Optimizing Reconstruction with Periorbital Transplantation: Clinical Indications and Anatomic Considerations

Complex periorbital subunit reconstruction is challenging because the goals of effective reconstruction vary from one individual to another. The purpose of this article is to explore the indications and anatomic feasibility of periorbital transplantation by reviewing our institutional repository of facial injury.

METHODS

Institutional review board approval was obtained at the R Adams Cowley Shock Trauma Center for a retrospective chart review conducted on patients with periorbital defects. Patient history, facial defects, visual acuity, and periorbital function were critically reviewed to identify indications for periorbital or total face (incorporating the periorbital subunit) vascularized composite allotransplantation. Cadaveric allograft harvest was then designed and performed for specific patient defects to determine anatomic feasibility. Disease conditions not captured by our patient population warranting consideration were reviewed.

RESULTS

A total of 7 facial or periorbital transplant candidates representing 6 different etiologies were selected as suitable indications for periorbital transplantation. Etiologies included trauma, burn, animal attack, and tumor, whereas proposed transplants included isolated periorbital and total face transplants. Allograft recovery was successfully completed in 4 periorbital subunits and 1 full face. Dual vascular supply was achieved in 5 of 6 periorbital subunits (superficial temporal and facial vessels).

CONCLUSIONS

Transplantation of isolated periorbital structures or full face transplantation including periorbital structures is technically feasible. The goal of periorbital transplantation is to re-establish protective mechanisms of the eye, to prevent deterioration of visual acuity, and to optimize aesthetic outcomes. Criteria necessary for candidate selection and allograft design are identified by periorbital defect, periorbital function, ophthalmologic evaluation, and defect etiology.

The Usage of a Conjunctival Flap to Improve Retention of Boston Type 1 Keratoprosthesis in Severe Ocular Surface Disease

PURPOSE

The Boston keratoprostheses type 1 devices (KPro) are utilized in cases unfavorable to penetrating keratoplasty. The prognosis remains guarded in cases of ocular surface disease due to risk of tissue necrosis. We describe a novel surgical approach using a conjunctival flap with a delayed opening to improve retention.

METHODS

In three patients with advanced cicatrizing conjunctivitis, a Type 1 keratoprosthesis was stabilized using a full tarsal conjunctival flap. Three months postoperatively, an opening was created in the flap overlying the optical portion of the device.

RESULTS

All patients had no device related complications over a mean follow-up period of 17.7 months (range 15-21 months) and vision remained excellent at better than 20/200 for all patients.

CONCLUSIONS

Utilization of a tarsal flap either primarily as part of a two stage modified technique or secondarily in cases of tissue necrosis and impending device extrusion might maximize retention of the type 1 KPro.

Ocular manifestations of xeroderma pigmentosum: long-term follow-up highlights the role of DNA repair in protection from sun damage

OBJECTIVE

Xeroderma pigmentosum (XP) is a rare autosomal recessive disease caused by mutations in DNA repair genes. Clinical manifestations of XP include mild to extreme sensitivity to ultraviolet radiation resulting in inflammation and neoplasia in sun-exposed areas of the skin, mucous membranes, and ocular surfaces. This report describes the ocular manifestations of XP in patients systematically evaluated in the Clinical Center at the National Institutes of Health.

DESIGN

Retrospective observational case series.

PARTICIPANTS

Eighty-seven participants, aged 1.3 to 63.4 years, referred to the National Eye Institute (NEI) for examination from 1964 to 2011. Eighty-three patients had XP, 3 patients had XP/Cockayne syndrome complex, and 1 patient had XP/trichothiodystrophy complex.

METHODS

Complete age- and developmental stage-appropriate ophthalmic examination.

MAIN OUTCOME MEASURES

Visual acuity; eyelid, ocular surface, and lens pathology; tear film and tear production measures; and cytologic analysis of conjunctival surface swabs.

RESULTS

Of the 87 patients, 91% had at least 1 ocular abnormality. The most common abnormalities were conjunctivitis (51%), corneal neovascularization (44%), dry eye (38%), corneal scarring (26%), ectropion (25%), blepharitis (23%), conjunctival melanosis (20%), and cataracts (14%). Thirteen percent of patients had some degree of visual axis impingement, and 5% of patients had no light perception in 1 or both eyes. Ocular surface cancer or a history of ocular surface cancer was present in 10% of patients. Patients with an acute sunburning skin phenotype were less likely to develop conjunctival melanosis and ectropion but more likely to develop neoplastic ocular surface lesions than nonburning patients. Some patients also showed signs of limbal stem cell deficiency.

CONCLUSIONS

Our longitudinal study reports the ocular status of the largest group of patients with XP systematically examined at 1 facility over an extended period of time. Structural eyelid abnormalities, neoplasms of the ocular surface and eyelids, tear film and tear production abnormalities, ocular surface disease and inflammation, and corneal abnormalities were present in this population. Burning and nonburning patients with XP exhibit different rates of important ophthalmologic findings, including neoplasia. In addition, ophthalmic characteristics can help refine diagnoses in the case of XP complex phenotypes. DNA repair plays a major role in protection of the eye from sunlight-induced damage.

Primary mucinous carcinoma of the periocular region: successful management with local resections over 30 years

Primary mucinous carcinoma of the skin is a rare malignant neoplasm, often with periocular involvement, believed to originate from eccrine sweat glands. It is slow growing and locally destructive, at times forming tumour satellites. We present a case with six local recurrences treated with surgical resections over a period of 30 years. We have not been able to find longer follow-up in the literature, and believe this case may offer insight into the management of these uniquely indolent malignancies.

Secondary infection affecting one of two simultaneously placed orbital wall implants

A 10-year-old boy experienced traumatic injuries to the right bony orbit, which were repaired with a nylon foil and a barrier porous polyethylene orbital implant. Three years after surgery, he presented with maxillary and ethmoid sinusitis with infection of the nylon foil plate. This plate was removed, yielding complete recovery.

Asymptomatic conjunctival mucosa-associated lymphoid tissue-type lymphoma with presumed intraocular involvement

PURPOSE

To report a case of conjunctival mucosa-associated lymphoid tissue (MALT) lymphoma with presumed intraocular involvement.

METHODS

Observational case report.

RESULTS

A 73-year-old white man presented for a routine eye examination and was found to have a salmon-colored bulbar conjunctival mass of the left eye. Ultrasound showed a low-reflective mass with diffuse thickening of the ciliary body and choroid. Immunohistochemistry and flow cytometry of an incisional biopsy specimen suggested a polyclonal lesion. Treatment with topical steroids yielded no clinical improvement, and excisional biopsy was performed. A diagnosis of MALT lymphoma was made after polymerase chain reaction (PCR) analysis of the immunoglobulin heavy chain (IgH) locus revealed a clonal B-cell population.

CONCLUSIONS

Conjunctival MALT lymphoma can present without symptoms and can extend intraocularly. PCR analysis of the IgH locus can identify lesion clonality when immunohistochemistry and flow cytometry fail to do so.

New Corticosteroid-eluting Porous Polyethylene Implant for the Management of Lower Eyelid Retraction: A Pilot Study

PURPOSE

Lower eyelid retraction after trauma presents a challenging management problem. We postulated that a porous polyethylene (pPE) eyelid spacer coated with a polyvinyl alcohol (PVA) and triamcinolone acetonide (TA) matrix could deliver corticosteroid locally over extended periods and modulate inflammation and scar formation. We designed a pPE corticosteroid-eluting implant and evaluated its characteristics in vitro and in vivo.

METHODS

The release characteristics of pPE implants coated with a PVA/TA matrix of low, intermediate, and high doses of TA were studied in vitro. The implants were then placed in the posterior lamella of lower eyelids of Dutch Belted rabbits for 12 weeks. Clinical events were recorded and eyelids were examined for gross and histologic features, including capsular thickness and degree of vascularity, fibrovascular ingrowth, and inflammatory response.

RESULTS

In vitro, implants coated with the intermediate and high doses of TA released the drug at a steady rate for at least 78 days. In rabbits, the PVA and PVA/TA coating prevented fibrovascular ingrowth, except where breaks in the PVA/TA coat were present. Implants with PVA/TA coating demonstrated less inflammation and capsule vascularity. An inverse correlation between TA dose and capsule thickness was noted.

CONCLUSIONS

We describe a novel drug-release pPE eyelid implant. The corticosteroid-eluting implant demonstrated antiangiogenic and anti-inflammatory properties, which could prove beneficial in the treatment of lower eyelid retraction.

Effect of 0.5% apraclonidine on ptosis in Horner syndrome

To demonstrate the effect of apraclonidine on anisocoria and ptosis in Horner syndrome, one drop of 0.5% apraclonidine was instilled in both eyes of 3 patients who presented with acute Horner syndrome, and the effect on ptosis and anisocoria was documented. As reported in the literature, one drop of 0.5% apraclonidine reverses the anisocoria of Horner syndrome. In addition, 0.5% apraclonidine leads to a complete resolution of the ptosis associated with Horner syndrome, a finding reported once in the literature. Apraclonidine is a safe and readily available alternative to cocaine for the diagnosis of Horner syndrome.

Periocular petrolatum

PURPOSE

This report describes the clinical and histopathologic features and discusses the diagnostic difficulties and management of periocular deposition of petrolatum-based materials.

METHODS

Excision of orbital and eyelid tissue, tissue processing, and histopathologic examination was performed in patients with deposition of petroleum-based products. Transmission electron microscopy was performed in 3 cases.

RESULTS

Between 1983 and 2003, 11 patients were diagnosed with periocular petrolatum deposition, based on clinical history and the characteristic histopathologic features of polymorphic dropout spaces, and varied from a noninflammatory lesion (paraffinoma) to those with an associated granulomatous inflammatory reaction.

CONCLUSIONS

The diagnosis of petrolatum deposition can be challenging due to the range of symptoms and variable delay in presentation. Petrolatum products should be avoided during surgery and used judiciously in the postoperative period. To avoid confusion with nonspecific cases of lipogranulomatous inflammation, the terms "ointment granuloma" or "orbital paraffinoma" should be used to refer to patients presenting with orbital/eyelid lesions caused by ointment use.

Simple Outpatient Postoperative Analgesia Using an Orbital CatheterAfter Enucleation

OBJECTIVE

To evaluate an indwelling orbital catheter, placed at enucleation, for repeatable delivery of local anesthetic on an outpatient basis.

METHODS

A retrospective, noncomparative, case series medical record review was performed of patients undergoing enucleation and receiving an indwelling orbital pain-control catheter at surgery by us from January 1, 1998, through December 31, 2001. Medical records were reviewed for hospitalization status postoperatively. Medical records of those patients treated on an outpatient basis were reviewed for patient and family comments about ease of use of the pain-control catheter and the degree of pain control and for any complications associated with catheter use. The main outcome measures included documented patient and family comments and physician medical record notes about catheter use and complications.

RESULTS

Of the 85 patients, 67 were treated on an outpatient basis. The other 18 patients required a postoperative hospital admission for unassociated medical problems. Of the 67 patients, 58 (87%) reported using the catheter at home at least once. Of these 58 patients, 10 reported mild discomfort with catheter use, but in no case did the patient discontinue catheter use because of discomfort. All patients using the catheter reported pain relief lasting from 1(1/2) to 4 hours. No postoperative complications associated with catheter placement were observed.

CONCLUSION

The orbital pain-control catheter allows a caregiver to easily and repeatedly deliver local anesthetic to the operative site following enucleation, resulting in effective postoperative analgesia while the patient recovers at home.

LASIK, blepharoplasty, and dry eyes

Because LASIK and blepharoplasty both may cause dry eye symptoms, the possible cumulative effect of these surgeries is a serious consideration. The author discusses the physiological mechanisms in these procedures that can lead to dry eye and provides practical guidelines for evaluating patients. (Aesthetic Surg J 2002;22:382-383.).

Histiocytoid variant of eccrine sweat gland carcinoma of the eyelid and orbit: report of five cases

OBJECTIVE

To study the clinicopathologic features of the histiocytoid variant of adenocarcinoma of the eccrine sweat gland of the eye and orbit.

DESIGN

Retrospective case series.

PARTICIPANTS

Five patients undergoing orbital and eyelid biopsy as a diagnostic procedure.

METHODS

The authors examined the clinical histories and pathologic findings of five patients with eccrine adenocarcinoma of the eyelid with orbital invasion.

MAIN OUTCOME MEASURES

Clinical and histopathologic examinations, including routine histopathology, immunohistochemistry, and electron microscopy studies.

RESULTS

The tumors presented as insidious, diffusely infiltrative, firm cutaneous masses in the periocular area that later infiltrated the orbit. Histopathologic examination revealed that the tumors infiltrated the dermis and were composed of cells with a histiocytic to signet ring appearance. Tumor cells exhibited intracellular mucin production. Immunohistochemical stains were positive in tumor cells for low and high molecular weight cytokeratins, carcinoembryonic antigen, and epithelial membrane antigen. Electron microscopic examination showed lumen formation and intracytoplasmic mucin in tumor cells.

CONCLUSIONS

The histiocytoid variant of adenocarcinoma of the eccrine sweat gland of the eyelid may present as an insidious tumor and diffusely invade the orbit. These cases may be confused with metastatic adenocarcinoma.

Exposure keratopathy after cosmetic CO2 laser skin resurfacing

PURPOSE

To report two cases of exposure keratopathy after cosmetic CO2 laser skin resurfacing.

METHODS

Two patients presented with bilateral intrapalpebral epitheliopathy. They were examined, treated, and followed for several weeks.

RESULTS

Nonsurgical treatment options, including a variety of lubricants, punctal plugs, and lid taping, did not lead to a complete resolution of symptoms. Surgical options were recommended.

CONCLUSION

Exposure keratopathy should be recognized as a potential side effect of not only incisional lid surgery but also facial CO2 laser skin resurfacing procedures.

Understanding the origin of visual percepts elicited by electrical stimulation of the human retina

BACKGROUND

The success of a retinal prosthesis for patients with outer retinal degeneration (ORD) depends on the ability to electrically stimulate retinal cells other than photoreceptors. Experiments were undertaken in human volunteers to ascertain whether electrical stimulation of cells other than photoreceptors will result in the perception of light.

METHODS

In two subjects, two areas of laser damage (argon green and krypton red) were created in an eye scheduled for exenteration due to recurrent cancer near the eye. In the operating room prior to exenteration, under local anesthesia, a hand-held stimulating device was inserted via the pars plana and positioned over the damaged areas and normal retina. Subjects' psychophysical responses to electrical stimulation were recorded.

RESULTS

In both subjects, electrical stimulation produced the following perceptions. Normal retina: dark oval (subject 1), dark half-moon (subject 2); krypton red laser-treated retina: small, white light (both subjects); argon green laser treated retina: thin thread (subject 1), thin hook (subject 2). Histologic evaluation of the krypton red-treated retina showed damage confined to the outer retinal layers, while the argon green-treated area evinced damage to both the outer and the inner nuclear layers.

CONCLUSION

The perception produced by electrical stimulation was dependent on the retinal cells present. Electrical stimulation of the krypton red-ablated area best simulated the electrically elicited visual perceptions of our blind, ORD patients, suggesting that the site of stimulation in blind patients is the inner retinal neurons.

Congenital cystic eye: report of two cases and review of the literature

A 13-month-old boy and a 2-week-old girl, who were considered to be anophthalmic and who later each developed a cystic lesion in the left orbit with protrusion of the lower eyelid, were studied. The fellow eye in case 1 was subsequently found to be microphthalmic with cyst and was normal in case 2. Histopathologic study of each case revealed a cyst lined externally by dense fibrous connective tissue to which skeletal muscle and adipose tissue were attached. The inner aspect of the cyst was lined by neuroglial tissue, possible immature retinal tissue, and cuboidal epithelium. No fully developed ocular structures or microphthalmos were identified. Fourteen cases of congenital cystic eye, including our cases, have been published in the English-language literature since 1964. We discuss and illustrate the findings in our cases and 10 others in which histopathologic findings were reported. Congenital cystic eye, microphthalmos with cyst, and microphthalmos with cystic teratoma should be suspected in patients with a small or unrecognizable eye and an orbital cystic mass that is detected by palpation or visualization.

Prevention of prolapsed silicone stents in lacrimal intubation using an intrasac fixation suture

Silicone stents are routinely used for the maintenance of patent mucosal passages in patients with nasolacrimal disorders. A common complication associated with the use of silicone stents is lateral migration or displacement of the tubes, which can be difficult to correct. This report describes a modified Quickert-Dryden approach with fixation of the tubes by an intrasac suture. From 1990 to 1996, 53 patients had silicone stents placed by this method with no complications related to tube displacement. The intrasac fixation suture has distinct advantages over other fixation methods.

Clinicopathological correlation of technetium bone scan in vascularization of hydroxyapatite implants. A primate model

OBJECTIVES

To report the histopathological and bone scan characteristics of the stages of hydroxyapatite fibrovascular integration and to consider the implications for the timing of peg drilling in a primate model.

DESIGN

Three monkeys received hydroxyapatite implants covered only anteriorly with a fascia lata button to which the rectus muscles were sutured. Weekly bone scans were evaluated quantitatively and qualitatively. The orbits were harvested at 2, 4, and 8 weeks and examined histopathologically.

RESULTS

Quantitatively, the implant's technetium uptake increased, then reached a plateau by 4 weeks. Peripheral uptake was present on the images and histologically at 2 weeks. When bone scan images suggested complete vascularization by the fourth week, the implant was 99% vascularized histologically. Completion of vascularization was ascertained at 8 weeks, without further discernible changes in the bone scans.

CONCLUSIONS

The technetium bone scan is sensitive to the vascularization of the hydroxyapatite implant and discerns when complete vascularization is approached. This primate study models closely the clinical findings we have recently reported. We advocate at least a 4-week interval between the time the bone scan suggests full vascularization and peg drilling.

Strategies for the treatment of enophthalmos

The surgical correction of post-traumatic enophthalmos is among the most challenging problems for the surgeon. A thorough understanding of orbital anatomy and the purposed mechanisms of enophthalmos is crucial to the ultimate success or failure of the procedures. The successful orbital reconstruction begins with a careful physical examination of the patient that is attentive to ocular function, soft-tissue position, and visible or palpable defects of the facial skeleton. The physical examination combined with thin section CT scanning in the axial and coronal planes provides the basis of the operative plan. The anatomy of the deformity should dictate the anatomy and shape in the surgical correction. In many cases, multiple surgical incisions will be required; therefore, care must be taken to maximize exposure and minimize the cosmetic problems associated with large incisions. We advocate a step-wise approach consisting of mobilization of the soft tissues in the area of the fracture, repositioning of the anterior and middle sections of the bony orbit, and reattachment of the soft tissue to the bone at the proper location. The approach to reconstruction of the bony orbit that we advocate is to first sequentially reposition each segment of the rim, carefully examining each articulation. Once rim reconstruction is complete, reconstruction of the internal wall is performed. Recall that the largest source of error is in inadequate reduction of the orbital rim, owing to the fact that this error is "squared" (according to the model) in the computation of the orbital volume. Through the application of these principles, the cosmetic and functional sequelae of post-traumatic enophthalmos can be improved greatly with minimal complications.

Less common orbital fracture patterns: the role of computed tomography in the management of depression of the inferior oblique origin and lateral rectus involvement in blow-in fractures

During the past decade, advances in radiographic imaging have made it possible for the surgeon managing orbital fractures to adopt a rational therapeutic strategy based on a knowledge of alterations in surgical anatomy secondary to traumatic injury. To illustrate the value of computed tomography in the surgeon's armamentarium for management of orbital fractures, cases are presented in which imaging proved decisive in planning a course of therapy. Two patients presented with two types of isolated lateral blow-in fracture, an uncommon fracture pattern. The other cases underscore the value of defining involvement of the inferior oblique origin and lateral rectus muscles in imaging complex orbital fractures, issues not emphasized in earlier literature. Although diplopia alone does not always warrant surgical intervention, diplopia in the context of computed tomography-defined muscle entrapment or muscle origin displacement justifies operative therapy. These cases demonstrate the value of computed tomography in directing surgical therapy with resolution of diplopia and prevention and correction of enophthalmos.

Quantitative measurement of vascularization and vascular ingrowth rate of coralline hydroxyapatite ocular implant by Tc-99m MDP bone imaging

Complete fibrovascular ingrowth of the hydroxyapatite ocular implant is necessary for peg drilling, the secondary procedure that couples the mobile sphere to the ocular prosthesis providing it with motility. This study was conducted to determine the usefulness of the bone scan for the evaluation and relative quantification of the vascularization of coralline hydroxyapatite ocular implants. In 23 patients (32 scans), vascularization of the ocular implant was measured by three-phase bone scintigraphy. There were 16 patients with left, and 7 with right orbital implants. At followup 0.5 to 8 months after successful hydroxyapatite implantation, the mean implant to normal intraorbital activity ratio on delayed bone scans in anterior view was 2.73 +/- 0.73 (mean +/- SD) with a range of 1.42-4.2. The normal right to left and left to right intraorbital bone activity ratios determined in anterior view from 10 normal delayed bone scans were 0.98 +/- 0.05 (mean +/- SD) and 1.02 +/- 0.05 (mean +/- SD) respectively, with a range of 0.93-1.07. The difference of the activity (count) ratios among the successfully implanted group and normals was statistically significant (P < 0.0001). A hydroxyapatite ocular implant to contralateral intraorbital bone activity ratio of greater than 1.12 with a homogeneous tracer distribution throughout the implant suggests adequate and diffuse vascularization is present. The progressive increase in activity ratio of the orbital implants seen in the early postimplantation period, which is indicative of the progression of vascularization, reaches a plateau after 1 month and remains relatively stable thereafter.(ABSTRACT TRUNCATED AT 250 WORDS)

Use of Medpor porous polyethylene implants in 140 patients with facial fractures

Use of alloplastic materials in facial bone reconstruction is still controversial. Medpor porous polyethylene is a relatively new implant material that is well suited for this purpose and has a number of advantages over other alloplasts. It is a pure polyethylene with a unique manufacturing process and pore size. Technically, it is easy to work with; it can be carved, contoured, adapted, and fixated to obtain a precise three-dimensional construct. Physically, it is a pure, biocompatible, strong substance that does not resorb or degenerate. It demonstrates long-term stability, high tensile strength, resistance to stress and fatigue, and a virtual lack of surrounding soft-tissue reaction. Rapid tissue ingrowth occurs into the pores. Extensive vascular ingrowth creates the potential to transport cellular products that fight infection deep into the implant. The implant was used in 140 patients from June 1988 to August 1991 to treat acute orbitozygomatic injuries (71), acute Le Fort injuries (24), delayed orbitozygomatic injuries (33), and delayed onlay augmentation (12). In this series, there was 1 instance of implant infection requiring removal, and no implant migration, or exposure.

The ophthalmic implications of the correction of late enophthalmos following severe midfacial trauma

Severe midfacial trauma presents several challenges to the reconstructive surgeon. Acute rigid fixation of the facial skeleton accompanied by bone grafting to restore the confines and volume of the orbit provide the best opportunity for acceptable aesthetic results. The severity of the trauma causes the late postoperative complication of enophthalmos. Injury to orbital structures with subsequent cicatricial change results in significant alteration in extraocular motility with resultant diplopia. There are no reports in the literature which critically evaluate the effect of late enophthalmos correction on extraocular motility, diplopia, and vision in patients who have suffered Le Fort or NOE fractures. A retrospective study is presented which reviews the results of late surgery for the correction of enophthalmos in 40 patients, all of whom had severe "impure" orbital fractures. This study addresses the following questions: (1) Can the globe effectively be repositioned?, (2) Is there a change in subjective diplopia?, (3) Does a change in extraocular motility occur, and if it does, is it predictable?, (4) Is there a risk to visual acuity? and finally, (5) Do the answers to questions 1 through 4 suggest that late surgical intervention for the correction of enophthalmos should be recommended for this patient population? During a 9-year period, 44 patients with severe diplopia trauma received surgery for enophthalmos correction. A review of 40 patients on whom 56 operations were performed is presented. Thirty-eight patients had enophthalmos and 35 had inferior displacement of the globe. Medial displacement of the globe occurred in 11 patients. Twenty-nine patients had diplopia. Six patients had vision too poor on the injured side to have diplopia. Enophthalmos was improved in 32 patients. Dystopia of the globe was improved in 31 cases. However, neither enophthalmos nor dystopia of the globe could be improved with every operation. Only 35 of the 48 operations for enophthalmos for which measurements were available produced an improvement; in 1 case the enophthalmos was thought to be worse postoperatively. Dystopia operations resulted in improvement in 40 of 48 operations; in 2 instances dystopia was worse postoperatively. Diplopia was unchanged by 33 operations, improved by 11 procedures, and worsened by 6. If patients are considered before and after their total reconstruction course, diplopia was improved in 9 of the 29 patients. In seven of these nine, diplopia was eliminated. There was no change in or production of diplopia in 19 patients, and 5 patients had worsening of their double vision.(ABSTRACT TRUNCATED AT 400 WORDS)

Rigid fixation of internal orbital fractures

When large portions of the internal orbit are destroyed (two to four walls), standard bone-grafting techniques for immediate and late orbital reconstruction may not yield predictable eye position. Critical bone support is most often deficient inferomedially. CT analysis of orbital volume in cases where eye position was unsatisfactory reveals that displacement of bone grafts is one mechanism of the unsatisfactory result. Other mechanisms include undercorrection and bone-graft resorption. In order to minimize postoperative bone-graft displacement, titanium implants were used to span large defects in the internal orbit to provide a platform for bone-graft support. Twenty-six implants were placed in immediate and 12 were placed in late orbital reconstructions. More reliable bone-graft position resulted. Two late infections have occurred resulting in implant removal in a 3-year period.

Nasoethmoidal and orbital fractures

It is helpful to consider fractures of the orbit both in terms of their location and fracture pattern. CT scanning is an invaluable aid to the diagnosis and treatment of all orbital fractures. Early operative intervention, wide exposure, and accurate and stable fixation accompanied by immediate bone grafting provide the most successful treatment of fractures of the orbit.

Early and late complications of orbital fractures

Complications, unfortunately, arise as a result of traumatic or iatrogenic injuries. The sequelae can range from the most insignificant to the most debilitating. The most common complications noted in the diagnosis and treatment of orbital fractures are outlined as well as discussed as appropriate to their appearance during the healing process. With better understanding and better management, complications can be prevented.

Hemangiopericytoma of the orbit treated with conservative surgery and radiotherapy

A 23-year-old man had two recurrences following local excision of a hemangiopericytoma of the right orbit. A third local excision was followed by a course of postoperative radiation therapy (64.8 Gy [6480 rad] in 36 treatments). Seven and a half years following therapy, the patient is disease free and has experienced no side effects.

Squamous cell carcinoma of the eyelids

A clinicopathologic study of 31 squamous cell carcinomas of the eyelid was conducted. The tumor was encountered less frequently than in previous reports, due largely to the refinement of the pathologic diagnosis. Eighteen cases originally diagnosed as squamous cell carcinoma were eliminated because the diagnoses were changed to sebaceous gland carcinoma (10), basal cell carcinoma (4), seborrheic keratosis (2), inverted follicular keratosis (1), and papilloma (1). One of our 31 patients experienced tumor metastasis and tumor-related mortality. Despite the low incidence of metastasis, management recommendations include complete surgical excision using intra-operative frozen-section monitoring of the surgical margins.

Deep orbital reconstruction for correction of post-traumatic enophthalmos

Post-traumatic enophthalmos is a complex orbital deformity resulting from an injury disrupting orbital bone and ligament support, allowing displacement and a change in shape of the orbital soft-tissue contents. Clinically, this is manifested by inferior and posterior displacement of the globe, pseudoptosis, and deepening of the supratarsal fold. Soft-tissue changes such as canthal malposition and shortening of the horizontal dimension of the palpebral fissure are present when unreduced nasoethmoidal orbital fractures exist. The essential principles of surgical correction include full dissection of the bony orbital soft tissues including the posterior orbit with restoration of bony orbital volume by the judicious insertion of bone grafts to correct the vertical as well as the anteroposterior position of the ocular globe. The combination of techniques of craniofacial exposure, osteotomy, and bone grafting allow the condition of post-traumatic enophthalmos to be greatly improved with minimal complications.

Mechanisms of global support and posttraumatic enophthalmos: I. The anatomy of the ligament sling and its relation to intramuscular cone orbital fat

The mechanisms of posttraumatic enophthalmos were evaluated to determine the interrelation between fat and ligaments in globe support. Anatomic studies demonstrate that the ligaments form an essential "sling" framework for the globe but are alone insufficient to maintain the globe's full forward position. Removal of extramuscular fat in cadavers and in patients undergoing blepharoplasty did not significantly change globe position. Loss of intramuscular cone fat (atrophy or displacement) in cadavers and patients produced enophthalmos. Fat atrophy is not a prominent feature in most patients with posttraumatic enophthalmos. Some loss of intramuscular cone fat from displacement outside the muscle cone is frequently present. The principal mechanism, however, of posttraumatic enophthalmos involves a displacement and change in the shape of orbital soft tissue. Loss of bone and ligament support permits posterior displacement and a reshaping of orbital soft tissue under the influence of gravity and the remodeling forces of fibrous scar contracture. The shape of the retrobulbar orbital contents changes from a modified cone to a sphere, and the globe sinks backward and downward. Given that the volume of orbital soft tissue is constant following trauma, procedures to restore the shape and position of the orbital soft tissue by mobilization and bone reconstruction will correct or significantly improve enophthalmos.

Hemangiopericytoma of the conjunctiva. Two cases

Two patients with hemangiopericytoma of the conjunctiva are reported. The first patient, a 40-year-old woman with a six-month history of a conjunctival mass, presented with a lesion confined to the conjunctiva. The second patient, a 43-year-old man, presented with a one-year history of a conjunctival mass. Excisional biopsy and histopathologic examination showed both lesions to be a hemangiopericytoma; an uncommon tumor of the conjunctiva.

Allergic periorbital mucopyocele in children

Two patients, an 11-year-old boy and a 13-year-old girl, with firm nontender progressive swelling in the medial canthal region also had histories of asthma and peripheral eosinophilia. Radiologic studies disclosed ethmoidal sinus ectasia and opacification. At surgery, a firm mass that filled the sinus was found in each case. Histologically, these masses consisted of inspissated mucus and a dense infiltrate in eosinophils. Surgical drainage resulted in a cure of one case and improvement in the other. Because of the marked allergic diathesis in both patients and the specific or unique character of the sinus contents, we propose the term allergic periorbital mucopyocele for this disorder.

Corneal astigmatism from conjunctival cysts

Two patients had decreasing visual acuity because of corneal astigmatism induced by a conjunctival cyst. In both cases, surgical removal of the cyst resulted in marked improvement because of a reduction in astigmatism. In one case, the cause of decreased visual acuity was unknown for two years; keratometry and a careful examination of the eyelids disclosed the cyst.

Spindle cell carcinoma of the conjunctiva

Spindle cell carcinoma, a variant of squamous cell carcinoma, has long been recognized in numerous tissues (including the skin, the upper respiratory tract, the oral cavity, and the esophagus). Two cases of spindle cell carcinoma of the conjunctiva are reported here. Histopathologic examination of these cases shows the characteristic spindle-shaped cells in continuity with the overlying epithelium. Electron microscopy of one case showed desmosomes and cytoplasmic tonofibril-like material. Our direct experience with one of these two cases has shown the malignant neoplasm to be aggressive.

Partial and total reconstruction of the lower eyelid

Our techniques for reconstruction of the lower lid are based on the maintenance of tarsal support in the reconstructed lid. The surgical approach is dictated by the position and extent of the defect produced by tumor excision. Lysis of the extension of the lateral canthal ligament to the lower lid allows closure of small, full-thickness defects. Mobilization of tarsal remnants by temporal advancement flaps provides for closure of larger defects. An advancement flap of split-thickness upper lid tarsus is combined with a pedicle flap of skin from the upper lid for total lower lid reconstruction.