Eyelid masses: a 10-year survey from a tertiary eye hospital in Tehran

The purpose of this study was to evaluate the demographics and clinical features of eyelid masses in a tertiary eye hospital over a 10-year period. A retrospective chart review was performed for patients admitted with eyelid tumors from 2000 to 2010. Data were collected and analyzed on the demographic features, location of the tumor, types of treatment, and pathologic findings. A total number of 182 patients were evaluated of which, 82 cases were benign and 100 cases were malignant neoplasms. The most common benign tumors included melanocytic nevi [35%], papilloma [19.5%], and cysts [11%]. The most frequent malignant tumors included basal cell carcinoma [BCC] [83%], squamous cell carcinoma [8%] and sebaceous gland carcinoma [6%]. The most common site for malignancy was the lower lid followed by the upper lid. BCC recurred in 16 cases that were most frequent in the lower lid. Melanocytic nevus, papilloma and cysts are the most common benign lesions and BCC is the most common malignant lesion in the eyelids. Recurrence is a feature of BCC especially in the lower lid

Recurrent orbital cavernous hemangioma due to overlooked multiple tumors

To report late recurrence of orbital cavernous hemangioma in a patient ten years after complete resection of the primary tumor. A 32-year-old woman with a history of progressive visual loss and proptosis underwent lateral orbitotomy for resection of a large cavernous hemangioma. Ten years later, proptosis recurred and the patient developed progressive ocular deviation. Imaging studies were in favor of a recurrent cavernous hemangioma and the tumor was excised via the previous incision site. Reassessment of previous orbital images suggested the presence of two separate tumors, only one of which had been excised at the time of initial surgery. Recurrent orbital cavernous hemangioma may follow incomplete excision of multiple orbital lesions with gradual growth of unidentified residual tumors. Accordingly, when an encapsulated cavernous hemangioma is removed, exploration is recommended to rule out multiple lesions.

Outcomes of Levator Resection at Tertiary Eye Care Center in Iran: A 10-Year Experience

PURPOSE: To assess outcomes of levator resection for the surgical correction of congenital and acquired upper lid ptosis in patients with fair to good levator function and evaluation of the relationship between demographic data and success of this operation. METHODS: In a retrospective study, medical records of patients with blepharoptosis who had undergone levator resection over a 10-year period and were followed for at least 3 months were reviewed. RESULTS: Overall, 136 patients including 60 (44.1%) male and 76 (55.9%) female subjects with a mean age of 20 +/- 13.8 years (range, 2 to 80 years) were evaluated, of whom 120 cases (88.2%) had congenital ptosis and the rest had acquired ptosis. The overall success rate after the first operation was 78.7%. The most common complication after the first operation was undercorrection in 26 cases (19.1%), which was more prevalent among young patients (p = 0.06). Lid fissure and margin reflex distance (MRD1) also increased after levator resection (p < 0.001). Age, sex, type of ptosis, amblyopia, levator function, MRD1, lid fissure and spherical equivalent were not predictive of surgical outcomes of levator resection. CONCLUSIONS: Levator resection has a high rate of success and few complications in the surgical treatment of congenital and acquired upper lid ptosis with fair to good levator function. Reoperation can be effective in most cases in which levator resection has been performed.

Clinical features and outcomes of treatment for fourth nerve palsy

To evaluate the clinical features, etiology and outcomes of treatment for superior oblique [SO] palsy over a 10-year period at Labbafinejad Medical Center. A complete ophthalmologic examination with particular attention to forced duction test [FDT] and tendon laxity was performed in all patients preoperatively. The palsy was divided into congenital and acquired types. Overall, 73 patients including 45 male [61.6%] and 28 female [38.4%] subjects with mean age of 19.7 +/- 11.7 [range, 1.5-62] years, were operated from 1997 to 2007. SO palsy was congenital in 56 [76%] and acquired in 17 [24%] cases. The most common chief complaint was ocular deviation [52.1%]. FDT was positive in only 7 [9.7%] cases. Other clinical findings included amblyopia [19.2%] head tilt [13.7%], chin down position [4.1%], facial asymmetry [6.8%] and tendon laxity [2.7%]. Mean preoperative vertical deviation was 16.1 prism diopters [PD] which was decreased to 1.9 PD postoperatively. Mean exotropia and esotropia were 15 and 13.9 PD respectively before the operation and both decreased to 1.5 PD of horizontal deviation postoperatively. The most common type of SO palsy based on Knapp's classification was type 3 [42.5%]. The most common operated muscle was the inferior oblique [83.6%] and the most common type of operation was inferior oblique myectomy [83.6%]. The success rate for initial surgery was 84% and was increased to 96% with a second intervention. The most common form of SO palsy requiring surgical intervention was congenital which occurred most frequently in young males. Most cases of SO palsy can be successfully treated with a single surgical procedure

Outcomes of surgical and non-surgical treatment for sixth nerve palsy

To report the outcomes of surgical and non-surgical treatment in sixth nerve paresis and palsy. This retrospective study was performed on hospital records of 33 consecutive patients [37 eyes] with sixth nerve dysfunction who were referred to Labbafinejad Medical Center from September 1996 to September 2006, and underwent surgical procedures or botulinum toxin injection. Patients were divided into three groups: group A had muscle surgery without transposition, group B underwent transposition procedures and group C received Botulinum toxin injection. Overall, 33 patients including 19 male and 14 female subjects with mean age of 20.4 +/- 17.2 years [range, 6 months to 66 years] were studied. Eye deviation improved from 50.3 +/- 16.8 to 6.0 +/- 9.8 prism diopters [PD] after the first operation and to 2.5 +/- 5.0 PD after the second operation in group A, from 56.9 +/- 24.3 to 5.5 +/- 16.0 PD after the first procedure and to almost zero following the second in group B, and from 44.3 +/- 10.5 to 15.0 +/- 20.0 PD 6 months following botulinum toxin injection in group C. Head posture and limitation of motility also improved significantly in all three groups. The overall rate of reoperations was 21%. Various procedures are effective for treatment of sixth nerve dysfunction; all improve ocular deviation, head turn and abduction deficit. The rate of reoperation is not high when treatment is appropriately selected according to clinical condition

[Isolated eyelid involvement as a rare presentation of orbital pseudotumor]

To report a case of isolated eyelid pseudotumor. A 40-year-old man presented with swelling and erythema of the right upper eyelid of 4 months duration. Multiple topical and systemic antibiotics had been administrated without any response. Incisional biopsy and evaluation of the lesion disclosed a diagnosis of eyelid pseudotumor. Oral prednisolone was initiated and then tapered slowly on the basis of clinical response. After six months, the eyelid lesion disappeared totally. Isolated eyelid involvement is a rare presentation of inflammatory pseudotumor of the orbit and should be considered in the differential diagnosis of eyelid lesions

[Orbital echinococcosis with two different features; hydatid and alveolar cysts]

To present two patients with hydatid and alveolar cysts of the orbit and to present their clinical, imaging, pathologic and therapeutic features. Two young children from rural areas were referred for progressive proptosis. Imaging showed intraorbital cysts. They were operated on with a clinical suspicion of hydatid and alveolar cysts. Pathologic evaluation confirmed the diagnoses in both instances. Clinical findings and imaging before the operation help the diagnosis of orbital echinococcosis. Knowing the nature of these lesions can prevent surgical complications. Alveolar cysts are much more invasive than hydatid cysts and their treatment is more difficult

Late probing for congenital nasolacrimal duct obstruction

To report the results of late nasolacrimal duct probing in patients with congenital nasolacrimal duct obstruction [NLDO]. This retrospective study was performed on a consecutive series of patients with congenital NLDO who underwent late [after 15 months of age] nasolacrimal duct probing for the first time. Over a period of five years, 158 patients including 75 [47.4%] male and 83 [52.6%] female subjects with mean age of 3 +/- 4.2 years [range, 15 months to 37 years] underwent initial probing for NLDO. Nasolacrimal duct probing was performed unilaterally in 78% and bilaterally in 22% of the patients. Success rate was 75% overall, 72% in unilateral cases and 83% in bilateral instances. Success rate was not correlated with age at intervention. Nasolacrimal duct probing seems to be reasonably successful for treatment of congenital NLDO in patients older than 15 months who are seen for the first time. Silicone intubation or dacryocystorhinostomy should be reserved for refractory cases

Effect of horizontal rectus surgery on clinical and paraclinical indices in congenital nystagmus

To determine the effect of horizontal rectus muscle surgery on visual acuity, head posture and electronystagmographic indices in patients with congenital nystagmus. This prospective comparative case series was conducted on 58 patients with congenital nystagmus over a period of three years. Patients were divided into three groups: the first group [29 cases] had head posture less than 20D, binocular visual acuity [BOVA] less than 20/30 and tropia less than 30D and underwent large recession of all four horizontal rectus muscles; the second group [23 cases] had head posture less than 20D, BOVA < 20/30 and tropia more than 30D who underwent large recession of two horizontal rectus muscles; and the third group [6 cases] had head posture more than 20D with any BOVA or tropia who underwent Kestenbaum-Anderson surgery. Mean age of the patients was 18.7 +/- 9.1 years and mean follow-up period was 17.5 +/- 7.4 months. Visual acuity improved in all three study groups and was statistically significant in the 2-rectus group [P < 0.001]. The speed and amplitude of nystagmus waves decreased in all groups which was statistically significant in the 4-rectus group [P values, 0.02 and 0.04, respectively]. A small myopic shift was seen in the 2-rectus and 4-rectus groups and a small hyperopic shift was found in the Kestenbaum-Anderson group. Statistically significant improvement was achieved in eye deviation in the 2-rectus group and in head posture in the Kestenbaum-Anderson group [P < 0.001]. Horizontal recti surgery in congenital nystagmus can improve visual acuity, ocular deviation and abnormal head posture, which is particularly marked with 2-rectus recession. Electronystagmographic indices improve especially with 4-rectus recession

Primary placement of titanium peg on hydroxyapatite orbital implant

To determine the efficacy of primary placement of a titanium sleeve and peg on hyroxyapatite [HA] orbital implants. This retrospective non-comparative interventional case series was performed on 34 patients undergoing enucleation. A standard enucleation technique with primary HA implantation was performed, in which titanium sleeve and peg were placed primarily during the initial surgery. The patients were visited one, three and six months after placement of the prosthesis for evaluating complications and prosthesis movement. Twelve patients [35.3%] had one or more complications including discharge [26.4%], peg drilled off center [23.5%]; conjunctival overgrowth [11.8%], implant and peg exposure [each in 8.8%], sleeve extrusion, conjunctival thinning, peg on an angle and conjunctival cyst [each in 5.9%] and sleeve obstruction [2.9%]. Movement of the prosthesis [2-3[+]] was achieved in 97% of the cases in supraduction, infraduction, abduction and adduction. Primary peg placement at the time of enucleation with the HA implant is a promising technique with relatively minor complications

[Lacrimal drainage obstruction as an early presentation of lacrimal sac lymphoma]

To report a case of lacrimal sac lymphoma presenting with nasolacrimal obstruction. A 35-year-old women presented with epiphora and swelling of the left lacrimal sac area and cervical lymphadenopathy. She had undergone dacryocystorhinostomy [DCR] 6 months before. Computed tomography demonstrated a lacrimal sac mass involving the nasal cavity. Histopathologic examination revealed diffuse large cell lymphoma. According to immunohistologic staining, the tumor was B-cell type. The patient was treated with irradiation and chemotherapy. Lacrimal sac tumors may present with epiphora and dacryocystits masquerading as nasolacrimal canal obstruction

[Outcomes of keratoprosthesis at Labbafinejad medical center]

To evaluate the results of keratoprosthesis [KPS] at Labbafinejad Medical Center. In this case-series 29 eyes of 27 patients who underwent KPS between 1995-2002 were evaluated for results and complications. Patients included 22 male and five female subjects. Diagnoses included chemical burn [17 cases], Stevens-Johnson syndrome [three cases], ocular cicatricial pemphigoid [seven cases], corneal retransplantation [one case] and old corneal scar [one case]. Preoperative visual acuity was hand motion or light perception [no light perception, hand motion, or light perception in the fellow eyes],. Prostheses were Girard in 20 cases, tibiakeratoprosthesis in 3 cases, and Dohlman type 1, Dohlman type 2 and Pintucci, each in two cases. Postoperative visual acuity improved in 21 patients [72.4%] of which 66.7% experienced major complications including bacterial endophthalmitis [42.9%], retinal detachment [28.6%], uncontrolled glaucoma [21.4%], and spontaneous extrusion [7.1%]. Although KPS is hopeful in the short term with acceptable initial results, the long-term complication rate is high and the prognosis is poor. So it is better that KPS be preceded with safer procedures such as keratolimbal graft especially in young patients

[Prevalence of different types of ptosis at a referral hospital in Tehran, Iran]

To assess etiology, demography, surgical management and postoperative complications of ptosis in a referral ophthalmologic center. We reviewed records of 233 ptosis patients managed at Labbafinejad Hospital during 1998-2003. Etiology, age, sex, laterality, family history, amblyopia, past medical history, margin reflex distance and levator function, type of surgery, and postoperative complications were evaluated. The study included 117 female and 116 male subjects with mean age of 18.7 +/- 12.8 years. There was past ocular surgery in 85%, female history of ptosis in 3.4% amblyopia in 19.2% and strabismus in 6.9%. Ptosis was unilateral in 85% and bilateral in 15% and was congenital in 79%. The most prevalent type of ptosis is congenital therefore early ditection and referral of affected children is necessary to prevent amblyopi

[Amniotic membrane transplantation for congenital distichiasis]

To evaluate the use of amniotic membrane transplantation [AMT] for management of congenital distichiasis. This interventional case series was performed on 16 eyelids of 5 patients with congenital distichiasis treated with posterior lamella resection and AMT. All patients were men aged 2 to 42 years. Mean follow up was 17 months [6-29months]. Post-operative symptoms of dry eye were controlled by medical treatment in all patients. Misdirected eyelashes recurred in 3 eyelids [18.8%] outside the AMT area and in 2 eyelids within the AMT area which were treated by gentle laser epilation. AMT is a useful option in management of distichiasis with a low rate of complications and acceptable eyelid contour

[Comparing two methods of fascia lata use for frontalis suspension]

To compare the results of two different methods of frontalis suspension using fascia lata in congenital ptosis. In randomized clinical trial, double triangle sling was compared with single triangle sling using fascia lata. Eight patients with unilateral and 11 patients with bilateral congenital ptosis were randomly assigned for each procedure. There was no statistically significant difference between the two groups in terms of age and sex. Mean increase in interpalpebral fissure was 4.35 +/- 2.32 mm in the double triangle group and 4.36 +/- 1.89 mm in the single triangle group. Increase in palpebral fissure was statistically significant in both groups [P=0.00] but there was no difference between the two groups regarding functions during [lid fissure height] and cosmetic [lid margin contour] results and early or late complications during follow up. Single triangle sling method using fascia lata is safe, easy, and fast with acceptable results and can be used instead of conventional double triangle fascia lata sling for treatment of low function ptosis

[Complications of hydroxyapatite pegging: comparison of polycarbonate versus titanium pegs]

To compare the complications of pegging between the polycarbonate peg system and the titanium peg system. Complications associated with pegging [polycarbonate: Bio-Eye or titanium: Dr-Perry new P-K] were reviewed from the hospital records of 153 patients over 5 years. Out of 153 cases, 96 [62.3%] were male and 57 [37.7%] were female. Mean age was 27.7 years [6-59 years]. In 88 cases, the peg was polycarbonate with sleeve system and in 65 cases, a titanium peg was used. There was at least one complication in 41 [46.6%] cases with polycarbonate and 18 [27.7%] cases with titanium [P= 0.018]. The rates of the most common complications including granulation tissue, discharge, conjunctiva over growth, and peg falling out were 35%, 23%, 13%, and 8%, respectively in the polycarbonate peg group and 15%, 5%, 1.5%, and 0 in the titanium peg group. The rate of the last 3 complications in the titanium peg group was statistically lower than the polycarbonate group. Twenty-five [28.4%] cases with polycarbonate peg and 5 [7.5%] cases with titanium peg had two or more complications [P= 0.03]. Peg removal for treatment of complications was required in 11 out of 41 complicated cases [28.8%] of the polycarbonate group but in 2 out of 18 complicated cases [11.1%] of the titanium group [P= 0.03]. Both pegging systems incurred complications which were less severe and less prevalent with the titanium peg system. Surgical intervention for treatment of complications in the titanium peg system was required less than the polycarbonate peg. It may be concluded that the titanium peg is a good substitute to the polycarbonate peg system

[Clinical features and results of surgery for Duane's retraction syndrome]

To report clinical features, types, and results of surgery for Duane's retraction syndrome [DRS]. This is an existing data study on the records of patients with DRS. The study was conducted on the hospital records of patients who were referred for DRS to a tertiacy eye center in Tehran, Iran during 8 years. The follow-up period after the surgery was at least 6 months. Data of 42 cases was studied. Mean age was 11.7 years [14 months to 25 years]. Twentyseven cases [64%] were female and 15 cases [36%] were male. The involved eye was left in 24 [57%], right in 13 [31%], and both eyes in 5 cases [12%]. Ocular alignment in primary position was esotropia in 20 [47.5%], exotropia in 14 [33.5%], and orthotropia in 8 cases [19%]. The most common type of DRS was type 1 [57%] followed by type 11 [31%] and type I11 [9%]. There was one case [3%] of synergistic divergence. Shooting phenomen was present in 17 [41%] patients. Ocular abnormalities were present in 16% and systemic abnormalities in 7%. Thirty-three cases [78.5%] underwent operation. Indications of surgery were ocular deviation [79%], abnormal head posture [51.5%], palpebral fissure changes and retraction [51.5%], and shooting [27%]. The operation was performed on one or two horizontal rectus muscles in 63% and on three or four muscles in 39%. Type of surgery was biomedial rectus recession and bilateral rectus recession in 63%, vertical muscles transposition in 27%, and splitting of the lateral rectus in 24%. In 61% of patients the affected eye improved with one operation. Abnormal head posture was improved in 76%. Cases with residual deviation, abnormal head posture, vertical deviation, or shooting phenomena were operated. DRS can be diagnosed clinically most of the times; signs and symptoms can be significantly improved with appropriately tailored operation on extraocular muscles

Botulinum Toxin injection into inferior Oblique Muscle for treatment of acquired superior Oblique Palsy

To evaluate the effect of Botulinum toxin-A [BTA] injection into the inferior oblique [10] muscle in releaving the symptoms of superior oblique [SO] palsy.The study was conducted on patients who were referred for acquired SO palsy with less than 2 years of duration. About 10-20 unit of BTA was injected into the belly of the inferior oblique muscle through the inferotemporal quadrant of the involved eye without opening the conjunctiva. Results: Eighteen eyes from 16 patients were injected. Mean age was 33.7 years and mean duration of paresis was 6 months. Trauma was the cause of paresis in 81.2%. Six months after the injection, mean deviation decreased from 6.4 A to 1.9A; mean I0 over-activity decreased from +6.4 to +1.9; mean SO upper-activity decreased from -1.7 to -0.6; mean subjective torsion decreased from 9.3° to 0.4°; and mean head tilt decreased from 8.4° to 1.1°.Botulinum toxin-A injection into the 10 muscle can decrease the symptoms of patients with SO palsy and cause faster rehabilitation of these patients before stabilization of signs for final decision