Steven C. Dresner

Animal model of porous polyethylene orbital implants.

Ophthalmologists continue to search for the ideal orbital implant for the anophthalmic socket. The successful long-term clinical performance of an implantable prosthesis is highly dependent on the materials from which the device is fabricated. Among the materials issues are chemistry, surface texture, and porosity. Polyethylene, a polymer comprised of simple hydrocarbon chains, is highly resistant to biological degradation and possesses mass and fabrication properties that would be favorable in an orbital implant. In this report, our early experimental experience with porous polyethylene orbital enucleation implants is reported. Our findings are sufficiently encouraging to warrant further exploration and refinement of the polyethylene device examined.

Further modifications of the Müller's muscle-conjunctival resection procedure for blepharoptosis.

A modified Müllers muscle-conjunctival resection procedure was performed to correct minimal to mild blepharoptosis with good levator function. A semilinear formula was used to excise specific amounts of Müllers muscle for different amounts of blepharoptosis. This formula was modified by less than adequate responses with the phenylephrine test. The phenylephrine test was also used to unmask contralateral ptosis so that bilateral surgery or less resection on the primarily ptotic eye could be planned. This modified technique and formula provides an approach to better quantitate minimal to mild ptosis surgery and yield more predictable results.

Intravascular papillary endothelial hyperplasia : Collection of four cases and a review of the literature

Summary Intravascular papillary endothelial hyperplasia is a benign tumor that rarely presents in the orbit and ocular adnexa. Generally, it occurs as an isolated eyelid mass, not associated with systemic or local disease. Histopathologically, it can be easily confused with angiosarcoma or Kimuras disease. We present our experience with four cases of this tumor in the ocular adnexa, along with a literature review.

Small incision preperiosteal midface lift for correction of lower eyelid retraction.

Purpose: Postblepharoplasty lower eyelid retraction is often due to scarring of the middle lamellae and/or vertical shortening of the anterior lamellae. Traditional reconstructive techniques involve a transconjunctival incision combined with a spacer graft. Other techniques involve a subperiosteal midface dissection or limited preperiosteal dissection. Elevation of the midface reduces the gravitational effect of the cheek on the eyelid and recruits skin for the anterior lamella. This study evaluates a technique for correction of lower eyelid retraction using a preperiosteal midface lift via a lateral canthal incision in a series of patients. Methods: Twenty-eight patients (56 eyes) with postblepharoplasty lower eyelid retraction were evaluated. Preoperative evaluations for inferior scleral show, corneal staining, and epiphora were documented. The patients underwent bilateral preperiosteal midface lift and canthoplasty via a lateral canthal incision. Follow-up ranged from 12 to 18 months. Results: Average preoperative inferior scleral show was 1.96 mm (range, 1–3 mm). Seventy-eight percent of patients had epiphora, and 54% had corneal staining. Average postoperative lower eyelid position was +0.07 mm (range, 0 to +1 mm) above the inferior limbus. Average change in lower eyelid position relative to the inferior limbus was 2.04 mm. In all eyes, the final lower eyelid position was either at the inferior limbus or above it. All eyes had resolution of epiphora and corneal staining. Two patients required revision of lateral canthus on one side to improve symmetry. Conclusion: Mobilizing the midface in the preperiosteal plane through a lateral canthal incision provides excellent elevation and support of the eyelid. The small incision allows easy access to adhesions along the inferior orbital rim and to the preperiosteal plane beneath the entire midface. Preperiosteal midface lift combined with canthoplasty provides significant improvement of postblepharoplasty lower eyelid retraction.

The smooth surface tunnel porous polyethylene enucleation implant.

BACKGROUND AND OBJECTIVE To describe early clinical results with the porous polyethylene smooth surface tunnel (SST) enucleation implant. PATIENTS AND METHODS Uncontrolled, prospective interventional case series of patients undergoing enucleation with placement of the SST implant. This implant consists of a porous polyethylene sphere with a smooth anterior surface containing pre-drilled tunnels to facilitate direct suturing of the rectus muscles to the implant without use of an implant wrap. Postoperatively, socket healing was assessed, and prosthesis and socket motility were evaluated by the surgeon using an ordinal scale (0 = no motility to 4 = excellent motility). RESULTS Thirty patients received the SST implant, with a mean follow-up of more than 23 months. Two cases of exposure occurred and were managed surgically without the need for explantation. Mean socket motility was 3.1 on a 0 to 4 ordinal scale, with mean prosthesis motility of 2.8. CONCLUSION The SST implant provides satisfactory socket motility and is generally well tolerated in the anophthalmic socket without the need for wrapping material.

The Modified Fasanella-Servat Procedure: Description and Quantified Analysis

Purpose: To describe a modified Fasanella-Servat procedure and nomogram for the correction of minimal amounts of ptosis. Methods: Retrospective review of this modified Fasanella-Servat procedure was performed on 118 eyelids in 86 consecutive patients over 2, 4-year periods by 1 surgeon (S.C.D.). The amount of tarsectomy was based on the amount of ptosis. Results: Mean pre- and postoperative margin-to-reflex distance 1 were +0.7 mm and +2.4mm, respectively. One hundred and twelve eyelids (95%) had satisfactory results with postoperative margin-to-reflex distance 1 ≥ 1.5 mm. Eyelid symmetry was achieved in 92% of eyelids to within 0.5 mm. There was no incidence of overcorrection, tarsal buckling, or corneal abrasion. One eyelid had a contour deficit. Tarsectomy amount ranged from 2 mm to 5 mm. Average amount of tarsectomy to eyelid elevation was 2.4:1. Conclusions: The modified Fasanella-Servat procedure is technically easy, time-efficient, and has a low complication rate for the treatment of minimal blepharoptosis (< 2.5 mm) with good levator function and negative phenylephrine test. In the authors’ hands, the ratio of tarsectomy to eyelid elevation is approximately 2:1. In addition to other techniques such as levator advancement and Müller’s muscle conjunctival resection, the modified Fasanella-Servat technique is a useful adjunct to the modern ptosis surgeon’s armamentarium.

Using the inferior oblique muscle to augment implant coverage in enucleation surgery.

Purpose: We present a technique modification for enucleation surgery that may decrease implant exposure or extrusion by using native tissue to reinforce the implant at the most susceptible area, specifically the anterior-most aspect. Methods: An enucleation procedure is performed, and an implant is placed into the orbit. The horizontal rectus muscles are attached to the implant, and the vertical rectus muscles are attached directly to the horizontal muscles. The inferior oblique muscle is then spread over the anterior implant surface and sutured to the superior rectus and lateral rectus muscles. Results: 15 patients underwent this procedure, with implantation of an SST porous polyethylene implant. The mean follow-up interval was 18 months with a range of 4–33 months. One patient suffered an implant exposure, and one experienced a post-operative orbital hemorrhage. Two patients required blepharoptosis surgery to achieve eyelid symmetry. Conclusions: This retrospective series demonstrates the potential usefulness of the inferior oblique muscle to augment coverage of the orbital implant. Reinforcement of the anterior surface of the implant with vascularized tissue may improve the integrity and strength of the tissues anterior to the implant, and thereby reduce the likelihood of implant exposure.

Conjunctival melting syndrome associated with the use of bovine pericardium wrapping material.

Purpose To report 18 cases of unusually large, early conjunctival breakdown occurring with the use of bovine pericardium wrapping material for orbital implants. Methods Retrospective case series. The clinical course and histopathologic features of 18 cases of early conjunctival breakdown in patients who had undergone orbital implantation of bovine pericardium–wrapped hydroxyapatite or porous polyethylene are reviewed. Results Eighteen patients presented with unusually large (average 13.44 mm) conjunctival defects over bovine pericardium–wrapped implants. The average time from enucleation to exposure was approximately 4 months. Implants had to be removed in 8 of 18 cases. There was clinical and histologic evidence of tissue inflammation and conjunctival melting. Conclusions The conjunctival melting phenomenon we report herein is alarming. We have abandoned the use of bovine pericardium as a wrapping material for implants after enucleation because of the unfavorable results.

Multipurpose conical orbital implant in evisceration.

Purpose: To evaluate the safety and efficacy of the porous polyethylene multipurpose conical orbital implant for use in evisceration. Methods: A retrospective review of 31 eyes that underwent evisceration and received the multipurpose conical orbital implant. The orbits were evaluated at 1 week, 1 month, and 6 months after final prosthetic fitting for implant exposure, superior sulcus deformity, and prosthetic motility. Results: There were no cases of extrusion, migration, or infection. All patients had a good cosmetic result after final prosthetic fitting. Prosthetic motility was good in all patients. Exposure developed in one eye (3%) and a superior sulcus deformity developed in one eye (3%). Conclusions: Placement of an multipurpose conical orbital implant in conjunction with evisceration is a safe and effective treatment for blind painful eye that achieves good motility and a good cosmetic result.

Orbital Volume Augmentation With Adjustable Prefabricated Methylmethacrylate Subperiosteal Implants

Prefabricated right and left subperiosteal implants were used in nine anophthalmic sockets to correct superior sulcus deformities. The advantages of these implants include increased stability, easy insertion under direct visualization and the possibility of easy retrieval if necessary, and custom modification for volume and shape intraoperatively, with the addition of methylmethacrylate. There were no extrusions, implant migrations, or infections. Complications included mild undercorrection, upper eyelid blepharoptosis, and transient ectropion.