 Good morning everyone. Thank you. Han Shush. Good morning everyone. Thank you for coming. Dr. Marx is a good friend of mine. He's a good friend of the Moran's, whether the old Moran. He did some work with us. In fact he did his internship here and then he went on to the dark side, went to Houston and for a few years I've been trying to get him over to come and lecture to us, meet with him and he's very kindly come along today. He has a great interest in both academic and clinical medicine so man after my own heart and he has done some superb work in pediatric plastics. Today we're going to concentrate on the clinical side but if you have any questions regarding general oculoplastics, pediatric oculoplastics, we're going to leave some time at the end to ask him. He has done some very good work in congenital ptosis and the dystrophic changes that happen in the levator muscle and we'll leave discussions for that until another day. So may I ask you all to welcome him in our traditional way. Welcome back. Thank you so much for having me. I'll turn this on. You'll be better. Okay, thanks so much for having me today. I actually wasn't interned here as Dr. Patel mentioned. I'm very grateful for him having me here in Dr. Olson as well. It's always a pleasure. Many of you take care of my family members here. I am very grateful. They always have very, very great things to say. Thank you so much. So my dad has had all kinds of eye issues. That's why I went into ophthalmology. He seems to be here all the time. So thank you. The main thing I should say is I do about 50% to 6% pediatric work and maybe 40% to 50% adult work in my practice and that's just kind of how it's worked out. Texas Children's Hospital is a very large pediatric hospital and so that keeps us very busy. I have no financial disclosures or interests by way of Texas. So I have been in Texas now nine years total and I have heard each of these. Now I found these on the internet but I have heard each of these. So as far as things that people say in Texas, these took me by surprise the first time I heard them and I had to be educated as to what these meant. So it's better than a poke in the eye with a sharp stick means it's just okay. He's all hat and no cattle is probably my favorite and that means a person who's rather boastful and difficult like putting socks on a rooster. The first time I heard that I could not quite laugh. So Houston is a great place. Texas is a great place. I've enjoyed practicing there. Here's Texas Children's Hospital. As you see it's a very large hospital. I think bed-wise it might be now the largest in the country as far as pediatric skills. I'd really like to emphasize with the work I do collaboration is really the key. So everything you'll see me talk about is really because of all of the people who are involved in this. So we have a team there at the cream facial team which all of us are part of. We really work together plastic surgery, otolaryngology, neurosurgery and interventional radiology. It's a very good working relationship and I think that's what gives you the best results. So an outline, it's all orbit today and I noticed this when I finished the talk itself. And for those of you who don't like orbit, I'm sorry, hopefully they'll be of some interest to you, regardless. I'm going to talk about orbital vascular abnormalities, orbital cellulitis and orbital deformities. These are things that I see a lot of. I do like congenital atosis. I see a lot of congenital atosis. I left that off for another day though, hopefully inviting you back. So classification of malformations based on hemodynamics. That's a good way to classify these vascular lesions in the orbit. I'm going to focus on the low or no-flow lymphatic malformations today also called lymphengeomas. We usually refer to them as lymphatic malformations or being on lymphatic malformations. So for those of you who are not interested in the orbit, this is just to try to keep your attention, entertain you a little bit. Hopefully I'll give you some slides or other entertaining. Case presentation. So I'm going to try to start each of these ideas with a specific case that I learned something from and then go into the data and the research that we have done so far. I am very interested in both clinical research and also basic science research. This is all clinical. Hopefully this will be somewhat applicable to everybody here. So the six-year-old boy presented to the emergency room in planning an acute, progressively worsening pain and swelling of his left eye. He had never had any episodes like this and parents said he had no other ocular problems or history. Review of systems, he did have a cough and a runny nose for about five days. On his exam, I limited the exams to things I think were the most permanent for the purposes of this presentation. His actual exam, he did have significant periorbital edema and ecumosis. He had severe proptosis and 3-plus cumosis as well as this inferior displacement of his globe, which the parents had never noticed and didn't really notice him when I pointed it out. His vision was decreased to 2070. He did have an aphor and pupillary defect and he had severe restricted movements of his left eye and his pressure was 50. Here he is right here. He's a happy kid. He was having some painful episodes though and you'll see another view of him here. He's quite proptotic. So we imaged him MRI. You see this very complex lesion that's preceptile, postceptile, both intraconal and extraconal. You see these fluid levels. Pretty classic venolymphatic malformation. And you see it's just a very infiltrative lesion. Here's another view. These are very, very difficult to treat surgically if you're trying to excise these. And that's kind of what this really talks about here. The mainstay and the path was surgical drainage and resection. But these lesions are often so infiltrative that totally excursions virtually impossible and there's so many morbidities associated with it. Like double vision lesions does not resolve. Long-term studies have shown these malformations have recurrence rates that are pretty high. 58% at like 3 years and 70% at 7 years if you try to excise these. Things change, right? Sometimes for the good, sometimes not necessarily for the better. I recall those days. And things have changed though, right? So I think this is the change that is for the better. This is bleomyosin. This is one of the agents that is used in sclerotherapy. It's the most common one we use at Texas Children's. It's an antibiotic that's isolated from streptomyces. It's used in chemotherapy. And one of the major systemic effects that's found when it's used in chemotherapy is pulmonary fibrosis. And it seems to be dose dependent, which I'll get to a little bit later. It is widely used and has been widely used for years in head and neck, basket abnormalities. In the last few years, it's really been used more in the orbit. It has this closing effect on the endothelial cells. It creates this non-specific inflammatory reaction and then you get proliferation of the stromal connective tissue. Here's Texas Children's. This is essentially our ambulatory surgical center. It's not truly ambulatory. This is a part of the hospital itself. This is where we do the treatment. This is the protocol that we have published. I think most places have a protocol. I know Dr. Patel and one of the pediatric intervention ideologists here who I just spoke with last week. I refer to the patient here who moved here, or it is moving here, our first base. And we were talking about doing this therapy and I know that patients as well have the same thing. I think these types of protocols are often very helpful. They at least give you some sort of a clue or an idea of how to approach these complex issues. They're not always perfect, but at least gives you a roadmap. So this is where the ophthalmologist still has a job. So you check the intracurricular pressure here before the procedure. The main concern I have with these is an orbital compartment syndrome. The pressure getting too high, and they can, and it's pretty scary when it does. For the preceptile lesions, a small 25-gauge needle is used with ultrasound guidance to get into the lesion, and that's how you can drain it. Here's just a view of the ultrasound of the needle going into the actual lesion so it can be drained. This is really good for the microsys. For the postceptile lesions, it's a large needle, 7-centimeter needle, 21-gauge. Ultrasam is being used here to help guide it. I think this is where our intervention radiologist has really, I think, made this, or has made her mark. Sheena Pebblewall has really added this CRMCT idea, to our institution, and this has greatly reduced the amount of treatments that these patients need. We're able to get better penetration into the lesions. We're able to treat more lesions, and she's also going to back her in the orbit. Now that she does it the first couple of times, we did it the first few years. It was kind of a heroin experience, and now she just, no big deal. Here you see the fluid is being drained. This is typically what you do once you get the needle into the appropriate space. They classically have, I'm going to try to see the pointer, let's see. I'm going to go back here. The pointer here, you see the fluid. This is classically what you see. Instead of the fluid, you find in these lesions, and see, you usually aspirate these before you put any bleomycin in. You want to actually get out of the fluid out of there that you can. Here's an example. There were two large cysts, and so you see two different catheters have been placed. The fluid is drained out. The bleomycin is then placed in the lesions. It's put on suction to try to get the walls to come together. I think this is where the CT arm is also nice because you see really good diffusion of the bleomycin into this whole lesion. So it shows you that what you're actually doing is working. Here we are checking the eye pressure following this. Notice that the chemosis in this kit is actually pretty stable at this time. This can get dramatically worse pretty quickly. And the thought is probably the chemosis happens from all the microsys and all the little extensions that there are through these lesions. And that's usually why we get some of the chemosis. Here you see again it's placed on a JP bulb drain inch for a couple of days typically. The kit just lets this drain when they go home with this. So the results have been published. The largest series was really that I've seen is 30 patients and the ones we did were approximately 20, so I'll talk to you about more than that now. We've done about 40. You see the results here. The classic thing you see is this chemosis is pretty telling of this type of lesion often. And in this case you really can't see any residual. And that's what you would hope for. This is what we published. This is really describing the CRMCT edition which I think for us has been a great addition to it. We looked at our results from November 2012 to May 2015. We had 17 total patients at the time of the patients. So our results, I think the important things here are we had resolution of presenting symptoms in all the cases at one month follow-up. And that's important because a lot of these kids have microsys as well that can become large again at a later time. The average number of sessions was 1.4 meaning that they required 1.4 treatments at the William Iason. The range was 1 to 3. So the most anybody had was 3. There's other reports when CRMCT has not been used. They have multiple treatments that are necessary. There was a cystically significant reduction in the lesion volume and proptosis which I think is important in the key and there was no lesion recurrence for a medium follow-up of 18 months. So I think for us to take home for that in our institution has been the CRMCT has really, really helped make the amount of anesthesia and the amount of procedures that each of these children needs less. Three patients that have transient inflammation of ILP, they're resolved. One patient that I'll never forget had very, very bad swelling and obvious orbital compartment syndrome. The pressure, I couldn't even read it on a ton of pen, did a canthotomy, I still couldn't read the pressure, and then did a counter-tival peritomy and all this flow just came out and the pressure just dropped completely. But it's scary, they have to be watched very carefully. And the protocol, that's really going to check in the pressure multiple times afterwards and following the patient very carefully. Report of complications that have been seen. Skin ulceration, I haven't seen it. Skin hyperpigmentation is actually a relatively common thing. And for whatever reason, adhesive tape seems to make this worse. So you like to use a non-stick type of treatment with anything you put onto the skin of these kids. And if you have to do any of the sticky, we typically take it off 48 hours later. Transient fever is really common. Diarrhea, local cellulitis, inflammation, and dorsiorgocompartment syndrome. What has not been reported, thankfully, are any of the systemic effects that you sometimes see with the chemotherapy. So mycositis, alopecia, and the pulmonary fibrosis. The concern I have is still the idea of people developing lymphoma associated with it. The pulmonary fibrosis appears to be dose-dependent, and you're never getting remotely close to that type of a dosage for that, you know, having no formations in an orbit. That could potentially be non-dose-dependent. No case reports of it yet to date, but that's something I think we'll never have to watch out for. Here he is. You notice he still has this inferior displacement of his eye. And I went back and looked at pictures of Mom and Dad, and he's always had that. But Mom and Dad didn't notice because that's just him. To them, that's just who he is. And then you see here, he still does have apoptosis, which goes along with the fact that even though you drain these, and even though you no longer have these macrosis, he still has this abnormal lesion in his orbit. All right, transition time. Just one fast question. Visually, they do just fine. There's no, you haven't noticed there's any gloss in vision, or from the pressure, there's not been glaucoma, optic nerve damage, or any of that. These kids have all seemed to come out just fine as far as their ocular function. That's a great question, but that draws on. So yeah, so fortunately, and I think a large portion of that is because of the protocol we see when they have this type of apoptosis, they get immediate imaging. They're kind of taken through the system quickly. They understand the importance of getting this done in a fast fashion. And so, no, today, none of ours have had any visual loss. Motility comes back completely, too? So the majority of the patients we have had, the motility will come back to where they were before they had the acute exacerbation of their lesion. So there's still some restriction? Some can have restriction if they still have some mass effect in there. The reason is these are microcystic, multi-loculated. They do not infiltrate the extracellular muscles, which is the good news. They do not affect the optic nerve, which is the good news. And until about ten years ago, by the time the patients were referred to us, we were well because surgeons would try and surgically debug these all the time. You know, they have a hammer and they would hammer it. And so, what we've been doing is an open drainage with directins and injection by the sodium tetrodesyl or gliomycin, they're all the same products. They work in sclerosis terms. You can reduce the density of the cysts, but you can never remove them completely. But next time the kid has a cold, especially so this part of the world, that Houston, in the winter months, they get some exacerbation. And a lot of the times, just to complete the presentation, you can control these with steroids, short term steroids. You don't always need to take them back and drain them or inject them. But in that acute situation, you have to drain them or the drain in, inject them directly. This is a purely mass effect, what we call in the old days, we used to call this sort of ischemia, getting the arm, Voldemort's ischemia. The orbit, that's why you get away with the optic nerve not being damaged and the actual killer muscles largely reversing, reverting back to normal. So these are what I call semi-virgin cases, we want to drain them sooner or later. We inject them directly and in that vision they seem to turn up as well. And your group made a great contribution to show how properly done interventional radiology can do it perfectly well with that tool. The takeover for me on that was it's really nice to have the collaboration with other people who bring in other thoughts. As an ophthalmologist I approach it from one vantage point and Sheena approaches it from another vantage point. Together I think we get a better idea potentially sometimes, in some cases. And like Dr. Patel is describing, the open way to treat that is great and the scruizing agents really, all of those have been I think really, really helpful in each institution because they have different jobs, a different one, but they all have had good results. I think very similar results. The other thing I would say as far as a lot of these kids go, Dr. Patel was talking about when they get like an upper respiratory infection, these get worse. That's typically the first standing sign. A lot of times they didn't even realize there was an issue. Then they give an upper respiratory infection and because it's lymphatic, they get this acute exacerbation and they get sometimes what they call the chocolate that says the bleed into the lesion. The pediatric organ cellulitis, I don't know why but we see a lot of this. So I think because of all the sinus disease in Houston, it's rare for me to get a CT scan or an MRI if someone doesn't have some sinus disease there. And so we see a fair amount of this. Another case here, so a nine year old boy who's ended up in the emergency room complaining of acute progressively worsening pain and swelling of his right eye. The past medical history was important or was pertinent to have seasonal allergies or he's known to have seasonal allergies. When he reviewed his systems, he did complain of a stuffy nose for like two days and a headache for two days that was getting worse. On his exam, he had a pretty significant period orbital edema. He didn't have as much erythema as I would have guessed and that's one of the reasons I show you him. He had no achemosis. His vision was good. He had no APD. He did have severe restriction of his eye traffic movements and his pressure was slightly elevated compared to the other side. I wasn't terribly impressed because we see worse than this. Even though this is bad, I certainly see worse as far as clinically how they appear. He was talking normally. He said he had a headache. We scan him. He has a diffuse empyema and he has a huge roof abscess in his orbit. So, neurosurgery and I take him to surgery at the same time. This is what they find. Looking at him here, I wouldn't have guessed that. This to me shows the importance of scanning these kids. You see this and they drain this and I drain his orbit. I put in a penrose drain. Notice all the skin breakdown he's got. So much inflammation. It was so tight that blood vessel supply probably isn't great there. Skin starts to kind of break down. You don't like that photo too well? Yeah. That's not my clearly. So, what they've done here, they've done a craniotomy and they actually have lifted off really the top half of his skull here. Here's his dura and there's his spous. So, right on his brain and you see this oozing off. It's crazy. So, we see this by like once a year or something in this band. I think he would have severe spinal. Look at that. I mean, this is a guy who should be a bacterial meningitis. Yep. He was talking normally. It was crazy to me. We saw this and I just and what's interesting too is you got a CT initially and the CT showed he had some fluid there but you couldn't really tell how much and then there was certain one in MRI and then you could really see it. So, different imaging modalities to illustrate different things. He has this, you see him here and this kid ends up healing fine. He has his mechanical ptosis from all the inflammation and everything but he has his post-inflammatory hyperpigmentation. This doesn't always go away. It didn't, you know. It typically does but this is one of those things that of course if you get to this sooner, if the kid comes in even sooner, you can hopefully keep some of this from happening. So, where exactly was this craniotomy? Is it just above? It's back. They usually put these right back behind their hairline about two or three centimeters. There's a terrible go over. And the interesting part of this is even when you do this case of them, this part takes like three and a half to four hours, right? When you do yours, it's like 30 minutes and they're just like, you get out of here. So, of course, they they keep very, very busy. So, hearing on, I think the main things to talk about in our research line is we see it a fair amount, I think, at times and we think, okay, well, it's just an infection it's not that serious. In this kid that could have been life threatening. That is life threatening. Could have killed it. Poor Cosmesis, as we're talking about with the one kid that just showed you the post-inflammatory hyperpigmentation and the potential ptosis as well as a motility restriction. I have seen that be permanent when they had a cavernous sinus thrombosis. I've seen it bilateral. It was permanent. Vision loss is very possible and then in the intracranial extension from the death. I don't know if I even remember Paul Steinkoeller some of the pediatric ophthalmology people probably would be Paul Steinkoeller. He worked at Texas Children's for like 40 years and I asked him about his experience with intracranial extension and how the kids did and he said as of until about 20 years ago each one he saw, they died. I bring this up because I drained so many of these abscesses I was wondering when did these really need to be drained and when do they not need to be drained? The data we have is really based on in my opinion this report on ophthalmology in 2000. That's 17 years ago. We looked at that paper very closely and wanted to try to see if things have changed enough because antibiotic resistance has changed, things change. Also the imaging modalities change whether you become more available things like that so maybe the treatments can be different. So Harris describes all of these different criteria for drainage and one of them he describes as an age greater than nine and it has to do with the way the sinuses are. The thought was you're more likely to get polymicrobial infections because of the ostomy size of the sinuses versus the sinus size so you get more polymicrobial infections. The presence of formal sinusitis in their series was very important. A non-mean location was as well and a large separeostal axis which was later defined as greater than 1.25 centimeters cubed wasn't initially defined in their study. And then also if you thought that there was an anaerobic infection you saw errors and like that we thought it was from like a tube infection you should drain that as well. They found that to be much more serious. So we looked at our data from May 2012 to April 2015 and we presented this to the A.Soppers meeting and the process of publishing it. We had 63 patients at that point and for whatever reason we had a majority of males I don't necessarily think I see that but that's why you look at the data and it's interesting to always kind of look at these things. And then some other things that I noticed the average amount of time until they would come in is three days. That seems like a fair amount of time to me. You know your eyes start swelling and you just kind of hang out. And then the majority of them had a motility deficit. And that's what I usually see and that's a good sign that something orbital is going on. As far as symptoms go majority of course had periodontal swelling they felt subjected to fever eye pain. I find this one always really interesting. It's only half of patients complain of nasal congestion even though the vast vast majority have sinus disease. And I ask them each time do you have a hard time breathing or your nose is congested do you have a right nose all the time and your nose is clogged and more often than not they say no. So in our study 98% of patients had some degree of sinus of pacification on CT scan at the time of initial presentation here you see all kinds of sinus disease, right? Only one patient had a dacrocystitis which I spelled wrong they did not have sinus disease. So we looked at the bacteria that we had in our study with the end of 37 so this means we had to use the ones that actually got culture 30% of polymicrobial but then 70% were either staff or strap this would be a good OCAP question all the following but now I'm getting a bit terrible, right? So polymicrobial cases all kinds of stuff and then as far as the indications if you look at we, when we look to see what was clinically significant or I should say statistically significant. We actually got different results now 17 years later and our amount of patients is pretty similar. So age greater than 9 was not statistically significant for us and then the presence of frontal sinus disease was not as well. This surprises me a while I still think they have frontal sinus disease and still I always think to myself do I need to drain it? A non-medial location we found that is important. If it was non-medial we usually needed to drain it and then also if it was large that was statistically significant as well so if you look at I think the take home messages because that's a fair amount of information concurrent sinus disease is almost the rule in pediatrics let me see this and the presence of frontal sinus disease for us was not a predictor of the need for surgical drainage a non-medial location was highly predictive of the need for surgical intervention rather than not it was separate and if the diameter is greater than 1.5 centimeters they tended to need surgical intervention as well majority were from staff or strap and I think this is also another thing which we concluded is that polymicrobial infections can occur at any age they do seem to be more likely to occur and when a person is older than 9 because of the anatomy we're finding it in Houston in all ages so like that kid he had multiple multiple bugs growing this is what I like to do I saw a guy this is my training in Portland, Oregon and I saw a guy crossing a bridge it has one lane bridge he was on one of these it's huge it's like 15 feet up it's a huge wheel and it's going like a mile an hour across this bridge and now I can pass him and it was a nice day and nobody harmed this reminds me of how difficult he started to treat I don't know if any of you know David Coates he is my division chief at Texas Children's he's a great guy this is the kind of thing you ask if I could fix this I thought long and hard about it I don't think I could fix that there's a lot of orbital reformanies that are very challenging to fix so case presentation for you here we had a 14 year old girl referred from Pakistan for evaluation of intermittent binocular diplopia one of the things I really do love about Texas Children's is we do get a lot of referrals internationally and that's fun doing that type of work so past medical history hemifacial, microsomia and this facial clefty is what the report was and it had some soft tissue repair in Pakistan at the age of nine reviewer system she complained of intermittent binocular diplopia and I asked her this multiple times and she said my double vision is intermittent it's not all the time so instead of showing this I'll just show you her picture her vision is reduced and her vision is reduced in the right her motility was normal I checked it multiple times this is her so you see here she's had the surgical scars the eye is really inferiorly displaced and she really has what you'll be able to see when CT scan a very hypoplastic midface so we scan her and I like this image this frankly isn't the image I don't use a whole lot except for these types of things I do like it for this the edges get softened when you use it so these are cool images to look at but I think when you're looking for a fracture or something like that this is not what I use personally you see this big cleft here and here's a couple more views over here but this is really what she had so looking at her clinically I knew she had something orbital going on but I didn't realize to what extent sometimes you can actually see a complete displacement of the entire orbit she doesn't have that her roof is in a good position actually it's just this whole cleft here which involves her entire floor and it comes all the way down into our maxillair so this is where I'll get that grass and talk a little bit about ideal orbital implants and just tell you briefly I don't think we have such a thing yet so you'd like them to be durable and yet pliable to stay in the right position as well as possible radio-pacing you can actually see if you place in the right place afterwards biocompatibility is really important you want to reduce the risk of extrusion and I think in these types of things infection this is a big issue unfortunately the ones I'm going to show you they did not meet this criteria limited operating time as well and then limited or no donor no more morbidity so there's a variety of different types of implants I think this is a talk for a different day but I think most people have gone to these non-resorbables you say I talk about porous polyethylene here I mentioned one other one here so these customizable implants I think are the future these are used for very very intense very difficult orbital cases where you have these big defects like this so porous polyethylene just really in the last little while that's been available as a customized implant meaning you go online you Skype it essentially and you talk to the engineers who design this I designed this implant last week and say it's a porous polyethylene implant it's right in the orbit you see here and they're taking their cuts this is computer generated and they've made this implant for me out of porous polyethylene 3D printing is that what they're doing? they're doing 3D printing it's awesome the turnover time on the porous polyethylene is about 3 weeks right now I'm going to show you another one though which I was a little reluctant to use and one of my creative facial colleagues was the one who has brought me into the lighted thing that I do like it as well so here's again the same girl pre-operatively here's another view so this is computer generation of the peak implant you see here what they've done the engineers have gone in they've generated this implant it notices in 3 pieces the reason is because you're not going to get that in in a cosmetically acceptable fashion or probably any fashion without making this into pieces they're made to fit together and it's crazy how well they work so this is the computer generation image you see it from the side here and it's interesting because when I look at some of the scans I don't know how much was affected here but it needs a big implant over this then you see it from the bottom view so this is first skull that they have made from the CT and it's a great representation they then made this peak implant to fit and see how it kind of had these grooves it fits like a puzzle so it locks in now the creative facial people still want to put on a million screws because that's just what they do and so we always, that's the one discussion we still have how many screws do you need so you see here it's been made, it's been fashioned see another view here another view here into the orbit this was the first I show you this case because it's interesting because this is the first time I put peak into an orbit and I was nervous to see how it would do it did great so here you can see another side view of it so here's her pre-operative view here she is post-operatively you see the floor yes she actually has a rim now very good Zygoma build up for her that's a life-changing surgery so I think in summary we're looking at our date and now we have now to date over from 2012 to 2017 February 2017 we have over 30 pages which now we are in the process of publishing the major concern I have is the same concern I have with most implants two things you can get this orbital adherence syndrome which is really been described in titanium I haven't seen that in any of the peak or medporium plants and I think a lot of it has to do with the material but also the way you do it if you put it underneath the appropriate position in the pores in these pores do they get tissue in growth into it so it gets incorporated into the it does so you have to make sure the peak doesn't the peak is non-porous I'm actually favoring that in that regard because the orbital tissue can just slide over it if I use that medporium plant I have to make sure I put it underneath the periosteum so that that's covering it entirely so no soft tissue can get down in there and then you can get restriction so I think that's a very important point that Dr. Olsen just mentioned the peak is non-porous so we don't see that in slides what I do notice though are what concerns me we have had one patient who had got an infection the peak implant had to be removed because it was infected I think the peak is probably more likely to get infected because it's non-porous potentially but different studies have shown different things we don't know for sure so the take-home is there's a lot of research to be done I think these customizable implants are the future for these types of huge problems and hopefully we'll just learn more and more and there'll be more and more things that are available as far as this goes um yes in Florida you haven't been this was the kids vacation for their spring break I'll stop it there thank you so residents how many of you know what a sea arm is you talked at length about the sea arm I've always thought about history and how many of you know what a sea arm is it's a little bit like me telling you how to fix an engine when you say to the end what is a cap shaft so you get lost a little bit anybody know what a sea arm is so this is this is my point of remembering who we are, where we come from where we're going so about 30 or 40 years ago a sea arm would be in every clinic would be in every emergency room you're looking for foreign bodies in the chest if you're looking gunshot wounds you're using a sea arm all the time they're now sitting as door stops everywhere so a few years ago we put them back into action when we would get somebody with a foreign body in the orbit there's a few being in the orbit with me when we're looking for a little bullet it gets lost in the fact you really can't find it a sea arm is a very very old fashioned way of doing a plain x-ray in a mobile way and you can move it so you can show you the section vertically you can show you the section so that's what he was talking about with the sea arm when we would use that old technology being used so that's what a sea arm is and we still use it once or twice a year when we're looking for foreign bodies in the operating theatre as far as this last congenital deformities thing is concerned you must remember if you send a patient to a proctologist to fix this preneufacial deformity via the rectum if you send it to a preneufacial surgeon they'll break all the bones and reposition them you send it to an orbital person who will put implants in there and the answer is what Doug said why to the beginning a multiple approach so here we have a great team a neurosurgery, preneufacial surgery and our orbital team and what we do is we first break the bones and fix them to the best of our ability using their own bones and then when it comes to these implants it's very easy to get seduced by new things but they're basically three one is a metal implant titanium or titanium the other one is a plastic implant called polypropylene nothing sticks to it the third one, which is the sexy one the polypropylene medpor the problem with medpor is it works beautifully when it works beautifully the minute you get a slight infection remember these implants are sitting over on the sides and so on the whole thing has come up so if you do enough of these you learn the hard way to have a great deal of respect for these things so my point of bringing this up is all of us must look at results of new materials carefully over 5-10 years before own saliently using them on every patient that we see always be a little bit critical and cynical about results before you get sort of sold in what is there about your orbital access talk which we won't talk about today we had an orbital conference just very recently where we covered Paris' paper and the criteria and all of that stuff so we won't be labored at but you did a beautiful job of presenting three vastly different types of problems and the approach to them so thank you any questions from the residents? thank you