On-Q pump for pain control after orbital implant surgery.

PURPOSE: To introduce an elastomeric continuous infusion pump for pain control after outpatient orbital implant surgery. METHODS: Retrospective, noncomparative consecutive case series of all patients undergoing enucleation, evisceration, or secondary orbital implantation using the On-Q pain system between August 2004 and January 2006. Postoperative pain score, need for narcotics, and adverse events were recorded. The On-Q catheter is inserted intraoperatively through the lateral lower eyelid into the muscle cone under direct visualization, prior to the orbital implant placement. The On-Q system continually infuses anesthesia (bupivacaine) to the retrobulbar site for 5 days. RESULTS: Among 20 patients, mean postoperative period pain score, with On-Q in place, was 1.3 (scale of 0 to 10). Nine patients (45%) did not need any adjunctive oral narcotics. Two patients experienced postoperative nausea. One catheter connector leaked, thereby decreasing delivery of retrobulbar anesthetic resulting a pain level of 6, the highest level in the study. There were no postoperative infections. No systemic toxic effects from bupivacaine were observed clinically. CONCLUSION: The On-Q pain pump is widely available, low cost, and requires minimal patient manipulation for the use in orbital implant surgery. The device was safe and appeared to minimize postoperative pain in the authors' case series.

The modified fasanella-servat procedure: description and quantified analysis.

PURPOSE: To describe a modified Fasanella-Servat procedure and nomogram for the correction of minimal amounts of ptosis. METHODS: Retrospective review of this modified Fasanella-Servat procedure was performed on 118 eyelids in 86 consecutive patients over 2, 4-year periods by 1 surgeon (S.C.D.). The amount of tarsectomy was based on the amount of ptosis. RESULTS: Mean pre- and postoperative margin-to-reflex distance 1 were +0.7 mm and +2.4mm, respectively. One hundred and twelve eyelids (95%) had satisfactory results with postoperative margin-to-reflex distance 1 ≥ 1.5 mm. Eyelid symmetry was achieved in 92% of eyelids to within 0.5 mm. There was no incidence of overcorrection, tarsal buckling, or corneal abrasion. One eyelid had a contour deficit. Tarsectomy amount ranged from 2 mm to 5 mm. Average amount of tarsectomy to eyelid elevation was 2.4:1. CONCLUSIONS: The modified Fasanella-Servat procedure is technically easy, time-efficient, and has a low complication rate for the treatment of minimal blepharoptosis (< 2.5 mm) with good levator function and negative phenylephrine test. In the authors' hands, the ratio of tarsectomy to eyelid elevation is approximately 2:1. In addition to other techniques such as levator advancement and Müller's muscle conjunctival resection, the modified Fasanella-Servat technique is a useful adjunct to the modern ptosis surgeon's armamentarium.

Efficacy and complications of the transconjunctival entropion repair for lower eyelid involutional entropion.

PURPOSE: To evaluate the efficacy of the transconjunctival entropion repair (TCER) for lower eyelid involutional entropion. DESIGN: Retrospective, noncomparative, interventional case series. PARTICIPANTS: One hundred fifty-one eyelids in 120 patients who underwent TCER for involutional entropion over a 12-year period from February 1991 through January 2003. METHODS: Surgical technique addressed all 3 anatomic factors underlying the entropion and was performed through a transconjunctival incision. Lateral tarsal strip procedure addressed horizontal eyelid laxity, lower eyelid retractor reinsertion addressed retractor disinsertion, and excision of a strip of the preseptal orbicularis oculi addressed preseptal orbicularis override. MAIN OUTCOME MEASURES: Entropion resolution, entropion recurrence, postoperative eyelid retraction, and complication rate. RESULTS: Transconjunctival entropion repair resulted in resolution of entropion, with a success rate of 96.7% (146 of 151 eyelids); entropion recurrence rate was 3.3% (5 of 151 eyelids). No patient had postoperative eyelid retraction or scleral show, and there were no overcorrections or secondary ectropions in any of the 151 eyelids. Postoperative complications occurred in 6 of 151 eyelids (4.0%) of 6 of 120 patients (5.0%) and included stitch abscess (1 eyelid, 0.7%), lateral tarsal strip dehiscence (2 eyelids, 1.3%), lateral canthal dystopia (2 eyelids, 1.3%), and conjunctivochalasis (1 eyelid, 0.7%). CONCLUSIONS: The transconjunctival lower eyelid entropion repair is effective and safe with low recurrence and complication rates. The TCER circumvents the risk of lower eyelid retraction and overcorrections that may occur with the transcutaneous approach.

Mechanical stability of microkeratome-assisted intracorneal keratoprosthesis implantation.

OBJECTIVE: To develop a laboratory model to study intracorneal keratoprosthesis implantation. METHODS: A combination microkeratome and artificial anterior chamber system was used to create a hinged lamellar keratectomy on 13 human corneas. After reflecting the flap, the posterior stroma was trephined at either 2.5 or 3.0 mm. A model keratoprosthesis was positioned in the bed. The flap was sutured closed. Intrachamber pressure was increased, and wound leak pressure was recorded. The anterior corneal lamella was trephined at either 3.0 or 3.5 mm to expose the keratoprosthesis. Leak pressure was again determined. RESULTS: After keratoprosthesis placement and prior to anterior trephination, all 13 corneas were watertight at maximum attainable intrachamber pressures. With posterior/anterior trephination combinations of 2.5/3.0 mm, 2.5/3.5 mm, or 3.0/3.5 mm, mean +/- SD wound leak pressure occurred at 95 +/- 12 mm Hg, 32 +/- 7 mm Hg, or 59 +/- 12 mm Hg, respectively (P<.01). CONCLUSIONS: With a posterior trephination of 2.5 mm, there is significant keratoprosthesis-cornea interface destabilization between a 3.0- and 3.5-mm anterior trephination. For an anterior trephination of 3.5 mm, interface destabilization improves by increasing the posterior trephination to 3.0 mm. CLINICAL RELEVANCE: An intracorneal keratoprosthesis may be implanted using microkeratome assistance. Our laboratory model provides a useful method for examining a range of posterior and anterior trephination diameters and their effects on the mechanical stability of intracorneal keratoprosthesis placement.

Orbitotemporal neurofibromatosis: classification and treatment.

PURPOSE: To review the clinical findings in orbitotemporal neurofibromatosis and discuss treatment options. Clinical features, histopathologic characteristics, and treatment options are reviewed. METHODS: A Medline literature search from 1966 to 2004 was performed, using the key words: orbitotemporal neurofibromatosis, orbitopalpebral neurofibromatosis, orbitofacial neurofibromatosis, cranio-orbital neurofibromatosis, and cranio-orbital-temporal neurofibromatosis, and the pertinent literature was reviewed. Additionally, our experience with two patients is reported. The surgical procedures are discussed. CONCLUSION: The management of orbitotemporal neurofibromatosis is challenging. The planned surgical approach and extent of resection depend on the severity of the orbital soft tissue and bony involvement and on the visual potential. Ultimately, orbital exenteration may be needed for rehabilitation and cosmesis.

Preclinical and clinical evaluation of sulforaphane for chemoprevention in the breast.

Consumers of higher levels of Brassica vegetables, particularly those of the genus Brassica (broccoli, Brussels sprouts and cabbage), reduce their susceptibility to cancer at a variety of organ sites. Brassica vegetables contain high concentrations of glucosinolates that can be hydrolyzed by the plant enzyme, myrosinase, or intestinal microflora to isothiocyanates, potent inducers of cytoprotective enzymes and inhibitors of carcinogenesis. Oral administration of either the isothiocyanate, sulforaphane, or its glucosinolate precursor, glucoraphanin, inhibits mammary carcinogenesis in rats treated with 7,12-dimethylbenz[a]anthracene. In this study, we sought to determine whether sulforaphane exerts a direct chemopreventive action on animal and human mammary tissue. The pharmacokinetics and pharmacodynamics of a single 150 mumol oral dose of sulforaphane were evaluated in the rat mammary gland. We detected sulforaphane metabolites at concentrations known to alter gene expression in cell culture. Elevated cytoprotective NAD(P)H:quinone oxidoreductase (NQO1) and heme oxygenase-1 (HO-1) gene transcripts were measured using quantitative real-time polymerase chain reaction. An observed 3-fold increase in NQO1 enzymatic activity, as well as 4-fold elevated immunostaining of HO-1 in rat mammary epithelium, provides strong evidence of a pronounced pharmacodynamic action of sulforaphane. In a subsequent pilot study, eight healthy women undergoing reduction mammoplasty were given a single dose of a broccoli sprout preparation containing 200 mumol of sulforaphane. Following oral dosing, sulforaphane metabolites were readily measurable in human breast tissue enriched for epithelial cells. These findings provide a strong rationale for evaluating the protective effects of a broccoli sprout preparation in clinical trials of women at risk for breast cancer.

Effect of unilateral blepharoptosis repair on contralateral eyelid position.

PURPOSE: This study evaluates the effect of unilateral blepharoptosis repair on contralateral eyelid position and assesses the relation between preoperative eyelid height interdependence, consistent with Hering law, and surgical outcome. METHODS: The medical records of 54 patients (21 men, 33 women; mean age, 65 years) who underwent external levator advancement for unilateral aponeurotic blepharoptosis were reviewed for preoperative and postoperative margin reflex distance (MRD) of the nonoperated eye. To assess the relation between preoperative Hering dependence (mechanical elevation of the ptotic eyelid causing a decrease in contralateral eyelid height) and postoperative eyelid position, the change in MRD of the nonoperated eye was compared between subjects who on preoperative evaluation did (n=18) and did not (n=36) demonstrate eyelid height interdependence, using the 2-sample t test. RESULTS: After unilateral blepharoptosis repair, the mean (+/- SD) change in contralateral MRD was -0.2 +/- 0.8 mm. There was no significant difference in contralateral MRD change in subjects with and without preoperative Hering dependence (-0.3 +/- 0.8 mm versus -0.2 +/- 0.9 mm, respectively, p=0.78). Seventeen percent (9 of 54) of patients had a contralateral MRD decrease of more than 1 mm. Three patients (5.6%) required contralateral blepharoptosis repair within 1 year of initial surgery. CONCLUSIONS: After levator advancement for unilateral blepharoptosis, roughly 17% of patients will have a decrease in contralateral eyelid height of more than 1 mm, with 5% of patients requiring surgical repair during the first postoperative year. The degree of change in contralateral eyelid height cannot be reliably predicted by preoperative assessment of Hering dependence.