Innovative Curriculum to Train Medical Students on Lateral Canthotomy and Cantholysis.

PURPOSE: Orbital compartment syndrome (OCS) is an ocular emergency requiring prompt decompression with a lateral canthotomy and cantholysis (LCC) within 2 hours. This study evaluates the feasibility and effectiveness of a standardized LCC curriculum to train medical students to identify and treat OCS. METHODS: This was a prospective, non-randomized, non-comparative cohort study of 39 novice first-year medical students with no prior LCC training who underwent a standardized LCC curriculum incorporating both didactic and hands-on procedural training. Didactic knowledge of orbital anatomy and OCS was evaluated with written pre- and post-knowledge testing. Expert performance criteria were determined by expert consensus based on the performance of three oculoplastic surgeons and were defined as correctly performing all 12 critical checklist steps of an LCC within 3 minutes twice consecutively on a Sonalyst LCC training system eye model. Utilizing the principles of mastery learning, participants learned how to perform an LCC in a classroom environment and were evaluated on a final test of proficiency in a training lane designed to simulate an austere military environment. RESULTS: Participants required a median of 3.0 practice iterations to achieve expert performance in the classroom environment. During the testing phase, all participants correctly identified the eye with OCS, and 77% (n = 30) of learners successfully performed an LCC at the expert level within their first attempt. The median completion time of those who passed on their first testing was 130 seconds. The mean LCC knowledge test scores significantly improved from 48.7% to 71.2% (P < .001). CONCLUSION: This study successfully developed a standardized LCC curriculum utilizing the principles of hands-on mastery learning to train novice learners to perform an LCC efficiently and effectively.

Fusobacterium necrophorum Orbital Cellulitis With Intraconal Abscess.

A 19-year-old male presented to the emergency department with progressive right eye proptosis and was subsequently diagnosed with bacterial orbital cellulitis and acute on chronic allergic fungal sinusitis. He experienced brief symptomatic improvement after endoscopic sinus surgery, initiation of antibiotics, and steroid treatment; however, he re-presented five days after discharge with significantly worsened symptoms and no light perception in the right eye. Cultures resulted in Aspergillus and Fusobacterium necrophorum, a rare, aggressive etiology of bacterial orbital cellulitis. He developed an intraconal abscess requiring multiple orbitotomies for decompression and abscess drainage. To our knowledge, only eight prior cases of F. necrophorum orbital cellulitis have been reported in the literature (excluding the present case) and our patient is the first case of this organism causing an intraconal abscess. The authors discuss the importance of early recognition and close follow-up of F. necrophorum orbital infections.

Single-staged Tunneled Forehead Flap for Medial Canthal and Eyelid Reconstruction.

Purpose: The paramedian forehead flap, while initially used for reconstruction of nasal defects, has been adapted for repair of anatomical subunits in the medial canthal and eyelid area. A significant obstacle for utilizing the flap has been the bulky, unsightly vascular pedicle that is maintained between surgical stages. We describe our surgical experience using the tunneled variation in a single stage procedure. Methods: A retrospective chart review was performed of three surgeons' charts over a 5-year period. All patients who underwent the tunneled paramedian forehead flap variation were selected. Outcomes measured included underlying pathology, Mohs defect area and depth, and canalicular involvement. Results: A total of 20 tunneled flaps were performed after successful Mohs excision of cutaneous malignancies. The average Mohs defect surface area was 13.57 cm2 with depth down to periosteum (n = 13), bone (n = 5), or orbital fat (n = 2). Five patients had full-thickness eyelid defects (25%), and nine (45%) had canalicular defects. The overall complication rate for this study was low with no flap failure. Two patients (10%) desired thinning of the subcutaneous flap for improved cosmesis, and one patient (5%) required further eyelid revision due to the complexity of the initial Mohs defect. The remaining 17 patients required no further surgical procedures. Conclusion: The tunneled paramedian forehead flap is a useful technique for medial canthal and eyelid reconstruction. This technique allows reconstruction of a challenging area. Complication rates are low, and this tunneled variation provides a single stage variation to the traditional multistage forehead pedicle flap.

Gastrointestinal stromal tumor metastatic to the orbit.

A 53-year-old woman was referred to the authors with a history of left eyelid swelling and retro-orbital pain. She had a history of a prior stomach gastrointestinal stromal tumor (GIST) with metastasis to the liver and intrahepatic bile duct. Examination showed global motility restriction with no relative afferent pupillary defect, and exophthalmometry confirmed 4 mm of left-sided proptosis. Computed tomography imaging showed a heterogeneous mass involving the left inferior rectus muscle with extension to the optic nerve measuring 32.5 mm anterior to posterior and abnormal thickening of the right inferior rectus muscle. An incisional biopsy was performed through a left inferior orbitotomy. Histopathological examination revealed an orbital mass with epithelioid morphology consistent with a metastatic GIST. Immunohistochemical analysis revealed positivity for CD-117 and Dog-1, and negativity for Myogenin. This represents the fifth biopsy-proven GIST metastatic to the orbit in the literature, only the second case with predominantly epithelioid morphology, and only the second case with bilateral orbital metastasis. The authors detail the relevant clinical history, imaging, and pathology.

Dexamethasone-Eluting Contact Lens for the Prevention of Postphotorefractive Keratectomy Scar in a New Zealand White Rabbit Model.

PURPOSE: To evaluate the safety and efficacy of an experimental dexamethasone-eluting contact lens (DCL) for the prevention of postphotorefractive keratectomy (PRK) corneal haze in a New Zealand White (NZW) rabbit model. METHODS: Both eyes of 29 NZW rabbits underwent PRK. The rabbits were randomized to one of the 5 study arms for 4 weeks: tarsorrhaphy only, tarsorrhaphy and bandage contact lens (BCL) replaced weekly, tarsorrhaphy and BCL for 1 week plus topical 0.1% dexamethasone ophthalmic solution (drops) for 4 weeks, tarsorrhaphy and BCL replaced weekly plus topical dexamethasone for 4 weeks, and tarsorrhaphy and DCL changed weekly for 4 weeks. Each week for 4 consecutive weeks postoperatively, the tarsorrhaphies were opened, the eyes underwent evaluation and imaging, and the tarsorrhaphies were replaced. Contact lenses were cultured on removal. Central corneal haze was assessed weekly with corneal densitometry. After 4 weeks, the animals were killed, and the eyes were enucleated for histopathologic analysis. RESULTS: The tarsorrhaphy only group displayed more haze with a greater change in optical densitometry from pre-op compared with the other treatment groups. There was no difference between the DCL group and the groups receiving a BCL and dexamethasone drops in densitometry or histopathology. No NZW rabbits developed clinical signs of infection, and cultures from DCLs and BCLs grew similar organisms. CONCLUSIONS: In the post-PRK rabbit model, DCLs worn weekly for 4 weeks were safe and as effective at preventing corneal haze as 0.1% dexamethasone drops applied 4 times a day for 4 weeks.