Timothy S. Wells

Direct fixation of extraocular muscles to a silicone sphere: a cost-sensitive, low-risk enucleation procedure.

Purpose: To describe a simple, cost-sensitive enucleation technique and to evaluate it in the context of intended benefits and long-term outcomes of alternate methods. Methods: A retrospective record review of patients who underwent enucleation using the described technique at a single institution by 2 surgeons. Surgery involved direct fixation of extraocular muscles to a solid silicone sphere, using nonabsorbable braided sutures with knots tied beneath the muscle insertions. Outcome measures included implant-related complications. Results: Seventy-five patients meeting inclusion criteria ranged in age from 3 to 94 years (mean, 54 years; median, 56 years). Surgical indications included a blind painful or disrupted eye in 56 cases; uveal melanoma in 15 cases; retinoblastoma in 2 cases; and endophthalmitis in 2 cases. Follow-up intervals ranged from 3 to 57 months (mean, 27 months; median, 22 months). Complications requiring surgical revision of the implant occurred in 2 of the 75 cases (one luxation; one exposure). There were no instances of chronic socket discharge or implant infection. Conclusions: Nonabsorbable-suture attachment of muscles to a solid silicone implant offers an inexpensive enucleation option, with minimal risk of implant migration, exposure, or infection. In light of widespread disaffection with pegging of porous implants, and with no motility advantage of unpegged porous over nonporous implants, consideration should be given to techniques that are equally effective, less costly, and perhaps more reliable.

Surgical timing and postoperative ocular motility in type B orbital blowout fractures.

Purpose: To determine whether patients with Type B orbital blowout fractures (soft-tissue distortion disproportionate to bone-fragment displacement) repaired within 7 days of injury have statistically greater postoperative vertical binocular fusion than similar patients who undergo later surgery. Methods: Prospective and retrospective surgical case series. Inclusion criteria were orbital floor (with or without medial wall) blowout fracture repair, preoperative coronal orbital CT scans, and patient age of at least 12 years at time of postoperative binocular visual field. Results: Twenty-five patients met inclusion criteria. Ten patients (group 1) had surgery within 7 days of injury, and 15 patients (group 2) had surgery more than 7 days after injury. The total cohort had a median postoperative vertical binocular fusion of 90°. Group 1 had postoperative vertical binocular fusion averaging 100°. Nine of 10 patients (90%) were above and 1 of 10 (10%) were below the median for the entire cohort. Group 2 had postoperative vertical binocular fusion averaging 70°. Three of 15 patients (20%) were above and 12 of 15 patients (80%) were below the median for the entire cohort. The difference between the average postoperative vertical binocular fusion of the 2 groups was statistically significant by two-tailed unpaired t test with p value 0.0022. Conclusions: Patients with Type B orbital blowout fractures (soft-tissue distortion disproportionate to bone-fragment displacement) have statistically greater average postoperative vertical binocular fusion if repaired within 7 days of injury than similar patients who undergo later surgery.

Attempted auto-enucleation in two incarcerated young men with psychosis

Auto-enucleation is a sign of untreated psychosis. We describe two patients who presented with attempted auto-enucleation while being incarcerated. This is an observation two-case series of two young men who suffered untreated psychosis while being incarcerated. These young men showed severe self-inflicted ocular trauma during episodes of untreated psychosis. Injuries included orbital bone fracture and dehiscence of the lateral rectus in one patient and severe retinal hemorrhage and partial optic nerve avulsion in the second patient. Auto-enucleation is a severe symptom of untreated psychosis. This urgent finding can occur in a jail setting in which psychiatric care may be minimal.

Orbital Varix Thrombosis and Review of Orbital Vascular Anomalies in Blue Rubber Bleb Nevus Syndrome.

A 57-year-old woman with cutaneous manifestations of (BRBNS) presented with acute left proptosis and venous congestion secondary to thrombosis within a superior ophthalmic vein varix. Multiple phleboliths were noted in the contralateral right orbit, and an incidental right middle cerebral artery aneurysm. Her symptoms spontaneously resolved within a few days. An English literature review found 7 reported cases of orbital vascular lesions in association with BRBNS from 1950 to 2012. All lesions showed contrast enhancement on CT or MRI: 4 had small orbital calcifications and 3 were distensible with raised venous pressure. The occurrence of a thrombosed orbital varix or cerebral artery aneurysm in BRBNS, to the best of the authors’ knowledge, has not been previously reported. Although orbital vascular lesions in BRBNS have been described as hemangiomas, the biologic behavior and histology of most of the reported orbital lesions are most compatible with venous malformations.

Two late complications of craniofacial trauma: case report and review of the literature

Injuries after blunt and penetrating trauma to the face are a common occurrence and are managed by specialists from several disciplines. After short-term care and immediate recovery, long-term complications can develop including cosmetic deformity, unsightly scarring, problems with soft tissue healing, malunion or nonunion of bony segments, diplopia or other visual complaints, malocclusion, hardware failure, and mucocele formation. Here, we present a report of 2 late complications recognized and treated in a patient 40 years after an episode of craniofacial trauma: epistaxis with symptomatic nasal congestion from fixation wires and mucocele formation. Management of this patient accompanied by endoscopic photographs and computed tomographic images is presented, and discussion of these complications along with review of the literature is provided.

Does delayed repair of eyelid lacerations compromise outcome

We designed a study to determine if the repair of traumatic eyelid lacerations can be delayed to allow for the most appropriate setting and surgeon without increasing complications. We conducted a retrospective chart review of all eyelid lacerations treated by the Ophthalmology service at the Medical College of Wisconsin over a 38-month period and identified 143 patients. Of these, 92 (64.3%) were adults and 51 (35.7%) were children under 18 years of age. Males accounted for 92 of 143 patients (64.3%). One hundred eight cases (75.5%) were repaired in an operating room. Seventy-seven cases (53.8%) had canalicular system involvement. The median time from injury-to-repair was 16.5 h (mean, 33.1 h; range, 2–584 h). Ninety-five patients (66.4%) underwent repair b24 h after injury; 48 (33.6%) were repaired after 24 h. Patients repaired b24 h after injury were more likely to be younger (24.5 years vs. 32.0 years, p = 0.02), children under the age of 18 (45.2% vs. 16.7%, p b 0.01), less likely to have canalicular involvement (36.8% vs. 87.5%, p b 0.01) and less likely to be repaired in the operating room (64.2% vs. 98.0%, p b 0.01). There were 9 complications noted in follow up care, with 6 occurring in patients repaired within 24 h of injury (6.3%) and 3 occurring in patients repaired after 24 h (2.0%), which did not reach the level of statistical significance (p = 0.14). Complications included: ptosis (4), lid retraction (2), epithelial cyst (1), pyogenic granuloma (1) and eyelid deformity (1). No patient developed infection, chronic epiphora, or slit canaliculus. Three of the 4 cases

Local Disease Control in Ocular Adnexal Lymphoproliferative Disorders: Comparative Outcomes of MALT Versus Non-MALT Histologies

Micro‐Abstract The efficacy of involved field radiotherapy (IFRT) in the outcomes of patients with different subtypes of ocular adnexal lymphoproliferative disorder is lacking. We retrospectively analyzed and compared the outcomes of patients with mucosa‐associated lymphoid tissue (MALT) and non‐MALT ocular adnexal lymphoproliferative disorder after being treated with IFRT. Our results reveal that IFRT provided excellent disease control with superior failure‐free survival in the MALT cohort when compared with the non‐MALT cohort. Introduction: Ocular adnexal lymphoproliferative disorders (OALDs) are almost exclusively of B‐cell origin, with the majority being extra‐nodal marginal zone lymphomas of mucosa‐associated lymphoid tissue (MALT). The comparative efficacy of involved field radiation therapy (IFRT) in MALT vs. non‐MALT OALDs is not known. Materials and Methods: We present a single‐center, large cohort, retrospective study of the efficacy of IFRT in OALDs. Failure‐free survival (FFS), complete remission, and local, regional, and distant failure were determined for 112 patients with MALT OALDs (n = 71) and non‐MALT OALDs (n = 41) cohorts. Results: Fifty‐six patients with MALT OALD and 26 patients with non‐MALT OALD received IFRT only (without any planned concurrent or sequential systemic chemothereapy or chemo‐immunotherapies). Among the OALD cohorts treated with only IFRT, complete remission was achieved in 49 (87.5%) patients in the MALT cohort and 23 (88.4%) in the non‐MALT cohort (P = .99). Clinically, resolution of symptoms occurred in 83.3% and 93.3% of the patients in the MALT and non‐MALT cohorts, respectively. Local failure occurred in 4 (7.1%) patients in the MALT cohort, compared with 4 (15.3%) patients in the non‐MALT cohort (P = .24). Regional failure (or extra‐orbital failure) occurred in 5 (8.9%) patients in the MALT cohort and in 3 (11.5%) patients in the non‐MALT cohort (P = .71). Distant failure was reported in 1 (1.7%) and 2 patients (7.6%) in the MALT and non‐MALT cohorts, respectively (P = .18). The median follow‐up of survivors was 5.1 years (range, 0.1‐22.5 years) in the MALT cohort and 3.9 years (range, 0.1‐22.9 years) in the non‐MALT cohort. The 5‐year and 10‐year FFS was 95% (95% confidence interval [CI], 88%‐100%) and 83% (95% CI, 70%‐98%) for the ocular MALT and 67% (95% CI, 48%‐94%) and 56% (95% CI, 34%‐91%) for the non‐MALT cohorts, respectively (log rank for P = .025). On multivariate analyses, age (hazard ratio [HR], 1.06; 95% CI, 1.10‐1.12; P = .03), presence of non‐MALT histology (HR, 13.9; 95% CI, 2.05‐94.4; P = .007), and radiation dose < 30.6 Gy (HR, 5.27; 95% CI, 1.14‐24.3; P = .03) were associated with worse FFS. The 5‐year and 10‐year overall survival was 92% (95%, CI 83%‐100%) and 80% (95% CI, 66%‐96%) for the MALT and 78% (95% CI, 61%‐100%) and 62% (95% CI, 38%‐100%) for the non‐MALT cohorts, respectively (P = .80). Conclusion: Our results reveal that IFRT provided excellent disease control with superior FFS in the MALT cohort when compared with the non‐MALT group.

Traumatic orbital encephalocele: Presentation and imaging

ABSTRACT Objective: Traumatic orbital encephalocele is a rare but severe complication of orbital roof fractures. We describe 3 cases of orbital encephalocele due to trauma in children. Methods: Retrospective case series from the University of Wisconsin – Madison and Medical College of Wisconsin. Results: Three cases of traumatic orbital encephalocele in pediatric patients were found. The mechanism of injury was motor vehicle accident in 2 patients and accidental self-inflicted gunshot wound in 1 patient. All 3 patients sustained orbital roof fractures (4 mm to 19 mm in width) and frontal lobe contusions with high intracranial pressure. A key finding in all 3 cases was progression of proptosis and globe displacement 4 to 11 days after initial injury. On initial CT, all were diagnosed with extraconal hemorrhage adjacent to the roof fractures, with subsequent enlargement of the mass and eventual diagnosis of encephalocele. Conclusion: Orbital encephalocele is a severe and sight-threatening complication of orbital roof fractures. Post-traumatic orbital encephalocele can be challenging to diagnose on CT as patients with this condition often have associated orbital and intracranial hematoma, which can be difficult to distinguish from herniated brain tissue. When there is a high index of suspicion for encephalocele, an MRI of the orbits and brain with contrast should be obtained for additional characterization. Imaging signs that should raise suspicion for traumatic orbital encephalocele include an enlarging heterogeneous orbital mass in conjunction with a roof fracture and/or widening fracture segments.