Preseptal transconjunctival approach in orbital floor fracture repairs to prevent postoperative lower eyelid malposition.

PURPOSE: Lower eyelid malposition can be a complication following orbital floor fracture surgeries. We present our incidence of lower eyelid malposition from a large case series of orbital floor fracture repairs using the 'swinging eyelid' approach and 'hang back' technique. METHODS: A retrospective review of all orbital fracture surgeries at our institution from November 2011 to March 2021 was performed. Primary outcomes included the incidence of lower eyelid malposition by category, the average time to presentation after primary surgery, and reoperation rates among cases with lower eyelid complications. RESULTS: A total of 438 cases that involved repair of the fractured orbital floor were identified. Six patients (1.37 %) developed lower eyelid malposition following primary orbital floor repair. Two patients (0.46 %) developed reverse ptosis of the lower eyelid. Two patients (0.46 %) returned with lower lid cicatricial ectropion. One patient (0.23 %) had postoperative lower eyelid retraction. One patient (0.23 %) had postoperative lower eyelid cicatricial entropion. No cases of lower lid flattening, lower eyelid fat flattening, or eyelid notch was noted. All patients with lower eyelid malposition underwent additional surgeries except one patient with reverse ptosis (83.3 %). The average time to the presentation of postoperative complications from the surgery date was 292.8 days (range = 49 days to 3.5 years). CONCLUSION: Lower eyelid malposition after orbital floor repair is a known complication that can be decreased by employing the 'swinging eyelid' with a preseptal approach and closure by the 'hang back' technique.

Outcome Comparison of Transconjunctival Müller's Muscle Recession With Levator Disinsertion (TMRLD) to Gold Weight Implantation in the Treatment of Paralytic Lagophthalmos.

PURPOSE: To compare clinical outcomes of transconjunctival Müller's muscle recession with levator disinsertion (TMRLD) to the traditional gold weight implantation in patients with paralytic lagophthalmos. METHODS: A retrospective nonrandomized comparative review of patients who had gold weight implantation and TMRLD surgeries for paralytic lagophthalmos from January 2016 to January 2023 was performed. The main outcome comparisons were measurement changes in lagophthalmos, marginal reflex distance 1, visual acuity, and corneal examination. Complication and reoperation rates were also compared. RESULTS: Twenty-six cases of gold weight implantation and 20 cases of TMRLD surgeries were identified. The changes in logMAR visual acuity between gold weight implantation and TMRLD groups were not statistically significant (-0.10 ± 0.48 vs. +0.05 ± 0.14, p > 0.05). The percent improvement in lagophthalmos (62.2% ± 51.8% vs. 58.4% ± 21.1%) and final marginal reflex distance 1 (2.22 ± 1.42 vs. 2.25 ± 1.41 mm) were also comparable between groups ( p > 0.05). Both groups showed similar changes in marginal reflex distance 1 (1.75 ± 1.31 vs. 2.83 ± 1.37 mm) and lagophthalmos (3.77 ± 3.92 vs. 3.36 ± 1.36 mm) ( p > 0.05). The overall complication (15.4% vs. 15.0%) and reoperation rates (15.4% vs. 15.0%) were comparable over the follow-up duration (291.6 ± 437.3 vs. 121.0 ± 177.8 days) ( p > 0.05). CONCLUSION: TMRLD is as safe and effective as the gold weight implantation in addressing paralytic lagophthalmos in patients with facial nerve palsy.

Acute Bilateral Vision Loss Following Unilateral Optic Nerve Sheath Fenestration.

Optic nerve sheath fenestration (ONSF) is a surgical technique commonly and effectively employed in the treatment of recalcitrant, vision-threatening papilledema. Unilateral blindness, a known risk of unilateral ONSF widely cited with 1%-2% incidence. In this case, a 58-year-old patient who presented symptomatic with bilateral hemorrhagic papilledema unresponsive to medical therapy underwent uneventful unilateral ONSF via standard superomedial eyelid crease incision. The patient presented postoperatively with severe bilateral vision loss. Workup revealed widespread metastatic malignant disease involving the optic chiasm and optic nerve sheath.

Silicone Sphere Implant Extrusion From Orbital Granulomatosis With Polyangiitis: A Rare Complication in the Anophthalmic Socket.

Orbital implant extrusion is a known complication following evisceration and enucleation. In this case report, we present a 45-year-old woman who presented with a left silicone implant exposure and infection 2 years following evisceration with saddle nose on examination. CT of the maxillofacial bones without contrast showed bilateral soft tissue infiltration around the superior recti muscles, as well as a nasal septum perforation from extensive sinus disease. Left orbitotomy revealed a small fibrotic mass near the orbital roof. Biopsy and serology results were consistent with granulomatosis with polyangiitis.

Extra-ocular movement restriction and diplopia following orbital fracture repair.

PURPOSE: To report a series of patients with extra-ocular movement restriction and diplopia after orbital fracture repair, and determine the effect of timing of repair and the type of implant used. METHODS: A chart review was conducted identifying all patients >18years of age at our institution between June 2005 and June 2008 who underwent orbital fracture repair, and presented with clinically significant diplopia and extra-ocular movement restriction persisting longer than one month after repair. Data collected included timing of repair, implant used within the orbit, and need for revision. RESULTS: Ten patients were identified with a mean time to primary orbital fracture repair at 9days (range 1-48). Seven patients underwent revision of their orbital fracture repair with removal of the previously placed implant and replacement with non-porous 0.4mm Supramid Foil, whereas one patient underwent lateral and inferior rectus recessions without revision of primary fracture repair. Titanium mesh was the intra-orbital implant found in all patients requiring revision of orbital fracture repair. All revisions resulted in resolution of clinically significant diplopia. CONCLUSIONS: Clinically significant diplopia and extra-ocular movement restriction is not an uncommon complication after orbital fracture repair. In our series, there was a strong association between these complications and the use of porous titanium mesh implants. Revision of fractures significantly improved diplopia in all but one patient. This suggests that meticulous fracture repair and the use of non-porous implants primarily or secondarily may preclude the need for strabismus surgery after orbital trauma.

A Case of Orbital Histoplasmosis.

Histoplasma capsulatum var capsulatum is a dimorphic fungus endemic to the Ohio and Mississippi River Valleys of the United States. In this case report, a 33-year-old woman who presented with a right orbital mass causing progressive vision loss, diplopia, and facial swelling is described. Lateral orbitotomy with lateral orbital wall bone flap was performed for excisional biopsy of the lesion. The 1.5 × 1.8 × 2.3 cm cicatricial mass demonstrated a granulomatous lesion with necrosis and positive staining consistent with Histoplasma capsulatum var capsulatum infection. To the authors' knowledge, this is the first case of orbital histoplasmosis to be reported in the United States and the first case worldwide of orbital histoplasmosis due to Histoplasma capsulatum var capsulatum.

The assessment of orbital apical temperature change with local cool compress application.

PURPOSE: To examine the change in orbital apical temperature over time, with a local ice/water admixture compress placed over the eyelid. METHODS: A six-month-old, 220-pound Landrace/Hampshire/Duroc mixed breed pig was intubated and maintained under anesthesia with a steady average body temperature. An incision in the lateral third of the right lower eyelid along the inferior orbital rim was made, and a digital thermometer was inserted and guided toward the orbital apex by fluoroscopic imaging of the orbit. After the baseline apical temperature was measured, an ice/water admixture compress was placed on the right eyelid, and serial temperatures were taken every 5 minutes for 20 minutes. A final measurement was taken at 45 minutes after the ice/water admixture compress placement. RESULTS: At an average core body temperature of 38.9°C, the baseline apical temperature was 37.2°C. After placement of a 0°C ice/water admixture, there was an exponential decrease in apical temperature, reaching a plateau after a period of 20 minutes, with a decrease of 1.4°C from baseline. The same apical temperature noted 20 minutes after placement of the cool compress was measured 45 minutes after ice/water compress placement. CONCLUSIONS: There was only a limited decrease in apical temperature by placing a local 0°C ice/water admixture over the eyelid. This information is useful in determining whether local hypothermia may be a potential alternative for traumatic optic neuropathy.

Orbital adherence syndrome secondary to titanium implant material.

PURPOSE: To report the association of extraocular motility restriction and/or eyelid retraction after orbital fracture repair using titanium. METHODS: Retrospective review of 10 consecutive patients who presented with diplopia and/or cicatricial eyelid retraction following the use of titanium implants for orbital fracture repair. RESULTS: Ten patients (8 male, mean age 29 years old) presented with orbital adherence syndrome after a primary procedure, by other surgeons, for an orbital fracture. Fractures had been repaired using titanium mesh along an orbital wall (10/10) and/or a titanium plate that was positioned over the orbital rim (4/10). Six of the 10 patients (60%) presented with cicatricial eyelid retraction and 9 of 10 (90%) presented with extraocular motility restriction resulting in diplopia. During the subsequent surgical repair of these patients, an intense fibrotic adherence was noted between the titanium implant within the orbit or periorbital tissues. All patients with diplopia undergoing secondary surgical intervention improved following the removal of the titanium and replacement with 0.4-mm nylon implants (Supramid), placed in a "wraparound" fashion along the orbital floor and medial wall. Cicatricial eyelid retraction was repaired by lysis of fibrotic tissue and elevation of the lower eyelid with full-thickness skin grafts. CONCLUSION: Titanium orbital implants may lead to the adherence of orbital and periorbital structures resulting in restrictive diplopia and/or eyelid retraction. Restrictive diplopia can be improved by the secondary replacement of titanium implants with nylon foil implants, although cicatricial eyelid retraction or ectropion requires additional reconstructive procedures for improvement.

Neglected basal cell carcinoma in a schizophrenic patient.

Obtaining informed consent from patients with mental disorders can be a complicated and involved process, potentially resulting in decisions contrary to the advice of physicians. We present a schizophrenic patient with an invasive basal cell carcinoma involving the periocular structures and the right orbit. Exenteration was recommended with en bloc resection of the tumor. The ethical and legal committees decided against surgical intervention. Rather, the patient was admitted for medical treatment of his mental illness. A multidisciplinary approach with consultation of a psychiatrist, social worker, and ethical and legal committees is often necessary in the care of patients with mental illness.

Corrigendum to "Ophthalmic considerations in patients with pfeiffer syndrome." [Am. J. Ophthalmol. Case Reports (2) 2016 1-3].

[This corrects the article DOI: 10.1016/j.ajoc.2016.04.001.].

Pigmented epithelioid melanocytoid tumor of the ocular adnexa.

An 8-year-old girl with a history of microphthalmia in the right eye presented with a left medial upper eyelid mass with a dark blue-green nodule that could be seen through the skin but did not appear to involve the overlying epidermis. A biopsy demonstrated a pigmented epithelioid melanocytoid tumor with rare mitoses arising in association with a congenital nevus and positive margins. Due to the pathological findings, the patient underwent excision of the tumor with 5-mm margins and a sentinel lymph node biopsy. The re-excision of the upper eyelid margins demonstrated residual benign congenital melanocytic nevus, but did not reveal residual melanocytic lesion. The parotid sentinel node biopsy revealed benign and cytologically mature nevus nests in the capsule and septa, but there was no evidence of involvement with the pigmented epithelioid melanocytoid tumor. The patient underwent successful eyelid reconstruction and had no evidence of recurrence or metastasis after 2 years.