Hui Bae Harold Lee

Objective: To correlate clinical outcomes in postoperative pain managed with opioid medications after orbital fracture repairs. Methods: A prospective observational study of all patients who underwent orbital fracture repairs and postoperative pain managed with hydrocodone-acetaminophen, oxycodone-acetaminophen or tramadol for three days was performed. Collected data included numerical pain rating scores, type of fractures, patient satisfaction, side effects and non-medicinal interventions. International Pain Outcomes (IPO) questionnaire was completed at postoperative week one visit. Results: Twenty-nine patients who underwent orbital fracture repairs and completed the IPO questionnaire reported having taken an average of 74.8 +/- 36.6 Morphine Milligram Equivalent (MME) in the first week after the surgery from 102.5 +/- 10.0 MME of total opioids prescribed (Table 1). The amount of opioids used was not related to patient satisfaction or pain relief (p>0.05). Smoking status showed a moderate correlation and linear association with total MME taken by patients (spearman correlation coefficient 0.34, p=0.051). Although patients reported 69.4 +/- 24.9% overall pain relief and 9 out of 10 (median, IQR 5-10) scores in satisfaction with the pain regimen, 27.8% of patients reported needing more pain medication. This group reported higher levels of anxiety and lower satisfaction scores (p<0.001). They reported having taken more opioids than those who did not report the need for additional pain medications (p=0.07). Conclusion: Postoperative pain is managed with less than the prescribed amount of opioids after orbital fracture repairs in most patients. Anxious patients who had more opioids than average in the postoperative period expressed low satisfaction.

Purpose: To compare clinical outcomes of transconjunctival Müller’s muscle recession with levator disinsertion (TMRLD) to the traditional gold weight implantation in patients with paralytic lagophthalmos. Methods: A retrospective nonrandomized comparative review of patients who had gold weight implantation and TMRLD surgeries for paralytic lagophthalmos from January 2016 to January 2023 was performed. The main outcome comparisons were measurement changes in lagophthalmos, marginal reflex distance 1, visual acuity, and corneal examination. Complication and reoperation rates were also compared. Results: Twenty-six cases of gold weight implantation and 20 cases of TMRLD surgeries were identified. The changes in logMAR visual acuity between gold weight implantation and TMRLD groups were not statistically significant (−0.10 ± 0.48 vs. +0.05 ± 0.14, p > 0.05). The percent improvement in lagophthalmos (62.2% ± 51.8% vs. 58.4% ± 21.1%) and final marginal reflex distance 1 (2.22 ± 1.42 vs. 2.25 ± 1.41 mm) were also comparable between groups (p > 0.05). Both groups showed similar changes in marginal reflex distance 1 (1.75 ± 1.31 vs. 2.83 ± 1.37 mm) and lagophthalmos (3.77 ± 3.92 vs. 3.36 ± 1.36 mm) (p > 0.05). The overall complication (15.4% vs. 15.0%) and reoperation rates (15.4% vs. 15.0%) were comparable over the follow-up duration (291.6 ± 437.3 vs. 121.0 ± 177.8 days) (p > 0.05). Conclusion: TMRLD is as safe and effective as the gold weight implantation in addressing paralytic lagophthalmos in patients with facial nerve palsy.

Orbital implant extrusion is a known complication following evisceration and enucleation. In this case report, we present a 45-year-old woman who presented with a left silicone implant exposure and infection 2 years following evisceration with saddle nose on examination. CT of the maxillofacial bones without contrast showed bilateral soft tissue infiltration around the superior recti muscles, as well as a nasal septum perforation from extensive sinus disease. Left orbitotomy revealed a small fibrotic mass near the orbital roof. Biopsy and serology results were consistent with granulomatosis with polyangiitis.

Optic nerve sheath fenestration (ONSF) is a surgical technique commonly and effectively employed in the treatment of recalcitrant, vision-threatening papilledema. Unilateral blindness, a known risk of unilateral ONSF widely cited with 1%–2% incidence. In this case, a 58-year-old patient who presented symptomatic with bilateral hemorrhagic papilledema unresponsive to medical therapy underwent uneventful unilateral ONSF via standard superomedial eyelid crease incision. The patient presented postoperatively with severe bilateral vision loss. Workup revealed widespread metastatic malignant disease involving the optic chiasm and optic nerve sheath.