Three Adult Cases of Orbital Hidrocystoma Presenting with Blepharoptosis.

PURPOSE: To report adult cases of superior orbital apocrine hidrocystoma. METHODS: Retrospective case series of three patients with superior orbital apocrine hidrocystoma and blepharoptosis with review of the clinical aspects of each of the cases. RESULTS: All three cases presented with blepharoptosis. Two of the cases had occult hidrocystoma, and one was visibly subcutaneous at presentation. CONCLUSIONS: Although rare and more common along the eyelid margin, apocrine hidrocystomas may occur in the orbit leading to secondary blepharoptosis and should be included within the differential diagnosis of orbital cysts. Physicians should therefore be aware of this possibility.

Enduragen patch grafts for exposed orbital implants.

PURPOSE: To present a new technique using the recently introduced Enduragen(®) material (Tissue Science Laboratories) as a patch graft for exposed ocular implants. METHODS: A retrospective, interventional, non-comparative case series of 3 patients who had Enduragen patch grafts for the closure of Tenon's capsule and conjunctiva over exposed ocular implants. Medical records were reviewed and the following parameters were collected: age, gender, indication for surgery, type of surgery, laterality, type of orbital implant, complications after repair and length of follow-up. RESULTS: Three patients were identified, 2 males and 1 female. One patient had a secondary quad-motility implant with supertemporal exposure. The second patient had a secondary implant with a fistula at the lateral aspect of the socket. The third patient had a centrally exposed primary hydroxyapatite implant. All patients received Enduragen patch grafts to cover the implant. Follow up ranged from 40 to 43 months (mean, 41.3 months; SD, ± 1.5). None of the 3 patients had any signs of implant re-exposure at the time of the last post-operative visit. There were no intra-operative or early complications observed. CONCLUSIONS: This consecutive case series suggests that Enduragen could be used as a safe and effective patch graft for exposed ocular implants. However, a larger prospective study with longer follow-up would be useful in further defining the indications and limitations of the Enduragen patch graft for the treatment of exposed orbital implants.

Orbital augmentation with injectable calcium hydroxylapatite for correction of postenucleation/evisceration socket syndrome.

PURPOSE: To demonstrate the utility of injectable calcium hydroxylapatite (Radiesse) for orbital volume augmentation to correct postenucleation/evisceration socket syndrome (PESS). METHODS: A retrospective chart review of all consecutive patients in our practice who received injectable calcium hydroxylapatite placed in the extraconal space to augment orbital volume was conducted. Patients with at least 6 months follow-up were included in the study. RESULTS: Among 26 patients with PESS who received injectable calcium hydroxylapatite for orbital volume augmentation, 15 individuals were identified with adequate follow-up. The mean amount of preoperative relative enophthalmos measured by Hertel exophthalmometry was 4 mm (range 0.5-7 mm). An average reduction of 2.4 mm of enophthalmos per syringe of filler was achieved. The mean follow-up obtained was 46 weeks (range 24-78 weeks). Most patients demonstrated clinical and aesthetic improvement that was observed to continue up to 1.5 years. Complications observed included anterior migration of filler, a peribulbar hemorrhage, and orbital discomfort. Two patients demonstrated little response to filler. CONCLUSIONS: Injectable calcium hydroxylapatite provides a novel, safe, simple, cost-effective technique to treat volume deficiency in the anophthalmic orbit. Augmentation achieved with this semipermanent filler has demonstrated a lasting effect in the orbit with little volume loss. Volume replacement can be titrated to the socket requirements. Correction of PESS using this technique may be limited in orbits that demonstrate significant fibrosis as a result of multiple surgeries, severe trauma, or radiation treatment.

Management of intractable postoperative blepharoplasty bleeding after thrombolysis for a pulmonary embolism.

A 61-year-old man underwent uneventful upper blepharoplasty but suffered a life-threatening pulmonary embolism requiring complex management for intractable bleeding following thrombolysis.

Injectable calcium hydroxylapatite for orbital volume augmentation.

OBJECTIVE: To describe a new method of augmenting orbital volume for anophthalmic enophthalmos correction. METHODS: A retrospective medical record review was conducted of 4 consecutive patients who had injectable calcium hydroxylapatite (Radiesse) placed in the extraconal space to augment orbital volume. RESULTS: Four patients were treated with 1 to 2 vials (1.3 mL per vial) of injectable calcium hydroxylapatite. The mean amount of preoperative enophthalmos measured by Hertel exophthalmometry was 4 mm (range, 2-7 mm). The mean follow-up was 57 weeks (range, 45-71 weeks). A reduction of enophthalmos, ranging from 2 to 5 mm (mean, 2.75 mm), was observed when comparing preoperative with postoperative measurements of the anophthalmic orbit with prosthesis in place. All patients demonstrated clinical and aesthetic improvement that was observed to continue at almost 1 year or more postoperatively. In one patient, injection was complicated by a peribulbar hemorrhage related to local anesthesia administration, which resolved without incident. CONCLUSIONS: Injectable calcium hydroxylapatite provides a new, safe, simple, cost-effective technique to treat volume deficiency in the anophthalmic orbit. Augmentation achieved with this semipermanent filler has demonstrated a lasting effect in the orbit of 1 year or more with little volume loss. The filler seems to last longer in areas with less movement, blood supply, and lymphatic drainage. Injection can even be performed in an office setting using local anesthesia. The amount of volume replacement can be titrated, and the procedure is repeatable until adequate volume is obtained.

Autologous dermis graft at the time of evisceration or enucleation.

AIM: To present a new technique using autologous dermis graft at the time of enucleation or evisceration to replace the ocular surface area lost when the corneal scleral button is excised. METHODS: A retrospective, interventional, non-comparative case series of patients who had an autologous dermis graft placed to assist in closure of Tenon's capsule and conjunctiva at the time of enucleation or evisceration. Medical records were reviewed and the following variables were recorded: age, sex, history of previous ocular surgery or radiation treatment, indication for surgery, type of surgery, laterality, type of orbital implant, size of implant, length of follow up, and complications. RESULTS: Nine patients were identified (three male, six female) Five had enucleation with implant placement and four had evisceration with implant placement. Four individuals received unwrapped porous polyethylene spherical implants, three received silicone implants, and two received hydroxylapatite implants. Follow up ranged from 30 to 112 weeks (mean (SD), 61 (28) weeks). No operative or early complications were observed. One patient who had enucleation after two rounds of brachytherapy for uveal melanoma developed subsequent late exposure of the implant. There were no complications involving the graft donor site. CONCLUSIONS: This small series shows that the use of a dermis graft is a safe and effective new technique to facilitate orbital rehabilitation. It is hypothesised that the extra surface area produced with a dermis graft preserves the fornices and allows a larger implant. It may also allow the implant to be placed more anteriorly which assists with both implant and prosthesis motility.

Asynchronous blepharospasm, facial and cervical dystonia, and bilateral asynchronous hemifacial spasm.

We present a patient with a facial movement disorder that has characteristics of both blepharospasm and bilateral asynchronous hemifacial spasm. Because of the increased incidence of blepharospasm in patients with hemifacial spasm, our patient's clinical presentation is probably not a chance occurrence, but rather a manifestation of some predisposition for these two movement disorders. This unusual constellation of signs and symptoms challenges the current diagnostic criteria and suggests that some of these facial movement disorders may lie on a spectrum, rather than represent distinct entities.

Preoperative assessment of the eye and periocular region.

Proper preoperative assessment of the eye and periocular region is essential to verify ocular health and vision and to obtain an optimal surgical result. A systematic approach to reviewing the ocular history, review of systems, and pertinent physical exam will be discussed. This is important to identify not only underlying ocular conditions but also potentially serious systemic conditions with ocular manifestations that can impact the patient's overall health. A thorough exam by a qualified provider is needed if there are any management issues regarding the presence of a condition(s) that can impact the surgical outcome.

Temporary suture tarsorrhaphy.

PURPOSE: To describe a technique for performing a bolsterless temporary tarsorrhaphy. DESIGN: Retrospective analysis and surgical technique description. METHODS: Temporary suture tarsorrhaphy (TST), which consists of a suture through the upper and lower eyelid posterior lamella, was performed after eyelid or socket surgery. RESULTS: Over 15 years, >1000 patients in the practice of one of the authors (R.L.A.) had TST that successfully maintained corneal coverage without complications in all but four eyes. In two patients, replacement was required because of tissue erosion; in two patients, the suture was placed too posteriorly and caused corneal irritation that required replacement. CONCLUSION: The TST is functionally equivalent to, or superior to, traditional bolster temporary tarsorrhaphy. The TST is faster and simpler, requires fewer materials, and avoids the risks of bolsters, which include eyelid margin necrosis, irregularities, and lash loss from vascular compromise.

Congenitally enlarged extraocular muscles: can congenital thyroid eye disease exist in a euthyroid infant?

A 2-month-old boy presented with hypotropia, eyelid retraction, and proptosis of the left eye. CT and ultrasound demonstrated enlarged extraocular muscles. Both the infant and mother were euthyroid. The patient underwent inferior rectus recession, lower eyelid retractor disinsertion, and entropion repair. Biopsy of the inferior rectus and oblique muscles was normal. The clinical presentation and workup appear to be most consistent with thyroid eye disease, which, to our knowledge, would be the first reported case of euthyroid congenital thyroid eye disease with a euthyroid mother.