Dermoid cysts are the most common orbital tumor in childhood. It is a developmental benign choristoma, arising from ectodermal sequestration along the lines of embryonic fusion of mesodermal processes. It is lined by keratinized stratified squamous epithelium and expands slowly due to constant desquamation and dermal glandular elements. They are usually smooth, painless, mobile, or partially mobile lesions mostly present at the fronto-zygomatic suture with proptosis, displacement, ptosis, or diplopia, depending on depth and extent1.
Although lateral orbital dermoid cysts are common, medial orbital dermoid cysts are rare2. Our patient had a right medial orbital congenital dermoid cyst since birth. At the presentation, the patient was 2 years old. On CT, the cyst measured 5 mm at the upper lid/medial canthus of the right orbit with subtle bone remodeling. He had a mildly clogged tear duct on the left but was otherwise asymptomatic. The decision was made to surgically remove the dermoid cyst.
In this video, we present a case of removal of a medial orbital dermoid cyst in a 2-year-old patient.
An incision was planned directly over the lesion. It was marked following the natural skin tension lines of the face to give the most natural esthetic appearance.
A small amount of Local anesthetic (0.5 ml of Lidocaine and Epinephrine) was injected under the skin to promote hemostasis and postoperative pain control.
A continuous Incision was made with a #15 blade on the skin.
Westcott scissors were used to dissect further through the subcutaneous tissue to expose the cyst and slowly dissect it from the normal tissue surrounding it.
Extra care was made to protect the integrity and avoid the rupture of the cyst.
After the entire cyst was freed from the surrounding tissue, it was carefully removed from its attachments to the periosteum using Westcott scissors.
The incision was closed in a two-layer fashion.
The deeper layer was closed by 6.0 Vicryl in a vertical mattress fashion with 2 interrupted sutures.
Next, wound edge eversion was achieved by placing two interrupted, superficial 5.0 fast-absorbing gut sutures. This will minimize the scar appearance.
Dermabond was applied next and the sutures were protected by a small piece of Tegaderm. This will be left in place until it spontaneously falls off.
Patient is an 18-month-old male with a history of Nasolacrimal Duct Obstruction (NLDO). He presented to the Children’s Hospital Outpatient Setting for NLD probing and stenting. After informed consent was performed, including consent for taking photos and video recordings, the patients underwent sedation without complication. The eyelids were cleaned of mucus and crusts using sterile water. The inferior puncta were dilated with a dilator. A Ritleng introducer was placed through the inferior puncta and guided along the canaliculus to a bony stop. The introducer was then rotated to coronal/vertical position and guided along the lacrimal sac through the NLD and valve of Hasner to be positioned under the inferior turbinate. Next, the introducer was removed, and the puncta was re-dilated. We used a Lacrijet 30 nasolacrimal duct stent, REF S1.1530 was opened and guided through the NLD. The inserter was removed gently, and the stent’s collarette was seated in the puncta using the disposable punctal plug inserter. The same procedure was performed on the fellow eye. Maxitrol drops were placed in the medial canthal region. The patient was awakened from sedation without complication and discharged home without complication.
In this video, we present a case of levator palpebrae resection in an 8-year-old patient with right eye ptosis.
In the pre-op photo, significant ptosis of the right eye can be appreciated. An incision was planned along the lid crease. 0.1 ml of 1: 100,000 epinephrine was injected. An incision was made by electro-cautery along the lid through the skin and orbicularis. Westcott scissors were used to further dissect horizontally. The septum was identified and opened. The preaponeurotic fat was identified and lifted, and the levator aponeurosis was identified. The levator was then tagged with two 6.0 Vicryle sutures, and isolated from surrounding tissues. Next, three6-0 Mersilene sutures were run from the upper tarsus to the levator. They are tightened with releasable notes. The lid elevation and contour were evaluated and adjustments were made until contour and height were equal and appropriate. The temporary surgical knots were transitioned into permanent surgical knots. Approximately 14 mm of excess levator was then excised. Next, three lid crease formation sutures were placed using 6-0 Vicryl. These were attached to the subcu-skin and levator to recreate the upper eyelid crease. Skin closure was performed with 6-0 fast-absorbing gut sutures. In this one-week post-op photo, the ptosis of his right eye was improved.
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This video demonstrates lacrimal probing and irrigation to investigate the anatomy, patency, and functional status of the lacrimal drainage system.
Dermis fat graft implantation has been used for decades to augment orbital volume and surface area in patients with congenital anophthalmia as well as those suffering complications of secondary anophthalmia following enucleation. It is most commonly performed as a means of socket reconstruction in patients with an exposed or extruded orbital implant and to prevent socket contracture. In this video, a dermis fat graft is harvested from the buttock and implanted into an anophthalmic socket for treatment of exposure of orbital implant in the right socket of a patient who was status post enucleation in both eyes for painful blind eyes.
Suzanne K. Freitag, MD
Victoria Starks, MD
Ophthalmic Plastic Surgery Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School
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