Exposure keratopathy after cosmetic CO2 laser skin resurfacing.

PURPOSE: To report two cases of exposure keratopathy after cosmetic CO2 laser skin resurfacing. METHODS: Two patients presented with bilateral intrapalpebral epitheliopathy. They were examined, treated, and followed for several weeks. RESULTS: Nonsurgical treatment options, including a variety of lubricants, punctal plugs, and lid taping, did not lead to a complete resolution of symptoms. Surgical options were recommended. CONCLUSION: Exposure keratopathy should be recognized as a potential side effect of not only incisional lid surgery but also facial CO2 laser skin resurfacing procedures.

Congenital cystic eye: report of two cases and review of the literature.

A 13-month-old boy and a 2-week-old girl, who were considered to be anophthalmic and who later each developed a cystic lesion in the left orbit with protrusion of the lower eyelid, were studied. The fellow eye in case 1 was subsequently found to be microphthalmic with cyst and was normal in case 2. Histopathologic study of each case revealed a cyst lined externally by dense fibrous connective tissue to which skeletal muscle and adipose tissue were attached. The inner aspect of the cyst was lined by neuroglial tissue, possible immature retinal tissue, and cuboidal epithelium. No fully developed ocular structures or microphthalmos were identified. Fourteen cases of congenital cystic eye, including our cases, have been published in the English-language literature since 1964. We discuss and illustrate the findings in our cases and 10 others in which histopathologic findings were reported. Congenital cystic eye, microphthalmos with cyst, and microphthalmos with cystic teratoma should be suspected in patients with a small or unrecognizable eye and an orbital cystic mass that is detected by palpation or visualization.

Prevention of prolapsed silicone stents in lacrimal intubation using an intrasac fixation suture.

Silicone stents are routinely used for the maintenance of patent mucosal passages in patients with nasolacrimal disorders. A common complication associated with the use of silicone stents is lateral migration or displacement of the tubes, which can be difficult to correct. This report describes a modified Quickert-Dryden approach with fixation of the tubes by an intrasac suture. From 1990 to 1996, 53 patients had silicone stents placed by this method with no complications related to tube displacement. The intrasac fixation suture has distinct advantages over other fixation methods.

Understanding the origin of visual percepts elicited by electrical stimulation of the human retina.

BACKGROUND: The success of a retinal prosthesis for patients with outer retinal degeneration (ORD) depends on the ability to electrically stimulate retinal cells other than photoreceptors. Experiments were undertaken in human volunteers to ascertain whether electrical stimulation of cells other than photoreceptors will result in the perception of light. METHODS: In two subjects, two areas of laser damage (argon green and krypton red) were created in an eye scheduled for exenteration due to recurrent cancer near the eye. In the operating room prior to exenteration, under local anesthesia, a hand-held stimulating device was inserted via the pars plana and positioned over the damaged areas and normal retina. Subjects' psychophysical responses to electrical stimulation were recorded. RESULTS: In both subjects, electrical stimulation produced the following perceptions. Normal retina: dark oval (subject 1), dark half-moon (subject 2); krypton red laser-treated retina: small, white light (both subjects); argon green laser treated retina: thin thread (subject 1), thin hook (subject 2). Histologic evaluation of the krypton red-treated retina showed damage confined to the outer retinal layers, while the argon green-treated area evinced damage to both the outer and the inner nuclear layers. CONCLUSION: The perception produced by electrical stimulation was dependent on the retinal cells present. Electrical stimulation of the krypton red-ablated area best simulated the electrically elicited visual perceptions of our blind, ORD patients, suggesting that the site of stimulation in blind patients is the inner retinal neurons.

Clinicopathological correlation of technetium bone scan in vascularization of hydroxyapatite implants. A primate model.

OBJECTIVES: To report the histopathological and bone scan characteristics of the stages of hydroxyapatite fibrovascular integration and to consider the implications for the timing of peg drilling in a primate model. DESIGN: Three monkeys received hydroxyapatite implants covered only anteriorly with a fascia lata button to which the rectus muscles were sutured. Weekly bone scans were evaluated quantitatively and qualitatively. The orbits were harvested at 2, 4, and 8 weeks and examined histopathologically. RESULTS: Quantitatively, the implant's technetium uptake increased, then reached a plateau by 4 weeks. Peripheral uptake was present on the images and histologically at 2 weeks. When bone scan images suggested complete vascularization by the fourth week, the implant was 99% vascularized histologically. Completion of vascularization was ascertained at 8 weeks, without further discernible changes in the bone scans. CONCLUSIONS: The technetium bone scan is sensitive to the vascularization of the hydroxyapatite implant and discerns when complete vascularization is approached. This primate study models closely the clinical findings we have recently reported. We advocate at least a 4-week interval between the time the bone scan suggests full vascularization and peg drilling.

Strategies for the treatment of enophthalmos.

The surgical correction of post-traumatic enophthalmos is among the most challenging problems for the surgeon. A thorough understanding of orbital anatomy and the purposed mechanisms of enophthalmos is crucial to the ultimate success or failure of the procedures. The successful orbital reconstruction begins with a careful physical examination of the patient that is attentive to ocular function, soft-tissue position, and visible or palpable defects of the facial skeleton. The physical examination combined with thin section CT scanning in the axial and coronal planes provides the basis of the operative plan. The anatomy of the deformity should dictate the anatomy and shape in the surgical correction. In many cases, multiple surgical incisions will be required; therefore, care must be taken to maximize exposure and minimize the cosmetic problems associated with large incisions. We advocate a step-wise approach consisting of mobilization of the soft tissues in the area of the fracture, repositioning of the anterior and middle sections of the bony orbit, and reattachment of the soft tissue to the bone at the proper location. The approach to reconstruction of the bony orbit that we advocate is to first sequentially reposition each segment of the rim, carefully examining each articulation. Once rim reconstruction is complete, reconstruction of the internal wall is performed. Recall that the largest source of error is in inadequate reduction of the orbital rim, owing to the fact that this error is "squared" (according to the model) in the computation of the orbital volume. Through the application of these principles, the cosmetic and functional sequelae of post-traumatic enophthalmos can be improved greatly with minimal complications.

Less common orbital fracture patterns: the role of computed tomography in the management of depression of the inferior oblique origin and lateral rectus involvement in blow-in fractures.

During the past decade, advances in radiographic imaging have made it possible for the surgeon managing orbital fractures to adopt a rational therapeutic strategy based on a knowledge of alterations in surgical anatomy secondary to traumatic injury. To illustrate the value of computed tomography in the surgeon's armamentarium for management of orbital fractures, cases are presented in which imaging proved decisive in planning a course of therapy. Two patients presented with two types of isolated lateral blow-in fracture, an uncommon fracture pattern. The other cases underscore the value of defining involvement of the inferior oblique origin and lateral rectus muscles in imaging complex orbital fractures, issues not emphasized in earlier literature. Although diplopia alone does not always warrant surgical intervention, diplopia in the context of computed tomography-defined muscle entrapment or muscle origin displacement justifies operative therapy. These cases demonstrate the value of computed tomography in directing surgical therapy with resolution of diplopia and prevention and correction of enophthalmos.

Quantitative measurement of vascularization and vascular ingrowth rate of coralline hydroxyapatite ocular implant by Tc-99m MDP bone imaging.

Complete fibrovascular ingrowth of the hydroxyapatite ocular implant is necessary for peg drilling, the secondary procedure that couples the mobile sphere to the ocular prosthesis providing it with motility. This study was conducted to determine the usefulness of the bone scan for the evaluation and relative quantification of the vascularization of coralline hydroxyapatite ocular implants. In 23 patients (32 scans), vascularization of the ocular implant was measured by three-phase bone scintigraphy. There were 16 patients with left, and 7 with right orbital implants. At followup 0.5 to 8 months after successful hydroxyapatite implantation, the mean implant to normal intraorbital activity ratio on delayed bone scans in anterior view was 2.73 +/- 0.73 (mean +/- SD) with a range of 1.42-4.2. The normal right to left and left to right intraorbital bone activity ratios determined in anterior view from 10 normal delayed bone scans were 0.98 +/- 0.05 (mean +/- SD) and 1.02 +/- 0.05 (mean +/- SD) respectively, with a range of 0.93-1.07. The difference of the activity (count) ratios among the successfully implanted group and normals was statistically significant (P < 0.0001). A hydroxyapatite ocular implant to contralateral intraorbital bone activity ratio of greater than 1.12 with a homogeneous tracer distribution throughout the implant suggests adequate and diffuse vascularization is present. The progressive increase in activity ratio of the orbital implants seen in the early postimplantation period, which is indicative of the progression of vascularization, reaches a plateau after 1 month and remains relatively stable thereafter.(ABSTRACT TRUNCATED AT 250 WORDS)

Use of Medpor porous polyethylene implants in 140 patients with facial fractures.

Use of alloplastic materials in facial bone reconstruction is still controversial. Medpor porous polyethylene is a relatively new implant material that is well suited for this purpose and has a number of advantages over other alloplasts. It is a pure polyethylene with a unique manufacturing process and pore size. Technically, it is easy to work with; it can be carved, contoured, adapted, and fixated to obtain a precise three-dimensional construct. Physically, it is a pure, biocompatible, strong substance that does not resorb or degenerate. It demonstrates long-term stability, high tensile strength, resistance to stress and fatigue, and a virtual lack of surrounding soft-tissue reaction. Rapid tissue ingrowth occurs into the pores. Extensive vascular ingrowth creates the potential to transport cellular products that fight infection deep into the implant. The implant was used in 140 patients from June 1988 to August 1991 to treat acute orbitozygomatic injuries (71), acute Le Fort injuries (24), delayed orbitozygomatic injuries (33), and delayed onlay augmentation (12). In this series, there was 1 instance of implant infection requiring removal, and no implant migration, or exposure.

The ophthalmic implications of the correction of late enophthalmos following severe midfacial trauma.

Severe midfacial trauma presents several challenges to the reconstructive surgeon. Acute rigid fixation of the facial skeleton accompanied by bone grafting to restore the confines and volume of the orbit provide the best opportunity for acceptable aesthetic results. The severity of the trauma causes the late postoperative complication of enophthalmos. Injury to orbital structures with subsequent cicatricial change results in significant alteration in extraocular motility with resultant diplopia. There are no reports in the literature which critically evaluate the effect of late enophthalmos correction on extraocular motility, diplopia, and vision in patients who have suffered Le Fort or NOE fractures. A retrospective study is presented which reviews the results of late surgery for the correction of enophthalmos in 40 patients, all of whom had severe "impure" orbital fractures. This study addresses the following questions: (1) Can the globe effectively be repositioned?, (2) Is there a change in subjective diplopia?, (3) Does a change in extraocular motility occur, and if it does, is it predictable?, (4) Is there a risk to visual acuity? and finally, (5) Do the answers to questions 1 through 4 suggest that late surgical intervention for the correction of enophthalmos should be recommended for this patient population? During a 9-year period, 44 patients with severe diplopia trauma received surgery for enophthalmos correction. A review of 40 patients on whom 56 operations were performed is presented. Thirty-eight patients had enophthalmos and 35 had inferior displacement of the globe. Medial displacement of the globe occurred in 11 patients. Twenty-nine patients had diplopia. Six patients had vision too poor on the injured side to have diplopia. Enophthalmos was improved in 32 patients. Dystopia of the globe was improved in 31 cases. However, neither enophthalmos nor dystopia of the globe could be improved with every operation. Only 35 of the 48 operations for enophthalmos for which measurements were available produced an improvement; in 1 case the enophthalmos was thought to be worse postoperatively. Dystopia operations resulted in improvement in 40 of 48 operations; in 2 instances dystopia was worse postoperatively. Diplopia was unchanged by 33 operations, improved by 11 procedures, and worsened by 6. If patients are considered before and after their total reconstruction course, diplopia was improved in 9 of the 29 patients. In seven of these nine, diplopia was eliminated. There was no change in or production of diplopia in 19 patients, and 5 patients had worsening of their double vision.(ABSTRACT TRUNCATED AT 400 WORDS)

Rigid fixation of internal orbital fractures.

When large portions of the internal orbit are destroyed (two to four walls), standard bone-grafting techniques for immediate and late orbital reconstruction may not yield predictable eye position. Critical bone support is most often deficient inferomedially. CT analysis of orbital volume in cases where eye position was unsatisfactory reveals that displacement of bone grafts is one mechanism of the unsatisfactory result. Other mechanisms include undercorrection and bone-graft resorption. In order to minimize postoperative bone-graft displacement, titanium implants were used to span large defects in the internal orbit to provide a platform for bone-graft support. Twenty-six implants were placed in immediate and 12 were placed in late orbital reconstructions. More reliable bone-graft position resulted. Two late infections have occurred resulting in implant removal in a 3-year period.

Early and late complications of orbital fractures.

Complications, unfortunately, arise as a result of traumatic or iatrogenic injuries. The sequelae can range from the most insignificant to the most debilitating. The most common complications noted in the diagnosis and treatment of orbital fractures are outlined as well as discussed as appropriate to their appearance during the healing process. With better understanding and better management, complications can be prevented.

Nasoethmoidal and orbital fractures.

It is helpful to consider fractures of the orbit both in terms of their location and fracture pattern. CT scanning is an invaluable aid to the diagnosis and treatment of all orbital fractures. Early operative intervention, wide exposure, and accurate and stable fixation accompanied by immediate bone grafting provide the most successful treatment of fractures of the orbit.

Hemangiopericytoma of the orbit treated with conservative surgery and radiotherapy.

A 23-year-old man had two recurrences following local excision of a hemangiopericytoma of the right orbit. A third local excision was followed by a course of postoperative radiation therapy (64.8 Gy [6480 rad] in 36 treatments). Seven and a half years following therapy, the patient is disease free and has experienced no side effects.

Squamous cell carcinoma of the eyelids.

A clinicopathologic study of 31 squamous cell carcinomas of the eyelid was conducted. The tumor was encountered less frequently than in previous reports, due largely to the refinement of the pathologic diagnosis. Eighteen cases originally diagnosed as squamous cell carcinoma were eliminated because the diagnoses were changed to sebaceous gland carcinoma (10), basal cell carcinoma (4), seborrheic keratosis (2), inverted follicular keratosis (1), and papilloma (1). One of our 31 patients experienced tumor metastasis and tumor-related mortality. Despite the low incidence of metastasis, management recommendations include complete surgical excision using intra-operative frozen-section monitoring of the surgical margins.

Deep orbital reconstruction for correction of post-traumatic enophthalmos.

Post-traumatic enophthalmos is a complex orbital deformity resulting from an injury disrupting orbital bone and ligament support, allowing displacement and a change in shape of the orbital soft-tissue contents. Clinically, this is manifested by inferior and posterior displacement of the globe, pseudoptosis, and deepening of the supratarsal fold. Soft-tissue changes such as canthal malposition and shortening of the horizontal dimension of the palpebral fissure are present when unreduced nasoethmoidal orbital fractures exist. The essential principles of surgical correction include full dissection of the bony orbital soft tissues including the posterior orbit with restoration of bony orbital volume by the judicious insertion of bone grafts to correct the vertical as well as the anteroposterior position of the ocular globe. The combination of techniques of craniofacial exposure, osteotomy, and bone grafting allow the condition of post-traumatic enophthalmos to be greatly improved with minimal complications.

Mechanisms of global support and posttraumatic enophthalmos: I. The anatomy of the ligament sling and its relation to intramuscular cone orbital fat.

The mechanisms of posttraumatic enophthalmos were evaluated to determine the interrelation between fat and ligaments in globe support. Anatomic studies demonstrate that the ligaments form an essential "sling" framework for the globe but are alone insufficient to maintain the globe's full forward position. Removal of extramuscular fat in cadavers and in patients undergoing blepharoplasty did not significantly change globe position. Loss of intramuscular cone fat (atrophy or displacement) in cadavers and patients produced enophthalmos. Fat atrophy is not a prominent feature in most patients with posttraumatic enophthalmos. Some loss of intramuscular cone fat from displacement outside the muscle cone is frequently present. The principal mechanism, however, of posttraumatic enophthalmos involves a displacement and change in the shape of orbital soft tissue. Loss of bone and ligament support permits posterior displacement and a reshaping of orbital soft tissue under the influence of gravity and the remodeling forces of fibrous scar contracture. The shape of the retrobulbar orbital contents changes from a modified cone to a sphere, and the globe sinks backward and downward. Given that the volume of orbital soft tissue is constant following trauma, procedures to restore the shape and position of the orbital soft tissue by mobilization and bone reconstruction will correct or significantly improve enophthalmos.

Hemangiopericytoma of the conjunctiva. Two cases.

Two patients with hemangiopericytoma of the conjunctiva are reported. The first patient, a 40-year-old woman with a six-month history of a conjunctival mass, presented with a lesion confined to the conjunctiva. The second patient, a 43-year-old man, presented with a one-year history of a conjunctival mass. Excisional biopsy and histopathologic examination showed both lesions to be a hemangiopericytoma; an uncommon tumor of the conjunctiva.