Autologous Fat Transfer Harvest-site Complications: Incidence, Risk Factors, and Management.

PURPOSE: Autologous fat transfer is an effective tool for volume restoration to the aging face. Although numerous reports exist regarding injection site complications, there is limited data on donor-site morbidity in the cosmetic surgery literature. METHODS: This study is a large-scale retrospective review to determine incidence of fat harvest-site complications, identify risk factors, and describe management strategies. Records of all patients who underwent autologous fat harvesting and facial grafting at a single oculofacial plastic surgery practice from 2010 to 2019 were reviewed. Patient demographics and clinical data were collected and assessed. A statistical analysis was performed using a two-tailed T-test with p values of <0.05 considered significant. RESULTS: Four-hundred sixteen patients were followed for an average of 6.2 months postoperatively. There was an overall 5.5% harvest-site complication rate. There was no correlation of harvest-site complications with gender (p = 0.249) or age (p = 0.881). Harvest location did not significantly correlate with complication rate. The most common complications were contour irregularities, prolonged induration, and prolonged erythema. Low body mass index was associated with higher complication rate (p = 0.003), even when excluding those patients with contour irregularities (p = 0.001). Various treatment modalities were used to manage donor-site morbidity with consistent improvement. CONCLUSIONS: Autologous fat transfer used for facial volume augmentation has low donor-site morbidity. Minor harvest-site complications occur more commonly in patients with low body mass index, irrespective of age, gender, or fat source.

Rifle Blast Exacerbating Hearing Loss in a Patient Treated With Teprotumumab for Thyroid Eye Disease.

Teprotumumab is a promising new immunomodulatory therapy for thyroid eye disease. One unique adverse effect observed in clinical trials was hearing impairment; however, all adverse auditory effects in prior clinical trials resolved spontaneously after completion of teprotumumab therapy. The authors present a case of a patient on teprotumumab for thyroid eye disease who experienced sustained hearing loss secondary to shooting a rifle without ear protection. In this case, it is suspected the teprotumumab infusions resulted in increased susceptibility of the inner ear hair cells to noise-induced trauma secondary to IGF-IR inhibition. Specific ear protection protocols may need to be implemented in the future for patients on teprotumumab therapy to prevent sustained hearing loss, especially for susceptible patient populations.

5-Fluorouracil With Microneedling Modulates Wound Healing in a Murine Model: An Immunohistochemical Analysis of Mechanism and Dose Efficacy.

PURPOSE: The purpose of this study is to assess the dose-dependent immunohistopathological effects of intradermal microneedle-delivered 5-fluorouracil (5-FU) for postincisional wound healing in a murine model. METHODS: A prospective experimental study was performed. Twelve hairless mice were randomized into 4 treatment groups for postincisional wound treatment: microneedling with topical saline, or microneeding with topically-applied 5-FU at concentrations of 25 mg/ml, 50 mg/ml, or 100 mg/ml. Two surgical wounds were created on each animal. Combination wound treatments were performed on postoperative days 14 and 28, and cutaneous biopsies were obtained on day 56. Specimens were analyzed by a dermatopathologist, blinded to the treatment group, for collagen thickness, lymphocytic infiltration, histiocytic response, sub-epidermal basement membrane zone thickness, and myofibroblast density. RESULTS: Histopathologic evaluation showed increased collagen thickness, lymphocyte infiltration, and granuloma density in the groups undergoing microneedling treatment with 5-FU, compared to saline. Immunohistochemical analysis revealed a trend toward thicker basement membranes with higher concentrations of 5-FU used, reaching statistical significance between controls and those treated with 100 mg/ml 5-FU ( p = 0.0493). A trend toward decreasing myofibroblast density with increasing doses of 5-FU was noted. No postincisional or treatment complications were observed. CONCLUSIONS: Our results demonstrate that microneedling is an effective topical subepithelial drug delivery system, and further suggest a beneficial dose-dependent immunomodulatory effect of 5-FU on intermediate wound healing when used in combination with microneedling. We recommend a 5-FU dose at the mid-range 50 mg/ml concentration to simultaneously maximize efficacy and minimize complication risk.

Simultaneous presentation of orbital mantle cell lymphoma and endocrine mucin-producing sweat gland carcinoma.

Mantle cell lymphoma is a rare malignancy to present in the orbit, comprising only 1-5% adnexal lymphomas. Endocrine mucin-producing sweat gland carcinoma (EMPSGC) is an equally uncommon adnexal tumor of sweat gland origin that may present on the eyelid. Herein we present a case of a 77-year old man with no previous cancer history who presented with painless progressive left globe proptosis and an enlarging left upper lid margin lesion, ultimately determined upon biopsy to be simultaneous orbital mantle cell lymphoma with systemic involvement and isolated eyelid EMPSGC. The pathogenesis, clinical manifestation, and management for each rare disease entity are reviewed and concept of collision tumors is discussed.

Wound Dehiscence Following Upper Blepharoplasty: A Review of 2,376 Cases.

PURPOSE: There have been limited studies evaluating specifically the incidence of wound dehiscence following isolated upper blepharoplasty. This is a large-scale upper blepharoplasty review to evaluate the rate of wound dehiscence, to assess risk factors, and to analyze management outcomes. METHODS: A retrospective review was performed of all patients who underwent upper blepharoplasty at a single surgery center. All incisions were closed using either 6-0 fast-absorbing plain gut or polypropylene suture in a running fashion, with an additional interrupted suture near the lateral wound edge. Incidence of wound dehiscence was determined and further assessed by patient age (≤67 or >67 years), gender, preexisting medical conditions, smoking history, and suture type. RESULTS: A total of 1,190 patients (2,376 eyelids) met inclusion criteria. In total, there were 34 instances (1.4%) of wound dehiscence in 32 patients at an average 9 days (range, 0-30 days) following surgery. Evaluation of wound dehiscence rates by demographic factors revealed male gender to be a significant predictor of wound dehiscence (p = 0.0062). Age, hypertension, heart disease, and diabetes were not predictors of wound dehiscence. Lifetime smoking history increased risk for wound dehiscence (p < 0.0001). Use of fast-absorbing plain gut suture was also significantly associated with dehiscence, when compared with polypropylene (p = 0.0025). Multivariate analysis revealed male gender and fast-absorbing plain gut suture to be independent risk factors for wound dehiscence. Seventeen eyelids with wound separation were observed for second-intention healing, 1 underwent delayed scar revision. Fourteen eyelids were repaired primarily using suture and 3 with cyanoacrylate surgical skin adhesive. All patients reported satisfaction with their final outcome, and objective final healing was deemed satisfactory. CONCLUSIONS: Wound dehiscence following isolated upper blepharoplasty is rare and associated with male gender and fast-absorbing plain gut suture. Patients with wound separation may be successfully managed with individualized care.

Ophthalmic Manifestations of Facial Dog Bites in Children.

PURPOSE: To characterize ophthalmic manifestations and periocular injuries of pediatric facial dog bites. METHODS: A retrospective review of all children younger than 18 years who sought medical attention after a dog bite to the face between January 1, 2003 and May 22, 2014 was performed at a large tertiary pediatric hospital. Data on type and location of injury, surgical intervention, and complications were collected. RESULTS: A total of 1,989 children aged 0.19 to 17 years were identified with dog bites. Dog bites to the face occurred in most patients (n = 1, 414 [71%]). Of those children with facial dog bite injuries, 230 (16%) suffered ophthalmic manifestations. The average age was 4.3 years. Eyelid injuries occurred in 227 (99%) of children, 47 (20%) sustained canalicular system injuries, 3 (1.3%) suffered corneal abrasions, and 2 patients sustained facial nerve injury resulting in lagophthalmos. No patients suffered vision loss. Complications occurred in 32 patients (14%), with the most common being epiphora in 9 patients (28%), upper eyelid ptosis in 8 (25%), and prominent scar formation in 4 patients (13%). Thirteen children (5.7%) needed one or more secondary procedure to correct complications. CONCLUSIONS: The authors report the clinical features and management on the largest series of ophthalmic and periocular injuries associated with pediatric facial dog bites. These injuries occur in about 1 in 6 dog bites to the face and primarily involve the ocular adnexa. Despite early and appropriate surgical management, complications and the need for revision surgery are relatively common.

Comparison of Revision Rates of Anterior- and Posterior-Approach Ptosis Surgery: A Retrospective Review of 1519 Cases.

PURPOSE: To compare revision rates for ptosis surgery between posterior-approach and anterior-approach ptosis repair techniques. METHODS: This is the retrospective, consecutive cohort study. All patients undergoing ptosis surgery at a high-volume oculofacial plastic surgery practice over a 4-year period. A retrospective chart review was conducted of all patients undergoing posterior-approach and anterior-approach ptosis surgery for all etiologies of ptosis between 2011 and 2014. Etiology of ptosis, concurrent oculofacial surgeries, revision, and complications were analyzed. The main outcome measure is the ptosis revision rate. RESULTS: A total of 1519 patients were included in this study. The mean age was 63 ± 15.4 years. A total of 1056 (70%) of patients were female, 1451 (95%) had involutional ptosis, and 1129 (74.3%) had concurrent upper blepharoplasty. Five hundred thirteen (33.8%) underwent posterior-approach ptosis repair, and 1006 (66.2%) underwent anterior-approach ptosis repair. The degree of ptosis was greater in the anterior-approach ptosis repair group. The overall revision rate for all patients was 8.7%. Of the posterior group, 6.8% required ptosis revision; of the anterior group, 9.5% required revision surgery. The main reason for ptosis revision surgery was undercorrection of one or both eyelids. Concurrent brow lifting was associated with a decreased, but not statistically significant, rate of revision surgery. Patients who underwent unilateral ptosis surgery had a 5.1% rate of Hering's phenomenon requiring ptosis repair in the contralateral eyelid. Multivariable logistic regression for predictive factors show that, when adjusted for gender and concurrent blepharoplasty, the revision rate in anterior-approach ptosis surgery is higher than posterior-approach ptosis surgery (odds ratio = 2.08; p = 0.002). CONCLUSIONS: The overall revision rate in patients undergoing ptosis repair via posterior-approach or anterior-approach techniques is 8.7%. There is a statistically higher rate of revision with anterior-approach ptosis repair.

Increased Incidence of Rhino-Orbital-Cerebral Mucormycosis After Colorado Flooding.

In September 2013, central Colorado experienced a record amount of rainfall resulting in widespread flooding. Within 1 month of the flooding, 4 patients presented to the authors' institution with rhino-orbital-cerebral mucormycosis. This represents the largest number of cases ever recorded over a 1-month period. The authors hypothesize that the combination of immunocompromised status and environmental exposure resulted in the increased incidence.

Dacryocystitis As the Initial Presentation of Invasive Fungal Sinusitis in Immunocompromised Children.

Sino-orbital fungal infection is a rare, but life-threatening disease seen mainly in immunocompromised patients. While initial clinical impression may vary, dacryocystitis has rarely been described as the initial presenting sign. The authors present 2 pediatric cases of dacryocystitis as the initial sign of invasive fungal sinusitis. To their knowledge, this presenting sign has not been previously reported in the pediatric population. Management strategies and outcomes are discussed.

Axial Globe Position Measurement: A Prospective Multicenter Study by the International Thyroid Eye Disease Society.

PURPOSE: Identify a reproducible measure of axial globe position (AGP) for multicenter studies on patients with thyroid eye disease (TED). METHODS: This is a prospective, international, multicenter, observational study in which 3 types of AGP evaluation were examined: radiologic, clinical, and photographic. In this study, CT was the modality to which all other methods were compared. CT AGP was measured from an orthogonal line between the anterior lateral orbital rims to the cornea. All CT measurements were made at a single institution by 3 individual clinicians. Clinical evaluation was performed with exophthalmometry. Three clinicians from each clinical site assessed AGP with 3 different exophthalmometers and horizontal palpebral width using a ruler. Each physician made 3 separate measurements with each type of exophthalmometer not in succession. All photographic measurements were made at a single institution. AGP was measured from lateral photographs in which a standard marker was placed at the anterior lateral orbital rim. Horizontal and vertical palpebral fissure were measured from frontal photographs. Three trained readers measured 3 separate times not in succession. Exophthalmometry and photography method validity was assessed by agreement with CT (mean differences calculation, intraclass correlation coefficients [ICCs], Bland-Altman figures). Correlation between palpebral fissure and CT AGP was assessed with Pearson correlation. Intraclinician and interclinician reliability was evaluated using ICCs. RESULTS: Sixty-eight patients from 7 centers participated. CT mean AGP was 21.37 mm (15.96-28.90 mm) right and 21.22 mm (15.87-28.70 mm) left (ICC 0.996 and 0.995). Exophthalmometry AGP fell between 18 mm and 25 mm. Intraclinician agreement across exophthalmometers was ideal (ICC 0.948-0.983). Agreement between clinicians was greater than 0.85 for all upright exophthalmometry measurements. Photographic mean AGP was 20.47 mm (10.92-30.88 mm) right and 20.30 mm (8.61-28.72 mm) left. Intrareader and interreader agreement was ideal (ICC 0.991-0.989). All exophthalmometers' mean differences from CT ranged between -0.06 mm (±1.36 mm) and 0.54 mm (±1.61 mm); 95% confidence interval fell within 1 mm. Magnitude of AGP did not affect exophthalmometry validity. Oculus best estimated CT AGP but differences from other exophthalmometers were not clinically meaningful in upright measurements. Photographic AGP (right ICC = 0.575, left ICC = 0.355) and palpebral fissure do not agree with CT. CONCLUSIONS: Upright clinical exophthalmometry accurately estimates CT AGP in TED. AGP measurement was reliably reproduced by the same clinician and between clinicians at multiple institutions using the protocol in this study. These findings allow reliable measurement of AGP that will be of considerable value in future outcome studies.

Infectious Complication Following Midface Reconstruction With Calcified Triglyceride.

This case report describes an infectious complication related to the use of calcified triglyceride (Kryptonite Bone Cement) in post-traumatic midface reconstruction. Ultimately, the infected material required removal, and the facial deformity was repaired with subsequent procedures. The literature suggests that bone cement products should be used with caution when in contact with the paranasal sinuses.

C-Reactive Protein As a Marker for Initiating Steroid Treatment in Children With Orbital Cellulitis.

PURPOSE: To determine both the benefit of systemic steroids in pediatric patients with orbital cellulitis and to assess the usefulness of C-reactive protein (CRP) levels as a marker for starting steroids. METHODS: Prospective, comparative interventional study. Pediatric patients aged 1 to 18 years admitted to a tertiary care children's hospital with a diagnosis of orbital cellulitis from October 2012 to March 2014 were included in the study. All patients were treated with intravenous antibiotics, and patients with subperiosteal abscess who met previously published criteria for surgical decompression underwent combined transorbital drainage and/or endoscopic sinus surgery. CRP was measured daily as a biomarker of inflammation, and when below 4 mg/dl, patients were started on oral prednisone 1 mg/kg per day for 7 days. Patients whose families did not consent to steroid treatment served as the control group. Patients were followed after discharge until symptoms resolved and all medications were discontinued. RESULTS: Thirty-one children were diagnosed with orbital cellulitis during the study period. Of these 31 children, 24 received oral steroids (77%) and 7 did not (23%). There were 19 males and 5 females in the steroid group with an average age of 8.1 years, and 6 males and 1 female in the nonsteroid group with an average age of 7.1 years (p = 0.618). Thirteen patients (54%) in the steroid group and 2 patients (29%) in the nonsteroid group underwent sinus surgery with or without orbitotomy (p = 0.394). The average CRP at the onset of steroid treatment was 2.8 mg/dl (range: 0.5-4). Patients who received oral steroids were admitted for an average of 3.96 days. In comparison, patients who did not receive steroids were admitted for an average of 7.17 days (p < 0.05). Once CRP was ≤4 mg/dl, patients treated with steroids remained in the hospital for another 1.1 days, while patients who did not receive steroids remained hospitalized for another 4.9 days (p < 0.01). In the steroid group, 2 families reported increased hyperactivity in their children while on steroids. There was 1 case in each group of recurrence of symptoms after discharge from the hospital. Average follow-up time was 2.4 months in the steroid group and 2 months in the nonsteroid group (p = 0.996). At last visit, all patients returned to their baseline ophthalmic examination. There were no cases of vision loss or permanent ocular disability in either group. CONCLUSIONS: Our results give further evidence of the safety and benefit of systemic steroids in children with orbital cellulitis. Futhermore, this is the first study to suggest a standardized starting point (CRP ≤ 4 mg/dl) and dosing schedule (oral prednisone 1 mg/kg for 7 days) for children with orbital cellulitis. Patients who received systemic steroids after CRP dropped below 4 mg/dl were discharged from the hospital earlier than patients who did not receive systemic steroids.

Perioperative pregabalin for attenuation of postoperative pain after eyelid surgery.

PURPOSE: To examine the effect of a 1-time dose of pregabalin (Lyrica) on the perception of pain and analgesic consumption after oculofacial plastic surgery. METHODS: In this prospective, randomized, double-blind, placebo-controlled trial, patients presenting to the oculofacial plastic surgery service at University of Colorado Eye Center for functional eyelid surgery and who met the study criteria were consecutively enrolled between October 2011 and September 2012. Subjects were randomized to either placebo or 150 mg pregabalin administered 15 minutes to an hour prior to the procedure. The procedure was then performed under the usual standard of care. Postoperatively, study subjects recorded pain scores on visual analog scales (range 0-100) at 1 to 2 hours, 2 to 4 hours, 8 to 12 hours, 20 to 28 hours, and 36 to 48 hours and the amount of acetaminophen consumed. Data were analyzed with Statistical Analysis System software using mixed-effects linear models. RESULTS: Fifty-two patients were enrolled. Three patients were excluded due to incomplete follow up (n = 2) and postoperative course requiring early unblinding (n = 1). Twenty-six subjects were men. Average age was 68 years (range, 25-89). Eyelid procedures performed included blepharoplasty (18), canthoplasty (11), ptosis repair (15), eyelid retraction repair (2), pentagonal wedge resection (1), and MOHS reconstruction (2). Twenty-six patients were randomized to receive pregabalin, while the remainder received placebo. There was no significant difference in demographics between the 2 groups. The pregabalin group reported pain scores that were 5.5 points lower on average compared with the placebo group (p = 0.0307). Patients in the pregabalin group also consumed half as much acetaminophen (1.3 g) on average as the placebo group (2.6 g) during the postoperative period. CONCLUSIONS: Pregabalin is effective in reducing postoperative pain after oculoplastic procedures when compared with placebo. It may be a useful adjunct for pain control in selected patients.

Tear Trough Incision for External Dacryocystorhinostomy.

PURPOSE: Scar formation is a frequently cited complication of external dacryocystorhinostomy (exDCR). The purpose of this study is to evaluate scar appearance after exDCR with the skin incision placed in the tear trough. METHODS: Multicenter, prospective, noncomparative interventional study was approved by the University of Colorado Institutional Review Board. Patients undergoing exDCR from February 2013 to January 2014 were included in the study, and surgeries were performed by all authors. The incision site for all patients started just under the medial canthal tendon and extended inferolaterally into the tear trough for 10 mm to 15 mm. External dacryocystorhinostomy was performed in the usual manner, and the incision was closed according to the surgeon's preference. At 3 months postop, all patients were asked to rate their scar on the basis of the following grading scale: 0, invisible incision; 1, minimally visible incision; 2, moderately visible incision; and 3, very visible incision. Functional success of the surgery was also determined by asking the patients if their symptoms resolved, improved, or did not change. External photographs taken at 3 months after surgery were graded by 3 independent oculofacial and facial plastic surgeons using the same grading scale. RESULTS: Seventy-two surgeries were performed in 68 consecutive exDCR patients with nasolacrimal duct obstruction during the study period. Sixty-nine out of 72 patients reported improved or resolved symptoms (95.8%). The average patient scar grade was 0.21, while the average surgeon scar grade was 0.99 (p < 0.001). Sixty out of the 72 patients graded the scar as invisible (83.3%), and only 3 patients graded the scar as moderately visible (4.2%). No patients graded the scar as very visible. Of the 216 surgeon grades, 55 scars were graded as invisible (25.5%), while 8 were graded as very visible (3.7%). CONCLUSIONS: Scar appearance after exDCR with the incision placed in the tear trough is minimally visible to surgeons, and more importantly, nearly invisible to patients.

Biodegradable Fixation of the Orbital Rim After Lateral Orbitotomy.

PURPOSE: To describe authors' experience with repair of the lateral orbital rim with poly-L/DL-lactic acid (PDLLA) biodegradable plates using ultrasonic pin fixation after lateral orbitotomy with bone flap. METHODS: The authors retrospectively reviewed all patients who underwent a lateral orbitotomy with bone flap for biopsy of orbital tumors at their institution from January 2010 to May 2013. All patients underwent an orbitotomy by either a lateral eyelid crease incision or lateral canthotomy/cantholysis approach. A lateral bone flap was fashioned in the usual manner, extending from the frontozygomatic suture down the lateral rim for approximately 2 cm. The bone flap was repaired in each case with either a 6 or 7 hole PDLLA plate and secured with ultrasonic PDLLA pin fixation. RESULTS: Twenty-four patients were identified who underwent a lateral orbitotomy with bone flap. Of these patients, 10 were repaired with PDLLA plates. The average age of the patients with PDLLA bone flap fixation was 55 years (range 5-85). The average follow-up time was 12.9 months (range 4-42). Indications included 4 lacrimal gland tumors, 4 intraconal tumors, and 2 lateral orbital tumors. Final diagnosis included lymphoma (3), squamous cell carcinoma (1), neuroblastoma (1), amyloid (1), fibrous tissue (1), sarcoidosis (1), cavernous hemangioma (1), and idiopathic orbital inflammation (1). Three patients had edema of the surrounding soft tissues after surgery, all but 1 resolved by postop month 3. There were 2 cases of transient temporal numbness that resolved by postop month 1. There were no cases of vision loss, extraocular motility deficit, infection, or need for removal of the implant before absorption. CONCLUSIONS: PDLLA biodegradable plates with ultrasonic pin placement provide a safe, effective means for lateral rim fixation after orbitotomy with bone flap.

Bilateral lacrimal gland disease: clinical features of 97 cases.

OBJECTIVE: Bilateral lacrimal gland (LG) disease is a unique presentation that can result from varied causes. We reviewed the diagnoses, clinical features, and outcomes of 97 patients with this entity. DESIGN: Case series. PARTICIPANTS: Ninety-seven patients with bilateral LG disease. METHODS: Retrospective review and statistical analysis using analysis of variance and the Fisher exact test. MAIN OUTCOME MEASURES: Patient demographics, clinical features, diagnostic testing, diagnosis, and treatment. RESULTS: Patient age ranging from 8 to 84 years (mean, 46 years). The predominant gender was female (77%), and race included black (49%), white (38%), and Hispanic (12%) patients. Diagnoses fell into 4 categories: inflammatory (n = 51; 53%), structural (n = 20; 21%), lymphoproliferative (n = 19; 20%), and uncommon (n = 7; 7%) entities. The most common diagnoses included idiopathic orbital inflammation (IOI; n = 29; 30%), sarcoidosis (n = 19; 20%), prolapsed LG (n = 15; 15%), lymphoma (n = 11; 11%), lymphoid hyperplasia (n = 8; 8%), and dacryops (n = 5; 5%). Inflammatory conditions were more likely in younger patients (P<0.05) and in those with pain (P<0.001) and mechanical blepharoptosis (P<0.01) at presentation, whereas lymphoma was more common in older patients (P<0.001) without active signs of inflammation at presentation. Black patients were more likely to have sarcoidosis (P<0.01). Laboratory results showed high angiotensin converting enzyme level being significantly more likely in patients with sarcoidosis (P<0.05). However, sensitivity was limited to 45%, with 25% of patients diagnosed with IOI also demonstrating positive results. Corticosteroid therapy was the treatment of choice in 38 cases, corresponding to resolution of symptoms in 29% and improvement in an additional 32%. Overall, chronic underlying disease was found in 71% of patients, among whom 26% achieved a disease-free state, whereas 3% succumbed to their underlying disease. CONCLUSIONS: The cause of bilateral lacrimal gland disease most commonly was inflammatory, followed by structural and lymphoproliferative. Patient characteristics and clinical presentations were key features distinguishing between competing possibilities. Despite local control with corticosteroids or radiotherapy, underlying disease continued in 71% of patients and led to death in 3%.

Clinical features and treatment of pediatric orbit fractures.

PURPOSE: To describe a series of orbital fractures and associated ophthalmic and craniofacial injuries in the pediatric population. METHODS: A retrospective case series of 312 pediatric patients over a 9-year period (2002-2011) with orbit fractures diagnosed by CT. RESULTS: Five hundred ninety-one fractures in 312 patients were evaluated. There were 192 boys (62%) and 120 girls (38%) with an average age of 7.3 years (range 4 months to 16 years). Orbit fractures associated with other craniofacial fractures were more common (62%) than isolated orbit fractures (internal fractures and fractures involving the orbital rim but without extension beyond the orbit) (38%). Roof and medial wall fractures were most common (30% and 28%, respectively), followed by orbital floor (24%) and lateral wall (18%) fractures. Orbital roof fractures are the most common fracture in patients <8 years old, whereas orbital floor fractures are the most common fracture in patients older than 8 years. Eighty-seven patients (28%) underwent surgical repair. There is an increasing incidence of surgery in older patients (p = 0.02). Associated neurologic injuries were more common (23%) than associated ophthalmic injuries (20%). CONCLUSIONS: Pediatric orbit fracture patterns are dictated by the age of the patient with respect to their craniofacial morphology and mechanism of injury. Orbital roof fractures are more likely to occur in younger patients and not require surgery, whereas orbital floor fractures are more common in older patients and are more likely to require surgery.

Radiation-induced dedifferentiated chondrosarcoma with orbital invasion.

PURPOSE: To report 2 interventional cases of dedifferentiated chondrosarcoma with orbital involvement after radiotherapy performed in childhood and to review the literature on chondrosarcoma in the orbit following radiation treatment. METHODS: Retrospective analysis of medical records of 2 patients with chondrosarcoma of the orbits with review of the literature. RESULTS: The first patient developed chondrosarcoma of the orbital and maxillary sinus 36 years after external beam radiation therapy to the OS to treat retinoblastoma. The second patient developed a large orbital chondrosarcoma 35 years after external beam radiation therapy in the treatment of craniofacial fibrous dysplasia. CONCLUSIONS: These cases highlight the risk of secondary chondrosarcoma in patients following radiotherapy and the importance of lifetime monitoring.