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Oculoplastic and Orbital Surgery

2015; Elsevier BV; Volume: 122; Issue: 2 Linguagem: Inglês

10.1016/j.ophtha.2014.09.017

1549-4713

George B. Bartley,

Anorectal Disease Treatments and Outcomes

As part of the American Ophthalmological Society's 150th birthday celebration in 2014,1Albert D.M. A sesquicentennial salute to the American Ophthalmological Society.Ophthalmol. 2014; 121: 1493-1494Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar a representative from each subspecialty was invited to provide a brief account of the past, present, and future of his or her respective area of interest. Before offering my perspective on oculoplastic and orbital surgery, I must begin with a disclaimer. The historian C. B. McCullagh, in a thoughtful essay about bias in reporting historical events, opined that “both nature and history are sublime, and any account of them is inevitably selective.”2McCullagh C.B. Bias in historical description, interpretation, and explanation.History and Theory. 2000; 39: 39-66Crossref Scopus (45) Google Scholar Therefore, the topics that I have selected to feature inevitably reflect my personal biases. I have grouped 15 highlights into the following rubrics: 5 milestones before 1864 (the year the American Ophthalmological Society [AOS] was founded), 5 notable advances between 1864 and the present, and 5 challenges for oculoplastic and orbital surgery going forward. Long before anyone knew about cupping, the choroid, or the chiasm, surgeons were whittling away on the ocular adnexa. Our first milestone is found nearly 38 centuries ago, around 1772 bce, with Hammurabi, the King of Babylon. The following passage from the Hammurabi Code has been interpreted putatively as a description of an infected dacryocele: “If a physician operate[s] on a man for a severe wound with a bronze lancet and cause the man's death; or open an abscess (in the eye) of a man with a bronze lancet and destroy the man's eye, they shall cut off his fingers.”3Harper R.F. The code of Hammurabi King of Babylon. University of Chicago Press, Chicago1904: 79Google Scholar Unfortunately, the account also confirms that severe penalties for malpractice or poor outcomes have dogged surgeons since antiquity. We jump ahead to the acme of the Roman Empire to milestone number 2: the writings of Celsus. Even though Hirschberg4Hirschberg J. Die Geschichte der Lidbildung. Handb.d. ges Augenh. 2nd ed. 14: zweite Abteilung. Graefe-Saemisch; 1911:96–109.Google Scholar disparagingly asserted that Celsus was merely an aggregator rather than an innovator, this work nevertheless is remarkable. Consider that, before the first book of the New Testament had been written, Celsus included descriptions of advancement and rotational flaps to repair skin defects. Additionally, his account of surgery for lax eyelids, from roughly 30 ce, is astonishingly recognizable to blepharoplasty surgeons: “seize a fold of skin between finger and thumb… consider how much to be removed for the lid to be in a natural position… where the incision is to be made… mark by two lines of ink… the edges of the wound are brought into apposition by one stitch… a sponge of cold is bandaged on… on the fourth day the sutures are taken out and a salve for repressing inflammation is smeared on.”5Celsus A.C. De Medicina. Spencer WG, trans. vol. 3. Harvard University Press, Cambridge, MA1935: 338-343Google Scholar Moving forward, any journey through medical history must at least pause and wave to Vesalius. However, my bias is not to label De Humani Corporis Fabrica a milestone in our subspecialty's history. Why? Because some of his ocular adnexal descriptions were just plain wrong. Rather, I confer my third milestone on Vesalius' student and ultimately his successor as chair of anatomy at Padua, Gabriele Falloppio, who, in his modest monograph in 1562,6Falloppio G. Observationes anatomicae. 1562.Google Scholar provided the first good description of the levator palpebrae superioris in addition to demonstrating that the retractor bulbi muscle does not exist in humans—an insight contrary to the teachings of Vesalius.7Albert D.M. Edwards E.D. The History of Ophthalmology. Blackwell Science, Cambridge, MA1996: 256Google Scholar Milestone 4 is for Georg Bartisch's monumental Ophthalmodouleia of 1583.8Bartisch G. Ophthalmodouleia, 1583. Blanchard D. J.-P., trans. Wayenborgh, Ostend, Belgium1996Google Scholar As with Celsus, many of Bartisch's depictions are easily recognizable: proptosis, ectropion, epibulbar and eyelid tumors, trichiasis, dacryocystitis, and dermatochalasis. Some might argue, however, that Bartisch's recommended treatment for removing excess eyelid skin—strangulation clamps—is a step backward from Celsus. Choosing a fifth and final milestone from before 1864 was a challenge. Carl von Graefe has been regarded by many as the founder of plastic surgery. His contributions indeed were colossal, not to mention the gift of his son, Albrecht, to our field. However, as with Vesalius and Falloppio, I have to move on from teacher to student and recognize Johann Dieffenbach as the founder of modern plastic surgery. Like Falloppio after Vesalius at Padua, Dieffenbach succeeded von Graefe as Professor of Surgery at the University of Berlin on von Graefe's death in 1840. Dieffenbach moved the field forward tremendously with his surgical textbooks in the 1840s,9Dieffenbach J.F. Die operative chirurgie. Brockhaus, Leipzig1845Google Scholar, 10Dieffenbach J.F. Die operative chirurgie. Brockhaus, Leipzig1848Google Scholar describing many operations that set the stage for modifications that we still use today. Next, I'd like to highlight 5 major advances from 1864 to the present. Given that plastic surgery is essentially applied anatomy, my first milestone recognizes the marvelous contributions of S. E. Whitnall, whose anatomy textbook,11Whitnall S.E. The anatomy of the human orbit and accessory organs of vision. Henry Frowde and Hodder & Stoughton, London1921Google Scholar first published in 1921, is a tour de force. In addition to his original observations, such as the eyelid ligament that bears his name, his descriptions are beautifully written and replete with timeless insights. Although Whitnall was an anatomist, his book reads like a surgical atlas. Milestone number 2 honors a member of the AOS, Wendell Hughes, whose AOS membership thesis in 1941 was so extensive that it was not published in the Transactions, but rather as a standalone monograph 2 years later.12Hughes W.L. Reconstructive surgery of the eyelids. C.V. Mosby Co, St. Louis1943Google Scholar His work set a new standard for eyelid reconstruction or a term that he preferred, blepharopoiesis (and one that I’ve not yet had the courage to include in a surgical dictation or in a bill to Medicare). Dr. Hughes is perhaps best known for his procedure to reconstruct large defects of the lower eyelid. Two important themes of his work were to repair “like with like” and to accomplish “more with less.” Before this time, many reconstructive operations were far more involved, that is to say, far more invasive, than was necessary. After retirement, Dr. Hughes continued to publish, including advice on using motor oil rather than water in lawn rollers13Hughes W.L. Another tip on old oil (letter).Popular Mechanics. 1977; 147: 26Google Scholar and instructions on how to carve the perfect grapefruit.14Hughes W.L. More thoughts on grapefruit [letter].Changing Times: The Kiplinger Magazine. 1984; 38: 91Google Scholar Ever the innovator. Milestone number 3: imaging. The first computed tomography scanner in North America was installed at Mayo Clinic in June 1973. The initial examinations focused on anatomic features north of the pituitary, but fortunately radiologists soon realized that the truly interesting pathology was in the orbits, and within 2 months, a patient with proptosis resulting from a retrobulbar cavernous hemangioma had been scanned. The highly pixilated images were included in a seminal article that was published the following year and coauthored by 2 AOS members, Thomas P. Kearns (recipient of the Howe Medal in 1994) and John W. Henderson.15Baker H.L. Kearns T.P. Campbell J.K. Henderson J.W. Computerized transaxial tomography in neuro-ophthalmology.Am J Ophthalmol. 1974; 78: 285-294Abstract Full Text PDF PubMed Scopus (22) Google Scholar Contemporary computed tomography and magnetic resonance images provide infinitely more information, including real-time intraoperative navigational guidance, while requiring far less imagination to interpret than those early scans. The future of imaging seems boundless and may include methods such as magnetic resonance elastography, which has proven to be particularly useful in the characterization of hepatic fibrosis and the subtypes of meningioma.16Litwiller D.V. Lee S.J. Kolipaka A. et al.Magnetic resonance elastography of the ex-vivo bovine globe.J Magn Reson Imaging. 2010; 32: 44-51Crossref PubMed Scopus (54) Google Scholar Finally, I include under the rubric of “imaging” the advent of endoscopy. When I began my career, the nose and the sinuses were dark, inaccessible, mysterious, and nasty. Nowadays, these areas are well-illuminated, accessible, familiar… but still sometimes nasty. My fourth milestone relates to the development of botulinum toxin by the 1998 Howe Medalist Alan Scott. Although Dr. Scott's initial research was on the treatment of strabismus, which was the theme of his AOS thesis in 1981,17Scott A.B. Botulinum toxin injection of eye muscles to correct strabismus.Trans Am Ophthalmol Soc. 1981; 79: 734-770PubMed Google Scholar the drug soon found use as a godsend therapy for patients with essential blepharospasm and hemifacial spasm.18Scott A.B. Kennedy R.A. Stubbs H.A. Botulinum A toxin injection as a treatment for blepharospasm.Arch Ophthalmol. 1985; 103: 347-350Crossref PubMed Scopus (381) Google Scholar Of course, periocular injections for functional purposes were noted to have side effects that could be exploited for cosmetic benefit, and the rest is history. For my final milestone of the present era, I wish to highlight the establishment of our subspecialty as a bona fide discipline. For instance, our member organization, the American Society of Ophthalmic Plastic and Reconstructive Surgery, has existed now for 45 years19The American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS). Reifler DM, ed. San Francisco: Norman Publishing, 1994.Google Scholar and our journal, Ophthalmic Plastic and Reconstructive Surgery, for 30. But Burt Brent's 1987 book, The Artistry of Reconstructive Surgery,20Brent B. The artistry of reconstructive surgery. CV Mosby Co, St. Louis1987Google Scholar for me exemplifies how the road to recognition has truly been achieved. The book's cover features an intriguing composite painting of more than 75 giants from the world of plastic surgery. Included in this pantheon is an ophthalmologist, the 2002 AOS Howe Medalist Crowell Beard, whose contributions earned the respect of plastic surgeons. Dr. Beard's original work, and that of many others, has helped to distinguish our field as a distinct entity. When I began my career, interactions with plastic surgery were minimal. Today, plastic surgery residents rotate on our service, we lecture to their department on a variety of oculoplastic and orbital topics, and we regularly work together side-by-side in the operating room. Such collaborations are a major advance, in my opinion, because patients are the true winners. What about the future of oculoplastic and orbital surgery? We have plenty of challenges. I shall mention just a handful. First, it is great that we have botulinum toxin to treat blepharospasm, but we don't know what causes the disease. Second, we still see way too many patients with Graves' ophthalmopathy, which has been the theme of any number of AOS theses, including my own. Two hundred years ago, Parry, Graves, and von Basedow conjectured that thyroid disease and eye disease somehow were linked. Two centuries later, we believe that the thyroid and the orbit are entwined in some kind of pernicious immunologic ballet, which we often treat by making holes in patients' heads—orbital decompression—to release evil humors. Using surgery to treat cytokines is fighting the wrong war. Third, on the theme of combat and of making holes in people's heads, when treating cancer, we need to figure out ways to eliminate the enemy without carpet bombing. Resorting to exenteration is end-stage ophthalmology. Regrettably, during my professional lifetime, our success treating sebaceous gland carcinoma, Merkel cell carcinoma, lacrimal gland adenoid cystic carcinoma, and melanoma has been disappointing at best. Fourth, in those instances when we must remove an eye, we need to identify the perfect socket implant. Surgeons have placed dozens of different varieties into innocent, unsuspecting sockets during the past century, but each has had major drawbacks. Finally, watching a socket enter the death spiral of severe contraction emphasizes that we need a better understanding of abnormal wound healing—why it occurs and how we can modulate it. Of note, the challenges that I have highlighted—blepharospasm, Graves ophthalmopathy, oncology, and wound healing—likely will be treated nonsurgically in the future, which may have significant implications for our subspecialty. On that theme, I would have liked to explore the advances that oculoplastic surgery has made in learning when not to operate, for instance, in many cases of orbital blowout fractures. We know that observation is often appropriate, but some surgeons in some specialties continue to operate on virtually every fracture. This is unconscionable in contemporary medicine and emphasizes the need for better interdisciplinary collaboration. Also, time constraints have prohibited more than a passing mention of lacrimal disease, which is a major part of our practices. It also would have been enlightening to review a few creative ideas that fortunately didn't quite catch on, such as the use of chopsticks rather than forceps and patient-torturing devices to bolster a skin graft.21Sheehan J.E. Plastic surgery of the orbit. Macmillan Company, New York1927:143: 303Google Scholar In closing, it is humbling to realize that Celsus, Bartisch, or Dieffenbach likely could scrub right in on some of the operations we do today. Although, come to think of it, scrubbing might seem to be a puzzling ritual to them. And they might well be puzzled by the embarrassing behavior that sometimes characterizes our specialty, for instance, billboards advertising that Medicare will pay for eyelid lifts. I suggested at the beginning of this editorial that our subspecialty is the oldest among our profession, and at times our actions seem to resemble the oldest profession. Perhaps I should have included the necessity to continually pursue professionalism as another challenge going forward. Regardless, oculoplastic and orbital surgery is a unique facet of ophthalmology, crossing boundaries with several other surgical and medical disciplines and comprising arguably the widest spectrum of operations in its repertoire: the repair of eyelid malpositions such as ptosis, retraction, ectropion, and entropion; trauma; trichiasis; a gamut of lacrimal disorders; evisceration, enucleation, and exenteration; tumors; the reconstruction of an endless variety of adnexal and facial defects; orbital, socket, and sinus surgery; and, of course, an increasing palette of cosmetic offerings. But one thing is certain: our subspecialty is the most fun. References 3–6 and 9–12 provided courtesy of Mayo Clinic Libraries History of Medicine Collection. This article was derived from a presentation at the sesquicentennial meeting of the American Ophthalmological Society in 2014.