A comparison of primary and secondary eye removal after open globe injury: A multi-centre study.

BACKGROUND/OBJECTIVES: Our goal was to compare the characteristics and surgical outcomes of patients who underwent primary eye removal surgery after open globe injury with those who underwent secondary eye removal surgery after open globe repair. SUBJECTS/METHODS: This was a retrospective review of subjects who underwent evisceration or enucleation within 3 months of an open globe injury, at three Level I trauma centres in three U.S. cities between July 2014 and July 2020. RESULTS: 19 patients underwent primary eye removal and 20 underwent secondary eye removal. The most common mechanism of trauma in patients who underwent primary eye removal was gunshot. Compared to the secondary eye removal group, patients who underwent primary eye removal were significantly more likely to be male; have longer hospital stays; be discharged to another care facility rather than home; have facial fractures; suffer intracranial injury; and be unable to consent themselves for surgery. Both groups had a low surgical complication rate with one case of socket contracture in each group. CONCLUSIONS: The standard of care for an open globe injury is prompt repair, but there are occasions when the globe is so damaged that it is deemed unrepairable. We found that globes that required primary eye removal were more often due to gunshot wounds, and that there was greater morbidity associated with these injuries. The authors' preferred surgical approach was evisceration with placement of a silicone sphere; patient outcomes demonstrate that this method was found to be safe, with a low complication and infection rate.

Synthetic cannabinoid induced ocular self-injury.

Synthetic cannabinoids are a relatively new and increasingly popular recreational drug. While used for their hallucinogenic properties similar to natural cannabis, they have a greater and more serious side effect profile, including potentially severe neuropsychiatric toxicity. We report the cases of two patients with untreated schizophrenia who presented after ocular self-injury while intoxicated on K2. Both patients hallucinated that a bug was behind their eye, and in their attempts at removing the bug, damaged the periocular soft tissue. To our knowledge these are the first reports of ocular self-injury from synthetic cannabinoid intoxication.

Advancements in the repair of large upper eyelid defects: A 10-year review.

PURPOSE: The reconstruction of large (>50%) upper eyelid margin defects can be technically challenging, with multiple approaches described in the literature. We sought to review the recent literature for new techniques or modifications to existing techniques. METHODS: We conducted a Pubmed search for technique papers on the reconstruction of large upper eyelid defects published within the past ten years with a minimum of four patients. RESULTS: We identified ten articles, and divided them into techniques that use a bridging flap from the lower eyelid and those that do not. The number of upper eyelids repaired in each article ranged from 4 to 17. Most techniques could be considered either a modification of the Cutler-Beard technique or a novel anterior lamella flap laid over a graft for the posterior lamella. Postoperative complications included upper or lower eyelid cicatricial retraction, trichiasis, entropion, and lagophthalmos. CONCLUSIONS: Surgeons continue to innovate for this challenging reconstructive surgery. Overall, the trend was to use a graft, most commonly tarsoconjunctiva from the contralateral upper lid, to replace the posterior lamella, and a skin flap, from the lower eyelid or from the adjacent periorbital area, to replace the anterior lamella. Bridging techniques utilized the skin; the skin, orbicularis, and conjunctiva; or a tarsoconjunctival flap from the lower eyelid. Non-bridging techniques generally used a tarsoconjunctival or substitute graft for the posterior lamella, and a skin flap for the anterior lamella.

Concurrent ophthalmomyiasis externa and aural myiasis: A case report in an urban hospital in the United States.

PURPOSE: To describe a case of concurrent ophthalmomyiasis externa and aural myiasis in a patient presenting with headache, right eye pain and blurred vision in an urban hospital in Philadelphia, PA. OBSERVATIONS: Myiasis is the parasitic infestation of a live mammal with fly larvae that feed and grow on host tissue. Predominantly described in the Middle East, Africa and Asia, it is rarely reported in the United States. We describe a case of concurrent ophthalmomyiasis externa and aural myiasis in a 44-year-old man who presented with headache, right eye pain and blurred vision in an urban hospital in Philadelphia, PA. After complete extraction and examination at bedside and in the operating room, the patient improved without complications after treatment with topical antibiotics and steroids. CONCLUSIONS: Although rare in urban settings in the United States, in certain demographic populations, it is important to consider myiasis in the setting of eye and ear pain and to perform a complete eye and ear examination.

Negative-pressure Wound Therapy for Periocular Necrotizing Fasciitis.

Periocular necrotizing fasciitis is a rare, but potentially blinding, or even fatal disease. The authors report a case of a 44-year-old man who presented with quiescent bilateral periocular and facial necrotizing fasciitis. The patient was treated with antibiotics and surgical debridement, followed by negative-pressure wound therapy (NPWT), until the wound bed was thought to be healthy enough to support bilateral upper eyelid full-thickness skin grafts. NPWT appeared to decrease local edema; speed reperfusion and granulation tissue formation; and served to stabilize the skin grafts against the wound bed, while not causing any ocular complications. NPWT can be a safe and effective adjunct treatment for periocular necrotizing fasciitis.

Foreign Body Granuloma Following Orbital Reconstruction with Porous Polyethylene.

Porous polyethylene is commonly used in the orbit for fracture repair and anophthalmic reconstruction; it reportedly has a good safety profile and integrates well into host tissue. Foreign body reaction to porous polyethylene has been reported in facial tissue, but to our knowledge, not in the orbit. The authors report 2 cases of foreign body inflammatory giant cell reaction in patients who underwent orbital fracture repairs with porous polyethylene implants.

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.

Nylon foil (supramid) orbital implants in pediatric orbital fracture repair.

PURPOSE: To present the authors experience with the nylon foil (Supramid) implant as a safe and effective method to repair pediatric orbital wall fractures. METHODS: A retrospective chart review of all pediatric patients (≤18 years) that underwent orbital wall fracture repair with an unsecured 0.4-mm Supramid implant between 2007 and 2010. Outcome variables were diplopia and surgical complications. This study was carried out with IRB approval. RESULTS: A total of 59 orbits in 57 patients underwent orbital fracture repair using solely the 0.4-mm Supramid implant that were included in this retrospective chart review with the average age being 12 years. Trauma related to daily activities (42.1%) was the most frequent cause of orbital fractures. Eight patients (14.0%) had associated ocular/orbital injuries. Thirty-one patients (54.8%) were symptomatic at presentation with the most common presenting symptom being diplopia (n = 19, 33.3%). The most common fracture pattern sustained was combined orbital floor and medial wall fractures, which occurred in 21 patients (36.8%). Of the 3 patients (5.3%) that required immediate intervention due to extraocular muscle entrapment resulting in vasovagal responses, all returned to full and normal extraocular motility. There were 2 postoperative complications without any permanent sequelae; no patient developed postoperative enophthalmos recognizable by both physician and parents, and diplopia improved in all the 6 patients who suffered from immediate postoperative diplopia (10.7%). CONCLUSIONS: The nylon foil implant is a safe and effective method to repair pediatric orbital wall fractures given the low complication rate.

Mercaptopurine-induced hepatoportal sclerosis in a patient with Crohn's disease.

Thiopurines play a pivotal role in the management of inflammatory bowel disease. Azathioprine and mercaptopurine have been associated with a number of liver abnormalities, including hepatitis, veno-occlusive disease, nodular regenerative hyperplasia, and peliosis hepatitis. Patients treated with azathioprine and mercaptopurine have their liver chemistry tests routinely checked due to this potential for hepatotoxicity. Hepatoportal sclerosis is a cause of non-cirrhotic portal hypertension that is increasingly being recognized; its etiopathogenesis is not well defined. We present the first case report of mercaptopurine-induced hepatoportal sclerosis leading to non-cirrhotic portal hypertension in a patient with Crohn's disease. He had been treated with mercaptopurine for five years, and his liver chemistry tests were always within normal limits. This case underscores the potential serious liver adverse events that may arise silently and go undetected during treatment with mercaptopurine, and should alert clinicians as to the potential need to discontinue mercaptopurine in this setting.

Treatment of malar festoon using modified subperiosteal midface lift.

PURPOSE: To describe a technique for treatment of malar festoons with partial subperiosteal midface lift, lower eyelid tarsal strips, and orbicularis muscle-skin flaps. METHODS: Retrospective case report. RESULTS: A 55-year-old Caucasian man developed extensive festoons on both cheeks shortly after deep brain stimulator surgery. The described surgical technique resulted in significant reduction in his festoons. This approach avoided direct excision of the festoon and made use of a more easily hidden incision. CONCLUSIONS: Festoons of the midface have been described in the literature, but little data exist regarding the ideal treatment for this difficult to manage problem. We report successful treatment of festoons with a modified subperiosteal midface lift.

Eyelid procedures in patients who have undergone Boston keratoprosthesis surgery.

PURPOSE: Artificial corneas or keratoprostheses such as the Boston keratoprosthesis (KPro) are being used more frequently to provide a clear corneal window in patients with severe corneal disease. A significant percentage of patients who undergo Boston KPro implantation require subsequent eyelid surgery. However, few articles in peer-reviewed literature evaluate the indication and outcome of eyelid procedures after Boston KPro implantation. This study examines the frequency, nature, and outcomes of oculoplastic procedures in patients with Boston KPro implantation. METHODS: A retrospective chart review was conducted of all KPro-1 procedures performed at the University of Illinois at Chicago between December 2006 and September 2010 and all KPro-1 and KPro-2 procedures performed at the University of Iowa between December 2008 and October 2010. RESULTS: One hundred and twenty eyes underwent Boston KPro-1 procedures, and 2 eyes underwent Boston KPro-2 procedures. Twenty-one (17.2%) of the 122 eyes required subsequent eyelid alterations. Chemical burn was the most common preoperative corneal diagnosis (8 of 21; 38.1%). A variety of oculoplastic procedures were performed; the most common procedure was a permanent lateral tarsorrhaphy. Seventeen (81.0%) of 21 KPro eyes that underwent oculoplastic procedures maintained the KPro at an average of 12.4 months of follow up. CONCLUSIONS: A significant number of patients with Boston KPros require subsequent eyelid surgery. With limited existing literature and increasing popularity for using Boston KPros to treat severe corneal disease, it is essential for oculoplastic and corneal surgeons to understand the need for eyelid alterations in these patients and the surgical intricacies surrounding these cases.

Silicone spacer repair of medial rectus after iatrogenic orbit fracture.

A 51-year-old woman underwent endoscopic nasal polypectomy and ethmoidectomy with accidental entry into the right orbit causing enophthalmos and transection of the medial rectus muscle (MR). The repair of a fracture and of a damaged MR is technically challenging, particularly when large portions of bone and muscle are missing. We report a rare case of repair of the bony defect with an implant and reattachment of the MR with a silicone retina band, through a combined transcaruncular and transconjunctival approach. Postoperatively, the patient had residual enophthalmos and strabismus; further surgical options are discussed.

Churches' responses to HIV/AIDS in two South African communities.

Churches have attracted controversy for how they have dealt with AIDS: they have been criticized for moral stigmatism, yet lauded for their charitable works. Our purpose was to examine what churches were doing at the grass-roots level to deal with the impact of AIDS on their communities. This study was conducted in a rural area and an urban area outside of Durban, South Africa, a region with high HIV prevalence rates. We examined 2 indigenous churches (Shembe and Zionist) and one international church (Roman Catholic) in each community. We found that there was a widespread awareness of AIDS among church leaders and community members, and that churches were used as health resources by their members, yet no AIDS programs were run by any of the churches in the study locations. We argue that 4 key characteristics dictated the churches' responses to AIDS: resources, organizational structure, cultural appeal, and discipline. There are distinct advantages to partnering with churches for AIDS programming, yet significant complexities to navigating a meaningful dialogue with them also exist.