Delayed onset porous polyethylene implant-related inflammation after orbital blowout fracture repair: four case reports.

BACKGROUND: Porous polyethylene implants are commonly used in orbital blowout fracture repair because of purported biocompatibility, durability, and low frequency of complications. Delayed inflammation related to porous polyethylene sheet implants is very rare and no case series of this condition have been reported. CASE PRESENTATION: This is a retrospective review of clinical presentations, radiographic findings, histopathological findings, treatments, and outcomes of patients who developed delayed complications in orbital blowout fracture repair using porous polyethylene sheets. Four male patients were included with a mean age of 49 years (range 35-69 years). Blowout fracture repair was complicated with implant-related inflammation 10 months, 2 years, 3 years, and 8 years after surgery. Chronic and subacute orbital inflammatory signs were noted in two patients and acute fulminant orbital inflammation was found in two patients. Three patients developed peri-implant abscesses and one patient had a soft tissue mass around the implant. All patients underwent implant removal and two of these patients with paranasal sinusitis had sinus surgery. Histopathological findings revealed chronic inflammatory changes with fibrosis, and one patient had foreign body granuloma with culture positive Staphylococcus aureus. CONCLUSIONS: Delayed complications with porous polyethylene sheets used in orbital blowout fracture repair may occur many years following the initial surgery in immunocompetent patients. Low-grade or fulminant inflammation could complicate blowout fracture repair related with the implant.

Prostaglandin Eyedrops Are Associated With Decreased Thicknesses of Eyelid Dermis and Orbicularis Oculi Muscle: Ultrasonographic Findings.

PURPOSE: To investigate the effect of prostaglandin analog eyedrops on the periorbital soft tissue using high-resolution ultrasonography. METHODS: In this cross-sectional study, the authors included patients with bilateral glaucoma on unilateral prostaglandin therapy for the past 12 or more contiguous months. High-resolution ultrasonography was performed bilaterally on the upper and lower eyelids of each subject to measure thicknesses of dermis, orbicularis oculi muscle, and skin to arcus marginalis distance. Comparisons were made between eyes on prostaglandin eyedrops versus those not on prostaglandin analogs. RESULTS: Twenty patients (16 females, 4 males) with a mean age of 67.2 ± 6.4 years were recruited. The mean duration of prostaglandin analog therapy was 5.4 ± 3.9 years. The authors found that eyes on prostaglandin analog therapy had statistically significantly reduced thicknesses of dermis, orbicularis oculi muscle, and skin to arcus marginalis distance in the upper and lower eyelids compared with the fellow eyes (p < 0.05 for all). In univariate regression analysis, the amount of changes in thicknesses of dermis, orbicularis oculi muscle, and skin to arcus marginalis distance among eyes on prostaglandin analog therapy and the fellow eyes was not statistically significantly associated with different variables including age, gender, years of being on prostaglandin analog therapy, type of prostaglandin analog, history of glaucoma and/or cataract surgeries, intraocular pressure, and number of glaucoma medications. CONCLUSIONS: The findings indicate that eyes on prostaglandin analog therapy have reduced thicknesses of dermis, orbicularis oculi muscle, and skin to arcus marginalis distance compared with the fellow eyes.

Localization and Retrieval of an Eyelid Metallic Foreign Body With an Oscillating Magnet and High-Resolution Ultrasonography.

A patient was found to have a metallic foreign body in the left anterior orbit on CT imaging, but the foreign body was not evident on clinical examination. On high-resolution ultrasonography, an object was identified in the left upper eyelid; however, the typical shadow with metallic foreign bodies was not seen. A high-power oscillating magnet was then applied to the eyelid, which revealed a subcutaneous metallic foreign body in the left upper eyelid. When used in conjunction, the high-resolution ultrasound and oscillating magnet successfully localized and facilitated retrieval of the metallic foreign body from the left upper eyelid.

Transorbital approach without craniotomy to orbital tumors with extradural intracranial extension.

PURPOSE: To review indications and clinical outcomes in a series of orbitocranial tumors treated surgically through a transorbital extradural approach without craniotomy. METHODS: In this retrospective case series, all patients who underwent surgery through a transorbital extradural approach without craniotomy for benign orbitocranial tumors involving the dura or extending into the anterior or middle cranial fossae were analyzed. RESULTS: Twenty-seven patients (20 females and 7 males) were included. Median age was 47.0 years (range: 6-74 years) and median follow-up time was 43.5 months (range: 3-148 months). The median preoperative best-corrected visual acuity (logMAR) was improved from 0.35 (range: 0-2.6) to 0.1 (range: 0-2.6) at the last follow-up (p < 0.03). The mean ± SD preoperative exophthalmos significantly decreased from 20.4 ± 3.4 mm to 13.1 ± 3.5 mm at the last follow-up visit (p < 0.01). Four postoperative complications were noted and included one case each of ptosis, numbness, diplopia (transient for 6 months), and cranial nerve VI palsy (transient for 4 months). CONCLUSIONS: The transorbital extradural approach provides access to the deep orbit and adjacent extradural cranial spaces. Benign orbital tumors that have eroded through the orbital roof, are located in the orbital apex abutting the anterior cavernous sinus and tumors requiring debulking are all processes that can be potentially approached through the transorbital extradural route. Compared to open craniotomy, the incision is smaller, the access more direct and specific risks of open craniotomy are reduced.

Hyaluronic acid gel injection for upper eyelid retraction in thyroid eye disease: functional and dynamic high-resolution ultrasound evaluation.

PURPOSE: The goal of this study is to determine the functional and dynamic effects of hyaluronic acid (HA) gel injection into the levator plane for improving upper eyelid retraction in patients with thyroid eye disease (TED). METHODS: This is a prospective, non-randomized study of consecutive patients with symptomatic unilateral upper eyelid retraction in the setting of active and inactive TED. Study participants underwent HA gel injection subconjunctivally into the levator plane and were examined before injection, 1 to 3 months after injection, and at the clinician's discretion thereafter. At each of the time points, high-resolution ultrasound imaging and clinical photographs were taken, and the marginal reflex distance 1 (MRD1) was measured. RESULTS: Eight patients (4 in the active stage of TED, 4 in the inactive stage of TED) were injected on average with 0.45 ml of HA gel. The average baseline MRD1 was 5.6 mm prior to HA injection, 4.6 mm at the first follow up after injection, and 5 mm at the final follow up after injection. HA was localized ultrasonographically to multiple anatomical locations and changed in morphology over time but not in anatomical location. All patients demonstrated increased fluidity of eyelid excursion on dynamic ultrasound after HA injection. There were no vision-threatening complications in this study. CONCLUSIONS: Despite variability in the HA gel distribution and long-term conformational changes on ultrasound examination, HA injection may be an effective and minimally invasive method to improve upper eyelid position for patients with mild eyelid retraction in both the active and inactive stages of TED.

Hyaluronic acid gel distribution pattern in periocular area with high-resolution ultrasound imaging.

BACKGROUND: High-resolution ultrasound (HRUS) is a useful tool in defining anatomic and dynamic soft tissue relationships in the periocular area. It also allows visualization of hyaluronic acid (HA) gel within the soft tissue. OBJECTIVES: The authors investigate the difference in the distribution pattern between 2 HA fillers in the periocular tissue using HRUS. METHODS: The charts of 10 patients who underwent periocular injection using HA gel filler and were subsequently examined with HRUS were reviewed. Half of the patients (n = 5) were treated with Restylane-L (Medicis Aesthetics, Inc, Scottsdale, Arizona) and the remaining 5 with Belotero Balance (Merz Aesthetics, Inc, San Mateo, California). Ultrasonographic evaluation (Logiq p6; GE Healthcare, Waukesha, Washington) was performed before and immediately after HA filler injection. RESULTS: The HA appears as a hypoechoic image within the soft tissue plane on HRUS. Restylane-L filler formed a localized hypoechoic image within the tissue, with some spread into bubbles or pearl-like configuration. Belotero Balance spread more widely into the tissue plane and diffused into an elongated or spindle-shaped hypoechoic image. CONCLUSIONS: Our preliminary data suggest that HA gel fillers with differing production technologies show distinct spread and distribution patterns in the periocular tissues on HRUS examination.

Dynamic high-resolution ultrasound in vivo imaging of hyaluronic acid filler injection.

BACKGROUND: High-resolution ultrasound (HRU) imaging is a useful tool to study hyaluronic acid (HA) filler injected in the face. OBJECTIVE: To observe real-time injection of HA using HRU and describe behavior of the gel injection in various anatomic layers and the effect of massage. METHODS: Deep (preperiosteal), intermediate (subdermal), and superficial (dermal) injections of HA were performed in the supraclavicular area under ultrasonography visualization on a healthy volunteer. Videos were obtained during injection and static images at several time points, including during injection, immediately after injection, 5 minutes after massage of the treated area, and at 2 weeks after injection. RESULTS: During injection, dermally injected HA stayed within the dermis, increasing its echogenicity; subdermally injected HA formed multiple anechoic pearls; and preperiosteal HA produced a single anechoic bubble with diffuse margins. No vertical transection of the planes was observed during injection or after massage. Two-week postinjection imaging showed persistence of the varying HA morphology in each plane. CONCLUSIONS: High-resolution ultrasound allows in vivo study of HA injection behavior. HA adopts different morphology within the tissue depending on the density and compliance of the tissues in the plane of injection.

Benign orbital apex tumors treated with multisession gamma knife radiosurgery.

OBJECTIVE: The orbital apex is an important anatomic landmark that hosts numerous critical neurovascular structures. Tumor resection performed at this complex region poses a therapeutic challenge to orbital surgeons and often is associated with significant visual morbidity. This article reports the efficacy and safety of multisession gamma knife radiosurgery (GKRS) in benign, well-circumscribed tumors located at the orbital apex. DESIGN: Retrospective interventional case series. PARTICIPANTS: Five patients with visual disturbances resulting from a benign, well-circumscribed orbital apex tumor (3 cases of cavernous hemangioma and 2 cases of schwannoma). METHODS: Each patient treated with GKRS with a total radiation dose of 20 Gy in 4 sessions (5 Gy in each session with an isodose line of 50%) delivered to the tumor margin. MAIN OUTCOME MEASURES: Best-corrected visual acuity, visual field changes, orbital imaging, tumor growth control, and side effects of radiation. RESULTS: All patients demonstrated improvement in visual acuity, pupillary responses, color vision, and visual field. Tumor shrinkage was observed in all patients and remained stable until the last follow-up. No adverse events were noted during or after the radiosurgery. None of the patients experienced any radiation-related ocular morbidity. CONCLUSIONS: From this experience, multisession GKRS seems to be an effective management strategy to treat solitary, benign, well-circumscribed orbital apex tumors.