This is a case series of 3 patients who presented with periocular changes in the treated eye following chronic administration of unilateral latanoprost 0.005%. The clinical changes included worsening of dermatochalasis, deepening of superior sulcus and hollowness of the lid. This similar observation was previously described in usage of bimatoprost 0.03% and travoprost 0.004%. However this has not been reported in latanoprost instillation. Therefore, patients should be made aware of these potential side effects.
To evaluate the efficacy, recurrence rate, and long-term complications of topical mitomycin C (MMC) 0.02% for conjunctival-corneal intraepithelial neoplasia (CCIN).
A prospective, nonrandomized, noncontrolled study was conducted of patients with primary or recurrent CCIN treated with topical MMC 0.02%, four times per day, for 28 consecutive days. The main outcome measures were complete resolution of the neoplasia by slit-lamp examination and cytology 1 month after treatment, tumor recurrence, and long-term complications.
Between June 1999 and September 2005, 23 patients were included. Eighteen had primary CCIN (group 1) and 5 had recurrent CCIN (group 2). The mean follow-up was 46 months in group 1 and 54 months in group 2. All patients were treated with MMC 0.02% for 28 consecutive days. Complete resolution of the lesion was achieved in all patients after 1 month of treatment. Recurrence occurred in 1 patient (4.3%) after 24 months of treatment. Four patients developed corneal erosion (17.4%), 2 of them with primary CCIN and 2 with recurrent CCIN. Corneal erosion occurred 4 to 24 months after treatment and was treated successfully. The probability for corneal erosions by the log-rank test was equal for both groups (p = 0.1705).
The use of topical MMC 0.02% for 28 consecutive days to treat primary or recurrent CCIN was effective and showed a low recurrence rate. Corneal erosion occurred in 17.4% of cases and can occur as late as 24 months after treatment.
To evaluate the efficacy of topical 0.25% timolol maleate gel for the treatment of cutaneous infantile capillary hemangiomas.
A retrospective, consecutive, nonrandomized, comparative single-masked cohort study of all patients presenting with nonvision-threatening periocular infantile capillary hemangiomas between August 2007 and January 2011 was performed. Parents chose twice daily topical 0.25% timolol maleate gel or observation. Photographs were taken at all visits and subsequently evaluated by masked examiners for change in lesion size, color, and thickness. Lesions were clinically defined as superficial, mixed, or deep. The primary outcome was response to treatment at 2 months, categorized as good (size decreased .50%), moderate (decrease 0-50%), or poor (enlarged or caused visually significant ptosis or induced astigmatism). The secondary outcome was response at latest follow-up visit.
Thirteen children received timolol, and 10 children were observed, with mean ages at presentation of 4.8 and 3.7 months (p 5 0.31), respectively. In the treated group, good response was observed in 8 (61.5%) infants, moderate response was seen in 4 (30.8%), and poor response was seen in one patient (7.7%). In the observed group, 0 (0%) demonstrated good response, one (10%) demonstrated moderate response, and 9 demonstrated poor response (90%) (p , 0.001). Responses were consistent on long-term follow-up (range 3-41 months). Both superficial (n 5 5; 100% good response) and mixed (n 5 7; 43% good, 57% moderate) lesions responded well to timolol; the one deep lesion did not. No adverse ocular or systemic effects were observed.
Topical timolol maleate gel 0.25% is effective in treatment of nonvision-threatening infantile capillary hemangiomas with a superficial component. Response at 2 months is stable over time.
To evaluate the effect of instillation of a specific alpha2-adrenergic agonist, topical 0.5% apraclonidine solution, on upper eyelid position in patients with blepharoptosis.
This study included 45 eyelids of 35 adult patients with blepharoptosis. Of these, 37 eyelids had acquired ptosis and 8 had congenital ptosis. Palpebral fissure height and margin-reflex distance in the upper eyelid were measured before and after instillation of 0.5% apraclonidine, 2.5% phenylephrine, and both drugs.
After instillation of 2.5% phenylephrine, 0.5% apraclonidine, and both drugs, the mean increases in palpebral fissure height were 2.12 mm+/-1.4 mm, 2.11 mm+/-1.4 mm, and 2.26 mm+/-1.3 mm, respectively, and the mean increases in margin-reflex distance were 1.93 mm+/-1.2 mm, 1.89 mm+/-1.3 mm, and 2.03 mm+/-1.2 mm, respectively (p=0.86 and p=0.85). The apraclonidine solution did not alter the test results in 14 eyelids in which the phenylephrine test results were negative.
Topical 0.5% apraclonidine solution can be as effective as topical 2.5% phenylephrine in elevating a ptotic upper eyelid, and may be used for preoperative evaluation of blepharoptosis. Combined use of both drugs may not provide any additional benefit.
To demonstrate the effect of apraclonidine on anisocoria and ptosis in Horner syndrome, one drop of 0.5% apraclonidine was instilled in both eyes of 3 patients who presented with acute Horner syndrome, and the effect on ptosis and anisocoria was documented. As reported in the literature, one drop of 0.5% apraclonidine reverses the anisocoria of Horner syndrome. In addition, 0.5% apraclonidine leads to a complete resolution of the ptosis associated with Horner syndrome, a finding reported once in the literature. Apraclonidine is a safe and readily available alternative to cocaine for the diagnosis of Horner syndrome.
To describe and evaluate an office-based technique to adjust the Fasanella-Servat procedure in the first postoperative week.
This retrospective case series reviewed all consecutive eyelids undergoing the Fasanella-Servat procedure between July 1, 2006, and July 1, 2007, by a single surgeon (R.D.L.). Charts were reviewed to determine the frequency, timing, safety, and efficacy of postoperative adjustment. Postadjustment photographs were reviewed by a blinded ophthalmic plastic surgeon for eyelid contour, height, symmetry, overall cosmesis, and picture quality as excellent, satisfactory, or poor.
The Fasanella-Servat procedure was performed on a total of 102 eyelids in 54 patients over the 12-month interval. Postoperative adjustments at the time of suture removal were performed to improve mild eyelid asymmetries for 22 eyelids (22%) in 19 patients. Postadjustment photographs, available for 17 patients, showed excellent eyelid contour (53%), height (88%), symmetry (82%), and cosmesis (65%). Satisfactory results were obtained in all remaining photographed eyelids.
The Fasanella-Servat procedure should be viewed as an adjustable ptosis correction with the adjustment as a standard component of postoperative suture removal. This manipulation takes only a few moments with minimal to no patient discomfort. It allows for improvements in eyelid height and contour. This series demonstrates a procedure that is simple, highly successful, and safe.
The aim is to measure and investigate the anatomic structures of orbital soft tissue and the relationships between the adjacent regions in 102 normal young Han Chinese adults using a computer-assisted photography system to provide reference data for periocular cosmetic and reconstructive surgery.
A random sample of 102 Han young Chinese adults (53 males and 49 females) aged from 18 to 25 years in Changsha, Hunan Province, was obtained. Standard digital images were taken and then processed using Image-Pro Plus 6.0 software. The linear and angular measurements, including intercanthal distance, outer canthal distance, palpebral fissure width (PFW), palpebral fissure height (PFH), orbit height (OH), upper lid height, lower lid height, nasal eyebrow height, central eyebrow height, temporal eyebrow height, reference line to lateral canthus'inclination of palpebral fissure, were measured. The proportional indices, including intercanthal distance/outer canthal distance, PFH/PFW, PFH/OH, OH/PFW, upper lid height/OH, lower lid height/OH, nasal eyebrow height/OH, central eyebrow height/OH, and temporal eyebrow height/OH, were investigated.
Means and standard deviations of all the items had been obtained and differences between male and female subjects were assessed.
The normal measurement values of anatomic structures of orbital soft tissue and the proportional indices for normal young Han Chinese adults provided reference data for periorbital cosmetic and reconstructive surgery.
To evaluate our initial experience with a porous polyethylene implant with embedded titanium in orbital reconstruction.
A retrospective review of the charts was performed for patients receiving at least 1 orbital porous polyethylene implant with embedded titanium from October 2004 through April 2006. Patient demographics, implant type and size, method of fixation, postoperative complications, and length of follow-up were recorded.
One-hundred six patients received at least one embedded titanium implant (80 men, 26 women). Age ranged from 3 years to 85 years (mean, 31 years). Indications included orbital fracture repair (102 patients), correction of enophthalmos (3 patients), and reconstruction after tumor resection (1 patient). The average floor implant used was 22.3 mm wide by 27.9 mm long. The average medial wall implant was 13.6 mm tall by 22 mm long. Implants were fixated with 1 or 2 microscrews in 75 patients (70.8%) and placed without fixation in 31 patients (29.2%). Four postoperative complications were noted: a retrobulbar hemorrhage on postoperative day 3 that resolved without sequelae, a vertical overcorrection requiring removal of the implant, a transient oculomotor disturbance, and a screw placed in proximity to the infraorbital nerve canal resulting in hypesthesia and chronic pain that required removal of the screw. In the 3 complications potentially related to the implant, the embedded titanium allowed postoperative implant visualization and guided subsequent management. No implant extrusions or postoperative infections were noted.
Porous polyethylene implants with embedded titanium provide a new alternative to alloplastic implant materials for orbital reconstruction with a profile that combines several advantages of porous polyethylene and titanium implants.
Venous malformations of the skin and subcutaneous tissue are compressible, blue-purple tumors that are present at birth. According to the location and symptoms caused, venous malformations can be treated with surgery, sclerotherapy, or a combination of both. Laser therapy can also be used, especially when surgery is contraindicated. We report the case of a 24-year-old man who presented with a venous malformation on the upper and lower left eyelids, which provoked a mechanical ptosis. Treatment with sequential pulsed-dye neodymium yttrium aluminum garnet (PDL-Nd:YAG) laser was performed. After 2 treatments, a marked reduction of volume and blanching of the venous malformation was observed, with satisfactory cosmetic results. The sequential PDL-Nd:YAG laser seems to be an effective and safe therapy for the treatment of cutaneous venous malformations. It penetrates deeper than pulsed-dye laser alone, and because it allows the use of lower fluencies than Nd:YAG laser alone, it reduces the risk of adverse effects.
To evaluate the role of computed tomography in patients with dacryostenosis.
One hundred seven cases of dacryostenosis (94 patients) were assessed by thorough clinical and lacrimal history and examination, and lacrimal region computerized tomography (CT). The lacrimal drainage system examination included the state and position of the puncta; Jones testing; lacrimal syringing; and, in the latter half of the study, telescopic nasal endoscopy. The patients were drawn from the hospital outpatients and private office of the operating lacrimal surgeon in this series (I.C.F.). Of the 107 cases, 79 either underwent dacryocystorhinostomy surgery or had this planned.
In 14 of the 107 cases (12 patients), preoperative CT led to an alteration of patient management, usually referral to an otolaryngologist for further evaluation or treatment. In addition to the detection of two tumors extrinsic to the sac, conditions such as ethmoiditis, lacrimal sac mucoceles, soft tissue opacity in the nasolacrimal duct, gross nasal polyposis, fungal sinusitis, and a dacryolith were observed by CT.
Similar to the role of functional endoscopic sinus surgery in otolaryngology, CT imaging will become increasingly important in the assessment of many patients with symptoms of lacrimal drainage obstruction.
To assess the problems associated with the Bioceramic (Aluminum oxide, Al(2)O(3)) orbital implant.
A consecutive case series of 107 patients receiving a Bioceramic orbital implant by two surgeons over a 3-year period were reviewed. The authors analyzed patient age, type of surgery, size of implant, peg system, follow-up duration, time of pegging, complications encountered, and treatment.
Seven patients were lost to follow-up after 2 months, leaving 100 patients who were followed from 3 to 38 months (average, 13.4 months). Three patients died during the follow-up period (one with 2 months' follow-up, one with 7 months' follow-up, and the third with 9 months' follow-up). Implant-related problems occurred in 11 (11%) patients. Discharge occurred in 5 (5%) patients, implant exposure in 2 (2%), socket discomfort in 1 (1%), trochleitis in 1 (1%), and conjunctival thinning in 2 (2%). Peg problems occurred in 11 (34.3%) of 32 pegged patients: discharge in 4 (12.5%) and in 1 patient (3.1%) each, pyogenic granuloma, conjunctiva overgrowing the peg, implant exposure around the sleeve, clicking, accumulation of black material, and broken peg during insertion. Infection did not occur in any patient.
The Bioceramic orbital implant represents an alternative porous orbital implant that is biocompatible with orbital tissues, easy to manufacture, structurally strong, and less expensive than other commercially available porous orbital implants (e.g., Bio-Eye hydroxyapatite implant). Problems encountered with its use are similar to those seen with the Bio-Eye orbital implants but appear to occur less often. The incidence of exposure associated with the Bioceramic implant is less than that reported for the Bio-Eye.
From 1977 through 1987, a total of 222 patients (166 male and 56 female patients) underwent surgical repair of canalicular laceration at Wills Eye Hospital. Demographic and clinical information were collected from the medical records and by written questionnaire or telephone interview. Most injuries occurred in children or young adults (median age, 20 years). Overall, blows from fists was the most common cause of injury (52 patients, 23.4%). Dog bites or scratches were the most frequent causes among children. A total of 147 injuries (66.2%) involved the lower eyelid, 61 (27.5%) the upper eyelid, and 14 (6.3%) the upper and lower eyelids on the same side. Constant or stress epiphora occurred postoperatively significantly more often among patients with combined upper and lower canalicular injuries (61.5%) than among those with single canalicular laceration (19.7%) (p less than 0.01). Analysis with logistic regression showed epiphora to be more common among adults than children (p less than 0.05) when the pigtail probe had been used intraoperatively (p less than 0.05), or when no canalicular stent had been placed at the time of surgical repair (p less than 0.05). No statistically significant associations were found between sex, cause of injury, type of canalicular stent, or time interval from injury to surgical repair and presence of postoperative epiphora.
To assess the problems and/or complications associated with the use of a synthetic hydroxyapatite implant (FCI, Cedex, France).
The authors analyzed all of the problems and/or complications associated with the use of a third-generation synthetic hydroxyapatite implant (FCI3) in 120 patients by one surgeon over 4 years. The following data were recorded: age, type of surgery performed, size of implant used, peg system used, follow-up duration, time of pegging, problems and/or complications encountered, and treatment.
Thirteen patients were lost to follow-up after 3 months, leaving 107 patients who were followed up from 4 to 48 months (average, 29 months). Discharge occurred in 21 (19.6%) patients, implant exposure in 3 (2.8%), socket discomfort in 2 (1.9%), trochleitis in 2 (1.9%), conjunctival thinning in 1 (0.93%), and pyogenic granuloma in 1 (0.93%). Peg problems occurred in 24 (35.2%) of 68 patients. Problems encountered with the peg were discharge in 10 (14.7%) patients, pyogenic granuloma in 9 (13.2%), conjunctiva overgrowing the peg in 4 (5.8%), hydroxyapatite exposure around the sleeve in 3 (4.4%), loose sleeve in 3 (4.4%), peg drilled on an angle in 1 (1.5%), implant infection in 1 (1.5%), and peg falling out in 1 (1.5%).
The FCI3 synthetic hydroxyapatite is a less costly alternative form of hydroxyapatite currently in use in many parts of the world. Problems and complications encountered with its use are similar to those seen with the Bio-Eye Integrated Orbital Implants, Inc., San Diego, CA, U.S.A. The incidence of exposure associated with the synthetic hydroxyapatite implant is lower than several other reports on the Bio-Eye. The synthetic hydroxyapatite implant is slightly softer than the Bio-Eye and fractured under extreme pressure in one case.
A 49-year-old woman with acute myeloid leukemia, FAB M1 subtype, and 12p deletion, presented with progressive right proptosis and diplopia for 1 week. Orbital CT revealed a homogenously enhancing, orbital mass engulfing the inferior rectus muscle. Histopathology revealed myeloid sarcoma for which she underwent external beam radiotherapy. Subsequently, there was no sign of local recurrence, but she succumbed to leukemia involving the central nervous system. This is the first case, to the authors' knowledge, of an orbital sarcoma of FAB M1 myeloblasts bearing a 12p deletion.
We describe the management of the eyelid anomaly associated with Patau syndrome. Trisomy 13 is the genotype of the syndrome's phenotype. The eyelid anomaly was a tarsal kink, a congenital malformation of the tarsus that causes entropion. A 2-month-old white girl presented with unilateral upper eyelid entropion and central corneal ulceration. To correct this condition, two 6-0 polyglactin sutures were passed through the gray line of the upper and lower eyelids and tied. Correction of the entropion and improvement in the corneal condition were achieved after surgery. No recurrence of the entropion or corneal ulceration was noted after 2 months of follow-up. This simple technique, which corrected the eyelid malposition, providing an excellent cosmetic result without incision of the tarsus, has been previously reported in other cases of tarsal kink but not in a patient with Patau syndrome.
Nasolacrimal outflow obstruction has been associated with high-dose (>150 mCi) radioactive iodine (I(131)) treatment. Commonly used for thyroid cancer treatment, I(131) is effectively transported in the targeted tissue by the Na(+)/I symporter (NIS). We hypothesized that NIS is expressed in the lacrimal sac and nasolacrimal duct and that active accumulation of I(131) is responsible for the clinical observations seen in these patients.
Reverse transcriptase-polymerase chain reaction and immunohistochemical analyses were used to evaluate NIS expression in both archived and fresh human tissues
Reverse transcriptase-polymerase chain reaction analysis showed that NIS mRNA is present in the lacrimal sac. Immunohistochemical analysis indicated that NIS protein is expressed in the stratified columnar epithelial cells of the lacrimal sac and nasolacrimal duct. NIS protein was undetectable in the lacrimal gland, Wolfring and Krause glands, conjunctiva, canaliculus, and nasal mucosa. NIS-expressing columnar epithelial cells were absent and fibrosis was evident in the lacrimal sacs from I(131)-treated patients undergoing dacryocystorhinostomy.
NIS is present in the lacrimal sac and nasolacrimal duct of humans, correlating to the anatomic areas of clinical obstruction that develop in patients treated with greater than 150 mCi of I(131). This suggests that NIS may be the vector of radiation-induced injury to the lacrimal system. To our knowledge, this is the first report of any ion transporter in the nasolacrimal outflow system and raises new questions as to the role the lacrimal sac plays in the modification of tears and in lacrimal outflow pathology.
To assess a new scale for grading functional disability in a series of patients operated on for blepharospasm resistant to treatment by botulinum toxin (BT) injections.
The bicentric study included 138 patients: 80 (58%) with essential blepharospasm; 46 (33%) with apraxia of eyelid opening; and 12 (9%) with intermediate forms. They had undergone orbicularis myectomy (92 cases, 67%), frontalis suspension (31 cases, 22%), or both (15 cases, 11%). Functional disability was assessed by using an original scale covering 6 daily life activities, each graded using 5 levels from 0 (no disability) to 4 (activity impossible). The score obtained was related to the total of activities actually performed to produce a functional disability score (FDS) from 0 to 100. Each patient's FDS was prospectively determined, before surgery and 3 months after surgery (M3). In patients who, after surgery, required a further course of BT injections, the FDS was assessed immediately before the third injection.
The mean FDS fell significantly, from 78 +/- 15 (standard deviation) before surgery to 45 +/- 21 at M3 (p < 0.01%), whatever the clinical form of essential blepharospasm or surgical procedure. The mean postoperative FDS was significantly lower in the 62 patients (45%) weaned off BT than in the unweaned group, respectively (31 +/- 17 versus 56 +/- 18; p < 0.01). In the latter group, the mean FDS after BT reinjection (34 +/- 19) fell to a level comparable with that of the weaned patients.
This accurate, easy-to-use scale makes it possible to quantify in patients with blepharospasm functional improvement as the result of surgery and, where applicable, of BT reinjection.
To examine whether orbital floor and/or medial wall fracture repair delayed for 15 to 29 days is as effective as early surgery.
A retrospective review is reported comparing outcomes of early fracture repairs (performed 1-14 days after trauma) to delayed fracture repairs (performed 15-29 days after trauma). Ocular motility, diplopia, and time to resolution of diplopia postoperatively are the main endpoints.
Fifty-eight patients were included in the study: 36 underwent early fracture repair (average 9 days after trauma) and 22 underwent delayed fracture repair (average 19 days after trauma). Ocular motility was equivalent in both groups, both before and after surgery. Patient reports of diplopia and frequency of strabisumus surgery were also equivalent in both groups. The time to resolution or stability of diplopia postoperatively is independent of the time to surgery within the first 29 days after trauma.
Although 14 days after trauma is commonly cited as a timeline target for orbital blowout repair, these data show that effective fracture repair can be performed up to 29 days after trauma. Patients with improving diplopia and at low risk for enophthalmos can therefore be observed for 3 to 4 weeks prior to undergoing surgery. This may help prevent unnecessary surgery in some cases. Fourteen days need not be considered a deadline for orbital floor and/or medial wall fracture repair.
To assess the problems seen in 158 patients with coralline hydroxyapatite (HA) orbital implants (Bio-Eye).
A consecutive case series of 170 patients receiving coralline HA implanted by two surgeons over a 5-year period were reviewed. The authors analyzed age, type of surgery, implant size, peg system, follow-up duration, time of pegging, problems encountered, and treatment.
Twelve patients were lost to follow-up after 5 months, leaving 158 patients who were followed from 6 to 130 months (average, 39 months). Problems in unpegged implants occurred in 36 (22.8%) patients. Discharge occurred in 18 (11.4%) patients, implant exposure in 12 (7.6%), socket discomfort in 1 (0.6%), conjunctival thinning in 3 (1.9%), chronic conjunctival swelling in 2 (1.3%), and implant infection in 3 (1.9%). Problems after pegging occurred in 68 (50.7%) of 134 patients: discharge in 27 (20.1%), pyogenic granuloma in 24 (17.9%), conjunctiva overgrowing the peg in 4 (3.0%), implant exposure around the sleeve in 5 (3.7%), clicking in 6 (4.5%), peg on an angle in 2 (1.5%), loose sleeve in 1 (0.7%), peg falling out in 18 (13.4%), popping peg in 1 (0.7%), poor transfer of movement in 3 (2.2%), pain with movement in 1 (0.7%), and implant infection in 2 (1.5%).
The Bio-Eye orbital implant represents a porous orbital implant that is biocompatible with orbital tissues and allows fibrovascular ingrowth and improved motility when coupled to the overlying artificial eye. It is more expensive than other commercially available porous orbital implants, such as synthetic FCI3 HA, porous polyethylene (Medpor), and aluminum oxide (Bioceramic) implant. Problems encountered with its use are similar to those problems seen in patients with the synthetic FCI3 hydroxyapatite and aluminum oxide orbital implants.
Vicryl mesh (polyglactin-910) implants were used to reconstruct the orbital floor to correct enophthalmos or hypo-ophthalmos (globe ptosis) in 16 patients. The main advantages of Vicryl mesh over other alloplastic implants is that (a) it is absorbed by host tissue, and, once absorbed, it will not cause long-term complications; (b) it is layered and is cut from folded sheets into the appropriate size, shape, and thickness for the treatment of enophthalmos or hypo-ophthalmos; and (c) it is soft and pliable and, therefore, is unlikely to erode orbital structures. We followed all patients for a minimum period of 6 months after surgery and observed no significant adverse reactions to the mesh; 15 of the patients had good surgical results with a mean improvement of 1.4 mm in enophthalmos and 0.6 mm in hypo-ophthalmos. After surgery, one patient with combined medial wall and floor fractures developed enophthalmos that was 2 mm more severe than the degree of preoperative enophthalmos. Vicryl mesh should be considered an alternative to both nonautogenous implants and autogenous grafts in orbital floor fracture repair especially for correction of mild and possibly moderate degrees of enophthalmos and hypo-ophthalmos.
A 16-year-old girl presented with diplopia and gradual-onset, painless proptosis of the left eye. Orbital CT showed a well-circumscribed, enhancing, extraconal mass in the superior orbit, and the surgical excision was performed. Histopathology was interpreted as capillary hemangioma. Five years later, her symptoms recurred, and she was referred to the Oncology Service, Wills Eye Institute. Repeat orbital MRI showed a well-defined, extraconal mass with loculated areas of enhancement in the left orbit superonasally. Complete surgical excision was performed. Histopathologic examination showed benign, patternless spindle-cell proliferation with prominent intrinsic vascularity and multinucleated giant cells, consistent with giant cell angiofibroma, a variant of solitary fibrous tumor. There was intense immunoreactivity for CD34. After 20 months follow-up, there was no recurrence or development of metastasis. Giant cell angiofibroma, a variant of solitary fibrous tumor, is a rare orbital tumor that presents as a well-circumscribed, enhancing mass and can be found in children.
Pilomatrixoma is a benign tumor of the hair follicle, occurring more frequently in the head and neck. There are relatively few published large case series in the ophthalmic literature. The purpose of this study was to evaluate additional case series of patients with periocular pilomatrixoma, treated in the institute from 1995 to 2011.
A retrospective analysis of all cases with periocular pilomatrixoma treated during 16 years was made. Data were collected regarding the age at the time of excision, gender, tumor location, tumor dimensions, suspected clinical diagnosis before biopsy, gross appearance, histopathological features, treatment, recurrence, and other syndromes related and family occurrence.
Only 16 cases with pilomatrixoma were treated during 16 years. Most of the cases (69%) presented in the first 2 decades of life with female predilection (62.5%). The most common affected site was the upper eyelid (62.5%). All patients were asymptomatic. Various diagnoses were suspected clinically prior to surgical removal and histopathological confirmation of the tumor, and only in 18.75%, pilomatrixoma was suspected. Simple resection was carried out in all cases. No recurrence or malignant transformation was reported.
Pilomatrixoma is a relatively infrequent periocular tumor, which isn't usually recognized clinically. The findings of the current case series, which is one of the largest published thus far in the ophthalmic literature, are in concordance with the other series of pilomatrixoma, confirming the epidemiologic, clinical, and histopathological features of this tumor in the periocular region.
Primary melanoma of the optic nerve is rare. Limited reports in the literature have been the subject of considerable controversy, as many of these melanomas have later been found to be metastatic disease or local extensions of a juxtapapillary choroidal melanoma. Moreover, these have often been reported in patients with a history of ocular or oculocutaneous pigmentary disorders. The authors present a case of primary melanoma of the optic nerve in a patient with no history of pigmentary disorder and 16 years of follow up.
A total of 145 patients with orbital dermoid cysts examined at the Orbital Clinic, Institute of Ophthalmology, School of Medicine, University of Naples "Federico II" over a period of 16 years were reviewed. The orbital cysts were classified as exophytic and endophytic, according to their site of attachment in relation to the orbital rims. This classification can explain the different natural history of these lesions. The exophytic cysts growing externally are discovered in childhood, whereas the endophytic ones are discovered later in life when they produce bone damage, with or without invasion of the adjacent structures.
To investigate the role of orbital computed tomography (CT) in the evaluation of patients after dacryocystorhinostomy (DCR).
Computed tomography scans of patients who underwent both successful and failed DCR were examined to determine the relationship of the soft-tissue changes to the surgical ostium, and the findings were correlated with postoperative results of office probing and irrigation.
After a successful DCR (n = 7), a patent fistulous tract was confirmed by office probing and irrigation. A characteristic "Y-on-its-side" configuration of the soft tissue was noted on a CT scan. Total occlusion of the osteotomy by soft tissue on probing and irrigation corresponded to a mucocelelike soft-tissue density with a central lucency and soft-tissue obstruction (n = 2). Total occlusion of the osteotomy by inadequate excision of bone and adjacent soft tissue, visualized by CT imaging, was confirmed by palpation of bone by office probing (n = 1). Partial obstruction on probing and irrigation was associated on a CT scan with an increased soft-tissue density (n = 4) and bone in the region of the osteotomy (n = 3).
Computed tomography allows visualization of a patent fistula after successful DCR as well as soft-tissue or bone obstruction of the surgically created fistula after failed DCR. When combined with probing and irrigation, CT helps to formulate a surgical plan after failed DCR.
Castleman's disease is an atypical lymphoproliferative disorder comprising hyaline vascular elements, plasma cells, or a mixture of both, which can present in unicentric or multicentric fashion. Resection of unicentric lesions is typically curative, but multicentric disease, also characterized by constitutional symptoms and a poorer prognosis, often requires treatment with chemotherapy, radiation, steroids, or immune modulators. Castleman's disease is rarely diagnosed in the orbit. The authors present the clinical and histopathological findings of a 17-year-old who was found to have a focal lesion in her orbit. She was successfully treated with surgical resection and was free of disease recurrence or other sequelae at 10-months follow up.
Canalicular lacerations are frequently found in conjunction with other facial lacerations occurring in dog bite injuries. A review of the treatment of 17 dog bite-induced canalicular lacerations is presented. Certain pathogens commonly found in the canine oral flora may cause severe secondary infections, which may result in sepsis and even death. These pathogens are reviewed along with a description of appropriate plans for antimicrobial prophylaxis. A surgical approach to such injuries is described.
A healthy, 17-year-old boy presented with a 2-month history of an epibulbar mass on the left eye. Slit lamp examination showed an amelanotic, translucent, round, well-circumscribed, superonasal subconjunctival nodule. On ultrasound biomicroscopy, the tumor was acoustically hollow. The lesion was excised intact, and cryotherapy was applied to the surrounding conjunctiva. Histopathologic examination revealed a tumor composed of spindle cells with slender cytoplasmic processes and bland cigar-shaped nuclei, consistent with schwannoma. Immunohistochemistry showed positivity for S100 protein. The patient had no signs of neurofibromatosis. There was no tumor recurrence after 18 months. This case shows that conjunctival schwannoma can present as a translucent, well-circumscribed subconjunctival mass.
To report patient outcomes after placement of porous polyethylene (PPE)/bioglass (BG) orbital implants for primary enucleation or secondary implantation.
Retrospective chart review in one surgeon's practice (J.D.N.).
A chart review of all patients who underwent placement of PPE/BG orbital implants was performed. Data included patient's age, gender, surgical indication, prior ocular surgery, medical history, procedure performed, implant size, and postoperative complications.
PPE/BG implants were placed in 170 sockets. Seventy-seven patients were women, and 85 were men. One hundred forty patients underwent primary enucleation and placement of an implant, and 22 patients underwent secondary implantation. One hundred sixty-one patients did well after orbital implantation with a comfortable socket, quiet conjunctiva, and motility. Complications occurred in 9 patients (5.3%). Excessive discharge alone occurred in 2 patients (1.2%). Seven sockets undergoing primary enucleation and implant placement had implant exposure. One patient had an early exposure, and 6 had late exposures. All exposures were successfully treated with antibiotics or additional surgery. Secondary surgeries were required by some patients, but not due to implant complications, included ectropion repair in 5 patients (2.9%) and volume augmentation in 3 patients (1.7%).
The PPE/BG orbital implant may be a useful implant for orbital reconstruction after primary enucleation or as a secondary implant.
The aim of this study was to introduce the use of the 18-gauge hypodermic needle as a simple and cost-effective alternative tool in frontalis silicone suspension ptosis surgery.
A retrospective, interventional, noncomparative case study was performed by reviewing 64 patients (82 eyes) who underwent this technique between February 2010 and January 2011. Patients with simple, severe congenital ptosis with poor levator excursion were included in the study. Patients with prior sling and levator resection surgery were excluded. All patients underwent unilateral or bilateral frontalis sling surgery with a silicone rod placed via a closed-incision pentagonal configuration. All surgeries were performed by a single surgeon at a tertiary referral institute using the 1.5 inch hypodermic 18-gauge needle as an insertion guide for the silicone rod. Intraoperative technique, ease of surgical maneuverability, operative time, and postoperative results and complications were noted.
The mean patient age was 10.3 years (range: 1-28 years). Fifty-six of 64 patients (87.5%) were between the ages of 1 and 18 years (mean: 8.5 years), and 8 of 64 (12.5%) between 9 and 28 years (mean: 23 years). Forty-two of 64 (65.7 %) patients were female and 22 of 64 (34.4%) were male. Forty-six of 64 (71.9%) patients underwent unilateral frontalis sling surgery and 18 of 64 (28.1%) patients underwent bilateral surgery. Follow up ranged from 12 to 18 months. In 2 of the 82 eyes (2.4%), the sharp end of the needle cut the silicone rod while introducing the needle from the medial suprabrow stab incision to the eyelid margin end in a closed technique, requiring replacement of the silicone rod. Average surgical time was 15 minutes for unilateral cases and 30 minutes for bilateral cases. The main advantages noted intraoperatively were the small incisions that allowed for less operative time and minimal bleeding, easy maneuverability and control of the needle during tissue passage, and smooth threading of the silicone rod. Blunting of the tip is also eliminated as the needles are disposable.
The 18-gauge hypodermic needle is a simple and cost-effective alternative to other needles used in frontalis silicone sling ptosis surgery. Its low cost and easy accessibility make it a particularly quick and useful option in community-based practices, tertiary referral centers, and large medical eye camps globally.
We read with interest the article titled “The 18-Gauge
Needle: An Innovative Simple Tool for Frontalis Sling Surgery”
that was published in the Ophthalmic Plastic and Reconstructive
Surgery journal.1 We would like to congratulate the authors for
introducing yet another useful version of using an 18-gauge
needle for silicone sling surgery among others.2,3
The authors have used the silicone rod provided by BD
Visitec that comes with a preswaged needle at either end. The
main disadvantage of this preswaged 20-gauge needle is its excess
malleability, which makes the passage difficult. The authors have
detached the silicone rod from the needle to feed it through a
disposable 18-gauge needle into a pentagon fashion and report
a reduced intraoperative time. We believe that the time taken to
detach the silicone sling from the needle and thread the much
flexible silicone rod into the 18-gauge needle is more likely to
slow down the procedure. We have been following the alternative
technique of retaining the preswaged needle, and “railroading”
it with a disposable 18-gauge needle passed from the opposite
stab incision (Fig.). This technique has worked well for us, while
retaining all the advantages of using an 18-gauge needle.
Since the BD Visitec silicone rod is available with preswaged
needle at either end, and a length sufficient for a bilateral
surgery, it may not be necessary to detach the silicone from the
needle unless one is using an indigenous cost-effective spool of silicone
rod for multiple cases. Such situations of a surgical “camp”
are certainly on the decline, even in developing countries. The only
situation where one might want to use the technique described by
the authors is during a revision surgery, where the same silicone rod
is being reused to make a fresh pass along the incisions.
We have experienced that using the 18-gauge needle
to enter from a smaller incision (lateral/medial brow stab) to
a larger one (central brow stab) certainly reduces the chances
of “dimpling” due to dermal entrapment that can occur in the
Finally, we would like to mention an additional use of
18-gauge needle in performing a transnasal wiring for medial
canthal dystopia (Fig.). The sharp tip of the needle helps penetrate
the bone easily, without the need for mechanized drilling
across the nasal bridge. It allows controlled and easy passage
of 26-gauge stainless steel wire or 4-0 polypropylene suture for
We commend the authors for sharing their experience
and propose that railroading might be a quicker option. We hope
that this correspondence reaches BD Visitec, and we have a less
malleable preswaged needle in the near future!
Malignant peripheral sheath tumor (malignant PNS tumor) is a rare, aggressive, and lethal orbital neoplasm that usually arises from sensory branches of the trigeminal nerve in adults. Malignant PNS tumor spreads along nerves to involve the brain, and most patients die within 5 years of clinical diagnosis. The clinical history and examination, imaging studies, surgical procedures, and pathologic specimens of a 23-year-old man with rapid, posttraumatic onset of left orbital proptosis and pain are reported. Biopsy specimens of the tumor were compared with specimens from the same orbit obtained 18 years previously. Histopathology of the left orbital tumor compared with that of an incomplete excision of a tumor 18 years previously in the same orbit revealed both to be malignant PNS tumor. The patient is alive without recurrence 8 months after orbital exenteration and 18 years after initial tumor presentation. This is the youngest age of occurrence and the longest documented survival of a patient with orbital malignant PNS tumor.
The SupraFOIL smooth nylon foil implant is a polyamide sheet available in varying thicknesses that has been used in orbital reconstruction following trauma. The authors report their experience with smooth nylon foil implants in the repair of orbital fractures.
A retrospective chart review of patients having undergone repair of orbital fractures between January 1, 1995 and December 31, 2003 was conducted. The Wilcoxon test was used to compare cases with complications and those with no complications.
Of 282 orbits that underwent fracture repair with alloplastic material, 87 were excluded because non-nylon foil implants were used alone or in combination with nylon foil to repair the orbital fracture. An additional 14 fractures were excluded because of insufficient clinical data or lack of follow-up, for a total of 181 orbits that underwent orbital fracture repair with only nylon foil. A transconjunctival approach was used in 98% cases, and all 181 implants were fixated with at least 1 titanium screw. Average follow-up was 362.8 days. The overall complication rate was 1.7%. One patient had an acute postoperative orbital hemorrhage (0.6% acute complication rate). Two patients had late orbital infections, 683 days and 984 days following repair (1.1% late complication rate).
The authors found the smooth nylon foil implant to be safe and effective in orbital fracture repair. The lower rate of complications the authors observed compared with previously reported series may be related to implant fixation. A titanium screw secured just posterior to the orbital rim may decrease long-term complications by providing more stability than implants left without fixation.
A 47-year-old woman with a history of invasive ductal carcinoma in the right breast reported decreased vision in the OD for the past 3 months. Her best corrected visual acuity was 0.1 OD and 1.0 OS. T1-weighted MRI revealed enlargement of the right lateral rectus muscle with a faint tumor outline and no contrast enhancement in the lesion. F-fluorodeoxyglucose positron emission tomography did not demonstrate intense uptake at the lesion. Because the patient demonstrated optic neuropathy due to compression by the enlarged muscle, balanced orbital decompression (of the deep lateral and medial orbital walls) was performed simultaneously with a tumor biopsy. Visual acuity of the OD was dramatically improved to 1.0. The histopathological examination demonstrated similar findings to her breast carcinoma. F-fluorodeoxyglucose positron emission tomography does not always show a positive result for an orbital tumor that has metastasized from the breast.
To study the predictive value of the initial quantified relative afferent pupillary defect (RAPD) in patients with indirect traumatic neuropathy as it relates to final visual outcome.
The RAPD was measured and quantified by neutral density filters in patients with unilateral indirect traumatic neuropathy. All patients were treated with megadose methylprednisolone by of the protocol established by the Second National Acute Spinal Cord Injury Study. Patients were followed twice daily during treatment and then at 3-month intervals.
Nineteen patients were enrolled over a 23-month period. Patients ranged in age from 12 to 78 years old; 18 of the 19 patients were male. No patient with an RAPD of 2.1 log units or greater had visual recovery to better than hand motion vision. The 7 patients with an initial RAPD of less than 2.1 log units showed improvement in their RAPD and were found to have vision of 20/30 or better during the follow-up period.
In patients treated with megadose methylprednisolone with an initial RAPD of less than 2.1 log units, visual acuity improved to 20/30 or better; however, patients with an initial RAPD of 2.1 or greater showed little visual improvement. The initial quantified RAPD appears to have a predictive value related to final visual outcome.
: To evaluate the frequencies of orbital space-occupying lesions seen at single orbital unit in a period of 35 years.
: In this retrospective case series, the authors reviewed the medical records of 2,480 consecutive patients referred to the authors' Orbital Unit for evaluation of an orbital mass between 1976 and 2011. The final diagnosis in each case was established by a combination of history, ocular findings, diagnostic imaging, and histopathologic analysis, when available. The number and percentage of benign and malignant tumors were determinated, also according to the age of the patients and the tumor location within the orbit. This study adhered to the principles of the Declaration of Helsinki.
: Of the 2,480 lesions, 1,697 (68%) were benign and 783 (32%) were malignant. The most frequent benign tumors were dermoid cyst (14%) and cavernous hemangioma (9%). The most common malignant tumors were non-Hodgkin lymphoma (12%), basal cell carcinoma (3%), and orbital metastases (3%). In patients younger than 60 years, benign tumors are more frequent, whereas in patients older than 60 years, the frequency of malignant tumors increased. Regarding the distribution in the orbit, the most common tumors were dermoid cyst (206 cases) in the upper-outer quadrant, mucocele (155 cases) in the upper-inner quadrant, basal cell epithelioma (35 cases) in the lower-inner quadrant, cavernous hemangioma (68 cases) in the lower-outer quadrant, and meningioma (90 cases) in central space. Most of the tumors were located in the upper-outer quadrant. In the lower-inner quadrant, malignant tumors were more frequent than benign tumors.
: The authors' findings highlight the distinctive nature of the orbital oncology experience at an ocular oncology department.
To describe the incidence, patient demographics, and response to treatment of benign essential blepharospasm (BEB) in a population-based cohort.
In this epidemiologic study, we searched the Rochester Epidemiology Project database for patients diagnosed with blepharospasm or related disorders between 1976 and 1995. The incident rate denominator was based on a linear interpolation of decennial census data from Olmsted County. The 95% confidence interval for the incidence rate was based on the Poisson distribution.
Olmsted County residents (n = 295) were diagnosed with blepharospasm or related disorders between 1976 and 1995. Of these, 8 patients met the criteria for BEB. The calculated incidence rate of BEB is 1.2 persons per 100,000 population per year (95% CI, 0.37 to 2.02). At the time of BEB diagnosis, the median patient age was 61.5 years, and symptoms had been present for a median of 24 months. Four patients were men and 4 were women. Four of the 8 patients had Meige syndrome. Three of 4 patients treated with oral medications reported symptomatic improvement. Botulinum toxin injection was offered to all patients, but only 4 elected treatment. All who were treated with botulinum toxin had temporary symptomatic improvement. No patient underwent surgical treatment for BEB. Two patients had resolution of symptoms within the follow-up period.
BEB is a rare disorder. In this small, population-based sample, women and men were affected with equal frequency, and half of patients had lower facial dystonia (Meige syndrome). Only half of patients with BEB elected botulinum toxin injections, and none required surgery. Disease remission occurred in 2 of 8 patients.
To determine the efficacy of eyelid protractor myectomy (subtotal excision of the orbicularis oculi, the corrugator supercilii, and the procerus muscles) for the treatment of essential blepharospasm, and to evaluate the need for and the effectiveness of botulinum toxin (BT) injections in these patients.
The medical records of all patients who underwent eyelid protractor myectomy at the Mayo Clinic (Rochester, MN) from 1980 through 1995 were reviewed. The Health Status Questionnaire was used to assess overall medical and mental health, and a questionnaire specific to eyelid spasms was developed.
Fifty-four white patients, of whom 32 (59%) were women, underwent myectomy. The average age at diagnosis of essential blepharospasm was 64 years (median, 65 years; range, 43 to 84 years), whereas the average age at the time of myectomy was 66 years (median, 66 years; range, 51 to 85 years). Of the 14 patients who were treated with BT injections before myectomy, the average interval between the initial injection and surgery was 21 months (median, 20 months; range, 2 to 51 months). Patients who had been treated with BT injections before myectomy were more likely to receive injections postoperatively than were those patients who had not been treated with BT (p < 0.001). Twenty patients were treated with BT injections after myectomy; the overall probability of receiving BT five years after surgery was 46%. Time from myectomy to treatment with BT varied considerably; mean, 880 days; median, 659 days; range, 3 to 4221 days. Postoperative follow-up for those patients who did not receive BT after myectomy ranged from 2 to 5935 days (mean, 2354 days; median, 1722 days). Although the probability of receiving BT injections after myectomy was not associated with age or sex, there was a significant association with the time interval during which the myectomy had been performed (related to the availability of BT as an adjunctive therapy). Of the 41 patients who were alive when the study was conducted, 32 (78%) completed a follow-up survey. Thirty of those (94%) said myectomy provided short-term and long-term benefits. Of the 11 patients who received BT injections before and after myectomy, six (55%) said the toxin was more effective in ameliorating eyelid spasms after surgery and four (36%) required injections less frequently after myectomy. Results from the Health Status Questionnaire showed no significant differences between patients who underwent myectomy and control subjects.
Eyelid protractor myectomy provides subjective benefit to patients with essential blepharospasm and decreases the long-term need for BT injections in approximately 50% of these patients. Although the probability of receiving postoperative BT paralleled its availability, patients who received both preoperative and postoperative BT perceived either increased efficacy of the toxin injections, longer-lasting effects, or both, after myectomy. Patients with severe disability from blepharospasm benefited more from myectomy than did patients with relatively mild symptoms.
Developmental abnormalities of the eyelids are reviewed, with special reference to abnormalities of the medial canthus. Included are Waardenburg's syndrome, the four types of epicanthus, hypertelorism, epiblepharon superioris and inferioris, and entropion. Various methods of repair are described, including Y-V and V-Y procedures, the double Z plasty, the W plasty, fascial slings, and skin grafts. Craniofacial deformities and trauma are not discussed. (C)1986The American Society of Opthalmic Plastic and Reconstructive Surgery, Inc.
To present data regarding the rate of upper eyelid blepharoplasty in the Medicare population at both the national and the regional levels from 1995 to 1999 and to analyze these data for any correlation with reimbursement, surgical criteria differences, or the number of ophthalmologists per capita.
This was a retrospective cohort study. The subjects consisted of a 5% random sample of the Medicare population who had blepharoplasty from 1995 to 1999. Number, rate, and reimbursements of blepharoplasty of the 10 Health Care Financing Administration (HCFA) regions were compared for the 5-year period. Number of ophthalmologists per capita and differences in the regional criteria for Medicare-approved upper eyelid blepharoplasty were compared among the 10 HCFA regions.
Across the nation, there was a 13% annual increase in the rate of blepharoplasty from 1995 to 1999 in the Medicare-population after adjusting for age, race, sex, and HCFA regions. During the same period, the average reimbursement per surgery decreased by $26.50 annually. There was a statistically significant inverse correlation between reimbursement and rate of blepharoplasty at the national level (r= - 0.74, P< 0.001). On the regional level, this relation was less profound (r= -0.29, P= 0.039). There was no correlation between the rate of blepharoplasty and the number of ophthalmologists per capita or the differences in surgical criteria.
The inverse relation between rate of Medicare-approved blepharoplasty and reimbursement between 1995 and 1999 was evident at both the national and regional levels. No relation between regional differences in the rates of blepharoplasty and regional differences in surgical criteria or the number of ophthalmologists per capita were identified. Though our study suggests no causal link between annual rate of blepharoplasty and Medicare reimbursement, such inverse correlation is interesting and may have been affected by other factors such as changing clinical indications for this procedure.
The dermoid cyst is one of the most common space-occupying orbital lesions, but there has been no large series that details the clinical, pathologic, and therapeutic aspects of this condition. Furthermore, despite the various presentations and types of dermoid cysts, there is no clinically applicable classification of these lesions. We performed a retrospective histopathologic study of 197 consecutive orbital and periorbital dermoid cysts excised at Wills Eye Hospital during a 32-year period, correlated the histopathologic findings with the recorded clinical and radiographic observations, and devised a clinically applicable classification of orbital dermoid cysts. The mean age at excision was 17 years (range, 5 months to 85 years), and the most frequent clinical finding was a painless subcutaneous mass, present in 89% of cases. In 72% of patients, the mass was located in the superotemporal orbital region and produced no abnormalities of vision or intraocular pressure. Computed tomography and magnetic resonance imaging, performed mainly in the more recent cases, disclosed a characteristic round to ovoid cystic lesion with a well-defined lining. Histopathologically, 165 of the cysts (84%) were lined by keratinizing, stratified squamous epithelium. Ten (5%) were lined by nonkeratinizing epithelium resembling conjunctival epithelium. Hair shafts were present in the wall or lumen of the cyst in 195 (99%) of specimens, sebaceous glands in 148 (75%), and sweat glands in 39 (20%); inflammation was present in 75 cases (38%). Based on these personal observations and a review of the literature, a classification of orbital dermoid cysts is proposed that we believe will provide guidance for the ophthalmologist in the management of these lesions.
To report five patients with intraocular invasion of conjunctival squamous cell carcinoma and to make recommendations regarding clinical recognition and treatment of this condition.
The authors reviewed the clinical records and pathology slides on five patients who had intraocular invasion of conjunctival squamous cell carcinoma, and they describe the presenting features and histopathology in these cases.
Intraocular invasion of conjunctival squamous cell carcinoma occurred in older patients who had one or more recurrences of a previously excised conjunctival epithelial tumor located near the comeoscleral limbus. The intraocular recurrence often was heralded by the onset of low-grade inflammation and secondary glaucoma, simulating a granulomatous iridocyclitis. A white mass generally was observed in the anterior chamber angle. Histopathologic examination revealed an ingrowth of malignant epithelial cells through the limbus with diffuse involvement of the anterior segment of the eye. The reported patients were managed by modified enucleation (standard enucleation with excision of affected conjunctival tissue). Metastatic disease did not develop in any of the patients.
The onset of signs of uveitis and glaucoma and a white mass in the anterior chamber angle in a patient with prior excision of a conjunctival squamous cell neoplasm tumor should raise suspicion of intraocular recurrence of conjunctival squamous cell carcinoma. Most affected patients require enucleation or subtotal orbital exenteration. The prognosis is good.