Management and prognosis of Merkel cell carcinoma of the eyelid.

OBJECTIVE: To evaluate the clinical presentation, treatment, and long-term follow-up of eyelid Merkel cell carcinoma. DESIGN: Retrospective noncomparative interventional case series. PARTICIPANTS: Fourteen patients with primary eyelid Merkel cell carcinoma. METHODS: Cases of Merkel cell carcinoma for which long-term follow-up was available were solicited from members of the American Society of Ophthalmic Plastic and Reconstructive Surgery through an on-line e-mail/news group. MAIN OUTCOME MEASURES: Follow-up period, treatment history, presence and type of recurrence, and mortality. RESULTS: Average follow-up was 33.4 months. Of the 14 cases identified, only 2 patients (14%) received prophylactic therapy beyond wide surgical excision. Three patients (21%) had recurrences, none of whom initially received prophylactic therapy (i.e., radiation therapy, lymph node dissection, and/or chemotherapy) beyond wide surgical excision. One patient (7%) died of metastatic Merkel cell carcinoma. CONCLUSIONS: Merkel cell carcinoma is a rare skin malignancy that occasionally affects the eyelid, with the potential for regional and distant metastasis. Consideration should be given to the use of prophylactic adjunctive therapies beyond wide surgical excision while simultaneously considering the morbidity of these therapies.

An animal model of lower eyelid spacer grafting with acellular dermis.

PURPOSE: Lower eyelid retraction is common in patients with dysthyroid orbitopathy and is seen less commonly in other conditions. Treatment typically requires vertical augmentation of the posterior eyelid lamella with an interpositional graft. Several autologous, homologous, and alloplastic materials have been used. We investigated the gross and microscopic in vivo histology of acellular homologous dermis used as a structural interpositional graft in the lower eyelids of Yucatan minipigs. METHODS: This prospective, experimental study was designed as follows: Surgery was performed on the left lower eyelid of 4 Yucatan minipigs in accordance with the Massachusetts General Hospital Subcommittee on Research Animal Care guidelines. A 4 x 20-mm strip of acellular porcine dermis was prepared and sutured into place between the tarsus and conjunctiva/lower lid retractors. Tissues were harvested at 6 and 12 weeks and were evaluated histologically. RESULTS: Gross examination revealed vertical elongation of the palpebral conjunctival surface. Histologic evaluation was performed with hematoxylin and eosin and Verhoeff elastin stains. Serial sections demonstrated incorporation of grafted dermal matrix into native tissues without evidence of inflammation. Definitive differentiation between grafted dermis and native dermis was not possible with light microscopy. Portions of the graft appeared to be epithelialized, whereas other histologic regions showed poorly adhesive epithelium. Inflammatory infiltrates including lymphocytes and polymorphonuclear leukocytes were not seen. No epithelioid or giant cells were identified in the sections examined. CONCLUSIONS: Acellular homologous dermis produced no measurable untoward effects when implanted as an interpositional graft in the lower eyelid of Yucatan minipigs. On the basis of its material characteristics, it appears to be suitable for this purpose: It is readily available, easily stored, easy to manipulate, and produces minimal inflammation. Long-term persistence, early postoperative histology, and clinical eyelid elevation in humans remain to be evaluated.

Orbital fractures in children.

PURPOSE: To describe the demographics, etiologic factors, clinical presentations, and outcomes of orbital fractures in children. METHODS: This was a retrospective case series of 96 consecutive patients under 18 years of age with orbital fractures presenting to the Massachusetts Eye and Ear Infirmary, including both hospitalized and nonhospitalized patients. RESULTS: Orbital fractures in children were most frequently the result of sports, assault, or motor vehicle accident. The majority of patients did not require hospitalization and were treated as outpatients. The medial wall and floor of the orbit were the most frequent locations of fracture. Approximately half of the patients in this series required surgery, most often for entrapment. There were no cases of persistent diplopia in patients in whom surgery was performed or was not indicated. Associated ocular injuries were observed in half of the patients. CONCLUSIONS: In this series of hospitalized and nonhospitalized patients, orbital fractures in children had a location pattern similar to that most frequently observed in adult patients (floor and medial wall). Orbital fractures in children frequently require surgery. The high prevalence of ocular injury in children with orbital fractures emphasizes the need for a comprehensive ophthalmic evaluation.

Primary placement of a titanium motility post in a porous polyethylene orbital implant: animal model with quantitative assessment of fibrovascular ingrowth and vascular density.

PURPOSE: To determine whether a Medpor porous polyethylene orbital implant, at the time of initial orbital implant surgery, will tolerate the insertion of a titanium screw on the anterior surface of the implant. METHODS: Twelve New Zealand white rabbits were enucleated and implanted with a porous polyethylene orbital implant. At the time of enucleation, the porous polyethylene orbital implants were drilled, and titanium motility coupling posts were inserted. The motility coupling posts were inserted at two projection heights (2 or 4 mm) and either covered within Tenon capsule/conjunctiva (eight implants) or left exposed (four implants). Rabbits were killed at 6 or 12 weeks. Clinical tissue tolerance, histologic response to the motility coupling post, and vascular density of the porous polyethylene orbital implant were evaluated. RESULTS: The motility coupling posts were well tolerated, and extrusion or migration of the motility coupling post did not occur. The average percentage cross-sectional area of the implant occupied by fibrovascular tissue at 6 and 12 weeks was 76.3% and 97.5%, respectively. In comparing the vascular density (number of vessels per square millimeter) in the porous polyethylene orbital implant within a 1-mm zone immediately surrounding the motility coupling post, no significant difference between this zone and the vascular density found within its entire corresponding annulus was found at either 6 or 12 weeks. CONCLUSIONS: During the 6- and 12-week observation periods, all implanted motility coupling posts demonstrated favorable tissue tolerance and stable interfaces with surrounding tissues. The extent of fibrovascular tissue ingrowth and vascular density verify that initial screw insertion does not adversely affect the healing process after porous polyethylene orbital implant implantation. Thus, primary placement of the motility coupling post may obviate the need for a secondary surgical procedure.

Inhibition of conjunctival scarring and contraction by a porous collagen-glycosaminoglycan implant.

PURPOSE: To study the healing processes of full-thickness wounds in the adult rabbit conjunctiva after grafting with a porous collagen-glycosaminoglycan (CG) copolymer matrix. METHODS: A 7-mm trephine was used to produce lesions of the bulbar conjunctiva down to the level of the bare sclera. Full-thickness removal of the conjunctiva and Tenon's capsule created a reproducible wound bed. Wounds either remained ungrafted (control) or were grafted with CG matrix. In previous studies, this CG matrix has induced partial regeneration of the dermis in the human, the swine, and the guinea pig. Healing of the conjunctival epithelium and underlying stroma was evaluated by histology, immunohistochemistry, and measurement of wound contraction kinetics. RESULTS: By 28 days, ungrafted wounds had closed by contraction (26.4% +/- 5.0% fornix shortening) and the formation of scarlike tissue comprising an aligned array of dense collagen populated with occasional fibroblasts. Grafting of identical defects with CG copolymer matrix resulted in inhibition of wound contraction (6.8% +/- 3.2% fornix shortening) and the formation of a tissue that resembled normal conjunctival stroma, being composed of a loose network of collagen fibers and fibroblasts. Contractile fibroblasts (myofibroblasts) were identified at the edge of both ungrafted and grafted wounds during the period of active contraction. Both ungrafted and grafted wounds were completely re-epithelialized by 28 days. CONCLUSIONS: Implantation of CG copolymer matrix drastically reduced contraction and promoted the formation of a nearly normal subconjunctival stroma.

Primary placement of a motility coupling post in porous polyethylene orbital implants.

The placement of a motility coupling post (MCP) to integrate the prosthesis with a porous orbital implant may enhance prosthetic motility following enucleation. Previously, MCP placement has required a second operation usually at least 6 months following enucleation. We developed a technique to place an MCP reliably and safely into a porous orbital implant at the time of enucleation. Eligibility criteria included high motivation to achieve maximal prosthetic motility, adequate conjunctiva to ensure desirable wound closure, and isolation of the 4 rectus muscles. Enucleation was performed in standard fashion with implantation of a conical porous polyethylene orbital implant. Implanted MCPs protruded anteriorly 2 to 4 mm. The Tenon capsule and conjunctiva were closed in separate layers over the protruding MCP. Thirty-two patients underwent primary placement. Follow-up ranged from 1 to 33 months (mean, 15 months). Nine MCPs spontaneously exposed within the first 4 months. One additional post autoexposed at 12 months. Three patients underwent a secondary procedure to expose the MCP. There were no cases of infection, explantation, or gross MCP malposition. Minor complications included pyogenic granuloma (n=2) and conjunctival overgrowth (n=1). All patients were successfully fit with prostheses. Prosthetic motility was acceptable in all patients. Motility coupling post placement at the time of enucleation surgery in selected patients is an effective, efficient surgical option. Arch Ophthalmol. 2000;118:826-832

Delayed orbital infection after endoscopic orbital decompression for dysthyroid orbitopathy.

OBJECTIVE: To present a delayed complication of endoscopic orbital decompression that has not been reported previously in the literature. DESIGN: Retrospective non-comparative small case series. PARTICIPANTS: Three patients with dysthyroid orbitopathy. INTERVENTION: The medical records of patients with dysthyroid orbitopathy who underwent endoscopic orbital decompression and subsequently developed orbital infection were reviewed. RESULTS: Three patients with dysthyroid orbitopathy developed orbital infection (cellulitis or abscess) originating from the frontal sinus more than 2 years after their endoscopic orbital decompression surgery. Management required drainage of the abscess, administration of antibiotics, and creation of adequate frontal sinus drainage. CONCLUSIONS: Delayed orbital infection can occur after endoscopic orbital decompression for dysthyroid orbitopathy when the frontal sinus ostium is obstructed by orbital fat or scar tissue. Infection within the frontal sinus can cause secondary orbital cellulitis or abscess. Early signs and symptoms of a frontal sinus infection can be easily misdiagnosed as progression of the patient's thyroid eye disease. Awareness of this possible complication followed by appropriate early intervention will prevent a potentially blinding condition. Furthermore, ever since this complication was observed, the authors' surgical technique of endoscopic decompression has been modified to leave the most anterosuperior portion of the lamina papyracea to prevent fat prolapse and scar formation into the region of the frontal recess.

Laser applications in oculoplastic surgery and their postoperative complications.

Laser surgery for oculoplastic or dermatological indications--whether incisional work, removal of pigmented or vascular lesions, removal of hair, or resurfacing--necessitates that the practitioner have appropriate training in and understanding of not only the techniques but also of their advantages and disadvantages. Understanding laser safety and how to handle complications is critical to appropriate management of laser-assisted surgery. Long-term results are limited at this time, but current information regarding the use of lasers in aesthetic oculoplastic surgery appears promising. New approaches to such operations include combining more than one type of laser or combining traditional cutting blades and lasers in an effort to reduce side effects and improve outcome.

Ophthalmic plastic applications of acellular dermal allografts.

PURPOSE: Clinical problems of contracted conjunctival fornices, superior sulcus defects, and soft tissue contour defects in the periorbital region have not shown good, sustained results with a range of autologous and alloplastic implants. AlloDerm (Lifecell Corp., Woodlands, TX) is an acellular dermal graft processed from human donor tissue. The authors sought to assess the efficacy of AlloDerm as a soft tissue replacement in a variety of oculoplastic applications. DESIGN: Retrospective, noncomparative case series. PARTICIPANTS: Twenty-three patients. METHODS: Applications were broadly classified as barrier/scaffolding (i.e., primary and secondary implant coverage, lid spacer graft) and volume augmentation (i.e., superior sulcus and other periorbital soft tissue contour defects). Barrier grafts were applied as single sheets. Stacked sheets or rolled grafts were used for augmentation. Collectively, this material was used in 29 cases with 3 to 16 months' follow-up. MAIN OUTCOME MEASURES: Clinical evaluation of outcome and complications. RESULTS: As a soft tissue scaffolding and barrier implant, AlloDerm persisted sufficiently to permit repopulation with native tissue. Rolled/stacked implants demonstrated unpredictable resorption. Upper eyelid grafts seemed to have higher resorption rates than lower eyelid grafts. One case of anophthalmic superior sulcus augmentation required two revision surgeries to provide sufficient volume augmentation. The grafts were well tolerated, with no cases of infection or explanation. CONCLUSION: Acellular human dermis is an excellent barrier and reconstructive grafting material that provides an alternative to autologous grafts and other alloplastic material, avoids harvesting autologous tissue, possesses excellent handling properties, and is associated with minimal inflammation. Long-term follow-up is required to evaluate persistence.

Functional indications for enophthalmos repair.

PURPOSE: In general, orbital augmentation to correct enophthalmos is pursued to prevent or address an aesthetic deformity. In some cases, however, functional deficits may accompany enophthalmos and may serve as an indication for surgical intervention. The authors describe a series of patients with such deficits. METHODS: A retrospective review at a tertiary health care center of all patients with enophthalmos was conducted to identify a subset of cases in which the enophthalmos was associated with nonaesthetic, functional deficits that could not be attributed to muscular or neural dysfunction, or soft tissue scarring. RESULTS: Six patients with either traumatic enophthalmos (orbital fractures) or non-traumatic enophthalmos (sinus disease and orbital soft tissue atrophy) demonstrated nonaesthetic ocular dysfunction, including gaze-evoked diplopia, eyelid retraction, lagophthalmos, and exposure keratitis. The symptoms and signs resolved in the three patients who underwent orbital augmentation. CONCLUSIONS: In some patients with enophthalmos and globe ptosis, globe malposition may alter the underlying eyelid mechanics or extraocular muscle alignment, resulting in functional as well as aesthetic problems. In these patients, restoring the native orbital anatomy through orbital augmentation can reverse eyelid malposition, ocular surface exposure, and symptomatic diplopia, avoiding the need for eyelid or strabismus surgery.

A multidisciplinary approach to atypical lacrimal obstruction in childhood.

PURPOSE: This study explores the diagnosis and management of unusual anomalies involving the canaliculi, nasolacrimal duct, nasal cavity, and sinuses in childhood. METHODS: A case series of eight children with lacrimal outflow anomalies ranging from distal nasolacrimal duct cyst formation to persistent dacryocystitis following failed probing or silicone intubation were reviewed retrospectively. Diagnostic studies including intranasal endoscopy and preoperative or intraoperative dacryocystography (DCG) were of value. RESULTS: Treatment modalities included endoscopically guided resection of lacrimal cyst mucosa, endoscopic dacryocystorhinostomy (DCR), and monocanalicular or bicanalicular intubation of the lacrimal outflow system. In our series, endoscopic surgery was well tolerated by all patients with improvement in symptoms. CONCLUSIONS: This initial experience suggests that endoscopic techniques may be useful in the management of atypical lacrimal outflow obstruction in childhood.

Prepartum mixed type cavernous-capillary hemangioma arising in nevus flammeus.

OBJECTIVE: Capillary hemangioma may appear de novo and involute during the first decade of life, but rarely during pregnancy. This study describes the clinical and histologic findings of an eyelid mixed type cavernous-capillary hemangioma arising in a nevus flammeus and discusses the differential diagnosis of this lesion. STUDY DESIGN: Clinicopathologic case report. INTERVENTION: A reddish, protruding eyelid mass arising from a nevus flammeus at the eyelid margin in a 26-year-old woman was monitored during her pregnancy. Postpartum, the mass was excised and examined histologically. RESULTS: The lobulated tumor recurred during the second pregnancy and partially regressed following delivery. It was composed of mixed elements of cavernous and capillary hemangioma that superficially resembled Kaposi sarcoma, set against the background of a nevus flammeus. CONCLUSION: The differential diagnosis of discrete prepartum vascular tumor arising in nevus flammeus includes mixed capillary-cavernous hemangioma, pseudo-Kaposi sarcoma, granuloma gravidarum, and angiodermatitis. A common stimulus during pregnancy may be the inciting factor for the development of these tumors.

Medpor Motility Coupling Post: a rabbit model.

PURPOSE: To verify if a Medpor porous polyethylene orbital implant (PPOI) (Porex Surgical, Atlanta, GA, U.S.A.), once vascularized, will tolerate a partially exposed titanium screw on its anterior surface. METHODS: Ten New Zealand white rabbits were enucleated and given Medpor PPOIs. Eight weeks postoperatively, Medpor Motility Coupling Posts (MCPs) (Porex Surgical) were placed into the orbital implants. Clinical tissue tolerance and histologic response to the new device were noted. RESULTS: The titanium screws were well tolerated by the animals. No case of post-operative infection, conjunctival inflammation, conjunctival erosion, MCP dislocation, or PPOI fragmentation was noted. A fibrous tissue growth over the titanium head was noted in all screws with a head height of 2.5 mm. The fibrous tissue overgrowth was not observed in screws with a head height of 4 mm or more. CONCLUSION: During the 6-month observation period, all implanted Medpor MCPs demonstrated favorable tissue tolerance and stable interfaces between the MCP and the conjunctiva and between the MCP and the PPOI.