Customized titanium reconstruction of post-traumatic orbital wall defects: a review of 22 cases.

The authors present the clinical results of their method of customized reconstruction of orbital wall defects using titanium mesh or sheet. High resolution computed tomography (CT) data are imported and processed to create a three-dimensional (3D) image which is used to reconstruct the orbital defect. Mirror imaging of the air in the contralateral maxillary sinus is used to overcome artefact defects in the floor. A stereolithographic model is constructed, from which titanium mesh or sheet is shaped and sized to the required contours for implantation. Twenty-two patients were treated using this technique from 2003 to 2008. Postoperatively 10 patients reported early resolution of their diplopia. Six patients noticed significant improvement of their symptoms with mild residual diplopia in one direction only and at the extremes of gaze at final review. One patient required ocular muscle surgery. Enophthalmos resolved in eight of the nine cases. No patients developed enophthalmos or diplopia as a postoperative complication. The use of titanium mesh for orbital floor reconstruction has been shown to be safe and effective. Customized titanium implants accurately reproduce orbital contours thus restoring orbital volume. This reduces operative time and improves the functional and aesthetic outcomes of post-traumatic orbital reconstruction.

A randomised controlled trial comparing fixation of mandibular angle fractures with a single miniplate placed either transbuccally and intra-orally, or intra-orally alone.

This study compared fixation of simple mandibular angle fractures with a single miniplate either placed from a combined transbuccal and intra-oral approach, or intra-orally alone. 140 consecutive patients were randomly allocated to the two treatment groups. Complications were noted and compared. An email questionnaire to all the participating surgeons examined their personal preferences between the two methods. 20% of plates needed to be removed during the 3 month study period in the combined transbuccal/intra-oral group compared with 36% in the intra-oral alone group (p

Recurrent ectasia in corneal grafts and outcomes of repeat keratoplasty for keratoconus.

AIM: To analyse cases of recurrent ectasia in donor corneas after penetrating keratoplasty (PK) for keratoconus. METHODS: Data on 25 patients (36 eyes) with recurrent ectasia were retrospectively analysed in this study. The main outcome measures were time to development of recurrent ectasia after first PK for keratoconus, change in keratometric sphere and astigmatism between final suture removal and development of recurrent ectasia, status of regrafts for recurrent ectasia, and histopathology of grafts excised for recurrent ectasia. RESULTS: The age at first PK was 32.6 (SD 8.5) years, and ectasia developed 21.9 (7.0) years after PK. The mean keratometric sphere and cylinder increased by 4.2 D and 3.0 D, respectively, between final suture removal and diagnosis of recurrent ectasia. Ectasia was often preceded by thinning without bulging of the recipient stroma at the graft-host junction. Fifteen eyes (13 patients) were regrafted for recurrent ectasia, and histopathology of the excised grafts showed changes characteristic of keratoconus in the donor tissue in all cases. Two regrafts (two eyes of one patient) developed ectasia again, with one eye requiring a third PK to improve vision. CONCLUSIONS: Recurrent ectasia was diagnosed on average two decades after PK. Ectatic changes were often bilateral and occasionally recurred after regrafting, suggesting that host cellular and/or biochemical factors may be responsible. Repeat PK for recurrent ectasia is successful in the intermediate term.

A comprehensive classification of mandibular fractures: a preliminary agreement validation study.

This study evaluates a comprehensive classification system for mandibular fractures based on imaging analysis. The AO/ASIF scheme, defining three fracture types (A, B, C), three groups within each type (e.g. A1, A2, A3) and three subgroups within each group (e.g. A1.1, A1.2, A1.3) with increasing severity from A1.1 (lowest) to C3.3 (highest) was used. The mandible is divided into two vertical units (I and V), two lateral horizontal units (II and IV) and one central unit (III) comprising the symphyseal and parasymphyseal region. Type A fractures are non-displaced, type B are displaced and type C are multifragmentary/defect injuries. Groups and subgroups are further defined in the classification system. Two classification sessions using semi-automatic software with 7 and 9 surgeons were performed to evaluate 100 fracture cases in the first session and 50 in the second. Inter-observer reliability and individual rater's accuracy were evaluated by kappa coefficient and latent class analysis, respectively. The analysis of inter-observer agreement for the detailed coding showed kappa coefficients around 0.50 with higher agreement among raters in the vertical units. This system allows standardization of documentation of mandibular fractures, although improvement in the definition of categories and their application is required.

Necrotising fasciitis of the submandibular region; a complication of odontogenic origin.

Inadequate treatment or neglect of odontogenic infections can have serious consequences. The potential for spreading through fascial planes and intracranially can cause compromise of the airway and cavernous sinus thrombosis respectively. On rare occasions this can lead to a rapidly progressing necrotising fasciitis, with destruction of soft tissue, making reconstruction difficult. Antibiotic administration without removal of the cause is inadequate and can complicate subsequent management. We report the presentation and successful management of a 13-year-old boy, who developed necrotising fasciitis in the submandibular region as a result of inadequate initial treatment of a carious, lower molar resulting in significant skin and soft tissue loss.

Bilateral mandibular condylysis in a patient with systemic sclerosis.

A case of progressive osteolysis of the mandibular condyles in a 55-year-old female patient with systemic sclerosis (SSc) is described. Orofacial involvement and radiological manifestations of SSc are discussed.

Nd:YAG capsulotomy rates after use of the AcrySof acrylic three piece and one piece intraocular lenses.

BACKGROUND/AIM: Acrylic lens size and shape may influence the rate of posterior capsule opacification (PCO) and need for Nd:YAG capsulotomy. The aim of this study is to compare the Nd:YAG capsulotomy rate of the three piece acrylic/PMMA AcrySof MA series lens with the one piece acrylic AcrySof SA series lens. METHODS: 434 eyes of 329 patients who had cataract extraction and implantation of one of four types of intraocular lenses (IOLs) were evaluated for rate of Nd:YAG capsulotomy. 176 eyes received the acrylic AcrySof MA30AC IOL, 71 eyes the acrylic AcrySof MA60AC IOL, 45 eyes the acrylic AcrySof SA30AL IOL, and 142 eyes the acrylic AcrySof SA60AT IOL. RESULTS: The rates of Nd:YAG capsulotomy with the three piece IOL (MA30AC/MA60AC) and the one piece IOL (SA30AL/SA60AT) were 1.2% and 2.1% at 6 months, 2.8% and 5.9% at 12 months, and 3.6% and 7.5% at 24 months, respectively. The incidence of Nd:YAG capsulotomy was higher in patients who received the one piece IOL (p=0.01, log rank test). There was no difference in Nd:YAG capsulotomy rates when comparing lens optic size, age, sex, history of pars plana vitrectomy, and diabetes mellitus. CONCLUSIONS: This study shows a greater incidence of Nd:YAG capsulotomy in patients who receive one piece acrylic AcrySof lenses when compared to those who receive three piece acrylic AcrySof lenses.

A form for referral of injured patients between maxillofacial and ophthalmology units.

We have designed a form to facilitate referral of injured patients between maxillofacial and ophthalmology units. This form improves communication, gives a written record of referral, and can be used for audit.

Blood transfusion requirements in bimaxillary osteotomies.

The over-ordering of cross-matched blood to cover operations can result in blood shortages and is costly; it can never be free of risk. Current published guidelines recommend cross-matching 2 units of blood for bimaxillary orthognathic procedures with an additional 2 units if combined with a genioplasty. We reviewed the records of 115 consecutive cases of simultaneous bimaxillary osteotomies at Morriston Hospital over a 5-year period (January 1996 to December 2000). Ordering and use of blood were investigated and the cost analysed. Blood loss was minimised using a strategy of controlled moderate hypotension and meticulous haemostasis. Nine patients were given transfusions of blood but five of these were deemed inappropriate. No predisposing factors for transfusion were identified. We recommend that the tariff for ordering blood for bimaxillary osteotomies should be revised to a "group and save" with antibody screen, providing that a 30-min indirect antibody cross-match is available.

Post-traumatic orbital cellulitis.

Orbital cellulitis is uncommon. It may arise as a sequel to eyelid infection, or from direct spread of infection from the paranasal sinuses; it may be of odontogenic origin and has been reported after meningitis and after nasoorbital fractures with pre-existing sinusitis. Clinically, orbital cellulitis is of great importance, as it is a severe disease with potentially disastrous consequences. It may lead to optic neuritis, optic atrophy, blindness, cavernous sinus thrombosis, superior orbital fissure syndrome, meningitis, subdural empyema, and even death. We report two cases of severe post-traumatic orbital cellulitis with subperiosteal abscesses. These were managed surgically and vision was preserved. We describe the anatomy, a classification of orbital infection, and the importance of multidisciplinary management of these cases.

Can warfarin be continued during dental extraction? Results of a randomized controlled trial.

A randomized controlled trial was set up to investigate whether patients who were taking warfarin and had an International Normalised Ratio (INR) within the normal therapeutic range require cessation of their anticoagulation drugs before dental extractions. Of 109 patients who completed the trial, 52 were allocated to the control group (warfarin stopped 2 days before extraction) and 57 patients were allocated to the intervention group (warfarin continued). The incidence of bleeding complications in the intervention group was higher (15/57, 26%) than in the control group (7/52, 14%) but this difference was not significant. Two patients in the study required hospital review for bleeding and all other episodes of bleeding were controlled by patients at home. Continuing warfarin when the INR is < 4.1 may lead to an increase in minor post-extraction bleeding after dental extractions but we found no evidence of an increase in clinically important bleeding. As there are risks associated with stopping warfarin, the practice of routinely discontinuing it before dental extractions should be reconsidered.