Ординатура / Офтальмология / Английские материалы / Oculoplasty and Reconstructive Surgery Made Easy_Garg,Touky, Nasralla_2009
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Miscellaneous Disorders 409
•Those who are immunocompromised due to lymphoma, AIDS, Lyme disease, etc. are at an increased risk.
•Ocular involvement varies greatly and is often confusing in the early stages.
•Extreme care should be taken in differentiating this condition from herpes simplex virus (HSV), particularly when cornea is involved. One important fact is that the dendritic keratitis occuring in HZO is infiltrative, while the HSV dendrites are ulcerative.
Symptoms
Herpes zoster ophthalmicus (HZO) presents with
•nondescript facial pain
•fever and
•general malaise.
•The pain is very severe during the inflammatory stage.
Signs (Figures 18)
•3 to 5 days later, a vesicular skin rash appears along the distribution of the fifth cranial nerve, and stays to one side of the vertical midline.
Figure 18: Herpes zoster ophthalmicus
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•Fluid is discharged from the vesicles and scab appears after about a week.
•Ocular involvement may incorporate
•follicular conjunctivitis
•epithelial and/or interstitial keratitis
•dendritic keratitis
•uveitis
•scleritis or episcleritis
•chorioretinitis
•optic neuropathy, and
•neurogenic motility disorders as well (especially thr 4th cranial nerve palsy).
•If vesicles appear at the tip of the nose (Hutchinson’s sign), there is 75% likelihood of ocular sequelae.
Pathophysiology
•HZO occurs with the invasion of the trigeminal ganglion, by the HZ virus.
•This is a varicella-type virus and is referred to as “chicken pox” in children and “shingles” in adults.
•The virus remains dormant in trigeminal nerve cells, and any reduction in the immune system can reactivate it even years later.
•The virus spreads along the neurons of the ophthalmic (1st) and less frequently the maxillary (2nd) division of the trigeminal nerve.
•Vesicular eruptions occur at the terminal ends of sensory innervation, causing extreme pain.
•Nasociliary branch involvement most likely causes ocular inflammation, affecting typically the tissues of the anterior segment and the cornea.
•Other cranial nerves may also be involved, causing optic neuropathy (2nd cranial nerve) or even isolated cranial nerve palsies (3rd, 4th or 6th cranial nerves).
Miscellaneous Disorders 411
Treatment
1.Systemic component of the disease—
•Is treated with oral Acyclovir, 600 to 800 mg, five times a day, for 7 to 10 days, starting the moment the condition is diagnosed.
•Famciclovir 500 mg three times a day has been shown to be as effective in treating herpes zoster ophthalmicus as acyclovir 800 mg fives times per day.
•To avoid post-herpetic neuralgia and to achieve maximum benefit from oral antiviral medication, start therapy within 72 hours of vesicular eruption. Otherwise, the patient may develop post-herpetic neuralgia and the oral antiviral therapy does not help.
•Oral steroids may also be used to alleviate pain and associated facial edema. 40 to 60 mg of prednisone is given daily, tapered slowly over the next 10 days.
•An antibiotic-steroid ointment may be applied to the affected areas twice daily, to treat the skin lesions.
2.Ocular management of the disease depends on the severity and tissues involved—
•In severe cases having uveitis or keratitis, use cycloplegia (homatropine 5% tid).
•After ruling out herpes simplex, we may also use topical steroids.
•In a compromised eye, prophylaxis with a broadspectrum antibiotic is a good idea.
•Palliative treatment consisting of cool compresses, and oral analgesics in extreme cases, can be comforting.
3.Possibility of more complex ocular sequelae (chorioretinitis, optic neuropathy, cranial nerve palsies, uveitic glaucoma) must also be kept in mind, and apt management strategies planned, in these cases.
INTRODUCTION
According to the American Society for Aesthetic Plastic Surgery, in the year 2000 over 5.7 million cosmetic surgical and nonsurgical procedures were performed in the United States which was a 25% increase above the total number performed in 1999. The most popular of these procedures was botulinum toxin injection, followed by chemical peels and microdermabrasion.1 In the past one decade lasers have revolutionized treatment of common oculoplastic problems. The more recent applications of lasers as reported in recent literature in oculoplastic conditions are highlighted here.
ADVANCES IN PRINCIPLES OF PHYSICS AND APPLICATION OF THE LASER IN PLASTIC SURGERY
Newer principles help it be a new tool for skin rejuvenation.2
a.Decreased collateral thermal injury
b.Higher absorption by tissue water
c.Controlled ablation.
In recent lasers the theory of selective photothermolysis is used in pulsed lasers, and advances have taken place in the science of laser: tissue interactions. Particular advances in skin cooling, hair removal, intense pulsed light, and uses
Update on Lasers in Oculoplasty 413
for aesthetic and nonaesthetic skin problems have made life simpler. Advances in skin cooling have allowed for wider use in all Fitzpatrick skin types without concomitant adverse reaction.4
TYPES OF LASERS
a.Conventional CO2 laser: These infrared lasers have helps the oculoplastic surgeons in terms of good hemostasis, facilitating high precision surgery and controlled tissue ablation
b.CO2 laser-scanned continuous-wave or pulsed delivery systems: Newer generation of carbon dioxide (CO2) lasers have sparked the development of newer procedures for certain oculoplastic disorders. With the advent of scanned continuous-wave or pulsed delivery systems which have an added advantage in resurfacing procedures on the skin.4
c.KTP 532 nm laser
d.Erb YAG laser
e.Ho:YAG
f.532 nm frequency doubled YAG laser
g.Nd:YAG laser-powered quartz laser scalpel.
WORD OF CAUTION
The unique characteristics of the CO2 laser mandate special attention to protection of the patient and surgical team, and careful preparation and training will help the prospective laser surgeon to successfully address the learning curve associated with this new technology.4
CONDITIONS
Treatments include5,7 conditions involving:
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a.Excessive blood vessels (e.g. port-wine stains),
b.Pigment (e.g. tattoos),
c.Inflammatory lesions (e.g. psoriasis),
d.Scars,
e.Excess hair,
f.Tumors, and
g.Wrinkles.
ADVANCES IN OCULOPLASTY8
a.Combining laser resurfacing with other aesthetic procedures, such as lower blepharoplasty and facelifting.
b.Laser assisted lacrimal surgery with the adjunctive use of mitomycin C.
c.Treatment of capillary hemangiomata with a tunable dye laser.
d.Advances in laser skin resurfacing, such as the combination of carbon dioxide and erbium:yttrium-aluminum-garnet lasers to achieve improved results
e.Lacrimal surgery9 -Nd:YAG, Ho:YAG, Er:YAG lasers and the Nd:YAG laser-powered quartz laser scalpel.
FUNDAMENTAL RISKS
Fundamental risks that laser surgery entails are hypoand hyper pigmentation and scar formation.10
AVOIDING POSTOPERATIVE COMPLICATIONS
Laser surgery for oculoplastic or dermatological indications— whether incisional work, removal of pigmented or vascular lesions, removal of hair, or resurfacing—necessitates that the practitioner have appropriate training in and understanding of not only the techniques but also of their advantages and
Update on Lasers in Oculoplasty 415
disadvantages. To wisely choose the correct laser for a given problem, it has been pointed out that one must be aware of both the spectrum of disorders for which each laser is suited and the potential side effects.11 New approaches to such operations include combining more than one type of laser or combining traditional cutting blades and lasers in an effort to reduce side effects and improve outcome.12
EVIDENCE OF TREATMENTS
Treatment of Port-wine Stain with KTP 532 nm Laser
Lesions of port-wine stain type are the most commonly occurring vascular malformations of the skin occurring in 0.3% of the population. Other therapies like cryosurgery, dermabrasion, radiation therapy or surgery and skin grafting produce unsatisfactory results. Introduction of highly selective lasers made port wine stains amenable to treatmenteffectively and safely.
Latlowski et al6 in a prospective analysis of treatment of Port-wine stains in 155 patients performed laser with at least 4-week intervals and on the basis of subjective scoring system comparing simultaneously shown pictures of the patients taken prior to and after the last procedure, classified them according to the outcome into a 4-degree scale: excellent outcome—75-100% improvement, with 100% perceived as eradication of the lesion; good—50-74% improvement; fair— 25-49% improvement and poor—less than 25% improvement, including no observable improvement. In 81% of the lesions treatment with KTP 532 nm laser they found significant improvement which was reported satisfactory by the patient. Excellent outcome of treatment was seen in 31% of patients (31%), good in 27%, fair in 23%. In their series the port wine stains which failed to treatment were most commonly located
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on the limbs. They did not report any episodes of scarring or persistent pigmentary changes in any of the patients.
Use of the KTP Laser in the Treatment of Rosacea and Solar Lentigines
Treatment regimens rosacea and solar lentigines range from avoidance of causative factors to the use of topical agents or other modalities that target the superficial layers of the skin. Lasers offer the physician and patient the ability to target specific chromophores in the skin. Advances in laser technology led to the implementation of targeting certain characteristic pigments of abnormal areas with minimal damage to surrounding normal tissue. Rosacea and solar lentigines have characteristic cells that are targeted by a potassium-titanyl-phosphate (KTP) laser. The lesions are different in their origins but share the ability to be treated successfully with the KTP laser.13
Comparison of Lasers
Lieb et al14 compared the erbium-YAG laser and the CO2 laser to conventional eyelid surgery with a scalpel in 58 patients using the erbium-YAG laser and on 32 using the CO2 laser, surgeries being benign tumor excisions and removal, xanthelasma removal, lower and upper eyelid blepharoplasties, and skin resurfacing in the area of the lower eyelid. They found that wound healing with the CO2 laser was significantly slower because of its larger thermal necrosis zone, but the hemostasis with the CO2 laser made removal of deeper lesions easier. Advantages are the wide application spectrum for incisional and ablative surgery. The erbium-YAG laser is an excellent for ablating superficial benign lesions, including that in the area of the lid margin and close to the lacrimal puncta without scars. The application spectrums of
Update on Lasers in Oculoplasty 417
the erbium-YAG and CO2 lasers complement one another. The erbium-YAG laser is superior for esthetic skin resurfacing and ablation of superficial lesions, and the CO2 laser allows hemorrhage-free noncontact incisional surgery (Figures 1A to C).
Figures 1A to C: (A) Pre-laser for trichiasis (B) Post-laser for trichiasis
(C) Immediate post-laser trichiasis
CONCLUSION
Lasers can now be considered an important addition to the armamentarium of the oculoplastic surgeon.
REFERENCES
1.Morgenstern KE, Foster JA. Advances in cosmetic oculoplastic surgery.Curr Opin Ophthalmol 2002 Oct;13(5):324-30.
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2.Pages JC, Gailloud-Matthieu MC, Egloff DV. Principles of physics and application of the laser in plastic surgery. Rev Med Suisse Romande 1999 Sep;119(9):739-42.
3.Nottingham LK, Ries WR. Update on lasers in facial plastic surgery. Curr Opin Otolaryngol Head Neck Surg 2004 Aug;12(4):323-6.
4.Goldbaum AM, Woog JJ. The CO2 laser in oculoplastic surgery. Surv Ophthalmol 1997 Nov-Dec;42(3):255-67.
5.Laser treatment for skin problems. Drug Ther Bull 2004 Oct;42(10):73-6.
6.Latlowski IT, Wysocki MS, Siewiera IP. Own clinical experience in treatment of port-wine stain with KTP 532 nm laserWiad Lek 2005;58(7-8):391-6.
7.DiBernardo BE, Cacciarelli A. Cutaneous lasers.Clin Plast Surg 2005 Apr;32(2):141-50.
8.Choo PH. Lasers in oculoplastics.Curr Opin Ophthalmol 2001 Oct;12(5):357-61.
9.Fankhauser F, Kwasniewska S. Applications of the neodymium: YAG laser in plastic surgery of the face and lacrimal surgery. Wound repair. A review Ophthalmologica 2002 Nov-Dec;216(6):381-98.
10.Kimmig W. Laser surgery in dermatology. Risks and chances Hautarzt 2003 Jul;54(7):583-93. Epub 2003 May 15.
11.Raulin C, Kimmig W, Werner S. Laser therapy in dermatology and esthetic medicine. Side effects, complications and treatment errors Hautarzt 2000 Jul;51(7):463-73.
12.Tayani R, Rubin PA. Laser applications in oculoplastic surgery and their postoperative complications. Int Ophthalmol Clin 2000 Winter ;40(1):13-26.
13.Bassichis BA, Swamy R, Dayan SH. Use of the KTP laser in the treatment of rosacea and solar lentigines. Facial Plast Surg 2004 Feb;20(1):77-83.
14.Lieb WE, Klink T, Munnich S. CO2 and erbium YAG laser in eyelid surgery. A comparison.Ophthalmologe 2000 Dec; 97(12):835-41.