Effect of retrobulbar prostaglandin analog injection on orbital fat in rats.

PURPOSE: Periorbital fat atrophy is a known side effect of topical prostaglandin analogs (PA). This side effect may have implications in the treatment of diseases like thyroid orbitopathy. In this in vivo study we aimed to evaluate the effects of retrobulbar injection of three different PAs on orbital fat. METHODS: Eighteen adult male Wistar-albino rats were divided into three groups of six animals. 0.1 ml of 0.03% bimatoprost, 0.005% latanoprost, or 0.005% travoprost was injected into the right orbits and saline was injected into the left orbits, as controls. Both orbits were exenterated after 3 weeks. Histological cross-sections were analyzed using ImageJ image analysis software. Intraconal adipocyte density was calculated. RESULTS: There was no significant difference in the adipocyte density between the PA injected orbits and the control side in each of the three groups. When calculations from all three groups were analyzed together, again the difference in the adipocyte density between the PA injected orbits and the control side was not significant. CONCLUSION: No significant fat atrophy was noted in this rat model three weeks after retrobulbar injection of PAs. To evaluate retrobulbar injection of PA as a potential therapy for orbital diseases with fat proliferation, in vivo studies in different animal models, higher concentrations of PA, or longer follow-up duration are required.

Comparison of Colorado Microdissection Needle Versus Scalpel Incision for Aesthetic Upper and Lower Eyelid Blepharoplasty.

PURPOSE: Traditionally, eyelid skin incisions with electro-cautery devices have been avoided due to the concerns of aesthetically unacceptable scar formation. The purpose of this study is to compare ecchymosis, cosmesis, and histologic tissue damage of incisions made with a scalpel or Colorado needle in patients undergoing upper and lower aesthetic blepharoplasty. To the best of authors' knowledge, no previous study has been performed before to compare these 2 modalities in aesthetic blepharoplasty surgery. METHODS: This is a multicenter, prospective, interventional, comparative case series. The study protocol was approved by Institutional Review Board in each institution. Patients underwent bilateral upper and/or transcutaneous lower blepharoplasty with 1 side randomly selected for skin incision with the scalpel, the other side with the Colorado needle. Ecchymosis was evaluated using a 10-point Likert scale and the wounds using a Hollander score. The margins of excised tissues were evaluated histologically. RESULTS: A total of 254 eyelids of 101 patients were included in the study. No significant difference was observed in ecchymosis on postoperative day 1 and 7 and scar cosmesis on day 30 and 180 between the 2 techniques. Histologically, necrosis was noted only with the Colorado needle sides (p = 0.001). No adverse events occurred on the Colorado needle side at any time after surgery. CONCLUSIONS: No clinical difference is noted between Colorado needle and scalpel incisions in terms of ecchymosis and scar cosmesis after aesthetic blepharoplasty.

The hot orbit: orbital cellulitis.

Orbital cellulitis is an uncommon condition previously associated with severe complications. If untreated, orbital cellulitis can be potentially sight and life threatening. It can affect both adults and children but has a greater tendency to occur in the pediatric age group. The infection most commonly originates from sinuses, eyelids or face, retained foreign bodies, or distant soources by hematogenous spread. It is characterized by eyelid edema, erythema, chemosis, proptosis, blurred vision, fever, headache, and double vision. A history of upper respiratory tract infection prior to the onset is very common especially in children. In the era prior to antibiotics, vision loss from orbital cellulitis was a dreaded complication. Currently, imaging studies for detection of orbital abcess, the use of antibiotics and early drainage have mitigated visual morbidity significantly. The purpose of this review is to describe current investigative strategies and management options in the treatment of orbital cellulitis, establish their effectiveness and possible complications due to late intervention.

Corneoscleral necrosis after episcleral Au-198 brachytherapy of uveal melanoma.

PURPOSE: To describe the risk factors for the development of corneoscleral necrosis (CSN) and its management in patients with primary choroidal or ciliochoroidal melanoma who underwent episcleral Au-198 brachytherapy. METHODS: Clinical records of patients with symptoms of dry eye, foreign body sensation, pain, and evidence of CSN after Au-198 brachytherapy for uveal melanoma treated over a 22-year period were reviewed retrospectively. Risk factors for the development of CSN were identified and various methods of management were evaluated. The data were analyzed using multivariant analysis. A P < 0.05 was taken as a level of statistical significance. RESULTS: Of the 202 eyes of 202 patients treated with Au-198 radioactive plaque, 15 (7.4%) patients with symptomatic complaints of dry eye and pain showed evidence of CSN. First signs were noted as early as 1 month to as late as 5 years (median time 5 months) after the treatment. Risk factors for the development of CSN included tumor thickness greater than 6 mm and ciliary body involvement (P < 0.05). Associated risk factor included intraocular pressure greater than 21 mmHg. Four patients required conservative management, 11 patients required scleral patch and/or conjunctival flaps, and 6 eyes eventually required enucleation. Eyes which developed CSN were more likely to undergo enucleation compared with eyes having no evidence of CSN (P < 0.05). None of the eyes with CSN, which required enucleation because of the failed treatment, had histopathologic evidence of recurrent tumor or tumor invading sclera. CONCLUSION: Corneoscleral necrosis may occur soon or several years after Au-198 brachytherapy for uveal melanoma. Risk factors for CSN include tumor thickness greater than 6 mm, ciliary body involvement, and intraocular pressure >21 mmHg. Closer follow-up, early recognition, and timely intervention may avert serious consequences.

Orbital pseudotumor: distinct diagnostic features and management.

PURPOSE: To provide an overview of the spectrum of diseases known as 'idiopathic orbital inflammatory syndrome' also known as orbital pseudotumor, with emphasis on specific diagnostic challenges in the evaluation and management of patients with this disorder. METHODS: Review of the relevant literature and summarize recent findings regarding the epidemiology, diagnosis, pathophysiology and treatment of orbital pseudotumor. RESULTS: Orbital pseudotumor is a benign intraorbital process confined to the orbit but extra orbital involvement can occur. It is among the 3(rd) most common orbital diseases along with thyroid orbitopathy and lymphoproliferative disorder and accounts for 5-10% of orbital processes. Clinically, orbital pseudotumor has been categorized as myositis, dacryoadenitis, anterior, apical and diffuse process. Patients may present with diplopia, conjunctival chemosis, proptosis or abnormal computed tomography scan (CT-scan) findings. Patients may also have associated optic neuropathy. Diagnosis is based on careful history, ultrasonography (U/S), CT-scan and magnetic resonance imaging (MRI) studies which may also provide prognostic information. Treatment consists of systemic corticosteroids in the form of oral or intravenous administration. Confirmation is made by orbital biopsy. In addition to radiation, cytotoxic agents, immunosuppressant, IV immunoglobulin, biological therapy, TNF-alpha inhibitor monoclonal antibody and Mycophenolate Moftil have been found to be useful in the management of refractory orbital pseudotumor. CONCLUSION: Understanding of the clinical features of patients with orbital pseudotumor, differentiating it from other orbital processes by use of imaging techniques and timely implementation of available treatment strategies may help prevent visual loss and associated morbidity from this condition.

Congenital cystic eye with intracranial anomalies: a clinicopathologic study.

PURPOSE: To describe clinical, imaging and histopathologic findings of congenital cystic eyes associated with intracranial malformations. METHODS: Retrospective, noncomparative, interventional, clinicopathologic case reports of two female children (ages 15 days and six months) who were found to have non-discernable eye globes at birth. The patients underwent complete clinical examination, imaging studies, surgical exploration and histopathological evaluation of the excised orbital cystic structures. RESULTS: The fellow socket in one patient was found to be anophthalmic and the fellow eye in the second patient was highly myopic. Clinical, imaging [ultrasonography, computerized tomography (CT) scan and magnetic resonance imaging (MRI)], and histopathologic evaluations were consistent with the diagnosis of congenital cystic eye in both cases. Intracranial abnormalities were found in both patients, requiring ventroperitoneal shunting. Orbital cysts in both patients were excised and no recognizable eye structures were identified at the time of surgery. Histopathologic study in each case revealed a cyst externally surrounded by dense fibrous connective tissue with the inner aspect of the cyst lined by primitive neuroglial tissue in one case and immature and dysplastic retinal elements in the other. No recognizable ocular structures or microphthalmos were identified in either case. Immunohistochemical staining for glial fibrillary acidic protein, neuron-specific enolase and neurofilament protein were positive without evidence of normal elements of cornea, lens, ciliary body, choroid or retina. CONCLUSION: Congenital cystic eye should be suspected in patients with an unrecognizable eye globe and the possible association with intracranial malformation investigated. Early recognition of the association may help in the diagnosis and treatment of anophthalmic socket and intracranial anomalies.

Outcome of treated orbital cellulitis in a tertiary eye care center in the middle East.

PURPOSE: To describe risk factors predisposing patients to orbital cellulitis and potential complications in patients treated at a tertiary eye care referral center in the Middle East. DESIGN: Noncomparative, interventional, retrospective case series. PARTICIPANTS: Patients diagnosed with orbital cellulitis. METHODS: A 15-year clinical review of patients with a diagnosis of orbital cellulitis referred to King Khaled Eye Specialist Hospital, an accredited (Joint Council on Accreditation of Healthcare Organizations, Washington, DC) tertiary care center in Riyadh, Saudi Arabia, was performed. Only those patients who had clinical signs and symptoms or radiologic evidence suggestive of orbital cellulitis were included in the study. MAIN OUTCOME MEASURES: Patient demographics, factors predisposing to orbital cellulitis, and resulting complications. RESULTS: A total of 218 patients (136 male, 82 female) fulfilling the diagnostic criteria for orbital cellulitis were identified. The average age of these patients was 25.7 years (range, 1 month-85 years). On imaging studies, there was evidence of inflammatory or infective changes to orbital structures; orbital abscesses were identified in 116 patients (53%). Sinus disease was the most common predisposing cause in 86 patients (39.4%), followed by trauma in 43 patients (19.7%). All patients received systemic antibiotic treatment before the identification of any responsible organisms. Of the 116 patients with orbital abscess, 101 patients (87%) required drainage. The results of cultures in patients in whom an orbital abscess was drained were positive for 91 patients (90%). The most common microorganisms isolated from the drained abscesses were Staphylococci and Streptococci species. Blood cultures were positive in only 4 patients from whom blood was drawn for cultures. Visual acuity improved in 34 eyes (16.1%) and worsened in 13 eyes (6.2%), including 9 (4.3%) eyes that sustained complete loss of vision, which was attributed to the delay in correct diagnosis and timely intervention (average 28 days vs. 9 days in patients with no loss of vision; P<0.05). There were 9 cases of intracranial extension of orbital abscesses that required either extended treatment with systemic antibiotics alone or in combination with neurosurgical intervention. Most patients received oral antibiotics on discharge for varying periods. There were 6 cases (2.7%) of strabismus and 4 cases (1.8%) of ptosis that persisted after treatment and resolution of orbital cellulitis. CONCLUSIONS: Untreated sinusitis and prior history of orbital trauma were the 2 major causes of orbital cellulitis in patients referred to a tertiary care eye center in the Middle East. Although rare, severe visual loss still remains a serious complication of delayed detection and intervention in most cases of orbital cellulitis.

Epidemiology of giant-cell arteritis in an Arab population: a 22-year study.

OBJECTIVE: To study the epidemiology of biopsy-proven giant-cell arteritis (GCA) in an Arab population with clinical features suggestive of GCA. METHODS: Clinical records of 102 patients who underwent temporal artery biopsy (TAB) at King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia from January 1983 to December 2004 were reviewed. RESULTS: Among the 56 men and 46 women who had TAB, 7 (6.8%) had biopsy-proven GCA. The mean (SD) age of the biopsy-positive group (71.7 (8.6) years) was higher than in the biopsy-negative group (65 (9.8) years; p = 0.005). None of the untreated patients with a negative TAB developed additional symptoms that are typical of GCA. CONCLUSION: The small absolute number of biopsy-proven cases of GCA implies a relatively low incidence of GCA in Arab population, confirming previous observations that GCA occurs primarily in the Caucasian population.

Congenital microphthalmos with orbital cysts: distinct diagnostic features and management.

PURPOSE: To review the clinical features and treatment strategies for microphthalmic globes with orbital cyst. METHODS: : The clinical records of 23 patients treated for microphthalmos associated with orbital cysts were reviewed retrospectively. RESULTS: Most cases of congenital microphthalmos with orbital cysts were first noted at birth, and all were confirmed by means of computed tomography and/or ultrasonography. Six of the 23 cases were bilateral. Sixty-seven percent of bilateral and 29% of unilateral cases also had other congenital malformations. Mild microphthalmos was noted in 3 orbits, moderate in 16 orbits, and severe in 10 orbits. On the basis of clinical findings, 8 orbits were treated with enucleation and cyst excision and 15 were treated with cyst excision only. Cyst aspiration was performed on 5 orbits; 2 required aspiration and subsequent cyst excision. Twenty-six orbits had good cosmesis and 2 had acceptable cosmesis. The mean follow-up interval was 5.15 years. CONCLUSIONS: Management of microphthalmos with orbital cyst is a cosmetic issue. Cyst size, degree of microphthalmos, and general condition of the patient determine the best treatment approach.