Lateral Cantholysis Research Articles

Modified Mustardé and Superolateral Periosteal Flaps for Full-Thickness Defects of Medial and Central Lower Eyelid: A Case Series.

Reconstructing full-thickness defects involving 50% to 75% of the horizontal length of the lower eyelid after medial and central full-thickness block resection can be challenging. As a disadvanatge, 1-stage reconstructions may require a free graft reconstruction of the posterior lamella. In addition, 2-stage reconstructions are associated with several complications, including erythema, and the eye must be temporarily closed after surgery. The present study describes a single-surgeon retrospective case series. Five patients diagnosed with basal cell carcinoma underwent wide full-thickness block resection with optimal excision margins (3-5 mm). Subsequently, 1-stage reconstruction was performed using the modified Mustardé flap, incised using the transconjunctival approach. This flap comprised the skin, muscle, tarsus, and conjunctival flap raised from the lateral canthus through a lateral cantholysis procedure, and then extended to the lateral cheek. The flap was medially transposed to cover the medial and central lower eyelid defect. The superolateral periosteal flap was harvested from the superolateral orbital rim attached to the lateral border of the tarsus of the modified Mustardé flap. The lateral forniceal conjunctiva was released from the retractor and advanced superiorly to cover the inner surface. The study included 3 men and 2 women, with a mean age of 71 years (range, 62-90 years). Histological evaluations confirmed tumor-free margins in all cases. The average follow-up duration was 20 months (6-60 months), with no tumor recurrence. None of the patients developed long-term complications, such as ectropion, entropion, lagophthalmos, trichiasis, symblepharon, erythema, wound dehiscence, or flap necrosis. All patients had minimal scarring, and no secondary surgical interventions were necessary. This case series demonstrates the efficacy of the combined modified Mustardé and superolateral periosteal flaps in 1-stage reconstruction of full-thickness defects involving 50% to 75% of the horizontal length of the medial and central lower eyelid without compromising functional and aesthetic outcomes.

Structural Limits of Orbital Compliance and Treatment Options for Pathologic Orbital Pressure.

The integrity of the orbit has a finite structural limit due to the compliance of its tissue. The authors investigate these limits to quantify them and inform the treatment of heightened ocular and orbital pressure. Cadaveric study with 12 orbits being volumized before randomization of treatment for pathologic levels of ocular and orbital pressure. First-line and second-line treatment was chosen randomly (lateral cantholysis, superior septolysis, inferior septolysis). Prior to treatment, IOP, orbital compartment pressure, and axial globe projection was measured after delivery of each 1cc aliquot and surgical treatment. Orbital compartment pressure and IOP were well correlated (r = 0.99). The average reduction in IOP after treatment averaged a 56.2 mm Hg reduction in IOP. All treatments were statistically equivalent ( p < 0.01). Loss of compliance (P LOC ) was determined when the mean plus 1 standard deviation of change in IOP/ml volume was achieved with simultaneous change in exophthalmometry of <0.5 mm change/ml added volume, indicating an acceleration in pressure in the face of a steady volume. This criteria was met for 11 of 12 orbits. The 12th orbit missed this threshold by 1 mm Hg in IOP. P LOC occurred at an average IOP of 43.0 mm Hg (±5.8 mm Hg, 90% CI) and after an average injection of 13 ml (±1.4 mm, 90% CI). Additionally, lateral cantholysis, superior septolysis, and inferior septolysis were statistically equivalent in reducing IOP after P LOC . IOP and orbital compartment pressure are excellent proxies for each other in the authors' model. Orbital compliance is a mathematic phenomenon that can be quantified, as evident in this investigation. P LOC can inform timing for orbital decompressions in the presence of heightened IOP. Multiple procedures can be used to extinguish dangerously high orbital compartment pressure.

Treatment strategies for orbital gas-producing necrotizing fasciitis secondary to odontogenic maxillary sinusitis: Technical notes

This paper presents treatment strategies for orbital necrotizing fasciitis (NF) in a case of a 33-year-old male diagnosed with orbital NF, which developed after dental root canal treatment. Although orbital NF is rare, it is rapidly progressive and can easily lead to the loss of tissue and visual function, sometimes to a life-threatening extent. Prompt and adequate treatment has been a challenge yet remains quite essential. In addition to the conventional approach to NF, such as immediate antibiotic administration and drainage, orbital NF patients like this case were often treated by incorporating additional steps, which include: 1) performing minimally invasive but adequate removal of necrotic tissue through intraoperative use of ultrasound equipment and postoperative use of proteolytic enzyme-containing ointment for chemical debridement; 2) managing intraorbital pressure by lateral cantholysis and orbital floor removal (decompression); and 3) maintaining the aerobic conditions of the wound after surgical drainage via orbital wall removal. Thus far, satisfactory results in patients with extensive NF of the orbit, including the presented case, were achieved with regards to preserving periorbital tissues, vision, and ocular motility through a multidisciplinary approach. These should be considered as optional means of preserving the orbital tissue and visual function.

Displaced Orbital Fractures with Concurrent Orbital Compartment Syndrome: A Case-Based Systematic Review.

Orbital compartment syndrome (OCS) is an emergency that complicates intra-orbital, retrobulbar hemorrhage in most cases. Bony orbital decompression is an effective treatment for OCS, and displaced orbital fractures are protective. Nevertheless, in rare cases, OCS occurs despite a displaced orbital fracture. The aim of the current review is to present its pathophysiology and management based on what is published in the medical literature, and our center's experience. A systematic review of literature was conducted through PubMed, Medline, Embase, and Cochrane from inception through February 2021. The following search query was used: "orbital fracture" and "trauma" and "orbital compartment syndrome." Studies tackling the pathophysiology and management of concurrent displaced orbital fracture with OCS were included and a cohort of patients was constituted. A cohort of 18 cases reported in the literature were included (49.3 ± 30.6 years, 50% M). Given that OCS occurs with or without orbital fracture, pathophysiology of OCS is mostly explained by the division of the orbital fat into many compartments, due to the presence of Koorneef's fibrous septa. Management of OCS in such circumstances consisted of inferior-lateral canthotomy and cantholysis in 50% of cases, subperiosteal drainage with myringotomy in 22.2% of cases, subperiosteal drainage in 16.7% of cases, and complete lateral cantholysis in 16.7% of cases. Two cases who presented to our tertiary care center were also added to this review. Physicians should be aware that OCS can occur even with displaced fractures of the orbital cavity. When clinical suspicion is present, an emergent management is needed.

Ophthalmic artery occlusion due to orbital compartment syndrome after a frontotemporal craniotomy.

A 32-year-old female with a right frontal lobe glioma underwent an elective frontotemporal craniotomy. One hour postoperatively, the patient developed a right orbital compartment syndrome (OCS) with unilateral acute vision loss, proptosis, afferent pupillary defect, and complete ophthalmoplegia. The patient underwent emergent lateral canthotomy and inferior cantholysis. Neuroimaging revealed extensive vascular congestion along the extraocular muscles at the orbital apex. Retinal imaging demonstrated an ophthalmic artery occlusion. OCS following a frontal or frontotemporal craniotomy relates to increased orbital venous congestion from direct compression of the myocutaneous flap and subsequent intraorbital pressure elevation, vascular compromise, and ocular ischemia.

Dengue hemorrhagic fever with severe ocular complication: case series

Introduction: Ocular complication associated with Dengue Haemorrhagic Fever (DHF) is a rare condition with varied manifestations, ranging from subconjunctival hemorrhage to optic neuropathy. This condition's pathophysiological mechanism is not well understood, with several unpredictable conditions resulting in permanent visual loss. In this case series, three patients with severe ocular complications associated with DHF are presented. Case Report: Case 1: a 16 years old girl presented with proptosis after diagnosed with DHF with no light perception. All findings were consistent with pan-ophthalmitis and retrobulbar hemorrhage. Unfortunately, the right eye turned into phthisis and spontaneous prolapse even with canthotomy with lateral cantholysis and steroid administration. Case 2: 10 years old boy presented with bilateral visual blurring within a month after being diagnosed with DHF with hand movement perception on both eyes and optic disc swelling. The visual acuity recovered to 20/20 in a month of steroid therapy with no optic disc swelling. Case 3: 52 years old man presented with proptosis and dengue shock syndrome with counting finger perception, swelled optic disc, and limited eye movement to all directions. The patient was diagnosed with optic neuritis and retrobulbar hemorrhage. Canthotomy with lateral cantholysis lateral and steroid therapy were planned, but the patient died before treatment was done.Conclusions: Severe ocular complications should be anticipated and monitored in DHF patients. Although visual recovery is possible, permanent ocular complications can be severe and cause permanent visual loss.

Efficacy of vertical lid split versus lateral canthotomy and cantholysis in the management of orbital compartment syndrome

ABSTRACT Purpose: To compare the efficacy of the vertical lid split (VLS) to the standard lateral canthotomy and cantholysis (LC/C) for orbital compartment syndrome (OCS) in the cadaveric model. Methods: Simulated OCS was achieved in seven fresh frozen cadaveric orbits. Orbital pressure (OP) was monitored in one control orbit and six interventional orbits. Initial OP was recorded before three right orbits underwent lateral canthotomy with superior and inferior cantholysis, and three left orbits underwent vertical lid split of the upper and lower eyelids. In all 7 orbits, OP was recorded for a total of 16 min. The main outcome measure was the amount of OP reduction at timed intervals. Results: Beginning OP in the control orbit was 109 mmHg, and average initial OP of the LC/C and VLS orbits were 90 and 103 mmHg, respectively. The control orbit maintained high OP without intervention. One minute after LC/C, OP decreased an average of 58.7 mmHg (65.2%; range 48–65 mmHg). One minute following VLS, OP decreased an average of 63 mmHg (61.0%; range 39–102 mmHg). At 16 min, OP reduction in the LC/C orbits averaged 65.3 mmHg (72.6%; range 56–71 mmHg), and OP reduction in the VLS orbits averaged 78 mmHg (75.5%; range 54–121 mmHg). Both interventions produced a comparable reduction in OP. Conclusions: Vertical lid split was found to be as effective as LC/C in reducing OP. The technical simplicity of the VLS lends itself well to utilization by physicians who are unfamiliar with eyelid surgery.

Combined central retinal vein, central retinal artery and cilioretinal artery occlusion with ischemic macular hole secondary to severe orbital cellulitis after black fly bite.

Background: Orbital cellulitis is an infection of the ocular adnexal and orbital tissues behind the orbital septum. The complications are poor prognosis. This paper is to describe some severe rare complications of orbital cellulitis.Case presentation: A case of 32-year-old female presented with acute severe progressive orbital cellulitis on the right eye after a black fly (Simuliidae spp.) bite. Orbital imaging with computed tomography and magnetic resonance imaging showed eyelid abscess with orbital abscess formation and superior ophthalmic vein thrombosis. She was promptly treated with intravenous vancomycin, piperacillin and had surgical procedures to release orbital pressure including lateral canthotomy, lateral cantholysis, and eyelid with orbital abscess drainage. Pus collection culture was positive for Staphylococcus aureus. Even though she responded well to antibiotics treatment, progression involved severe orbital inflammation with marked increased orbital pressure, and her visual acuity was such that she had no light perception. Combined central retinal vein, central retinal artery and cilioretinal artery occlusion were identified. Fundus examination showed retinal whitening at the posterior pole and a few scattered flame-shaped retinal hemorrhages. The cilioretinal artery presented with perivascular retinal whitening. A fundus fluorescein angiogram revealed cilioretinal and retinal artery filling delay and also delayed arteriovenous transit time. She also developed an ischemic macular hole after a week of treatment. We demonstrate an optical coherence tomography image showing the intact posterior hyaloid membrane that represents no traction on the macula to support the ischemic cause.Conclusion: Multiple retinal vascular occlusion and ischemic macular hole could be an early complication of severe orbital cellulitis from increased orbital pressure; therefore, close monitoring of visual acuity with IOP, and prompt treatment when indicated might reduce the risk of consequent blindness.

Bilateral orbital compartment syndrome in a patient with disseminated intravascular coagulation

ABSTRACTA 39-year-old male developed bilateral periorbital oedema and tense orbits in keeping with orbital compartment syndrome (OCS) shortly after presenting to the emergency department for uncontrollable epistaxis. Bilateral lateral canthotomy and inferior cantholysis was performed within 30 minutes of onset, with the left side further decompressed via superior cantholysis. Computed tomography demonstrated bilateral proptosis and optic nerve stretch, but no intraorbital haemorrhage or haematoma. Laboratory findings were consistent with disseminated intravascular coagulation (DIC) and sepsis of unknown origin. The right visual acuity recovered to 6/6 -2 from counting fingers, but the left eye failed to improve beyond light perception. This unique case of OCS is the first associated with DIC which had no evidence of intraorbital haemorrhage.

Orbital Compartment Syndrome (OCS): An Ocular Emergency How to Perform a Sight-Saving Lateral Canthotomy and Cantholysis

Orbital Compartment Syndrome (OCS): An Ocular Emergency How to Perform a Sight-Saving Lateral Canthotomy and Cantholysis

Emergency lateral canthotomy and cantholysis to relieve intraocular pressure following severe motor vehicle collision

A young woman displayed a dilated and fixed pupil following a motor vehicle collision with blunt force trauma to face. This was associated with drastically elevated intraocular pressure and proptosis. It was believed that a retrobulbar bleed was causing ocular compartment syndrome, an ischemic condition whereby elevated pressure within the orbit occludes blood flow to the retina and ocular nerves. This is a rare ocular emergency, and must be promptly treated to prevent permanent damage. Ophthalmology was consulted by telephone to confirm the diagnosis and direct treatment. A lateral canthotomy and cantholysis was performed under guidance from Ophthalmology and free open access medical education resources. The trauma team managed to save the eye, with visual acuity remaining near normal. In this report, the mechanism of orbital compartment syndrome is explained, and the lateral canthotomy and cantholysis procedure is outlined. This case highlights the importance of telephone consultation and easily accessible medical education resources in the acute care of rare conditions that may arise following trauma.

Upper fornix approach combined with a superior lateral cantholysis: a minimally invasive approach to the superonasal intraconal space.

To present a new minimally invasive approach to the deep superonasal orbit. This retrospective study reviewed seven consecutive patients who underwent orbital surgery using an upper conjunctival fornix approach combined with a superior lateral cantholysis for tumors in the superonasal intraconal space. Charts were reviewed for demographic, radiological, clinical, and surgical data including surgical outcome and morbidities for each patient. Six benign tumors of the superonasal intraconal orbit were successfully exposed and removed using this approach, and one malignant tumor was biopsied for diagnosis. Histopathology revealed cavernous haemangioma (3 cases), solitary fibrous tumor (2 cases), schwannoma (1 case), and diffuse large B cell lymphoma (1 case). Visual acuity and ocular motility were unchanged or improved in all cases. There were no visible scars or other complications related to this approach. The upper fornix approach combined with a superior lateral cantholysis is a novel technique that provides safe and excellent exposure of the deep superonasal orbit. In addition, it avoids the unnecessary morbidity of upper lid splitting, medial rectus muscle detachment, or bone removal.

Aesthetic Unit-Based Reconstruction of Periorbital Defects.

The aim of this study was to perform a retrospective analysis of patients who underwent periorbital area reconstructions, determine their sociodemographic characteristics, analyze the effects of defect etiologies and locations classified according to periorbital subunits on our reconstruction options, and to present our treatment outcomes and clinical experience. A retrospective chart review of 23 patients operated in our department between January 2010 and March 2013 and underwent periorbital area reconstructions, was performed. In addition to the demographic characteristics of the patients; defect etiologies, locations according to Spinelli aesthetic subunits, and the degrees of involvement were determined. Analysis of the reconstructive methods showed that primary closure with lateral cantholysis was performed in 1 patient with a defect involving less than 50% of zone 1 along with a partial defect involving less than 50% of zone 2. In another patient with a full-thickness defect involving 75% of zone 1, reconstruction was made with a temporally based monopedicle forehead transposition (Fricke) flap prepared from the lower eyelid, and a conchal cartilage graft. In 2 other patients with partial defects involving more than 50% of zone 2; reconstruction was made with full-thickness skin grafts taken from the retroauricular area. Four patients had full-thickness defects that involved 50% to 75% of zone 2; 3 of them were reconstructed with a Tenzel lateral semicircular rotation flap and 1 with a Tripier flap. In 3 patients who had full-thickness defects involving 75% of zone 2; reconstruction was made with a paramedian forehead flap and conchal cartilage graft. In 3 patients with full-thickness defects involving more than 75% of zone 2, a Mustarde cheek rotation flap was used for reconstruction. Six patients had defects in zone 3, 3 of them were reconstructed with a glabellar flap, 2 with a paramedian forehead flap, and 1 with a bilobed flap. One patient with a defect that involved 50% of zone 4 was reconstructed with a McGregor flap. Construction of a reconstructive algorithm by separation of the eyelid into aesthetic units and use of local healthy tissues provide functionally and aesthetically acceptable results.

Retrobulbar hemorrhage during or after endonasal or periorbital surgery: what to do, when and how to do it.

Retrobulbar hemorrhage (RBH) is an uncommon complication of endoscopic sinus surgery or periorbital surgery consisting in an accumulation of blood within the orbit posteriorly to the eyeball. It must be treated within 90-100 minutes to avoid irreversible visual loss. The present paper tries to pinpoint the key steps in diagnosis and treatment of RBM.On the wake of a new case, the authors review and update their clinical experience and propose a step-by-step protocol to diagnose and to treat RBH developing under different circumstances: during endoscopic sinus surgery, during periorbital surgery, immediately after the surgery, in the awakening room, or postoperatively in the ward.A therapeutic ladder is proposed that starts with lateral canthotomy and inferior cantholysis and progresses to a lower lid transconjunctival incision with retrocaruncular extension.Based on our experience, the proposed guidelines are effective in diagnosing and treating RBH. They allow to preserve vision and minimize reliquates of this rare and dangerous surgical emergency.

Pleomorphic adenoma of the eyelid: A case report

Chondroid syringoma or pleomorphic adenoma of the skin is a rare tumor arising from the eccrine glands. It is an asymptomatic slow growing tumor. We report a case of chondroid syringoma of the lower eyelid margin and lateral canthus in a middle-aged man, which was excised. The lid was reconstructed by lateral cantholysis and advancement flap for lid reconstruction. A possible diagnosis of chondroid syringoma should be borne in mind when solitary, firm tumors of the lid are presented.

Delayed closure of lateral cantholysis post orbital floor repair

Delayed closure of lateral cantholysis post orbital floor repair

Inferior Ophthalmic Vein Varix Complicated by Acute Thrombosis

Orbital venous varix is an uncommon venous malformation of the orbit, divided into primary and secondary types. Orbital varix most commonly involves the superior ophthalmic vein and is rarely complicated by thrombosis. We report a case of inferior ophthalmic vein varix complicated by acute thrombosis, who presented with acute visual loss and proptosis. Lateral cantholysis was performed and high-dose steroid was given to relieve the patient’s symptoms. The thrombus of the orbital varix gradually regressed in 1 month and completely resolved in 6 months.

Internal Cantholysis for Repair of Moderate and Large Full-Thickness Eyelid Defects

To determine the safety and efficacy of internal cantholysis for closure of larger full-thickness eyelid defects. Retrospective review of a consecutive case series. Eighteen patients (18 eyelids) underwent internal cantholysis for repair of a moderate or large full-thickness eyelid defect during the study period. Retrospective review of a consecutive case series of all patients undergoing transconjunctival lateral cantholysis for repair of moderate and large full-thickness eyelid defects between October 2008 and November 2010. Moderate was defined as ≥ 14 mm in horizontal length, and large was defined as ≥ 20 mm in horizontal length. Charts were reviewed for patient demographics; indication for surgery; defect size, type, and location; other concomitant repair; follow-up interval; and complications. Eighteen patients (18 eyelids) underwent internal cantholysis for repair of a moderate or large full-thickness eyelid defect during the study period. Average patient age was 73 years (range, 45-94 years), and there were 10 male and 8 female patients. Average defect size was 19.0 mm (range, 14-25 mm). Average follow-up interval was 4.6 months (range, 1-12 months). Complications included eyelid margin notch (3 cases), persistent canthal dystopia (3 cases), trichiasis (2 cases), pyogenic granuloma (2 cases), eyelid margin nodule (1 case), lower eyelid elevation of 1 mm (1 case), and mild resolving medial lagophthalmos (1 case). No patient requested or required further surgery on the operated eyelid for any reason during the study period. Internal cantholysis allows for closure of moderate and large full-thickness eyelid defects. Complications are acceptable in light of the morbidity of other therapeutic options, such as semicircular flap or shared eyelid flap procedures.

A Unique Association of Granuloma of the Lower Eyelid to Prior Trauma

A 5-year-old girl presented with a mass of the lower eyelid causing lower eyelid retraction and traction in upgaze. The patient had a recent history of minor trauma to the area. An orbitotomy was performed with lateral canthotomy and cantholysis to allow for dissection of the lesion, which was found in the anterior lamella of the lower eyelid. Pathologic review showed non-necrotizing granulomatous inflammation with granulation tissue. Reports of granulomas of the oral mucosa secondary to trauma are common in the dental literature. This is a unique case in that it is the first report of a subcutaneous granuloma of the eyelid arising secondary to trauma.

Transconjunctival Lateral Cantholysis for Closure of Full-Thickness Eyelid Defects

To report a novel technique for closure of full-thickness eyelid defects too large for primary closure that avoids an external lateral canthotomy. Retrospective review of a consecutive case series of all patients undergoing transconjunctival lateral cantholysis. Thirteen eyelids of 12 patients underwent transconjuctival lateral cantholysis for closure of a full-thickness eyelid defect. Each defect occurred after excision of an eyelid cutaneous malignancy. Each defect would not close primarily without undue wound tension. Average horizontal defect size measured 13.7 mm (range, 11-20 mm). Average follow-up interval was 2.3 months (range, 0.5-5 months). All defects healed well with no evidence of dehiscence, notching or other complication related to closure. No patient requested or required further surgery for any reason. Transconjunctival lateral cantholysis allows for closure of larger full-thickness eyelid defects and avoids morbidity from lateral canthotomy/cantholysis.