Transconjunctival versus subciliary approach to the infraorbital margin for open reduction of zygomaticomaxillary complex fractures: a randomized feasibility study.

INTRODUCTION: Although some studies addressed the differences between subciliary and transconjunctival approaches, no previous prospective comparative study on displaced zygomaticomaxillary complex (ZMC) fracture that repaired by three-point internal fixation using also upper gingivolabial incision and upper eye lid incision. So, the effect of these incisions on the comparison was not investigated. PURPOSE: The purpose of this study was to compare transconjunctival and subciliary approaches for open reduction and internal rigid fixation (OR/IF) of ZMC fractures. METHODS: This prospective study was carried out on 40 patients had displaced ZMC fractures repaired by OR/IF. Patients were randomly assigned into two equal groups (20 patients for each); subciliary group subjected to subciliary approach and transconjunctival group subjected to transconjunctival approach for inferior orbital rim repair. In both groups, frontozygomatic and zygomaticomaxillary buttresses were also approached by lateral eye brow and superior gingivolabial incision, respectively. Primary outcome measures include accessibility (need for lateral canthotomy), the exposure duration, postoperative pain, early postoperative edema, and operative complications. Secondary outcome measures include dental occlusion, average intrinsic vertical mouth opening, post subciliary scar assessment, late postoperative complication, and opthalmological assessment concerning ectropion, entropion, scleral show, and eye globe affection (enophthalmos or diplopia). RESULTS: The mean duration from incisions to fracture exposure was 13.7 ± 2.17 min in subciliary approach and 14.6 ± 2.31 min in transconjunctival approach with nonsignificant difference (p = 0.1284). Lateral canthotomy was required for proper exposure of the fracture and OR/IF using transconjunctival approach while not needed with subciliary approach. Ectropion and scleral show occurred in 10 and 15% respectively in subciliary group and were not encountered in transconjunctival group. Although postoperative periorbital edema was significantly more sever in transconjunctival group within the first postoperative week (p = 0.028), no persistent periorbital edema was reported. Infection, hematoma, and globe complication were not detected in any patient. All authors characterized all scars of the subciliary group as unnoticeable. CONCLUSION: Transconjunctival approach mostly needs lateral canthotomy that was not needed with subciliary approach. Transient postoperative edema is more in transconjunctival approach while postoperative ectropion and sclera show was detected only with subciliary approach. So, building up of experience in transconjunctival approach will be beneficial for maxillofacial surgeons and more measures to avoid ectropion are needed with subciliary approach.

Orbital steroid injection versus oral steroid therapy in management of thyroid-related ophthalmopathy.

BACKGROUND: The aim of this study was to evaluate the efficacy, safety and complications of orbital steroid injection versus oral steroid therapy in the management of thyroid-related ophthalmopathy. METHODS: A total of 29 patients suffering from thyroid ophthalmopathy were included in this study. Patients were randomized into two groups: group I included 15 patients treated with oral prednisolone and group II included 14 patients treated with peribulbar triamcinolone orbital injection. Only 12 patients in both groups (16 female and 8 male) completed the study. RESULTS: Both groups showed improvement in symptoms and in clinical evidence of inflammation with improvement of eye movement and proptosis in most cases. Mean exophthalmometry value before treatment was 22.6 ± 1.98 mm that decreased to 18.6 ± 0.996 mm in group I, compared with 23 ± 1.86 mm that decreased to 19.08 ± 1.16 mm in group II. Mean initial clinical activity score was 4.75 ± 1.2 and 5 ± 1.3 for group I and group II before treatment, respectively, which dropped to 0.83 ± 1.2 and 0.83 ± 1.02, 6 months after treatment, respectively. There was no change in the best-corrected visual acuity in both groups. There was an increase in body weight, blood sugar, blood pressure and gastritis in group I in 66.7%, 33.3%, 50% and 75%, respectively, compared with 0%, 0%, 8.3% and 8.3% in group II. No adverse local side effects were observed in group II. CONCLUSION: Orbital steroid injection for thyroid-related ophthalmopathy is effective and safe. It eliminates the adverse reactions associated with oral corticosteroid use.

Management of neovascular glaucoma with panretinal photocoagulation, intravitreal bevacizumab, and subsequent trabeculectomy with mitomycin C.

PURPOSE: The aim of this study was to evaluate the safety and efficacy of using intravitreal bevacizumab, panretinal photocoagulation, and trabeculectomy with mitomycin C in the management of neovascular glaucoma. PATIENTS AND METHODS: The study included 17 eyes of 15 patients with neovascular glaucoma. Panretinal photocoagulation was performed combined with intravitreal bevacizumab injection (1.25 mg in 0.05 mL). A fornix-based conjunctival flap trabeculectomy with intraoperative mitomycin C (0.4mg/mL for 3min) was then performed. RESULTS: The causes of neovascular glaucoma included: diabetic retinopathy (10 eyes), central retinal vein occlusion (5 eyes), and branch retinal vein occlusion (2 eyes). Complete regression of iris neovascularization after intravitreal bevacizumab injection and panretinal photocoagulation occurred in 14 eyes (82.4%). After trabeculectomy with mitomycin C, mean intraocular pressure was reduced from 42.9±4.2 mm Hg preoperatively to 15.1±2.2, 16.3±2.0, and 19.7±2.1 mm Hg at first week, first month, and sixth months postoperatively, respectively. This reduction was statistically significant (P<0.05). The mean number of antiglaucoma medications used before surgery was 2.8±0.4 (range: 2 to 3) that decreased to 0.8±0.6 (range: 0 to 3) after surgery. Postoperative hypotony (intraocular pressure 7 mm Hg) was observed in 17.6% (3 of 17 eyes), conjunctival dehiscence in 5.9%, shallow anterior chamber in 11.8%, hyphema in 23.5%, choroidal detachment in 11.8%, and epithelial corneal erosions related to applications of mitomycin C in 1 eye (5.9%). CONCLUSIONS: Trabeculectomy with intraoperative mitomycin C after an adjunctive treatment with intravitreal bevacizumab and panretinal photocoagulation is a good treatment modality in the management of eyes with neovascular glaucoma.