Giant cell angiofibroma of the ocular adnexae.
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Adult↗
Biomedical subjects
Keith D Carter
Publications and source records attributed to Keith D Carter.
Modification of the Cutler-Beard procedure using donor achilles tendon for upper eyelid reconstruction.
PURPOSE: Large upper eyelid defects are typically repaired by the two-stage Cutler-Beard procedure. Replacing the tarsal plate is integral in reconstructing the upper eyelid. Currently, autogenous cartilage is the most frequently used tarsal substitute. We propose using donor Achilles tendon as an alternative for increased stability of the upper eyelid when repairing large defects by the Cutler-Beard procedure. METHODS: We present a retrospectively reviewed case series of four patients with large upper eyelid defects. Each had the traditional Cutler-Beard procedure with the variation of using donor Achilles tendon as the tarsal replacement. Patients were examined and photographed in follow-up ranging from 6 months to 4 years. RESULTS: All cases were successful in recreating the upper eyelid without complication. The tendon graft supplied structure, motility, and cosmesis throughout follow-up. The human Achilles tendon was investigated by literature review and compared with currently available posterior lamellar substitutes. CONCLUSIONS: The replacement of upper eyelid tarsus with Achilles tendon as part of the Cutler-Beard procedure was successful in repairing large upper eyelid defects in four patients. The tendon graft is easily placed and incorporated in the normal eyelid anatomy. It is pliable and mobile yet stable. Repair is not limited by the size of the defect, as the tissue is readily available. The modification produced excellent functional and cosmetic results.
Achilles Tendon↗
Response of visual loss in allergic fungal sinusitis to oral corticosteroids.
Visual loss associated with allergic fungal sinusitis is most often treated with surgery followed by oral corticosteroids. A case is presented in which, because of substantial medical comorbidities, surgery could not be initially performed and the visual loss was corrected with prednisone alone. This case serves to reinforce the central role of corticosteroids in treatment of this enigmatic condition.
Aged↗
Managing the new mandate in resident education: a blueprint for translating a national mandate into local compliance.
OBJECTIVE: The Accreditation Council for Graduate Medical Education (ACGME) has mandated that all residency programs implement an assessment process of 6 core competencies. Assessment of surgical competence is also included in the mandate. We describe our local efforts to meet this new mandate. DESIGN: Systematic literature review. METHODS: A systematic MEDLINE search (1996-2003) of the literature on residency assessment tools was performed. All relevant titles were reviewed by a content expert, abstracts were selected, and all appropriate full articles were reviewed. The Department of Ophthalmology at the University of Iowa formalized the competency review process by forming an ad hoc departmental task force for "Meeting the Competencies" composed of clinicians, technical staff, education specialists, the program director, the director of residency curriculum, the medical student director, and residents. RESULTS: The task force reviewed the available literature, reviewed potential best practices, and reached consensus on an implementation plan. The following specific criteria for the assessment process were proposed: (1) there should be multiple assessments by multiple observers using multiple tools at multiple time points, (2) the tools should be reliable, reproducible, and valid; (3) the tools must be practical (i.e., feasible, convenient, low time commitment, easy to use, and inexpensive to implement and maintain); (4) the tools must produce qualitative and quantitative data, with direct linkage to improvement in educational outcomes in the future; (5) the assessment process must be linked to explicit and public learning objectives; and (6) the grading scale should be open and clearly defined, and the process should be judged as fair and accurate by both faculty and residents. The Meeting the Competencies task force reviewed all of the available tools from the literature and recommended a pilot implementation matrix matching specific tools to individual competencies. The 6 pilot tools include (1) written and oral examinations, (2) a 360 degrees global evaluation form (using multiple observers from different perspectives, including nurses, technicians, fellow residents, and patients, to provide a wider assessment), (3) a resident portfolio, (4) direct observation of operative performance and clinical examination, (5) a phone encounter tool, and (6) a journal club tool. CONCLUSION: We propose a potential blueprint for meeting the challenge of assessing the new ACGME competencies in ophthalmology and translating the national mandate into local compliance.
Accreditation↗
Medial and lateral orbital wall surgery for balanced decompression in thyroid eye disease.
OBJECTIVES/HYPOTHESIS: Diplopia remains a major potential complication of orbital decompression performed for thyroid eye disease. We sought to examine the effect of medial and lateral wall surgery with sparing of the orbital floor on the incidence of postoperative diplopia. STUDY DESIGN: Retrospective review. METHODS: A retrospective review was made of 63 consecutive medial and lateral orbital wall surgeries (40 patients) performed between December 1996 and May 2002 for orbital decompression of thyroid eye disease. RESULTS: The average patient age was 50.9 years of age (age range, 14-83 y). The studied group was predominantly female (sex ratio, 36:4). Indications were compressive optic neuropathy (34), exposure keratopathy (25), and aesthetic concerns (4). The mean time since surgery was 31.5 months (range, 3-69 mo). The medial wall was approached by a transcaruncular (59) or endoscopic (4) technique. Two patients had fat removal. The average improvement in exophthalmos was 4.1 mm (range, 0-10 mm). The average palpebral fissure improvement was 2.0 mm (range, 0-7 mm). Two patients had cerebrospinal fluid leaks during excavation of the sphenoid bone. These were diagnosed and repaired primarily without complication. New-onset diplopia occurred in four patients. Two of these patients required strabismus surgery. CONCLUSION: A 10% new-onset diplopia rate compares favorably with other surgical series. Medial and lateral wall surgery only, sparing the floor, may reduce diplopia after surgery for orbital decompression in thyroid eye disease.
Adolescent↗
Persistent visual loss following retrobulbar hemorrhage.
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Aged↗
The transcaruncular approach to the medial orbital wall.
OBJECTIVE: To demonstrate the safety and use of the transcaruncular approach as a surgical technique that provides rapid exposure of the medial orbital wall and apex through a small cosmetic conjunctival incision. METHODS: The transcaruncular anterior orbitotomy incision is made through the conjunctiva, between the plica and caruncle, with dissection to a subperiorbital plane along the medial orbital wall. This technique was used in 49 patients (58 orbits) between July 1995 and December 2000. The patients' ages ranged from 5 to 89 years (mean, 50 y). RESULTS: The transcaruncular anterior orbitotomy approach provided appropriate surgical exposure in all cases of orbital decompression for thyroid-related orbitopathy (in 33 orbits [26 patients]); for biopsy of medial orbital or orbital apex masses in 12 patients; and for drainage of an orbital abscess or marsupialization of a mucocele in 7 orbits (6 patients). Five patients (6 orbits) underwent a transcaruncular approach for release of medial rectus entrapment after fracture. The single complication was 1 patient who required a revision procedure for treatment of medial fornix scarring with resolution of diplopia. CONCLUSIONS: The transcaruncular approach provides a safe, rapid, and cosmetically pleasing surgical approach to the medial orbital wall and orbital apex. This technique can be used for a variety of indications.
Abscess↗
Bilateral traumatic globe subluxation.
A 41-year-old woman was involved in a motor vehicle accident. On examination, the patient was intubated but responsive. Visual acuity was no light perception OU. Bilateral anterior globe subluxation was noted. The globes were intact. CT scans of the head and orbits revealed extensive facial fractures. The globes were gently reduced in the orbits. After surgery, the patient had not regained vision but was grateful that her eyes were intact and was coping with her vision loss. Prompt positioning of the eyes in the orbits and their subsequent preservation reduced the psychological stress associated with the patient's loss of vision.
Accidents, Traffic↗
Management of the orbital floor in silent sinus syndrome.
BACKGROUND: Enophthalmos in a patient with an opacified hypoplastic maxillary sinus, without sinus symptomatology, describes the silent sinus syndrome. A current trend is to perform endoscopic maxillary antrostomy and orbital floor reconstruction as a single-staged operation. A two-staged approach is performed at our institution to avoid placement of an orbital floor implant in the midst of potential infection and allow for the possibility that enophthalmos and global ptosis may resolve with endoscopic antrostomy alone, obviating the need for orbital floor reconstruction. METHODS: A retrospective review identified four patients with silent sinus syndrome evaluated between June 1999 and August 2001. Patients presented to our ophthalmology department with ocular asymmetry, and computerized tomography (CT) scanning confirmed the diagnosis in each case. RESULTS: There were three men and one woman, with ages ranging from 27 to 40 years. All patients underwent endoscopic maxillary antrostomy. Preoperative enophthalmos determined by Hertel's measurements ranged from 3 to 4 mm. After endoscopic maxillary antrostomy, the range of reduction in enophthalmos was 1-2 mm. Case 2 had a preoperative CT scan and a CT scan 9 months after left endoscopic maxillary antrostomy. Volumetric analysis of the left maxillary sinus revealed a preoperative volume of 16.85 +/- 0.06 cm3 and a postoperative volume of 19.56 +/- 0.07 cm3. This represented a 16% increase in maxillary sinus volume postoperatively. Orbital floor augmentation was avoided in two patients because of satisfactory improvement in enophthalmos. In the other two patients, orbital reconstruction was performed as a second-stage procedure. There were no complications. CONCLUSION: Orbital floor augmentation can be offered as a second-stage procedure for patients with silent sinus syndrome. Some patients' enophthalmos may improve with endoscopic antrostomy alone.
Adult↗
Pediatric medial subperiosteal orbital abscess: medical management where possible.
BACKGROUND: Controversy exists about the optimal management of subperiosteal orbital abscesses (SPOAs) in pediatric patients. Some otolaryngologists advocate immediate surgical drainage while others recommend medical management initially and reserve surgery for nonresponders. We hypothesized that patients who can be managed without surgery have identifiable features on presentation that may aid in predicting their response to medical therapy. METHODS: A retrospective chart review was performed on all patients < or =18 years of age who were admitted to the University of Iowa between 1984 and 2001 with findings consistent with an SPOA on computed tomography imaging. Patients were divided into two groups: group I received medical treatment only while group II underwent surgical drainage of the abscess. Presenting features were compared between the two groups. RESULTS: Forty-two patients were identified with 17 group I patients and 25 group II patients. All patients had resolution of their SPOA and favorable outcomes. The following variables attained significance: group I patients were younger than group II patients (5.1 years versus 11 years; p < 0.0001), had less restriction of ocular motility (-1.0 versus -2.3), and were hospitalized for fewer days (6.5 days versus 9.6 days; p = 0.011). The following clinical variables did not vary significantly between the groups: gender, side of abscess, temperature, total white blood cell count, neutrophil count, chemosis, visual acuity, and proptosis. Culture results predominantly showed growth of anaerobic organisms (7/23). With increasing age, there was an increase in the number of organisms cultured (p = 0.005). CONCLUSION: A subset of patients with SPOAs can be managed medically. These patients tend to be younger and present with minimal restriction of ocular motility.
Abscess↗