Biomedical subjects
A M Putterman
Publications and source records attributed to A M Putterman.
Dacryocystorhinostomy in Wegener's granulomatosis.
Dacryocystorhinostomy was performed on two patients with Wegener's granulomatosis that had been quiescent for many years. Excellent results were attained, with elimination of dacryocystitis, complete relief from epiphora, and maintenance of a patent outflow tract. No wound necrosis occurred postoperatively, in contrast to a previous report in the literature. Our experience suggests that nasolacrimal duct obstruction in the setting of quiescent Wegener's granulomatosis can be treated safely and effectively with dacryocystorhinostomy.
Patient satisfaction in oculoplastic surgery.
Patient satisfaction in oculoplastic surgery was evaluated through questionnaires sent to patients, referring physicians, and oculoplastic surgeons. Two oculoplastic surgical procedures, cosmetic blepharoplasty and acquired blepharoptosis treatment, were analyzed. One hundred forty-five patients and 85 referring physicians of the practices of five oculoplastic surgeons were questioned. Sixty-nine additional oculoplastic surgeons were also surveyed. The results of treatment were consistently emphasized as the most important factor in patient satisfaction, a finding that contrasted greatly with the decreased emphasis on the cost of treatment. This implies that patients value the quality of medical care and are willing to pay for it. The preference of patients contrasts sharply with the trend of government and third-party payers to emphasize cost containment at the possible sacrifice of quality of care. The surveys also showed that pain and discomfort and office waiting time are more important to patient satisfaction than oculoplastic surgeons realize and that the surgeons will have to address these issues in order to improve satisfaction. Also, there is a falloff of surgeon-patient communication postoperatively which is less satisfying to patients and recognized, but not acted on, by surgeons. Therefore, more postoperative surgeon-patient communication by telephone is also likely to improve patient satisfaction.
Muller's muscle-conjunctival resection procedure in the treatment of ptosis in Horner's syndrome.
The predictability of the phenylephrine test and the efficacy of the Muller's muscle-conjunctival resection procedure in the management of blepharoptosis in six cases of Horner's syndrome were assessed. Before phenylephrine testing or surgery, an average of 2.3 mm of ptosis was present. Topical phenylephrine elevated upper lids an average of 2.2 mm. The amount of elevation produced by the phenylephrine guided the amount of Muller's muscle and conjunctiva resected. Postoperative upper lid levels were exactly symmetrical in five of six patients. In one patient the previously ptotic lid was 0.5 mm higher than the contralateral lid. Even though Muller's muscle is rendered nonfunctional in Horner's syndrome by denervation, the Muller's muscle-conjunctival resection procedure proved to be a very effective method of treating ptosis in this setting. Our findings imply that the mechanism by which this procedure alleviates ptosis is independent of active contraction of Muller's muscle.
Comparison of 2.5% and 10% phenylephrine in the elevation of upper eyelids with ptosis.
The Mueller's muscle-conjunctival resection procedure has been effective in treating ptosis in eyelids that elevate upon instillation of topical 10% phenylephrine (Neo-Synephrine). The small risk of an adverse systemic reaction to phenylephrine could be even further decreased by using 2.5% phenylephrine instead of 10% phenylephrine. In order to assess the feasibility of using 2.5% phenylephrine instead of 10% phenylephrine in ptosis evaluation, we compared the amount of upper eyelid elevation produced by the two solutions. Thirty ptotic upper eyelids in 20 patients exposed to 10% phenylephrine rose an average of 0.2 mm higher than the same lids exposed to 2.5% phenylephrine. Although this difference was statistically significant, we suspect that the small magnitude of this difference would have little effect on the decision to perform a Mueller's muscle-conjunctival resection procedure or on the calculation of the amount of tissue to resect.
Custom orbital implant in the repair of late posttraumatic enophthalmos.
We repaired late, posttraumatic enophthalmos in 21 patients by inserting a large, soft, Silastic block through a lower eyelid flap and transconjunctival approach to the orbit. These blocks were hand carved at the time of surgery to match bony defects as characterized by hypocycloidal tomographic biometry. Enophthalmos and hypo-ophthalmos were ameliorated with acceptable appearance in all cases. No implant rejections, migrations, or infections were found. Complications included upper eyelid blepharoptosis, lower eyelid retraction, and conjunctival prolapse. The improvements were stable over a median follow-up of 13 months.
Reconstruction of nasal fistulas of the medial canthus.
Invasive carcinomas of the medial canthus may require the removal of skin, subcutaneous tissue, and nasal bone, which can result in a nasal fistula of the medial canthus. I applied a nasolabial flap on the inside of the fistula and a forehead flap on the outside to reconstruct such a fistula. This technique was successful in three patients.
Conjunctival flap-cosmetic shell-ptosis procedure. Treatment of blepharoptosis in severe keratopathy.
The correction of marked blepharoptosis in patients with severe or potential keratopathy will worsen the keratopathy and possibly lead to the complications of corneal ulceration and endophthalmitis. The conjunctival flap--cosmetic shell--ptosis procedure is well suited to this difficult management problem. Patients are initially treated with a conjunctival flap to protect their cornea. Subsequently they are fit with a cosmetic shell, and finally they undergo surgery to correct their ptosis. This three-stage procedure has produced excellent cosmetic and functional results in two patients, one of whom had ptosis and severe radiation-induced keratopathy following the treatment of a rhabdomyosarcoma; the other patient had severe ptosis associated with lack of corneal sensation and orbicularis function following removal of a cerebral meningioma.
Recurrent Jones tube extrusions successfully treated with a modified glass tube.
Displacement or extrusion of the standard glass Jones tube causes conjunctivodacryocystorhinostomy to fail in many cases. Patients who have had trauma, a tumor excised, or have received radiation therapy in the medial canthal area are particularly susceptible to this complication. Gladstone and Putterman developed a modified glass tube that has a second flange 3 to 6 mm from the top flange. The second flange anchors the tube and reduces its mobility. Eleven patients who could not retain a standard Jones tube were fitted with a modified glass tube. Seven of these patients were able to wear the originally placed modified tube comfortably. Two additional patients extruded the originally placed modified tube but were able to retain a shorter modified tube. Follow-up ranged from 3 weeks to 49 months (average, 22.4 months).
Cicatricial entropion: an analysis of its treatment with transverse blepharotomy and marginal rotation.
Transverse blepharotomy with marginal rotation is a simple and effective procedure to treat cicatricial entropion of diverse etiology in upper and lower eyelids. The surgeon can vary the site of incision and suture placement to control the amount of marginal rotation required. We treated 152 eyelids (98 patients) with this technique, obtaining an 85% overall success rate. Eleven recurrences were found in 7 of 18 lids with ocular pemphigoid; the success rate for this subgroup was 39% compared with 92% for all others. We recommend this procedure as a technically easy treatment for cicatricial entropion not caused by ocular pemphigoid.
Combined viable composite grafting and eyelid sharing techniques to prevent blepharoptosis after extensive tumor excision.
Five patients underwent tumor excision involving either the entire upper eyelid and temporal lower eyelid (three patients) or the entire lower eyelid and temporal upper eyelid (two patients), followed by reconstruction with an eyelid sharing procedure combined with viable composite grafting to the upper eyelid and a temporal semicircular flap. None of the five patients developed postoperative blepharoptosis, and all had excellent functional and cosmetic results. Follow-up ranged from 23 to 94 months.
Combined excision and drainage with intralesional corticosteroid injection in the treatment of chronic chalazia.
We surgically excised 146 chronic chalazia either with or without intralesional corticosteroid injections. Our results showed an 89% cure rate (79/88) for those chalazia surgically excised compared with a 96.6% cure rate (56/58) for those excised and treated with intralesional steroids as well. Encouraged by these findings, we treated an additional 149 chalazia using the combined technique of excision and steroidal injection for a total cure rate of 97.6% (202/207). Although complications were minimal for both groups, there appeared to be less edema and inflammation in the patients receiving the combined treatment.
Reconstruction of the partially contracted ocular socket or fornix.
Foreshortening of the conjunctival fornices by symblepharon or scar formation can result in a variety of cosmetic and functional abnormalities for the anophthalmic and the sighted patient. To correct this problem, we have modified a technique for the treatment of totally contracted ocular sockets. Unlike the procedure for total reconstruction of the socket that uses a custom-designed conformer wrapped with a full-thickness mucous membrane graft, reconstruction of a partially contracted socket uses a 0.5-mm-thick mucous membrane graft sutured to the resected socket conjunctiva and splinted in place by a custom-designed conformer. Seventeen patients with a variety of underlying pathologic conditions associated with trauma and prior surgery underwent successful ocular fornix reconstruction using this technique.
Elective excision of permanent eyeliner. Case report.
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Silicone intubation for the treatment of congenital lacrimal duct obstruction: successful results removing the tubes after six weeks.
There is little agreement in the ophthalmic literature on the optimum length of time that silicone tubes should be left in place after lacrimal intubation for the treatment of congenital nasolacrimal duct obstruction. Various authors have recommended leaving the tubes in for 3 to 6 months. The authors of this article believe this to be an excessive amount of time. Lacrimal probing, inferior turbinate fracture, and silicone intubation were performed in children ranging in age from 3 months to 5 years. The tubes were removed after 6 weeks in all cases. Resolution of epiphora and dacryocystitis was achieved in all cases. Follow-up ranged from 4 to 81 months. The authors recommend that the silicone tubes be removed after 6 weeks. They also believe that fracture of the inferior turbinate should be performed along with silicone intubation.
A surgical technique for the successful and stable reconstruction of the totally contracted ocular socket.
We describe the successful and stable reconstruction of 47 severely contracted sockets over a 10-year period. The surgical technique employed in all these cases used a large custom-designed, C-shaped conformer wrapped with a full-thickness oral mucous membrane graft. After all cicatricial tissue within the socket was excised, the wrapped conformer was sutured at its midperiphery to the inferior and superior orbital rims. In contrast to other procedures using flatter conformers, which direct their force in a vertical dimension, this uniquely designed conformer directs its force both vertically and deeply posteriorly within the socket. A somewhat modified but similar conformer also can be used for sockets compromised by total symblepharon formation. Excluding six patients with inadequate follow-up, we were able to successfully reform spacious and stable fornices in 40 of 41 severely contracted sockets. The average postoperative follow-up after reconstruction in these cases was 23.9 months. This technique represents an effective approach to successfully reconstruct and maintain stable ocular cul-de-sacs in cases of severe socket contracture or total symblepharon formation.
Dacryocystography: the technique and its role in the practice of ophthalmology.
Modern lacrimal tract imaging has most recently been enhanced by computerized digital subtraction techniques. Current standard dacryocystography technique includes the injection of a water-soluble agent and the use of topical anesthesia. In this article the dacryocystogram of the normal lacrimal system and those with various types of obstruction are presented.
Management of orbital floor blowout fractures.
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