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BACKGROUND: Numerous materials have been used to accomplish soft tissue augmentation, but the ideal implant remains elusive. Dermaplant is a recently introduced soft tissue matrix derived from human cadaveric dermis and intended for use in soft tissue reconstruction. This product is U.S. Food and Drug Administration (FDA) approved, but there is a paucity of data regarding its clinical performance. OBJECTIVE: To report histopathologic findings of an explanted Dermaplant specimen. METHODS: A healthy 52-year-old man underwent repair of postblepharoplasty eyelid retraction and a prominent tear trough defect. At the patient's request the tear trough implant was removed in the seventh postoperative week. Gross and microscopic evaluations were performed. RESULTS: Fibroblastic infiltration and new collagen production were demonstrated within the implant and at its periphery. Occasional macrophages and giant cells were also noted around the implant. CONCLUSION: In this patient the Dermaplant was well tolerated and supported ingrowth of host tissues. The behavior of this material over the long-term cannot be extrapolated from this study.

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PURPOSE: Tetanus toxin can cause localized neuromuscular weakness, but it also can produce systemic tetany. The action of tetanus toxin on the orbicularis muscle has not been studied in animals immunized to prevent systemic tetany. Our objective was to determine whether tetanus toxin could be used to treat orbicularis oculi muscle spasms. METHODS: We analyzed the clinical, electrophysiologic, and histopathologic effects of tetanus toxin injected into the orbicularis oculi muscle of rabbits with passive immunity to tetanus toxin. In six rabbits, the orbicularis oculi function in both eyes was assessed clinically, and the baseline orbicularis oculi muscle action potential was measured physiologically with electromyography (EMG). The rabbits then were immunized against tetanus toxin with tetanus immunoglobulin for immediate and definitive immunity. Tetanus toxin was injected into the left orbicularis oculi muscles, leaving the right eyes as controls. Ten days later, the rabbits were again assessed by clinical examination and with EMGs on both the injected side and the noninjected side. The animals were killed at 14 days, and the orbicularis muscle was removed from both sides. The injected and control tissues were examined microscopically for signs of neuromuscular denervation. RESULTS: All six rabbits showed weakness in eye closure on the side injected with tetanus toxin. In addition, four rabbits developed complete ear ptosis on the tetanus toxin injected side because of spread of the toxin to adjacent ear muscles. EMGs showed both a denervation of the orbicularis oculi muscle and a poor blink potential on the side injected with tetanus toxin. Histopathologic studies of the orbicularis oculi muscle injected with tetanus toxin showed angulation of both slow and fast types of muscle fibers compatible with neuromuscular denervation. CONCLUSIONS: Tetanus toxin can cause localized orbicularis oculi weakness, as documented clinically, physiologically, and microscopically, without producing systemic tetany in immunized rabbits. Tetanus toxin may have a potential application in the treatment of blepharospasm and hemifacial spasm.

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BACKGROUND: The surgical placement of orbital implants for eviscerations, enucleations, and secondary implantations can cause severe postoperative pain that may not be relieved with high doses of narcotics. We analyzed the effectiveness of a method for postoperative pain control in orbital implant surgery using an orbital epidural pain catheter connected to a patient-controlled analgesia bupivacaine hydrochloride pump. METHODS: One hundred nineteen patients undergoing orbital hydroxyapatite implant surgery received placement of an orbital epidural catheter for the infusion of local anesthetics at the conclusion of their surgery. Patients were asked to gauge their level of comfort into the following 3 categories: total, some, or no pain relief in the first week after surgery. A separate numerical grading scale was used to further quantitate pain. Blood samples were collected in 4 patients to assess the systemic levels of bupivacaine. RESULTS: Most patients (88.2%) responded with total or some pain relief, with only 11.8% suffering severe pain. The mean numerical pain score was 2.8, within a range of 0 (no pain) to 10 (severe pain). The average plasma bupivacaine level in the 4 patients in whom this was measured was 0.38 microg/mL, which is well below the toxic level of 4.0 microg/mL. Furthermore, there were only 5 minor complications caused by the catheters, ie, 1 retrobulbar hemorrhage and 4 catheters that did not work. No permanent problems arose from any of the complications. CONCLUSIONS: The orbital epidural pain catheter is an effective means to achieve postoperative pain control after orbital implant surgery. The simple technique of insertion and management of the catheters was well tolerated in our patient population.

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PURPOSE: 5-FU administered systemically for cancer treatment can cause punctal and canalicular stenosis leading to symptoms of tearing. While some patients receiving 5-FU have resolution of their tearing with cessation of the drug, many patients require surgical treatment of their lacrimal outflow system. We studied the severity of punctal and canalicular stenosis in patients on 5-FU and the various treatments required to correct symptoms of tearing. METHODS: Nineteen patients (16 with colon cancer and 3 with breast cancer) who were treated with systemic 5-FU with complaints of tearing were studied retrospectively. Treatment modalities were based on punctal stenosis evaluated by slit lamp exam, and probing and irrigation of the lacrimal outflow system. RESULTS: All patients demonstrated bilateral punctal and canalicular stenosis on exam. Fifteen of the 19 patients underwent surgery with 4 declining any surgical intervention. Of those 15 patients who underwent surgery; 5 had bilateral silicone tube intubation, 3 had bilateral conjunctivodacryocystorhinostomies (CDCR), 1 had a silicone tube on one side and a CDCR on the other side, 1 had a bilateral DCR, 4 had bilateral punctal 3-snip procedures, and 1 failed bilateral silicone tube intubation and will require bilateral CDCR. CONCLUSION: This is the largest single study in the literature evaluating patients on systemic 5-FU for the sequela and treatment of tearing. Although we found varying degrees of punctal and canalicular stenosis among our 19 patients, almost all had stenosis severe enough to warrant surgical intervention with either silicone tubes or CDCR. In our study 4 of 15 patients who elected surgery (26.7%) required CDCR, because of the permanent, severe stenosis of the lacrimal outflow system. Physicians should be aware that early recognition and treatment of tearing in patients on 5-FU with silicone tubes may salvage the canalicular system and prevent the need for CDCR.

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OBJECTIVE: To determine if shaving eyebrows can lead to permanent brow loss. METHODS: Five patients had a single brow randomly shaven, while the unshaven brow served as a control. These patients were evaluated prospectively for brow regrowth during 6 months, and photographs were taken at each visit. Two masked observers analyzed the final photographs to determine if they could identify the side that was shaven. RESULTS: All patients had full brow regrowth by 6 months. The masked observers could not identify shaven side with any consistency. One female patient with sparser, lighter-colored brow cilia waited longer than the other patients for full brow regrowth. CONCLUSION: This small study demonstrates for the first time that full brow cilia regrowth is possible after completely shaving an eyebrow.

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Patients with the inherited, bilateral form of retinoblastoma have an increased incidence of osteogenic sarcoma such that the mortality from the secondary tumor exceeds that of the initial bilateral retinoblastoma. We report a 29-year-old male survivor of bilateral retinoblastomas originally diagnosed at 8 months of age, whose treatment eventually included bilateral enucleation, bilateral orbital radiation, and systemic chemotherapy. At age 26, a tumor removed from his right maxillary sinus was diagnosed as fibroma. At age 29, he developed an inferior orbital mass that extended into the right maxillary sinus. A biopsy and comparison with the previous maxillary sinus mass revealed both lesions to be leiomyosarcoma. Both light and electron microscopy supported the diagnosis. The patient has survived treatment with orbital exenteration and maxillectomy combined with postoperative radiation to the right orbital-maxillary area. This appears to be the fourth case of leiomyosarcoma in the third decade of life in a male patient with a previously irradiated orbit after enucleation for bilateral retinoblastoma. Leiomyosarcoma appears to be another orbital tumor associated with bilateral retinoblastoma.

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Enlarged extraocular muscles usually occur from inflammatory conditions, but in rare instances metastatic tumors that invade the muscles will require a biopsy and specific treatment. The authors report what they believe to be the third case of metastases to the extraocular muscles from signet ring cell adenocarcinoma of an unknown primary site.

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The authors developed a rabbit model of the brown recluse (BR) spider envenomation of the human eyelid. The spider bite causes cutaneous necrosis and systemic toxicity in human eyelids, possibly leading to disseminated intravascular coagulation, hemolysis, and death. The treatment has been controversial. The animal model evaluated the effects of single- and combined-agent therapy in four phases: venom dose response, time course, therapeutic effectiveness (steroid vs. dapsone vs. antivenom), and optimal therapy (steroid and dapsone; steroid and antivenom; and dapsone and antivenom combination groups). The combination dapsone and antivenom treatment group was the optimal animal regimen, although not completely effective in eliminating microscopic necrosis. The authors also report dramatic clinical improvement in human inflammatory response with dapsone therapy and recommend immediate dapsone therapy combined with specific BR venom, if available, in humans.

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Several authors have investigated the success of nasolacrimal duct intubation in children as well as the length of time for tubes to remain in place. The treatment of congenital amniocele with potential for life-threatening septicemia has been investigated. Other topics have included the bacteriology of dacryocystitis emphasizing the risk of endophthalmitis after intraocular surgery, balloon treatment for functional nasolacrimal duct obstruction, anatomical measurements of the lacrimal system relative to intracranial space, and new procedures for punctal stenosis. Diagnostic tests for epiphora and methods of punctal occlusion are evaluated.

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BACKGROUND: Computerized imaging of complex fractures of the orbit and facial skeleton have brought about demands for methods of anatomic restoration. In this article, the author outlines techniques for metallic rigid anatomic fixation of facial fractures and the cranial bone graft method of augmentation. METHODS: Clinical results of fracture repair using various types of metallic plates and replacement of missing bone with cranial bone grafts are presented and techniques are described. CONCLUSION: Rigid three-dimensional fixation of the facial skeleton with metallic plate fixation and augmentation with cranial bone grafts has produced more predictable correction of severe fractures of the orbit and facial skeleton.

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Methyl methacrylate (plastic bone cement) can be prepared by mixing a vial of liquid monomer with a powder. The monomer can release a toxic vapor. We measured the exposure of operating room personnel to this toxic substance. We believe that an awareness of the potential toxicity of the monomer is important and that devices to limit its exposure to personnel should be used in operating rooms.

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Thrombin can stop bleeding during ophthalmic surgery by directly converting fibrinogen to fibrin. Little attention has been given to the potential risk of inadvertent intravenous administration of thrombin causing massive intravascular coagulation. We injected rabbits with a dose of thrombin, adjusted for body weight, equivalent to the amount used in ocular surgery. We also studied the effects of treating the rabbits with heparin. The rabbit injected with thrombin alone died within 30 seconds due to total intravascular coagulation. Three additional rabbits injected with thrombin but treated with heparin (intraperitoneally 40 minutes before thrombin, intravenously 30 minutes before thrombin, and intravenously immediately after thrombin injection) survived without any ill effects noted over the next month. For extraocular cases we recommend color coding the thrombin with some methylene blue. Using an eye dropper, rather than a syringe, reduces the chance of intravascular injection.

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Wooden foreign bodies in the orbit can extend into the intracranial cavity without diagnostic clues from the small eyelid entrance wound, from neurologic examination, and from imaging studies such as ultrasound, plain x-rays, or computed tomography (CT) scans. In cadaver magnetic resonance imaging (MRI) studies, dry wood in the orbit can be seen as a negative or hypointense image in contrast to orbital fat. We studied fresh, green wood in dogs to determine the reliability of CT and MRI scans to image hydrated wood. Wood was placed into each orbit of two dogs. After 24 h the wood was removed from one orbit, but not the other. The dogs were then scanned with CT and MRI. Radiologists were asked to determine if any wood had been left in either or both orbits. The fresh wooden foreign bodies could not be detected despite an intensive effort. MRI does not appear to reliably demonstrate fresh wood in the orbit. MRI can show dry wooden foreign bodies that have not become hydrated, but has not yet been reliable in the clinical situation to rule out the presence of wood in the orbit.

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A 52-year-old man developed proptosis from an orbital mass which was documented histopathologically to be an inflammatory orbital pseudotumor. When the lesion failed to resolve after six months of adrenocorticosteroid treatment, a second biopsy showed an inflammatory mass with nests of eosinophilic granuloma. The patient soon developed a lymphoma of the soft palate and a glioblastoma multiforme which led to the patient's rapid demise. Eosinophilic granuloma is known to represent the more benign end of the spectrum of histiocytic disorders in which a proliferation of Langerhans' cells and an abnormality of T-suppressor cells occur. Our case represents the first report of multifocal tumor immunoincompetence occurring with eosinophilic granuloma in an orbital inflammatory pseudotumor.

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We report CT visualization of both a rare congenital lacrimal fistula and a large mucocele of the lacrimal sac on the opposite side of the same patient. CT scan visualization of a patent anlage fistula has not been reported previously. CT scans can demonstrate extensive orbital abnormalities not detectable by routine clinical or radiologic evaluation.

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