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.

Traumatic orbital encephalocele: Presentation and imaging.

OBJECTIVE: Traumatic orbital encephalocele is a rare but severe complication of orbital roof fractures. We describe 3 cases of orbital encephalocele due to trauma in children. METHODS: Retrospective case series from the University of Wisconsin - Madison and Medical College of Wisconsin. RESULTS: Three cases of traumatic orbital encephalocele in pediatric patients were found. The mechanism of injury was motor vehicle accident in 2 patients and accidental self-inflicted gunshot wound in 1 patient. All 3 patients sustained orbital roof fractures (4 mm to 19 mm in width) and frontal lobe contusions with high intracranial pressure. A key finding in all 3 cases was progression of proptosis and globe displacement 4 to 11 days after initial injury. On initial CT, all were diagnosed with extraconal hemorrhage adjacent to the roof fractures, with subsequent enlargement of the mass and eventual diagnosis of encephalocele. CONCLUSION: Orbital encephalocele is a severe and sight-threatening complication of orbital roof fractures. Post-traumatic orbital encephalocele can be challenging to diagnose on CT as patients with this condition often have associated orbital and intracranial hematoma, which can be difficult to distinguish from herniated brain tissue. When there is a high index of suspicion for encephalocele, an MRI of the orbits and brain with contrast should be obtained for additional characterization. Imaging signs that should raise suspicion for traumatic orbital encephalocele include an enlarging heterogeneous orbital mass in conjunction with a roof fracture and/or widening fracture segments.

Osseointegrated implants for orbito-facial prostheses: Preoperative planning tips and intraoperative pearls.

PURPOSE: Implant-retained facial prostheses are becoming increasingly sophisticated. We describe our experience with successful implant placement. METHODS: Retrospective case series. Patients with severe unilateral orbital deformity who underwent socket reconstruction with placement of orbital implants were identified. Data on patient age, gender, mechanism of eye, soft tissue, and bone loss, prior reconstructive surgeries and radiation, and orbital imaging were collected and analyzed. RESULTS: Four patients (9 implants) between 2010 and 2014, who had osseointegrated implants placed for orbito-facial prostheses were identified. Three were male, one female. Average age was 59 years (range 34-86). Reason for eye loss was trauma in two patients, exenteration for recurrent rhabdomyosarcoma in one patient, and enucleation for retinoblastoma in one patient. All patients had Vistafix® (Gothenburg, Sweden) osseointegrated titanium implants (4 mm) placed in a 2-stage procedure over a span of 3-6 months with subsequent successful prosthesis fitting. CONCLUSION: Implant-retained orbito-facial prostheses are safe, easy, and reliable. The ideal socket has minimal dead space, robust bone, and soft tissue 4-5 mm in depth. Preoperative planning should consist of: 1) orbit CT; 2) careful clinical exam of the orbital deformity; and, 3) analysis of socket topography. Operative tips for successful implant placement include: 1) 2-3 points of fixation; 2) placement of implants in bone of adequate thickness; and 3) implant placement as a 2-stage rather than 1-stage procedure. There appears to be no difference in outcome in irradiated and non-irradiated sockets in this series, but should be a consideration and discussed with the patient.

Treating Buccinator With Botulinum Toxin in Patients With Facial Synkinesis: A Previously Overlooked Target.

OBJECTIVE: Synkinesis after facial nerve injury produces functional and cosmetic concerns for patients. The purpose of this study was to review the authors' experience of treating buccinator synkinesis with botulinum toxin. METHODS: This was a retrospective medical records review. All patients seen at the University of Wisconsin Neuromuscular Retraining Clinic who were treated with botulinum injections to the buccinator muscle were included. After a period of neuromuscular retraining lasting 6 to 12 months, botulinum injections were administered to the anterior, middle, and/or posterior aspect of buccinator by the senior author via an intraoral approach. The sites and dosage of the injections depended substantially on input from the therapist overseeing the patient's neuromuscular retraining therapy. Data on patient age, gender, indication for treatment, location and dose of botulinum administration, and outcome were collected. The Synkinesis Assessment Questionnaire (SAQ) was used as a patient-reported outcome measure. Descriptive statistics were computed for all recorded variables. RESULTS: A total of 42 patients with synkinesis involving the buccinator were treated. Female-to-male ratio was 9:1, and follow up ranged from 5 months to 18 years. The indications for treatment included significant retraction and immobility of the affected oral commissure at rest and during volitional and spontaneous facial expressions, difficulty manipulating food during mastication, and biting the inside of the affected cheek. Mean total dose of botulinum administered to buccinator per session was 2.0 units (range, 0.6-2.5 units). SAQ scores improved from a mean of 66.6 preinjection to 45.0 postinjection. In general, patient satisfaction with the procedure was high, and there were no serious complications. CONCLUSIONS: To the authors' knowledge, this is the first report of a cohort of patients with buccinator synkinesis treated with botulinum toxin. This treatment has become a valuable adjunct in the comprehensive management of patients with facial synkinesis.

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.

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.

Orbital osteoma: clinical features and management options.

PURPOSE: This study reviews the clinical presentation and management of 11 cases of sino-orbital osteoma. METHODS: The medical records of patients with primary (originating from orbital bone) and secondary (originating from the paranasal sinuses) orbital osteoma from the academic practices of 4 surgeons (A.V.C., M.J.L., P.J.D., V.D.D.) were reviewed for clinical presentation and course, pathologic study, and radiologic reports. A Medline search of English-language literature on orbital osteomas was conducted for comparison with these findings. RESULTS: Eleven cases of primary (1) and secondary (10) orbital osteoma were reviewed, with a mean follow up of 16 months. Seven patients were women. Ages ranged from 15-68 years, with a median of 40 years. Presenting complaints included slowly progressive globe displacement, palpable bony nodule, pain, and diplopia. Surgery was performed in 10 cases. Surgical approach varied according to location and size of each lesion and was performed in combination with otolaryngology and neurosurgery services as needed. Reconstruction included sculpting osteomatous bone to natural orbital contours, repair of orbital wall defects with implants, and obliteration of frontal sinus. Lesions demonstrated mixed compact, cancellous, and fibrous histologic subtypes. CONCLUSIONS: Osteomas are the most common tumor of the paranasal sinuses (noted in up to 3% of coronal CT images), but secondary extension in or primary involvement of the orbit is rare. A variety of surgical approaches led to successful outcomes in this series. Complete surgical removal is not always necessary, and partial sculpting may relieve symptoms and cause less surgical morbidity in selected cases.

Performance characteristics of a straight versus bent 25-gauge vitrector.

BACKGROUND AND OBJECTIVE: During vitrectomy in phakic patients, lens damage can occur while shaving the peripheral vitreous. Modifying the vitrector with a slight bend can diminish this risk. MATERIALS AND METHODS: To assess whether the bent vitrector performs to standard, the cutting and aspiration functionality of a straight and bent cutter was tested on both the vitreous from an enucleated porcine eye and balanced salt solution. Data were analyzed using a paired two-tailed t-test for comparison of two small sample means. RESULTS: The average time for removal of vitreous was 19.32 seconds with the straight cutter and 19.26 seconds for the bent cutter. There was no statistically significant difference between the removal rates (P = .87). The average time for aspiration of balanced salt solution was 14.3 seconds with the straight tip and 14.16 seconds with the bent tip. There was no statistically significant difference between the aspiration rates (P = .55). CONCLUSION: Both unmodified and bent vitrectors demonstrate an equally efficient rate of removal of vitreous and balanced salt solution in vitro.

Pediatric facial fractures from dog bites.

PURPOSE: To report a series of pediatric facial fractures associated with dog bites. METHODS: Retrospective review of all dog bite injuries to the face with facial fractures in children from January 1, 2003, to October 31, 2011, at Children's Hospital Colorado (Aurora, Colorado). Patient demographics, location and number of fractures, clinical course, surgical repair, and complications were recorded and analyzed using Excel statistical software. RESULTS: Seventeen of 1,201 (1.4%) children with dog bite injuries to the face also sustained facial fractures. The average age of patients was 3.9 ± 3.2 years and 53% were female. Thirty-five percent of patients presented with multiple facial fractures. The most common fracture involved the nasal bone (29%), while the remainder sustained fractures of the zygomatic arch, orbital rim, orbital floor, skull, mandible, maxilla, and/or sinuses. Of the 17 patients, 41% also sustained eyelid lacerations, 24% had injuries to the facial nerve, and 18% had canalicular lacerations. Fourteen of the 17 patients required surgical repair under general anesthesia. CONCLUSIONS: Although uncommon, facial fractures associated with dog bites are a significant source of morbidity, often requiring complex surgical repair. Severe injuries to the face from dog bites should be evaluated for possible fractures in addition to soft tissue injuries.

Pediatric orbital floor fractures.

PURPOSE: To summarize the unique aspects of orbital floor fractures in children with regard to clinical presentation, management, and outcomes. METHODS: MEDLINE was searched using PubMed for English-language articles on orbital floor fractures in children. All 154 indexed articles pertaining to floor fractures in patients under 18 years of age in PubMed were reviewed. Studies looking at primarily complex fractures and case reports and studies that included pediatric patients but did not analyze them separately were excluded. Overall, 25 studies were included for the review. RESULTS: Inferior trapdoor fractures with muscle and soft tissue incarceration are the most common type of orbital fracture in children (27.8%-93%). They often present uniquely with severely restricted extraocular motility and diplopia (44%-100%), nausea and vomiting (14.7-55.6%), and minimal signs of external trauma. The majority of studies (83%) that analyzed time to surgery in relation to outcomes found that children who present early after initial injury and undergo prompt surgical repair appear to recover faster and have better postoperative motility than those receiving delayed treatment. CONCLUSIONS: Our understanding of pediatric orbital floor fractures continues to evolve. For young patients with symptomatic diplopia with positive forced ductions, soft tissue entrapment confirmed by computed axial tomography, and/or trapdoor fracture plus restricted ocular movement, having surgery within 2-5 days has been shown to result in better postoperative outcomes. It is recommended that surgery be considered within 48 hours of diagnosis. Long-term prospective studies are still needed to further characterize orbital floor fractures in children.

The Confusion Assessment Method: a systematic review of current usage.

OBJECTIVES: To examine the psychometric properties, adaptations, translations, and applications of the Confusion Assessment Method (CAM), a widely used instrument and diagnostic algorithm for identification of delirium. DESIGN: Systematic literature review. SETTING: Not applicable. MEASUREMENTS: Electronic searches of PubMED, EMBASE, PsychINFO, CINAHL, Ageline, and Google Scholar, augmented by reviews of reference listings, were conducted to identify original English-language articles using the CAM from January 1, 1991, to December 31, 2006. Two reviewers independently abstracted key information from each article. PARTICIPANTS: Not applicable. RESULTS: Of 239 original articles, 10 (4%) were categorized as validation studies, 16 (7%) as adaptations, 12 (5%) as translations, and 222 (93%) as applications. Validation studies evaluated performance of the CAM against a reference standard. Results were combined across seven high-quality studies (N=1,071), demonstrating an overall sensitivity of 94% (95% confidence interval (CI)=91-97%) and specificity of 89% (95% CI=85-94%). The CAM has been adapted for use in the intensive care unit, emergency, and institutional settings and for scoring severity and subsyndromal delirium. The CAM has been translated into 10 languages where published articles are available. In application studies, CAM-rated delirium is most commonly used as a risk factor or outcome but also as an intervention or reference standard. CONCLUSION: The CAM has helped to improve identification of delirium in clinical and research settings. To optimize performance, the CAM should be scored based on observations made during formal cognitive testing, and training is recommended. Future action is needed to optimize use of the CAM and to improve the recognition and management of delirium.