Periorbital desmoplastic squamous cell carcinoma.

Desmoplasia is the formation of a dense collagenous stroma around a neoplasm. It occurs in a variety of malignancies including squamous cell carcinoma (SCC). While desmoplasia is uncommonly seen in cutaneous SCC, it is an independent risk factor for recurrence and metastasis. We report a case series of desmoplastic SCC in the periorbital region. Seven cases were identified: the median age was 68, four were men. The mean follow-up was 48 months. Two patients (29%) had aggressive local recurrence: one required salvage surgery including orbital exenteration, parotidectomy, and neck dissection to excise involved parotid and cervical lymph nodes; the other required repeat excision and adjuvant radiotherapy. Desmoplastic SCC is an uncommon but highly aggressive subtype. In the periorbital region, due to the high risk of orbital invasion, it is potentially sight and life-threatening.

Eyelid reconstruction using the "Hughes" tarsoconjunctival advancement flap: Long-term outcomes in 122 consecutive cases over a 13-year period.

This article evaluates the complications and long term functional and cosmetic outcomes of tarsoconjunctival advancement flaps for repairing a range of lower eyelid defects in a large cohort of consecutive cases. A retrospective series of 122 consecutive cases of eyelid reconstruction using tarsoconjunctival-advancement flaps was conducted at Waikato Hospital, or Hamilton Eye Clinic, New Zealand. All cases of lid reconstruction using tarsoconjunctival-advancement flaps between January 1, 2001 until April 3, 2014 were included for analysis. All patients provided written consent for surgery and the study complied with New Zealand Health and Disability Ethics Committee guidelines and the Declaration of Helsinki. Data were collected on patient demographics, lesion histology, defect size, adjuvant surgical procedures required for reconstruction, surgical and postoperative complications, cosmesis and patient satisfaction. Patients requiring lower eyelid reconstruction were predominantly male (56%) and basal cell carcinoma was the most common pathology (>80%). Male gender was associated with larger tarsoconjunctival-advancement-flap width (P-value = 0.0432), larger maximum flap width (20 vs 15 mm), and required on average more adjuvant procedures for reconstruction (1.80 vs 1.48, P-value = 0.02). Mean duration to flap division was 37 days and decreased over the duration of the study. Complicated cases were associated with shorter duration to flap division. Mean follow-up was 7 months, complications were observed in 14% with revision required in 4%. Tarsoconjunctival flap reconstruction of the lower lid is suitable for a range of defect sizes and produces excellent functional and cosmetic outcomes. Complications are relatively infrequent and may be associated in some cases with decreased duration to flap division.

Orbital adherence with titanium mesh floor implants: a review of 10 cases.

BACKGROUND: Multiple materials have been used in the repair of orbital floor fractures. We report 10 cases of complications relating to the use of titanium mesh orbital floor implants. METHOD: A retrospective review of 10 cases in 2 centres in New Zealand. Patients presented with diplopia or eyelid retraction following repair of an orbital floor fracture with titanium mesh implants. RESULTS: Ten patients (7 male, 3 female) aged between 15-78 years old (mean 39 years) presented with significant restriction of eye movement and/or eyelid retraction following repair of an orbital floor fracture with a titanium mesh implant. Seven patients presented with restriction of eye movement alone. Three patients had lower lid retraction in addition to restriction of eye movement. One patient presented with epiphora following erosion of the implant through the nasolacrimal duct. Seven patients underwent surgical removal of the implant with all patients showing improvement of extraocular movement post-operatively. Three cases did not undergo implant removal with one case showing mild improvement over 9 months, and 2 cases showing no improvement. The mean interval between the initial surgery and removal of the implant was 7.1 months. DISCUSSION: In our series, 7 cases required explantation of the original titanium implant. In these cases a vigorous fibrotic reaction had taken place between the orbital contents and the titanium mesh implant. We postulate that the fibrous reaction between the implant and the orbital contents caused the eye movement restriction and the lid retraction. Implant materials used in orbital floor fracture surgery should be inert with a flat profile rather than a mesh to prevent adhesions through the mesh that may cause cicatricial eye movement restriction and eyelid retraction.

Primary orbital extraskeletal osteosarcoma.

The authors describe a case of orbital extraskeletal osteosarcoma. A 78-year-old man with a history of rheumatoid arthritis on long-term corticosteroids had a left medial canthal basal cell carcinoma excision followed by adjuvant radiotherapy. Twelve months later, he re-presented with a large rapidly-growing calcified mass involving his left medial canthus and orbit. An incisional biopsy demonstrated an infiltrate of atypical cells exhibiting mitotic activity with a rosette arrangement around partially calcified necrotic tissue. The patient underwent orbital exenteration and a partial maxillectomy. Histopathology demonstrated an extraskeletal osteosarcoma. It is extremely rare for this tumor to occur in the orbit. Immunosuppression and adjuvant radiotherapy were possible predisposing factors in the development of this tumor. Extraskeletal osteosarcoma (ESOS) is a malignant tumour that produces osteoid. It develops in soft tissue without continuity to bone or periosteum. It is rare and comprises fewer than 5% of all osteosarcomas. Extraskeletal osteosarcoma primarily affects patients above 50 years of age and has a poor prognosis. In this report, we describe the clinical, radiologic, and pathologic records of a rare case of primary ESOS of the orbit.

Outcomes of orbital blowout fracture surgery in children and adolescents.

BACKGROUND/AIM: To describe the features and outcomes of orbital blowout fracture surgery in children and adolescents <20 years old. METHODS: Retrospective chart review of consecutive patients undergoing orbital blowout fracture surgery at a tertiary referral hospital. RESULTS: A single surgeon performed all surgeries between October 2000 and April 2008. All patients had symptoms and signs of orbital soft tissue entrapment and radiographical evidence of orbital blowout fractures involving the orbital floor and/or medial wall. The characteristics and outcomes of 19 consecutive patients undergoing surgery are presented. The median delay from injury to surgery was 7 (range 0-113) days, with 13 cases having late surgery (>72 h post-injury). The median follow-up was 2 months. Two patients had follow-up of less than 1 week. One patient required subsequent strabismus surgery. Of the remaining 16 patients, none had significant diplopia postoperatively. There was a trend to longer recovery times with increasing delay to surgery. CONCLUSION: Previous series suggest that significant delays between injury and surgery lead to poorer outcomes in young patients with orbital blowout fractures. The data from this series show that despite delays, excellent outcomes can be obtained.

Primary banked scleral patch graft in the prevention of exposure of hydroxyapatite orbital implants.

PURPOSE: The most frequently reported complication of hydroxyapatite orbital implantation is exposure of the implant, which may result in infection or extrusion of the implant. This study describes the use of banked sclera patch grafts to prevent implant exposure. DESIGN: A retrospective noncomparative interventional case series. PARTICIPANTS: The procedure was performed on 110 patients over a 2-year period. Hydroxyapatite implantation was performed either at the time of enucleation or as a secondary procedure to correct postenucleation socket syndrome. INTERVENTION: A banked scleral patch graft from the second eye of the same donor was placed over a scleral-wrapped hydroxyapatite implant at the time of operation. The case records were reviewed retrospectively. OUTCOME MEASURES: The primary outcome measure was the number of patients who developed exposure of their hydroxyapatite implant. The number of patients who had a postoperative conjunctival wound dehiscence was also recorded. RESULTS: No patients developed exposure of the implant. A significant percentage of patients developed conjunctival wound dehiscence (33%). Further surgery was not required in any of these cases, because the dehiscence spontaneously reconjunctivalized over the surface of the scleral patch graft. CONCLUSIONS: Insertion of a banked scleral patch graft at the time of hydroxyapatite orbital implantation is an effective means of preventing implant exposure, even in more complex cases. It thereby reduces the morbidity resulting from the procedure and obviates the need for further surgery when there is breakdown of the conjunctival wound postoperatively.