Case of the Week (COTW) - Graphic Pictures

As we all know, HIV is a terrible disease, especially untreated.  One of the tough things in the eye unit is diagnosing lots of people with HIV for the first time.  The eyes can often harbor the first hints that someone has HIV/AIDS.  One such clue is a particular type of eye cancer, Squamous Cell Carcinoma (SCC) of the conjunctiva (thin layer of tissue covering the white part of the eye).  Often this can be treated successfully with early removal.  Unfortunately, the woman who is this COTW presented very late in the course of her disease.  She initially had to have her eye removed a year before at an outside facility due to the cancer.  This is usually not necessary if caught early.  Sadly, they did not have clean margins (the tumor extended beyond the edge of what they removed).  The tumor re-grew and had the appearance seen in the first two photos when I saw her.  She was quite poor and had very little social support.  HIV often has this painful repercussion, especially in Africa.  In fact, she had still not begun anti-retrovirals a year after diagnosis despite treatment being free in Kenya.

A somewhat unique fact about SCC is that it likes to travel along nerves.  Thus, a "small" tumor can send off fronds and have much further spread than one might imagine.  Because our patient's tumor now involved the orbit (the eye socket) and her lids, I decided it best to do an orbital exenteration (everything in the orbit is removed down to the bone) including the eyelids in this case.  If we didn't get it all, it's next target would be inside the skull, where all the nerves of the orbit come from.  It would then prove to be inoperable and slowly fatal.  The pictures to the left show my incision going down to bone.  The dissection was then carried to the back of the orbit between the bony orbit and its covering, the periosteum.  The optic nerve was then cut as the last remaining attachment.  This is the largest of the cranial nerves, and it took a bit of force to cut.  I then packed the orbit with gauze to stop bleeding (big nerves tend to have big vessels as partners).

As we waited for hemostasis, I turned my attention to harvesting a skin graft from the leg to cover the empty orbit.  If you hadn't guessed, this is not the usual work of an ophthalmologist.  We like to keep it above nose level if at all possible.  Thankfully, I had done a few skin grafts with my dad as a kid growing-up at a mission hospital in Togo, West Africa.  

As we returned to the orbit and unpacked it, things got interesting.  It didn't bleed, but it did fill up with a clear fluid.  Not good, CSF (central spinal fluid that bathes the brain and spinal cord)!!!  In my attempt to get as much optic nerve as possible, I had made a hairline fracture in the thin roof of the orbit (which happens to be the floor of the brain!).  Having never encountered this particular problem in training, I was open to suggestions, preferably ASAP.  My Kenyan assistant brilliantly suggested bone wax.  We tried, but it just wouldn't stick well enough.  The leak at this point had become pulsatile (the brain creates significant fluctuations in pressure as it fills and empties blood with each heart beat).  Not good.  I decided to consult the nearest non-eye surgeon who happened to be an orthopedist.  Dr. Galat said, "When I get CSF leaks, I plug it with fat."  Good enough for me.  So, with the assistance of a passing general surgery resident, we harvested a fat graft from the abdomen.  It seemed big, but then again, the orbit is a big hole, and we literally needed it to be water tight.  Thankfully, it seemed to do the trick, but we knew it only had a few days before the fat would die and need to be removed.  Our hope was that the leak would be sealed by then.  

Abdominal fat graft with its overlying skin being placed in the orbit.  

The next day, she states, "Daktari, my eye socket feels pretty good, but I've got a stitch in my side and a pain in the leg like you can't believe.  Aren't you an eye doctor?"  (slight translational liberty taken).    

As expected, the fat graft died and had to be removed about a week after placement.  We were quite thankful she did not get a CSF infection nor did she leak upon removal of the graft.  Some of the fat actually was alive and covering the bony orbit which provided a nice substrate for her to granulate the orbit.

At her last follow-up, she continued to heal well, but still had not gotten on anti-retrovirals.  It was explained to me that she was unable to meet the commitment level needed by the HIV clinic to be on anti-retrovirals responsibly, largely due to her lack of social support.