Todd R. Shepler

The porous polyethylene (Medpor) spherical orbital implant: a retrospective study of 136 cases.

Purpose To evaluate complications and risk factors associated with the placement of wrapped and unwrapped porous polyethylene (PP) spherical implants after evisceration, enucleation, or secondary implantation. Methods A retrospective, interventional, noncomparative case series of consecutive cases of PP implant placement after anophthalmic socket surgery performed by three surgeons over a 5-year period. A PP spherical implant was placed in 133 patients, 61 women (2 bilaterally) and 72 men (1 bilaterally). There were 91 enucleations, 30 eviscerations, and 15 secondary implant placements. Sixty-six (48.5%) implants were wrapped prior to placement. Parameters evaluated included: age, sex, prior ocular surgery or radiation treatment, indications for surgery, procedure performed, size of PP sphere, material used to wrap the implant, and complications. Results A total of 17 of 136 (12.5%) cases had documented postoperative complications, with implant exposure being the most common. In 5 patients (3.7%), implant exposure developed: 1 after evisceration and 4 after primary enucleation. Three of the five exposures were small and resolved with either observation alone or in one case with surgical revision of the socket. In two cases, the exposures were large enough that removal of the implant was indicated, one after evisceration and the other after enucleation with placement of a wrapped PP sphere. Conclusions Our series revealed no significant difference in exposure rate between wrapped and unwrapped PP sphere implants, nor was the exposure rate affected by whether an eye was eviscerated or enucleated.

Nasolacrimal duct obstruction associated with radioactive iodine therapy for thyroid carcinoma.

A 50-year-old woman presented with a 5-year history of unilateral epiphora that began shortly after 131I therapy for thyroid carcinoma. A recent recombinant human thyroid-stimulating hormone (Thyrogen) scan had shown a focus of uptake adjacent to the right eye that was initially thought to be a possible metastasis. Probing and irrigation revealed complete blockage of the right nasolacrimal duct. The patient underwent a right dacryocystorhinostomy (DCR) and biopsy of the lacrimal sac. Histopathologic examination of the lacrimal sac and nasal mucosa revealed foreign-body reaction and fibrosis with no malignant cells. A repeat Thyrogen scan after DCR showed no residual focus of activity in the nose or near the lacrimal sac and confirmed reestablishment of lacrimal drainage on the right side. This case demonstrates that 131I therapy for thyroid carcinoma can be associated with nasolacrimal duct obstruction. The appearance of a focus of uptake near the lacrimal sac on Thyrogen scanning in a patient with a history of thyroid carcinoma may not be due to a new focus of metastasis and may indeed be due to pooling of 131I in the lacrimal sac due to nasolacrimal duct blockage.

Expression of the epidermal growth factor receptor in conjunctival squamous cell carcinoma

Purpose: To determine whether the tyrosine kinase epidermal growth factor receptor (EGFR) is expressed in squamous cell carcinoma of the conjunctiva. Methods: A retrospective, observational case series of 5 patients with biopsy-proven conjunctival squamous cell carcinoma treated at one institution between January 1996 and April 2004. Medical records and tissue specimens from the 5 patients were reviewed. A control specimen of normal conjunctiva was also obtained from one of the 5 patients. Immunohistochemical analysis was performed using antibodies against EGFR. Results: Immunohistochemical staining showed that EGFR expression was moderate to strong in all tissue specimens, both in the normal mucosa and in the in situ and invasive components of the conjunctival squamous cell carcinomas. Conclusions: An intense expression of EGFR occurs in squamous cell carcinoma of the conjunctiva. Further study is needed to determine whether an EGFR inhibitor that targets this expression would have potential therapeutic benefit in treating squamous cell carcinoma of the conjunctiva.

Use of isobutyl cyanoacrylate tissue adhesive to stabilize external eyelid weights in temporary treatment of facial palsies

Purpose To describe a technique for stabilizing external eyelid load weights with isobutyl cyanoacrylate tissue adhesive for the temporary treatment of facial palsies. Methods This was a nonrandomized, prospective study of six consecutive patients with unilateral facial paralysis treated with external eyelid load weights stabilized with isobutyl cyanoacrylate tissue adhesive instead of adhesive tape. Follow-up assessment included corneal exposure, patient comfort, amount of artificial tear usage, and complications associated with the weights. Results Of the six patients studied, five had decreased corneal exposure, decreased artificial tear usage, and increased patient comfort with use of the weights. One patient had no improvement of symptoms. Weights were retained for a mean of 10.7 days. Two patients had difficulty with the weights; one was secondary to dermatochalasis and blepharoptosis obscuring his vision, and the other patient’s weight fell off after 1 day. No weights were lost. Conclusions The use of isobutyl cyanoacrylate tissue adhesive is a simple, quick, and inexpensive method for placement of external eyelid weights for temporary treatment of ocular exposure associated with facial paralysis and for determining the correct weight for implantation. Furthermore, isobutyl cyanoacrylate tissue adhesive used to stabilize external eyelid weights is better tolerated and lasts longer than the previously described fixation method with adhesive tape.

Growth factor receptor expression in orbital lymphangioma: possible therapeutic implications.

objective To examine the expression of molecules targeted by imatinib mesylate (STI571;Gleevec) and epidermal growth factor receptor (EGFR) inhibitors in orbital lymphangiomas. design Retrospective observational case series. participants Six patients with orbital lymphangioma treated at four institutions between March 2000 and December 2002. methods Tissue specimens and medical records from six patients were collected. Immunohistochemical analysis was performed using antibodies against c-kit and platelet-derived growth factor receptor (PDGFR) alpha and beta and EGFR tyrosine kinase.

Periocular abscesses following brow epilation.

Purpose: The aim of this article was to report the clinical presentation, radiography, culture results, treatment modalities, and outcomes of periocular abscesses associated with brow epilation. Methods: This was a retrospective case series including 26 patients referred for periocular abscess following brow epilation. Results: Twenty-six female patients with a median age of 20.5 (range, 12–73) years were referred for oculoplastic evaluation of periocular abscesses related to recent brow epilation. All patients were treated with incision and drainage along with systemic antibiotics. Culture results revealed 16 cases of methicillin-resistant Staphylococcus aureus, 3 of methicillin-sensitive Staphylococcus aureus, and 7 cultures that showed no growth. All patients had resolution of their abscesses at 1-month follow-up visits without progression to orbital cellulitis. Conclusions: Periocular abscess formation after brow epilation has been previously described in only a single case report in the literature. The authors believe this entity is underreported given their current report describing 26 such cases. Given the high prevalence of cosmetic brow epilation in females, the authors believe a careful history regarding brow epilation in any patient presenting with a periocular abscess or preseptal cellulitis is essential to explore the possible cause of their infection. The majority of patients in the current study’s cohort had methicillin-resistant Staphylococcus aureus-related abscesses, and treatment with antibiotics with methicillin-resistant Staphylococcus aureus coverage may be a prudent first line choice in such patients.

Re: "comparison of the exposure rate of wrapped hydroxyapatite (Bio-Eye) versus unwrapped porous polyethylene (Medpor) orbital implants in enucleated patients".

To the Editor: We read with great interest the report by Tabatabaee et al. entitled “Comparison of the Exposure Rate of Wrapped Hydroxyapatite (Bio-Eye) Versus Unwrapped Porous Polyethylene (Medpor) Orbital Implants in Enucleated Patients.” The report insightfully outlines the difficulty in comparing the exposure rates of previous reports due to differing indications for surgery, the size of the implant placed, the presence of previous infection, and the variability among surgical techniques. However, based on our previous experience with unwrapped porous polyethylene (PP) orbital implants, we were surprised by the 34% exposure rate as outlined in the report. This is much higher than previous reports and certainly higher than what we have experienced in our own practice. In their discussion, the authors emphasize the difficulty in comparing exposure rates among different surgeons. However, the outcomes of 2 different surgeons are reported in this study. While their description of the surgical technique used for placement of both implants mirrors a classic textbook description of an enucleation, we are led to assume that the exact procedure is followed by both surgeons. They control for many variables in their study, but interestingly, they do not specify whether both oculoplastic surgeons (Z.T., A.K.) were using PP and hydroxyapatite implants or whether one surgeon was using one implant solely. This could possibly explain the high rate of exposure in relation to one surgeon’s technique. Sadiq et al. described 26 cases of each implant type placed by a single surgeon and reported only one exposure in each group. If both surgeons (Z.T., A.K.) in fact used each implant equally, then factors influencing the selection of the implant type would be helpful in comparing exposure rates. The follow-up duration as outlined by Tabatabaee et al. was 25.7 months for the PP implants with a mean time of 13.5 months for implant exposure to occur. Our exposure rate was 4.4%: 4 out of 91 patients who had unwrapped PP orbital implant following enucleation over a mean period of 10.4 months. While the authors point out the relatively shorter follow-up period of our article, based on their report, a number of patients had exposure of the implant within 10 months following surgery, making our follow-up period relevant for postoperative implant exposure to occur. Other studies in the literature had exposure rates of unwrapped PP orbital implants specifically following enucleation closer to our exposure rate but over a longer follow-up period. We are currently reviewing the 136 cases from our original case series plus subsequent cases in which an unwrapped PP was implanted following enucleation or evisceration. We will report the data when they are available. We do not anticipate that a significantly longer follow-up duration will reveal exposure rates that even approach the 34% reported in this article. We certainly welcome clarification of the points outlined above. The data presented in Tabatabaee’s important article could then be revisited and reanalyzed, which would contribute greatly to our current knowledge of the exposure rate of porous orbital implants following enucleation and to our understanding of appropriate orbital implant selection and improve the surgical techniques used for enucleation.

Lacrimal intubation during dacryocystorhinostomy utilizing the STENTube.

ABSTRACT The traditional use of the Crawford tube for lacrimal intubation during dacryocystorhinostomy (DCR) carries several drawbacks. We describe the use of the STENTube for DCR intubation and detail its advantages. Retrospective, noncomparative, interventional case series; 313 patients with nasolacrimal duct obstruction (NLDO) underwent 339 DCRs (216 external, 123 endonasal) with the STENTube from January 2007 – June 2013 by 5 surgeons (RS, QN, TS, SB, TN) across 3 institutions (SUNY Downstate Medical Center, Texas Oculoplastics Consultants, and Moorfields Eye Hospital). Study outcome measures included patient demographics, surgical complications, and epiphora improvement/resolution. 206 (66%) females and 107 (34%) males had a mean age of 63 years (range 2–94 years). Distribution of diagnoses included: 314 complete idiopathic acquired NLDO, 20 partial idiopathic acquired NLDO, and 5 congenital complete NLDO. 316 (93%) were primary DCRs and 23 (7%) were revisions. Epiphora improved in 312 (92%) cases with 294 (86%) experiencing resolution with patent lacrimal irrigation at a mean last follow-up of 9.4 months. Twenty-eight (8%) patients experienced surgical complications with 16 (5%) experiencing tube prolapse, and 20 (6%) requiring re-operation. The STENTube represents a simple method for lacrimal intubation during external or endonasal DCR at a comparable cost to the Crawford tube. It allows for low prolapse rates without the need for additional endonasal fixation procedures, resulting in a simple and comfortable post-operative extraction without risk of lacrimal trauma. The STENTube is our preferred intubation technique during DCR, and should be considered by oculofacial surgeons performing DCR with intubation.

Orbital floor fracture with entrapment: Imaging and clinical correlations in 45 cases

ABSTRACT Orbital floor fractures (OFF) with entrapment require prompt clinical and radiographic recognition for timely surgical correction. Correct CT radiographic interpretation of entrapped fractures can be subtle and thus missed. We reviewed the clinical, radiographic and intraoperative findings of 45 cases of entrapped OFF to correlate pre- and intraoperative findings with radiography. Retrospective review and statistical analysis of 45 patients with OFF using the chi squared and Kruskal–Wallis tests. Main outcome measures included patient demographics, clinical features, radiologic interpretation, intraoperative findings, and treatment outcomes. Twenty-one cases (47%) had radiologic evaluations of orbital CT scans that included commentary on possible entrapment. Intraoperatively, 16 (76%) of these patients had the inferior rectus muscle incarcerated in the fracture, while 5 (24%) patients had incarceration of the orbital fat. Possibility of entrapment was not commented on in the radiology reports of the remaining 24 (53%) cases. Intraoperatively, 13 (54%) of these patients had the inferior rectus muscle incarcerated in the fracture, while 11 (46%) patients had incarceration of the orbital fat. It is vital to assess the possibility of entrapment, especially in young patients, in the setting of OFF as a delay in diagnosis may lead to persistent diplopia, disfigurement, or bradycardia. Most radiology reports did not mention the possibility of entrapment in this cohort. A key concept is that entrapment occurs when any orbital tissue (muscle or fat) is trapped in the fracture site.

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.