Good anesthetic for good esthetic: Blocks in oculoplasty.

Background: : A good anesthesia not only makes the patient comfortable during surgery, but also has a huge impact on the postoperative recovery. It also makes the operating surgeon carry out each step of the surgery precisely and beautifully. The art of giving a good local anesthesia is to be learnt and practiced not only by anesthetists, but also by the practicing ophthalmologists. Purpose: : This video gives an overview of anatomy in terms of the nerve supply of the orbit, the surface marking, and the techniques of giving regional and nerve blocks. Synopsis: : In this video, we describe the anatomy, the surface marking, the technique of regional anesthesia including peribulbar, retrobulbar, and subtenon blocks and of nerve blocks, specifically of facial, frontal nerve and its branches, infraorbital, nasociliary, infratrochlear, and dorsal nasal nerves, with their application in ocular plastic surgery. Highlights: : This video highlights the essence of providing appropriate and good anesthesia so that the surgeon works in an optimal field with maximum comfort to the patients. Video link https://youtu.be/h8EgTMQAsyE.

Evaluation of a modified infraorbital approach for a maxillary nerve block for rhinoscopy with nasal biopsy of dogs.

OBJECTIVE To determine whether a maxillary nerve block via a modified infraorbital approach, applied before rhinoscopy and nasal biopsy of dogs, would decrease procedural nociception, minimize cardiorespiratory anesthetic effects, and improve recovery quality. ANIMALS 8 healthy adult hound-type dogs PROCEDURES In a crossover study, dogs received 0.5% bupivacaine (0.1 mL/kg) or an equivalent volume of saline (0.9% NaCl) solution as a maxillary nerve block via a modified infraorbital approach. A 5-cm, 20-gauge over-the-needle catheter was placed retrograde within each infraorbital canal, and bupivacaine or saline solution was administered into each pterygopalatine region. Rhinoscopy and nasal biopsy were performed. Variables monitored included heart rate, systolic arterial blood pressure (SAP), mean arterial blood pressure (MAP), diastolic arterial blood pressure (DAP), plasma cortisol and norepinephrine concentrations, purposeful movement, and pain scores. After a 14-day washout period, the other treatment was administered on the contralateral side, and rhinoscopy and nasal biopsy were repeated. RESULTS SAP, MAP, and DAP were significantly higher for the saline solution treatment than for the bupivacaine treatment, irrespective of the time point. Plasma cortisol concentrations after saline solution treatment were significantly higher 5 minutes after nasal biopsy than at biopsy. Heart rate, norepinephrine concentration, purposeful movement, and pain score were not significantly different between treatments. CONCLUSIONS AND CLINICAL RELEVANCE Maxillary nerve block via a modified infraorbital approach prior to rhinoscopy and nasal biopsy reduced procedural nociception as determined on the basis of blood pressures and plasma cortisol concentrations during anesthesia. These findings warrant further evaluation in dogs with nasal disease.

Current trends in the management of thyroid eye disease.

PURPOSE OF REVIEW: The present review summarizes the body of literature concerning the medical and surgical treatment of thyroid eye disease (TED) from 1 January 2014 through 30 March 2015. RECENT FINDINGS: Corticosteroids continue to be the primary medical therapy for TED. Recent research has offered insight into potential differences between oral corticosteroid and intravenous corticosteroid treatment regimens in terms of efficacy and side-effect profiles. Steroid-sparing medications, for example, rituximab and others, are an area of active study. There has been renewed interest in the role of radiation therapy as a nonmedical treatment for TED with some promising data. The use of balanced orbital decompression techniques have become popular, although the data regarding postoperative diplopia are mixed, and 'fat decompression' offers an alternative or an augmentation to bony decompression. Stereotactic image guidance is a useful adjunct to orbital decompression surgery. SUMMARY: TED continues to be a difficult condition for the patient to cope with and for the clinician to treat, and recent research builds on the present foundation of knowledge and treatments, but unfortunately does not offer paradigm-shifting information at the present time.

An Adverse Implication of Radiation Therapy for Implant-Retained Maxillofacial Prostheses.

We report the 19-year postoperative course of a patient whose maxillary defect was reconstructed with maxillofacial implant-retained facial prostheses. The patient received 60 Gy of radiation therapy. Adjunctive hyperbaric oxygen therapy was administered and four 4.0-mm long maxillofacial implants were inserted. Four years and 6 months after insertion surgery, two of the four implants were lost and the others showed bone regression in the surrounding bone. All implants were replaced with Epitec System maxillofacial implants placed in non-irradiated bone. Eleven years and 6 months after replacement, the Epitec System has been maintaining good and firm osseointegration. Appropriate selection of implant sites and no history of radiation therapy are keys to successful implant reconstruction. However, adjunctive hyperbaric oxygen therapy is believed to be effective, osseointegrated implant should be inserted at a point appropriately distant from an irradiated lesion.

Current practice of ophthalmic anesthesia in Nigeria.

PURPOSE: To assess the current techniques of ophthalmic anesthesia in Nigeria. MATERIALS AND METHODS: A cross sectional survey among Nigerian ophthalmology delegates attending the 36(th) Annual Scientific Congress of the Ophthalmology Society of Nigeria. Self administered and anonymous questionnaires were used and data were collected to include details of the institution, preferred local anesthesia techniques, the grade of doctor who administers the local anesthesia, complications, preferred facial block techniques (if given separately), and type of premedication (if used). RESULTS: Out of the 120 questionnaires distributed, 81 forms were completed (response rate 67.5%). Out of the 74 who indicated their grade, 49 (66.2%) were consultants, 22 (29.7%) were trainees, and 3 (7.1%) were ophthalmic medical officers. For cataract surgery, peribulbar anesthesia was performed by 49.1% of the respondents, followed by retrobulbar anesthesia (39.7%). Others techniques used were topical anesthesia (5.2%), subtenon anesthesia (4.3%), subconjunctival anesthesia (2.6%), and intracameral anesthesia (0.9%). For glaucoma surgery, 47.2% of the respondents use peribulbar anesthesia, 32.1% use retrobulbar anesthesia, 9.4% used general anesthesia, and 6.6% used subconjunctival anesthesia. Among the trainees, 57.8% routinely perform retrobulbar anesthesia while 55.6% routinely perform peribulbar anesthesia. At least one complication from retrobulbar anesthesia within 12 months prior to the audit was reported by 25.9% of the respondents. Similarly, 16.1% of the respondents had experienced complications from peribulbar anesthesia within the same time period. Retrobulbar hemorrhage is the most common complication experienced with both peribulbar and retrobulbar anesthesia. CONCLUSION: Presently, the most common technique of local anesthesia for an ophthalmic procedure in Nigeria is peribulbar anesthesia, followed by retrobulbar anesthesia. Twelve months prior to the study, 25.9% of the respondents had experienced at least one complication from retrobulbar anesthesia and 16.1% from peribulbar anesthesia. Retrobulbar hemorrhage was the most common complication reported.

Pediatric anophthalmic sockets and orbital implants: outcomes with polymer-coated implants.

PURPOSE: To compare wrapped and polymer-coated hydroxyapatite implants in children undergoing primary enucleation with no adjuvant therapies. DESIGN: Retrospective, interventional cohort study. PARTICIPANTS: All children undergoing primary enucleation without adjuvant therapies between 1999 and 2009 at a tertiary pediatric cancer hospital. METHODS: Review and analysis of patient records. MAIN OUTCOME MEASURES: Implant exposure, extrusion and migration, socket contracture, and formation of pyogenic granuloma. RESULTS: Sixty consecutive patients undergoing primary enucleation with no adjuvant chemotherapy or radiation with follow-up of at least 12 months were included. Retinoblastoma was the diagnosis in 59 eyes (98.3%). Median follow-up was 3.6 years (range, 1.0-9.3 years). Two implant sizes were used: 20 mm in 47 patients (78.3%) and 18 mm in 13 patients (21.7%). Overall, 52 patients (86.7%) had an event-free recovery. Polymer-coated hydroxyapatite implants (43/60, 71.7%), when compared with wrapped ones (17/60, 28.3%), had a trend toward greater event-free recovery (odds ratio [OR], 1.6; 95% confidence interval [CI], 0.3-7.7) and lower exposure rate (OR, 2.1; 95% CI, 0.4-10.5). CONCLUSIONS: The use of polymer-coated hydroxyapatite implants is associated with favorable outcomes in the pediatric population. Despite observed complications, long-term implant retention is possible in most children. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Treatment of mild, moderate-to-severe and very severe Graves' orbitopathy.

Treatment of Graves' orbitopathy (GO) is better performed through a multidisciplinary approach. Euthyroidism should be promptly restored. Antithyroid drug and thyroidectomy are not disease-modifying treatments, whereas radioiodine may be associated with worsening of GO. This risk is eliminated by glucocorticoid prophylaxis. Treatments for GO differ depending on its severity and activity. Mild forms should be treated with local measures. In addition a course of selenium may be beneficial. Glucocorticoids (oral or intravenous) represent the main treatment of moderate-to-severe GO, the intravenous route being more effective. Weekly pulses of methylprednisolone are used and the cumulative dose should not exceed 8 g. Severe adverse events have been reported, particularly with higher doses. Orbital radiotherapy can be used either alone or associated with glucocorticoids. In very severe sight-threatening GO high dose intravenous glucocorticoid should be the initial treatment, orbital decompression being considered in nonresponding patients. Rehabilitative surgery should be deferred until GO becomes inactive.

Calcium phosphate cement in orbital reconstructions.

Treatment of facial trauma sequelae is a complex and challenging process. There is still controversy over suitable materials for orbital wall reconstruction. This study evaluated calcium phosphate cement (CPC) implants manufactured by rapid prototyping in the repair of orbital wall defects secondary to trauma. Computed tomographic scans of 5 patients were used for surgery planning and production of CPC implants. Implants were used to restore orbital wall anatomy, ocular alignment, and facial contour. Benefits resulting from the use of implants, such as a reduced operating time, patient response to biomaterial implantation, biomaterial integrity and stability, and patient satisfaction with treatment, were analyzed qualitatively. Our results suggest that CPC is an effective and safe material for orbital reconstruction because of its biocompatibility and easy production and placement.

The bioceramic implant: evaluation of implant exposures in 419 implants.

PURPOSE: To compare the rate of exposure in the immediate 3-month postoperative follow-up period with the rate of exposure after the immediate postoperative period in 419 anophthalmic patients with a bioceramic (aluminum oxide) orbital implant. METHODS: This is a retrospective, clinical case series of 419 patients who received a bioceramic orbital implant. All patients who presented to five oculofacial surgeons (D.J., S.G., J.D., S.K., L.M.) from January 1, 2000, to June 1, 2007, who received a bioceramic orbital implant and had a minimum of 3 months of follow-up were included in this study. The authors analyzed age, gender, type of surgery, implant size, peg system, follow-up duration, time of pegging, and problems encountered. The data from the patients with greater than 3 months of follow-up with exposure of the bioceramic implant are detailed in this report. RESULTS: There were 353 patients followed for 3 to 96 months with an average of 30 months of follow-up (median 23 months). Implant exposure occurred in 32/353 bioceramic implants (9.1%). Six of the 32 (19%) exposures occurred during the 90-day postoperative period (average 2.1 months). Twenty-six (81%) exposures occurred outside of the 90-day postoperative period (average 27.5 months, range 4-82 months). CONCLUSIONS: Implant exposures can occur anytime postimplant placement. This review discovered an implant exposure rate of 9.1%, with the majority of the exposures occurring after the postoperative follow-up period. Patients with porous orbital implants should be followed on a long-term basis to detect this complication.

A prospective study of the improvement in periorbital wrinkles and eyebrow elevation with a novel fractional CO2 laser--the fractional eyelift.

BACKGROUND AND OBJECTIVE: The purpose of this study was to assess the efficacy and safety of a new fractional CO2 laser system for improving periorbital rhytids, tightening skin and elevating the eyebrow. MATERIALS AND METHODS: One hundred subjects with periocular wrinkles, tissue laxity, photoaged skin and moderate dermatochalasis of the face were prospectively treated one to four times in the periorbital area with a fractional CO2 laser device equipped with a scanning handpiece. Improvements in eyelid wrinkles, crow's feet and skin laxity were evaluated photographically by two blinded, independent observers. Eyebrow elevation was measured by the investigators. Subjects also scored satisfaction and tolerability. RESULTS: Approximately half of subjects achieved or maintained 26-50% improvement at 12 months. Nearly 40% of subjects maintained 1-2 mm elevation of the brow at six and 12 months after treatment. Subject satisfaction was high and the procedure was well tolerated. Mild-to-moderate erythema and edema persisted for up to three to four days. CONCLUSION: Treatment with a fractional CO2 laser device improves periorbital rhytids, tightens skin and elevates the eyebrow with minimal adverse effects.

Predictors of blood loss in fronto-orbital advancement and remodeling.

Fronto-orbital advancement and remodeling for craniosynostosis is extensive surgery and is associated with potential risks; the most significant of these is blood loss. We prospectively studied 116 consecutive patients undergoing fronto-orbital advancement by the same surgical team for a 5-year 6-month period to determine what factors are associated with blood loss and transfusion of blood products. The data collected on the calvarial sutures involved were whether the patient had a diagnosed syndrome, the age at operation, the length of the operation, the estimated blood volume lost during the perioperative course, the number of units of packed cells transfused (donor exposures), and the use of other blood products. The mean (SD) total blood volume lost was 116% (5.4) of the estimated preoperative volume. The median number of whole units of packed cells transfused was 2 units. Other blood products were given in 28% of the cases. There was significantly greater blood loss in those patients with recognized craniofacial syndromes, pansynostosis, an operating time longer than 5 hours, and an age of 18 months or younger at operation. The use of other blood products was associated with those patients losing a blood volume higher than the mean.

Late exposure of the bioceramic orbital implant.

PURPOSE: To investigate the long-term outcome of the Bioceramic orbital implant. DESIGN: A retrospective, comparative, nonrandomized study. METHODS: Data were collected from the patients receiving Bioceramic orbital implants at National Taiwan University Hospital between June 1, 2001 and November 1, 2005. The implant was wrapped with Vicryl mesh, adding anteriorly with a scleral patch graft following enucleation with primary or secondary implantation. The unwrapped implant was inserted into an eviscerated globe with posterior sclerotomy and cornea preserved. Primary or secondary placement of sleeve was performed in some patients. RESULTS: A total of 112 cases were reviewed. Four patients were excluded attributable to insufficient follow-up. The other 108 patients had a mean follow-up period of 35.8 +/- 10.6 months (range, 24 to 70 months). Fifty patients (46.3%) received the pegging procedure. Eight of 108 (7.4%) cases of late exposure were identified on average 20.7 months after implantation. We identified no cases of implant exposure in 30 cases of enucleation and eight cases of secondary implant when the implant was wrapped in Vicryl mesh and an anterior scleral cap was used. All exposures developed in eviscerated patients (70 cases): two without pegging, three with primary placement, and three with secondary placement of the sleeve. The exposure rate was higher in patients with eviscerated globes, pegged implants, and prior ocular operations (P < .005). CONCLUSIONS: Late exposures of Bioceramic implants were found after long-term follow-up, associated with evisceration, pegging, and prior ocular surgeries. The modified wrapping technique can prevent exposure following secondary implantation and enucleation.

[The oculocardiac reflex in blepharoplasties]. / Der okulokardiale Reflex bei Blepharoplastiken.

The oculocardiac reflex (OCR) is a well-known phenomenon in ophthalmic surgery, but is rarely described in aesthetic blepharoplasty surgery. It was first mentioned in 1908 by Ascher and Dagnini. Since then, ophthalmologists and anaesthesiologists have regarded the onset of the oculocardiac reflex as a significant intraoperative problem, which is undermined by several case reports that describe dysrhythmias which have haved caused morbidity and death. Per definition the OCR is caused by ocular manipulation and involves intraoperative bradycardia by a change of 20 beats/minute compared to the preoperative heart rate or any dysrhythmia during the manipulation via a trigeminal-vagal-mediated reflex arc. Having operated on a 48-year-old, healthy woman in our clinic, who underwent a cardiac arrest during the blepharoplasty procedure, followed by a successful resuscitation, we investigated the onset of the OCR in our blepharoplasty patients within the last 3 years. The onset of the OCR was noted in 22 of 110 (20 %) blepharoplasty patients, mainly affecting younger, low-weighted patients operated under local anaesthesia. Awareness and treatment of this potentially life-threatening oculocardiac reflex are necessary. In most cases the onset of the reflex may be avoided by a gentle operation technique and by refraining from severe traction to the muscle or fat pad. The best treatment of a profound bradycardia caused by the OCR is to release tension to the muscle or fat pad in order to permit the heart rate to return to normal. Intraoperative monitoring is of utmost importance.

Extension of the one-piece orbitozygomatic frontotemporal approach to the glenoid fossa: cadaveric study.

OBJECTIVE: Resection of the glenoid fossa has been described as part of cranial approaches to the clivus and subtemporal approaches. However, radical resection carries a significant risk of postoperative temporomandibular joint dysfunction. We examine a simple variation of our previously described one-piece frontotemporal orbitozygomatic (FTOZ) osteotomy that adds en bloc resection of the root of the zygomatic arch and a portion of the glenoid fossa. METHODS: Five cadaveric fixed heads injected with colored silicone underwent an FTOZ osteotomy that extended to the root of the zygomatic arch and glenoid fossa. RESULTS: A step-by-step guide to the surgical technique is described, with illustrations to depict the glenoid fossa keyhole and bony cuts that free the zygomatic arch and portions of glenoid fossa. The first cut was made through the posterior root, and the second cut was made through the anterior root of the zygomatic arch. CONCLUSION: In this cadaveric study, extension of the one-piece FTOZ approach included the posterior root of the zygoma and the lateral part of the glenoid fossa. En bloc resection of the glenoid fossa and root of the zygomatic arch, together with the FTOZ osteotomy, facilitated reconstruction of the temporomandibular joint and increased the amount of exposure obtained with this FTOZ osteotomy. Comprehensive understanding of functional outcomes awaits further clinical study.

Quantitative analysis of exposure of staged orbitozygomatic and retrosigmoid craniotomies for lesions of the clivus with supratentorial extension.

OBJECTIVE: A two-stage approach using orbitozygomatic (OZ) and retrosigmoid (RS) craniotomies is one option for the management of petroclival lesions with supratentorial extension. The goal of this study was to investigate the supratentorial and infratentorial exposures of the clivus obtained through this staged approach. METHODS: Formalin-fixed, silicon-injected specimens underwent stereotactic imaging. Six paired OZ and RS craniotomies were performed. Neuronavigation was used to determine the areas and limits of exposure and to plot these areas on three-dimensional reconstructions of the skull base. RESULTS: The mean area of exposure of the parasellar region and clivus through the OZ craniotomy was 640 +/- 75 mm. Visualization of the parasellar region, cavernous sinus, and upper cranial nerves was achieved. The ventral brainstem corresponding to the cranial quarter of the clivus was visualized. The mean area of exposure of the clivus and petrous bone through the RS was 1930 +/- 250 mm. In the cranial quarter of the clivus, there was a small region of overlap in exposure between the two craniotomies. The limits of exposure are described. CONCLUSION: OZ and RS craniotomies provide complementary exposure with limited redundancy. Significant visualization of the parasellar region, clivus, and surrounding bony landmarks is obtained. The primary limitation is exposure of the contralateral half of Zones II and III of the clivus. This strategy represents a reasonable option for accessing paracentral petroclival lesions with a supratentorial extension.

Implantation of episcleral electrodes via anterior orbitotomy for stimulation of the retina with induced photoreceptor degeneration: an in vivo feasibility study on a conceptual visual prosthesis.

BACKGROUND: A visual prosthesis is a conceptual device designed to harnesses the function of residual afferent neurons in the visual pathway to produce artificial vision. Such implant, when applied to stimulate the vitreous surface of the retina, has proven feasible in producing the perception of light in both animals and humans. However the practicality of such device has been challenged by the difficulty of surgical access and the risks of damaging the neuroretina. Positioning a visual implant over the scleral surface of the eye could present a safer alternative but this stimulation modality has not been tested in diseased retinas and little is known about the altered electrophysiological properties of the retina in influencing the feasibility of such approach. METHODS: Experimental photoreceptor degeneration was induced in four pigmented rabbit eyes with systematic administration of a retinotoxic agent, sodium iodate. A multielectrode array was implanted onto the surface of the sclera to target the central and peripheral parts of the retina via an anterior orbitotomy approach. The efficacy of retinal stimulation was assessed by recording electrical evoked potential over the primary visual cortex. FINDINGS: The electrical evoked potentials were obtained from both injected and control eyes. The charge density thresholds were found to be similar in both groups and were below the bioelectric safety limit. Spatially differentiated cortical activation profiles were obtained from the central and peripheral retina and the pattern of activation corresponded to the retinotopography of the rabbit primary visual cortex. CONCLUSION: This study proves that episcleral stimulation of the retina is a feasible alternative to intraocular approaches for the development of a visual prosthesis for retinas with photoreceptor loss.

Porous orbital implants, wraps, and PEG placement in the pediatric population after enucleation.

PURPOSE: To investigate complications of various porous orbital implants and wrapping materials in the pediatric population after enucleation. DESIGN: A retrospective, comparative, nonrandomized study. METHODS: Between November 1992 and November 2006, patients younger than 15 years old were collected for study participation. They underwent enucleation with porous orbital implants primarily or secondarily at National Taiwan University Hospital. The authors used the hydroxyapatite (HA), Medpor, and Bioceramic orbital implant. The HA implant was wrapped with four different materials: donor sclera, Lyodura, porcine sclera, and Vicryl mesh. A part of HA implants and all bioceramic implants were wrapped with Vicryl mesh, added anteriorly with scleral patch grafts. All Medpor implants were unwrapped. RESULTS: Forty-seven cases had more than a two-year follow-up. The exposure rates according to implants and wraps were: donor sclera-wrapped HA (two of nine, 22%), porcine sclera-wrapped HA (three of three, 100%), Vicryl mesh-wrapped HA (one of five, 20%), and unwrapped Medpor (one of four, 25%). No exposure was found in four Lyodura-wrapped HA implants, and 22 Vicryl mesh-wrapped HA and Bioceramic implants with anteriorly scleral coating. The exposure rate was lower in cases with implants wrapped by our method and Lyodura than in those with implants wrapped by other materials (P < .001). Of 47 patients, 20 (42.5%) were fitted with peg-coupled prostheses and all had good prosthetic movements subjectively. CONCLUSIONS: Different types of implants and wraps resulted in various exposure rates in the pediatric population. The modified wrapping technique may prevent porous implants from exposure in children.

Use of osseointegrated implants in the restoration of head and neck defects.

Osseointegrated implants can be applied to facilitate retention, stability, and support for facial and intraoral prostheses used to restore head and neck defects. At the University of California, Los Angeles, Maxillofacial Prosthetics Clinic, retrospective studies have indicated that in nonirradiated maxillectomy patients, implant survival rates are 82.6 percent. In mandibles reconstructed with fibula free flaps, survival rates are 94.6 percent. Similarly, high implant survival rates have been observed for most sites used to support facial prostheses. Cumulative six-year survival rates for auricular sites exceed 95 percent and for floor of nose sites, success rates exceed 87 percent. However, survival rates are low (53 percent) for implants placed in the frontal bone for retention of orbital prostheses and even lower for irradiated bone sites ranging from 63 percent in the maxilla to 27 percent in the orbit.