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A case of rofecoxib-associated stevens-johnson syndrome with corneal and conjunctival changes.

PURPOSE: To report a case of rofecoxib (Vioxx)-associated Stevens-Johnson syndrome with corneal and conjunctival changes. DESIGN: Interventional case report. METHODS: Case report of a 62-year-old woman with systemic lupus erythematosus (SLE) taking rofecoxib for arthritis for 3 weeks. RESULTS: Stevens-Johnson syndrome after 3 weeks of rofecoxib therapy. CONCLUSION: This case report suggests that oral rofecoxib may trigger Stevens-Johnson syndrome, potentially causing symblepharons, corneal neovascularization and cicatricial ectropions.

Arthralgia↗

Atypical mycobacterial infection of the periocular region after periocular and facial surgery.

PURPOSE: To delineate the clinicopathologic features of patients who have atypical mycobacterial infections of the periorbital region after periocular and facial surgery and to define the sequelae after treatment and their management. METHODS: A case series of patients from 7 practices of ophthalmic plastic and reconstructive surgeons was analyzed retrospectively. RESULTS: Thirteen patients had infection in the following clinical settings: 8 patients had infections after blepharoplasty, 2 patients had infections that involved the anophthalmic socket, 1 patient had orbital cellulitis after orbital fracture repair with an alloplastic implant, and 2 patients had infections involving the lacrimal system, one after silicone tube insertion and the other after dacryocystorhinostomy with silicone tube intubation. Sequelae of infection included eyelid retraction and ectropion requiring surgical repair (two patients) and enophthalmos (one patient). Twelve of 13 patients required extensive antibiotic therapy. One infection resolved after local excision of eyelid lesions. Another patient had recurrent infection after 4 weeks of antibiotic treatment. CONCLUSIONS: Delayed infection with erythematous nodules, particularly when a foreign body is implanted weeks after periocular surgery, should arouse suspicion of an atypical mycobacterial infection. Delayed infection after blepharoplasty may mimic a chalazion, develop in a sutured incision, or occur without any inflammatory signs. Orbital abscess formation may occur in the setting of transconjunctival blepharoplasty. Cultures for acid-fast bacilli and excisional biopsy of nodules with performance of acid-fast stains may be necessary for diagnosis. The selection of systemic antibiotic therapy, usually clarithromycin, and the length of treatment should be guided by results of culture and sensitivity laboratory studies, biopsy results, and clinical response to treatment. Surgical removal of any implanted foreign bodies should be performed expeditiously. Consultation with an infectious disease specialist may be useful in selected cases. Sequelae of infection may include eyelid scarring and retraction and enophthalmos.

Adolescent↗

Ocular surface, ocular adnexal, and lacrimal complications associated with the use of systemic 5-fluorouracil.

PURPOSE: To determine the prevalence rates and associated characteristics of patients who have ocular surface, ocular adnexal, and lacrimal complications associated with the systemic use of the cancer chemotherapeutic agent 5-Fluorouracil (5-FU). METHODS: An exposure-based cohort study was designed. Adult patients who had completed at least 3 months of systemic 5-FU therapy within the past 5 years were eligible for enrollment. Study subjects had a detailed medical history taken with emphasis on preexisting conditions known to be associated with the development of ocular surface, ocular adnexal, and lacrimal complications. An ocular examination was then performed. A complete nasolacrimal system evaluation was performed if symptoms or findings were identified. The prevalence was then determined for each ocular symptom and each ocular finding identified that was not present pretreatment. An exploratory analysis was then performed to identify patient characteristics that might influence the likelihood of developing any of the above complications. RESULTS: Fifty-two patients were enrolled in the study. The prevalence rates of the following ocular abnormalities were calculated: ocular irritation, 5.8%; blepharitis, 3.8%; conjunctivitis, 3.8%; keratitis, 3.8%; eyelid dermatitis, 5.8%; cicatricial ectropion, 1.9%; tearing, 26.9%; punctal-canalicular stenosis, 5.8%; and blurred vision, 11.5%. Blacks had tearing at a significantly higher rate when compared with whites (P = 0.022, 2-sided Fisher exact test). Three patients had permanent complications that will require surgery for correction. Of the 7 patients who had a single abnormality, 6 had tearing and one had eyelid dermatitis. All of the 8 patients who had multiple findings had tearing as one of their abnormalities. CONCLUSIONS: Ninety-three percent of the patients who had an ocular abnormality had tearing as one of the complications. Patients who are receiving systemic 5-FU and begin to tear should have an ocular examination, looking for ocular surface, ocular adnexal, and lacrimal complications.

Adult↗

Tarsal strip procedure for the correction of tearing.

PURPOSE: To evaluate the tarsal strip procedure in the treatment of tearing related to lacrimal pump failure. METHODS: A retrospective chart review of all tearing patients undergoing the tarsal strip procedure was done. Patients with ectropion, nasolacrimal duct obstruction, and punctal eversion and stenosis were excluded. Data collected included patient age, sex, procedures performed, follow-up, and resolution of tearing. The main outcome measure is resolution of tearing. RESULTS: Thirty-four eyelids of 21 patients underwent a tarsal strip procedure for the correction of tearing. Complete resolution of tearing was noted in 14 eyes. Seventeen eyes were partially improved and required no further intervention. Three eyes were unimproved over the follow-up period. Two eyes eventually required another procedure. CONCLUSIONS: Patients undergoing tarsal strip for tearing caused by presumed lacrimal pump failure showed a significant rate of improvement in their tearing symptom after the procedure. The tarsal strip procedure appears to be effective in the surgical treatment of tearing secondary to laxity of the lower eyelid.

Aged↗

Lateral tarsal strip and quickert sutures for lower eyelid entropion.

PURPOSE: To evaluate the long-term outcome of involutional entropion repair by means of a combined procedure of lateral tarsal strip and Quickert everting sutures. METHODS: Noncomparative interventional case series of patients who underwent a combined procedure of lateral tarsal strip and Quickert sutures for treatment of involutional entropion between September 1999 and September 2002. Of 75 patients who underwent surgery, 36 were followed for at least 2 years. At the 2-year clinical examination, patient comfort, complications, recurrence rates, overcorrection, and cosmetic appearance were assessed. RESULTS: The average age of the 36 patients was 76.67 years. There were 5 bilateral cases, for a total of 41 eyelids. Nine eyelids underwent the procedure to correct recurrent entropion. The recurrence rate was 0% at 1 month after surgery, 2 of 41(4.9%) at 6 months, and 5 of 41 (12.2%) at 2 years. The recurrence rate after a primary procedure was 3 of 32 (9.4%), and, after a failed previous procedure, 2 of 9 (22.2%). There were no cases of secondary ectropion, and all patients were happy with their cosmetic appearance. CONCLUSIONS: A combined lateral tarsal strip and Quickert sutures procedure is effective, simple, and addresses all of the factors that contribute to involutional entropion formation, with a good long-term success rate and cosmetic outcome.

Aged↗

Multiple periorbital dermoid cysts, clefting and mental retardation: a new malformation syndrome?

We report a child with multiple anomalies that was born to healthy nonconsanguineous parents after an unremarkable pregnancy. The female infant had bilateral cleft lip and palate, bilateral toe syndactyly (second and third with no bony fusion), multiple bilateral periorbital tumors, ectropion, lagophthalmos, strabismus and prominent eyes. High frontal hairline and everted lower lip were also noted. Soon after delivery, she was referred to the 'Cleft Clinic' where she underwent cleft lip and palate repair. Seven dermoid cysts were also removed from both periorbital areas. Follow-up documented moderate developmental retardation, hypothyroidism and hydronephrosis. Although some features of our patient overlap with those described in ectrodactyly, ectodermal dysplasia and cleft lip/palate, Martinez, Zlotogora-Ogur, Filippi, Freihofer and Blepharocheilodontic syndromes, our patient has a combination of features not previously reported.

Abnormalities, Multiple↗

Lower eyelid splinting: An alternative to the Frost suture.

OBJECTIVES: To describe a new method of postoperative eyelid suspension used for the prevention of eyelid malposition and to report its efficacy through an outcome study. STUDY DESIGN: An outcome study was performed on 10 patients who would potentially need postoperative eyelid suspension. Candidates included patients with entropion, ectropion, or orbital fractures requiring transconjunctival approaches. Patients were photographed pre- and postoperatively and followed for signs of eyelid malposition. METHODS: At the conclusion of the surgical procedure, a sheet of Xeroform gauze was folded into 6 overlapping layers and cut to conform to the shape of the inferior orbital rim. The superior edge of the gauze was sutured to the lower eyelid using interrupted 5-0 nylon suture. Sutures were placed at the medial and lateral canthi to raise the eyelid above the inferior limbus and along the inferior orbital rim. The splint was removed between postoperative days 7 and 14. RESULTS: There were no perioperative complications related to the surgery or placement of the splint. No cutaneous marks persisted after healing. No complications such as shifting of the splint, ocular damage, or recurrent eyelid malposition occurred. One patient had asymptomatic restriction of lower eyelid elevation on upward gaze, which resolved at 6 months. CONCLUSIONS: The lower eyelid splint appears effective in maintaining lower eyelid position postoperatively. There were no complications with its use, and the splint was tolerated well. Benefits of the splint over the Frost suture include less risk of corneal abrasion, ability to check visual function, and ability to use the splint bilaterally.

Adult↗

Eyelid reconstruction: the state of the art.

PURPOSE OF REVIEW: The goals of eyelid reconstruction are corneal protection, restoration of the integrity of the lid lamellae, and improvement of facial symmetry. Inadequate reconstruction may lead to corneal exposure and sight-threatening keratopathy; in the younger patient, visual deprivation and amblyopia may also follow. The purpose of this review is to describe new materials and approaches used in reconstructing the damaged eyelid. RECENT FINDINGS: Although the surgical principles of lid reconstruction remain unchallenged, new materials and techniques have emerged. These include the use of both autogenous and cadaveric acellular dermis in the management of lower eyelid retraction, and amniotic membrane transplantation in the management of tarsal conjunctival disease. Recent work on upper facial nerve branch reinnervation in the animal model may also offer hope for eyelid reanimation after facial palsy. SUMMARY: The lid surgeon requires a sound knowledge of the principles involved in reconstructing the respective lamellae of the lid. Anterior lamellar reconstruction carries a significant risk of ectropion, and large defects may require several interposition flaps for optimum skin texture and color reconstruction. New materials (autogenous and cadaveric) for posterior lid reconstruction may reduce donor site morbidity and surgical time, but they may contract significantly after surgery. Recent experience with amniotic membrane transplantation may improve the prognosis for patients with entropion and symblepharon caused by conjunctival cicatricial changes.

Amnion↗

The midface sling: a new technique to rejuvenate the midface.

In the early 1990s, the midface became the focus of facial rejuvenation, and various techniques effected elevation by plicating, or on, the midface. Recent analyses of facial aging demonstrate that selective ptosis of the midfacial tissues lateral to the nasolabial fold results in an infraorbital hollow and deepening of the nasolabial fold. Therefore, the authors propose that the midface, from the lower portion of the cheek mass, will result in superior midface positioning. Since 1996, the authors have elevated the midface in select patients by placing a sling of prosthetic (Gore-Tex) or autogenous (tendon or fascia) material through the cheek mass. The sling is secured medially to the infraorbital rim using a nonabsorbable periosteal suture or a mechanical anchor. As variable tension is applied laterally toward the superficial temporal fascia, the sling functions as a fulcrum to return the cheek mass to a more youthful anatomical position. Elevating the cheek mass in this fashion fills the infraorbital hollow and results in amelioration of deep nasolabial folds and jowling. With a mean follow-up of 18 months, 50 patients treated with the midface sling report satisfaction with the procedure. There have been no instances of nerve damage, infection, or hematoma in the midface. None of the slings have required removal and ectropion has not occurred. Because of postoperative asymmetry in one patient, additional elevation of the ipsilateral cheek mass was performed by increasing the tension on the lateral cheek portion of the midface sling. Mathematical models demonstrate the biomechanical superiority of lift through the use of multiple vectors as compared with linear pull techniques. In this fashion, the midface sling supports the cheek mass, providing rapid, simple, and secure elevation. Because of the limited subcutaneous dissection, there is a reduced risk of facial nerve damage and cutaneous vascular compromise. Unlike with other techniques, the lateral portion of the sling may be easily identified through a small incision in the temporal scalp, facilitating subsequent postoperative adjustment of the midface suspension. Furthermore, because the entire cheek mass is permanently supported with an inelastic sling, the results may last longer than those with techniques that rely on sutures to plicate or lift portions of the superficial musculoaponeurotic system.

Aging↗

Lower eyelid orbicularis oculi musculocutaneous flap for reconstruction of nasal tip and supratip defects.

BACKGROUND: In clinical practice, there are many ways to reconstruct nasal defects. Despite this fact, achieving a desirable image and better functional results is still a problem. Banner, bilobed, and dorsal nasal flaps have recently been used to reconstruct defects up to 2 cm. For defects larger than 2 cm, flaps raised from the frontal region and face are used. The major disadvantages of these flaps are the visible scar and the frequent need for a second session. METHODS: The authors used orbicularis oculi musculocutaneous flaps raised from the lower eyelid, containing branches of the angular artery and the infraorbital artery in its pedicle, to reconstruct nasal tip and supratip defects. Between February of 2002 and March of 2004, reconstruction with orbicularis oculi musculocutaneous island flaps raised from the lower eyelid was performed on 15 patients (eight men and seven women) with nasal tip and supratip defects. Thirteen defects were secondary to basal cell carcinoma and two were secondary to congenital melanocytic nevus. The diameter of the defects ranged between 2.1 and 3.1 cm (average diameter, 2.5 cm). Patients were between 25 and 72 years old (average age, 52 years). RESULTS: Patients were followed up for an average period of 6 months (range, 1 to 12 months). In two patients (13.3 percent), postoperative venous problems were seen but resolved in 3 days. Partial necrosis developed in one patient (6.6 percent). In one patient (6.6 percent), minimal scleral show was seen in tolerable ranges. Neither ectropion nor other eyelid deformities were seen. CONCLUSIONS: The authors believe that this flap is a good alternative for reconstruction of nasal defects because of its advantages, namely, the need for only a single session, minimal donor-site morbidity, better color and thickness match, and easy and faster surgery.

Adult↗

Subcutaneous island pedicle flap: variations and versatility for facial reconstruction.

PURPOSE: Reconstruction of facial skin defects may be a clinical challenge in respect to esthetic considerations, and the V-Y advancement island pedicle flap has been a versatile and reliable method. Besides the V-Y flap, this article is to introduce the variations of subcutaneous island pedicle flaps and their versatility for facial reconstruction. METHODS: From August 1994 to August 2005, 179 cases of medium-sized facial skin defects within 1 cosmetic unit were reconstructed with the variations of island pedicle flaps, and the length and width of the defects following removal of lesion ranged from 1.2 cm x 0.8 cm to 6.2 cm x 5.4 cm. RESULTS: Ninety-nine facial defects all over the face were reconstructed with the V-Y flaps, and the traditional and modified transposition island pedicle flaps were used to reconstruct 80 cases of relatively larger width of defects in the nose, lip, and upper cheek, especially in the young patients. Through careful planning and implementation, all flaps survived with primary healing postoperatively. With a follow-up from 6 to 30 months, well-concealed, soft, flat scars, together with good matching of the recipient sites and the flaps, were recorded. Patients and surgeons judged final overall outcome as excellent or good in 94.4% and 92.2% of evaluated patients, respectively. The main complications included visible trapdoor deformation in 9 patients, bulky flap pedicle in 8 patients, and low-grade ectropion of lower eyelid in a young boy, which all were readily revised at the second stage. Temporary alteration of sensation in the flap skin was another possible complication but usually improved with time. CONCLUSIONS: Variations of subcutaneous island pedicle flaps can be designed and may be versatile and reliable methods for esthetic reconstruction of medium-sized facial defects.

Adolescent↗

Total lower eyelid reconstruction using paranasal flap.

The main aim of this study is to evaluate the advantages, disadvantages, and aesthetic results of the total lower eyelid reconstruction with paranasal flap. The other reconstruction methods are also revisited.Ten patients, who were operated for the reconstruction of total lower eyelid defects between November, 1999 and April, 2005 in our department were included in this study. The total lower eyelid defects of all patients were reconstructed using paranasal flap for anterior lamella and chondromucosal, chondrocutaneous or mucosal graft for posterior lamella. Follow-up time was ranged between 3-35 months. The advantages, disadvantages and complications were defined and aesthetic results of the patients were also evaluated by using a questionnaire which was filled by patients at third month after reconstruction. All flaps and grafts survived, partial or total necrosis was not encountered but one patient with ectropion had a secondary reconstructive procedure. The aesthetic results of the patients were also satisfactory. The paranasal flap is very reliable and safe method for total lower eyelid reconstruction.

Adult↗

Clinical, light and electron microscopic features of recessive congenital ichthyosis type I.

Based on electron microscopic features, recessive congenital ichthyoses have recently been divided into four subgroups designated ichthyosis congenita (IC) types I, II, III and IV. Type II is characterized by cholesterol clefts in the horny cells, type III by perinuclear elongated membranes in the granular and horny cells, and type IV by masses of lipid membranes in granular and horny cells. Clear electron microscopic criteria for type I are lacking, although the presence of lipid droplets in the horny cells has been suggested as a criterion. In the present study we included ichthyosis patients with (i) recessive inheritance, (ii) erythrodermic fine scaling, (iii) lack of fine structural markers of IC types II-IV. Patients with ichthyotic syndromes were excluded. The case material consisted of 21 patients from 14 families. Eight were collodion babies at birth, but three were normal. Nine had ectropion, the flexures were affected in 12, and the palms and soles were thickened in all but one patient. On electron microscopy lipid vacuoles in the horny cells were common, but were absent in four patients. Changes in other lipid-related structures, including keratinosomes, were common. We conclude that currently type I can be diagnosed only by excluding the other types of ichthyosis. Clinically, IC type I corresponds to classical non-bullous congenital ichthyosiform erythroderma, but there is marked heterogeneity among affected individuals.

Adolescent↗

Ichthyosis congenital fetalis (Harlequin fetus).

A male fetus which was the product of full-term pregnancy and normal delivery with no family history is presented. The skin was hard and thick, waxy, yellowish in color, and was crossed by horizontal and or perpendicular red fissures. The eyelids were semiclosed, hard, and stiff resulting in ectropion and the conjunctivae were red. The eyelashes and the eyebrows were absent. The nose appeared to be flattened while the nostrils were partly stenosed. The mouth was round and the mucosa was red everted giving a fish-like appearance to the mouth (Fig. 1). There were no ears and they had been replaced by intensive hyperkeratosis with deep fissures, resembling ear lobes without auditory canal, where there was an hyperkeratotic plug (Fig. 2). The inelasticity of the hard and thick skin limited the physiologic movements of the upper and lower extremities and immobilized the interphalangial articular movements. The fetus was treated with corticosteroid ointment but succumbed within the first twenty four hours.

Diagnosis, Differential↗

Successful treatment of type I adult-onset pityriasis rubra pilaris with infliximab.

A 59-year-old woman presented with a painful, pruritic eruption that had commenced as an erythematous, dry patch on the upper back but progressed to erythroderma. Examination revealed orange-tinged erythroderma, scalp scaling, ectropion, palmoplantar keratoderma and nail changes. A diagnosis of type I adult-onset pityriasis rubra pilaris was made, and a subsequent skin biopsy was consistent with this. She was treated with a number of topical and systemic agents with minimal improvement or major side-effects. The patient was then treated with intravenous infliximab 5 mg/kg. She improved dramatically within 2 weeks and was no longer erythrodermic. Five further infusions resulted in additional improvement. Methotrexate was briefly added to the regime, but was ceased owing to nausea. Topical tar and keratolytics were used on the scalp. The patient was left with minimal disease activity and was maintained on emollients.

Abdomen↗

Adnexal surgery in dogs and cats.

Abnormalities in eyelid position and function can lead to chronic irritation of cornea and conjunctiva. Corneal ulceration, vascularization and pigmentation are common consequences. Loss of vision, or loss of the globe may be the end result. The combination of ptosis and entropion of the upper eyelid is commonly seen in breeds with abundant forehead skin folds. Treatment options include surgical reduction of skin folds, suspending the brows, enforced secondary granulation of the upper eyelid, or a combination of procedures. Lid-shortening procedures reduce corneal exposure, improve functional blinking and reduce likelihood of traumatic proptosis. Although a lateral canthoplasty is technically easier to perform, a medial canthoplasty is the preferred method of eyelid shortening. An involuted lateral canthus with entropion is seen in certain dog breeds with a broad skull base and redundant facial skin. Surgical correction is by either applying traction to the lateral canthus, or by resection of the lateral canthal ligament. A combination of entropion, ectropion and macroblepharon may result in the presence of diamond shaped eyelids. Surgical correction involves the combination of several procedures. Upper eyelid agenesis is a congenital absence of part of the upper eyelid in cats. Treatment options include a skin-orbicularis flap from the lower eyelid with a conjunctival pedical graft, the transposition of the lower eyelid to the upper eyelid, cross lid flap and subdermal plexus flap, and subdermal collagen injection. Several techniques for reconstruction of upper and lower eyelid defects are described.

Animals↗

'Erosion' of the uterine cervix; an anachronism.

The conclusion arrived at after a review of the relevant literature, coupled with current knowledge of the morphophysiological changes which take place in the transformation zone of the cervix, is that the term cervical erosion is an anachronism. The term should therefore be abandoned. More appropriate terms for the clinical appearance of the cervix are ectropion or ectopy. The metaplastic process and its role in neoplasia is also discussed.

Cell Transformation, Neoplastic↗

Surgical correction of deformities on upper oral lips and lower eyelids.

Two cases of deformities on upper lips, one from a neurofibroma and another from spontaneous regression of a hemangioma, and two cases of ectropion caused by scars resulting from infection in one and radiodermatitis in the other were corrected surgically. The methods of correction are described and illustrated.

Adult↗