughs in the past during the latter half of the 20th century, medical technology and innovation had often fallen short of providing an artificial eye that looked and moved like a normal eye. Over the past 15 years, there have been numerous developments and refinements in anophthalmic socket surgery with respect to implant material and design, implant wrapping, implant–prosthesis coupling, and socket volume considerations. It is now, more than ever, possible to provide the anophthalmic patient with an artificial eye that looks andmoves almost as naturally as a normal eye.

Evaluation and Management of the Anophthalmic Socket and Socket Reconstruction

The absence of an eye due to malformation, disease, or trauma is an exceptionally difficult situation for patients, and the management of the anophthalmic socket has long been a challenge for the ophthalmologist and ocularist. In the past decade, there have been numerous developments and refinements in anophthalmic socket surgery with respect to implant material and design, implant wrapping, implant–prosthesis coupling, and socket volume considerations. Anophthalmic surgery is no longer simply about replacing a diseased eye with an orbital implant and delegating the procedure to inexperienced surgeons or to the junior resident staff. As with other microsurgical ophthalmic procedures, enucleation and eviscerations should be performed meticulously to attain the best functional and cosmetic result and to avoid deformities that may compound the patients’ already challenging situation.

Controversies in Enucleation Technique and Implant Selection: Whether to Wrap, Attach Muscles, and Peg?

The advent of porous orbital implants has greatly advanced the field of anophthalmic surgery. The development of hydroxyapatite (HA) implants initiated a new generation of porous implants. Porous polyethylene and aluminum oxide are now commonly used alternatives. Orbital implants are available in spherical, mounded, egg, and conical shapes. Implant material selection is determined by several factors, including patient age and medical history, cost, availability, and surgeon preference. A variety of techniques may be utilized to determine the appropriate implant size. Adults undergoing enucleation surgery most frequently require a 20- to 22-mm sphere, whereas 18- to 20-mm spherical implants may be adequate for evisceration procedures. Patients younger than 5 years old typically receive a nonporous implant as this facilitates replacement with a larger porous implant later in childhood or adolescence. Older pediatric patients may do well with porous implants. Appropriate implant size selection depends on the age and development of the patient. Surgeons who use porous polyethylene as their implant of choice commonly do not use an implant-wrapping material. Wrapping HA and aluminum oxide implants facilitates implant insertion and rectus muscle attachment to the implant. Several implant-wrapping materials are commercially available. Polyglactin 910 (Vicryl®) is simple to use, is readily available, and may permit earlier implant fibrovascularization than other available materials. Porous implants can be coupled to the overlying artificial eye with a titanium peg system. These coupling systems may allow for greater prosthesis motility. Implant peg use has declined due to the high incidence of postpegging complications (increased discharge, recurrent pyogenic granulomas, implant exposure around the peg, implant infection, tissue overgrowth, clicking).