Optic nerve sheath fenestration through a lateral canthotomy incision.

Optic nerve sheath fenestration is an increasingly useful surgical technique for relief of visual loss due to a number of optic disc pathologic conditions. To date, surgeons have employed either a medial approach with disinsertion of the medial rectus muscle or a lateral approach with removal of the lateral orbital rim to gain access to the retrobulbar optic nerve. We report herein a technique for approaching the optic nerve through a lateral canthotomy incision that does not require removal of bone or disinsertion of an extraocular muscle.

Rhabdomyosarcoma manifesting as acquired nasolacrimal duct obstruction.

A 5-month-old boy with acquired epiphora developed a right inferonasal lower eyelid mass, which was shown on computed tomography to involve the inferior and medial recti muscles and the nasolacrimal duct. Orbital exploration and excision of the mass disclosed this to be an embryonal rhabdomyosarcoma. This case illustrates the importance of distinguishing acquired nasolacrimal duct obstruction in infancy from true congenital nasolacrimal duct obstruction.

Medial canthoplasty with microplate fixation.

Six patients with malpositioned or surgically excised medial canthal tendons underwent repair with titanium microplate, and two patients underwent repair with titanium miniplate fixation. The T-shaped rigid fixation plates were chosen for medial canthal reconstruction to allow for stabilization of the plate along the anterior lacrimal crest and extension of the plate over the posterior lacrimal crest. The medial canthal tissue was reattached to the titanium plate with 3.

Extended access/internal approaches for the management of facial trauma.

The two most significant recent developments in the treatment of facial trauma are the introduction of plating systems, which provide rigid internal fixation and the development of surgical approaches that allow wide exposure of the entire facial skeleton while minimizing external incisions. These approaches (referred to as extended access/internal approaches) are hemicoronal and coronal flaps, the sublabial approach to the midface, the transconjunctival approach to the orbital floor and orbital rim, and the intraoral management of mandibular fractures. These approaches work well, and have become standard techniques for managing facial trauma; however, each one has definite technical points that need to be adhered to to assure their success.

Tarsotomy for the treatment of cicatricial entropion with trichiasis.

Transverse tarsotomy and lid margin rotation is a simple procedure that is effective in repositioning the entropic lid margin without requiring external incisions or grafting. We report the results of this procedure in 81 eyelids of 58 patients with cicatricial entropion and trichiasis who were followed up for a minimum of 6 months after surgery. Fifty-nine (94%) of sixty-three eyelids with mild to moderate cicatricial entropion were cured with this procedure.

Congenital entropion with intact lower eyelid retractor insertion.

Congenital lower eyelid entropion is generally considered to result from improper development of the retractor aponeurosis insertion to the inferior portion of the tarsal plate. We treated three patients with this uncommon disorder. At operation, aponeurotic defects were anticipated and specifically sought, but in each case the lower eyelid retractors were inserted normally.

Lipomatous hamartoma of the orbit.

Proliferations of mature adipose tissue, while common in retroperitoneal and subcutaneous sites, rarely occur in the orbit. We describe the clinical, radiographic, and histopathologic findings of a nonencapsulated lipomatous tissue overgrowth of the right orbit in a 35-year-old man. The mass had caused proptosis since childhood and was apparently present since birth.

Management of lower-lid retraction with hard-palate mucosa grafting.

Lower eyelid retraction is frequently managed by recession of the lower-lid retractors and interposition of a "spacer graft." We have used hard-palate mucosa as our spacer material in 25 eyelids of 18 patients. A graft twice the height of the measured amount of lid retraction was used and resulted in predictable, satisfactory results.

Combined approach to orbital decompression.

Upon occasion, surgical orbital decompression is indicated to treat thyroid ophthalmopathy. Of the various approaches described, we feel a combined ophthalmic-otolaryngologic technique is the safest and most effective means of decompressing the orbit.

Management of congenital lacrimal sac fistula.

Fourteen patients who were treated for symptomatic congenital lacrimal sac fistula were retrospectively reviewed to evaluate surgical success. Excision of the fistula alone was performed on 9 patients and excision with nasolacrimal intubation on 5 patients (to our knowledge, the latter has not been previously described in the English literature). None of the 14 patients were symptomatic postoperatively during a mean follow-up of 16 months, with a range from 3 to 39 months.

The value of intranasal surgery in assuring the success of a conjunctivodacryocystorhinostomy.

Conjunctivodacryocystorhinostomy is a much maligned procedure, and there are widely varying opinions about its efficacy and long-term success. We present our modification of the procedure used in 38 eyes of 29 patients over 10 years, with an average follow-up of 2.5 years, which has resulted in a very high rate of success.

Cryotherapy for trichiasis in trachoma.

Trichiasis secondary to trachoma was treated in 137 eyelids from 64 patients in Saudi Arabia. Cryotherapy with high-flow nitrous oxide was applied to the lid margin for 45 seconds in a freeze-thaw-freeze cycle. The success rate of treated eyelids was 56% after one treatment and increased to 90% after a second treatment.

An orbital hemangiopericytoma recurrent after 33 years.

A middle-aged woman developed a recurrent orbital hemangiopericytoma 33 years following its initial removal. Preoperative computed tomographic and magnetic resonance imaging scans revealed a well-circumscribed superotemporal orbital mass. A tumor that appeared grossly encapsulated was removed intact via a lateral orbitotomy.

Management of cosmetically objectionable veins in the lower eyelids.

We have examined three patients with cosmetically objectionable prominent veins in the lower eyelids. Segmental interruption of the vessels through multiple skin incisions has proved to be a satisfactory treatment.

Staple closure of the retroauricular donor site.

Suturing is the usual method employed to close retroauricular skin graft donor sites. We present our 8-year experience with 163 cases demonstrating that such donor sites can be closed with equal efficacy using skin staples. This technique is simple and takes less surgical time.