Ophthalmic Plastic and Reconstructive Surgery最新文献

A 64-year-old male with no medical care over the last decade was transferred from his local emergency room to a level 1 trauma center following an unwitnessed fall. Upon ophthalmic evaluation, he was noted to have significant lethargy and bilateral large festoons with secondary ectropion. Laboratory workup revealed severe hypothyroidism, consistent with myxedema coma, and his lethargy improved with medical treatment. The festoons were surgically removed to address the ectropion, and the patient was satisfied with the results following a single procedure. This case report features the largest reported festoons to date in the literature and emphasizes the importance of balancing cosmesis with function during surgical excision and correction of ectropion.

Periocular and orbital myiasis are rare, vision-threatening conditions characterized by the infestation of dipterous fly larvae into periorbital and orbital tissues. While it has been primarily reported in tropical and subtropical regions where the climate is ideal for fly larval breeding, any patient with inadequate wound care regardless of geography may be predisposed. Infestations can progress rapidly over the course of several days with significant risk of life-threatening intracranial extension. Despite this, there is a paucity of oculoplastic literature describing protocols to treat periocular and orbital myiasis in the acute setting. Here, the authors present a case of periocular and orbital myiasis seen at the Duke University Hospital in Durham, North Carolina (U.S.A.), and describe a protocol that was effective in the eradication of the infestation without surgical tissue debridement.

Purpose: Evaluation of platelet-rich fibrin as an adjuvant in surface healing of contracted orbital sockets.

Methods: Prospective, interventional, and comparative study of 25 patients with moderate to severe contracted sockets conducted over 2 years (February 2020-February 2022). Group 1 underwent a dermis-fat graft with fornix forming sutures supplemented by a platelet-rich fibrin membrane, while group 2 received a dermis-fat graft with fornix forming sutures only. Patients over 18 years were evaluated as per prefixed inclusion and exclusion criteria. Assessments were conducted at 1, 3, and 12 months postsurgery, focusing on wound evaluation, socket epithelialization, postoperative pain, prosthesis rehabilitation, and complications, if any. Wound evaluation and pain intensity were assessed utilizing the wound evaluation score and visual analog scale, respectively. Socket epithelization was documented clinically at every visit.

Results: The study showed a mean age of 38.8 ± 8.8 years, with a 2:1 male-to-female ratio. Group 1 consistently scored higher on wound evaluation score than group 2 at all follow-up points. In group 1, 81.8% achieved a maximum wound evaluation score at 4 weeks and 100% at 3 and 12 months, compared to group 2's 42.8%, 50%, and 57.1%, respectively ( p < 0.05). Postoperative contracture occurred in 3 group 2 patients at the final follow-up, with 6 showing unsatisfactory appearance. Group 1 demonstrated significantly lower pain intensity on postoperative day 1 ( p = 0.03), and greater epithelization at 4 weeks.

Conclusion: platelet-rich fibrin appears to be an effective solution for enhancing wound healing during socket reconstruction, attributed to its sustained release of growth factors and mesenchymal stem cells.

Conjunctival melanoma is a rare, life- and sight-threatening ocular malignancy sharing molecular features with cutaneous and mucosal melanoma. Despite current clinical approaches, high recurrence rates and frequent metastases pose significant challenges in management. Immune checkpoint inhibitors such as ipilimumab and nivolumab have revolutionized cutaneous melanoma treatment, but their efficacy in conjunctival melanoma remains largely unexplored. Herein, the authors present the case of metastatic palpebral conjunctival melanoma in a 59-year-old male successfully treated with a first-line combination of ipilimumab and nivolumab without adjuvant therapies or local surgeries. Local disease resolution was achieved after only 7 months of treatment, and the immune checkpoint inhibitor regimen was well-tolerated with limited systemic adverse effects and no ocular side effects.

Purpose: To examine microscopically the distribution of the lymphatic channels in comparison with the blood vessels in the upper eyelid.

Methods: Central sagittal sections of 13 upper eyelids (8 right, 5 left) from 11 Japanese cadavers, aged 36 to 87 years old (average age: 66.6 years), were histologically examined. The specimens were fixed in 10% formalin. Staining with D2-40 for lymphatic channels and with the antibody for α-smooth muscle actin for blood vessels was utilized.

Results: The lymphatic channels were mainly distributed superficially, just under the skin, but the blood vessels were situated deeper, and diffusely spread throughout the upper eyelid.

Conclusion: The positional predispositions of the lymphatic channels and the blood vessels were different. The former is mainly superficial and the latter is deeper and diffuse.

A 54-year-old female with myelodysplastic syndrome on chemotherapy presented with 10 days of periocular erythema and edema worsening on oral antibiotics. Computed Tomography scan showed periorbital soft tissue swelling without postseptal extension or abscess. Intravenous broad-spectrum antibiotics were administered. However, she developed necrosis of the upper eyelid requiring aggressive debridement. Nine days after debridement, the defect measuring 5.5 × 3 cm was covered using an umbilical amniotic tissue graft (AmnioGuard, BioTissue, Miami, FL). At postoperative week 4, 5-fluorouracil was injected to prevent the shortening of anterior lamella. At postoperative week 20, the graft had dissolved and been replaced by regenerated skin. Final eyelid exam demonstrated normal eyelid elevation and minimal lagophthalmos. Herein, we present a case of umbilical amniotic membrane as a substrate graft to support the healing of the eyelid defect by secondary intention.

Purpose: To report the long-term surgical outcomes of acquired ankyloblepharon correction using mucous membrane graft.

Methods: Five eyes of 4 patients (median age, 19 years) with acquired ankyloblepharon were managed using eyelid splitting and mucous membrane graft anchored to the recti muscles on the bulbar surface in the respective quadrant and onto the bare tarsal surface. Outcome measures include a change in the palpebral fissure width, ability to fit scleral contact lenses, visual acuity, and cosmesis.

Results: The underlying etiologies of ankyloblepharon were chronic Stevens-Johnson syndrome (n = 3), and chemical injury (n = 2). All 5 eyes had conjunctival shortening, and 3 had severe dry eyes (median Schirmer 4.5 mm). Four eyes had limbal stem cell deficiency. The median horizontal palpebral fissure width improved to 22 mm from 8 mm. This single-staged surgical technique allowed for fornix formation and prosthetic replacement of the ocular surface ecosystem lens fitting in all 5 eyes. Median logMAR visual acuity improved from 2.1 to 0.7 following ankyloblepharon release, prosthetic replacement of the ocular surface ecosystem lens fitting in 4 eyes, and keratoprosthesis in 1 eye. Repeat mucous membrane graft for recurrent symblepharon in 1 quadrant was required in 2 eyes where complete 360 degrees bulbar and tarsal conjunctiva loss were present preoperatively. At the median follow-up period of 27 months, all patients reported better cosmesis and had no symblepharon recurrence following repeat surgery in 2 eyes and single surgery in 3 eyes. The donor site healed well without any complications. No mitomycin C or symblepharon ring was used.

Conclusion: Ocular surface and adnexal reconstruction using bulbar and tarsal mucous membrane grafts help visually rehabilitate patients with acquired ankyloblepharon secondary to cicatrizing ocular surface disorders.

A 40-year-old woman presented with a mass in her OS for 2 years. Examination revealed a large conjunctival lesion on the nasal bulbar conjunctiva OS and a small upper tarsal conjunctival lesion in the OD. Biopsy OD revealed inflammatory granulation tissue, and OS revealed pseudoepitheliomatous hyperplasia with granulation tissue. The lesion responded well to steroids. She was lost to follow-up and returned with an enlarged lesion with orbital extension and corneal perforation. Orbital exenteration was performed. The entire conjunctiva showed extensive epithelial downgrowth and mononuclear round cell infiltrates, predominantly plasma cells admixed with neutrophils suggestive of aggressive pseudoepitheliomatous hyperplasia. Orbital tissue showed ill-defined granuloma formation with acute on chronic inflammation and plasma cells. The tissue IgG4/IgG ratio was 34%, suggestive of probable IgG4-related orbital disease. Based on this case, we conclude that IgG4-related orbital disease can rarely cause conjunctival and scleral inflammation with secondary pseudoepitheliomatous hyperplasia-like changes.