Hinged tarsal flap: A novel technique for canthal tendon reconstruction.

BACKGROUND/OBJECTIVES: Reconstruction of the medial canthal region is challenging due to the complex regional anatomy. Options to reconstruct a medial canthal tendon sacrificed during tumour removal is limited. We present a novel surgical technique where hinged tarsal flap serves to substitute the canthal tendons. METHODS: This is a retrospective consecutive case series of five patients that underwent canthal reconstruction using this novel technique between May and December 2020. Electronic patient records and medical photograph database were reviewed. Patient demographics, co-morbidities, location and histology of the lesion, size of the resultant defect, reconstructive technique and post-operative complications were noted. RESULTS: All patients had good eyelid stability with no malposition, lagophthalmos or exposure keratopathy. No or minimal distraction of the eyelid from the globe, good cosmetic outcomes and no troublesome watering was reported. No wound dehiscence, no sight loss and no further surgical intervention was warranted. CONCLUSION: Multiple techniques have previously been described to reattach the medial canthal tendon with silk or supramid sutures. Transnasal wiring, stainless-steel screw and mini-plate fixation are also described, but carry a high risk of complications and are unfamiliar amongst most oculoplastic surgeons. Our technique is quick and simple and utilises autogenous tissue without breaching the periosteum which acts as a natural barrier to tumour infiltration.Refashioning the canthal tendon aids to lengthen the remaining eyelid stump, reducing the horizontal length required to reform the newly constructed eyelid and facilitates the reconstruction.

Orbital infantile haemangioma: radiological features and treatment - case series and literature review.

AIM: The aim of this study is to report a retrospective case series on orbital infantile haemangiomas (OIH). Radiological features and treatment with oral propranolol (OP) are illustrated along with an updated literature review. METHODS: A retrospective chart review of six children, diagnosed with OIH from November 2015 to October 2016, was carried out. Only children with deep documented orbital involvement were included. All patients underwent magnetic resonance imaging (MRI) under general anaesthesia. OP was administered to the infants according to the Nottingham Children's Hospital guideline. As per the guideline, a preliminary paediatric assessment was performed and a 1 mg/kg test dose was administered, followed by definitive treatment at a dosage of 2 mg/kg in three divided doses. RESULTS: Average age at presentation was within the first 3 weeks of life. T1 hypointensity, T2 hyperintensity, avid enhancement with contrast, and the presence of flow-voids appear a fixed pattern of OIH on MRI. Response to treatment was noticed within 4 weeks in all children, and two of them (33.3%) responded within the first 7 days. In two children (33.3%), the haemangioma became clinically undetectable by the seventh month of treatment, while the other four (66.6%) experienced an almost complete regression of the OIH by the last follow-up. No complications were found. CONCLUSIONS: Our series strengthens the understanding that MRI is the preferred imaging modality in the investigation of OIH, showing vascular features, detailed orbital extension, and possible associated malformations. OP is the treatment of choice for OIH, and our study confirms its safety and effectiveness.

A new perspective in oculoplastic surgical management of symptomatic distichiasis in lymphedema-distichiasis syndrome.

Lymphedema-distichiasis syndrome (LDS) is an autosomal dominant condition associated with FOXC2 mutations. Patients with distichiasis are mostly symptomatic, and efforts to deal with their ocular complaints comprise of electrolysis, cryotherapy and a variety of surgical techniques. We describe an enhanced surgical technique for a case of symptomatic distichiasis of the right eye with scarred, irregular eyelid margins secondary to initial cryotherapy, whereby the distorted tarsus was excised to remove the aberrant hair follicles, the levator palpebrae superioris was released to extend the upper lid and prevent lagophthalmos and a mucous membrane graft was used to cover the exposed portion of the tarsal plate. At 14 months follow up, the lid cosmesis and position remained satisfactory, with no infection or rejection of the mucous membrane graft. Therefore, this surgical technique provides a sound option for symptomatic distichiasis, where cryotherapy can cause lid irregularity and keratinization.

A prospective, multicentre study of malignant and premalignant lesions at the base of periocular cutaneous horns.

PURPOSE: The primary objective of the study was to determine the incidence of the various pathological conditions present at the base of the periocular cutaneous horns. The secondary objective was to study the presentation of these cutaneous horns with a view to finding any clinical indicators for premalignant, malignant and benign lesions at the base. METHODS: Prospective multicentre study of patients presenting with cutaneous horns. Informed consent followed by excision biopsy of the base lesion was performed in all the cases included for the study. The biopsy specimens were examined histologically and results analysed. RESULTS: Twenty-six patients presented with cutaneous horns in the periocular region over a period of 2 years, of these two patients presented with more than one cutaneous horn. 23 patients underwent excision biopsy. There were a total of 25 specimens. Of the base lesions 2/25 (8%) were malignant, 7/25 (28%) were pre-malignant and the remaining 16/25 (64%) were benign. Analysis of the findings on clinical presentation revealed no clinical indicators to correlate with the final histology. CONCLUSION: The incidence of malignant and pre-malignant lesions present at the base of periocular cutaneous horns was 36% with 8% of them being malignant. It is important to perform an excision biopsy with histological diagnosis of the base of the cutaneous horn as there are no definite clinical features that point towards a potential for malignancy.

The role of intravenous methylprednisolone immunosuppression in the management of active thyroid eye disease.

PURPOSE: To analyze the efficacy of intravenous methylprednisolone (IVMP) immunosuppression in the management of active thyroid eye disease (TED). METHODS: This is a consecutive case series of 36 patients treated with 1 g of IVMP over 3 days, between January 2000 and January 2008. The indications for this treatment were moderate to severe active TED with or without optic nerve compression. RESULTS: There were 32 hyperthyroid, 2 hypothyroid, and 2 euthyroid patients in this series. Nine patients presented with optic nerve compromise, 3 had severe active TED and 24 had moderately active TED. Twenty-seven patients received one course of IVMP and nine patients received two courses. All patients had tapering oral prednisolone over 1 month following the IVMP. The mean improvement in proptosis was 1.31 mm (range = 0-3 mm). Optic nerve function improved in seven of nine patients (77.8%). Extra ocular muscle movement improved in 18 patients (50%). Overall benefit from IVMP was seen at 1/12 in 27 patients (75%) and at 3/12 in 30 patients (83%). After IVMP one patient underwent radiotherapy and three patients had nonsteroidal immunosuppression. CONCLUSIONS: IVMP immunosuppression is effective in 83% of patients. The effect lasts from 3 months to 8 years, with a mean of 15 months in 30.5%. It remains a useful modality of treatment especially when the optic nerve or cornea is threatened because of moderate to severe active TED. We encountered no severe side effects of pulsed IVMP and 3 g over 3 days is a safe dose.

Comparison of biomechanical parameters in penetrating keratoplasty and normal eyes using the Ocular Response Analyser.

BACKGROUND: To compare corneal hysteresis (CH) and corneal resistance factor (CRF) in eyes 1 year following penetrating keratoplasty (PK) with that of normal eyes using the Ocular Response Analyser. METHODS: Prospective case comparison of 166 normal right eyes and 34 unilateral post-PK eyes presenting to a teaching hospital in Birmingham, UK. The CH, CRF and Goldmann-correlated intraocular pressure, of each eye was measured using the Ocular Response Analyser. The central corneal thickness (CCT) was measured using an ultrasonic pachymeter. RESULTS: The mean CH was 10.6 ± 2.0 mmHg, standard deviation (SD) and CRF was 10.2 ± 2.0 mmHg (SD) in normal eyes and 8.9 ± 3.3 mmHg and 8.1 ± 3.3 mmHg in post-PK eyes, respectively. The mean CCT was 541.8 ± 36.1 µm in normal eyes and 556.0 ± 69.2 µm in post-PK eyes. The Goldmann-correlated intraocular pressure was 16.1 ± 3.1 mmHg and 12.4 ± 2.9 mmHg in normal eyes and post-PK eyes, respectively. The CCT was found to be higher in post-PK eyes compared with normal eyes but the difference was not statistically significant (P > 0.5). CONCLUSION: Reduced biomechanical measures were found in post-PK eyes despite a higher mean CCT. This may be due to the altered corneal structure following PK.

Relationship of infantile periocular hemangioma depth to growth and regression pattern.

PURPOSE: Most infantile periocular hemangiomas undergo rapid growth in the first year of life, followed by gradual resolution over years. Treatment is indicated if vision is compromised and is usually continued through the growth phase. The objective of this study was to determine which clinical characteristics might aid in the prediction of growth and/or regression patterns of periocular hemangiomas. METHODS: Retrospective review of medical records and photographs of children with periocular hemangiomas presenting to a UK pediatric eye unit over a 7-year period. Age at presentation, growth pattern, size, location, amblyopia, and refractive status were documented. RESULTS: Forty-two infants with periocular hemangiomas were evaluated between 2000 and 2007, with a mean follow-up of 24 months (range, 6 months to 5 years). One-third (n=14, 33%) of the hemangiomas were superficial (strawberry nevi); one-third were subcutaneous (n=13, 31%), and the remainder were mixed (n=8, 19%) and orbital (n=7, 17%). There was a marked difference between the growth patterns of superficial (strawberry nevi) and deeper hemangiomas (orbital and subcutaneous), with a more prolonged period of growth noted in the deeper hemangiomas. CONCLUSIONS: Periocular hemangiomas with a deep component tend to have a later onset and prolonged period of growth compared to strawberry nevi. Clinically evident depth of the hemangioma appears to be a valuable predictor of rapidity of resolution. This finding may be useful in assessing prognosis and planning treatment of infantile periocular hemangiomas.

Yellow lid sign in Wegener's granulomatosis.

Orbital manifestations in Wegener's granulomatosis develop in over 50% of patients. Ischemic vasculitis and optic nerve compression result in visual impairment. This case report highlights the importance of the yellow lid sign in the diagnosis of orbital granulomatosis as well as provides an explanation for the reversal of this phenomenon.

Successful treatment of nasolacrimal duct obstruction secondary to fibrous dysplasia by external dacryocystorhinostomy with mitomycin C.

A 60-year-old woman developed polyostotic fibrous dysplasia involving the right zygomatic and maxillary bones, which led to swelling along the right side of her nose that was associated with constant epiphora. A sac washout revealed a blocked right nasolacrimal duct, which was confirmed by CT dacryocystography. CT also showed signs of fibrous dysplasia in the maxillary and zygomatic bones in the form of bony expansion and ground-glass bone density. The patient underwent external dacryocystorhinostomy with mitomycin C and O'Donoghue tube insertion. Bone punched out while fashioning the bony nasal ostium was subjected to histopathologic examination, which confirmed the diagnosis of fibrous dysplasia. The O'Donoghue tubes were removed 8 weeks later. At 15 months postoperatively, the dacryocystorhinostomy was patent and the patient was completely relieved of her symptoms.

A histopathologic study of orbital implant vascularization.

PURPOSE: To histopathologically assess the extent and pattern of vascularization of explanted porous polyethylene (PP) and hyrdoxyapatite (HA) orbital implants. To compare the vascularization in PP implants harvested after enucleation versus after evisceration. METHODS: This is a comparative case series of six orbital implants explanted between 11 months and 5 years and 4 months post implantation. The implants were subjected to histopathological examination with various stains, after complete decalcification. RESULTS: There were 2 post evisceration, 3 post enucleation and 1 secondary implant. The size of the implants varied from 18 to 23 mm diameter. The reason for explantation was exposure in all the 6 cases with additional infection in 2 cases. Histopathology revealed complete vascularization up to the core of the implant in all the cases. There was evidence of chronic inflammation within all the explanted specimens. Acute inflammation was present at the site of exposure in four of the implants. Three of these implants had additional evidence of necrosis. Two cases with clinically evident infection had Gram positive cocci within the implant. Foreign-body type giant-cells, melanophages and haemosiderin laden macrophages were also observed. Eviscerated specimens showed scleral remodelling and thickening. CONCLUSION: All the implants were vascularized up to the core. There was histologic evidence of chronic inflammation in all the explanted implants possibly indicating the foreign nature of the implant material. The sclera did not impede vascularization of the implants in eviscerated specimens. We found no difference in the degree of vascularization of the implant in enucleated versus eviscerated implants.

The use of AlloDerm in the reconstruction of full-thickness eyelid defects.

PURPOSE: To demonstrate the potential for the use of AlloDerm as a posterior lamellar graft in the reconstruction of full-thickness lid defects. METHOD: In our case series, we evaluated the surgical outcome of three consecutive patients, two with an upper eyelid defect and one with a lower eyelid defect who underwent lid reconstruction using AlloDerm grafts. RESULTS: AlloDerm was readily taken up into the wound defect, with complete coverage of its bulbar surface by conjunctiva. In all the cases, the cornea was not affected by its contact to the AlloDerm. A mucocutaneous junction formed over the margin of the AlloDerm graft with good cosmesis. CONCLUSION: AlloDerm has the potential to act as an effective posterior lamellar substitute in situations where there is an adequate amount of skin muscle cover available to drape over it. It is rigid enough to replace tarsus and its structure behaves as a scaffold allowing conjunctiva to readily grow over it.

Lateral cantholysis for cataract surgery.

A patient with narrow palpebral aperture who required an elaborate lateral cantholysis prior to uncomplicated phacoemulsification surgery is described. Surgery was followed by a lateral tarsal strip procedure to reattach the lower lid.

Unusual presentation of Amsler's sign in Fuchs' heterochromic uveitis.

Hyphema occurring after ocular paracentesis has been described as a classic feature of Fuchs' heterochromic uveitis (FHU) (Amsler's sign). We describe a case of hyphema occurring after peribulbar anesthesia in a patient with FHU. The bleeding occurred before the surgery began. Although the occurrence of this phenomenon does not preclude successful surgical outcomes, topical anesthesia may lower the risk preoperatively.

Delleman (oculocerebrocutaneous) syndrome: few variations in a classical case.

Delleman syndrome involves a group of congenital abnormalities affecting the eye, skin and central nervous system. It is a rare and sporadic disorder. We report on a 4-year-old male child who presented to us with oculocerebrocutaneous syndrome featuring: focal alopecia on the left side of the scalp, left periorbital skin appendages, a left-sided orbital dermoid, a large left-sided intracranial cyst,optic atrophy. About 35 such cases have been reported in the literature so far. To our knowledge optic atrophy associated with oculocerebrocutaneous syndrome has not been reported previously. Our patient had only a single seizure and his IQ was normal.