oculoplastics – Tropical Ophthalmology

Cicatricial upper eyelid ectropion (thermal burns), case #2 – Part II

Part I was here. It was the case of a young boy, who dropped himself into fire during epilepsy attack and got extensive left upper face burn with eventual upper and lower eyelids cicatricial ectropion. In Part I I described the first 74 days after he got burns, together with the repair of the ectropion of upper lid (performed in August 2017).

Here I will display the photos of outcome, which were taken precisely 2 months after the skin grafting for upper lid.

Cicatricial ectropion upper lid after skin-grafting

Cicatricial ectropion upper lid 2 months after skin-grafting (137 days after burn)

Lower lid cicatricial ectropion was progressing and required a surgery later. But it was definitely not that dangerous for the cornea, and the timing allowed to postpone the surgery until burn scarring process completion. I felt therefore my duty to prevent the unnecessary blindness in this kid was fully accomplished. (Lower lid surgery was performed by general plastic surgeon upon my departure from Zambia).

Случай августа 2017 года. Хотел поделиться случаем рубцового выворота с коррекцией кожным трансплантатом (с внутренней стороны плеча) у мальчика лет 8, который пострадал в результате падения на огонь во время приступа эпилепсии. В первой части я показал прогрессирование рубцевания за первые 70 дней, что в верхнем веке было настолько выражено, что привело даже к экспозиции слёзной железы (и, естественно, роговицы). Что было неотложным показанием к операции, в других условиях проводящейся в гораздо более поздние сроки из-за прогрессирующего послеожогового рубцевания. На втором коллаже представлены фотографии 2 месяца спустя после операции рубцового выворота. Рубцовый выворот нижнего века также прогрессировал, но срочности не представлял.

Ах два. Интересный факт. Тарзорафию это рубцевание рвало дважды (фотография 1, слева сверху под свежим ожогом), варианта оттянуть экспозицию роговицы практически не оставалось.

18.08.2019 Add Comment

Dacryops (simple lacrimal gland cyst)

A case of December 2015.
Lady 75yo, presented with cyst in lateral canthal area of right eye. According to the patient, the size is dynamic, the lesion is present since 2010. She managed at least once pricking the cyst herself. She has also a history of bilateral trachoma (not treated). Trachoma is a known risk factor for lacrimal ducts scarring, which triggers so called “dacryops” – a simple cyst of lacrimal gland. The lesion is shown at the photo together with canthus involvement, corneal pannus, opacity and cataract.
DDx for etiology of dacryops nowadays is dacryoadenitis and scarring conditions of conjunctiva apart from trachoma (Stevens-Johnson, cicatrizing pemphigoid, chemical burns). In trachoma-endemic regions trachoma is the main reason for dacryops.
Marsupialization of cyst or its complete excision is indicated and was performed. The patient also had had bilateral aponeurotic ptosis (more on the right), which was that time managed by visiting british oculoplastic team.

Случай от декабря 2015 года.

Женщина лет 75. В анамнезе кистообразное образование в области наружной спайки век со стороны конъюнктивы.
Появилось в 2010 г. В размерах динамично, может как увеличиваться, так и уменьшаться. В анамнезе самостоятельное прокалывание со слизисто-гнойным (со слов) отделяемым. Иногда – самопроизвольное отделяемое. Кроме этого, в анамнезе давняя саморазрешившаяся двусторонняя трахома.
Наружный вид образования – на фото. Примечательна трансиллюминация, поверхностная васкуляризация, вовлечение края века снизу и спайки век. Синеватый оттенок поверхности. Состояние одностороннее. Роговичный паннус с обеих сторон (больше справа).

Данный случай интересен тем, что дакриопс (простая киста слёзной железы) – достаточно редкое состояние, и в современном мире может быть связан главным образом с дакриоаденитом или рубцующими состояниями конъюнктивы (Стивенс Джонсон, пемфигоид, химический ожог). Однако в регионах, где эндемична трахома (ещё одно рубцующее конъюнктивальное состояние), это заболевание встречается чаще.

Киста подлежит удалению (иссечение или марсупиализация) в виду неудовлетворённости пациентки внешним видом глаза, а также из-за периодически мешающего отделяемого.

Дифдиагноз хорошо описан в eyewiki. Однако сам диагноз является клиническим. Основным пунктом дифдиагноза является аденоидная кистозная карцинома слёзной железы.

http://eyewiki.aao.org/Dacryops

Dacryops after trachoma — Dacryops. Transillumination. Corneal scars and pannus.

25.01.2019 Add Comment

Artificial eyes for bilaterally blind patient: very important

This story is to discourage those who think that artificial eyes are not important, if person is bilaterally blind. The lady had phthitic eye after previous failed cataract surgery (done some decade ago). Her other eye is also blind, and also as a result of failed cataract surgery or whatever reason like uveitis was the cause. The left eye was painful, and very small. And she desired it to be removed and artificial eye to be placed instead.

Evisceration was planned but found extremely difficult due to phthisis, and procedure shifted to enucleation. Conformer placed for three weeks, tarsorrhaphy applied for a week. Custom prostheses are unavailable, so stock ready-made artificial eye of medium size was placed instead. The result looks great cosmetically. And despite the fact that lady cannot see herself in the mirror, she is very happy, as the daughter nearby explains everything she sees.

P.S. I am not enjoying PMMA orbital implants for enucleation though, and motility with PMMA implants is superior after evisceration.

Eye prosthesis for blind patient. One will hardly find out, that left eye is artificial.

28.06.2017 Add Comment

Cicatricial upper lid ectropion (Part II)

This is an extension of the previous case, where a skin graft was used to correct cicatrix of the upper lid. Luckily, my first skin graft survived and healed very well. Unfortunately though, there was a relapse of lagophthalmos and some amount of graft contraction.

Despite all my attempts to prevent future contraction, the graft has contracted. I did a small root cause analysis through a consultation with Dr. Goran Jovic (consultant plastic surgeon) and my favourite “Ophthalmic Plastic Surgery” textbook by Sidney Fox. That helped much.

I think, best will be to provide quotes from Fox’s textbook, which I have consulted before surgery as well:

One of the main elements in successful skin grafting is infinite attention to detail. Full understanding of these details is perhaps better obtained by the trial and error of experience than by formal exposition, However, broad essential principles can be outlined. Some are obvious. Others are learned only through failure. All are important.

…

… in preparation of the graft bed… First and foremost is the removal of scar tissue. This cannot be overemphasized. The extent to which a graft can shrink almost to nothing as the surgeon stands by helplessly in horrified amazement is something hard to describe. After one such experience, however, one will never again fail to resect all scar tissue from the recipient bed.

…

If lid skin is used, the graft is cut just a trifle larger than the recipient bed. Grafts from other areas should be taken at least one-quarter and preferably one-third larger.

Those words in bold are all possible causes of my surgery failure. So:

Despite that I had removed a lot of scarred orbicularis, I had probably not removed enough.
I had taken the skin graft of a same size as a graft bed from retroauricular sulcus. Apparently, it should have been larger by quarter or third.
I had to do this mistake once to learn it forever.

Finally, I don’t think my release of tarsorrhaphy was too early. Ten days is enough according to many textbooks. Key reasons are probably listed above.

Skin graft contraction – 21st postop day

17.06.2017 Add Comment